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Fritz BA, Pugazenthi S, Budelier TP, Tellor Pennington BR, King CR, Avidan MS, Abraham J. User-Centered Design of a Machine Learning Dashboard for Prediction of Postoperative Complications. Anesth Analg 2024; 138:804-813. [PMID: 37339083 PMCID: PMC10730770 DOI: 10.1213/ane.0000000000006577] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/22/2023]
Abstract
BACKGROUND Machine learning models can help anesthesiology clinicians assess patients and make clinical and operational decisions, but well-designed human-computer interfaces are necessary for machine learning model predictions to result in clinician actions that help patients. Therefore, the goal of this study was to apply a user-centered design framework to create a user interface for displaying machine learning model predictions of postoperative complications to anesthesiology clinicians. METHODS Twenty-five anesthesiology clinicians (attending anesthesiologists, resident physicians, and certified registered nurse anesthetists) participated in a 3-phase study that included (phase 1) semistructured focus group interviews and a card sorting activity to characterize user workflows and needs; (phase 2) simulated patient evaluation incorporating a low-fidelity static prototype display interface followed by a semistructured interview; and (phase 3) simulated patient evaluation with concurrent think-aloud incorporating a high-fidelity prototype display interface in the electronic health record. In each phase, data analysis included open coding of session transcripts and thematic analysis. RESULTS During the needs assessment phase (phase 1), participants voiced that (a) identifying preventable risk related to modifiable risk factors is more important than nonpreventable risk, (b) comprehensive patient evaluation follows a systematic approach that relies heavily on the electronic health record, and (c) an easy-to-use display interface should have a simple layout that uses color and graphs to minimize time and energy spent reading it. When performing simulations using the low-fidelity prototype (phase 2), participants reported that (a) the machine learning predictions helped them to evaluate patient risk, (b) additional information about how to act on the risk estimate would be useful, and (c) correctable problems related to textual content existed. When performing simulations using the high-fidelity prototype (phase 3), usability problems predominantly related to the presentation of information and functionality. Despite the usability problems, participants rated the system highly on the System Usability Scale (mean score, 82.5; standard deviation, 10.5). CONCLUSIONS Incorporating user needs and preferences into the design of a machine learning dashboard results in a display interface that clinicians rate as highly usable. Because the system demonstrates usability, evaluation of the effects of implementation on both process and clinical outcomes is warranted.
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Affiliation(s)
| | | | | | | | | | | | - Joanna Abraham
- From the Department of Anesthesiology
- Institute for Informatics, Washington University School of Medicine, St. Louis, Missouri
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2
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Khan AS, Scherer M, Panni R, Cullinan D, Martens G, Kangarga I, King CR, Benzinger R, Wellen JR, Chapman WC, Doyle MB. Total robotic liver transplant: the final frontier of minimally invasive surgery. Am J Transplant 2024:S1600-6135(24)00240-5. [PMID: 38556089 DOI: 10.1016/j.ajt.2024.03.030] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2023] [Revised: 03/20/2024] [Accepted: 03/20/2024] [Indexed: 04/02/2024]
Abstract
The use of robotic surgery in transplantation is increasing; however, robotic liver transplantation (RLT) remains a challenging undertaking. To our knowledge, this is a report of the first RLT in North America and the first RLT using a whole graft from a deceased donor in the world. This paper describes the preparation leading to the RLT and the surgical technique of the operation. The operation was performed in a 62-year-old man with hepatitis C cirrhosis and hepatocellular carcinoma with a native Model for End-Stage Liver Disease score of 10. The total console time for the operation was 8 hours 30 minutes, and the transplant hepatectomy took 3 hours 30 minutes. Warm ischemia time was 77 minutes. Biliary reconstruction was performed in a primary end-to-end fashion and took 19 minutes to complete. The patient had an uneventful recovery without early allograft dysfunction or surgical complications and continues to do well after 6-months follow-up. This paper demonstrates the feasibility of this operation in highly selected patients with chronic liver disease. Additional experience is required to fully understand the role of RLT in the future of transplant surgery. Narrated video is available at https://youtu.be/TkjDwLryd3I.
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Affiliation(s)
- Adeel S Khan
- Division of Transplant Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri, USA.
| | - Meranda Scherer
- Division of Transplant Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Roheena Panni
- Division of Transplant Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Darren Cullinan
- Division of Transplant Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Greg Martens
- Division of Transplant Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Ivan Kangarga
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Christopher R King
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Richard Benzinger
- Department of Anesthesiology, Washington University of Medicine, St Louis, MO
| | - Jason R Wellen
- Division of Transplant Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - William C Chapman
- Division of Transplant Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Majella B Doyle
- Division of Transplant Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
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Tripathi S, Fritz BA, Abdelhack M, Avidan MS, Chen Y, King CR. Multi-view representation learning for tabular data integration using inter-feature relationships. J Biomed Inform 2024; 151:104602. [PMID: 38346530 DOI: 10.1016/j.jbi.2024.104602] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Revised: 01/31/2024] [Accepted: 02/01/2024] [Indexed: 02/16/2024]
Abstract
OBJECTIVE An applied problem facing all areas of data science is harmonizing data sources. Joining data from multiple origins with unmapped and only partially overlapping features is a prerequisite to developing and testing robust, generalizable algorithms, especially in healthcare. This integrating is usually resolved using meta-data such as feature names, which may be unavailable or ambiguous. Our goal is to design methods that create a mapping between structured tabular datasets derived from electronic health records independent of meta-data. METHODS We evaluate methods in the challenging case of numeric features without reliable and distinctive univariate summaries, such as nearly Gaussian and binary features. We assume that a small set of features are a priori mapped between two datasets, which share unknown identical features and possibly many unrelated features. Inter-feature relationships are the main source of identification which we expect. We compare the performance of contrastive learning methods for feature representations, novel partial auto-encoders, mutual-information graph optimizers, and simple statistical baselines on simulated data, public datasets, the MIMIC-III medical-record changeover, and perioperative records from before and after a medical-record system change. Performance was evaluated using both mapping of identical features and reconstruction accuracy of examples in the format of the other dataset. RESULTS Contrastive learning-based methods overall performed the best, often substantially beating the literature baseline in matching and reconstruction, especially in the more challenging real data experiments. Partial auto-encoder methods showed on-par matching with contrastive methods in all synthetic and some real datasets, along with good reconstruction. However, the statistical method we created performed reasonably well in many cases, with much less dependence on hyperparameter tuning. When validating feature match output in the EHR dataset we found that some mistakes were actually a surrogate or related feature as reviewed by two subject matter experts. CONCLUSION In simulation studies and real-world examples, we find that inter-feature relationships are effective at identifying matching or closely related features across tabular datasets when meta-data is not available. Decoder architectures are also reasonably effective at imputing features without an exact match.
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Affiliation(s)
- Sandhya Tripathi
- Department of Anesthesiology, Washington University in St Louis, MO, USA.
| | - Bradley A Fritz
- Department of Anesthesiology, Washington University in St Louis, MO, USA
| | - Mohamed Abdelhack
- Krembil Centre for NeuroInformatics, Centre for Addiction and Mental Health, Toronto, Ontario, Canada
| | - Michael S Avidan
- Department of Anesthesiology, Washington University in St Louis, MO, USA
| | - Yixin Chen
- Department of Computer Science and Engineering, Washington University in St Louis, MO, USA
| | - Christopher R King
- Department of Anesthesiology, Washington University in St Louis, MO, USA
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Abdelhack M, Tripathi S, Chen Y, Avidan MS, King CR. Social Vulnerability and Surgery Outcomes: A Cross-sectional Analysis. Res Sq 2023:rs.3.rs-3580911. [PMID: 38077013 PMCID: PMC10705703 DOI: 10.21203/rs.3.rs-3580911/v1] [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] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/22/2023]
Abstract
Background Post-operative complications present a challenge to the healthcare system due to the high unpredictability of their incidence. However, the socioeconomic factors that relate to postoperative complications are still unclear as they can be heterogeneous based on communities, types of surgical services, and sex and gender. Methods In this study, we conducted a large population cross-sectional analysis of social vulnerability and the odds of various post-surgical complications. We built statistical logistic regression models of postsurgical complications with social vulnerability index as the independent variable along with sex interaction. Results We found that social vulnerability was associated with abnormal heart rhythm with socioeconomic status and housing status being the main association factors. We also found associations of the interaction of social vulnerability and female sex with an increase in odds of heart attack and surgical wound infection. Conclusions Our results indicate that social vulnerability measures such as socioeconomic status and housing conditions could be related to health outcomes. This suggests that the domain of preventive medicine should place social vulnerability as a priority to achieve its goals.
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Affiliation(s)
- Mohamed Abdelhack
- Department of Anesthesiology, Washington University School of Medicine, St. Louis MO
- Krembil Centre for Neuroinformatics, Centre for Addiction and Mental Health, Toronto, ON
| | - Sandhya Tripathi
- Department of Anesthesiology, Washington University School of Medicine, St. Louis MO
| | - Yixin Chen
- Department of Computer Science, Washington University in St. Louis, St. Louis MO
| | - Michael S Avidan
- Department of Anesthesiology, Washington University School of Medicine, St. Louis MO
| | - Christopher R King
- Department of Anesthesiology, Washington University School of Medicine, St. Louis MO
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Khan A, Killick R, Wirth D, Hoogland D, Hristova K, Ulmschneider JP, King CR, Ulmschneider MB. Masking the transmembrane region of the amyloid β precursor protein as a safe means to lower amyloid β production. Alzheimers Dement (N Y) 2023; 9:e12428. [PMID: 37954165 PMCID: PMC10632552 DOI: 10.1002/trc2.12428] [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] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Accepted: 09/19/2023] [Indexed: 11/14/2023]
Abstract
Introduction Reducing brain levels of both soluble and insoluble forms of amyloid beta (Aβ) remains the primary goal of most therapies that target Alzheimer's disease (AD). However, no treatment has so far resulted in patient benefit, and clinical trials of the most promising drug candidates have generally failed due to significant adverse effects. This highlights the need for safer and more selective ways to target and modulate Aβ biogenesis. Methods Peptide technology has advanced to allow reliable synthesis, purification, and delivery of once-challenging hydrophobic sequences. This is opening up new routes to target membrane processes associated with disease. Here we deploy a combination of atomic detail molecular dynamics (MD) simulations, living-cell Förster resonance energy transfer (FRET), and in vitro assays to elucidate the atomic-detail dynamics, molecular mechanisms, and cellular activity and selectivity of a membrane-active peptide that targets the Aβ precursor protein (APP). Results We demonstrate that Aβ biogenesis can be downregulated selectively using an APP occlusion peptide (APPOP). APPOP inhibits Aβ production in a dose-dependent manner, with a mean inhibitory concentration (IC50) of 450 nM toward exogenous APP and 50 nM toward endogenous APP in primary rat cortical neuronal cultures. APPOP does not impact the γ-secretase cleavage of Notch-1, or exhibit toxicity toward cultured primary rat neurons, suggesting that it selectively shields APP from proteolysis. Discussion Drugs targeting AD need to be given early and for very long periods to prevent the onset of clinical symptoms. This necessitates being able to target Aβ production precisely and without affecting the activity of key cellular enzymes such as γ-secretase for other substrates. Peptides offer a powerful way for targeting key pathways precisely, thereby reducing the risk of adverse effects. Here we show that protecting APP from proteolytic processing offers a promising route to safely and specifically lower Aβ burden. In particular, we show that the amyloid pathway can be targeted directly and specificically. This reduces the risk of off-target effects and paves the way for a safe prophylactic treatment.
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Affiliation(s)
| | - Richard Killick
- Living Systems InstituteUniversity of ExeterExeterUK
- King's College LondonMaurice Wohl Clinical Neuroscience InstituteCamberwellLondonUK
| | - Daniel Wirth
- Department of Materials Science and Engineering and Institute for NanoBioTechnologyJohns Hopkins UniversityBaltimoreMarylandUSA
| | | | - Kalina Hristova
- Department of Materials Science and Engineering and Institute for NanoBioTechnologyJohns Hopkins UniversityBaltimoreMarylandUSA
| | | | - Christopher R. King
- National Institutes of HealthNational Institute of Neurological Disorders and StrokeBethesdaMarylandUSA
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King CR, Gregory S, Fritz BA, Budelier TP, Ben Abdallah A, Kronzer A, Helsten DL, Torres B, McKinnon S, Goswami S, Mehta D, Higo O, Kerby P, Henrichs B, Wildes TS, Politi MC, Abraham J, Avidan MS, Kannampallil T. An Intraoperative Telemedicine Program to Improve Perioperative Quality Measures: The ACTFAST-3 Randomized Clinical Trial. JAMA Netw Open 2023; 6:e2332517. [PMID: 37738052 PMCID: PMC10517374 DOI: 10.1001/jamanetworkopen.2023.32517] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2023] [Accepted: 07/30/2023] [Indexed: 09/23/2023] Open
Abstract
Importance Telemedicine for clinical decision support has been adopted in many health care settings, but its utility in improving intraoperative care has not been assessed. Objective To pilot the implementation of a real-time intraoperative telemedicine decision support program and evaluate whether it reduces postoperative hypothermia and hyperglycemia as well as other quality of care measures. Design, Setting, and Participants This single-center pilot randomized clinical trial (Anesthesiology Control Tower-Feedback Alerts to Supplement Treatments [ACTFAST-3]) was conducted from April 3, 2017, to June 30, 2019, at a large academic medical center in the US. A total of 26 254 adult surgical patients were randomized to receive either usual intraoperative care (control group; n = 12 980) or usual care augmented by telemedicine decision support (intervention group; n = 13 274). Data were initially analyzed from April 22 to May 19, 2021, with updates in November 2022 and February 2023. Intervention Patients received either usual care (medical direction from the anesthesia care team) or intraoperative anesthesia care monitored and augmented by decision support from the Anesthesiology Control Tower (ACT), a real-time, live telemedicine intervention. The ACT incorporated remote monitoring of operating rooms by a team of anesthesia clinicians with customized analysis software. The ACT reviewed alerts and electronic health record data to inform recommendations to operating room clinicians. Main Outcomes and Measures The primary outcomes were avoidance of postoperative hypothermia (defined as the proportion of patients with a final recorded intraoperative core temperature >36 °C) and hyperglycemia (defined as the proportion of patients with diabetes who had a blood glucose level ≤180 mg/dL on arrival to the postanesthesia recovery area). Secondary outcomes included intraoperative hypotension, temperature monitoring, timely antibiotic redosing, intraoperative glucose evaluation and management, neuromuscular blockade documentation, ventilator management, and volatile anesthetic overuse. Results Among 26 254 participants, 13 393 (51.0%) were female and 20 169 (76.8%) were White, with a median (IQR) age of 60 (47-69) years. There was no treatment effect on avoidance of hyperglycemia (7445 of 8676 patients [85.8%] in the intervention group vs 7559 of 8815 [85.8%] in the control group; rate ratio [RR], 1.00; 95% CI, 0.99-1.01) or hypothermia (7602 of 11 447 patients [66.4%] in the intervention group vs 7783 of 11 672 [66.7.%] in the control group; RR, 1.00; 95% CI, 0.97-1.02). Intraoperative glucose measurement was more common among patients with diabetes in the intervention group (RR, 1.07; 95% CI, 1.01-1.15), but other secondary outcomes were not significantly different. Conclusions and Relevance In this randomized clinical trial, anesthesia care quality measures did not differ between groups, with high confidence in the findings. These results suggest that the intervention did not affect the targeted care practices. Further streamlining of clinical decision support and workflows may help the intraoperative telemedicine program achieve improvement in targeted clinical measures. Trial Registration ClinicalTrials.gov Identifier: NCT02830126.
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Affiliation(s)
- Christopher R. King
- Department of Anesthesiology, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Stephen Gregory
- Department of Anesthesiology, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Bradley A. Fritz
- Department of Anesthesiology, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Thaddeus P. Budelier
- Department of Anesthesiology, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Arbi Ben Abdallah
- Department of Anesthesiology, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Alex Kronzer
- Department of Anesthesiology, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Daniel L. Helsten
- Department of Anesthesiology, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Brian Torres
- Department of Anesthesiology, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Sherry McKinnon
- Department of Anesthesiology, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Shreya Goswami
- Department of Anesthesiology, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Divya Mehta
- Department of Anesthesiology, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Omokhaye Higo
- Department of Anesthesiology, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Paul Kerby
- Department of Anesthesiology, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Bernadette Henrichs
- Department of Anesthesiology, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Troy S. Wildes
- Department of Anesthesiology, University of Nebraska Medical Center, Omaha
| | - Mary C. Politi
- Department of Anesthesiology, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Joanna Abraham
- Department of Anesthesiology, Washington University School of Medicine in St Louis, St Louis, Missouri
- Institute for Informatics, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Michael S. Avidan
- Department of Anesthesiology, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Thomas Kannampallil
- Department of Anesthesiology, Washington University School of Medicine in St Louis, St Louis, Missouri
- Institute for Informatics, Washington University School of Medicine in St Louis, St Louis, Missouri
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Fritz BA, King CR, Mehta D, Somerville E, Kronzer A, Ben Abdallah A, Wildes T, Avidan MS, Lenze EJ, Stark S. Association of a Perioperative Multicomponent Fall Prevention Intervention With Falls and Quality of Life After Elective Inpatient Surgical Procedures. JAMA Netw Open 2022; 5:e221938. [PMID: 35275166 PMCID: PMC8917421 DOI: 10.1001/jamanetworkopen.2022.1938] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
IMPORTANCE Falls after elective inpatient surgical procedures are common and have physical, emotional, and financial consequences. Close interactions between patients and health care teams before and after surgical procedures may offer opportunities to address modifiable risk factors associated with falls. OBJECTIVE To assess whether a multicomponent intervention that incorporates education, home medication review, and home safety assessment is associated with reductions in the incidence of falls after elective inpatient surgical procedures. DESIGN, SETTING, AND PARTICIPANTS This prospective propensity score-matched cohort study was a prespecified secondary analysis of data from the Electroencephalography Guidance of Anesthesia to Alleviate Geriatric Syndromes (ENGAGES) randomized clinical trial, which was conducted at a single academic medical center between January 16, 2015, and May 7, 2018. Patients in the intervention group of the present study were enrolled in either arm of the ENGAGES clinical trial. Patients in the control group were selected from the Systematic Assessment and Targeted Improvement of Services Following Yearly Surgical Outcomes Surveys prospective observational cohort study, which created a registry of patient-reported postoperative outcomes at the same single center. The propensity score-matched cohort in the present study included 1396 patients (698 pairs) selected from a pool of 2013 eligible patients. All patients underwent elective surgical procedures with general anesthesia and had a hospital stay of 2 or more days. Data were analyzed from January 2, 2020, to January 11, 2022. INTERVENTIONS The multicomponent safety intervention (offered to all patients in the ENGAGES clinical trial) included patient education on fall prevention techniques, home medication review by a geriatric psychiatrist (with communication of recommended changes to the surgeon), a self-administered home safety assessment, and targeted occupational therapy home visits with home hazard removal (offered to patients with a preoperative history of falls). MAIN OUTCOMES AND MEASURES The primary outcome was patient-reported falls within 1 year after an elective inpatient surgical procedure. The secondary outcome was quality of life 1 year after an elective surgical procedure, which was measured using the physical and mental composite summary scores on the Veterans RAND 12-item health survey (score range, 0-100 points, with 0 indicating lowest quality of life and 100 indicating highest quality of life). RESULTS Among 1396 patients, the median age was 69 years (IQR, 64-75 years), and 739 patients (52.9%) were male. With regard to race, 5 patients (0.4%) were Asian, 97 (6.9%) were Black or African American, 2 (0.1%) were Native Hawaiian or Pacific Islander, 1237 (88.6%) were White, 3 (0.2%) were of other race, and 52 (3.7%) were of unknown race; with regard to ethnicity, 12 patients (0.9%) were Hispanic or Latino, 1335 (95.6%) were non-Hispanic or non-Latino, and 49 (3.5%) were of unknown ethnicity. Adherence to individual intervention components was modest (from 22.9% for completion of the self-administered home safety assessment to 28.2% for implementation of the geriatric psychiatrist's recommended medication changes). Falls within 1 year after surgical procedures were reported by 228 of 698 patients (32.7%) in the intervention group and 225 of 698 patients (32.2%) in the control group. No significant difference was found in falls between the 2 groups (standardized risk difference, 0.4%; 95% CI, -4.5% to 5.3%). After adjusting for preoperative quality of life, patients in the intervention group had higher physical composite summary scores (3.8 points; 95% CI, 2.4-5.1 points) and higher mental composite summary scores (5.7 points; 95% CI, 4.7-6.7 points) at 1 year compared with patients in the control group. CONCLUSIONS AND RELEVANCE In this cohort study, a multicomponent safety intervention was not associated with reductions in falls within the first year after an elective surgical procedure; however, an increase in quality of life at 1 year was observed. These results suggest a need for other interventions, such as those designed to increase adherence, to lower the incidence of falls after surgical procedures.
