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Are New Oral Anticoagulants Ready for Use in Patients With Cancer?

Paul C. Hendrie and David A. Garcia

Patients with cancer have long been an important and enigmatic part of basic science and clinical research in thromboembolic disease. The reciprocal deleterious effects on outcomes of a cancer diagnosis on patients with thrombosis and a thrombotic event on patients with cancer have been observed and documented for more than a century. Patients with cancer continue to be one of the more difficult populations to manage using the available unfractionated and low-molecular-weight heparins and the oral vitamin K antagonists. High rates of failure and bleeding complications have made researchers and practitioners alike seek newer more effective anticoagulation agents. The novel oral direct thrombin and activated factor Xa inhibitors have been shown in large clinical trials to be safe and efficacious in many prophylaxis and treatment settings. However, practitioners who treat patients with cancer should be cautious using these agents until more studies are specifically performed in this thrombophilic patient population.

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Development of a Hematology/Oncology ICD-10 Documentation Job Aid

Daniel B. Martin, Sean Silas, Audrey Covner, Paul C. Hendrie, and F. Marc Stewart

Conversion to the International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) was mandated for October 1, 2014, but was delayed by one year. ICD-10 accommodates newly developed diagnoses and procedures and is expected to help measure quality of care. When implemented, it will impact oncology practices because of conversion costs, loss of productivity, and billing problems. Clinical documentation must meet the specificity required by ICD-10 codes or risk denial of payments, which are projected to dramatically increase. In preparation for the now delayed conversion, the ICD-10 transition team at the Seattle Cancer Care Alliance (SCCA) examined the ICD-10 codes for primary hematology/oncology diagnoses and comorbidities of cancer and therapy seen at our institution to identify the need for and feasibility of developing a printable job aid to guide clinical documentation. We found that the variable complexity of ICD-10 codes in hematology/oncology frequently requires nonintuitive specificity likely to be overlooked without prompting. We were able to develop a succinct and facile documentation aid usable in both electronic and printed forms that includes all hematology/oncology diagnoses and the comorbidities most frequently seen in our multidisciplinary institution. This document is organized in a notebook format for easy review and will be continuously improved with feedback from practitioners. It is available for free download from the SCCA Web site.

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Managing Cancer Care During the COVID-19 Pandemic: Agility and Collaboration Toward a Common Goal

Masumi Ueda, Renato Martins, Paul C. Hendrie, Terry McDonnell, Jennie R. Crews, Tracy L. Wong, Brittany McCreery, Barbara Jagels, Aaron Crane, David R. Byrd, Steven A. Pergam, Nancy E. Davidson, Catherine Liu, and F. Marc Stewart

The first confirmed case of coronavirus disease 2019 (COVID-19) in the United States was reported on January 20, 2020, in Snohomish County, Washington. At the epicenter of COVID-19 in the United States, the Seattle Cancer Care Alliance, Fred Hutchinson Cancer Research Center, and University of Washington are at the forefront of delivering care to patients with cancer during this public health crisis. This Special Feature highlights the unique circumstances and challenges of cancer treatment amidst this global pandemic, and the importance of organizational structure, preparation, agility, and a shared vision for continuing to provide cancer treatment to patients in the face of uncertainty and rapid change.

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Financial Implications of Early Hospital Discharge After AML-Like Induction Chemotherapy: A 4-Year Retrospective Analysis

Nathan J. Moore, Megan Othus, Anna B. Halpern, Nicholas P. Howard, Linyi Tang, Kyle E. Bastys, Mary-Elizabeth M. Percival, Paul C. Hendrie, Garrett A. Hartley, Verna L. Welch, Elihu H. Estey, and Roland B. Walter

Background: Early hospital discharge (EHD) after intensive acute myeloid leukemia (AML) induction chemotherapy has become routine at the University of Washington/Seattle Cancer Care Alliance over the past several years. We assessed the financial implications of EHD over the first 4 years after its broad adoption for patients with AML and other high-grade myeloid neoplasms undergoing AML-like induction chemotherapy. Patients and Methods: We retrospectively compared charges between 189 patients with EHD who received all postinduction inpatient/outpatient care within our care system between August 2014 and July 2018 and 139 medically matched control patients who remained hospitalized for logistical reasons. Charges from the day of initial discharge (patients with EHD) or end of chemotherapy (control patients) until blood count recovery, additional chemotherapy or care transition, hospital discharge (for control patients only), an elapse of 42 days, or death were extracted from financial databases and separated into categories: facility/provider, emergency department, transfusions, laboratory, imaging, pharmacy, and miscellaneous. Results: Combined charges averaged $4,157/day (range, $905–$13,119/day) for patients with EHD versus $9,248/day (range, $4,363–$48,522/day) for control patients (P<.001). The EHD cohort had lower mean facility/provider, transfusion, laboratory, and pharmacy charges but not imaging or miscellaneous charges. During readmissions, there was no statistically significant difference in daily inpatient charges between the EHD and control cohorts. After multivariable adjustment, average charges were $3,837/day lower for patients with EHD (P<.001). Conclusions: Together with previous data from our center showing that EHD is safe and associated with reduced healthcare resource utilization, this study further supports this care approach for AML and other high-grade myeloid neoplasms if infrastructure is available to enable close outpatient follow-up.

