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Choi S, Borowsky PA, Morgan O, Kwon D, Zhao W, Koru-Sengul T, Gilna G, Net J, Kesmodel S, Goel N, Patel Y, Griffiths A, Feinberg JA, Kangas-Dick A, Andaz C, Giuliano C, Zelenko N, Manasseh DM, Borgen P, Rojas KE. A Multi-institutional Analysis of Factors Influencing the Rate of Positive MRI Biopsy Among Women with Early-Stage Breast Cancer. Ann Surg Oncol 2024; 31:3141-3153. [PMID: 38286883 DOI: 10.1245/s10434-024-14954-1] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Accepted: 01/09/2024] [Indexed: 01/31/2024]
Abstract
BACKGROUND The use of preoperative magnetic resonance imaging (MRI) for early-stage breast cancer (ESBC) is increasing, but its utility in detecting additional malignancy is unclear and delays surgical management (Jatoi and Benson in Future Oncol 9:347-353, 2013. https://doi.org/10.2217/fon.12.186 , Bleicher et al. J Am Coll Surg 209:180-187, 2009. https://doi.org/10.1016/j.jamcollsurg.2009.04.010 , Borowsky et al. J Surg Res 280:114-122, 2022. https://doi.org/10.1016/j.jss.2022.06.066 ). The present study sought to identify ESBC patients most likely to benefit from preoperative MRI by assessing the positive predictive values (PPVs) of ipsilateral and contralateral biopsies. METHODS A retrospective cohort study included patients with cTis-T2N0-N1 breast cancer from two institutions during 2016-2021. A "positive" biopsy result was defined as additional cancer (PositiveCancer) or cancer with histology often excised (PositiveSurg). The PPV of MRI biopsies was calculated with respect to age, family history, breast density, and histology. Uni- and multivariate logistic regression determined whether combinations of age younger than 50 years, dense breasts, family history, and pure ductal carcinoma in situ (DCIS) histology led to higher biopsy yield. RESULTS Of the included patients, 447 received preoperative MRI and 131 underwent 149 MRI-guided biopsies (96 ipsilateral, 53 contralateral [18 bilateral]). PositiveCancer for ipsilateral biopsy was 54.2%, and PositiveCancer for contralateral biopsy was 17.0%. PositiveSurg for ipsilateral biopsy was 62.5%, and PositiveSurg for contralateral biopsy was 24.5%. Among the contralateral MRI biopsies, patients younger than 50 years were less likely to have PositiveSurg (odds ratio, 0.02; 95% confidence interval, 0.00-0.84; p = 0.041). The combinations of age, density, family history, and histology did not lead to a higher biopsy yield. CONCLUSION Historically accepted factors for recommending preoperative MRI did not appear to confer a higher MRI biopsy yield. To prevent delays to surgical management, MRI should be carefully selected for individual patients most likely to benefit from additional imaging.
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Affiliation(s)
- Seraphina Choi
- Division of Surgical Oncology, Dewitt Daughtry Department of Surgery, University of Miami, Miami, FL, USA
| | - Peter A Borowsky
- Division of Surgical Oncology, Dewitt Daughtry Department of Surgery, University of Miami, Miami, FL, USA
| | - Orly Morgan
- Division of Surgical Oncology, Dewitt Daughtry Department of Surgery, University of Miami, Miami, FL, USA
| | - Deukwoo Kwon
- Division of Biostatistics, Department of Public Health Sciences, Sylvester Comprehensive Cancer Center, University of Miami, Miami, FL, USA
| | - Wei Zhao
- Division of Biostatistics, Department of Public Health Sciences, Sylvester Comprehensive Cancer Center, University of Miami, Miami, FL, USA
| | - Tulay Koru-Sengul
- Division of Biostatistics, Department of Public Health Sciences, Sylvester Comprehensive Cancer Center, University of Miami, Miami, FL, USA
| | - Gareth Gilna
- Division of Surgical Oncology, Dewitt Daughtry Department of Surgery, University of Miami, Miami, FL, USA
| | - Jose Net
- Division of Breast Imaging, Sylvester Comprehensive Cancer Center, University of Miami, Miami, FL, USA
| | - Susan Kesmodel
- Division of Surgical Oncology, Dewitt Daughtry Department of Surgery, University of Miami, Miami, FL, USA
- Sylvester Comprehensive Cancer Center, University of Miami, Miami, FL, USA
| | - Neha Goel
- Division of Surgical Oncology, Dewitt Daughtry Department of Surgery, University of Miami, Miami, FL, USA
- Sylvester Comprehensive Cancer Center, University of Miami, Miami, FL, USA
| | - Yamini Patel
- Wright Center for Graduate Medical Education, Scranton, PA, USA
| | - Alexa Griffiths
- Department of Surgery, Maimonides Medical Center, Brooklyn, NY, USA
| | | | | | | | | | - Natalie Zelenko
- Department of Radiology, Maimonides Medical Center, Brooklyn, NY, USA
| | | | - Patrick Borgen
- Department of Surgery, Maimonides Medical Center, Brooklyn, NY, USA
| | - Kristin E Rojas
- Division of Surgical Oncology, Dewitt Daughtry Department of Surgery, University of Miami, Miami, FL, USA.
- Sylvester Comprehensive Cancer Center, University of Miami, Miami, FL, USA.
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Etra AM, El Jurdi N, Katsivelos N, Kwon D, Gergoudis SC, Morales G, Spyrou N, Kowalyk S, Aguayo-Hiraldo P, Akahoshi Y, Ayuk FA, Baez J, Betts BC, Chanswangphuwana C, Chen YB, Choe HK, DeFilipp Z, Gleich S, Hexner EO, Hogan WJ, Holler E, Kitko CL, Kraus S, Al Malki MM, MacMillan ML, Pawarode A, Quagliarella F, Qayed M, Reshef R, Schechter-Finkelstein T, Vasova I, Weisdorf DJ, Wölfl M, Young R, Nakamura R, Ferrara JLM, Levine JE, Holtan SG. Amphiregulin, ST2,and REG3α Biomarker Risk Algorithms as Predictors of Non-Relapse Mortality in Patients with Acute GVHD. Blood Adv 2024:bloodadvances.2023011049. [PMID: 38640195 DOI: 10.1182/bloodadvances.2023011049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Revised: 03/29/2024] [Accepted: 03/29/2024] [Indexed: 04/21/2024] Open
Abstract
Graft-vs-host disease (GVHD) is a major cause of non-relapse mortality (NRM) following allogeneic hematopoietic cell transplant (HCT). Algorithms containing either the GI GVHD biomarker amphiregulin (AREG) or a combination of two GI GVHD biomarkers, (ST2+REG3α) when measured at GVHD diagnosis are validated predictors of NRM risk, but have never been assessed in the same patients using identical statistical methods. We measured serum concentrations of ST2, REG3, and AREG by ELISA at the time of GVHD diagnosis in 715 patients divided by date of transplant into training (2004-2015) and validation (2015-2017) cohorts. The training cohort (n=341) was used to develop algorithms for predicting probability of 12 month NRM that contained all possible combinations of 1-3 biomarkers and a threshold corresponding to the concordance probability was used to stratify patients for risk of NRM. Algorithms were compared to each other based on several metrics including the area under the receiver operating characteristics curve (AUC), proportion of patients correctly classified, sensitivity, and specificity using only the validation cohort (n=374). All algorithms were strong discriminators of 12 month NRM, whether or not patients were systemically treated (n=321). An algorithm containing only ST2+REG3α had the highest AUC (0.757), correctly classified the most patients (75%), and more accurately risk stratified those who developed Minnesota standard risk GVHD and for patients who received post-transplant cyclophosphamide-based prophylaxis. An algorithm containing only AREG more accurately risk stratified patients with Minnesota high risk GVHD. Combining ST2, REG3α, and AREG into a single algorithm did not improve performance.
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Affiliation(s)
- Aaron M Etra
- Icahn School of Medicine at Mount Sinai, New York, New York, United States
| | - Najla El Jurdi
- University of Minnesota, Minneapolis, Minnesota, United States
| | | | - Deukwoo Kwon
- Icahn School of Medicine at Mount Sinai, New York, New York, United States
| | | | - George Morales
- Icahn School of Medicine at Mount Sinai, New York, New York, United States
| | - Nikolaos Spyrou
- Icahn School of Medicine at Mount Sinai, New York, New York, United States
| | - Steven Kowalyk
- Icahn School of Medicine at Mount Sinai, New York, New York, United States
| | - Paibel Aguayo-Hiraldo
- Children's Hospital Los Angeles, University of Southern California, Los Angeles, California, United States
| | - Yu Akahoshi
- Icahn School of Medicine at Mount Sinai, New York, New York, United States
| | | | - Janna Baez
- Icahn School of Medicine at Mount Sinai, New York, New York, United States
| | - Brian C Betts
- University of Minnesota, Buffalo, New York, United States
| | - Chantiya Chanswangphuwana
- Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Yi-Bin Chen
- Massachusetts General Hospital, Boston, Massachusetts, United States
| | - Hannah K Choe
- The Ohio State University, Columbus, Ohio, United States
| | | | | | - Elizabeth O Hexner
- University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, United States
| | | | - Ernst Holler
- University Hospital Regensburg, Regensburg, Germany
| | - Carrie L Kitko
- Vanderbilt University Medical Center, Nashville, Tennessee, United States
| | | | - Monzr M Al Malki
- City of Hope National Medical Center, Duarte, California, United States
| | | | | | | | - Muna Qayed
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, and Emory University, Atlanta, Georgia, United States
| | - Ran Reshef
- Columbia University Medical Center, New York, New York, United States
| | | | - Ingrid Vasova
- University Hospital Erlangen, Erlangen, Germany, Erlangen, Germany
| | | | | | - Rachel Young
- Icahn School of Medicine at Mount Sinai, New York, New York, United States
| | - Ryotaro Nakamura
- City of Hope National Medical Center, Duarte, California, United States
| | - James L M Ferrara
- Icahn School of Medicine at Mount Sinai, New York, New York, United States
| | - John E Levine
- Icahn School of Medicine at Mount Sinai, New York, New York, United States
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Spyrou N, Akahoshi Y, Kowalyk S, Morales G, Beheshti R, Aguayo-Hiraldo P, Al Malki MM, Ayuk F, Bader P, Baez J, Capellini A, Choe H, DeFilipp Z, Eder M, Eng G, Etra A, Gleich S, Grupp SA, Hexner E, Hoepting M, Hogan WJ, Kasikis S, Katsivelos N, Khan A, Kitko CL, Kraus S, Kwon D, Merli P, Portelli J, Qayed M, Reshef R, Schechter T, Vasova I, Wölfl M, Wudhikarn K, Young R, Holler E, Chen YB, Nakamura R, Levine JE, Ferrara JLM. A Day 14 Endpoint for Acute GVHD Clinical Trials. Transplant Cell Ther 2024; 30:421-432. [PMID: 38320730 PMCID: PMC11009039 DOI: 10.1016/j.jtct.2024.01.079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2023] [Revised: 01/15/2024] [Accepted: 01/25/2024] [Indexed: 02/19/2024]
Abstract
The overall response rate (ORR) 28 days after treatment has been adopted as the primary endpoint for clinical trials of acute graft versus host disease (GVHD). However, physicians often need to modify immunosuppression earlier than day (D) 28, and non-relapse mortality (NRM) does not always correlate with ORR at D28. We studied 1144 patients that received systemic treatment for GVHD in the Mount Sinai Acute GVHD International Consortium (MAGIC) and divided them into a training set (n=764) and a validation set (n=380). We used a recursive partitioning algorithm to create a Mount Sinai model that classifies patients into favorable or unfavorable groups that predicted 12 month NRM according to overall GVHD grade at both onset and D14. In the Mount Sinai model grade II GVHD at D14 was unfavorable for grade III/IV GVHD at onset and predicted NRM as well as the D28 standard response model. The MAGIC algorithm probability (MAP) is a validated score that combines the serum concentrations of suppression of tumorigenicity 2 (ST2) and regenerating islet-derived 3-alpha (REG3α) to predict NRM. Inclusion of the D14 MAP biomarker score with the D14 Mount Sinai model created three distinct groups (good, intermediate, poor) with strikingly different NRM (8%, 35%, 76% respectively). This D14 MAGIC model displayed better AUC, sensitivity, positive and negative predictive value, and net benefit in decision curve analysis compared to the D28 standard response model. We conclude that this D14 MAGIC model could be useful in therapeutic decisions and may offer an improved endpoint for clinical trials of acute GVHD treatment.
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Affiliation(s)
- Nikolaos Spyrou
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Yu Akahoshi
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Steven Kowalyk
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - George Morales
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Rahnuma Beheshti
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Paibel Aguayo-Hiraldo
- Division of Hematology, Oncology and Blood and Marrow Transplantation, Children's Hospital of Los Angeles, Los Angeles, CA
| | - Monzr M Al Malki
- Hematology/Hematopoietic Cell Transplant, City of Hope National Medical Center, Duarte, CA
| | - Francis Ayuk
- Department of Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Peter Bader
- Division for Stem Cell Transplantation and Immunology, Department for Children and Adolescents, University Hospital, Goethe University, Frankfurt, Germany
| | - Janna Baez
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Alexandra Capellini
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Hannah Choe
- Division of Hematology, The James Comprehensive Cancer Center, The Ohio State University, Columbus, OH
| | - Zachariah DeFilipp
- Hematopoietic Cell Transplant and Cellular Therapy Program, Massachusetts General Hospital, Boston, MA
| | - Matthias Eder
- Department of Hematology, Hemostasis, Oncology, and Stem Cell Transplantation, Hannover Medical School, Hannover, Germany
| | - Gilbert Eng
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Aaron Etra
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Sigrun Gleich
- Department of Hematology and Oncology, Internal Medicine III, University of Regensburg, Regensburg, Germany
| | - Stephan A Grupp
- Division of Oncology, Children's Hospital of Philadelphia, and Perelman School of Medicine, Philadelphia, PA
| | - Elizabeth Hexner
- Blood and Marrow Transplantation Program, Abramson Cancer Center, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Matthias Hoepting
- Department of Hematology and Oncology, Internal Medicine III, University of Regensburg, Regensburg, Germany
| | | | - Stelios Kasikis
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Nikolaos Katsivelos
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Alina Khan
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Carrie L Kitko
- Pediatric Stem Cell Transplant Program, Vanderbilt University Medical Center, Nashville TN
| | - Sabrina Kraus
- Department of Internal Medicine II, University Hospital Würzburg, Würzburg, Germany
| | - Deukwoo Kwon
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Pietro Merli
- Department of Hematology/Oncology, Cell and Gene Therapy, Bambino Gesù Children's Hospital, Rome, Italy
| | - Joseph Portelli
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Muna Qayed
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Atlanta, GA
| | - Ran Reshef
- Blood and Marrow Transplantation Program, Columbia University Medical Center, New York, NY
| | - Tal Schechter
- Division of Haematology/Oncology, The Hospital for Sick Children, Toronto, Canada
| | - Ingrid Vasova
- Dept. of Internal Medicine 5, Hematology/Oncology, University Hospital Erlangen, Erlangen, Germany
| | - Matthias Wölfl
- Pediatric Blood and Marrow Transplantation Program, Children's Hospital, University of Würzburg, Würzburg, Germany
| | - Kitsada Wudhikarn
- Department of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Rachel Young
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Ernst Holler
- Department of Hematology and Oncology, Internal Medicine III, University of Regensburg, Regensburg, Germany
| | - Yi-Bin Chen
- Hematopoietic Cell Transplant and Cellular Therapy Program, Massachusetts General Hospital, Boston, MA
| | - Ryotaro Nakamura
- Hematology/Hematopoietic Cell Transplant, City of Hope National Medical Center, Duarte, CA
| | - John E Levine
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - James L M Ferrara
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY.
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Yang C, Berkalieva A, Mazumdar M, Kwon D. Power calculation for detecting interaction effect in cross-sectional stepped-wedge cluster randomized trials: an important tool for disparity research. BMC Med Res Methodol 2024; 24:57. [PMID: 38431550 DOI: 10.1186/s12874-024-02162-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Accepted: 01/25/2024] [Indexed: 03/05/2024] Open
Abstract
BACKGROUND The stepped-wedge cluster randomized trial (SW-CRT) design has become popular in healthcare research. It is an appealing alternative to traditional cluster randomized trials (CRTs) since the burden of logistical issues and ethical problems can be reduced. Several approaches for sample size determination for the overall treatment effect in the SW-CRT have been proposed. However, in certain situations we are interested in examining the heterogeneity in treatment effect (HTE) between groups instead. This is equivalent to testing the interaction effect. An important example includes the aim to reduce racial disparities through healthcare delivery interventions, where the focus is the interaction between the intervention and race. Sample size determination and power calculation for detecting an interaction effect between the intervention status variable and a key covariate in the SW-CRT study has not been proposed yet for binary outcomes. METHODS We utilize the generalized estimating equation (GEE) method for detecting the heterogeneity in treatment effect (HTE). The variance of the estimated interaction effect is approximated based on the GEE method for the marginal models. The power is calculated based on the two-sided Wald test. The Kauermann and Carroll (KC) and the Mancl and DeRouen (MD) methods along with GEE (GEE-KC and GEE-MD) are considered as bias-correction methods. RESULTS Among three approaches, GEE has the largest simulated power and GEE-MD has the smallest simulated power. Given cluster size of 120, GEE has over 80% statistical power. When we have a balanced binary covariate (50%), simulated power increases compared to an unbalanced binary covariate (30%). With intermediate effect size of HTE, only cluster sizes of 100 and 120 have more than 80% power using GEE for both correlation structures. With large effect size of HTE, when cluster size is at least 60, all three approaches have more than 80% power. When we compare an increase in cluster size and increase in the number of clusters based on simulated power, the latter has a slight gain in power. When the cluster size changes from 20 to 40 with 20 clusters, power increases from 53.1% to 82.1% for GEE; 50.6% to 79.7% for GEE-KC; and 48.1% to 77.1% for GEE-MD. When the number of clusters changes from 20 to 40 with cluster size of 20, power increases from 53.1% to 82.1% for GEE; 50.6% to 81% for GEE-KC; and 48.1% to 79.8% for GEE-MD. CONCLUSIONS We propose three approaches for cluster size determination given the number of clusters for detecting the interaction effect in SW-CRT. GEE and GEE-KC have reasonable operating characteristics for both intermediate and large effect size of HTE.
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Affiliation(s)
- Chen Yang
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Institute for Healthcare Delivery Science, Mount Sinai Health System, New York, NY, USA
- Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Asem Berkalieva
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Institute for Healthcare Delivery Science, Mount Sinai Health System, New York, NY, USA
- Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Madhu Mazumdar
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Institute for Healthcare Delivery Science, Mount Sinai Health System, New York, NY, USA
- Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Deukwoo Kwon
- Division of Clinical and Translational Sciences, Department of Internal Medicine, University of Texas Health Science Center at Houston, Houston, TX, USA.
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Kryvenko ON, Epstein JI, Merhe A, Iakymenko OA, E Silva RDA, Chanamolu DK, Briski LM, Kwon D, Nemov I, Punnen S, Pollack A, Stoyanova R, Parekh DJ, Jorda M, Gonzalgo ML. Radical prostatectomy cancer grade and percentage of Gleason pattern 4 estimated by global vs individual tumor grading correlate differently with the risk of biochemical recurrence in Grade Group 2 and 3 cancers. Am J Clin Pathol 2024:aqae003. [PMID: 38412318 DOI: 10.1093/ajcp/aqae003] [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: 08/31/2023] [Accepted: 01/17/2024] [Indexed: 02/29/2024] Open
Abstract
OBJECTIVES There are 2 grading approaches to radical prostatectomy (RP) in multifocal cancer: Grade Group (GG) and percentage of Gleason pattern 4 (GP4%). We investigated whether RP GG and GP4% generated by global vs individual tumor grading correlate differently with biochemical recurrence. METHODS We reviewed 531 RP specimens with GG2 or GG3 cancer. Each tumor was scored separately with assessment of tumor volume and GP4%. Global grade and GP4% were assigned by combining Gleason pattern 3 and 4 volumes for all tumors. Correlation of GG and GP4% generated by 2 methods with biochemical recurrence was assessed by Cox proportional hazard regression and receiver operating characteristic curves, with optimism adjustment using a bootstrap analysis. RESULTS Median age was 63 (range, 42-79) years. Median prostate-specific antigen was 6.3 (range, 0.3-62.9) ng/mL. In total, the highest-grade tumor in 371 (36.9%) men was GG2 and in 160 (30.1%) men was GG3. Global grading was downgraded from GG3 to GG2 in 37 of 121 (30.6%) specimens with multifocal disease, and 145 of 404 (35.9%) specimens had GP4% decreased by at least 10%. Ninety-eight men experienced biochemical recurrence within a median of 13 (range, 3-119) months. Men without biochemical recurrence were followed up for a median of 47 (range, 12-205) months. Grade Group, GP4%, and margin status correlated with the risk of biochemical recurrence using highest-grade tumor and global grading, but the degrees of these correlations varied and were statistically significantly different between the 2 grading approaches. CONCLUSIONS Grade Group, GP4%, and margin status derived by global vs individual tumor grading predict postoperative biochemical recurrence statistically significantly differently. This difference has important implications if results derived from cohorts graded using different methods are compared.
