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Juckett M, Dandoy C, DeFilipp Z, Kindwall-Keller TL, Spellman SR, Ustun C, Waldman BM, Weisdorf DJ, Wood WA, Horowitz MM, Burns LJ, Khera N. How do we improve the translation of new evidence into the practice of hematopoietic cell transplantation and cellular therapy? Blood Rev 2023; 60:101079. [PMID: 37087394 PMCID: PMC10330269 DOI: 10.1016/j.blre.2023.101079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Revised: 04/05/2023] [Accepted: 04/06/2023] [Indexed: 04/24/2023]
Abstract
The field of hematopoietic cell transplantation and cell therapy (HCT/CT) is advancing rapidly to bring an ever-expanding collection of potentially curative therapies to patients with malignant and non-malignant diseases. The impact of these therapies depends on our ability to implement them as new evidence becomes available to advance the quality of care. There is often a long delay between evidence development and adoption of therapies based on that evidence into clinical practice. In this review, we describe the potential factors based on an implementation framework that could act as facilitators or barriers to adoption of therapies in the context of HCT/CT. We highlight two examples, the first to showcase the efforts to improve the efficiency of adoption of new findings and accelerate improvement in care of HCT/CT patients and the second to discuss the challenges in real world implementation of chimeric antigen receptor T cell therapy. We conclude by reviewing strategies to improve translation of evidence and ways to measure their success.
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Affiliation(s)
- Mark Juckett
- University of Minnesota, Minneapolis, MN, United States of America
| | - Christopher Dandoy
- University of Cincinnati College of Medicine, Cincinnati, OH, United States of America
| | | | | | - Stephen R Spellman
- CIBMTR® (Center for International Blood and Marrow Transplant Research), Milwaukee, WI, United States of America
| | - Celalettin Ustun
- Rush University Medical Center, Chicago, IL, United States of America
| | - Bryce M Waldman
- Center for International Blood and Marrow Transplant, Milwaukee, WI, United States of America
| | | | - William A Wood
- University of North Carolina, Chapel Hill, NC, United States of America
| | - Mary M Horowitz
- CIBMTR® (Center for International Blood and Marrow Transplant Research), Milwaukee, WI, United States of America; Medical College of Wisconsin, Milwaukee, WI, United States of America
| | - Linda J Burns
- CIBMTR® (Center for International Blood and Marrow Transplant Research), Milwaukee, WI, United States of America
| | - Nandita Khera
- College of Medicine, Mayo Clinic, Phoenix, AZ, United States of America.
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Bradley CJ, Kitchen S, Bhatia S, Bynum J, Darien G, Lichtenfeld JL, Oyer R, Shulman LN, Sheldon LK. Policies and Practices to Address Cancer's Long-term Adverse Consequences. J Natl Cancer Inst 2022; 114:1065-1071. [PMID: 35438165 PMCID: PMC9360463 DOI: 10.1093/jnci/djac086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Revised: 04/05/2022] [Accepted: 04/12/2022] [Indexed: 11/13/2022] Open
Abstract
As cancer detection and treatment improve, the number of long-term survivors will continue to grow, as will the need to improve their survivorship experience and health outcomes. We need to better understand cancer and its treatment's short- and long-term adverse consequences, and to prevent, detect, and treat these consequences effectively. Delivering care through a collaborative care model, standardizing information offered to and collected from patients, standardizing approaches to documenting, treating, and reducing adverse effects, and creating a data infrastructure to make population-based information widely available are all actions that can improve survivors' outcomes. National policies that address gaps in insurance coverage, the cost and value of treatment and survivorship care, and worker benefits such as paid sick leave can also concurrently reduce cancer burden. The National Cancer Policy Forum and the Forum on Aging, Disability, and Independence at the National Academies of Sciences, Engineering, and Medicine sponsored a virtual workshop on Addressing the Adverse Consequences of Cancer Treatment, November 9-10, 2020, to examine long-term adverse consequences of cancer treatment and to identify practices and policies to reduce treatment's negative impact on survivors. This commentary discusses high-priority issues raised during the workshop and offers a path forward.
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3
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Gale RP, Barosi G. Transplant indications, guidelines and recommendations: Caveat Emptor. Bone Marrow Transplant 2021; 57:149-151. [PMID: 34711915 DOI: 10.1038/s41409-021-01510-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Revised: 10/13/2021] [Accepted: 10/15/2021] [Indexed: 11/09/2022]
Affiliation(s)
- Robert Peter Gale
- Haematology Research Centre, Department of Immunology and Inflammation, Imperial College London, London, UK.
