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Pfeiler G, Hlauschek D, Mayer EL, Deutschmann C, Kacerovsky-Strobl S, Martin M, Meisel JL, Zdenkowski N, Loibl S, Balic M, Park H, Prat A, Isaacs C, Bajetta E, Balko JM, Bellet-Ezquerra M, Bliss J, Burstein H, Cardoso F, Fohler H, Foukakis T, Gelmon KA, Goetz M, Haddad TC, Iwata H, Jassem J, Lee SC, Linderholm B, Los M, Mamounas EP, Miller KD, Morris PG, Munzone E, Gal-Yam EN, Ring A, Shepherd L, Singer C, Thomssen C, Tseng LM, Valagussa P, Winer EP, Wolff AC, Zoppoli G, Machacek-Link J, Schurmans C, Huang X, Gauthier E, Fesl C, Dueck AC, DeMichele A, Gnant M. Impact of BMI in Patients With Early Hormone Receptor-Positive Breast Cancer Receiving Endocrine Therapy With or Without Palbociclib in the PALLAS Trial. J Clin Oncol 2023; 41:5118-5130. [PMID: 37556775 DOI: 10.1200/jco.23.00126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Revised: 05/03/2023] [Accepted: 06/21/2023] [Indexed: 08/11/2023] Open
Abstract
PURPOSE BMI affects breast cancer risk and prognosis. In contrast to cytotoxic chemotherapy, CDK4/6 inhibitors are given at a fixed dose, irrespective of BMI or weight. This preplanned analysis of the global randomized PALLAS trial investigates the impact of BMI on the side-effect profile, treatment adherence, and efficacy of palbociclib. METHODS Patients were categorized at baseline according to WHO BMI categories. Neutropenia rates were assessed with univariable and multivariable logistic regression. Time to early discontinuation of palbociclib was analyzed with Fine and Gray competing risk models. Unstratified Cox models were used to investigate the association between BMI category and time to invasive disease-free survival (iDFS). 95% CIs were derived. RESULTS Of 5,698 patients included in this analysis, 68 (1.2%) were underweight, 2,082 (36.5%) normal weight, 1,818 (31.9%) overweight, and 1,730 (30.4%) obese at baseline. In the palbociclib arm, higher BMI was associated with a significant decrease in neutropenia (unadjusted odds ratio for 1-unit change, 0.93; 95% CI, 0.91 to 0.94; adjusted for age, race ethnicity, region, chemotherapy use, and Eastern Cooperative Oncology Group at baseline, 0.93; 95% CI, 0.92 to 0.95). This translated into a significant decrease in treatment discontinuation rate with higher BMI (adjusted hazard ratio [HR] for 10-unit change, 0.75; 95% CI, 0.67 to 0.83). There was no significant improvement in iDFS with the addition of palbociclib to ET in any weight category (normal weight HR, 0.84; 95% CI, 0.63 to 1.12; overweight HR, 1.10; 95% CI, 0.82 to 1.49; and obese HR, 0.95; 95% CI, 0.69 to 1.30) in this analysis early in follow-up (31 months). CONCLUSION This preplanned analysis of the PALLAS trial demonstrates a significant impact of BMI on side effects, dose reductions, early treatment discontinuation, and relative dose intensity. Additional long-term follow-up will further evaluate whether BMI ultimately affects outcome.
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Affiliation(s)
- Georg Pfeiler
- Department of Gynecology and Gynecological Oncology, Medical University of Vienna, Vienna, Austria
| | | | | | - Christine Deutschmann
- Department of Gynecology and Gynecological Oncology, Medical University of Vienna, Vienna, Austria
| | | | - Miguel Martin
- Hospital General Universitario Gregorio Marañón, Universidad Complutense, Madrid, Spain
| | | | | | - Sibylle Loibl
- German Breast Group, Neu-Isenburg, Germany
- Goethe University Frankfurt/M, Frankfurt/M, Germany
- Centre for Haematology and Oncology/Bethanien, Frankfurt/M, Germany
| | - Marija Balic
- Division of Oncology, Department of Internal Medicine, Medical University Graz, Graz, Austria
| | - Haeseong Park
- Siteman Cancer Center, Washington University, St Louis, MO
| | - Aleix Prat
- Department of Medical Oncology, Hospital Clinic, IDIBAPS, University of Barcelona, Barcelona, Spain
| | | | - Emilio Bajetta
- Gruppo I.T.M.O., Monza, Italy
- Fondazione Policlinico di Monza, Monza, Italy
| | - Justin M Balko
- Vanderbilt-Ingram Cancer Center, Vanderbilt University Medical Center, Nashville, TN
| | | | - Judith Bliss
- The Institute of Cancer Research, London, United Kingdom
| | - Harold Burstein
- Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA
| | - Fatima Cardoso
- Breast Unit, Champalimaud Clinical Center/Champalimaud Foundation, Lisbon, Portugal
| | - Hannes Fohler
- Austrian Breast and Colorectal Cancer Study Group, Vienna, Austria
| | - Theodoros Foukakis
- Breast Center, Theme Cancer, Karolinska University Hospital, Stockholm, Sweden
- Department of Oncology/Pathology, Karolinska Institute, Stockholm, Sweden
| | | | | | - Tufia C Haddad
- Mayo Clinic College of Medicine and Science, Rochester, MN
| | | | - Jacek Jassem
- Department of Oncology and Radiotherapy, Medical University of Gdańsk, Gdańsk, Poland
| | - Soo-Chin Lee
- Department of Haematology-Oncology, National University Cancer Institute (NCIS), Singapore, Singapore
- Cancer Science Institute (CSI), Singapore, Singapore
- National University of Singapore (NUS), Singapore, Singapore
| | - Barbro Linderholm
- Department of Oncology, Sahlgrenska University Hospital, Gothenburg, Sweden
- Department of Oncology, Institution of Clinical Sciences, Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden
| | - Maartje Los
- St Antonius Ziekenhuis Nieuwegein, Utrecht, the Netherlands
| | | | - Kathy D Miller
- Indiana University Melvin and Bren Simon Comprehensive Cancer Center, Indianapolis, IN
| | - Patrick G Morris
- Cancer Trials Ireland, Dublin, Ireland
- Beaumont RCSI Cancer Centre, Dublin, Ireland
| | | | - Einav Nili Gal-Yam
- The Talpiot Medical Leadership Program, Breast Oncology Institute, Sheba Medical Center, Ramat-Gam, Israel
| | - Alistair Ring
- Royal Marsden Hospital, NHS Foundation Trust, London, United Kingdom
| | - Lois Shepherd
- Canadian Cancer Trials Group, Queen's University, Kingston, ON, Canada
| | - Christian Singer
- Department of Gynecology and Gynecological Oncology, Medical University of Vienna, Vienna, Austria
- Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
| | | | - Ling-Ming Tseng
- Taipei-Veterans General Hospital, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | | | - Eric P Winer
- Yale Cancer Center, Smilow Cancer Network, Yale University, New Haven, CT
| | | | - Gabriele Zoppoli
- Gruppo Oncologico Italiano di Ricerca Clinica (GOIRC), Università degli Studi di Genova, Genoa, Italy
- IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | | | | | | | | | - Christian Fesl
- Austrian Breast and Colorectal Cancer Study Group, Vienna, Austria
| | - Amylou C Dueck
- Alliance Statistics and Data Center, Mayo Clinic, Phoenix, AZ
| | | | - Michael Gnant
- Austrian Breast and Colorectal Cancer Study Group, Vienna, Austria
- Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
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2
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Hilton LK, Ngu HS, Collinge B, Dreval K, Ben-Neriah S, Rushton CK, Wong JC, Cruz M, Roth A, Boyle M, Meissner B, Slack GW, Farinha P, Craig JW, Gerrie AS, Freeman CL, Villa D, Rodrigo JA, Song K, Crump M, Shepherd L, Hay AE, Kuruvilla J, Savage KJ, Kridel R, Karsan A, Marra MA, Sehn LH, Steidl C, Morin RD, Scott DW. Relapse Timing Is Associated With Distinct Evolutionary Dynamics in Diffuse Large B-Cell Lymphoma. J Clin Oncol 2023; 41:4164-4177. [PMID: 37319384 PMCID: PMC10852398 DOI: 10.1200/jco.23.00570] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Revised: 04/17/2023] [Accepted: 05/08/2023] [Indexed: 06/17/2023] Open
Abstract
PURPOSE Diffuse large B-cell lymphoma (DLBCL) is cured in more than 60% of patients, but outcomes remain poor for patients experiencing disease progression or relapse (refractory or relapsed DLBCL [rrDLBCL]), particularly if these events occur early. Although previous studies examining cohorts of rrDLBCL have identified features that are enriched at relapse, few have directly compared serial biopsies to uncover biological and evolutionary dynamics driving rrDLBCL. Here, we sought to confirm the relationship between relapse timing and outcomes after second-line (immuno)chemotherapy and determine the evolutionary dynamics that underpin that relationship. PATIENTS AND METHODS Outcomes were examined in a population-based cohort of 221 patients with DLBCL who experienced progression/relapse after frontline treatment and were treated with second-line (immuno)chemotherapy with an intention-to-treat with autologous stem-cell transplantation (ASCT). Serial DLBCL biopsies from a partially overlapping cohort of 129 patients underwent molecular characterization, including whole-genome or whole-exome sequencing in 73 patients. RESULTS Outcomes to second-line therapy and ASCT are superior for late relapse (>2 years postdiagnosis) versus primary refractory (<9 months) or early relapse (9-24 months). Diagnostic and relapse biopsies were mostly concordant for cell-of-origin classification and genetics-based subgroup. Despite this concordance, the number of mutations exclusive to each biopsy increased with time since diagnosis, and late relapses shared few mutations with their diagnostic counterpart, demonstrating a branching evolution pattern. In patients with highly divergent tumors, many of the same genes acquired new mutations independently in each tumor, suggesting that the earliest mutations in a shared precursor cell constrain tumor evolution toward the same genetics-based subgroups at both diagnosis and relapse. CONCLUSION These results suggest that late relapses commonly represent genetically distinct and chemotherapy-naïve disease and have implications for optimal patient management.
