1
|
Fountzilas C, Witkiewicz A, Chatley S, Fitzpatrick V, Zonneville J, Alruwaili M, Rosenheck H, Mager D, Wang J, Krishnamurthy A, Switzer B, Attwood K, Puzanov I, Iyer R, Bakin A. YIA24-003: A Phase I Study of TAS102 Plus Talazoparib in Advanced Colorectal (CRC) and Esophagogastric (EGC) Adenocarcinomas. J Natl Compr Canc Netw 2024; 22:YIA24-003. [PMID: 38579886 DOI: 10.6004/jnccn.2023.7124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/07/2024]
Affiliation(s)
| | | | - Sarah Chatley
- 1Roswell Park Comprehensive Cancer Center, Buffalo, NY
| | | | | | | | | | - Donald Mager
- 3University at Buffalo, State University of New York, Buffalo, NY
| | - Jianxin Wang
- 1Roswell Park Comprehensive Cancer Center, Buffalo, NY
| | | | | | | | - Igor Puzanov
- 1Roswell Park Comprehensive Cancer Center, Buffalo, NY
| | - Renuka Iyer
- 1Roswell Park Comprehensive Cancer Center, Buffalo, NY
| | - Andrei Bakin
- 1Roswell Park Comprehensive Cancer Center, Buffalo, NY
| |
Collapse
|
2
|
Switzer B, Puzanov I, Gandhi S, Repasky EA. Targeting beta-adrenergic receptor pathways in melanoma: how stress modulates oncogenic immunity. Melanoma Res 2024; 34:89-95. [PMID: 38051781 PMCID: PMC10906201 DOI: 10.1097/cmr.0000000000000943] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Accepted: 10/26/2023] [Indexed: 12/07/2023]
Abstract
The intricate pathways of the sympathetic nervous system hold an inherently protective role in the setting of acute stress. This is achieved through dynamic immunomodulatory and neurobiological networks. However, excessive and chronic exposure to these stress-induced stimuli appears to cause physiologic dysfunction through several mechanisms that may impair psychosocial, neurologic, and immunologic health. Numerous preclinical observations have identified the beta-2 adrenergic receptor (β2-AR) subtype to possess the strongest impact on immune dysfunction in the setting of chronic stressful stimuli. This prolonged expression of β2-ARs appears to suppress immune surveillance and promote tumorigenesis within multiple cancer types. This occurs through several pathways, including (1) decreasing the frequency and function of CD8 + T-cells infiltrating the tumor microenvironment (TME) via inhibition of metabolic reprogramming during T cell activation, and (2) establishing an immunosuppressive profile within the TME including promotion of an exhausted T cell phenotype while simultaneously enhancing local and paracrine metastatic potential. The use of nonselective β-AR antagonists appears to reverse many chronic stress-induced tumorigenic pathways and may also provide an additive therapeutic benefit for various immune checkpoint modulating agents including commonly utilized immune checkpoint inhibitors. Here we review the translational and clinical observations highlighting the foundational hypotheses that chronic stress-induced β-AR signaling promotes a pro-tumoral immunophenotype and that blockade of these pathways may augment the therapeutic response of immune checkpoint inhibition within the scope of melanoma.
Collapse
Affiliation(s)
- Benjamin Switzer
- Department of Medicine, Roswell Park Comprehensive Cancer Center
| | - Igor Puzanov
- Department of Medicine, Roswell Park Comprehensive Cancer Center
| | - Shipra Gandhi
- Department of Medicine, Roswell Park Comprehensive Cancer Center
| | - Elizabeth A. Repasky
- Department of Immunology, Roswell Park Comprehensive Cancer Center, Buffalo, New York, USA
| |
Collapse
|
3
|
Switzer B, Piperno-Neumann S, Lyon J, Buchbinder E, Puzanov I. Evolving Management of Stage IV Melanoma. Am Soc Clin Oncol Educ Book 2023; 43:e397478. [PMID: 37141553 DOI: 10.1200/edbk_397478] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/06/2023]
Abstract
Significant advancements have been made in the treatment of advanced melanoma with the use of immune checkpoint inhibitors, novel immunotherapies, and BRAF/MEK-targeted therapies with numerous frontline treatment options. However, there remains suboptimal evidence to guide treatment decisions in many patients. These include patients with newly diagnosed disease, immune checkpoint inhibitor (ICI)-resistant/ICI-refractory disease, CNS metastases, history of autoimmune disease, and/or immune-related adverse events (irAEs). Uveal melanoma (UM) is a rare melanoma associated with a poor prognosis in the metastatic setting. Systemic treatments, including checkpoint inhibitors, failed to demonstrate any survival benefit. Tebentafusp, a bispecific molecule, is the first treatment to improve overall survival (OS) in patients with HLA A*02:01-positive metastatic UM.
Collapse
Affiliation(s)
- Benjamin Switzer
- Department of Medicine, Roswell Park Comprehensive Cancer Center, Buffalo, NY
| | | | - James Lyon
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
| | | | - Igor Puzanov
- Department of Medicine, Roswell Park Comprehensive Cancer Center, Buffalo, NY
| |
Collapse
|
4
|
Stefanovic F, Gomez-Caminero A, Jacobs DM, Subramanian P, Puzanov I, Chilbert MR, Feuerstein SG, Yatsynovich Y, Switzer B, Schentag JJ. Neural Net Modeling of Checkpoint Inhibitor Related Myocarditis and Steroid Response. Clin Pharmacol 2022; 14:69-90. [PMID: 35975122 PMCID: PMC9376002 DOI: 10.2147/cpaa.s369008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Accepted: 08/02/2022] [Indexed: 02/02/2023]
Abstract
Background Serious but rare side effects associated with immunotherapy pose a difficult problem for regulators and practitioners. Immune checkpoint inhibitors (ICIs) have come into widespread use in oncology in recent years and are associated with rare cardiotoxicity, including potentially fatal myocarditis. To date, no comprehensive model of myocarditis progression and outcomes integrating time-series based laboratory and clinical signals has been constructed. In this paper, we describe a time-series neural net (NN) model of ICI-related myocarditis derived using supervised machine learning. Methods We extracted and modeled data from electronic medical records of ICI-treated patients who had an elevation in their troponin. All data collection was performed using an electronic case report form, with approximately 300 variables collected on as many occasions as available, yielding 6000 data elements per patient over their clinical course. Key variables were scored 0-5 and sequential assessments were used to construct the model. The NN model was developed in MatLab and applied to analyze the time course and outcomes of treatments. Results We identified 23 patients who had troponin elevations related to their ICI therapy, 15 of whom had ICI-related myocarditis, while the remaining 8 patients on ICIs had other causes for troponin elevation, such as myocardial infarction. Our model showed that troponin was the most predictive biomarker of myocarditis, in line with prior studies. Our model also identified early and aggressive use of steroid treatment as a major determinant of survival for cases of grade 3 or 4 ICI-related myocarditis. Conclusion Our study shows that a supervised learning NN can be used to model rare events such as ICI-related myocarditis and thus provide clinical insight into drivers of progression and treatment outcomes. These findings direct attention to early detection biomarkers and clinical symptoms as the best means of implementing early and potentially life-saving steroid treatment.
