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Zukin E, Culver JO, Liu Y, Yang Y, Ricker CN, Hodan R, Sturgeon D, Kingham K, Chun NM, Rowe-Teeter C, Singh K, Zell JA, Ladabaum U, McDonnell KJ, Ford JM, Parmigiani G, Braun D, Kurian AW, Gruber SB, Idos GE. Clinical implications of conflicting variant interpretations in the cancer genetics clinic. Genet Med 2023; 25:100837. [PMID: 37057674 PMCID: PMC10416421 DOI: 10.1016/j.gim.2023.100837] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Revised: 04/03/2023] [Accepted: 04/05/2023] [Indexed: 04/15/2023] Open
Abstract
PURPOSE The aim of this study was to describe the clinical impact of commercial laboratories issuing conflicting classifications of genetic variants. METHODS Results from 2000 patients undergoing a multigene hereditary cancer panel by a single laboratory were analyzed. Clinically significant discrepancies between the laboratory-provided test reports and other major commercial laboratories were identified, including differences between pathogenic/likely pathogenic and variant of uncertain significance (VUS) classifications, via review of ClinVar archives. For patients carrying a VUS, clinical documentation was assessed for evidence of provider awareness of the conflict. RESULTS Fifty of 975 (5.1%) patients with non-negative results carried a variant with a clinically significant conflict, 19 with a pathogenic/likely pathogenic variant reported in APC or MUTYH, and 31 with a VUS reported in CDKN2A, CHEK2, MLH1, MSH2, MUTYH, RAD51C, or TP53. Only 10 of 28 (36%) patients with a VUS with a clinically significant conflict had a documented discussion by a provider about the conflict. Discrepant counseling strategies were used for different patients with the same variant. Among patients with a CDKN2A variant or a monoallelic MUTYH variant, providers were significantly more likely to make recommendations based on the laboratory-reported classification. CONCLUSION Our findings highlight the frequency of variant interpretation discrepancies and importance of clinician awareness. Guidance is needed on managing patients with discrepant variants to support accurate risk assessment.
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Affiliation(s)
- Elyssa Zukin
- City of Hope National Medical Center, Center for Precision Medicine, Duarte, CA; University of California, Irvine, Irvine, CA
| | - Julie O Culver
- University of Southern California, Keck School of Medicine, Los Angeles, CA
| | - Yuxi Liu
- Dana-Farber Cancer Institute, Boston, MA; Harvard T.H. Chan School of Public Health, Boston, MA
| | - Yunqi Yang
- Dana-Farber Cancer Institute, Boston, MA
| | - Charité N Ricker
- University of Southern California, Keck School of Medicine, Los Angeles, CA
| | - Rachel Hodan
- Stanford University School of Medicine, Stanford, CA
| | - Duveen Sturgeon
- City of Hope National Medical Center, Center for Precision Medicine, Duarte, CA
| | - Kerry Kingham
- Stanford University School of Medicine, Stanford, CA
| | | | | | | | | | - Uri Ladabaum
- Stanford University School of Medicine, Stanford, CA
| | - Kevin J McDonnell
- City of Hope National Medical Center, Center for Precision Medicine, Duarte, CA
| | - James M Ford
- Stanford University School of Medicine, Stanford, CA
| | - Giovanni Parmigiani
- Dana-Farber Cancer Institute, Boston, MA; Harvard T.H. Chan School of Public Health, Boston, MA
| | - Danielle Braun
- Dana-Farber Cancer Institute, Boston, MA; Harvard T.H. Chan School of Public Health, Boston, MA
| | | | - Stephen B Gruber
- City of Hope National Medical Center, Center for Precision Medicine, Duarte, CA
| | - Gregory E Idos
- City of Hope National Medical Center, Center for Precision Medicine, Duarte, CA.
