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Fleshner L, Lagree A, Shiner A, Alera MA, Bielecki M, Grant R, Kiss A, Krzyzanowska MK, Cheng I, Tran WT, Gandhi S. Drivers of Emergency Department Use Among Oncology Patients in the Era of Novel Cancer Therapeutics: A Systematic Review. Oncologist 2023; 28:1020-1033. [PMID: 37302801 PMCID: PMC10712716 DOI: 10.1093/oncolo/oyad161] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Accepted: 05/04/2023] [Indexed: 06/13/2023] Open
Abstract
BACKGROUND Patients diagnosed with cancer are frequent users of the emergency department (ED). While many visits are unavoidable, a significant portion may be potentially preventable ED visits (PPEDs). Cancer treatments have greatly advanced, whereby patients may present with unique toxicities from targeted therapies and are often living longer with advanced disease. Prior work focused on patients undergoing cytotoxic chemotherapy, and often excluded those on supportive care alone. Other contributors to ED visits in oncology, such as patient-level variables, are less well-established. Finally, prior studies focused on ED diagnoses to describe trends and did not evaluate PPEDs. An updated systematic review was completed to focus on PPEDs, novel cancer therapies, and patient-level variables, including those on supportive care alone. METHODS Three online databases were used. Included publications were in English, from 2012-2022, with sample sizes of ≥50, and reported predictors of ED presentation or ED diagnoses in oncology. RESULTS 45 studies were included. Six studies highlighted PPEDs with variable definitions. Common reasons for ED visits included pain (66%) or chemotherapy toxicities (69.1%). PPEDs were most frequent amongst breast cancer patients (13.4%) or patients receiving cytotoxic chemotherapy (20%). Three manuscripts included immunotherapy agents, and only one focused on end-of-life patients. CONCLUSION This updated systematic review highlights variability in oncology ED visits during the last decade. There is limited work on the concept of PPEDs, patient-level variables and patients on supportive care alone. Overall, pain and chemotherapy toxicities remain key drivers of ED visits in cancer patients. Further work is needed in this realm.
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Affiliation(s)
- Lauren Fleshner
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, Toronto, Canada
- Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
- Radiogenomics Laboratory, Sunnybrook Health Sciences Centre, Toronto, Canada
- Institute of Medical Sciences, University of Toronto, Toronto, Canada
| | - Andrew Lagree
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, Toronto, Canada
- Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
- Radiogenomics Laboratory, Sunnybrook Health Sciences Centre, Toronto, Canada
- Temerty Centre for AI Research and Education, University of Toronto, Toronto, Canada
| | - Audrey Shiner
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, Toronto, Canada
- Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
- Radiogenomics Laboratory, Sunnybrook Health Sciences Centre, Toronto, Canada
- Institute of Medical Sciences, University of Toronto, Toronto, Canada
| | - Marie Angeli Alera
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, Toronto, Canada
- Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
- Radiogenomics Laboratory, Sunnybrook Health Sciences Centre, Toronto, Canada
| | - Mateusz Bielecki
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, Toronto, Canada
- Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
- Radiogenomics Laboratory, Sunnybrook Health Sciences Centre, Toronto, Canada
| | - Robert Grant
- Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
- Division of Medical Oncology, Department of Medicine, University of Toronto, Toronto, Canada
| | - Alex Kiss
- Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
- ICES, Toronto, Ontario, Canada
| | - Monika K Krzyzanowska
- Institute of Medical Sciences, University of Toronto, Toronto, Canada
- Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
- Division of Medical Oncology, Department of Medicine, University of Toronto, Toronto, Canada
- The Cancer Quality Lab, Princess Margaret Cancer Centre, Toronto, Ontario, Canada
- ICES, Toronto, Ontario, Canada
| | - Ivy Cheng
- Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
- Department of Emergency Medicine, Sunnybrook Health Sciences Centre, Toronto, Canada
- Department of Emergency Medicine, University of Toronto, Toronto, Canada
| | - William T Tran
