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Ahn IE, Brander DM, Ren Y, Zhou Y, Tyekucheva S, Walker HA, Black R, Montegaard J, Alencar A, Shune L, Omaira M, Jacobson CA, Armand P, Ng SY, Crombie J, Fisher DC, LaCasce AS, Arnason J, Hochberg EP, Takvorian RW, Abramson JS, Brown JR, Davids MS. Five-year follow-up of a phase 2 study of ibrutinib plus fludarabine, cyclophosphamide, and rituximab as initial therapy in CLL. Blood Adv 2024; 8:832-841. [PMID: 38163317 PMCID: PMC10874751 DOI: 10.1182/bloodadvances.2023011574] [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: 09/01/2023] [Revised: 11/21/2023] [Accepted: 11/22/2023] [Indexed: 01/03/2024] Open
Abstract
ABSTRACT We previously reported high rates of undetectable minimal residual disease <10-4 (uMRD4) with ibrutinib plus fludarabine, cyclophosphamide, and rituximab (iFCR) followed by 2-year ibrutinib maintenance (I-M) in treatment-naïve chronic lymphocytic leukemia (CLL). Here, we report updated data from this phase 2 study with a median follow-up of 63 months. Of 85 patients enrolled, including 5 (6%) with deletion 17p or TP53 mutation, 91% completed iFCR and 2-year I-M. Five-year progression-free survival (PFS) and overall survival were 94% (95% confidence interval [CI], 89%-100%) and 99% (95% CI, 96%-100%), respectively. No additional deaths have occurred with this extended follow-up. No difference in PFS was observed by immunoglobulin heavy-chain variable region gene status or duration of I-M. High rates of peripheral blood (PB) uMRD4 were maintained (72% at the end of iFCR, 66% at the end of 2-year I-M, and 44% at 4.5 years from treatment initiation). Thirteen patients developed MRD conversion without clinical progression, mostly (77%) after stopping ibrutinib. None had Bruton tyrosine kinase (BTK) mutations. One patient had PLCG2 mutation. Six of these patients underwent ibrutinib retreatment per protocol. Median time on ibrutinib retreatment was 34 months. The cumulative incidence of atrial fibrillation was 8%. Second malignancy or nonmalignant hematologic disease occurred in 13%, mostly nonmelanoma skin cancer. Overall, iFCR with 2-year I-M achieved durably deep responses in patients with diverse CLL genetic markers. Re-emergent clones lacked BTK mutation and retained sensitivity to ibrutinib upon retreatment. This trial is registered at www.clinicaltrials.gov as #NCT02251548.
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Affiliation(s)
- Inhye E. Ahn
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
- Harvard Medical School, Boston, MA
| | | | - Yue Ren
- Department of Data Science, Dana-Farber Cancer Institute, Boston, MA
| | - Yinglu Zhou
- Department of Data Science, Dana-Farber Cancer Institute, Boston, MA
| | | | - Heather A. Walker
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
| | - Robert Black
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
| | - Josie Montegaard
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
| | - Alvaro Alencar
- Division of Hematology, University of Miami Sylvester Comprehensive Cancer Center, Miami, FL
| | - Leyla Shune
- Department of Hematologic Malignancies, University of Kansas Cancer Center, Westwood, KS
| | - Mohammad Omaira
- Department of Medical Oncology, West Michigan Cancer Center, Kalamazoo, MI
| | - Caron A. Jacobson
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
- Harvard Medical School, Boston, MA
| | - Philippe Armand
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
- Harvard Medical School, Boston, MA
| | - Samuel Y. Ng
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
- Harvard Medical School, Boston, MA
| | - Jennifer Crombie
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
- Harvard Medical School, Boston, MA
| | - David C. Fisher
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
- Harvard Medical School, Boston, MA
| | - Ann S. LaCasce
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
- Harvard Medical School, Boston, MA
| | - Jon Arnason
- Harvard Medical School, Boston, MA
- Department of Medical Oncology, Beth Israel Deaconess Medical Center, Boston, MA
| | - Ephraim P. Hochberg
- Harvard Medical School, Boston, MA
- Department of Medical Oncology, Massachusetts General Hospital, Boston, MA
| | - Ronald W. Takvorian
- Harvard Medical School, Boston, MA
- Department of Medical Oncology, Massachusetts General Hospital, Boston, MA
| | - Jeremy S. Abramson
- Harvard Medical School, Boston, MA
- Department of Medical Oncology, Massachusetts General Hospital, Boston, MA
| | - Jennifer R. Brown
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
- Harvard Medical School, Boston, MA
| | - Matthew S. Davids
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
- Harvard Medical School, Boston, MA
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2
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Nemec R, Scherrer-Crosbie M, Abramson JS, Redd R, Gilman HK, Ho T, Wu J, Heemelaar J, Neuberg D, Hochberg EP, Barnes JA, Armand P, Jacobsen ED, Jacobson CA, Kim AI, Friedman RS, LaCasce AS, Neilan TG, Soumerai JD. Effect of atorvastatin versus placebo on efficacy in patients with diffuse large B-cell lymphoma receiving R-CHOP. Leuk Lymphoma 2024:1-6. [PMID: 38380861 DOI: 10.1080/10428194.2024.2317343] [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: 10/18/2023] [Accepted: 02/06/2024] [Indexed: 02/22/2024]
Abstract
STOP-CA was a multicenter, double-blind, randomized, placebo-controlled trial comparing atorvastatin to placebo in treatment-naïve lymphoma patients receiving anthracycline-based chemotherapy. We performed a preplanned subgroup to analyze the impact of atorvastatin on efficacy in patients with diffuse large B-cell lymphoma (DLBCL). Patients received rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone (R-CHOP) at standard doses for six 21-day cycles and were randomly assigned to receive atorvastatin 40 mg daily (n = 55) or placebo (n = 47) for 12 months. The complete response (CR) rate was numerically higher in the atorvastatin arm (95% [52/55] vs. 85% [40/47], p = .18), but this was not statistically significant. Adverse event rates were similar between the atorvastatin and placebo arms. In summary, atorvastatin did not result in a statistically significant improvement in the CR rate or progression-free survival, but both were numerically improved in the atorvastatin arm. These data warrant further investigation into the potential therapeutic role of atorvastatin added to anthracycline-based chemotherapies.
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Affiliation(s)
- Ronald Nemec
- Center for Lymphoma, Massachusetts General Hospital Cancer Center, Boston, MA, USA
| | | | - Jeremy S Abramson
- Center for Lymphoma, Massachusetts General Hospital Cancer Center, Boston, MA, USA
| | - Robert Redd
- Department of Data Science, Dana Farber Cancer Institute, Boston, MA, USA
| | - Hannah K Gilman
- Division of Cardiology, Massachusetts General Hospital, Boston, MA, USA
| | - Terry Ho
- Division of Cardiology, Massachusetts General Hospital, Boston, MA, USA
| | - Jessica Wu
- Division of Cardiology, Massachusetts General Hospital, Boston, MA, USA
| | - Julius Heemelaar
- Division of Cardiology, Massachusetts General Hospital, Boston, MA, USA
| | - Donna Neuberg
- Department of Data Science, Dana Farber Cancer Institute, Boston, MA, USA
| | - Ephraim P Hochberg
- Center for Lymphoma, Massachusetts General Hospital Cancer Center, Boston, MA, USA
| | - Jeffrey A Barnes
- Center for Lymphoma, Massachusetts General Hospital Cancer Center, Boston, MA, USA
| | - Philippe Armand
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Eric D Jacobsen
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Caron A Jacobson
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Austin I Kim
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Robb S Friedman
- Division of Medical Oncology, Newton-Wellesley Hospital, Newton, MA, USA
| | - Ann S LaCasce
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Tomas G Neilan
- Division of Cardiology, Massachusetts General Hospital, Boston, MA, USA
| | - Jacob D Soumerai
- Center for Lymphoma, Massachusetts General Hospital Cancer Center, Boston, MA, USA
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3
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Karschnia P, Arrillaga-Romany IC, Eichler A, Forst DA, Gerstner E, Jordan JT, Ly I, Plotkin SR, Wang N, Martinez-Lage M, Winter SF, Tonn JC, Rejeski K, von Baumgarten L, Cahill DP, Nahed BV, Shankar GM, Abramson JS, Barnes JA, El-Jawahri A, Hochberg EP, Johnson PC, Soumerai JD, Takvorian RW, Chen YB, Frigault MJ, Dietrich J. Neurotoxicity and management of primary and secondary central nervous system lymphoma after adoptive immunotherapy with CD19-directed chimeric antigen receptor T-cells. Neuro Oncol 2023; 25:2239-2249. [PMID: 37402650 PMCID: PMC10708936 DOI: 10.1093/neuonc/noad118] [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] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Indexed: 07/06/2023] Open
Abstract
BACKGROUND Chimeric antigen receptor (CAR) T-cells targeting CD19 have been established as a leading engineered T-cell therapy for B-cell lymphomas; however, data for patients with central nervous system (CNS) involvement are limited. METHODS We retrospectively report on CNS-specific toxicities, management, and CNS response of 45 consecutive CAR T-cell transfusions for patients with active CNS lymphoma at the Massachusetts General Hospital over a 5-year period. RESULTS Our cohort includes 17 patients with primary CNS lymphoma (PCNSL; 1 patient with 2 CAR T-cell transfusions) and 27 patients with secondary CNS lymphoma (SCNSL). Mild ICANS (grade 1-2) was observed after 19/45 transfusions (42.2%) and severe immune effector cell-associated neurotoxicity syndrome (ICANS) (grade 3-4) after 7/45 transfusions (15.6%). A larger increase in C-reactive protein (CRP) levels and higher rates of ICANS were detected in SCNSL. Early fever and baseline C-reactive protein levels were associated with ICANS occurrence. CNS response was seen in 31 cases (68.9%), including a complete response of CNS disease in 18 cases (40.0%) which lasted for a median of 11.4 ± 4.5 months. Dexamethasone dose at time of lymphodepletion (but not at or after CAR T-cell transfusion) was associated with an increased risk for CNS progression (hazard ratios [HR] per mg/d: 1.16, P = .031). If bridging therapy was warranted, the use of ibrutinib translated into favorable CNS-progression-free survival (5 vs. 1 month, HR 0.28, CI 0.1-0.7; P = .010). CONCLUSIONS CAR T-cells exhibit promising antitumor effects and a favorable safety profile in CNS lymphoma. Further evaluation of the role of bridging regimens and corticosteroids is warranted.
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Affiliation(s)
- Philipp Karschnia
- Department of Neurology, Division of Neuro-Oncology, Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, Massachusetts, USA
- Department of Neurosurgery, Section for Neuro-Oncology, Ludwig-Maximilians-University, Munich, Germany
- German Cancer Consortium (DKTK), Partner Site Munich, Germany
| | - Isabel C Arrillaga-Romany
- Department of Neurology, Division of Neuro-Oncology, Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, Massachusetts, USA
| | - April Eichler
- Department of Neurology, Division of Neuro-Oncology, Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Deborah A Forst
- Department of Neurology, Division of Neuro-Oncology, Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Elizabeth Gerstner
- Department of Neurology, Division of Neuro-Oncology, Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Justin T Jordan
- Department of Neurology, Division of Neuro-Oncology, Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Ina Ly
- Department of Neurology, Division of Neuro-Oncology, Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Scott R Plotkin
- Department of Neurology, Division of Neuro-Oncology, Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Nancy Wang
- Department of Neurology, Division of Neuro-Oncology, Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Maria Martinez-Lage
- Department of Pathology, Division of Neuropathology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Sebastian F Winter
- Department of Neurology, Division of Neuro-Oncology, Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Joerg-Christian Tonn
- Department of Neurosurgery, Section for Neuro-Oncology, Ludwig-Maximilians-University, Munich, Germany
- German Cancer Consortium (DKTK), Partner Site Munich, Germany
| | - Kai Rejeski
- German Cancer Consortium (DKTK), Partner Site Munich, Germany
- Department of Medicine III, Section for Cellular Immunotherapy, Ludwig-Maximilians-University, Munich, Germany
| | - Louisa von Baumgarten
- Department of Neurosurgery, Section for Neuro-Oncology, Ludwig-Maximilians-University, Munich, Germany
| | - Daniel P Cahill
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Brian V Nahed
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Ganesh M Shankar
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Jeremy S Abramson
- Department of Medicine, Hematology, and Oncology Division, Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Jeffrey A Barnes
- Department of Medicine, Hematology, and Oncology Division, Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Areej El-Jawahri
- Department of Medicine, Hematology, and Oncology Division, Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Ephraim P Hochberg
- Department of Medicine, Hematology, and Oncology Division, Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, Massachusetts, USA
| | - P Connor Johnson
- Department of Medicine, Hematology, and Oncology Division, Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Jacob D Soumerai
- Department of Medicine, Hematology, and Oncology Division, Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Ronald W Takvorian
- Department of Medicine, Hematology, and Oncology Division, Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Yi-Bin Chen
- Department of Medicine, Cellular Immunotherapy Program, Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Matthew J Frigault
- Department of Medicine, Cellular Immunotherapy Program, Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Jorg Dietrich
- Department of Neurology, Division of Neuro-Oncology, Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, Massachusetts, USA
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4
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Neilan TG, Quinaglia T, Onoue T, Mahmood SS, Drobni ZD, Gilman HK, Smith A, Heemelaar JC, Brahmbhatt P, Ho JS, Sama S, Svoboda J, Neuberg DS, Abramson JS, Hochberg EP, Barnes JA, Armand P, Jacobsen ED, Jacobson CA, Kim AI, Soumerai JD, Han Y, Friedman RS, Lacasce AS, Ky B, Landsburg D, Nasta S, Kwong RY, Jerosch-Herold M, Redd RA, Hua L, Januzzi JL, Asnani A, Mousavi N, Scherrer-Crosbie M. Atorvastatin for Anthracycline-Associated Cardiac Dysfunction: The STOP-CA Randomized Clinical Trial. JAMA 2023; 330:528-536. [PMID: 37552303 PMCID: PMC10410476 DOI: 10.1001/jama.2023.11887] [Citation(s) in RCA: 15] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Accepted: 06/12/2023] [Indexed: 08/09/2023]
Abstract
Importance Anthracyclines treat a broad range of cancers. Basic and retrospective clinical data have suggested that use of atorvastatin may be associated with a reduction in cardiac dysfunction due to anthracycline use. Objective To test whether atorvastatin is associated with a reduction in the proportion of patients with lymphoma receiving anthracyclines who develop cardiac dysfunction. Design, Setting, and Participants Double-blind randomized clinical trial conducted at 9 academic medical centers in the US and Canada among 300 patients with lymphoma who were scheduled to receive anthracycline-based chemotherapy. Enrollment occurred between January 25, 2017, and September 10, 2021, with final follow-up on October 10, 2022. Interventions Participants were randomized to receive atorvastatin, 40 mg/d (n = 150), or placebo (n = 150) for 12 months. Main Outcomes and Measures The primary outcome was the proportion of participants with an absolute decline in left ventricular ejection fraction (LVEF) of ≥10% from prior to chemotherapy to a final value of <55% over 12 months. A secondary outcome was the proportion of participants with an absolute decline in LVEF of ≥5% from prior to chemotherapy to a final value of <55% over 12 months. Results Of the 300 participants randomized (mean age, 50 [SD, 17] years; 142 women [47%]), 286 (95%) completed the trial. Among the entire cohort, the baseline mean LVEF was 63% (SD, 4.6%) and the follow-up LVEF was 58% (SD, 5.7%). Study drug adherence was noted in 91% of participants. At 12-month follow-up, 46 (15%) had a decline in LVEF of 10% or greater from prior to chemotherapy to a final value of less than 55%. The incidence of the primary end point was 9% (13/150) in the atorvastatin group and 22% (33/150) in the placebo group (P = .002). The odds of a 10% or greater decline in LVEF to a final value of less than 55% after anthracycline treatment was almost 3 times greater for participants randomized to placebo compared with those randomized to atorvastatin (odds ratio, 2.9; 95% CI, 1.4-6.4). Compared with placebo, atorvastatin also reduced the incidence of the secondary end point (13% vs 29%; P = .001). There were 13 adjudicated heart failure events (4%) over 24 months of follow-up. There was no difference in the rates of incident heart failure between study groups (3% with atorvastatin, 6% with placebo; P = .26). The number of serious related adverse events was low and similar between groups. Conclusions and Relevance Among patients with lymphoma treated with anthracycline-based chemotherapy, atorvastatin reduced the incidence of cardiac dysfunction. This finding may support the use of atorvastatin in patients with lymphoma at high risk of cardiac dysfunction due to anthracycline use. Trial Registration ClinicalTrials.gov Identifier: NCT02943590.
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Affiliation(s)
- Tomas G. Neilan
- Cardiovascular Imaging Research Center, Division of Cardiology, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston
- Division of Cardiology, Massachusetts General Hospital, Harvard Medical School, Boston
| | - Thiago Quinaglia
- Cardiovascular Imaging Research Center, Division of Cardiology, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston
| | - Takeshi Onoue
- Division of Cardiology, Hospital of the University of Pennsylvania, Philadelphia
| | - Syed S. Mahmood
- Cardiovascular Imaging Research Center, Division of Cardiology, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston
| | - Zsofia D. Drobni
- Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - Hannah K. Gilman
- Cardiovascular Imaging Research Center, Division of Cardiology, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston
| | - Amanda Smith
- Division of Cardiology, Hospital of the University of Pennsylvania, Philadelphia
| | - Julius C. Heemelaar
- Cardiovascular Imaging Research Center, Division of Cardiology, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston
| | - Priya Brahmbhatt
- Division of Cardiology, Hospital of the University of Pennsylvania, Philadelphia
| | - Jor Sam Ho
- Cardiovascular Imaging Research Center, Division of Cardiology, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston
| | - Supraja Sama
- Cardiovascular Imaging Research Center, Division of Cardiology, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston
| | - Jakub Svoboda
- Division of Hematology/Oncology, Hospital of the University of Pennsylvania, Philadelphia
| | - Donna S. Neuberg
- Department of Data Science, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Jeremy S. Abramson
- Division of Hematology-Oncology, Massachusetts General Hospital, Harvard Medical School, Boston
| | - Ephraim P. Hochberg
- Division of Hematology-Oncology, Massachusetts General Hospital, Harvard Medical School, Boston
| | - Jefferey A. Barnes
- Division of Hematology-Oncology, Massachusetts General Hospital, Harvard Medical School, Boston
| | - Philippe Armand
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Eric D. Jacobsen
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Caron A. Jacobson
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Austin I. Kim
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Jacob D. Soumerai
- Division of Hematology-Oncology, Massachusetts General Hospital, Harvard Medical School, Boston
| | - Yuchi Han
- Division of Cardiology, Hospital of the University of Pennsylvania, Philadelphia
| | - Robb S. Friedman
- Division of Hematology-Oncology, Massachusetts General Hospital, Harvard Medical School, Boston
| | - Ann S. Lacasce
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Bonnie Ky
- Division of Cardiology, Hospital of the University of Pennsylvania, Philadelphia
| | - Dan Landsburg
- Division of Hematology/Oncology, Hospital of the University of Pennsylvania, Philadelphia
| | - Sunita Nasta
- Division of Hematology/Oncology, Hospital of the University of Pennsylvania, Philadelphia
| | - Raymond Y. Kwong
- Cardiology Division, Brigham and Women’s Hospital, Boston, Massachusetts
| | | | - Robert A. Redd
- Department of Data Science, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Lanqi Hua
- Division of Cardiology, Massachusetts General Hospital, Harvard Medical School, Boston
- Cardiac Ultrasound Laboratory, Massachusetts General Hospital, Harvard Medical School, Boston
| | - James L. Januzzi
- Division of Cardiology, Massachusetts General Hospital, Harvard Medical School, Boston
- Heart Failure Trials, Baim Institute for Clinical Research, Boston, Massachusetts
| | - Aarti Asnani
- Division of Cardiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Negareh Mousavi
- Division of Cardiology, McGill University Hospital, Montreal, Quebec, Canada
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5
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Dias-Santagata D, Heist RS, Bard AZ, da Silva AFL, Dagogo-Jack I, Nardi V, Ritterhouse LL, Spring LM, Jessop N, Farahani AA, Mino-Kenudson M, Allen J, Goyal L, Parikh A, Misdraji J, Shankar G, Jordan JT, Martinez-Lage M, Frosch M, Graubert T, Fathi AT, Hobbs GS, Hasserjian RP, Raje N, Abramson J, Schwartz JH, Sullivan RJ, Miller D, Hoang MP, Isakoff S, Ly A, Bouberhan S, Watkins J, Oliva E, Wirth L, Sadow PM, Faquin W, Cote GM, Hung YP, Gao X, Wu CL, Garg S, Rivera M, Le LP, John Iafrate A, Juric D, Hochberg EP, Clark J, Bardia A, Lennerz JK. Implementation and Clinical Adoption of Precision Oncology Workflows Across a Healthcare Network. Oncologist 2022; 27:930-939. [PMID: 35852437 PMCID: PMC9632318 DOI: 10.1093/oncolo/oyac134] [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] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2022] [Accepted: 06/17/2022] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND Precision oncology relies on molecular diagnostics, and the value-proposition of modern healthcare networks promises a higher standard of care across partner sites. We present the results of a clinical pilot to standardize precision oncology workflows. METHODS Workflows are defined as the development, roll-out, and updating of disease-specific molecular order sets. We tracked the timeline, composition, and effort of consensus meetings to define the combination of molecular tests. To assess clinical impact, we examined order set adoption over a two-year period (before and after roll-out) across all gastrointestinal and hepatopancreatobiliary (GI) malignancies, and by provider location within the network. RESULTS Development of 12 disease center-specific order sets took ~9 months, and the average number of tests per indication changed from 2.9 to 2.8 (P = .74). After roll-out, we identified significant increases in requests for GI patients (17%; P < .001), compliance with testing recommendations (9%; P < .001), and the fraction of "abnormal" results (6%; P < .001). Of 1088 GI patients, only 3 received targeted agents based on findings derived from non-recommended orders (1 before and 2 after roll-out); indicating that our practice did not negatively affect patient treatments. Preliminary analysis showed 99% compliance by providers in network sites, confirming the adoption of the order sets across the network. CONCLUSION Our study details the effort of establishing precision oncology workflows, the adoption pattern, and the absence of harm from the reduction of non-recommended orders. Establishing a modifiable communication tool for molecular testing is an essential component to optimize patient care via precision oncology.