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Peterson JR, Cole JA, Pfeiffer JR, Norris GH, Zhang Y, Lopez-Ramos D, Pandey T, Biancalana M, Esslinger HR, Antony AK, Takiar V. Novel computational biology modeling system can accurately forecast response to neoadjuvant therapy in early breast cancer. Breast Cancer Res 2023; 25:54. [PMID: 37165441 PMCID: PMC10170712 DOI: 10.1186/s13058-023-01654-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2022] [Accepted: 05/02/2023] [Indexed: 05/12/2023] Open
Abstract
BACKGROUND Generalizable population-based studies are unable to account for individual tumor heterogeneity that contributes to variability in a patient's response to physician-chosen therapy. Although molecular characterization of tumors has advanced precision medicine, in early-stage and locally advanced breast cancer patients, predicting a patient's response to neoadjuvant therapy (NAT) remains a gap in current clinical practice. Here, we perform a study in an independent cohort of early-stage and locally advanced breast cancer patients to forecast tumor response to NAT and assess the stability of a previously validated biophysical simulation platform. METHODS A single-blinded study was performed using a retrospective database from a single institution (9/2014-12/2020). Patients included: ≥ 18 years with breast cancer who completed NAT, with pre-treatment dynamic contrast enhanced magnetic resonance imaging. Demographics, chemotherapy, baseline (pre-treatment) MRI and pathologic data were input into the TumorScope Predict (TS) biophysical simulation platform to generate predictions. Primary outcomes included predictions of pathological complete response (pCR) versus residual disease (RD) and final volume for each tumor. For validation, post-NAT predicted pCR and tumor volumes were compared to actual pathological assessment and MRI-assessed volumes. Predicted pCR was pre-defined as residual tumor volume ≤ 0.01 cm3 (≥ 99.9% reduction). RESULTS The cohort consisted of eighty patients; 36 Caucasian and 40 African American. Most tumors were high-grade (54.4% grade 3) invasive ductal carcinomas (90.0%). Receptor subtypes included hormone receptor positive (HR+)/human epidermal growth factor receptor 2 positive (HER2+, 30%), HR+/HER2- (35%), HR-/HER2+ (12.5%) and triple negative breast cancer (TNBC, 22.5%). Simulated tumor volume was significantly correlated with post-treatment radiographic MRI calculated volumes (r = 0.53, p = 1.3 × 10-7, mean absolute error of 6.57%). TS prediction of pCR compared favorably to pathological assessment (pCR: TS n = 28; Path n = 27; RD: TS n = 52; Path n = 53), for an overall accuracy of 91.2% (95% CI: 82.8% - 96.4%; Clopper-Pearson interval). Five-year risk of recurrence demonstrated similar prognostic performance between TS predictions (Hazard ratio (HR): - 1.99; 95% CI [- 3.96, - 0.02]; p = 0.043) and clinically assessed pCR (HR: - 1.76; 95% CI [- 3.75, 0.23]; p = 0.054). CONCLUSION We demonstrated TS ability to simulate and model tumor in vivo conditions in silico and forecast volume response to NAT across breast tumor subtypes.
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Affiliation(s)
- Joseph R Peterson
- SimBioSys, Inc., 180 N La Salle St. Suite 3250, Chicago, IL, 60601, USA.
| | - John A Cole
- SimBioSys, Inc., 180 N La Salle St. Suite 3250, Chicago, IL, 60601, USA
| | - John R Pfeiffer
- SimBioSys, Inc., 180 N La Salle St. Suite 3250, Chicago, IL, 60601, USA
| | - Gregory H Norris
- SimBioSys, Inc., 180 N La Salle St. Suite 3250, Chicago, IL, 60601, USA
| | - Yuhan Zhang
- SimBioSys, Inc., 180 N La Salle St. Suite 3250, Chicago, IL, 60601, USA
| | - Dorys Lopez-Ramos
- SimBioSys, Inc., 180 N La Salle St. Suite 3250, Chicago, IL, 60601, USA
| | - Tushar Pandey
- SimBioSys, Inc., 180 N La Salle St. Suite 3250, Chicago, IL, 60601, USA
| | | | - Hope R Esslinger
- Department of Radiation Oncology, University of Cincinnati, College of Medicine, Cincinnati, OH, USA
| | - Anuja K Antony
- SimBioSys, Inc., 180 N La Salle St. Suite 3250, Chicago, IL, 60601, USA
| | - Vinita Takiar
- Department of Radiation Oncology, University of Cincinnati, College of Medicine, Cincinnati, OH, USA
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3
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Schwartzberg L, Broder MS, Ailawadhi S, Beltran H, Blakely LJ, Budd GT, Carr L, Cecchini M, Cobb P, Kansal A, Kim A, Monk BJ, Wong DJ, Campos C, Yermilov I. Impact of early detection on cancer curability: A modified Delphi panel study. PLoS One 2022; 17:e0279227. [PMID: 36542647 PMCID: PMC9770338 DOI: 10.1371/journal.pone.0279227] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Accepted: 12/03/2022] [Indexed: 12/24/2022] Open
Abstract
Expert consensus on the potential benefits of early cancer detection does not exist for most cancer types. We convened 10 practicing oncologists using a RAND/UCLA modified Delphi panel to evaluate which of 20 solid tumors, representing >40 American Joint Committee on Cancer (AJCC)-identified cancer types and 80% of total cancer incidence, would receive potential clinical benefits from early detection. Pre-meeting, experts estimated how long cancers take to progress and rated the current curability and benefit (improvement in curability) of an annual hypothetical multi-cancer screening blood test. Post-meeting, experts rerated all questions. Cancers had varying estimates of the potential benefit of early cancer detection depending on estimates of their curability and progression by stage. Cancers rated as progressing quickly and being curable in earlier stages (stomach, esophagus, lung, urothelial tract, melanoma, ovary, sarcoma, bladder, cervix, breast, colon/rectum, kidney, uterus, anus, head and neck) were estimated to be most likely to benefit from a hypothetical screening blood test. Cancer types rated as progressing quickly but having comparatively lower cure rates in earlier stages (liver/intrahepatic bile duct, gallbladder, pancreas) were estimated to have medium likelihood of benefit from a hypothetical screening blood test. Cancer types rated as progressing more slowly and having higher curability regardless of stage (prostate, thyroid) were estimated to have limited likelihood of benefit from a hypothetical screening blood test. The panel concluded most solid tumors have a likelihood of benefit from early detection. Even among difficult-to-treat cancers (e.g., pancreas, liver/intrahepatic bile duct, gallbladder), early-stage detection was believed to be beneficial. Based on the panel consensus, broad coverage of cancers by screening blood tests would deliver the greatest potential benefits to patients.