| | - Giovanni Barosi
- Center for the Study of Myelofibrosis. IRCCS Policlinico S. Matteo Foundation, Pavia, Italy
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4
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Implementation of New Biology-Based Radiation Therapy Technology: When Is It Ready So "Perfect Makes Practice?". Int J Radiat Oncol Biol Phys 2020; 105:934-937. [PMID: 31748143 DOI: 10.1016/j.ijrobp.2019.08.013] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2019] [Revised: 08/08/2019] [Accepted: 08/11/2019] [Indexed: 11/21/2022]
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5
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Vanderbeek AM, Ventz S, Rahman R, Fell G, Cloughesy TF, Wen PY, Trippa L, Alexander BM. To randomize, or not to randomize, that is the question: using data from prior clinical trials to guide future designs. Neuro Oncol 2019; 21:1239-1249. [PMID: 31155679 PMCID: PMC6784282 DOI: 10.1093/neuonc/noz097] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Understanding the value of randomization is critical in designing clinical trials. Here, we introduce a simple and interpretable quantitative method to compare randomized designs versus single-arm designs using indication-specific parameters derived from the literature. We demonstrate the approach through application to phase II trials in newly diagnosed glioblastoma (ndGBM). METHODS We abstracted data from prior ndGBM trials and derived relevant parameters to compare phase II randomized controlled trials (RCTs) and single-arm designs within a quantitative framework. Parameters included in our model were (i) the variability of the primary endpoint distributions across studies, (ii) potential for incorrectly specifying the single-arm trial's benchmark, and (iii) the hypothesized effect size. Strengths and weaknesses of RCT and single-arm designs were quantified by various metrics, including power and false positive error rates. RESULTS We applied our method to show that RCTs should be preferred to single-arm trials for evaluating overall survival in ndGBM patients based on parameters estimated from prior trials. More generally, for a given effect size, the utility of randomization compared with single-arm designs is highly dependent on (i) interstudy variability of the outcome distributions and (ii) potential errors in selecting standard of care efficacy estimates for single-arm studies. CONCLUSIONS A quantitative framework using historical data is useful in understanding the utility of randomization in designing prospective trials. For typical phase II ndGBM trials using overall survival as the primary endpoint, randomization should be preferred over single-arm designs.
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Affiliation(s)
- Alyssa M Vanderbeek
- Program in Regulatory Science, Boston, Massachusetts
- Department of Biostatistics and Computational Biology, Boston, Massachusetts
| | - Steffen Ventz
- Program in Regulatory Science, Boston, Massachusetts
- Department of Biostatistics and Computational Biology, Boston, Massachusetts
| | - Rifaquat Rahman
- Department of Radiation Oncology, Boston, Massachusetts
- Center for Neuro-Oncology, Boston, Massachusetts, Dana-Farber Cancer Institute, Boston, Massachusetts
- Harvard Radiation Oncology Program, Boston, Massachusetts
| | - Geoffrey Fell
- Program in Regulatory Science, Boston, Massachusetts
- Department of Biostatistics and Computational Biology, Boston, Massachusetts
| | - Timothy F Cloughesy
- UCLA Neuro-Oncology Program and Department of Neurology, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California
| | - Patrick Y Wen
- Center for Neuro-Oncology, Boston, Massachusetts, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Lorenzo Trippa
- Program in Regulatory Science, Boston, Massachusetts
- Department of Biostatistics and Computational Biology, Boston, Massachusetts
| | - Brian M Alexander
- Program in Regulatory Science, Boston, Massachusetts
- Department of Radiation Oncology, Boston, Massachusetts
- Center for Neuro-Oncology, Boston, Massachusetts, Dana-Farber Cancer Institute, Boston, Massachusetts
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6
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Gale RP, Lazarus HM. Does a durian smell like a rose? The dangers of jargon. Bone Marrow Transplant 2019; 55:280-282. [PMID: 31570782 DOI: 10.1038/s41409-019-0704-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2019] [Revised: 09/06/2019] [Accepted: 09/16/2019] [Indexed: 02/08/2023]
Affiliation(s)
- Robert Peter Gale
- Haematology Research Centre, Division of Experimental Medicine, Department of Medicine, Imperial College, London, UK.
| | - Hillard M Lazarus
- Department of Medicine, Division of Hematology and Oncology, Case Western Reserve University, Cleveland, OH, USA
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7
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Unger JM, Nghiem VT, Hershman DL, Vaidya R, LeBlanc M, Blanke CD. Association of National Cancer Institute-Sponsored Clinical Trial Network Group Studies With Guideline Care and New Drug Indications. JAMA Netw Open 2019; 2:e1910593. [PMID: 31483471 PMCID: PMC6727679 DOI: 10.1001/jamanetworkopen.2019.10593] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
IMPORTANCE National Cancer Institute Clinical Trial Network (NCTN) groups serve a vital role in identifying effective new antineoplastic regimens. However, the downstream clinical effect of their trials has not been systematically examined. OBJECTIVE To examine the association of NCTN trials with guideline care and new drug indications. DESIGN, SETTING, AND PARTICIPANTS This retrospective cohort study evaluated phase 3 SWOG Cancer Research Network clinical trials from January 1, 1980, through June 30, 2017. Only completed trials with published results were included. To be considered practice influential (PI), a trial must have been associated with guideline care through its inclusion in National Comprehensive Cancer Network (NCCN) clinical guidelines or US Food and Drug Administration (FDA) new drug approvals in favor of a recommended treatment. Data were analyzed from June 15, 2018, through March 29, 2019. MAIN OUTCOMES AND MEASURES Estimated overall rate of PI trials, as well as trends over time. The total federal investment supporting the set of trials was also determined. RESULTS In total, 182 trials consisting of 148 028 patients were studied. Eighty-two studies (45.1%; 95% CI, 37.7%-52.6%) were PI, of which 70 (38.5%) influenced NCCN guidelines, 6 (3.3%) influenced FDA new drug approvals, and 6 (3.3%) influenced both. The number of PI trials was 47 of 65 (72.3%) among those with positive findings and 35 of 117 (29.9%) among those with negative findings. Thus, 35 of 82 PI trials (42.7%) were based on studies with negative findings, with nearly half of these studies (17 of 35 [48.6%]) reaffirming standard of care compared with experimental therapy. The total federal investment spent in conducting the trials was $1.36 billion (2017 US dollars), a rate of $7.5 million per study or $16.6 million per PI trial. CONCLUSIONS AND RELEVANCE Nearly half of all phase 3 trials by one of the NCTN's largest groups were associated with guideline care or new drug indications, including those with positive and negative findings. Compared with the costs of a new drug approval in pharmaceutical companies, typically estimated at more than $1 billion, the amount of federal funds invested to provide this valuable evidence was modest. These results suggest that the NCTN program contributes clinically meaningful, cost-efficient evidence to guide patient care.
