Nurse-initiated bowel management strategies for first-line management of faecal incontinence

Abstract Background The role of anthracyclines in the management of Grade 3 (G3) FL is unclear. Furthermore, the patterns of care and outcomes of first-line treatment strategies for G3 FL in older adults are not clearly established. We describe the patterns of use, determinants of treatment, and survival outcomes of first-line management strategies for G3 FL with emphasis on four common first-line regimens: cyclophosphamide, doxorubicin, vincristine, and prednisone (CHOP), rituximab (R) plus CHOP (R-CHOP), cyclophosphamide, vincristine, and prednisone (CVP), and R plus CVP (R-CVP). Methods We used the linked Surveillance, Epidemiology, and End Results -Medicare database to identify 1,308 G3 FL patients (pts) diagnosed between 1995 and 2009 and focused on pts diagnosed between 1999 and 2009 when claims with R appear. We ascertained first-line management strategies from Medicare claims made within 90 days of diagnosis. We used multiple variable logistic regression models to evaluate the relationship between pt characteristics and the use of first-line R-CHOP. We used Kaplan-Meier estimators stratified by FL stage to evaluate survival functions for first-line management strategies and performed multiple variable Cox proportional hazards regressions adjusted for pt demographics, comorbidity index, disease characteristics, and year of diagnosis to compare the impact of first-line management strategies on survival. Results Of the 1,308 G3 FL pts, 59% were female, 91% were Caucasian, 3% were African American, 44% had stage III/IV disease, 6% had B-symptoms, and 36% had extranodal involvement. The median age at diagnosis was 75 (interquartile range 70-80). Common first-line management strategies were: observation (obs), 29%; R-CHOP, 26%; CHOP, 9%; radiotherapy alone (XRT), 8%; R alone, 8%; R-CVP, 7%; and CVP, 5%. The use of R-CVP and R-CHOP increased over time (Figure 1). In the cohort of pts diagnosed between 1999 and 2009 the use of R-CHOP was less commonly associated with age >80 years (ref. age 66-70 years; OR 0.19; 95% CI 0.11-0.31), comorbidity index ≥ 2 (ref. index =0; OR 0.54; 95% CI 0.31-0.92), and more commonly associated with stage III/IV FL (OR 1.46; 95% CI 1.05-2.02), and year of diagnosis (ref. years 1999-2001; OR for 2002 3.68; 95% CI 1.77-7.64; steady increase thereafter). The table displays median survival and hazard ratios (HRs) for first-line management strategies. The most favorable outcomes were associated with first-line R-chemotherapy (R-Chemo). Among first-line R-chemo regimens, R-CHOP was associated with the most favorable outcomes (Figure 2). Conclusion R-CHOP is the most commonly used first-line regimen in the United States for older adult pts with FL G3. Even after controlling for disease characteristics and comorbidity, R-CHOP was associated with the most favorable survival outcome. Disclosures: No relevant conflicts of interest to declare.

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Disease Characteristics, Patterns Of Care, and Outcomes Of Follicular Lymphoma (FL) In The Oldest Old

Blood ◽

10.1182/blood.v122.21.1817.1817 ◽

2013 ◽

Vol 122 (21) ◽

pp. 1817-1817

Author(s):

Loretta J. Nastoupil ◽

Ashish Rai ◽

Joseph Lipscomb ◽

Chadi Nabhan ◽

Jessica N Williams ◽

...

Keyword(s):