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Affiliation(s)
- Oleksandr N Kryvenko
- Department of Pathology & Laboratory Medicine
- Desai Sethi Urology Institute
- Department of Radiation Oncology
- Sylvester Comprehensive Cancer Center
| | - Jonathan I Epstein
- Departments of Pathology, Urology, and Oncology, Johns Hopkins Medicine, Baltimore, MD, US
| | | | | | | | | | - Laurence M Briski
- 1 Department of Pathology & Laboratory Medicine
- Sylvester Comprehensive Cancer Center
| | - Deukwoo Kwon
- Sylvester Comprehensive Cancer Center
- Department of Public Health Sciences, University of Miami Miller School of Medicine, Miami, FL, US
- Division of Clinical and Translational Sciences, Department of Internal Medicine, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX, US
| | - Ivan Nemov
- 1 Department of Pathology & Laboratory Medicine
| | - Sanoj Punnen
- Desai Sethi Urology Institute
- Sylvester Comprehensive Cancer Center
| | - Alan Pollack
- Department of Radiation Oncology
- Sylvester Comprehensive Cancer Center
| | - Radka Stoyanova
- Department of Radiation Oncology
- Sylvester Comprehensive Cancer Center
| | - Dipen J Parekh
- Desai Sethi Urology Institute
- Sylvester Comprehensive Cancer Center
| | - Merce Jorda
- 1 Department of Pathology & Laboratory Medicine
- Desai Sethi Urology Institute
- Sylvester Comprehensive Cancer Center
| | - Mark L Gonzalgo
- Desai Sethi Urology Institute
- Sylvester Comprehensive Cancer Center
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Goel N, Hernandez A, Kwon D, Antoni MH, Cole S. Impact of Neighborhood Disadvantage on Tumor Biology and Breast Cancer Survival. Ann Surg 2024; 279:346-352. [PMID: 37638386 DOI: 10.1097/sla.0000000000006082] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/29/2023]
Abstract
OBJECTIVE The aim of this study was to evaluate the association between neighborhood disadvantage and Oncotype DX score, a surrogate for tumor biology, among a national cohort. BACKGROUND Women living in disadvantaged neighborhoods have shorter breast cancer (BC) survival, even after accounting for individual-level, tumor, and treatment characteristics. This suggests unaccounted social and biological mechanisms by which neighborhood disadvantage may impact BC survival. METHODS This cross-sectional study included stage I and II, ER + /HER2 - BC patients with Oncotype DX score data from the National Cancer Database (NCDB) from 2004 to 2019. Multivariate regression models tested the association of neighborhood-level income on Oncotype DX score controlling for age, race/ethnicity, insurance, clinical stage, and education. Cox regression assessed overall survival. RESULTS Of the 294,283 total BC patients selected, the majority were non-Hispanic White (n=237,197, 80.6%) with 7.6% non-Hispanic Black (n=22,495) and 4.5% other (n=13,383). 27.1% (n=797,254) of the population lived in the disadvantaged neighborhoods with an annual neighborhood-level income of <$48,000, while 59.62% (n=175,305) lived in advantaged neighborhoods with a neighborhood-level income of >$48,000. On multivariable analysis controlling for age, race/ethnicity, insurance status, neighborhood-level education, and pathologic stage, patients in disadvantaged neighborhoods had greater odds of high-risk versus low-risk Oncotype DX scores compared with those in advantaged neighborhoods [odds ratio=1.04 (1.01-1.07), P =0.0067]. CONCLUSION AND RELEVANCE This study takes a translational epidemiologic approach to identify that women living in the most disadvantaged neighborhoods have more aggressive tumor biology, as determined by the Oncotype DX score.
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Affiliation(s)
- Neha Goel
- Department of Surgery, Division of Surgical Oncology, University of Miami Miller School of Medicine, Miami, FL
- Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, FL
- Harvard T.H. Chan School of Public Health, Harvard University, Boston, MA
| | - Alexandra Hernandez
- Department of Surgery, Division of Surgical Oncology, University of Miami Miller School of Medicine, Miami, FL
- Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, FL
| | - Deukwoo Kwon
- Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, FL
- Department of Internal Medicine, Division of Clinical and Translational Sciences, McGovern Medical School, The University of Texas Health Science Center at Houston. Houston, TX
| | - Michael H Antoni
- Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, FL
- Department of Psychology, University of Miami Miller School of Medicine, Miami, FL
| | - Steve Cole
- Department of Psychiatry/Biobehavioral Sciences and Medicine, University of California Los Angeles David Geffen School of Medicine, Los Angeles, CA
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Kwon D, Simon SL, Hoffman FO, Pfeiffer RM. Frequentist model averaging for analysis of dose-response in epidemiologic studies with complex exposure uncertainty. PLoS One 2023; 18:e0290498. [PMID: 38096309 PMCID: PMC10721059 DOI: 10.1371/journal.pone.0290498] [Citation(s) in RCA: 2] [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] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Accepted: 08/10/2023] [Indexed: 12/17/2023] Open
Abstract
In epidemiologic studies, association estimates of an exposure with disease outcomes are often biased when the uncertainties of exposure are ignored. Consequently, corresponding confidence intervals (CIs) will not have correct coverage. This issue is particularly problematic when exposures must be reconstructed from physical measurements, for example, for environmental or occupational radiation doses that were received by a study population for which radiation doses cannot be measured directly. To incorporate complex uncertainties in reconstructed exposures, the two-dimensional Monte Carlo (2DMC) dose estimation method has been proposed and used in various dose reconstruction efforts. The 2DMC method generates multiple exposure realizations from dosimetry models that incorporate various sources of errors to reflect the uncertainty of the dose distribution as well as the uncertainties in individual doses in the exposed population. Traditional measurement-error model approaches, typically based on using mean doses in the dose-exposure analysis, do not fully account exposure uncertainties. A recently developed statistical approach that overcomes many of these limitations by analyzing multiple exposure realizations in relation to disease risk is Bayesian model averaging (BMA). The analytic advantage of the BMA is its ability to better accommodate complex exposure uncertainty in the risk estimation, but a practical. Drawback is its significant computational complexity. In this present paper, we propose a novel frequentist model averaging (FMA) approach which has all the analytical advantages of the BMA method but is much simpler to implement and computationally faster. We show in simulations that, like BMA, FMA yields 95% confidence intervals for association parameters that close to 95% coverage rate. In simulations, the FMA has shorter length of CIs than those of another frequentist approach, the corrected information matrix (CIM) method. We illustrate the similarities in performance of BMA and FMA from a study of exposures from radioactive fallout in Kazakhstan.
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Affiliation(s)
- Deukwoo Kwon
- Department of Internal Medicine, McGovern Medical School, Houston, Texas, United States of America
| | - Steven L. Simon
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Bethesda, Maryland, United States of America
| | - F. Owen Hoffman
- Oak Ridge Center for Risk Analysis, Oak Ridge, Tennessee, United States of America
| | - Ruth M. Pfeiffer
- Biostatistics Branch, Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Bethesda, Maryland, United States of America
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Mouzannar A, Delgado J, Kwon D, Atluri VS, Mason MM, Prakash NS, Zhao W, Nahar B, Swain S, Punnen S, Gonzalgo ML, Parekh DJ, Deane LA, Ritch CR. Racial disparity in the utilization of immunotherapy for advanced prostate cancer. J Natl Med Assoc 2023; 115:566-576. [PMID: 37903694 DOI: 10.1016/j.jnma.2023.09.007] [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: 04/03/2023] [Revised: 08/16/2023] [Accepted: 09/26/2023] [Indexed: 11/01/2023]
Abstract
PURPOSE To identify whether there was a disparity in the utilization of immunotherapy in the treatment of black patients with metastatic castration resistant prostate cancer (mCRPC). METHODS Using the National Cancer Database, we identified patients between 2010- 2015 with likely minimally/asymptomatic mCRPC. We analyzed annual trends for chemotherapy and immunotherapy use and compared utilization by demographic and clinical features. Multivariable analysis was performed to determine predictors of receiving immunotherapy vs chemotherapy. RESULTS We identified 1301 patients with likely mCRPC. The majority were non Hispanic White (NHW - 63 %) and 23 % were non-Hispanic Black (NHB). Overall, there was increased utilization of immunotherapy in mCRPC from 2010 onwards, with the peak occurring in 2014 (4.6 %). Chemotherapy use increased significantly, peaking in 2014 to 26.1 %. However, the increased utilization of immunotherapy in the mCRPC was mainly seen in White patients: from 50 % to 74.2 % of the cohort. Conversely, there was a decrease in utilization of immunotherapy among Black mCPRC patients: from 50 % to 25.8 %. On multivariable analysis, there was no statistically significant difference between treatment types by race. CONCLUSION FDA approval of Sipuleucel-T for mCRPC led to increased utilization of immunotherapy shortly thereafter, but this was mainly noted in white patients. Black patients comparatively did not exhibit increased utilization of this novel agent after 2010. Further studies are necessary to help understand barriers to access to new treatment in mCRPC and eliminate the burden of disease in minority populations."
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Affiliation(s)
| | | | - Deukwoo Kwon
- Biostatistics, University of Miami, Miller School of Medicine, 1120 NW 14th Street, 15th Floor, Miami, FL 33136, USA; Sylvester Comprehensive Cancer Center, 1475 NW 12th Ave, Miami, FL 33136, USA
| | | | | | | | - Wei Zhao
- Biostatistics, University of Miami, Miller School of Medicine, 1120 NW 14th Street, 15th Floor, Miami, FL 33136, USA
| | - Bruno Nahar
- Department of Urology, USA; Sylvester Comprehensive Cancer Center, 1475 NW 12th Ave, Miami, FL 33136, USA
| | - Sanjaya Swain
- Department of Urology, USA; Sylvester Comprehensive Cancer Center, 1475 NW 12th Ave, Miami, FL 33136, USA
| | - Sanoj Punnen
- Department of Urology, USA; Sylvester Comprehensive Cancer Center, 1475 NW 12th Ave, Miami, FL 33136, USA
| | - Mark L Gonzalgo
- Department of Urology, USA; Sylvester Comprehensive Cancer Center, 1475 NW 12th Ave, Miami, FL 33136, USA
| | - Dipen J Parekh
- Department of Urology, USA; Sylvester Comprehensive Cancer Center, 1475 NW 12th Ave, Miami, FL 33136, USA
| | | | - Chad R Ritch
- Department of Urology, USA; Sylvester Comprehensive Cancer Center, 1475 NW 12th Ave, Miami, FL 33136, USA
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Montoya C, Spieler B, Welford SM, Kwon D, Pra AD, Lopes G, Mihaylov IB. Predicting response to immunotherapy in non-small cell lung cancer- from bench to bedside. Front Oncol 2023; 13:1225720. [PMID: 38033493 PMCID: PMC10686412 DOI: 10.3389/fonc.2023.1225720] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Accepted: 10/27/2023] [Indexed: 12/02/2023] Open
Abstract
Background Immune checkpoint inhibitor (ICI) therapy is first-line treatment for many advanced non-small cell lung cancer (aNSCLC) patients. Predicting response could help guide selection of intensified or alternative anti-cancer regimens. We hypothesized that radiomics and laboratory variables predictive of ICI response in a murine model would also predict response in aNSCLC patients. Methods Fifteen mice with lung carcinoma tumors implanted in bilateral flanks received ICI. Pre-ICI laboratory and computed tomography (CT) data were evaluated for association with systemic ICI response. Baseline clinical and CT data for 117 aNSCLC patients treated with nivolumab were correlated with overall survival (OS). Models for predicting treatment response were created and subjected to internal cross-validation, with the human model further tested on 42 aNSCLC patients who received pembrolizumab. Results Models incorporating baseline NLR and identical radiomics (surface-to-mass ratio, average Gray, and 2D kurtosis) predicted ICI response in mice and OS in humans with AUCs of 0.91 and 0.75, respectively. The human model successfully sorted pembrolizumab patients by longer vs. shorter predicted OS (median 35 months vs. 6 months, p=0.026 by log-rank). Discussion This study advances precision oncology by non-invasively classifying aNSCLC patients according to ICI response using pre-treatment data only. Interestingly, identical radiomics features and NLR correlated with outcomes in the preclinical study and with ICI response in 2 independent patient cohorts, suggesting translatability of the findings. Future directions include using a radiogenomic approach to optimize modeling of ICI response.
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Affiliation(s)
- Chris Montoya
- Department of Radiation Oncology, Sylvester Comprehensive Cancer Center, Miller School of Medicine, Miami, FL, United States
| | - Benjamin Spieler
- Department of Radiation Oncology, Sylvester Comprehensive Cancer Center, Miller School of Medicine, Miami, FL, United States
| | - Scott M. Welford
- Department of Radiation Oncology, Sylvester Comprehensive Cancer Center, Miller School of Medicine, Miami, FL, United States
| | - Deukwoo Kwon
- Division of Clinical and Translational Sciences, Department of Internal Medicine, University of Texas Health Science Center, Houston, TX, United States
| | - Alan Dal Pra
- Department of Radiation Oncology, Sylvester Comprehensive Cancer Center, Miller School of Medicine, Miami, FL, United States
| | - Gilberto Lopes
- Department of Medical Oncology, Sylvester Comprehensive Cancer Center, Miller School of Medicine, Miami, FL, United States
| | - Ivaylo B. Mihaylov
- Department of Radiation Oncology, Sylvester Comprehensive Cancer Center, Miller School of Medicine, Miami, FL, United States
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Stoyanova R, Zavala-Romero O, Kwon D, Breto AL, Xu IR, Algohary A, Alhusseini M, Gaston SM, Castillo P, Kryvenko ON, Davicioni E, Nahar B, Spieler B, Abramowitz MC, Dal Pra A, Parekh DJ, Punnen S, Pollack A. Clinical-Genomic Risk Group Classification of Suspicious Lesions on Prostate Multiparametric-MRI. Cancers (Basel) 2023; 15:5240. [PMID: 37958414 PMCID: PMC10647832 DOI: 10.3390/cancers15215240] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Revised: 10/12/2023] [Accepted: 10/24/2023] [Indexed: 11/15/2023] Open
Abstract
The utilization of multi-parametric MRI (mpMRI) in clinical decisions regarding prostate cancer patients' management has recently increased. After biopsy, clinicians can assess risk using National Comprehensive Cancer Network (NCCN) risk stratification schema and commercially available genomic classifiers, such as Decipher. We built radiomics-based models to predict lesions/patients at low risk prior to biopsy based on an established three-tier clinical-genomic classification system. Radiomic features were extracted from regions of positive biopsies and Normally Appearing Tissues (NAT) on T2-weighted and Diffusion-weighted Imaging. Using only clinical information available prior to biopsy, five models for predicting low-risk lesions/patients were evaluated, based on: 1: Clinical variables; 2: Lesion-based radiomic features; 3: Lesion and NAT radiomics; 4: Clinical and lesion-based radiomics; and 5: Clinical, lesion and NAT radiomic features. Eighty-three mpMRI exams from 78 men were analyzed. Models 1 and 2 performed similarly (Area under the receiver operating characteristic curve were 0.835 and 0.838, respectively), but radiomics significantly improved the lesion-based performance of the model in a subset analysis of patients with a negative Digital Rectal Exam (DRE). Adding normal tissue radiomics significantly improved the performance in all cases. Similar patterns were observed on patient-level models. To the best of our knowledge, this is the first study to demonstrate that machine learning radiomics-based models can predict patients' risk using combined clinical-genomic classification.
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Affiliation(s)
- Radka Stoyanova
- Department of Radiation Oncology, University of Miami Miller School of Medicine, Miami, FL 33136, USA
- Sylvester Comprehensive Cancer Center, University of Miami, Miami, FL 33136, USA
| | - Olmo Zavala-Romero
- Department of Radiation Oncology, University of Miami Miller School of Medicine, Miami, FL 33136, USA
| | - Deukwoo Kwon
- Sylvester Comprehensive Cancer Center, University of Miami, Miami, FL 33136, USA
- Department of Public Health Sciences, University of Miami Miller School of Medicine, Miami, FL 33136, USA
| | - Adrian L. Breto
- Department of Radiation Oncology, University of Miami Miller School of Medicine, Miami, FL 33136, USA
| | - Isaac R. Xu
- Department of Radiation Oncology, University of Miami Miller School of Medicine, Miami, FL 33136, USA
| | - Ahmad Algohary
- Department of Radiation Oncology, University of Miami Miller School of Medicine, Miami, FL 33136, USA
| | - Mohammad Alhusseini
- Department of Radiation Oncology, University of Miami Miller School of Medicine, Miami, FL 33136, USA
| | - Sandra M. Gaston
- Department of Radiation Oncology, University of Miami Miller School of Medicine, Miami, FL 33136, USA
- Sylvester Comprehensive Cancer Center, University of Miami, Miami, FL 33136, USA
| | - Patricia Castillo
- Department of Radiology, University of Miami Miller School of Medicine, Miami, FL 33136, USA
| | - Oleksandr N. Kryvenko
- Department of Radiation Oncology, University of Miami Miller School of Medicine, Miami, FL 33136, USA
- Sylvester Comprehensive Cancer Center, University of Miami, Miami, FL 33136, USA
- Department of Pathology and Laboratory Medicine, University of Miami Miller School of Medicine, Miami, FL 33136, USA
- Desai Sethi Urology Institute, University of Miami Miller School of Medicine, Miami, FL 33136, USA
| | - Elai Davicioni
- Research and Development, Veracyte Inc., San Francisco, CA 94080, USA
| | - Bruno Nahar
- Sylvester Comprehensive Cancer Center, University of Miami, Miami, FL 33136, USA
- Desai Sethi Urology Institute, University of Miami Miller School of Medicine, Miami, FL 33136, USA
| | - Benjamin Spieler
- Department of Radiation Oncology, University of Miami Miller School of Medicine, Miami, FL 33136, USA
- Sylvester Comprehensive Cancer Center, University of Miami, Miami, FL 33136, USA
| | - Matthew C. Abramowitz
- Department of Radiation Oncology, University of Miami Miller School of Medicine, Miami, FL 33136, USA
- Sylvester Comprehensive Cancer Center, University of Miami, Miami, FL 33136, USA
| | - Alan Dal Pra
- Department of Radiation Oncology, University of Miami Miller School of Medicine, Miami, FL 33136, USA
- Sylvester Comprehensive Cancer Center, University of Miami, Miami, FL 33136, USA
| | - Dipen J. Parekh
- Sylvester Comprehensive Cancer Center, University of Miami, Miami, FL 33136, USA
- Desai Sethi Urology Institute, University of Miami Miller School of Medicine, Miami, FL 33136, USA
| | - Sanoj Punnen
- Sylvester Comprehensive Cancer Center, University of Miami, Miami, FL 33136, USA
- Desai Sethi Urology Institute, University of Miami Miller School of Medicine, Miami, FL 33136, USA
| | - Alan Pollack
- Department of Radiation Oncology, University of Miami Miller School of Medicine, Miami, FL 33136, USA
- Sylvester Comprehensive Cancer Center, University of Miami, Miami, FL 33136, USA
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Araya A, Thornton LR, Kwon D, Ferguson GM, Highfield LD, Hwang KO, Holmes HM, Bernstam EV. Medication Reconciliation during Transitions of Care Across Institutions: A Quantitative Analysis of Challenges and Opportunities. Appl Clin Inform 2023; 14:923-931. [PMID: 37726022 PMCID: PMC10665121 DOI: 10.1055/a-2178-0197] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2023] [Accepted: 08/06/2023] [Indexed: 09/21/2023] Open
Abstract
OBJECTIVE Medication discrepancies between clinical systems may pose a patient safety hazard. In this paper, we identify challenges and quantify medication discrepancies across transitions of care. METHODS We used structured clinical data and free-text hospital discharge summaries to compare active medications' lists at four time points: preadmission (outpatient), at-admission (inpatient), at-discharge (inpatient), and postdischarge (outpatient). Medication lists were normalized to RxNorm. RxNorm identifiers were further processed using the RxNav API to identify the ingredient. The specific drugs and ingredients from inpatient and outpatient medication lists were compared. RESULTS Using RxNorm drugs, the median percentage intersection when comparing active medication lists within the same electronic health record system ranged between 94.1 and 100% indicating substantial overlap. Similarly, when using RxNorm ingredients the median percentage intersection was 94.1 to 100%. In contrast, the median percentage intersection when comparing active medication lists across EHR systems was significantly lower (RxNorm drugs: 6.1-7.1%; RxNorm ingredients: 29.4-35.0%) indicating that the active medication lists were significantly less similar (p < 0.05).Medication lists in the same EHR system are more similar to each other (fewer discrepancies) than medication lists in different EHR systems when comparing specific RxNorm drug and the more general RxNorm ingredients at transitions of care. Transitions of care that require interoperability between two EHR systems are associated with more discrepancies than transitions where medication changes are expected (e.g., at-admission vs. at-discharge). Challenges included lack of access to structured, standardized medication data across systems, and difficulty distinguishing medications from orderable supplies such as lancets and diabetic test strips. CONCLUSION Despite the challenges to medication normalization, there are opportunities to identify and assist with medication reconciliation across transitions of care between institutions.