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Affiliation(s)
- Dora Dias-Santagata
- Department of Pathology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Rebecca S Heist
- Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, MA, USA
| | - Adam Z Bard
- Department of Pathology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | | | - Ibiayi Dagogo-Jack
- Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, MA, USA
| | - Valentina Nardi
- Department of Pathology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Lauren L Ritterhouse
- Department of Pathology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Laura M Spring
- Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, MA, USA
| | - Nicholas Jessop
- Department of Pathology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Alexander A Farahani
- Department of Pathology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Mari Mino-Kenudson
- Department of Pathology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Jill Allen
- Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, MA, USA
| | - Lipika Goyal
- Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, MA, USA
| | - Aparna Parikh
- Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, MA, USA
| | - Joseph Misdraji
- Department of Pathology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
- Present affiliation: Department of Pathology, Yale University, New Haven, CT, USA
| | - Ganesh Shankar
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Justin T Jordan
- Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, MA, USA
| | - Maria Martinez-Lage
- Department of Pathology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Matthew Frosch
- Department of Pathology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Timothy Graubert
- Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, MA, USA
| | - Amir T Fathi
- Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, MA, USA
| | - Gabriela S Hobbs
- Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, MA, USA
| | - Robert P Hasserjian
- Department of Pathology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Noopur Raje
- Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, MA, USA
| | - Jeremy Abramson
- Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, MA, USA
| | - Joel H Schwartz
- Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, MA, USA
| | - Ryan J Sullivan
- Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, MA, USA
| | - David Miller
- Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, MA, USA
| | - Mai P Hoang
- Department of Pathology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Steven Isakoff
- Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, MA, USA
| | - Amy Ly
- Department of Pathology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Sara Bouberhan
- Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, MA, USA
| | - Jaclyn Watkins
- Department of Pathology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Esther Oliva
- Department of Pathology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Lori Wirth
- Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, MA, USA
| | - Peter M Sadow
- Department of Pathology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - William Faquin
- Department of Pathology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Gregory M Cote
- Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, MA, USA
| | - Yin P Hung
- Department of Pathology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Xin Gao
- Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, MA, USA
| | - Chin-Lee Wu
- Department of Pathology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Salil Garg
- Department of Pathology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Miguel Rivera
- Department of Pathology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Long P Le
- Department of Pathology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - A John Iafrate
- Department of Pathology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Dejan Juric
- Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, MA, USA
| | - Ephraim P Hochberg
- Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, MA, USA
| | - Jeffrey Clark
- Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, MA, USA
| | - Aditya Bardia
- Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, MA, USA
| | - Jochen K Lennerz
- Department of Pathology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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6
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McGuire J, Hubbell HT, Hochberg EP, Foley C, Ryan DP, Mulvey TM. Patient-reported outcomes: Completion, access, and equity. J Clin Oncol 2022. [DOI: 10.1200/jco.2022.40.28_suppl.141] [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
141 Background: Patient Reported Outcomes CTCAE (PROM) completion has demonstrated improvements in survival for patients with advanced cancer. Little is known about completion rates by race and gender for questionnaires assigned to all patients receiving IV infusions. Methods: Beginning in 2019 all patients who had a visit associated with an IV infusion were assigned a PROM PRO-CTCAE questionnaire through the EHR portal 72 hours prior to the visit and again using an in- clinic tablet if not completed upon check-in. The PROMs questionnaires are available in 6 languages via both electronic platforms. At registration, all patients self- identify as White, Black/African American, Asian or other (multiple, do not prefer to answer) by race. We collected 2021 data on all eligible patients who were assigned a questionnaire and cross referenced that by completion and self-assigned race and gender at registration. Data from breast, thoracic and GI clinics are presented. Results: 1715 patients were eligible and self-identified as White, Black or Asian for a PROM CTCAE questionnaire across the three clinics (519 breast clinic, 390 thoracic, 806 GI). 3872 questionnaires were completed (average 2.26 questionnaires per eligible patient). 2875 (73%) were completed by EHR portal and 1027 (27%) were completed in clinic on the tablet. White patients completed questionnaires 67% when assigned, Asian 68% and Black/African American 52% of the time. 81% of breast clinic patients completed questionnaires, 62% of thoracic patients and 54% of GI patients. Overall, in thoracic and GI clinics White women completed questionnaires 58%, Black women 41% and Asian women 70% compared to White men 59%, Asian men 56% and Black men 57%. All patients who completed questionnaires in breast clinic identified as women. Conclusions: We assigned PROM CTCAE questionnaires to all eligible patients who had an IV infusion encounter associated with their visits in the breast, thoracic and GI clinics by both the electronic chart portal and again in clinic by tablet, if not completed prior to the in person visit. PROM questionnaires are available in 6 languages through both methods. We identified differences in completion rates by race with fewer African American/Black patient completion rates compared to White or Asian self-identification, (52% vs 67.5%). The largest differences were between White or Asian women, 58% and 70% completion rates compared to Black women 41%. Differences in gender may explain differences across disease groups as all breast clinic patients were self-identified as female, 81% completion rate compared to 62% thoracic and 54% GI.
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Affiliation(s)
| | | | - Ephraim P. Hochberg
- Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, MA
| | - Cara Foley
- Massachusetts General Hospital, Boston, MA
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7
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Hoppe RT, Advani RH, Ai WZ, Ambinder RF, Armand P, Bello CM, Benitez CM, Chen W, Dabaja B, Daly ME, Gordon LI, Hansen N, Herrera AF, Hochberg EP, Johnston PB, Kaminski MS, Kelsey CR, Kenkre VP, Khan N, Lynch RC, Maddocks K, McConathy J, Metzger M, Morgan D, Mulroney C, Pullarkat ST, Rabinovitch R, Rosenspire KC, Seropian S, Tao R, Torka P, Winter JN, Yahalom J, Yang JC, Burns JL, Campbell M, Sundar H. NCCN Guidelines® Insights: Hodgkin Lymphoma, Version 2.2022. J Natl Compr Canc Netw 2022; 20:322-334. [PMID: 35390768 DOI: 10.6004/jnccn.2022.0021] [Citation(s) in RCA: 31] [Impact Index Per Article: 15.5] [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
Hodgkin lymphoma (HL) is an uncommon malignancy of B-cell origin. Classical HL (cHL) and nodular lymphocyte-predominant HL are the 2 main types of HL. The cure rates for HL have increased so markedly with the advent of modern treatment options that overriding treatment considerations often relate to long-term toxicity. These NCCN Guidelines Insights discuss the recent updates to the NCCN Guidelines for HL focusing on (1) radiation therapy dose constraints in the management of patients with HL, and (2) the management of advanced-stage and relapsed or refractory cHL.
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Affiliation(s)
| | | | - Weiyun Z Ai
- UCSF Helen Diller Family Comprehensive Cancer Center
| | | | | | | | | | - Weina Chen
- UT Southwestern Simmons Comprehensive Cancer Center
| | | | | | - Leo I Gordon
- Robert H. Lurie Comprehensive Cancer Center of Northwestern University
| | | | | | | | | | | | | | | | | | - Ryan C Lynch
- Fred Hutchinson Cancer Research Center/University of Washington
| | - Kami Maddocks
- The Ohio State University Comprehensive Cancer Center - James Cancer Hospital and Solove Research Institute
| | | | - Monika Metzger
- St. Jude Children's Research Hospital/The University of Tennessee Health Science Center
| | | | | | | | | | | | | | - Randa Tao
- Huntsman Cancer Institute at the University of Utah
| | | | - Jane N Winter
- Robert H. Lurie Comprehensive Cancer Center of Northwestern University
| | | | - Joanna C Yang
- Siteman Cancer Center at Barnes-Jewish Hospital and Washington University School of Medicine; and
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8
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Zubiri L, Rosovsky RP, Mooradian MJ, Piper-Vallillo AJ, Gainor JF, Sullivan RJ, Marte D, Boland GM, Gao X, Hochberg EP, Ryan DP, McEwen C, Mai M, Sharova T, Soumerai TE, Bardia A, Reynolds KL. Temporal Trends in Inpatient Oncology Census Before and During the COVID-19 Pandemic and Rates of Nosocomial COVID-19 Among Patients with Cancer at a Large Academic Center. Oncologist 2021; 26:e1427-e1433. [PMID: 33932247 PMCID: PMC8242879 DOI: 10.1002/onco.13807] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [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: 12/02/2020] [Accepted: 04/16/2021] [Indexed: 12/19/2022] Open
Abstract
Background The coronavirus disease 2019 (COVID‐19) pandemic has significantly impacted health care systems. However, to date, the trend of hospitalizations in the oncology patient population has not been studied, and the frequency of nosocomial spread to patients with cancer is not well understood. The objectives of this study were to evaluate the impact of COVID‐19 on inpatient oncology census and determine the nosocomial rate of COVID‐19 in patients with cancer admitted at a large academic center. Materials and Methods Medical records of patients with cancer diagnosed with COVID‐19 and admitted were reviewed to evaluate the temporal trends in inpatient oncology census during pre–COVID‐19 (January 2019 to February 2020), COVID‐19 (March to May 2020), and post–COVID‐19 surge (June to August 2020) in the region. In addition, nosocomial infection rates of SARS‐CoV‐2 were reviewed. Results Overall, the daily inpatient census was steady in 2019 (median, 103; range, 92–118) and until February 2020 (median, 112; range, 102–114). However, there was a major decline from March to May 2020 (median, 68; range, 57–104), with 45.4% lower admissions during April 2020. As the COVID‐19 surge eased, the daily inpatient census over time returned to the pre–COVID‐19 baseline (median, 103; range, 99–111). One patient (1/231, 0.004%) tested positive for SARS‐CoV‐2 13 days after hospitalization, and it is unclear if it was nosocomial or community spread. Conclusion In this study, inpatient oncology admissions decreased substantially during the COVID‐19 surge but over time returned to the pre–COVID‐19 baseline. With aggressive infection control measures, the rates of nosocomial transmission were exceedingly low and should provide reassurance to those seeking medical care, including inpatient admissions when medically necessary. Implications for Practice The COVID‐19 pandemic has had a major impact on the health care system, and cancer patients are a vulnerable population. This study observes a significant decline in the daily inpatient oncology census from March to May 2020 compared with the same time frame in the previous year and examines the potential reasons for this decline. In addition, nosocomial rates of COVID‐19 were investigated, and rates were found to be very low. These findings suggest that aggressive infection control measures can mitigate the nosocomial infection risk among cancer patients and the inpatient setting is a safe environment, providing reassurance. To understand the overall impact of COVID‐19 on health care delivery in the oncology setting, this study evaluated the inpatient oncology census, in comparison to historical data and infusion volume, at an institution with a high volume of COVID‐19 admissions.
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Affiliation(s)
- Leyre Zubiri
- Division of Hematology and Oncology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Rachel P Rosovsky
- Division of Hematology and Oncology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Meghan J Mooradian
- Division of Hematology and Oncology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - A J Piper-Vallillo
- Division of Hematology and Oncology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Justin F Gainor
- Division of Hematology and Oncology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Ryan J Sullivan
- Division of Hematology and Oncology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Daniel Marte
- Rutgers New Jersey Medical School, Newark, New Jersey, USA
| | - Genevieve M Boland
- Department of Surgical Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Xin Gao
- Division of Hematology and Oncology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Ephraim P Hochberg
- Division of Hematology and Oncology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - David P Ryan
- Division of Hematology and Oncology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Corey McEwen
- Department of Pharmacy, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Minh Mai
- Massachusetts General Hospital Cancer Center, Boston, MA, USA
| | - Tanya Sharova
- Department of Surgical Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Tara E Soumerai
- Division of Hematology and Oncology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Aditya Bardia
- Division of Hematology and Oncology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Kerry L Reynolds
- Division of Hematology and Oncology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
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9
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Phadke NA, Luk SO, Hochberg EP, Banerji A. Immediate reaction to ibrutinib amenable to oral desensitization. J Oncol Pharm Pract 2021; 27:1802-1805. [PMID: 33793357 DOI: 10.1177/10781552211004689] [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] [Indexed: 11/17/2022]
Abstract
INTRODUCTION Although up to half of patients receiving chemotherapeutic agents develop hypersensitivity reactions to the same, desensitization protocols can induce temporary tolerance to allow patients to continue to receive first-line treatment. Approximately 25% of patients develop cutaneous hypersensitivity reactions to ibrutinib, but there are no published management guidelines. CASE REPORT We describe the case of a 71-year-old woman with chronic lymphocytic leukemia who developed a delayed maculopapular rash with lip tingling and swelling following ibrutinib therapy. MANAGEMENT AND OUTCOME We performed a novel 11-step desensitization procedure to ibrutinib allowing us to successfully induce tolerance against IgE-mediated symptoms in this patient. DISCUSSION As indications for ibrutinib use expand and more patients present with IgE-mediated symptoms, we expect that this protocol will provide benefit for many such patients.
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Affiliation(s)
- Neelam A Phadke
- Division of Rheumatology Allergy and Immunology, Department of Medicine, Massachusetts General Hospital, Boston, USA.,Harvard Medical School, Boston, USA.,Massachusetts General Physicians Organization, Boston, USA
| | - Samantha O Luk
- Department of Pharmacy, Massachusetts General Hospital, Boston, USA
| | - Ephraim P Hochberg
- Massachusetts General Hospital Cancer Center, Massachusetts General Hospital, Boston, USA
| | - Aleena Banerji
- Division of Rheumatology Allergy and Immunology, Department of Medicine, Massachusetts General Hospital, Boston, USA.,Harvard Medical School, Boston, USA
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10
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Winter SF, Martinez-Lage M, Clement NF, Hochberg EP, Dietrich J. Fatal neurotoxicity after chimeric antigen receptor T-cell therapy: An unexpected case of fludarabine-associated progressive leukoencephalopathy. Eur J Cancer 2020; 144:178-181. [PMID: 33360262 DOI: 10.1016/j.ejca.2020.11.021] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Accepted: 11/15/2020] [Indexed: 11/17/2022]
Affiliation(s)
- Sebastian F Winter
- Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, MA, USA; Division of Neuro-Oncology, Department of Neurology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA; Department of Neurosurgery, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Maria Martinez-Lage
- Department of Pathology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Nathan F Clement
- Department of Pathology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Ephraim P Hochberg
- Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, MA, USA; Division of Hematology and Oncology, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Jorg Dietrich
- Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, MA, USA; Division of Neuro-Oncology, Department of Neurology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA.
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11
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Durbin SM, Zubiri L, Niemierko A, Bardia A, Sullivan RJ, McEwen C, Mulvey TM, Allen IM, Lawrence DP, Cohen JV, Hochberg EP, Ryan DP, Petrillo LA, Reynolds KL. Clinical Outcomes of Patients with Metastatic Cancer Receiving Immune Checkpoint Inhibitors in the Inpatient Setting. Oncologist 2020; 26:49-55. [PMID: 33044765 DOI: 10.1002/onco.13561] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2020] [Accepted: 10/05/2020] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND As indications for immune checkpoint inhibitor (ICI) therapy have increased in recent years, so has the proportion of patients eligible for this type of therapy. However, a lack of data exists about the risks and benefits of ICI therapy in hospitalized patients, who tend to be frailer and sicker than patients enrolled in clinical trials. MATERIAL AND METHODS We conducted a retrospective cohort study among hospitalized patients with metastatic solid tumors who received ICI therapy at a large academic cancer center over the course of 4 years. We analyzed the characteristics and outcomes of these patients and identified demographic and clinical factors that could be used to predict mortality. RESULTS During the 4-year study period, 106 patients were treated with ICI therapy while admitted to the hospital; 70 (66%) had Eastern Cooperative Oncology Group Performance Status ≥2, which would have prevented them from enrolling in most clinical trials of ICIs. Fifty-two patients (49%) died either during admission or within 30 days of discharge; median overall survival was 1.0 month from discharge, and 16 patients (15%) were alive 6 months after discharge. Independent predictors of death following receipt of inpatient ICI included a diagnosis of non-small cell lung cancer relative to melanoma and prior treatment with two or more lines of therapy. CONCLUSION The poor overall outcomes observed in this study may give clinicians pause when considering ICI therapy for hospitalized patients, particularly those with characteristics that are associated with a greater risk of mortality. IMPLICATIONS FOR PRACTICE Immunotherapy strategies for patients with cancer are rapidly evolving and their use is expanding, but not all patients will develop a response, and secondary toxicity can be significant and challenging. This is especially evident in hospitalized patients, where the economic cost derived from inpatient immune checkpoint inhibitor (ICI) administration is important and the clinical benefit is sometimes unclear. The poor overall outcomes evidenced in the ICI inpatient population in this study highlight the need to better identify the patients that will respond to these therapies, which will also help to decrease the financial burden imposed by these highly priced therapies.