Oldest Old ◽

Management Strategies ◽

Patterns Of Care ◽

Stage Iii ◽

First Line ◽

Disease Characteristics ◽

Comorbidity Index ◽

Grade 3 ◽

The Impact ◽

Line Management

Abstract Background The oldest old constitute a large proportion of the total patient (pt) population with FL. Therapeutic decision making in this group is limited by comorbidities, adverse disease and pts' characteristics, potential treatment toxicity, and limited life expectancy. Further, randomized clinical trials have rarely included this pt population. Whether current practice patterns for these pts affect their outcome remains unanswered. Therefore, we aimed to determine treatment selections, patterns of care, prognostic factors, and survival outcomes of first-line management strategies in a large United States (US) based cohort of the oldest old (pts aged > 80 years at diagnosis). Methods We used the linked Surveillance, Epidemiology, and End Results -Medicare database to identify 1,878 FL cases in pts > 80 years diagnosed between 1995 and 2009 and focused on the period when rituximab (R) claims occurred. We ascertained first-line management strategies from Medicare claims made within 90 days of diagnosis. We used multiple variable logistic regression models to evaluate the relationship between pt characteristics and the use of two common first-line management strategies—observation (obs) and treatment with R, cyclophosphamide, doxorubicin, vincristine, and prednisone (R-CHOP). We used Kaplan-Meier estimators stratified by stage to evaluate survival functions for first-line management strategies and Cox proportional hazards models adjusted for pt demographics, comorbidity index, disease characteristics, and year of diagnosis to compare the impact of first-line management strategies on survival. Results Of the 1,878 oldest adult pts, 63% were female, 95% were white, 2% were African American, 52% had stage III/IV FL, 17% had grade 3 FL, 5 % had B-symptoms, 35% had extranodal involvement, and 14% had a comorbidity index ≥ 2. Common first-line management strategies were: obs, 46%; R, 17%; chemotherapy (chemo) plus R, 11%; chemo, 11%; and radiotherapy (XRT), 11%. In the cohort of pts diagnosed between 1995 and 2009, obs was more commonly associated with urban pts (ref. less urban/rural pts; OR 1.91; 95% CI 1.15-3.18), and comorbidity index of ≥ 1 (ref. index=0; OR 1.28; 95% CI 1.00-1.64). Obs was less commonly associated with stage III/IV FL (ref. stage I/II; OR 0.67; 95% CI 0.54-0.84), grade 3 FL (ref. grade 1/2; OR 0.35; 95% CI 0.26-0.47), and year of diagnosis (ref. year 1995; OR for 1997 0.23; 95% CI 0.07-0.75; steady decrease thereafter). In the cohort of pts diagnosed between 1999 and 2009, the use of R-CHOP was associated with grade3 FL (ref. grade 1/2; OR 8.20; 95% CI 3.83-17.55) and presence of B-symptoms (ref. absent; OR 4.18; 95% CI 1.81-9.62). R-CHOP use did not vary with year of diagnosis. The table displays median survival and hazard ratios (HRs) for first-line management strategies. Most favorable outcomes were associated with first-line R-Chemo. Among stage III/IV cases, the least favorable outcomes were observed in the group that received chemo without R. The HRs did not vary with more recent years of diagnosis. Conclusion In this largest retrospective analysis of the oldest old US-based FL pts, we demonstrate that first-line R-Chemo is associated with improved survival. Confirmatory prospective studies specifically designed for this pt population are warranted. CVP-cyclophosphamide, vincristine, prednisone; CHOP- cyclophosphamide, doxorubicin, vincristine, prednisone; R-CVP- rituximab, cyclophosphamide, vincristine, prednisone. Disclosures: No relevant conflicts of interest to declare.

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Patterns and Outcomes Of First-Line Management Strategies In Older Adults With Low-Grade Follicular Lymphoma (FL)

Blood ◽

10.1182/blood.v122.21.1805.1805 ◽

2013 ◽

Vol 122 (21) ◽

pp. 1805-1805

Author(s):

Ashish Rai ◽

Loretta J. Nastoupil ◽

Joseph Lipscomb ◽

Kevin Ward ◽

David H. Howard ◽

...