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Affiliation(s)
- Lee Schwartzberg
- Division of Medical Oncology and Hematology, Renown Institute for Cancer, Reno, Nevada, United States of America
| | - Michael S. Broder
- Partnership for Health Analytic Research (PHAR), LLC, Beverly Hills, California, United States of America
| | - Sikander Ailawadhi
- Department of Medicine, Division of Hematology/Oncology, Mayo Clinic, Jacksonville, Florida, United States of America
| | - Himisha Beltran
- Department of Medical Oncology, Divisions of Genitourinary Oncology and Molecular and Cellular Oncology, Dana Farber Cancer Institute, Boston, Massachusetts, United States of America
| | - L. Johnetta Blakely
- Health Economics and Outcomes Research, Tennessee Oncology, Nashville, Tennessee, United States of America
| | - G. Thomas Budd
- Department of Hematology and Medical Oncology, Cleveland Clinic Taussig Cancer Institute, Cleveland, Ohio, United States of America
| | - Laurie Carr
- Department of Medicine, Division of Medical Oncology, National Jewish Health, Denver, Colorado, United States of America
| | - Michael Cecchini
- Department of Internal Medicine, Division of Medical Oncology, Yale University School of Medicine, New Haven, Connecticut, United States of America
| | - Patrick Cobb
- Oncology Research, Intermountain Healthcare, Billings, Montana, United States of America
| | - Anuraag Kansal
- Health Economics and Outcomes Research, GRAIL, LLC, a subsidiary of Illumina Inc., currently held separate from Illumina Inc. under the terms of the Interim Measures Order of the European Commission dated 29 October 2021, Menlo Park, California, United States of America
| | - Ashley Kim
- Health Economics and Outcomes Research, GRAIL, LLC, a subsidiary of Illumina Inc., currently held separate from Illumina Inc. under the terms of the Interim Measures Order of the European Commission dated 29 October 2021, Menlo Park, California, United States of America
- * E-mail:
| | - Bradley J. Monk
- Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, HonorHealth Research Institute, University of Arizona, Creighton University, Phoenix, Arizona, United States of America
| | - Deborah J. Wong
- Department of Medicine, Division of Hematology/Oncology, UCLA Health, Los Angeles, California, United States of America
| | - Cynthia Campos
- Partnership for Health Analytic Research (PHAR), LLC, Beverly Hills, California, United States of America
| | - Irina Yermilov
- Partnership for Health Analytic Research (PHAR), LLC, Beverly Hills, California, United States of America
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Jaber Chehayeb R, Hood A, Wang X, Miksad R, Schellhorn Mougalian S, Lustberg MB, Wang SY, Greenup RA, Pusztai L, Kunst N. Treatment Sequencing Patterns and Associated Direct Medical Costs of Metastatic Breast Cancer Care in the United States, 2011 to 2021. JAMA Netw Open 2022; 5:e2244204. [PMID: 36445704 PMCID: PMC9709649 DOI: 10.1001/jamanetworkopen.2022.44204] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
IMPORTANCE Advances in treatment of metastatic breast cancer (MBC) led to changes in clinical practice and treatment costs in the US over the past decade. There is limited information on current MBC treatment sequences and associated costs by MBC subtype in the US. OBJECTIVES To identify treatment patterns by MBC subtype and associated anticancer and supportive drug costs from health care sector and Medicare perspectives. DESIGN, SETTING, AND PARTICIPANTS This economic evaluation analyzed data of patients with MBC obtained from the nationwide Flatiron Health database, an electronic health record-derived, deidentified database with data from community and academic practices across the US from 2011 to 2021. Participants included women aged at least 18 years diagnosed with MBC, who had at least 6 months of follow-up data, known hormone receptor (HR) and human epidermal growth factor receptor 2 (ERBB2) receptor status, and at least 1 documented line of therapy. Patients with documented receipt of clinical study drugs were excluded. Data were analyzed from June 2021 to May 2022. MAIN OUTCOMES AND MEASURES Outcomes of interest were frequency of different drug regimens received as a line of therapy by subtype for the first 5 lines and mean medical costs of documented anticancer treatment and supportive care drugs per patient by MBC subtype and years since metastatic diagnosis, indexed to 2021 US dollars. RESULTS Among 15 215 patients (10 171 patients [66.85%] with HR-positive and ERBB2-negative MBC; 2785 patients [18.30%] with HR-positive and ERBB2-positive MBC; 802 patients [5.27%] with HR-negative and ERBB2-positive MBC; 1457 patients [9.58%] with triple-negative breast cancer [TNBC]) who met eligibility criteria, 1777 (11.68%) were African American, 363 (2.39%) were Asian, and 9800 (64.41%) were White; the median (range) age was 64 (21-84) years. The mean total per-patient treatment and supportive care drug cost using publicly available Medicare prices was $334 812 for patients with HR-positive and ERBB2-positive MBC, $284 609 for patients with HR-negative and ERBB2-positive MBC, $104 774 for patients with HR-positive and ERBB2-negative MBC, and $54 355 for patients with TNBC. From 2011 to 2019 (most recent complete year 1 data are for patients diagnosed in 2019), annual costs in year 1 increased from $12 986 to $80 563 for ERBB2-negative and HR-positive MBC, $99 997 to $156 712 for ERBB2-positive and HR-positive MBC, and $31 397 to $53 775 for TNBC. CONCLUSIONS AND RELEVANCE This economic evaluation found that drug costs related to MBC treatment increased between 2011 and 2021 and differed by tumor subtype. These findings suggest the growing financial burden of MBC treatment in the US and highlights the importance of performing more accurate cost-effectiveness analysis of novel adjuvant therapies that aim to reduce metastatic recurrence rates for early-stage breast cancer.