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Affiliation(s)
- Joseph M. Unger
- SWOG Statistics and Data Management Center, Seattle, Washington
- Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Van T. Nghiem
- SWOG Statistics and Data Management Center, Seattle, Washington
- Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Dawn L. Hershman
- Department of Epidemiology, Mailman School of Public Health, Columbia University Medical Center, New York, New York
| | - Riha Vaidya
- SWOG Statistics and Data Management Center, Seattle, Washington
- Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Michael LeBlanc
- SWOG Statistics and Data Management Center, Seattle, Washington
- Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Charles D. Blanke
- SWOG Group Chair’s Office, Knight Cancer Institute, Oregon Health & Science University, Portland
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8
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Wildes TJ, Flores CT, Mitchell DA. Concise Review: Modulating Cancer Immunity with Hematopoietic Stem and Progenitor Cells. Stem Cells 2019; 37:166-175. [PMID: 30353618 PMCID: PMC6368859 DOI: 10.1002/stem.2933] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2018] [Revised: 09/19/2018] [Accepted: 10/02/2018] [Indexed: 12/17/2022]
Abstract
Hematopoietic stem and progenitor cells (HSPCs) are the progenitor cells that can regenerate the entire blood compartment, including the immune system. Recent studies have unearthed considerable immune-modulating potential of these cells. They can migrate through chemotactic gradients, differentiate into functional immune cells, and crosstalk with immune cells during infections, autoimmune diseases, and cancers. Although the primary role of HSPCs during solid malignancies is considered immunosuppressive, recent studies have discovered immune-activating HSPCs and progeny. In this review, we will discuss the recent evidence that HSPCs act as immunomodulators during solid cancers and highlight the future directions of discovery. Stem Cells 2019;37:166-175.
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Affiliation(s)
- Tyler J. Wildes
- University of Florida Brain Tumor Immunotherapy Program, Preston A. Wells, Jr. Center for Brain Tumor Therapy, Lillian S. Wells Department of NeurosurgeryMcKnight Brain Institute, University of FloridaGainesvilleFloridaUSA
| | - Catherine T. Flores
- University of Florida Brain Tumor Immunotherapy Program, Preston A. Wells, Jr. Center for Brain Tumor Therapy, Lillian S. Wells Department of NeurosurgeryMcKnight Brain Institute, University of FloridaGainesvilleFloridaUSA
| | - Duane A. Mitchell
- University of Florida Brain Tumor Immunotherapy Program, Preston A. Wells, Jr. Center for Brain Tumor Therapy, Lillian S. Wells Department of NeurosurgeryMcKnight Brain Institute, University of FloridaGainesvilleFloridaUSA
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Khera N, Mau LW, Denzen EM, Meyer C, Houg K, Lee SJ, Horowitz MM, Burns LJ. Translation of Clinical Research into Practice: An Impact Assessment of the Results from the Blood and Marrow Transplant Clinical Trials Network Protocol 0201 on Unrelated Graft Source Utilization. Biol Blood Marrow Transplant 2018; 24:2204-2210. [PMID: 29966761 DOI: 10.1016/j.bbmt.2018.06.028] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2018] [Accepted: 06/23/2018] [Indexed: 01/16/2023]
Abstract
Barriers and facilitators to adoption of results of clinical trials are substantial and poorly understood. We sought to examine whether the results of the randomized, multicenter Blood and Marrow Transplant Clinical Trials Network (BMT CTN) 0201 study comparing peripheral blood (PB) with bone marrow (BM) stem cells for unrelated donor (URD) hematopoietic cell transplantation (HCT) changed practice from PB to BM graft utilization and explored factors that impact graft selection and translation of research results into practice. The difference between use of URD BM and PB in the 2 years before and after publication of results in 2012 was examined using observational data collected by the Center for Blood and Marrow Transplant Research. A web-based survey of transplant physicians was conducted to understand the change in physician-reported personal and center preferred URD graft. No significant change in use of BM versus PB grafts occurred after 2012. Both BMT CTN participating and nonparticipating centers continued to use PB. Ninety-two percent of respondents were aware of the study results; 18% reported a change in personal and 16% reported a change in their center's practice of requesting BM instead of PB for URD HCT. Patient characteristics and the perception that engaging local champions to increase the evidence uptake were factors associated with personal or center change in practice. Despite awareness of the trial results, fewer than one-fifth of HCT physicians reported practice change in response to the BMT CTN 0201 results. Observational data confirmed no discernible change in practice.