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Affiliation(s)
- Laura K. Hilton
- Centre for Lymphoid Cancer, BC Cancer, Vancouver, British Columbia, Canada
- Department of Molecular Biology and Biochemistry, Simon Fraser University, Burnaby, British Columbia, Canada
| | - Henry S. Ngu
- Centre for Lymphoid Cancer, BC Cancer, Vancouver, British Columbia, Canada
| | - Brett Collinge
- Centre for Lymphoid Cancer, BC Cancer, Vancouver, British Columbia, Canada
- Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Kostiantyn Dreval
- Department of Molecular Biology and Biochemistry, Simon Fraser University, Burnaby, British Columbia, Canada
- Canada's Michael Smith Genome Sciences Centre, BC Cancer Research Institute, Vancouver, British Columbia, Canada
| | - Susana Ben-Neriah
- Centre for Lymphoid Cancer, BC Cancer, Vancouver, British Columbia, Canada
| | - Christopher K. Rushton
- Department of Molecular Biology and Biochemistry, Simon Fraser University, Burnaby, British Columbia, Canada
| | - Jasper C.H. Wong
- Centre for Lymphoid Cancer, BC Cancer, Vancouver, British Columbia, Canada
| | - Manuela Cruz
- Department of Molecular Biology and Biochemistry, Simon Fraser University, Burnaby, British Columbia, Canada
| | - Andrew Roth
- Department of Molecular Oncology, BC Cancer Research Institute, Vancouver, British Columbia, Canada
| | - Merrill Boyle
- Centre for Lymphoid Cancer, BC Cancer, Vancouver, British Columbia, Canada
| | - Barbara Meissner
- Centre for Lymphoid Cancer, BC Cancer, Vancouver, British Columbia, Canada
| | - Graham W. Slack
- Centre for Lymphoid Cancer, BC Cancer, Vancouver, British Columbia, Canada
- Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Pedro Farinha
- Centre for Lymphoid Cancer, BC Cancer, Vancouver, British Columbia, Canada
- Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Jeffrey W. Craig
- Centre for Lymphoid Cancer, BC Cancer, Vancouver, British Columbia, Canada
- Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Alina S. Gerrie
- Centre for Lymphoid Cancer, BC Cancer, Vancouver, British Columbia, Canada
- Division of Medical Oncology, Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Ciara L. Freeman
- Department of Blood and Marrow Transplant and Cellular Immunotherapy, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL
| | - Diego Villa
- Centre for Lymphoid Cancer, BC Cancer, Vancouver, British Columbia, Canada
- Division of Medical Oncology, Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Judith A. Rodrigo
- Department of Hematology, Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
- Leukemia/BMT Program of BC, Vancouver General Hospital, Vancouver, British Columbia, Canada
| | - Kevin Song
- Department of Hematology, Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
- Leukemia/BMT Program of BC, Vancouver General Hospital, Vancouver, British Columbia, Canada
| | - Michael Crump
- Princess Margaret Cancer Center, University Health Network, Toronto, Ontario, Canada
| | - Lois Shepherd
- Canadian Cancer Trials Group, Queens University, Kingston, Ontario, Canada
- Department of Medicine, Queens University, Kingston, Ontario, Canada
| | - Annette E. Hay
- Canadian Cancer Trials Group, Queens University, Kingston, Ontario, Canada
- Department of Medicine, Queens University, Kingston, Ontario, Canada
| | - John Kuruvilla
- Princess Margaret Cancer Center, University Health Network, Toronto, Ontario, Canada
| | - Kerry J. Savage
- Centre for Lymphoid Cancer, BC Cancer, Vancouver, British Columbia, Canada
- Division of Medical Oncology, Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Robert Kridel
- Princess Margaret Cancer Center, University Health Network, Toronto, Ontario, Canada
| | - Aly Karsan
- Canada's Michael Smith Genome Sciences Centre, BC Cancer Research Institute, Vancouver, British Columbia, Canada
| | - Marco A. Marra
- Centre for Lymphoid Cancer, BC Cancer, Vancouver, British Columbia, Canada
- Canada's Michael Smith Genome Sciences Centre, BC Cancer Research Institute, Vancouver, British Columbia, Canada
- Department of Medical Genetics, University of British Columbia, Vancouver, British Columbia, Canada
| | - Laurie H. Sehn
- Centre for Lymphoid Cancer, BC Cancer, Vancouver, British Columbia, Canada
- Division of Medical Oncology, Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Christian Steidl
- Centre for Lymphoid Cancer, BC Cancer, Vancouver, British Columbia, Canada
- Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Ryan D. Morin
- Centre for Lymphoid Cancer, BC Cancer, Vancouver, British Columbia, Canada
- Department of Molecular Biology and Biochemistry, Simon Fraser University, Burnaby, British Columbia, Canada
- Canada's Michael Smith Genome Sciences Centre, BC Cancer Research Institute, Vancouver, British Columbia, Canada
| | - David W. Scott
- Centre for Lymphoid Cancer, BC Cancer, Vancouver, British Columbia, Canada
- Division of Medical Oncology, Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
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3
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El Kababji S, Mitsakakis N, Fang X, Beltran-Bless AA, Pond G, Vandermeer L, Radhakrishnan D, Mosquera L, Paterson A, Shepherd L, Chen B, Barlow WE, Gralow J, Savard MF, Clemons M, El Emam K. Evaluating the Utility and Privacy of Synthetic Breast Cancer Clinical Trial Data Sets. JCO Clin Cancer Inform 2023; 7:e2300116. [PMID: 38011617 DOI: 10.1200/cci.23.00116] [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: 06/19/2023] [Revised: 08/24/2023] [Accepted: 09/19/2023] [Indexed: 11/29/2023] Open
Abstract
PURPOSE There is strong interest from patients, researchers, the pharmaceutical industry, medical journal editors, funders of research, and regulators in sharing clinical trial data for secondary analysis. However, data access remains a challenge because of concerns about patient privacy. It has been argued that synthetic data generation (SDG) is an effective way to address these privacy concerns. There is a dearth of evidence supporting this on oncology clinical trial data sets, and on the utility of privacy-preserving synthetic data. The objective of the proposed study is to validate the utility and privacy risks of synthetic clinical trial data sets across multiple SDG techniques. METHODS We synthesized data sets from eight breast cancer clinical trial data sets using three types of generative models: sequential synthesis, conditional generative adversarial network, and variational autoencoder. Synthetic data utility was evaluated by replicating the published analyses on the synthetic data and assessing concordance of effect estimates and CIs between real and synthetic data. Privacy was evaluated by measuring attribution disclosure risk and membership disclosure risk. RESULTS Utility was highest using the sequential synthesis method where all results were replicable and the CI overlap most similar or higher for seven of eight data sets. Both types of privacy risks were low across all three types of generative models. DISCUSSION Synthetic data using sequential synthesis methods can act as a proxy for real clinical trial data sets, and simultaneously have low privacy risks. This type of generative model can be one way to enable broader sharing of clinical trial data.
