The Impact of a Multidisciplinary Clinic on Diagnosis and Management of Patients with Cutaneous T-cell Lymphoma

The Impact of a Multidisciplinary Clinic on Diagnosis and Management of Patients with Cutaneous T-cell Lymphoma | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article The Impact of a Multidisciplinary Clinic on Diagnosis and Management of Patients with Cutaneous T-cell Lymphoma Sierra Thomas, Mitchell Taylor, Molly Antonson, Ochanya Ogah, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4708793/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 4 You are reading this latest preprint version Abstract Multidisciplinary clinics (MDCs) have been shown to improve patient outcomes and reduce disease-specific mortality. This study aims to evaluate the impact of a MDS clinic on diagnosis, management, and clinical outcomes of patients diagnosed with CTCL. A retrospective cohort analysis of a CTCL MDS clinic was conducted between January 2018 to August 2023 at a large academic institution. Patients diagnosed with CTCL with at least one visit to the CTCL MDS clinic were included. Medical records were reviewed for patient demographics, diagnosis change, treatment management, survival outcomes, and clinicopathologic disease characteristics at 6-month intervals. A descriptive analysis was performed. 55 patients were identified (mean age 62.7; 58.1% male; 89.1% White). 80.0% of patients were diagnosed with CTCL, however, 78% were previously diagnosed with other dermatologic conditions. At initial presentation, 20% had a change in diagnosis with 12.7% changing to a benign dermatologic condition. Only 9% of patients had staging prior to initial visit, while majority (62%) received initial staging evaluation during their first visit. At the initial visit, 50.2% had an escalation of treatment, mainly of skin-directed therapy (36.4%). Over 6-month intervals, majority of patients had an escalation of treatment (21.1–51.1%). The modified severity weighted assessment tool (mSWAT) decreased over time (41.8 to 3.5), with many achieving stable disease (18.4–50%). MDS management is highly recommended for patients with CTCL. This study further highlights the important role of a CTCL MDS clinic, specifically in establishing accurate diagnoses, managing appropriate treatments, and stabilizing disease progression. cutaneous t-cell lymphoma lymphoma skin cancer multidisciplinary clinic Introduction Cutaneous T-cell lymphoma (CTCL) is a rare form of non-Hodgkin lymphoma, defined by its manifestations within the skin in the absence of extracutaneous manifestations at diagnosis. 1 The incidence of CTCL is approximately 0.96 per 100,000, with mycosis fungoides (MF) and Sézary Syndrome (SS) subtypes most recognized. 2 The clinical presentation of CTCL varies significantly and features often overlap with benign inflammatory skin conditions such as atopic dermatitis, psoriasis, and parapsoriasis. Due to the low incidence of CTCL and its shared clinical manifestations with other conditions, diagnosis is challenging. Consequently, diagnosis and treatment of CTCL are often delayed, sometimes greater than four decades, resulting in disease progression and poor patient outcomes. 3 Given the considerable diagnostic difficulty, patients with CTCL are likely to benefit from multidisciplinary (MDS) consultation and management. MDS care has become widely accepted across multiple disciplines. Dermatology MDS clinics, such as combined dermatology-rheumatology clinics, have been shown to improve patient outcomes, raise patient and physician satisfaction, and design effective treatment regimens. 4 Furthermore, a 2020 systematic review found that caring for patients with dermatologic disease and psychosocial comorbidities in a MDS setting limited inaccurate diagnoses, ineffective treatments, and led to improved patient outcomes. 5 In addition, MDS clinics have positively impacted patients with cancer leading to decreased time to treatment, accurate staging, improved treatment adherence, and disease-specific survival. 6–9 While many patients with CTCL only experience limited disease confined to the skin, the clinical course of CTCL is unpredictable and those who progress to late-stage disease often require systemic and skin directed therapy from multiple providers including dermatologists, hematologists/oncologists, and radiation oncologists. 10 Although MDS care is recommended, 11 few CTCL specific MDS clinics exist. The University of Nebraska Medical Center established a MDS CTCL clinic in 2018 to provide accessible, comprehensive patient-centered care. To assess the impact of our CTCL MDS clinic, a retrospective cohort analysis was conducted to highlight the impact of an MDS clinic on diagnosis, treatment, and outcomes of patients with CTCL. Methods We conducted a retrospective cohort analysis of the Cutaneous T-cell Lymphoma Multidisciplinary clinic at the University of Nebraska Medical Center, which was reviewed and approved by the University of Nebraska Medical Center Institutional Review Board. Patients diagnosed with CTCL with at least one visit to the CTCL MDS clinic between January 2018 and August 2023 were included in the study. Patients were seen by both an attending dermatologist and medical oncologist with a radiation oncologist in close collaboration as needed. Patients diagnosed with lymphomatoid papulosis were excluded from the study due to its benign clinical course. The electronic medical records were reviewed for patient demographics, staging, diagnosis change, treatment management, survival outcomes, and clinicopathological disease characteristics at 6-month intervals for 5 years. All patients had an initial visit documented; however, some patients were lost to follow up or did not return every 6 months. If patients had more than one visit within a 6-month time interval, all treatment as well as the highest Modified Severity Weighted Assessment Tool (mSWAT) and LDH was documented. An escalation in treatment was defined as a change or addition of skin directed and/or systemic therapy, while a de-escalation of treatment was defined as decreasing from systemic to skin directed therapy or a decrease in number of total treatment modalities. Skin assessment and response to treatment was assessed with the mSWAT. Treatment response and staging was documented using the definition and criteria from Olsen et al. 12,13 Advanced stage was considered stages IIB through IVB. A descriptive analysis using frequencies and percentages to highlight changes in diagnosis and disease management was performed. Results A total of 55 unique patients had an initial visit to the CTCL multidisciplinary clinic, of which the majority were male (58.1%), White (89.1%), and had a mean age of 62.7 ( Table 1 ). 80.0% of patients were previously diagnosed with CTCL before presenting to MDS clinic, however 78% were previously diagnosed with other dermatologic conditions, with dermatitis (56.5%) being the most common followed by psoriasis (23.3%). 20.0% of patients had an initial change in diagnosis, with 12.7% changing to a benign dermatologic condition. Only 9% of patients underwent staging prior to initial CTCL MDS clinic visit, while 62% of patients received initial staging evaluation during their first visit. 36.6% of patients were diagnosed with advanced-stage disease, including 24% with blood involvement. Upon initial visit, 50.2% had an escalation in treatment comprising mostly of skin-directed therapy (36.4%). Over 6-month intervals, the majority of patients continued to have an escalation of therapy ranging from 21.1–51.1% ( Table 2 ). The modified Severity Weighted Assessment Tool (mSWAT) decreased over 6-month intervals from a mean of 41.8 to 3.5, with most achieving stable disease (18.4–50%). 23.6% patients experienced a median time to large cell transformation of 7.5 months (range 0–38). No visceral metastasis was recorded, although 14.5% had nodal involvement. 12.7% of patients expired during the study, with a median time to death of 12 months (range 4–41). Discussion Herein, we found that our CTCL MDS clinic positively impacts patient care, specifically in establishing accurate diagnoses, treatment management, and stabilizing disease progression. Diagnosing CTCL is challenging, and many patients often experience a delay in diagnosis. In a multicenter study evaluating disease course of CTCL, patients with skin lesions related to CTCL experienced an average delay of diagnosis of two years, with some exceeding 50 years before receiving a definitive diagnosis. 14 In our study, 78% of patients were previously diagnosed with a benign dermatologic condition, and 13% of patients diagnosed with CTCL received a benign diagnostic change after presenting to CTCL MDS clinic, which further highlights the challenges of distinguishing this disease. Minimizing delays in CTCL diagnosis is essential for patient outcomes, as those with early-stage disease, specifically stage IA, experience similar survival outcomes to age-matched healthy controls, 15 while those with late-stage disease have overall poor survival outcomes. 16 However, on the contrary, receiving a false-positive cancer diagnosis can lead to unnecessary testing, additional medical costs, and significant emotional burden. 17 Because CTCL diagnosis can be challenging, prompt referral to a dermatologist or MDS CTCL clinic may improve diagnostic accuracy and decrease delays in diagnosis and management. In our study, only 9% patients had complete staging before presenting to CTCL MDS, while 62% were evaluated for stage during their first visit. Dermatologists play a pivotal role in staging, specifically for assessing T stage, which is solely based on skin evaluation. 18 Staging is one of the most important aspects for determining treatment strategies, as early-stage disease is largely managed by skin directed therapy. Even in late-stage disease, skin-directed therapy in combination with systemic therapy can improve symptoms and skin tumor burden. 19 At initial presentation to the UNMC MDS CTCL clinic, 53% of patients underwent an escalation in therapy, with the majority comprising of skin directed therapy (36%). As time progressed, majority of patients had no subsequent change in treatment regimen as most achieved stable, partial, or complete response to therapy. Skin directed therapy remains first-line treatment for those with early-stage disease, while systemic therapy may be initiated or added in patients with late-stage, refractory, or if relapse of disease occurs. 