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Background 5-fluorouracil, leucovorin, irinotecan and oxaliplatin (FOLFIRINOX) is superior to gemcitabine in patients with metastatic pancreatic cancer who have a good performance status. We investigated this combination as neoadjuvant therapy for locally advanced pancreatic cancer (LAPC). Methods In this retrospective series, we included patients with unresectable LAPC who received neoadjuvant FOLFIRINOX with growth factor support. The primary analysis endpoint was R0 resection rate. Results Eighteen treatment-naïve patients with unresectable or borderline resectable LAPC were treated with neoadjuvant FOLFIRINOX. The median age was 57.5 years and all had ECOG PS of 0 or 1. Eleven (61 %) had tumors in the head of the pancreas and 9 (50 %) had biliary stents placed prior to chemotherapy. A total of 146 cycles were administered with a median of 8 cycles (range 3-17) per patient. At maximum response or tolerability, 7 (39 %) were converted to resectability by radiological criteria; 5 had R0 resections, 1 had an R1 resection, and 1 had unresectable disease. Among the 11 patients who remained unresectable after FOLFIRINOX, 3 went on to have R0 resections after combined chemoradiotherapy, giving an overall R0 resection rate of 44 % (95 % CI 22–69 %). After a median follow-up of 13.4 months, the 1-year progression-free survival was 83 % (95 % CI 59-96 %) and the 1-year overall survival was 100 % (95 % CI 85-100 %). Grade 3/4 chemotherapy-related toxicities were neutropenia (22 %), neutropenic fever (17 %), thrombocytopenia (11 %), fatigue (11 %), and diarrhea (11 %). Common grade 1/2 toxicities were neutropenia (33 %), anemia (72 %), thrombocytopenia (44 %), fatigue (78 %), nausea (50 %), diarrhea (33 %) and neuropathy (33 %). Conclusions FOLFIRINOX followed by chemoradiotherapy is feasible as neoadjuvant therapy in patients with unresectable LAPC. The R0 resection rate of 44 % in this population is promising. Further studies are warranted.

Significance & Background: Through observations and discussions in clinical practice, healthcare providers perceive ACD discussions as held mainly by Palliative Medicine, or Social Workers. This assumption within the interdisciplinary team may be attributed to either provider time constraints, lack of awareness and/or comfort discussing end-of-life, and/or culture. Assessing baseline knowledge, identifying gaps, and reinforcing ACD education amongst the interdisciplinary team may increase confidence in having ACD discussions. Purpose: To identify gaps in Nurse Navigator's (NN's) baseline knowledge and reinforce education when having ACD discussions with patients and families. As NN's develop rapport with patients, they can assist in introducing the topic of ACD earlier in a patient's cancer journey and promote advance directive completion. Interventions: This quality improvement (QI) project collected data from 40 NN's, capturing changes before and after an educational intervention. All participants were registered nurses. A multiple-choice questionnaire was provided using the same questions pre-and post-intervention. The questions included defining Healthcare Surrogates, Living Wills, and Proxies, identifying where ACD forms were located, and elaborating on State and Federal laws, including the Patient Self-Determination Act. After the pre-intervention questionnaire was completed, an educational presentation was conducted during the NN's weekly huddle. Afterward, the post-intervention questionnaire was distributed. Evaluation: Responses from the questionnaire were analyzed. Descriptive percentages were obtained. Results indicated NN's scored 95% on average on pre and post-questionnaires in 8/10 questions. However, there were two areas that scored lower. The first differentiating Health Care Surrogates versus Proxies, with 52% median score pre and 69% post-education. The second area was whether the Patient Self-Determination Act was a Florida Statute or a Federal Law, with 53% median score pre and 69% post-education. Despite these two areas, knowledge still improved post-intervention. Discussion: This QI project aimed to determine NN's baseline knowledge and confidence in ACD discussions. It found that oncology nurses could benefit from repetitive and ongoing discussions on how to build their confidence and explore when to initiate these discussions in a cancer patient's journey. Engaging in ACD discussions and promoting ACD completion across the interdisciplinary team can empower patients to make sure their preferences for critical or end-of-life care are met.

