Use of 18F-FDG PET/CT as an Initial Staging Procedure for Stage II-III Breast Cancer: A Multicenter Value Analysis.

BACKGROUND: Metastatic staging imaging is not recommended for asymptomatic patients with stage I-II breast cancer. Greater distant metastatic disease risk may warrant baseline imaging in patients with stage II-III with high-risk biologic subtypes. NCCN Guidelines recommend considering CT of the chest, abdomen, and pelvis (CT CAP) and bone scan in appropriate patients. CT CAP and bone scan are considered standard of care (SoC), although PET/CT is a patient-centered alternative. METHODS: Data were available for 799 high-risk patients with clinical stage II-III disease who initiated screening for the I-SPY2 trial at 4 institutions. A total of 564 complete records were reviewed to compare PET/CT versus SoC. Costs were determined from the payer perspective using the national 2018 Medicare Physician Fee Schedule and representative reimbursements to the University of California, San Francisco (UCSF). Incremental cost-effectiveness ratio (ICER) measured cost of using PET/CT per percent of patients who avoided a false-positive (FP). RESULTS: The de novo metastatic disease rate was 4.6%. Imaging varied across the 4 institutions (P<.0001). The FP rate was higher using SoC versus PET/CT (22.1% vs 11.1%; P=.0009). Mean time between incidental finding on baseline imaging to FP determination was 10.8 days. Mean time from diagnosis to chemotherapy initiation was 44.3 days with SoC versus 37.5 days with PET/CT (P=.0001). Mean cost per patient was $1,132 (SoC) versus $1,477 (PET/CT) using the Medicare Physician Fee Schedule, with an ICER of $31. Using representative reimbursements to UCSF, mean cost per patient was $1,236 (SoC) versus $1,073 (PET/CT) for Medicare, and $3,083 (SoC) versus $1,656 (PET/CT) for a private payer, with ICERs of -$15 and -$130, respectively. CONCLUSIONS: Considerable variation exists in metastatic staging practices. PET/CT reduced FP risk by half and decreased workup of incidental findings, allowing for earlier treatment start. PET/CT may be cost-effective, and at one institution was shown to be cost-saving. Better alignment is needed between hospital pricing strategies and payer coverage policies to deliver high-value care.

Reducing Infusion Clinic Wait Times Using Quality Improvement.

PURPOSE: Long wait times are a common occurrence for chemotherapy infusion patients and are a source of decreased patient satisfaction. Our facility sought to decrease outpatient infusion clinic wait times by 20% using the Model for Improvement, quality improvement tools, and Plan-Do-Study-Act cycles. METHODS: A multidisciplinary team was formed to address clinic wait times. Patient interviews, time studies, process mapping, brainstorming sessions, affinity diagrams, fishbone diagrams, and surveys were used to define the problem and to develop an intervention. Wait times from check-in until medication administration were analyzed using statistical process control charts. Our Plan-Do-Study-Act cycle led to the addition of a "fast-track" clinic title for patients not waiting for laboratory results on the day of treatment and changes in clinic communication. The fast-track clinic signaled for those patients to have priority for vital sign collection and earlier notification to pharmacy to begin preparing medications. RESULTS: Baseline wait times for patients not requiring laboratories on the day of treatment averaged 1 hour and 33 minutes. After intervention, using statistical process control charts, a shift was observed with a new average wait time of 1 hour and 12 minutes (a 23% decrease). Wait times for patients requiring laboratories on the day of treatment did not change significantly. CONCLUSION: Implementation of a fast-track clinic title and improving communication resulted in a significant reduction in wait times for patients not requiring laboratories on the day of treatment. Future efforts will focus on sustainment and improving wait times for all patients.

Outcomes of patients with multiple myeloma refractory to CD38-targeted monoclonal antibody therapy.

The introduction of CD38-targeting monoclonal antibodies (CD38 MoABs), daratumumab and isatuximab, has significantly impacted the management of patients with multiple myeloma (MM). Outcomes of patients with MM refractory to CD38 MoABs have not been described. We analyzed outcomes of 275 MM patients at 14 academic centers with disease refractory to CD38 MoABs. Median interval between MM diagnosis and refractoriness to CD38 MoAB (T0) was 50.1 months. The median overall survival (OS) from T0 for the entire cohort was 8.6 [95% C.I. 7.5-9.9] months, ranging from 11.2 months for patients not simultaneously refractory to an immunomodulatory (IMiD) agent and a proteasome inhibitor (PI) to 5.6 months for "penta-refractory" patients (refractory to CD38 MoAB, 2 PIs and 2 IMiDs). At least one subsequent treatment regimen was employed after T0 in 249 (90%) patients. Overall response rate to first regimen after T0 was 31% with median progression-free survival (PFS) and OS of 3.4 and 9.3 months, respectively. PFS was best achieved with combinations of carfilzomib and alkylator (median 5.7 months), and daratumumab and IMiD (median 4.5 months). Patients with MM refractory to CD38 MoAB have poor prognosis and this study provides benchmark for new therapies to be tested in this population.

Clinical Case of the Month: Hypereosinophilia in a Young Woman with a History of Childhood Asthma.

Hypereosinophillia is a rare clinical entity. It is associated with a wide differential diagnosis including neoplasm, infection, and allergic etiologies. Clinicians should have a well defined approach to hypereosinophilia in order to find treatable causes. We present a case of hypereosinophillia caused by parasitic infection with Toxocara canis. We also review epidemiology, transmission, microbiology, and management of Toxocara canis.