Collapse
Affiliation(s)
- Filip Stefanovic
- Department of Biomedical Engineering, University at Buffalo School of Engineering and Applied Sciences, Buffalo, NY, USA,CPL Associates LLC, Buffalo, NY, USA
| | - Andres Gomez-Caminero
- Worldwide Health Economic and Outcomes Research, Bristol Myers Squibb, Princeton, NJ, USA
| | - David M Jacobs
- CPL Associates LLC, Buffalo, NY, USA,Department of Pharmacy Practice, University at Buffalo School of Pharmacy and Pharmaceutical Sciences, Buffalo, NY, USA
| | | | - Igor Puzanov
- Department of Medicine, Roswell Park Comprehensive Cancer Center, Buffalo, NY, USA,Department of Medicine, University at Buffalo Jacobs School of Medicine, Buffalo, NY, USA
| | - Maya R Chilbert
- Department of Pharmacy Practice, University at Buffalo School of Pharmacy and Pharmaceutical Sciences, Buffalo, NY, USA
| | - Steven G Feuerstein
- Department of Pharmacy Practice, University at Buffalo School of Pharmacy and Pharmaceutical Sciences, Buffalo, NY, USA
| | - Yan Yatsynovich
- Department of Medicine, University at Buffalo Jacobs School of Medicine, Buffalo, NY, USA,Kettering Medical Center, Kettering, OH, USA
| | - Benjamin Switzer
- Department of Medicine, Roswell Park Comprehensive Cancer Center, Buffalo, NY, USA
| | - Jerome J Schentag
- CPL Associates LLC, Buffalo, NY, USA,Department of Pharmacy Practice, University at Buffalo School of Pharmacy and Pharmaceutical Sciences, Buffalo, NY, USA,Department of Medicine, Roswell Park Comprehensive Cancer Center, Buffalo, NY, USA,Correspondence: Jerome J Schentag, CPL Associates LLC, 73 High St. Suite 310, Buffalo, NY, 14203, USA, Tel +1 716-867-0550, Fax +1 716-633-3331, Email
| |
Collapse
|
5
|
Switzer B, Pandey MR, Valentine A, Witkiewicz A, Knudsen E, Attwood K, Tario J, Funchain P, Drabick JJ, Mohammadpour H, Ernstoff MS, Puzanov I, Repasky EA, Gandhi S. Abstract CT568: β-2 adrenergic receptor (AR): Another immune checkpoint (IC)" A phase II clinical trial of propranolol (P) with pembrolizumab (Pem) in patients with unresectable stage III and stage IV melanoma. Cancer Res 2022. [DOI: 10.1158/1538-7445.am2022-ct568] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
Background: Adrenergic stress (AS) reduces anti-tumor response by decreasing the frequency and function of CD8+ T- cells in the tumor microenvironment (TME), resulting in an increase in those with an “exhausted” phenotype.1 Additionally, AS increases the quantity and immunosuppressive phenotype of myeloid-derived suppressor cells (MDSC) in the TME.2 The data above suggests that β-2 AR acts akin to a tumorigenic IC which can be abrogated by using P, a well-known and highly cost efficient non-selective β-blocker. Synergistic activity of anti-PD-1 with P has been reported in several murine tumor models, including the B-16 OVA mouse model.3,4 A retrospective study has shown an improvement in overall survival (OS) in patients (pts) with metastatic melanoma (MM) treated concurrently with non-selective β-blocker and immunotherapy.5 This formed the basis for our phase I study of the combination of P (at dose levels; 10 mg, 20 mg BID, and 30mg BID) and pem 200 mg every 3 weeks in pts with MM. Our published phase I results found all 3 dose levels of P to be well tolerated, and an objective response was observed in 7/9 pts.6 A decrease in perceived stress score (PSS) in pts over time was observed. Intra-tumor ratio of (CD4+T cells + CD8+T-cells)/(MDSC+ Treg) >1 in the pre-treatment biopsy was predictive of treatment response. Based on the results of the phase I study, we chose P 30 mg BID as the recommended phase II dose. These results, though preliminary, strongly support our subsequent phase II clinical trial.
Methods: In this prospective, single-arm, phase II, multicenter trial, pts with unresectable stage III/IV MM and measurable disease per RECIST v1.1 will be treated with P (30 mg BID) + Pem. Pts with active CNS disease, prior therapy with PD-1/PD-L1 inhibitors, or contraindications to β-blocker are excluded. The primary objective is to evaluate the overall response rate (ORR) by immune-modified RECIST v1.1. The secondary objectives are the assessment of progression free survival and OS. A Simon two-stage design will be employed, requiring a minimum of 29 pts (17 in stage 1 and 12 in stage 2) to achieve approximately 80% power to detect a 20% increase (0.35 to 0.55) in the ORR. As an exploratory analysis, we will further report a) Baseline and on-treatment PSS and b) Chronotropic effect of P after 5-minute treadmill walk as a biomarker of response; c) Post therapy changes in the TME, with a 12 week on therapy optional biopsy d) Peripheral blood changes in T cell and MDSC subsets, and cytokines/chemokines. To date, 10 pts have been accrued on the study (NCT0384836).
