Introduction

Approximately 10% of patients diagnosed with pancreatic ductal adenocarcinoma (PDAC) carry a pathogenic variant in a PDAC susceptibility gene. Current guidelines recommend offering germline cancer susceptibility testing for all individuals with PDAC regardless of family history. Previous studies have shown moderate rates of uptake of gene testing, highlighting the need for efficient and accessible clinical pathways for delivering gene testing education and counseling. We evaluated the uptake of gene testing when offered at the point-of-care by an oncology nurse specialist in an outpatient setting.

Aims & Methods

We undertook a retrospective chart review of PDAC patients treated at the Johns Hopkins Hospital between January 2021 and December 2023. Patients were educated about germline testing by an oncology nurse specialist during their initial clinic visit, and provided with instructional handouts, links to videos, instructions on kit ordering and given time to consider testing. “MyChart” reminders are sent as needed. Patients who desired testing were sent a saliva kit to their home that they had to send back to the testing lab. Results were communicated by the oncology nurse to the patients, and those with pathogenic variants or variants of uncertain significance (VUS) are referred to formal genetic counseling.

Results

Of 1022 patients seen by the oncology and surgery teams, all but 2 were seen by oncology, 377 underwent surgery, 52% were male, 74.9% were White, 15.8% African American (AA), 6% were Asian, 3% were Hispanic, and 17.5% had a family history of pancreatic cancer. At diagnosis, median age was 67.1 +/- 10.6 years; 51.9% of cases had resectable-stage disease.
Among the 87.5% of patients offered gene testing, 77.6% completed testing. Completion rates among those offered testing increased from 72.4% (2021) to 78.5% (2022) and 82.2% (2023).
Factors significantly associated with reduced gene testing uptake included African American patients, those that were single, had advanced-stage disease, did not receive chemotherapy and of older age at diagnosis (Table 1).
Among tested individuals, 55 (7.9%) involving PDAC susceptibility genes, with BRCA2, ATM and PALB2 being the most common. 50 out of these 55 patients (91%) were referred to genetic counseling, with 76% completing their counseling visit to date. Germline testing results led to a change in the treatment regimen in 23 of the 55 patients.

Conclusion

The implementation of point-of-care encounters for cancer susceptibility gene testing by an oncology nurse specialist in the outpatient setting yielded a high uptake of testing. African American, older-age, single and advanced-stage disease individuals had lower rates of completing gene testing.

Introduction

Sodium picosulfate (SP)/magnesium citrate (MC) and polyethylene glycol (PEG) plus ascorbic acid are recommended by Western guidelines as laxative solutions for bowel preparation. The standard formulation for bowel preparation is PEG; however, it requires a large dose and has a distinctive taste that is considered unpleasant. SP/MC requires a small dose and ensures fluid intake because it is administered in another beverage. Therefore, clinical studies have shown that SP/MC is superior to PEG in terms of acceptability.

Aims & Methods

Our aim was to compare the novel bowel cleansing method (test group) consisting of SP/MC with elobixibat hydrate and the standard bowel cleansing method consisting of PEG plus ascorbic acid (standard group) in patients preparing for outpatient colonoscopy. This was a multicenter, single-blind, non-inferiority, randomized controlled trial. Patients 40-69 years of age scheduled for outpatient colonoscopy were enrolled. Patients with a history of abdominal or pelvic surgery, constipation, inflammatory bowel disease, or severe organ dysfunction were excluded. The target number of study participants was 540 (standard group, 270 cases; test group, 270 cases). The primary endpoint was bowel cleansing (Boston Bowel Preparation Scale [BBPS] score ≥6). Secondary endpoints were patient acceptability, adverse events, polyp/adenoma detection rate, number of polyps/adenomas detected, degree of bowel cleansing according to BBPS (BBPS score ≥8), degree of bowel cleansing according to Aronchik scale, and bowel cleansing time. The non-inferiority margin for the primary endpoint was 10%. A study protocol of the present study has already been published in a peer-reviewed journal.

