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Turgeman I, Benaim AR, Regev-Tsur S, Turgeman S, Abu Amna M, Badran O, Bar-Sela G. Too Much of a Good Thing: The Association of Elevated Vitamin B12 Levels and Outcomes in Patients With Cancer Treated With Immunotherapy. J Immunother 2024; 47:117-122. [PMID: 37909180 DOI: 10.1097/cji.0000000000000493] [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: 09/08/2023] [Accepted: 10/03/2023] [Indexed: 11/02/2023]
Abstract
Metabolic pathways may regulate responses to cancer immunotherapy (IO). Due to its immunomodulatory properties, we sought to examine the association between serum vitamin B12 (VitB12) and survival in individuals with cancer treated with immune checkpoint inhibitors, compared with biological and chemotherapy. We collected data on patients with advanced cancer initiating intravenous antineoplastic treatment and a concomitant VitB12 measurement (elevated: >820 ng/L), between January 2010 and January 2022. Patients on IO and other regimens (control) were compared using the Mann-Whitney test for continuous variables, χ 2 test or Fisher test for categorical variables, and multivariate Cox regression models assessed the effect of VitB12 on overall survival and progression-free survival, adjusting for confounders. Patient groups (control: n = 408; IO: n = 93) were balanced for the treatment line and VitB12 (elevated 29.9% vs 23.7%; mean 762.4 vs 687.6 ng/L). In multivariate analysis, overall survival in all patients was negatively associated with VitB12 [control: hazard ratio (HR): 1.4, 95% CI: 1.01-1.96, P = 0.04, false discovery rate (FDR): 0.069; IO: HR: 2.74 as sum of linear baseline and interaction effects, log scale], age (HR: 1.03, 95% CI: 1.02-1.04, P < 0.01), male sex (HR: 0.66, 95% CI: 0.50-0.88, P < 0.01), and neutrophil-to-lymphocyte ratio (HR: 1.05, 95% CI: 0.48-0.99, P = 0.01). However, VitB12 was significantly negatively associated with progression-free survival only in the IO group ( P < 0.001, FDR < 0.001, calculated HR: 8.34; biological treatment P = 0.08; FDR: 0.111; neutrophil-to-lymphocyte ratio, P = 0.07; FDR: 0.09). Taken together, elevated VitB12 was a negative predictor for outcomes on IO, independently of other known prognostic factors. Further research is needed to elucidate the immune-metabolic interplay and its interaction with the gut microbiome, as well as interventional strategies to enhance IO responses.
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Affiliation(s)
| | - Anat Reiner Benaim
- Department of Epidemiology, Biostatistics, and Community Health Sciences, School of Public Health, Ben Gurion University of the Negev, Beer Sheba
| | | | | | | | - Omar Badran
- Department of Oncology, Emek Medical Center, Afula
| | - Gil Bar-Sela
- Department of Oncology, Emek Medical Center, Afula
- Department Technion Integrated Cancer Center, Technion-Israel Institute of Technology, Haifa, Israel
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Cohen M, Shamay Y, Czamanski-Cohen J, Shulman K, Keren Rosenberg S, Abu-Amna M, Turgeman I, Merkin Livshits L, Birenboim R, Dines M, Bar-Sela G. Linkage between Psychological Factors and Response to Immune Checkpoint Inhibitor Therapy: A Preliminary Study. Cells 2023; 12:2471. [PMID: 37887315 PMCID: PMC10605722 DOI: 10.3390/cells12202471] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Revised: 10/02/2023] [Accepted: 10/11/2023] [Indexed: 10/28/2023] Open
Abstract
Substantial evidence has accumulated showing that psychological distress affects immune regulation, the response to cancer treatment, and survival. The effect of psychological parameters on the effectiveness of immune checkpoint inhibitor (ICI) treatment has not yet been studied. This preliminary study aimed to (a) examine the associations between psychological factors and responses to ICI treatment and (b) assess the associations between psychological factors and blood measures of sPD-1, sCTLA-4, and cytokines that may alter the effect of ICI treatment. The participants were 62 individuals with advanced cancer, aged 18 years or older, who were candidates for ICI treatment as a new line of treatment. The participants answered questionnaires and provided blood samples and medical data prior to the start of ICI treatment and 3 months after. Perceived health status was positively associated with better responses to ICI treatment. In the subsample of participants with biomarkers, worse health-related quality of life was associated with higher IL-6 and sCTLA-4; emotional distress and sleep difficulties were associated with higher sCTLA-4; and better perceived health was associated with lower IL-6 and TNFα. sPD-1 was not associated with psychological measures. This preliminary study found for the first time that some psychological measures could be linked to responses to cancer treatment, possibly via pro-inflammatory cytokines and sCTLA-4.