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Affiliation(s)
- Bradley A. Fritz
- Department of Anesthesiology, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Christopher R. King
- Department of Anesthesiology, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Divya Mehta
- Department of Anesthesiology, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Emily Somerville
- Program in Occupational Therapy, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Alex Kronzer
- Department of Anesthesiology, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Arbi Ben Abdallah
- Department of Anesthesiology, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Troy Wildes
- Department of Anesthesiology, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Michael S. Avidan
- Department of Anesthesiology, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Eric J. Lenze
- Department of Psychiatry, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Susan Stark
- Program in Occupational Therapy, Washington University School of Medicine in St Louis, St Louis, Missouri
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Fritz BA, King CR, Mickle AM, Wildes TS, Budelier TP, Oberhaus J, Park D, Maybrier HR, Ben Abdallah A, Kronzer A, McKinnon SL, Torres BA, Graetz TJ, Emmert DA, Palanca BJ, Stevens TW, Stark SL, Lenze EJ, Avidan MS. Effect of electroencephalogram-guided anaesthesia administration on 1 yr mortality: 1 yr follow-up of a randomised clinical trial. Br J Anaesth 2021; 127:386-395. [PMID: 34243940 DOI: 10.1016/j.bja.2021.04.036] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Revised: 03/25/2021] [Accepted: 04/23/2021] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Intraoperative EEG suppression duration has been associated with postoperative delirium and mortality. In a clinical trial testing anaesthesia titration to avoid EEG suppression, the intervention did not decrease the incidence of postoperative delirium, but was associated with reduced 30 day mortality. The present study evaluated whether the EEG-guided anaesthesia intervention continued to be associated with reduced 1 yr mortality. METHODS This manuscript reports 1 yr follow-up of patients from a single-centre RCT, including a post-hoc secondary outcome (1 yr mortality) in addition to pre-specified secondary outcomes. The trial included patients aged 60 yr or older undergoing surgery with general anaesthesia between January 2015 and May 2018. Patients were randomised to receive EEG-guided anaesthesia or usual care. The previously reported primary outcome was postoperative delirium. The outcome of the current study was all-cause 1 yr mortality. RESULTS Of the 1232 patients enrolled, 614 patients were randomised to EEG-guided anaesthesia and 618 patients to usual care. One year mortality was 57/591 (9.6%) in the guided group and 62/601 (10.3%) in the usual-care group. No significant difference in mortality was observed (adjusted absolute risk difference, -0.7%; 99.5% confidence interval, -5.8% to 4.3%; P=0.68). CONCLUSIONS An EEG-guided anaesthesia intervention aiming to decrease duration of EEG suppression during surgery did not significantly decrease 1 yr mortality. These findings, in the context of other studies, do not provide supportive evidence for EEG-guided anaesthesia to prevent intermediate term postoperative death. CLINICAL TRIAL REGISTRATION NCT02241655.
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Affiliation(s)
- Bradley A Fritz
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, MO, USA.
| | - Christopher R King
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, MO, USA
| | - Angela M Mickle
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, MO, USA
| | - Troy S Wildes
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, MO, USA
| | - Thaddeus P Budelier
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, MO, USA
| | - Jordan Oberhaus
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, MO, USA
| | - Daniel Park
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, MO, USA
| | - Hannah R Maybrier
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, MO, USA
| | - Arbi Ben Abdallah
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, MO, USA
| | - Alex Kronzer
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, MO, USA
| | - Sherry L McKinnon
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, MO, USA
| | - Brian A Torres
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, MO, USA
| | - Thomas J Graetz
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, MO, USA
| | - Daniel A Emmert
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, MO, USA
| | - Ben J Palanca
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, MO, USA
| | - Tracey W Stevens
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, MO, USA
| | - Susan L Stark
- Program in Occupational Therapy, Washington University School of Medicine, St. Louis, MO, USA
| | - Eric J Lenze
- Department of Psychiatry, Washington University School of Medicine, St. Louis, MO, USA
| | - Michael S Avidan
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, MO, USA
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Xue B, Li D, Lu C, King CR, Wildes T, Avidan MS, Kannampallil T, Abraham J. Use of Machine Learning to Develop and Evaluate Models Using Preoperative and Intraoperative Data to Identify Risks of Postoperative Complications. JAMA Netw Open 2021; 4:e212240. [PMID: 33783520 PMCID: PMC8010590 DOI: 10.1001/jamanetworkopen.2021.2240] [Citation(s) in RCA: 85] [Impact Index Per Article: 28.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
IMPORTANCE Postoperative complications can significantly impact perioperative care management and planning. OBJECTIVES To assess machine learning (ML) models for predicting postoperative complications using independent and combined preoperative and intraoperative data and their clinically meaningful model-agnostic interpretations. DESIGN, SETTING, AND PARTICIPANTS This retrospective cohort study assessed 111 888 operations performed on adults at a single academic medical center from June 1, 2012, to August 31, 2016, with a mean duration of follow-up based on the length of postoperative hospital stay less than 7 days. Data analysis was performed from February 1 to September 31, 2020. MAIN OUTCOMES AND MEASURES Outcomes included 5 postoperative complications: acute kidney injury (AKI), delirium, deep vein thrombosis (DVT), pulmonary embolism (PE), and pneumonia. Patient and clinical characteristics available preoperatively, intraoperatively, and a combination of both were used as inputs for 5 candidate ML models: logistic regression, support vector machine, random forest, gradient boosting tree (GBT), and deep neural network (DNN). Model performance was compared using the area under the receiver operating characteristic curve (AUROC). Model interpretations were generated using Shapley Additive Explanations by transforming model features into clinical variables and representing them as patient-specific visualizations. RESULTS A total of 111 888 patients (mean [SD] age, 54.4 [16.8] years; 56 915 [50.9%] female; 82 533 [73.8%] White) were included in this study. The best-performing model for each complication combined the preoperative and intraoperative data with the following AUROCs: pneumonia (GBT), 0.905 (95% CI, 0.903-0.907); AKI (GBT), 0.848 (95% CI, 0.846-0.851); DVT (GBT), 0.881 (95% CI, 0.878-0.884); PE (DNN), 0.831 (95% CI, 0.824-0.839); and delirium (GBT), 0.762 (95% CI, 0.759-0.765). Performance of models that used only preoperative data or only intraoperative data was marginally lower than that of models that used combined data. When adding variables with missing data as input, AUROCs increased from 0.588 to 0.905 for pneumonia, 0.579 to 0.848 for AKI, 0.574 to 0.881 for DVT, 0.5 to 0.831 for PE, and 0.6 to 0.762 for delirium. The Shapley Additive Explanations analysis generated model-agnostic interpretation that illustrated significant clinical contributors associated with risks of postoperative complications. CONCLUSIONS AND RELEVANCE The ML models for predicting postoperative complications with model-agnostic interpretation offer opportunities for integrating risk predictions for clinical decision support. Such real-time clinical decision support can mitigate patient risks and help in anticipatory management for perioperative contingency planning.
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Affiliation(s)
- Bing Xue
- Department of Electrical and Systems Engineering, McKelvey School of Engineering, Washington University in St Louis, St Louis, Missouri
| | - Dingwen Li
- Department of Computer Science and Engineering, McKelvey School of Engineering, Washington University in St Louis, St Louis, Missouri
| | - Chenyang Lu
- Department of Electrical and Systems Engineering, McKelvey School of Engineering, Washington University in St Louis, St Louis, Missouri
- Department of Computer Science and Engineering, McKelvey School of Engineering, Washington University in St Louis, St Louis, Missouri
- Institute for Informatics, Washington University in St Louis School of Medicine, St Louis, Missouri
| | - Christopher R. King
- Department of Anesthesiology, Washington University in St Louis School of Medicine, St Louis, Missouri
| | - Troy Wildes
- Department of Anesthesiology, Washington University in St Louis School of Medicine, St Louis, Missouri
| | - Michael S. Avidan
- Department of Anesthesiology, Washington University in St Louis School of Medicine, St Louis, Missouri
| | - Thomas Kannampallil
- Institute for Informatics, Washington University in St Louis School of Medicine, St Louis, Missouri
- Department of Anesthesiology, Washington University in St Louis School of Medicine, St Louis, Missouri
| | - Joanna Abraham
- Institute for Informatics, Washington University in St Louis School of Medicine, St Louis, Missouri
- Department of Anesthesiology, Washington University in St Louis School of Medicine, St Louis, Missouri
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10
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Abstract
BACKGROUND Handoffs or care transitions from the operating room (OR) to intensive care unit (ICU) are fragmented and vulnerable to communication errors. Although protocols and checklists for standardization help reduce errors, such interventions suffer from limited sustainability. An unexplored aspect is the potential role of developing personalized postoperative transition interventions using artificial intelligence (AI)-generated risks. OBJECTIVES This study was aimed to (1) identify factors affecting sustainability of handoff standardization, (2) utilize a human-centered approach to develop design ideas and prototyping requirements for a sustainable handoff intervention, and (3) explore the potential role for AI risk assessment during handoffs. METHODS We conducted four design workshops with 24 participants representing OR and ICU teams at a large medical academic center. Data collection phases were (1) open-ended questions, (2) closed card sorting of handoff information elements, and (3) scenario-based design ideation and prototyping for a handoff intervention. Data were analyzed using thematic analysis. Card sorts were further tallied to characterize handoff information elements as core, flexible, or unnecessary. RESULTS Limited protocol awareness among clinicians and lack of an interdisciplinary electronic health record (EHR)-integrated handoff intervention prevented long-term sustainability of handoff standardization. Clinicians argued for a handoff intervention comprised of core elements (included for all patients) and flexible elements (tailored by patient condition and risks). They also identified unnecessary elements that could be omitted during handoffs. Similarities and differences in handoff intervention requirements among physicians and nurses were noted; in particular, clinicians expressed divergent views on the role of AI-generated postoperative risks. CONCLUSION Current postoperative handoff interventions focus largely on standardization of information transfer and handoff processes. Our design approach allowed us to visualize accurate models of user expectations for effective interdisciplinary communication. Insights from this study point toward EHR-integrated, "flexibly standardized" care transition interventions that can automatically generate a patient-centered summary and risk-based report.
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Affiliation(s)
- Joanna Abraham
- Department of Anesthesiology, School of Medicine, Washington University, St. Louis, Missouri, United States.,Institute for Informatics, Department of Medicine, School of Medicine, Washington University in St. Louis, Missouri, United States
| | - Christopher R King
- Department of Anesthesiology, School of Medicine, Washington University, St. Louis, Missouri, United States
| | - Alicia Meng
- Department of Anesthesiology, School of Medicine, Washington University, St. Louis, Missouri, United States
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11
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Gregory SH, King CR, Ben Abdallah A, Kronzer A, Wildes TS. Abnormal preoperative cognitive screening in aged surgical patients: a retrospective cohort analysis. Br J Anaesth 2020; 126:230-237. [PMID: 32943193 DOI: 10.1016/j.bja.2020.08.026] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Revised: 07/24/2020] [Accepted: 08/09/2020] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Preoperative cognitive dysfunction has been associated with adverse postoperative outcomes. There are limited data characterising the epidemiology of preoperative cognitive dysfunction in older surgical patients. METHODS This retrospective cohort included all patients ≥65 yr old seen at the Washington University preoperative clinic between January 2013 and June 2018. Cognitive screening was performed using the Short-Blessed Test (SBT) and Eight-Item Interview to Differentiate Aging and Dementia (AD8) screen. The primary outcome of abnormal cognitive screening was defined as SBT score ≥5 or AD8 score ≥2. Multivariable logistic regression was used to identify associated factors. RESULTS Overall, 21 666 patients ≥65 yr old completed screening during the study period; 23.5% (n=5099) of cognitive screens were abnormal. Abnormal cognitive screening was associated with increasing age, decreasing BMI, male sex, non-Caucasian race, decreased functional independence, and decreased metabolic functional capacity. Patients with a history of stroke or transient ischaemic attack, chronic obstructive pulmonary disease, diabetes mellitus, hepatic cirrhosis, and heavy alcohol use were also more likely to have an abnormal cognitive screen. Predictive modelling showed no combination of patient factors was able to reliably identify patients who had a <10% probability of abnormal cognitive screening. CONCLUSIONS Routine preoperative cognitive screening of unselected aged surgical patients often revealed deficits consistent with cognitive impairment or dementia. Such deficits were associated with increased age, decreased function, decreased BMI, and several common medical comorbidities. Further research is necessary to characterise the clinical implications of preoperative cognitive dysfunction and identify interventions that may reduce related postoperative complications.
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Affiliation(s)
- Stephen H Gregory
- Department of Anesthesiology, Washington University in St. Louis, St. Louis, MO, USA.
| | - Christopher R King
- Department of Anesthesiology, Washington University in St. Louis, St. Louis, MO, USA
| | - Arbi Ben Abdallah
- Department of Anesthesiology, Washington University in St. Louis, St. Louis, MO, USA
| | - Alex Kronzer
- Department of Anesthesiology, Washington University in St. Louis, St. Louis, MO, USA
| | - Troy S Wildes
- Department of Anesthesiology, Washington University in St. Louis, St. Louis, MO, USA
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12
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Fritz BA, King CR, Ben Abdallah A, Lin N, Mickle AM, Budelier TP, Oberhaus J, Park D, Maybrier HR, Wildes TS, Avidan MS, Apakama G, Aranake-Chrisinger A, Bolzenius J, Burton J, Cui V, Emmert DA, Goswami S, Graetz TJ, Gupta S, Jordan K, Kronzer A, McKinnon SL, Muench MR, Murphy MR, Palanca BJ, Patel A, Spencer JW, Stevens TW, Strutz P, Tedeschi CM, Torres BA, Trammel ER, Upadhyayula RT, Winter AC, Jacobsohn E, Fong T, Gallagher J, Inouye SK, Schmitt EM, Somerville E, Stark S, Lenze EJ, Melby SJ, Tappenden J. Preoperative Cognitive Abnormality, Intraoperative Electroencephalogram Suppression, and Postoperative Delirium: A Mediation Analysis. Anesthesiology 2020; 132:1458-1468. [PMID: 32032096 DOI: 10.1097/aln.0000000000003181] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Postoperative delirium is a common complication that hinders recovery after surgery. Intraoperative electroencephalogram suppression has been linked to postoperative delirium, but it is unknown if this relationship is causal or if electroencephalogram suppression is merely a marker of underlying cognitive abnormalities. The hypothesis of this study was that intraoperative electroencephalogram suppression mediates a nonzero portion of the effect between preoperative abnormal cognition and postoperative delirium. METHODS This is a prespecified secondary analysis of the Electroencephalography Guidance of Anesthesia to Alleviate Geriatric Syndromes (ENGAGES) randomized trial, which enrolled patients age 60 yr or older undergoing surgery with general anesthesia at a single academic medical center between January 2015 and May 2018. Patients were randomized to electroencephalogram-guided anesthesia or usual care. Preoperative abnormal cognition was defined as a composite of previous delirium, Short Blessed Test cognitive score greater than 4 points, or Eight Item Interview to Differentiate Aging and Dementia score greater than 1 point. Duration of intraoperative electroencephalogram suppression was defined as number of minutes with suppression ratio greater than 1%. Postoperative delirium was detected via Confusion Assessment Method or chart review on postoperative days 1 to 5. RESULTS Among 1,113 patients, 430 patients showed evidence of preoperative abnormal cognition. These patients had an increased incidence of postoperative delirium (151 of 430 [35%] vs.123 of 683 [18%], P < 0.001). Of this 17.2% total effect size (99.5% CI, 9.3 to 25.1%), an absolute 2.4% (99.5% CI, 0.6 to 4.8%) was an indirect effect mediated by electroencephalogram suppression, while an absolute 14.8% (99.5% CI, 7.2 to 22.5%) was a direct effect of preoperative abnormal cognition. Randomization to electroencephalogram-guided anesthesia did not change the mediated effect size (P = 0.078 for moderation). CONCLUSIONS A small portion of the total effect of preoperative abnormal cognition on postoperative delirium was mediated by electroencephalogram suppression. Study precision was too low to determine if the intervention changed the mediated effect.
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Affiliation(s)
- Bradley A Fritz
- From the Department of Anesthesiology (B.A.F., C.R.K., A.B., A.M.M., T.P.B., J.O., D.P., H.R.M., T.S.W., M.S.A) the Division of Biostatistics (N.L.), Washington University School of Medicine, St. Louis, Missouri the Department of Mathematics and Statistics, Washington University in St. Louis, St. Louis, Missouri (N.L.). Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri Department of Anesthesiology, University of Manitoba, Winnipeg, Canada Department of Medicine, Beth Israel-Deaconess Medical Center, Boston, Massachusetts Department of Medicine, Beth Israel-Deaconess Medical Center, Boston, Massachusetts Department of Medicine, Beth Israel-Deaconess Medical Center, Boston, Massachusetts Department of Medicine, Beth Israel-Deaconess Medical Center, Boston, Massachusetts Department of Occupational Therapy, Washington University School of Medicine, St. Louis, Missouri Department of Occupational Therapy, Washington University School of Medicine, St. Louis, Missouri Department of Psychiatry, Washington University School of Medicine, St. Louis, Missouri Department of Surgery, Washington University School of Medicine, St. Louis, Missouri Department of Surgery, Washington University School of Medicine, St. Louis, Missouri
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13
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Nickols NG, Ganapathy E, Nguyen C, Kane N, Lin L, Diaz-Perez S, Nazarian R, Mathis C, Felix C, Basehart V, Zomorodian N, Kwak J, Kishan AU, King CR, Kupelian PA, Rettig MB, Steinberg ML, Cao M, Knudsen BS, Chu FI, Romero T, Elashoff D, Reiter RE, Schaue D. The intraprostatic immune environment after stereotactic body radiotherapy is dominated by myeloid cells. Prostate Cancer Prostatic Dis 2020; 24:135-139. [PMID: 32647353 PMCID: PMC7794088 DOI: 10.1038/s41391-020-0249-8] [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] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Revised: 06/08/2020] [Accepted: 06/30/2020] [Indexed: 01/05/2023]
Abstract
BACKGROUND: Hundreds of ongoing clinical trials combine radiation therapy, mostly delivered as stereotactic body radiotherapy (SBRT), with immune checkpoint blockade. However, our understanding of the effect of radiotherapy on the intratumoral immune balance is inadequate, hindering the optimal design of trials that combine radiation therapy with immunotherapy. Our objective was to characterize the intratumoral immune balance of the malignant prostate after SBRT in patients. METHODS: 16 patients with high-risk, non-metastatic prostate cancer at comparable Gleason Grade disease underwent radical prostatectomy with (n=9) or without (n=7) neoadjuvant SBRT delivered in 3 fractions of 8 Gy over 5 days completed 2 weeks before surgery. Freshly resected prostate specimens were processed to obtain single-cell suspensions, and immune-phenotyped for major lymphoid and myeloid cell subsets by staining with 2 separate 14-antibody panels and multicolor flow cytometry analysis. RESULTS: Malignant prostates two weeks after SBRT had an immune infiltrate dominated by myeloid cells, whereas malignant prostates without preoperative treatment were more lymphoid-biased (myeloid CD45+ cells 48.4 ± 19.7% vs 25.4 ± 7.0%; adjusted p value=0.11; and CD45+ lymphocytes 51.6 ± 19.7% vs 74.5 ± 7.0%; p=0.11; CD3+ T cells 35.2 ± 23.8% vs 60.9 ± 9.7%; p=0.12; mean±SD). CONCLUSION: SBRT drives a significant lymphoid to myeloid shift in the prostate tumor immune infiltrate. This may be of interest when combining SBRT with immunotherapies, particularly in prostate cancer.