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Affiliation(s)
- Alejandro Araya
- D. Bradley McWilliams School of Biomedical Informatics, The University of Texas Health Science Center (UTHealth), Houston, Texas, United States
| | - Logan R. Thornton
- Division of Population Health and Evidence-Based Practice, Healthcare Transformation Initiatives, The University of Texas Health Science Center at Houston (UTHealth) John P. and Kathrine G. McGovern Medical School, Houston, Texas, United States
| | - Deukwoo Kwon
- Division of Clinical and Translation Sciences, Department of Internal Medicine, The University of Texas Health Science Center at Houston (UTHealth) John P. and Kathrine G. McGovern Medical School, Houston, Texas, United States
| | - Gayla M. Ferguson
- Department of Management, Policy and Community Health, The University of Texas Health Science Center at Houston (UTHealth) School of Public Health, Houston, Texas, United States
| | - Linda D. Highfield
- Department of Management, Policy and Community Health, The University of Texas Health Science Center at Houston (UTHealth) School of Public Health, Houston, Texas, United States
- Department of Epidemiology, Human Genetics and Environmental Sciences, The University of Texas Health Science Center at Houston (UTHealth) School of Public Health, Houston, Texas, United States
- Department of Internal Medicine, The University of Texas Health Science Center at Houston (UTHealth) John P. and Kathrine G. McGovern Medical School, Houston, Texas, United States
| | - Kevin O. Hwang
- Division of General Internal Medicine, Department of Internal Medicine, The University of Texas Health Science Center at Houston (UTHealth) John P. and Kathrine G. McGovern Medical School, Houston, Texas, United States
| | - Holly M. Holmes
- Division of Geriatrics, Department of Internal Medicine, The University of Texas Health Science Center at Houston (UTHealth) John P. and Kathrine G. McGovern Medical School, Houston, Texas, United States
| | - Elmer V. Bernstam
- D. Bradley McWilliams School of Biomedical Informatics, The University of Texas Health Science Center (UTHealth), Houston, Texas, United States
- Division of General Internal Medicine, Department of Internal Medicine, The University of Texas Health Science Center at Houston (UTHealth) John P. and Kathrine G. McGovern Medical School, Houston, Texas, United States
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Keyzner A, Azzi J, Jakubowski R, Sinitsyn Y, Tindle S, Shpontak S, Kwon D, Isola L, Iancu-Rubin C. Cryopreservation of Allogeneic Hematopoietic Cell Products During COVID-19 Pandemic: Graft Characterization and Engraftment Outcomes. Transplant Proc 2023; 55:1799-1809. [PMID: 37210273 PMCID: PMC10121136 DOI: 10.1016/j.transproceed.2023.03.070] [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] [Received: 02/22/2023] [Revised: 02/22/2023] [Accepted: 03/30/2023] [Indexed: 05/22/2023]
Abstract
BACKGROUND The COVID-19 pandemic triggered the deployment of unfamiliar measures to safeguard successful allogeneic hematopoietic cell transplantation (allo-HCT). Among these measures, cryopreservation offered logistical benefits that could outlast the pandemic, including graft availability and timely clinical service. The purpose of this study was to evaluate graft quality and hematopoietic reconstitution in patients transplanted with cryopreserved allogeneic stem cell products during the COVID-19 pandemic. METHODS We evaluated 44 patients who underwent allo-HCT using cryopreserved grafts consisting of hematopoietic progenitor cells (HPC) apheresis (A) and bone marrow (BM) products at Mount Sinai Hospital. Comparative analyses of 37 grafts infused fresh during the one-year period preceding the pandemic were performed. Assessment of cellular therapy products included total nucleated cell and CD34+ cell enumeration, viability, and post-thaw recovery. The primary clinical endpoint was the evaluation of engraftment (absolute neutrophil count [ANC] and platelet count) and donor chimerism (presence of CD33+ and CD3+ donor cells) at day +30 and +100 post-transplant. Adverse events related to cell infusion were also analyzed. RESULTS Patient characteristics were comparable between the fresh and cryopreserved groups with 2 exceptions in the HPC-A cohort: the number of patients in the cryopreserved group that received haploidentical grafts was 6 times that in the fresh group, and the number of patients in the fresh group with a Karnofsky performance score >90 was double that in the cryopreserved group. The quality of HPC-A and HPC-BM products was not affected by cryopreservation, and all grafts met the release criteria for infusion. The pandemic did not affect the time between collection and cryopreservation (median, 24 hours) and time in storage (median, 15 days). Median time to ANC recovery was significantly delayed in recipients of cryopreserved HPC-A (15 vs 11 days, P = .0121), and there was a trend toward delayed platelet engraftment (24 vs 19 days, P = .0712). The delay in ANC and platelet recovery was not observed when only matched graft recipients were compared. Cryopreservation did not affect the ability of HPC-BM grafts to engraft and reconstitute hematopoiesis, and there was no difference in the rates of ANC and platelet recovery. Achievement of donor CD3/CD33 chimerism was not affected by cryopreservation of either HPC-A or HPC-BM products. Graft failure was observed in only 1 case, a recipient of cryopreserved HPC-BM. Three recipients of cryopreserved HPC-A grafts died before ANC engraftment from infectious complications. Remarkably, 22% of our studied population had myelofibrosis, and almost half received cryopreserved HPC-A grafts with no graft failure observed. Finally, patients receiving cryopreserved grafts were at a higher risk of infusion-related adverse events than those receiving fresh grafts. CONCLUSIONS Cryopreservation of allogeneic grafts results in adequate product quality with minimal impact on short-term clinical outcomes, except for an increased risk of infusion-related adverse events. Cryopreservation is a safe option in terms of graft quality and hematopoietic reconstitution with logistical benefits, but additional data are needed to determine long-term outcomes and assess whether this is a suitable strategy for at-risk patients.
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Affiliation(s)
- Alla Keyzner
- Stem Cell Transplantation and Cellular Therapy Program, Division of Hematology and Medical Oncology, Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Jacques Azzi
- Stem Cell Transplantation and Cellular Therapy Program, Division of Hematology and Medical Oncology, Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, New York
| | | | | | | | | | - Deukwoo Kwon
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Luis Isola
- Stem Cell Transplantation and Cellular Therapy Program, Division of Hematology and Medical Oncology, Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Camelia Iancu-Rubin
- Stem Cell Transplantation and Cellular Therapy Program, Division of Hematology and Medical Oncology, Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, New York; Department of Pathology, Molecular and Cell-Based Medicine, Icahn School of Medicine at Mount Sinai, New York, New York.
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Thomas J, Atluri S, Zucker I, Reis I, Kwon D, Kim E, Tewari A, Patel V, Wagaskar V, Konety B, Kasraeian A, Czarniecki S, Thoreson G, Soodana-Prakash N, Ritch C, Nahar B, Gonzalgo M, Kava B, Parekh D, Punnen S. A multi-institutional study of 1,111 men with 4K score, multiparametric magnetic resonance imaging, and prostate biopsy. Urol Oncol 2023; 41:430.e9-430.e16. [PMID: 37544833 DOI: 10.1016/j.urolonc.2023.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Revised: 06/13/2023] [Accepted: 07/03/2023] [Indexed: 08/08/2023]
Abstract
OBJECTIVE Prostate magnetic resonance imaging (MRI) and biomarkers are often used in conjunction to enhance the selection process for prostate biopsy. However, the optimal sequence of ordering these tests has not been established. A comprehensive evaluation was conducted on a large multi-institutional cohort of patients who underwent MRI, 4K score, and biopsy of the prostate to examine the impact of utilizing both tests vs. either test alone and to determine if the order in which these tests are administered affects the ability to detect clinically significant prostate cancer (csCaP). METHODS AND MATERIALS We evaluated men from 8 different institutions who were referred for prostate cancer evaluation and underwent MRI, 4K score test, and prostate biopsy. The primary outcome was the presence of csCaP, defined as grade group 2 or higher cancer on a biopsy of the prostate. We used logistic regression, calibration plots, and decision curve analysis to evaluate using a 4K score or MRI alone vs. both tests together for detecting csCaP. In addition, we evaluated several strategies using one or both tests for selecting men for biopsy and compared them based on the proportion of biopsies avoided and the csCaP's missed. RESULTS Among the 1,111 men who formed the final cohort, 553 (49.8%) had prostate cancer, and 353 (31.8%) had csCaP. We found that using MRI and 4K score together had better discrimination, calibration, and a higher clinical utility on decision curve analysis compared to using either test individually. Using both tests together resulted in fewer biopsies avoided and missed cancers compared to using either test alone. Strategies that sequence MRI and 4K score tests resulted in the largest biopsy reduction, with no appreciable difference between starting with an MRI vs. a biomarker. CONCLUSIONS We found that using both an MRI and 4K score together was superior to using either test alone but found no appreciable difference between starting with an MRI vs. starting with a 4K score. Prospective studies are needed to identify the best strategy to sequence MRI and biomarkers in the evaluation of csCaP.
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Affiliation(s)
- Jamie Thomas
- Desai Sethi Urology Institute, University of Miami Miller School of Medicine and Sylvester Cancer Center, Miami, FL
| | - Shrikanth Atluri
- Desai Sethi Urology Institute, University of Miami Miller School of Medicine and Sylvester Cancer Center, Miami, FL
| | - Isaac Zucker
- Desai Sethi Urology Institute, University of Miami Miller School of Medicine and Sylvester Cancer Center, Miami, FL
| | - Isildinha Reis
- Division of Biostatistics, Department of Public Health Sciences, University of Miami Miller School of Medicine, Miami, FL
| | - Deukwoo Kwon
- Division of Biostatistics, Department of Public Health Sciences, University of Miami Miller School of Medicine, Miami, FL
| | - Eric Kim
- Department of Surgery, Washington University School of Medicine, St. Louis, MO
| | - Ashutosh Tewari
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Vipul Patel
- Global Robotics Institute, Florida Hospital-Celebration Health, University of Central Florida College of Medicine, Orlando, FL
| | - Vinayak Wagaskar
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, NY
| | | | | | - Stefan Czarniecki
- HIFU Clinic, Department of Urology, St. Elizabeth Hospital, Warsaw, Poland
| | | | - Nachiketh Soodana-Prakash
- Desai Sethi Urology Institute, University of Miami Miller School of Medicine and Sylvester Cancer Center, Miami, FL
| | - Chad Ritch
- Desai Sethi Urology Institute, University of Miami Miller School of Medicine and Sylvester Cancer Center, Miami, FL
| | - Bruno Nahar
- Desai Sethi Urology Institute, University of Miami Miller School of Medicine and Sylvester Cancer Center, Miami, FL
| | - Mark Gonzalgo
- Desai Sethi Urology Institute, University of Miami Miller School of Medicine and Sylvester Cancer Center, Miami, FL
| | - Bruce Kava
- Desai Sethi Urology Institute, University of Miami Miller School of Medicine and Sylvester Cancer Center, Miami, FL
| | - Dipen Parekh
- Desai Sethi Urology Institute, University of Miami Miller School of Medicine and Sylvester Cancer Center, Miami, FL
| | - Sanoj Punnen
- Desai Sethi Urology Institute, University of Miami Miller School of Medicine and Sylvester Cancer Center, Miami, FL.
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Watson AN, Shah SA, Shalhoub SD, Piedra KM, Komanduri KV, Kwon D, Pereira DL. Melphalan on day -1 versus day -2 in patients with plasma cell disorders undergoing autologous stem cell transplant. J Oncol Pharm Pract 2023; 29:1398-1403. [PMID: 36245321 DOI: 10.1177/10781552221125871] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
High-dose melphalan-based autologous stem cell transplant (ASCT) remains a standard of care for plasma cell disorders (PCDs). Currently, there is variability in the literature surrounding the timing of melphalan administration to avoid potential cytotoxic effects, although the administration has been safely proposed when given at least 8 hours prior to stem cell infusion. The objectives of this study were to assess differences in safety and efficacy outcomes between day -1 and day -2 single-dose melphalan administration in patients undergoing ASCT for PCDs. A retrospective chart review was performed at our institution comparing patients receiving melphalan on day -1 to an equal number of patients receiving melphalan on day -2. The primary endpoint was time to neutrophil engraftment from stem cell infusion. Univariate analyses were performed. Mean time to neutrophil engraftment from stem cell infusion was identical at 10.7 days for both cohorts (p = 0.88). Mean time to platelet engraftment from stem cell infusion was shorter with day -1 administration (17.4 vs. 18.6 days, p = 0.06). Mean time to neutrophil and platelet engraftment from melphalan infusion were significantly shorter with day -1 administration. Similar outcomes were observed for length of hospitalization, infection- and mucositis-related toxicities, hematologic response, transplant-related mortality, and overall survival. Our findings show no difference in time to neutrophil engraftment from stem cell infusion and a trend toward shorter time to platelet engraftment with day -1 administration. Based on our study, day -1 melphalan administration is an acceptable and safe practice.
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Affiliation(s)
- Aleksandra N Watson
- Department of Pharmacy, Sylvester Comprehensive Cancer Center, University of Miami Health System, Miami, FL, USA
| | - Shreya A Shah
- Department of Pharmacy, Sylvester Comprehensive Cancer Center, University of Miami Health System, Miami, FL, USA
| | - Sila D Shalhoub
- Department of Pharmacy, Sylvester Comprehensive Cancer Center, University of Miami Health System, Miami, FL, USA
| | - Katrina M Piedra
- Department of Pharmacy, Sylvester Comprehensive Cancer Center, University of Miami Health System, Miami, FL, USA
| | - Krishna V Komanduri
- Division of Transplantation and Cellular Therapy, Department of Medicine and Sylvester Comprehensive Cancer Center, University of Miami Health System, Miami, FL, USA
| | - Deukwoo Kwon
- Division of Biostatistics, Department of Public Health Sciences, University of Miami Leonard M. Miller School of Medicine, Miami, FL, USA
| | - Denise L Pereira
- Division of Transplantation and Cellular Therapy, Department of Medicine and Sylvester Comprehensive Cancer Center, University of Miami Health System, Miami, FL, USA
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15
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de Almeida S R, Thomas J, Mason MM, Becerra MF, Merhe A, Reis IM, Kwon D, Soodana‐Prakash N, Tewari A, Patel V, Wagaskar V, Konety B, Kasraeian A, Czarniecki S, Thoreson GR, Kim EH, Swain S, Parekh DJ, Punnen S. Optimum threshold of the 4Kscore for biopsy in men with negative or indeterminate multiparametric magnetic resonance imaging. BJUI Compass 2023; 4:591-596. [PMID: 37636212 PMCID: PMC10447206 DOI: 10.1002/bco2.235] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2023] [Revised: 02/28/2023] [Accepted: 03/05/2023] [Indexed: 08/29/2023] Open
Abstract
Objective The study aims to identify the optimal 4Kscore thresholds to determine the need for a prostate biopsy when multiparametric magnetic resonance imaging (MRI) (mpMRI) is negative or indeterminate. Materials and methods We analysed retrospective data from men in eight different institutions who underwent an mpMRI, 4Kscore and prostate biopsy for evaluation of prostate cancer. We selected men with a negative (PIRADS ≤2) or indeterminate (PIRADS 3) mpMRI. 4Kscore values were categorized into ranges of 1-7, 8-19, 20-32 and greater than 32. We evaluated the proportion of men with grade group 2 or higher (GG2+) cancer in groups defined by PIRADS and 4Kscore. We also evaluated the number of biopsies avoided and GG2+ cancer missed in each group reported depend on 4Kscore cutoff points. Results Among 1111 men who had an mpMRI, 4Kscore and biopsy, 625 of them had PIRADS ≤3 on mpMRI: 374 negative (PIRADS ≤2) and 251 indeterminate (PIRADS 3). In men with a negative mpMRI, we found a 4Kscore cut-point of 33 resulted in an increased risk of GG2+ cancer on biopsy. In patients with an equivocal lesion on mpMRI, men with a 4Kscore cutoff ≥8 had a greater risk of GG2+ cancer on biopsy. Decision curve analysis supported the proposed cut-points in each mpMRI group. Conclusions In men with negative and indeterminate mpMRI, we found the best 4Kscore threshold to determine the need for biopsy to be 33 and 8 respectively. Future prospective studies in independent populations are needed to confirm these findings.
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Affiliation(s)
- Ricardo de Almeida S
- Desai Sethi Urology Institute, Miller School of Medicine, Sylvester Cancer CenterUniversity of MiamiMiamiFloridaUSA
| | - Jamie Thomas
- Desai Sethi Urology Institute, Miller School of Medicine, Sylvester Cancer CenterUniversity of MiamiMiamiFloridaUSA
| | | | - Maria F. Becerra
- Desai Sethi Urology Institute, Miller School of Medicine, Sylvester Cancer CenterUniversity of MiamiMiamiFloridaUSA
| | - Ali Merhe
- Desai Sethi Urology Institute, Miller School of Medicine, Sylvester Cancer CenterUniversity of MiamiMiamiFloridaUSA
| | - Isildinha M. Reis
- Division of Biostatistics, Department of Public Health Sciences, School of MedicineUniversity of Miami MillerMiamiFloridaUSA
| | - Deukwoo Kwon
- Division of Biostatistics, Department of Public Health Sciences, School of MedicineUniversity of Miami MillerMiamiFloridaUSA
| | - Nachiketh Soodana‐Prakash
- Desai Sethi Urology Institute, Miller School of Medicine, Sylvester Cancer CenterUniversity of MiamiMiamiFloridaUSA
| | - Ashutosh Tewari
- Department of UrologyIcahn School of Medicine at Mount SinaiNew YorkNew YorkUSA
| | - Vipul Patel
- Global Robotics Institute, Florida Hospital‐Celebration Health, College of MedicineUniversity of Central FloridaOrlandoFloridaUSA
| | - Vinayak Wagaskar
- Department of UrologyIcahn School of Medicine at Mount Sinai HospitalNew YorkNew YorkUSA
| | | | | | - Stefan Czarniecki
- HIFU Clinic, Department of UrologySt. Elizabeth HospitalWarsawPoland
| | | | - Eric H. Kim
- School of MedicineWashington UniversitySt. LouisMissouriUSA
| | - Sanjaya Swain
- Desai Sethi Urology Institute, Miller School of Medicine, Sylvester Cancer CenterUniversity of MiamiMiamiFloridaUSA
| | - Dipen J. Parekh
- Desai Sethi Urology Institute, Miller School of Medicine, Sylvester Cancer CenterUniversity of MiamiMiamiFloridaUSA
| | - Sanoj Punnen
- Desai Sethi Urology Institute, Miller School of Medicine, Sylvester Cancer CenterUniversity of MiamiMiamiFloridaUSA
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16
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Aihie NS, Hougen HY, Kwon D, Punnen S, Nahar B, Parekh DJ, Gonzalgo ML, Ritch CR. Predictors of discharge to home following major surgery for urologic malignancies: Results from the national surgical quality improvement program. Urol Oncol 2023; 41:392.e19-392.e25. [PMID: 37495474 DOI: 10.1016/j.urolonc.2023.07.003] [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: 03/18/2023] [Revised: 06/16/2023] [Accepted: 07/03/2023] [Indexed: 07/28/2023]
Abstract
OBJECTIVES To identify patient risk factors that predict nonhome discharge after surgery for urologic malignancies as well as determine whether discharge status had an impact on readmission rates in patients undergoing surgery for urologic malignancies. METHODS We identified patients who had undergone surgery for urologic malignancies including prostate, bladder, kidney, or upper tract urothelial cancer from 2011 to 2019 in the American College of Surgeon National Surgical Quality Improvement Program (ACS-NSQIP) database. Multivariable logistic regression analyses were performed to identify patient characteristics that were associated with nonhome discharges and 30-day postoperative readmission. RESULTS Nonhome discharge occurred in 2.8% of our study population. Women were less likely to be discharged to home (OR 0.60 p < 0.0001). Nonhome discharge was more common in patients who underwent cystectomy when compared to nephrectomy (OR 1.41 p < 0.0001) or prostatectomy (OR 4.16 p < 0.0001). Those with elevated BMI were less likely to experience non-home discharge (OR 0.86 p=0.0095) while patients who were identified as underweight and those with unexpected weight loss prior to surgery were more likely to have nonhome discharges (OR 1.76 p = 0.0002, OR 1.67, p < 0.0001). Comorbidities and presence of postoperative complications were also found to be significant independent predictors of nonhome discharges. Thirty-day postoperative readmission occurred in 6.9% of our study population. Of the patients who were readmitted 93.1% were initially discharged home, and 6.9% had nonhome discharges. Higher risk of readmission was seen in elderly patients and those with significant comorbidities. When controlling for predictors of readmission, on multivariate analysis, non-home discharge was associated with a decreased likelihood of readmission (OR 0.79, p = 0.0004). CONCLUSIONS Patient factors including age, gender, weight, comorbidities, postoperative complications, and site of procedure were found to be independent predictors of non-home discharge following surgery for urologic malignancies. Patients with these risk factors should be counseled preoperatively on the likelihood of requiring a non-home discharge to help manage expectations and create a standardized transition of care pathway following surgery.
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Affiliation(s)
- Nehizena S Aihie
- Desai Sethi Urology Institute, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Helen Y Hougen
- Desai Sethi Urology Institute, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Deukwoo Kwon
- Division of Clinical and Translational Sciences, Department of Internal Medicine, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Sanoj Punnen
- Desai Sethi Urology Institute, University of Miami Miller School of Medicine, Miami, FL, USA; Sylvester ComprehensiveCancerCenter, Miami, FL, USA
| | - Bruno Nahar
- Desai Sethi Urology Institute, University of Miami Miller School of Medicine, Miami, FL, USA; Sylvester ComprehensiveCancerCenter, Miami, FL, USA
| | - Dipen J Parekh
- Desai Sethi Urology Institute, University of Miami Miller School of Medicine, Miami, FL, USA; Sylvester ComprehensiveCancerCenter, Miami, FL, USA
| | - Mark L Gonzalgo
- Desai Sethi Urology Institute, University of Miami Miller School of Medicine, Miami, FL, USA; Sylvester ComprehensiveCancerCenter, Miami, FL, USA
| | - Chad R Ritch
- Desai Sethi Urology Institute, University of Miami Miller School of Medicine, Miami, FL, USA; Sylvester ComprehensiveCancerCenter, Miami, FL, USA.
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Akahoshi Y, Spyrou N, Hogan WJ, Ayuk F, DeFilipp Z, Weber D, Choe HK, Hexner EO, Rösler W, Etra AM, Sandhu K, Yanik GA, Chanswangphuwana C, Kitko CL, Reshef R, Kraus S, Wölfl M, Eder M, Bertrand H, Qayed M, Merli P, Grupp SA, Aguayo-Hiraldo P, Schechter T, Ullrich E, Baez J, Beheshti R, Gleich S, Kowalyk S, Morales G, Young R, Kwon D, Nakamura R, Levine JE, Ferrara JLM, Chen YB. Incidence, clinical presentation, risk factors, outcomes, and biomarkers in de novo late acute GVHD. Blood Adv 2023; 7:4479-4491. [PMID: 37315175 PMCID: PMC10440469 DOI: 10.1182/bloodadvances.2023009885] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Revised: 05/24/2023] [Accepted: 05/31/2023] [Indexed: 06/16/2023] Open
Abstract
Late acute graft-versus-host disease (GVHD) is defined as de novo acute GVHD presenting beyond 100 days after allogeneic hematopoietic cell transplantation (HCT) without manifestations of chronic GVHD. Data are limited regarding its characteristics, clinical course, and risk factors because of underrecognition and changes in classification. We evaluated 3542 consecutive adult recipients of first HCTs at 24 Mount Sinai Acute GVHD International Consortium (MAGIC) centers between January 2014 and August 2021 to better describe the clinical evolution and outcomes of late acute GVHD. The cumulative incidence of classic acute GVHD that required systemic treatment was 35.2%, and an additional 5.7% of patients required treatment for late acute GVHD. At the onset of symptoms, late acute GVHD was more severe than classic acute GVHD based on both clinical and MAGIC algorithm probability biomarker parameters and showed a lower overall response rate on day 28. Both clinical and biomarker grading at the time of treatment stratified the risk of nonrelapse mortality (NRM) in patients with classic and late acute GVHD, respectively, but long-term NRM and overall survival did not differ between patients with classic and late acute GVHD. Advanced age, female-to-male sex mismatch, and the use of reduced intensity conditioning were associated with the development of late acute GVHD, whereas the use of posttransplant cyclophosphamide-based GVHD prevention was protective mainly because of shifts in GVHD timing. Because overall outcomes were comparable, our findings, although not definitive, suggest that similar treatment strategies, including eligibility for clinical trials, based solely on clinical presentation at onset are appropriate.