Citation Format: Benjamin Switzer, Manu R. Pandey, Alexandra Valentine, Agnieszka Witkiewicz, Erik Knudsen, Kristopher Attwood, Joseph Tario, Pauline Funchain, Joseph J. Drabick, Hemn Mohammadpour, Marc S. Ernstoff, Igor Puzanov, Elizabeth A. Repasky, Shipra Gandhi. β-2 adrenergic receptor (AR): Another immune checkpoint (IC)" A phase II clinical trial of propranolol (P) with pembrolizumab (Pem) in patients with unresectable stage III and stage IV melanoma [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2022; 2022 Apr 8-13. Philadelphia (PA): AACR; Cancer Res 2022;82(12_Suppl):Abstract nr CT568.
Collapse
Affiliation(s)
| | | | | | | | - Erik Knudsen
- 1Roswell Park Comprehensive Cancer Center, Buffalo, NY
| | | | - Joseph Tario
- 1Roswell Park Comprehensive Cancer Center, Buffalo, NY
| | | | | | | | - Marc S. Ernstoff
- 5National Institutes of Health - National Cancer Institute, Bethesda, MD
| | - Igor Puzanov
- 1Roswell Park Comprehensive Cancer Center, Buffalo, NY
| | | | - Shipra Gandhi
- 1Roswell Park Comprehensive Cancer Center, Buffalo, NY
| |
Collapse
|
6
|
Switzer B, Alaklabi S, Roy AM, Attwood K, Wang C, Hamad L, Sessanna T, Nanni M, Patel Y, Puzanov I. Toxicity and outcomes of BRAF and MEK inhibitor “ramp-up” dosing strategies for patients with melanoma: A real-world institutional experience. J Clin Oncol 2022. [DOI: 10.1200/jco.2022.40.16_suppl.e21600] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
e21600 Background: Combination BRAF inhibitor (BRAFi) and MEK inhibitor (MEKi) therapy is a widely accepted treatment option for patients (pts) with BRAF-V600E mutant melanoma. Although effective, these combinations exhibit high rates of adverse events (AEs), with 44% - 66% requiring dose modification or interruption and up to 26% discontinuing due to AEs in the adjuvant setting. Enhanced tolerance to BRAFi/MEKi is expected to improve pts quality of life and potentially enhance clinical outcomes. Clinicians at Roswell Park Comprehensive Cancer Center (RPCCC) have implemented a dose escalation regimen upon initiation of BRAFi/MEKi in efforts to enhance the tolerance of these combinations for pts with BRAF-V600E mutant melanoma in the adjuvant and advanced setting. Here we present a retrospective analysis of the toxicity profiles and outcomes associated with this “ramp-up” approach. Methods: Pts presenting to RPCCC in Buffalo, NY for management of stage III or IV melanoma harboring BRAF-V600E mutations were retrospectively observed from 1/2012 to 12/2020. Pts starting BRAFi/MEKi combinations, regardless of prior lines of therapy, were included unless concurrently receiving immune checkpoint inhibition. The “ramp-up” regimen involves a 25% dose of BRAFi and 50% dose of MEKi, which is gradually increased over 4 weekly intervals until full dose is achieved. Pts started on full-dose BRAFi/MEKi were included as a comparison arm. Observations included 1) demographics, 2) treatment regimens and disruptions, 3) rate and severity of AEs, 4) outcomes including best overall response rates (ORR), progression-free survival (PFS) and overall survival (OS). Results: A total of 88 pts were analyzed (21 and 35 receiving “ramp-up” BRAFi/MEKi in the adjuvant and advanced (unresectable stage III or stage IV) setting, respectively, and 32 received full-dose (non-ramp-up) BRAFi/MEKi in the advanced setting). Demographics were similar except pts in the “ramp-up” cohorts were higher in average age (62.0 vs 56.0, p = 0.032) than pts starting at full-dose. Pts receiving adjuvant BRAFi/MEKi at “ramp-up” dosing exhibited a 4.8% (n = 1) rate of grade 3 or higher (Gr3+) AEs and 33.3% (n = 7) AE-related discontinuation rate (9.9 month average time to discontinuation). In the advanced setting, “ramp-up” vs full-dose treated pts exhibited Gr3+ AE rates of 25.7% (n = 9) vs 43.8% (n = 14; p = 0.197) and AE-related discontinuation rates of 34.4% (n = 12) vs 40.6% (n = 13; p = 0.592), respectively. Trends in overall AEs, ORR, PFS, and OS were similar to historical observations across all groups. Conclusions: This real-world analysis suggests that “ramp-up” incremental dosing of BRAFi/MEKi for pts with melanoma in the adjuvant and advanced setting may improve the tolerance and toxicity profiles of these agents without compromising their clinical efficacy, and may be of particular utility in pts with advanced age.
Collapse
Affiliation(s)
| | | | | | | | - Chong Wang
- Roswell Park Comprehensive Cancer Center, Buffalo, NY
| | | | | | - Michele Nanni
- Roswell Park Comprehensive Cancer Center, Buffalo, NY
| | - Yeliam Patel
- Roswell Park Comprehensive Cancer Center, Buffalo, NY
| | - Igor Puzanov
- Roswell Park Comprehensive Cancer Center, Buffalo, NY
| |
Collapse
|
7
|
Abstract
Cutaneous melanoma remains the most lethal of the primary cutaneous neoplasms, and although the incidence of primary melanoma continues to rise, the mortality from metastatic disease remains unchanged, in part through advances in treatment. Major developments in immunomodulatory and targeted therapies have provided robust improvements in response and survival trends that have transformed the clinical management of patients with metastatic melanoma. Additional advances in immunologic and cancer cell biology have contributed to further optimization in (1) risk stratification, (2) prognostication, (3) treatment, (4) toxicity management, and (5) surveillance approaches for patients with an advanced melanoma diagnosis. In this review, we provide a comprehensive overview of the historical and future advances regarding the translational and clinical implications of advanced melanoma and share multidisciplinary recommendations to aid clinicians in the navigation of current treatment approaches for a variety of patient cohorts.