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Affiliation(s)
- Nicholas G Nickols
- Radiation Oncology at UCLA, Los Angeles, CA, USA.,Urology at UCLA, Los Angeles, CA, USA.,VA Greater Los Angeles Healthcare System, Radiation Therapy Service, Los Angeles, CA, USA.,UCLA Jonsson Compressive Cancer Center, Los Angeles, CA, USA
| | | | | | | | - Lin Lin
- Urology at UCLA, Los Angeles, CA, USA
| | | | | | | | - Care Felix
- Radiation Oncology at UCLA, Los Angeles, CA, USA
| | | | | | - Jae Kwak
- Urology at UCLA, Los Angeles, CA, USA
| | - Amar U Kishan
- Radiation Oncology at UCLA, Los Angeles, CA, USA.,Urology at UCLA, Los Angeles, CA, USA.,UCLA Jonsson Compressive Cancer Center, Los Angeles, CA, USA
| | | | | | - Matthew B Rettig
- Urology at UCLA, Los Angeles, CA, USA.,UCLA Jonsson Compressive Cancer Center, Los Angeles, CA, USA
| | - Michael L Steinberg
- Radiation Oncology at UCLA, Los Angeles, CA, USA.,UCLA Jonsson Compressive Cancer Center, Los Angeles, CA, USA
| | - Minsong Cao
- Radiation Oncology at UCLA, Los Angeles, CA, USA
| | - Beatrice S Knudsen
- Pathology and Laboratory Medicine and Biomedical Sciences at Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Fang-I Chu
- Radiation Oncology at UCLA, Los Angeles, CA, USA
| | - Tahmineh Romero
- Division of General Internal Medicine and Health Services Research at UCLA, Los Angeles, CA, USA
| | - David Elashoff
- UCLA Jonsson Compressive Cancer Center, Los Angeles, CA, USA.,Division of General Internal Medicine and Health Services Research at UCLA, Los Angeles, CA, USA
| | - Robert E Reiter
- Urology at UCLA, Los Angeles, CA, USA.,UCLA Jonsson Compressive Cancer Center, Los Angeles, CA, USA
| | - Dörthe Schaue
- Radiation Oncology at UCLA, Los Angeles, CA, USA. .,UCLA Jonsson Compressive Cancer Center, Los Angeles, CA, USA.
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14
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Maranhao B, Scott AW, Scott AR, Maeng J, Song Z, Baddigam R, King CR, McCormick M, Kangrga I, Guffey R. Probability of fit failure with reuse of N95 mask respirators. Br J Anaesth 2020; 125:e322-e324. [PMID: 32682553 PMCID: PMC7318975 DOI: 10.1016/j.bja.2020.06.023] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Revised: 06/15/2020] [Accepted: 06/16/2020] [Indexed: 11/10/2022] Open
Affiliation(s)
- Bruno Maranhao
- Department of Anaesthesiology, Washington University School of Medicine, Saint Louis, MO, USA
| | - Alex W Scott
- Department of Anaesthesiology, Washington University School of Medicine, Saint Louis, MO, USA
| | - Alex R Scott
- School of Medicine, Washington University School of Medicine, Saint Louis, MO, USA
| | - Jooyoung Maeng
- Department of Anaesthesiology, Washington University School of Medicine, Saint Louis, MO, USA
| | - Ziyan Song
- Department of Anaesthesiology, Washington University School of Medicine, Saint Louis, MO, USA
| | - Ramya Baddigam
- Department of Anaesthesiology, Washington University School of Medicine, Saint Louis, MO, USA
| | - Christopher R King
- Department of Anaesthesiology, Washington University School of Medicine, Saint Louis, MO, USA
| | - Molly McCormick
- Department of Anaesthesiology, Washington University School of Medicine, Saint Louis, MO, USA
| | - Ivan Kangrga
- Department of Anaesthesiology, Washington University School of Medicine, Saint Louis, MO, USA
| | - Ryan Guffey
- Department of Anaesthesiology, Washington University School of Medicine, Saint Louis, MO, USA.
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15
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Parikh NR, Kishan AU, Kane N, Diaz-Perez S, Ganapathy E, Nazarian R, Felix C, Mathis C, Bradley M, Sachdeva A, Wyatt B, Basehart V, Zomorodian N, Lin L, King CR, Kupelian PA, Rettig MB, Steinberg ML, Cao M, Knudsen BS, Elashoff D, Schaue D, Reiter RE, Nickols NG. Phase 1 Trial of Stereotactic Body Radiation Therapy Neoadjuvant to Radical Prostatectomy for Patients With High-Risk Prostate Cancer. Int J Radiat Oncol Biol Phys 2020; 108:930-935. [PMID: 32562839 DOI: 10.1016/j.ijrobp.2020.06.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2020] [Revised: 05/19/2020] [Accepted: 06/04/2020] [Indexed: 11/17/2022]
Abstract
PURPOSE This study aimed to evaluate the feasibility and safety of prostate stereotactic body radiation therapy (SBRT) neoadjuvant to radical prostatectomy (RP) in a phase 1 trial. The primary endpoint was treatment completion rate without severe acute surgical complications. Secondary endpoints included patient-reported quality of life and physician-reported toxicities. METHODS AND MATERIALS Patients with nonmetastatic high-risk or locally advanced prostate cancer received 24 Gy in 3 fractions to the prostate and seminal vesicles over 5 days, completed 2 weeks before RP. Patients with pN1 disease were treated after multidisciplinary discussion and shared decision making. Patient-reported quality of life (International Prostate Symptom Score and Expanded Prostate Cancer Index Composite 26-item version questionnaires) and physician-reported toxicity (Common Terminology Criteria for Adverse Events, version 4.03) were assessed before SBRT, immediately before surgery, and at 3-month intervals for 1 year. RESULTS Twelve patients were enrolled, and 11 completed treatment (1 patient had advanced disease on prostate-specific membrane antigen positron emission tomography after enrollment but before treatment). There were no significant surgical complications. After RP, 2 patients underwent additional radiation therapy to nodes with androgen suppression for pN1 disease. Median follow-up after completion of treatment was 20.1 months, with 9 of 11 patients having a follow-up period of >12 months. Two patients had biochemical recurrence (prostate-specific antigen ≥0.05) within the first 12 months, with an additional 2 patients found to have biochemical recurrence after the 12-month period. The highest Common Terminology Criteria for Adverse Events genitourinary grades were 0, 1, 2, and 3 (n = 1, 4, 4, and 2, respectively), and the highest gastrointestinal grades were 0, 1, and 2 (n = 9, 1, and 1, respectively). At 12 months, incontinence was the only grade ≥2 toxicity. One and 2 of 9 patients had grade 2 and 3 incontinence, respectively. On the Expanded Prostate Cancer Index Composite (26-item version), the mean/median changes in scores from baseline to 12 months were -32.8/-31.1 for urinary incontinence, -1.6/-6.2 for urinary irritative/obstructive, -2.1/0 for bowel, -34.4/-37.5 for sexual function, and -10.6/-2.5 for hormonal. The mean/median change in International Prostate Symptom Score from baseline to 12 months was 0.5/0.5. CONCLUSIONS RP after neoadjuvant SBRT appears to be feasible and safe at the dose tested. The severity of urinary incontinence may be higher than RP alone.
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Affiliation(s)
- Neil R Parikh
- Department of Radiation Oncology, University of California Los Angeles, Los Angeles, California
| | - Amar U Kishan
- Department of Radiation Oncology, University of California Los Angeles, Los Angeles, California; Department of Urology, University of California Los Angeles, Los Angeles, California
| | - Nathanael Kane
- Department of Radiation Oncology, University of California Los Angeles, Los Angeles, California
| | - Silvia Diaz-Perez
- Department of Radiation Oncology, University of California Los Angeles, Los Angeles, California
| | - Ekambaram Ganapathy
- Department of Radiation Oncology, University of California Los Angeles, Los Angeles, California
| | - Ramin Nazarian
- Department of Urology, University of California Los Angeles, Los Angeles, California
| | - Carol Felix
- Department of Radiation Oncology, University of California Los Angeles, Los Angeles, California
| | - Colleen Mathis
- Department of Urology, University of California Los Angeles, Los Angeles, California
| | - Margaret Bradley
- Department of Urology, University of California Los Angeles, Los Angeles, California
| | - Ankush Sachdeva
- Department of Urology, University of California Los Angeles, Los Angeles, California
| | - Bashir Wyatt
- Department of Urology, University of California Los Angeles, Los Angeles, California
| | - Vince Basehart
- Department of Radiation Oncology, University of California Los Angeles, Los Angeles, California
| | - Nazy Zomorodian
- Department of Urology, University of California Los Angeles, Los Angeles, California
| | - Lin Lin
- Department of Urology, University of California Los Angeles, Los Angeles, California
| | - Christopher R King
- Department of Radiation Oncology, University of California Los Angeles, Los Angeles, California
| | - Patrick A Kupelian
- Department of Radiation Oncology, University of California Los Angeles, Los Angeles, California
| | - Matthew B Rettig
- Department of Urology, University of California Los Angeles, Los Angeles, California
| | - Michael L Steinberg
- Department of Radiation Oncology, University of California Los Angeles, Los Angeles, California
| | - Minsong Cao
- Department of Radiation Oncology, University of California Los Angeles, Los Angeles, California
| | - Beatrice S Knudsen
- Departments of Pathology and Laboratory Medicine and Biomedical Sciences, Cedars-Sinai Medical Center, Los Angeles, California
| | - David Elashoff
- Department of Medicine, University of California Los Angeles, Los Angeles, California
| | - Dorthe Schaue
- Department of Radiation Oncology, University of California Los Angeles, Los Angeles, California
| | - Robert E Reiter
- Department of Urology, University of California Los Angeles, Los Angeles, California
| | - Nicholas G Nickols
- Department of Radiation Oncology, University of California Los Angeles, Los Angeles, California; Department of Urology, University of California Los Angeles, Los Angeles, California; Radiation Therapy Service, VA Greater Los Angeles Healthcare System, Los Angeles, California.
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16
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Valle LF, Ruan D, Dang A, Levin-Epstein RG, Patel AP, Weidhaas JB, Nickols NG, Lee PP, Low DA, Qi XS, King CR, Steinberg ML, Kupelian PA, Cao M, Kishan AU. Development and Validation of a Comprehensive Multivariate Dosimetric Model for Predicting Late Genitourinary Toxicity Following Prostate Cancer Stereotactic Body Radiotherapy. Front Oncol 2020; 10:786. [PMID: 32509582 PMCID: PMC7251156 DOI: 10.3389/fonc.2020.00786] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [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] [Received: 12/06/2019] [Accepted: 04/22/2020] [Indexed: 12/31/2022] Open
Abstract
Purpose: Dosimetric predictors of toxicity after Stereotactic Body Radiation Therapy (SBRT) are not well-established. We sought to develop a multivariate model that predicts Common Terminology Criteria for Adverse Events (CTCAE) late grade 2 or greater genitourinary (GU) toxicity by interrogating the entire dose-volume histogram (DVH) from a large cohort of prostate cancer patients treated with SBRT on prospective trials. Methods: Three hundred and thirty-nine patients with late CTCAE toxicity data treated with prostate SBRT were identified and analyzed. All patients received 40 Gy in five fractions, every other day, using volumetric modulated arc therapy. For each patient, we examined 910 candidate dosimetric features including maximum dose, volumes of each organ [CTV, organs at risk (OARs)], V100%, and other granular volumetric/dosimetric indices at varying volumetric/dosimetric values from the entire DVH as well as ADT use to model and predict toxicity from SBRT. Training and validation subsets were generated with 90 and 10% of the patients in our cohort, respectively. Predictive accuracy was assessed by calculating the area under the receiver operating curve (AROC). Univariate analysis with student t-test was first performed on each candidate DVH feature. We subsequently performed advanced machine-learning multivariate analyses including classification and regression tree (CART), random forest, boosted tree, and multilayer neural network. Results: Median follow-up time was 32.3 months (range 3–98.9 months). Late grade ≥2 GU toxicity occurred in 20.1% of patients in our series. No single dosimetric parameter had an AROC for predicting late grade ≥2 GU toxicity on univariate analysis that exceeded 0.599. Optimized CART modestly improved prediction accuracy, with an AROC of 0.601, whereas other machine learning approaches did not improve upon univariate analyses. Conclusions: CART-based machine learning multivariate analyses drawing from 910 dosimetric features and ADT use modestly improves upon clinical prediction of late GU toxicity alone, yielding an AROC of 0.601. Biologic predictors may enhance predictive models for identifying patients at risk for late toxicity after SBRT.
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Affiliation(s)
- Luca F Valle
- Department of Radiation Oncology, University of California, Los Angeles, Los Angeles, CA, United States
| | - Dan Ruan
- Department of Radiation Oncology, University of California, Los Angeles, Los Angeles, CA, United States
| | - Audrey Dang
- Department of Radiation Oncology, University of California, Los Angeles, Los Angeles, CA, United States
| | - Rebecca G Levin-Epstein
- Department of Radiation Oncology, University of California, Los Angeles, Los Angeles, CA, United States
| | - Ankur P Patel
- David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, United States
| | - Joanne B Weidhaas
- Department of Radiation Oncology, University of California, Los Angeles, Los Angeles, CA, United States
| | - Nicholas G Nickols
- Department of Radiation Oncology, University of California, Los Angeles, Los Angeles, CA, United States
| | - Percy P Lee
- Department of Radiation Oncology, University of California, Los Angeles, Los Angeles, CA, United States
| | - Daniel A Low
- Department of Radiation Oncology, University of California, Los Angeles, Los Angeles, CA, United States
| | - X Sharon Qi
- Department of Radiation Oncology, University of California, Los Angeles, Los Angeles, CA, United States
| | - Christopher R King
- Department of Radiation Oncology, University of California, Los Angeles, Los Angeles, CA, United States
| | - Michael L Steinberg
- Department of Radiation Oncology, University of California, Los Angeles, Los Angeles, CA, United States
| | - Patrick A Kupelian
- Department of Radiation Oncology, University of California, Los Angeles, Los Angeles, CA, United States
| | - Minsong Cao
- Department of Radiation Oncology, University of California, Los Angeles, Los Angeles, CA, United States
| | - Amar U Kishan
- Department of Radiation Oncology, University of California, Los Angeles, Los Angeles, CA, United States
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Pan X, Levin-Epstein R, Huang J, Ruan D, King CR, Kishan AU, Steinberg ML, Qi XS. Dosimetric predictors of patient-reported toxicity after prostate stereotactic body radiotherapy: Analysis of full range of the dose-volume histogram using ensemble machine learning. Radiother Oncol 2020; 148:181-188. [PMID: 32388444 DOI: 10.1016/j.radonc.2020.04.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2019] [Revised: 03/22/2020] [Accepted: 04/10/2020] [Indexed: 12/31/2022]
Abstract
BACKGROUND AND PURPOSE This study aims to evaluate the associations between dosimetric parameters and patient-reported outcomes, and to identify latent dosimetric parameters that most correlate with acute and subacute patient-reported urinary and rectal toxicity after prostate stereotactic body radiotherapy (SBRT) using machine learning methods. MATERIALS AND METHODS Eighty-six patients who underwent prostate SBRT (40 Gy in 5 fractions) were included. Patient-reported health-related quality of life (HRQOL) outcomes were derived from bowel and bladder symptom scores on the Expanded Prostate Cancer Index Composite (EPIC-26) at 3 and 12 months post-SBRT. We utilized ensemble machine learning (ML) to interrogate the entire dose-volume histogram (DVH) to evaluate relationships between dose-volume parameters and HRQOL changes. The latent predictive dosimetric parameters that were most associated with HRQOL changes in urinary and rectal function were thus identified. An external cohort of 26 prostate SBRT patients was acquired to further test the predictive models. RESULTS Bladder dose-volume metrics strongly predicted patient-reported urinary irritative and incontinence symptoms (area under the curves [AUCs] of 0.79 and 0.87, respectively) at 12 months. Maximum bladder dose, bladder V102.5%, bladder volume, and conformity indices (V50/VPTV and V100/VPTV) were most predictive of HRQOL changes in both urinary domains. No strong rectal toxicity dosimetric association was identified (AUC = 0.64). CONCLUSION We demonstrated the application of advanced ML methods to identify a set of dosimetric variables that most highly correlated with patient-reported urinary HRQOL. DVH quantities identified with these methods may be used to achieve outcome-driven planning objectives to further reduce patient-reported toxicity with prostate SBRT.
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Affiliation(s)
- Xiaoying Pan
- School of Computer Science and Technology, Xi'an University of Posts & Telecommunications, China; Shaanxi Key Laboratory of Network Data Analysis and Intelligent Processing, Xi'an University of Posts and Telecommunications, China; Department of Radiation Oncology, University of California Los Angeles, Los Angeles, United States
| | - Rebecca Levin-Epstein
- Department of Radiation Oncology, University of California Los Angeles, Los Angeles, United States
| | - Jiahao Huang
- School of Computer Science and Technology, Xi'an University of Posts & Telecommunications, China
| | - Dan Ruan
- Department of Radiation Oncology, University of California Los Angeles, Los Angeles, United States
| | - Christopher R King
- Department of Radiation Oncology, University of California Los Angeles, Los Angeles, United States
| | - Amar U Kishan
- Department of Radiation Oncology, University of California Los Angeles, Los Angeles, United States
| | - Michael L Steinberg
- Department of Radiation Oncology, University of California Los Angeles, Los Angeles, United States
| | - X Sharon Qi
- Department of Radiation Oncology, University of California Los Angeles, Los Angeles, United States.