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Affiliation(s)
- Yu Akahoshi
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
- Division of Hematology, Jichi Medical University Saitama Medical Center, Saitama, Japan
| | - Nikolaos Spyrou
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | | | - Francis Ayuk
- Department of Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Zachariah DeFilipp
- Hematopoietic Cell Transplant and Cellular Therapy Program, Massachusetts General Hospital, Boston, MA
| | - Daniela Weber
- Department of Hematology and Oncology, Internal Medicine III, University of Regensburg, Regensburg, Germany
| | - Hannah K. Choe
- Blood and Marrow Transplantation Program, The Ohio State University, Columbus, OH
| | - Elizabeth O. Hexner
- Department of Medicine, Division of Hematology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Wolf Rösler
- Department of Internal Medicine 5, Hematology and Oncology, Friedrich-Alexander-Universität Erlangen-Nürnberg and University Hospital Erlangen, Erlangen, Germany
| | - Aaron M. Etra
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Karamjeet Sandhu
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope National Medical Center, Duarte, CA
| | - Gregory A. Yanik
- Blood and Marrow Transplantation Program, University of Michigan, Ann Arbor, MI
| | - Chantiya Chanswangphuwana
- Department of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Carrie L. Kitko
- Pediatric Stem Cell Transplant Program, Vanderbilt University Medical Center, Nashville, TN
| | - Ran Reshef
- Blood and Marrow Transplantation Program and Columbia Center for Translational Immunology, Columbia University Medical Center, New York, NY
| | - Sabrina Kraus
- Department of Internal Medicine II, University Hospital of Würzburg, Würzburg, Germany
| | - Matthias Wölfl
- Pediatric Blood and Marrow Transplantation Program, Children's Hospital, University Hospital of Würzburg, Würzburg, Germany
| | - Matthias Eder
- Department of Hematology, Hemostasis, Oncology and Stem Cell Transplantation, Hannover Medical School, Hannover, Germany
| | - Hannah Bertrand
- Department of Medicine I, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Muna Qayed
- Emory University School of Medicine, Atlanta, GA
| | - Pietro Merli
- Department of Haematology-Oncology and Cell and Gene Therapy, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Stephan A. Grupp
- Division of Oncology, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Paibel Aguayo-Hiraldo
- Cancer and Blood Disease Institute, Children's Hospital Los Angeles, Los Angeles, CA
| | - Tal Schechter
- Division of Hematology/Oncology/BMT, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Evelyn Ullrich
- Frankfurt Cancer Institute, Goethe University Frankfurt, Frankfurt am Main, Germany
| | - Janna Baez
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Rahnuma Beheshti
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Sigrun Gleich
- Department of Hematology and Oncology, Internal Medicine III, University of Regensburg, Regensburg, Germany
| | - Steven Kowalyk
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - George Morales
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Rachel Young
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Deukwoo Kwon
- Department of Population Health Science and Policy, Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Ryotaro Nakamura
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope National Medical Center, Duarte, CA
| | - John E. Levine
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - James L. M. Ferrara
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Yi-Bin Chen
- Hematopoietic Cell Transplant and Cellular Therapy Program, Massachusetts General Hospital, Boston, MA
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Fine JR, Ransdell JM, Pinheiro PS, Kwon D, Reis IM, Barredo JC, Isrow DM. The Effect of Health Insurance on Pediatric Cancer Survival: An Analysis of Children Evaluated for Radiation Therapy in Diverse Multicenter Health Systems. J Pediatr Hematol Oncol 2023; 45:e662-e670. [PMID: 37278568 DOI: 10.1097/mph.0000000000002678] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Accepted: 03/21/2023] [Indexed: 06/07/2023]
Abstract
BACKGROUND Understanding the role of health insurance in cancer survival in a diverse population of pediatric radiation oncology patients could help to identify patients at risk of adverse outcomes. MATERIALS AND METHODS Data were collected from cancer patients evaluated for radiation therapy, age < 19, diagnosed from January 1990 to August 2019. Predictors of recurrence-free survival (RFS) and overall survival (OS) were analyzed by univariable and multivariable Cox regression. Variables included health insurance, diagnosis type, sex, race/ethnicity, and socioeconomic status deprivation index. RESULTS The study included 459 patients with a median diagnosis age of 9 years. Demographic breakdown was 49.5% Hispanic, 27.2% non-Hispanic White, and 20.7% non-Hispanic Black. There were 203 recurrences and 86 deaths observed over a median follow-up of 2.4 years. Five-year RFS was 59.8% (95% CI, 51.6, 67.0) versus 36.5% (95% CI, 26.6, 46.6), and 5-year OS was 87.5% (95% CI, 80.9, 91.9) versus 71.0% (95% CI, 60.3, 79.3) in private pay insurance versus Medicaid/Medicare, respectively. Multivariable showed Medicaid/Medicare patients experienced a 54% higher risk of recurrence (hazard ratio: 1.54, 95% CI, 1.08, 2.20) and 79% higher risk of death (hazard ratio: 1.79, 95% CI, 1.02, 3.14) than privately insured patients. CONCLUSIONS Significant disadvantages in RFS and OS were identified in radiation oncology patients with Medicaid/Medicare insurance, even after adjusting for clinical and demographic variables.
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Affiliation(s)
| | | | - Paulo S Pinheiro
- Sylvester Comprehensive Cancer Center
- Department of Public Health Science, University of Miami Miller School of Medicine
| | - Deukwoo Kwon
- Division of Biostatistics, Department of Public Health Sciences, Miller School of Medicine, University of Miami
- Biostatistics and Bioinformatics Core Resource, Sylvester Comprehensive Cancer Center, Miller School of Medicine, University of Miami
| | - Isildinha M Reis
- Division of Biostatistics, Department of Public Health Sciences, Miller School of Medicine, University of Miami
- Biostatistics and Bioinformatics Core Resource, Sylvester Comprehensive Cancer Center, Miller School of Medicine, University of Miami
| | | | - Derek M Isrow
- Radiation Oncology, Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, FL
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19
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Samuel D, Kwon D, Huang M, Zhao W, Roy M, Tabuyo-Martin A, Siemon J, Schlumbrecht MP, Pearson JM, Sinno AK. Disparities in refusal of surgery for gynecologic cancer. Gynecol Oncol 2023; 174:1-10. [PMID: 37141816 DOI: 10.1016/j.ygyno.2023.04.017] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [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: 12/28/2022] [Revised: 04/07/2023] [Accepted: 04/17/2023] [Indexed: 05/06/2023]
Abstract
OBJECTIVE To identify sociodemographic and clinical factors associated with refusal of gynecologic cancer surgery and to estimate its effect on overall survival. METHODS The National Cancer Database was surveyed for patients with uterine, cervical or ovarian/fallopian tube/primary peritoneal cancer treated between 2004 and 2017. Univariate and multivariate logistic regression were used to assess associations between clinico-demographic variables and refusal of surgery. Overall survival was estimated using the Kaplan-Meier method. Trends in refusal over time were evaluated using joinpoint regression. RESULTS Of 788,164 women included in our analysis, 5875 (0.75%) patients refused surgery recommended by their treating oncologist. Patients who refused surgery were older at diagnosis (72.4 vs 60.3 years, p < 0.001) and more likely Black (OR 1.77 95% CI 1.62-1.92). Refusal of surgery was associated with uninsured status (OR 2.94 95% CI 2.49-3.46), Medicaid coverage (OR 2.79 95% CI 2.46-3.18), low regional high school graduation (OR 1.18 95% CI 1.05-1.33) and treatment at a community hospital (OR 1.59 95% CI 1.42-1.78). Patients who refused surgery had lower median overall survival (1.0 vs 14.0 years, p < 0.01) and this difference persisted across disease sites. Between 2008 and 2017, there was a significant increase in refusal of surgery annually (annual percent change +1.41%, p < 0.05). CONCLUSIONS Multiple social determinants of health are independently associated with refusal of surgery for gynecologic cancer. Given that patients who refuse surgery are more likely from vulnerable, underserved populations and have inferior survival, refusal of surgery should be considered a surgical healthcare disparity and tackled as such.
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Affiliation(s)
- David Samuel
- University of Miami, Miller School of Medicine, Department of Obstetrics, Gynecology & Reproductive Sciences, Division of Gynecologic Oncology, Miami, FL, United States of America.
| | - Deukwoo Kwon
- Icahn School of Medicine at Mount Sinai, Department of Population Health Science and Policy, New York, NY, United States of America
| | - Marilyn Huang
- University of Miami, Miller School of Medicine, Department of Obstetrics, Gynecology & Reproductive Sciences, Division of Gynecologic Oncology, Miami, FL, United States of America; Sylvester Comprehensive Cancer Center, Division of Gynecologic Oncology, Miami, FL, United States of America
| | - Wei Zhao
- Sylvester Comprehensive Cancer Center, Biostatistics and Bioinformatics Shared Resource, Miami, FL, United States of America
| | - Molly Roy
- University of Miami, Miller School of Medicine, Department of Obstetrics, Gynecology & Reproductive Sciences, Division of Gynecologic Oncology, Miami, FL, United States of America
| | - Angel Tabuyo-Martin
- University of Miami, Miller School of Medicine, Department of Obstetrics, Gynecology & Reproductive Sciences, Division of Gynecologic Oncology, Miami, FL, United States of America
| | - John Siemon
- University of Miami, Miller School of Medicine, Department of Obstetrics, Gynecology & Reproductive Sciences, Division of Gynecologic Oncology, Miami, FL, United States of America
| | - Matthew P Schlumbrecht
- University of Miami, Miller School of Medicine, Department of Obstetrics, Gynecology & Reproductive Sciences, Division of Gynecologic Oncology, Miami, FL, United States of America; Sylvester Comprehensive Cancer Center, Division of Gynecologic Oncology, Miami, FL, United States of America
| | - J Matt Pearson
- University of Miami, Miller School of Medicine, Department of Obstetrics, Gynecology & Reproductive Sciences, Division of Gynecologic Oncology, Miami, FL, United States of America; Sylvester Comprehensive Cancer Center, Division of Gynecologic Oncology, Miami, FL, United States of America
| | - Abdulrahman K Sinno
- University of Miami, Miller School of Medicine, Department of Obstetrics, Gynecology & Reproductive Sciences, Division of Gynecologic Oncology, Miami, FL, United States of America; Sylvester Comprehensive Cancer Center, Division of Gynecologic Oncology, Miami, FL, United States of America
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20
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Zhang L, Troccoli CI, Mateo-Victoriano B, Lincheta LM, Jackson E, Shu P, Plastini T, Tao W, Kwon D, Chen X, Sharma J, Jorda M, Gulley JL, Bilusic M, Lockhart AC, Beuve A, Rai P. The soluble guanylyl cyclase pathway is inhibited to evade androgen deprivation-induced senescence and enable progression to castration resistance. bioRxiv 2023:2023.05.03.537252. [PMID: 37205442 PMCID: PMC10187243 DOI: 10.1101/2023.05.03.537252] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/21/2023]
Abstract
Castration-resistant prostate cancer (CRPC) is fatal and therapeutically under-served. We describe a novel CRPC-restraining role for the vasodilatory soluble guanylyl cyclase (sGC) pathway. We discovered that sGC subunits are dysregulated during CRPC progression and its catalytic product, cyclic GMP (cGMP), is lowered in CRPC patients. Abrogating sGC heterodimer formation in castration-sensitive prostate cancer (CSPC) cells inhibited androgen deprivation (AD)-induced senescence, and promoted castration-resistant tumor growth. We found sGC is oxidatively inactivated in CRPC. Paradoxically, AD restored sGC activity in CRPC cells through redox-protective responses evoked to protect against AD-induced oxidative stress. sGC stimulation via its FDA-approved agonist, riociguat, inhibited castration-resistant growth, and the anti-tumor response correlated with elevated cGMP, indicating on-target sGC activity. Consistent with known sGC function, riociguat improved tumor oxygenation, decreasing the PC stem cell marker, CD44, and enhancing radiation-induced tumor suppression. Our studies thus provide the first evidence for therapeutically targeting sGC via riociguat to treat CRPC. Statement of significance Prostate cancer is the second highest cancer-related cause of death for American men. Once patients progress to castration-resistant prostate cancer, the incurable and fatal stage, there are few viable treatment options available. Here we identify and characterize a new and clinically actionable target, the soluble guanylyl cyclase complex, in castration-resistant prostate cancer. Notably we find that repurposing the FDA-approved and safely tolerated sGC agonist, riociguat, decreases castration-resistant tumor growth and re-sensitizes these tumors to radiation therapy. Thus our study provides both new biology regarding the origins of castration resistance as well as a new and viable treatment option.
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21
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Patel R, Kwon D, Van Hyfte G, Sparano J, Tiersten A. Abstract PD1-09: Associations between the 21-gene Oncotype DX Recurrence Score (RS), Ki67, and Race in Early Breast Cancer (EBC) Using the National Cancer Database (NCDB). Cancer Res 2023. [DOI: 10.1158/1538-7445.sabcs22-pd1-09] [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: 03/06/2023]
Abstract
Abstract
Background: The 21-gene RS (Oncotype DX) is a validated genomic signature that provides prognostic information for distant recurrence risk and is predictive of adjuvant chemotherapy benefit in patients with hormone receptor (HR)-positive, HER2-negative early breast cancer (EBC). Ki67 protein expression is a proliferation marker that is determined by immunohistochemistry (IHC) and is a prognostic biomarker in HR-positive EBC. Black race is associated with poorer prognosis in patients with EBC. RS, Ki67 and race have not been evaluated together and the impact of race on the association between Ki67 and RS is unknown. The goal of this study was to evaluate the association between the 21-gene RS and Ki67 based on race in patients with HR-positive EBC using the NCDB.
Methods: Women with HR-positive EBC with 0-3 involved lymph nodes, diagnosed between 2018 and 2019, who had available information on RS, IHC-measured Ki67, and race in the NCDB dataset were identified. Patients were stratified by RS of low (0-10), intermediate (11-25) and high (26-100) and categorized into Ki67 low (/=30%) based on the International Ki67 Working Group prognostic classification (PMID: 33369635). Wilcoxon rank test was used to test for continuous variables and chi-square test was used for categorical variables. Agreement between Ki67 and RS was estimated using Fleiss Kappa statistic and corresponding p-value was reported.
Results: 43,898 eligible women were included. 17.43% were lymph node positive. 78% were Non-Hispanic White, 7.98% Non-Hispanic Black, 6.42% Hispanic, and 4.26% Asian American/Pacific Islander (AAPI). The table below describes the distribution of Ki67 and RS in the overall population and racial subgroups. The distribution of Ki67 scores was significantly different between races with a higher proportion of Black patients having high Ki67 scores, p< 0.0001. RS distribution varied as well with a greater percentage of high RS in the Black group, p< 0.0001. There was only slight agreement (Kappa 0.01-0.20) between Ki67 and RS in the overall population (Kappa=0.1929, p< 0.0001), low Ki67 subgroup (Kappa=0.069, p< 0.0001) and intermediate group (Kappa=0.066, p< 0.0001). However, there was fair agreement (Kappa 0.21-0.40) between high Ki67 and RS (Kappa=0.351, p< 0.0001). Based on race as a covariate, in the overall population, agreement between Ki67 and RS remained slight for White, Hispanic, and AAPI groups but was fair for Black patients (Kappa=0.2345, p< 0.0001). In the low Ki67 and intermediate Ki67 groups, agreement remained slight across all races, p< 0.0001. While there was fair agreement between high Ki67 and RS in all racial subgroups, agreement between high Ki67 and RS was highest in the Black subgroup (Kappa=0.392, p< 0.0001) followed by the AAPI (Kappa=0.363, p< 0.0001), White (Kappa=0.342, p< 0.0001) and Hispanic (Kappa=0.339, p< 0.0001) groups.
Conclusions: In this large patient population from the NCDB, there was only slight agreement between Ki67 and RS in the overall, low Ki67, and intermediate Ki67 groups but fair agreement in the high Ki67 group. Agreement between high Ki67 and RS was greatest in the Black subgroup compared to other races. This may be attributed to the higher proportion of patients with high Ki67 and RS in the Black subgroup. Future analyses on overall survival will determine the impact of race on the prognostic value of Ki67 and RS.
Table 1. Distribution of Ki67 and RS by Racial/Ethnic Subgroup AAPI: Asian American/Pacific Islander AIAN: American Indian and Alaska Native
Citation Format: Rima Patel, Deukwoo Kwon, Grace Van Hyfte, Joseph Sparano, Amy Tiersten. Associations between the 21-gene Oncotype DX Recurrence Score (RS), Ki67, and Race in Early Breast Cancer (EBC) Using the National Cancer Database (NCDB) [abstract]. In: Proceedings of the 2022 San Antonio Breast Cancer Symposium; 2022 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2023;83(5 Suppl):Abstract nr PD1-09.
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Affiliation(s)
- Rima Patel
- 1Icahn School of Medicine at Mount Sinai
| | - Deukwoo Kwon
- 2Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai
| | - Grace Van Hyfte
- 3Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai
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Ogobuiro I, Collier AL, Khan K, de Castro Silva I, Kwon D, Wilson GC, Schwartz PB, Parikh AA, Hammill C, Kim HJ, Kooby DA, Abbott D, Maithel SK, Snyder RA, Ahmad SA, Merchant NB, Datta J. ASO Visual Abstract: Racial Disparity in Pathologic Response Following Neoadjuvant Chemotherapy in Resected Pancreatic Cancer-A Multi-institutional Analysis from the Central Pancreatic Consortium. Ann Surg Oncol 2023; 30:1498-1499. [PMID: 36564655 DOI: 10.1245/s10434-022-12912-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Affiliation(s)
- Ifeanyichukwu Ogobuiro
- Division of Surgical Oncology, Department of Surgery, Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Amber L Collier
- Division of Surgical Oncology, Department of Surgery, Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Khadeja Khan
- Division of Surgical Oncology, Department of Surgery, Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Iago de Castro Silva
- Division of Surgical Oncology, Department of Surgery, Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Deukwoo Kwon
- Icahn School of Medicine at Mount Sinai Department of Population Health Science and Policy, New York, NY, USA
| | - Gregory C Wilson
- University of Cincinnati School of Medicine, Cincinnati, OH, USA
| | - Patrick B Schwartz
- University of Wisconsin School of Medicine, Carbone Cancer Center, Madison, WI, USA
| | | | - Chet Hammill
- Washington University School of Medicine, St. Louis, MO, USA
| | - Hong J Kim
- University of North Carolina School of Medicine, Lineberger Cancer Center, Chapel Hill, NC, USA
| | - David A Kooby
- Emory University School of Medicine, Winship Cancer Institute, Atlanta, GA, USA
| | - Daniel Abbott
- University of Wisconsin School of Medicine, Carbone Cancer Center, Madison, WI, USA
| | - Shishir K Maithel
- Emory University School of Medicine, Winship Cancer Institute, Atlanta, GA, USA
| | - Rebecca A Snyder
- East Carolina University Brody School of Medicine, Greenville, NC, USA
| | - Syed A Ahmad
- University of Cincinnati School of Medicine, Cincinnati, OH, USA
| | - Nipun B Merchant
- Division of Surgical Oncology, Department of Surgery, Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Jashodeep Datta
- Division of Surgical Oncology, Department of Surgery, Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, FL, USA.
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Ogobuiro I, Collier AL, Khan K, de Castro Silva I, Kwon D, Wilson GC, Schwartz PB, Parikh AA, Hammill C, Kim HJ, Kooby DA, Abbott D, Maithel SK, Snyder RA, Ahmad SA, Merchant NB, Datta J. Racial Disparity in Pathologic Response following Neoadjuvant Chemotherapy in Resected Pancreatic Cancer: A Multi-Institutional Analysis from the Central Pancreatic Consortium. Ann Surg Oncol 2023; 30:1485-1494. [PMID: 36316508 DOI: 10.1245/s10434-022-12741-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Accepted: 10/10/2022] [Indexed: 11/18/2022]
Abstract
BACKGROUND Major pathologic response (MPR) following neoadjuvant therapy (NAT) in pancreatic ductal adenocarcinoma (PDAC) patients undergoing resection is associated with improved survival. We sought to determine whether racial disparities exist in MPR rates following NAT in patients with PDAC undergoing resection. METHODS Patients with potentially operable PDAC receiving at least 2 cycles of neoadjuvant FOLFIRINOX or gemcitabine/nab-paclitaxel ± radiation followed by pancreatectomy (2010-2019) at 7 high-volume centers were reviewed. Self-reported race was dichotomized as Black and non-Black, and multivariable models evaluated the association between race and MPR (i.e., pathologic complete response [pCR] or near-pCR). Cox regression evaluated the association between race and disease-free (DFS) and overall survival (OS). RESULTS Results of 486 patients who underwent resection following NAT (mFOLFIRINOX 56%, gemcitabine/nab-paclitaxel 25%, radiation 29%), 67 (13.8%) patients were Black. Black patients had lower CA19-9 at diagnosis (median 67 vs. 204 U/mL; P = 0.003) and were more likely to undergo mild/moderate chemotherapy dose modification (40 vs. 20%; P = 0.005) versus non-Black patients. Black patients had significantly lower rates of MPR compared with non-Black patients (13.4 vs. 25.8%; P = 0.039). Black race was independently associated with worse MPR (OR 0.26, 95% confidence interval [CI] 0.10-0.69) while controlling for NAT duration, CA19-9 dynamics, and chemotherapy modifications. There was no significant difference in DFS or OS between Black and non-Black cohorts. CONCLUSIONS Black patients undergoing pancreatectomy appear less likely to experience MPR following NAT. The contribution of biologic and nonbiologic factors to reduced chemosensitivity in Black patients warrants further investigation.
