This pilot study demonstrates that a formal algorithm for LRNF management combined with provider education can improve current inpatient standard of care and length of stay without an increase in morbidity.
Background
Venous thromboembolism (
VTE
) is a major cause of morbidity, mortality, and hospitalization in cancer patients.
Objectives
To evaluate the feasibility of an electronic alert to identify and screen at‐risk individuals and gather rates of early detection of deep vein thrombosis (
DVT
).
Patients/Methods
An alert was built into the electronic medical record based on a validated risk tool (Khorana Score [
KS
]) and outcomes evaluated in an initial silent phase. The alert functioned in real time to warn physicians of high‐risk patients (
KS
≥ 3) and suggested lower extremity screening ultrasonography in a subsequent active phase.
Results
Of 194 consecutive patients identified as high risk in the silent phase, 14 (7.2%) developed subsequent
DVT
or pulmonary embolism (
PE
) over 90‐day follow‐up, with a median of 27 days. Mean 90‐day emergency room (
ER
) visits, all‐cause admissions, and length of stay (days) for patients with
DVT
were 1.2, 1.6, and 9.1 compared to 0.89, 0.93, and 5.1 for all patients, respectively. In the active phase, 197 consecutive alerts met inclusion criteria, and 40 patients (20.3%) received a screening ultrasound. Five (12.5%) had a
DVT
and were started on therapeutic anticoagulation. Of patients with alerts who had screening deferred, 13 (8.3%) were later diagnosed with
DVT
(median 50.5 days) and 7 (4.5%) with
PE
.
Conclusion
An automated alert may have value in early detection of
DVT
in high‐risk cancer patients leading to earlier intervention, and could potentially prevent
VTE
‐related morbidity.
Proton therapy has been shown to have higher skin dose compared to photon therapy due to physical property differences between photon and proton energy deposition. We sought to analyze rates of acute radiation dermatitis (RD) and skin hyperpigmentation (SH) in patients undergoing adjuvant radiation therapy (RT) to the breast after lumpectomy (BCS) or mastectomy in locally advanced breast cancer (LABC). Materials/Methods: A retrospective database was constructed of consecutive patients diagnosed with LABC treated with either proton or photon radiation between September 2015 and December 2017. Patients were excluded based on receipt of hypofractionation, re-RT, or lack of recorded acute toxicity data. Skin toxicity was scored using CTCAE v 4.0 criteria on a weekly basis during on-treatment visits. This highest recorded RD and HP toxicity was analyzed for each patient, and chi-square analysis and logistic regression were performed. Results: Eighty-six patients (39 proton, 47 photon) met inclusion criteria and were available for analysis. Median age was 53 y (range, 24-78y), median RT dose was 60 Gy (range, 45-80 Gy), RT fraction size ranged 1.8-2.0 Gy per fraction. An imbalance between race existed on chi-square, with more black patients receiving photon radiation. Body mass index, smoking status, ECOG PS, diabetes mellitus, stage, radiation dose, use of concurrent or neoadjuvant chemotherapy and boost radiation were equivalent between groups. On chi-square analysis, grade 2 RD was present in 69.2% vs 29.8% of patients receiving proton and photon therapy, respectively (pZ0.002, Table 1). Rates of grade 3 RD were 5.1% vs 4.3% for proton vs photon radiation, respectively. In white patients where erythema is more prominent, the rate of grade 2 RD was 55% vs 34% in black patients where hyperpigmentation is more prominent (pZ0.056). There were no significant differences in rates of SH between modalities. There were no grade 4-5 toxicities. Conclusion: When compared with patients receiving photon therapy, a higher rate grade 2 dermatitis was seen in patients undergoing proton therapy. Rates of grade 3 toxicity were very low in both groups. This transient increased acute toxicity is managed conservatively and did not result in treatment breaks or increased healthcare expenditures. Women should be counseled regarding the possibility of increased grade 2 toxicities; however this does not outweigh the dosimetric heart and lung benefits seen in proton therapy.
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