Long-Term Risk of Cardiac Events Requiring Interventions in Survivors of Hodgkin's Lymphoma (HL)...
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2637 Long-Term Risk of Cardiac Events Requiring Interventions in Survivors of Hodgkin’s Lymphoma (HL) Treated With Mediastinal Irradiation S. L. Galper 1 , S. Li 2 , Y. Feng 2 , D. Neuberg 2 , B. Silver 3 , A. K. Ng 3 , P. M. Mauch 3 1 Department of Therapeutic Radiology, Yale University School of Medicine, New Haven, CT, 2 Department of Biostatistics, Dana-Farber Cancer Institute, Boston, MA, 3 Department of Radiation Oncology, Brigham and Women’s Hospital, Boston, MA Purpose/Objective(s): To assess the incidence and actuarial risk of clinically-significant cardiac disease requiring intervention in HL patients treated with mediastinal irradiation. Materials/Methods: Between 1968–1998, 1279 HL patients were treated with mediastinal irradiation at our institution. To quan- tify and analyze myocardial infarctions (MI) and procedure-based interventions, we retrospectively reviewed hospital records and patient questionnaires. Cardiac events were defined as: coronary artery disease (MI, percutaneous transluminal coronary angio- plasty [PTCA] with or without stenting, coronary artery bypass graft surgery [CABG] or 75% stenosis on angiogram); arrhythmia (pacemaker, automatic implantable cardioverter defibrillator [AICD] implantation or significant disturbance documented by elec- trocardiogram or Holter monitoring); valve disease (valve repair or moderate or severe valve dysfunction on echocardiogram or angiogram); or pericardial disease (pericardial surgery or pericardiocentesis). In the estimation of incidence and actuarial risk over time, we focused on MI and procedure-based cardiac interventions. Multiple logistic regression models were used to explore factors associated with development of all cardiac complications. Results: 187 patients (15%) were identified as having a cardiac event. Median age at treatment was 25 years (range, 3–93). Median follow-up time for this cohort was 17.2 years (range, 1–41.5 years). 87% of patients had $5 years, 67% had $10 years and 48% had $15 years of follow-up. The cumulative incidence rates (adjusted for competing mortality) for all cardiac events were 2.1%, 4.5%, 9.6% and 15.4% at 5, 10, 15 and 20 years. Incidence and actuarial risk for MI and the four most common cardiac interven- tions are listed in Table 1. Older age at diagnosis (age 40–50 vs. age #20, p \ 0.0001), longer follow-up (10–15 years vs. 15–20 years, p = 0.007) and male gender (p = 0.006) were independent predictors for cardiac events. Conclusions: Increased risk of cardiac disease after mediastinal irradiation in HL survivors has been described in multiple studies. In this study, we specifically quantified cardiac events requiring interventions over time in this population. The results may help in guideline development for both the types and the timing of cardiac surveillance studies in survivors of HL. Incidence Actuarial Risk (%) N (%) 5-yr 10-yr 15-yr 20-yr 25-yr MI 83 (6.5) 0.9 1.9 3.7 6.9 9.9 PTCA 37 (2.9) 0.4 0.7 1.6 3.0 4.9 CABG 35 (2.7) 0.1 0.4 0.9 2.9 4.1 Valve Repair 27 (2.1) 0.1 0.3 0.4 1.1 3.0 Pacemaker 16 (1.2) 0.2 0.2 0.6 0.9 1.8 Author Disclosure: S.L. Galper, None; S. Li, None; Y. Feng, None; D. Neuberg, None; B. Silver, None; A.K. Ng, None; P.M. Mauch, None. 2638 Evolution of a Novel Radiation Oncology Cancer Disparities Research Program in an Indigent Los Angeles Community D. C. Khan 1 , D. Huang 1 , R. Kwon 1 , O. Streeter 2 , M. L. Steinberg 1 1 Centinela Freeman Regional Oncology, Inglewood, CA, 2 USC-Norris Cancer Center, Los Angeles, CA Purpose/Objective: Disparities in cancer treatment outcome in racial/ethnic minorities and low-income patients abound. Under the auspices of the National Cancer Institute (NCI) Cancer Disparities Research Program (CDRP), the Urban Latino African Amer- ican Cancer Disparities Project (ULAAC) investigates and addresses root causes of disparity and offers access to clinical trials for an underserved community. We report the