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Affiliation(s)
- Ifeanyichukwu Ogobuiro
- Department of Surgery, Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, 1120 NW 14th Street, Suite 410, Miami, FL, 33136, USA
| | - Amber L Collier
- Department of Surgery, Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, 1120 NW 14th Street, Suite 410, Miami, FL, 33136, USA
| | - Khadeja Khan
- Department of Surgery, Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, 1120 NW 14th Street, Suite 410, Miami, FL, 33136, USA
| | - Iago de Castro Silva
- Department of Surgery, Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, 1120 NW 14th Street, Suite 410, Miami, FL, 33136, USA
| | - Deukwoo Kwon
- Department of Surgery, Icahn School of Medicine at Mount Sinai Department of Population Health Science and Policy, New York, NY, USA
| | - Gregory C Wilson
- Department of Surgery, University of Cincinnati School of Medicine, Cincinnati, OH, USA
| | - Patrick B Schwartz
- Department of Surgery, Carbone Cancer Center, University of Wisconsin School of Medicine, Madison, WI, USA
| | - Alexander A Parikh
- Department of Surgery, East Carolina University Brody School of Medicine, Greenville, NC, USA
| | - Chet Hammill
- Department of Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Hong J Kim
- Department of Surgery, Lineberger Cancer Center, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - David A Kooby
- Department of Surgery, Emory University School of Medicine, Winship Cancer Institute, Atlanta, GA, USA
| | - Daniel Abbott
- Department of Surgery, Carbone Cancer Center, University of Wisconsin School of Medicine, Madison, WI, USA
| | - Shishir K Maithel
- Department of Surgery, Emory University School of Medicine, Winship Cancer Institute, Atlanta, GA, USA
| | - Rebecca A Snyder
- Department of Surgery, East Carolina University Brody School of Medicine, Greenville, NC, USA
| | - Syed A Ahmad
- Department of Surgery, University of Cincinnati School of Medicine, Cincinnati, OH, USA
| | - Nipun B Merchant
- Department of Surgery, Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, 1120 NW 14th Street, Suite 410, Miami, FL, 33136, USA
| | - Jashodeep Datta
- Department of Surgery, Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, 1120 NW 14th Street, Suite 410, Miami, FL, 33136, USA.
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Patel R, Kwon D, Hovstadius M, Tiersten A. Abstract P6-05-04: Patterns in palliative care use and their impact on survival in the elderly metastatic breast cancer (MBC) population: a National Cancer Database (NCDB) Analysis. Cancer Res 2023. [DOI: 10.1158/1538-7445.sabcs22-p6-05-04] [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: 03/06/2023]
Abstract
Abstract
Background: About 6% of patients diagnosed with breast cancer (BC) will have metastatic disease at time of diagnosis. In this case, treatment is palliative and focused on systemic therapies. Both American Society of Clinical Oncology (ASCO) and National Comprehensive Cancer Network (NCCN) recommend early integration of palliative care (PC) for patients with metastatic disease to improve symptom management and quality of life while potentially decreasing mortality. However, the frequency by which elderly patients with metastatic breast cancer (MBC) receive PC is unknown. This is especially relevant as improvements in health care have allowed for longer life expectancy and an increase in America’s aged population. The goal of this study was to use the NCDB to describe national patterns in PC use in elderly patients over 75 years of age with MBC and evaluate differences in overall survival (OS).
Methods: Women with a diagnosis of BC at age >/= 75 years and with metastases at time of initial diagnosis from 2010 to 2019 were identified from the NCDB. Patients were stratified into age subgroups of 75-79, 80-84, and >/= 85 years. Chi-square tests were used to compare categorical variables. Kaplan Meier curves were used to determine OS distributions for patients by age and receipt of PC. Log-rank tests and multivariable cox proportional hazards modeling was performed to assess the difference in OS between patients who received and did not receive PC.
Results: Of 17,325 eligible women included in the final analysis, 39.4% were 75-79, 30.1% 80-84, and 30.4% >/= 85 years of age. Overall, 20.5% of patients utilized PC. The table below describes the baseline characteristics of patients who received PC versus those who did not. Rates of PC utilization varied among the age subgroups, with the lowest utilization in the >/= 85 years of age group, p< 0.0001. Performance status as measured by Charlson-Deyo Score did not impact rates of PC use, p=0.3196. Use of PC varied across races with higher use in Non-Hispanic White patients and lower in Hispanic and Non-Hispanic Black subgroups, p< 0.0001. In the overall population, the use of PC increased from 17.9% in 2010 to 23.2% in 2019, p=0.0003. This was primarily driven by the statistically significant increase in the 75-79 age group (18.4% to 26.8%, p=0.0003). Although there were numeric increases in PC use from 2010 to 2019 in the 80-84 (20.9% to 24%, p=0.2899) and >/= 85 (13.9% to 17.9%, p=0.1082) age groups, these differences were not statistically significant. Palliative care receipt did not impact overall survival. Three-year OS rates were 27.8% (CI: 26.1-29.5) and 27.8% (CI: 27.0-28.7), for patients who received PC compared to those who did not, respectively, p=0.512.
Conclusions: Over the last decade, we observed an increase in PC utilization in patients >/= 75 years with MBC. However, significant increases were only seen in the 75-79 age group. Palliative care use was lower among patients >/= 85 years compared to those 75-79 or 80-84 years of age. Performance status did not influence receipt of PC. There were no differences in OS between elderly patients who received PC versus those who did not. Future follow up analyses will be needed to determine the impact of PC on OS in this population. Clinicians should be encouraged to integrate PC into the treatment of elderly patients with MBC, particularly those >/= 85 years, as this can improve symptoms and quality of life.
Table 1. Patient Baseline Characteristics by Palliative Care Receipt.
Citation Format: Rima Patel, Deukwoo Kwon, Malin Hovstadius, Amy Tiersten. Patterns in palliative care use and their impact on survival in the elderly metastatic breast cancer (MBC) population: a National Cancer Database (NCDB) Analysis [abstract]. In: Proceedings of the 2022 San Antonio Breast Cancer Symposium; 2022 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2023;83(5 Suppl):Abstract nr P6-05-04.
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Affiliation(s)
- Rima Patel
- 1Icahn School of Medicine at Mount Sinai
| | - Deukwoo Kwon
- 2Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai
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Etra A, Capellini A, Alousi A, Al Malki MM, Choe H, DeFilipp Z, Hogan WJ, Kitko CL, Ayuk F, Baez J, Gandhi I, Kasikis S, Gleich S, Hexner E, Hoepting M, Kapoor U, Kowalyk S, Kwon D, Langston A, Mielcarek M, Morales G, Özbek U, Qayed M, Reshef R, Rösler W, Spyrou N, Young R, Chen YB, Ferrara JLM, Levine JE. Effective treatment of low-risk acute GVHD with itacitinib monotherapy. Blood 2023; 141:481-489. [PMID: 36095841 PMCID: PMC9936304 DOI: 10.1182/blood.2022017442] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [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] [Received: 06/16/2022] [Revised: 07/27/2022] [Accepted: 07/31/2022] [Indexed: 02/07/2023] Open
Abstract
The standard primary treatment for acute graft-versus-host disease (GVHD) requires prolonged, high-dose systemic corticosteroids (SCSs) that delay reconstitution of the immune system. We used validated clinical and biomarker staging criteria to identify a group of patients with low-risk (LR) GVHD that is very likely to respond to SCS. We hypothesized that itacitinib, a selective JAK1 inhibitor, would effectively treat LR GVHD without SCS. We treated 70 patients with LR GVHD in a multicenter, phase 2 trial (NCT03846479) with 28 days of itacitinib 200 mg/d (responders could receive a second 28-day cycle), and we compared their outcomes to those of 140 contemporaneous, matched control patients treated with SCSs. More patients responded to itacitinib within 7 days (81% vs 66%, P = .02), and response rates at day 28 were very high for both groups (89% vs 86%, P = .67), with few symptomatic flares (11% vs 12%, P = .88). Fewer itacitinib-treated patients developed a serious infection within 90 days (27% vs 42%, P = .04) due to fewer viral and fungal infections. Grade ≥3 cytopenias were similar between groups except for less severe leukopenia with itacitinib (16% vs 31%, P = .02). No other grade ≥3 adverse events occurred in >10% of itacitinib-treated patients. There were no significant differences between groups at 1 year for nonrelapse mortality (4% vs 11%, P = .21), relapse (18% vs 21%, P = .64), chronic GVHD (28% vs 33%, P = .33), or survival (88% vs 80%, P = .11). Itacitinib monotherapy seems to be a safe and effective alternative to SCS treatment for LR GVHD and deserves further investigation.
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Affiliation(s)
- Aaron Etra
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Alexandra Capellini
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Amin Alousi
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Monzr M. Al Malki
- Hematology/Hematopoietic Cell Transplant, City of Hope National Medical Center, Duarte, CA
| | - Hannah Choe
- Division of Hematology, James Cancer Center, The Ohio State University, Columbus, OH
| | - Zachariah DeFilipp
- Hematopoietic Cell Transplant and Cellular Therapy Program, Massachusetts General Hospital, Boston, MA
| | | | - Carrie L. Kitko
- Pediatric Stem Cell Transplant Program, Vanderbilt University Medical Center, Nashville, TN
| | - Francis Ayuk
- Department of Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Janna Baez
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Isha Gandhi
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Stelios Kasikis
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Sigrun Gleich
- Department of Hematology and Oncology, Internal Medicine III, University of Regensburg, Regensburg, Germany
| | - Elizabeth Hexner
- Blood and Marrow Transplantation Program, Abramson Cancer Center, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Matthias Hoepting
- Department of Hematology and Oncology, Internal Medicine III, University of Regensburg, Regensburg, Germany
| | - Urvi Kapoor
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Steven Kowalyk
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Deukwoo Kwon
- Department of Population Health Science and Policy, Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | | | - Marco Mielcarek
- Adult Blood and Marrow Transplant Program, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - George Morales
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Umut Özbek
- Department of Population Health Science and Policy, Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Muna Qayed
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Atlanta, GA
| | - Ran Reshef
- Blood and Marrow Transplantation Program, Columbia University Medical Center, New York, NY
| | - Wolf Rösler
- Med. Klinik III/Poliklinik, Universitatsklinik Erlangen, Erlangen, Germany
| | - Nikolaos Spyrou
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Rachel Young
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Yi-Bin Chen
- Hematopoietic Cell Transplant and Cellular Therapy Program, Massachusetts General Hospital, Boston, MA
| | - James L. M. Ferrara
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - John E. Levine
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
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Kareff SA, Gawri K, Khan K, Kwon D, Rodriguez E, Lopes GDL, Dawar R. Efficacy and outcomes of ramucirumab and docetaxel in patients with metastatic non-small cell lung cancer after disease progression on immune checkpoint inhibitor therapy: Results of a monocentric, retrospective analysis. Front Oncol 2023; 13:1012783. [PMID: 37025595 PMCID: PMC10072276 DOI: 10.3389/fonc.2023.1012783] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Accepted: 02/08/2023] [Indexed: 04/08/2023] Open
Abstract
Current first-line standard therapy for metastatic non-small cell lung cancer without driver mutations involves chemotherapy and immunotherapy combination. Prior to the advent of immune checkpoint inhibition, REVEL, a randomized phase III trial demonstrated improved progression-free and overall survival with ramucirumab and docetaxel (ram+doc) in patients who failed platinum-based first-line therapy. Long-term outcomes related to second-line ramucirumab and docetaxel after first-line immunotherapy exposure remain unknown. We analyzed outcomes for 35 patients from our center whom received ramucirumab and docetaxel following disease progression on chemotherapy and immunotherapy combination. Median progression-free survival among patients who received ram+doc after exposure to immunotherapy was 6.6 months (95% CI = 5.5 to 14.9 months; p<0.0001), and median overall survival was 20.9 months (95% CI = 13.4 months to infinity; p<0.0001). These outcomes suggest that there may a synergistic benefit to combining chemotherapy with anti-angiogenic therapy after immunotherapy exposure. Future analyses should be evaluated prospectively and among a larger patient subset.
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Affiliation(s)
- Samuel A. Kareff
- Department of Graduate Medical Education, University of Miami Sylvester Comprehensive Cancer Center/Jackson Memorial Hospital, Miami, FL, United States
| | - Kunal Gawri
- Department of Medicine, State University of New York-Buffalo, Buffalo, NY, United States
| | - Khadeja Khan
- Department of Undergraduate Medical Education, University of Miami Miller School of Medicine, Miami, FL, United States
| | - Deukwoo Kwon
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Estelamari Rodriguez
- Department of Medical Oncology, University of Miami Sylvester Comprehensive Cancer Center, Miami, FL, United States
| | - Gilberto de Lima Lopes
- Department of Medical Oncology, University of Miami Sylvester Comprehensive Cancer Center, Miami, FL, United States
| | - Richa Dawar
- Department of Medical Oncology, University of Miami Sylvester Comprehensive Cancer Center, Miami, FL, United States
- *Correspondence: Richa Dawar,
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Chalise P, Kwon D, Fridley BL, Mo Q. Statistical Methods for Integrative Clustering of Multi-omics Data. Methods Mol Biol 2023; 2629:73-93. [PMID: 36929074 PMCID: PMC10950392 DOI: 10.1007/978-1-0716-2986-4_5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/18/2023]
Abstract
Cancers are heterogeneous diseases caused by accumulated mutations or abnormal alterations at multi-levels of biological processes including genomics, epigenomics, transcriptomics, and proteomics. There is a great clinical interest in identifying cancer molecular subtypes for disease prognosis and personalized medicine. Integrative clustering is a powerful unsupervised learning method that has been increasingly used to identify cancer molecular subtypes using multi-omics data including somatic mutations, DNA copy numbers, DNA methylation, and gene expression. Integrative clustering methods are generally classified into model-based or nonparametric approaches. In this chapter, we will give an overview of the frequently used model-based methods, including iCluster, iClusterPlus, and iClusterBayes, and the nonparametric method, integrative nonnegative matrix factorization (intNMF). We will use the integrative analyses of uveal melanoma and lower-grade glioma to illustrate these representative methods. Finally, we will discuss the strengths and limitations of these representative methods and give suggestions for performing integrative analyses of cancer multi-omics data in practice.
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Affiliation(s)
- Prabhakar Chalise
- Department of Biostatistics & Data Science, University of Kansas Medical Center, Kansas City, KS, USA
| | - Deukwoo Kwon
- Department of Population Health Science & Policy, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Brooke L Fridley
- Department of Biostatistics & Bioinformatics, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL, USA
| | - Qianxing Mo
- Department of Biostatistics & Bioinformatics, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL, USA.
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Patel S, Rich BJ, Schumacher LED, Sargi ZB, Masforroll M, Washington C, Kwon D, Rueda-Lara MA, Freedman LM, Samuels SE, Abramowitz MC, Samuels MA, Carmona R, Azzam GA. ED visits, hospital admissions and treatment breaks in head/neck cancer patients undergoing radiotherapy. Front Oncol 2023; 13:1147474. [PMID: 36937396 PMCID: PMC10014878 DOI: 10.3389/fonc.2023.1147474] [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: 01/18/2023] [Accepted: 02/08/2023] [Indexed: 03/05/2023] Open
Abstract
Objectives Radiation therapy (RT) is an integral part of treatment of head/neck cancer (HNC) but is associated with many toxicities. We sought to evaluate sociodemographic, pathologic, and clinical factors associated with emergency department (ED) visits, hospital admissions (HA), and RT breaks in HNC patients undergoing curative-intent RT. Methods We completed a Level 3 (Oxford criteria for evidence-based medicine) analysis of a cohort of HNC patients who underwent curative-intent RT at our institution from 2013 to 2017. We collected demographic characteristics and retrospectively assessed for heavy opioid use, ED visits or HA during RT as well as RT breaks. Treatment breaks were defined as total days to RT fractions ratio ≥1.6. Multivariable stepwise logistic regression analyses were done to determine the association of various sociodemographic, pathologic, and clinical characteristics with ED visits, HA and RT treatment breaks. Results The cohort included 376 HNC patients (294 male, 82 female, median age 61). On multivariable analysis, significant factors associated with ED visits during RT were heavy opioid use and black race. Receipt of concomitant chemotherapy was the only factor associated with hospital admissions during RT. Advanced age, lower socioeconomic class, glandular site, and receipt of chemotherapy were all independently associated with RT breaks. Lower cancer stage and lack of substance abuse history were independently associated with lack of treatment breaks. Conclusion HNC patients with factors such as heavy opioid use, Black race, receipt of concomitant chemotherapy, and lower socioeconomic class may require closer monitoring during RT.
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Affiliation(s)
- Shareen Patel
- Department of Radiation Oncology, Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, FL, United States
| | - Benjamin J. Rich
- Department of Radiation Oncology, Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, FL, United States
| | - Leif-Erik D. Schumacher
- Department of Radiation Oncology, Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, FL, United States
| | - Zoukaa B. Sargi
- Department of Otolaryngology, University of Miami Miller School of Medicine, Miami, FL, United States
| | - Melissa Masforroll
- Department of Medicine, Florida International University, Miami, FL, United States
| | - Cyrus Washington
- Department of Radiation Oncology, Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, FL, United States
| | - Deukwoo Kwon
- Department of Public Health Sciences, Biostatistics and Bioinformatics Shared Resource, Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, FL, United States
| | - Maria A. Rueda-Lara
- Department of Psychiatry, University of Miami Miller School of Medicine, Miami, FL, United States
| | - Laura M. Freedman
- Department of Radiation Oncology, Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, FL, United States
| | - Stuart E. Samuels
- Department of Radiation Oncology, Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, FL, United States
| | - Matthew C. Abramowitz
- Department of Radiation Oncology, Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, FL, United States
| | - Michael A. Samuels
- Department of Radiation Oncology, Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, FL, United States
| | - Ruben Carmona
- Department of Radiation Oncology, Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, FL, United States
| | - Gregory A. Azzam
- Department of Radiation Oncology, Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, FL, United States
- *Correspondence: Gregory A. Azzam,
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Delgadillo R, Spieler BO, Deana AM, Ford JC, Kwon D, Yang F, Studenski MT, Padgett KR, Abramowitz MC, Dal Pra A, Stoyanova R, Dogan N. Cone-beam CT delta-radiomics to predict genitourinary toxicities and international prostate symptom of prostate cancer patients: a pilot study. Sci Rep 2022; 12:20136. [PMID: 36418901 PMCID: PMC9684516 DOI: 10.1038/s41598-022-24435-8] [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] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Accepted: 11/15/2022] [Indexed: 11/24/2022] Open
Abstract
For prostate cancer (PCa) patients treated with definitive radiotherapy (RT), acute and late RT-related genitourinary (GU) toxicities adversely impact disease-specific quality of life. Early warning of potential RT toxicities can prompt interventions that may prevent or mitigate future adverse events. During intensity modulated RT (IMRT) of PCa, daily cone-beam computed tomography (CBCT) images are used to improve treatment accuracy through image guidance. This work investigated the performance of CBCT-based delta-radiomic features (DRF) models to predict acute and sub-acute International Prostate Symptom Scores (IPSS) and Common Terminology Criteria for Adverse Events (CTCAE) version 5 GU toxicity grades for 50 PCa patients treated with definitive RT. Delta-radiomics models were built using logistic regression, random forest for feature selection, and a 1000 iteration bootstrapping leave one analysis for cross validation. To our knowledge, no prior studies of PCa have used DRF models based on daily CBCT images. AUC of 0.83 for IPSS and greater than 0.7 for CTCAE grades were achieved as early as week 1 of treatment. DRF extracted from CBCT images showed promise for the development of models predictive of RT outcomes. Future studies will include using artificial intelligence and machine learning to expand CBCT sample sizes available for radiomics analysis.