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Affiliation(s)
- Miri Cohen
- School of Social Work, University of Haifa, Haifa 3498838, Israel;
| | - Yosi Shamay
- Biomedical Engineering, Technion—Israel Institute of Technology, Haifa 3109601, Israel;
| | - Johanna Czamanski-Cohen
- Emili Sagol Creative Arts Therapies Research Center, School of Creative Arts Therapies, University of Haifa, Haifa 3498838, Israel; (J.C.-C.); (M.D.)
| | - Katerina Shulman
- Carmel Medical Center, Haifa 3436212, Israel; (K.S.); (L.M.L.)
- Bruce Rappaport Faculty of Medicine, Technion—Israel Institute of Technology, Haifa 3109601, Israel
- Lin Medical Center, Haifa 6688304, Israel;
| | | | - Mahmoud Abu-Amna
- Cancer Center, Emek Medical Center, Afula 1834111, Israel; (M.A.-A.); (I.T.)
| | - Ilit Turgeman
- Cancer Center, Emek Medical Center, Afula 1834111, Israel; (M.A.-A.); (I.T.)
| | - Ludmila Merkin Livshits
- Carmel Medical Center, Haifa 3436212, Israel; (K.S.); (L.M.L.)
- Lin Medical Center, Haifa 6688304, Israel;
| | | | - Monica Dines
- Emili Sagol Creative Arts Therapies Research Center, School of Creative Arts Therapies, University of Haifa, Haifa 3498838, Israel; (J.C.-C.); (M.D.)
| | - Gil Bar-Sela
- Bruce Rappaport Faculty of Medicine, Technion—Israel Institute of Technology, Haifa 3109601, Israel
- Cancer Center, Emek Medical Center, Afula 1834111, Israel; (M.A.-A.); (I.T.)
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Turgeman I, West HJ. Adolescents and Young Adults With Cancer. JAMA Oncol 2023; 9:440. [PMID: 36633859 DOI: 10.1001/jamaoncol.2022.6132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
This JAMA Oncology Patient Page describes genetic testing, fertility concerns, adverse treatment effects, and psychosocial challenges among adolescents and young adults with cancer.
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Affiliation(s)
| | - Howard Jack West
- Medical Oncology, City of Hope Cancer Center, Seattle, Washington
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Badran O, Abu Amna M, Turgeman I, Bar-Sela G. Rhabdomyolysis Induced by the Interaction Between Ribociclib and Statins- Case Report and Literature Review. Breast Cancer (Dove Med Press) 2023; 15:47-50. [PMID: 36718280 PMCID: PMC9883986 DOI: 10.2147/bctt.s380485] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/10/2022] [Accepted: 01/07/2023] [Indexed: 01/24/2023]
Abstract
Cyclin-dependent kinase (CDK) 4/6 inhibitors given with endocrine therapy are standard of care for the treatment of women with advanced hormone receptor (HR) positive and human epidermal growth factor receptor 2 (HER-2) negative breast cancer. Ribociclib is a CDK 4/6 inhibitor with moderate to solid inhibition of CYP3A4, a member of the cytochrome P450 family oxidase system, which may lead to interactions with medicinal substrates that are metabolized via CYP3A4. Statins are among the most widely prescribed medications worldwide, predominantly metabolized by the CYP3A4 isoenzyme. Rhabdomyolysis is a known rare side effect of statins, commonly triggered by drug interactions. We report a case of a 73-year-old woman with metastatic HR-positive and HER-2 negative breast cancer who developed rhabdomyolysis and acute kidney injury due to interaction between simvastatin and ribociclib with a literature review.