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Affiliation(s)
- Nandita Khera
- Department of Hematology/Oncology, Mayo Clinic, Phoenix, Arizona.
| | - Lih-Wen Mau
- Health Services Research Program, National Marrow Donor Program/ Be the Match Minneapolis, Minnesota
| | - Ellen M Denzen
- Health Services Research Program, National Marrow Donor Program/ Be the Match Minneapolis, Minnesota
| | - Christa Meyer
- Health Services Research Program, National Marrow Donor Program/ Be the Match Minneapolis, Minnesota
| | - Kate Houg
- Health Services Research Program, National Marrow Donor Program/ Be the Match Minneapolis, Minnesota
| | - Stephanie J Lee
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Mary M Horowitz
- Department of Medicine, CIBMTR and Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Linda J Burns
- Health Services Research Program, National Marrow Donor Program/ Be the Match Minneapolis, Minnesota
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10
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Gale RP. Standardizing haematopoietic cell transplants in China. J Hematol Oncol 2018; 11:34. [PMID: 29495965 PMCID: PMC5833050 DOI: 10.1186/s13045-018-0565-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2018] [Accepted: 02/02/2018] [Indexed: 01/09/2023] Open
Affiliation(s)
- Robert Peter Gale
- Haematology Research Centre, Division of Experimental Medicine, Department of Medicine, Imperial College London, London, SW7 2AZ, UK.
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11
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Barosi G, Gale RP. Is there expert consensus on expert consensus? Bone Marrow Transplant 2018; 53:1055-1060. [DOI: 10.1038/s41409-018-0128-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2018] [Accepted: 01/11/2018] [Indexed: 01/09/2023]
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Howard DH, Soulos PR, Chagpar AB, Mougalian S, Killelea B, Gross CP. Contrary To Conventional Wisdom, Physicians Abandoned A Breast Cancer Treatment After A Trial Concluded It Was Ineffective. Health Aff (Millwood) 2016; 35:1309-15. [DOI: 10.1377/hlthaff.2015.1490] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Affiliation(s)
- David H. Howard
- David H. Howard ( ) is an associate professor in the Department of Health Policy and Management and Winship Cancer Institute at Emory University, in Atlanta, Georgia
| | - Pamela R. Soulos
- Pamela R. Soulos is a program manager and data analyst at the Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) Center at the Yale University School of Medicine and the Yale Cancer Center, in New Haven, Connecticut
| | - Anees B. Chagpar
- Anees B. Chagpar is an associate professor of surgery in the Department of Surgery at the Yale University School of Medicine
| | - Sarah Mougalian
- Sarah Mougalian is an associate professor of surgery at the COPPER Center at the Yale University School of Medicine and the Yale Cancer Center
| | - Brigid Killelea
- Brigid Killelea is an associate professor of surgery at the COPPER Center at the Yale University School of Medicine and the Yale Cancer Center
| | - Cary P. Gross
- Cary P. Gross is a professor of medicine in the Section of General Internal Medicine at the Yale University School of Medicine
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13
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Giralt S, Korngold R, Lazarus HM. Peer review in hematopoietic cell transplantation: are we doing our fair share? Bone Marrow Transplant 2016; 51:1159-62. [PMID: 27159173 DOI: 10.1038/bmt.2016.108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2016] [Accepted: 03/19/2016] [Indexed: 11/09/2022]
Abstract
Peer review is believed to be important in maintaining the quality and integrity of research in academic endeavors. Recently, the value of the current peer review process, which is more than 100 years old has come into question. In the field of hematopoietic cell transplantation (HCT), peer review was unable to prevent the publication of the largest and most notorious scientific fraud in our field. In order to assess how the HCT community views and how engaged it is with the peer review process, the American Society of Blood and Marrow Transplantation conducted a survey of all of its members in 2014. The survey was sent to all active members through multiple email communications in August and September 2014. Of a total of 1183 members, 149 responded. Almost all of the respondents had participated in the peer review process, with few respondents declining ever to review manuscripts. The most common cause for declining review requests was lack of time. Most respondents (68%) thought that the current peer review process was relatively fair and unbiased, whereas only 9% of the respondents stated that they did not believe in the peer review process. In conclusion, among the respondents of this survey most felt the peer review process to be valuable and fair, however, the lack of response suggests that further study into improving the peer review process in the field of HCT is warranted in the era of electronic publishing and communication.
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Affiliation(s)
- S Giralt
- Department of Medicine, Weill Cornell College of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - R Korngold
- John Theurer Cancer Center, Hackensack University Medical Center, Hackensack, NJ, USA
| | - H M Lazarus
- Case Western Reserve University, Cleveland, OH, USA
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14
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Schouten PC, Gluz O, Harbeck N, Mohrmann S, Diallo-Danebrock R, Pelz E, Kruizinga J, Velds A, Nieuwland M, Kerkhoven RM, Liedtke C, Frick M, Kates R, Linn SC, Nitz U, Marme F. BRCA1-like profile predicts benefit of tandem high dose epirubicin-cyclophospamide-thiotepa in high risk breast cancer patients randomized in the WSG-AM01 trial. Int J Cancer 2016; 139:882-9. [PMID: 26946057 DOI: 10.1002/ijc.30078] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2015] [Accepted: 01/13/2016] [Indexed: 01/07/2023]
Abstract
BRCA1 is an important protein in the repair of DNA double strand breaks (DSBs), which are induced by alkylating chemotherapy. A BRCA1-like DNA copy number signature derived from tumors with a BRCA1 mutation is indicative for impaired BRCA1 function and associated with good outcome after high dose (HD) and tandem HD DSB inducing chemotherapy. We investigated whether BRCA1-like status was a predictive biomarker in the WSG AM 01 trial. WSG AM 01 randomized high-risk breast cancer patients to induction (2× epirubicin-cyclophosphamide) followed by tandem HD chemotherapy with epirubicin, cyclophosphamide and thiotepa versus dose dense chemotherapy (4× epirubicin-cyclophospamide followed by 3× cyclophosphamide-methotrexate-5-fluorouracil). We generated copy number profiles for 143 tumors and classified them as being BRCA1-like or non-BRCA1-like. Twenty-six out of 143 patients were BRCA1-like. BRCA1-like status was associated with high grade and triple negative tumors. With regard to event-free-survival, the primary endpoint of the trial, patients with a BRCA1-like tumor had a hazard rate of 0.2, 95% confidence interval (CI): 0.07-0.63, p = 0.006. In the interaction analysis, the combination of BRCA1-like status and HD chemotherapy had a hazard rate of 0.19, 95% CI: 0.067-0.54, p = 0.003. Similar results were observed for overall survival. These findings suggest that BRCA1-like status is a predictor for benefit of tandem HD chemotherapy with epirubicin-thiotepa-cyclophosphamide.
