Quality Improvement/Clinical Outcomes
Roi Weiser, MD
Assistant Professor
Department of Surgical Oncology, MD Anderson Cancer Center
Houston, Texas, United States
Roi Weiser, MD
Assistant Professor
Department of Surgical Oncology, MD Anderson Cancer Center
Houston, Texas, United States
Joel Ho, MD
Assistant Professor
Medical Oncology, University of Washington School of Medicine, United States
Thomas Szabo Yamashita, MD (he/him/his)
Assistant Professor
Emory
Atlanta, Georgia, United States
Jeena Varghese, MD
Assistant Professor
MD Anderson Cancer Center, United States
Jennifer Wargo, MD MMsC
Surgical Oncology and Genomic Medicine
MD Anderson Cancer Center
Houston, Texas, United States
Anthony Lucci, Jr., MD
Professor
Department of Breast Surgical Oncology, MD Anderson Cancer Center, Houston, TX, USA
Houston, Texas, United States
Emily Z. Keung, MD (she/her/hers)
Assistant Professor of Surgical Oncology
The University of Texas MD Anderson Cancer Center
Houston, Texas, United States
Ashley M. Holder, MD
Assistant Professor of Surgical Oncology
The University of Texas MD Anderson Cancer Center, United States
Rodabe Amaria, MD
Melanoma Medical Oncology
MD Anderson Cancer Center, United States
Jeffrey E. Lee, MD
Vice President of Clinical Operations
The University of Texas MD Anderson Cancer Center
Houston, Texas, United States
Merrick I. Ross, MD
Surgical Oncologist
MD Anderson Cancer Center
Houston, Texas, United States
Jeffrey E. Gershenwald, MD (he/him/his)
Professor
Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center
Houston, Texas, United States
Sarah B. Fisher, MD
Assistant Professor
MD Anderson Cancer Center
Houston, Texas, United States
Adrenal insufficiency (AI) is a rare but serious complication after immunotherapy (IO). Failure to recognize AI in the perioperative setting may have significant consequences. Although IO is increasingly utilized for melanoma patients, indications for AI screening in asymptomatic patients are not well established. Our objectives were to evaluate the incidence of (1) clinically relevant AI in this population and (2) AI screening before and after an educational intervention.
Methods:
All patients diagnosed with melanoma and planned for surgery at a single institution were asssessed for treatment with IO and screening for AI, defined as morning ACTH and cortisol levels drawn within 30d prior to surgery. Screening rates were collected for 3 months prior to the educational intervention (pre-), the month of the intervention (peri-), and 3 months post-intervention (post-). The educational intervention consisted of verbal communication and email correspondence with clinical providers and a poster displayed in the clinic space describing screening methods. Patients with known AI prior to the study period were excluded.
Results:
During the study period (7 months) 480 patients had surgery for melanoma (203 pre-, 68 peri-, and 209 post-intervention). Of these, 77 (16%) had prior IO (37 pre-, 13 peri-, and 27 post-), 3 with known AI were excluded (2 pre-, 1 post-). Screening was performed in 32 of the 74 eligible IO patients (44%; 6 pre-, 5 peri-, and 21 post-). Of those, 6 (18.8%) had abnormal results; 4 underwent additional evaluation with ACTH stimulation test; and 2 (6.2%) were abnormal. Three patients with abnormal screening were treated with intraoperative stress dose steroids, 2 of whom continued postoperatively on physiologic replacement steroids. Of the 42 unscreened patients, one was re-admitted in the postoperative period and diagnosed with AI. The overall rate of AI identified in the study cohort was 4.1% (3/74). Screening rates were 17.7% (6/35) pre-, 35.7% (5/14) peri-, and increased to 80.8% (21/26) post-intervention (p< .0001, pre- vs. post-, Figure).
Conclusions:
A brief educational intervention increased awareness of and screening for AI prior to surgery in patients with melanoma treated with IO. With an incidence of at least 4.1%, screening for asymptomatic AI should be considered in this patient population.