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Affiliation(s)
- Omar Badran
- Department of Oncology, Emek Medical Center, Afula, Israel
| | - Mahmoud Abu Amna
- Department of Oncology, Emek Medical Center, Afula, Israel,Technion Integrated Cancer Center, Faculty of Medicine, Technion, Haifa, Israel
| | - Ilit Turgeman
- Department of Oncology, Emek Medical Center, Afula, Israel
| | - Gil Bar-Sela
- Department of Oncology, Emek Medical Center, Afula, Israel,Technion Integrated Cancer Center, Faculty of Medicine, Technion, Haifa, Israel,Correspondence: Gil Bar-Sela, Oncology & Hematology Division, Emek Medical Center, Yitshak Rabin Boulevard 21, Afula, 1834111, Israel, Tel +972 04-6495725, Fax +972 04-6163992, Email
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Turgeman I, Campisi-Pinto S, Habiballah M, Bar-Sela G. Approach to Cancer Pain Management in Emergency Departments: Comparison of General and Oncology Based Settings. Pharmaceuticals (Basel) 2022; 15:ph15070805. [PMID: 35890103 PMCID: PMC9320698 DOI: 10.3390/ph15070805] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Revised: 06/13/2022] [Accepted: 06/21/2022] [Indexed: 11/22/2022] Open
Abstract
Cancer-related pain constitutes a dominant reason for admission to emergency services, and a significant patient and healthcare challenge. Evidence points to the rising prevalence of opioid misuse in this patient group. We sought to compare drug delivery in an oncology-dedicated emergency department (OED) and a general emergency department (GED) within the same hospital. As such, we obtained patient and drug-related data for OED and GED during a designated three-month period, and compared them using Fisher’s exact test, chi-square tests and the Mann-Whitney test. In total, 584 patients had 922 visits to emergency services (OED n = 479; GED n = 443), and were given 1478 drugs (OED n = 557; GED n = 921). Pain was a prominent chief complaint among visitors to the OED (17%) and GED (21%). Approximately a fifth of all drugs used were analgesics (OED—18.5%; GED—20.4%), however, in the GED, 51.6% (n = 97) were used for non-pain-related admissions, compared with 33.0% (n = 34) in OED. Opioid usage significantly differed between emergency settings. The GED administered three times as many intravenous opioids (p <0.001), a narrower spectrum of oral and intravenous drugs (p = 0.003) and no rapid-acting opioids, significantly fewer pain adjuvants (10.9% versus 18.7%, p < 0.001), and, finally, non-guideline-recommended drugs for pain, such as meperidine and benzodiazepines. Taken together, compared with the GED, the management of cancer-related pain in the OED was more personalized, and characterized by fewer intravenous opioids, enhanced diversity in drug type, route and method of delivery. Efforts should be directed toward reduction of disparities in the treatment of cancer pain in emergency settings.
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Affiliation(s)
- Ilit Turgeman
- Cancer Center, Emek Medical Center, Afula 1834111, Israel;
| | | | - Maher Habiballah
- Division of Oncology, Rambam Health Care Center, Haifa 31096, Israel;
| | - Gil Bar-Sela
- Cancer Center, Emek Medical Center, Afula 1834111, Israel;
- Technion Integrated Cancer Center, Faculty of Medicine, Technion—Israel Institute of Technology, Haifa 31096, Israel
- Correspondence: ; Tel.: +4-6495725; Fax: +4-6163992
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Turgeman I, Turgeman S, Lutsyk M, Bar-Sela G. P-295 Prognostic impact of clinico-pathologic parameters in early- and average-onset curatively resected colorectal cancer. Ann Oncol 2022. [DOI: 10.1016/j.annonc.2022.04.384] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
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Turgeman I, Campisi-Pinto S, Habiballah M, Bar-Sela G. Pain management in oncology-dedicated and general emergency departments. J Clin Oncol 2022. [DOI: 10.1200/jco.2022.40.16_suppl.e24076] [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
e24076 Background: Cancer-related pain constitutes a dominant reason for admission to emergency services, and a significant patient and healthcare challenge. Evidence points to the rising prevalence of opioid misuse in this patient group. We sought to compare drug delivery in an oncology-dedicated emergency department (OED) and a general emergency department (GED) within the same hospital. Methods: Electronic files of patients with cancer seeking emergency services in a three-month period were obtained from the hospital registry. Data on patient demographics and drug-related characteristics were determined. Drug administration was compared between groups and thereafter according to admission types, using Fisher’s exact test, chi-square test and Mann-Whitney test. Results: In total, 584 patients had 922 visits to emergency services (OED n = 479; GED n = 443), and were administered 1815 drugs (OED n = 825; GED n = 990). Patient demographics and admission types were balanced between groups. Pain was the most common chief complaint (17% OED; 21% GED). In the OED, 12.5% of drugs were direct analgesics, compared with 19% in the GED. Opioids were prescribed more often in the GED than the OED (p = 0.008), significant for both pain related and non-pain related admissions, notably gastrointestinal and infectious conditions. Treatment in the GED was associated with delivery of three times as many intravenous opioids (p < 0.001), a narrower spectrum in selection of oral and intravenous opioids (p = 0.003) and non-opioid analgesics, lower usage of pain adjuvants and rapid-acting opioids (p = 0.003), and finally, the administration of agents not recommended for cancer pain treatment, such as meperidine and benzodiazepines (p = 0.003). Similar utilization of resuscitative fluids, gastrointestinal agents and antiemetics was observed between groups, with larger variation in drug choice in the OED (p = 0.001). The OED showed greater usage of bisphosphonates and growth factors; conversely, antibiotics, blood products, clotting agents, antihypertensive and diabetic drugs, predominated in the GED. Conclusions: Compared to the GED, management of cancer-related pain in the OED is characterized by fewer opioids, enhanced diversity in drug type, route and method of delivery. Emergency services should be incorporated in cancer programs to promote safe and effective urgent care.