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Affiliation(s)
| | | | - Xi Fang
- Replica Analytics Ltd, Ottawa, ON, Canada
| | - Ana-Alicia Beltran-Bless
- Ottawa Hospital Research Institute, Ottawa, ON, Canada
- Division of Medical Oncology, Department of Medicine, University of Ottawa, ON, Canada
| | - Greg Pond
- McMaster University, Hamilton, ON, Canada
| | | | - Dhenuka Radhakrishnan
- CHEO Research Institute, Ottawa, ON, Canada
- Department of Paediatrics, University of Ottawa, Ottawa, ON, Canada
| | - Lucy Mosquera
- CHEO Research Institute, Ottawa, ON, Canada
- Replica Analytics Ltd, Ottawa, ON, Canada
| | | | | | | | | | | | - Marie-France Savard
- Ottawa Hospital Research Institute, Ottawa, ON, Canada
- Division of Medical Oncology, Department of Medicine, University of Ottawa, ON, Canada
| | - Mark Clemons
- Ottawa Hospital Research Institute, Ottawa, ON, Canada
- Division of Medical Oncology, Department of Medicine, University of Ottawa, ON, Canada
| | - Khaled El Emam
- CHEO Research Institute, Ottawa, ON, Canada
- Replica Analytics Ltd, Ottawa, ON, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
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4
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Chen D, Shepherd L. Is There a Doctor in the House? Am J Bioeth 2023; 23:47-50. [PMID: 37450521 PMCID: PMC10494221 DOI: 10.1080/15265161.2023.2217148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/18/2023]
Affiliation(s)
- Donna Chen
- Center for Health Humanities and Ethics, University of Virginia School of Medicine
| | - Lois Shepherd
- Center for Health Humanities and Ethics, University of Virginia School of Medicine
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5
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Mian H, Ringash J, Meyer R, Hay AE, Shepherd L, Djurfeldt M, Winter JN, Sussman J, Pater J, Chen BE, Prica A. Health-related quality of life in early-stage Hodgkin lymphoma: a longitudinal analysis of the ABVD arm in the randomized controlled trial HD.6. Support Care Cancer 2023; 31:256. [PMID: 37043087 DOI: 10.1007/s00520-023-07717-3] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2022] [Accepted: 03/29/2023] [Indexed: 04/13/2023]
Abstract
Early-stage Hodgkin lymphoma has become one of the most curable hematologic malignancies. Depending upon the disease location, possible toxicities, and patient preference, chemotherapy alone with ABVD remains an accepted treatment modality for this disease. There remains a paucity of data regarding the longitudinal trajectory of health-related quality of life (HRQoL) in patients treated for HL. The impact of disease and treatment on HRQoL is increasingly important to understand as the number of long-term survivors increases. We report the longitudinal HRQoL using data prospectively collected from diagnosis up to 10 years post-treatment in the ABVD arm of the HD.6 randomized controlled trial for early-stage HL patients (N=169). We analyzed HRQoL using the EORTC QLQ-C30 collected at baseline, 3 months, 6 months, and 12 months after completion of chemotherapy and yearly up to year 10. Clinically and statistically significant improvements were noted for specific domains including emotional (3 months post-treatment), social (12 months post-treatment) and financial functioning (2 years post-treatment), and the specific symptom of fatigue (6 months post-treatment) during the follow-up period. To our knowledge, this is the first prospective, longitudinal analysis of HRQoL specifically among patients with early-stage HL treated with ABVD therapy alone. Although improvements were noted, sustained clinically and statistically significant improvements were noted only in select symptoms emphasizing the need to better understand and optimize HRQoL among this patient group.
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Affiliation(s)
- Hira Mian
- Department of Oncology, McMaster University, 699 Concession St, Hamilton, ON, L8V 5C2, Canada.
| | - Jolie Ringash
- Cancer Clinical Research Unit (CCRU), Princess Margaret Cancer Centre/UHN, University of Toronto, Toronto, Canada
- Department of Radiation Oncology, University of Toronto, Toronto, Canada
| | - Ralph Meyer
- Department of Oncology, McMaster University, 699 Concession St, Hamilton, ON, L8V 5C2, Canada
| | - Annette E Hay
- Canadian Cancer Trials Group, Department of Medicine, Queen's University, Kingston, Canada
| | - Lois Shepherd
- Canadian Cancer Trials Group, Department of Pathology & Molecular Medicine, Queen's University, Kingston, Canada
| | - Marina Djurfeldt
- Canadian Cancer Trials Group, Queen's University, Kingston, Canada
| | - Jane N Winter
- Northwestern University, Feinberg School of Medicine, Illinois, USA
| | - Jonathan Sussman
- Department of Oncology, McMaster University, 699 Concession St, Hamilton, ON, L8V 5C2, Canada
| | - Joseph Pater
- Canadian Cancer Trials Group, Queen's University, Kingston, Canada
| | - Bingshu E Chen
- Canadian Cancer Trials Group, Department of Public Health Sciences and Department of Mathematics and Statistics, Queen's University, Kingston, Canada
| | - Anca Prica
- Department of Medical Oncology and Hematology, Princess Margaret Cancer Centre, University of Toronto, Toronto, Canada
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6
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Hilton LK, Ngu HS, Collinge B, Dreval K, Ben-Neriah S, Rushton CK, Wong JC, Cruz M, Roth A, Boyle M, Meissner B, Slack GW, Farinha P, Craig JW, Gerrie AS, Freeman CL, Villa D, Crump M, Shepherd L, Hay AE, Kuruvilla J, Savage KJ, Kridel R, Karsan A, Marra MA, Sehn LH, Steidl C, Morin RD, Scott DW. Relapse timing is associated with distinct evolutionary dynamics in DLBCL. medRxiv 2023:2023.03.06.23286584. [PMID: 36945587 PMCID: PMC10029038 DOI: 10.1101/2023.03.06.23286584] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/10/2023]
Abstract
Diffuse large B-cell lymphoma (DLBCL) is cured in over 60% of patients, but outcomes are poor for patients with relapsed or refractory disease (rrDLBCL). Here, we performed whole genome/exome sequencing (WGS/WES) on tumors from 73 serially-biopsied patients with rrDLBCL. Based on the observation that outcomes to salvage therapy/autologous stem cell transplantation are related to time-to-relapse, we stratified patients into groups according to relapse timing to explore the relationship to genetic divergence and sensitivity to salvage immunochemotherapy. The degree of mutational divergence increased with time between biopsies, yet tumor pairs were mostly concordant for cell-of-origin, oncogene rearrangement status and genetics-based subgroup. In patients with highly divergent tumors, several genes acquired exclusive mutations independently in each tumor, which, along with concordance of genetics-based subgroups, suggests that the earliest mutations in a shared precursor cell constrain tumor evolution. These results suggest that late relapses commonly represent genetically distinct and chemotherapy-naïve disease.