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Affiliation(s)
- Rodrigo Delgadillo
- grid.26790.3a0000 0004 1936 8606Department of Radiation Oncology, University of Miami Miller School of Medicine, 1475 NW 12th Ave, Miami, FL 33136 USA
| | - Benjamin O. Spieler
- grid.26790.3a0000 0004 1936 8606Department of Radiation Oncology, University of Miami Miller School of Medicine, 1475 NW 12th Ave, Miami, FL 33136 USA
| | - Anthony M. Deana
- grid.26790.3a0000 0004 1936 8606Department of Biomedical Engineering, University of Miami, Miami, FL USA
| | - John C. Ford
- grid.26790.3a0000 0004 1936 8606Department of Radiation Oncology, University of Miami Miller School of Medicine, 1475 NW 12th Ave, Miami, FL 33136 USA
| | - Deukwoo Kwon
- grid.267308.80000 0000 9206 2401Center for Clinical and Translational Sciences, The University of Texas Health Science Center at Houston, Houston, TX USA
| | - Fei Yang
- grid.26790.3a0000 0004 1936 8606Department of Radiation Oncology, University of Miami Miller School of Medicine, 1475 NW 12th Ave, Miami, FL 33136 USA
| | - Matthew T. Studenski
- grid.26790.3a0000 0004 1936 8606Department of Radiation Oncology, University of Miami Miller School of Medicine, 1475 NW 12th Ave, Miami, FL 33136 USA
| | - Kyle R. Padgett
- grid.26790.3a0000 0004 1936 8606Department of Radiation Oncology, University of Miami Miller School of Medicine, 1475 NW 12th Ave, Miami, FL 33136 USA
| | - Matthew C. Abramowitz
- grid.26790.3a0000 0004 1936 8606Department of Radiation Oncology, University of Miami Miller School of Medicine, 1475 NW 12th Ave, Miami, FL 33136 USA
| | - Alan Dal Pra
- grid.26790.3a0000 0004 1936 8606Department of Radiation Oncology, University of Miami Miller School of Medicine, 1475 NW 12th Ave, Miami, FL 33136 USA
| | - Radka Stoyanova
- grid.26790.3a0000 0004 1936 8606Department of Radiation Oncology, University of Miami Miller School of Medicine, 1475 NW 12th Ave, Miami, FL 33136 USA
| | - Nesrin Dogan
- grid.26790.3a0000 0004 1936 8606Department of Radiation Oncology, University of Miami Miller School of Medicine, 1475 NW 12th Ave, Miami, FL 33136 USA
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Silva IDC, Bianchi A, Deshpande N, Sharma P, Mehra S, Hosein P, Kwon D, Merchant N, Datta J. Abstract C020: Neutrophil-mediated stromal-tumor IL-6/STAT-3 signaling underlies the association between neutrophil-to-lymphocyte ratio dynamics and chemotherapy response in localized pancreatic cancer: A hybrid clinical-preclinical study. Cancer Res 2022. [DOI: 10.1158/1538-7445.panca22-c020] [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: 11/17/2022]
Abstract
Abstract
Background: Partial/complete pathologic response following neoadjuvant chemotherapy (NAC) in pancreatic cancer (PDAC) patients undergoing pancreatectomy is associated with improved survival. We sought to determine whether neutrophil-to-lymphocyte ratio (NLR) dynamics predict pathologic response following chemotherapy in PDAC, and if manipulating NLR impacts chemosensitivity in preclinical models and uncovers potential mechanistic underpinnings underlying these effects. Methods: Pathologic response in PDAC patients (n=94) undergoing NAC and pancreatectomy (7/2015-12/2019) was dichotomized as partial/complete or poor/absent (case-cohort design). Bootstrap-validated multivariable models assessed associations between pre-chemotherapy NLR (%neutrophils÷%lymphocytes) or NLR dynamics during chemotherapy (ΔNLR=pre-surgery—pre-chemotherapy NLR) and pathologic response, disease-free survival (DFS), and overall survival (OS). To preclinically model effects of NLR attenuation on chemosensitivity, C57BL/6 mice (n=8-10/arm) were orthotopically injected with KrasG12D/+;Trp53fl/+;PdxCre(KPC) cells and randomized to vehicle, NLR-attenuating anti-Ly6G, gemcitabine/paclitaxel, or gemcitabine/paclitaxel+anti-Ly6G treatments. Results: In 94 PDAC patients undergoing NAC (median:4 months), pre-chemotherapy NLR (P<0.001) and ΔNLR attenuation during NAC (P=0.002) were independently associated with partial/complete pathologic response. An NLR score=pre-chemotherapy NLR+ΔNLR correlated with DFS (P=0.006) and OS (P=0.002). Upon preclinical modeling, combining NLR-attenuating anti-Ly6G treatment with gemcitabine/paclitaxel—compared with gemcitabine/paclitaxel or anti-Ly6G alone—not only significantly reduced tumor burden and metastatic outgrowth, but also augmented tumor-infiltrating CD107a+-degranulating CD8+ T-cells (P<0.01) while dampening inflammatory cancer-associated fibroblast (CAF) polarization (P=0.006) and chemoresistant IL-6/STAT-3 signaling in vivo. Neutrophil-derived IL-1β emerged as a novel mediator of stromal inflammation, inducing inflammatory CAF polarization and CAF-tumor cell IL-6/STAT-3 signaling in ex vivo co-cultures. Conclusions: Therapeutic strategies to mitigate neutrophil-CAF-tumor cell IL-1β/IL-6/STAT-3 signaling during NAC may improve pathologic responses and/or survival in PDAC.
Citation Format: Iago De Castro Silva, Anna Bianchi, Nilesh Deshpande, Prateek Sharma, Siddharth Mehra, Peter Hosein, Deukwoo Kwon, Nipun Merchant, Jashodeep Datta. Neutrophil-mediated stromal-tumor IL-6/STAT-3 signaling underlies the association between neutrophil-to-lymphocyte ratio dynamics and chemotherapy response in localized pancreatic cancer: A hybrid clinical-preclinical study [abstract]. In: Proceedings of the AACR Special Conference on Pancreatic Cancer; 2022 Sep 13-16; Boston, MA. Philadelphia (PA): AACR; Cancer Res 2022;82(22 Suppl):Abstract nr C020.
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Affiliation(s)
| | - Anna Bianchi
- 1University of Miami Miller School of Medicine, Miami, FL,
| | | | | | | | - Peter Hosein
- 1University of Miami Miller School of Medicine, Miami, FL,
| | - Deukwoo Kwon
- 1University of Miami Miller School of Medicine, Miami, FL,
| | - Nipun Merchant
- 1University of Miami Miller School of Medicine, Miami, FL,
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Bradley T, Kwon D, Monge J, Sekeres M, Chandhok N, Thomassen A, Swords R, Padron E, Lancet J, Talati C, Watts J. Molecular characteristics and outcomes in Hispanic and non-Hispanic patients with acute myeloid leukemia. EJHaem 2022; 3:1231-1240. [PMID: 36467830 PMCID: PMC9713060 DOI: 10.1002/jha2.589] [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] [Received: 09/16/2022] [Accepted: 09/17/2022] [Indexed: 06/17/2023]
Abstract
Hispanic patients have been reported to have an increased incidence of AML and possibly inferior outcomes compared to non-Hispanics. We conducted a retrospective study of 225 AML patients (58 Hispanic and 167 non-Hispanic) at two academic medical centers in Florida. Disease characteristics, cytogenetics, mutation profiles, and clinical outcomes were assessed. Hispanic patients were younger at presentation than non-Hispanics (p = 0.0013). We found associations between single gene mutations and ethnicity, with IDH1 mutations being more common in non-Hispanics (95.2% vs. 4.8%, p = 0.0182) and WT1 mutations more common in Hispanics (62.5% vs. 37.5%, p = 0.0455). We also found an emerging trend towards adverse risk cytogenetics in Hispanic patients (p = 0.1796), as well as high risk fusions such as MLL-r (70% vs. 30%, p = 0.004). There was no difference in overall survival (OS) between Hispanic and non-Hispanics patients. When examining only newly diagnosed patients (n = 105), there was improved OS in Hispanics (median 44.7 months vs. 14 months, p = 0.026) by univariate analysis and equivalent OS by multivariate analysis (hazard ratio = 1.52 [95% CI = 0.74-3.15]). Hispanics with a driver mutation not class-defining had improved survival compared to non-Hispanics. Our study demonstrates significant genetic differences between Floridian Hispanics and non-Hispanics, but no difference in OS in patients treated at an academic medical center.
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Affiliation(s)
- Terrence Bradley
- Division of Hematology, Sylvester Comprehensive Cancer CenterUniversity of MiamiMiamiFloridaUSA
| | - Deukwoo Kwon
- Division of Biostatistics, Sylvester Comprehensive Cancer CenterUniversity of MiamiMiamiFloridaUSA
| | - Jorge Monge
- Division of Hematology and Medical OncologyWeill Cornell Medical CollegeNew YorkNew YorkUSA
| | - Mikkael Sekeres
- Division of Hematology, Sylvester Comprehensive Cancer CenterUniversity of MiamiMiamiFloridaUSA
| | - Namrata Chandhok
- Division of Hematology, Sylvester Comprehensive Cancer CenterUniversity of MiamiMiamiFloridaUSA
| | - Amber Thomassen
- Division of Hematology, Sylvester Comprehensive Cancer CenterUniversity of MiamiMiamiFloridaUSA
| | - Ronan Swords
- Division of Hematology and Medical OncologyOregon Health Sciences UniversityPortlandOregonUSA
| | - Eric Padron
- Department of Malignant HematologyMoffitt Cancer CenterTampaFloridaUSA
| | - Jeff Lancet
- Department of Malignant HematologyMoffitt Cancer CenterTampaFloridaUSA
| | - Chetasi Talati
- Department of Malignant HematologyMoffitt Cancer CenterTampaFloridaUSA
| | - Justin Watts
- Division of Hematology, Sylvester Comprehensive Cancer CenterUniversity of MiamiMiamiFloridaUSA
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Gurayah AA, Peters VA, Jin W, Kalahasty K, Kwon D, Zhao W, Patel NV, Markoe AM, Correa ZM, Studenski MT, Harbour JW, Samuels SE. Predictors of Local Recurrence and Progression-Free Survival in Iodine-125 Brachytherapy-Treated Uveal Melanomas: A Modern Institutional Study. Ocul Oncol Pathol 2022; 8:175-180. [PMID: 37431398 PMCID: PMC10329746 DOI: 10.1159/000526771] [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: 05/17/2022] [Accepted: 08/13/2022] [Indexed: 11/03/2023] Open
Abstract
Introduction Iodine-125 brachytherapy is an effective eye-sparing treatment for uveal melanoma. Previous work has shown that uveal melanomas cluster into distinct molecular classes based on gene expression profiles - discriminating low-grade from high-grade tumors. Our objective was to identify clinical and molecular predictors of local recurrence (LR) and progression-free survival (PFS). Methods We constructed a retrospective database of uveal melanoma patients from the University of Miami's electronic medical records that were treated between January 8, 2012, and January 5, 2019, with either COMS-style or Eye Physics plaque. Data on tumor characteristics, pretreatment retinal complications, post-plaque treatments, LR, and PFS were collected. Univariate and multivariate Cox models for cumulative incidence of LR and PFS were conducted using SAS version 9.4. Results We identified 262 patients, with a median follow-up time of 33.5 months. Nineteen patients (7.3%) had LR, and 56 patients (21.4%) were classified as PFS. We found that ocular melanocytosis (hazard ratio = 5.55, p < 0.001) had the greatest impact on PFS. Genetic expression profile did not predict LR outcomes (hazard ratio = 0.51, p = 0.297). Conclusion These findings help physicians identify predictors for short-term brachytherapy outcomes, allowing better shared decision making with patients preoperatively when deciding between brachytherapy versus enucleation. Patients stratified to higher risk groups based on preoperative characteristics such as ocular melanocytosis should be monitored more closely. Future studies must validate these findings using a prospective cohort study.
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Affiliation(s)
- Aaron A. Gurayah
- University of Miami Miller School of Medicine, Miami, Florida, USA
| | | | - William Jin
- Department of Radiation Oncology, University of Miami, Miami, Florida, USA
- Sylvester Comprehensive Cancer Center, Miami, Florida, USA
| | | | - Deukwoo Kwon
- Department of Biostatistics and Bioinformatics Shared Resource and Department of Public Health Sciences, University of Miami/Sylvester Comprehensive Cancer Center, Miami, Florida, USA
| | - Wei Zhao
- Department of Biostatistics and Bioinformatics Shared Resource and Department of Public Health Sciences, University of Miami/Sylvester Comprehensive Cancer Center, Miami, Florida, USA
| | - Nirav V. Patel
- Department of Radiation Oncology, University of Miami, Miami, Florida, USA
- Sylvester Comprehensive Cancer Center, Miami, Florida, USA
| | - Arnold M. Markoe
- Department of Radiation Oncology, University of Miami, Miami, Florida, USA
- Sylvester Comprehensive Cancer Center, Miami, Florida, USA
| | - Zelia M. Correa
- Sylvester Comprehensive Cancer Center, Miami, Florida, USA
- Department of Ophthalmology, University of Miami Bascom Palmer Eye Institute, Miami, Florida, USA
| | - Matthew T. Studenski
- Department of Radiation Oncology, University of Miami, Miami, Florida, USA
- Sylvester Comprehensive Cancer Center, Miami, Florida, USA
| | - J. William Harbour
- Department of Ophthalmology, University of Texas Southwestern, Dallas, Texas, USA
- Simmons Comprehensive Cancer Center, University of Texas Southwestern, Dallas, Texas, USA
| | - Stuart E. Samuels
- Department of Radiation Oncology, University of Miami, Miami, Florida, USA
- Sylvester Comprehensive Cancer Center, Miami, Florida, USA
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Rich BJ, Kwon D, Soni YS, Bell JB, John D, Azzam G, Mellon EA, Yechieli R, Meshman J, Abramowitz MC, Marques J, Benjamin CG, Komotar RJ, Ivan M, Diwanji T. Survival and Yield of Surveillance Imaging in Long-Term Survivors of Brain Metastasis Treated with Stereotactic Radiosurgery. World Neurosurg 2022; 167:e738-e746. [PMID: 36028107 DOI: 10.1016/j.wneu.2022.08.079] [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: 08/03/2022] [Revised: 08/16/2022] [Accepted: 08/17/2022] [Indexed: 10/31/2022]
Abstract
OBJECTIVES The optimal frequency of surveillance brain magnetic resonance imaging (MRI) in long-term survivors with brain metastases after stereotactic radiosurgery (SRS) is unknown. Our aim was to identify the optimal frequency of surveillance imaging in long-term survivors with brain metastases after SRS. METHODS Eligible patients were identified from a cohort treated with SRS definitively or postoperatively at our institution from 2014 to 2019 with no central nervous system (CNS) failure within 12 months from SRS. Time to CNS disease failure diagnosis and cost per patient were estimated using theoretical MRI schedules of 2, 3, 4, and 6 months starting 1 year after SRS until CNS failure. Time to diagnosis was calculated from the date of CNS progression to the theoretical imaging date on each schedule. RESULTS This cohort included 55 patients (median follow-up from SRS: 2.48 years). During the study period, 20.0% had CNS disease failure (median: 2.26 years from SRS treatment). In this cohort, a theoretical 2-month, 3-month, 4-month, and 6-month MRI brain surveillance schedule produced a respective estimated time to diagnosis of CNS disease failure of 1.11, 1.74, 1.65, and 3.65 months. The cost of expedited diagnosis for the cohort (dollars/month) for each theoretical imaging schedule compared with a 6-month surveillance schedule was $6600 for a 2-month protocol, $4496 for a 3-month protocol, and $2180 for a 4-month protocol. CONCLUSIONS Based on cost-benefit, a 4-month MRI brain schedule should be considered in patients with metastatic disease to the brain treated definitively or postoperatively with SRS without evidence of CNS recurrence at 1 year.
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Affiliation(s)
- Benjamin J Rich
- Department of Radiation Oncology, Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, Florida, USA.
| | - Deukwoo Kwon
- Department of Public Health Sciences, Biostatistics and Bioinformatics Shared Resource, Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Yash S Soni
- University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Jonathan B Bell
- Department of Radiation Oncology, Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Danny John
- University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Gregory Azzam
- Department of Radiation Oncology, Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Eric A Mellon
- Department of Radiation Oncology, Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Raphael Yechieli
- Department of Radiation Oncology, Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Jessica Meshman
- Department of Radiation Oncology, Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Matthew C Abramowitz
- Department of Radiation Oncology, Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Joao Marques
- University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Carolina G Benjamin
- Department of Neurosurgery, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Ricardo J Komotar
- Department of Neurosurgery, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Michael Ivan
- Department of Neurosurgery, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Tejan Diwanji
- Department of Radiation Oncology, Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, Florida, USA
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Peters V, Gurayah A, Jin W, Kwon D, Zhao W, Patel NV, Markoe A, Correa Z, Studenski MT, Harbour JW, Samuels SE. Clinical characteristics and postoperative complications as predictors of radiation toxicity after treatment with I125 Eye Plaque Brachytherapy for Uveal Melanomas. Brachytherapy 2022; 21:896-903. [PMID: 36137939 DOI: 10.1016/j.brachy.2022.08.006] [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: 05/13/2022] [Revised: 07/13/2022] [Accepted: 08/10/2022] [Indexed: 12/14/2022]
Abstract
PURPOSE I125 Eye Plaque brachytherapy is the standard treatment for medium-sized uveal melanomas (UM). Patients develop radiation toxicities (RTT), including radiation maculopathy (RM), radiation neovascular glaucoma/iris neovascularization (RNGI) and radiation optic neuropathy (RON). We aim to investigate demographics, pretreatment tumor characteristics and posttreatment complications as predictors of RTT. METHODS AND MATERIALS An IRB-approved single-institution retrospective chart review was performed from 2011 to 2019 for patients with posterior UM treated with brachytherapy. We collected demographics, pretreatment tumor characteristics and posttreatment complications. Univariate analysis (UVA) and multivariate analysis (MVA) were performed using logistic regression model. Hazard ratios (HR) and corresponding p-values were reported. All tests were two-sided; statistical significance was considered when p<0.05. RESULTS Two hundred and fifty eight patients were evaluated. Median follow-up was 33.50 months (range 3.02-97.31). 178 patients (69.0%) had RTT. 131 patients (50.8%) developed RM. Fifty-six patients (21.7%) developed RON. Nineteen patients (7.4%) developed RNGI. UVA found shorter distance to fovea (DF) (p = 0.04), posttreatment exudative retinal detachment (PERD) (p = 0.001) and posttreatment vitreous hemorrhage (PVH) (p = 0.001) are associated with RTT. MVA found shorter DF (HR=1.03, p = 0.04), PERD (HR=2.52, p = 0.01) and PVH (HR=3.34, p = 0.006) are associated with RTT. MVA found female sex (HR=1.731, p = 0.031) and tumor height (HR=1.13, p = 0.013) are associated with RM and pretreatment retinal detachment (HR=3.41, p<0.001) is associated with RON. CONCLUSIONS Shorter DF, PERD and PVH are associated with RTT; female sex and tumor height are associated with RM and tumor height is associated with RON. These findings serve as prognostic tools to counsel patients and promote early intervention in management of RTT.
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Affiliation(s)
- Vanessa Peters
- University of Miami Miller School of Medicine, Miami, FL
| | - Aaron Gurayah
- University of Miami Miller School of Medicine, Miami, FL
| | - William Jin
- Department of Radiation Oncology, University of Miami, Miami, FL; Sylvester Comprehensive Cancer Center, Miami, FL
| | - Deukwoo Kwon
- Department of Biostatistics and Bioinformatics Shared Resource and Department of Public Health Sciences, University of Miami/Sylvester Comprehensive Cancer Center, Miami, FL
| | - Wei Zhao
- Department of Biostatistics and Bioinformatics Shared Resource and Department of Public Health Sciences, University of Miami/Sylvester Comprehensive Cancer Center, Miami, FL
| | - Nirav V Patel
- Department of Radiation Oncology, University of Miami, Miami, FL; Sylvester Comprehensive Cancer Center, Miami, FL
| | - Arnold Markoe
- Department of Radiation Oncology, University of Miami, Miami, FL; Sylvester Comprehensive Cancer Center, Miami, FL
| | - Zelia Correa
- Sylvester Comprehensive Cancer Center, Miami, FL; Department of Ophthalmology, University of Miami Bascom Palmer Eye Institute, Miami, FL
| | - Matthew T Studenski
- Department of Radiation Oncology, University of Miami, Miami, FL; Sylvester Comprehensive Cancer Center, Miami, FL
| | - J William Harbour
- Sylvester Comprehensive Cancer Center, Miami, FL; Department of Ophthalmology, University of Miami Bascom Palmer Eye Institute, Miami, FL
| | - Stuart E Samuels
- Department of Radiation Oncology, University of Miami, Miami, FL; Sylvester Comprehensive Cancer Center, Miami, FL.
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Kuker RA, Lehmkuhl D, Kwon D, Zhao W, Lossos IS, Moskowitz CH, Alderuccio JP, Yang F. A Deep Learning-Aided Automated Method for Calculating Metabolic Tumor Volume in Diffuse Large B-Cell Lymphoma. Cancers (Basel) 2022; 14:5221. [PMID: 36358642 PMCID: PMC9653575 DOI: 10.3390/cancers14215221] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [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: 08/23/2022] [Revised: 10/18/2022] [Accepted: 10/20/2022] [Indexed: 08/20/2023] Open
Abstract
Metabolic tumor volume (MTV) is a robust prognostic biomarker in diffuse large B-cell lymphoma (DLBCL). The available semiautomatic software for calculating MTV requires manual input limiting its routine application in clinical research. Our objective was to develop a fully automated method (AM) for calculating MTV and to validate the method by comparing its results with those from two nuclear medicine (NM) readers. The automated method designed for this study employed a deep convolutional neural network to segment normal physiologic structures from the computed tomography (CT) scans that demonstrate intense avidity on positron emission tomography (PET) scans. The study cohort consisted of 100 patients with newly diagnosed DLBCL who were randomly selected from the Alliance/CALGB 50,303 (NCT00118209) trial. We observed high concordance in MTV calculations between the AM and readers with Pearson's correlation coefficients and interclass correlations comparing reader 1 to AM of 0.9814 (p < 0.0001) and 0.98 (p < 0.001; 95%CI = 0.96 to 0.99), respectively; and comparing reader 2 to AM of 0.9818 (p < 0.0001) and 0.98 (p < 0.0001; 95%CI = 0.96 to 0.99), respectively. The Bland-Altman plots showed only relatively small systematic errors between the proposed method and readers for both MTV and maximum standardized uptake value (SUVmax). This approach may possess the potential to integrate PET-based biomarkers in clinical trials.