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Histiocytic Neoplasms, Version 2.2021, NCCN Clinical Practice Guidelines in Oncology

Ronald S. Go, Eric Jacobsen, Robert Baiocchi, Ilia Buhtoiarov, Erin B. Butler, Patrick K. Campbell, Don W. Coulter, Eli Diamond, Aron Flagg, Aaron M. Goodman, Gaurav Goyal, Dita Gratzinger, Paul C. Hendrie, Meghan Higman, Michael D. Hogarty, Filip Janku, Reem Karmali, David Morgan, Anne C. Raldow, Alexandra Stefanovic, Srinivas K. Tantravahi, Kelly Walkovich, Ling Zhang, Mary Anne Bergman, and Susan D. Darlow

Histiocytic neoplasms are rare hematologic disorders accounting for less than 1% of cancers of the soft tissue and lymph nodes. Clinical presentation and prognosis of these disorders can be highly variable, leading to challenges for diagnosis and optimal management of these patients. Treatment often consists of systemic therapy, and recent studies support use of targeted therapies for patients with these disorders. Observation (“watch and wait”) may be sufficient for select patients with mild disease. These NCCN Guidelines for Histiocytic Neoplasms include recommendations for diagnosis and treatment of adults with the most common histiocytic disorders: Langerhans cell histiocytosis, Erdheim-Chester disease, and Rosai-Dorfman disease.

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Venous Thromboembolic Disease

Michael B. Streiff, Paula L. Bockenstedt, Spero R. Cataland, Carolyn Chesney, Charles Eby, John Fanikos, Annemarie E. Fogerty, Shuwei Gao, Samuel Z. Goldhaber, Hani Hassoun, Paul Hendrie, Bjorn Holmstrom, Nicole Kuderer, Jason T. Lee, Michael M. Millenson, Anne T. Neff, Thomas L. Ortel, Tanya Siddiqi, Judy L. Smith, Gary C. Yee, Anaadriana Zakarija, Nicole McMillian, and Maoko Naganuma

Venous thromboembolism (VTE) remains a common and life-threatening complication among patients with cancer. Thromboprophylaxis can be used to prevent the occurrence of VTE in patients with cancer who are considered at high risk for developing this complication. Therefore, it is critical to recognize the various risk factors for VTE in patients with cancer. Risk assessment tools are available to help identify patients for whom discussions regarding the potential benefits and risks of thromboprophylaxis would be appropriate. The NCCN Clinical Practice Guidelines in Oncology for VTE provide recommendations on risk evaluation, diagnosis, prevention, and treatment of VTE in patients with cancer.

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Cancer-Associated Venous Thromboembolic Disease, Version 1.2015

Michael B. Streiff, Bjorn Holmstrom, Aneel Ashrani, Paula L. Bockenstedt, Carolyn Chesney, Charles Eby, John Fanikos, Randolph B. Fenninger, Annemarie E. Fogerty, Shuwei Gao, Samuel Z. Goldhaber, Paul Hendrie, Nicole Kuderer, Alfred Lee, Jason T. Lee, Mirjana Lovrincevic, Michael M. Millenson, Anne T. Neff, Thomas L. Ortel, Rita Paschal, Sanford Shattil, Tanya Siddiqi, Kristi J. Smock, Gerald Soff, Tzu-Fei Wang, Gary C. Yee, Anaadriana Zakarija, Nicole McMillian, and Anita M. Engh

The NCCN Guidelines for Cancer-Associated Venous Thromboembolic Disease outline strategies for treatment and prevention of venous thromboembolism (VTE) in adult patients with a diagnosis of cancer or for whom cancer is clinically suspected. VTE is a common complication in patients with cancer, which places them at greater risk for morbidity and mortality. Therefore, risk-appropriate prophylaxis is an essential component for the optimal care of inpatients and outpatients with cancer. Critical to meeting this goal is ensuring that patients get the most effective medication in the correct dose. Body weight has a significant impact on blood volume and drug clearance. Because obesity is a common health problem in industrialized societies, cancer care providers are increasingly likely to treat obese patients in their practice. Obesity is a risk factor common to VTE and many cancers, and may also impact the anticoagulant dose needed for safe and effective prophylaxis. These NCCN Guidelines Insights summarize the data supporting new dosing recommendations for VTE prophylaxis in obese patients with cancer.

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Venous Thromboembolic Disease

Michael B. Streiff, Paula L. Bockenstedt, Spero R. Cataland, Carolyn Chesney, Charles Eby, John Fanikos, Patrick F. Fogarty, Shuwei Gao, Julio Garcia-Aguilar, Samuel Z. Goldhaber, Hani Hassoun, Paul Hendrie, Bjorn Holmstrom, Kimberly A. Jones, Nicole Kuderer, Jason T. Lee, Michael M. Millenson, Anne T. Neff, Thomas L. Ortel, Judy L. Smith, Gary C. Yee, and Anaadriana Zakarija