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Levin-Epstein R, Qiao-Guan G, Juarez JE, Shen Z, Steinberg ML, Ruan D, Valle L, Nickols NG, Kupelian PA, King CR, Cao M, Kishan AU. Clinical Assessment of Prostate Displacement and Planning Target Volume Margins for Stereotactic Body Radiotherapy of Prostate Cancer. Front Oncol 2020; 10:539. [PMID: 32373529 PMCID: PMC7177009 DOI: 10.3389/fonc.2020.00539] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [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] [Received: 10/17/2019] [Accepted: 03/25/2020] [Indexed: 12/25/2022] Open
Abstract
Purpose: To assess the optimal planning target volume (PTV) margins for stereotactic body radiotherapy (SBRT) of prostate cancer based on inter- and intra-fractional prostate motion determined from daily image guidance. Methods and Materials: Two hundred and five patients who were enrolled on two prospective studies of SBRT (8 Gy × 5 fractions) for localized prostate cancer treated at a single institution between 2012 and 2017 had complete inter- and intra-fractional shift data available. All patients had scheduled kilovoltage planar imaging during SBRT with rigid registration to intraprostatic fiducials prior to each of four half-arcs delivered per fraction, as well as cone beam CT verification of anatomy prior to each fraction. Inter- and intra- fractional shift data were obtained to estimate the required PTV margins based on the classic van Herk formula. Inter- and intra-fractional motion were compared between patients with and without severe toxicities using the independent two-sample Wilcoxon test. Results: The margins required to account for inter-fractional motion were estimated to be 0.99, 1.52, and 1.45 cm in lateral (LR), longitudinal (SI), and vertical (AP) directions, respectively. The margins required to account for intra-fractional motion were estimated to be 0.19, 0.27, and 0.31 cm in LR, SI and AP directions, respectively. Large intra-fractional shifts were mostly observed in the SI and AP directions, with 2.0 and 5.4% of patients experiencing average intra-fractional motion >3 mm in the SI and AP directions, respectively, compared with none experiencing mean shifts >3 mm in the LR direction. Six patients experienced grade 3 gastrointestinal or genitourinary toxicity. There were no significant differences in mean inter- or intra-fractional motion in any of the cardinal directions compared to patients without severe toxicity (inter-fractional p = 0.46-0.99, intra-fractional p = 0.10-0.84). Conclusion: The inter- and intra-fractional margins estimated from this study are in line with prior reported values. Intra-fractional prostate motion was generally small with larger margins required for the SI and AP directions, notably just slightly exceeding the commonly used 3 mm posterior PTV margin even with realignment between half-arcs. Development of severe toxicity was not significantly associated with the degree of inter- or intra-fractional motion.
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Affiliation(s)
- Rebecca Levin-Epstein
- Department of Radiation Oncology, University of California, Los Angeles, Los Angeles, CA, United States
| | - George Qiao-Guan
- Case Western Reserve School of Medicine, Cleveland, OH, United States
| | - Jesus E. Juarez
- Department of Radiation Oncology, University of California, Los Angeles, Los Angeles, CA, United States
| | - Zhouhuizi Shen
- Department of Radiation Oncology, University of California, Los Angeles, Los Angeles, CA, United States
| | - Michael L. Steinberg
- Department of Radiation Oncology, University of California, Los Angeles, Los Angeles, CA, United States
| | - Dan Ruan
- Department of Radiation Oncology, University of California, Los Angeles, Los Angeles, CA, United States
| | - Luca Valle
- Department of Radiation Oncology, University of California, Los Angeles, Los Angeles, CA, United States
| | - Nicholas G. Nickols
- Department of Radiation Oncology, University of California, Los Angeles, Los Angeles, CA, United States
- Department of Radiation Oncology, VA Greater Los Angeles Healthcare System, Los Angeles, CA, United States
- Department of Urology, University of California, Los Angeles, Los Angeles, CA, United States
| | - Patrick A. Kupelian
- Department of Radiation Oncology, University of California, Los Angeles, Los Angeles, CA, United States
| | - Christopher R. King
- Department of Radiation Oncology, University of California, Los Angeles, Los Angeles, CA, United States
| | - Minsong Cao
- Department of Radiation Oncology, University of California, Los Angeles, Los Angeles, CA, United States
| | - Amar U. Kishan
- Department of Radiation Oncology, University of California, Los Angeles, Los Angeles, CA, United States
- Department of Urology, University of California, Los Angeles, Los Angeles, CA, United States
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19
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King CR, Fritz BA, Escallier K, Ju YES, Lin N, McKinnon S, Avidan MS, Palanca BJ. Association Between Preoperative Obstructive Sleep Apnea and Preoperative Positive Airway Pressure With Postoperative Intensive Care Unit Delirium. JAMA Netw Open 2020; 3:e203125. [PMID: 32310284 PMCID: PMC7171553 DOI: 10.1001/jamanetworkopen.2020.3125] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
IMPORTANCE Obstructive sleep apnea has been associated with postoperative delirium, which predisposes patients to major adverse outcomes. Positive airway pressure may be an effective intervention to reduce delirium in this population. OBJECTIVES To determine if preoperative obstructive sleep apnea is associated with postoperative incident delirium in the intensive care unit and if preoperative positive airway pressure adherence modifies the association. DESIGN, SETTING, AND PARTICIPANTS A retrospective single-center cohort study was conducted at a US tertiary hospital from November 1, 2012, to August 31, 2016, among 7792 patients admitted to an intensive care unit who underwent routine Confusion Assessment Method for the intensive care unit after major surgery. Patients were adults who had undergone a complete preoperative anesthesia assessment, received general anesthesia, underwent at least 1 delirium assessment, were not delirious preoperatively, and had a preoperative intensive care unit stay of less than 6 days. Statistical analysis was conducted from August 20, 2019, to January 11, 2020. EXPOSURES Self-reported obstructive sleep apnea, billing diagnosis of obstructive sleep apnea, or STOP-BANG (Snoring, Tiredness, Observed Apnea, Blood Pressure, Body Mass Index, Age, Neck Circumference and Gender) questionnaire score greater than 4, as well as self-reported use of preoperative positive airway pressure. MAIN OUTCOMES AND MEASURES Delirium within 7 days of surgery. RESULTS A total of 7792 patients (4562 men; mean [SD] age, 59.2 [15.3] years) met inclusion criteria. Diagnosed or likely obstructive sleep apnea occurred in 2044 patients (26%), and delirium occurred in 3637 patients (47%). The proportion of patients with incident delirium was lower among those with obstructive sleep apnea than those without (897 of 2044 [44%] vs 2740 of 5748 [48%]; unadjusted risk difference, -0.04; 99% credible interval [CrI], -0.07 to -0.00). Positive airway pressure adherence had minimal association with delirium (risk difference, -0.00; 99% CrI, -0.09 to 0.09). Doubly robust confounder adjustment eliminated the association between obstructive sleep apnea and delirium (risk difference, -0.01; 99% CrI, -0.04 to 0.03) and did not change that of preoperative positive airway pressure adherence (risk difference, -0.00, 99% CrI, -0.07 to 0.07). The results were consistent across multiple sensitivity analyses. CONCLUSIONS AND RELEVANCE After risk adjustment, this study found no association between obstructive sleep apnea and postoperative delirium in the context of usual care in the intensive care unit, with 99% CrIs excluding clinically meaningful associations. With limited precision, no association was found between positive airway pressure adherence and delirium. Selection bias and measurement error limit the validity and generalizability of these observational associations; however, they suggest that interventions targeting sleep apnea and positive airway pressure are unlikely to have a meaningful association with postoperative intensive care unit delirium.
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Affiliation(s)
- Christopher R. King
- Department of Anesthesiology, Washington University in St Louis, St Louis, Missouri
| | - Bradley A. Fritz
- Department of Anesthesiology, Washington University in St Louis, St Louis, Missouri
| | - Krisztina Escallier
- Department of Anesthesiology and Perioperative Medicine, University of California Los Angeles
| | - Yo-El S. Ju
- Department of Neurology, Washington University in St Louis, St Louis, Missouri
| | - Nan Lin
- Department of Mathematics and Statistics, Washington University in St Louis, St Louis, Missouri
| | - Sherry McKinnon
- Department of Anesthesiology, Washington University in St Louis, St Louis, Missouri
| | - Michael S. Avidan
- Department of Anesthesiology, Washington University in St Louis, St Louis, Missouri
| | - Ben Julian Palanca
- Department of Anesthesiology, Washington University in St Louis, St Louis, Missouri
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Cui Z, Fritz BA, King CR, Avidan MS, Chen Y. A Factored Generalized Additive Model for Clinical Decision Support in the Operating Room. AMIA Annu Symp Proc 2020; 2019:343-352. [PMID: 32308827 PMCID: PMC7153157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Logistic regression (LR) is widely used in clinical prediction because it is simple to deploy and easy to interpret. Nevertheless, being a linear model, LR has limited expressive capability and often has unsatisfactory performance. Generalized additive models (GAMs) extend the linear model with transformations of input features, though feature interaction is not allowed for all GAM variants. In this paper, we propose a factored generalized additive model (F-GAM) to preserve the model interpretability for targeted features while allowing a rich model for interaction with features fixed within the individual. We evaluate F-GAM on prediction of two targets, postoperative acute kidney injury and acute respiratory failure, from a single-center database. We find superior model performance of F-GAM in terms of AUPRC and AUROC compared to several other GAM implementations, random forests, support vector machine, and a deep neural network. We find that the model interpretability is good with results with high face validity.
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Affiliation(s)
- Zhicheng Cui
- Department of Computer Science and Engineering, Washington University in St Louis, St Louis, MO
| | - Bradley A Fritz
- Department of Anesthesiology, Washington University in St Louis, St Louis, MO
| | - Christopher R King
- Department of Anesthesiology, Washington University in St Louis, St Louis, MO
| | - Michael S Avidan
- Department of Anesthesiology, Washington University in St Louis, St Louis, MO
| | - Yixin Chen
- Department of Computer Science and Engineering, Washington University in St Louis, St Louis, MO
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21
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Nickols NG, Ganapathy E, Nguyen C, Kane N, Lin L, Diaz-Perez S, Nazarian R, Kishan AU, King CR, Kupelian P, Rettig M, Steinberg ML, Cao M, Knudsen B, Chu FI, Elashoff D, Reiter RE, Schaue D. The intraprostatic immune balance after prostate SBRT in patients. J Clin Oncol 2020. [DOI: 10.1200/jco.2020.38.6_suppl.339] [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
339 Background: Stereotactic Body Radiotherapy (SBRT) delivers high dose per fraction radiotherapy to targets with high precision. Such hypofractionated RT appears to act as an immune adjuvant, altering the tumor infiltrating immune landscape and enriching it for lymphocytes as numerous preclinical investigations would suggest. Based on this hypothesis, hundreds of ongoing trials listed in clinicaltrials.gov currently test the combination of RT (largely SBRT) with various immunotherapies. However, studies directly measuring the representation of infiltrating immune cells after SBRT in patients are few and far between and none exist in the context of prostate cancer. We therefore sought to interrogate the tumor-immune interface after prostate SBRT using fresh tissue in patients. Methods: Fresh prostate tissue from patients (N=10) enrolled in a clinical trial of prostate SBRT (three fractions of 8 Gy directed to the prostate and seminal vesicles) in the neoadjuvant setting two weeks prior to radical prostatectomy was subjected to multicolor flow cytometry and compared to that of Gleason Grade and T stage matched controls who did not undergo neoadjuvant therapy. Results: With a threshold of significance level of 0.05 for unadjusted p-values, using two-sided two-sample t-test, myeloid cells and particularly CD14+/hiCD16+DR+ intermediate monocytes/macrophages were enriched, while lymphocytes, including T cells and CD56+16− NK cells were decreased in SBRT-treated prostates as compared to unirradiated controls. Conclusions: The immune infiltrates in prostates two weeks after SBRT demonstrates a significant lymphoid to myeloid shift consistent with a tumor microenvironment after SBRT that is likely immunosuppressive beyond what can be targeted through the PD-1/L1 or CTLA-4 axis alone. This may have implications for the design of immunotherapy trials, especially in prostate cancer, that test SBRT in combination with immunotherapies.
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Affiliation(s)
| | | | | | | | - Lin Lin
- Cleveland Clinic, Cleveland, OH
| | | | | | | | | | - Patrick Kupelian
- University of California Los Angeles Health Syst, Los Angeles, CA
| | - Matthew Rettig
- UCLA Jonsson Comprehensive Cancer Center, Los Angeles, CA
| | | | - Minsong Cao
- University of California, Los Angeles, Los Angeles, CA
| | | | - Fang-I Chu
- University of California Los Angeles, Los Angeles, CA
| | | | - Robert Evan Reiter
- Institute of Urologic Oncology, University of California, Los Angeles, Los Angeles, CA
| | - Dörthe Schaue
- UCLA David Geffen School of Medicine, Los Angeles, CA
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22
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Kishan AU, Wang X, Seiferheld W, Collette L, Sandler KA, Sandler HM, Bolla M, Maingon P, De Reijke T, Hanks GE, Nickols NG, Rettig M, Drakaki A, Reiter RE, Spratt DE, Kupelian PA, Steinberg ML, King CR. Association of Gleason Grade With Androgen Deprivation Therapy Duration and Survival Outcomes: A Systematic Review and Patient-Level Meta-analysis. JAMA Oncol 2019; 5:91-96. [PMID: 30326032 DOI: 10.1001/jamaoncol.2018.3732] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Importance Androgen deprivation therapy (ADT) improves survival outcomes in patients with high-risk prostate cancer (PCa) treated with radiotherapy (RT). Whether this benefit differs between patients with Gleason grade group (GG) 4 (formerly Gleason score 8) and GG 5 (formerly Gleason score 9-10) disease remains unknown. Objective To determine whether the effectiveness of ADT duration varies between patients with GG 4 vs GG 5 PCa. Design, Setting, and Participants Traditional and network individual patient data meta-analyses of 992 patients (593 GG 4 and 399 GG 5) who were enrolled in 6 randomized clinical trials were carried out. Main Outcomes and Measures Multivariable Cox proportional hazard models were used to obtain hazard ratio (HR) estimates of ADT duration effects on overall survival (OS) and distant metastasis-free survival (DMFS). Cause-specific competing risk models were used to estimate HRs for cancer-specific survival (CSS). The interaction of ADT with GS was incorporated into the multivariable models. Traditional and network meta-analysis frameworks were used to compare outcomes of patients treated with RT alone, short-term ADT (STADT), long-term ADT (LTADT), and lifelong ADT. Results Five hundred ninety-three male patients (mean age, 70 years; range, 43-88 years) with GG 4 and 399 with GG 5 were identified. Median follow-up was 6.4 years. Among GG 4 patients, LTADT and STADT improved OS over RT alone (HR, 0.43; 95% CI, 0.26-0.70 and HR, 0.59; 95% CI, 0.38-0.93, respectively; P = .03 for both), whereas lifelong ADT did not (HR, 0.84; 95% CI, 0.54-1.30; P = .44). Among GG 5 patients, lifelong ADT improved OS (HR, 0.48; 95% CI, 0.31-0.76; P = .04), whereas neither LTADT nor STADT did (HR, 0.80; 95% CI, 0.45-1.44 and HR, 1.13; 95% CI, 0.69-1.87; P = .45 and P = .64, respectively). Among all patients, and among those receiving STADT, GG 5 patients had inferior OS compared with GG 4 patients (HR, 1.25; 95% CI, 1.07-1.47 and HR, 1.40; 95% CI, 1.05-1.88, respectively; P = .02). There was no significant OS difference between GG 5 and GG 4 patients receiving LTADT or lifelong ADT (HR, 1.21; 95% CI, 0.89-1.65 and HR, 0.85; 95% CI, 0.53-1.37; P = .23 and P = .52, respectively). Conclusions and Relevance These data suggest that prolonged durations of ADT improve survival outcomes in both GG 4 disease and GG 5 disease, albeit with different optimal durations. Strategies to maintain the efficacy of ADT while minimizing its duration (potentially with enhanced potency agents) should be investigated.
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Affiliation(s)
- Amar U Kishan
- Department of Radiation Oncology, University of California, Los Angeles, Los Angeles.,Department of Urology, University of California, Los Angeles, Los Angeles
| | - Xiaoyan Wang
- Department of General Internal Medicine and Health Services Research, University of California, Los Angeles, Los Angeles
| | - Wendy Seiferheld
- NRG Oncology Statistics and Data Management Center, Philadelphia, Pennsylvania
| | - Laurence Collette
- European Organization for Research and Treatment of Cancer Headquarters, Brussels, Belgium
| | - Kiri A Sandler
- Department of Radiation Oncology, University of California, Los Angeles, Los Angeles
| | - Howard M Sandler
- Department of Radiation Oncology, Cedars Sinai, Los Angeles, California
| | - Michel Bolla
- Department of Radiation Oncology, Centre Hospitalier Universitaire de Grenoble, Grenoble, France
| | - Philippe Maingon
- Centre Georges-François Leclerc, Dijon, Sorbonne Université Paris, Paris, France
| | - Theo De Reijke
- Amsterdam University Medical Centers, Academic Medical Center, Amsterdam, the Netherlands
| | - Gerald E Hanks
- Department of Radiation Oncology, Fox Chase Cancer Center, Philadelphia, Pennsylvania
| | - Nicholas G Nickols
- Department of Radiation Oncology, University of California, Los Angeles, Los Angeles.,Department of Radiation Oncology, Veteran Affairs Greater Los Angeles Healthcare System, Los Angeles, California
| | - Matthew Rettig
- Division of Hematology and Oncology, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles.,Division of Hematology and Oncology, VA Greater Los Angeles Healthcare System, Los Angeles, Los Angeles, California
| | - Alexandra Drakaki
- Division of Hematology and Oncology, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles
| | - Robert E Reiter
- Department of Urology, University of California, Los Angeles, Los Angeles
| | - Daniel E Spratt
- Department of Radiation Oncology, University of Michigan, Ann Arbor
| | - Patrick A Kupelian
- Department of Radiation Oncology, University of California, Los Angeles, Los Angeles
| | - Michael L Steinberg
- Department of Radiation Oncology, University of California, Los Angeles, Los Angeles
| | - Christopher R King
- Department of Radiation Oncology, University of California, Los Angeles, Los Angeles
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King CR, Abraham J, Kannampallil TG, Fritz BA, Ben Abdallah A, Chen Y, Henrichs B, Politi M, Torres BA, Mickle A, Budelier TP, McKinnon S, Gregory S, Kheterpal S, Wildes T, Avidan MS. Protocol for the Effectiveness of an Anesthesiology Control Tower System in Improving Perioperative Quality Metrics and Clinical Outcomes: the TECTONICS randomized, pragmatic trial. F1000Res 2019; 8:2032. [PMID: 32201572 PMCID: PMC7076336 DOI: 10.12688/f1000research.21016.1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/12/2019] [Indexed: 01/25/2023] Open
Abstract
Introduction: Perioperative morbidity is a public health priority, and surgical volume is increasing rapidly. With advances in technology, there is an opportunity to research the utility of a telemedicine-based control center for anesthesia clinicians that assess risk, diagnoses negative patient trajectories, and implements evidence-based practices. Objectives: The primary objective of this trial is to determine whether an anesthesiology control tower (ACT) prevents clinically relevant adverse postoperative outcomes including 30-day mortality, delirium, respiratory failure, and acute kidney injury. Secondary objectives are to determine whether the ACT improves perioperative quality of care metrics including management of temperature, mean arterial pressure, mean airway pressure with mechanical ventilation, blood glucose, anesthetic concentration, antibiotic redosing, and efficient fresh gas flow. Methods and analysis: We are conducting a single center, randomized, controlled, phase 3 pragmatic clinical trial. A total of 58 operating rooms are randomized daily to receive support from the ACT or not. All adults (eighteen years and older) undergoing surgical procedures in these operating rooms are included and followed until 30 days after their surgery. Clinicians in operating rooms randomized to ACT support receive decision support from clinicians in the ACT. In operating rooms randomized to no intervention, the current standard of anesthesia care is delivered. The intention-to-treat principle will be followed for all analyses. Differences between groups will be presented with 99% confidence intervals; p-values <0.005 will be reported as providing compelling evidence, and p-values between 0.05 and 0.005 will be reported as providing suggestive evidence. Registration: TECTONICS is registered on ClinicalTrials.gov, NCT03923699; registered on 23 April 2019.