19 While some guidelines do exist, there is a lack of randomized controlled trials assessing therapeutic strategies in patients with CTCL. 20 Many treatment options with similar efficacy exist for skin-directed and systemic treatment. 21 Selection of appropriate therapy will differ across providers and will often depend on provider preference, clinical presentation, and availability of treatment. 19 Utilizing the expertise of a dermatologist in conjunction with oncology and radiation oncology in MDS setting may better optimize patient treatment strategies and outcomes. While many dermatologists primarily manage early stage CTCL with skin directed therapy, they play an active role in managing and guiding treatment decisions in late stage or refractory disease. Specifically, a dermatologist’s unique expertise in skin manifestation can help identify early cutaneous disease progression and differentiate adverse skin reactions, which may mitigate early termination of treatment or premature escalation of therapy. 22 A MDS care model has been highly emphasized for managing patients with CTCL, largely due to the logistically complex shift from skin directed therapy under the supervision of a dermatologist, to oncology-driven care. 23 Centralizing patient care allows specialists to communicate directly and make prompt treatment decisions while ensuring shared understanding of all involved parties. 23 Patients with CTCL should be seen regularly once diagnosis is established to monitor for signs of disease progression. The ESMO guidelines recommend that follow-up be individualized depending on clinical scenarios. Those with indolent subtypes of CTCL or stable disease can be seen every 6–12 months, while those with active or progressive disease are often seen every 4–6 weeks. 11 Some patients with CTCL may undergo a process of large-cell transformation (LCT), which is characterized by an aggressive disease course and is associated with poor survival. 24,25 LCT is often difficult to diagnose, as clinical presentation can vary from a single papule emerging in a pre-existing plaque to multiple standalone nodules and tumors with ulceration. 25 In our MDS CTCL clinic, 24% of patients were diagnosed with LCT. Although diagnosis is made histologically, dermatologists play a crucial role in identifying early signs of LCT to facilitate further work up. Furthermore, regular follow-up with a MDS CTCL clinic may mitigate progression of disease with early identification of LCT and initiation of aggressive treatment as needed. The use and benefit of a disease-specific MDS has been well documented across multiple medical specialties. Specifically, MDS cancer clinics have most notably improved disease-specific survival. 6,26–28 While we were unable to assess disease-specific survival due to low sample size, patients from our MDS CTCL clinic had a decreasing trend in average mSWAT (41.8 to 3.5), with many patients achieving at least partial response to treatment without disease progression. Reasons for improved clinical outcomes associated with MDS specialty clinics may be multifactorial. In a previous study, treatment adherence to NCCN guidelines of patients with prostate cancer was improved after implementing a prostate MDS clinic, while multiple studies have shown cancer specific MDS clinics decrease time to treatment initiation and improve treatment adherence. 7,9,26,29,30 In addition, patient satisfaction tends to be improved with MDS clinics, as many reported reductions in number of office visits while experiencing an improved understanding of their condition and treatment regimen. 31 This is one of the first studies to report on the impact of a MDS CTCL clinic. Like previous disease-specific studies, we found that MDS management positively impacts diagnosis and management of patients with CTCL as well as minimizes disease progression. Limitations of our study include a small sample size and a relatively homogenous cohort, which may limit generalizability of our findings. Nonetheless, MDS care should be accessible to all patients diagnosed with CTCL, and this study further underscores the importance of a MDS CTCL clinic to improve patient-centered care. Declarations Conflict of Interest The authors have no conflicts of interest to disclose. Funding none Ethical Approval Approved by UNMC IRB #0577-23-EP Author Contribution S.T and M.A. wrote the main manuscript. S.T. and M.T. performed data collection.M.S. was the lead investigator.All authors reviewed and edited the manuscript. Data Availability The participants of this study did not give written consent for their data to be shared publicly, so due to the sensitive nature of the research supporting data is not available. References Stoll JR, Willner J, Oh Y et al (2021) Primary cutaneous T-cell lymphomas other than mycosis fungoides and Sézary syndrome. Part I: Clinical and histologic features and diagnosis. J Am Acad Dermatol 85(5):1073–1090 Morgenroth S, Roggo A, Pawlik L, Dummer R, Ramelyte E (2023) What Is New in Cutaneous T Cell Lymphoma? Curr Oncol Rep 25(11):1397–1408 Hristov AC, Tejasvi T, Wilcox RA (2023) Cutaneous T-cell lymphomas: 2023 update on diagnosis, risk-stratification, and management. Am J Hematol 98(1):193–209 Soleymani T, Reddy SM, Cohen JM, Neimann AL (2017) Early Recognition and Treatment Heralds Optimal Outcomes: the Benefits of Combined Rheumatology-Dermatology Clinics and Integrative Care of Psoriasis and Psoriatic Arthritis Patients. Curr Rheumatol Rep 20(1):1 Patel A, Jafferany M (2020) Multidisciplinary and Holistic Models of Care for Patients With Dermatologic Disease and Psychosocial Comorbidity: A Systematic Review. JAMA Dermatol 156(6):686–694 Hoehn RS, Rieser CJ, Winters S et al (2021) A Pancreatic Cancer Multidisciplinary Clinic Eliminates Socioeconomic Disparities in Treatment and Improves Survival. Ann Surg Oncol 28(5):2438–2446 Gardner TB, Barth RJ, Zaki BI et al (2010) Effect of initiating a multidisciplinary care clinic on access and time to treatment in patients with pancreatic adenocarcinoma. J Oncol Pract 6(6):288–292 Davies AR, Deans DAC, Penman I et al (2006) The multidisciplinary team meeting improves staging accuracy and treatment selection for gastro-esophageal cancer. Dis Esophagus 19(6):496–503 Schiffman SC, Abberbock S, Winters S et al (2016) A pancreatic cancer multidisciplinary clinic: insights and outcomes. J Surg Res 202(2):246–252 Parker SRS, Bradley B (2006) Treatment of cutaneous T-cell lymphoma/mycosis fungoides. Dermatol Nurs 18(6):566–570 Willemze R, Hodak E, Zinzani PL, Specht L, Ladetto M (2018) Primary cutaneous lymphomas: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up†. Ann Oncol 29:iv30–iv40 Olsen EA, Whittaker S, Kim YH et al (2011) Clinical end points and response criteria in mycosis fungoides and Sézary syndrome: a consensus statement of the International Society for Cutaneous Lymphomas, the United States Cutaneous Lymphoma Consortium, and the Cutaneous Lymphoma Task Force of the European Organisation for Research and Treatment of Cancer. J Clin Oncol 29(18):2598–2607 Olsen E, Vonderheid E, Pimpinelli N et al (2007) Revisions to the staging and classification of mycosis fungoides and Sezary syndrome: a proposal of the International Society for Cutaneous Lymphomas (ISCL) and the cutaneous lymphoma task force of the European Organization of Research and Treatment of Cancer (EORTC). Blood 110(6):1713–1722 van Doorn R, Van Haselen CW, van Voorst Vader PC et al (2000) Mycosis fungoides: disease evolution and prognosis of 309 Dutch patients. Arch Dermatol 136(4):504–510 Litvinov IV, Jones DA, Sasseville D, Kupper TS (2010) Transcriptional profiles predict disease outcome in patients with cutaneous T-cell lymphoma. Clin Cancer Res 16(7):2106–2114 Scarisbrick JJ, Prince HM, Vermeer MH et al (2015) Cutaneous Lymphoma International Consortium Study of Outcome in Advanced Stages of Mycosis Fungoides and Sézary Syndrome: Effect of Specific Prognostic Markers on Survival and Development of a Prognostic Model. J Clin Oncol 33(32):3766–3773 Singh H, Sethi S, Raber M, Petersen LA (2007) Errors in cancer diagnosis: current understanding and future directions. J Clin Oncol 25(31):5009–5018 Olsen EA, Hodak E, Geskin L, Scarisbrick J, ISCL, USCLC (2024) Bridging the specialty gap: Update on primary cutaneous lymphomas. J Am Acad Dermatol 90(2):257–260 Latzka J, Assaf C, Bagot M et al (2023) EORTC consensus recommendations for the treatment of mycosis fungoides/Sézary syndrome - Update 2023. Eur J Cancer 195:113343 Denis D, Beneton N, Laribi K, Maillard H (2019) Management of mycosis fungoides-type cutaneous T-cell lymphoma (MF-CTCL): focus on chlormethine gel. Cancer Manag Res 11:2241–2251 Wain T, Venning VL, Consuegra G, Fernandez-Peñas P, Wells J (2019) Management of cutaneous T-cell lymphomas: Established and emergent therapies. Australas J Dermatol 60(3):200–208 Poligone B, Querfeld C (2015) Management of advanced cutaneous T-cell lymphoma: role of the dermatologist in the multidisciplinary team. Br J Dermatol 173(4):1081–1083 Tyler KH, Haverkos BM, Hastings J et al (2015) The Role of an Integrated Multidisciplinary Clinic in the Management of Patients with Cutaneous Lymphoma. Front Oncol 5:136 Diamandidou E, Colome-Grimmer M, Fayad L, Duvic M, Kurzrock R (1998) Transformation of mycosis fungoides/Sezary syndrome: clinical characteristics and prognosis. Blood 92(4):1150–1159 Herrmann JL, Hughey LC (2012) Recognizing large-cell transformation of mycosis fungoides. J Am Acad Dermatol 67(4):665–672 Mark JR, Gomella LG, Lallas CD et al (2023) Enhancing bladder cancer care through the multidisciplinary clinic approach. Can J Urol 30(3):11526–11531 Kubicek GJ, Yocum N, Thomas C, Goldman HW (2020) Neuro-oncology Multidisciplinary Clinic and Improvements in Patient Outcome. Am J Clin Oncol 43(11):798–801 Albany C, Adra N, Snavely AC et al (2018) Multidisciplinary clinic approach improves overall survival outcomes of patients with metastatic germ-cell tumors. Ann Oncol 29(2):341–346 Starmer H, Sanguineti G, Marur S, Gourin CG (2011) Multidisciplinary head and neck cancer clinic and adherence with speech pathology. Laryngoscope 121(10):2131–2135 Stone CJL, Robinson A, Brown E et al (2019) Improving Timeliness of Oncology Assessment and Cancer Treatment Through Implementation of a Multidisciplinary Lung Cancer Clinic. J Oncol