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Affiliation(s)
- Laura K. Hilton
- Centre for Lymphoid Cancer, BC Cancer Research Institute, Vancouver, BC, Canada
- Department of Molecular Biology and Biochemistry, Simon Fraser University, Burnaby, BC, Canada
| | - Henry S. Ngu
- Centre for Lymphoid Cancer, BC Cancer Research Institute, Vancouver, BC, Canada
| | - Brett Collinge
- Centre for Lymphoid Cancer, BC Cancer Research Institute, Vancouver, BC, Canada
- Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Kostiantyn Dreval
- Department of Molecular Biology and Biochemistry, Simon Fraser University, Burnaby, BC, Canada
- Canada’s Michael Smith Genome Sciences Centre, BC Cancer Research Institute, Vancouver, BC, Canada
| | - Susana Ben-Neriah
- Centre for Lymphoid Cancer, BC Cancer Research Institute, Vancouver, BC, Canada
| | - Christopher K. Rushton
- Department of Molecular Biology and Biochemistry, Simon Fraser University, Burnaby, BC, Canada
| | - Jasper C.H. Wong
- Centre for Lymphoid Cancer, BC Cancer Research Institute, Vancouver, BC, Canada
| | - Manuela Cruz
- Department of Molecular Biology and Biochemistry, Simon Fraser University, Burnaby, BC, Canada
| | - Andrew Roth
- Department of Molecular Oncology, BC Cancer Research Institute, Vancouver, BC, Canada
| | - Merrill Boyle
- Centre for Lymphoid Cancer, BC Cancer Research Institute, Vancouver, BC, Canada
| | - Barbara Meissner
- Centre for Lymphoid Cancer, BC Cancer Research Institute, Vancouver, BC, Canada
| | - Graham W. Slack
- Centre for Lymphoid Cancer, BC Cancer Research Institute, Vancouver, BC, Canada
- Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Pedro Farinha
- Centre for Lymphoid Cancer, BC Cancer Research Institute, Vancouver, BC, Canada
- Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Jeffrey W. Craig
- Centre for Lymphoid Cancer, BC Cancer Research Institute, Vancouver, BC, Canada
- Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Alina S. Gerrie
- Centre for Lymphoid Cancer, BC Cancer Research Institute, Vancouver, BC, Canada
- Division of Medical Oncology, Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Ciara L. Freeman
- Department of Blood and Marrow Transplant and Cellular Immunotherapy, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL
| | - Diego Villa
- Centre for Lymphoid Cancer, BC Cancer Research Institute, Vancouver, BC, Canada
- Division of Medical Oncology, Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Michael Crump
- Princess Margaret Cancer Center, University Health Network, Toronto, ON, Canada
| | - Lois Shepherd
- Canadian Cancer Trials Group, Queens University, Kingston, ON, Canada
- Department of Medicine, Queens University, Kingston, ON, Canada
| | - Annette E. Hay
- Canadian Cancer Trials Group, Queens University, Kingston, ON, Canada
- Department of Medicine, Queens University, Kingston, ON, Canada
| | - John Kuruvilla
- Princess Margaret Cancer Center, University Health Network, Toronto, ON, Canada
| | - Kerry J. Savage
- Centre for Lymphoid Cancer, BC Cancer Research Institute, Vancouver, BC, Canada
- Division of Medical Oncology, Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Robert Kridel
- Princess Margaret Cancer Center, University Health Network, Toronto, ON, Canada
| | - Aly Karsan
- Canada’s Michael Smith Genome Sciences Centre, BC Cancer Research Institute, Vancouver, BC, Canada
| | - Marco A. Marra
- Centre for Lymphoid Cancer, BC Cancer Research Institute, Vancouver, BC, Canada
- Canada’s Michael Smith Genome Sciences Centre, BC Cancer Research Institute, Vancouver, BC, Canada
- Department of Medical Genetics, University of British Columbia, Vancouver, BC, Canada
| | - Laurie H. Sehn
- Centre for Lymphoid Cancer, BC Cancer Research Institute, Vancouver, BC, Canada
- Division of Medical Oncology, Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Christian Steidl
- Centre for Lymphoid Cancer, BC Cancer Research Institute, Vancouver, BC, Canada
- Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Ryan D. Morin
- Centre for Lymphoid Cancer, BC Cancer Research Institute, Vancouver, BC, Canada
- Department of Molecular Biology and Biochemistry, Simon Fraser University, Burnaby, BC, Canada
- Canada’s Michael Smith Genome Sciences Centre, BC Cancer Research Institute, Vancouver, BC, Canada
| | - David W. Scott
- Centre for Lymphoid Cancer, BC Cancer Research Institute, Vancouver, BC, Canada
- Division of Medical Oncology, Department of Medicine, University of British Columbia, Vancouver, BC, Canada
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7
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McCartney A, Biagioni C, Chen B, Shepherd L, Gelmon K, Joy AA, Parulekar W, Bergqvist M, Migliaccio I, Leo A, Benelli M, Risi E, Moretti E, Livraghi L, Biganzoli L, Malorni L. Abstract P5-02-27: Serum thymidine kinase activity as a prognostic marker in women with metastatic breast cancer treated with two different schedules of palbociclib plus second-line endocrine therapy within the CCTG MA38 trial. Cancer Res 2023. [DOI: 10.1158/1538-7445.sabcs22-p5-02-27] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/06/2023]
Abstract
Abstract
Background: Thymidine kinase-1 is a cell proliferation marker downstream of the CDK4/6 pathway, whose activity can be measured in serum to reflect tumor proliferation. The CDK4/6 inhibitor palbociclib (P) is approved for the treatment of patients (pts) with hormone receptor positive metastatic breast cancer (MBC) in first or second line endocrine-based treatment settings. Approximately 10-15% of pts exhibit de novo resistance to P, with circulating levels of thymidine kinase activity (TKa) previously shown as a potential marker of early treatment resistance. Therapeutic strategies to address primary resistance to P are currently lacking. Little is known of the clinical efficacy of alternative dosing schedules of P, and its effect on TKa. Here we report serum TKa measured at different timepoints from samples collected within the MA38 (NCT02630693) study. Methods: MA38 is an open label randomised Phase 2 trial comparing two different schedules of P plus second-line ET in pts with ER-positive, HER2-negative MBC. Pts were assigned to receive physician’s choice ET plus either standard P dosing (125mg daily for 21 days on a 28-day cycle), or 100mg daily continuously. Serum samples were collected at baseline (BL; n=135), at 12 weeks (W12; n=122) and 24 weeks (W24; n=95). TKa was measured with DiviTum®, a refined ELISA-based assay (lower limit of detection [LLOD] = 100 DuA). Kaplan-Meier method estimated BL, W12 and W24 (95% CI) median PFS (mPFS; from randomization until progression by RECIST criteria or death) and overall survival (OS; from randomization until death from any cause) in groups of patients defined by dichotomizing TKa as “high” or “low” at the median. Results: MA38 enrolled 180 pts from December 2015 and February 2017 across Canada. Median follow up was 19 months. Overall, the median age was 60, and 90% of pts were post-menopausal. All pts had estrogen receptor-positive disease, and 64% had visceral metastases. On study, 56% received fulvestrant with P, 34% aromatase inhibitor and 10% tamoxifen. TKa was successfully measured in 100% of samples. Median TKa (mTKa) at BL was 234 DuA (IQR 138.5 - 438). BL TKa was not associated with clinical or pathological characteristics. TKa was prognostic at BL with mPFS of 5.5 months (mo) in pts with high TKa vs 16.3 mo with low TKa (HR=2.43; 95% CI, 1.6-3.7; p< 0.001). Similar results were obtained employing other previously reported cut off values. At multivariate analysis, BL TKa was independent from other prognostic factors including age, ECOG status and presence of visceral metastases (adjusted HR= 2.34; 95%CI 1.5- 3.6; p < 0.001). In terms of OS, BL TKa was an independent prognostic factor (adjusted HR=2.0; 95% CI, 1.1-3.7; p=0.02). At 12 mo, OS rate was 68% in pts with high BL TKa vs 92% in low TKa. Both for PFS and OS, no interaction between BL TKa and study arm was observed. At W12 mTKa was 129.5 DuA (IQR 100 - 219.8) and below LLOD (IQR 100 - 180) at W24. At these timepoints, landmark analyses showed no significant difference in PFS according to TKa. However, at W12 high TKa was significantly associated with worse OS (HR 2.0; 95%CI 1.0- 4.0; p=0.03), with a similar trend at W24 (HR 2.5; 95%CI 0.9-6.4; p=0.06). Conclusions: Baseline TKa is a reliable prognostic marker of both PFS and OS in pts treated with P and ET, further substantiating previous data. Monitoring TKa during treatment may provide important clinical information. A significant relationship between TKa and assigned treatment arm was not observed, suggesting TKa is not influenced by P treatment dose or intensity. These data confirm the role of baseline TKa as a new marker for patient stratification, and supports further investigation for the assessment of the clinical utility of TKa as a monitoring biomarker in the advanced setting.