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, Toronto, Canada
- Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
- Radiogenomics Laboratory, Sunnybrook Health Sciences Centre, Toronto, Canada
- Institute of Medical Sciences, University of Toronto, Toronto, Canada
- Temerty Centre for AI Research and Education, University of Toronto, Toronto, Canada
- Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada
| | - Sonal Gandhi
- Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
- Institute of Medical Sciences, University of Toronto, Toronto, Canada
- Division of Medical Oncology, Department of Medicine, University of Toronto, Toronto, Canada
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Shiner A, Kiss A, Saednia K, Jerzak KJ, Gandhi S, Lu FI, Emmenegger U, Fleshner L, Lagree A, Alera MA, Bielecki M, Law E, Law B, Kam D, Klein J, Pinard CJ, Shenfield A, Sadeghi-Naini A, Tran WT. Predicting Patterns of Distant Metastasis in Breast Cancer Patients following Local Regional Therapy Using Machine Learning. Genes (Basel) 2023; 14:1768. [PMID: 37761908 PMCID: PMC10531341 DOI: 10.3390/genes14091768] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Revised: 09/05/2023] [Accepted: 09/06/2023] [Indexed: 09/29/2023] Open
Abstract
Up to 30% of breast cancer (BC) patients will develop distant metastases (DM), for which there is no cure. Here, statistical and machine learning (ML) models were developed to estimate the risk of site-specific DM following local-regional therapy. This retrospective study cohort included 175 patients diagnosed with invasive BC who later developed DM. Clinicopathological information was collected for analysis. Outcome variables were the first site of metastasis (brain, bone or visceral) and the time interval (months) to developing DM. Multivariate statistical analysis and ML-based multivariable gradient boosting machines identified factors associated with these outcomes. Machine learning models predicted the site of DM, demonstrating an area under the curve of 0.74, 0.75, and 0.73 for brain, bone and visceral sites, respectively. Overall, most patients (57%) developed bone metastases, with increased odds associated with estrogen receptor (ER) positivity. Human epidermal growth factor receptor-2 (HER2) positivity and non-anthracycline chemotherapy regimens were associated with a decreased risk of bone DM, while brain metastasis was associated with ER-negativity. Furthermore, non-anthracycline chemotherapy alone was a significant predictor of visceral metastasis. Here, clinicopathologic and treatment variables used in ML prediction models predict the first site of metastasis in BC. Further validation may guide focused patient-specific surveillance practices.
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Affiliation(s)
- Audrey Shiner
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, Toronto, ON M4N 3M5, Canada; (A.S.)
- Biological Sciences Platform, Sunnybrook Research Institute, Toronto, ON M4N 3M5, Canada
- Institute of Medical Sciences, University of Toronto, Toronto, ON M5S 1A8, Canada
| | - Alex Kiss
- Institute of Clinical Evaluative Sciences, Sunnybrook Health Sciences Centre, Toronto, ON M4N 3M5, Canada
| | - Khadijeh Saednia
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, Toronto, ON M4N 3M5, Canada; (A.S.)
- Department of Electrical Engineering and Computer Science, Lassonde School of Engineering, York University, Toronto, ON M3J 1P3, Canada
| | - Katarzyna J. Jerzak
- Division of Medical Oncology, Department of Medicine, University of Toronto, Toronto, ON M5S 1A8, Canada
| | - Sonal Gandhi
- Division of Medical Oncology, Department of Medicine, University of Toronto, Toronto, ON M5S 1A8, Canada
| | - Fang-I Lu
- Department of Anatomic Pathology, Sunnybrook Health Sciences Centre, Toronto, ON M4N 3M5, Canada
| | - Urban Emmenegger
- Division of Medical Oncology, Department of Medicine, University of Toronto, Toronto, ON M5S 1A8, Canada
| | - Lauren Fleshner
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, Toronto, ON M4N 3M5, Canada; (A.S.)
- Biological Sciences Platform, Sunnybrook Research Institute, Toronto, ON M4N 3M5, Canada
- Institute of Medical Sciences, University of Toronto, Toronto, ON M5S 1A8, Canada
| | - Andrew Lagree
- Biological Sciences Platform, Sunnybrook Research Institute, Toronto, ON M4N 3M5, Canada
| | - Marie Angeli Alera
- Biological Sciences Platform, Sunnybrook Research Institute, Toronto, ON M4N 3M5, Canada
| | - Mateusz Bielecki
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, Toronto, ON M4N 3M5, Canada; (A.S.)