Significance & Background: With rapid advances and the growing complexity of cancer care, it is critical to support Advanced Practice Providers (APPs), like nurse practitioners (NPs) and physician assistants (PAs) entering the oncology field. Specialty practices, like oncology, require specific education and clinical training to deliver optimal patient care. APP Fellowship programs provide opportunities for dedicated support, mentorship, and education. Beyond transitional orientation, education, and clinical onboarding, simulation training offers a valuable opportunity to develop skills and gain hands-on experience in a safe and controlled environment. Purpose: The purpose of integrating oncology-based simulation training was to increase confidence in essential skills needed to care for oncology patients in early career APPs. Interventions: As part of an institutional oncology APP fellowship program and to support newly hired APPs, the first simulation-based training session was conducted in the summer of 2024, focusing on two relevant oncology scenarios. The first scenario was focused on a new patient cancer visit and the second scenario was focused on identifying a follow-up patient with neutropenic fever, one of the more common oncologic emergencies. A pilot of six APPs participated; two APPs were part of the Oncology APP Fellowship Program and four were newly hired APPs. Before starting the simulations, a general overview, the case scenarios, orientation to the environment, and resources were provided. A questionnaire assessing confidence in the key areas of oncology care was also administered prior to starting the simulation. Debriefing sessions were performed after each scenario. The Debriefing Assessment for Simulation in Healthcare (DASH) Student Version© was utilized to assess the quality of the debriefs. Of note, both simulations utilized standardized patients (SPs) and replica clinic rooms where the APPs practiced. Results: Exact Mc- Nemar's test was utilized to examine the association between level of confidence and the intervention. Although, there was not a statistical significance in the results, likely due to a small sample size, the level of confidence with all learners increased from the category of strongly disagree, disagree, and neutral to agree and strongly agree. Discussion: Integrating technology and oncology-based simulations resulted in an increase in individual learner confidence in a secure and supportive learning environment. Additionally, it unintentionally served as a team building experience. Future directions will be to continue to add relevant oncology case scenarios critical to skill building in new APPs in oncology.

When South Florida became a hot spot for COVID-19 disease in March 2020, we faced an urgent need to develop test capability to detect SARS-CoV-2 infection. We assembled a transdisciplinary team of knowledgeable and dedicated physicians, scientists, technologists, and administrators who rapidly built a multiplatform, polymerase chain reaction- and serology-based detection program, established drive-through facilities, and drafted and implemented guidelines that enabled efficient testing of our patients and employees. This process was extremely complex, due to the limited availability of needed reagents, but outreach to our research scientists and multiple diagnostic laboratory companies, and government officials enabled us to implement both Food and Drug Administration authorized and laboratory-developed testing–based testing protocols. We analyzed our workforce needs and created teams of appropriately skilled and certified workers to safely process patient samples and conduct SARS-CoV-2 testing and contact tracing. We initiated smart test ordering, interfaced all testing platforms with our electronic medical record, and went from zero testing capacity to testing hundreds of health care workers and patients daily, within 3 weeks. We believe our experience can inform the efforts of others when faced with a crisis situation.

Racial and ethnic disparities in patient-reported outcomes (PROs) among gynecologic cancer survivors are not well studied. We evaluated whether individual-level characteristics were associated with PROs in diverse gynecologic cancer survivors. Gynecologic cancer patients in an ambulatory oncology clinic completed a psychosocial and practical needs assessment before their appointments through the electronic medical record (EMR) patient portal. Assessments were available in English and Spanish. Fatigue, pain, physical function, depression, and anxiety were assessed with Patient-Reported Outcomes Measurement Information System (PROMIS®) computer adaptive tests, and health-related quality of life was assessed by FACT-G7. PROs were dichotomized based on severity (normal/mild vs moderate/severe). Demographic and clinical information was collected. Analyses were performed using Chi-square, t-tests, and Kruskal-Wallis tests. A total of 582 women completed the assessment; 20% (n = 116) were racial minorities, and 54.5% (n = 310) were Hispanic. A total of 192 (32.8%) completed the assessments in Spanish. Hispanic patients had lower mean fatigue scores (49.31 vs 51.74, p = 0.01), and patients whose preferred language was Spanish had lower mean depression (47.63 vs 48.97, p = 0.05) and fatigue scores (48.27 vs 51.27, p < 0.01). There were no significant differences in the severity of PROs by race, ethnicity, or preferred language. QOL scores were worse in patients with high symptom severity for anxiety (p = 0.04) and physical functioning (p < 0.01). Current smokers had worse physical functioning (13.4% vs 6.5%, p = 0.03). We found no significant differences in severity of PROs by race, ethnicity, or preferred language. Quality of life scores were worse for patients with high symptom severity for physical functioning and anxiety.