Pract 15(2):e169–e177 Li KL, Fang CH, Ferastraoaru D, Akbar NA, Jerschow E, Abuzeid WM (2020) Patient Satisfaction and Efficiency Benefits of a Novel Multidisciplinary Rhinology and Allergy Clinic. Ann Otol Rhinol Laryngol 129(7):699–706 Tables Table 1. Clinical characteristics of patients in a CTCL MDS clinic Characteristic Total, No. (%) Age, mean (SD) (n=55) 62.7 (15.7) Sex (n=55) Male 32 (58.1) Female 23 (41.8) Race (n=55) White 49 (89.1) Other 1 6 (10.9) Ethnicity , Non-Hispanic (n=55) 55 (100) Previous Dermatology Visit (n=53) 49 (92.5) Previously Diagnosed with CTCL (n=55) 44 (80) Other Previous Diagnoses 2 (n=55) 43 (78) Dermatitis 20 (56.5) Psoriasis 10 (23.3) None 11 (25.6) Other 3 8 (18.6) Diagnosis Change (n=55) 11 (20) To other CTCL subtype 4 (7.3) From CTCL to other 4 7 (12.7) New Diagnosis 9 (16.4) CTCL Subtypes (n=53) Mycosis Fungoides 37 (69.8) Sezary Syndrome 7 (13.2) CD4+ Lymphoproliferative Disorder 2 (3.8) Anaplastic Large Cell Lymphoma 1 (1.9) Subcutaneous Panniculitis-Like 1 (1.9) Tumor Board (n=55) 8 (14.5) Stage (n=41) T Stage T1/T2 28 (68.3) T3/T4 13 (31.7) N Stage N1/N1 4 (9.8) N3/N4 6 (14.6) M Stage - B Stage B1 4 (9.8) B2 9 (22.0) Stage Changes (n=41) Up Stage 4 (9.8) Down Stage 1 (2.1) Large Cell Transformation (n=55) 13 (23.6) Time to Large Cell Transformation, median months, range 7.5, 0-38 Metastasis (n=55) Nodal Involvement 8 (14.5) Visceral 0 Deceased (n=55) 7 (12.7) Time to Death , month, range 12, (4-41) 1 Black (n=5), American Indian and Alaskan Native (n=1); 2 Pityriasis rubra pilaris, tinea, tinea versicolor, rosacea, peripheral T-cell lymphoma, atypical lymphocytic infiltrate, keratosis pilaris; 3 Can have more than one; 4 Pseudolymphoma, CD30+ cutaneous proliferation, dermatitis, psoriasiform dermatitis, solar lentigo CTCL, Cutaneous T-cell lymphoma; MDS, multidisciplinary, SD, standard deviation Table 2. Changes in disease progression and management Initial (n=55) 0-6 m (n=47) 6-12 m (n=38) 12-18 m (n=31) 18-24 m (n=19) +24 m (n=32) Treatment No Change 22 (40) 17 (36.2) 15 (39.5) 13 (41.9) 11 (57.9) 19 (59.4) Escalated Treatment 1 29 (52.7) 24 (51.1) 11 (28.9) 10 (32.3) 4 (21.1) 8 (25) SDT 20 (36.4) 10 (21.3) 2 (5.3) 6 (19.4) 1 (5.3) 4 (12.5) Systemic 5 (9.1) 9 (19.1) 4 (10.5) 0 (0) 2 (10.5) 4 (12.5) SDT+Systemic 4 (7.3) 5 (10.6) 5 (13.2) 4 (12.9) 1 (5.3) 0 (0) De-Escalated Treatment 5 (9.1) 3 (6.4) 6 (15.8) 4 (12.9) 2 (10.5) 5 (25.6) Systemic to SDT 5 (9.1) 3 (6.4) 2 (5.3) 2 (6.5) 1 (5.3) 1 (3.1) Decrease SDT 0 (0) 0 (0) 4 (10.5) 2 (6.5) 1 (5.3) 4 (12.5) Unknown 0 (0) 3 (6.4) 6 (15.8) 4 (12.9) 2 (10.5) 1 (3.1) mSWAT 41.8 (40.0) 29.1 (29.1) 19.2 (25.9) 21.4 (34.0) 16.5 (26.9) 3.5 (15.6) Unknown 17 (30.9) 14 (29.8) 11 (28.9) 11 (35.5) 5 (29.4) 11 (34.4) Treatment Response 2 Stable - 19 (40.4) 7 (18.4) 7 (22.6) 9 (47.4) 16 (50) Partial Response - 5 (10.6) 5 (13.2) 5 (16.1) 2 (10.5) 4 (12.5) Complete Response - 2 (4.3) 2 (5.3) (6.5) 2 (10.5) 0 (0) Progression - 6 (12.8) 3 (7.9) 3 (9.7) 1 (5.3) 3 (9.4) Relapse - 1 (2.1) 1 (2.6) 2 (6.5) 0 (0) 0 (0) Unknown - 14 (29.8) 20 (52.6) 12 (38.7) 5 (26.3) 9 (28.1) Flow Cytometry Positive 7 (12.7) 4 (8.5) 3 (7.9) 2 (6.5) 1 (5.3) 2 (6.3) Negative 20 (36.4) 6 (12.8) 7 (18.4) 4 (12.9) 4 (21.1) 3 (9.4) Unknown 28 (50.9) 38 (80.9) 28 (73.7) 25 (80.7) 14 (73.7) 27 (84.4) LDH , mean (SD) use 222.8 (87.5) 219 (82.0) 203.1 (81.6) 211.7 (57.9) 205.8 (81.1) 221.5 (97.3) Unknown 39 (70.9) 32 (74.4) 23 (60.5) 22 (71.0) 14 (73.7) 26 (81.3) 1 Added or changed skin directed/systemic therapy SDT, skin directed therapy; mSWAT, modified severity weighted assessment tool Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Revision requested 24 Jul, 2024 Editor assigned by journal 09 Jul, 2024 Submission checks completed at journal 09 Jul, 2024 First submitted to journal 08 Jul, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4708793","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":331422855,"identity":"2df46256-9eba-4c71-8dd7-17abfa5e21db","order_by":0,"name":"Sierra Thomas","email":"data:image/png;base64,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","orcid":"","institution":"University of Utah School of Medicine","correspondingAuthor":true,"prefix":"","firstName":"Sierra","middleName":"","lastName":"Thomas","suffix":""},{"id":331422856,"identity":"201180cf-ee0b-4da6-a6ff-f85b1ff20401","order_by":1,"name":"Mitchell Taylor","email":"","orcid":"","institution":"Creighton University School of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Mitchell","middleName":"","lastName":"Taylor","suffix":""},{"id":331422857,"identity":"5b223aa7-36c3-4651-8c5d-2dbc4d2484e8","order_by":2,"name":"Molly Antonson","email":"","orcid":"","institution":"University of Nebraska Medical Center","correspondingAuthor":false,"prefix":"","firstName":"Molly","middleName":"","lastName":"Antonson","suffix":""},{"id":331422858,"identity":"dd651518-dc25-4655-b7c2-eb4b2f0ae306","order_by":3,"name":"Ochanya Ogah","email":"","orcid":"","institution":"University of Southern California","correspondingAuthor":false,"prefix":"","firstName":"Ochanya","middleName":"","lastName":"Ogah","suffix":""},{"id":331422859,"identity":"2fd2c741-77fa-4471-af4b-c1b76b87811b","order_by":4,"name":"Ashley Wysong","email":"","orcid":"","institution":"University of Nebraska Medical Center","correspondingAuthor":false,"prefix":"","firstName":"Ashley","middleName":"","lastName":"Wysong","suffix":""},{"id":331422860,"identity":"8d2a1740-747e-466c-a168-868297e6968c","order_by":5,"name":"Matthew Stephany","email":"","orcid":"","institution":"University of Nebraska Medical Center","correspondingAuthor":false,"prefix":"","firstName":"Matthew","middleName":"","lastName":"Stephany","suffix":""}],"badges":[],"createdAt":"2024-07-09 03:23:17","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4708793/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4708793/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":61551732,"identity":"02ce9d9b-5955-474f-9359-7605de8cb77b","added_by":"auto","created_at":"2024-08-01 06:39:03","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":550105,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4708793/v1/95a23cdf-738d-4134-bbdf-5b6f81358964.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"The Impact of a Multidisciplinary Clinic on Diagnosis and Management of Patients with Cutaneous T-cell Lymphoma","fulltext":[{"header":"Introduction","content":"\u003cp\u003eCutaneous T-cell lymphoma (CTCL) is a rare form of non-Hodgkin lymphoma, defined by its manifestations within the skin in the absence of extracutaneous manifestations at diagnosis.\u003csup\u003e1\u003c/sup\u003e The incidence of CTCL is approximately 0.96 per 100,000, with mycosis fungoides (MF) and S\u0026eacute;zary Syndrome (SS) subtypes most recognized.\u003csup\u003e2\u003c/sup\u003e The clinical presentation of CTCL varies significantly and features often overlap with benign inflammatory skin conditions such as atopic dermatitis, psoriasis, and parapsoriasis. Due to the low incidence of CTCL and its shared clinical manifestations with other conditions, diagnosis is challenging. Consequently, diagnosis and treatment of CTCL are often delayed, sometimes greater than four decades, resulting in disease progression and poor patient outcomes.\u003csup\u003e3\u003c/sup\u003e Given the considerable diagnostic difficulty, patients with CTCL are likely to benefit from multidisciplinary (MDS) consultation and management.\u003c/p\u003e \u003cp\u003eMDS care has become widely accepted across multiple disciplines. Dermatology MDS clinics, such as combined dermatology-rheumatology clinics, have been shown to improve patient outcomes, raise patient and physician satisfaction, and design effective treatment regimens.\u003csup\u003e4\u003c/sup\u003e Furthermore, a 2020 systematic review found that caring for patients with dermatologic disease and psychosocial comorbidities in a MDS setting limited inaccurate diagnoses, ineffective treatments, and led to improved patient outcomes.\u003csup\u003e5\u003c/sup\u003e In addition, MDS clinics have positively impacted patients with cancer leading to decreased time to treatment, accurate staging, improved treatment adherence, and disease-specific survival.\u003csup\u003e6\u0026ndash;9\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eWhile many patients with CTCL only experience limited disease confined to the skin, the clinical course of CTCL is unpredictable and those who progress to late-stage disease often require systemic and skin directed therapy from multiple providers including dermatologists, hematologists/oncologists, and radiation oncologists.\u003csup\u003e10\u003c/sup\u003e Although MDS care is recommended,\u003csup\u003e11\u003c/sup\u003e few CTCL specific MDS clinics exist. The University of Nebraska Medical Center established a MDS CTCL clinic in 2018 to provide accessible, comprehensive patient-centered care. To assess the impact of our CTCL MDS clinic, a retrospective cohort analysis was conducted to highlight the impact of an MDS clinic on diagnosis, treatment, and outcomes of patients with CTCL.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e We conducted a retrospective cohort analysis of the Cutaneous T-cell Lymphoma Multidisciplinary clinic at the University of Nebraska Medical Center, which was reviewed and approved by the University of Nebraska Medical Center Institutional Review Board. Patients diagnosed with CTCL with at least one visit to the CTCL MDS clinic between January 2018 and August 2023 were included in the study. Patients were seen by both an attending dermatologist and medical oncologist with a radiation oncologist in close collaboration as needed. Patients diagnosed with lymphomatoid papulosis were excluded from the study due to its benign clinical course.\u003c/p\u003e \u003cp\u003e The electronic medical records were reviewed for patient demographics, staging, diagnosis change, treatment management, survival outcomes, and clinicopathological disease characteristics at 6-month intervals for 5 years. All patients had an initial visit documented; however, some patients were lost to follow up or did not return every 6 months. If patients had more than one visit within a 6-month time interval, all treatment as well as the highest Modified Severity Weighted Assessment Tool (mSWAT) and LDH was documented. An escalation in treatment was defined as a change or addition of skin directed and/or systemic therapy, while a de-escalation of treatment was defined as decreasing from systemic to skin directed therapy or a decrease in number of total treatment modalities. Skin assessment and response to treatment was assessed with the mSWAT. Treatment response and staging was documented using the definition and criteria from Olsen et al.