- Biological Sciences Platform, Sunnybrook Research Institute, Toronto, ON M4N 3M5, Canada
| | - Ethan Law
- Biological Sciences Platform, Sunnybrook Research Institute, Toronto, ON M4N 3M5, Canada
| | - Brianna Law
- Biological Sciences Platform, Sunnybrook Research Institute, Toronto, ON M4N 3M5, Canada
| | - Dylan Kam
- Biological Sciences Platform, Sunnybrook Research Institute, Toronto, ON M4N 3M5, Canada
| | - Jonathan Klein
- Department of Radiation Oncology, Albert Einstein College of Medicine, New York, NY 10461, USA
| | - Christopher J. Pinard
- Biological Sciences Platform, Sunnybrook Research Institute, Toronto, ON M4N 3M5, Canada
| | - Alex Shenfield
- Department of Engineering and Mathematics, Sheffield Hallam University, Sheffield S1 1WB, UK
| | - Ali Sadeghi-Naini
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, Toronto, ON M4N 3M5, Canada; (A.S.)
- Department of Electrical Engineering and Computer Science, Lassonde School of Engineering, York University, Toronto, ON M3J 1P3, Canada
| | - William T. Tran
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, Toronto, ON M4N 3M5, Canada; (A.S.)
- Biological Sciences Platform, Sunnybrook Research Institute, Toronto, ON M4N 3M5, Canada
- Institute of Medical Sciences, University of Toronto, Toronto, ON M5S 1A8, Canada
- Department of Radiation Oncology, University of Toronto, Toronto, ON M5S 1A8, Canada
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Wise J, Tiwari R, O'Halloran S, Fleshner L, Nguyen S, Hersey K, Fallah-Rad N, Fleshner N. Time trends for drug specific adverse events in patients on sunitinib; implications for remote monitoring. Can J Urol 2022; 29:11136-11141. [PMID: 35691034] [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] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
INTRODUCTION Sunitinib is a multi-targeted receptor tyrosine kinase inhibitor used to treat metastatic renal cell carcinoma (mRCC). Patients on sunitinib do require regular in-person appointments to monitor for adverse events (AEs). Given the Covid-19 pandemic, regular in-person visits expose patients to an increased risk of infection in addition to potentially preventable travel costs. This study investigated the feasibility of implementing a remote monitoring strategy for patients being treated with sunitinib for mRCC by examining the time trends of AEs. MATERIALS AND METHODS In this retrospective chart review of patients with a diagnosis of mRCC, 167 patients received sunitinib during their treatment. The time between initiation of treatment and the first AE was recorded. The AEs were categorized according to the Common Terminology Criteria for Adverse Events (CTCAE), version 5. Survival analysis was used to calculate the time-to-AE. RESULTS Of the 167 patients identified, 145 experienced an AE (86.8%). Hypertension was the most common AE with 80% of AEs were ≤ Grade 2. Incidence of AE dropped by 91% after 3 months follow up and a further 36% after 6 months. The cumulative incidence of AEs were 87.8%, 94.6% and 98.0%, at 3, 6 and 9 months respectively. The severity of AEs observed were 39.3%, 38.6%, 20.7%, 1.4%,0% of Grade 1-5 events respectively. A trend of grade migration to less severe grades was also shown over time, with percentage of Grade ≥ 3 toxicity dropping from 22% between 0-3 months to 14% beyond 6 months follow up. CONCLUSIONS The role of remote monitoring for mRCC patients on sunitinib remains relevant now with new waves of the Covid-19 pandemic, triggered by novel variants. The majority of AEs observed were of low severity ≤ Grade 2, with a trend of reduced AE frequency and severity most prevalent beyond 3 months of follow up. This data appears to support the implementation of a remote monitoring strategy 3 months after initiation of treatment.