Citation Format: Amelia McCartney, Chiara Biagioni, Bingshu Chen, Lois Shepherd, Karen Gelmon, Anil A. Joy, Wendy Parulekar, Mattias Bergqvist, Ilenia Migliaccio, Angela Leo, Matteo Benelli, Emanuela Risi, Erica Moretti, Luca Livraghi, Laura Biganzoli, Luca Malorni. Serum thymidine kinase activity as a prognostic marker in women with metastatic breast cancer treated with two different schedules of palbociclib plus second-line endocrine therapy within the CCTG MA38 trial [abstract]. In: Proceedings of the 2022 San Antonio Breast Cancer Symposium; 2022 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2023;83(5 Suppl):Abstract nr P5-02-27.
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Affiliation(s)
- Amelia McCartney
- 1School of Clinical Sciences, Monash University, Melbourne, Australia
| | - Chiara Biagioni
- 2Bioinformatics Unit, Hospital of Prato, AUSL Toscana Centro, Prato, Italy
| | | | - Lois Shepherd
- 4Canadian Cancer Trials Group, Queen’s University, Kingston, Ontario, Canada
| | - Karen Gelmon
- 5BC Cancer Agency, Vancouver, British Columbia, Canada
| | - Anil A. Joy
- 6University of Alberta, Department of Oncology, Cross Cancer Institute, Division of Medical Oncology, Edmonton, Alberta, Canada
| | | | | | - Ilenia Migliaccio
- 9Translational Research Unit, Hospital of Prato, AUSL Toscana Centro, Prato, Italy
| | - Angela Leo
- 10Translational Research Unit, Hospital of Prato, AUSL Toscana Centro, Prato, Italy
| | - Matteo Benelli
- 11Bioinformatics Unit, Hospital of Prato, AUSL Toscana Centro, Prato, Italy
| | - Emanuela Risi
- 12Medical Oncology Unit, Hospital of Prato, AUSL Toscana Centro, Prato, Italy
| | - Erica Moretti
- 13Medical Oncology Unit, Hospital of Prato, AUSL Toscana Centro, Prato, Italy
| | - Luca Livraghi
- 14Medical Oncology Unit, Hospital of Prato, AUSL Toscana Centro, Prato, Italy
| | - Laura Biganzoli
- 15Medical Oncology Unit, Hospital of Prato, AUSL Toscana Centro, Prato, Italy
| | - Luca Malorni
- 16Translational Research Unit, Hospital of Prato, AUSL Toscana Centro, Prato, Italy
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Bartoszko J, Martinez-Perez S, Callum J, Karkouti K, Farouh ME, Scales DC, Heddle NM, Crowther M, Rao V, Hucke HP, Carroll J, Grewal D, Brar S, Brussières J, Grocott H, Harle C, Pavenski K, Rochon A, Saha T, Shepherd L, Syed S, Tran D, Wong D, Zeller M. Impact of cardiopulmonary bypass duration on efficacy of fibrinogen replacement with cryoprecipitate compared with fibrinogen concentrate: a post hoc analysis of the Fibrinogen Replenishment in Surgery (FIBRES) randomised controlled trial. Br J Anaesth 2022; 129:294-307. [DOI: 10.1016/j.bja.2022.05.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Revised: 04/16/2022] [Accepted: 05/06/2022] [Indexed: 11/28/2022] Open
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Shepherd L, Beveridge A. A tiered approach to inpatient psychosocial screening in an adult UK burns service. Burns 2022; 48:698-702. [PMID: 34120780 DOI: 10.1016/j.burns.2021.05.017] [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: 11/23/2020] [Revised: 05/19/2021] [Accepted: 05/28/2021] [Indexed: 12/15/2022]
Abstract
National guidance in the UK advises that psychosocial screening is completed for all inpatients admitted to burns services for over 24 h. Acceptable methods of psychosocial screening have been nationally agreed. However, little is known about how different services conduct psychosocial screening. Moreover, data related to validity and reliability are lacking. This paper describes a tiered approach to inpatient psychosocial screening in a UK adult burns service and considers implications for services. Data collected over a seven-year period was analysed retrospectively. Of 891 patients, almost half (48%; n = 431) were screened face-to-face by a graduate level assistant psychologist. Almost one quarter (23%, n = 205) were screened face-to-face by a qualified clinical psychologist. Around a fifth (22%, n = 193) were screened indirectly through psychological discussions at multi-disciplinary team meetings with a member of the burns clinical psychology team present. A minority of patients were screened face-to-face by liaison psychiatry, or by both liaison psychiatry and a clinical psychologist. Screening and delivery of low-level psychological interventions by a graduate level assistant psychologist appeared to protect resources of qualified clinical psychologists for the most distressed patients. Results highlight the value and cost-effectiveness of a tiered approach to psychosocial screening and in guiding subsequent intervention. Future study is needed in relation to inpatient psychosocial screening and its validity and reliability. Investigating the predictive value of screening methods in identifying those with longer-term psychological difficulties would also be important clinically.
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Affiliation(s)
- L Shepherd
- Nottingham University Hospitals NHS Trust, Department of Clinical Psychology & Neuropsychology, Queens Medical Centre Campus, Derby Road, Nottingham NG7 2UH, United Kingdom.
| | - A Beveridge
- Nottingham University Hospitals NHS Trust, Department of Clinical Psychology & Neuropsychology, Queens Medical Centre Campus, Derby Road, Nottingham NG7 2UH, United Kingdom
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10
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Mayer EL, Fesl C, Hlauschek D, Garcia-Estevez L, Burstein HJ, Zdenkowski N, Wette V, Miller KD, Balic M, Mayer IA, Cameron D, Winer EP, Ponce Lorenzo JJ, Lake D, Pristauz-Telsnigg G, Haddad TC, Shepherd L, Iwata H, Goetz M, Cardoso F, Traina TA, Sabanathan D, Breitenstein U, Ackerl K, Metzger Filho O, Zehetner K, Solomon K, El-Abed S, Theall KP, Lu DR, Dueck A, Gnant M, DeMichele A. Treatment Exposure and Discontinuation in the PALbociclib CoLlaborative Adjuvant Study of Palbociclib With Adjuvant Endocrine Therapy for Hormone Receptor-Positive/Human Epidermal Growth Factor Receptor 2-Negative Early Breast Cancer (PALLAS/AFT-05/ABCSG-42/BIG-14-03). J Clin Oncol 2022; 40:449-458. [PMID: 34995105 PMCID: PMC9851679 DOI: 10.1200/jco.21.01918] [Citation(s) in RCA: 24] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
PURPOSE The PALLAS study investigated whether the addition of palbociclib, an oral CDK4/6 inhibitor, to adjuvant endocrine therapy (ET) improves invasive disease-free survival (iDFS) in early hormone receptor-positive (HR+), human epidermal growth factor receptor 2-negative (HER2-) breast cancer. In this analysis, we evaluated palbociclib exposure and discontinuation in PALLAS. METHODS Patients with stage II-III HR+, HER2- disease were randomly assigned to 2 years of palbociclib with adjuvant ET versus ET alone. The primary objective was to compare iDFS between arms. Continuous monitoring of toxicity, dose modifications, and early discontinuation was performed. Association of baseline covariates with time to palbociclib reduction and discontinuation was analyzed with multivariable competing risk models. Landmark and inverse probability weighted per-protocol analyses were performed to assess the impact of drug persistence and exposure on iDFS. RESULTS Of the 5,743 patient analysis population (2,840 initiating palbociclib), 1,199 (42.2%) stopped palbociclib before 2 years, the majority (772, 27.2%) for adverse effects, most commonly neutropenia and fatigue. Discontinuation of ET did not differ between arms. Discontinuations for non-protocol-defined reasons were greater in the first 3 months of palbociclib, and in the first calendar year of accrual, and declined over time. No significant relationship was seen between longer palbociclib duration or ≥ 70% exposure intensity and improved iDFS. In the weighted per-protocol analysis, no improvement in iDFS was observed in patients receiving palbociclib versus not (hazard ratio 0.89; 95% CI, 0.72 to 1.11). CONCLUSION Despite observed rates of discontinuation in PALLAS, analyses suggest that the lack of significant iDFS difference between arms was not directly related to inadequate palbociclib exposure. However, the discontinuation rate illustrates the challenge of introducing novel adjuvant treatments, and the need for interventions to improve persistence with oral cancer therapies.