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Affiliation(s)
| | - Annette Hood
- Smilow Cancer Hospital, Yale New Haven Hospital, New Haven, Connecticut
| | | | | | | | | | - Shi-Yi Wang
- Cancer Outcomes, Public Policy and Effectiveness Research Center, Yale University School of Medicine, New Haven, Connecticut
- Yale School of Public Health, New Haven, Connecticut
| | - Rachel A. Greenup
- Department of Surgery and Smilow Cancer Hospital, Yale School of Medicine, New Haven, Connecticut
| | - Lajos Pusztai
- Yale Cancer Center, Yale School of Medicine, New Haven, Connecticut
| | - Natalia Kunst
- Cancer Outcomes, Public Policy and Effectiveness Research Center, Yale University School of Medicine, New Haven, Connecticut
- Yale School of Public Health, New Haven, Connecticut
- Department of Health Management and Health Economics, University of Oslo, Oslo, Norway
- Harvard Medical School & Harvard Pilgrim Health Care Institute, Boston, Massachusetts
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5
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Vyas A, Mantaian T, Kamat S, Kurian S, Kogut S. Association of guideline-concordant initial systemic treatment with clinical and economic outcomes among older women with metastatic breast cancer in the United States. J Geriatr Oncol 2021; 12:1092-1099. [PMID: 34099411 DOI: 10.1016/j.jgo.2021.05.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Revised: 04/02/2021] [Accepted: 05/27/2021] [Indexed: 10/21/2022]
Abstract
PURPOSE We examined guideline-concordant initial systemic treatment among women with metastatic breast cancer, its predictors, and if guideline-concordant treatment was associated with mortality, healthcare utilization and Medicare expenditures. METHODS This retrospective observational cohort study was conducted using the Surveillance, Epidemiology, End Results-Medicare linked database. Women aged 66-90 years diagnosed with metastatic breast cancer during 2010-2013 (N = 1282) were included. The National Comprehensive Cancer Network treatment guidelines were used to determine the guideline-concordant initial systemic treatment following cancer diagnosis. A logistic regression analysis was conducted to examine significant predictors of guideline-concordant treatment. Generalized linear regressions were used to examine the association between guideline-concordant treatment and healthcare utilization and average monthly Medicare expenditures. RESULTS About 74% of the study cohort received guideline-concordant initial systemic treatment. Women who received guideline-concordant treatment were significantly more likely to be comparatively younger (p < 0.05), were married/partnered (p = 0.0038), had HER2 positive tumors, and had good performance status. Adjusted hazards ratios for all-cause (2.364, p < 0.0001) and breast-cancer specific mortality (2.179, p < 0.0001) were higher for women who did not receive guideline-concordant treatment. Rates of healthcare utilization were also higher for women not receiving guideline-concordant treatment. Average monthly Medicare expenditures were 100.4% higher (95% confidence interval: $77.3%-126.5%) for women who did not receive guideline-concordant treatment compared to those who received guideline-concordant treatment (p < 0.0001). CONCLUSION One fourth of the study cohort did not receive guideline-concordant initial systemic treatment. Guideline-concordant initial treatment was associated with reduced mortality, and lower healthcare utilization and Medicare expenditures in women with metastatic breast cancer.
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Affiliation(s)
- Ami Vyas
- University of Rhode Island, College of Pharmacy, Department of Pharmacy Practice, Kingston, RI, United States of America.