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Affiliation(s)
- Jacob Wise
- Division of Urology, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Raj Tiwari
- Division of Urology, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Sophie O'Halloran
- Division of Urology, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Lauren Fleshner
- Division of Urology, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Susan Nguyen
- Division of Urology, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Karen Hersey
- Division of Urology, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Nazanin Fallah-Rad
- Division of Medical Oncology, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Neil Fleshner
- Division of Urology, University Health Network, University of Toronto, Toronto, Ontario, Canada
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Lagree A, Shiner A, Alera MA, Fleshner L, Law E, Law B, Lu FI, Dodington D, Gandhi S, Slodkowska EA, Shenfield A, Jerzak KJ, Sadeghi-Naini A, Tran WT. Assessment of Digital Pathology Imaging Biomarkers Associated with Breast Cancer Histologic Grade. Curr Oncol 2021; 28:4298-4316. [PMID: 34898544 PMCID: PMC8628688 DOI: 10.3390/curroncol28060366] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [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: 09/16/2021] [Revised: 10/17/2021] [Accepted: 10/23/2021] [Indexed: 12/31/2022] Open
Abstract
Background: Evaluating histologic grade for breast cancer diagnosis is standard and associated with prognostic outcomes. Current challenges include the time required for manual microscopic evaluation and interobserver variability. This study proposes a computer-aided diagnostic (CAD) pipeline for grading tumors using artificial intelligence. Methods: There were 138 patients included in this retrospective study. Breast core biopsy slides were prepared using standard laboratory techniques, digitized, and pre-processed for analysis. Deep convolutional neural networks (CNNs) were developed to identify the regions of interest containing malignant cells and to segment tumor nuclei. Imaging-based features associated with spatial parameters were extracted from the segmented regions of interest (ROIs). Clinical datasets and pathologic biomarkers (estrogen receptor, progesterone receptor, and human epidermal growth factor 2) were collected from all study subjects. Pathologic, clinical, and imaging-based features were input into machine learning (ML) models to classify histologic grade, and model performances were tested against ground-truth labels at the patient-level. Classification performances were evaluated using receiver-operating characteristic (ROC) analysis. Results: Multiparametric feature sets, containing both clinical and imaging-based features, demonstrated high classification performance. Using imaging-derived markers alone, the classification performance demonstrated an area under the curve (AUC) of 0.745, while modeling these features with other pathologic biomarkers yielded an AUC of 0.836. Conclusion: These results demonstrate an association between tumor nuclear spatial features and tumor grade. If further validated, these systems may be implemented into pathology CADs and can assist pathologists to expeditiously grade tumors at the time of diagnosis and to help guide clinical decisions.
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Affiliation(s)
- Andrew Lagree
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, Toronto, ON M4N 3M5, Canada; (A.L.); (A.S.); (M.A.A.); (L.F.); (E.L.); (B.L.); (A.S.-N.)
- Biological Sciences Platform, Sunnybrook Research Institute, Toronto, ON M4N 3M5, Canada
- Temerty Centre for AI Research and Education, University of Toronto, Toronto, ON M5S 1A8, Canada
- Radiogenomics Laboratory, Sunnybrook Health Sciences Centre, Toronto, ON M4N 3M5, Canada; (F.-I.L.); (S.G.)
| | - Audrey Shiner
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, Toronto, ON M4N 3M5, Canada; (A.L.); (A.S.); (M.A.A.); (L.F.); (E.L.); (B.L.); (A.S.-N.)
- Biological Sciences Platform, Sunnybrook Research Institute, Toronto, ON M4N 3M5, Canada
- Radiogenomics Laboratory, Sunnybrook Health Sciences Centre, Toronto, ON M4N 3M5, Canada; (F.-I.L.); (S.G.)
| | - Marie Angeli Alera
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, Toronto, ON M4N 3M5, Canada; (A.L.); (A.S.); (M.A.A.); (L.F.); (E.L.); (B.L.); (A.S.-N.)
- Biological Sciences Platform, Sunnybrook Research Institute, Toronto, ON M4N 3M5, Canada
- Radiogenomics Laboratory, Sunnybrook Health Sciences Centre, Toronto, ON M4N 3M5, Canada; (F.-I.L.); (S.G.)
| | - Lauren Fleshner
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, Toronto, ON M4N 3M5, Canada; (A.L.); (A.S.); (M.A.A.); (L.F.); (E.L.); (B.L.); (A.S.-N.)
- Biological Sciences Platform, Sunnybrook Research Institute, Toronto, ON M4N 3M5, Canada
- Radiogenomics Laboratory, Sunnybrook Health Sciences Centre, Toronto, ON M4N 3M5, Canada; (F.-I.L.); (S.G.)
| | - Ethan Law
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, Toronto, ON M4N 3M5, Canada; (A.L.); (A.S.); (M.A.A.); (L.F.); (E.L.); (B.L.); (A.S.-N.)
- Biological Sciences Platform, Sunnybrook Research Institute, Toronto, ON M4N 3M5, Canada
- Radiogenomics Laboratory, Sunnybrook Health Sciences Centre, Toronto, ON M4N 3M5, Canada; (F.-I.L.); (S.G.)
| | - Brianna Law
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, Toronto, ON M4N 3M5, Canada; (A.L.); (A.S.); (M.A.A.); (L.F.); (E.L.); (B.L.); (A.S.-N.)
