How Well Does Non-mass Enhancement Correlate With DCIS/Invasive Cancer?

INTRODUCTION: Contiguous non-mass enhancement (NME) often coexists with a solid tumor component on MRI, but it can be challenging to predict whether NME represents invasive breast cancer, ductal carcinoma in situ (DCIS), benign disease, or biopsy site reaction. The purpose of this study was to determine the association between the size/extent of NME and the presence of invasive cancer and/or DCIS on final pathology. METHODS: This was a single institution retrospective analysis of a prospectively maintained breast cancer registry (2010-2020). Female patients who underwent surgical resection were included if they had a diagnosis of invasive breast cancer (with or without DCIS) and had an MRI showing both a solid mass and contiguous NME. The size of NME on MRI was compared with the size of invasive cancer and/or DCIS on the final pathology. RESULTS: From a total of 3443 patients, 225 patients were included. 86.2% had invasive ductal carcinoma (IDC), and 12.0% had invasive lobular carcinoma 76.9% were ER+, 16.4% were HER2+, and 13.3% were triple negative breast cancer (TNBC). 18.7% received neoadjuvant chemotherapy (NCT) of whom 31% achieved a complete radiographic/pathologic response. Pearson correlation coefficients (r) between the size of NME and invasive cancer/DCIS showed a strong and positive correlation of MRI NME with DCIS on pathology in patients without NCT. Subgroup analysis showed the strongest correlations for NME and DCIS among non-white (r = .70) and HER2 + patients (r = .74) who did not receive NCT. CONCLUSIONS: Strong correlations between NME and DCIS were found for HER2 + disease and non-white patients, but only modest correlations were found for other patient/disease characteristics. These correlations may impact decisions in surgical approach.

Circulating tumor DNA for breast cancer: Review of active clinical trials.

BACKGROUND: The new diagnostic concept of liquid biopsy is based on the analysis of circulating tumor cells (CTCs) and cell-free DNA (ctDNA). In addition to providing a more comprehensive view of the tumor characteristics including molecular variations, ctDNA analysis through liquid biopsies may also allow for a non-invasive, rapid, and cost-effective identification of biomarkers for tumor detection and monitoring of tumor progression. OBJECTIVE: In this review, we summarize key active clinical trial studies involving utilization of ctDNA derived from liquid biopsy in the early and metastatic breast cancer setting. With this, we also provide a brief overview of the potential future implementations of the LB technology and outlining how ctDNA analysis needs to be standardized through the performance of similar clinical studies. METHODS: A review was conducted on Clinicaltrials.gov to identify active trials related to use of circulating tumor DNA (ctDNA) for breast cancer. Search terms included "breast cancer," "liquid biopsy," and "ctDNA." CONCLUSION: While LB is gaining traction in many cancer settings, its use in BC is still early and warrants more investigation in breast cancer diagnostic and treatment settings, including early detection of disease recurrence.

Association of Abdominal Arterial Calcification Score with Patients' Survival and Kidney Allograft Function after Kidney Transplant.

BACKGROUND: Abdominal arterial calcification (AAC) is common among candidates for kidney transplant. The aim of this study is to correlate AAC score value with post-kidney transplant outcomes. METHODS: We modified the coronary calcium score by changing the intake data points and used it to quantitate the AAC. We conducted a retrospective clinical study of all adult patients who were transplanted at our center, between 2010 and 2013, and had abdominal computed tomography scan done before transplantation. Outcomes included mortality, pulse pressure (PP) measured by 24 h ambulatory blood pressure monitoring system, and kidney allograft function measured by iothalamate clearance. RESULTS: For each 1000 increase of AAC score value, there is an associated 1.05 increase in the risk of death (95% CI 1.02, 1.08) (p < 0.001). Overall median AAC value for all patients was 1784; Kaplan-Meier curve showed reduced survival of all-cause mortality for patients with AAC score value above median and reduced survival among patients with cardiac related mortality. The iothalamate clearance was lower among patients with total AAC score value above the median. Patients with abnormal PP (< 40 or > 60 mmHg) had an elevated median AAC score value at 4319.3 (IQR 1210.4, 11097.1) compared to patients with normal PP with AAC score value at 595.9 (IQR 9.9, 2959.9) (p < 0.001). CONCLUSION: We showed an association of AAC with patients' survival and kidney allograft function after kidney transplant. The AAC score value could be used as a risk stratification when patients are considered for kidney transplant.

Age-related Survival Outcomes for Pancreatic Cancer by Age.

Background/Aim: Pancreatic cancer has a very poor prognosis, though outcomes based on age are not well characterized. The aim of current study was to analyze the survival of patients with pancreatic cancer based on age. Patients and Methods: Using National Cancer Data Base (NCDB), we determined survival outcome based on age among patients with pancreatic cancer. Results: A total of 423,482 patients between 2004 and 2017 were included in the study. Patients aged between 18 and 40-years-old had the worst 3-year survival rate among stage 1 disease. Conversely, patients over 65-years-old had the worst 3-year survival rate and presented with more advanced disease (clinical stages 3 and 4). Conclusion: Older patients with more advanced disease had worse survival.