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Affiliation(s)
- Sienna M Durbin
- Division of Hematology and Oncology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Leyre Zubiri
- Division of Hematology and Oncology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Andrzej Niemierko
- Division of Hematology and Oncology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Aditya Bardia
- Division of Hematology and Oncology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Ryan J Sullivan
- Division of Hematology and Oncology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Corey McEwen
- Department of Pharmacy, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Therese M Mulvey
- Division of Hematology and Oncology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Ian M Allen
- Division of Hematology and Oncology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Donald P Lawrence
- Division of Hematology and Oncology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Justine V Cohen
- Division of Oncology, Department of Medicine, University of Pennsylvania, Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Ephraim P Hochberg
- Division of Hematology and Oncology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - David P Ryan
- Division of Hematology and Oncology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Laura A Petrillo
- Division of Palliative Care and Geriatric Medicine, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Kerry L Reynolds
- Division of Hematology and Oncology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
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12
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Reynolds KL, Klempner SJ, Parikh A, Hochberg EP, Michaelson MD, Mooradian MJ, Lee RJ, Soumerai TE, Hobbs G, Piotrowska Z, Sykes DB, Farago AF, Bardia A, Rosovsky RP, Ryan DP. The Art of Oncology: COVID-19 Era. Oncologist 2020; 25:997-1000g. [PMID: 32697887 PMCID: PMC7405267 DOI: 10.1634/theoncologist.2020-0512] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Accepted: 07/06/2020] [Indexed: 11/17/2022] Open
Affiliation(s)
- Kerry L. Reynolds
- Division of Hematology and Oncology, Department of Medicine, Massachusetts General Hospital, Harvard Medical SchoolBostonMassachusettsUSA
| | - Samuel J. Klempner
- Division of Hematology and Oncology, Department of Medicine, Massachusetts General Hospital, Harvard Medical SchoolBostonMassachusettsUSA
| | - Aparna Parikh
- Division of Hematology and Oncology, Department of Medicine, Massachusetts General Hospital, Harvard Medical SchoolBostonMassachusettsUSA
| | - Ephraim P. Hochberg
- Division of Hematology and Oncology, Department of Medicine, Massachusetts General Hospital, Harvard Medical SchoolBostonMassachusettsUSA
| | - M. Dror Michaelson
- Division of Hematology and Oncology, Department of Medicine, Massachusetts General Hospital, Harvard Medical SchoolBostonMassachusettsUSA
| | - Meghan J. Mooradian
- Division of Hematology and Oncology, Department of Medicine, Massachusetts General Hospital, Harvard Medical SchoolBostonMassachusettsUSA
| | - Richard J. Lee
- Division of Hematology and Oncology, Department of Medicine, Massachusetts General Hospital, Harvard Medical SchoolBostonMassachusettsUSA
| | - Tara E. Soumerai
- Division of Hematology and Oncology, Department of Medicine, Massachusetts General Hospital, Harvard Medical SchoolBostonMassachusettsUSA
| | - Gabriela Hobbs
- Division of Hematology and Oncology, Department of Medicine, Massachusetts General Hospital, Harvard Medical SchoolBostonMassachusettsUSA
| | - Zofia Piotrowska
- Division of Hematology and Oncology, Department of Medicine, Massachusetts General Hospital, Harvard Medical SchoolBostonMassachusettsUSA
| | - David B. Sykes
- Division of Hematology and Oncology, Department of Medicine, Massachusetts General Hospital, Harvard Medical SchoolBostonMassachusettsUSA
| | - Anna F. Farago
- Division of Hematology and Oncology, Department of Medicine, Massachusetts General Hospital, Harvard Medical SchoolBostonMassachusettsUSA
| | - Aditya Bardia
- Division of Hematology and Oncology, Department of Medicine, Massachusetts General Hospital, Harvard Medical SchoolBostonMassachusettsUSA
| | - Rachel P. Rosovsky
- Division of Hematology and Oncology, Department of Medicine, Massachusetts General Hospital, Harvard Medical SchoolBostonMassachusettsUSA
| | - David P. Ryan
- Division of Hematology and Oncology, Department of Medicine, Massachusetts General Hospital, Harvard Medical SchoolBostonMassachusettsUSA
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13
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Hoppe RT, Advani RH, Ai WZ, Ambinder RF, Armand P, Bello CM, Benitez CM, Bierman PJ, Boughan KM, Dabaja B, Gordon LI, Hernandez-Ilizaliturri FJ, Herrera AF, Hochberg EP, Huang J, Johnston PB, Kaminski MS, Kenkre VP, Khan N, Lynch RC, Maddocks K, McConathy J, McKinney M, Metzger M, Morgan D, Mulroney C, Rabinovitch R, Rosenspire KC, Seropian S, Tao R, Winter JN, Yahalom J, Burns JL, Ogba N. Hodgkin Lymphoma, Version 2.2020, NCCN Clinical Practice Guidelines in Oncology. J Natl Compr Canc Netw 2020; 18:755-781. [DOI: 10.6004/jnccn.2020.0026] [Citation(s) in RCA: 50] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
The NCCN Clinical Practice Guidelines in Oncology for Hodgkin Lymphoma (HL) provide recommendations for the management of adult patients with HL. The NCCN panel meets at least annually to review comments from reviewers within their institutions, examine relevant data, and reevaluate and update their recommendations. Current management of classic HL involves initial treatment with chemotherapy alone or combined modality therapy followed by restaging with PET/CT to assess treatment response. Overall, the introduction of less toxic and more effective regimens has significantly advanced HL cure rates. This portion of the NCCN Guidelines focuses on the management of classic HL.
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Affiliation(s)
| | | | - Weiyun Z. Ai
- 2UCSF Helen Diller Family Comprehensive Cancer Center
| | | | | | | | | | | | - Kirsten M. Boughan
- 7Case Comprehensive Cancer Center/University Hospitals Seidman Cancer Center and Cleveland Clinic Taussig Cancer Institute
| | | | - Leo I. Gordon
- 9Robert H. Lurie Comprehensive Cancer Center of Northwestern University
| | | | | | | | - Jiayi Huang
- 13Siteman Cancer Center at Barnes-Jewish Hospital and Washington University School of Medicine
| | | | | | | | | | - Ryan C. Lynch
- 18Fred Hutchinson Cancer Research Center/Seattle Cancer Care Alliance
| | - Kami Maddocks
- 19The Ohio State University Comprehensive Cancer Center - James Cancer Hospital and Solove Research Institute
| | | | | | - Monika Metzger
- 22St. Jude Children’s Research Hospital/The University of Tennessee Health Science Center
| | | | | | | | | | | | - Randa Tao
- 28Huntsman Cancer Institute at the University of Utah
| | - Jane N. Winter
- 9Robert H. Lurie Comprehensive Cancer Center of Northwestern University
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14
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Newcomb RA, Nipp RD, Waldman LP, Greer JA, Lage DE, Hochberg EP, Jackson VA, Fuh C, Ryan DP, Temel JS, El‐Jawahri AR. Symptom burden in patients with cancer who are experiencing unplanned hospitalization. Cancer 2020; 126:2924-2933. [DOI: 10.1002/cncr.32833] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2019] [Revised: 11/17/2019] [Accepted: 12/20/2019] [Indexed: 11/08/2022]
Affiliation(s)
- Richard A. Newcomb
- Division of Hematology and Oncology Department of Medicine Massachusetts General Hospital Cancer Center Harvard Medical School Boston Massachusetts
| | - Ryan D. Nipp
- Division of Hematology and Oncology Department of Medicine Massachusetts General Hospital Cancer Center Harvard Medical School Boston Massachusetts
| | - Lauren P. Waldman
- Division of Hematology and Oncology Department of Medicine Massachusetts General Hospital Cancer Center Harvard Medical School Boston Massachusetts
| | - Joseph A. Greer
- Department of Psychiatry Massachusetts General Hospital Harvard Medical School Boston Massachusetts
| | - Daniel E. Lage
- Division of Hematology and Oncology Department of Medicine Massachusetts General Hospital Cancer Center Harvard Medical School Boston Massachusetts
| | - Ephraim P. Hochberg
- Division of Hematology and Oncology Department of Medicine Massachusetts General Hospital Cancer Center Harvard Medical School Boston Massachusetts
| | - Vicki A. Jackson
- Division of Palliative Care Department of Medicine Massachusetts General Hospital Harvard Medical School Boston Massachusetts
| | - Charn‐Xin Fuh
- Department of Psychiatry Massachusetts General Hospital Harvard Medical School Boston Massachusetts
| | - David P. Ryan
- Division of Hematology and Oncology Department of Medicine Massachusetts General Hospital Cancer Center Harvard Medical School Boston Massachusetts
| | - Jennifer S. Temel
- Division of Hematology and Oncology Department of Medicine Massachusetts General Hospital Cancer Center Harvard Medical School Boston Massachusetts
| | - Areej R. El‐Jawahri
- Division of Hematology and Oncology Department of Medicine Massachusetts General Hospital Cancer Center Harvard Medical School Boston Massachusetts
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15
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Davids MS, Brander DM, Kim HT, Tyekucheva S, Bsat J, Savell A, Hellman JM, Bazemore J, Francoeur K, Alencar A, Shune L, Omaira M, Jacobson CA, Armand P, Ng S, Crombie J, LaCasce AS, Arnason J, Hochberg EP, Takvorian RW, Abramson JS, Fisher DC, Brown JR. Ibrutinib plus fludarabine, cyclophosphamide, and rituximab as initial treatment for younger patients with chronic lymphocytic leukaemia: a single-arm, multicentre, phase 2 trial. Lancet Haematol 2019; 6:e419-e428. [PMID: 31208944 PMCID: PMC7036668 DOI: 10.1016/s2352-3026(19)30104-8] [Citation(s) in RCA: 56] [Impact Index Per Article: 11.2] [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: 05/17/2019] [Revised: 05/28/2019] [Accepted: 05/28/2019] [Indexed: 01/25/2023]
Abstract
BACKGROUND Fludarabine, cyclophosphamide, and rituximab (FCR) can improve disease-free survival for younger (age ≤65 years) fit patients with chronic lymphocytic leukaemia with mutated IGHV. However, patients with unmutated IGHV rarely have durable responses. Ibrutinib is active for patients with chronic lymphocytic leukaemia irrespective of IGHV mutation status but requires continuous treatment. We postulated that time-limited ibrutinib plus FCR would induce durable responses in younger fit patients with chronic lymphocytic leukaemia. METHODS We did a multicentre, open-label, non-randomised, single-arm phase 2 trial at seven sites in the USA. We enrolled patients aged 65 years or younger with previously untreated chronic lymphocytic leukaemia. Our initial cohort (original cohort) was not restricted by prognostic marker status and included patients who had del(17p) or TP53 aberrations. After a protocol amendment (on March 21, 2017), we enrolled an additional cohort (expansion cohort) that included patients without del(17p). Ibrutinib was given orally (420 mg/day) for 7 days, then up to six 28-day cycles were administered intravenously of fludarabine (25 mg/m2, days 1-3), cyclophosphamide (250 mg/m2, days 1-3), and rituximab (375 mg/m2 day 1 of cycle 1; 500 mg/m2 day 1 of cycles 2-6) with continuous oral ibrutinib (420 mg/day). Responders continued on ibrutinib maintenance for up to 2 years, and patients with undetectable minimal residual disease in bone marrow after 2 years were able to discontinue treatment. The primary endpoint was the proportion of patients who achieved a complete response with undetectable minimal residual disease in bone marrow 2 months after the last cycle of ibrutinib plus FCR. Analyses were done per-protocol in all patients who received at least one dose of study treatment. This trial is registered with ClinicalTrials.gov (NCT02251548) and is ongoing. FINDINGS Between Oct 23, 2014, and April 23, 2018, 85 patients with chronic lymphocytic leukaemia were enrolled. del(17p) was detected in four (5%) of 83 patients and TP53 mutations were noted in three (4%) of 81 patients; two patients had both del(17p) and TP53 mutations. Median patients' age was 55 years (IQR 50-58). At data cutoff, median follow-up was 16·5 months (IQR 10·6-34·1). A complete response and undetectable minimal residual disease in bone marrow 2 months after the last cycle of ibrutinib plus FCR was achieved by 28 (33%, 95% CI 0·23-0·44) of 85 patients (p=0·0035 compared with a 20% historical value with FCR alone). A best response of undetectable minimal residual disease in bone marrow was achieved by 71 (84%) of 85 patients during the study. One patient had disease progression and one patient died (sudden cardiac death after 17 months of ibrutinib maintenance, assessed as possibly related to ibrutinib). The most common all-grade toxic effects were haematological, including thrombocytopenia in 63 (74%) patients, neutropenia in 53 (62%), and anaemia in 41 (49%). Grade 3 or 4 non-haematological serious adverse events included grade 3 atrial fibrillation in three (4%) patients and grade 3 Pneumocystis jirovecii pneumonia in two (2%). INTERPRETATION The proportion of patients who achieved undetectable minimal residual disease in bone marrow with ibrutinib plus FCR is, to our knowledge, the highest ever published in patients with chronic lymphocytic leukaemia unrestricted by prognostic marker status. Ibrutinib plus FCR is promising as a time-limited combination regimen for frontline chronic lymphocytic leukaemia treatment in younger fit patients. FUNDING Pharmacyclics and the Leukemia & Lymphoma Society.
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Affiliation(s)
- Matthew S Davids
- Dana-Farber Cancer Institute, Department of Medical Oncology, Boston, MA, USA.
| | | | - Haesook T Kim
- Dana-Farber Cancer Institute, Department of Data Sciences, Harvard T H Chan School of Public Health, Department of Biostatistics, Boston, MA, USA
| | - Svitlana Tyekucheva
- Dana-Farber Cancer Institute, Department of Data Sciences, Harvard T H Chan School of Public Health, Department of Biostatistics, Boston, MA, USA
| | - Jad Bsat
- Dana-Farber Cancer Institute, Department of Medical Oncology, Boston, MA, USA
| | - Alexandra Savell
- Dana-Farber Cancer Institute, Department of Medical Oncology, Boston, MA, USA
| | - Jeffrey M Hellman
- Dana-Farber Cancer Institute, Department of Medical Oncology, Boston, MA, USA
| | - Josie Bazemore
- Dana-Farber Cancer Institute, Department of Medical Oncology, Boston, MA, USA
| | - Karen Francoeur
- Dana-Farber Cancer Institute, Department of Medical Oncology, Boston, MA, USA
| | - Alvaro Alencar
- University of Miami Sylvester Comprehensive Cancer Center, Department of Hematology and Oncology, Miami, FL, USA
| | - Leyla Shune
- University of Kansas Cancer Center, Department of Hematologic Malignancies, Westwood, KS, USA
| | - Mohammad Omaira
- West Michigan Cancer Center, Department of Medical Oncology, Kalamazoo, MI, USA
| | - Caron A Jacobson
- Dana-Farber Cancer Institute, Department of Medical Oncology, Boston, MA, USA
| | - Philippe Armand
- Dana-Farber Cancer Institute, Department of Medical Oncology, Boston, MA, USA
| | - Samuel Ng
- Dana-Farber Cancer Institute, Department of Medical Oncology, Boston, MA, USA
| | - Jennifer Crombie
- Dana-Farber Cancer Institute, Department of Medical Oncology, Boston, MA, USA
| | - Ann S LaCasce
- Dana-Farber Cancer Institute, Department of Medical Oncology, Boston, MA, USA
| | - Jon Arnason
- Beth Israel Deaconess Medical Center, Department of Medical Oncology, Boston, MA, USA
| | - Ephraim P Hochberg
- Massachusetts General Hospital, Department of Medical Oncology, Boston, MA, USA
| | - Ronald W Takvorian
- Massachusetts General Hospital, Department of Medical Oncology, Boston, MA, USA
| | - Jeremy S Abramson
- Massachusetts General Hospital, Department of Medical Oncology, Boston, MA, USA
| | - David C Fisher
- Dana-Farber Cancer Institute, Department of Medical Oncology, Boston, MA, USA
| | - Jennifer R Brown
- Dana-Farber Cancer Institute, Department of Medical Oncology, Boston, MA, USA
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Pablo-Trinidad A, Butterworth I, Ledesma-Carbayo MJ, Vettenburg T, Sánchez-Ferro Á, Soenksen L, Durr NJ, Muñoz-Barrutia A, Cerrato C, Humala K, Fabra Urdiol M, Del Rio C, Valles B, Chen YB, Hochberg EP, Castro-González C, Bourquard A. Automated detection of neutropenia using noninvasive video microscopy of superficial capillaries. Am J Hematol 2019; 94:E219-E222. [PMID: 31120579 PMCID: PMC6684956 DOI: 10.1002/ajh.25516] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2019] [Revised: 05/20/2019] [Accepted: 05/21/2019] [Indexed: 11/10/2022]
Affiliation(s)
- Alberto Pablo-Trinidad
- Biomedical Image Technologies, Universidad Politécnica de Madrid and CIBER-BBN, Madrid, Spain
- Leuko Labs Inc., Cambridge, Massachusetts
| | - Ian Butterworth
- Leuko Labs Inc., Cambridge, Massachusetts
- Research Laboratory of Electronics, Massachusetts Institute of Technology, Cambridge, Massachusetts
| | - María J Ledesma-Carbayo
- Biomedical Image Technologies, Universidad Politécnica de Madrid and CIBER-BBN, Madrid, Spain
| | - Tom Vettenburg
- Research Laboratory of Electronics, Massachusetts Institute of Technology, Cambridge, Massachusetts
| | - Álvaro Sánchez-Ferro
- Leuko Labs Inc., Cambridge, Massachusetts
- Research Laboratory of Electronics, Massachusetts Institute of Technology, Cambridge, Massachusetts
| | - Luis Soenksen
- Department of Mechanical Engineering, Massachusetts Institute of Technology, Cambridge, Massachusetts
| | - Nicholas J Durr
- Department of Biomedical Engineering, Johns Hopkins University, Baltimore, Maryland
| | - Arrate Muñoz-Barrutia
- Department of Bioengineering and Aerospace Engineering, Carlos III University of Madrid, Madrid, Spain
| | - Carolina Cerrato
- Departamento de Hematología, Hospital Universitario La Paz, Madrid, Spain
| | - Karem Humala
- Departamento de Hematología, Hospital Universitario La Paz, Madrid, Spain
| | - Marta Fabra Urdiol
- Departamento de Hematología, Hospital Universitario La Paz, Madrid, Spain
| | - Candice Del Rio
- Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, Massachusetts
| | - Betsy Valles
- Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, Massachusetts
| | - Yi-Bin Chen
- Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, Massachusetts
| | - Ephraim P Hochberg
- Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, Massachusetts
| | - Carlos Castro-González
- Biomedical Image Technologies, Universidad Politécnica de Madrid and CIBER-BBN, Madrid, Spain
- Leuko Labs Inc., Cambridge, Massachusetts
- Research Laboratory of Electronics, Massachusetts Institute of Technology, Cambridge, Massachusetts
| | - Aurélien Bourquard
- Biomedical Image Technologies, Universidad Politécnica de Madrid and CIBER-BBN, Madrid, Spain
- Leuko Labs Inc., Cambridge, Massachusetts
- Research Laboratory of Electronics, Massachusetts Institute of Technology, Cambridge, Massachusetts
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Karmali R, Abramson JS, Stephens DM, Barnes JA, Kaplan JB, Winter JN, Ma S, Petrich AM, Hochberg EP, Takvorian T, Nelson V, Gordon LI, Pro B. Ibrutinib maintenance following induction for untreated mantle cell lymphoma (MCL): Initial safety report. J Clin Oncol 2019. [DOI: 10.1200/jco.2019.37.15_suppl.7542] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
7542 Background: Maintenance rituximab in MCL has improved survival, though the optimal approach is not yet defined. Ibrutinib, a selective BTK inhibitor, has profound activity in R/R MCL. Ibrutinib maintenance (I-M) following induction for treatment-naive MCL has not been explored. We report preliminary results of a multicenter phase II trial assessing efficacy and safety of I-M for MCL after frontline induction. Methods: Patients with MCL with CR/PR to frontline chemo-immunotherapy (+/- autoSCT) received I-M 560 mg daily for up to 4 years. Primary objective was 3 year PFS rate. Secondary objectives were PR to CR conversions, median OS at 4 years and toxicity with MRD assessments planned. Results: Accrual is complete with 36 patients, median age of 60 (range 46-90), 28 males, 28 with advanced stage and 9 with extranodal disease. 18 (50%), 7 (19%) and 11 (31%) had low vs intermediate vs high risk MIPI respectively. 8/24 patients had a Ki-67 > / = 30%. For induction, 17 (47%) received BR, 18 (50%) a cytarabine-based regimen, 1 (3%) R-CHOP. 18 (50%) had autoSCT in CR1 prior to enrollment. 33 (92%) and 3 (8%) had CR and PR with induction respectively with 1 PR to CR conversion on I-M. At median follow-up of 19 mos, 24/36 (67%) patients remain on I-M (median 15 cycles, range 1-49) with 1 PD and 1 death. TRAEs led to dose reductions/interruptions in 25 (69%) patients, including permanent dose reductions in 7 (19%) and treatment discontinuation in 9 (25%; Table). 3 additional patients discontinued I-M, 1 for endometrial adenocarcinoma, 1 PD, 1 death, cause unknown. Conclusions: Ibrutinib maintenance is feasible in MCL patients who respond to frontline chemo-immunotherapy +/- autoSCT with manageable toxicities consistent with prior reports of ibrutinib. Additional follow-up and MRD status correlations with PFS and OS will provide insight on clinical relevance for this approach. Clinical trial information: NCT02242097. [Table: see text]
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Affiliation(s)
- Reem Karmali
- Northwestern University Feinberg School of Medicine; Robert H. Lurie Comprehensive Cancer Center of Northwestern University, Chicago, IL
| | - Jeremy S. Abramson
- Massachusetts General Hospital Cancer Center/Harvard Medical School, Boston, MA
| | | | - Jeffrey A. Barnes
- Massachusetts General Hospital Cancer Center; Harvard Medical School, Boston, MA
| | - Jason B. Kaplan
- Department of Medicine, Division of Hematology/Oncology, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Jane N. Winter
- Northwestern University Feinberg School of Medicine; Robert H. Lurie Comprehensive Cancer Center of Northwestern University, Chicago, IL
| | - Shuo Ma
- Northwestern University Feinberg School of Medicine; Robert H. Lurie Comprehensive Cancer Center of Northwestern University, Chicago, IL
| | | | - Ephraim P. Hochberg
- Massachusetts General Hospital Cancer Center; Harvard Medical School, Boston, MA
| | - Tak Takvorian
- Massachusetts General Hospital Cancer Center; Harvard Medical School, Boston, MA
| | | | - Leo I. Gordon
- Northwestern University, Feinberg School of Medicine, Robert H. Lurie Comprehensive Cancer Center, Chicago, IL
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Durbin S, Zubiri L, Niemierko A, Petrillo LA, Bardia A, Sullivan RJ, McEwan C, Mulvey TM, Allen IM, Lawrence DP, Cohen JV, Hochberg EP, Ryan DP, Reynolds KL. Clinical outcomes of patients with stage IV cancer receiving immune checkpoint inhibitors in the inpatient setting. J Clin Oncol 2019. [DOI: 10.1200/jco.2019.37.15_suppl.6634] [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
6634 Background: Immune checkpoint inhibitors (ICI) represent a major leap in the treatment of many cancers. Use has rapidly expanded in recent years, yet it is unknown whether hospitalized patients, who are often sicker than those who were studied in clinical trials, derive benefit from ICI. The primary objectives of this study were to characterize the clinical features and outcomes of inpatients receiving ICI at a single institution, and to identify predictors of survival. Methods: After IRB approval, we conducted a retrospective chart review of inpatients with Stage IV solid tumors receiving ICI between 2015 – 2018 at a tertiary care referral hospital. Patients receiving ICI on clinical trial were excluded. We examined the clinical characteristics, readmission rate, and post-discharge survival. We then conducted a Cox multivariable regression analysis to identify predictors of post-discharge survival. Results: A total of 103 patients with Stage IV solid tumors were treated with ICI as inpatients between 2015 – 2018. Average age was 57 years (range = 26 to 85); 57% were male; 27% had ECOG performance status (PS) 3-4; average Charlson Comorbidity Index score was 8.3. Most common tumor types were melanoma (35%) and lung (22%). Seventy-six percent began ICI as an inpatient and 24% received ICI as continuation of outpatient therapy. Seventeen percent experienced an immunotherapy related adverse event, most commonly colitis and pneumonitis. The 30 day readmission rate was 41%. The median post-discharge survival was 31 days; 47% of patients died during admission or within 30 days of discharge; 14% survived more than 6 months. Factors predictive of shorter post-discharge survival were PS of 3-4 relative to PS 0-2 (HR 2.0, p < 0.004), and lung cancer (HR 2.0, p < 0.024) and other tumor types (HR 2.1, p < 0.004) relative to melanoma. Conclusions: While the majority of inpatients receiving ICI died during admission or within 30 days of discharge, a subset of patients with stage IV disease were alive at 6 months. Tumor type and ECOG PS predict post-discharge survival and may be used to identify inpatients more likely to benefit from ICI. These novel findings, which are unique to a single institution, require additional validation.