\u003csup\u003e12,13\u003c/sup\u003e Advanced stage was considered stages IIB through IVB. A descriptive analysis using frequencies and percentages to highlight changes in diagnosis and disease management was performed.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eA total of 55 unique patients had an initial visit to the CTCL multidisciplinary clinic, of which the majority were male (58.1%), White (89.1%), and had a mean age of 62.7 (\u003cb\u003eTable\u0026nbsp;1\u003c/b\u003e). 80.0% of patients were previously diagnosed with CTCL before presenting to MDS clinic, however 78% were previously diagnosed with other dermatologic conditions, with dermatitis (56.5%) being the most common followed by psoriasis (23.3%). 20.0% of patients had an initial change in diagnosis, with 12.7% changing to a benign dermatologic condition. Only 9% of patients underwent staging prior to initial CTCL MDS clinic visit, while 62% of patients received initial staging evaluation during their first visit. 36.6% of patients were diagnosed with advanced-stage disease, including 24% with blood involvement. Upon initial visit, 50.2% had an escalation in treatment comprising mostly of skin-directed therapy (36.4%).\u003c/p\u003e \u003cp\u003eOver 6-month intervals, the majority of patients continued to have an escalation of therapy ranging from 21.1\u0026ndash;51.1% (\u003cb\u003eTable\u0026nbsp;2\u003c/b\u003e). The modified Severity Weighted Assessment Tool (mSWAT) decreased over 6-month intervals from a mean of 41.8 to 3.5, with most achieving stable disease (18.4\u0026ndash;50%). 23.6% patients experienced a median time to large cell transformation of 7.5 months (range 0\u0026ndash;38). No visceral metastasis was recorded, although 14.5% had nodal involvement. 12.7% of patients expired during the study, with a median time to death of 12 months (range 4\u0026ndash;41).\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003e Herein, we found that our CTCL MDS clinic positively impacts patient care, specifically in establishing accurate diagnoses, treatment management, and stabilizing disease progression. Diagnosing CTCL is challenging, and many patients often experience a delay in diagnosis. In a multicenter study evaluating disease course of CTCL, patients with skin lesions related to CTCL experienced an average delay of diagnosis of two years, with some exceeding 50 years before receiving a definitive diagnosis.\u003csup\u003e14\u003c/sup\u003e In our study, 78% of patients were previously diagnosed with a benign dermatologic condition, and 13% of patients diagnosed with CTCL received a benign diagnostic change after presenting to CTCL MDS clinic, which further highlights the challenges of distinguishing this disease. Minimizing delays in CTCL diagnosis is essential for patient outcomes, as those with early-stage disease, specifically stage IA, experience similar survival outcomes to age-matched healthy controls,\u003csup\u003e15\u003c/sup\u003e while those with late-stage disease have overall poor survival outcomes.\u003csup\u003e16\u003c/sup\u003e However, on the contrary, receiving a false-positive cancer diagnosis can lead to unnecessary testing, additional medical costs, and significant emotional burden.\u003csup\u003e17\u003c/sup\u003e Because CTCL diagnosis can be challenging, prompt referral to a dermatologist or MDS CTCL clinic may improve diagnostic accuracy and decrease delays in diagnosis and management.\u003c/p\u003e \u003cp\u003eIn our study, only 9% patients had complete staging before presenting to CTCL MDS, while 62% were evaluated for stage during their first visit. Dermatologists play a pivotal role in staging, specifically for assessing T stage, which is solely based on skin evaluation.\u003csup\u003e18\u003c/sup\u003e Staging is one of the most important aspects for determining treatment strategies, as early-stage disease is largely managed by skin directed therapy. Even in late-stage disease, skin-directed therapy in combination with systemic therapy can improve symptoms and skin tumor burden.\u003csup\u003e19\u003c/sup\u003e At initial presentation to the UNMC MDS CTCL clinic, 53% of patients underwent an escalation in therapy, with the majority comprising of skin directed therapy (36%). As time progressed, majority of patients had no subsequent change in treatment regimen as most achieved stable, partial, or complete response to therapy.\u003c/p\u003e \u003cp\u003eSkin directed therapy remains first-line treatment for those with early-stage disease, while systemic therapy may be initiated or added in patients with late-stage, refractory, or if relapse of disease occurs.\u003csup\u003e19\u003c/sup\u003e While some guidelines do exist, there is a lack of randomized controlled trials assessing therapeutic strategies in patients with CTCL.\u003csup\u003e20\u003c/sup\u003e Many treatment options with similar efficacy exist for skin-directed and systemic treatment.\u003csup\u003e21\u003c/sup\u003e Selection of appropriate therapy will differ across providers and will often depend on provider preference, clinical presentation, and availability of treatment.\u003csup\u003e19\u003c/sup\u003e Utilizing the expertise of a dermatologist in conjunction with oncology and radiation oncology in MDS setting may better optimize patient treatment strategies and outcomes.\u003c/p\u003e \u003cp\u003eWhile many dermatologists primarily manage early stage CTCL with skin directed therapy, they play an active role in managing and guiding treatment decisions in late stage or refractory disease. Specifically, a dermatologist\u0026rsquo;s unique expertise in skin manifestation can help identify early cutaneous disease progression and differentiate adverse skin reactions, which may mitigate early termination of treatment or premature escalation of therapy.\u003csup\u003e22\u003c/sup\u003e A MDS care model has been highly emphasized for managing patients with CTCL, largely due to the logistically complex shift from skin directed therapy under the supervision of a dermatologist, to oncology-driven care.\u003csup\u003e23\u003c/sup\u003e Centralizing patient care allows specialists to communicate directly and make prompt treatment decisions while ensuring shared understanding of all involved parties.\u003csup\u003e23\u003c/sup\u003e\u003c/p\u003e \u003cp\u003ePatients with CTCL should be seen regularly once diagnosis is established to monitor for signs of disease progression. The ESMO guidelines recommend that follow-up be individualized depending on clinical scenarios. Those with indolent subtypes of CTCL or stable disease can be seen every 6\u0026ndash;12 months, while those with active or progressive disease are often seen every 4\u0026ndash;6 weeks.\u003csup\u003e11\u003c/sup\u003e Some patients with CTCL may undergo a process of large-cell transformation (LCT), which is characterized by an aggressive disease course and is associated with poor survival.\u003csup\u003e24,25\u003c/sup\u003e LCT is often difficult to diagnose, as clinical presentation can vary from a single papule emerging in a pre-existing plaque to multiple standalone nodules and tumors with ulceration.\u003csup\u003e25\u003c/sup\u003e In our MDS CTCL clinic, 24% of patients were diagnosed with LCT. Although diagnosis is made histologically, dermatologists play a crucial role in identifying early signs of LCT to facilitate further work up. Furthermore, regular follow-up with a MDS CTCL clinic may mitigate progression of disease with early identification of LCT and initiation of aggressive treatment as needed.\u003c/p\u003e \u003cp\u003eThe use and benefit of a disease-specific MDS has been well documented across multiple medical specialties. Specifically, MDS cancer clinics have most notably improved disease-specific survival.\u003csup\u003e6,26\u0026ndash;28\u003c/sup\u003e While we were unable to assess disease-specific survival due to low sample size, patients from our MDS CTCL clinic had a decreasing trend in average mSWAT (41.8 to 3.5), with many patients achieving at least partial response to treatment without disease progression. Reasons for improved clinical outcomes associated with MDS specialty clinics may be multifactorial. In a previous study, treatment adherence to NCCN guidelines of patients with prostate cancer was improved after implementing a prostate MDS clinic, while multiple studies have shown cancer specific MDS clinics decrease time to treatment initiation and improve treatment adherence.\u003csup\u003e7,9,26,29,30\u003c/sup\u003e In addition, patient satisfaction tends to be improved with MDS clinics, as many reported reductions in number of office visits while experiencing an improved understanding of their condition and treatment regimen.\u003csup\u003e31\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eThis is one of the first studies to report on the impact of a MDS CTCL clinic. Like previous disease-specific studies, we found that MDS management positively impacts diagnosis and management of patients with CTCL as well as minimizes disease progression. Limitations of our study include a small sample size and a relatively homogenous cohort, which may limit generalizability of our findings. Nonetheless, MDS care should be accessible to all patients diagnosed with CTCL, and this study further underscores the importance of a MDS CTCL clinic to improve patient-centered care.\u003c/p\u003e "},{"header":"Declarations","content":"\u003ch2\u003eConflict of Interest\u003c/h2\u003e\n\u003cp\u003eThe authors have no conflicts of interest to disclose.\u003c/p\u003e\u003ch2\u003eFunding\u003c/h2\u003e \u003cp\u003enone\u003c/p\u003e \u003ch2\u003eEthical Approval\u003c/strong\u003e \u003cp\u003eApproved by UNMC IRB #0577-23-EP\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eS.T and M.A. wrote the main manuscript. S.T. and M.T. performed data collection.M.S. was the lead investigator.All authors reviewed and edited the manuscript.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eThe participants of this study did not give written consent for their data to be shared publicly, so due to the sensitive nature of the research supporting data is not available.