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Affiliation(s)
- Philip C Schouten
- Department of Molecular Pathology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Oleg Gluz
- West German Study Group, Germany.,Breast Centre Niederrhein, Moenchengladbach, Germany
| | - Nadia Harbeck
- West German Study Group, Germany.,Brustzentrum, Ludwig-Maximillian University Munich, Germany
| | | | | | - Enrico Pelz
- Breast Centre Niederrhein, Moenchengladbach, Germany
| | | | - Arno Velds
- Genomics Core Facility, NKI-AVL, Amsterdam, The Netherlands
| | | | | | - Cornelia Liedtke
- West German Study Group, Germany.,Universitäts-Frauenklinik Lübeck, Germany
| | | | | | - Sabine C Linn
- Department of Molecular Pathology, Netherlands Cancer Institute, Amsterdam, The Netherlands.,Division of Medical Oncology, Netherlands Cancer Institute, Amsterdam, The Netherlands Department of Pathology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Ulrike Nitz
- West German Study Group, Germany.,Breast Centre Niederrhein, Moenchengladbach, Germany
| | - Frederik Marme
- Universitäts-Frauenklinik, University of Heidelberg, Germany.,National Center for Tumour Diseases, University of Heidelberg, Germany
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15
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Khera N. From evidence to clinical practice in blood and marrow transplantation. Blood Rev 2015; 29:351-7. [PMID: 25934009 PMCID: PMC4610823 DOI: 10.1016/j.blre.2015.04.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2014] [Revised: 03/04/2015] [Accepted: 04/14/2015] [Indexed: 10/23/2022]
Abstract
Clinical practice in the field of blood and marrow transplantation (BMT) has evolved over time, as a result of thousands of basic and clinical research studies. While it appears that scientific discovery and adaptive clinical research may be well integrated in case of BMT, there is lack of sufficient literature to definitively understand the process of translation of evidence to practice and if it may be selective . In this review, examples from BMT and other areas of medicine are used to highlight the state of and potential barriers to evidence uptake. Strategies to help improve knowledge transfer are discussed and the role of existing framework provided by the Center for International Blood and Marrow Transplant Registry (CIBMTR) to monitor uptake and BMT Clinical Trials Network (BMT CTN) to enhance translation of evidence into practice is highlighted.
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Affiliation(s)
- Nandita Khera
- College of Medicine, Mayo Clinic, 5777 E Mayo Blvd, Phoenix, AZ 85054, USA.
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16
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Niven DJ, Mrklas KJ, Holodinsky JK, Straus SE, Hemmelgarn BR, Jeffs LP, Stelfox HT. Towards understanding the de-adoption of low-value clinical practices: a scoping review. BMC Med 2015; 13:255. [PMID: 26444862 PMCID: PMC4596285 DOI: 10.1186/s12916-015-0488-z] [Citation(s) in RCA: 206] [Impact Index Per Article: 22.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2015] [Accepted: 09/15/2015] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Low-value clinical practices are common in healthcare, yet the optimal approach to de-adopting these practices is unknown. The objective of this study was to systematically review the literature on de-adoption, document current terminology and frameworks, map the literature to a proposed framework, identify gaps in our understanding of de-adoption, and identify opportunities for additional research. METHODS MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials, the Cochrane Database of Systematic Reviews, the Cochrane Database of Abstracts and Reviews of Effects, and CINAHL Plus were searched from 1 January 1990 to 5 March 2014. Additional citations were identified from bibliographies of included citations, relevant websites, the PubMed 'related articles' function, and contacting experts in implementation science. English-language citations that referred to de-adoption of clinical practices in adults with medical, surgical, or psychiatric illnesses were included. Citation selection and data extraction were performed independently and in duplicate. RESULTS From 26,608 citations, 109 were included in the final review. Most citations (65%) were original research with the majority (59%) published since 2010. There were 43 unique terms referring to the process of de-adoption-the most frequently cited was "disinvest" (39% of citations). The focus of most citations was evaluating the outcomes of de-adoption (50%), followed by identifying low-value practices (47%), and/or facilitating de-adoption (40%). The prevalence of low-value practices ranged from 16% to 46%, with two studies each identifying more than 100 low-value practices. Most articles cited randomized clinical trials (41%) that demonstrate harm (73%) and/or lack of efficacy (63%) as the reason to de-adopt an existing clinical practice. Eleven citations described 13 frameworks to guide the de-adoption process, from which we developed a model for facilitating de-adoption. Active change interventions were associated with the greatest likelihood of de-adoption. CONCLUSIONS This review identified a large body of literature that describes current approaches and challenges to de-adoption of low-value clinical practices. Additional research is needed to determine an ideal strategy for identifying low-value practices, and facilitating and sustaining de-adoption. In the meantime, this study proposes a model that providers and decision-makers can use to guide efforts to de-adopt ineffective and harmful practices.