Keyword(s):

Older Adults ◽

Management Strategies ◽

The United States ◽

Stage I ◽

Stage Iii ◽

Treatment Modalities ◽

Low Grade ◽

First Line ◽

The Impact ◽

Line Management

Abstract Background Therapeutic decision making for patients with low-grade (grade 1 and 2) FL involves deciding whether to treat, when to treat, and which among the numerous treatment modalities to administer. The lack of trials comparing outcomes of these treatment modalities makes it a complex process. This study seeks to examine the evolving treatment paradigm and evaluate the outcomes of first-line management strategies for low-grade FL in adults aged ≥ 66. Methods We used the linked Surveillance, Epidemiology, and End Results (SEER)-Medicare database to identify 4,233 low grade FL patients (pts) aged 66 years and older diagnosed between 1995 and 2009. We ascertained first-line management strategies from Medicare claims made within 90 days of diagnosis. We used Kaplan-Meier estimators stratified by stage to evaluate survival functions for first-line management strategies. We used multivariate Cox proportional hazards models—stratified by stage and adjusted for patient demographics, comorbidity index, and year of diagnosis—to compare the impact of first-line management strategies on overall survival (OS). Results Of the 4,233 pts, 57% were female, 3% were African American, 93% were White, 51% resided in big metropolitan areas, 70% were diagnosed after 2000, 44% had stage III/IV disease, and 38% had extranodal involvement. The median age at diagnosis was 74 years (interquartile range 70-80). Common first-line management strategies were: observation (obs), 47%; chemotherapy (chemo) plus rituximab (R), 20%; chemo alone, 12%; R alone, 9%; and radiotherapy (XRT) alone, 9%. Among pts receiving chemo plus R (R-chemo), the most commonly used regimens were: R-CHOP (R, cyclophosphamide, doxorubicin, vincristine, and prednisone; 36%), R-CVP (R, cyclophosphamide, vincristine, and prednisone; 47%), R-Fludarabine based (9%), and R-other (7%). The table displays median survival and hazard ratios (HRs) for first-line management strategies. Among stage I/II cases, most favorable outcomes were observed in cases receiving XRT alone, whereas among stage III/IV cases most favorable outcomes were observed in the group that received R-chemo. In the subset of stage III/IV pts that received R-chemo, R-CHOP was associated with the most favorable outcomes. HRs decreased steadily with increasing years of diagnosis. Conclusion First-line R-chemo is commonly used in older adults with low-grade FL in the United States and is associated with most favorable survival outcomes. XRT is associated with very favorable outcomes in stage I/II pts. Outcomes have improved steadily in the past 10 years. CVP–cyclophosphamide, vincristine, prednisone; CHOP- cyclophosphamide, doxorubicin, vincristine, prednisone Disclosures: No relevant conflicts of interest to declare.

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Patterns Of First-Line Management Strategies In Older Adults With Follicular Lymphoma (FL)

Blood ◽

10.1182/blood.v122.21.2983.2983 ◽

2013 ◽

Vol 122 (21) ◽

pp. 2983-2983

Author(s):

Ashish Rai ◽

Loretta J. Nastoupil ◽

Jessica N Williams ◽

Joseph Lipscomb ◽

Kevin Ward ◽

...

Keyword(s):