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Affiliation(s)
- Christopher R. King
- Department of Anesthesiology, Washington University in St Louis, St Louis, MO, 63110, USA
| | - Joanna Abraham
- Department of Anesthesiology, Washington University in St Louis, St Louis, MO, 63110, USA
- Institute for Informatics, Washington University in St Louis, St Louis, MO, 63110, USA
| | - Thomas G. Kannampallil
- Department of Anesthesiology, Washington University in St Louis, St Louis, MO, 63110, USA
- Institute for Informatics, Washington University in St Louis, St Louis, MO, 63110, USA
| | - Bradley A. Fritz
- Department of Anesthesiology, Washington University in St Louis, St Louis, MO, 63110, USA
| | - Arbi Ben Abdallah
- Department of Anesthesiology, Washington University in St Louis, St Louis, MO, 63110, USA
| | - Yixin Chen
- Department of Computer Science and Engineering, Washington University in St Louis, St Louis, MO, 63110, USA
| | - Bernadette Henrichs
- Department of Anesthesiology, Washington University in St Louis, St Louis, MO, 63110, USA
| | - Mary Politi
- Department of Surgery, Washington University in St Louis, St Louis, MO, 63110, USA
| | - Brian A. Torres
- Department of Anesthesiology, Washington University in St Louis, St Louis, MO, 63110, USA
| | - Angela Mickle
- Department of Anesthesiology, Washington University in St Louis, St Louis, MO, 63110, USA
| | - Thaddeus P. Budelier
- Department of Anesthesiology, Washington University in St Louis, St Louis, MO, 63110, USA
| | - Sherry McKinnon
- Department of Anesthesiology, Washington University in St Louis, St Louis, MO, 63110, USA
| | - Stephen Gregory
- Department of Anesthesiology, Washington University in St Louis, St Louis, MO, 63110, USA
| | - Sachin Kheterpal
- Department of Anesthesiology, University of Michigan, Ann Arbor, MI, 48109, USA
| | - Troy Wildes
- Department of Anesthesiology, Washington University in St Louis, St Louis, MO, 63110, USA
| | - Michael S. Avidan
- Department of Anesthesiology, Washington University in St Louis, St Louis, MO, 63110, USA
| | - TECTONICS Research Group
- Department of Anesthesiology, Washington University in St Louis, St Louis, MO, 63110, USA
- Institute for Informatics, Washington University in St Louis, St Louis, MO, 63110, USA
- Department of Computer Science and Engineering, Washington University in St Louis, St Louis, MO, 63110, USA
- Department of Surgery, Washington University in St Louis, St Louis, MO, 63110, USA
- Department of Anesthesiology, University of Michigan, Ann Arbor, MI, 48109, USA
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Kishan AU, Chu FI, King CR, Seiferheld W, Spratt DE, Tran P, Wang X, Pugh SE, Sandler KA, Bolla M, Maingon P, De Reijke T, Nickols NG, Rettig M, Drakaki A, Liu ST, Reiter RE, Chang AJ, Feng FY, Sajed D, Nguyen PL, Kupelian PA, Steinberg ML, Boutros PC, Elashoff D, Collette L, Sandler HM. Local Failure and Survival After Definitive Radiotherapy for Aggressive Prostate Cancer: An Individual Patient-level Meta-analysis of Six Randomized Trials. Eur Urol 2019; 77:201-208. [PMID: 31718822 DOI: 10.1016/j.eururo.2019.10.008] [Citation(s) in RCA: 30] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2019] [Accepted: 10/15/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND The importance of local failure (LF) after treatment of high-grade prostate cancer (PCa) with definitive radiotherapy (RT) remains unknown. OBJECTIVE To evaluate the clinical implications of LF after definitive RT. DESIGN, SETTING, AND PARTICIPANTS Individual patient data meta-analysis of 992 patients (593 Gleason grade group [GG] 4 and 399 GG 5) enrolled in six randomized clinical trials. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS Multivariable Cox proportional hazard models were developed to evaluate the relationship between overall survival (OS), PCa-specific survival (PCSS), and distant metastasis (DM)-free survival (DMFS) and LF as a time-dependent covariate. Markov proportional hazard models were developed to evaluate the impact of specific transitions between disease states on these endpoints. RESULTS AND LIMITATIONS Median follow-up was 6.4 yr overall and 7.2 yr for surviving patients. LF was significantly associated with OS (hazard ratio [HR] 1.70 [95% confidence interval {CI} 1.37-2.10]), PCSS (3.10 [95% CI 2.33-4.12]), and DMFS (HR 1.92 [95% CI 1.54-2.39]), p < 0.001 for all). Patients who had not transitioned to the LF state had a significantly lower hazard of transitioning to a PCa-specific death state than those who transitioned to the LF state (HR 0.13 [95% CI 0.04-0.41], p < 0.001). Additionally, patients who transitioned to the LF state had a greater hazard of DM or death (HR 2.46 [95% CI 1.22-4.93], p = 0.01) than those who did not. CONCLUSIONS LF is an independent prognosticator of OS, PCSS, and DMFS in high-grade localized PCa and a subset of DM events that are anteceded by LF events. LF events warrant consideration for intervention, potentially suggesting a rationale for upfront treatment intensification. However, whether these findings apply to all men or just those without significant comorbidity remains to be determined. PATIENT SUMMARY Men who experience a local recurrence of high-grade prostate cancer after receiving upfront radiation therapy are at significantly increased risks of developing metastases and dying of prostate cancer.
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Affiliation(s)
- Amar U Kishan
- Department of Radiation Oncology, University of California, Los Angeles, CA, USA; Department of Urology, University of California, Los Angeles, CA, USA.
| | - Fang-I Chu
- Department of Radiation Oncology, University of California, Los Angeles, CA, USA
| | - Christopher R King
- Department of Radiation Oncology, University of California, Los Angeles, CA, USA
| | - Wendy Seiferheld
- NRG Oncology Statistics and Data Management Center, Philadelphia, PA, USA
| | - Daniel E Spratt
- Department of Radiation Oncology, University of Michigan, Ann Arbor, MI, USA
| | - Phuoc Tran
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Xiaoyan Wang
- Department of General Internal Medicine and Health Services Research, University of California, Los Angeles, CA, USA
| | - Stephanie E Pugh
- NRG Oncology Statistics and Data Management Center, Philadelphia, PA, USA
| | - Kiri A Sandler
- Department of Radiation Oncology, University of California, Los Angeles, CA, USA
| | - Michel Bolla
- Department of Radiation Oncology, Centre Hospitalier Universitaire de Grenoble, Grenoble, France
| | - Philippe Maingon
- Centre Georges-François Leclerc, Dijon, France; Sorbonne Université Paris, Paris, France
| | - Theo De Reijke
- Department of Urology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
| | - Nicholas G Nickols
- Department of Radiation Oncology, University of California, Los Angeles, CA, USA; Department of Radiation Oncology, Veteran Affairs Greater Los Angeles Healthcare System, Los Angeles, CA, USA
| | - Matthew Rettig
- Division of Hematology and Oncology, David Geffen School of Medicine, University of California, Los Angeles, CA, USA; Division of Hematology and Oncology, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
| | - Alexandra Drakaki
- Division of Hematology and Oncology, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
| | - Sandy T Liu
- Division of Hematology and Oncology, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
| | - Robert E Reiter
- Department of Urology, University of California, Los Angeles, CA, USA
| | - Albert J Chang
- Department of Radiation Oncology, University of California, Los Angeles, CA, USA
| | - Felix Y Feng
- Departments of Radiation Oncology, Urology, and Medicine, University of California, San Francisco, CA, USA
| | - Dipti Sajed
- Department of Pathology, University of California, Los Angeles, CA, USA
| | - Paul L Nguyen
- Department of Radiation Oncology, Brigham and Women's Hospital/Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
| | - Patrick A Kupelian
- Department of Radiation Oncology, University of California, Los Angeles, CA, USA
| | - Michael L Steinberg
- Department of Radiation Oncology, University of California, Los Angeles, CA, USA
| | - Paul C Boutros
- Department of Urology, University of California, Los Angeles, CA, USA; Department of Human Genetics, University of California, Los Angeles, CA, USA
| | - David Elashoff
- Department of General Internal Medicine and Health Services Research, University of California, Los Angeles, CA, USA
| | - Laurence Collette
- European Organization for Research and Treatment of Cancer Headquarters, Brussels, Belgium
| | - Howard M Sandler
- Department of Radiation Oncology, Cedars Sinai, Los Angeles, CA, USA
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25
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Wang C, Kishan AU, Yu JB, Raldow A, King CR, Iwamoto KS, Chu FI, Steinberg ML, Kupelian PA. Association between Long-Term Second Malignancy Risk and Radiation: A Comprehensive Analysis of the Entire Surveillance, Epidemiology, and End Results Database (1973-2014). Adv Radiat Oncol 2019; 4:738-747. [PMID: 31673667 PMCID: PMC6817555 DOI: 10.1016/j.adro.2019.05.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2018] [Revised: 05/02/2019] [Accepted: 05/03/2019] [Indexed: 11/12/2022] Open
Abstract
Purpose Second malignancies (SMs) after radiation therapy are rare but serious sequelae of treatment. This study investigates whether radiation therapy use is associated with changes in baseline SM risk. Methods and Materials We extracted all patients with cancer, with or without SM, in the Surveillance, Epidemiology, and End Results database from 1973 to 2014. Cumulative incidence of SM for patients stratified by radiation therapy status was calculated using a competing risk model, both for the entire cohort and for subgroups based on the primary tumor's anatomic location. Results We identified 2,872,063 patients with cancer, including 761,289 patients who received radiation therapy and 2,110,774 who did not. The SM rate at 20 years for patients receiving radiation therapy versus no radiation therapy was 21.4% versus 18.8%. The relative risk for SM associated with radiation therapy for the overall group was 1.138 at 20 years. The relative risks for SM associated with radiation therapy to malignancies arising from central nervous system and orbits, head and neck, thorax, abdomen, and pelvis at 20 years were 0.704, 1.011, 0.559, 0.646, and 1.106 for men and 0.792, 1.298, 1.265, 0.780, and 0.988 for women, respectively. Conclusions The association between SM and radiation therapy varies with both sex and disease anatomic location, with the largest increase in SM seen in females irradiated to the head and neck region. Overall, the absolute change in SM rates associated with radiation therapy remains small, with differences in various clinical contexts.
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Affiliation(s)
- Chenyang Wang
- Department of Radiation Oncology, University of California, Los Angeles, Los Angeles, California
| | - Amar U Kishan
- Department of Radiation Oncology, University of California, Los Angeles, Los Angeles, California
| | - James B Yu
- Department of Therapeutic Radiology, Yale New Haven Hospital, New Haven, Connecticut
| | - Ann Raldow
- Department of Radiation Oncology, University of California, Los Angeles, Los Angeles, California
| | - Christopher R King
- Department of Radiation Oncology, University of California, Los Angeles, Los Angeles, California
| | - Keisuke S Iwamoto
- Department of Radiation Oncology, University of California, Los Angeles, Los Angeles, California
| | - Fang-I Chu
- Department of Radiation Oncology, University of California, Los Angeles, Los Angeles, California
| | - Michael L Steinberg
- Department of Radiation Oncology, University of California, Los Angeles, Los Angeles, California
| | - Patrick A Kupelian
- Department of Radiation Oncology, University of California, Los Angeles, Los Angeles, California
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Fritz BA, Cui Z, Zhang M, He Y, Chen Y, Kronzer A, Ben Abdallah A, King CR, Avidan MS. Deep-learning model for predicting 30-day postoperative mortality. Br J Anaesth 2019; 123:688-695. [PMID: 31558311 DOI: 10.1016/j.bja.2019.07.025] [Citation(s) in RCA: 51] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2019] [Revised: 06/21/2019] [Accepted: 07/22/2019] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Postoperative mortality occurs in 1-2% of patients undergoing major inpatient surgery. The currently available prediction tools using summaries of intraoperative data are limited by their inability to reflect shifting risk associated with intraoperative physiological perturbations. We sought to compare similar benchmarks to a deep-learning algorithm predicting postoperative 30-day mortality. METHODS We constructed a multipath convolutional neural network model using patient characteristics, co-morbid conditions, preoperative laboratory values, and intraoperative numerical data from patients undergoing surgery with tracheal intubation at a single medical centre. Data for 60 min prior to a randomly selected time point were utilised. Model performance was compared with a deep neural network, a random forest, a support vector machine, and a logistic regression using predetermined summary statistics of intraoperative data. RESULTS Of 95 907 patients, 941 (1%) died within 30 days. The multipath convolutional neural network predicted postoperative 30-day mortality with an area under the receiver operating characteristic curve of 0.867 (95% confidence interval [CI]: 0.835-0.899). This was higher than that for the deep neural network (0.825; 95% CI: 0.790-0.860), random forest (0.848; 95% CI: 0.815-0.882), support vector machine (0.836; 95% CI: 0.802-870), and logistic regression (0.837; 95% CI: 0.803-0.871). CONCLUSIONS A deep-learning time-series model improves prediction compared with models with simple summaries of intraoperative data. We have created a model that can be used in real time to detect dynamic changes in a patient's risk for postoperative mortality.
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Affiliation(s)
- Bradley A Fritz
- Department of Anesthesiology, Washington University in St Louis, St Louis, MO, USA.
| | - Zhicheng Cui
- Department of Computer Science and Engineering, Washington University in St Louis, St Louis, MO, USA
| | - Muhan Zhang
- Department of Computer Science and Engineering, Washington University in St Louis, St Louis, MO, USA
| | - Yujie He
- Department of Computer Science and Engineering, Washington University in St Louis, St Louis, MO, USA
| | - Yixin Chen
- Department of Computer Science and Engineering, Washington University in St Louis, St Louis, MO, USA
| | - Alex Kronzer
- Department of Anesthesiology, Washington University in St Louis, St Louis, MO, USA
| | - Arbi Ben Abdallah
- Department of Anesthesiology, Washington University in St Louis, St Louis, MO, USA
| | - Christopher R King
- Department of Anesthesiology, Washington University in St Louis, St Louis, MO, USA
| | - Michael S Avidan
- Department of Anesthesiology, Washington University in St Louis, St Louis, MO, USA
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27
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King CR, Escallier KE, Ju YES, Lin N, Palanca BJ, McKinnon SL, Avidan MS. Obstructive sleep apnoea, positive airway pressure treatment and postoperative delirium: protocol for a retrospective observational study. BMJ Open 2019; 9:e026649. [PMID: 31455698 PMCID: PMC6720237 DOI: 10.1136/bmjopen-2018-026649] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2018] [Revised: 06/07/2019] [Accepted: 07/18/2019] [Indexed: 12/02/2022] Open
Abstract
INTRODUCTION Obstructive sleep apnoea (OSA) is common among older surgical patients, and delirium is a frequent and serious postoperative complication. Emerging evidence suggests that OSA increases the risk for postoperative delirium. We hypothesise that OSA is an independent risk factor for postoperative delirium, and that in patients with OSA, perioperative adherence to positive airway pressure (PAP) therapy decreases the incidence of postoperative delirium and its sequelae. The proposed retrospective cohort analysis study will use existing datasets to: (i) describe and compare the incidence of postoperative delirium in surgical patients based on OSA diagnosis and treatment with PAP; (ii) assess whether preoperatively untreated OSA is independently associated with postoperative delirium; and (iii) explore whether preoperatively untreated OSA is independently associated with worse postoperative quality of life (QoL). The findings of this study will inform on the potential utility and approach of an interventional trial aimed at preventing postoperative delirium in patients with diagnosed and undiagnosed OSA. METHODS AND ANALYSIS Observational data from existing electronic databases will be used, including over 100 000 surgical patients and ~10 000 intensive care unit (ICU) admissions. We will obtain the incidence of postoperative delirium in adults admitted postoperatively to the ICU who underwent structured preoperative assessment, including OSA diagnosis and screening. We will use doubly robust propensity score methods to assess whether untreated OSA independently predicts postoperative delirium. Using similar methodology, we will assess if untreated OSA independently predicts worse postoperative QoL. ETHICS AND DISSEMINATION This study has been approved by the Human Research Protection Office at Washington University School of Medicine. We will publish the results in a peer-reviewed venue. Because the data are secondary and high risk for reidentification, we will not publicly share the data. Data will be destroyed after 1 year of completion of active Institutional Review Board (IRB) approved projects.
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Affiliation(s)
- Christopher R King
- Anesthesiology, Washington University in Saint Louis School of Medicine, Saint Louis, Missouri, US
| | - Krisztina E Escallier
- Anesthesiology, Washington University in Saint Louis School of Medicine, Saint Louis, Missouri, US
| | - Yo-El S Ju
- Neurology, Washington University in Saint Louis School of Medicine, Saint Louis, Missouri, US
| | - Nan Lin
- Mathematics, Washington University in Saint Louis, St. Louis, Missouri, USA
- Division of Biostatistics, Washington Univiersity in Saint Louis, St. Louis, Missouri, USA
| | - Ben Julian Palanca
- Anesthesiology, Washington University in Saint Louis School of Medicine, Saint Louis, Missouri, US
| | - Sherry Lynn McKinnon
- Anesthesiology, Washington University in Saint Louis School of Medicine, Saint Louis, Missouri, US
| | - Michael Simon Avidan
- Anesthesiology, Washington University in Saint Louis School of Medicine, Saint Louis, Missouri, US
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28
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Jiang NY, Dang AT, Yuan Y, Chu FI, Shabsovich D, King CR, Collins SP, Aghdam N, Suy S, Mantz CA, Miszczyk L, Napieralska A, Namysl-Kaletka A, Bagshaw H, Prionas N, Buyyounouski MK, Jackson WC, Spratt DE, Nickols NG, Steinberg ML, Kupelian PA, Kishan AU. Multi-Institutional Analysis of Prostate-Specific Antigen Kinetics After Stereotactic Body Radiation Therapy. Int J Radiat Oncol Biol Phys 2019; 105:628-636. [PMID: 31276777 DOI: 10.1016/j.ijrobp.2019.06.2539] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2019] [Revised: 05/17/2019] [Accepted: 06/17/2019] [Indexed: 10/26/2022]
Abstract
PURPOSE Understanding prostate-specific antigen (PSA) kinetics after radiation therapy plays a large role in the management of patients with prostate cancer (PCa). This is particularly true in establishing expectations regarding PSA nadir (nPSA) and PSA bounces, which can be disconcerting. As increasingly more patients are being treated with stereotactic body radiation therapy (SBRT) for low- and intermediate-risk PCa, it is imperative to understand the PSA response to SBRT. METHODS AND MATERIALS PSA data from 5 institutions were retrospectively analyzed for patients with localized PCa treated definitively with SBRT alone from 2004 to 2016. Patients received 35 to 40 Gy in 5 fractions, per institutional standards. Patients who had less than 12 months of PSA data or received androgen deprivation therapy were excluded from this study. Linear and logistic multivariable analysis were performed to identify predictors of nPSA, bounce, and biochemical recurrence, and joint latent class models were developed to identify significant predictors of time to biochemical failure. RESULTS A total of 1062 patients were included in this study. Median follow-up was 66 months (interquartile range [IQR], 36.4-89.9 months). Biochemical failure per the Phoenix criteria occurred in 4% of patients. Median nPSA was 0.2 ng/mL, median time to nPSA was 40 months, 84% of patients had an nPSA ≤0.5 ng/mL, and 54% of patients had an nPSA ≤0.2 ng/mL. On multivariable analysis, nPSA was a significant predictor of biochemical failure. Benign PSA bounce was noted in 26% of patients. The median magnitude of PSA bounce was 0.52 ng/mL (IQR, 0.3-1.0 ng/mL). Median time to PSA bounce was 18.1 months (IQR, 12.0-31.1 months). On multivariable analysis, age and radiation dose were significantly associated with a lower incidence of bounce. Joint latent class models modeling found that nPSA and radiation dose were significantly associated with longer time to biochemical failure. CONCLUSIONS In this multi-institutional cohort of patients with long-term follow-up, we found that SBRT led to low nPSAs. In turn, lower nPSAs are associated with reduced incidence of, and longer time to, biochemical failure. Benign PSA bounces occurred in a quarter of patients, as late as several years after treatment. Further studies are needed to directly compare the PSA response of patients who receive SBRT versus other treatment modalities.