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Affiliation(s)
| | - Leyre Zubiri
- Massachusetts General Hospital Cancer Center, Boston, MA
| | | | - Laura A Petrillo
- Massachusetts General Hospital Division of Palliative Care and Geriatric Medicine, Boston, MA
| | - Aditya Bardia
- Massachusetts General Hospital Cancer Center, Boston, MA
| | | | - Corey McEwan
- Massachusetts General Hospital Pharmacy Department, Boston, MA
| | | | | | | | | | | | - David P. Ryan
- Massachusetts General Hospital Cancer Center, Boston, MA
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19
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Soumerai JD, Davids MS, Werner L, Fisher DC, Armand P, Amrein PC, Neuberg D, Hochberg EP, Brown JR, Abramson JS. Phase 1 study of lenalidomide, bendamustine, and rituximab in previously untreated patients with chronic lymphocytic leukemia. Leuk Lymphoma 2019; 60:2931-2938. [DOI: 10.1080/10428194.2019.1608533] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
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20
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Johnson PC, Xiao Y, Wong RL, D'Arpino S, Moran SMC, Lage DE, Temel B, Ruddy M, Traeger LN, Greer JA, Hochberg EP, Temel JS, El-Jawahri A, Nipp RD. Potentially Avoidable Hospital Readmissions in Patients With Advanced Cancer. J Oncol Pract 2019; 15:e420-e427. [PMID: 30946642 DOI: 10.1200/jop.18.00595] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
PURPOSE Patients with cancer often prefer to avoid time in the hospital; however, data are lacking on the prevalence and predictors of potentially avoidable readmissions (PARs) among those with advanced cancer. METHODS We enrolled patients with advanced cancer from September 2, 2014, to November 21, 2014, who had an unplanned hospitalization and assessed their patient-reported symptom burden (Edmonton Symptom Assessment System) at the time of admission. For 1 year after enrollment, we reviewed patients' health records to determine the primary reason for every hospital readmission and we classified readmissions as PARs using adapted Graham's criteria. We examined predictors of PARs using nonlinear mixed-effects models with binomial distribution. RESULTS We enrolled 200 (86.2%) of 232 patients who were approached. For these 200 patients, we reviewed 277 total hospital readmissions and identified 108 (39.0%) of these as PARs. The most common reasons for PARs were premature discharge from a prior hospitalization (30.6%) and failure of timely follow-up (28.7%). PAR hospitalizations were more likely than non-PAR hospitalizations to experience symptoms as the primary reason for admission (28.7% v 13.0%; P = .001). We found that married patients were less likely to experience PARs (odds ratio, 0.30; 95% CI, 0.15 to 0.57; P < .001) and that those with a higher physical symptom burden were more likely to experience PARs (odds ratio, 1.03; 95% CI, 1.01 to 1.05; P = .012). CONCLUSION We observed that a substantial proportion of hospital readmissions are potentially avoidable and found that patients' symptom burdens predict PARs. These findings underscore the need to assess and address the symptom burden of hospitalized patients with advanced cancer in this highly symptomatic population.
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Affiliation(s)
- P Connor Johnson
- 1 Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, MA
| | - Yian Xiao
- 2 Boston Medical Center, Boston University School of Medicine, Boston, MA
| | | | - Sara D'Arpino
- 1 Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, MA
| | - Samantha M C Moran
- 1 Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, MA
| | - Daniel E Lage
- 1 Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, MA
| | - Brandon Temel
- 1 Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, MA
| | - Margaret Ruddy
- 1 Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, MA
| | - Lara N Traeger
- 1 Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, MA
| | - Joseph A Greer
- 1 Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, MA
| | - Ephraim P Hochberg
- 1 Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, MA
| | - Jennifer S Temel
- 1 Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, MA
| | - Areej El-Jawahri
- 1 Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, MA
| | - Ryan D Nipp
- 1 Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, MA
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Nipp RD, El-Jawahri A, Ruddy M, Fuh C, Temel B, D'Arpino SM, Cashavelly BJ, Jackson VA, Ryan DP, Hochberg EP, Greer JA, Temel JS. Pilot randomized trial of an electronic symptom monitoring intervention for hospitalized patients with cancer. Ann Oncol 2019; 30:274-280. [PMID: 30395144 PMCID: PMC6386022 DOI: 10.1093/annonc/mdy488] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [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: 11/13/2022] Open
Abstract
BACKGROUND Hospitalized patients with cancer experience a high symptom burden, which is associated with poor health outcomes and increased health care utilization. However, studies investigating symptom monitoring interventions in this population are lacking. We conducted a pilot randomized trial to assess the feasibility and preliminary efficacy of a symptom monitoring intervention to improve symptom management in hospitalized patients with advanced cancer. PATIENTS AND METHODS We randomly assigned patients with advanced cancer who were admitted to the inpatient oncology service to a symptom monitoring intervention or usual care. Patients in both arms self-reported their symptoms daily (Edmonton Symptom Assessment System and Patient Health Questionnaire-4). Patients assigned to the intervention had their symptom reports presented graphically with alerts for moderate/severe symptoms during daily team rounds. The primary end point of the study was feasibility. We defined the intervention as feasible if >75% of participants hospitalized >2 days completed >2 symptom reports. We observed daily rounds to determine whether clinicians discussed and developed a plan to address patients' symptoms. We used regression models to assess intervention effects on patients' symptoms throughout their hospitalization, readmission risk, and hospital length of stay (LOS). RESULTS Among 150 enrolled patients (81.1% enrollment), 94.2% completed >2 symptom reports. Clinicians discussed 60.4% of the symptom reports and developed a plan to address the symptoms highlighted by the symptom reports 20.8% of the time. Compared with usual care, intervention patients had a greater proportion of days with lower psychological distress (B = 0.12, P = 0.008), but no significant difference in the proportion of days with improved Edmonton Symptom Assessment System-physical symptoms (B = 0.07, P = 0.138). Intervention patients had lower readmission risk (hazard ratio = 0.68, P = 0.224), although this difference was not significant. We found no significant intervention effects on hospital LOS (B = 0.16, P = 0.862). CONCLUSIONS This symptom monitoring intervention is feasible and demonstrates encouraging preliminary efficacy for improving patients' symptoms and readmission risk.ClinicalTrials.gov identifier NCT02891993.
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Affiliation(s)
- R D Nipp
- Division of Hematology and Oncology, Department of Medicine, Massachusetts General Hospital & Harvard Medical School, Boston, USA.
| | - A El-Jawahri
- Division of Hematology and Oncology, Department of Medicine, Massachusetts General Hospital & Harvard Medical School, Boston, USA
| | - M Ruddy
- Division of Hematology and Oncology, Department of Medicine, Massachusetts General Hospital & Harvard Medical School, Boston, USA
| | - C Fuh
- Division of Hematology and Oncology, Department of Medicine, Massachusetts General Hospital & Harvard Medical School, Boston, USA
| | - B Temel
- Division of Hematology and Oncology, Department of Medicine, Massachusetts General Hospital & Harvard Medical School, Boston, USA
| | - S M D'Arpino
- Department of Psychiatry, Massachusetts General Hospital & Harvard Medical School, Boston, USA
| | - B J Cashavelly
- Division of Hematology and Oncology, Department of Medicine, Massachusetts General Hospital & Harvard Medical School, Boston, USA
| | - V A Jackson
- Division of Palliative Care, Department of Medicine, Massachusetts General Hospital & Harvard Medical School, Boston, USA
| | - D P Ryan
- Division of Hematology and Oncology, Department of Medicine, Massachusetts General Hospital & Harvard Medical School, Boston, USA
| | - E P Hochberg
- Division of Hematology and Oncology, Department of Medicine, Massachusetts General Hospital & Harvard Medical School, Boston, USA
| | - J A Greer
- Department of Psychiatry, Massachusetts General Hospital & Harvard Medical School, Boston, USA
| | - J S Temel
- Division of Hematology and Oncology, Department of Medicine, Massachusetts General Hospital & Harvard Medical School, Boston, USA
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Waldman L, Newcomb R, Nipp RD, Hochberg EP, Jackson V, Greer J, Ryan DP, Temel JS, El-Jawahri A. Symptom burden in hospitalized patients with curable and incurable cancers. J Clin Oncol 2018. [DOI: 10.1200/jco.2018.36.34_suppl.190] [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
190 Background: Inpatient supportive care interventions are targeted to patients with advanced solid tumors due to perceived higher symptom burden. Yet, few studies have characterized symptom prevalence in hospitalized patients with curable cancers. We aimed to describe and compare symptom burden and palliative care utilization in hospitalized patients with curable and incurable cancers to determine the allocation of such supportive care resources. Methods: We conducted a single center study of 1549 patients (238 curable hematologic, 239 curable solid, 123 incurable hematologic, 949 incurable solid cancers) who experienced an unplanned hospitalization between 9/14 - 4/17. On admission, we assessed patients’ physical symptoms (Edmonton Symptom Assessment System) and psychological distress (Patient Health Questionnaire - 4 and Primary Care PTSD Screen). Results: The median number of moderate to severe symptoms reported by patients with curable hematologic, curable solid, incurable hematologic, and incurable solid cancers were 5 [3-6], 5 [3-7], 5 [4-6], and 6 [4-7], respectively. Most patients reported moderate to severe fatigue (83.6%, 82.9%, 81.3%, 86.9%). Table 1 depicts rates of psychological distress. In adjusted analyses patients with incurable solid cancers reported higher symptom burden (β = 7.6, p < 0.01), depression (β = 0.4, p = 0.01), and anxiety (β = 0.3, p = 0.03) symptoms, but no difference in PTSD symptoms. Among patients in top quartile of symptom burden, palliative care was consulted in 16.2%, 7.9%, 23.8%, and 49.6% (p < 0.01) of patients with curable hematologic, curable solid, incurable hematologic, and incurable solid cancers, respectively. Conclusions: Hospitalized patients with solid and hematologic cancers experience substantial physical and psychological symptoms regardless of the curability of their illness. Palliative care is rarely consulted for highly symptomatic patients with curable cancers. Inpatient supportive care interventions should target the needs of all highly symptomatic patients with cancer. [Table: see text]
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Parikh AR, Soriano M, Hochberg EP, McLeish C, Lennes IT, Souza E, Mulvey TM. Pilot study of iPad-based patient-reported outcomes at the MGH Cancer Center. J Clin Oncol 2018. [DOI: 10.1200/jco.2018.36.30_suppl.190] [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
190 Background: Patient reported outcomes (PROs) have been shown to improve outcomes in cancer patients in clinical trials and have also been shown to improve the patient experience, provide real-time access to patient reported symptoms and are increasingly used across disciplines. Given the importance of PROs, at the MGH Cancer Center, we implemented a pilot using iPADs to capture patient reported outcomes for patients receiving IV chemotherapy in the breast and lymphoma clinics as well all IV chemotherapy patients at one of the MGH satellite clinics where patients across all disease groups are seen. Methods: 12 measures from the PRO-CTCAE were selected to be applicable to all cancer patients. Working with the technology team and EPIC team at MGH the selected PROs were loaded into iPADs and are automatically assigned to patients receiving IV chemotherapy. Staff and clinicians were trained in the breast, lymphoma and satellite clinic. Patient who were receiving IV chemotherapy were assigned iPADs at check in. Patients completed the questionnaire and in real-time, the data was available in the EPIC chart. The objectives of the pilot were to assess the feasibility of collecting iPAD based PROs at the MGH Cancer Center. Results: In the 4-month pilot, there were 2,304 visit types that were eligible to receive an iPAD for PRO collection, 79% (N = 1,1816) patients were assigned an iPAD. Of the 1,816 patients assigned an iPAD, 65% (N = 1,173) patients completed the PROs, 4% (N = 36) partially completed the PROs. In terms of completion at the main disease specialty clinic vs the satellite, completion rates were higher at the satellite (77% vs 44%). During one week, we asked the front desk to record why patients did not complete the PROs-93 patients were assessed, 45% of patient refused the iPAD, in 28% of these patients the staff did not capture the reason and 22% were not given an iPAD. Conclusions: This pilot demonstrates the feasibility of collecting PROs in an oncology clinic for patients receiving IV chemotherapy. We plan to continue to improve the assignment of PROs to eligible patients, educate staff, providers and patients on the important of PROs and plan to expand to all the clinics at MGH Cancer Center and satellite centers.
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Wong RL, El-Jawahri A, D'Arpino SM, Fuh CX, Johnson PC, Lage DE, Irwin KE, Pirl WF, Traeger L, Cashavelly BJ, Jackson VA, Greer JA, Ryan DP, Hochberg EP, Temel JS, Nipp RD. Use of Antidepressant Medications Moderates the Relationship Between Depressive Symptoms and Hospital Length of Stay in Patients with Advanced Cancer. Oncologist 2018; 24:117-124. [PMID: 30082486 PMCID: PMC6324633 DOI: 10.1634/theoncologist.2018-0096] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2018] [Accepted: 05/31/2018] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND Among patients with cancer, depressive symptoms are associated with worse clinical outcomes, including greater health care utilization. As use of antidepressant medications can improve depressive symptoms, we sought to examine relationships among depressive symptoms, antidepressant medications, and hospital length of stay (LOS) in patients with advanced cancer. MATERIALS AND METHODS From September 2014 to May 2016, we prospectively enrolled patients with advanced cancer who had an unplanned hospitalization. We performed chart review to obtain information regarding documented depressive symptoms in the 3 months prior to admission and use of antidepressant medications at the time of admission. We compared differences in hospital LOS by presence or absence of depressive symptoms and used adjusted linear regression to examine if antidepressant medications moderated these outcomes. RESULTS Of 1,036 patients, 126 (12.2%) had depressive symptoms documented prior to admission, and 288 (27.8%) were taking antidepressant medications at the time of admission. Patients with depressive symptoms experienced longer hospital LOS (7.25 vs. 6.13 days; p = .036). Use of antidepressant medications moderated this relationship; among patients not on antidepressant medications, depressive symptoms were associated with longer hospital LOS (7.88 vs. 6.11 days; p = .025), but among those on antidepressant medications, depressive symptoms were not associated with hospital LOS (6.57 vs. 6.17 days; p = .578). CONCLUSION Documented depressive symptoms prior to hospital admission were associated with longer hospital LOS. This effect was restricted to patients not on antidepressant medications. Future studies are needed to investigate if use of antidepressant medications decreases LOS for patients hospitalized with advanced cancer and the mechanisms by which this may occur. IMPLICATIONS FOR PRACTICE This study investigated the prevalence of documented depressive symptoms in patients with advanced cancer in the 3 months prior to an unplanned hospitalization and the prevalence of use of antidepressant medications at time of hospital admission. The relationship of these variables with hospital length of stay was also examined, and it was found that documented depressive symptoms were associated with prolonged hospital length of stay. Interestingly, antidepressant medications moderated the relationship between depressive symptoms and hospital length of stay. These findings support the need to recognize and address depressive symptoms among patients with advanced cancer, with potential implications for optimizing health care utilization.