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eStoll JR, Willner J, Oh Y et al (2021) Primary cutaneous T-cell lymphomas other than mycosis fungoides and S\u0026eacute;zary syndrome. Part I: Clinical and histologic features and diagnosis. J Am Acad Dermatol 85(5):1073\u0026ndash;1090\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMorgenroth S, Roggo A, Pawlik L, Dummer R, Ramelyte E (2023) What Is New in Cutaneous T Cell Lymphoma? Curr Oncol Rep 25(11):1397\u0026ndash;1408\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHristov AC, Tejasvi T, Wilcox RA (2023) Cutaneous T-cell lymphomas: 2023 update on diagnosis, risk-stratification, and management. Am J Hematol 98(1):193\u0026ndash;209\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSoleymani T, Reddy SM, Cohen JM, Neimann AL (2017) Early Recognition and Treatment Heralds Optimal Outcomes: the Benefits of Combined Rheumatology-Dermatology Clinics and Integrative Care of Psoriasis and Psoriatic Arthritis Patients. Curr Rheumatol Rep 20(1):1\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePatel A, Jafferany M (2020) Multidisciplinary and Holistic Models of Care for Patients With Dermatologic Disease and Psychosocial Comorbidity: A Systematic Review. JAMA Dermatol 156(6):686\u0026ndash;694\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHoehn RS, Rieser CJ, Winters S et al (2021) A Pancreatic Cancer Multidisciplinary Clinic Eliminates Socioeconomic Disparities in Treatment and Improves Survival. Ann Surg Oncol 28(5):2438\u0026ndash;2446\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGardner TB, Barth RJ, Zaki BI et al (2010) Effect of initiating a multidisciplinary care clinic on access and time to treatment in patients with pancreatic adenocarcinoma. J Oncol Pract 6(6):288\u0026ndash;292\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDavies AR, Deans DAC, Penman I et al (2006) The multidisciplinary team meeting improves staging accuracy and treatment selection for gastro-esophageal cancer. Dis Esophagus 19(6):496\u0026ndash;503\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSchiffman SC, Abberbock S, Winters S et al (2016) A pancreatic cancer multidisciplinary clinic: insights and outcomes. J Surg Res 202(2):246\u0026ndash;252\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eParker SRS, Bradley B (2006) Treatment of cutaneous T-cell lymphoma/mycosis fungoides. Dermatol Nurs 18(6):566\u0026ndash;570\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWillemze R, Hodak E, Zinzani PL, Specht L, Ladetto M (2018) Primary cutaneous lymphomas: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up\u0026dagger;. Ann Oncol 29:iv30\u0026ndash;iv40\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOlsen EA, Whittaker S, Kim YH et al (2011) Clinical end points and response criteria in mycosis fungoides and S\u0026eacute;zary syndrome: a consensus statement of the International Society for Cutaneous Lymphomas, the United States Cutaneous Lymphoma Consortium, and the Cutaneous Lymphoma Task Force of the European Organisation for Research and Treatment of Cancer. J Clin Oncol 29(18):2598\u0026ndash;2607\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOlsen E, Vonderheid E, Pimpinelli N et al (2007) Revisions to the staging and classification of mycosis fungoides and Sezary syndrome: a proposal of the International Society for Cutaneous Lymphomas (ISCL) and the cutaneous lymphoma task force of the European Organization of Research and Treatment of Cancer (EORTC). Blood 110(6):1713\u0026ndash;1722\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003evan Doorn R, Van Haselen CW, van Voorst Vader PC et al (2000) Mycosis fungoides: disease evolution and prognosis of 309 Dutch patients. Arch Dermatol 136(4):504\u0026ndash;510\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLitvinov IV, Jones DA, Sasseville D, Kupper TS (2010) Transcriptional profiles predict disease outcome in patients with cutaneous T-cell lymphoma. Clin Cancer Res 16(7):2106\u0026ndash;2114\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eScarisbrick JJ, Prince HM, Vermeer MH et al (2015) Cutaneous Lymphoma International Consortium Study of Outcome in Advanced Stages of Mycosis Fungoides and S\u0026eacute;zary Syndrome: Effect of Specific Prognostic Markers on Survival and Development of a Prognostic Model. J Clin Oncol 33(32):3766\u0026ndash;3773\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSingh H, Sethi S, Raber M, Petersen LA (2007) Errors in cancer diagnosis: current understanding and future directions. J Clin Oncol 25(31):5009\u0026ndash;5018\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOlsen EA, Hodak E, Geskin L, Scarisbrick J, ISCL, USCLC (2024) Bridging the specialty gap: Update on primary cutaneous lymphomas. J Am Acad Dermatol 90(2):257\u0026ndash;260\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLatzka J, Assaf C, Bagot M et al (2023) EORTC consensus recommendations for the treatment of mycosis fungoides/S\u0026eacute;zary syndrome - Update 2023. Eur J Cancer 195:113343\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDenis D, Beneton N, Laribi K, Maillard H (2019) Management of mycosis fungoides-type cutaneous T-cell lymphoma (MF-CTCL): focus on chlormethine gel. Cancer Manag Res 11:2241\u0026ndash;2251\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWain T, Venning VL, Consuegra G, Fernandez-Pe\u0026ntilde;as P, Wells J (2019) Management of cutaneous T-cell lymphomas: Established and emergent therapies. Australas J Dermatol 60(3):200\u0026ndash;208\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePoligone B, Querfeld C (2015) Management of advanced cutaneous T-cell lymphoma: role of the dermatologist in the multidisciplinary team. Br J Dermatol 173(4):1081\u0026ndash;1083\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTyler KH, Haverkos BM, Hastings J et al (2015) The Role of an Integrated Multidisciplinary Clinic in the Management of Patients with Cutaneous Lymphoma. Front Oncol 5:136\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDiamandidou E, Colome-Grimmer M, Fayad L, Duvic M, Kurzrock R (1998) Transformation of mycosis fungoides/Sezary syndrome: clinical characteristics and prognosis. Blood 92(4):1150\u0026ndash;1159\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHerrmann JL, Hughey LC (2012) Recognizing large-cell transformation of mycosis fungoides. J Am Acad Dermatol 67(4):665\u0026ndash;672\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMark JR, Gomella LG, Lallas CD et al (2023) Enhancing bladder cancer care through the multidisciplinary clinic approach. Can J Urol 30(3):11526\u0026ndash;11531\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKubicek GJ, Yocum N, Thomas C, Goldman HW (2020) Neuro-oncology Multidisciplinary Clinic and Improvements in Patient Outcome. Am J Clin Oncol 43(11):798\u0026ndash;801\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAlbany C, Adra N, Snavely AC et al (2018) Multidisciplinary clinic approach improves overall survival outcomes of patients with metastatic germ-cell tumors. Ann Oncol 29(2):341\u0026ndash;346\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eStarmer H, Sanguineti G, Marur S, Gourin CG (2011) Multidisciplinary head and neck cancer clinic and adherence with speech pathology. Laryngoscope 121(10):2131\u0026ndash;2135\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eStone CJL, Robinson A, Brown E et al (2019) Improving Timeliness of Oncology Assessment and Cancer Treatment Through Implementation of a Multidisciplinary Lung Cancer Clinic. J Oncol Pract 15(2):e169\u0026ndash;e177\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLi KL, Fang CH, Ferastraoaru D, Akbar NA, Jerschow E, Abuzeid WM (2020) Patient Satisfaction and Efficiency Benefits of a Novel Multidisciplinary Rhinology and Allergy Clinic. Ann Otol Rhinol Laryngol 129(7):699\u0026ndash;706\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"570\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" colspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003eTable 1. Clinical characteristics of patients in a CTCL MDS clinic\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"55.78947368421053%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eCharacteristic\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"44.21052631578947%\"\u003e\n \u003cp\u003eTotal, No. (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"55.78947368421053%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge, mean (SD)\u0026nbsp;\u003c/strong\u003e(n=55)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"44.21052631578947%\"\u003e\n \u003cp\u003e62.7 (15.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"55.78947368421053%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eSex\u003c/strong\u003e (n=55)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"44.21052631578947%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"55.78947368421053%\" valign=\"top\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"44.21052631578947%\"\u003e\n \u003cp\u003e32 (58.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"55.78947368421053%\" valign=\"top\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"44.21052631578947%\"\u003e\n \u003cp\u003e23 (41.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"55.78947368421053%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eRace\u003c/strong\u003e (n=55)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"44.21052631578947%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"55.78947368421053%\" valign=\"top\"\u003e\n \u003cp\u003eWhite\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"44.21052631578947%\"\u003e\n \u003cp\u003e49 (89.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"55.78947368421053%\" valign=\"top\"\u003e\n \u003cp\u003eOther\u003csup\u003e1\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"44.21052631578947%\"\u003e\n \u003cp\u003e6 (10.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"55.78947368421053%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eEthnicity\u003c/strong\u003e, Non-Hispanic (n=55)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"44.21052631578947%\"\u003e\n \u003cp\u003e55 (100)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"55.78947368421053%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003ePrevious Dermatology Visit\u003c/strong\u003e (n=53)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"44.21052631578947%\"\u003e\n \u003cp\u003e49 (92.