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Affiliation(s)
- Russ A. Kuker
- Department of Radiology, Division of Nuclear Medicine, University of Miami Miller School of Medicine, Miami, FL 33136, USA
| | - David Lehmkuhl
- Department of Radiology, Division of Nuclear Medicine, University of Miami Miller School of Medicine, Miami, FL 33136, USA
| | - Deukwoo Kwon
- Department of Public Health Sciences, University of Miami Miller School of Medicine, Miami, FL 33136, USA
| | - Weizhao Zhao
- Department of Biomedical Engineering, University of Miami, Coral Gables, FL 33146, USA
| | - Izidore S. Lossos
- Sylvester Comprehensive Cancer Center, Department of Medicine, Division of Hematology, University of Miami Miller School of Medicine, Miami, FL 33136, USA
| | - Craig H. Moskowitz
- Sylvester Comprehensive Cancer Center, Department of Medicine, Division of Hematology, University of Miami Miller School of Medicine, Miami, FL 33136, USA
| | - Juan Pablo Alderuccio
- Sylvester Comprehensive Cancer Center, Department of Medicine, Division of Hematology, University of Miami Miller School of Medicine, Miami, FL 33136, USA
| | - Fei Yang
- Sylvester Comprehensive Cancer Center, Department of Radiation Oncology, University of Miami Miller School of Medicine, Miami, FL 33136, USA
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Roy M, Finch L, Kwon D, Jordan SE, Yadegarynia S, Wolfson AH, Slomovitz B, Portelance L, Huang M. Factors contributing to delays in initiation of front-line cervical cancer therapy: disparities in a diverse south Florida population. Int J Gynecol Cancer 2022; 32:1387-1394. [PMID: 36198435 PMCID: PMC9664089 DOI: 10.1136/ijgc-2022-003475] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
Objective Delay in initiating cervical cancer treatment may impact outcomes. In a cohort of patients initially treated by surgery, chemoradiation, chemotherapy, or in a clinical trial, we aim to define factors contributing to prolonged time to treatment initiation. Methods Data from patients initiating treatment for cervical cancer at a single institution was abstracted. Time to treatment initiation was defined as the interval from the date of cancer diagnosis to the date of treatment initiation. Poisson regression model was used for analysis. Results Of 274 patients studied, the median time to treatment initiation was 60 days (range 0–551). The median times to initiate surgery (54 days, range 3–96) and chemoradiation (58 days, range 4–187) were not significantly different (relative risk (RR) 1.01, 95% CI 0.98 to 1.04, p=0.54). The shortest median initiation time was for chemotherapy (47 days; RR 1.13, 95% CI 1.08 to 1.19, p<0.0001) and the longest was for clinical trial (62 days; RR 1.18, 95% CI 1.12 to 1.24, p<0.0001). Charity care (RR 1.09, 95% CI 1.05 to 1.14, p<0.0001), Medicare or Medicaid (RR 1.10, 95% CI 1.06 to 1.14, p<0.0001), and self-pay (RR 1.38, 95% CI 1.32 to 1.45, p<0.0001) delayed treatment initiation more than private insurance. Hispanic White women (RR 0.69, 95% CI 0.66 to 0.73, p<0.0001) had a shorter treatment initiation time compared with non-Hispanic White patients, while Afro-Caribbean/Afro-Latina women (RR 0.86, 95% CI 0.81 to 0.90, p<0.0001) and African-American patients (RR 1.13, 95% CI 1.07 to 1.19, p<0.0001) had longer initiation times. Spanish speaking patients did not have a prolonged treatment initiation (RR 0.68, 95% CI 0.66 to 0.71, p<0.0001), though Haitian-Creole speaking patients did (RR 1.07, 95% CI 1.01 to 1.13, p<0.002). Diagnosis at an outside institution delayed treatment initiation time (RR 1.24, 95% CI 1.18 to 1.30, p<0.0001) compared with diagnosis at the cancer center. Conclusion Factors associated with prolonged time to treatment initiation include treatment modality, insurance status, language spoken, and institution of diagnosis. By closely examining each of these factors, barriers to treatment can be identified and modified to shorten treatment initiation time.
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Affiliation(s)
- Molly Roy
- Gynecologic Oncology, University of Miami Miller School of Medicine/Jackon Memorial Hospital, Miami, Florida, USA
| | - Lindsey Finch
- Obstetrics and Gynecology, Jackson Memorial Hospital, Miami, Florida, USA
| | - Deukwoo Kwon
- Department of Public Health Sciences, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Scott E Jordan
- Gynecologic Oncology, University of Miami Miller School of Medicine/Jackon Memorial Hospital, Miami, Florida, USA
| | - Sina Yadegarynia
- University of Miami Miller School of Medicine, Miami, Florida, USA
| | | | - Brian Slomovitz
- Gynecologic Oncology, Mount Sinai Medical Center, Miami Beach, Florida, USA
| | | | - Marilyn Huang
- Gynecologic Oncology, Mount Sinai Medical Center, Miami Beach, Florida, USA
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Anderson J, Handa S, Petrone G, Chowdhury N, Kwon D, Bhardwaj AS, Jain P, Smith CB, Berger NS. Palliative care utilization and mortality in patients who received inpatient chemotherapy. J Clin Oncol 2022. [DOI: 10.1200/jco.2022.40.28_suppl.198] [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
198 Background: Early integration of palliative care (PC) into advanced cancer care has been shown to improve quality of life and prognostic understanding. However, there is a paucity of data on utilization of inpatient PC consultation and survival outcomes in patients (pts) receiving inpatient chemotherapy (IC). Methods: A retrospective review was performed at a single academic center of pts receiving IC between Jan 2016 and Dec 2017. We evaluated utilization of PC services, reasons for consult, code status, disposition, and 60-day mortality. Descriptive statistics and odds ratios (OR) were estimated from logistic regression models with mixed-effect, taking into account correlations from multiple admissions per patient. Cumulative incidence plot and Cox proportional hazard regression models were used to assess the association between mortality and study covariates. Results: Of 880 admissions, 733 (83%) were hematologic malignancies (HM) and 147 (17%) were solid tumors (ST). PC consults were more likely in ST than HM (OR 3.19, 95% CI 1.85 - 5.50) and for KPS ≤50% (OR 22.20, 95% CI 11.51- 42.79). Of 159 PC consults, 91 (57%) were for pain and 25 (16%) for goals of care. 66 pts (10%) who received IC died within 60 days of admission, 44 (67%) HM and 22 (33%) ST (p = 0.002). In pts who died within 60 days, 63% had PC consult. Median time from admission to PC consult was 2 days for ST and 9 for HM. Of those with PC consult, 40% had a change from full code to DNR/DNI and were more likely to have a health care proxy (HCP) assigned (OR 7.31, p = 0.001). PC consults were also associated with significantly higher odds of discharge to hospice (OR 10.52, 95% CI: 4.3-25.6; p = < 0.0001; Table). Mortality risk was higher in those admitted for symptoms/complications related to their disease or with progression (HR 3.24, 95% CI (2.50-4.19), p < 0.001) and in those with advanced stage disease: Stage 3 (p = 0.033); Stage 4 (p = 0.0003). Of the pts who died within 60 days, 33 (50%) died during the admission and 24 (36%) in hospice. Conclusions: Significant 60-day mortality after receiving IC is consistent with aggressive end-of- life care. Pts with ST and those with poor performance status more frequently utilized inpatient PC services; however, there is opportunity to increase utilization amongst pts with HM and introduce PC earlier in the inpatient clinical course. PC consultations improve advanced care planning with appropriate transitions in code status, HCP assignments and discharge to hospice.[Table: see text]
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Affiliation(s)
| | - Shivani Handa
- Icahn School of Medicine at Mount Sinai, Division of Hematology and Medical Oncology, New York, NY
| | - Giulia Petrone
- Icahn School of Medicine/Mount Sinai Morningside-West Hospital, New York, NY
| | - Nobel Chowdhury
- Icahn School of Medicine/Mount Sinai Morningside-West Hospital, New York, NY
| | - Deukwoo Kwon
- Icahn School of Medicine at Mount Sinai, New York, NY
| | - Aarti Sonia Bhardwaj
- Icahn School of Medicine at Mount Sinai, Division of Hematology and Medical Oncology, New York, NY
| | - Priya Jain
- Icahn School of Medicine at Mount Sinai, Division of Hematology and Medical Oncology, New York, NY
| | - Cardinale B. Smith
- Icahn School of Medicine at Mount Sinai, Division of Hematology and Medical Oncology, New York, NY
| | - Natalie S Berger
- Icahn School of Medicine at Mount Sinai, Division of Hematology and Medical Oncology, New York, NY
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Bhardwaj AS, Jain P, Hernandez DP, Handa S, Petrone G, Anderson J, Chowdhury N, Yum K, Kwon D, Mato J, Berger NS, Smith CB. Novel use of an objective scoring rubric to guide inpatient chemotherapy stewardship. J Clin Oncol 2022. [DOI: 10.1200/jco.2022.40.28_suppl.020] [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
20 Background: The cost of cancer care is an enormous healthcare burden. Most inpatient chemotherapy is not reimbursed because of diagnosis-related group codes. We have previously reported inpatient chemotherapy and immunotherapy (IC) is associated with poorer outcomes for patients with advanced stage solid tumor (ST) vs hematologic malignancy (HM) patients. 1 We piloted the use of a novel objective scoring rubric to guide and automate IC stewardship at an academic cancer center to decrease the inappropriate use of inpatient administration of costly therapies in patients especially at the end of life. Methods: Using an iterative process, an interdisciplinary group of physicians, nurses and pharmacists developed objective criteria of patient, cancer and treatment factors to guide chemotherapy stewardship. IC that is on formulary and being given as standard of care (i.e., induction of leukemia) are automatically approved. IC that is non-formulary requires evaluation using the developed criteria. Treatment factors include information on the level of existing evidence to support use: type and phase of trial, FDA and NCCN approvals. Patient factors include: performance status, line and goal of therapy. The scoring rubric positively weights regimens with strong levels of evidence or positive patient factors and negatively weights regimens with poor levels of evidence and adverse patient factors. Clinicians must complete the criteria via a form in RedCap. Upon completion, a score is automatically calculated by the tool and 2 disease specific physicians and a clinical pharmacist review for accuracy. If the threshold score is met, IC is approved for inpatient administration and if it is not met, IC is not approved for administration. Results: From January 2022 until May 2022 there have been 30 cases reviewed. 50% were ST requests and 50% were for HM requests. 20 cases (67%) were approved and 8 cases (26%) were not. Two cases were retracted by the requestor. This resulted in cost savings of $63,920. Table illustrates clinical outcomes and characteristics of the approved cases. Conclusions: This pilot illustrates that 67% of the time our cancer physicians chose the administration of inpatient chemotherapy that aligned with objective criteria which is reassuring and serves to validate the use of this tool. Alternatively, this objective rubric prevented inappropriate administration of chemotherapy 26% of the time. Our pilot indicates that there is a role for an objective tool for automated inpatient chemotherapy stewardship. Reference: Evaluation of inpatient chemotherapy among patients with cancer. Petrone G et al. JCO.2022.40.16_suppl.6566.[Table: see text]
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Affiliation(s)
- Aarti Sonia Bhardwaj
- Icahn School of Medicine at Mount Sinai, Division of Hematology and Medical Oncology, New York, NY
| | - Priya Jain
- Icahn School of Medicine at Mount Sinai, Division of Hematology and Medical Oncology, New York, NY
| | | | - Shivani Handa
- Icahn School of Medicine at Mount Sinai, Division of Hematology and Medical Oncology, New York, NY
| | - Giulia Petrone
- Icahn School of Medicine/Mount Sinai Morningside-West Hospital, New York, NY
| | | | - Nobel Chowdhury
- Icahn School of Medicine/Mount Sinai Morningside-West Hospital, New York, NY
| | - Kendra Yum
- Mount Sinai Hospital, Department of Pharmacy, New York, NY
| | - Deukwoo Kwon
- Icahn School of Medicine at Mount Sinai, New York, NY
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de Castro Silva I, Bianchi A, Deshpande NU, Sharma P, Mehra S, Garrido VT, Saigh SJ, England J, Hosein PJ, Kwon D, Merchant NB, Datta J. Neutrophil-mediated fibroblast-tumor cell IL-6/STAT-3 signaling underlies the association between neutrophil-to-lymphocyte ratio dynamics and chemotherapy response in localized pancreatic cancer: a hybrid clinical-preclinical study. eLife 2022; 11:78921. [PMID: 36107485 PMCID: PMC9512403 DOI: 10.7554/elife.78921] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [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: 03/24/2022] [Accepted: 09/13/2022] [Indexed: 11/13/2022] Open
Abstract
Background: Partial/complete pathologic response following neoadjuvant chemotherapy (NAC) in pancreatic cancer (PDAC) patients undergoing pancreatectomy is associated with improved survival. We sought to determine whether neutrophil-to-lymphocyte ratio (NLR) dynamics predict pathologic response following chemotherapy in PDAC, and if manipulating NLR impacts chemosensitivity in preclinical models and uncovers potential mechanistic underpinnings underlying these effects. Methods: Pathologic response in PDAC patients (n=94) undergoing NAC and pancreatectomy (7/2015-12/2019) was dichotomized as partial/complete or poor/absent. Bootstrap-validated multivariable models assessed associations between pre-chemotherapy NLR (%neutrophils÷%lymphocytes) or NLR dynamics during chemotherapy (ΔNLR = pre-surgery—pre-chemotherapy NLR) and pathologic response, disease-free survival (DFS), and overall survival (OS). To preclinically model effects of NLR attenuation on chemosensitivity, Ptf1aCre/+; KrasLSL-G12D/+;Tgfbr2flox/flox (PKT) mice and C57BL/6 mice orthotopically injected with KrasLSL-G12D/+;Trp53LSL-R172H/+;Pdx1Cre(KPC) cells were randomized to vehicle, gemcitabine/paclitaxel alone, and NLR-attenuating anti-Ly6G with/without gemcitabine/paclitaxel treatment. Results: In 94 PDAC patients undergoing NAC (median:4 months), pre-chemotherapy NLR (p<0.001) and ΔNLR attenuation during NAC (p=0.002) were independently associated with partial/complete pathologic response. An NLR score = pre-chemotherapy NLR+ΔNLR correlated with DFS (p=0.006) and OS (p=0.002). Upon preclinical modeling, combining NLR-attenuating anti-Ly6G treatment with gemcitabine/paclitaxel—compared with gemcitabine/paclitaxel or anti-Ly6G alone—not only significantly reduced tumor burden and metastatic outgrowth, but also augmented tumor-infiltrating CD107a+-degranulating CD8+ T-cells (p<0.01) while dampening inflammatory cancer-associated fibroblast (CAF) polarization (p=0.006) and chemoresistant IL-6/STAT-3 signaling in vivo. Neutrophil-derived IL-1β emerged as a novel mediator of stromal inflammation, inducing inflammatory CAF polarization and CAF-tumor cell IL-6/STAT-3 signaling in ex vivo co-cultures. Conclusions: Therapeutic strategies to mitigate neutrophil-CAF-tumor cell IL-1β/IL-6/STAT-3 signaling during NAC may improve pathologic responses and/or survival in PDAC. Funding: Supported by KL2 career development grant by Miami CTSI under NIH Award UL1TR002736, Stanley Glaser Foundation, American College of Surgeons Franklin Martin Career Development Award, and Association for Academic Surgery Joel J. Roslyn Faculty Award (to J. Datta); NIH R01 CA161976 (to N.B. Merchant); and NCI/NIH Award P30CA240139 (to J. Datta and N.B. Merchant).
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Affiliation(s)
| | | | | | - Prateek Sharma
- Department of Surgery, University of Nebraska Medical Center
| | | | | | | | | | | | - Deukwoo Kwon
- Department of Public Health Sciences, The University of Texas Health Science Center at Houston
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Algohary A, Alhusseini M, Breto AL, Kwon D, Xu IR, Gaston SM, Castillo P, Punnen S, Spieler B, Abramowitz MC, Dal Pra A, Kryvenko ON, Pollack A, Stoyanova R. Longitudinal Changes and Predictive Value of Multiparametric MRI Features for Prostate Cancer Patients Treated with MRI-Guided Lattice Extreme Ablative Dose (LEAD) Boost Radiotherapy. Cancers (Basel) 2022; 14:cancers14184475. [PMID: 36139635 PMCID: PMC9496901 DOI: 10.3390/cancers14184475] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2022] [Revised: 09/01/2022] [Accepted: 09/10/2022] [Indexed: 11/16/2022] Open
Abstract
We investigated the longitudinal changes in multiparametric MRI (mpMRI) (T2-weighted, Apparent Diffusion Coefficient (ADC), and Dynamic Contrast Enhanced (DCE-)MRI) of prostate cancer patients receiving Lattice Extreme Ablative Dose (LEAD) radiotherapy (RT) and the capability of their imaging features to predict RT outcome based on endpoint biopsies. Ninety-five mpMRI exams from 25 patients, acquired pre-RT and at 3-, 9-, and 24-months post-RT were analyzed. MRI/Ultrasound-fused biopsies were acquired pre- and at two-years post-RT (endpoint). Five regions of interest (ROIs) were analyzed: Gross tumor volume (GTV), normally-appearing tissue (NAT) and peritumoral volume in both peripheral (PZ) and transition (TZ) zones. Diffusion and perfusion radiomics features were extracted from mpMRI and compared before and after RT using two-tailed Student t-tests. Selected features at the four scan points and their differences (Δ radiomics) were used in multivariate logistic regression models to predict the endpoint biopsy positivity. Baseline ADC values were significantly different between GTV, NAT-PZ, and NAT-TZ (p-values < 0.005). Pharmaco-kinetic features changed significantly in the GTV at 3-month post-RT compared to baseline. Several radiomics features at baseline and three-months post-RT were significantly associated with endpoint biopsy positivity and were used to build models with high predictive power of this endpoint (AUC = 0.98 and 0.89, respectively). Our study characterized the RT-induced changes in perfusion and diffusion. Quantitative imaging features from mpMRI show promise as being predictive of endpoint biopsy positivity.
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Affiliation(s)
- Ahmad Algohary
- Department of Radiation Oncology, University of Miami Miller School of Medicine, Miami, FL 33136, USA
| | - Mohammad Alhusseini
- Department of Radiation Oncology, University of Miami Miller School of Medicine, Miami, FL 33136, USA
| | - Adrian L. Breto
- Department of Radiation Oncology, University of Miami Miller School of Medicine, Miami, FL 33136, USA
| | - Deukwoo Kwon
- Biostatistics and Bioinformatics Shared Resource, Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, FL 33136, USA
- Department of Public Health Sciences, University of Miami Miller School of Medicine, Miami, FL 33136, USA
- Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, FL 33136, USA
| | - Isaac R. Xu
- Department of Radiation Oncology, University of Miami Miller School of Medicine, Miami, FL 33136, USA
| | - Sandra M. Gaston
- Department of Radiation Oncology, University of Miami Miller School of Medicine, Miami, FL 33136, USA
- Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, FL 33136, USA
| | - Patricia Castillo
- Department of Radiology, University of Miami Miller School of Medicine, Miami, FL 33136, USA
| | - Sanoj Punnen
- Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, FL 33136, USA
- Desai Sethi Urology Institute, University of Miami Miller School of Medicine, Miami, FL 33136, USA
| | - Benjamin Spieler
- Department of Radiation Oncology, University of Miami Miller School of Medicine, Miami, FL 33136, USA
- Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, FL 33136, USA
| | - Matthew C. Abramowitz
- Department of Radiation Oncology, University of Miami Miller School of Medicine, Miami, FL 33136, USA
- Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, FL 33136, USA
| | - Alan Dal Pra
- Department of Radiation Oncology, University of Miami Miller School of Medicine, Miami, FL 33136, USA
- Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, FL 33136, USA
| | - Oleksandr N. Kryvenko
- Department of Radiation Oncology, University of Miami Miller School of Medicine, Miami, FL 33136, USA
- Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, FL 33136, USA
- Desai Sethi Urology Institute, University of Miami Miller School of Medicine, Miami, FL 33136, USA
- Department of Pathology and Laboratory Medicine, University of Miami Miller School of Medicine, Miami, FL 33136, USA
| | - Alan Pollack
- Department of Radiation Oncology, University of Miami Miller School of Medicine, Miami, FL 33136, USA
- Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, FL 33136, USA
| | - Radka Stoyanova
- Department of Radiation Oncology, University of Miami Miller School of Medicine, Miami, FL 33136, USA
- Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, FL 33136, USA
- Correspondence: ; Tel.: +1-305-243-5856
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Graf GH, Li X, Kwon D, Belsky DW, Widom CS. Biological aging in maltreated children followed up into middle adulthood. Psychoneuroendocrinology 2022; 143:105848. [PMID: 35779342 DOI: 10.1016/j.psyneuen.2022.105848] [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] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Revised: 06/20/2022] [Accepted: 06/20/2022] [Indexed: 11/18/2022]
Abstract
BACKGROUND Childhood adversity has been linked to many indicators of shorter healthy lifespan, including earlier onset of disease and disability as well as early mortality. These observations suggest the hypothesis that childhood maltreatment may accelerate aging. OBJECTIVE To characterize the relationship between childhood maltreatment and accelerated biological aging in a prospective cohort of 357 individuals with documented cases of childhood maltreatment and 250 controls matched on demographic and socioeconomic factors. METHODS Cases were drawn from juvenile and adult court records from the years 1967 through 1971 in a large Midwest metropolitan geographic area. Cases were defined as having court-substantiated cases of childhood physical or sexual abuse, or neglect occurring at age 11 or younger. Controls were selected from the same schools and hospitals of birth and matched on age, sex, race, and approximate socioeconomic status. We compared biological aging in these two groups using two blood-chemistry algorithms, the Klemera-Doubal method Biological Age (KDM BA) and the PhenoAge. Algorithms were developed and validated in data from the National Health and Nutrition Examination Surveys (NHANES) using published methods and publicly available software. RESULTS Participants (55% women, 49% non-White) had mean age of 41 years (SD=4). Those with court substantiated childhood maltreatment history exhibited more advanced biological aging as compared with matched controls, although this difference was statistically different for only the KDM BA measure (KDM BA Cohen's D=0.20, 95% CI=[0.03,0.36], p = 0.02; PhenoAge Cohen's D=0.09 95% CI=[-0.08,0.25], p = 0.296). In subgroup analyses, maltreatment effect sizes were larger for women as compared to men and for White participants as compared to non-White participants, although these differences were not statistically significant at the α= 0.05 level. CONCLUSIONS AND RELEVANCE As of midlife, effects of childhood maltreatment on biological aging are small in magnitude but discernible. Interventions to treat psychological and behavioral sequelae of exposure to childhood maltreatment, including in midlife adults, have potential to protect survivors from excess burden of disease, disability, and mortality in later life.