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Affiliation(s)
- Risa L Wong
- Division of Hematology & Oncology, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Areej El-Jawahri
- Division of Hematology & Oncology, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Sara M D'Arpino
- Department of Psychiatry, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Charn-Xin Fuh
- Department of Psychiatry, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - P Connor Johnson
- Division of Hematology & Oncology, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Daniel E Lage
- Division of Hematology & Oncology, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Kelly E Irwin
- Department of Psychiatry, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - William F Pirl
- Department of Psychiatry, Sylvester Comprehensive Cancer Center and University of Miami, Miami, Florida, USA
| | - Lara Traeger
- Department of Psychiatry, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Barbara J Cashavelly
- Division of Hematology & Oncology, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Vicki A Jackson
- Division of Palliative Care, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Joseph A Greer
- Department of Psychiatry, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - David P Ryan
- Division of Hematology & Oncology, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Ephraim P Hochberg
- Division of Hematology & Oncology, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Jennifer S Temel
- Division of Hematology & Oncology, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Ryan D Nipp
- Division of Hematology & Oncology, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
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Barnes JA, Redd R, Fisher DC, Hochberg EP, Takvorian T, Neuberg D, Jacobsen E, Abramson JS. Panobinostat in combination with rituximab in heavily pretreated diffuse large B-cell lymphoma: Results of a phase II study. Hematol Oncol 2018; 36:633-637. [PMID: 29956350 DOI: 10.1002/hon.2515] [Citation(s) in RCA: 12] [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: 04/20/2018] [Accepted: 04/21/2018] [Indexed: 11/08/2022]
Abstract
This is a phase II study of panobinostat, an oral pan-HDAC inhibitor, combined with rituximab in patients with relapsed diffuse large B cell lymphoma. Panobinostat was administered orally 3 times a week every other week on a 28-day cycle. Rituximab was administered weekly during the first cycle, then on Day 1 of cycles 2 to 6. Patients without disease progression after 6 cycles continued panobinostat monotherapy for up to 6 additional cycles in the absence of disease progression. Eighteen eligible subjects were enrolled, and 18 were evaluable for response. The overall response rate was 11% (90% CI [2%-34%]) with 2 subjects having a partial response. The duration of response in these subjects was 51 and 60 days. Five additional subjects had stable disease with 3 subjects having tumor reduction between 27 and 44%, not meeting criteria for partial response. One subject with stable disease remained on therapy a total of 12 cycles. The most common toxicities while on study were thrombocytopenia (14 patients, 78%); fatigue (11, 61%); anemia (10, 56%); diarrhea (8, 44%); and nausea, lymphopenia, anorexia, and hypophosphatemia (5 each, 28% of patients), the majority of which was grade 2 or less. These data indicate that the combination of panobinostat with rituximab is able to induce responses in a limited number of subjects with relapsed diffuse large B cell lymphoma.
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Affiliation(s)
- Jeffrey A Barnes
- Massachusetts General Hospital Cancer Center, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Robert Redd
- Dana-Farber Cancer Institute, Boston, MA, USA
| | | | - Ephraim P Hochberg
- Massachusetts General Hospital Cancer Center, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Tak Takvorian
- Massachusetts General Hospital Cancer Center, Dana-Farber Cancer Institute, Boston, MA, USA
| | | | | | - Jeremy S Abramson
- Massachusetts General Hospital Cancer Center, Dana-Farber Cancer Institute, Boston, MA, USA
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26
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Nipp RD, El-Jawahri A, D'Arpino SM, Chan A, Fuh CX, Johnson PC, Lage DE, Wong RL, Pirl WF, Traeger L, Cashavelly BJ, Jackson VA, Ryan DP, Hochberg EP, Temel JS, Greer JA. Symptoms of posttraumatic stress disorder among hospitalized patients with cancer. Cancer 2018; 124:3445-3453. [PMID: 29905935 DOI: 10.1002/cncr.31576] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [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: 03/18/2018] [Revised: 05/01/2018] [Accepted: 05/07/2018] [Indexed: 12/21/2022]
Abstract
BACKGROUND Patients with cancer experience many stressors placing them at risk for posttraumatic stress disorder (PTSD) symptoms, yet little is known about factors associated with PTSD symptoms in this population. This study explored relationships among patients' PTSD symptoms, physical and psychological symptom burden, and risk for hospital readmissions. METHODS We prospectively enrolled patients with cancer admitted for an unplanned hospitalization from August 2015-April 2017. Upon admission, we assessed patients' PTSD symptoms (Primary Care PTSD Screen), as well as physical (Edmonton Symptom Assessment System [ESAS]) and psychological (Patient Health Questionnaire 4 [PHQ-4]) symptoms. We examined associations between PTSD symptoms and patients' physical and psychological symptom burden using linear regression. We evaluated relationships between PTSD symptoms and unplanned hospital readmissions within 90-days using Cox regression. RESULTS We enrolled 954 of 1,087 (87.8%) patients approached, and 127 (13.3%) screened positive for PTSD symptoms. The 90-day hospital readmission rate was 38.9%. Younger age, female sex, greater comorbidities, and genitourinary cancer type were associated with higher PTSD scores. Patients' PTSD symptoms were associated with physical symptoms (ESAS physical: B = 3.41; P < .001), the total symptom burden (ESAS total: B = 5.97; P < .001), depression (PHQ-4 depression: B = 0.67; P < .001), and anxiety symptoms (PHQ-4 anxiety: B = 0.71; P < .001). Patients' PTSD symptoms were associated with a lower risk of hospital readmissions (hazard ratio, 0.81; P = .001). CONCLUSIONS A high proportion of hospitalized patients with cancer experience PTSD symptoms, which are associated with a greater physical and psychological symptom burden and a lower risk of hospital readmissions. Interventions to address patients' PTSD symptoms are needed and should account for their physical and psychological symptom burden. Cancer 2018. © 2018 American Cancer Society.
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Affiliation(s)
- Ryan D Nipp
- Division of Hematology and Oncology, Department of Medicine, Massachusetts General Hospital Cancer Center and Harvard Medical School, Boston, Massachusetts
| | - Areej El-Jawahri
- Division of Hematology and Oncology, Department of Medicine, Massachusetts General Hospital Cancer Center and Harvard Medical School, Boston, Massachusetts
| | - Sara M D'Arpino
- Department of Psychiatry, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Andy Chan
- Division of Hematology and Oncology, Department of Medicine, Massachusetts General Hospital Cancer Center and Harvard Medical School, Boston, Massachusetts
| | - Charn-Xin Fuh
- Department of Psychiatry, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - P Connor Johnson
- Division of Hematology and Oncology, Department of Medicine, Massachusetts General Hospital Cancer Center and Harvard Medical School, Boston, Massachusetts
| | - Daniel E Lage
- Division of Hematology and Oncology, Department of Medicine, Massachusetts General Hospital Cancer Center and Harvard Medical School, Boston, Massachusetts
| | - Risa L Wong
- Division of Hematology and Oncology, Department of Medicine, Massachusetts General Hospital Cancer Center and Harvard Medical School, Boston, Massachusetts
| | - William F Pirl
- Department of Psychiatry, Sylvester Comprehensive Cancer Center and University of Miami, Miami, Florida
| | - Lara Traeger
- Department of Psychiatry, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Barbara J Cashavelly
- Division of Hematology and Oncology, Department of Medicine, Massachusetts General Hospital Cancer Center and Harvard Medical School, Boston, Massachusetts
| | - Vicki A Jackson
- Division of Palliative Care, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - David P Ryan
- Division of Hematology and Oncology, Department of Medicine, Massachusetts General Hospital Cancer Center and Harvard Medical School, Boston, Massachusetts
| | - Ephraim P Hochberg
- Division of Hematology and Oncology, Department of Medicine, Massachusetts General Hospital Cancer Center and Harvard Medical School, Boston, Massachusetts
| | - Jennifer S Temel
- Division of Hematology and Oncology, Department of Medicine, Massachusetts General Hospital Cancer Center and Harvard Medical School, Boston, Massachusetts
| | - Joseph A Greer
- Department of Psychiatry, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
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27
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Fuh CX, Ruddy M, Temel B, D'arpino S, Cashavelly BJ, Hochberg EP, Jackson V, Greer J, Ryan DP, El-Jawahri A, Temel JS, Nipp RD. Randomized trial of a symptom monitoring intervention for hospitalized patients with cancer. J Clin Oncol 2018. [DOI: 10.1200/jco.2018.36.15_suppl.10005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
| | | | - Brandon Temel
- Massachusetts General Hospital Cancer Center, Boston, MA
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28
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Reynolds KL, Cohen JV, Ryan DP, Hochberg EP, Dougan M, Thomas M, Guidon A, Channick C, Chen ST, Schoenfeld S, Sise M, Leaf R, Neilan TG, Chu JN, Hur C, Murciano-Goroff Y, Villani AC, Nasrallah M, Sullivan RJ, Bardia A. Severe immune-related adverse effects (irAE) requiring hospital admission in patients treated with immune checkpoint inhibitors for advanced malignancy: Temporal trends and clinical significance. J Clin Oncol 2018. [DOI: 10.1200/jco.2018.36.15_suppl.3096] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | | | - Chin Hur
- Institute for Technology Assessment, Massachusetts General Hospital, Boston, MA
| | | | | | | | | | - Aditya Bardia
- Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, MA
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29
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Newcomb R, Nipp RD, Chan AT, Hochberg EP, Jackson VA, Cashavelly BJ, Wong RL, Greer J, Ryan DP, Temel JS, El-Jawahri A. Symptom burden in hospitalized patients with curable and incurable cancers. J Clin Oncol 2018. [DOI: 10.1200/jco.2018.36.15_suppl.10004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
| | | | - Andrew T. Chan
- Massachusetts General Hospital/Harvard Medical School, Boston, MA
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30
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Bourquard A, Pablo-Trinidad A, Butterworth I, Sánchez-Ferro Á, Cerrato C, Humala K, Fabra Urdiola M, Del Rio C, Valles B, Tucker-Schwartz JM, Lee ES, Vakoc BJ, Padera TP, Ledesma-Carbayo MJ, Chen YB, Hochberg EP, Gray ML, Castro-González C. Non-invasive detection of severe neutropenia in chemotherapy patients by optical imaging of nailfold microcirculation. Sci Rep 2018; 8:5301. [PMID: 29593221 PMCID: PMC5871877 DOI: 10.1038/s41598-018-23591-0] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [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: 11/17/2017] [Accepted: 03/15/2018] [Indexed: 01/06/2023] Open
Abstract
White-blood-cell (WBC) assessment is employed for innumerable clinical procedures as one indicator of immune status. Currently, WBC determinations are obtained by clinical laboratory analysis of whole blood samples. Both the extraction of blood and its analysis limit the accessibility and frequency of the measurement. In this study, we demonstrate the feasibility of a non-invasive device to perform point-of-care WBC analysis without the need for blood draws, focusing on a chemotherapy setting where patients’ neutrophils—the most common type of WBC—become very low. In particular, we built a portable optical prototype, and used it to collect 22 microcirculatory-video datasets from 11 chemotherapy patients. Based on these videos, we identified moving optical absorption gaps in the flow of red cells, using them as proxies to WBC movement through nailfold capillaries. We then showed that counting these gaps allows discriminating cases of severe neutropenia (<500 neutrophils per µL), associated with increased risks of life-threatening infections, from non-neutropenic cases (>1,500 neutrophils per µL). This result suggests that the integration of optical imaging, consumer electronics, and data analysis can make non-invasive screening for severe neutropenia accessible to patients. More generally, this work provides a first step towards a long-term objective of non-invasive WBC counting.
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Affiliation(s)
- Aurélien Bourquard
- Research Laboratory of Electronics, Massachusetts Institute of Technology, Cambridge, MA, USA. .,Biomedical Image Technologies, Universidad Politécnica de Madrid and CIBER-BBN, Madrid, Spain.
| | - Alberto Pablo-Trinidad
- Biomedical Image Technologies, Universidad Politécnica de Madrid and CIBER-BBN, Madrid, Spain
| | - Ian Butterworth
- Research Laboratory of Electronics, Massachusetts Institute of Technology, Cambridge, MA, USA
| | - Álvaro Sánchez-Ferro
- Research Laboratory of Electronics, Massachusetts Institute of Technology, Cambridge, MA, USA.,Centro Integral en Neurociencias HM CINAC, HM Hospitales, Móstoles, Madrid, Spain
| | - Carolina Cerrato
- Departamento de Hematología, Hospital Universitario La Paz, Madrid, Spain
| | - Karem Humala
- Departamento de Hematología, Hospital Universitario La Paz, Madrid, Spain
| | | | - Candice Del Rio
- Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, MA, USA
| | - Betsy Valles
- Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, MA, USA
| | - Jason M Tucker-Schwartz
- Research Laboratory of Electronics, Massachusetts Institute of Technology, Cambridge, MA, USA
| | - Elizabeth S Lee
- Institute of Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, MA, USA
| | - Benjamin J Vakoc
- Wellman Center for Photomedicine, Harvard Medical School and Massachusetts General Hospital, Boston, MA, USA
| | - Timothy P Padera
- Edwin L. Steele Laboratories, Department of Radiation Oncology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - María J Ledesma-Carbayo
- Biomedical Image Technologies, Universidad Politécnica de Madrid and CIBER-BBN, Madrid, Spain
| | - Yi-Bin Chen
- Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, MA, USA
| | - Ephraim P Hochberg
- Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, MA, USA
| | - Martha L Gray
- Research Laboratory of Electronics, Massachusetts Institute of Technology, Cambridge, MA, USA.,Institute of Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, MA, USA
| | - Carlos Castro-González
- Research Laboratory of Electronics, Massachusetts Institute of Technology, Cambridge, MA, USA. .,Biomedical Image Technologies, Universidad Politécnica de Madrid and CIBER-BBN, Madrid, Spain.
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Hoppe RT, Advani RH, Ai WZ, Ambinder RF, Aoun P, Armand P, Bello CM, Benitez CM, Bierman PJ, Chen R, Dabaja B, Dean R, Forero A, Gordon LI, Hernandez-Ilizaliturri FJ, Hochberg EP, Huang J, Johnston PB, Kaminski MS, Kenkre VP, Khan N, Maddocks K, Maloney DG, Metzger M, Moore JO, Morgan D, Moskowitz CH, Mulroney C, Rabinovitch R, Seropian S, Tao R, Winter JN, Yahalom J, Burns JL, Ogba N. NCCN Guidelines Insights: Hodgkin Lymphoma, Version 1.2018. J Natl Compr Canc Netw 2018. [DOI: 10.6004/jnccn.2018.0013] [Citation(s) in RCA: 41] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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Hoppe RT, Advani RH, Ai WZ, Ambinder RF, Aoun P, Bello CM, Benitez CM, Bernat K, Bierman PJ, Blum KA, Chen R, Dabaja B, Forero A, Gordon LI, Hernandez-Ilizaliturri FJ, Hochberg EP, Huang J, Johnston PB, Kaminski MS, Kenkre VP, Khan N, Maloney DG, Mauch PM, Metzger M, Moore JO, Morgan D, Moskowitz CH, Mulroney C, Poppe M, Rabinovitch R, Seropian S, Smith M, Winter JN, Yahalom J, Burns J, Ogba N, Sundar H. Hodgkin Lymphoma Version 1.2017, NCCN Clinical Practice Guidelines in Oncology. J Natl Compr Canc Netw 2017; 15:608-638. [PMID: 28476741 DOI: 10.6004/jnccn.2017.0064] [Citation(s) in RCA: 67] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
This portion of the NCCN Guidelines for Hodgkin lymphoma (HL) focuses on the management of classical HL. Current management of classical HL involves initial treatment with chemotherapy or combined modality therapy followed by restaging with PET/CT to assess treatment response using the Deauville criteria (5-point scale). The introduction of less toxic and more effective regimens has significantly advanced HL cure rates. However, long-term follow-up after completion of treatment is essential to determine potential long-term effects.
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33
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Lage DE, Nipp RD, D'Arpino SM, Moran SM, Johnson PC, Wong RL, Pirl WF, Hochberg EP, Traeger LN, Jackson VA, Cashavelly BJ, Martinson HS, Greer JA, Ryan DP, Temel JS, El-Jawahri A. Predictors of Posthospital Transitions of Care in Patients With Advanced Cancer. J Clin Oncol 2017; 36:76-82. [PMID: 29068784 DOI: 10.1200/jco.2017.74.0340] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Purpose Patients with advanced cancer experience potentially burdensome transitions of care after hospitalizations. We examined predictors of discharge location and assessed the relationship between discharge location and survival in this population. Methods We conducted a prospective study of 932 patients with advanced cancer who experienced an unplanned hospitalization between September 2014 and March 2016. Upon admission, we assessed patients' physical symptoms (Edmonton Symptom Assessment System) and psychological distress (Patient Health Questionnaire-4). The primary outcome was discharge location (home without hospice, postacute care [PAC], or hospice [any setting]). The secondary outcome was survival. Results Of 932 patients, 726 (77.9%) were discharged home without hospice, 118 (12.7%) were discharged to PAC, and 88 (9.4%) to hospice. Those discharged to PAC and hospice reported high rates of severe symptoms, including dyspnea, constipation, low appetite, fatigue, depression, and anxiety. Using logistic regression, patients discharged to PAC or hospice versus home without hospice were more likely to be older (odds ratio [OR], 1.03; 95% CI, 1.02 to 1.05; P < .001), live alone (OR, 1.95; 95% CI, 1.25 to 3.02; P < .003), have impaired mobility (OR, 5.08; 95% CI, 3.46 to 7.45; P < .001), longer hospital stays (OR, 1.15; 95% CI, 1.11 to 1.20; P < .001), higher Edmonton Symptom Assessment System physical symptoms (OR, 1.02; 95% CI, 1.003 to 1.032; P < .017), and higher Patient Health Questionnaire-4 depression symptoms (OR, 1.13; 95% CI, 1.01 to 1.25; P < .027). Patients discharged to hospice rather than PAC were more likely to receive palliative care consultation (OR, 4.44; 95% CI, 2.12 to 9.29; P < .001) and have shorter hospital stays (OR, 0.84; 95% CI, 0.77 to 0.91; P < .001). Patients discharged to PAC versus home had lower survival (hazard ratio, 1.53; 95% CI, 1.22 to 1.93; P < .001). Conclusion Patients with advanced cancer who were discharged to PAC facilities and hospice had substantial physical and psychological symptom burden, impaired physical function, and inferior survival compared with those discharged to home. These patients may benefit from interventions to enhance their quality of life and care.
