Integration of Genetic Testing and Counseling in Patients With Breast Cancer in a Large, Multisite Community-Based Practice.

PURPOSE: Despite data-driven consensus recommendations, there remains significant nonadherence to genetic screening and testing. More than 300,000 patients are diagnosed with breast cancer annually, with one third of these estimated to be eligible for homologous recombination deficiency (HRD)/BRCA testing following National Comprehensive Cancer Network (NCCN) guidelines. Only 35% of eligible patients are referred for genetic counseling. METHODS: The goal of this project was to apply NCCN guidelines for germline genetic testing to all new patients with breast cancer within a large community oncology practice to improve HRD/BRCA testing. Plan-Do-Study-Act methodology was used, and cycles were built on a proven teaching infrastructure. In cycle 1, providers were educated and directed to use electronic health record (EHR) templates in the setting of an initial diagnosis visit and treatment planning. Discreet data fields were created in the EHR during cycle 2 to streamline and automate the process. Appropriate patients were referred to the genetics team for further evaluation, counseling, and testing. Adherence to the plan was maintained and measured using data analytic reports and chart audits. RESULTS: Of the 1,203 patients with breast cancer eligible for inclusion, 1,200 (99%) were screened according to NCCN guidelines. Of the screened patients, 631 (52.5%) met the referral/testing criteria. In total, 585 (92.7%) of the 631 were referred to a genetic specialist. Seven percent had previous referrals. A total of 449 (71%) patients were acceptable to genetics referral while 136 (21.5%) patients refused. CONCLUSION: The implemented methods of education, NCCN guidelines imbedded within provider notes, and discreet data fields in the EHR have proven to be highly effective in screening appropriate patients and ordering subsequent genetic referrals.

Closing the Testing Gap: Standardization of Comprehensive Biomarker Testing for Metastatic Non-Small-Cell Lung Cancer in a Large Community Oncology Practice.

PURPOSE: Non-small-cell lung cancer (NSCLC), the leading cause of cancer death in the United States, accounts for 85% of all lung cancer cases. Biomarker testing is an integral part of the care of patients with NSCLC. Despite broad consensus recommendations that all patients with metastatic NSCLC (mNSCLC) undergo comprehensive biomarker testing (comprehensive genomic profiling and PD-L1), testing rates remain suboptimal. METHODS: The primary goal of this project was to apply National Comprehensive Cancer Network (NCCN) guidelines for comprehensive biomarker testing to all new patients with mNSCLC within a large community practice. Plan-Do-Study-Act methodology was used, with cycle 1 focused on provider education and the creation of a mNSCLC initial consult Note (electronic health record template/McKesson iKnowMed G2) and accompanying order set. Staging, template/order set utilization, and comprehensive biomarker testing rates were recorded while workflow processes were monitored. Cycle 2 centered on improved cancer staging, data analytic reporting, auditing, and reeducation. RESULTS: The comprehensive biomarker testing rates increased from a historic rate of 68% to 92.7% during the 1-year intervention period. The template utilization rate was 71% with complete staging (TNM stage and relevant biomarkers) documented in 40%. CONCLUSION: Implementation and standardization of comprehensive biomarker testing of patients with mNSCLC in a large multisite community-based oncology practice is feasible and results in significant improvement in comprehensive biomarker testing and reporting. Establishing reliable and measurable tracking metrics to ensure that these new processes are used and maintained can assist in scaling these processes. Efforts to scale this best practice are planned across the US Oncology Network.

Non-functional thyroid cystadenoma in three boxer dogs.

BACKGROUND: Thyroid neoplasia is a common endocrine neoplasm in dogs. The boxer is one of the reported breeds predisposed to malignant thyroid neoplasia. However, the association between thyroid neoplasia, malignancy and breed should be considered with caution. CASES PRESENTATION: This article describes the presentation, clinical pathological findings, computed tomographic (CT) imaging findings and histopathological features of benign cystic thyroid tumour (cystadenoma) diagnosed in three boxers. These three dogs were presented for investigation of unilateral (n = 2) or bilateral (n = 1) cervical masses with no associated clinical signs of thyroid dysfunction. In each case, post-contrast CT scan identified a large, lateralised, non-invasive, well-defined homogeneous cystic structure with a hyperattenuating contrast-enhancing capsule of suspected thyroid origin displacing the surrounding cervical tissues. Ultrasound-guided fine needle aspiration of the cysts yielded fluid with a high thyroxine concentration in each case. Histopathology was consistent with thyroid cystadenoma in all cases. One dog was concurrently diagnosed with oral melanoma and euthanased. Two dogs underwent surgical excision with one lost to follow-up after 36 months and the other euthanased after 16 months following diagnosis of mast cell tumour. CONCLUSIONS: To the authors' knowledge, this is the first detailed report of non-functional benign thyroid cystadenoma in dogs and provides relevant information about case management for this type of tumour. The presence of a large cystic structure associated with benign non-functional thyroid neoplasia may be a condition to which boxer dogs are predisposed.