- Biological Sciences Platform, Sunnybrook Research Institute, Toronto, ON M4N 3M5, Canada
- Radiogenomics Laboratory, Sunnybrook Health Sciences Centre, Toronto, ON M4N 3M5, Canada; (F.-I.L.); (S.G.)
| | - Fang-I Lu
- Radiogenomics Laboratory, Sunnybrook Health Sciences Centre, Toronto, ON M4N 3M5, Canada; (F.-I.L.); (S.G.)
- Department of Laboratory Medicine and Molecular Diagnostics, Sunnybrook Health Sciences Centre, Toronto, ON M4N 3M5, Canada; (D.D.); (E.A.S.)
| | - David Dodington
- Department of Laboratory Medicine and Molecular Diagnostics, Sunnybrook Health Sciences Centre, Toronto, ON M4N 3M5, Canada; (D.D.); (E.A.S.)
| | - Sonal Gandhi
- Radiogenomics Laboratory, Sunnybrook Health Sciences Centre, Toronto, ON M4N 3M5, Canada; (F.-I.L.); (S.G.)
- Division of Medical Oncology, Department of Medicine, University of Toronto, Toronto, ON M5S 3H2, Canada;
| | - Elzbieta A. Slodkowska
- Department of Laboratory Medicine and Molecular Diagnostics, Sunnybrook Health Sciences Centre, Toronto, ON M4N 3M5, Canada; (D.D.); (E.A.S.)
| | - Alex Shenfield
- Department of Engineering and Mathematics, Sheffield Hallam University, Howard St, Sheffield S1 1WB, UK;
| | - Katarzyna J. Jerzak
- Division of Medical Oncology, Department of Medicine, University of Toronto, Toronto, ON M5S 3H2, Canada;
| | - Ali Sadeghi-Naini
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, Toronto, ON M4N 3M5, Canada; (A.L.); (A.S.); (M.A.A.); (L.F.); (E.L.); (B.L.); (A.S.-N.)
- Department of Electrical Engineering and Computer Science, York University, Toronto, ON M3J 2S5, Canada
| | - William T. Tran
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, Toronto, ON M4N 3M5, Canada; (A.L.); (A.S.); (M.A.A.); (L.F.); (E.L.); (B.L.); (A.S.-N.)
- Biological Sciences Platform, Sunnybrook Research Institute, Toronto, ON M4N 3M5, Canada
- Temerty Centre for AI Research and Education, University of Toronto, Toronto, ON M5S 1A8, Canada
- Radiogenomics Laboratory, Sunnybrook Health Sciences Centre, Toronto, ON M4N 3M5, Canada; (F.-I.L.); (S.G.)
- Department of Radiation Oncology, University of Toronto, Toronto, ON M5T 1P5, Canada
- Correspondence: ; Tel.: +1-416-480-6100 (ext. 3746)
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Fleshner L, Berlin A, Hersey K, Kenk M, Lajkosz K, Nguyen S, Wise J, O'Halloran S. Time trends of drug-specific actionable adverse events among patients on androgen receptor antagonists: Implications for remote monitoring. Can Urol Assoc J 2021; 16:E146-E149. [PMID: 34672938 DOI: 10.5489/cuaj.7437] [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: 11/19/2022]
Abstract
INTRODUCTION In light of COVID-19, reducing patient exposure via remote monitoring is desirable. Patients prescribed abiraterone/enzalutamide are scheduled for monthly in-person appointments to screen for adverse events (AEs). We determined time trends of drug-specific actionable AEs among users of abiraterone/enzalutamide to assess the safety of remote monitoring. METHODS A chart review was conducted on 828 prostate cancer patients prescribed abiraterone and/or enzalutamide. Data were collected to determine time to actionable first AEs, including hypertension, elevated liver enzymes (aspartate transaminase [AST], alanine transaminase [ALT]), hyperbilirubinemia, and hypokalemia. Survival analysis was used to determine time to AEs. RESULTS In this study, 425 and 403 patients received enzalutamide and abiraterone, respectively. In total, 25.6% of those who took enzalutamide experienced an AE, compared to 28.8% of patients on abiraterone. For patients using abiraterone and experiencing an AE, cumulative incidence of AEs at three, six, nine, and 12 months were: 67.2%, 81.9%, 90.5%, and 93.9%, respectively. Among enzalutamide users experiencing an AE, cumulative incidence of AEs at three, six, nine, and 12 months were 51.4%, 70.7%, 82.6%, and 88.1%, respectively. The AEs associated with enzalutamide were hypertension and liver dysfunction (77.1% and 22.9%, respectively). In the abiraterone group, associated AEs were liver dysfunction (47.4%), hypertension (47.4%), and hypokalemia (5.2%). CONCLUSIONS Attaining AEs secondary to abiraterone/enzalutamide decreases over time and tends to occur within the first six months of therapy. Most actionable AEs can be remotely monitored. Given COVID-19, remote monitoring after six months of initiating abiraterone or enzalutamide appears appropriate.