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Affiliation(s)
- Daniel E Lage
- Daniel E. Lage, Ryan D. Nipp, Sara M. D'Arpino, Samantha M. Moran, P. Connor Johnson, Risa L. Wong, Ephraim P. Hochberg, Barbara J. Cashavelly, Holly S. Martinson, David P. Ryan, Jennifer S. Temel, and Areej El-Jawahri, Massachusetts General Hospital Cancer Center; Daniel E. Lage, Ryan D. Nipp, P. Connor Johnson, Risa L. Wong, Ephraim P. Hochberg, Lara N. Traeger, Vicki A. Jackson, Joseph A. Greer, David P. Ryan, Jennifer S. Temel, and Areej El-Jawahri, Harvard Medical School; Lara N. Traeger, Vicki A. Jackson, and Joseph A. Greer, Massachusetts General Hospital, Boston, MA; and William F. Pirl, Sylvester Comprehensive Cancer Center and University of Miami, Miami, FL
| | - Ryan D Nipp
- Daniel E. Lage, Ryan D. Nipp, Sara M. D'Arpino, Samantha M. Moran, P. Connor Johnson, Risa L. Wong, Ephraim P. Hochberg, Barbara J. Cashavelly, Holly S. Martinson, David P. Ryan, Jennifer S. Temel, and Areej El-Jawahri, Massachusetts General Hospital Cancer Center; Daniel E. Lage, Ryan D. Nipp, P. Connor Johnson, Risa L. Wong, Ephraim P. Hochberg, Lara N. Traeger, Vicki A. Jackson, Joseph A. Greer, David P. Ryan, Jennifer S. Temel, and Areej El-Jawahri, Harvard Medical School; Lara N. Traeger, Vicki A. Jackson, and Joseph A. Greer, Massachusetts General Hospital, Boston, MA; and William F. Pirl, Sylvester Comprehensive Cancer Center and University of Miami, Miami, FL
| | - Sara M D'Arpino
- Daniel E. Lage, Ryan D. Nipp, Sara M. D'Arpino, Samantha M. Moran, P. Connor Johnson, Risa L. Wong, Ephraim P. Hochberg, Barbara J. Cashavelly, Holly S. Martinson, David P. Ryan, Jennifer S. Temel, and Areej El-Jawahri, Massachusetts General Hospital Cancer Center; Daniel E. Lage, Ryan D. Nipp, P. Connor Johnson, Risa L. Wong, Ephraim P. Hochberg, Lara N. Traeger, Vicki A. Jackson, Joseph A. Greer, David P. Ryan, Jennifer S. Temel, and Areej El-Jawahri, Harvard Medical School; Lara N. Traeger, Vicki A. Jackson, and Joseph A. Greer, Massachusetts General Hospital, Boston, MA; and William F. Pirl, Sylvester Comprehensive Cancer Center and University of Miami, Miami, FL
| | - Samantha M Moran
- Daniel E. Lage, Ryan D. Nipp, Sara M. D'Arpino, Samantha M. Moran, P. Connor Johnson, Risa L. Wong, Ephraim P. Hochberg, Barbara J. Cashavelly, Holly S. Martinson, David P. Ryan, Jennifer S. Temel, and Areej El-Jawahri, Massachusetts General Hospital Cancer Center; Daniel E. Lage, Ryan D. Nipp, P. Connor Johnson, Risa L. Wong, Ephraim P. Hochberg, Lara N. Traeger, Vicki A. Jackson, Joseph A. Greer, David P. Ryan, Jennifer S. Temel, and Areej El-Jawahri, Harvard Medical School; Lara N. Traeger, Vicki A. Jackson, and Joseph A. Greer, Massachusetts General Hospital, Boston, MA; and William F. Pirl, Sylvester Comprehensive Cancer Center and University of Miami, Miami, FL
| | - P Connor Johnson
- Daniel E. Lage, Ryan D. Nipp, Sara M. D'Arpino, Samantha M. Moran, P. Connor Johnson, Risa L. Wong, Ephraim P. Hochberg, Barbara J. Cashavelly, Holly S. Martinson, David P. Ryan, Jennifer S. Temel, and Areej El-Jawahri, Massachusetts General Hospital Cancer Center; Daniel E. Lage, Ryan D. Nipp, P. Connor Johnson, Risa L. Wong, Ephraim P. Hochberg, Lara N. Traeger, Vicki A. Jackson, Joseph A. Greer, David P. Ryan, Jennifer S. Temel, and Areej El-Jawahri, Harvard Medical School; Lara N. Traeger, Vicki A. Jackson, and Joseph A. Greer, Massachusetts General Hospital, Boston, MA; and William F. Pirl, Sylvester Comprehensive Cancer Center and University of Miami, Miami, FL
| | - Risa L Wong
- Daniel E. Lage, Ryan D. Nipp, Sara M. D'Arpino, Samantha M. Moran, P. Connor Johnson, Risa L. Wong, Ephraim P. Hochberg, Barbara J. Cashavelly, Holly S. Martinson, David P. Ryan, Jennifer S. Temel, and Areej El-Jawahri, Massachusetts General Hospital Cancer Center; Daniel E. Lage, Ryan D. Nipp, P. Connor Johnson, Risa L. Wong, Ephraim P. Hochberg, Lara N. Traeger, Vicki A. Jackson, Joseph A. Greer, David P. Ryan, Jennifer S. Temel, and Areej El-Jawahri, Harvard Medical School; Lara N. Traeger, Vicki A. Jackson, and Joseph A. Greer, Massachusetts General Hospital, Boston, MA; and William F. Pirl, Sylvester Comprehensive Cancer Center and University of Miami, Miami, FL
| | - William F Pirl
- Daniel E. Lage, Ryan D. Nipp, Sara M. D'Arpino, Samantha M. Moran, P. Connor Johnson, Risa L. Wong, Ephraim P. Hochberg, Barbara J. Cashavelly, Holly S. Martinson, David P. Ryan, Jennifer S. Temel, and Areej El-Jawahri, Massachusetts General Hospital Cancer Center; Daniel E. Lage, Ryan D. Nipp, P. Connor Johnson, Risa L. Wong, Ephraim P. Hochberg, Lara N. Traeger, Vicki A. Jackson, Joseph A. Greer, David P. Ryan, Jennifer S. Temel, and Areej El-Jawahri, Harvard Medical School; Lara N. Traeger, Vicki A. Jackson, and Joseph A. Greer, Massachusetts General Hospital, Boston, MA; and William F. Pirl, Sylvester Comprehensive Cancer Center and University of Miami, Miami, FL
| | - Ephraim P Hochberg
- Daniel E. Lage, Ryan D. Nipp, Sara M. D'Arpino, Samantha M. Moran, P. Connor Johnson, Risa L. Wong, Ephraim P. Hochberg, Barbara J. Cashavelly, Holly S. Martinson, David P. Ryan, Jennifer S. Temel, and Areej El-Jawahri, Massachusetts General Hospital Cancer Center; Daniel E. Lage, Ryan D. Nipp, P. Connor Johnson, Risa L. Wong, Ephraim P. Hochberg, Lara N. Traeger, Vicki A. Jackson, Joseph A. Greer, David P. Ryan, Jennifer S. Temel, and Areej El-Jawahri, Harvard Medical School; Lara N. Traeger, Vicki A. Jackson, and Joseph A. Greer, Massachusetts General Hospital, Boston, MA; and William F. Pirl, Sylvester Comprehensive Cancer Center and University of Miami, Miami, FL
| | - Lara N Traeger
- Daniel E. Lage, Ryan D. Nipp, Sara M. D'Arpino, Samantha M. Moran, P. Connor Johnson, Risa L. Wong, Ephraim P. Hochberg, Barbara J. Cashavelly, Holly S. Martinson, David P. Ryan, Jennifer S. Temel, and Areej El-Jawahri, Massachusetts General Hospital Cancer Center; Daniel E. Lage, Ryan D. Nipp, P. Connor Johnson, Risa L. Wong, Ephraim P. Hochberg, Lara N. Traeger, Vicki A. Jackson, Joseph A. Greer, David P. Ryan, Jennifer S. Temel, and Areej El-Jawahri, Harvard Medical School; Lara N. Traeger, Vicki A. Jackson, and Joseph A. Greer, Massachusetts General Hospital, Boston, MA; and William F. Pirl, Sylvester Comprehensive Cancer Center and University of Miami, Miami, FL
| | - Vicki A Jackson
- Daniel E. Lage, Ryan D. Nipp, Sara M. D'Arpino, Samantha M. Moran, P. Connor Johnson, Risa L. Wong, Ephraim P. Hochberg, Barbara J. Cashavelly, Holly S. Martinson, David P. Ryan, Jennifer S. Temel, and Areej El-Jawahri, Massachusetts General Hospital Cancer Center; Daniel E. Lage, Ryan D. Nipp, P. Connor Johnson, Risa L. Wong, Ephraim P. Hochberg, Lara N. Traeger, Vicki A. Jackson, Joseph A. Greer, David P. Ryan, Jennifer S. Temel, and Areej El-Jawahri, Harvard Medical School; Lara N. Traeger, Vicki A. Jackson, and Joseph A. Greer, Massachusetts General Hospital, Boston, MA; and William F. Pirl, Sylvester Comprehensive Cancer Center and University of Miami, Miami, FL
| | - Barbara J Cashavelly
- Daniel E. Lage, Ryan D. Nipp, Sara M. D'Arpino, Samantha M. Moran, P. Connor Johnson, Risa L. Wong, Ephraim P. Hochberg, Barbara J. Cashavelly, Holly S. Martinson, David P. Ryan, Jennifer S. Temel, and Areej El-Jawahri, Massachusetts General Hospital Cancer Center; Daniel E. Lage, Ryan D. Nipp, P. Connor Johnson, Risa L. Wong, Ephraim P. Hochberg, Lara N. Traeger, Vicki A. Jackson, Joseph A. Greer, David P. Ryan, Jennifer S. Temel, and Areej El-Jawahri, Harvard Medical School; Lara N. Traeger, Vicki A. Jackson, and Joseph A. Greer, Massachusetts General Hospital, Boston, MA; and William F. Pirl, Sylvester Comprehensive Cancer Center and University of Miami, Miami, FL
| | - Holly S Martinson
- Daniel E. Lage, Ryan D. Nipp, Sara M. D'Arpino, Samantha M. Moran, P. Connor Johnson, Risa L. Wong, Ephraim P. Hochberg, Barbara J. Cashavelly, Holly S. Martinson, David P. Ryan, Jennifer S. Temel, and Areej El-Jawahri, Massachusetts General Hospital Cancer Center; Daniel E. Lage, Ryan D. Nipp, P. Connor Johnson, Risa L. Wong, Ephraim P. Hochberg, Lara N. Traeger, Vicki A. Jackson, Joseph A. Greer, David P. Ryan, Jennifer S. Temel, and Areej El-Jawahri, Harvard Medical School; Lara N. Traeger, Vicki A. Jackson, and Joseph A. Greer, Massachusetts General Hospital, Boston, MA; and William F. Pirl, Sylvester Comprehensive Cancer Center and University of Miami, Miami, FL
| | - Joseph A Greer
- Daniel E. Lage, Ryan D. Nipp, Sara M. D'Arpino, Samantha M. Moran, P. Connor Johnson, Risa L. Wong, Ephraim P. Hochberg, Barbara J. Cashavelly, Holly S. Martinson, David P. Ryan, Jennifer S. Temel, and Areej El-Jawahri, Massachusetts General Hospital Cancer Center; Daniel E. Lage, Ryan D. Nipp, P. Connor Johnson, Risa L. Wong, Ephraim P. Hochberg, Lara N. Traeger, Vicki A. Jackson, Joseph A. Greer, David P. Ryan, Jennifer S. Temel, and Areej El-Jawahri, Harvard Medical School; Lara N. Traeger, Vicki A. Jackson, and Joseph A. Greer, Massachusetts General Hospital, Boston, MA; and William F. Pirl, Sylvester Comprehensive Cancer Center and University of Miami, Miami, FL
| | - David P Ryan
- Daniel E. Lage, Ryan D. Nipp, Sara M. D'Arpino, Samantha M. Moran, P. Connor Johnson, Risa L. Wong, Ephraim P. Hochberg, Barbara J. Cashavelly, Holly S. Martinson, David P. Ryan, Jennifer S. Temel, and Areej El-Jawahri, Massachusetts General Hospital Cancer Center; Daniel E. Lage, Ryan D. Nipp, P. Connor Johnson, Risa L. Wong, Ephraim P. Hochberg, Lara N. Traeger, Vicki A. Jackson, Joseph A. Greer, David P. Ryan, Jennifer S. Temel, and Areej El-Jawahri, Harvard Medical School; Lara N. Traeger, Vicki A. Jackson, and Joseph A. Greer, Massachusetts General Hospital, Boston, MA; and William F. Pirl, Sylvester Comprehensive Cancer Center and University of Miami, Miami, FL
| | - Jennifer S Temel
- Daniel E. Lage, Ryan D. Nipp, Sara M. D'Arpino, Samantha M. Moran, P. Connor Johnson, Risa L. Wong, Ephraim P. Hochberg, Barbara J. Cashavelly, Holly S. Martinson, David P. Ryan, Jennifer S. Temel, and Areej El-Jawahri, Massachusetts General Hospital Cancer Center; Daniel E. Lage, Ryan D. Nipp, P. Connor Johnson, Risa L. Wong, Ephraim P. Hochberg, Lara N. Traeger, Vicki A. Jackson, Joseph A. Greer, David P. Ryan, Jennifer S. Temel, and Areej El-Jawahri, Harvard Medical School; Lara N. Traeger, Vicki A. Jackson, and Joseph A. Greer, Massachusetts General Hospital, Boston, MA; and William F. Pirl, Sylvester Comprehensive Cancer Center and University of Miami, Miami, FL
| | - Areej El-Jawahri
- Daniel E. Lage, Ryan D. Nipp, Sara M. D'Arpino, Samantha M. Moran, P. Connor Johnson, Risa L. Wong, Ephraim P. Hochberg, Barbara J. Cashavelly, Holly S. Martinson, David P. Ryan, Jennifer S. Temel, and Areej El-Jawahri, Massachusetts General Hospital Cancer Center; Daniel E. Lage, Ryan D. Nipp, P. Connor Johnson, Risa L. Wong, Ephraim P. Hochberg, Lara N. Traeger, Vicki A. Jackson, Joseph A. Greer, David P. Ryan, Jennifer S. Temel, and Areej El-Jawahri, Harvard Medical School; Lara N. Traeger, Vicki A. Jackson, and Joseph A. Greer, Massachusetts General Hospital, Boston, MA; and William F. Pirl, Sylvester Comprehensive Cancer Center and University of Miami, Miami, FL
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Nipp RD, El-Jawahri A, Moran SM, D'Arpino SM, Johnson PC, Lage DE, Wong RL, Pirl WF, Traeger L, Lennes IT, Cashavelly BJ, Jackson VA, Greer JA, Ryan DP, Hochberg EP, Temel JS. The relationship between physical and psychological symptoms and health care utilization in hospitalized patients with advanced cancer. Cancer 2017; 123:4720-4727. [PMID: 29057450 DOI: 10.1002/cncr.30912] [Citation(s) in RCA: 135] [Impact Index Per Article: 19.3] [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: 05/24/2017] [Revised: 06/28/2017] [Accepted: 07/05/2017] [Indexed: 01/14/2023]
Abstract
BACKGROUND Patients with advanced cancer often experience frequent and prolonged hospitalizations; however, the factors associated with greater health care utilization have not been described. We sought to investigate the relation between patients' physical and psychological symptom burden and health care utilization. METHODS We enrolled patients with advanced cancer and unplanned hospitalizations from September 2014-May 2016. Upon admission, we assessed physical (Edmonton Symptom Assessment System [ESAS]) and psychological symptoms (Patient Health Questionnaire 4 [PHQ-4]). We examined the relationship between symptom burden and healthcare utilization using linear regression for hospital length of stay (LOS) and Cox regression for time to first unplanned readmission within 90 days. We adjusted all models for age, sex, marital status, comorbidity, education, time since advanced cancer diagnosis, and cancer type. RESULTS We enrolled 1,036 of 1,152 (89.9%) consecutive patients approached. Over one-half reported moderate/severe fatigue, poor well being, drowsiness, pain, and lack of appetite. PHQ-4 scores indicated that 28.8% and 28.0% of patients had depression and anxiety symptoms, respectively. The mean hospital LOS was 6.3 days, and the 90-day readmission rate was 43.1%. Physical symptoms (ESAS: unstandardized coefficient [B], 0.06; P < .001), psychological distress (PHQ-4 total: B, 0.11; P = .040), and depression symptoms (PHQ-4 depression: B, 0.22; P = .017) were associated with longer hospital LOS. Physical (ESAS: hazard ratio, 1.01; P < .001), and anxiety symptoms (PHQ-4 anxiety: hazard ratio, 1.06; P = .045) were associated with a higher likelihood for readmission. CONCLUSIONS Hospitalized patients with advanced cancer experience a high symptom burden, which is significantly associated with prolonged hospitalizations and readmissions. Interventions are needed to address the symptom burden of this population to improve health care delivery and utilization. Cancer 2017;123:4720-4727. © 2017 American Cancer Society.
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Affiliation(s)
- Ryan D Nipp
- Department of Medicine, Division of Hematology and Oncology, Massachusetts General Hospital Cancer Center and Harvard Medical School, Boston, Massachusetts
| | - Areej El-Jawahri
- Department of Medicine, Division of Hematology and Oncology, Massachusetts General Hospital Cancer Center and Harvard Medical School, Boston, Massachusetts
| | - Samantha M Moran
- Department of Psychiatry, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Sara M D'Arpino
- Department of Psychiatry, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - P Connor Johnson
- Department of Medicine, Division of Hematology and Oncology, Massachusetts General Hospital Cancer Center and Harvard Medical School, Boston, Massachusetts
| | - Daniel E Lage
- Department of Medicine, Division of Hematology and Oncology, Massachusetts General Hospital Cancer Center and Harvard Medical School, Boston, Massachusetts
| | - Risa L Wong
- Department of Medicine, Division of Hematology and Oncology, Massachusetts General Hospital Cancer Center and Harvard Medical School, Boston, Massachusetts
| | - William F Pirl
- Department of Psychiatry, Sylvester Comprehensive Cancer Center and University of Miami, Miami, Florida
| | - Lara Traeger
- Department of Psychiatry, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Inga T Lennes
- Department of Medicine, Division of Hematology and Oncology, Massachusetts General Hospital Cancer Center and Harvard Medical School, Boston, Massachusetts
| | - Barbara J Cashavelly
- Department of Medicine, Division of Hematology and Oncology, Massachusetts General Hospital Cancer Center and Harvard Medical School, Boston, Massachusetts
| | - Vicki A Jackson
- Department of Medicine, Division of Palliative Care, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Joseph A Greer
- Department of Psychiatry, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - David P Ryan
- Department of Medicine, Division of Hematology and Oncology, Massachusetts General Hospital Cancer Center and Harvard Medical School, Boston, Massachusetts
| | - Ephraim P Hochberg
- Department of Medicine, Division of Hematology and Oncology, Massachusetts General Hospital Cancer Center and Harvard Medical School, Boston, Massachusetts
| | - Jennifer S Temel
- Department of Medicine, Division of Hematology and Oncology, Massachusetts General Hospital Cancer Center and Harvard Medical School, Boston, Massachusetts
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Ryan RJH, Petrovic J, Rausch DM, Zhou Y, Lareau CA, Kluk MJ, Christie AL, Lee WY, Tarjan DR, Guo B, Donohue LKH, Gillespie SM, Nardi V, Hochberg EP, Blacklow SC, Weinstock DM, Faryabi RB, Bernstein BE, Aster JC, Pear WS. A B Cell Regulome Links Notch to Downstream Oncogenic Pathways in Small B Cell Lymphomas. Cell Rep 2017; 21:784-797. [PMID: 29045844 PMCID: PMC5687286 DOI: 10.1016/j.celrep.2017.09.066] [Citation(s) in RCA: 55] [Impact Index Per Article: 7.9] [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: 04/05/2017] [Revised: 07/26/2017] [Accepted: 09/20/2017] [Indexed: 12/12/2022] Open
Abstract
Gain-of-function Notch mutations are recurrent in mature small B cell lymphomas such as mantle cell lymphoma (MCL) and chronic lymphocytic leukemia (CLL), but the Notch target genes that contribute to B cell oncogenesis are largely unknown. We performed integrative analysis of Notch-regulated transcripts, genomic binding of Notch transcription complexes, and genome conformation data to identify direct Notch target genes in MCL cell lines. This B cell Notch regulome is largely controlled through Notch-bound distal enhancers and includes genes involved in B cell receptor and cytokine signaling and the oncogene MYC, which sustains proliferation of Notch-dependent MCL cell lines via a Notch-regulated lineage-restricted enhancer complex. Expression of direct Notch target genes is associated with Notch activity in an MCL xenograft model and in CLL lymph node biopsies. Our findings provide key insights into the role of Notch in MCL and other B cell malignancies and have important implications for therapeutic targeting of Notch-dependent oncogenic pathways.