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Affiliation(s)
- G H Graf
- Department of Epidemiology, Columbia University Mailman School of Public Health, New York, NY 10032, USA; Robert N Butler Columbia Aging Center, Columbia University Mailman School of Public Health, New York, NY 10032, USA.
| | - X Li
- Psychology Department, John Jay College, City University of New York, New York, USA; Graduate Center, City University of New York, New York, USA
| | - D Kwon
- Department of Epidemiology, Columbia University Mailman School of Public Health, New York, NY 10032, USA; Robert N Butler Columbia Aging Center, Columbia University Mailman School of Public Health, New York, NY 10032, USA
| | - D W Belsky
- Department of Epidemiology, Columbia University Mailman School of Public Health, New York, NY 10032, USA; Robert N Butler Columbia Aging Center, Columbia University Mailman School of Public Health, New York, NY 10032, USA.
| | - C S Widom
- Psychology Department, John Jay College, City University of New York, New York, USA; Graduate Center, City University of New York, New York, USA.
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Deshmukh P, De Kouchkovsky I, Zhang L, Jindal T, Reyes K, Hernandez Romero E, Chan E, Desai A, Borno H, Kwon D, Wong A, Bose R, Aggarwal R, Porten S, Fong L, Small E, Chou J, Friedlander T, Koshkin V. 1751P Impact of squamous histology on clinical outcomes and molecular profiling in metastatic urothelial carcinoma (mUC) patients (pts) treated with newer therapies. Ann Oncol 2022. [DOI: 10.1016/j.annonc.2022.07.1829] [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: 11/30/2022] Open
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Jindal T, Han H, Deshmukh P, De Kouchkovsky I, Kwon D, Borno H, Koshkin V, Desai A, Bose R, Chou J, Friedlander T, Small E, Angelidakis A, Johnson M, Feng S, Patnaik A, Fong L, Alumkal J, Aggarwal R. 1404P A phase II study of ZEN-3694 (ZEN), enzalutamide (ENZ), and pembrolizumab (P) in metastatic castration resistant prostate cancer (mCRPC): Interim safety results. Ann Oncol 2022. [DOI: 10.1016/j.annonc.2022.07.1890] [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: 11/01/2022] Open
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Aggarwal R, Trihy L, Hernandez Romero E, Luch Sam S, Rastogi M, De Kouchkovsky I, Small E, Feng F, Kwon D, Friedlander T, Borno H, Bose R, Chou J, Koshkin V, Desai A, Feng S, Angelidakis A, Johnson M, Fong L, Hope T. 1379P A phase Ib study of a single priming dose of 177Lu-PSMA-617 coupled with pembrolizumab in metastatic castration resistant prostate cancer (mCRPC). Ann Oncol 2022. [DOI: 10.1016/j.annonc.2022.07.1511] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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Siemon J, George S, Kwon D, Miao F, Tabuyo-Martin A, Roy M, Samuel D, Huang M, Pearson J, Sinno A, Schlumbrecht M. Determinants of treatment and survival in sex cord stromal tumors of the ovary (294). Gynecol Oncol 2022. [DOI: 10.1016/s0090-8258(22)01515-3] [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: 11/04/2022]
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Anderson J, Handa S, Petrone G, Chowdhury N, Kwon D, Bhardwaj AS, Jain P, Smith CB, Berger NS. Palliative care utilization and mortality in patients who received inpatient chemotherapy. J Clin Oncol 2022. [DOI: 10.1200/jco.2022.40.16_suppl.e24074] [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
e24074 Background: Early integration of palliative care (PC) into advanced cancer care has been shown to improve quality of life and prognostic understanding. However, there is a paucity of data on utilization of inpatient PC consultation and survival outcomes in patients (pts) receiving inpatient chemotherapy (IC). Methods: A retrospective review was performed at a single academic center of pts receiving IC between Jan 2016 and Dec 2017. We evaluated utilization of PC services, reasons for consult, code status, disposition, and 60-day mortality. Descriptive statistics and odds ratios (OR) were estimated from logistic regression models with mixed-effect, taking into account correlations from multiple admissions per patient. Cumulative incidence plot and Cox proportional hazard regression models were used to assess the association between mortality and study covariates. Results: Of 880 admissions, 733 (83%) were hematologic malignancies (HM) and 147 (17%) were solid tumors (ST). PC consults were more likely in ST than HM (OR 3.19, 95% CI 1.85 - 5.50) and for KPS ≤50% (OR 22.20, 95% CI 11.51- 42.79). Of 159 PC consults, 91 (57%) were for pain and 25 (16%) for goals of care. 66 pts (10%) who received IC died within 60 days of admission, 44 (67%) HM and 22 (33%) ST (p = 0.002). In pts who died within 60 days, 63% had PC consult. Median time from admission to PC consult was 2 days for ST and 9 for HM. Of those with PC consult, 40% had a change from full code to DNR/DNI and were more likely to have a health care proxy (HCP) assigned (OR 7.31, p = 0.001). PC consults were also associated with significantly higher odds of discharge to hospice (OR 10.52, 95% CI: 4.3-25.6; p = < 0.0001; Table). Mortality risk was higher in those admitted for symptoms/complications related to their disease or with progression (HR 3.24, 95% CI (2.50-4.19), p < 0.001) and in those with advanced stage disease: Stage 3 (p = 0.033); Stage 4 (p = 0.0003). Of the pts who died within 60 days, 33 (50%) died during the admission and 24 (36%) in hospice. Conclusions: Significant 60-day mortality after receiving IC is consistent with aggressive end-of-life care. Pts with ST and those with poor performance status more frequently utilized inpatient PC services; however, there is opportunity to increase utilization amongst pts with HM and introduce PC earlier in the inpatient clinical course. PC consultations improve advanced care planning with appropriate transitions in code status, HCP assignments, and discharge to hospice.[Table: see text]
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Affiliation(s)
| | - Shivani Handa
- Icahn School of Medicine at Mount Sinai, Division of Hematology and Medical Oncology, New York, NY
| | - Giulia Petrone
- Icahn School of Medicine/Mount Sinai Morningside-West Hospital, New York, NY
| | - Nobel Chowdhury
- Icahn School of Medicine/Mount Sinai Morningside-West Hospital, New York, NY
| | - Deukwoo Kwon
- Icahn School of Medicine at Mount Sinai, New York, NY
| | - Aarti Sonia Bhardwaj
- Icahn School of Medicine at Mount Sinai, Division of Hematology and Medical Oncology, New York, NY
| | - Priya Jain
- Icahn School of Medicine at Mount Sinai, Division of Hematology and Medical Oncology, New York, NY
| | | | - Natalie S Berger
- Icahn School of Medicine at Mount Sinai, Division of Hematology and Medical Oncology, New York, NY
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Frydman JL, Gelfman LP, Morillo J, Allen OS, Bickell NA, Kwon D, Pollak KI, Smith CB. Racial/ethnic disparities in serious illness communication for patients with cancer. J Clin Oncol 2022. [DOI: 10.1200/jco.2022.40.16_suppl.6540] [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
6540 Background: Racial/ethnic disparities in serious illness communication exist between patients with cancer and their oncologists. Our prior work has shown that goals of care discussions are three minutes shorter with racial/ethnic minority patients. In this study, we sought to compare oncologist's use of serious illness communication skills, patient participatory behavior, and overall communication quality during encounters with patients with advanced cancer of different self-reported races/ethnicities. Methods: We analyzed baseline recordings from a two-arm multisite randomized controlled trial to test a coaching model of communication skills training for solid tumor oncologists and their newly diagnosed advanced cancer patients. We audio recorded post-imaging patient-oncologist encounters for patients receiving systemic cancer treatment and coded transcripts for oncologist's use of serious illness communication skills (coded as count/encounter): open-ended questions, reflections, empathic responses to patient empathic opportunities, empathic statements, “sorry” statements, and elicitation of questions. We also assessed global codes of oncologist communication (assessed on 5-point Likert scales): flow, concerns addressed, attention, warmth, and respect. Finally, we coded patient participatory behavior (coded as count/encounter): asking questions and assertive responses. We compared the skills and behaviors by race/ethnicity of the patient using the non-parametric Kruskal-Wallis test. Results: We included the 56 (38%) recordings with oncologists who did not receive the intervention. The patients in these encounters were 25 (45%) female; 32 (57%) over the age of 65; 23 (41%) White Non-Hispanic, 20 (36%) Black Non-Hispanic, and 11 (20%) Hispanic. Overall, oncologists responded empathically to patients’ emotions only 19% of the time. Oncologists used fewer reflective statements with Black Non-Hispanic patients (mean 0.3 statements/encounter) as compared to White Non-Hispanic patients (1.1) and Hispanic patients (1.1), p = 0.02. Furthermore, coders rated oncologists as being less likely to address concerns of Black Non-Hispanic patients (mean Likert scale 3.1) as compared to White Non-Hispanic (3.8) and Hispanic (3.4) patients, p = 0.04. Finally, coders rated oncologists as having less warmth with Black Non-Hispanic patients (mean Likert scale 2.9) as compared to White Non-Hispanic (3.8) and Hispanic (3.3) patients, p = 0.04. Conclusions: In this diverse sample of patients with advanced cancer, oncologists used fewer reflective statements, were less attentive to concerns, and expressed less warmth with Black Non-Hispanic patients. Interventions are needed to overcome these striking racial/ethnic disparities in serious illness communication for patients with cancer.
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Affiliation(s)
| | | | - Jose Morillo
- Icahn School of Medicine at Mount Sinai, New York, NY
| | | | - Nina A. Bickell
- Division of Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Deukwoo Kwon
- Icahn School of Medicine at Mount Sinai, New York, NY
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Petrone G, Chowdhury N, Handa S, Anderson J, Kwon D, Bhardwaj AS, Jain P, Smith CB, Berger NS. Evaluation of inpatient chemotherapy among patients with cancer. J Clin Oncol 2022. [DOI: 10.1200/jco.2022.40.16_suppl.6566] [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
6566 Background: Administration of inpatient chemotherapy (IC) is associated with more aggressive end of life care, reduced use of palliative care (PC) and decreased quality of life (QOL). This study aims to identify risk factors associated with overutilization of IC. Methods: We conducted a retrospective chart review of all admissions where IC was administered at an academic center between January 2016 and December 2017. Patients (pts) were stratified by solid tumors (ST) versus hematologic malignancies (HM) and urgency for IC was assessed. We evaluated other variables which can impact patient care such as length of stay (LOS), reason for admission and for IC. Descriptive statistics and odds ratios (OR) were estimated from logistic regression models with mixed-effect taking into account correlations from multiple admissions per patient. All tests were two-sided and statistical significance was considered when p<.05. Results: We analyzed 880 admissions (17% ST). Table 1 summarizes outcomes. HM pts required frequent direct admission for IC compared to ST. ST pts (p<.0001), pts >65 years (p=0.004) and pts with KPS ≤50% (p<.0001) were most likely admitted for cancer complications rather than for IC. LOS (>7 days) was significantly longer in HM admissions (p=0.0001), among pts with stage 4 cancer (p=0.014) and KPS ≤50% (p=0.0001). ST (p=0.006) and pts with KPS ≤50% (p=0.0001) received IC for a non-urgent indication significantly more often than HM. In 20% of ST admissions, pts received IC because the admission coincided with a non-urgent planned cycle compared to 3% of HM. In the adjusted analysis, tumor type was the most important factor correlated with urgency of IC (OR 0.42, 95% CI: 0.25-0.72; p=0.001). ST pts (p=0.0001), older pts (p=0.004) and pts with KPS ≤50% (p=0.0001) were less likely to respond to chemotherapy. Only 15% of HM admissions and 46% of ST admissions had a PC consult. 60-day mortality was significantly higher in ST pts than HM (p=0.002). Conclusions: IC is associated with poorer outcomes for pts with advanced stage ST, pts with poor functional status and pts admitted for acute indications. Additionally, ST pts have a higher mortality after IC compared to HM. Utilization of IC should be standardized to account for different patient characteristics and to reduce the incidence of non-urgent administration. Based on this data, we created a standardized protocol to better assess the appropriateness of IC to improve patient care, QOL, and reduce chemotherapy and healthcare utilization at the end of life. [Table: see text]
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Affiliation(s)
- Giulia Petrone
- Icahn School of Medicine/Mount Sinai Morningside-West Hospital, New York, NY
| | - Nobel Chowdhury
- Icahn School of Medicine/Mount Sinai Morningside-West Hospital, New York, NY
| | - Shivani Handa
- Icahn School of Medicine at Mount Sinai, Division of Hematology and Medical Oncology, New York, NY
| | | | - Deukwoo Kwon
- Icahn School of Medicine at Mount Sinai, Division of Hematology and Medical Oncology, New York, NY
| | - Aarti Sonia Bhardwaj
- Icahn School of Medicine at Mount Sinai, Division of Hematology and Medical Oncology, New York, NY
| | - Priya Jain
- Icahn School of Medicine at Mount Sinai, Division of Hematology and Medical Oncology, New York, NY
| | - Cardinale B. Smith
- Icahn School of Medicine at Mount Sinai, Division of Hematology and Medical Oncology, New York, NY
| | - Natalie S Berger
- Icahn School of Medicine at Mount Sinai, Division of Hematology and Medical Oncology, New York, NY
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Simpson G, Jin W, Spieler B, Portelance L, Mellon E, Kwon D, Ford JC, Dogan N. Predictive Value of Delta-Radiomics Texture Features in 0.35 Tesla Magnetic Resonance Setup Images Acquired During Stereotactic Ablative Radiotherapy of Pancreatic Cancer. Front Oncol 2022; 12:807725. [PMID: 35515129 PMCID: PMC9063004 DOI: 10.3389/fonc.2022.807725] [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] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Accepted: 03/21/2022] [Indexed: 11/22/2022] Open
Abstract
Purpose The purpose of this work is to explore delta-radiomics texture features for predicting response using setup images of pancreatic cancer patients treated with magnetic resonance image guided (MRI-guided) stereotactic ablative radiotherapy (SBRT). Methods The total biological effective dose (BED) was calculated for 30 patients treated with MRI-guided SBRT that delivered physical doses of 30–60 Gy in three to five fractions. Texture features were then binned into groups based upon BED per fraction by dividing BED by the number of fractions. Delta-radiomics texture features were calculated after delivery of 20 Gy BED (BED20 features) and 40 Gy BED (BED40 features). A random forest (RF) model was constructed using BED20 and then BED40 features to predict binary outcome. During model training, the Gini Index, a measure of a variable’s importance for accurate prediction, was calculated for all features, and the two features that ranked the highest were selected for internal validation. The two features selected from each bin were used in a bootstrapped logistic regression model to predict response and performance quantified using the area under the receiver operating characteristic curve (AUC). This process was an internal validation analysis. Results After RF model training, the Gini Index was highest for gray-level co-occurrence matrix-based (GLCM) sum average, and neighborhood gray tone difference matrix-based (NGTDM) busyness for BED20 features and gray-level size zone matrix-based (GLSZM) large zones low gray-level emphasis and gray-level run length matrix-based (GLRLM) run percentage was selected from the BED40-based features. The mean AUC obtained using the two BED20 features was AUC = 0.845 with the 2.5 percentile and 97.5 percentile values ranging from 0.794 to 0.856. Internal validation of the BED40 delta-radiomics features resulted in a mean AUC = 0.567 with a 2.5 and 97.5 percentile range of 0.502–0.675. Conclusion Early changes in treatment quantified with the BED20 delta-radiomics texture features in low field images acquired during MRI-guided SBRT demonstrated better performance in internal validation than features calculated later in treatment. Further analysis of delta-radiomics texture analysis in low field MRI is warranted.
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Affiliation(s)
- Garrett Simpson
- Radiation Oncology, Miller School of Medicine, University of Miami, Miami, FL, United States
| | - William Jin
- Radiation Oncology, Miller School of Medicine, University of Miami, Miami, FL, United States
| | - Benjamin Spieler
- Radiation Oncology, Miller School of Medicine, University of Miami, Miami, FL, United States
| | - Lorraine Portelance
- Radiation Oncology, Miller School of Medicine, University of Miami, Miami, FL, United States
| | - Eric Mellon
- Radiation Oncology, Miller School of Medicine, University of Miami, Miami, FL, United States
| | - Deukwoo Kwon
- Radiation Oncology, Miller School of Medicine, University of Miami, Miami, FL, United States
| | - John C Ford
- Radiation Oncology, Miller School of Medicine, University of Miami, Miami, FL, United States
| | - Nesrin Dogan
- Radiation Oncology, Miller School of Medicine, University of Miami, Miami, FL, United States
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50
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Alderuccio JP, Arcaini L, Watkins MP, Beaven AW, Shouse G, Epperla N, Spina M, Stefanovic A, Sandoval-Sus J, Torka P, Alpert AB, Olszewski AJ, Kim SH, Hess B, Gaballa S, Ayyappan S, Castillo JJ, Argnani L, Voorhees TJ, Saba R, Chowdhury SM, Vargas F, Reis IM, Kwon D, Alexander JS, Zhao W, Edwards D, Martin P, Cencini E, Kamdar M, Link BK, Logothetis CN, Herrera AF, Friedberg JW, Kahl BS, Luminari S, Zinzani PL, Lossos IS. An international analysis evaluating frontline bendamustine with rituximab in extranodal marginal zone lymphoma. Blood Adv 2022; 6:2035-2044. [PMID: 35196377 PMCID: PMC9006265 DOI: 10.1182/bloodadvances.2021006844] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Accepted: 02/13/2022] [Indexed: 11/20/2022] Open
Abstract
Extranodal marginal zone lymphoma (EMZL) is a heterogeneous non-Hodgkin lymphoma. No consensus exists regarding the standard-of-care in patients with advanced-stage disease. Current recommendations are largely adapted from follicular lymphoma, for which bendamustine with rituximab (BR) is an established approach. We analyzed the safety and efficacy of frontline BR in EMZL using a large international consortium. We included 237 patients with a median age of 63 years (range, 21-85). Most patients presented with Eastern Cooperative Oncology Group (ECOG) performance status 0 to 1 (n = 228; 96.2%), stage III/IV (n = 179; 75.5%), and intermediate (49.8%) or high (33.3%) Mucosa Associated Lymphoid Tissue International Prognosis Index (MALT-IPI). Patients received a median of 6 (range, 1-8) cycles of BR, and 20.3% (n = 48) received rituximab maintenance. Thirteen percent experienced infectious complications during BR therapy; herpes zoster (4%) was the most common. Overall response rate was 93.2% with 81% complete responses. Estimated 5-year progression-free survival (PFS) and overall survival (OS) were 80.5% (95% CI, 73.1% to 86%) and 89.6% (95% CI, 83.1% to 93.6%), respectively. MALT-IPI failed to predict outcomes. In the multivariable model, the presence of B symptoms was associated with shorter PFS. Rituximab maintenance was associated with longer PFS (hazard ratio = 0.16; 95% CI, 0.04-0.71; P = .016) but did not impact OS. BR is a highly effective upfront regimen in EMZL, providing durable remissions and overcoming known adverse prognosis factors. This regimen is associated with occurrence of herpes zoster; thus, prophylactic treatment may be considered.
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Affiliation(s)
| | - Luca Arcaini
- Division of Hematology, Fondazione IRCCS San Mateo and Department of Molecular Medicine, University of Pavia, Pavia, Italy
| | | | - Anne W. Beaven
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC
| | | | | | - Michele Spina
- Medical Oncology Division, Centro Riferimento Oncologico, Aviano, Italy
| | | | - Jose Sandoval-Sus
- Moffitt Cancer Center at Memorial Healthcare System, Pembroke Pines, FL
| | - Pallawi Torka
- Roswell Park Comprehensive Cancer Center, Buffalo, NY
| | - Ash B. Alpert
- Center for Gerontology and Healthcare Research, Department of Health Services, Policy & Practice, Brown University School of Public Health, Providence, RI
| | | | - Seo-Hyun Kim
- Division of Hematology/Oncology, Rush University Medical Center, Chicago, IL
| | - Brian Hess
- Hollings Cancer Center at Medical University of South Carolina, Charleston, SC
| | | | - Sabarish Ayyappan
- Division of Hematology, Oncology, and Blood & Marrow Transplantation, University of Iowa, Iowa City, IA
| | | | - Lisa Argnani
- IRCCS Azienda Ospedaliero-Universitaria di Bologna Istituto di Ematologia “Seràgnoli”
- Dipartimento di Medicina Specialistica, Diagnostica e Sperimentale Università di Bologna, Bologna, Italy
| | - Timothy J. Voorhees
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC
| | - Raya Saba
- Washington University in St. Louis, St. Louis, MO
| | | | - Fernando Vargas
- Moffitt Cancer Center at Memorial Healthcare System, Pembroke Pines, FL
| | | | - Deukwoo Kwon
- Sylvester Comprehensive Cancer Center, Miami, FL
| | | | - Wei Zhao
- Sylvester Comprehensive Cancer Center, Miami, FL
| | - Dali Edwards
- Roswell Park Comprehensive Cancer Center, Buffalo, NY
| | - Peter Martin
- Division of Hematology/Oncology, Weill Cornell Medicine, New York, NY
| | - Emanuele Cencini
- Unit of Hematology, Azienda Ospedaliera Universitaria Senese and University of Siena, Siena SI, Italy
| | | | - Brian K. Link
- Division of Hematology, Oncology, and Blood & Marrow Transplantation, University of Iowa, Iowa City, IA
| | | | | | | | - Brad S. Kahl
- Washington University in St. Louis, St. Louis, MO
| | - Stefano Luminari
- CHIMOMO Department University of Modena and Reggio Emilia, Reggio Emilia, Italy; and
- Department of Hematology, Azienda USL IRCCS of Reggio Emilia, Reggio Emilia, Italy
| | - Pier Luigi Zinzani
- IRCCS Azienda Ospedaliero-Universitaria di Bologna Istituto di Ematologia “Seràgnoli”
- Dipartimento di Medicina Specialistica, Diagnostica e Sperimentale Università di Bologna, Bologna, Italy
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