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Affiliation(s)
- Lauren Fleshner
- Division of Urology, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Alejandro Berlin
- Department of Radiation Oncology, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Karen Hersey
- Division of Urology, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Miran Kenk
- Division of Urology, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Katherine Lajkosz
- Division of Urology, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Susan Nguyen
- Division of Urology, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Jacob Wise
- Division of Urology, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Sophie O'Halloran
- Division of Urology, University Health Network, University of Toronto, Toronto, ON, Canada
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Meti N, Saednia K, Lagree A, Tabbarah S, Mohebpour M, Kiss A, Lu FI, Slodkowska E, Gandhi S, Jerzak KJ, Fleshner L, Law E, Sadeghi-Naini A, Tran WT. Machine Learning Frameworks to Predict Neoadjuvant Chemotherapy Response in Breast Cancer Using Clinical and Pathological Features. JCO Clin Cancer Inform 2021; 5:66-80. [PMID: 33439725 DOI: 10.1200/cci.20.00078] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
PURPOSE Neoadjuvant chemotherapy (NAC) is used to treat locally advanced breast cancer (LABC) and high-risk early breast cancer (BC). Pathological complete response (pCR) has prognostic value depending on BC subtype. Rates of pCR, however, can be variable. Predictive modeling is desirable to help identify patients early who may have suboptimal NAC response. Here, we test and compare the predictive performances of machine learning (ML) prediction models to a standard statistical model, using clinical and pathological data. METHODS Clinical and pathological variables were collected in 431 patients, including tumor size, patient demographics, histological characteristics, molecular status, and staging information. A standard multivariable logistic regression (MLR) was developed and compared with five ML models: k-nearest neighbor classifier, random forest (RF) classifier, naive Bayes algorithm, support vector machine, and multilayer perceptron model. Model performances were measured using a receiver operating characteristic (ROC) analysis and statistically compared. RESULTS MLR predictors of NAC response included: estrogen receptor (ER) status, human epidermal growth factor-2 (HER2) status, tumor size, and Nottingham grade. The strongest MLR predictors of pCR included HER2+ versus HER2- BC (odds ratio [OR], 0.13; 95% CI, 0.07 to 0.23; P < .001) and Nottingham grade G3 versus G1-2 (G1-2: OR, 0.36; 95% CI, 0.20 to 0.65; P < .001). The area under the curve (AUC) for the MLR was AUC = 0.64. Among the various ML models, an RF classifier performed best, with an AUC = 0.88, sensitivity of 70.7%, and specificity of 84.6%, and included the following variables: menopausal status, ER status, HER2 status, Nottingham grade, tumor size, nodal status, and presence of inflammatory BC. CONCLUSION Modeling performances varied between standard versus ML classification methods. RF ML classifiers demonstrated the best predictive performance among all models.