African American ◽

Management Strategies ◽

Single Agent ◽

Stage I ◽

Stage Iii ◽

First Line ◽

White Race ◽

Grade 3 ◽

African American Race ◽

Line Management

Abstract Background The treatment paradigm for FL has evolved greatly since the advent of rituximab (R) in 1997. However, a standard of care for first-line management of FL is yet to emerge (Friedberg, JCO 2009). This study seeks to describe the determinants of and temporal patterns in the use of first-line management strategies. Methods We used the linked Surveillance, Epidemiology, and End Results (SEER)-Medicare database to identify 7,931 FL patients (pts) aged ≥ 66 years diagnosed between 1995 and 2009. We ascertained first-line management strategies from Medicare claims made within 90 days of diagnosis. Pts with no FL related treatment claims were classified as observation (obs). We used multiple variable logistic regression models to evaluate the relationship between pt characteristics and the use of two common first-line management strategies—obs and immunochemotherapy with R, cyclophosphamide, doxorubicin, vincristine, and prednisone (R-CHOP). Results Of the 7,931 pts, 57% were female, 3% were African American, 93% were White, 51% resided in big metropolitan areas, 52% were diagnosed after the year 2000, 44% had stage III/IV disease, 17% had grade 3 disease, and 39% had extranodal involvement. The median age at diagnosis was 75 years (interquartile range 70-80). Common first-line management strategies were: obs, 41%; chemotherapy (chemo) plus R, 26%; chemo alone, 11%; R alone, 10%; and radiotherapy (rad) alone, 9%. Among pts receiving chemo plus R the most commonly used regimens were: R-CHOP (50%), R-CVP (R, cyclophosphamide, vincristine, and prednisone, 35%), R-Fludarabine based (7%), R-Other (7%). Trends in the use of first-line management strategies are displayed in the figure. Obs was more commonly associated with age ≥81 years (ref. age 66-70 years; OR 1.41; 95% CI 1.22-1.62) and African American race (ref. White race; OR 1.77; 95% CI 1.33-2.37), and less commonly associated with stage III/IV FL (ref. stage I/II FL; OR 0.84; 95% CI 0.76-0.93); grade 3 FL (ref. grade 1/2 FL; OR 0.37; 95% CI 0.32-0.43), presence of B symptoms (ref. absent; OR 0.54; 95% CI 0.41-0.71), and year of diagnosis (ref. year 1995; OR for 2002 0.57; 95% CI 0.35-0.94; steady decrease thereafter). In the cohort of patients diagnosed between 1999 and 2000, first-line R-CHOP was more commonly associated with stage III/IV FL (ref. stage I/II; OR 1.53; 95% CI 1.27-1.83), grade 3 FL (ref. grade 1/2; OR 7.30; 95% CI 5.86-9.09), presence of B symptoms (ref. absent; OR 1.46; 95% CI 1.04-2.04), and year of diagnosis (ref. years 1999-2001; OR for 2002 3.74; 95% CI 2.38-5.87; steady increase thereafter), and less commonly associated with age 76-80 years (ref. age 66-70 years; OR 0.65; 95% CI 0.51-0.82), age ≥81 years (OR 0.20; 95% CI 0.15-0.27), African American race (ref. White race; OR 0.46; 95% CI 0.25-0.85) and comorbidity index ≥2 (ref. index 0; OR 0.55; 95% CI 0.41-0.76). Conclusions As anticipated, the use of chemo plus R and single-agent R increased steadily after the introduction of R in1997, while that of obs and chemo alone decreased over the same period. Disclosures: No relevant conflicts of interest to declare.

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Diagnosis and Multimodality Management of Cushing’s Disease: A Practical Review

International Journal of Endocrinology ◽

10.1155/2013/893781 ◽

2013 ◽

Vol 2013 ◽

pp. 1-7 ◽

Cited By ~ 10

Author(s):

Gabriel Zada

Keyword(s):

Pituitary Adenoma ◽

Cushing’S Disease ◽

Patient Survival ◽

Clinical Laboratory ◽

Management Strategies ◽

Serum Cortisol ◽

Cushing's Disease ◽

First Line ◽

Stepwise Approach

Cushing’s Disease is caused by oversecretion of ACTH from a pituitary adenoma and results in subsequent elevations of systemic cortisol, ultimately contributing to reduced patient survival. The diagnosis of Cushing’s Disease frequently involves a stepwise approach including clinical, laboratory, neuroimaging, and sometimes interventional radiology techniques, often mandating multidisciplinary collaboration from numerous specialty practitioners. Pituitary microadenomas that do not appear on designated pituitary MRI or dynamic contrast protocols may pose a particularly challenging subset of this disease. The treatment of Cushing’s Disease typically involves transsphenoidal surgical resection of the pituitary adenoma as a first-line option, yet may require the addition of adjunctive measures such as stereotactic radiosurgery or medical management to achieve normalization of serum cortisol levels. Vigilant long-term serial endocrine monitoring of patients is imperative in order to detect any recurrence that may occur, even years following initial remission. In this paper, a stepwise approach to the diagnosis, and various management strategies and associated outcomes in patients with Cushing’s Disease are discussed.

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