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Raymond Elsoueidi, Jessica Craig, Hesham Mourad and Elie M. Richa

Both 5-FU and oxaliplatin have been used as single agents in patients with colorectal cancer and severe liver dysfunction, but the combination of these drugs has not yet been investigated. A 67-year-old man diagnosed with colorectal cancer in 2008 presented in April 2011 to Appalachian Regional Healthcare Cancer Center with obstructive jaundice and weight loss. Imaging studies were compatible with a liver mass and dilatation of the intrahepatic bile ducts. A liver biopsy confirmed metastatic colorectal cancer. Because his total bilirubin level was 23.1 mg/dL, a percutaneous catheter was placed in May 2011. His total bilirubin level decreased to 5.9 mg/dL, but then increased to 9.4 mg/dL in June 2011. He was started on a FOLFOX regimen, with a 50% dose reduction of 5-FU bolus (200 mg/m2) and continuous infusion (1200 mg/m2) over 46 hours, and a 15% dose reduction of oxaliplatin (75 mg/m2) every 2 weeks. He tolerated this regimen very well, with normalization of his bilirubin level, a significant decrease in his tumor markers, and a partial response seen on PET/CT scan. His only significant toxicity was a grade 2 stomatitis. He received 21 cycles of FOLFOX, and was later switched to cetuximab treatment after disease progression. These findings suggest that FOLFOX might be effective in metastatic colon cancer with severe liver dysfunction, with minimal toxicity, and deserves further investigation.

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Shi-Yi Wang, Jane Hall, Craig E. Pollack, Kerin Adelson, Amy J. Davidoff, Jessica B. Long and Cary P. Gross

Background: The purpose of this study was to examine the extent to which patterns of intensive end-of-life care explain geographic variation in end-of-life care expenditures among cancer decedents. Methods: Using the SEER-Medicare database, we identified 90,465 decedents who were diagnosed with cancer in 2004–2011. Measures of intensive end-of-life care included chemotherapy received within 14 days of death; more than 1 emergency department visit, more than 1 hospitalization, or 1 or more intensive care unit (ICU) admissions within 30 days of death; in-hospital death; and hospice enrollment less than 3 days before death. Using hierarchical generalized linear models, we estimated risk-adjusted expenditures in the last month of life for each hospital referral region and identified key contributors to variation in expenditures. Results: The mean expenditure per cancer decedent in the last month of life was $10,800, ranging from $8,300 to $15,400 in the lowest and highest expenditure quintile areas, respectively. There was considerable variation in the percentage of decedents receiving intensive end-of-life care intervention, with 41.7% of decedents receiving intensive care in the lowest quintile of expenditures versus 57.9% in the highest quintile. Regional patterns of late chemotherapy or late hospice use explained only approximately 1% of the expenditure difference between the highest and lowest quintile areas. In contrast, the proportion of decedents who had ICU admissions within 30 days of death was a major driver of variation, explaining 37.6% of the expenditure difference. Conclusions: Promoting appropriate end-of-life care has the potential to reduce geographic variation in end-of-life care expenditures.

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Craig Sauter, W. Jeffrey Baker, Elizabeth Rodriguez, Silvia Willumsen, Barbara Morcerf, Kristi Gafford, Jessica Kennington, Richard Korman, Peter Yu, David Pfister and Sergio Giralt

Background: Memorial Sloan Kettering Cancer Center (MSK) created the MSK Cancer Alliance in 2014, a dynamic and bidirectional collaboration with high-quality community providers to enhance access to state-of-the-art cancer care close to home. Hartford HealthCare Cancer Institute (HHC), joined the MSK Cancer Alliance as the first member in 2014. Research suggests that bone marrow transplant (BMT) is an underutilized definitive therapy (Yao et al, Biol Blood Bone Marrow Transplant 2013) for patients with hematologic malignancies and the timing of a referral for transplant has significant impact on patient outcomes (National Marrow Donor Program, available at: https://bethematchclinical.org/transplant-indications-and-outcomes/additional-outcomes/timing-impact-on-outcomes/). MSK and HHC developed the BMT Shared Care program to improve access to transplant, ensure BMT specialist consults for appropriate candidates occur during initial treatment planning, reduce burdensome travel for patients by facilitating care locally, and enhance seamless coordination between local oncologists and BMT providers from initial consult through post-transplant care. Methods: To achieve these goals, MSK and HHC physicians, nurses, and staff created a program that includes: HHC hiring a BMT nurse, who trained for 4 weeks at MSK, and works with MSK counterparts to create a streamlined referral process, pretransplant care at HHC, and travel logistics to MSK; MSK and HHC physicians hold virtual tumor boards to jointly evaluate patients and provide BMT consults at the optimal time; onsite lectures and observer-ships focused on advances in BMT, supportive care, and management of complications like graft versus host disease, leading to the integration of additional clinical services like infectious disease and dermatology; and research, including an MSK clinical trial open at HHC to identify and understand barriers to transplant in the community for patients with newly diagnosed or relapsed acute leukemia. Results: Since November 2015, HHC has referred 86 patients for BMT consult through this Shared Care program, with 35 patients transplanted or receiving immune effector cells (IEC) to date. Conclusions: The BMT Shared Care program effectively facilitates the referral and transplant of appropriate patients while allowing them to receive much of their pre- and post-transplant care in their local communities. Collaboration between BMT nurse coordinators and robust physician engagement are essential to this program. Future opportunities include expanding the use of telemedicine, enhancing electronic data sharing, quantifying and analyzing patient satisfaction, and expanding BMT research at HHC.