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Affiliation(s)
- Russell J H Ryan
- Department of Pathology, Massachusetts General Hospital, Boston, MA 02114, USA; Broad Institute of MIT and Harvard University, Cambridge, MA 02142, USA
| | - Jelena Petrovic
- Department of Pathology and Laboratory Medicine, Abramson Family Cancer Research Institute, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Dylan M Rausch
- Department of Pathology, Massachusetts General Hospital, Boston, MA 02114, USA; Broad Institute of MIT and Harvard University, Cambridge, MA 02142, USA
| | - Yeqiao Zhou
- Department of Pathology and Laboratory Medicine, Abramson Family Cancer Research Institute, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Caleb A Lareau
- Department of Pathology, Massachusetts General Hospital, Boston, MA 02114, USA; Broad Institute of MIT and Harvard University, Cambridge, MA 02142, USA
| | - Michael J Kluk
- Department of Pathology, Weill Cornell School of Medicine, New York, NY 10065, USA
| | - Amanda L Christie
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA 02115, USA
| | - Winston Y Lee
- Department of Pathology, Brigham and Women's Hospital, Boston, MA 02115, USA
| | - Daniel R Tarjan
- Department of Pathology, Massachusetts General Hospital, Boston, MA 02114, USA; Broad Institute of MIT and Harvard University, Cambridge, MA 02142, USA
| | - Bingqian Guo
- Department of Biological Chemistry and Molecular Pharmacology, Harvard Medical School, Boston, MA 02115, USA
| | - Laura K H Donohue
- Department of Pathology, Massachusetts General Hospital, Boston, MA 02114, USA; Broad Institute of MIT and Harvard University, Cambridge, MA 02142, USA
| | - Shawn M Gillespie
- Department of Pathology, Massachusetts General Hospital, Boston, MA 02114, USA; Broad Institute of MIT and Harvard University, Cambridge, MA 02142, USA
| | - Valentina Nardi
- Department of Pathology, Massachusetts General Hospital, Boston, MA 02114, USA
| | - Ephraim P Hochberg
- Department of Medicine, MGH Cancer Center, Massachusetts General Hospital, Boston, MA 02140, USA
| | - Stephen C Blacklow
- Department of Biological Chemistry and Molecular Pharmacology, Harvard Medical School, Boston, MA 02115, USA
| | - David M Weinstock
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA 02115, USA
| | - Robert B Faryabi
- Department of Pathology and Laboratory Medicine, Abramson Family Cancer Research Institute, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Bradley E Bernstein
- Department of Pathology, Massachusetts General Hospital, Boston, MA 02114, USA; Broad Institute of MIT and Harvard University, Cambridge, MA 02142, USA.
| | - Jon C Aster
- Department of Pathology, Brigham and Women's Hospital, Boston, MA 02115, USA.
| | - Warren S Pear
- Department of Pathology and Laboratory Medicine, Abramson Family Cancer Research Institute, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA 19104, USA.
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El-Jawahri A, Lau-Min K, Nipp RD, Greer JA, Traeger LN, Moran SM, D'Arpino SM, Hochberg EP, Jackson VA, Cashavelly BJ, Martinson HS, Ryan DP, Temel JS. Processes of code status transitions in hospitalized patients with advanced cancer. Cancer 2017; 123:4895-4902. [PMID: 28881383 DOI: 10.1002/cncr.30969] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2017] [Revised: 08/06/2017] [Accepted: 08/08/2017] [Indexed: 11/10/2022]
Abstract
BACKGROUND Although hospitalized patients with advanced cancer have a low chance of surviving cardiopulmonary resuscitation (CPR), the processes by which they change their code status from full code to do not resuscitate (DNR) are unknown. METHODS We conducted a mixed-methods study on a prospective cohort of hospitalized patients with advanced cancer. Two physicians used a consensus-driven medical record review to characterize processes that led to code status order transitions from full code to DNR. RESULTS In total, 1047 hospitalizations were reviewed among 728 patients. Admitting clinicians did not address code status in 53% of hospitalizations, resulting in code status orders of "presumed full." In total, 275 patients (26.3%) transitioned from full code to DNR, and 48.7% (134 of 275 patients) of those had an order of "presumed full" at admission; however, upon further clarification, the patients expressed that they had wished to be DNR before the hospitalization. We identified 3 additional processes leading to order transition from full code to DNR acute clinical deterioration (15.3%), discontinuation of cancer-directed therapy (17.1%), and education about the potential harms/futility of CPR (15.3%). Compared with discontinuing therapy and education, transitions because of acute clinical deterioration were associated with less patient involvement (P = .002), a shorter time to death (P < .001), and a greater likelihood of inpatient death (P = .005). CONCLUSIONS One-half of code status order changes among hospitalized patients with advanced cancer were because of full code orders in patients who had a preference for DNR before hospitalization. Transitions due of acute clinical deterioration were associated with less patient engagement and a higher likelihood of inpatient death. Cancer 2017;123:4895-902. © 2017 American Cancer Society.
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Affiliation(s)
- Areej El-Jawahri
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts.,Division of Hematology/Oncology, Massachusetts General Hospital, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
| | - Kelsey Lau-Min
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
| | - Ryan D Nipp
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
| | - Joseph A Greer
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
| | - Lara N Traeger
- Harvard Medical School, Boston, Massachusetts.,Department of Psychiatry, Massachusetts General Hospital, Boston, Massachusetts
| | - Samantha M Moran
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
| | - Sara M D'Arpino
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
| | - Ephraim P Hochberg
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
| | - Vicki A Jackson
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
| | | | - Holly S Martinson
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - David P Ryan
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
| | - Jennifer S Temel
- Harvard Medical School, Boston, Massachusetts.,Department of Psychiatry, Massachusetts General Hospital, Boston, Massachusetts
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Lage DE, Nipp RD, D'Arpino S, Moran SM, Hochberg EP, Traeger L, Jackson VA, Cashavelly BJ, Martinson HS, Ryan DP, Greer JA, Temel JS, El-Jawahri A. Post-discharge transitions of care for hospitalized patients with advanced cancer. J Clin Oncol 2017. [DOI: 10.1200/jco.2017.35.15_suppl.6504] [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
6504 Background: Patients with advanced cancer experience frequent hospitalizations and burdensome transitions of care post-discharge. We examined predictors of discharge location for patients with advanced cancer. Methods: We prospectively enrolled patients with advanced cancer with unplanned hospitalizations from 9/14 to 3/16. Upon admission, we used the Edmonton Symptom Assessment Scale and Patient Health Questionnaire-4 to assess physical and psychological symptoms, respectively. We used logistic regression models to identify predictors of discharge to location other than home, including post-acute care (PAC) [skilled nursing facility or long term acute care hospital] or hospice [any setting]. We used Cox regression models adjusted for clinical variables to assess the relationship between discharge location and survival. Results: Out of 932 patients, 726 (77.9%) were discharged home, 118 (12.7%) to PAC and 88 (9.4%) to hospice. Compared with patients discharged home, those discharged to PAC or hospice had higher symptom burden, including dyspnea, constipation, low appetite, drowsiness, fatigue, depression, and anxiety (all p < 0.05). Patients discharged to PAC or hospice vs. home were more likely to be older (OR 1.03, p < 0.0001), live alone (OR 1.95, 95% CI: 1.25-3.02, p < 0.003), have impaired mobility (OR 5.08, 95% CI: 3.46-7.45, p < 0.0001), longer length of stay (OR 1.15, 95% CI: 1.11-1.20, p < 0.0001), higher ESAS physical symptoms (OR 1.02, 95% CI: 1.003-1.032, p < 0.017), and higher PHQ-2 depression symptoms (OR 1.13, 95% CI: 1.01-1.25, p < 0.027). Patients discharged to hospice vs. PAC were more likely to receive palliative care consultation (OR 4.44, 95% CI: 2.12 to 9.29, p < 0.0001) and have shorter length of stay (OR 0.84, 95% CI: 0.77 to 0.91, p < 0.0001). Compared with patients discharged home, those discharged to PAC had lower survival (HR 1.53, 95% CI 1.22-1.93, p < 0.0001). Conclusions: Patients with advanced cancer discharged to PAC or hospice have substantial physical and psychological symptom burden and poor physical function. Patients discharged to PAC also have inferior survival compared with those discharged home. They may benefit from targeted interventions to improve their quality of life and care.
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Affiliation(s)
| | - Ryan David Nipp
- Department of Medical Oncology, Massachusetts General Hospital, Boston, MA
| | | | | | | | | | | | | | | | - David P. Ryan
- Cancer Center at the Massachusetts General Hospital, Boston, MA
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D'Arpino S, El-Jawahri A, Moran SM, Johnson C, Lage D, Wong R, Xiao Y, Ruddy M, Temel B, Pirl WF, Traeger L, Lennes IT, Cashavelly BJ, Martinson HS, Jackson VA, Greer JA, Ryan DP, Hochberg EP, Temel JS, Nipp RD. Symptom burden and hospital length of stay among patients with curable cancer. J Clin Oncol 2017. [DOI: 10.1200/jco.2017.35.15_suppl.6579] [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
6579 Background: Prolonged hospital admissions are often inconsistent with patients’ preferences and incur significant costs. While patients’ symptoms may result in hospitalizations, the relationship between patients’ symptom burden and their hospital length-of-stay (LOS) has not been fully explored in patients with curable cancers. Methods: We prospectively enrolled patients with curable cancer and unplanned hospital admissions between 8/2015 and 12/2016. Within the first 5 days of admission, we assessed patients’ physical (Edmonton Symptom Assessment System [ESAS]; scored 0-10 with higher scores indicating greater symptom burden) and psychological symptoms (Patient Health Questionnaire 4 [PHQ-4]; scored categorically and continuous with higher scores indicating greater distress). We created summated ESAS total and physical symptom variables. To assess the relationship between patients’ symptom burden and their hospital LOS, we used separate linear regression models adjusted for age, sex, marital status, education level, time since cancer diagnosis, and cancer type. Results: We enrolled 452 of 497 (91%) approached patients (mean age = 61.9 years; 188 [42%] female). Over half had hematologic cancers (n = 249, 55%). Mean hospital LOS was 8.3 days. Over one-tenth of patients screened positive for PHQ-4 depression (n = 74, 16%) and anxiety (n = 60, 13%) symptoms. Mean ESAS symptom scores were highest for fatigue (6.6), drowsiness (5.4), pain (4.9), and lack of appetite (4.8). In multivariable regression analysis, patients’ physical and psychological symptoms were associated with longer hospital LOS (table). Conclusions: Patients with curable cancer and unplanned hospital admissions experience a substantial symptom burden, which predicts for prolonged hospitalizations. Importantly, patients’ symptoms are modifiable risk factors that, if properly addressed, can improve care delivery and may have the potential to help decrease prolonged hospitalizations. [Table: see text]
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Affiliation(s)
| | | | | | | | | | - Risa Wong
- Massachusetts General Hospital, Boston, MA
| | - Yian Xiao
- Boston University School of Medicine, Boston, MA
| | | | - Brandon Temel
- Massachusetts General Hospital Cancer Center, Boston, MA
| | - William F. Pirl
- Sylvester Comprehensive Cancer Center, University of Miami, Miami, FL
| | | | | | | | | | | | | | - David P. Ryan
- Cancer Center at the Massachusetts General Hospital, Boston, MA
| | | | | | - Ryan David Nipp
- Department of Medical Oncology, Massachusetts General Hospital, Boston, MA
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Wong R, El-Jawahri A, Irwin K, D'Arpino S, Moran SM, Johnson C, Lage D, Ruddy M, Temel B, Traeger L, Lennes IT, Cashavelly BJ, Martinson HS, Jackson V, Greer JA, Ryan DP, Hochberg EP, Pirl WF, Temel JS, Nipp RD. The importance of recognizing and addressing depression in patients with advanced cancer. J Clin Oncol 2017. [DOI: 10.1200/jco.2017.35.15_suppl.10050] [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
10050 Background: Patients with cancer often experience depression, which is associated with worse outcomes, including longer hospital length of stay (LOS). Although antidepressant medication can improve depressive symptoms in patients with cancer, it is unclear whether their use translates into better outcomes. We sought to clarify the relationship between depressive symptoms, antidepressant medication, and hospital LOS in patients with advanced cancer. Methods: We enrolled hospitalized patients with advanced cancer from 9/2014 to 4/2016 as part of a longitudinal data repository. We examined patients’ medical records to obtain information about documented depressive symptoms in the 3 months prior to admission and use of antidepressant medication at the time of admission. Using descriptive statistics, we compared differences in patient characteristics and hospital LOS across these groups. We used linear regression to examine associations and moderation effects between depressive symptoms, use of antidepressant medication, and hospital LOS. Results: Of 1,036 enrolled patients (89.9% of approached), 126 (12.2%) had documented depressive symptoms in the 3 months prior to admission and 288 (27.8%) were taking an antidepressant medication at the time of admission. Patients with depressive symptoms were more likely to be on antidepressant medication at admission than those without depressive symptoms (48.4% vs 24.9%, p < .001). Patients taking antidepressant medication were younger (62.4 vs 64.4 years, p = .026) and more likely to be female (55.2% vs 47.2%, p = .021). Depressive symptoms were associated with longer hospital LOS (7.3 vs 6.1 days, p = .036), and antidepressant medication was a moderator of this relationship. Among patients not on antidepressant medication, depressive symptoms were associated with longer hospital LOS (7.9 vs 6.1 days, p = .025), but among those on antidepressant medication, depressive symptoms were not associated with hospital LOS (6.6 vs 6.2 days, p = .588). Conclusions: Antidepressant medication moderated the relationship between depressive symptoms and longer hospital LOS. Our results support the need to recognize and address depressive symptoms in patients with advanced cancer.
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Affiliation(s)
- Risa Wong
- Massachusetts General Hospital, Boston, MA
| | | | | | | | | | | | | | | | - Brandon Temel
- Massachusetts General Hospital Cancer Center, Boston, MA
| | | | | | | | | | | | | | | | | | - William F. Pirl
- Sylvester Comprehensive Cancer Center, University of Miami, Miami, FL
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Johnson C, Xiao Y, El-Jawahri A, Wong R, D'Arpino S, Moran SM, Lage DE, Temel B, Ruddy M, Pirl WF, Traeger L, Lennes IT, Cashavelly BJ, Martinson HS, Jackson V, Greer JA, Ryan DP, Hochberg EP, Temel JS, Nipp RD. Potentially avoidable hospitalizations in patients with advanced cancer. J Clin Oncol 2017. [DOI: 10.1200/jco.2017.35.15_suppl.e18275] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [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
e18275 Background: Cancer patients and their clinicians often wish to avoid preventable hospital admissions, but efforts to understand the predictors of avoidable hospitalizations are lacking. We sought to examine reasons for hospital admissions in patients with advanced cancer, identify potentially avoidable hospitalizations (PAH), and explore predictors of PAH. Methods: We prospectively enrolled hospitalized patients with advanced cancer from 9/2014 - 11/2014 as part of a longitudinal data repository to define symptom burden in this population. Upon admission, we assessed patients’ symptom burden (Edmonton Symptom Assessment System [ESAS]; scored 0-10). We created a summated ESAS physical symptom variable. We used consensus-driven medical record review to identify the primary reason for each hospital admission and categorize it as PAH or not based on of an adaptation of Graham’s criteria for PAH. We used mixed multivariable logistic regression analyses to identify predictors of PAH. Results: We assessed 477 hospital admissions in 200 consecutively admitted patients (mean age = 64.6; 47% female; 67% married). Over half of admissions came through the emergency department (56%). The most common reasons for admissions were fever/infection (30%), symptoms (26%), and planned admission for chemotherapy or procedure (10%). We identified 149 (31%) as PAH. Among these PAH, 45 (30%) were readmissions due to failure of timely outpatient follow-up (within 7 days of discharge) and 44 (30%) were due to premature discharge from prior hospitalization. In a mixed logistic regression model, being married (odds ratio [OR] 0.48 [0.28-0.81]; p < 0.01) was associated with lower likelihood of PAH, while higher physical symptom burden (OR 1.02 [1.00-1.04]; p = 0.04) was associated with greater likelihood of PAH. Conclusions: We identified that a substantial proportion of hospitalizations in patients with advanced cancer are potentially avoidable, often related to failure of timely outpatient follow-up and premature hospital discharge. Our results demonstrate that patients’ symptom burden predicts PAH, thus underscoring the need to address patients’ symptoms in order to reduce preventable hospital admissions.