evolution through continuous quality improvement (CQI) mechanisms of a novel in- frastructure designed to address barriers to care, supply patient navigation and access to clinical trials (CT). Material/Methods: Our patient population is 71% Black, 13% Latino with mean family incomes below the poverty level. Infra- structure implemented to address critical patient needs includes training and management of lay patient navigators (LPN), rigorous tracking and focus on solution for barriers to care, clinical trials infrastructure, and ongoing CQI of all aspects of the program. Utilizing feedback from interviews, focus groups and survey instruments; training, barrier identification process, patient satisfac- tion and CT acceptance practice are critically examined to implement alteration of process to enhance program quality. Results: Of 68 ethnically and linguistically appropriate LPNs trained (7 training groups), 26 continue to navigate patients. Of 493 patients offered navigation, 297 accepted. Six most prevalent barriers to care are designated in the Table 1. Initially, the mean time to solution identification for barriers was 42 days. CQI process improvement allowed mean time to resolution to fall to one day. Originally, to facilitate clinical trial acceptance, LPN met with patients at initial consultation. However, navigator focus groups revealed that LPN’s possessed similar negative bias towards clinical trials as the community at large. Therefore training of LPN was modified from 6 to 9 hours and early LPN patient contact was reintroduced. In 24 months, 29 patients were enrolled in 32 clinical trials. Of 29 patients, 18 accepted navigation. 15/29 patients enrolled in RTOG trials. Conclusions: The ULAAC program has put into operation an infrastructure designed to deal with the needs of indigent cancer patients. The program’s goal to decrease barriers to receiving care while assisting accrual to clinical trials appears facilitated by the lay patient navigation program described. The CQI program allows for essential programmatic adjustments and management. S558 I. J. Radiation Oncology d Biology d Physics Volume 69, Number 3, Supplement, 2007
Transcript of Long-Term Risk of Cardiac Events Requiring Interventions in Survivors of Hodgkin's Lymphoma (HL)...
S558 I. J. Radiation Oncology d Biology d Physics Volume 69, Number 3, Supplement, 2007
2637 Long-Term Risk of Cardiac Events Requiring Interventions in Survivors of Hodgkin’s Lymphoma (HL)
Treated With Mediastinal IrradiationS. L. Galper1, S. Li2, Y. Feng2, D. Neuberg2, B. Silver3, A. K. Ng3, P. M. Mauch3
1Department of Therapeutic Radiology, Yale University School of Medicine, New Haven, CT, 2Department of Biostatistics,Dana-Farber Cancer Institute, Boston, MA, 3Department of Radiation Oncology, Brigham and Women’s Hospital, Boston, MA
Purpose/Objective(s): To assess the incidence and actuarial risk of clinically-significant cardiac disease requiring intervention inHL patients treated with mediastinal irradiation.
Materials/Methods: Between 1968–1998, 1279 HL patients were treated with mediastinal irradiation at our institution. To quan-tify and analyze myocardial infarctions (MI) and procedure-based interventions, we retrospectively reviewed hospital records andpatient questionnaires. Cardiac events were defined as: coronary artery disease (MI, percutaneous transluminal coronary angio-plasty [PTCA] with or without stenting, coronary artery bypass graft surgery [CABG] or 75% stenosis on angiogram); arrhythmia(pacemaker, automatic implantable cardioverter defibrillator [AICD] implantation or significant disturbance documented by elec-trocardiogram or Holter monitoring); valve disease (valve repair or moderate or severe valve dysfunction on echocardiogram orangiogram); or pericardial disease (pericardial surgery or pericardiocentesis). In the estimation of incidence and actuarial riskover time, we focused on MI and procedure-based cardiac interventions. Multiple logistic regression models were used to explorefactors associated with development of all cardiac complications.