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Affiliation(s)
- Erica L. Mayer
- Dana-Farber Cancer Institute, Boston, MA,Erica L. Mayer, MD, MPH, Dana-Farber Cancer Institute, 450 Brookline Ave, Boston, MA 02215; e-mail:
| | - Christian Fesl
- Austrian Breast and Colorectal Cancer Study Group, Vienna, Austria
| | | | - Laura Garcia-Estevez
- MD Anderson Cancer Center, Madrid, Spain,GEICAM Spanish Breast Cancer Group, Madrid, Spain
| | | | | | | | - Kathy D. Miller
- Indiana University Melvin and Bren Simon Comprehensive Cancer Center, Indianapolis, IN
| | | | | | - David Cameron
- Cancer Research UK Edinburgh Centre, Edinburgh, United Kingdom
| | | | - José Juan Ponce Lorenzo
- GEICAM Spanish Breast Cancer Group, Madrid, Spain,Hospital General Universitario de Alicante, Alicante, Spain
| | - Diana Lake
- Memorial Sloan Kettering Cancer Center, New York, NY
| | | | | | | | | | | | - Fatima Cardoso
- Breast Unit, Champalimaud Clinical Center/Champalimaud Foundation, Lisboa, Portugal
| | | | - Dhanusha Sabanathan
- Lakeside Specialist Breast Clinic and Nepean Cancer Care Centre, Norwest, NSW, Australia
| | | | - Kerstin Ackerl
- Austrian Breast and Colorectal Cancer Study Group, Vienna, Austria
| | | | - Karin Zehetner
- Austrian Breast and Colorectal Cancer Study Group, Vienna, Austria
| | | | | | | | | | - Amylou Dueck
- Alliance Statistics and Data Center, Mayo Clinic, Phoenix, AZ
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Magness C, Kang M, Kennedy M, Alexander S, O'Boyle C, Hasham S, Shepherd L. 1312 Characteristics of Those Who Present with Self-Inflicted Burns: A Burns Unit Service Evaluation Which Challenges Stereotypes. Br J Surg 2021. [DOI: 10.1093/bjs/znab259.725] [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: 11/12/2022]
Abstract
Abstract
Introduction
Self-harm rates in the UK are increasing. Healthcare professionals’ beliefs regarding repeat attendance; attention-seeking; and poor treatment compliance may contribute to patients’ stigma. Self-inflicted burns (SIB) constitute a minority of burns cases, but require disproportionate healthcare input, yet little is known about these patients. Our aim was to evaluate presentations, compliance and outcomes in this patient group.
Method
A retrospective audit of outpatients with SIBs attending a UK Burns Unit over four years (Jan 2016-Dec 2019).
Results
Over the study period, 58 patients presented with 94 burn wounds. Incidence doubled over one year (2018-2019). Most patients were female (85%) with a median age of 29 years (range 19-62). The most commonly associated psychiatric diagnosis was personality disorder. On presentation 22% (n = 21) were admitted under the Mental Health Act. For 83% (n = 48) it was their first presentation with a SIB, although 74% had previously presented with non-burn self-harm. Median burn size was 0.5% TBSA, the most common mechanism was contact (48%) and 77% were deep (n = 77). 92% were compliant with treatment and did not tamper with their wounds or dressings.
Conclusions
The majority, 70% (n = 41), of patients only presented once to the Burns Department during the study period. This challenges the commonly held stereotype that those who self-harm will also seek attention through repeat presentation. Ongoing education among health professionals may dispel some myths regarding these individuals. Further, larger investigations, may permit rigorous comparison of treatment outcomes with non-SIB patients.
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Affiliation(s)
- C Magness
- Burns and Plastic Surgery Department, Nottingham University Hospitals NHS Trust, City Hospital Campus, Nottingham, United Kingdom
| | - M Kang
- Burns and Plastic Surgery Department, Nottingham University Hospitals NHS Trust, City Hospital Campus, Nottingham, United Kingdom
| | - M Kennedy
- Burns and Plastic Surgery Department, Nottingham University Hospitals NHS Trust, City Hospital Campus, Nottingham, United Kingdom
| | - S Alexander
- Burns and Plastic Surgery Department, Nottingham University Hospitals NHS Trust, City Hospital Campus, Nottingham, United Kingdom
| | - C O'Boyle
- Burns and Plastic Surgery Department, Nottingham University Hospitals NHS Trust, City Hospital Campus, Nottingham, United Kingdom
| | - S Hasham
- Burns and Plastic Surgery Department, Nottingham University Hospitals NHS Trust, City Hospital Campus, Nottingham, United Kingdom
| | - L Shepherd
- Burns and Plastic Surgery Department, Nottingham University Hospitals NHS Trust, City Hospital Campus, Nottingham, United Kingdom
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Chen DT, Shepherd L, Taylor J, Marshall MF. Who will receive the last ventilator: why COVID-19 policies should not prioritise healthcare workers. J Med Ethics 2021; 47:599-602. [PMID: 34172525 PMCID: PMC8238528 DOI: 10.1136/medethics-2021-107248] [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] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Accepted: 05/28/2021] [Indexed: 06/13/2023]
Abstract
Policies promoted and adopted for allocating ventilators during the COVID-19 pandemic have often prioritised healthcare workers or other essential workers. While the need for such policies has so far been largely averted, renewed stress on health systems from continuing surges, as well as the experience of allocating another scarce resource-vaccination-counsel revisiting the justifications for such prioritisation. Prioritising healthcare workers may have intuitive appeal, but the ethical justifications for doing so and the potential harms that could follow require careful analysis. Ethical justifications commonly offered for healthcare worker prioritisation for ventilators rest on two social value criteria: (1) instrumental value, also known as the 'multiplier effect', which may preserve the ability of healthcare workers to help others, and (2) reciprocity, which rewards past usefulness or sacrifice. We argue that these justifications are insufficient to over-ride the common moral commitment to value each person's life equally. Institutional policies prioritising healthcare workers over other patients also violate other ethical norms of the healthcare professions, including the commitment to put patients first. Furthermore, policy decisions to prioritise healthcare workers for ventilators could engender or deepen existing distrust of the clinicians, hospitals and health systems where those policies exist, even if they are never invoked.
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Affiliation(s)
- Donna T Chen
- Center for Health Humanities and Ethics, University of Virginia School of Medicine, Charlottesville, Virginia, USA
| | - Lois Shepherd
- Center for Health Humanities and Ethics, University of Virginia School of Medicine, Charlottesville, Virginia, USA
| | - Jordan Taylor
- Center for Health Humanities and Ethics, University of Virginia School of Medicine, Charlottesville, Virginia, USA
| | - Mary Faith Marshall
- Center for Health Humanities and Ethics, University of Virginia School of Medicine, Charlottesville, Virginia, USA
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Monteith BE, Venner CP, Cheung MC, Pater J, Shepherd L, Richardson H, Reece D, Gul E, Lalancette M, Castonguay V, Kukreti V, Tiedemann R, Phua C, Bhella S, Dudebout J, Sherry M, Yen H, Chen BE, Hay AE. A descriptive cost-analysis of MYX.1/MCRN003, a phase 2 clinical trial evaluating high-dose weekly carfilzomib, cyclophosphamide, and dexamethasone in relapsed and refractory multiple myeloma. Eur J Haematol 2021; 107:333-342. [PMID: 34053112 DOI: 10.1111/ejh.13671] [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: 03/23/2021] [Revised: 05/18/2021] [Accepted: 05/21/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND The prevalence of multiple myeloma is increasing and there is a need to evaluate escalating therapy costs (Canadian Cancer Statistics A, 2020). The MYX.1 phase II trial showed that high-dose weekly carfilzomib, cyclophosphamide, and dexamethasone (wKCD) is efficacious in relapsed and refractory disease. We conducted a descriptive cost analysis, from the perspective of the Canadian public healthcare system, using trial data. METHODS The primary outcome was the mean total cost per patient. Resource utilization data were collected from all 75 trial patients over a trial time horizon. Costs are presented in Canadian dollars (2020). RESULTS The cost of treatment was calculated from the time of patient (pt) enrollment until the second data lock. The mean total cost was $203 336.08/pt (range $17 891.27-$505 583.55) Canadian dollars (CAD, where 1 CAD = 0.67 Euro (EUR)) and $14 081.45/pt per cycle. The median number of cycles was 15. The predominant cost driver was the cost of chemotherapy accounting for an average of $179 332.78/pt or $12 419.17/pt per cycle. Carfilzomib acquisition accounted for the majority of chemotherapy costs - $162 471.65/pt or $11 251.50/pt per cycle. Fifty-six percent (56%) of patients had at least one hospitalization during the trial period with an average cost of $12 657.86 per hospitalization. Three patients developed thrombotic microangiopathy (TMA) with an average cost of $18 863.32/pt including the cost of hospitalizations and therapeutic plasma exchange. CONCLUSIONS High-dose wKCD is an active triplet regimen for relapsed and refractory multiple myeloma (RRMM) associated with reduced total cost compared with twice-weekly carfilzomib-based regimens.