| | - Tyler Mantaian
- University of Rhode Island, College of Pharmacy, Department of Pharmacy Practice, Kingston, RI, United States of America
| | - Shweta Kamat
- University of Rhode Island, College of Pharmacy, Department of Pharmacy Practice, Kingston, RI, United States of America
| | - Sobha Kurian
- West Virginia University, School of Medicine, Morgantown, WV, United States of America
| | - Stephen Kogut
- University of Rhode Island, College of Pharmacy, Department of Pharmacy Practice, Kingston, RI, United States of America
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Werutsky G, Reinert T, Rosa ML, Barrios CH. Real-world Data on First-line Systemic Therapy for Hormone Receptor-positive HER2-negative Metastatic Breast Cancer: A Trend Shift in the Era of CDK 4/6 Inhibitors. Clin Breast Cancer 2021; 21:e688-e692. [PMID: 33992526 DOI: 10.1016/j.clbc.2021.04.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2020] [Revised: 03/24/2021] [Accepted: 04/05/2021] [Indexed: 12/24/2022]
Abstract
Hormone receptor-positive (HR+) human epidermal growth factor receptor-2 negative (HER2-) tumors represent the most common subtype of metastatic breast cancer (MBC). International guidelines clearly state that endocrine therapy (ET) should be considered the preferred first-line therapy for these patients in the absence of very symptomatic visceral disease or evidence of endocrine resistance. Nonetheless compliance with guidelines significantly vary worldwide for many different reasons. Historically, a substantial proportion of patients with HR+ HER2- MBC have been treated with chemotherapy (CT) in first-line setting, jeopardizing patients' quality of life without a significant benefit in outcome. In 17 observational studies, including more than 63,000 patients, ET was most frequently used in first-line treatment of HR+/HER2- MBC (range, 42%-87%), nonetheless a high proportion of patients received CT (13%-66%) as initial therapy. More recently, results of clinical trials with CDK 4/6 inhibitors improved response, progression-free and overall survival in this population and are currently the standard of care. There was a trend toward increased use of ET in recent years. This review article aims to evaluate real-world data on patterns of first-line treatment of HR+ HER2- MBC with a special focus on the use of CT in this setting and the potential implications and perceived preliminary changes after the introduction of CDK 4/6 inhibitors.
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Affiliation(s)
- Gustavo Werutsky
- Latin American Cooperative Oncology Group (LACOG), Porto Alegre, Brazil.
| | - Tomás Reinert
- Latin American Cooperative Oncology Group (LACOG), Porto Alegre, Brazil; Grupo Oncoclínicas, Porto Alegre, Brazil
| | - Mahira Lopes Rosa
- Latin American Cooperative Oncology Group (LACOG), Porto Alegre, Brazil
| | - Carlos Henrique Barrios
- Latin American Cooperative Oncology Group (LACOG), Porto Alegre, Brazil; Grupo Oncoclínicas, Porto Alegre, Brazil
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7
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Vyas A, Gabriel M, Kurian S. Disparities in Guideline-Concordant Initial Systemic Treatment in Women with HER2-Negative Metastatic Breast Cancer: A SEER-Medicare Analysis. BREAST CANCER: TARGETS AND THERAPY 2021; 13:259-269. [PMID: 33880062 PMCID: PMC8053132 DOI: 10.2147/bctt.s295526] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/24/2020] [Accepted: 03/11/2021] [Indexed: 12/31/2022]
Abstract
Background Methods Results Conclusion
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Affiliation(s)
- Ami Vyas
- Department of Pharmacy Practice, College of Pharmacy, University of Rhode Island, Kingston, RI, USA
- Correspondence: Ami Vyas Department of Pharmacy Practice, College of Pharmacy, University of Rhode Island, 7 Greenhouse Road, Kingston, RI, 02881, USATel +1-401-874-7255Fax +1-401-874-2717 Email
| | | | - Sobha Kurian
- West Virginia University, School of Medicine, Morgantown, WV, USA
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Gilbert A, Williams C, Azuero A, Burkard ME, Kenzik K, Garrett-Mayer E, Meersman S, Rocque G. Utilizing Data Visualization to Identify Survival and Treatment Differences Between Women With De Novo and Recurrent Metastatic Breast Cancer. Clin Breast Cancer 2020; 21:292-301. [PMID: 33309481 DOI: 10.1016/j.clbc.2020.11.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2020] [Revised: 10/26/2020] [Accepted: 11/11/2020] [Indexed: 12/01/2022]
Abstract
INTRODUCTION De novo stage IV metastatic breast cancer (MBC) and recurrent MBC are considered the same when determining guideline-based care, but differences in treatment patterns exist. Data visualization can be used to understand these differences and optimize treatment delivery. PATIENTS AND METHODS This retrospective study evaluated treatment patterns for de novo and recurrent MBC using the American Society of Clinical Oncology's CancerLinQ Discovery database. Spatiotemporal graphics depicting treatment data were generated for MBC subtype and stratified by de novo and recurrent MBC. Descriptive statistics for categorical and continuous variables were calculated. RESULTS We identified 1668 patients diagnosed and treated for MBC: 391 patients with HER2+ MBC, 767 patients with HR+/HER2- MBC, and 510 patients with triple-negative MBC. Median survival from MBC diagnosis for patients with de novo MBC and recurrent MBC was 1.4 years (interquartile range, 0.6-3.0) and 1.8 years (interquartile range, 0.7-4.5), respectively. Both patients with de novo and recurrent HER2+ MBC were often treated with continuous HER2-targeted therapy. Patients with de novo HR+/HER2- MBC often received chemotherapy followed by hormone therapy. This contrasted with treatment trends observed among patients with recurrent HR+/HER2- MBC who, after receiving chemotherapy, seldom went on to receive hormone therapy. Patients diagnosed with triple-negative MBC displayed less heterogeneous treatment trends. CONCLUSION There are observable differences in survival and practice patterns between de novo and recurrent MBC. Visualization techniques are effective in assessing large databases and could give researchers and clinicians a clearer understanding of how survival differs by disease subtype, diagnosis status, and practice patterns.