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Turgeman I, Goshen‐Lago T, Waldhorn I, Karov K, Groisman L, Reiner Benaim A, Almog R, Halberthal M, Ben‐Aharon I. Psychosocial perspectives among cancer patients during the coronavirus disease 2019 (COVID-19) crisis: An observational longitudinal study. Cancer Rep (Hoboken) 2022; 5:e1506. [PMID: 34405968 PMCID: PMC8420321 DOI: 10.1002/cnr2.1506] [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] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Revised: 05/20/2021] [Accepted: 05/26/2021] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND The coronavirus disease 2019 (COVID-19) crisis and consequent changes in medical practice have engendered feelings of distress in diverse populations, potentially adversely affecting the psychological well-being of cancer patients. AIM The purpose of this observational longitudinal study was to evaluate psychosocial perspectives among patients with cancer on intravenous treatment during the COVID-19 pandemic. METHODS AND RESULTS The study recruited 164 cancer patients undergoing intravenous anti-neoplastic therapy in a tertiary cancer center. Psychosocial indices were assessed at two points in time, corresponding with the beginning of the first wave of COVID-19 pandemic in Israel (March 2020) and the time of easing of restrictions implemented to curtail spread of infection (May 2020). At Time 1 (T1), elevated COVID-19 distress levels (score 1 and 2 on 5-point scale) were observed in 44% of patients, and associated with pre-existing hypertension and lung disease in multivariate analyses but no demographic or cancer related factors. At Time 2 (T2), 10% had elevated anxiety and 24% depression as indicated by Hospital Anxiety and Depression Scale (HADS-A/D). COVID-19 distress at T1 was related to higher levels of HADS-A at T2 (Spearman 0.33 p < .01), but not HADS-D. Patients with breast cancer expressed greater COVID-19 distress compared with other cancer types (p < .01), while both HADS-A and HADS-D were highest for patients with GI cancer. Patient report of loneliness and decreased support from relatives were factors associated with HADS-A (p = .03 and p < .01, respectively), while HADS-D was not similarly related to the factors evaluated. CONCLUSION Patients with cancer undergoing intravenous treatment may be vulnerable to acute adverse psychological ramifications of COVID-19, specifically exhibiting high levels of anxiety. These appear unrelated to patient age or disease stage. Those with underlying comorbidities, breast cancer or reduced social support may be at higher risk.
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Affiliation(s)
- Ilit Turgeman
- Division of OncologyRambam Health Care CenterHaifaIsrael
| | | | - Ithai Waldhorn
- Division of OncologyRambam Health Care CenterHaifaIsrael
| | - Keren Karov
- Division of OncologyRambam Health Care CenterHaifaIsrael
| | - Leora Groisman
- Division of OncologyRambam Health Care CenterHaifaIsrael
| | | | - Ronit Almog
- Technion Integrated Cancer Center (TICC)Faculty of MedicineHaifaIsrael
- Epidemiology Department and BiobankRambam Health Care CampusHaifaIsrael
| | - Michael Halberthal
- Technion Integrated Cancer Center (TICC)Faculty of MedicineHaifaIsrael
- General ManagementRambam Health Care CampusHaifaIsrael
| | - Irit Ben‐Aharon
- Division of OncologyRambam Health Care CenterHaifaIsrael
- Technion Integrated Cancer Center (TICC)Faculty of MedicineHaifaIsrael
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Lutsyk M, Turgeman I, Bar-Sela G. Rapid Initiation of Neoadjuvant Chemoradiotherapy After Diagnosis is Associated With Improved Pathologic Response in Locally Advanced Rectal Cancer. Am J Clin Oncol 2022; 45:1-8. [PMID: 34857697 DOI: 10.1097/coc.0000000000000872] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
INTRODUCTION In rectal cancer, neoadjuvant chemoradiation (NCRT) is preferred because of toxicity profile, improved resectability and sphincter preservation, although with no impact on overall survival. Pathologic complete response (pCR) to NCRT has been linked with longer disease-free survival (DFS). The study purpose was to evaluate an association between clinical factors and treatment schedule with tumor response and treatment outcome, among patients with locally advanced rectal cancer. PATIENTS AND METHODS In this single-center retrospective study, conducted over 9 years (2011 to 2020), patients with stage II to III rectal cancer who had received NCRT were enrolled. The standard radiotherapy was 45 Gy to the pelvis, with a simultaneous integrated 50 Gy boost to the primary tumor. Continuous 5-Fluorouracil or oral capecitabine was administered concurrently. Surgery was preplanned within 6 to 8 weeks. Multinomial logistic regressions for evaluation of clinical factors, Kaplan-Meier method for DFS estimation, and receiver operating characteristic analysis for determination of the optimal timeframe were used. RESULTS Of 279 cases, pCR was observed in 72 (25.8%). In 207 cases, pTis-4N-negative was obtained in 137 (66.2%), pT0N-positive in 6 (2.9%), and pTis-4N-positive in 64 (30.9%). The pCR group had shorter diagnosis-NCRT time (P<0.01) and on-treatment time (P=0.05). DFS was longer for pCR and partial responders with clinical stage II and III (P<0.0001). Diagnosis-NCRT time was shown different between pCR and non-pCR groups. receiver operating characteristic analysis (P<0.01) showed that a diagnosis-NCRT time of <4.5 weeks predicts pCR with a sensitivity of 88% and specificity of 81% accuracy. CONCLUSION The time elapsed between rectal cancer diagnosis and NCRT initiation is significantly associated with pCR. Reducing this time may increase the probability of achieving pCR.