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Affiliation(s)
- Bethany E Monteith
- Canadian Cancer Trials Group, Queen's University, Kingston, ON, Canada.,Cancer Center of Southeastern Ontario, Queen's University, Kingston, ON, Canada
| | | | - Matthew C Cheung
- Odette Cancer Centre, University of Toronto, Toronto, ON, Canada
| | - Joe Pater
- Canadian Cancer Trials Group, Queen's University, Kingston, ON, Canada
| | - Lois Shepherd
- Canadian Cancer Trials Group, Queen's University, Kingston, ON, Canada
| | | | - Donna Reece
- Princess Margaret Cancer Centre, University of Toronto, Toronto, ON, Canada
| | - Engin Gul
- Canadian Myeloma Research Group (formerly the Myeloma Canada Research Network), Vaughan, ON, Canada
| | - Marc Lalancette
- CHU de Québec, Hôtel-Dieu de Québec, Université Laval, Quebec City, QC, Canada
| | - Vincent Castonguay
- CHU de Québec, Hôtel-Dieu de Québec, Université Laval, Quebec City, QC, Canada
| | - Vishal Kukreti
- Princess Margaret Cancer Centre, University of Toronto, Toronto, ON, Canada
| | - Rodger Tiedemann
- Princess Margaret Cancer Centre, University of Toronto, Toronto, ON, Canada
| | - Chai Phua
- Victoria Hospital, Western University, London, ON, Canada
| | - Sita Bhella
- Cancer Center of Southeastern Ontario, Queen's University, Kingston, ON, Canada
| | - Jill Dudebout
- Cancer Center of Southeastern Ontario, Queen's University, Kingston, ON, Canada
| | - Max Sherry
- Canadian Cancer Trials Group, Queen's University, Kingston, ON, Canada
| | - Hope Yen
- Canadian Cancer Trials Group, Queen's University, Kingston, ON, Canada
| | - Bingshu E Chen
- Canadian Cancer Trials Group, Queen's University, Kingston, ON, Canada
| | - Annette E Hay
- Canadian Cancer Trials Group, Queen's University, Kingston, ON, Canada.,Cancer Center of Southeastern Ontario, Queen's University, Kingston, ON, Canada
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15
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Ethier JL, Anderson GM, Austin PC, Clemons M, Parulekar W, Shepherd L, Summers Trasiewicz L, Tu D, Amir E. Influence of the competing risk of death on estimates of disease recurrence in trials of adjuvant endocrine therapy for early-stage breast cancer: A secondary analysis of MA.27, MA.17 and MA.17R. Eur J Cancer 2021; 149:117-127. [PMID: 33853037 DOI: 10.1016/j.ejca.2021.02.034] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Revised: 02/17/2021] [Accepted: 02/22/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Many women diagnosed with early-stage hormone-sensitive breast cancer die of causes other than their breast cancer. These competing risks can create challenges in analysing and clearly communicating data on risk of breast cancer recurrence or death. Here, we quantify the impact of competing risks on estimates of disease recurrence and benefit from therapy. PATIENTS AND METHODS Using data from the MA.27, MA.17 and MA.17R trials of adjuvant endocrine therapy in early breast cancer, we compared Kaplan-Meier (KM) and competing risk methods for disease-free survival (DFS) and distant recurrence-free survival (DRFS). Each trial was analysed separately. In KM analyses, participants were censored at the time of non-breast cancer death. Competing risk analyses comprised cumulative incidence functions in which non-breast cancer death was a competing risk. RESULTS Non-breast cancer deaths were observed more often in older participants, in those with lower risk of breast cancer and after longer follow-up. Compared with conventional analyses, estimates of the proportion of participants with DFS or DRFS events were lower in competing risk analyses, with this difference increasing over the course of follow-up. The absolute treatment benefit was similar or modestly lower in competing risk analyses. CONCLUSION Compared with KM methods, competing risk analyses result in lower estimates of DFS and DRFS events and similar or modestly lower absolute benefit from experimental endocrine therapy. Over a long time horizon, competing risk methods may be preferable to KM methods when estimating future risk of recurrence in early-stage hormone-sensitive breast cancer. CLINICAL TRIALS REGISTRATION Clinicaltrials.gov; NCT00003140, NCT00754845, NCT00066573.
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Affiliation(s)
| | - Geoffrey M Anderson
- Institute of Health Policy, Management and Evaluation, University of Toronto, Canada
| | - Peter C Austin
- ICES, Toronto, Ontario, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Canada
| | - Mark Clemons
- The Ottawa Hospital Cancer Centre, University of Ottawa, Ottawa, Canada
| | | | - Lois Shepherd
- Canadian Cancer Trials Group, Kingston, Ontario, Canada
| | | | - Dongsheng Tu
- Canadian Cancer Trials Group, Kingston, Ontario, Canada
| | - Eitan Amir
- Princess Margaret Cancer Centre, Toronto, Ontario, Canada.
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Lemelin A, Savard J, Chen M, Burnell M, Levine MN, Shepherd L, Chen BE, Lemieux J. Abstract PD12-01: Evaluation of sleep problems and their association with febrile neutropenia, leucopenia and infections in women receiving adjuvant chemotherapy for breast cancer in the Canadian Cancer Trials Group MA.21 trial. Cancer Res 2021. [DOI: 10.1158/1538-7445.sabcs20-pd12-01] [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: 11/16/2022]
Abstract
Abstract
BackgroundInsomnia is a frequent complaint in patients with cancer. Sleep problems can affect immune functioning in healthy individuals. Our aim was to evaluate the association between sleep disturbance and the risk of febrile neutropenia, leukopenia and infections in patients treated with chemotherapy in an adjuvant setting for breast cancer.MethodologyThis is a retrospective study using the Canadian Cancer Trial Group data collected for the MA.21 trial, in which three adjuvant chemotherapy regimens (CEF, EC-T dose dense or AC-T) were compared in 2104 patients with node positive or high-risk node negative breast cancer. A total of 1731 patients had completed the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire C30 (EORTC QLQ-C30) and 1727 patients had completed the Breast Cancer Chemotherapy Questionnaire (BCQ) quality of life questionnaires, which both include a question about sleep difficulties. The primary definition for patients with insomnia was a score of three (quite a bit) or greater at Question 11 (Have you had trouble sleeping? with answers ranging from one (not at all) to four (very much)) on the EORTC QLQ-C30 questionnaire. We compared patients classified as having “clinical insomnia” based on their response to this question with patients considered “good sleepers”. The primary endpoint was the risk of febrile neutropenia. Secondary endpoints were the risks of grade one or more leukopenia, neutropenia and infection. ResultsFebrile neutropenia was more frequent in patients with sleep problems compared with those without, with 16.3% and 12.2% of patients having at least one episode in each group respectively (p value = 0.01 in the univariate analysis (table 1)). However, after adjustment for potential confounders in the multi-variate analysis, it was not statistically significant with an odds ratio of 1.07, a 95% confidence interval of 0.76-1.50 and a p value of 0.71. Similarly, no statistically significant difference in the risk of leukopenia could be demonstrated in the multi-variate analysis for patients with sleep problems with an odds ratio of 0.92 a 95% confidence interval of 0.69-1.24 and a p value of 0.59. No significant association could be found between sleep problems and neutropenia and infections. In an unplanned exploratory analysis, chemotherapy dose reductions were significantly more frequent in patients with sleep problems with 30.6% in this group compared to 21.8% in good sleepers, with a p value <0.0001. ConclusionWhile our univariate analysis suggested an increased risk of febrile neutropenia and leucopenia in patients with sleep problems, after adjustment for confounders, we could not show a statistically significant association in women undergoing adjuvant chemotherapy for high-risk locoregional breast cancer.