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Affiliation(s)
- Naomi Y Jiang
- Department of Radiation Oncology, University of California, Los Angeles, Los Angeles, California
| | - Audrey T Dang
- Department of Radiation Oncology, University of California, Los Angeles, Los Angeles, California
| | - Ye Yuan
- Department of Radiation Oncology, University of California, Los Angeles, Los Angeles, California
| | - Fang-I Chu
- Department of Radiation Oncology, University of California, Los Angeles, Los Angeles, California
| | - David Shabsovich
- Department of Radiation Oncology, University of California, Los Angeles, Los Angeles, California
| | - Christopher R King
- Department of Radiation Oncology, University of California, Los Angeles, Los Angeles, California
| | - Sean P Collins
- Department of Radiation Medicine, Georgetown University Hospital, Washington, DC
| | - Nima Aghdam
- Department of Radiation Medicine, Georgetown University Hospital, Washington, DC
| | - Simeng Suy
- Department of Radiation Medicine, Georgetown University Hospital, Washington, DC
| | | | - Leszek Miszczyk
- Maria Sklodowska-Curie Memorial Cancer Center and Institute of Oncology Gliwice Branch, Gliwice, Poland
| | - Aleksandra Napieralska
- Maria Sklodowska-Curie Memorial Cancer Center and Institute of Oncology Gliwice Branch, Gliwice, Poland
| | - Agnieszka Namysl-Kaletka
- Maria Sklodowska-Curie Memorial Cancer Center and Institute of Oncology Gliwice Branch, Gliwice, Poland
| | - Hilary Bagshaw
- Department of Radiation Oncology, Stanford University School of Medicine, Palo Alto, California
| | - Nicolas Prionas
- Department of Radiation Oncology, Stanford University School of Medicine, Palo Alto, California
| | - Mark K Buyyounouski
- Department of Radiation Oncology, Stanford University School of Medicine, Palo Alto, California
| | - William C Jackson
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan
| | - Daniel E Spratt
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan
| | - Nicholas G Nickols
- Department of Radiation Oncology, University of California, Los Angeles, Los Angeles, California
| | - Michael L Steinberg
- Department of Radiation Oncology, University of California, Los Angeles, Los Angeles, California
| | - Patrick A Kupelian
- Department of Radiation Oncology, University of California, Los Angeles, Los Angeles, California
| | - Amar U Kishan
- Department of Radiation Oncology, University of California, Los Angeles, Los Angeles, California.
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29
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Yuan Y, Aghdam N, King CR, Fuller DB, Weng J, Chu FI, Mardirossian G, Patel A, Nickols NG, Kupelian PA, Steinberg ML, Collins SP, Kishan AU. Testosterone Levels and Sexual Quality of Life After Stereotactic Body Radiation Therapy for Prostate Cancer: A Multi-Institutional Analysis of Prospective Trials. Int J Radiat Oncol Biol Phys 2019; 105:149-154. [PMID: 31108142 DOI: 10.1016/j.ijrobp.2019.05.014] [Citation(s) in RCA: 4] [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] [Received: 02/08/2019] [Revised: 04/18/2019] [Accepted: 05/05/2019] [Indexed: 01/04/2023]
Abstract
PURPOSE The impact of higher scatter doses per fraction on testicular function and quality of life after prostate stereotactic body radiation therapy (SBRT) is poorly studied. METHODS AND MATERIALS Six hundred thirty-six patients treated with SBRT for low- to intermediate-risk prostate cancer from 2009 to 2014 were included. Changes in testosterone and in sexual and hormonal domain scores on the Expanded Prostate Cancer Index Composite-26 (EPIC) questionnaire over a 24-month period were evaluated via a 1-sided t test. EPIC score changes were evaluated in comparison with a distribution-based minimal clinically important difference threshold, wherein changes of greater than one half or greater than one third of the standard deviation in each domain were considered as medium-sized or small-sized effects, respectively. RESULTS Median and mean percent changes in testosterone at the 3- to 6-month, 7- to 12-month, 13- to 18-month, and 19- to 24-month time periods were -13.41% and -4.49% (P = .02); -12.23% and -2.77% (P = .13); -11.20% and -0.29% (P = .47); -5.00% and + 1.20% (P = .65). When analyzed after dividing the cohort into 3 groups based on baseline testosterone values using tertiles, testosterone tended to increase in patients in the first group and decrease in patients in the third group. Overall, the decline in EPIC hormonal domain scores never exceeded the threshold for a small-sized effect, though the decline in EPIC sexual domain scores did pass this threshold at the 19- to 24-month time period (mean 10.90 point decline). This decline was not present when groups were examined individually. CONCLUSIONS In this large cohort of prospectively followed patients, there was a transient decline in testosterone shortly after SBRT that normalized by 24 months posttreatment. There was no significant change in EPIC hormonal domain scores. A significant decline in EPIC sexual domain scores, consistent with a small-sized clinically detectable difference, manifested between 19 and 24 months of follow-up. These results are consistent with testosterone decline patterns and sexual function changes seen after other forms of photon-based radiation therapy.
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Affiliation(s)
- Ye Yuan
- Department of Radiation Oncology, UCLA, Los Angeles, California
| | - Nima Aghdam
- Department of Radiation Oncology, Georgetown University, Washington, DC
| | | | | | - Julius Weng
- David Geffen School of Medicine, UCLA, Los Angeles, California
| | - Fang-I Chu
- Department of Radiation Oncology, UCLA, Los Angeles, California
| | | | - Ankur Patel
- Department of Radiation Oncology, UCLA, Los Angeles, California
| | - Nicholas G Nickols
- Department of Radiation Oncology, UCLA, Los Angeles, California; Radiation Therapy Service, VA Greater Los Angeles, Los Angeles, California
| | | | | | - Sean P Collins
- Department of Radiation Oncology, Georgetown University, Washington, DC
| | - Amar U Kishan
- Department of Radiation Oncology, UCLA, Los Angeles, California.
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30
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Kishan AU, Cook RR, King CR. Reply to Marieke J. Krimphove, Junaid Nabi, Alexander P. Cole, and Quoc-Dien Trinh's Letter to the Editor re: Ronald D. Ennis, Liangyuan Hu, Shannon N. Ryemon, Joyce Lin, Madhu Mazumdar. Brachytherapy-based Radiotherapy and Radical Prostatectomy Are Associated with Similar Survival in High-risk Localized Prostate Cancer. J Clin Oncol 2018;36:1192-8: Setting the Standard: The Importance of Defining the Standard of Care for Comparative Effectiveness Analyses. Eur Urol Oncol 2019; 2:224-225. [PMID: 31017101 DOI: 10.1016/j.euo.2018.08.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2018] [Accepted: 08/23/2018] [Indexed: 11/17/2022]
Affiliation(s)
- Amar U Kishan
- Radiation Oncology, University of California, Los Angeles, CA, USA.
| | - Ryan R Cook
- Radiation Oncology, University of California, Los Angeles, CA, USA
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Jiang NY, King CR, Katz AJ, Collins SP, Aghdam N, Suy S, Stephans KL, Reddy CA, Kaplan ID, Appelbaum L, Dang A, Yuan Y, Nickols NG, Steinberg ML, Kupelian P, Kishan AU. Multi-institutional analysis of high-risk prostate cancer patients treated with stereotactic body radiotherapy. J Clin Oncol 2019. [DOI: 10.1200/jco.2019.37.7_suppl.51] [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
51 Background: Stereotactic Body Radiotherapy (SBRT) delivers ablative doses of radiation (RT) over a course of five treatments and has been increasingly used as a definitive RT option for low- and intermediate-risk prostate cancer (PCa). Ongoing prospective trials are evaluating the efficacy of SBRT for high-risk PCa, but clinical outcomes reports are limited. Methods: Patients treated for high-risk PCa between 2006-2017 at any of five institutions were included. SBRT doses ranged from 35-40 Gy in 5 fractions per institutional standards, with one institution using an integrated boost approach. The Phoenix definition was used to define biochemical failure (BCR). Physician-reported genitourinary (GU) and gastrointestinal (GI) toxicity outcomes were scored using the Radiation Therapy Oncology Group or Common Terminology Criteria for Adverse Events systems. Results: In total, 182 patients were included in this study with a median follow-up time of 38.4 months (mos). The median age was 72. Most patients (72%) had Gleason 8-10 disease. Sixty-eight percent of patients received androgen deprivation therapy (ADT) for a median of 9 mos (interquartile range 6-9 mos). The rate of distant metastases was 3.8%. There were no acute Grade 3 (G3) or higher GU or GI toxicities. Three patients (1.6%) experienced a late G3 GU toxicity and one patient (0.5%) experienced a late G3 GI toxicity. The incidence of BCR was significantly higher in patients who did not receive ADT (30% vs. 15%, p = 0.02 by Chi-square). Conclusions: In this multi-institutional study, SBRT demonstrated an acceptable safety profile for the treatment of high-risk PCa. Longer term follow-up is necessary to evaluate the oncologic efficacy of this approach, but given the potentially higher incidence of BCR without ADT, ADT likely has an important oncologic role even with SBRT regimens.
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Affiliation(s)
- Naomi Y Jiang
- University of California Los Angeles, Los Angeles, CA
| | | | | | | | - Nima Aghdam
- Georgetown University Hospital, Washington, DC
| | - Simeng Suy
- Georgetown University Hospital, Washington, DC
| | | | | | | | | | - Audrey Dang
- University of California Los Angeles, Los Angeles, CA
| | - Ye Yuan
- UCLA School of Medicine, Los Angeles, CA
| | | | | | - Patrick Kupelian
- University of California Los Angeles Health Syst, Los Angeles, CA
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Parikh NR, Nickols NG, Rettig M, King CR, Raldow AC, Steinberg ML, Tran PT, Kishan AU. Cost-effectiveness of metastasis-directed therapy in the setting of oligometastatic hormone-sensitive prostate cancer. J Clin Oncol 2019. [DOI: 10.1200/jco.2019.37.7_suppl.147] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [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
147 Background: Androgen deprivation therapy (ADT) has historically been used as the backbone of treatment in patients with newly-diagnosed hormone-sensitive metastatic prostate cancer. However, recent literature has suggested the potential utility of metastasis-directed therapy (MDT) in a subset of patients with oligometastatic prostate cancer (OPC), potentially allowing for ADT-free survival. Methods: A cost-effectiveness analysis was performed comparing (1) ADT upfront versus (2) MDT followed by salvage ADT in patients with asymptomatic hormone-sensitive OPC. MDT was delivered via stereotactic body radiation therapy (SBRT) over 3 fractions. ADT consisted of Lupron injections every 3 months. Costs were calculated from a payor’s perspective based on Medicare CPT codes, CLAB fee schedule, and ASP drug prices. ADT-free survival was modeled based on results from STOMP trial; costs of retreatment were not considered in the MDT arm. Based on prior literature, health utility was assumed to be 0.9 without ADT, and 0.82 with ADT. Given paucity of long-term data on survival effect of MDT with delayed ADT, both arms were assumed to have identical long-term disease transition state probabilities. Results: Total cost of ADT upfront vs. MDT + salvage ADT was $3,430 vs. $9,434 at 1 year, and $10,289 vs. $13,806 at 3 years. Compared to ADT alone, MDT + salvage ADT showed improvements in quality-adjusted life years (QALYs) of 0.07 and 0.15 at 1 and 3 years respectively, translating to incremental cost-effectiveness ratio (ICER) of $85,385/QALY at 1 year and $24,118/QALY at 3 years. Conclusions: Using a willingness-to-pay ICER threshold of $100,000/QALY, MDT with SBRT is shown to be a cost-effective option compared to ADT alone in patients with OPC, particularly when utilizing a longer follow-up time period.
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Affiliation(s)
| | | | - Matthew Rettig
- UCLA Jonsson Comprehensive Cancer Center, Los Angeles, CA
| | | | - Ann C. Raldow
- David Geffen School of Medicine at UCLA, Los Angeles, CA
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Wang C, Raldow AC, Nickols NG, Nguyen PL, Spratt DE, Dess RT, Yu JB, King CR, Chu FI, Chamie K, Litwin MS, Saigal CS, Reiter RE, Liu ST, Rettig MB, Chang AJ, Steinberg ML, Kupelian PA, Kishan AU. Underutilization of Androgen Deprivation Therapy with External Beam Radiotherapy in Men with High-grade Prostate Cancer. Eur Urol Oncol 2019; 4:327-330. [PMID: 31411981 DOI: 10.1016/j.euo.2019.01.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2018] [Revised: 12/15/2018] [Accepted: 01/07/2019] [Indexed: 11/26/2022]
Abstract
Multiple randomized trials have shown a survival benefit to long durations of androgen deprivation therapy (ADT) in patients with Gleason grade group (GG) 4-5 (ie, Gleason score 8-10) prostate cancer (PCa) undergoing definitive external beam radiotherapy (EBRT). We conducted a population-based retrospective study utilizing the complete Surveillance, Epidemiology, and End Results (SEER)-Medicare-linked database from 2008 to 2011, extracting PCa patients of non-Hispanic white (NHW) and African-American (AA) race diagnosed with GG 4-5PCa who received EBRT with or without concomitant ADT. Of 961 patients receiving definitive EBRT, 225 (23.4%) received no ADT, 297 (30.9%) received 1-6mo of ADT, 313 (32.6) received 7-23mo of ADT, and 126 (13.1%) received ≥24mo of ADT. On multinomial logistic regression after inverse probability treatment weighting to balance for differences in other covariates, AA men still had significantly lower odds of receiving 1-6mo of ADT versus no ADT compared with NHW men (odds ratios 0.519 [95% confidence interval, 0.384-0.700]). In conclusion, long-duration ADT is underutilized, with nearly 90% of patients with GG 4-5PCa receiving <24mo of concomitant ADT, and AA men are less likely to receive ADT than NHW men. PATIENT SUMMARY: In this report, we examined the utilization of concomitant androgen deprivation therapy (ADT) among men with high-grade prostate cancer undergoing definitive external beam radiotherapy. We found that long-duration ADT was underutilized overall; moreover, African-American men were less likely to receive concomitant ADT than non-Hispanic white men.
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Affiliation(s)
- Chenyang Wang
- Department of Radiation Oncology, University of California, Los Angeles, Los Angeles, CA, USA
| | - Ann C Raldow
- Department of Radiation Oncology, University of California, Los Angeles, Los Angeles, CA, USA
| | - Nicholas G Nickols
- Department of Radiation Oncology, University of California, Los Angeles, Los Angeles, CA, USA
| | - Paul L Nguyen
- Department of Radiation Oncology, Brigham and Women's Hospital/Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
| | - Daniel E Spratt
- Department of Radiation Oncology, University of Michigan, MI, USA
| | - Robert T Dess
- Department of Radiation Oncology, University of Michigan, MI, USA
| | - James B Yu
- Department of Therapeutic Radiology, Yale New Haven Hospital, New Haven, CT, USA
| | - Christopher R King
- Department of Radiation Oncology, University of California, Los Angeles, Los Angeles, CA, USA
| | - Fang-I Chu
- Department of Radiation Oncology, University of California, Los Angeles, Los Angeles, CA, USA
| | - Karim Chamie
- Department of Urology, University of California, Los Angeles, Los Angeles, CA, USA
| | - Mark S Litwin
- Department of Urology, University of California, Los Angeles, Los Angeles, CA, USA; Department of Health Policy and Management, Fielding School of Public Health, University of California, Los Angeles, Los Angeles, CA, USA
| | - Christopher S Saigal
- Department of Urology, University of California, Los Angeles, Los Angeles, CA, USA
| | - Robert E Reiter
- Department of Urology, University of California, Los Angeles, Los Angeles, CA, USA
| | - Sandy T Liu
- Division of Hematology and Oncology, Department of Medicine, University of California, Los Angeles, Los Angeles, CA, USA
| | - Matthew B Rettig
- Division of Hematology and Oncology, Department of Medicine, University of California, Los Angeles, Los Angeles, CA, USA
| | - Albert J Chang
- Department of Radiation Oncology, University of California, Los Angeles, Los Angeles, CA, USA
| | - Michael L Steinberg
- Department of Radiation Oncology, University of California, Los Angeles, Los Angeles, CA, USA
| | - Patrick A Kupelian
- Department of Radiation Oncology, University of California, Los Angeles, Los Angeles, CA, USA
| | - Amar U Kishan
- Department of Radiation Oncology, University of California, Los Angeles, Los Angeles, CA, USA; Department of Urology, University of California, Los Angeles, Los Angeles, CA, USA.
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Kishan AU, Dang A, Katz AJ, Mantz CA, Collins SP, Aghdam N, Chu FI, Kaplan ID, Appelbaum L, Fuller DB, Meier RM, Loblaw DA, Cheung P, Pham HT, Shaverdian N, Jiang N, Yuan Y, Bagshaw H, Prionas N, Buyyounouski MK, Spratt DE, Linson PW, Hong RL, Nickols NG, Steinberg ML, Kupelian PA, King CR. Long-term Outcomes of Stereotactic Body Radiotherapy for Low-Risk and Intermediate-Risk Prostate Cancer. JAMA Netw Open 2019; 2:e188006. [PMID: 30735235 PMCID: PMC6484596 DOI: 10.1001/jamanetworkopen.2018.8006] [Citation(s) in RCA: 202] [Impact Index Per Article: 40.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2018] [Accepted: 12/13/2018] [Indexed: 02/05/2023] Open
Abstract
Importance Stereotactic body radiotherapy harnesses improvements in technology to allow the completion of a course of external beam radiotherapy treatment for prostate cancer in the span of 4 to 5 treatment sessions. Although mounting short-term data support this approach, long-term outcomes have been sparsely reported. Objective To assess long-term outcomes after stereotactic body radiotherapy for low-risk and intermediate-risk prostate cancer. Design, Setting, and Participants This cohort study analyzed individual patient data from 2142 men enrolled in 10 single-institution phase 2 trials and 2 multi-institutional phase 2 trials of stereotactic body radiotherapy for low-risk and intermediate-risk prostate cancer between January 1, 2000, and December 31, 2012. Statistical analysis was performed based on follow-up from January 1, 2013, to May 1, 2018. Main Outcomes and Measures The cumulative incidence of biochemical recurrence was estimated using a competing risk framework. Physician-scored genitourinary and gastrointestinal toxic event outcomes were defined per each individual study, generally by Radiation Therapy Oncology Group or Common Terminology Criteria for Adverse Events scoring systems. After central review, cumulative incidences of late grade 3 or higher toxic events were estimated using a Kaplan-Meier method. Results A total of 2142 men (mean [SD] age, 67.9 [9.5] years) were eligible for analysis, of whom 1185 (55.3%) had low-risk disease, 692 (32.3%) had favorable intermediate-risk disease, and 265 (12.4%) had unfavorable intermediate-risk disease. The median follow-up period was 6.9 years (interquartile range, 4.9-8.1 years). Seven-year cumulative rates of biochemical recurrence were 4.5% (95% CI, 3.2%-5.8%) for low-risk disease, 8.6% (95% CI, 6.2%-11.0%) for favorable intermediate-risk disease, 14.9% (95% CI, 9.5%-20.2%) for unfavorable intermediate-risk disease, and 10.2% (95% CI, 8.0%-12.5%) for all intermediate-risk disease. The crude incidence of acute grade 3 or higher genitourinary toxic events was 0.60% (n = 13) and of gastrointestinal toxic events was 0.09% (n = 2), and the 7-year cumulative incidence of late grade 3 or higher genitourinary toxic events was 2.4% (95% CI, 1.8%-3.2%) and of late grade 3 or higher gastrointestinal toxic events was 0.4% (95% CI, 0.2%-0.8%). Conclusions and Relevance In this study, stereotactic body radiotherapy for low-risk and intermediate-risk disease was associated with low rates of severe toxic events and high rates of biochemical control. These data suggest that stereotactic body radiotherapy is an appropriate definitive treatment modality for low-risk and intermediate-risk prostate cancer.