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Affiliation(s)
- Daniel J Niven
- Department of Critical Care Medicine, University of Calgary, Calgary, Alberta, T1Y 6J4, Canada. .,Department of Community Health Sciences, University of Calgary, Calgary, Alberta, T2N 4Z6, Canada.
| | - Kelly J Mrklas
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, T2N 4Z6, Canada.
| | - Jessalyn K Holodinsky
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, T2N 4Z6, Canada.
| | - Sharon E Straus
- Li Ka Shing Knowledge Institute of St. Michael's Hospital, Toronto, Ontario, M5B 1T8, Canada.
| | - Brenda R Hemmelgarn
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, T2N 4Z6, Canada. .,Department of Medicine, University of Calgary, Calgary, Alberta, T2N 4Z6, Canada.
| | - Lianne P Jeffs
- Li Ka Shing Knowledge Institute of St. Michael's Hospital, Toronto, Ontario, M5B 1T8, Canada.
| | - Henry Thomas Stelfox
- Department of Critical Care Medicine, University of Calgary, Calgary, Alberta, T1Y 6J4, Canada. .,Department of Community Health Sciences, University of Calgary, Calgary, Alberta, T2N 4Z6, Canada. .,Department of Medicine, University of Calgary, Calgary, Alberta, T2N 4Z6, Canada.
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17
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Howard DH, Bach PB, Berndt ER, Conti RM. Pricing in the Market for Anticancer Drugs. THE JOURNAL OF ECONOMIC PERSPECTIVES : A JOURNAL OF THE AMERICAN ECONOMIC ASSOCIATION 2015; 29:139-62. [PMID: 28441702 DOI: 10.1257/jep.29.1.139] [Citation(s) in RCA: 286] [Impact Index Per Article: 31.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/24/2023]
Abstract
In 2011, Bristol-Myers Squibb set the price of its newly approved melanoma drug ipilimumab—brand name Yervoy—at $120,000 for a course of therapy. The drug was associated with an incremental increase in life expectancy of four months. Drugs like ipilimumab have fueled the perception that the launch prices of new anticancer drugs and other drugs in the so-called “specialty” pharmaceutical market have been increasing over time and that increases are unrelated to the magnitude of the expected health benefits. In this paper, we discuss the unique features of the market for anticancer drugs and assess trends in the launch prices for 58 anticancer drugs approved between 1995 and 2013 in the United States. We restrict attention to anticancer drugs because the use of median survival time as a primary outcome measure provides a common, objective scale for quantifying the incremental benefit of new products. We find that the average launch price of anticancer drugs, adjusted for inflation and health benefits, increased by 10 percent annually—or an average of $8,500 per year—from 1995 to 2013. We argue that the institutional features of the market for anticancer drugs enable manufacturers to set the prices of new products at or slightly above the prices of existing therapies, giving rise to an upward trend in launch prices. Government-mandated price discounts for certain classes of buyers may have also contributed to launch price increases as firms sought to offset the growth in the discount segment by setting higher prices for the remainder of the market.
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Affiliation(s)
- David H Howard
- Department of Health Policy and Management, Rollins School of Public Health and Department of Economics, Emory University, Atlanta, Georgia.
| | - Peter B Bach
- Center for Health Policy and Outcomes, Memorial Sloan Kettering Cancer Center, New York City, New York
| | - Ernst R Berndt
- Sloan School of Management, Massachusetts Institute of Technology, Cambridge, Massachusetts
| | - Rena M Conti
- Departments of Pediatrics and Public Health Sciences, University of Chicago, Chicago, Illinois
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18
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Palma DA, Salama JK, Lo SS, Senan S, Treasure T, Govindan R, Weichselbaum R. The oligometastatic state - separating truth from wishful thinking. Nat Rev Clin Oncol 2014; 11:549-57. [PMID: 24958182 DOI: 10.1038/nrclinonc.2014.96] [Citation(s) in RCA: 215] [Impact Index Per Article: 21.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
The oligometastatic paradigm implies that patients who develop a small number of metastatic lesions might achieve long-term survival if all these lesions are ablated with surgery or stereotactic radiotherapy. Clinical data indicate that the number of patients with oligometastatic disease receiving aggressive treatment is increasing rapidly. We examine the key evidence supporting or refuting the existence of an oligometastatic state. Numerous single-arm studies suggest that long-term survival is 'better-than-expected' after ablative treatment. However, the few studies with adequate controls raise the possibility that this long-term survival might not be due to the treatments themselves, but rather to the selection of patients based on favourable inclusion criteria. Furthermore, ablative treatments carry a risk of harming healthy tissue, yet the risk-benefit ratio cannot be quantified if the benefits are unmeasured. If the strategy of treating oligometastases is to gain widespread acceptance as routine clinical practice, there should be stronger evidence supporting its efficacy.