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Affiliation(s)
| | - Yian Xiao
- Boston University School of Medicine, Boston, MA
| | | | - Risa Wong
- Massachusetts General Hospital, Boston, MA
| | | | | | | | - Brandon Temel
- Massachusetts General Hospital Cancer Center, Boston, MA
| | | | - William F. Pirl
- Sylvester Comprehensive Cancer Center, University of Miami, Miami, FL
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Hochberg EP, Bierer MF, Winkfield KM, Chen YB, Muse VV, Louissaint A. Case 11-2017 - A 61-Year-Old Woman with Leg Swelling, Back Pain, and Hydronephrosis. N Engl J Med 2017; 376:1461-1471. [PMID: 28402765 DOI: 10.1056/nejmcpc1616023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- Ephraim P Hochberg
- From the Departments of Hematology-Oncology (E.P.H., Y.-B.C.), Internal Medicine (M.F.B.), Radiation Oncology (K.M.W.), Radiology (V.V.M.), and Pathology (A.L.), Massachusetts General Hospital, and the Departments of Hematology-Oncology (E.P.H., Y.-B.C.), Internal Medicine (M.F.B.), Radiation Oncology (K.M.W.), Radiology (V.V.M.), and Pathology (A.L.), Harvard Medical School - both in Boston
| | - Michael F Bierer
- From the Departments of Hematology-Oncology (E.P.H., Y.-B.C.), Internal Medicine (M.F.B.), Radiation Oncology (K.M.W.), Radiology (V.V.M.), and Pathology (A.L.), Massachusetts General Hospital, and the Departments of Hematology-Oncology (E.P.H., Y.-B.C.), Internal Medicine (M.F.B.), Radiation Oncology (K.M.W.), Radiology (V.V.M.), and Pathology (A.L.), Harvard Medical School - both in Boston
| | - Karen M Winkfield
- From the Departments of Hematology-Oncology (E.P.H., Y.-B.C.), Internal Medicine (M.F.B.), Radiation Oncology (K.M.W.), Radiology (V.V.M.), and Pathology (A.L.), Massachusetts General Hospital, and the Departments of Hematology-Oncology (E.P.H., Y.-B.C.), Internal Medicine (M.F.B.), Radiation Oncology (K.M.W.), Radiology (V.V.M.), and Pathology (A.L.), Harvard Medical School - both in Boston
| | - Yi-Bin Chen
- From the Departments of Hematology-Oncology (E.P.H., Y.-B.C.), Internal Medicine (M.F.B.), Radiation Oncology (K.M.W.), Radiology (V.V.M.), and Pathology (A.L.), Massachusetts General Hospital, and the Departments of Hematology-Oncology (E.P.H., Y.-B.C.), Internal Medicine (M.F.B.), Radiation Oncology (K.M.W.), Radiology (V.V.M.), and Pathology (A.L.), Harvard Medical School - both in Boston
| | - Victorine V Muse
- From the Departments of Hematology-Oncology (E.P.H., Y.-B.C.), Internal Medicine (M.F.B.), Radiation Oncology (K.M.W.), Radiology (V.V.M.), and Pathology (A.L.), Massachusetts General Hospital, and the Departments of Hematology-Oncology (E.P.H., Y.-B.C.), Internal Medicine (M.F.B.), Radiation Oncology (K.M.W.), Radiology (V.V.M.), and Pathology (A.L.), Harvard Medical School - both in Boston
| | - Abner Louissaint
- From the Departments of Hematology-Oncology (E.P.H., Y.-B.C.), Internal Medicine (M.F.B.), Radiation Oncology (K.M.W.), Radiology (V.V.M.), and Pathology (A.L.), Massachusetts General Hospital, and the Departments of Hematology-Oncology (E.P.H., Y.-B.C.), Internal Medicine (M.F.B.), Radiation Oncology (K.M.W.), Radiology (V.V.M.), and Pathology (A.L.), Harvard Medical School - both in Boston
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Asnani A, Manning A, Mansour M, Ruskin J, Hochberg EP, Ptaszek LM. Management of atrial fibrillation in patients taking targeted cancer therapies. Cardiooncology 2017; 3:2. [PMID: 32153998 PMCID: PMC7048041 DOI: 10.1186/s40959-017-0021-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/09/2016] [Accepted: 01/18/2017] [Indexed: 01/12/2023]
Abstract
Atrial fibrillation (AF) is frequently observed in patients being treated for cancer and can lead to increased morbidity and mortality in this population. With the use of newer, targeted cancer therapies, several drug-drug interactions have emerged that complicate the use of antiarrhythmic drugs (AADs) in patients with active malignancy. Moreover, specific targeted therapies such as ibrutinib may contribute directly to the development of AF. The decision to pursue systemic anticoagulation can be challenging in patients with malignancy due to a number of factors, including the need for frequent procedures, the presence of malignancy-related risk factors for bleeding, and limited data regarding the safety of the novel oral anticoagulants (NOACs) in cancer patients. This review describes the challenges associated with AF management in patients with cancer and highlights a number of important drug-drug interactions that can impact patient management.
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Affiliation(s)
- Aarti Asnani
- 1Cardio-Oncology Program, Corrigan Minehan Heart Center, Massachusetts General Hospital, 149 13th Street, Room 4.302, Boston, MA 02129 USA
| | | | - Moussa Mansour
- 3Cardiac Arrhythmia Service, Corrigan-Minehan Heart Center, Massachusetts General Hospital, 55 Fruit Street, GRB 109, Boston, MA 02114 USA
| | - Jeremy Ruskin
- 3Cardiac Arrhythmia Service, Corrigan-Minehan Heart Center, Massachusetts General Hospital, 55 Fruit Street, GRB 109, Boston, MA 02114 USA
| | - Ephraim P Hochberg
- 4Hematology/Oncology, Cancer Center, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114 USA
| | - Leon M Ptaszek
- 3Cardiac Arrhythmia Service, Corrigan-Minehan Heart Center, Massachusetts General Hospital, 55 Fruit Street, GRB 109, Boston, MA 02114 USA
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Abstract
PURPOSE To determine the impact of the establishment of a dedicated oncofertility clinic on the frequency of patient referrals for fertility preservation (FP) consultation and the time from patient referral to consultation. METHODS A retrospective chart review of all women aged 21 to 44 years with an active cancer diagnosis who were referred for FP consultation from 2011 to 2015. RESULTS A total of 6895 female patients eligible for FP were seen at the Massachusetts General Hospital (MGH) Cancer Center. Of those eligible, a total of 209 patients were referred for FP consultation with 150 included in the final analysis. Since the establishment of the oncofertility clinic, the mean time to nonemergent consultation with a reproductive endocrinologist decreased by 27%, from 10.4 to 7.6 days (P = .03). Furthermore, the proportion of reproductive-aged females seen at the MGH Cancer Center referred for FP consultation increased from 1.7% to 3.0% (P < .01). CONCLUSION A dedicated oncofertility clinic increases physician referrals for FP and decreases the mean time to consultation, improving access to FP consultation for reproductive-aged women with cancer.
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Affiliation(s)
- Eduardo Hariton
- Division of Reproductive Endocrinology and Infertility, Vincent Obstetrics and Gynecology, Massachusetts General Hospital, Boston, MA, USA
- Eduardo Hariton and Pietro Bortoletto contributed equally to this work and are co-first authors
| | - Pietro Bortoletto
- Division of Reproductive Endocrinology and Infertility, Vincent Obstetrics and Gynecology, Massachusetts General Hospital, Boston, MA, USA
- Eduardo Hariton and Pietro Bortoletto contributed equally to this work and are co-first authors
| | - Eden R Cardozo
- Division of Reproductive Endocrinology and Infertility, Vincent Obstetrics and Gynecology, Massachusetts General Hospital, Boston, MA, USA
| | - Ephraim P Hochberg
- Division of Hematology/Oncology, Department of Medicine, Yawkey Center for Outpatient Care, Massachusetts General Hospital, Boston, MA, USA
| | - Mary E Sabatini
- Division of Reproductive Endocrinology and Infertility, Vincent Obstetrics and Gynecology, Massachusetts General Hospital, Boston, MA, USA
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Nipp RD, El-Jawahri A, Moran SM, D'Arpino S, Johnson C, Lage DE, Wong R, Xiao Y, VanDusen H, Pirl WF, Traeger L, Lennes IT, Cashavelly BJ, Martinson HS, Jackson VA, Greer JA, Ryan DP, Hochberg EP, Temel JS. Symptom burden to predict health care utilization in hospitalized patients with incurable cancer. J Clin Oncol 2016. [DOI: 10.1200/jco.2016.34.26_suppl.98] [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
98 Background: Patients with incurable cancer are often hospitalized and have frequent readmissions after discharge. Considering the high physical and psychological symptom burden in this population, we sought to investigate symptoms as predictors of hospital length of stay (LOS) and time to first unplanned readmission. Methods: We consecutively enrolled incurable cancer patients with unplanned hospital admissions from 9/2014-4/2016. Within the first 5 days of admission, we assessed physical (Edmonton Symptom Assessment System [ESAS]; scored 0-10) and mood symptoms (Patient Health Questionnaire 4 [PHQ-4]; scored categorically). We created summated ESAS total and physical symptom variables. To identify predictors of LOS we used linear regression and for time to readmission we used Cox regression, with all models adjusted for age, sex, marital status, comorbidity, education, cancer type and time since incurable diagnosis. Results: We enrolled 1,000 of 1,227 (81%) eligible patients (mean age = 63.4; 50% female; 66% married). Gastrointestinal (33%) and lung (18%) cancers were the most common. Mean hospital LOS was 6.2 days and 30-day readmission rate was 25%. Over half of patients reported moderate/severe fatigue, drowsiness, lack of appetite, pain and poor well-being. Over one-fourth screened positive for PHQ depression and anxiety. All physical and mood symptoms individually predicted for longer LOS. Pain, nausea, poor well-being, ESAS total, ESAS physical and PHQ anxiety predicted for shorter time to readmission. Conclusions: Hospitalized patients with incurable cancer experience a high symptom burden, which correlates with their health care utilization. Both physical and psychological symptoms predict for longer hospital LOS and shorter time to readmission. These findings can inform interventions targeting patients’ symptoms during hospital admissions in an effort to improve health care delivery and utilization. [Table: see text]
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Affiliation(s)
| | | | | | | | | | | | - Risa Wong
- Massachusetts General Hospital, Boston, MA
| | - Yian Xiao
- Brigham and Women's Hospital, Brookline, MA
| | | | - William F. Pirl
- Sylvester Comprehensive Cancer Center, University of Miami, Miami, FL
| | - Lara Traeger
- Massachusetts General Hospital Cancer Center, Boston, MA
| | | | | | | | | | | | - David P. Ryan
- Massachusetts General Hospital Cancer Center, Boston, MA
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Nipp RD, El-Jawahri A, Moran SM, D'Arpino S, Johnson C, Lage D, Wong R, Xiao Y, VanDusen H, Pirl WF, Traeger L, Kumar P, Lennes IT, Cashavelly BJ, Martinson HS, Jackson VA, Greer JA, Ryan DP, Hochberg EP, Temel JS. Relationship between symptom burden and hospital length of stay (LOS) in patients with incurable cancer. J Clin Oncol 2016. [DOI: 10.1200/jco.2016.34.15_suppl.10123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
| | | | | | | | | | | | - Risa Wong
- Massachusetts General Hospital, Boston, MA
| | - Yian Xiao
- Brigham and Women's Hospital, Brookline, MA
| | | | | | | | - Pallavi Kumar
- Dana-Farber Cancer Institute/Massachusetts General Hosp, Jamaica Plain, MA
| | | | | | | | | | | | - David P. Ryan
- Massachusetts General Hospital Cancer Center, Boston, MA
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Moran SM, El-Jawahri A, Pirl WF, Traeger L, Kumar P, Ryan DP, Lennes IT, Cashavelly BJ, Martinson HS, VanDusen H, Hochberg EP, Jackson VA, Greer JA, Temel JS, Nipp RD. Symptom burden in hospitalized patients with advanced cancer. J Clin Oncol 2015. [DOI: 10.1200/jco.2015.33.29_suppl.100] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [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
100 Background: Patients with advanced cancer experience high rates of both physical and psychological morbidity, but data describing patients’ symptoms during hospital admissions are lacking. We sought to describe symptom burden in hospitalized patients with incurable solid and hematologic malignancies. Methods: We prospectively enrolled patients with incurable cancers admitted to the Massachusetts General Hospital from 9/1/2014 through 5/1/2015. Within the first week of their admission, we assessed physical and psychological symptoms using the Edmonton Symptom Assessment System-revised (ESAS-r). Beginning 11/15/2015, we also administered the Patient Health Questionnaire 4 (PHQ-4), scored categorically. Results: We enrolled 457 of 547 (84%) eligible patients. Participants (mean age=63.8 years; n=231, 51% female) had the following malignancies: gastrointestinal (n=149, 33%), lung (n=77, 17%), genitourinary (n=52, 11%), breast (n=33, 7%), hematologic (n=24, 5%), and other solid tumors (n=122, 27%). Using the ESAS-r, tiredness, drowsiness, anorexia, and pain were the most common severe symptoms. Using the PHQ-4, approximately one-third of participants screened positive for depression (91/271, 34%) and anxiety (86/273, 32%). Conclusions: Hospitalized patients with incurable solid and hematologic malignancies experience substantial physical and psychological symptoms. Most patients reported at least moderate tiredness, drowsiness, anorexia and pain. Additionally, a concerning proportion reported depression and anxiety. Our data demonstrate the need for efforts to alleviate the physical symptoms experienced by this population, while also seeking to understand and address their psychological needs. [Table: see text]
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Affiliation(s)
| | | | | | - Lara Traeger
- Massachusetts General Hospital Cancer Center, Boston, MA
| | - Pallavi Kumar
- University of Pennsylvania Health System, Philadelphia, PA
| | - David P. Ryan
- Massachusetts General Hospital Cancer Center, Boston, MA
| | | | | | | | | | | | | | | | | | - Ryan David Nipp
- Dana-Farber Cancer Institute/Harvard Cancer Center, Boston, MA
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Wang L, Tan TC, Halpern EF, Neilan TG, Francis SA, Picard MH, Fei H, Hochberg EP, Abramson JS, Weyman AE, Kuter I, Scherrer-Crosbie M. Major Cardiac Events and the Value of Echocardiographic Evaluation in Patients Receiving Anthracycline-Based Chemotherapy. Am J Cardiol 2015; 116:442-6. [PMID: 26071994 DOI: 10.1016/j.amjcard.2015.04.064] [Citation(s) in RCA: 74] [Impact Index Per Article: 8.2] [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: 03/20/2015] [Revised: 04/30/2015] [Accepted: 04/30/2015] [Indexed: 11/15/2022]
Abstract
Anthracyclines are an important component of cancer treatments; however, their use is limited by the occurrence of cardiotoxicity. There are limited data on the occurrence of heart failure and the value of baseline and follow-up measurements of left ventricular (LV) ejection fraction (EF) in the current era. Therefore, the objectives of the present study were twofold: (1) to characterize the occurrence of and risk factors for major adverse cardiac events (MACEs: symptomatic heart failure and cardiac death) in a large contemporaneous population of adult patients treated with anthracyclines and (2) to test the value of LVEF and LV dimensions obtained using echocardiography in the prediction of MACE. Five thousand fifty-seven patients were studied, of whom 124 (2.4%) developed MACE. Of the total cohort, 2,285 patients had an available echocardiogram pre-chemotherapy. Patients with MACE were older (p <0.0001), predominantly men (p = 0.03), and with a higher incidence of cardiovascular risk factors and cardiac treatments. Patients with hematologic cancers had a higher incidence of cardiac events than patients with breast cancer (4.2% vs 0.7%, p <0.0001). Baseline LVEF, LVEF ≤5 points above the lower limits of normal, and LV internal diameter were predictive of the rate of occurrence of MACE. In conclusion, older patients with hematologic cancers and patients with a baseline LVEF ≤5 points above the lower limit of normal have higher incidence of MACE and should be closely monitored.
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Affiliation(s)
- Lin Wang
- Cardiac Ultrasound Laboratory, Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Timothy C Tan
- Cardiac Ultrasound Laboratory, Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Elkan F Halpern
- Institute for Technology Assessment, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Tomas G Neilan
- Cardio-Oncology Program, Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Sanjeev A Francis
- Cardio-Oncology Program, Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Michael H Picard
- Cardiac Ultrasound Laboratory, Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Hongwen Fei
- Cardiac Ultrasound Laboratory, Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Ephraim P Hochberg
- Center for Lymphoma, Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, Massachusetts
| | - Jeremy S Abramson
- Center for Lymphoma, Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, Massachusetts
| | - Arthur E Weyman
- Cardiac Ultrasound Laboratory, Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Irene Kuter
- Center for Breast Cancer, Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, Massachusetts
| | - Marielle Scherrer-Crosbie
- Cardiac Ultrasound Laboratory, Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts; Cardio-Oncology Program, Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts.
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Ryan RJH, Drier Y, Whitton H, Cotton MJ, Kaur J, Issner R, Gillespie S, Epstein CB, Nardi V, Sohani AR, Hochberg EP, Bernstein BE. Detection of Enhancer-Associated Rearrangements Reveals Mechanisms of Oncogene Dysregulation in B-cell Lymphoma. Cancer Discov 2015; 5:1058-71. [PMID: 26229090 DOI: 10.1158/2159-8290.cd-15-0370] [Citation(s) in RCA: 91] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2015] [Accepted: 07/27/2015] [Indexed: 02/07/2023]
Abstract
UNLABELLED B-cell lymphomas frequently contain genomic rearrangements that lead to oncogene activation by heterologous distal regulatory elements. We used a novel approach called "pinpointing enhancer-associated rearrangements by chromatin immunoprecipitation," or PEAR-ChIP, to simultaneously map enhancer activity and proximal rearrangements in lymphoma cell lines and patient biopsies. This method detects rearrangements involving known cancer genes, including CCND1, BCL2, MYC, PDCD1LG2, NOTCH1, CIITA, and SGK1, as well as novel enhancer duplication events of likely oncogenic significance. We identify lymphoma subtype-specific enhancers in the MYC locus that are silenced in lymphomas with MYC-activating rearrangements and are associated with germline polymorphisms that alter lymphoma risk. We show that BCL6-locus enhancers are acetylated by the BCL6-activating transcription factor MEF2B, and can undergo genomic duplication, or target the MYC promoter for activation in the context of a "pseudo-double-hit" t(3;8)(q27;q24) rearrangement linking the BCL6 and MYC loci. Our work provides novel insights regarding enhancer-driven oncogene activation in lymphoma. SIGNIFICANCE We demonstrate a novel approach for simultaneous detection of genomic rearrangements and enhancer activity in tumor biopsies. We identify novel mechanisms of enhancer-driven regulation of the oncogenes MYC and BCL6, and show that the BCL6 locus can serve as an enhancer donor in an "enhancer hijacking" translocation.
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Affiliation(s)
- Russell J H Ryan
- Department of Pathology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts. Broad Institute of Harvard University and MIT, Cambridge, Massachusetts
| | - Yotam Drier
- Department of Pathology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts. Broad Institute of Harvard University and MIT, Cambridge, Massachusetts
| | - Holly Whitton
- Broad Institute of Harvard University and MIT, Cambridge, Massachusetts
| | - M Joel Cotton
- Department of Pathology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts. Broad Institute of Harvard University and MIT, Cambridge, Massachusetts
| | - Jasleen Kaur
- Department of Pathology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts. Broad Institute of Harvard University and MIT, Cambridge, Massachusetts
| | - Robbyn Issner
- Broad Institute of Harvard University and MIT, Cambridge, Massachusetts
| | - Shawn Gillespie
- Department of Pathology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts. Broad Institute of Harvard University and MIT, Cambridge, Massachusetts
| | - Charles B Epstein
- Broad Institute of Harvard University and MIT, Cambridge, Massachusetts
| | - Valentina Nardi
- Department of Pathology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Aliyah R Sohani
- Department of Pathology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Ephraim P Hochberg
- Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Bradley E Bernstein
- Department of Pathology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts. Broad Institute of Harvard University and MIT, Cambridge, Massachusetts.
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Abramson JS, Arnason JE, LaCasce AS, Redd R, Barnes JA, Sokol L, Joyce R, Avigan D, Neuberg DS, Takvorian T, Hochberg EP, Bello CM. Brentuximab vedotin plus AVD for non-bulky limited stage Hodgkin lymphoma: A phase II trial. J Clin Oncol 2015. [DOI: 10.1200/jco.2015.33.15_suppl.8505] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
| | | | | | | | | | | | | | - David Avigan
- Beth Israel Deaconess Medical Center, Boston, MA
| | | | - Tak Takvorian
- Massachusetts General Hospital Cancer Center, Boston, MA
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50
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Abramson JS, Davids MS, Werner L, Fisher DC, Armand P, Amrein PC, Neuberg DS, Hochberg EP, Brown JR. Lenalidomide added to bendamustine-rituximab for untreated chronic lymphocytic leukemia (CLL): A phase 1 study. J Clin Oncol 2015. [DOI: 10.1200/jco.2015.33.15_suppl.7082] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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