Anderson, Benjamin O.

426 Background: Testing for DPYD gene variations prior to administration of fluoropyrimidines ([FP] e.g. 5-FU or capecitabine) can determine if patients are at risk of significant toxicity and may benefit from dose reduction or elimination of chemotherapy. Barriers to testing include lack of recommendations in US guidelines for routine DPYD testing, absence of insurance coverage, and limitations in provider support. We designed an electronic health record (EHR)-based intervention to support shared decision-making (SDM) between providers and patients regarding DPYD testing. Methods: We built an EHR alert identifying all patients initiating FP without DPYD testing. The alert fired to remind providers upon signing FP. Clinical decision support (CDS) was included in the alert to help with DPYD testing selection along with an educational note template containing the incidence of DPYD deficiency, rationale for testing, test costs, and turnaround time. Interactions with the EHR were recorded to determine why providers declined ordering pharmacogenomic testing. Testing rates and results for patients initiating FP were collected from the EHR. Finally, providers were surveyed to determine the impact of the alert on conversations with patients as well as the utility of the embedded CDS and educational note template. Results: Within the first 8 months after alert activation, 34 patients completed DPYD testing of 444 starting FP (testing rate of 7.7%) vs the baseline testing rate in the 3 months prior to alert go-live of 6.8% (p = 0.86 via chi-squared analysis, two-tailed). Of the 34 patients, 5 were intermediate DPYD metabolizers. Reasons for alert dismissal per provider selection were: “Patient already tolerated prior fluoropyrimidines” (15.7%), “Patient declines” (12.9%), “Will order separately” (5.7%), “Not discussed as not appropriate” (5.3%), and “Not discussed, deferred” (60.4%). Thirty-nine providers (n = 77 eligible) responded to the survey; 22 prescribed FP in their practice and had encountered the alert. 21 (95.5%) of these reported the alert was “Very Useful” or “Somewhat Useful” and 18 (81.8%) used the DPYD testing options available in the alert. Sixteen (72.7%) discussed DPYD testing more frequently with patients as a result of the alert. Barriers to DPYD testing were “Concerned about the impact of lowering FP dosing” and “Lack of knowledge about DPYD testing”, while “Cost of DPYD testing” was scored lowest. Conclusions: Utilizing an EHR alert with embedded CDS had a positive impact on provider awareness and led to more discussions regarding DPYD pharmacogenomic testing with patients in line with current FDA recommendations. Limitations in provider knowledge regarding DPYD testing and concerns about lowering chemotherapy doses posed barriers to ordering testing. Further interventions including additional education are required.

Abstract Background Optimizing antimicrobial regimens for outpatients with community-acquired pneumonia (CAP) represents an area of opportunity for ambulatory antimicrobial stewardship programs. A pre-populated, antibiotic order panel for outpatient respiratory syndromes was implemented in the Mayo Clinic Enterprise on 1/4/2021. For CAP, it provides national guideline adherent regimens (i.e., selection, dosing, and durations) by patient comorbidity and beta-lactam allergy status. We aimed to assess impacts of panel use on antibiotic prescribing in outpatients with CAP. Methods This retrospective review included Mayo Clinic outpatient encounters from Minnesota in 2021 and 2022. Eligible encounters used a CAP-related primary ICD-10 code, conveyed intention to treat CAP in encounter notes, and were performed by primary care, emergency department, or urgent care clinicians who managed ≥1 CAP patient with the panel and ≥1 without the panel during the study period. Encounters were excluded if patients were already receiving antibiotics at the time of encounter. The primary outcome was adherence (drug and duration) to guideline recommendations. Secondary outcomes included utilization rate by agent and therapy duration. Outcomes were analyzed with Kruskal-Wallis rank sum and Pearson’s chi-squared tests (α level = 0.05). Results 352 encounters (134 panel vs. 218 non-panel) were included. Prescribing was guideline adherent in 61.9% and 29.4% (p< 0.01) of panel and non-panel encounters, respectively. The most common reason for guideline non-adherence during panel use was inappropriate drug selection (n = 45/51, 88.2%). This was predominantly driven by use of the incorrect section of the treatment panel based on patient comorbidity status (n = 30/45, 66.7%). Individual antibiotic utilization rates differed between panel and non-panel cohorts (Table 1), with higher rates of amoxicillin and amoxicillin/clavulanate use and lower rates of azithromycin and doxycycline use in the panel cohort. Durations >5 days were more common in the non-panel as compared to the panel cohort (34.4% vs. 7.5%, p < 0.01). Conclusion Use of a pre-populated antimicrobial order panel in outpatients with CAP resulted in greater adherence to national guideline recommendations. Disclosures Paschalis Vergidis, MD, MSc, AbbVie: Advisor/Consultant|Ansun: Grant/Research Support|Cidara: Grant/Research Support|Scynexis: Grant/Research Support

Background: The management of patients with triple-negative breast cancer (TNBC) is challenging with several controversies and unmet needs. During the 12th Breast-Gynaecological & Immuno-oncology International Cancer Conference (BGICC) Egypt, 2020, a panel of 35 breast cancer experts from 13 countries voted on consensus guidelines for the clinical management of TNBC. The consensus was subsequently updated based on the most recent data evolved lately. Methods: A consensus conference approach adapted from the American Society of Clinical Oncology (ASCO) was utilized. The panellists voted anonymously on each question, and a consensus was achieved when ≥75% of voters selected an answer. The final consensus was later circulated to the panellists for critical revision of important intellectual content. Results and conclusion: These recommendations represent the available clinical evidence and expert opinion when evidence is scarce. The percentage of the consensus votes, levels of evidence and grades of recommendation are presented for each statement. The consensus covered all the aspects of TNBC management starting from defining TNBC to the management of metastatic disease and highlighted the rapidly evolving landscape in this field. Consensus was reached in 70% of the statements (35/50). In addition, areas of warranted research were identified to guide future prospective clinical trials.

Several new systemic therapy options have become available for patients with metastatic breast cancer, which have led to improvements in survival. In addition to patient and clinical factors, the treatment selection primarily depends on the tumor biology (hormone-receptor status and HER2-status). The NCCN Guidelines specific to the workup and treatment of patients with recurrent/stage IV breast cancer are discussed in this article.

These NCCN Guidelines Insights highlight the updated recommendations for use of multigene assays to guide decisions on adjuvant systemic chemotherapy therapy for women with hormone receptor–positive, HER2-negative early-stage invasive breast cancer. This report summarizes these updates and discusses the rationale behind them.