Collapse
Affiliation(s)
- Benjamin Switzer
- Department of Medicine, Roswell Park Comprehensive Cancer Center, Buffalo, NY
| | - Igor Puzanov
- Department of Medicine, Roswell Park Comprehensive Cancer Center, Buffalo, NY
| | - Joseph J. Skitzki
- Department of Surgical Oncology, Roswell Park Comprehensive Cancer Center, Buffalo, NY
| | - Lamya Hamad
- Department of Pharmacy, Roswell Park Comprehensive Cancer Center, Buffalo, NY
| | - Marc S. Ernstoff
- ImmunoOncology Branch, Developmental Therapeutics Program, Division of Cancer Treatment and Diagnosis, National Cancer Institute, Rockville, MD,Marc S. Ernstoff, MD, National Cancer Institute, Rockville, MD 20850; e-mail:
| |
Collapse
|
8
|
Switzer B, Puzanov I. Tavokinogene telsaplasmid. DNA-based interleukin-12 (IL-12), Gene therapy, Treatment of metastatic melanoma, Treatment of triple-negative breast cancer, Treatment of head and neck cancer. DRUG FUTURE 2022. [DOI: 10.1358/dof.2022.47.6.3367991] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
|
9
|
Switzer B, Haanen J, Lorigan PC, Puzanov I, Turajlic S. Clinical and immunologic implications of COVID-19 in patients with melanoma and renal cell carcinoma receiving immune checkpoint inhibitors. J Immunother Cancer 2021; 9:e002835. [PMID: 34272309 PMCID: PMC8288220 DOI: 10.1136/jitc-2021-002835] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/21/2021] [Indexed: 12/13/2022] Open
Abstract
The clinical and immunologic implications of the SARS-CoV-2 pandemic for patients with cancer receiving systemic anticancer therapy have introduced a multitude of clinical challenges and academic controversies. This review summarizes the current evidence, discussion points, and recommendations regarding the use of immune checkpoint inhibitors (ICIs) in patients with cancer during the SARS-CoV-2 pandemic, with a focus on patients with melanoma and renal cell carcinoma (RCC). More specifically, we summarize the theoretical concepts and available objective data regarding the relationships between ICIs and the antiviral immune response, along with recommended clinical approaches to the management of melanoma and RCC patient cohorts receiving ICIs throughout the course of the COVID-19 pandemic. Additional insights regarding the use of ICIs in the setting of current and upcoming COVID-19 vaccines and broader implications toward future pandemics are also discussed.
Collapse
Affiliation(s)
- Benjamin Switzer
- Department of Medicine, Roswell Park Comprehensive Cancer Center, Buffalo, New York, USA
| | - John Haanen
- Division of Medical Oncology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Paul C Lorigan
- Division of Cancer Sciences, The University of Manchester, Manchester, UK
- Division of Medical Oncology, The Christie NHS Foundation Trust, Manchester, UK
| | - Igor Puzanov
- Department of Medicine, Roswell Park Comprehensive Cancer Center, Buffalo, New York, USA
| | - Samra Turajlic
- Renal and Skin Units, Royal Marsden NHS Foundation Trust, London, UK
- Cancer Dynamics Laboratory, The Francis Crick Institute, London, UK
| |
Collapse
|
10
|
Puzanov I, Subramanian P, Yatsynovich YV, Jacobs DM, Chilbert MR, Sharma UC, Ito F, Feuerstein SG, Stefanovic F, Switzer B, Hicar MD, Curtis AB, Spangenthal EJ, Dy GK, Ernstoff MS, Vachhani P, Page BJ, Agrawal N, Khunger A, Kapoor A, Hattoum A, Jerome SJ. Clinical characteristics, time course, treatment and outcomes of patients with immune checkpoint inhibitor-associated myocarditis. J Immunother Cancer 2021; 9:jitc-2021-002553. [PMID: 34162715 PMCID: PMC8231054 DOI: 10.1136/jitc-2021-002553] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/27/2021] [Indexed: 11/23/2022] Open
Abstract
Background Immune checkpoint inhibitors (ICI) have emerged as a front-line therapy for a variety of solid tumors. With the widespread use of these agents, immune-associated toxicities are increasingly being recognized, including fatal myocarditis. There are limited data on the outcomes and prognostic utility of biomarkers associated with ICI-associated myocarditis. Our objective was to examine the associations between clinical biomarkers of cardiomyocyte damage and mortality in patients with cancer treated with ICIs. Methods We retrospectively studied 23 patients who developed symptomatic and asymptomatic troponin elevations while receiving ICI therapy at a National Cancer Institute-designated comprehensive cancer center. We obtained serial ECGs, troponin I, and creatine kinase-MD (CK-MB), in addition to other conventional clinical biomarkers, and compared covariates between survivors and non-survivors. Results Among patients with myocarditis, higher troponin I (p=0.037) and CK-MB (p=0.034) levels on presentation correlated with progression to severe myocarditis. Higher troponin I (p=0.016), CK (p=0.013), and CK-MB (p=0.034) levels were associated with increased mortality, while the presence of advanced atrioventricular block on presentation (p=0.088) trended toward increased mortality. Weekly troponin monitoring lead to earlier hospitalization for potential myocarditis (p=0.022) and was associated with decreased time to steroid initiation (p=0.053) and improved outcomes. Conclusions Routine troponin surveillance may be helpful in predicting mortality in ICI-treated patients with cancer in the early phase of ICI therapy initiation. Early detection of troponin elevation is associated with earlier intervention and improved outcomes in ICI-associated myocarditis. The recommended assessment and diagnostic studies guiding treatment decisions are presented.