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Affiliation(s)
- Aidan Gilbert
- Division of Hematology & Oncology, University of Alabama at Birmingham, Birmingham, AL
| | - Courtney Williams
- Division of Hematology & Oncology, University of Alabama at Birmingham, Birmingham, AL
| | - Andres Azuero
- School of Nursing, University of Alabama at Birmingham, Birmingham, AL
| | - Mark E Burkard
- Department of Medicine and the UW Carbone Cancer Center, University of Wisconsin-Madison, Madison, WI
| | - Kelly Kenzik
- Division of Hematology & Oncology, University of Alabama at Birmingham, Birmingham, AL; Institute for Cancer Outcomes & Survivorship, University of Alabama at Birmingham, Birmingham, AL
| | - Elizabeth Garrett-Mayer
- Center for Research & Analytics (CENTRA), American Society of Clinical Oncology, Alexandria, VA
| | - Stephen Meersman
- Center for Research & Analytics (CENTRA), American Society of Clinical Oncology, Alexandria, VA
| | - Gabrielle Rocque
- Division of Hematology & Oncology, University of Alabama at Birmingham, Birmingham, AL.
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9
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Hull O, Niranjan SJ, Wallace AS, Williams BR, Turkman YE, Ingram SA, Williams CP, Smith T, Knight SJ, Bhatia S, Rocque GB. Should we be talking about guidelines with patients? A qualitative analysis in metastatic breast cancer. Breast Cancer Res Treat 2020; 184:115-121. [PMID: 32737711 DOI: 10.1007/s10549-020-05832-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Accepted: 07/22/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND Little data exist on perceptions of guideline-based care in oncology. This qualitative analysis describes patients' and oncologists' views on the value of guideline-based care as well as discussing guidelines when making metastatic breast cancer (MBC) treatment decisions. PATIENTS AND METHODS In-person interviews completed with MBC patients and community oncologists and focus groups with academic oncologists were audio-recorded and transcribed. Two coders utilized a content analysis approach to analyze transcripts independently using NVivo. Major themes and exemplary quotes were extracted. RESULTS Participants included 20 MBC patients, 6 community oncologists, and 5 academic oncologists. Most patients were unfamiliar with the term "guidelines." All patients desired to know if they were receiving guideline-discordant treatment but were often willing to accept this treatment. Five themes emerged explaining this including trusting the oncologist, relying on the oncologist's experiences, being informed of rationale for deviation, personalized treatment, and openness to novel therapies. Physician discussions regarding the importance of guidelines revealed three themes: consistency with scientific evidence, insurance coverage, and limiting unusual practices. Oncologists identified three major limitations in using guidelines: lack of consensus, inability to "think outside the box" to personalize treatment, and lack of guideline timeliness. Although some oncologists discussed guidelines, it was often not considered a priority. CONCLUSIONS Patients expressed a desire to know whether they were receiving guideline-based care but were amenable to guideline-discordant treatment if the rationale was made clear. Providers' preference to limit discussions of guidelines is discordant with patients' desire for this information and may limit shared decision-making.
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Affiliation(s)
- Olivia Hull
- Division of Hematology and Oncology, Department of Medicine, The University of Alabama at Birmingham, WTI 240, 1720 2nd Avenue South, Birmingham, AL, 35294, USA
| | - Soumya J Niranjan
- School of Health Professions, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Audrey S Wallace
- Department of Radiation Oncology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Beverly R Williams
- Division of Gerontology, Geriatrics and Palliative Care, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Yasemin E Turkman
- School of Nursing, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Stacey A Ingram
- Division of Hematology and Oncology, Department of Medicine, The University of Alabama at Birmingham, WTI 240, 1720 2nd Avenue South, Birmingham, AL, 35294, USA
| | - Courtney P Williams
- Division of Hematology and Oncology, Department of Medicine, The University of Alabama at Birmingham, WTI 240, 1720 2nd Avenue South, Birmingham, AL, 35294, USA
| | - Tom Smith
- Division of Palliative Care, The Johns Hopkins Hospital, Baltimore, MD, USA
| | - Sara J Knight
- Department of Internal Medicine, Division of Epidemiology, University of Utah, Salt Lake City, UT, USA.,Informatics, Decision-Enhancement, and Analytical Sciences (IDEAS) Center, Department of Veteran Affairs, Salt Lake City Health Care System, Salt Lake City, UT, USA
| | - Smita Bhatia
- Institute for Cancer Outcomes and Survivorship, University of Alabama at Birmingham, Birmingham, AL, USA.,Comprehensive Cancer Center, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Gabrielle B Rocque
- Division of Hematology and Oncology, Department of Medicine, The University of Alabama at Birmingham, WTI 240, 1720 2nd Avenue South, Birmingham, AL, 35294, USA. .,Division of Gerontology, Geriatrics and Palliative Care, University of Alabama at Birmingham, Birmingham, AL, USA. .,Comprehensive Cancer Center, University of Alabama at Birmingham, Birmingham, AL, USA.