Results: 187 patients (15%) were identified as having a cardiac event. Median age at treatment was 25 years (range, 3–93). Medianfollow-up time for this cohort was 17.2 years (range, 1–41.5 years). 87% of patients had $5 years, 67% had $10 years and 48%had $15 years of follow-up. The cumulative incidence rates (adjusted for competing mortality) for all cardiac events were 2.1%,4.5%, 9.6% and 15.4% at 5, 10, 15 and 20 years. Incidence and actuarial risk for MI and the four most common cardiac interven-tions are listed in Table 1. Older age at diagnosis (age 40–50 vs. age #20, p\0.0001), longer follow-up (10–15 years vs. 15–20years, p = 0.007) and male gender (p = 0.006) were independent predictors for cardiac events.
Conclusions: Increased risk of cardiac disease after mediastinal irradiation in HL survivors has been described in multiple studies.In this study, we specifically quantified cardiac events requiring interventions over time in this population. The results may help inguideline development for both the types and the timing of cardiac surveillance studies in survivors of HL.
Incidence Actuarial Risk (%)
N (%)
5-yr 10-yr 15-yr 20-yr 25-yrMI
83 (6.5) 0.9 1.9 3.7 6.9 9.9PTCA
37 (2.9) 0.4 0.7 1.6 3.0 4.9CABG
35 (2.7) 0.1 0.4 0.9 2.9 4.1Valve Repair
27 (2.1) 0.1 0.3 0.4 1.1 3.0Pacemaker
16 (1.2) 0.2 0.2 0.6 0.9 1.8Author Disclosure: S.L. Galper, None; S. Li, None; Y. Feng, None; D. Neuberg, None; B. Silver, None; A.K. Ng, None;P.M. Mauch, None.
2638 Evolution of a Novel Radiation Oncology Cancer Disparities Research Program in an Indigent Los Angeles
CommunityD. C. Khan1, D. Huang1, R. Kwon1, O. Streeter2, M. L. Steinberg1
1Centinela Freeman Regional Oncology, Inglewood, CA, 2USC-Norris Cancer Center, Los Angeles, CA
Purpose/Objective: Disparities in cancer treatment outcome in racial/ethnic minorities and low-income patients abound. Underthe auspices of the National Cancer Institute (NCI) Cancer Disparities Research Program (CDRP), the Urban Latino African Amer-ican Cancer Disparities Project (ULAAC) investigates and addresses root causes of disparity and offers access to clinical trials foran underserved community. We report the evolution through continuous quality improvement (CQI) mechanisms of a novel in-frastructure designed to address barriers to care, supply patient navigation and access to clinical trials (CT).
Material/Methods: Our patient population is 71% Black, 13% Latino with mean family incomes below the poverty level. Infra-structure implemented to address critical patient needs includes training and management of lay patient navigators (LPN), rigoroustracking and focus on solution for barriers to care, clinical trials infrastructure, and ongoing CQI of all aspects of the program.Utilizing feedback from interviews, focus groups and survey instruments; training, barrier identification process, patient satisfac-tion and CT acceptance practice are critically examined to implement alteration of process to enhance program quality.
Results: Of 68 ethnically and linguistically appropriate LPNs trained (7 training groups), 26 continue to navigate patients. Of 493patients offered navigation, 297 accepted. Six most prevalent barriers to care are designated in the Table 1. Initially, the mean timeto solution identification for barriers was 42 days. CQI process improvement allowed mean time to resolution to fall to one day.Originally, to facilitate clinical trial acceptance, LPN met with patients at initial consultation. However, navigator focus groupsrevealed that LPN’s possessed similar negative bias towards clinical trials as the community at large. Therefore training ofLPN was modified from 6 to 9 hours and early LPN patient contact was reintroduced. In 24 months, 29 patients were enrolledin 32 clinical trials. Of 29 patients, 18 accepted navigation. 15/29 patients enrolled in RTOG trials.
Conclusions: The ULAAC program has put into operation an infrastructure designed to deal with the needs of indigent cancerpatients. The program’s goal to decrease barriers to receiving care while assisting accrual to clinical trials appears facilitated bythe lay patient navigation program described. The CQI program allows for essential programmatic adjustments and management.
