Diagnostic accuracy of general dermatologists and supportive oncodermatologists for biopsied cutaneous immune-related adverse events.

PURPOSE: Supportive oncodermatology has been shown to improve several aspects of care for patients with cancer, but research showing improved diagnostic accuracy as a benefit of supportive oncodermatology is largely lacking. We thus aimed to evaluate different dermatologist groups' diagnostic accuracy for heterogenous cutaneous toxicities, using cutaneous immune-related adverse events (cirAEs) from immune checkpoint inhibitors (ICIs) as a test model. METHODS: Billing/requisition codes were used to identify patients who initiated programmed death-1/ligand-1 (PD-1/PD-L1) ICIs between 2010 and 2019 at Dana-Farber Cancer Institute/Brigham and Women's Hospital/Massachusetts General Hospital and underwent a subsequent skin biopsy. For each biopsied cirAE, pre-biopsy clinical diagnoses and post-biopsy clinico-pathologic diagnoses were retrospectively obtained from the medical record. Each biopsy-ordering dermatology provider was categorized as a general dermatologist or supportive oncodermatologist on the basis of providing clinical care within a cancer-center or attending on a hospital/clinic service dedicated to anti-cancer drug-related skin toxicities. RESULTS: Of 4,183 patients who initiated anti-PD-1/PD-L1 therapy between 2010 and 2019, 101 (2.4%) patients collectively had 104 biopsied cirAEs. In more than one-third of all reviewed biopsied cirAEs (n = 39, 37.5%), histopathology results frequently led to revision of the pre-biopsy clinical diagnosis. The rate of initial cirAE misclassification amongst supportive oncodermatologists was significantly lower than that amongst general dermatologists (18/66, 27.3% vs. 21/38, 55.3%; Fischer's-exact-test p = 0.006). CONCLUSION: Experienced supportive oncodermatologists may benefit patient care through increased diagnostic accuracy for skin toxicities from ICIs. Collectively, these results underscore that both skin biopsy from any dermatology provider and oncodermatology referral (where available) are valuable resources that should be integrated into supportive cancer care.

Medical student perceptions of assessment systems, subjectivity, and variability on introductory dermatology clerkships.

BACKGROUND: Elective introductory clerkships in dermatology serve a critical function in providing formative experiences to medical students interested in the field. Although dermatology clerkships play a pivotal role in students' career choices and residency preparation, the assessment systems used to evaluate students on these clerkships are widely different and likely affect student experiences. OBJECTIVE: This study aimed to explore the relationship between dermatology clerkship assessment systems and student experiences through interviews with students about their clerkship reflections and perceptions of assessment. METHODS: The authors contacted clerkship directors via the Association of Professors of Dermatology mailing list and invited them to provide a description of the assessment system at their institution. The authors, via contacted clerkship directors, then invited students who had completed an introductory dermatology clerkship in between 2018 and 2019 to provide a description of the assessment system at their institution and to participate in a qualitative interview about their experiences with assessment systems. The authors then iteratively synthesized interview transcripts using phenomenological analysis, in which a templated approach was used to achieve comprehensive thematic categorization. RESULTS: Prior to clerkship onset, students expressed a limited understanding of their clinical role and the assessment system. During the clerkship, students endorsed variable expectations across preceptors, limited feedback experiences, and pressures to perform for evaluators. After their clerkship, students continued to perceive assessment systems as nontransparent, subjective, and preordained. CONCLUSION: Medical students perceived assessment systems on introductory dermatology clerkships to be unclear and arbitrary. Encouragingly, students also viewed these challenges in assessment as malleable, identifying several opportunities for educational reform in dermatology clerkships.

Patterns of Cutaneous and Noncutaneous Immune-Related Adverse Events Among Patients With Advanced Cancer.

Importance: Cutaneous immune-related adverse events (cirAEs) are some of the earliest toxic reactions to emerge following immune-checkpoint inhibitor (ICI) initiation. As an early indicator of robust inflammatory response, cirAEs may be associated with patterns of immune-mediated toxic effects, but associations between these events and noncutaneous immune-related adverse events (irAEs) remain underexplored. Objectives: To characterize patterns of cirAEs and irAEs across care settings and examine associations between the features of first cirAE, overall irAE risk, and risk of specific irAE subtypes. Design, Setting, and Participants: A retrospective cohort study was conducted at a single academic medical center. The cohort included 358 patients with cancer who initiated anti-programmed death 1/ligand 1 and/or anticytotoxic-T-lymphocyte-4 ICI therapy between January 1, 2016, and March 8, 2019, and developed 1 or more cirAEs, identified using International Statistical Classification of Diseases and Related Health Problems, Tenth Revision codes and confirmed via manual medical record review. All relevant information documented before March 31, 2020, was included. Exposures: Anti-programmed death 1/ligand 1 and/or anticytotoxic-T-lymphocyte-4 therapy. Main Outcomes and Measures: Associations between specific cirAE morphologic classes and patterns of irAEs (occurrence, timeline, organ class, and specific toxic effects). Given the potential that shared underlying factors are associated with the risk of both noncutaneous and cutaneous toxic effects, the presence of observed positive associations between certain cirAE and irAE subtypes was hypothesized. Results: Of the 358 patients, 213 were men (59.5%); median age was 65 years (interquartile range, 55-73 years). Nearly half of the patients (177 [49.4%]) with cirAE also developed a noncutaneous irAE. Most patients (128 [72.3%]) experienced their first cirAE before developing any irAE. Several cirAE morphologic classes were found to be associated with overall, organ-based, and specific irAEs. More specifically, mucositis was found to be associated with overall irAE risk (odds ratio [OR], 5.28; 95% CI, 1.11-24.26; P = .04), gastrointestinal irAEs (OR, 5.70; 95% CI, 1.11-29.40; P = .04), and the specific diagnosis of gastroenterocolitis (OR, 6.80; 95% CI, 1.24-37.39; P = .03). In addition, psoriasis was associated with an increased risk of endocrine irAEs (OR, 4.54; 95% CI, 1.21-17.04; P = .03). Conclusions and Relevance: In this cohort study, these findings underscore the risk of multisystem toxic effects in patients experiencing cirAEs and highlight potential opportunities for dermatologists in the management of noncutaneous toxic effects.