Advanced Tumor Imaging Approaches in Human Tumors.

The management of cancer has always relied heavily on the imaging modalities used to detect and monitor it. While many of these modalities have been around for decades, the technology surrounding them is always improving, and much has been discovered in recent years about the nature of tumors because of this. There have been several areas that have aided those discoveries. The use of artificial intelligence has already helped immensely in the quality of images taken but has not yet been widely implemented in clinical settings. Molecular imaging has proven to be useful in diagnosing different types of cancers based on the specificity of the probes/contrast agents used. Intravital imaging has already uncovered new information regarding the heterogeneity of the tumor vasculature. These three areas have provided a lot of useful information for the diagnosis and treatment of cancer, but further research and development in human trials is necessary to allow these techniques to fully utilize the information obtained thus far.

Superior mesenteric venous thrombosis: Endovascular management and outcomes.

BACKGROUND: Superior mesenteric venous thrombosis (SMVT) is a rare but fatal condition that is typically treated initially with anticoagulation therapy, and if this fails, with endovascular interventions. However, due to its rarity, there are not many studies that have explored the effectiveness of anticoagulation and endovascular therapies in treating SMVT. AIM: To evaluate patients diagnosed with SMVT who received endovascular therapy in addition to anticoagulation and report technical and clinical outcomes. METHODS: A retrospective analysis of the patients who underwent endovascular treatment for SMVT at Mayo Clinic from 2000-2019 was performed. Technical success was defined as angiographic improvement in SMV flow after intervention. Primary patency was defined as the interval from reestablishing mesenteric venous flow until the first repeat thrombotic event or need for additional intervention. Secondary patency was defined as successful restoration of flow after repeat intervention until rethrombosis or last follow-up. The adverse events were reported through Clavien-Dindo classification. RESULTS: Twenty-four patients were included for analysis. The median age at intervention was 60 years (35-74 years) and 16 (67%) were men. Nineteen patients presented with acute thrombosis (79.2%) and 5 with chronic thrombosis with acute manifestations (20.8%). The most commonly used endovascular modalities were thrombectomy in 12 patients (50.0%) and catheter-directed thrombolysis in 10 patients (41.7%). Technical success was achieved in 18 patients (75%). The 14-d and 30-d primary patency rates were 88.9% and 83.3%, respectively. Adverse events were reported in two patients (8.3%), one marked as grade IIIB, and 1 death marked as grade V. Five-year overall survival rate was 82% (58%-100%). CONCLUSION: Endovascular intervention with anticoagulation appears to be effective for managing SMVT. This treatment combination may be considered as first-line therapy for SMVT management in select patients.

A complicated course for an infected endovascular stent graft.

The management of an infected endovascular aortic stent graft can be complex and morbid. Therefore, caution should be exercised before an endovascular approach is considered in patients presenting with a saccular aneurysm who are younger than 65 years and without risk factors for this may indicate a mycotic aneurysm. An open approach with consideration of aneurysm excision should be entertained to prevent an endovascular implantation in the setting of an infected aorta. We report a case of endovascular aortic stent graft infection that led to complex surgical management and prolonged postoperative care.

The Effect of a Pediatric Rare Disease on Subscriber Retention Rates for Commercial Health Insurers in the United States.

BACKGROUND: The advent of personalized medicine creates opportunities for regenerative therapies to deliver extended clinical benefit from a single administration. Policymakers and health insurers in the United States are evaluating coverage and payment arrangements for these therapies. One challenge involved in these evaluations is the perception that subscribers change insurers relatively often. However, the effect of pediatric rare diseases on retention rates for commercial health insurers has not been well studied. OBJECTIVE: To develop estimates for subscriber retention by a commercial insurer for up to 10 years. METHODS: Three population cohorts were examined: (1) all subscribers, (2) subscribers with any dependent aged 16 years or younger, and (3) subscribers with any dependent aged 16 years or younger diagnosed with a chronic rare disease that typically results in a debilitating state or high mortality, usually associated with high health care costs regardless of whether a treatment is available. The analysis was conducted for a sample of fully insured and self-insured group business within the commercial health insurance market for these study cohorts. The MarketScan Commercial Claims and Encounters research database covering the time period from January 1, 2007, through December 31, 2016, was used as the basis for the analysis. Subscribers were included in the family-based cohorts beginning with the first observed month with a dependent aged 16 years or younger and were retained in the analysis until the subscriber or insurer withdrew from the dataset (whichever came first). Subscribers were included in the family-based rare disease cohorts if their qualifying dependent was reported with at least 2 occurrences for any of the rare diseases studied. A Kaplan-Meier estimator was used to produce retention rates for all populations for up to 120 months. An adjustment for interval censoring was applied to the family-based cohorts. A log rank test with chi-square statistic was used to determine statistical significance. RESULTS: The analysis found that the subscriber retention rate within the self-insured groups was higher than within the fully insured groups (P < 0.0001). In addition, the probability of retaining subscribers with a dependent aged 16 years or younger compared with all subscribers was significantly greater (P < 0.0001). The analysis also found the probability of retaining subscribers with a qualifying dependent with a rare disease compared with subscribers with any dependent aged 16 years or younger was significantly greater (P < 0.0001). CONCLUSIONS: This study demonstrated that families with a child with a rare disease remained with their commercial health insurer longer than families who did not have a child with a rare disease. The analysis will be a useful resource when evaluating alternative payment arrangements and cost/benefit analyses of regenerative therapies that offer an extended duration of clinical benefit. DISCLOSURES: This study was sponsored by AveXis, which provided input into the study design, decided to submit the study results for publication, and performed an editorial review of the manuscript. Kuester, Jackson, and Runyan received consulting fees from AveXis during the conduct of this study. Pezalla and Nussbaum received consulting fees from Milliman during the conduct of this study. Nussbaum reports consulting fees from Sarepta Therapeutics and Ultragenyx Pharmaceutical outside of this study and serves on the Commercial Advisory Board of Gilead Sciences. A variation on this topic was presented at the Academy of Managed Care Pharmacy Nexus 2018; October 22-25, 2018; Orlando, FL.