Collapse
Affiliation(s)
- Igor Puzanov
- Department of Medicine, Roswell Park Comprehensive Cancer Center, Buffalo, New York, USA
| | | | - Yan V Yatsynovich
- Department of Medicine, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York, USA
| | - David M Jacobs
- CPL Associates, Buffalo, New York, USA.,Department of Pharmacy Practice, University at Buffalo School of Pharmacy and Pharmaceutical Sciences, Buffalo, New York, USA
| | - Maya R Chilbert
- Department of Pharmacy Practice, University at Buffalo School of Pharmacy and Pharmaceutical Sciences, Buffalo, New York, USA
| | - Umesh C Sharma
- Department of Medicine, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York, USA
| | - Fumito Ito
- Center for Immunotherapy, Roswell Park Comprehensive Cancer Center, Buffalo, New York, USA.,Department of Surgical Oncology, Roswell Park Comprehensive Cancer Center, Buffalo, NY, USA.,Department of Surgery, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, NY, USA
| | - Steven G Feuerstein
- CPL Associates, Buffalo, New York, USA.,Department of Pharmacy Practice, University at Buffalo School of Pharmacy and Pharmaceutical Sciences, Buffalo, New York, USA
| | - Filip Stefanovic
- CPL Associates, Buffalo, New York, USA.,Department of Biomedical Engineering, University at Buffalo School of Engineering and Applied Sciences, Buffalo, New York, USA
| | - Benjamin Switzer
- Department of Medicine, Roswell Park Comprehensive Cancer Center, Buffalo, New York, USA
| | - Mark D Hicar
- Department of Pediatrics, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York, USA
| | - Anne B Curtis
- Department of Medicine, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York, USA
| | - Edward J Spangenthal
- Department of Medicine, Roswell Park Comprehensive Cancer Center, Buffalo, New York, USA
| | - Grace K Dy
- Department of Medicine, Roswell Park Comprehensive Cancer Center, Buffalo, New York, USA
| | - Marc S Ernstoff
- Division of Cancer Treatment and Diagnosis/Developmental Therapeutics Program, National Cancer Institute, Rockville, Maryland, USA
| | - Pankit Vachhani
- Department of Medicine, Division of Hematology and Oncology, The University of Alabama at Birmingham School of Medicine, Birmingham, Alabama, USA
| | - Brian J Page
- Department of Medicine, Roswell Park Comprehensive Cancer Center, Buffalo, New York, USA
| | - Nikhil Agrawal
- Department of Cardiovascular Medicine, The University of Texas at Houston/MD Anderson Cancer Center, Houston, Texas, USA
| | - Arjun Khunger
- Department of Internal Medicine, Memorial Hospital West, Pembroke Pines, Florida, USA
| | - Ankita Kapoor
- Department of Internal Medicine, Rochester General Hospital, Rochester, New York, USA
| | - Alexander Hattoum
- Department of Cardiovascular Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA
| | - Schentag J Jerome
- CPL Associates, Buffalo, New York, USA.,Department of Pharmacy Practice, University at Buffalo School of Pharmacy and Pharmaceutical Sciences, Buffalo, New York, USA
| |
Collapse
|
11
|
Sleiman J, Savage DJ, Switzer B, Colbert CY, Chevalier C, Neuendorf K, Harris D. Teaching residents how to break bad news: piloting a resident-led curriculum and feedback task force as a proof-of-concept study. BMJ Simul Technol Enhanc Learn 2021; 7:568-574. [DOI: 10.1136/bmjstel-2021-000897] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 06/12/2021] [Indexed: 11/04/2022]
Abstract
BackgroundBreaking bad news (BBN) is a critically important skill set for residents. Limited formal supervision and unpredictable timing of bad news delivery serve as barriers to the exchange of meaningful feedback.Purpose of studyThe goal of this educational innovation was to improve internal medicine residents’ communication skills during challenging BBN encounters. A formal BBN training programme and innovative on-demand task force were part of this two-phase project.Study designInternal medicine residents at a large academic medical centre participated in an interactive workshop focused on BBN. Workshop survey results served as a needs assessment for the development of a novel resident-led BBN task force. The task force was created to provide observations at the bedside and feedback after BBN encounters. Training of task force members incorporated video triggers and a feedback checklist. Inter-rater reliability was analysed prior to field testing, which provided data on real-world implementation challenges.Results148 residents were trained during the 2-hour communications skills workshop. Based on survey results, 73% (108 of 148) of the residents indicated enhanced confidence in BBN after participation. Field testing of the task force on a hospital ward revealed potential workflow barriers for residents requesting observations and prompted troubleshooting. Solutions were implemented based on field testing results.ConclusionsA trainee-led BBN task force and communication skills workshop is offered as an innovative model for improving residents’ interpersonal and communication skills in BBN. We believe the model is both sustainable and reproducible. Lessons learnt are offered to aid in implementation in other settings.
Collapse
|
12
|
Brateanu A, Switzer B, Scott SC, Ramsey J, Thomascik J, Nowacki AS, Colbert CY. Higher Grit Scores Associated With Less Burnout in a Cohort of Internal Medicine Residents. Am J Med Sci 2020; 360:357-362. [PMID: 32631577 DOI: 10.1016/j.amjms.2020.05.045] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Revised: 04/08/2020] [Accepted: 05/28/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND The association between grit, defined as perseverance and passion for long-term goals, and professional burnout has not been studied in internal medicine residents. Our objective was to examine whether internal medicine residents' scores on a grit scale were associated with various measures of burnout. METHODS All residents from a single internal medicine program were invited to participate in a study of grit and burnout. Grit and burnout were measured using the Short Grit Scale and modified Maslach Burnout Inventory, respectively. In addition, demographics, last In-Training Examination (ITE) score, and interest in a subspecialty were captured. RESULTS A total of 139 of 168 eligible residents (83%) participated. Emotional exhaustion and depersonalization (i.e., burn out) were identified in 63% and 42% of residents, respectively. Endorsement of emotional exhaustion was higher for residents living with family members, postgraduate year (PGY)1 and PGY2 compared with PGY3 residents, and residents scoring above the 50th percentile on the last ITE. Grit scores were higher for residents not reporting emotional exhaustion. As grit score increases, the odds of reporting emotional exhaustion significantly decreased, after adjustments for demographics, ITE scores, type of medical school, PGY level, and interest in a subspecialty (odds ratio = 0.36, 95% CI 0.15-0.84). CONCLUSIONS Grit appeared to be an independent predictor of burnout in internal medicine residents in this sample, with lower grit scores associated with higher burnout scores. By measuring grit early in residency, programs can potentially identify residents at risk for symptoms of burnout, specifically emotional exhaustion, and implement targeted interventions.
Collapse
Affiliation(s)
- Andrei Brateanu
- Department of Internal Medicine, Cleveland Clinic (AB, BS, SCS), Cleveland, Ohio; Cleveland Clinic Lerner College of Medicine of Case Western Reserve University (AB, JR, ASN, CYC), Cleveland, Ohio.