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"55.78947368421053%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003ePreviously Diagnosed with CTCL\u003c/strong\u003e (n=55)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"44.21052631578947%\"\u003e\n \u003cp\u003e44 (80)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"55.78947368421053%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eOther Previous Diagnoses\u003c/strong\u003e\u003csup\u003e2\u003c/sup\u003e (n=55)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"44.21052631578947%\"\u003e\n \u003cp\u003e43 (78)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"55.78947368421053%\" valign=\"top\"\u003e\n \u003cp\u003eDermatitis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"44.21052631578947%\"\u003e\n \u003cp\u003e20 (56.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"55.78947368421053%\" valign=\"top\"\u003e\n \u003cp\u003ePsoriasis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"44.21052631578947%\"\u003e\n \u003cp\u003e10 (23.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"55.78947368421053%\" valign=\"top\"\u003e\n \u003cp\u003eNone\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"44.21052631578947%\"\u003e\n \u003cp\u003e11 (25.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"55.78947368421053%\" valign=\"top\"\u003e\n \u003cp\u003eOther\u003csup\u003e3\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"44.21052631578947%\"\u003e\n \u003cp\u003e\u0026nbsp;8 (18.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"55.78947368421053%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eDiagnosis Change\u0026nbsp;\u003c/strong\u003e(n=55)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"44.21052631578947%\"\u003e\n \u003cp\u003e11 (20)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"55.78947368421053%\" valign=\"top\"\u003e\n \u003cp\u003eTo other CTCL subtype\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"44.21052631578947%\"\u003e\n \u003cp\u003e4 (7.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"55.78947368421053%\" valign=\"top\"\u003e\n \u003cp\u003eFrom CTCL to other\u003csup\u003e4\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"44.21052631578947%\"\u003e\n \u003cp\u003e7 (12.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"55.78947368421053%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eNew Diagnosis\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"44.21052631578947%\"\u003e\n \u003cp\u003e9 (16.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"55.78947368421053%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eCTCL Subtypes\u0026nbsp;\u003c/strong\u003e(n=53)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"44.21052631578947%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"55.78947368421053%\" valign=\"top\"\u003e\n \u003cp\u003eMycosis Fungoides\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"44.21052631578947%\"\u003e\n \u003cp\u003e37 (69.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"55.78947368421053%\" valign=\"top\"\u003e\n \u003cp\u003eSezary Syndrome\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"44.21052631578947%\"\u003e\n \u003cp\u003e7 (13.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"55.78947368421053%\" valign=\"top\"\u003e\n \u003cp\u003eCD4+ Lymphoproliferative Disorder\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"44.21052631578947%\"\u003e\n \u003cp\u003e2 (3.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"55.78947368421053%\" valign=\"top\"\u003e\n \u003cp\u003eAnaplastic Large Cell Lymphoma\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"44.21052631578947%\"\u003e\n \u003cp\u003e1 (1.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"55.78947368421053%\" valign=\"top\"\u003e\n \u003cp\u003eSubcutaneous Panniculitis-Like\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"44.21052631578947%\"\u003e\n \u003cp\u003e1 (1.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"55.78947368421053%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eTumor Board\u0026nbsp;\u003c/strong\u003e(n=55)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"44.21052631578947%\"\u003e\n \u003cp\u003e8 (14.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"55.78947368421053%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eStage\u003c/strong\u003e (n=41)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"44.21052631578947%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"55.78947368421053%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eT Stage\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"44.21052631578947%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"55.78947368421053%\" valign=\"top\"\u003e\n \u003cp\u003eT1/T2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"44.21052631578947%\"\u003e\n \u003cp\u003e28 (68.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"55.78947368421053%\" valign=\"top\"\u003e\n \u003cp\u003eT3/T4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"44.21052631578947%\"\u003e\n \u003cp\u003e13 (31.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"55.78947368421053%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eN Stage\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"44.21052631578947%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"55.78947368421053%\" valign=\"top\"\u003e\n \u003cp\u003eN1/N1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"44.21052631578947%\"\u003e\n \u003cp\u003e4 (9.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"55.78947368421053%\" valign=\"top\"\u003e\n \u003cp\u003eN3/N4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"44.21052631578947%\"\u003e\n \u003cp\u003e6 (14.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"55.78947368421053%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eM Stage\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"44.21052631578947%\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"55.78947368421053%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eB Stage\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"44.21052631578947%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"55.78947368421053%\" valign=\"top\"\u003e\n \u003cp\u003eB1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"44.21052631578947%\"\u003e\n \u003cp\u003e4 (9.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"55.78947368421053%\" valign=\"top\"\u003e\n \u003cp\u003eB2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"44.21052631578947%\"\u003e\n \u003cp\u003e9 (22.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"55.78947368421053%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eStage Changes\u003c/strong\u003e (n=41)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"44.21052631578947%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"55.78947368421053%\" valign=\"top\"\u003e\n \u003cp\u003eUp Stage\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"44.21052631578947%\"\u003e\n \u003cp\u003e4 (9.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"55.78947368421053%\" valign=\"top\"\u003e\n \u003cp\u003eDown Stage\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"44.21052631578947%\"\u003e\n \u003cp\u003e1 (2.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"55.78947368421053%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eLarge Cell Transformation\u003c/strong\u003e (n=55)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"44.21052631578947%\"\u003e\n \u003cp\u003e13 (23.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"55.78947368421053%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eTime to Large Cell Transformation,\u003c/strong\u003e median months, range\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"44.21052631578947%\"\u003e\n \u003cp\u003e7.5, 0-38\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"55.78947368421053%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eMetastasis\u0026nbsp;\u003c/strong\u003e(n=55)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"44.21052631578947%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"55.78947368421053%\" valign=\"top\"\u003e\n \u003cp\u003eNodal Involvement\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"44.21052631578947%\"\u003e\n \u003cp\u003e8 (14.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"55.78947368421053%\" valign=\"top\"\u003e\n \u003cp\u003eVisceral\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"44.21052631578947%\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"55.78947368421053%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eDeceased\u003c/strong\u003e (n=55)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"44.21052631578947%\"\u003e\n \u003cp\u003e7 (12.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"55.78947368421053%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eTime to Death\u003c/strong\u003e, month, range\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"44.21052631578947%\"\u003e\n \u003cp\u003e12, (4-41)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003csup\u003e1\u003c/sup\u003eBlack (n=5), American Indian and Alaskan Native (n=1); \u003csup\u003e2\u003c/sup\u003ePityriasis rubra pilaris, tinea, tinea versicolor, rosacea, peripheral T-cell lymphoma, atypical lymphocytic infiltrate, keratosis pilaris; \u003csup\u003e3\u003c/sup\u003eCan have more than one; \u003csup\u003e4\u003c/sup\u003ePseudolymphoma, CD30+ cutaneous proliferation, dermatitis, psoriasiform dermatitis, solar lentigo\u003c/p\u003e\n \u003cp\u003eCTCL, Cutaneous T-cell lymphoma; MDS, multidisciplinary, SD, standard deviation\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"756\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" colspan=\"7\"\u003e\n \u003cp\u003e\u003cstrong\u003eTable 2. Changes in disease progression and management\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25.396825396825395%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.698412698412698%\"\u003e\n \u003cp\u003eInitial (n=55)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.11111111111111%\"\u003e\n \u003cp\u003e0-6 m\u003c/p\u003e\n \u003cp\u003e(n=47)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.698412698412698%\"\u003e\n \u003cp\u003e6-12 m\u003c/p\u003e\n \u003cp\u003e(n=38)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.698412698412698%\"\u003e\n \u003cp\u003e12-18 m\u003c/p\u003e\n \u003cp\u003e(n=31)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.698412698412698%\"\u003e\n \u003cp\u003e18-24 m\u003c/p\u003e\n \u003cp\u003e(n=19)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.698412698412698%\"\u003e\n \u003cp\u003e+24 m\u003c/p\u003e\n \u003cp\u003e(n=32)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" colspan=\"7\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eTreatment\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25.396825396825395%\" valign=\"top\"\u003e\n \u003cp\u003eNo Change\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.698412698412698%\"\u003e\n \u003cp\u003e22 (40)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.11111111111111%\"\u003e\n \u003cp\u003e17 (36.