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Vlad Sandulache, Anita Sabichi, George Chen and Scott Charnitsky

Background: The Veterans Health Administration (VHA) is the only nationally integrated healthcare delivery system in the United States. The vertical and horizontal integration of the VHA make it an ideal environment for development of tools designed to streamline cancer diagnosis and treatment. Head and neck cancer (HNC) remains a difficult disease to diagnose and treat. Delivery of multimodality treatment for advanced HNC is challenging at both academic centers and in the community setting. This problem is magnified by the increased incidence of HNC, powered by an epidemic increase in the incidence of human papilloma virus (HPV)–associated oropharyngeal cancer (OPC). Objective: To develop a non–resource-intensive approach to improving: (1) time to treatment initiation and (2) compliance with optimal treatment package time for HNC patients. Methods: Retrospective analysis of 300 patients with a diagnosis of HNC from the Michael E. DeBakey VA Medical Center (MEDVAMC) was used to generate baseline data (2000–2010) for: (1) time to treatment (surgery, 24 days; radiation, 48 days) and (2) treatment package time <100 days compliance (68%). We developed a tool available to providers and clinic staff to prospectively track patients from initial referral, through diagnosis and treatment, along with completion of ancillary studies (modified barium swallow) and completion of the survivorship care plan. Between June 2016 and October 2018, 350 patients were tracked using this tool; 275 patients were new HNC diagnoses. Results: Implementation of the tracking tool reduced diagnosis to treatment start (mean, 44 days; median, 26 days). Compliance with treatment package time <100 days was increased to 95%; compliance with initiation of adjuvant radiation within 6 weeks of surgery was increased to 75%. Utilization of the tool allowed for streamlined surgical care, particularly through integration of dental extractions into the oncologic resection, and facilitated timely initiation of adjuvant radiation for advanced HNC. Conclusions: It is possible to improve: (1) time to diagnosis, (2) time to treatment initiation, and (3) treatment completion rates for complex HNC requiring multimodality treatment without additional resource utilization. However, appropriate implementation requires a robust multidisciplinary treatment team, with appropriate “buy in” from all participants and is facilitated by the presence of a fully integrated health care delivery system.

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Potjana Jitawatanarat, Arpita Desai, Pradeep Sharda, Hong Liu, Maureen Ross, Francisco J. Hernandez-llizaliturri, Philip L. McCarthy and George L. Chen

This case report presents a patient with poor-prognosis chronic lymphocytic leukemia (CLL) who was treated with chemotherapy and underwent allogeneic hematopoietic cell transplant (alloHCT) but ultimately progressed. The application of the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines) for CLL and the impact of alloHCT on secondary therapy for progressive CLL are discussed.

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Eric Lu, George V. Thomas, Yiyi Chen, Alexander W. Wyatt, Paul Lloyd, Jack Youngren, David Quigley, Raymond Bergan, Shawna Bailey, Tomasz M. Beer, Felix Y. Feng, Eric J. Small and Joshi J. Alumkal

Background: PARP inhibition is a promising therapeutic strategy for the treatment of men with metastatic castration-resistant prostate cancer whose tumors harbor homologous recombination DNA repair gene alterations. However, questions remain for many practicing clinicians about which patients are ideally suited for PARP inhibitor treatment. This report details our institutional experience using PARP inhibitor therapy in patients whose tumors harbored specific DNA repair gene alterations. Patients and Methods: We performed a retrospective chart review to identify patients at Oregon Health & Science University who were treated with PARP inhibition. We identified 8 patients and determined the impact of the specific DNA repair gene alterations on tumor response and time on treatment with PARP inhibition. Results: A number of DNA repair gene alterations were identified. Three patients had pathogenic BRCA2 mutations and one had a BRCA2 mutation of uncertain significance. Conversely, the 4 other patients' tumors harbored alterations in other DNA repair genes, none of which were clearly pathogenic. A statistically significant difference in benefit was seen between patients whose tumors harbored BRCA2 gene alterations and those whose tumors did not, as measured by >50% decline in prostate-specific antigen levels (100% vs 0%; P=.03) and duration on therapy (31.4 vs 6.4 weeks; P=.03). Conclusions: Our results demonstrate that not all DNA repair alterations are equally predictive of PARP inhibitor response. Importantly, all responding patients had tumors harboring BRCA2 DNA repair alterations, including one without a known pathogenic mutation. Conversely, among the 4 nonresponders, several DNA repair alterations in genes other than BRCA2 were identified that were not clearly pathogenic. This demonstrates the need to carefully examine the functional relevance of the DNA repair alterations identified, especially in genes other than BRCA2, when considering patients for PARP inhibitor treatment.