| | - Benjamin Switzer
- Department of Internal Medicine, Cleveland Clinic (AB, BS, SCS), Cleveland, Ohio
| | - Susan C Scott
- Department of Internal Medicine, Cleveland Clinic (AB, BS, SCS), Cleveland, Ohio
| | - Jennifer Ramsey
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University (AB, JR, ASN, CYC), Cleveland, Ohio; Department of Palliative Medicine, Taussig Cancer Institute, Cleveland Clinic (JR), Cleveland, Ohio
| | - James Thomascik
- Department of Quality, Cleveland Clinic (JT), Cleveland, Ohio
| | - Amy S Nowacki
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University (AB, JR, ASN, CYC), Cleveland, Ohio; Department of Quantitative Health Sciences, Cleveland Clinic (ASN), Cleveland, Ohio
| | - Colleen Y Colbert
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University (AB, JR, ASN, CYC), Cleveland, Ohio; Education Institute, Cleveland Clinic (CYC), Cleveland, Ohio
| |
Collapse
|
13
|
Switzer B, Savage DJ, Song JM, Stanek C, Funchain P. Patterns in progression from early stage melanoma to late stage melanoma: Implications for survivorship follow up. J Clin Oncol 2020. [DOI: 10.1200/jco.2020.38.15_suppl.e24055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
e24055 Background: Despite an encouraging 99% five-year survival in patients diagnosed with early-stage melanoma, a higher proportion of fatal melanomas initially present with thin ( < 1mm) rather than thick ( > 4mm) melanoma.1 Therefore, early-stage melanoma survivorship remains a topic of high interest. We examined a cohort of early-stage melanomas which progressed to stage IV to inform survivorship and risk-stratification approaches in this large, understudied population. Methods: From a retrospective single-center study of 880 consecutive melanoma patients from 2016-2020, we identified new, non- de novo diagnoses of stage IV melanoma which progressed from an initial early-stage (IA-IIA) diagnosis. Descriptive data were collected via chart review on demographics, clinical features, presentation at time of progression, and follow up prior to progression. Results: A total of 50 patients met the inclusion criterion of an initial stage IA-IIA diagnosis with subsequent progression to stage IV melanoma. Primary early stage melanomas were diagnosed an average of 6.1 years prior to metastatic disease progression, with 46% (n = 23) diagnosed within 3 years, 22% (n = 11) between 4-6 years, 12% (n = 6) between 7-10 years, 8% (n = 4) between 10-12 years, and 12% (n = 6) beyond the 12 year mark from their initial early-stage diagnosis. Average age at time of diagnosis was 57.7 (median 60, range 21-68), and 62% (n = 31) were male. The two most common early-stage diagnostic sites were lower extremities (27.5%, n = 14) and back (23.5%, n = 12). The two most common sites of metastatic disease were lung (46%, n = 23) and brain (28%, n = 14). A total of 30% (n = 15) and 34% (n = 17) of this cohort maintained follow up with oncology and dermatology, respectively, prior to their stage IV diagnosis. Symptomatic disease lead to 80% (n = 40) of stage IV diagnoses, while 14% (n = 7) were diagnosed through routine oncologic or dermatologic follow up, and the final 6% were diagnosed incidentally. Conclusions: Early stage melanoma patients who develop stage IV disease exhibit wide ranges in onset of disease progression, thus survivorship plans for this group could include a combination of early provider screening and patient education for later presentations of metastatic disease. Due to relatively common metastatic involvement of the lung and brain, a high suspicion to screen for metastatic disease with symptoms involving these organs may be appropriate.
Collapse
Affiliation(s)
| | | | - Jung Min Song
- Cleveland Clinic Taussig Cancer Institute, Cleveland, OH
| | - Carolyn Stanek
- Cleveland Clinic Taussig Cancer Institute, Cleveland, OH
| | | |
Collapse
|
14
|
Khan M, Switzer B, Lee S, Hooley J, Poole C, Chandra Kunapareddy G, Lagman R, Montero A. QIM20-127: A Team-Based Model to Promoting Hospice Utilization in High Risk Oncology Patients Through Individual Care Plan Development. J Natl Compr Canc Netw 2020. [DOI: 10.6004/jnccn.2019.7521] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Mohammad Khan
- aCleveland Clinic Foundation, Taussig Cancer Center, Cleveland, OH
| | - Benjamin Switzer
- aCleveland Clinic Foundation, Taussig Cancer Center, Cleveland, OH
| | - Sarah Lee
- aCleveland Clinic Foundation, Taussig Cancer Center, Cleveland, OH
| | - Joseph Hooley
- bCleveland Clinic Foundation, Marymount Hospital, Garfield Heights, OH
| | - Christa Poole
- aCleveland Clinic Foundation, Taussig Cancer Center, Cleveland, OH
| | | | - Ruth Lagman
- aCleveland Clinic Foundation, Taussig Cancer Center, Cleveland, OH
| | - Alberto Montero
- aCleveland Clinic Foundation, Taussig Cancer Center, Cleveland, OH
| |
Collapse
|
15
|
Switzer B, Jazieh K, Bernstein E, Harris D. Impact of an Electronic Medical Record Alert on Code Status Documentation for Hospitalized Patients With Advanced Cancer. JCO Oncol Pract 2020; 16:e257-e263. [DOI: 10.1200/jop.19.00408] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE: Cardiopulmonary resuscitation in hospitalized patients with advanced cancer is associated with high rates of morbidity and mortality. Although advance care planning (ACP) in this population improves quality, patient satisfaction, hospice use, rates of harm, and health care costs, ACP documentation rates remain low. We observed changes in ACP documentation by internal medicine residents within a tertiary hospital’s inpatient oncology service after a mandatory training module and enterprise-wide modification in electronic health medical records (EHMR). METHODS: For patients admitted to the Cleveland Clinic oncology service, this 16-week retrospective review observed resident code status (CS) documentation through admission notes and direct EHMR orders before and after implementation of an ACP training module and CS best practice alert (BPA). In addition, residents were surveyed on perceived barriers to CS documentation. RESULTS: In 535 unique admissions (244 before BPA, 291 after BPA), residents exhibited a 14.4% increase (from 47.1% to 61.5%) in admission note CS documentation and an 18.2% increase (from 12.7% to 30.9%) in CS orders at time of discharge. The most common self-reported barrier to ACP documentation was forgetting to discuss, with first-, second-, and third-year residents admitting to feeling uncomfortable in orchestrating ACP conversations at rates of 58%, 6%, and 5%, respectively. CONCLUSION: Resident ACP documentation remains suboptimal in the high-risk cohort of hospitalized patients with advanced cancer. However, rates seem to be positively influenced by online modules and EHMR-based interventions. Additional efforts to improve the current practice and culture of ACP remain a crucial aspect in the quality and safety of our approach to patient care.