Results

Of 540 participants enrolled, efficacy was analyzed in 524 participants (test group, n=263; standard group, n=261) in the full analysis set. Non-inferiority of the test group was demonstrated for the primary endpoint (BBPS ≥6): 96.2% vs. 97.7% for test and standard group, respectively difference was -1.5%, [95%confidence interval (CI), -4.8 to 1.6%] with P<0.001 for non-inferiority. For the secondary endpoint BBPS≥8 was lower in test group (79.5% vs 91.2%: difference -11.7% [95% CI, -17.8 to -5.8%]). Patient acceptability was superior in the test group in the key questions (1. Was the bowel preparation medication easy to use? 2. Were all bowel preparation medications administered internally? 3. What is your overall impression of the bowel preparation? 4. How did the bowel preparation medicine taste? 5. Would you like to use the same bowel preparation medicine for your next colonoscopy?) Adverse events were similar in both groups.

Conclusion

A new regimen of elobixibat plus sodium picosulfate with magnesium citrate was non-inferior in bowel cleansing and superior in patient’s acceptability compared to split-dose 2-L polyethylene glycol with ascorbic acid.

References

1) Hotta K, Otake Y, Yamaguchi D, et al. Comparison of the efficacy and tolerability of elobixibat plus sodium picosulfate with magnesium citrate and split‑dose 2‑L polyethylene glycol with ascorbic acid for bowel preparation before outpatient colonoscopy: a study protocol for the multicentre, randomised, controlled E‑PLUS trial. BMC Gastroenterol 2024 Feb 3;24(1):61.doi: 10.1186/s12876-024-03146-6.

Disclosure

The primary investigator (Kinichi Hotta) had received research funding from Nippon Chemiphar Co. Ltd.

Introduction

Acetic acid chromoendoscopy (AAC) is frequently used in Barrett esophagus (BE) surveillance endoscopies. AAC is believed to be useful as a ‘red flag’ technique, thereby improving the overall neoplasia detection and the diagnostic yield of targeted biopsies. Accurate targeted neoplasia detection with AAC therefore holds the promise of abandoning random four-quadrant biopsies at 2cm intervals of the BE segment. Although some data exist on the use of AAC in expert centers, the added value in a non-dysplastic surveillance population in routine clinical practice is currently unclear.

Aims & Methods

A prospective stepped wedge cluster randomized trial was conducted in 18 Dutch community hospitals. BE patients undergoing surveillance endoscopies were eligible, while those with known or previously treated dysplasia were excluded. Participating hospitals shifted from usual care (no AAC; control group) to the incorporation of AAC (AAC; intervention group) in randomized order. Endoscopists were trained in the use and assessment of AAC immediately prior to its implementation. In both study groups, targeted biopsies were obtained in the presence of visible lesions before the acquisition of random four-quadrant biopsies. Primary endpoint was the overall neoplasia detection rate, defined as the percentage of patients with low-grade dysplasia (LGD), high-grade dysplasia (HGD) and esophageal adenocarcinoma (EAC) in both targeted and random biopsies, confirmed by an experienced GI pathologist. Secondary endpoint was the neoplasia detection rate of targeted biopsies. Data were analyzed using an as-treated approach, employing mixed effects regression analyses with a random intercept per hospital and correction for calendar time and BE length.

Results

We included 2,267 patients (1570 males; mean age 66) between June 2020 and November 2023. A total of 1,438/2,267 (63%) patients were allocated to usual care and 829/2,267 (37%) to AAC. In patients allocated to AAC, AAC was applied in 679/829 patients (82%). Overall, 163/2,267 patients (7.2%) were diagnosed with neoplasia, which encompassed LGD in 111/2,267 patients (4.9%), HGD in 30/2,267 patients (1.3%), and EAC in 22/2,267 patients (1.0%). The use of AAC did not result in a significantly higher overall neoplasia detection rate (7.4% with AAC [50/679 patients] versus 7.1% without AAC [113/1,588 patients]; OR 0.97; 95% CI 0.65-1.44). Visible lesions were detected in 95/679 (14.0%) patients receiving AAC versus 101/1,588 (6.4%) patients receiving usual care (p<0.001), yet the targeted neoplasia detection rate was not significantly higher (2.1% [14/679 patients] versus 1.8% [29/1,588 patients]; OR 1.05; 95% CI 0.49-2.24). Neoplasia was detected by random four-quadrant biopsies in the majority of patients: 39/50 patients (78%) receiving AAC and 81/113 patients (72%) receiving usual care.

Conclusion

The use of AAC does not improve the overall or targeted neoplasia detection rate in BE patients undergoing endoscopic surveillance in routine clinical practice. Endoscopic surveillance with AAC-guided targeted biopsies cannot replace the random biopsy protocol.

Disclosure

Pentax Medical, C2 Therapeutics