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Affiliation(s)
- David A Palma
- Division of Radiation Oncology, London Health Sciences Centre, 790 Commissioners Road East, London, ON N6A 4L6, Canada
| | - Joseph K Salama
- Department of Radiation Oncology, Duke University School of Medicine, 508 Fulton Street, Durham, NC 27705, USA
| | - Simon S Lo
- Department of Radiation Oncology, University Hospitals Seidman Cancer Center, Case Comprehensive Cancer Center, 11100 Euclid Avenue, Cleveland, OH 44106, USA
| | - Suresh Senan
- Department of Radiation Oncology, VU University Medical Centre, De Boelelaan 1117, PO Box 7057, Amsterdam, 1007 MB, Netherlands
| | - Tom Treasure
- Clinical Operational Research Unit, University College London, 4 Taviton Street, London WC1H 0BT, UK
| | - Ramaswamy Govindan
- Washington University School of Medicine, 660 South Euclid Avenue, St Louis, MO 63110, USA
| | - Ralph Weichselbaum
- University of Chicago Medical Center, 5841 South Maryland Avenue, Chicago, IL 60637, USA
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19
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Mohan AV, Fazel R, Huang PH, Shen YC, Howard D. Changes in Geographic Variation in the Use of Percutaneous Coronary Intervention for Stable Ischemic Heart Disease After Publication of the Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation (COURAGE) Trial. Circ Cardiovasc Qual Outcomes 2014; 7:125-30. [DOI: 10.1161/circoutcomes.113.000282] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background—
Clinical uncertainty is cited as a cause of geographic variation. However, little is known about the effect of comparative effectiveness research on variation. We examined whether geographic variation in the use of percutaneous coronary intervention (PCI) for stable ischemic heart disease (SIHD) declined after publication of the Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation (COURAGE) trial.
Methods and Results—
We examined changes in utilization and geographic variation in 67 hospital referral regions using the State Inpatient Databases. We compared age- and sex-adjusted rates of PCI for SIHD before (2006) and after (2008) publication of the COURAGE trial and compared those with contemporaneous changes in PCI volume for acute coronary syndrome. A total of 272 659 PCIs for SIHD from 526 hospitals were included in the analysis. After the publication of the COURAGE trial, PCI volume for SIHD declined by 25% (
P
<0.001) and decreased by 12% for acute coronary syndrome (
P
<0.001). This was predominantly attributable to changes in hospital referral regions with the highest levels of utilization pre-COURAGE trial (35% decline in the highest tertile versus 18% in the lowest). As measured by the systematic component of variation, there was substantial geographic variation in the use of PCI for SIHD preceding the publication of the COURAGE trial. Variation declined by 28% (0.53 versus 0.40) after publication, but geographic variation remained higher for SIHD than acute coronary syndrome (0.40 versus 0.17).
Conclusions—
There was a substantial decline in the use of and geographic variation in PCI for SIHD after the publication of the COURAGE trial. However, geographic variation in the use of PCI for SIHD remained high.
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Affiliation(s)
- Arun V. Mohan
- From the Department of Medicine, Divisions of Hospital Medicine (A.M.) and Cardiology (R.F.), Emory University School of Medicine, Atlanta, GA; Division of Cardiovascular Medicine, Brigham and Women’s Hospital, Boston, MA (P.-H.H.); Department of Economics, Naval Postgraduate School, Monterey, CA (Y.-C.S.); Associate Professor of Economics, Department of Economics, Naval Postgraduate School, Monterrey, CA (Y.-C.S.); Faculty Research Fellow, National Bureau of Economic Research, Cambridge, MA (Y.-C.S
| | - Reza Fazel
- From the Department of Medicine, Divisions of Hospital Medicine (A.M.) and Cardiology (R.F.), Emory University School of Medicine, Atlanta, GA; Division of Cardiovascular Medicine, Brigham and Women’s Hospital, Boston, MA (P.-H.H.); Department of Economics, Naval Postgraduate School, Monterey, CA (Y.-C.S.); Associate Professor of Economics, Department of Economics, Naval Postgraduate School, Monterrey, CA (Y.-C.S.); Faculty Research Fellow, National Bureau of Economic Research, Cambridge, MA (Y.-C.S
| | - Pei-Hsiu Huang
- From the Department of Medicine, Divisions of Hospital Medicine (A.M.) and Cardiology (R.F.), Emory University School of Medicine, Atlanta, GA; Division of Cardiovascular Medicine, Brigham and Women’s Hospital, Boston, MA (P.-H.H.); Department of Economics, Naval Postgraduate School, Monterey, CA (Y.-C.S.); Associate Professor of Economics, Department of Economics, Naval Postgraduate School, Monterrey, CA (Y.-C.S.); Faculty Research Fellow, National Bureau of Economic Research, Cambridge, MA (Y.-C.S
| | - Yu-Chu Shen
- From the Department of Medicine, Divisions of Hospital Medicine (A.M.) and Cardiology (R.F.), Emory University School of Medicine, Atlanta, GA; Division of Cardiovascular Medicine, Brigham and Women’s Hospital, Boston, MA (P.-H.H.); Department of Economics, Naval Postgraduate School, Monterey, CA (Y.-C.S.); Associate Professor of Economics, Department of Economics, Naval Postgraduate School, Monterrey, CA (Y.-C.S.); Faculty Research Fellow, National Bureau of Economic Research, Cambridge, MA (Y.-C.S
| | - David Howard
- From the Department of Medicine, Divisions of Hospital Medicine (A.M.) and Cardiology (R.F.), Emory University School of Medicine, Atlanta, GA; Division of Cardiovascular Medicine, Brigham and Women’s Hospital, Boston, MA (P.-H.H.); Department of Economics, Naval Postgraduate School, Monterey, CA (Y.-C.S.); Associate Professor of Economics, Department of Economics, Naval Postgraduate School, Monterrey, CA (Y.-C.S.); Faculty Research Fellow, National Bureau of Economic Research, Cambridge, MA (Y.-C.S
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20
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Howard DH, Shen YC. Trends in PCI volume after negative results from the COURAGE trial. Health Serv Res 2013; 49:153-70. [PMID: 23829189 DOI: 10.1111/1475-6773.12082] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
OBJECTIVE To describe trends in the use of percutaneous coronary intervention (PCI) following the COURAGE trial, which found that medical therapy is as effective as PCI for patients with stable angina. DATA SOURCES We used the National Hospital Discharge Survey; inpatient and outpatient discharge data from Florida, Maryland, and New Jersey; and the English Hospital Episode Statistics database. STUDY DESIGN We report trends in PCI volume by diagnosis (stable angina vs. unstable angina or AMI) before and after publication of the COURAGE trial. PRINCIPAL FINDINGS The number of PCIs in patients without a diagnosis of AMI or unstable angina in Florida, Maryland, and New Jersey declined from 48,000 in 2006 to 40,000 in 2008 (-17 percent). There was no change in the number of PCIs in patients with a diagnosis of AMI. We observed similar patterns in U.S. community hospitals. PCI volume did not decline in England. CONCLUSIONS PCI volume declined after publication of the COURAGE trial. The experience of the COURAGE trial suggests that comparative effectiveness research can lead to cost-saving changes in medical practice patterns. However, there are many patients with stable coronary disease who continue to receive PCI post-COURAGE.