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Affiliation(s)
- Amar U. Kishan
- Department of Urology, University of California, Los Angeles
- Department of Radiation Oncology, University of California, Los Angeles
| | - Audrey Dang
- Department of Radiation Oncology, University of California, Los Angeles
| | - Alan J. Katz
- Flushing Radiation Oncology Services, Flushing, New York
| | | | - Sean P. Collins
- Department of Radiation Oncology, Georgetown University, Washington, DC
| | - Nima Aghdam
- Department of Radiation Oncology, Georgetown University, Washington, DC
| | - Fang-I Chu
- Department of Radiation Oncology, University of California, Los Angeles
| | - Irving D. Kaplan
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Limor Appelbaum
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Donald B. Fuller
- Division of Genesis Healthcare Partners Inc, CyberKnife Centers of San Diego Inc, San Diego, California
| | | | - D. Andrew Loblaw
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Patrick Cheung
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Huong T. Pham
- Section of Radiation Oncology, Virginia Mason Medical Center, Seattle, Washington
| | - Narek Shaverdian
- Department of Radiation Oncology, University of California, Los Angeles
- Now with Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Naomi Jiang
- Department of Radiation Oncology, University of California, Los Angeles
| | - Ye Yuan
- Department of Radiation Oncology, University of California, Los Angeles
| | - Hilary Bagshaw
- Department of Radiation Oncology, Stanford University School of Medicine, Stanford, California
| | - Nicolas Prionas
- Department of Radiation Oncology, Stanford University School of Medicine, Stanford, California
| | - Mark K. Buyyounouski
- Department of Radiation Oncology, Stanford University School of Medicine, Stanford, California
| | - Daniel E. Spratt
- Department of Radiation Oncology, University of Michigan, Ann Arbor
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Kang JJ, Reiter RE, Steinberg ML, King CR. First Postprostatectomy Ultrasensitive Prostate-specific Antigen Predicts Survival in Patients with High-risk Prostate Cancer Pathology. Eur Urol Oncol 2018; 1:378-385. [PMID: 31158076 DOI: 10.1016/j.euo.2018.07.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2018] [Revised: 07/04/2018] [Accepted: 07/23/2018] [Indexed: 11/29/2022]
Abstract
BACKGROUND Ultrasensitive prostate-specific antigen (uPSA) has untapped potential for optimizing management following radical prostatectomy (RP) in terms of facilitating early salvage, minimizing overtreatment, and identifying those at risk of occult systemic disease. OBJECTIVE To test first postoperative uPSA for prediction of outcome in patients with adverse pathology after RP. DESIGN, SETTING, AND PARTICIPANTS Patients with extraprostatic extension and/or a positive margin who did not receive immediate adjuvant therapy. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS First uPSA was measured at 3 mo after RP. The study endpoints were biochemical relapse (BCR), defined as PSA ≥0.2ng/ml, bone metastasis-free survival (BMFS), prostate cancer-specific survival (PCSS), overall survival (OS), and salvage radiation therapy (SRT) success. Outcome results were compared using the Kaplan-Meier method and multivariate analysis (MVA). RESULTS AND LIMITATIONS The cohort consisted of 269 RP patients from 1991-2015 with median follow-up of 77 mo. Sensitivity analysis identified first postoperative uPSA of ≥0.03ng/ml as the optimal threshold for predicting BCR. First postoperative uPSA ≥0.03 versus <0.03ng/ml was associated with worse 5-yr BCR (86%, 95% confidence interval [CI] 71-93% vs 39%, 95% CI 25-51%; p<0.00001), 10-yr BMFS (75%, 95% CI 62-92% vs 95%, 95% CI 88-100%; p=0.0001), 10-yr PCSS (84%, 95% CI 73-96% vs 100%, 95% CI 100-100%; p=0.005), and 10-yr OS (81%, 95% CI 70-93% vs 98%, 95% CI 94-100%; p=0.009). On MVA, first postoperative uPSA ≥0.03ng/ml was an independent predictor of BCR (hazard ratio [HR] 9.4, 95% CI 5.8-15.4; p<0.00001) and the only predictor for BMFS (HR 9.7, 95% CI 2.1-44.6; p=0.0034), PCSS (HR 13.5, 95% CI 1.7-107.9; p=0.014), and OS (HR 5.0, 95% CI 1.4-18.3; p=0.014). Following SRT, first postoperative uPSA ≥0.03ng/ml independently predicted worse BMFS (HR 5.9, 95% CI 1.3-26.9; p=0.021), PCSS (HR 6.9, 95% CI 0.9-55.8; p=0.07), and OS (4.5, 95% CI 1.0-20.1; p=0.057). Limitations include the retrospective design and potential selection bias. CONCLUSIONS First postoperative uPSA ≥0.03ng/ml independently predicts BCR, BMFS, PCSS, and OS better than traditional risk factors. SRT alone may be insufficient for patients with high-risk disease when first postoperative uPSA is ≥0.03ng/ml. PATIENT SUMMARY When the first postprostatectomy ultrasensitive prostate-specific antigen level is ≥0.03ng/ml, patients are at higher risk of recurrent and occult prostate cancer. They should be considered for early salvage radiotherapy, possibly with hormone therapy.
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Affiliation(s)
- Jung Julie Kang
- Department of Radiation Oncology, UCLA School of Medicine, Los Angeles, CA, USA.
| | - Robert E Reiter
- Department of Urology, UCLA School of Medicine, Los Angeles, CA, USA
| | - Michael L Steinberg
- Department of Radiation Oncology, UCLA School of Medicine, Los Angeles, CA, USA
| | - Christopher R King
- Department of Radiation Oncology, UCLA School of Medicine, Los Angeles, CA, USA
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Affiliation(s)
- Amar U Kishan
- Department of Radiation Oncology, University of California, Los Angeles
| | - Ryan R Cook
- Department of Epidemiology, University of California, Los Angeles, Fielding School of Public Health
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Sandler KA, Cook RR, Ciezki JP, Ross AE, Pomerantz MM, Nguyen PL, Shaikh T, Tran PT, Stock RG, Merrick GS, Demanes DJ, Spratt DE, Abu-Isa EI, Wedde TB, Lilleby W, Krauss DJ, Shaw GK, Alam R, Reddy CA, Song DY, Klein EA, Stephenson AJ, Tosoian JJ, Hegde JV, Yoo SM, Fiano R, D'Amico AV, Nickols NG, Aronson WJ, Sadeghi A, Greco SC, Deville C, McNutt T, DeWeese TL, Reiter RE, Said JW, Steinberg ML, Horwitz EM, Kupelian PA, King CR, Kishan AU. Clinical Outcomes for Patients With Gleason Score 10 Prostate Adenocarcinoma: Results From a Multi-institutional Consortium Study. Int J Radiat Oncol Biol Phys 2018; 101:883-888. [DOI: 10.1016/j.ijrobp.2018.03.060] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2018] [Revised: 03/20/2018] [Accepted: 03/29/2018] [Indexed: 11/15/2022]
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Kishan AU, Cook RR, Ciezki JP, Ross AE, Pomerantz MM, Nguyen PL, Shaikh T, Tran PT, Sandler KA, Stock RG, Merrick GS, Demanes DJ, Spratt DE, Abu-Isa EI, Wedde TB, Lilleby W, Krauss DJ, Shaw GK, Alam R, Reddy CA, Stephenson AJ, Klein EA, Song DY, Tosoian JJ, Hegde JV, Yoo SM, Fiano R, D’Amico AV, Nickols NG, Aronson WJ, Sadeghi A, Greco S, Deville C, McNutt T, DeWeese TL, Reiter RE, Said JW, Steinberg ML, Horwitz EM, Kupelian PA, King CR. Radical Prostatectomy, External Beam Radiotherapy, or External Beam Radiotherapy With Brachytherapy Boost and Disease Progression and Mortality in Patients With Gleason Score 9-10 Prostate Cancer. JAMA 2018; 319:896-905. [PMID: 29509865 PMCID: PMC5885899 DOI: 10.1001/jama.2018.0587] [Citation(s) in RCA: 224] [Impact Index Per Article: 37.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
IMPORTANCE The optimal treatment for Gleason score 9-10 prostate cancer is unknown. OBJECTIVE To compare clinical outcomes of patients with Gleason score 9-10 prostate cancer after definitive treatment. DESIGN, SETTING, AND PARTICIPANTS Retrospective cohort study in 12 tertiary centers (11 in the United States, 1 in Norway), with 1809 patients treated between 2000 and 2013. EXPOSURES Radical prostatectomy (RP), external beam radiotherapy (EBRT) with androgen deprivation therapy, or EBRT plus brachytherapy boost (EBRT+BT) with androgen deprivation therapy. MAIN OUTCOMES AND MEASURES The primary outcome was prostate cancer-specific mortality; distant metastasis-free survival and overall survival were secondary outcomes. RESULTS Of 1809 men, 639 underwent RP, 734 EBRT, and 436 EBRT+BT. Median ages were 61, 67.7, and 67.5 years; median follow-up was 4.2, 5.1, and 6.3 years, respectively. By 10 years, 91 RP, 186 EBRT, and 90 EBRT+BT patients had died. Adjusted 5-year prostate cancer-specific mortality rates were RP, 12% (95% CI, 8%-17%); EBRT, 13% (95% CI, 8%-19%); and EBRT+BT, 3% (95% CI, 1%-5%). EBRT+BT was associated with significantly lower prostate cancer-specific mortality than either RP or EBRT (cause-specific HRs of 0.38 [95% CI, 0.21-0.68] and 0.41 [95% CI, 0.24-0.71]). Adjusted 5-year incidence rates of distant metastasis were RP, 24% (95% CI, 19%-30%); EBRT, 24% (95% CI, 20%-28%); and EBRT+BT, 8% (95% CI, 5%-11%). EBRT+BT was associated with a significantly lower rate of distant metastasis (propensity-score-adjusted cause-specific HRs of 0.27 [95% CI, 0.17-0.43] for RP and 0.30 [95% CI, 0.19-0.47] for EBRT). Adjusted 7.5-year all-cause mortality rates were RP, 17% (95% CI, 11%-23%); EBRT, 18% (95% CI, 14%-24%); and EBRT+BT, 10% (95% CI, 7%-13%). Within the first 7.5 years of follow-up, EBRT+BT was associated with significantly lower all-cause mortality (cause-specific HRs of 0.66 [95% CI, 0.46-0.96] for RP and 0.61 [95% CI, 0.45-0.84] for EBRT). After the first 7.5 years, the corresponding HRs were 1.16 (95% CI, 0.70-1.92) and 0.87 (95% CI, 0.57-1.32). No significant differences in prostate cancer-specific mortality, distant metastasis, or all-cause mortality (≤7.5 and >7.5 years) were found between men treated with EBRT or RP (cause-specific HRs of 0.92 [95% CI, 0.67-1.26], 0.90 [95% CI, 0.70-1.14], 1.07 [95% CI, 0.80-1.44], and 1.34 [95% CI, 0.85-2.11]). CONCLUSIONS AND RELEVANCE Among patients with Gleason score 9-10 prostate cancer, treatment with EBRT+BT with androgen deprivation therapy was associated with significantly better prostate cancer-specific mortality and longer time to distant metastasis compared with EBRT with androgen deprivation therapy or with RP.
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Affiliation(s)
- Amar U. Kishan
- Department of Radiation Oncology, University of California, Los Angeles
| | - Ryan R. Cook
- Department of Epidemiology, Fielding School of Public Health, University of California, Los Angeles
| | - Jay P. Ciezki
- Department of Radiation Oncology, Cleveland Clinic, Cleveland, Ohio
| | - Ashley E. Ross
- Department of Urology, The James Buchanan Brady Urological Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Mark M. Pomerantz
- Lank Center for Genitourinary Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts
| | - Paul L. Nguyen
- Department of Radiation Oncology, Brigham and Women's Hospital/Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts
| | - Talha Shaikh
- Department of Radiation Oncology, Fox Chase Cancer Center, Philadelphia, Pennsylvania
| | - Phuoc T. Tran
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Kiri A. Sandler
- Department of Radiation Oncology, University of California, Los Angeles
| | - Richard G. Stock
- Department of Radiation Oncology, The Icahn School of Medicine at Mount Sinai, New York, New York
| | - Gregory S. Merrick
- Schiffler Cancer Center, Wheeling Hospital, Wheeling Jesuit University, Wheeling, West Virginia
| | | | - Daniel E. Spratt
- Department of Radiation Oncology, University of Michigan, Ann Arbor
| | - Eyad I. Abu-Isa
- Department of Radiation Oncology, University of Michigan, Ann Arbor
| | - Trude B. Wedde
- Department of Oncology, Oslo University Hospital, the Norwegian Radium Hospital, Oslo, Norway
| | - Wolfgang Lilleby
- Department of Oncology, Oslo University Hospital, the Norwegian Radium Hospital, Oslo, Norway
| | - Daniel J. Krauss
- Oakland University William Beaumont School of Medicine, Royal Oak, Michigan
| | - Grace K. Shaw
- Lank Center for Genitourinary Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts
| | - Ridwan Alam
- Department of Urology, The James Buchanan Brady Urological Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | | | - Andrew J. Stephenson
- Department of Urology, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, Ohio
| | - Eric A. Klein
- Department of Urology, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, Ohio
| | - Daniel Y. Song
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Jeffrey J. Tosoian
- Department of Urology, The James Buchanan Brady Urological Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - John V. Hegde
- Department of Radiation Oncology, University of California, Los Angeles
| | - Sun Mi Yoo
- Department of Radiation Oncology, University of California, Los Angeles
| | - Ryan Fiano
- Schiffler Cancer Center, Wheeling Hospital, Wheeling Jesuit University, Wheeling, West Virginia
| | - Anthony V. D’Amico
- Department of Radiation Oncology, Brigham and Women's Hospital/Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts
| | - Nicholas G. Nickols
- Department of Radiation Oncology, University of California, Los Angeles
- Department of Radiation Oncology, Veteran Affairs Greater Los Angeles Healthcare System, Los Angeles, California
| | | | - Ahmad Sadeghi
- Department of Radiation Oncology, Veteran Affairs Greater Los Angeles Healthcare System, Los Angeles, California
| | - Stephen Greco
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Curtiland Deville
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Todd McNutt
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Theodore L. DeWeese
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | | | | | | | - Eric M. Horwitz
- Department of Radiation Oncology, Fox Chase Cancer Center, Philadelphia, Pennsylvania
| | - Patrick A. Kupelian
- Department of Radiation Oncology, University of California, Los Angeles
- Varian Medical Systems, Palo Alto, California
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Sandler KA, Chu FI, Ciezki JP, Stock R, Merrick GS, Demanes DJ, Spratt DE, Abu-Isa EI, Pomerantz M, Ross A, Tran PT, Nguyen PL, Wedde TB, Lilleby W, Krauss D, Alam R, Steinberg ML, Horwitz EM, King CR, Kishan AU. Clinical outcomes following biochemical recurrence among patients with Gleason score 9-10 prostate adenocarcinoma. J Clin Oncol 2018. [DOI: 10.1200/jco.2018.36.6_suppl.102] [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
102 Background: Patients with Gleason score (GS) 9-10 prostate cancer (PCa) have a high risk of early biochemical recurrence (BCR). Salvage therapy options differ depending on the upfront management strategy. Patients who received upfront surgery (RP) may be curable with salvage external beam radiation therapy (EBRT). However those who underwent EBRT or EBRT with a brachytherapy boost (EBRT+BT) are less likely to receive local salvage therapy and are commonly treated with androgen deprivation therapy (ADT). In this study, we examine the risk of distant metastases (DM) and prostate-cancer specific mortality (PCSM) among patients with GS 9-10 PCa who had BCR following RP, EBRT, or EBRT+BT. Methods: 712 patients with GS 9-10 PCa treated between 2000-2013 at 12 institutions who had BCR were included (346 RP, 282 EBRT, 84 EBRT+BT). Time to DM and PCSM were compared between groups using Cox proportional hazards models with propensity score adjustment. Propensity scores were calculated using age, T-stage, PSA, and GS. Results: In patients who had a BCR, incidence rates of DM and PCSM after RP were 40% and 28%. Rates after EBRT were 60% and 46% and after EBRT+BT were 49% and 31%. Median times to DM and PCSM were 3.5 and 4.9 years after RP, 3.7 and 5.1 years after EBRT, and 3.3 and 6.8 years after EBRT+BT. The rates of local salvage RT and systemic salvage therapy among RP patients were 38% and 59%, respectively. Local and systemic salvage rates were 5% and 31% for EBRT patients and 5% and 28% for EBRT+BT patients. EBRT patients had a shorter time interval to DM compared with RP (HR 1.4, p = .02) and EBRT+BT (HR 1.9, p < .01). EBRT patients also had a shorter time interval to PCSM compared with RP (HR 1.5, p = .02). Conclusions: Among patients with GS 9-10 PCa who experience BCR after definitive management, those treated with EBRT have a shorter time interval to DM and PCSM compared with RP and EBRT+BT. While this analysis is confounded by the differential thresholds for diagnosing a BCR after different modalities, it does suggest that outcomes following BCR after EBRT+BT and RP are similar. It also suggests that extreme dose escalation delays the onset of DM and PCSM even after BCR, when compared with conventionally-dosed EBRT alone.