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10
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Rocque GB, Gilbert A, Williams CP, Kenzik KM, Nakhmani A, Kandhare PG, Bhatia S, Burkard ME, Azuero A. Prior Treatment Time Affects Survival Outcomes in Metastatic Breast Cancer. JCO Clin Cancer Inform 2020; 4:500-513. [PMID: 32479187 PMCID: PMC7444642 DOI: 10.1200/cci.20.00008] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/10/2020] [Indexed: 12/29/2022] Open
Abstract
PURPOSE Sequential drug treatments in metastatic breast cancer (MBC) are disparate. Clinical trial data includes limited reporting of treatment context, primarily including the number of prior therapies. This study evaluates the relationship between prior treatment time, prior lines of treatment, and survival using a novel visualization technique coupled with statistical analyses. PATIENTS AND METHODS This retrospective cohort study used a nationwide, de-identified electronic health record-derived database to identify women with hormone receptor-positive, human epidermal growth factor receptor 2-negative MBC diagnosed in 2014 who subsequently received paclitaxel. Images were created, with individual patients represented on the y-axis and time, on the x-axis. Specific treatments were represented by colored bars, with Kaplan-Meier curves overlaying the image. Separate images assessed progression-free survival and overall survival (OS). Hazard ratios (HRs) and 95% CIs from Cox proportional hazards models evaluated the association between prior treatment time and OS. RESULTS Of 234 patients, median survival from first paclitaxel administration was 20 months (interquartile range, 8-53 months). An inverse relationship was observed between OS after paclitaxel and timing of administration. In adjusted models, each year on treatment prior to paclitaxel was associated with a 16% increased hazard of death after paclitaxel (HR, 1.16; 95% CI, 1.05 to 1.29). CONCLUSION OS after a specific treatment is dependent on when a drug is given in the disease context, highlighting the potential for an overall OS benefit to be observed on the basis of treatment timing. Prior time on treatment should be considered as a stratifying factor in randomized trials and a confounding factor when examining survival in observational data.
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Affiliation(s)
- Gabrielle B. Rocque
- O’Neal Comprehensive Cancer Center, University of Alabama at Birmingham (UAB), Birmingham, AL
- Department of Medicine, Division of Hematology and Oncology, UAB, Birmingham, AL
| | - Aidan Gilbert
- Department of Medicine, Division of Hematology and Oncology, UAB, Birmingham, AL
| | - Courtney P. Williams
- Department of Medicine, Division of Hematology and Oncology, UAB, Birmingham, AL
| | - Kelly M. Kenzik
- O’Neal Comprehensive Cancer Center, University of Alabama at Birmingham (UAB), Birmingham, AL
- Department of Medicine, Division of Hematology and Oncology, UAB, Birmingham, AL
- Institute for Cancer Outcomes and Survivorship, UAB, Birmingham, AL
| | - Arie Nakhmani
- Department of Electrical and Computer Engineering, UAB, Birmingham, AL
| | | | - Smita Bhatia
- O’Neal Comprehensive Cancer Center, University of Alabama at Birmingham (UAB), Birmingham, AL
- Institute for Cancer Outcomes and Survivorship, UAB, Birmingham, AL
| | - Mark E. Burkard
- Department of Medicine, Division of Hematology, Medical Oncology, and Palliative Care, University of Wisconsin, Madison, WI
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11
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Sheng JY, Visvanathan K, Thorner E, Wolff AC. Breast cancer survivorship care beyond local and systemic therapy. Breast 2020; 48 Suppl 1:S103-S109. [PMID: 31839149 DOI: 10.1016/s0960-9776(19)31135-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Despite persistent inequities in access to care and treatments, advances in combined modality care have led to a steady improvement in outcomes for breast cancer patients across the globe. When estimating the magnitude of clinical benefit of therapies, providers and patients must contend with a multitude of factors that impact treatment decisions and can have long-term effects on quality of life and survival. These include commonly described early toxicities, like aromatase inhibitor-associated musculoskeletal syndrome and neuropathy. But longer-term comorbidities often observed among cancer survivors including weight gain, obesity, infertility, psychological distress, sexual dysfunction, second cancers, bone loss, and body image issues can have lasting effects on quality of life. Equally important, system-level factors such as access to care and resource allocation can have a systemic impact on survival and on the quality of survivorship. Financial toxicity including underemployment can have a lasting impact on patients and caregivers. The resulting disparities in access to treatment can help explain much of the observed variability in outcomes, even within high-income countries like the US. This article revisits some of secondary effects from therapies discussed in a prior 2015 review article, along with other impediments to the optimal delivery of breast cancer care that can affect patients anywhere.
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Affiliation(s)
- Jennifer Y Sheng
- The Johns Hopkins University School of Medicine, The Johns Hopkins Bloomberg School of Public Health, and The Johns Hopkins Sidney Kimmel Comprehensive Cancer Center, Baltimore, MD, USA
| | - Kala Visvanathan
- The Johns Hopkins University School of Medicine, The Johns Hopkins Bloomberg School of Public Health, and The Johns Hopkins Sidney Kimmel Comprehensive Cancer Center, Baltimore, MD, USA
| | - Elissa Thorner
- The Johns Hopkins University School of Medicine, The Johns Hopkins Bloomberg School of Public Health, and The Johns Hopkins Sidney Kimmel Comprehensive Cancer Center, Baltimore, MD, USA
| | - Antonio C Wolff
- The Johns Hopkins University School of Medicine, The Johns Hopkins Bloomberg School of Public Health, and The Johns Hopkins Sidney Kimmel Comprehensive Cancer Center, Baltimore, MD, USA.