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Affiliation(s)
- David H Howard
- Department of Health Policy and Management, Emory University, Atlanta, GA
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21
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McCarthy PL, Hahn T, Hassebroek A, Bredeson C, Gajewski J, Hale G, Isola L, Lazarus HM, Lee SJ, Lemaistre CF, Loberiza F, Maziarz RT, Rizzo JD, Joffe S, Parsons S, Majhail NS. Trends in use of and survival after autologous hematopoietic cell transplantation in North America, 1995-2005: significant improvement in survival for lymphoma and myeloma during a period of increasing recipient age. Biol Blood Marrow Transplant 2013; 19:1116-23. [PMID: 23660172 PMCID: PMC3694566 DOI: 10.1016/j.bbmt.2013.04.027] [Citation(s) in RCA: 82] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2013] [Accepted: 04/26/2013] [Indexed: 12/22/2022]
Abstract
Autologous hematopoietic cell transplantation (auto-HCT) is performed to treat relapsed and recurrent malignant disorders and as part of initial therapy for selected malignancies. This study evaluated changes in use, techniques, and survival in a population-based cohort of 68,404 patients who underwent first auto-HCT in a US or Canadian center between 1994 and 2005 and were reported to the Center for International Blood and Marrow Transplant Research (CIBMTR). The mean annual number of auto-HCTs performed was highest during 1996-1999 (6948), and decreased subsequently 2000-2003 (4783), owing mainly to fewer auto-HCTs done to treat breast cancer. However, the mean annual number of auto-HCTs increased from 5278 annually in 1994-1995 to 5459 annually in 2004-2005, reflecting increased use for multiple myeloma, non-Hodgkin lymphoma, and Hodgkin lymphoma. Despite an increase in the median recipient age from 44 to 53 years, there has been a significant improvement in overall survival (OS) from 1994 to 2005 in patients with chemotherapy-sensitive relapsed non-Hodgkin lymphoma (day +100 OS, from 85% to 96%; 1-year OS, from 68% to 80%; P < .001) and chemotherapy-sensitive multiple myeloma (day +100 OS, from 96% to 98%; 1-year OS, from 83% to 92%; P < .001). This improvement in OS was most pronounced in middle-aged (>40 years) and older (>60 years) individuals.
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Affiliation(s)
- Philip L McCarthy
- Department of Medicine, Roswell Park Cancer Institute, Buffalo, NY, USA
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22
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Can major systematic reviews influence practice patterns? A case study of episiotomy trends. Arch Gynecol Obstet 2013; 288:1285-93. [DOI: 10.1007/s00404-013-2904-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2013] [Accepted: 05/16/2013] [Indexed: 10/26/2022]
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23
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Current world literature. Curr Opin Organ Transplant 2013; 18:241-50. [PMID: 23486386 DOI: 10.1097/mot.0b013e32835f5709] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Howard D, Brophy R, Howell S. Evidence of no benefit from knee surgery for osteoarthritis led to coverage changes and is linked to decline in procedures. Health Aff (Millwood) 2013; 31:2242-9. [PMID: 23048105 DOI: 10.1377/hlthaff.2012.0644] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Patients and physicians may be reluctant to abandon widely used treatments that have been found to be ineffective. In 2002 and 2008 the New England Journal of Medicine published the results of clinical trials showing that arthroscopic debridement and lavage--surgical treatments to remove damaged tissue and debris--do not benefit patients with osteoarthritis of the knee. To determine whether the trials' publication was associated with changes in practice patterns, we examined ambulatory surgery data from Florida and found that the number of debridement and lavage procedures per 100,000 adults declined 47 percent between 2001 and 2010. The reduction translates into national savings of $82-$138 million annually. These reductions may be offset by increases in the use of other procedures. The results indicate that clinical trials of widely used therapies can lead to cost-saving changes in practice patterns.
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Affiliation(s)
- David Howard
- Department of Health Policy and Management, Emory University, Atlanta, Georgia, USA.
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Howard DH, Shen YC. Comparative Effectiveness Research, Technological Abandonment, and Health Care Spending. THE ECONOMICS OF MEDICAL TECHNOLOGY 2012; 23:103-21. [DOI: 10.1108/s0731-2199(2012)0000023007] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
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