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.698412698412698%\"\u003e\n \u003cp\u003e15 (39.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.698412698412698%\"\u003e\n \u003cp\u003e13 (41.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.698412698412698%\"\u003e\n \u003cp\u003e11 (57.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.698412698412698%\"\u003e\n \u003cp\u003e19 (59.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25.396825396825395%\" valign=\"top\"\u003e\n \u003cp\u003eEscalated Treatment\u003csup\u003e1\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.698412698412698%\"\u003e\n \u003cp\u003e29 (52.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.11111111111111%\"\u003e\n \u003cp\u003e24 (51.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.698412698412698%\"\u003e\n \u003cp\u003e11 (28.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.698412698412698%\"\u003e\n \u003cp\u003e10 (32.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.698412698412698%\"\u003e\n \u003cp\u003e4 (21.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.698412698412698%\"\u003e\n \u003cp\u003e8 (25)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25.396825396825395%\" valign=\"top\"\u003e\n \u003cp\u003eSDT\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.698412698412698%\"\u003e\n \u003cp\u003e20 (36.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.11111111111111%\"\u003e\n \u003cp\u003e10 (21.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.698412698412698%\"\u003e\n \u003cp\u003e2 (5.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.698412698412698%\"\u003e\n \u003cp\u003e6 (19.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.698412698412698%\"\u003e\n \u003cp\u003e1 (5.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.698412698412698%\"\u003e\n \u003cp\u003e4 (12.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25.396825396825395%\" valign=\"top\"\u003e\n \u003cp\u003eSystemic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.698412698412698%\"\u003e\n \u003cp\u003e5 (9.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.11111111111111%\"\u003e\n \u003cp\u003e9 (19.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.698412698412698%\"\u003e\n \u003cp\u003e4 (10.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.698412698412698%\"\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.698412698412698%\"\u003e\n \u003cp\u003e2 (10.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.698412698412698%\"\u003e\n \u003cp\u003e4 (12.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25.396825396825395%\" valign=\"top\"\u003e\n \u003cp\u003eSDT+Systemic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.698412698412698%\"\u003e\n \u003cp\u003e4 (7.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.11111111111111%\"\u003e\n \u003cp\u003e5 (10.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.698412698412698%\"\u003e\n \u003cp\u003e5 (13.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.698412698412698%\"\u003e\n \u003cp\u003e4 (12.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.698412698412698%\"\u003e\n \u003cp\u003e1 (5.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.698412698412698%\"\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25.396825396825395%\" valign=\"top\"\u003e\n \u003cp\u003eDe-Escalated Treatment\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.698412698412698%\"\u003e\n \u003cp\u003e5 (9.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.11111111111111%\"\u003e\n \u003cp\u003e3 (6.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.698412698412698%\"\u003e\n \u003cp\u003e6 (15.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.698412698412698%\"\u003e\n \u003cp\u003e4 (12.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.698412698412698%\"\u003e\n \u003cp\u003e2 (10.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.698412698412698%\"\u003e\n \u003cp\u003e5 (25.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25.396825396825395%\" valign=\"top\"\u003e\n \u003cp\u003eSystemic to SDT\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.698412698412698%\"\u003e\n \u003cp\u003e5 (9.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.11111111111111%\"\u003e\n \u003cp\u003e3 (6.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.698412698412698%\"\u003e\n \u003cp\u003e2 (5.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.698412698412698%\"\u003e\n \u003cp\u003e2 (6.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.698412698412698%\"\u003e\n \u003cp\u003e1 (5.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.698412698412698%\"\u003e\n \u003cp\u003e1 (3.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25.396825396825395%\" valign=\"top\"\u003e\n \u003cp\u003eDecrease SDT\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.698412698412698%\"\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.11111111111111%\"\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.698412698412698%\"\u003e\n \u003cp\u003e4 (10.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.698412698412698%\"\u003e\n \u003cp\u003e2 (6.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.698412698412698%\"\u003e\n \u003cp\u003e1 (5.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.698412698412698%\"\u003e\n \u003cp\u003e4 (12.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25.396825396825395%\" valign=\"top\"\u003e\n \u003cp\u003eUnknown\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.698412698412698%\"\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.11111111111111%\"\u003e\n \u003cp\u003e3 (6.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.698412698412698%\"\u003e\n \u003cp\u003e6 (15.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.698412698412698%\"\u003e\n \u003cp\u003e4 (12.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.698412698412698%\"\u003e\n \u003cp\u003e2 (10.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.698412698412698%\"\u003e\n \u003cp\u003e1 (3.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25.396825396825395%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003emSWAT\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.698412698412698%\"\u003e\n \u003cp\u003e41.8 (40.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.11111111111111%\"\u003e\n \u003cp\u003e29.1 (29.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.698412698412698%\"\u003e\n \u003cp\u003e19.2 (25.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.698412698412698%\"\u003e\n \u003cp\u003e21.4 (34.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.698412698412698%\"\u003e\n \u003cp\u003e16.5 (26.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.698412698412698%\"\u003e\n \u003cp\u003e3.5 (15.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25.396825396825395%\" valign=\"top\"\u003e\n \u003cp\u003eUnknown\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.698412698412698%\"\u003e\n \u003cp\u003e17 (30.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.11111111111111%\"\u003e\n \u003cp\u003e14 (29.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.698412698412698%\"\u003e\n \u003cp\u003e11 (28.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.698412698412698%\"\u003e\n \u003cp\u003e11 (35.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.698412698412698%\"\u003e\n \u003cp\u003e5 (29.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.698412698412698%\"\u003e\n \u003cp\u003e11 (34.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" colspan=\"7\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eTreatment Response\u003c/strong\u003e\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25.396825396825395%\" valign=\"top\"\u003e\n \u003cp\u003eStable\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.698412698412698%\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.11111111111111%\"\u003e\n \u003cp\u003e19 (40.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.698412698412698%\"\u003e\n \u003cp\u003e7 (18.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.698412698412698%\"\u003e\n \u003cp\u003e7 (22.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.698412698412698%\"\u003e\n \u003cp\u003e9 (47.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.698412698412698%\"\u003e\n \u003cp\u003e16 (50)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25.396825396825395%\" valign=\"top\"\u003e\n \u003cp\u003ePartial Response\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.698412698412698%\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.11111111111111%\"\u003e\n \u003cp\u003e5 (10.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.698412698412698%\"\u003e\n \u003cp\u003e5 (13.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.698412698412698%\"\u003e\n \u003cp\u003e5 (16.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.698412698412698%\"\u003e\n \u003cp\u003e2 (10.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.698412698412698%\"\u003e\n \u003cp\u003e4 (12.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25.396825396825395%\" valign=\"top\"\u003e\n \u003cp\u003eComplete Response\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.698412698412698%\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.11111111111111%\"\u003e\n \u003cp\u003e2 (4.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.698412698412698%\"\u003e\n \u003cp\u003e2 (5.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.698412698412698%\"\u003e\n \u003cp\u003e(6.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.698412698412698%\"\u003e\n \u003cp\u003e2 (10.