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12
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Rocque GB, Williams GR. Bridging the Data-Free Zone: Decision Making for Older Adults With Cancer. J Clin Oncol 2019; 37:3469-3471. [PMID: 31675251 DOI: 10.1200/jco.19.02588] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
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13
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Giladi AM, Giberson-Chen CC, Parker AM, Desale S, Rozental TD. Adhering to Radiographic Clinical Practice Guidelines for Distal Radial Fracture Management Is Associated with Improved Outcomes and Lower Costs. J Bone Joint Surg Am 2019; 101:1829-1837. [PMID: 31626007 DOI: 10.2106/jbjs.18.01245] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND The American Academy of Orthopaedic Surgeons Clinical Practice Guideline on the Treatment of Distal Radius Fractures has not been evaluated in clinical practice. We hypothesized that adhering to the distal radial fracture radiographic clinical practice guideline (CPG) improves outcomes and reduces costs. METHODS We reviewed 266 patients with distal radial fractures treated at 1 institution. Based on CPG radiographic parameters (Recommendation 3), care was rated as "appropriate" or "inappropriate." QuickDASH (an abbreviated version of the Disabilities of the Arm, Shoulder and Hand [DASH] questionnaire) scores were collected. The direct costs of distal radial fracture care were determined. Descriptive statistics and nonparametric tests were used to evaluate demographic characteristics and outcomes across groups. QuickDASH scores, grouped by postoperative time interval, were analyzed using linear mixed effect models to predict outcome trends. RESULTS In this study, 145 patients in the operative treatment group and 121 patients in the nonoperative treatment group were included. Of the 145 patients in the operative treatment group, 6 underwent an inappropriate surgical procedure, limiting any analyses of that group. Of the 121 patients in the nonoperative treatment group, 68 were treated inappropriately. For the patients in the nonoperative treatment group, appropriate care provided a significant outcome benefit by 1 year; the median QuickDASH score was 10.1 points for the appropriate treatment group and 19.5 points for the inappropriate treatment group (p = 0.05). The total direct costs for inappropriate nonoperative treatment were, on average, 60% higher than appropriate nonoperative treatment. In predictive models, patients with appropriate care in the operative treatment group and the nonoperative treatment group had better outcomes than patients with inappropriate nonoperative treatment at all time points after 29 days. CONCLUSIONS When nonoperative distal radial fracture management was aligned with radiographic CPG criteria, patients in our cohort had improved patient-reported outcomes with lower costs. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Aviram M Giladi
- The Curtis National Hand Center, MedStar Union Memorial Hospital, Baltimore, Maryland
| | - Carew C Giberson-Chen
- Department of Orthopedic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Amber M Parker
- Department of Orthopedic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Sameer Desale
- Department of Biostatistics and Bioinformatics, MedStar Health Research Institute, Hyattsville, Maryland
| | - Tamara D Rozental
- Department of Orthopedic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
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Rocque GB, Kandhare PG, Williams CP, Nakhmani A, Azuero A, Burkard ME, Forero A, Bhatia S, Kenzik KM. Visualization of Sequential Treatments in Metastatic Breast Cancer. JCO Clin Cancer Inform 2019; 3:1-8. [PMID: 30840488 DOI: 10.1200/cci.18.00095] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
PURPOSE Treatment sequencing of metastatic breast cancer (MBC) is heterogeneous. The primary objective of this study was to develop a visualization technique to understand population-level treatment sequencing for MBC. Secondary outcomes were to describe the heterogeneity of MBC treatment sequencing, as measured by the proportion of patients with a rare sequence, and to generate hypotheses about the impact of sequencing on overall survival. METHODS This retrospective review evaluated treatment sequencing for patients with MBC in the SEER-Medicare database. Patients with either de novo MBC or International Classification of Diseases, Ninth Revision, diagnosis codes for secondary metastasis (197.XX-198.XX) on two separate dates, excluding breast (198.81, 198.82, 198.2) and lymph nodes (196.XX), were included. Complete Medicare Parts A, B, and D coverage was required. A treatment sequence that fewer than 11 patients received was considered rare. A graphic was created with each nonrare treatment-sequence grouping on the y-axis and time on the x-axis. Bars representing time on hormonal therapy, chemotherapy, human epidermal growth factor receptor 2-targeted therapy, and other targeted therapies were color coded. Kaplan-Meier-like curves were overlaid on treatment maps, using estimated median survival for each sequence. RESULTS Of 6,639 patients with MBC, 56% received a treatment sequence that fewer than 11 other patients received, with 2,985 other unique, rare sequences were identified. Sequence visualization demonstrated differential survival, with longer median survival for those initially receiving hormonal therapy. The median time receiving initial treatment was similar for patients receiving first-line chemotherapy. CONCLUSION Treatment-sequence visualization can enhance the capacity to effectively conceptualize treatment patterns and patient outcomes.
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Affiliation(s)
| | | | | | | | | | | | | | - Smita Bhatia
- University of Alabama at Birmingham, Birmingham, AL
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