Collapse
|
16
|
Lee S, Switzer B, Khan M, Pinnamaneni P, Hooley J, Kunapareddy GC, Lagman R, Poole C, Montero AJ. Implementing individualized care plans in high-risk oncology patients: A team-based model to increase hospice utilization. J Clin Oncol 2019. [DOI: 10.1200/jco.2019.37.27_suppl.64] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
64 Background: In the era of increasing therapeutic options and complexity of disease, some cancer patients (pts) continue aggressive treatment even within days of death. Previous studies report 30-66% of pts do not receive hospice or palliative services in the last month of life and many are enrolled in hospice < 3 days before death. Quality measures are endorsed by ASCO, National Quality Forum, and Oncology Care Model to increase hospice utilization. It is shown that pts enrolled in hospice have increased survival time with reduced in-hospital resources. These benefits increase the longer pts are in hospice. We hypothesize early identification of high risk pts by a multidisciplinary group and formulation of a care plan will prompt early discussion for hospice eligibility, increasing referrals to hospice and the number of days spent in hospice. Methods: As reported (ASCO 2018, Abst 6547), an Interdisciplinary Care Team (ICT) was created with palliative medicine and oncology physicians, nurses, and social workers. Twice monthly pts with high utilization over a 60-day period were identified. Care plans (CP) were created using a team based approach with parallel input from outpatient teams. CP was communicated back to the primary team. Results: 112 pts were discussed over 24 months; 39 pts died with a solid tumor malignancy and this was our study cohort. 85% pts (33/39) were referred to or had a hospice discussion and 82% pts (27/33) enrolled. 6 pts declined and 6 acutely died. Of the 27 pts that entered hospice 78% (21/27) were enrolled > 3 days and 22 % (6/27) < 3 days. Average number days in hospice was 19.7 (median 11) for all who entered hospice. In the subgroup that were enrolled for > 3 days, average number days was 25 (median 21). 62% pts (17/27) entered hospice within 60 days of ICT meeting and CP. Conclusions: Early identification of high-utilizing cancer patients along with review by ICT may correlate with early recognition of hospice eligibility, enrollment, and therefore greater number days spent in hospice. This increases hospice utilization allowing patients and families to experience the full benefit of hospice-directed care. Further interventions should be explored in optimizing transitions of care.
Collapse
Affiliation(s)
| | | | | | | | | | | | - Ruth Lagman
- Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH
| | - Christa Poole
- Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH
| | | |
Collapse
|
17
|
Switzer B, Jazieh K, Bernstein E, Khan M, Harris D. The impact of an electronic medical record alert on code status documentation for hospitalized patients with advanced cancer. J Clin Oncol 2019. [DOI: 10.1200/jco.2019.37.27_suppl.319] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
319 Background: Cardiopulmonary resuscitation in hospitalized patients with advanced cancer is associated with high rates of morbidity and mortality. Advanced care planning (ACP) in this population has exhibited improvements in quality, patient satisfaction, hospice utilization, rates of harm, and healthcare costs. We have sought to observe the changes in ACP documentation by Internal Medicine residents within a tertiary hospital’s inpatient oncology service following a mandatory caregiver training module and enterprise-wide modification in Epic, as well as identify self-reported barriers in code status documentation. Methods: Patients admitted to the Cleveland Clinic’s oncology service were retrospectively reviewed for 8 weeks before and after the implementation of an ACP caregiver training module and code-status best-practice-alert (BPA) into Epic. ACP documentation was assessed in admission notes and direct orders into Epic. In addition, Internal Medicine residents were surveyed on behaviors and perceived barriers contributing to code status documentation. Results: A total of 551 patients (181 pre and 370 post-BPA) were reviewed, exhibiting a 17.2% (44.2 to 61.4) increase of code status documentation in resident admission notes and a 17.6% (10.5 to 28.1) increase in code status orders by residents into patient Epic charts by the time of discharge. Observed 30, 60, and 90-day mortality rates from the day of admission were 18.2, 24.9, and 32%, respectively. The most common self-reported barrier to resident ACP documentation was “forgetting to discuss during the admission process”, and 58% of first-year residents admitted to feeling “uncomfortable” in orchestrating goals-of-care conversations. Conclusions: Resident ACP documentation continues to be suboptimal in the high-risk cohort of hospitalized advanced cancer patients. However, documentation rates appear to be positively influenced by large-scale and multimodal approaches. Further efforts to improve the current practice and culture of advanced directives and code status for the inpatient oncology patient population remains a crucial aspect in the quality and safety of our approach to patient care.
Collapse
Affiliation(s)
| | | | | | | | - David Harris
- Cleveland Clinic Taussig Cancer Institute, Cleveland, OH
| |
Collapse
|
18
|
Switzer B, Savage DJ, Parikh R, Song JM, Stanek C, Yurco A, Funchain P, Marcus JD. The impact of interdisciplinary shared medical appointments in newly diagnosed early-stage melanoma patients: The Cleveland Clinic experience. J Clin Oncol 2019. [DOI: 10.1200/jco.2019.37.27_suppl.230] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
230 Background: Shared Medical Appointments (SMA) serve as a unique means of improving outcomes and patient satisfaction while reducing clinic wait times and healthcare costs. Early-stage melanoma survivors may benefit from a targeted SMA. This cohort exhibits high rates of psychosocial distress, with up to 30% warranting clinical intervention (Kasparian, 2013). Additionally,numerically more melanoma deaths are related to thin ( < 1mm) melanomas than those with thick ( > 4mm) on presentation (Whitehall et al, 2015). We hypothesized that an SMA targeting early-stage melanoma patients may reducepsychologic fear and stress, as well as improve patients’ melanoma-related knowledge and adherence to their individualized care plans. Methods: The Cleveland Clinic’s Early Stage Melanoma Survivorship SMA interdisciplinary care team focused on crucial survivorship and prevention techniques, in addition to targeting modifiable behaviors for patients to collaboratively explore (format introduced ASCO Quality 2018, abst 69). A retrospective chart review assessed for demographics, participation rates, changes in depression scores, follow-up show-rates, and post-SMA survey results. Results: Of 477 early stage melanoma patients seen during the time of SMA implementation (6/2018-4/2019), only 91 (19.1%) attended oncology follow-up appointments, and 34 (7.1%) participated in an SMA. Participants expressed high rates of satisfaction and improvement in melanoma-related knowledge, whileexhibiting a > 92% show rate in subsequent oncologic and dermatologic medical appointments compared to 74% and 73%, respectively, in the non-SMA group. No significant improvement in depression and anxiety scoring was noted in SMA vs. non-SMA groups. SMA attendance was notably higher in younger (mean age 56 vs 61) and female (56% vs 30%) patient cohorts without appreciable differences in social history, marital status, or socioeconomic region. Conclusions: Survivorship SMAs for early stage melanoma patients appear to exhibit high rates of patient satisfaction, improvement in clinical knowledge, and adherence to routine dermatology and oncology follow-up appointments.