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.698412698412698%\"\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25.396825396825395%\" valign=\"top\"\u003e\n \u003cp\u003eProgression\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.698412698412698%\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.11111111111111%\"\u003e\n \u003cp\u003e6 (12.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.698412698412698%\"\u003e\n \u003cp\u003e3 (7.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.698412698412698%\"\u003e\n \u003cp\u003e3 (9.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.698412698412698%\"\u003e\n \u003cp\u003e1 (5.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.698412698412698%\"\u003e\n \u003cp\u003e3 (9.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25.396825396825395%\" valign=\"top\"\u003e\n \u003cp\u003eRelapse\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.698412698412698%\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.11111111111111%\"\u003e\n \u003cp\u003e1 (2.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.698412698412698%\"\u003e\n \u003cp\u003e1 (2.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.698412698412698%\"\u003e\n \u003cp\u003e2 (6.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.698412698412698%\"\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.698412698412698%\"\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25.396825396825395%\" valign=\"top\"\u003e\n \u003cp\u003eUnknown\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.698412698412698%\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.11111111111111%\"\u003e\n \u003cp\u003e14 (29.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.698412698412698%\"\u003e\n \u003cp\u003e20 (52.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.698412698412698%\"\u003e\n \u003cp\u003e12 (38.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.698412698412698%\"\u003e\n \u003cp\u003e5 (26.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.698412698412698%\"\u003e\n \u003cp\u003e9 (28.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25.396825396825395%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eFlow Cytometry\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.698412698412698%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.11111111111111%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.698412698412698%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.698412698412698%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.698412698412698%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.698412698412698%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25.396825396825395%\" valign=\"top\"\u003e\n \u003cp\u003ePositive\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.698412698412698%\"\u003e\n \u003cp\u003e7 (12.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.11111111111111%\"\u003e\n \u003cp\u003e4 (8.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.698412698412698%\"\u003e\n \u003cp\u003e3 (7.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.698412698412698%\"\u003e\n \u003cp\u003e2 (6.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.698412698412698%\"\u003e\n \u003cp\u003e1 (5.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.698412698412698%\"\u003e\n \u003cp\u003e2 (6.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25.396825396825395%\" valign=\"top\"\u003e\n \u003cp\u003eNegative\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.698412698412698%\"\u003e\n \u003cp\u003e20 (36.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.11111111111111%\"\u003e\n \u003cp\u003e6 (12.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.698412698412698%\"\u003e\n \u003cp\u003e7 (18.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.698412698412698%\"\u003e\n \u003cp\u003e4 (12.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.698412698412698%\"\u003e\n \u003cp\u003e4 (21.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.698412698412698%\"\u003e\n \u003cp\u003e3 (9.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25.396825396825395%\" valign=\"top\"\u003e\n \u003cp\u003eUnknown\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.698412698412698%\"\u003e\n \u003cp\u003e28 (50.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.11111111111111%\"\u003e\n \u003cp\u003e38 (80.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.698412698412698%\"\u003e\n \u003cp\u003e28 (73.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.698412698412698%\"\u003e\n \u003cp\u003e25 (80.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.698412698412698%\"\u003e\n \u003cp\u003e14 (73.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.698412698412698%\"\u003e\n \u003cp\u003e27 (84.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25.396825396825395%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eLDH\u003c/strong\u003e, mean (SD) use\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.698412698412698%\"\u003e\n \u003cp\u003e222.8 (87.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.11111111111111%\"\u003e\n \u003cp\u003e219 (82.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.698412698412698%\"\u003e\n \u003cp\u003e203.1 (81.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.698412698412698%\"\u003e\n \u003cp\u003e211.7 (57.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.698412698412698%\"\u003e\n \u003cp\u003e205.8 (81.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.698412698412698%\"\u003e\n \u003cp\u003e221.5 (97.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25.396825396825395%\" valign=\"top\"\u003e\n \u003cp\u003eUnknown\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.698412698412698%\"\u003e\n \u003cp\u003e39 (70.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.11111111111111%\"\u003e\n \u003cp\u003e32 (74.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.698412698412698%\"\u003e\n \u003cp\u003e23 (60.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.698412698412698%\"\u003e\n \u003cp\u003e22 (71.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.698412698412698%\"\u003e\n \u003cp\u003e14 (73.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.698412698412698%\"\u003e\n \u003cp\u003e26 (81.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" colspan=\"7\" valign=\"top\"\u003e\n \u003cp\u003e\u003csup\u003e1\u003c/sup\u003eAdded or changed skin directed/systemic therapy\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eSDT, skin directed therapy; mSWAT, modified severity weighted assessment tool\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"archives-of-dermatological-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"","sideBox":"Learn more about [Archives of Dermatological Research](https://www.springer.com/journal/403)","snPcode":"403","submissionUrl":"https://submission.nature.com/new-submission/403/3","title":"Archives of Dermatological Research","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"cutaneous t-cell lymphoma, lymphoma, skin cancer, multidisciplinary clinic","lastPublishedDoi":"10.21203/rs.3.rs-4708793/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4708793/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eMultidisciplinary clinics (MDCs) have been shown to improve patient outcomes and reduce disease-specific mortality. This study aims to evaluate the impact of a MDS clinic on diagnosis, management, and clinical outcomes of patients diagnosed with CTCL. A retrospective cohort analysis of a CTCL MDS clinic was conducted between January 2018 to August 2023 at a large academic institution. Patients diagnosed with CTCL with at least one visit to the CTCL MDS clinic were included. Medical records were reviewed for patient demographics, diagnosis change, treatment management, survival outcomes, and clinicopathologic disease characteristics at 6-month intervals. A descriptive analysis was performed. 55 patients were identified (mean age 62.7; 58.1% male; 89.1% White). 80.0% of patients were diagnosed with CTCL, however, 78% were previously diagnosed with other dermatologic conditions. At initial presentation, 20% had a change in diagnosis with 12.7% changing to a benign dermatologic condition. Only 9% of patients had staging prior to initial visit, while majority (62%) received initial staging evaluation during their first visit. At the initial visit, 50.2% had an escalation of treatment, mainly of skin-directed therapy (36.4%). Over 6-month intervals, majority of patients had an escalation of treatment (21.1\u0026ndash;51.1%). The modified severity weighted assessment tool (mSWAT) decreased over time (41.8 to 3.5), with many achieving stable disease (18.4\u0026ndash;50%). MDS management is highly recommended for patients with CTCL. This study further highlights the important role of a CTCL MDS clinic, specifically in establishing accurate diagnoses, managing appropriate treatments, and stabilizing disease progression.\u003c/p\u003e","manuscriptTitle":"The Impact of a Multidisciplinary Clinic on Diagnosis and Management of Patients with Cutaneous T-cell Lymphoma","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-08-01 06:30:56","doi":"10.21203/rs.3.rs-4708793/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-07-24T21:51:11+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-07-09T08:15:20+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-07-09T08:14:43+00:00","index":"","fulltext":""},{"type":"submitted","content":"Archives of Dermatological Research","date":"2024-07-09T03:14:49+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"archives-of-dermatological-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"","sideBox":"Learn more about [Archives of Dermatological Research](https://www.springer.com/journal/403)","snPcode":"403","submissionUrl":"https://submission.nature.com/new-submission/403/3","title":"Archives of Dermatological Research","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"16419491-c1ba-4fcc-897b-abdeafa0a906","owner":[],"postedDate":"August 1st, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2024-09-14T15:31:26+00:00","versionOfRecord":[],"versionCreatedAt":"2024-08-01 06:30:56","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4708793","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4708793","identity":"rs-4708793","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}