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Affiliation(s)
| | | | - Gil Bar-Sela
- Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa
- Cancer Center, Emek Medical Center, Afula, Israel
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Ben-Aharon I, Turgeman I, Nemzov S, Karov K, Bagon S, Silman-Cohen H, Israeli H, Goshen - Lago T. 1502O OncoYoung program: A multidisciplinary program for young cancer patients. Ann Oncol 2021. [DOI: 10.1016/j.annonc.2021.08.831] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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Turgeman I, Bar-Sela G. Reply to D.B. Scarpelli et al. JCO Oncol Pract 2021; 17:645-646. [PMID: 34436953 DOI: 10.1200/op.21.00487] [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)
- Ilit Turgeman
- Ilit Turgeman, MD, Division of Oncology, Rambam Health Care Campus, Haifa, Israel and Gil Bar-Sela, MD, Cancer Center, Emek Medical Center, Afula, Israel, Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Gil Bar-Sela
- Ilit Turgeman, MD, Division of Oncology, Rambam Health Care Campus, Haifa, Israel and Gil Bar-Sela, MD, Cancer Center, Emek Medical Center, Afula, Israel, Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
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Finkel I, Sternschuss M, Wollner M, Shamai S, Peled N, Turgeman I, Shochat T, Dudnik E. Immune-related Neutropenia Following Treatment With Immune Checkpoint Inhibitors. J Immunother 2021; 43:67-74. [PMID: 31498181 DOI: 10.1097/cji.0000000000000293] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
The existing data with regard to immune-related neutropenia (irN), a rare (incidence-1%) immune-related adverse event of immune checkpoint inhibitors, are scarce. Eight patients with irN were identified through internal databases of 3 participating Israeli cancer centers. In addition, 11 original articles focusing on the clinical course of 24 patients with irN were selected during the PubMed search. Descriptive analysis of clinical and pathologic factors related to irN was performed (n=32); the effect of these on the irN outcomes was assessed. An algorithm for irN evaluation and treatment was proposed. The median time-to-onset of irN (n=32) was 60 days (range, 10-465 d). Grade 3-5 irN, febrile neutropenia, and irN-related death occurred in 81%, 50%, and 9% of patients, respectively. In all, 56%, 22%, 62%, and 25% of patients received PO corticosteroids, IV corticosteroids, granulocyte colony-stimulating factor (GCSF), and intravenous immunoglobulins (IVIG), respectively, with an improvement/resolution rate of 84%. Odds ratios for irN improvement/resolution were as follows: 1.40 [95% confidence interval (CI), 0.03-68.72], 0.43 (95% CI, 0.04-4.22), 2.60 (95% CI, 0.07-97.24), 0.36 (95% CI, 0.03-4.38), 4.02 (95% CI, 0.16-99.48), 2.01 (95% CI, 0.32-12.70), 1.08 (95% CI, 0.02-49.89), 0.42 (95% CI, 0.06-2.91), and 2.73 (95% CI, 0.42-17.51) for granulocyte hyperplasia, granulocyte/all lineage hypoplasia, granulocyte maturation blockade, lymphocyte infiltration on bone marrow biopsy, IV corticosteroids, PO corticosteroids, cyclosporine, IVIG, and GCSF, respectively (P>0.05 for all factors). IrN recurrence rate following immune checkpoint inhibitors rechallenge was 80%. IrN is a rare, life-threatening, early-onset immune-related adverse event. Differentiating between the central, peripheral, and modified peripheral types allows a better prognosis definition. Corticosteroids and GCSF represent the main treatment approaches; IVIG and cyclosporine should be used as salvage treatment.