Collapse
Affiliation(s)
| | | | | | - Jung Min Song
- Cleveland Clinic Taussig Cancer Institute, Cleveland, OH
| | - Carolyn Stanek
- Cleveland Clinic Taussig Cancer Institute, Cleveland, OH
| | - Ann Yurco
- Cleveland Clinic Foundation, Cleveland, OH
| | | | | |
Collapse
|
19
|
Kunapareddy G, Switzer B, Jain P, Conces M, Chen Y, Patel B, Patel S, Pinnamaneni P, Pohlman B, Angelini DE, McCrae KR, Khorana AA. Implementation of an electronic medical record tool for early detection of deep vein thrombosis in the ambulatory oncology setting. Res Pract Thromb Haemost 2019; 3:226-233. [PMID: 31011706 PMCID: PMC6462749 DOI: 10.1002/rth2.12176] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2018] [Accepted: 11/09/2018] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Venous thromboembolism (VTE) is a major cause of morbidity, mortality, and hospitalization in cancer patients. OBJECTIVES To evaluate the feasibility of an electronic alert to identify and screen at-risk individuals and gather rates of early detection of deep vein thrombosis (DVT). PATIENTS/METHODS An alert was built into the electronic medical record based on a validated risk tool (Khorana Score [KS]) and outcomes evaluated in an initial silent phase. The alert functioned in real time to warn physicians of high-risk patients (KS ≥ 3) and suggested lower extremity screening ultrasonography in a subsequent active phase. RESULTS Of 194 consecutive patients identified as high risk in the silent phase, 14 (7.2%) developed subsequent DVT or pulmonary embolism (PE) over 90-day follow-up, with a median of 27 days. Mean 90-day emergency room (ER) visits, all-cause admissions, and length of stay (days) for patients with DVT were 1.2, 1.6, and 9.1 compared to 0.89, 0.93, and 5.1 for all patients, respectively. In the active phase, 197 consecutive alerts met inclusion criteria, and 40 patients (20.3%) received a screening ultrasound. Five (12.5%) had a DVT and were started on therapeutic anticoagulation. Of patients with alerts who had screening deferred, 13 (8.3%) were later diagnosed with DVT (median 50.5 days) and 7 (4.5%) with PE. CONCLUSION An automated alert may have value in early detection of DVT in high-risk cancer patients leading to earlier intervention, and could potentially prevent VTE-related morbidity.
Collapse
Affiliation(s)
- Girish Kunapareddy
- Department of Hematology and Medical OncologyTaussig Cancer InstituteCleveland ClinicClevelandOhio
| | | | - Prantesh Jain
- Department of Hematology/OncologyUniversity Hospitals Seidman Cancer CenterCase Comprehensive Cancer CenterClevelandOhio
| | - Madison Conces
- Department of Internal MedicineCleveland ClinicClevelandOhio
| | - Yu‐Wei Chen
- Department of Internal MedicineCleveland ClinicClevelandOhio
| | - Bhumika Patel
- Department of Hematology and Medical OncologyTaussig Cancer InstituteCleveland ClinicClevelandOhio
| | - Sagar Patel
- Department of Hematology and Medical OncologyTaussig Cancer InstituteCleveland ClinicClevelandOhio
| | - Pramod Pinnamaneni
- Department of Hematology and Medical OncologyTaussig Cancer InstituteCleveland ClinicClevelandOhio
| | - Brad Pohlman
- Department of Hematology and Medical OncologyTaussig Cancer InstituteCleveland ClinicClevelandOhio
| | - Dana E. Angelini
- Department of Hematology and Medical OncologyTaussig Cancer InstituteCleveland ClinicClevelandOhio
| | - Keith R. McCrae
- Department of Hematology and Medical OncologyTaussig Cancer InstituteCleveland ClinicClevelandOhio
| | - Alok A. Khorana
- Department of Hematology and Medical OncologyTaussig Cancer InstituteCleveland ClinicClevelandOhio
| |
Collapse
|
20
|
Kunapareddy GC, Switzer B, Pinnamaneni P, Hooley J, Varella L, Poole C, Tackitt H, Best C, Hallman C, Torres A, Lagman R, Montero AJ. Implementation of individualized care plans in high risk oncology patients: A team based model to decrease unnecessary utilization. J Clin Oncol 2018. [DOI: 10.1200/jco.2018.36.15_suppl.6547] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
| | | | | | | | - Leticia Varella
- Department of Hematology/Oncology, Weill Cornell Medicine, New York, NY
| | - Christa Poole
- Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH
| | - Helen Tackitt
- Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH
| | | | | | | | - Ruth Lagman
- Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH
| | | |
Collapse
|
21
|
|
22
|
Abstract
A study of the relationship of DDE to reproductive success of an inland breeding population of common terns. Sterna hirundo, had been carried out in 1969 and 1970 at Chip Lake, Alberta. Although a continuing decrease of DDE residues in eggs bad occurred, eggshell thickness remained unchanged. In addition, reproductive success markedly increased in 1970; however, the percentage of eggs suffering breakage did not change between years. Low correlations between DDE and eggshell thickness or weight in both years suggest that DDE is unrelated to these eggshell parameters, which in turn are not related to reproductive success in this population.
Collapse
|
23
|
Switzer B, Lewin V, Wolfe FH. Shell thickness, DDE levels in eggs, and reproductive success in common terns (Sterna hirundo), in Alberta. CAN J ZOOL 1971; 49:69-73. [PMID: 5543180 DOI: 10.1139/z71-011] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
A comprehensive study of reproductive success of an isolated colony of common terns (Sterna hirundo) reveals that DDE, the principal chlorinated hydrocarbon insecticide found in the terns, cannot be correlated to eggshell thickness. The low reproductive success observed was attributed in large measure to disappearance of eggs and nest abandonment, responsible for 76% of the failures, while cracked or broken eggs accounted for only 16%. It is suggested that the direct correlation of DDE to eggshell thickness, implicated in the reproductive failure of other avian species, may be an oversimplification in the case of the common tern.
Collapse
|