The potential impact of monitoring disease activity biomarkers on rheumatoid arthritis outcomes and costs.

Rheumatoid arthritis (RA) management requires monitoring of disease activity to determine course of treatment. Global assessments are used in clinical practice to determine RA disease activity. Monitoring disease activity via biomarkers may also help providers optimize biologic and nonbiologic drug use while decreasing overall drug spend by delaying use of expensive biologic therapies. By testing multiple biologic domains at the same time, a multibiomarker disease activity test may have utility in RA patient management, through improved intra- and inter-rater reliability. This report provides a comprehensive review of studies of objective measures, single biomarkers and multibiomarker disease activity tests as disease activity measures to decrease uncertainty in treatment decisions, and of biomarkers' potential impact on economic and clinical outcomes of treatment choices.

An Economic Evaluation of the Impact, Cost, and Medicare Policy Implications of Chronic Nonhealing Wounds.

OBJECTIVE: The aim of this study was to determine the cost of chronic wound care for Medicare beneficiaries in aggregate, by wound type and by setting. METHODS: This retrospective analysis of the Medicare 5% Limited Data Set for calendar year 2014 included beneficiaries who experienced episodes of care for one or more of the following: arterial ulcers, chronic ulcers, diabetic foot ulcers, diabetic infections, pressure ulcers, skin disorders, skin infections, surgical wounds, surgical infections, traumatic wounds, venous ulcers, or venous infections. The main outcomes were the prevalence of each wound type, Medicare expenditure for each wound type and aggregate, and expenditure by type of service. RESULTS: Nearly 15% of Medicare beneficiaries (8.2 million) had at least one type of wound or infection (not pneumonia). Surgical infections were the largest prevalence category (4.0%), followed by diabetic infections (3.4%). Total Medicare spending estimates for all wound types ranged from $28.1 to $96.8 billion. Including infection costs, the most expensive estimates were for surgical wounds ($11.7, $13.1, and $38.3 billion), followed by diabetic foot ulcers ($6.2, $6.9, and $18.7 billion,). The highest cost estimates in regard to site of service were for hospital outpatients ($9.9-$35.8 billion), followed by hospital inpatients ($5.0-$24.3 billion). CONCLUSIONS: Medicare expenditures related to wound care are far greater than previously recognized, with care occurring largely in outpatient settings. The data could be used to develop more appropriate quality measures and reimbursement models, which are needed for better health outcomes and smarter spending for this growing population.

Quality Varies Across Health Insurance Marketplace Pricing Regions.

BACKGROUND: Although consumers purchasing health plans in the new Health Insurance Marketplace will be provided information on the cost and quality of participating health plans, it is unclear whether the state-wide plan quality averages that will be reported will accurately represent quality at the pricing region level where care will be received. OBJECTIVES: To evaluate whether currently reported state-wide health plan quality scores accurately represent quality within pricing regions established for the Health Insurance Marketplace. RESEARCH DESIGN: Observational, historical cohort study using health plan administrative and pharmacy data. SUBJECTS: A total of 5.2 million members enrolled in the preferred provider organization health plans of 1 large commercial California insurer in 2012. MEASURES: State-wide and pricing region performance on each of the 17 Healthcare Effectiveness Data and Information Set (HEDIS) measures. RESULTS: Across the 17 measures assessed in each of the 19 pricing regions, scores were statistically different (P<0.05) than the overall plan rate for 176 (54%). Variations in scores across regions were observed for each measure ranging from 6.4-percentage points for engagement in treatment for people with dependence of alcohol or other drugs to 47.2-percentage points for appropriate testing for pharyngitis among children. CONCLUSIONS: Quality scores in California vary greatly across geographic regions. Statewide averages may misrepresent the quality of care that consumers are likely to receive within a geographic area making difficult assessments about the value of the health care.