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Affiliation(s)
| | | | - Mira Wollner
- Thoracic Cancer Service, Rambam Health Care Campus, Haifa
| | - Sivan Shamai
- Thoracic Cancer Service, Tel Aviv Sourasky Medical Center, Tel Aviv
| | - Nir Peled
- The Legacy Heritage Oncology Center, Soroka Medical Center.,Ben Gurion University of Negev, Beer-Sheva, Israel
| | - Ilit Turgeman
- Thoracic Cancer Service, Rambam Health Care Campus, Haifa
| | - Tzippy Shochat
- Statistical Consulting Unit, Rabin Medical Center, Petah Tikva
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Abstract
PURPOSE: Emergency cancer care constitutes a significant health care and patient burden. The purpose of this study was to identify characteristics of patients most fitting for treatment in an oncology-dedicated emergency department (OED). METHODS: Electronic files of patients with cancer seeking emergency services between April and June 2017 were retrospectively obtained from the hospital registry. Efficacy parameters were compared between patients treated in the OED and those treated in the general emergency department (GED). Using descriptive statistics and logistic regressions, patient- and treatment-related factors were correlated with effective care in the OED. RESULTS: More than half of the total 799 patients presented initially to the OED, of which 10.4% required GED referral. Treatment in the GED was associated with a higher rate of consultations, imaging, and hospitalization (P < .001), with the cost of imaging alone four times that of the OED ($23,263 US dollars difference). The relative proportion of patients with cancer visiting the GED was reduced after founding the OED. In the OED, patient diagnoses included lung (33%), GI, and breast cancer, of which 85% were metastatic. Frequent chief complaints were pain (45%), GI, malaise, and respiratory symptoms. Referral to the GED was significant in those with genitourinary cancer, back pain (P < .001), and neurologic symptoms, on biologic therapy, and with suspected oncological emergencies; conversely, disease symptoms (30% admissions) were well-controlled in the OED (P = .003). CONCLUSION: Using minimal resources, the OED provides efficacious, cancer-focused care, suitable for the majority of acute admissions. Careful triage is recommended, as high-risk patients should be referred to the GED, where advanced multidisciplinary management is more readily available.
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Affiliation(s)
- Ilit Turgeman
- Division of Oncology, Rambam Health Care Campus, Haifa, Israel
| | - Gil Bar-Sela
- Cancer Center, Emek Medical Center, Afula, Israel.,Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
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Abstract
A heterogenous disease with a dismal prognosis, esophageal cancer poses a major health challenge worldwide. In recent years, the treatment landscape for esophageal adenocarcinoma and squamous cell carcinoma (SCC) has undergone major evolution, with the elucidation of underlying biologic pathways and predispositions. Neoadjuvant chemoradiation has emerged as a leading approach for the management of locoregional esophageal cancer, while perioperative chemotherapy has shown promising outcomes specifically in adenocarcinoma of the lower esophagus and gastroesophageal junction (GEJ). Studies also explore the implementation of chemoradiation in various sequential preoperative strategies, as well as in the adjuvant setting. Definitive chemoradiation is considered a valid alternative for non-surgical candidates with SCC. Clinical trials currently evaluating the potential benefits of different approaches may shed light on existing controversies regarding optimal management of locoregional disease. For patients with metastatic cancer, chemotherapy remains the backbone of antineoplastic treatment alongside palliative care, moreover the discovery of novel biological targets has led to the initiation of targeted and immune therapy for specific subpopulations. Taken together, an era of burgeoning clinical trials and changing paradigms has evolved in esophageal oncology. Multidisciplinary collaboration is key to effective combination and sequencing of treatment modalities tailored per patient and per tumor histology. This work aims to provide a comprehensive overview of state-of-the-art oncological management of esophageal cancer, with consideration of new challenges and obstacles to be overcome.