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Affiliation(s)
- Nicholas Meti
- Division of Medical Oncology, Department of Medicine, University of Toronto, ON, Canada.,Temerty Centre for AI Research and Education in Medicine, University of Toronto, ON, Toronto, Canada
| | - Khadijeh Saednia
- Department of Electrical Engineering and Computer Science, Lassonde School of Engineering, York University, Toronto, ON, Canada
| | - Andrew Lagree
- Department of Radiation Oncology, Sunnybrook Health Sciences Center, Toronto, ON, Canada
| | - Sami Tabbarah
- Department of Radiation Oncology, Sunnybrook Health Sciences Center, Toronto, ON, Canada
| | - Majid Mohebpour
- Department of Radiation Oncology, Sunnybrook Health Sciences Center, Toronto, ON, Canada
| | - Alex Kiss
- Institute of Clinical Evaluative Sciences, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Fang-I Lu
- Department of Laboratory Medicine and Molecular Diagnostics, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Elzbieta Slodkowska
- Department of Laboratory Medicine and Molecular Diagnostics, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Sonal Gandhi
- Division of Medical Oncology, Department of Medicine, University of Toronto, ON, Canada.,Division of Medical Oncology, Sunnybrook Health Sciences Center, Toronto, ON, Canada
| | - Katarzyna Joanna Jerzak
- Division of Medical Oncology, Department of Medicine, University of Toronto, ON, Canada.,Division of Medical Oncology, Sunnybrook Health Sciences Center, Toronto, ON, Canada
| | - Lauren Fleshner
- Department of Radiation Oncology, Sunnybrook Health Sciences Center, Toronto, ON, Canada
| | - Ethan Law
- Department of Radiation Oncology, Sunnybrook Health Sciences Center, Toronto, ON, Canada
| | - Ali Sadeghi-Naini
- Temerty Centre for AI Research and Education in Medicine, University of Toronto, ON, Toronto, Canada.,Department of Electrical Engineering and Computer Science, Lassonde School of Engineering, York University, Toronto, ON, Canada.,Department of Radiation Oncology, Sunnybrook Health Sciences Center, Toronto, ON, Canada
| | - William T Tran
- Temerty Centre for AI Research and Education in Medicine, University of Toronto, ON, Toronto, Canada.,Department of Radiation Oncology, Sunnybrook Health Sciences Center, Toronto, ON, Canada.,Department of Radiation Oncology, University of Toronto, Toronto, ON, Canada
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Fleshner L, O'Halloran S, Lajkosz K, Wise J, Kenk M, Nguyen S, Fleshner NE. Time trends of drug specific adverse events among patients on androgen receptor antagonists: Implications for remote monitoring. J Clin Oncol 2021. [DOI: 10.1200/jco.2021.39.6_suppl.40] [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
40 Background: In light of the global pandemic, reducing patient exposure via remote monitoring is desirable. Currently, advanced prostate cancer patients prescribed Abiraterone or Enzalutamide are scheduled for an in-person appointment monthly, to screen for adverse events (AEs). We set out to determine time trends of drug specific AEs in order to determine whether reducing in-person visits for patients taking either Abiraterone or Enzalutamide is feasible. Methods: This chart review was conducted on 667 unique advanced prostate cancer patients, being either metastatic hormone sensitive or castration resistant and utilizing Abiraterone or Enzalutamide. Patients who switched courses of treatment and received both drugs were included twice in the data, resulting in 828 “subjects” overall. Data were collected via accessing electronic patient records, to determine the first sign of an AE related to either Abiraterone or Enzalutamide. These AEs include; hypertension, elevated liver enzymes (bilirubin, AST, ALT) or hypokalemia. Survival analysis was used to determine the time to adverse event. All grade AEs are included in this analysis. Results: In this study, 425 and 403 patients received Enzalutamide and Abiraterone, respectively. In total, 36.3% of those who took Enzalutamide experienced an AE, compared to 43.4% of patients on Abiraterone. For patients utilizing Abiraterone, cumulative incidence of AEs at 3,6,9 and 12 months were: 65.0%, 81.2%, 90.9% and 93.9%, respectively. Among Enzalutamide users, cumulative incidence of AEs at 3,6,9 and 12 months were: 46.8%, 67.5%, 81.2% and 88.3%, respectively. The primary first AEs associated with Enzalutamide consumption were hypertension and liver dysfunction (77.48% and 22.52%). In the Abiraterone group, the first associated AEs were liver dysfunction (48.78%), hypertension (46.34%), and hypokalemia (4.88%). Conclusions: These data suggest that the likelihood of attaining AEs associated with Abiraterone or Enzalutamide utilization decreases over time and tend to occur within the first 6 months of therapy. Furthermore, the vast majority of these AEs can be remotely monitored via outside laboratories and remote blood pressure monitoring. In light of the COVID-19 crisis, remote monitoring after 6 months of taking Abiraterone or Enzalutamide would appear appropriate. Efforts to further safely reduce in person visits should be explored.
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Affiliation(s)
| | | | | | - Jacob Wise
- University Health Network, Toronto, ON, Canada
| | - Miran Kenk
- Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
| | | | - Neil Eric Fleshner
- Division of Urologic Oncology, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
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