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Affiliation(s)
| | - Fang-I Chu
- University of California Los Angeles, Los Angeles, CA
| | | | | | | | | | | | | | - Mark Pomerantz
- Lank Center for Genitourinary Oncology, Dana-Farber Cancer Institute, Boston, MA
| | | | | | - Paul L. Nguyen
- Brigham and Women's Hospital/ Dana-Farber Cancer Institute, Boston, MA
| | | | | | - Daniel Krauss
- Oakland University William Beaumont Medical School, Royal Oak, MI
| | - Ridwan Alam
- James Buchanan Brady Urological Institute, Johns Hopkins University School of Medicine, Baltimore, MD
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Laviana AA, Saigal C, Resnick MJ, Reiter RE, King CR, Demanes DJ, Steinberg ML, Horwitz EM, Kishan AU. Costs and of treating Gleason score 9 and 10 prostate cancer vary widely based on need for adjuvant therapy: A critical assessment into the long-term cost implications of additional treatment modalities. J Clin Oncol 2018. [DOI: 10.1200/jco.2018.36.6_suppl.53] [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
53 Background: The costs of treating localized, Gleason score 9 and 10 prostate cancer remain poorly described, especially when the particularly aggressive nature of the disease often requires a multimodal approach. We report the results of time-driven activity-based costing to assess the long-term costs of treating this subset of patients with either RALP, high-dose EBRT, or EBRT with a high-dose rate brachytherapy (BT) boost. Methods: Based on a multi-institutional cohort of 487 patients with Gleason score 9-10 prostate cancer, we generated process maps for each phase of care from the initial urologic visit through a median follow-up of 3.76 years, incorporating all prostate cancer treatment over this horizon. Costs were calculated per unit time, and the proportion of capacity for each step was determined. TDABC was defined as the sum of its resources. Results: Substantial cost variation was demonstrated between treatment modalities with an estimated median cost of $49,681 for EBRT, $35,140 for RALP, and $31,647 for EBRT + BT at 3.76 years. The primary driver in cost variation was the use of ADT. RALP (170 pts) ranged from $18,896 (29.5%) for no postoperative therapy to $63,270 for immediate long-term ADT (5.3%). EBRT (230 pts) had the greatest cost variation [Table 1]. Finally, EBRT + BT (336 pts) ranged from $26,522 for EBRT + BT alone (12.6%) to $37,834 for EBRT + BT + salvage ADT + HIFU (1.2%). Conclusions: Characterizing the costs associated with the distribution of treatments for men with high-risk prostate cancer is essential as we move towards health care accountability. There is substantial long-term cost variation between treatments in this subset of patients, and understanding these differences may affect treatment implications as we shift toward accountable payment models.[Table: see text]
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Kishan AU, Katz AJ, Mantz C, Chu FI, Appelbaum L, Loblaw A, Cheung P, Kaplan ID, Fuller DB, Pham HT, Meier R, Buyyounouski MK, Shaverdian N, Dang A, Yuan Y, Bagshaw H, Prionas N, Kupelian P, Steinberg ML, King CR. Long-term outcomes of stereotactic body radiotherapy for low- and intermediate-risk prostate adenocarcinoma: A multi-institutional consortium study. J Clin Oncol 2018. [DOI: 10.1200/jco.2018.36.6_suppl.84] [Citation(s) in RCA: 5] [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
84 Background: While a growing body of evidence supports the use of stereotactic body radiotherapy (SBRT) for the treatment of low- and intermediate-risk prostate adenocarcinoma (PCa), some trepidation exists regarding its long-term efficacy and safety. Methods: Men with low- and intermediate-risk PCa, as defined per the National Comprehensive Cancer Network guidelines, who were enrolled on various institutional phase II trials of SBRT between 2000-2012 were included in a multi-institutional consortium. Biochemical relapse (BCR) was defined as PSA > “nadir +2” or initiation of androgen deprivation therapy (ADT). Toxicity data were scored according to the CTCAE v 3.0 or Radiation Therapy Oncology Group scoring systems. Results: A total of 1644 men were eligible for analysis, with a median followup of 7.2 years. 297 patients (18.1%) had at least 9 years of followup. Fractionation schemes ranged from 33.50-40 Gy in 4-5 fractions. 892 patients had low-risk disease and 752 had intermediate-risk disease. 59 patients (3.6%) received short-term ADT. 100 patients (6.0%) experienced BCR, and 7 (0.4%) experienced distant metastases. No patients died of PCa. By Kaplan-Meier analysis, 5- and 10-year BCR-free survival rates were 98% and 94% in the low-risk group and 96% and 90% in the intermediate-risk group (p < 0.05 by log-rank test). 5- and 10-year overall survival rates were 93% and 86% in the low-risk group and 95% and 91% in the intermediate-risk group (p > 0.05 by log-rank test). Five patients (0.3%) experienced grade 3 acute genitourinary (GU) toxicities, including urinary retention, hematuria, and frequency. 30 (2%) experienced grade 3 late GU toxicity, including urinary strictures, hematuria, and retention. One late grade 4 GU toxicity (hemorrhagic urethritis) and one late grade 4 gastrointestinal toxicity (fistula-in-ano) were seen. Conclusions: To the best of our knowledge, this is the largest analysis of long-term outcomes following SBRT for PCa. The results indicate that SBRT has an efficacy and toxicity profile that compares favorably to more widespread forms of treatment, such as conventionally-fractionated external beam radiotherapy and brachytherapy.
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Affiliation(s)
| | | | | | - Fang-I Chu
- University of California Los Angeles, Los Angeles, CA
| | | | - Andrew Loblaw
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Patrick Cheung
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | | | | | | | | | | | | | - Audrey Dang
- University of California Los Angeles, Los Angeles, CA
| | - Ye Yuan
- Northwestern University Feinberg School of Medicine, Chicago, IL
| | | | | | - Patrick Kupelian
- University of California Los Angeles Health Syst, Los Angeles, CA
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King CR, Lippincott-Schwartz J. Direct Detection of ER-mitochondrial Contacts with Fully Quantified Fluorescence Microscopy. Biophys J 2018. [DOI: 10.1016/j.bpj.2017.11.2948] [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: 11/28/2022] Open
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43
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Kishan AU, Cheng EM, Schmidt E, Saigal C, Reiter RE, Kupelian PA, Steinberg ML, King CR. Use of the Electronic Medical Record to Facilitate Intervention for Patients With Rising Prostate-Specific Antigen Values After Radical Prostatectomy: A Feasibility Study. JCO Clin Cancer Inform 2017; 1:1-6. [PMID: 30657383 DOI: 10.1200/cci.17.00046] [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
PURPOSE Salvage radiotherapy (SRT) is the standard of care offered when postprostatectomy prostate-specific antigen (PSA) levels are ≥ 0.2 ng/mL. However, emerging evidence suggests that early SRT (ie, SRT delivered at PSA values < 0.2 ng/mL, but generally ≥ 0.05 ng/mL) improves oncologic outcomes. We evaluated the feasibility of improving referral rates for discussion of early SRT by using a dynamic registry that identifies through the electronic medical record patients with rising postprostatectomy PSA levels. METHODS We developed an iteratively updated registry that identifies patients who fall within two postoperative PSA strata: ≥ 0.05 to < 0.1 ng/mL and ≥ 0.1 to < 0.2 ng/mL. We compared referral rates to radiation oncology during a 3-year period before use of this registry with those during a 1-year period after promotion of the registry in multidisciplinary tumor board settings. RESULTS Before promotion of the registry, referral rates for patients with PSA values ≥ 0.05 to < 0.1 ng/mL and ≥ 0.1 to < 0.2 ng/mL were 35% and 65%, respectively. After promotion of the registry, referral rates within each stratum increased significantly to 82% and 94%, respectively ( P < .05 for both by Fisher's exact test). The overall rate of referral for patients with PSA values ≥ 0.05 to < 0.2 ng/mL rose from 48% to 90% ( P < .001). CONCLUSION The creation of a registry of patients with rising postprostatectomy PSA values can facilitate increased referral rates for early SRT without burdening providers with a clinical support tool embedded within the EMR itself. This is true even in the case of already high baseline rates of referral for early SRT. The changes reported herein most likely reflect a Hawthorne effect wherein the ability to track referrals rather than a direct function of the registry influenced practice patterns. Nonetheless, the registry provided an integral framework to allow for tracking.
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Affiliation(s)
- Amar U Kishan
- All authors: University of California, Los Angeles, Los Angeles, CA
| | - Eric M Cheng
- All authors: University of California, Los Angeles, Los Angeles, CA
| | - Eric Schmidt
- All authors: University of California, Los Angeles, Los Angeles, CA
| | | | - Robert E Reiter
- All authors: University of California, Los Angeles, Los Angeles, CA
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Hegde JV, Demanes DJ, Veruttipong D, Raince J, Park SJ, Raman SS, Nickols NG, King CR, Kishan AU, Steinberg ML, Kamrava M. Pretreatment 3T multiparametric MRI staging predicts for biochemical failure in high-risk prostate cancer treated with combination high-dose-rate brachytherapy and external beam radiotherapy. Brachytherapy 2017; 16:1106-1112. [PMID: 28807747 DOI: 10.1016/j.brachy.2017.07.008] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2017] [Revised: 07/02/2017] [Accepted: 07/13/2017] [Indexed: 11/26/2022]
Abstract
PURPOSE To determine whether pretreatment 3T multiparametric MRI (mpMRI) staging impacts biochemical recurrence-free survival (BRFS) or distant metastasis-free survival (DMFS) for men with high-risk prostate cancer treated with combination high-dose-rate (HDR) brachytherapy and external beam radiation therapy (EBRT). MATERIALS AND METHODS This institutional review board-approved retrospective study included a cohort of 37 men with high-risk prostate cancer treated with HDR brachytherapy and EBRT after 3T mpMRI. Kaplan-Meier analysis was used to evaluate whether mpMRI evidence of extracapsular extension or seminal vesicle invasion (SVI) resulted in differences in BRFS or DMFS. Pretreatment and treatment-related variables were evaluated for association with biochemical failure (Phoenix definition) and distant metastatic failure using univariate Cox regression analysis. RESULTS The median prostate-specific antigen at diagnosis was 9 ng/mL (range 2-100). Biopsy Gleason score (bGS) was ≤8 in 38% and nine in 62%. Clinical T-category was T1-T2 in 89%, T3a in 8%, and T3b in 3%. With a median followup of 30.6 months, actuarial 3-year BRFS and DMFS were 76% and 86%, respectively. Kaplan-Meier analysis revealed that mpMRI evidence of extracapsular extension or SVI resulted in significantly higher rates of both biochemical recurrence and distant failure. Using Cox regression analysis, only mpMRI evidence of SVI vs. no SVI predicted for biochemical failure (hazard ratio 13.98, p = 0.0055). CONCLUSIONS For high-risk prostate cancer treated with combination HDR brachytherapy and EBRT, mpMRI evidence of SVI predicted for biochemical failure, whereas traditional pretreatment variables did not. Therefore, pretreatment 3T mpMRI appears useful for identifying men who may benefit from treatment intensification.
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Affiliation(s)
- John V Hegde
- Department of Radiation Oncology, University of California Los Angeles, David Geffen School of Medicine, Los Angeles, CA.
| | - D Jeffrey Demanes
- Department of Radiation Oncology, University of California Los Angeles, David Geffen School of Medicine, Los Angeles, CA
| | - Darlene Veruttipong
- Department of Radiation Oncology, University of California Los Angeles, David Geffen School of Medicine, Los Angeles, CA
| | - Jagdeep Raince
- Department of Radiation Oncology, University of California Los Angeles, David Geffen School of Medicine, Los Angeles, CA
| | - Sang-June Park
- Department of Radiation Oncology, University of California Los Angeles, David Geffen School of Medicine, Los Angeles, CA
| | - Steven S Raman
- Departments of Radiology, Urology, and Surgery, University of California Los Angeles, David Geffen School of Medicine, Los Angeles, CA
| | - Nicholas G Nickols
- Department of Radiation Oncology, University of California Los Angeles, David Geffen School of Medicine, Los Angeles, CA
| | - Christopher R King
- Department of Radiation Oncology, University of California Los Angeles, David Geffen School of Medicine, Los Angeles, CA
| | - Amar U Kishan
- Department of Radiation Oncology, University of California Los Angeles, David Geffen School of Medicine, Los Angeles, CA
| | - Michael L Steinberg
- Department of Radiation Oncology, University of California Los Angeles, David Geffen School of Medicine, Los Angeles, CA
| | - Mitchell Kamrava
- Department of Radiation Oncology, Samuel Oschin Cancer Center, Cedars-Sinai Medical Center, Los Angeles, CA
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45
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Wang C, Kishan AU, Kamrava M, Steinberg ML, King CR. External Beam Radiation Therapy With a Brachytherapy Boost Versus Radical Prostatectomy in Gleason Pattern 5 Prostate Cancer: A Population-Based Cohort Study. Int J Radiat Oncol Biol Phys 2017; 98:1045-1052. [DOI: 10.1016/j.ijrobp.2017.03.040] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2016] [Revised: 03/15/2017] [Accepted: 03/23/2017] [Indexed: 11/27/2022]
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46
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Shaverdian N, Steinberg ML, King CR. In Reply to Scott. Int J Radiat Oncol Biol Phys 2017; 98:217. [DOI: 10.1016/j.ijrobp.2017.02.012] [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] [Received: 02/06/2017] [Accepted: 02/08/2017] [Indexed: 10/19/2022]
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47
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Walling AM, Beron PJ, Kaprealian T, Kupelian PA, Wenger NS, McCloskey SA, King CR, Steinberg M. Considerations for Quality Improvement in Radiation Oncology Therapy for Patients with Uncomplicated Painful Bone Metastases. J Palliat Med 2017; 20:478-486. [PMID: 28437208 DOI: 10.1089/jpm.2016.0339] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Background: There is an increasing need for evidence-based efficiency in providing a growing amount of cancer care. One example of a quality gap is the use of multiple-fraction palliative radiation for patients with advanced cancer who have uncomplicated bone metastases; evidence suggests similar pain outcomes for treatment regimens with a lower burden of treatments. Methods: During the first phase of quality improvement work, we used RAND/UCLA appropriateness methodology to understand how radiation oncologists at one academic medical center rate the appropriateness of different treatment regimens for painful uncomplicated bone metastases. We compared radiation oncologist appropriateness ratings for radiation treatments with radiation therapy provided by these oncologists to patients with painful bone metastases between July 2012 and June 2013. Results: Appropriateness ratings showed that single-fraction (8 Gy) treatment (a low burden treatment) was consistently considered an appropriate option to treat a variety of uncomplicated bone metastases. The use of >10 fractions was consistently rated as inappropriate regardless of other factors. Eighty-one patients receiving radiation therapy for painful bone metastases during the study period had an available medical record for chart abstraction. Almost one-third of metastases were considered complicated because of a concern of spinal cord compression, a history of prior irradiation, or an associated pathological fracture. Among uncomplicated bone metastases, 25% were treated with stereotactic body radiation treatment (SBRT). Among the 54 uncomplicated bone metastases treated with conformal radiation, only one was treated with single-fraction treatment and 32% were treated with greater than 10 fractions. Conclusions: Treatment at the study site demonstrates room for improvement in providing low-burden radiation oncology treatments for patients with painful bone metastases. Choosing a radiation treatment schedule for patients with advanced cancer and painful bone metastases requires consideration of many medical and patient-centered factors. Our experience suggests that it will take more than the existence of guidelines to change practice in this area.
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Affiliation(s)
- Anne M Walling
- VA Greater Los Angeles Healthcare System, Los Angeles, California.,Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine at University of California, Los Angeles, California.,RAND Health, Santa Monica, California
| | - Phillip J Beron
- Department of Radiation Oncology, David Geffen School of Medicine at University of California, Los Angeles, California
| | - Tania Kaprealian
- Department of Radiation Oncology, David Geffen School of Medicine at University of California, Los Angeles, California
| | - Patrick A Kupelian
- Department of Radiation Oncology, David Geffen School of Medicine at University of California, Los Angeles, California
| | - Neil S Wenger
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine at University of California, Los Angeles, California.,RAND Health, Santa Monica, California
| | - Susan A McCloskey
- Department of Radiation Oncology, David Geffen School of Medicine at University of California, Los Angeles, California
| | - Christopher R King
- Department of Radiation Oncology, David Geffen School of Medicine at University of California, Los Angeles, California
| | - Michael Steinberg
- Department of Radiation Oncology, David Geffen School of Medicine at University of California, Los Angeles, California
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Abstract
With over a decade׳s worth of clinical experience to guide stereotactic body radiotherapy (SBRT) for the treatment of clinically localized prostate cancer (PCa), sufficient data exist for robust conclusions to be made regarding its efficacy and the toxicities associated with this treatment. We briefly review the fundamental radiobiological basis of SBRT for PCa and provide a comprehensive synthesis of the medical literature to date, focusing on clinical outcomes and toxicities. When possible, we draw comparisons to comparable data for conventionally fractionated radiotherapy. Finally, a brief overview of technical considerations is presented. Although randomized clinical trials comparing SBRT with conventionally fractionated radiotherapy are underway, the current body of evidence supports the efficacy and safety of SBRT for PCa.
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Affiliation(s)
- Amar U Kishan
- Department of Radiation Oncology, University of California, Los Angeles, Los Angeles, CA.
| | - Christopher R King
- Department of Radiation Oncology, University of California, Los Angeles, Los Angeles, CA
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49
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Kishan AU, Ciezki JP, Shaikh T, Stock R, Merrick GS, Jeffrey Demanes D, Wang J, Said JW, Fiano R, Raghavan G, Sandler KA, Reddy CA, Nickols NG, Aronson WJ, Sadeghi A, Kamrava M, Steinberg ML, Horwitz EM, Kupelian P, King CR. Radiotherapy versus radical prostatectomy for Gleason score 9-10 prostate adenocarcinoma: A multi-institutional comparative analysis of 1001 patients treated in the modern era. J Clin Oncol 2017. [DOI: 10.1200/jco.2017.35.6_suppl.7.2017.1.test] [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)
| | | | | | | | | | - D. Jeffrey Demanes
- Department of Radiation Oncology, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Jason Wang
- Department of Radiation Oncology, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | | | | | | | | | - Chandana A. Reddy
- Department of Urology, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH
| | | | | | | | | | | | | | - Patrick Kupelian
- University of California Los Angeles Health Syst, Los Angeles, CA
| | - Christopher R. King
- Department of Radiation Oncology, University of California, Los Angeles School of Medicine, Los Angeles, CA
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50
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Kishan AU, Fuller DB, Steinberg ML, Ramirez V, Agazaryan N, Ruan D, Cao M, Kupelian P, King CR. Stereotactic body radiotherapy for high-risk prostate cancer (5 treatment days): Toxicity results of a phase II trial. J Clin Oncol 2017. [DOI: 10.1200/jco.2017.35.6_suppl.46] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [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
46 Background: Stereotactic body radiotherapy (SBRT) for high-risk prostate cancer (CaP) remains investigational not only due to undetermined efficacy but also due to concerns for the potential toxicity when the treatment volumes extend beyond the prostate gland itself. Methods: Men with high-risk CaP, as defined by Gleason score > = 8, clinical stage T3-T4, or initial PSA > = 20 ng/mL, were enrolled on a multicenter phase II trial and were treated with 40 Gy to prostate and 25 Gy to pelvic nodes in 5 fractions and 9 months neoadjuvant and concurrent ADT. Treatment with ADT and pelvic nodal radiation was at the discretion of the treating physician. Follow-up assessment was with CTCAE v4 and Expanded Prostate Composite Index (EPIC). Results: A total of 61 patients were treated, with a median follow-up of 12 months. Forty (64.4%) received ADT and 23 (37.1%) received nodal radiation. The median initial PSA was 8.1 ng/mL and 8% of patients had clinical T3-T4 disease; 45.9% and 39.3% had Gleason score 8 and 9-10 disease, respectively. No grade 3 or higher toxicities were seen. Rates of acute and late grade 2 genitourinary toxicities were 13.1% and 6.7%, respectively; rates of acute and late grade 2 gastrointestinal toxicities were 6.6% and 8.2%, respectively. Mean changes in EPIC urinary incontinence, urinary obstructive, and bowel domain scores at 4 months were -0.35, +1.44, and -2.38, respectively. For the 32 patients with evaluable EPIC scores at 12 months, mean changes on EPIC urinary incontinence, urinary obstructive, and bowel domain scores at 4 months were -1.04, -2.70, and -6.76, respectively. The percentages of patients with minimum clinically important change in EPIC urinary incontinence, urinary obstructive, and bowel domain scores at 4 months were 11.9%, 21.4%, and 26.2%, respectively. At 12 months, these figures were 13.9%, 30.6% and 27.8%. The receipt of ADT and/or nodal radiation had no significant effect on either physician- or patient-reported toxicity profiles (p > 0.1, Fisher’s exact test). Conclusions: SBRT regimens can be safely utilized to deliver the entire course in 5 treatment days in patients with high-risk localized CaP. Clinical trial information: NCT02296229.
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Affiliation(s)
| | | | | | | | | | - Dan Ruan
- University of California, Los Angeles, Los Angeles, CA
| | - Minsong Cao
- University of California, Los Angeles, Los Angeles, CA
| | - Patrick Kupelian
- University of California Los Angeles Health Syst, Los Angeles, CA
| | - Christopher R. King
- Department of Radiation Oncology, University of California, Los Angeles School of Medicine, Los Angeles, CA
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