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Affiliation(s)
- Ilit Turgeman
- Division of Oncology, Rambam Health Care Campus, Haifa, Israel
| | - Irit Ben-Aharon
- Division of Oncology, Rambam Health Care Campus, Haifa, Israel
- Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
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15
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Bar-Sela G, Choen I, Campisi-Pinto S, Lewitus G, Oz-Ari L, Jehassi A, Peer A, Turgeman I, Vernicova O, Berman P, Wollner M, Moskovitz M, Meiri D. 1852P Chronic cannabis used by patients with advanced cancer during Immunotherapy initiation: clinical outcomes and endocannabinoid levels evaluation. Ann Oncol 2020. [DOI: 10.1016/j.annonc.2020.08.1499] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
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Goshen-Lago T, Szwarcwort-Cohen M, Benguigui M, Almog R, Turgeman I, Zaltzman N, Halberthal M, Shaked Y, Ben-Aharon I. The Potential Role of Immune Alteration in the Cancer-COVID19 Equation-A Prospective Longitudinal Study. Cancers (Basel) 2020; 12:E2421. [PMID: 32859016 PMCID: PMC7563644 DOI: 10.3390/cancers12092421] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Revised: 08/22/2020] [Accepted: 08/24/2020] [Indexed: 12/22/2022] Open
Abstract
Background: The risk of cancer patients to develop COVID19 infection is unclear. We aimed to prospectively study cancer patients and oncology healthcare workers for COVID19 serology. In IgG+ cases, immune profile was determined to portray the pattern of immune response to SARS-CoV2. Methods: Cancer patients on active treatment and healthcare workers were enrolled. During the study period (3/2020-6/2020), demographic data and blood were collected at three time points. Expression of IgG, IgM, and IgA were assessed. In SARS-CoV-2 IgG+ cases and matched negative cases, we performed mass cytometry time of flight (CyTOF) analysis on the basis of the expression of surface markers. Results: The study included 164 cancer patients on active intravenous treatment and 107 healthcare workers at the cancer center. No symptomatic cases were reported during the study period. Serology analysis revealed four IgG+ patients (2.4%) and two IgG+ healthcare workers (1.9%)-all were asymptomatic. CyTOF analysis demonstrated substantial reduction in myeloid cells in healthcare workers who were SARS-CoV-2 IgG+ compared to those who were SARS-CoV-2 IgG-, whereas in cancer patients, the reduction was relatively milder (≈50% reduction in SARS-CoV-2 IgG+ cancer patients compared with ≈90% reduction in SARS-CoV-2 IgG+ workers). Conclusion: Our results indicate a similar rate of asymptomatic COVID19 infection in cancer patients and healthcare workers in a longitudinal study throughout the pandemic time. Due to differential immune cell profiles of cancer patients who are treated with immunomodulatory agents, the host response to the SARS-COV2 may play a role in COVID19 course and representation. The immunological perspective of cancer treatments on the risk for COVID19 infection should be further explored.
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Affiliation(s)
- Tal Goshen-Lago
- Division of Oncology, Rambam Health Care Campus, Haifa 31096, Israel
| | | | | | - Ronit Almog
- Rappaport Faculty of Medicine, Technion, Haifa 3525428, Israel
- Epidemiology Department and Biobank, Rambam Health Care Campus, Haifa 31096, Israel
| | - Ilit Turgeman
- Division of Oncology, Rambam Health Care Campus, Haifa 31096, Israel
| | - Nelly Zaltzman
- Virology Laboratory, Rambam Health Care Campus, Haifa 31096, Israel
| | - Michael Halberthal
- Rappaport Faculty of Medicine, Technion, Haifa 3525428, Israel
- General Management, Rambam Health Care Campus, Haifa 31096, Israel
| | - Yuval Shaked
- Rappaport Faculty of Medicine, Technion, Haifa 3525428, Israel
- Technion-Integrated Cancer Center, Technion, Haifa 3525428, Israel
| | - Irit Ben-Aharon
- Division of Oncology, Rambam Health Care Campus, Haifa 31096, Israel
- Rappaport Faculty of Medicine, Technion, Haifa 3525428, Israel
- Technion-Integrated Cancer Center, Technion, Haifa 3525428, Israel
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17
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Ben-Aharon I, Goshen-Lago T, Turgeman I, Fontana E, Smyth E, Lordick F. Young patients with cancer and a digital social network: the voice beyond the clinic. ESMO Open 2020; 5:e000651. [PMID: 32385087 PMCID: PMC7228558 DOI: 10.1136/esmoopen-2019-000651] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2019] [Revised: 01/23/2020] [Accepted: 01/27/2020] [Indexed: 11/10/2022] Open
Abstract
Introduction Digital social networks have become a key player in the ecosystem of young patients with cancer, with regard to their unique perspectives and unmet needs. This study aims to investigate the web-based social community tools and to characterise the user profile, unmet needs and goals of young patients with cancer. Methods A web-based survey was distributed via large-scale social network designated for young patients with cancer (age 18–45 years) Stop Cancer. The survey collected demographic data and oncological status. Primary outcome was potential goals of accessing the network; secondary outcomes were emotional impact, effect of disease status, education, marital status and employment, on user satisfaction rate. Results The survey was available for 5 days (10/2018) and was filled by 523 participants. Breast cancer, haematological malignancies and colorectal cancer were the most common diagnoses. The majority had non-metastatic disease at diagnosis, 79% had no evidence of disease at time of the survey. Forty-five per cent considered the network as a reliable source for medical information. Academic education was associated with higher satisfaction from the platform. There were no differences between cancer survivors and patients with active disease in patterns of platform usage. The social network had an allocated section for ‘patient mentoring’ of newly diagnosed members by survivors. Discussion Our study portrayed the user prototype of a social digital network among young adult patients with cancer, indicating challenging trends. Whereas social media may prove a powerful tool for patients and physicians alike, it may also serve as a research tool to appraise wide practices within a heterogeneous population. Nevertheless, it acts as a double-edged sword in the setting of uncontrolled medical information. It is our role as healthcare providers to join this race and play an active role in shaping its medical perspectives.