Significance & Background: The goal of cancer prevention is to improve survival outcomes by detecting early-stage disease. Identifying cancer risk can improve awareness, education, and support screening recommendations. Recommendations are frequently overlooked resulting in patients being lost to follow-up. As a result, a multidisciplinary clinic was developed to reduce barriers to care and provide ongoing, comprehensive support for those identified with a high risk for cancer or genetic predisposition. Utilizing various nursing roles, including Nurse Practitioners (NPs) and Nurse Navigators (NNs), has illustrated improvements in access, follow up, and outcomes. Purpose: The purpose of the nurse led clinic is to decrease wait times to see a provider and increase adherence to recommended screening protocols and follow up for risk reduction treatments. Interventions: Before the initial appointment, the NN reaches out to new patients to perform an intake; ensure they are scheduled with the appropriate provider; and gather pertinent medical records. The NN discusses each case with the NP prior to their initial visit and the NP develops a pedigree. On the initial visit, the NP performs a history and physical exam; confirms pedigree; reviews pertinent records; identifies appropriate screening protocols based on their risk level; and orders for genetic testing and other relevant labs and imaging. Results: Before implementation of the nurse led clinic, the wait time to see a provider was four months. Post implementation, between June 2023 to May 2024, provider wait times for risk evaluation decreased to one week and wait times for cancer patients in need of testing for treatment decisions decreased to 11 days. Additionally, time to initial NN patient contact and intake completion was within one business day. Cancellations also decreased by 10%; while the number of appointments increased 42%. Patient satisfaction scores remain at 100%. Furthermore, the NN has significantly improved completion rates, with specialty physician follow-through increasing from 29% to 57% and radiology completion rates from 23% to 59%; highlighting the crucial role NNs and NPs play in coordination of care. Discussion: Findings indicate a nurse led high risk clinic has a positive influence on resource utilization and care coordination. NPs and NNs can efficiently evaluate patients and provide comprehensive visits. The nursing led clinic has enhanced scheduling efficiency and adherence to recommended guidelines, ensuring early detection and risk reduction for patients at high risk for cancer.

Survivorship Significance & Background: Access to primary care is essential for cancer survivors (CS), yet many lack a primary care provider (PCP). The PCP manages chronic conditions, offers preventive care, promotes healthy behaviors, and facilitates care coordination and communication with specialists. Coordinating to establish long-term survivorship care with a PCP is essential in the care of CS. Purpose: The Sylvester Survivorship and Supportive Care program ensures all patients have an established PCP. We aimed to implement a process that streamlined and increased referrals to PCPs for patients from the Sylvester Comprehensive Cancer Center (Sylvester) Survivorship Clinics through collaboration with the University of Miami Health System (UHealth) internal and family medicine clinics. Interventions: In collaboration with primary care leaders at UHealth, we assessed the need for primary care in our cancer patient population. Data from the electronic medical record (EMR) suggested that about 25% had no PCP. As a result, we identified PCPs within the health system who were interested in providing survivorship care and developed education and training in this area. A specific order referral was then created in the EMR to expedite scheduling appointments with PCPs. Additionally, we identified patients in the Sylvester Survivorship Wellness clinics without a PCP and referrals were placed. A Survivorship Care Plan (SCP) was created and delivered for each patient seen, alongside assessments of unmet needs and referrals. The SCP was shared via the EMR. Results: Out of 44 patients seen in the Survivorship clinic and referred to a Survivorship PCP from August 2023 to August 2024, 43 were contacted. Of these, 17 patients (39.5%) were successfully seen, while 15 (35%) could not be contacted. Additionally, 11 (25.5%) patients were not scheduled for various reasons, including refusal, cancellation, or left without being seen. Discussion: This initiative highlights the need to develop successful referral processes to improve cancer survivors' access to primary care. Future directions will address identified barriers to scheduling and enhancing follow-up to ensure optimal care continuity for this population. These challenges are a stark reminder of the complexities in the field of cancer survivorship care, but they also serve as opportunities for growth and improvement.