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Affiliation(s)
- Irit Ben-Aharon
- Oncology, Rambam Health Care Campus, Haifa, Israel; Gastrointestinal Tract Cancer Group, EORTC, Brussels, Belgium.
| | | | | | - Elisa Fontana
- Gastrointestinal Tract Cancer Group, EORTC, Brussels, Belgium; The Institute of Cancer Research and The Royal Marsden Hospital, London, United Kingdom
| | - Elizabeth Smyth
- Gastrointestinal Tract Cancer Group, EORTC, Brussels, Belgium; Medical Oncology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, Cambridgeshire, UK
| | - Florian Lordick
- Gastrointestinal Tract Cancer Group, EORTC, Brussels, Belgium; Hematology, Cell Therapy, Medical Oncology, Hemostaseology, University of Leipzig Faculty of Medicine, Leipzig, Sachsen, Germany
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18
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Turgeman I, Bar-Sela G. Cannabis for cancer - illusion or the tip of an iceberg: a review of the evidence for the use of Cannabis and synthetic cannabinoids in oncology. Expert Opin Investig Drugs 2018; 28:285-296. [PMID: 30572744 DOI: 10.1080/13543784.2019.1561859] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
INTRODUCTION A flowering plant of variegated ingredients and psychoactive qualities, Cannabis has long been used for medicinal and recreational purposes. Regulatory approvals have been gained across a broad range of palliative and therapeutic indications, and in some cases, included in standard treatment guidelines. AREAS COVERED The use of Cannabis and cannabinoid-based-medicines in oncology is summarized in this article. Cannabinoids are classified according to natural and synthetic subtypes and their mechanisms of action expounded. The variability of available products is discussed in the clinical context and data regarding chemotherapy-induced nausea and vomiting, cancer-related pain, anorexia, insomnia, and anxiety are presented. Moreover, immunological and antineoplastic effects in preclinical and clinical trials are addressed. Concepts such as synergism or opposition with conventional treatment modalities, the sequence of administration and dosage, molecular cross-talk and malignancy-cannabinoid congruence, are explored. Finally, side-effects, limitations in trial design and legislation barriers are related. EXPERT OPINION Sufficient evidence supports the use of Cannabis for palliative indications in oncology; however, patients should be carefully selected, guided and followed. Promising research suggests the potent antineoplastic activity, but more data must be accrued before conclusions can be drawn.
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Affiliation(s)
- Ilit Turgeman
- a Division of Oncology , Rambam Health Care Campus , Haifa , Israel
| | - Gil Bar-Sela
- b Center for Malignant Diseases , Emek Medical Center , Afula , Israel.,c Faculty of Medicine , Technion-Israel Institute of Technology , Haifa , Israel
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Turgeman I, Bar-Sela G. Cannabis Use in Palliative Oncology: A Review of the Evidence for Popular Indications. Isr Med Assoc J 2017; 19:85-88. [PMID: 28457056] [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] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
A flowering plant of variegated ingredients and psychoactive qualities, cannabis has long been used for medicinal and recreational purposes. Currently, cannabis is approved in several countries for indications of symptomatic alleviation. However, limited knowledge on the benefits and risks precludes inclusion of cannabis in standard treatment guidelines. This review provides a summary of the available literature on the use of cannabis and cannabinoid-based medicines in palliative oncology. Favorable outcomes are demonstrated for chemotherapy-induced nausea and vomiting and cancer-related pain, with evidence of advantageous neurological interactions. Benefit in the treatment of anorexia, insomnia and anxiety is also suggested. Short- and long-term side effects appear to be manageable and to subside after discontinuation of the drug. Finally, cannabinoids have shown anti-neoplastic effects in preclinical studies in a wide range of cancer cells and some animal models. Further research is needed before cannabis can become a part of evidence-based oncology practice.
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Affiliation(s)
- Ilit Turgeman
- Division of Oncology, Rambam Health Care Campus, Haifa, Israel
| | - Gil Bar-Sela
- Division of Oncology, Rambam Health Care Campus, Haifa, Israel
- Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
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