Table 1: Univariate analysis of primary and secondary outcomes in patients with sleep problems and good sleepersCharacteristicsSleep problem= yesSleep problem = noFebrile neutropeniaNo781 (83.7%)701 (87.8%)Yes152 (16.3%)97 (12.2%)P-value0.01White blood cell count (WBC)Grade 0157 (16.8%)141 (17.7%)Grade 1135 (14.5%)138 (17.3%)Grade 2184 (19.7%)186 (23.3%)Grade 3214 (22.9%)173 (21.7%)Grade 4243 (26.1%)160 (20.1%)P-value0.02NeutropeniaGrade 0778 (83.4%)700 (87.7%)Grade 10 (0%)1 (0.1%)Grade 22 (0.2%)0 (0%)Grade 3152 (16.3%)96 (12.0%)Grade 41 (0.1%)1 (0.1%)P-value0.014InfectionGrade 0619 (66.4%)564 (70.7%)Grade 168 (7.3%)62 (7.8%)Grade 2158 (16.9%)110 (13.8%)Grade 387 (9.3%)61 (7.6%)Grade 41 (0.1%)1 (0.1%)P-value0.24Chemotherapy delayNo1 (0.1%)12 (1.5%)Yes932 (99.9%)786 (98.5%)P-value0.0008Chemotherapy dose reductionNo648 (69.4%)624 (78.2%)Yes285 (30.6%)174 (21.8%)P-value< 0.0001
Citation Format: Audreylie Lemelin, Josée Savard, Michelle Chen, Margot Burnell, Mark N Levine, Lois Shepherd, Bingshu E Chen, Julie Lemieux. Evaluation of sleep problems and their association with febrile neutropenia, leucopenia and infections in women receiving adjuvant chemotherapy for breast cancer in the Canadian Cancer Trials Group MA.21 trial [abstract]. In: Proceedings of the 2020 San Antonio Breast Cancer Virtual Symposium; 2020 Dec 8-11; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2021;81(4 Suppl):Abstract nr PD12-01.
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Affiliation(s)
| | - Josée Savard
- 1CHU de Québec - Université Laval, Québec, QC, Canada
| | - Michelle Chen
- 2Canadian Cancer Trials Group - Queens University, Kingston, ON, Canada
| | | | | | - Lois Shepherd
- 2Canadian Cancer Trials Group - Queens University, Kingston, ON, Canada
| | - Bingshu E Chen
- 2Canadian Cancer Trials Group - Queens University, Kingston, ON, Canada
| | - Julie Lemieux
- 1CHU de Québec - Université Laval, Québec, QC, Canada
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17
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Pimentel I, Chen BE, Lohmann AE, Ennis M, Ligibel J, Shepherd L, Hershman DL, Whelan T, Stambolic V, Mayer I, Hobday T, Lemieux J, Thompson A, Rastogi P, Gelmon K, Rea D, Rabaglio M, Ellard S, Mates M, Bedard P, Pitre L, Vandenberg T, Dowling RJO, Parulekar W, Goodwin PJ. The Effect of Metformin vs Placebo on Sex Hormones in Canadian Cancer Trials Group MA.32. J Natl Cancer Inst 2021; 113:192-198. [PMID: 33527137 PMCID: PMC7850529 DOI: 10.1093/jnci/djaa082] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [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: 03/02/2020] [Revised: 05/08/2020] [Accepted: 06/01/2020] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Metformin has been associated with lower breast cancer (BC) risk and improved outcomes in observational studies. Multiple biologic mechanisms have been proposed, including a recent report of altered sex hormones. We evaluated the effect of metformin on sex hormones in MA.32, a phase III trial of nondiabetic BC subjects who were randomly assigned to metformin or placebo. METHODS We studied the subgroup of postmenopausal hormone receptor-negative BC subjects not receiving endocrine treatment who provided fasting blood at baseline and at 6 months after being randomly assigned. Sex hormone-binding globulin, bioavailable testosterone, and estradiol levels were assayed using electrochemiluminescence immunoassay. Change from baseline to 6 months between study arms was compared using Wilcoxon sum rank tests and regression models. RESULTS 312 women were eligible (141 metformin vs 171 placebo); the majority of subjects in each arm had T1/2, N0, HER2-negative BC and had received (neo)adjuvant chemotherapy. Mean age was 58.1 (SD=6.9) vs 57.5 (SD=7.9) years, mean body mass index (BMI) was 27.3 (SD=5.5) vs 28.9 (SD=6.4) kg/m2 for metformin vs placebo, respectively. Median estradiol decreased between baseline and 6 months on metformin vs placebo (-5.7 vs 0 pmol/L; P < .001) in univariable analysis and after controlling for baseline BMI and BMI change (P < .001). There was no change in sex hormone-binding globulin or bioavailable testosterone. CONCLUSION Metformin lowered estradiol levels, independent of BMI. This observation suggests a new metformin effect that has potential relevance to estrogen sensitive cancers.
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Affiliation(s)
- Isabel Pimentel
- Vall d`Hebron Institute of Oncology (VHIO), Barcelona, Spain
| | - Bingshu E Chen
- Canadian Cancer Trials Group, Queen’s University–Cancer Research Institute, Kingston, ON, Canada
| | | | | | | | - Lois Shepherd
- Canadian Cancer Trials Group, Queen’s University–Cancer Research Institute, Kingston, ON, Canada
| | - Dawn L Hershman
- Herbert Irving Cancer Center, Columbia University, New York, NY, USA
| | - Timothy Whelan
- Juravinski Cancer Centre at Hamilton Health Sciences, Hamilton, ON, Canada
| | - Vuk Stambolic
- University Health Network, Princess Margaret Hospital, Toronto, ON, Canada
| | - Ingrid Mayer
- Vanderbilt University, Vanderbilt-Ingram Cancer Center, Nashville, TN, USA
| | | | - Julie Lemieux
- CHA-Hopital Du St-Sacrement, Hopital Enfant Jesus Site, Quebec City, Canada
| | | | - Priya Rastogi
- National Surgical Adjuvant Breast and Bowel Project, Pittsburgh, PA, USA
| | - Karen Gelmon
- BCCA–Vancouver Cancer Centre, Vancouver, BC, Canada
| | - Daniel Rea
- Institute of Cancer Research, Clinical Trials and Statistics Unit, Sutton, UK
| | | | - Susan Ellard
- BCCA-Cancer Centre for the Southern Interior, Kelowna, BC, Canada
| | - Mihaela Mates
- Cancer Centre of Southeastern Ontario, Kingston, ON, Canada
| | - Philippe Bedard
- University Health Network, Princess Margaret Hospital, Toronto, ON, Canada
| | | | | | - Ryan J O Dowling
- University Health Network, Princess Margaret Hospital, Toronto, ON, Canada
| | - Wendy Parulekar
- Canadian Cancer Trials Group , Queen’s University–Cancer Research Institute, Kingston, ON, Canada
| | - Pamela J Goodwin
- Lunenfeld Tanenbaum Research Institute at Mount Sinai Hospital, University of Toronto, Toronto, ON, Canada
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18
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Thomas N, Hilton LK, Michaud N, Bushell K, Rys R, Jain M, Shepherd L, Marra MA, Kuruvilla J, Crump M, Mann K, Assouline S, Steidl C, Cragg MS, Scott DW, Johnson N, Morin RD, Rushton CK, Arthur SE, Alcaide M, Cheung M, Jiang A, Coyle KM, Cleary KLS. Abstract IA42: Detecting and quantifying mutations associated with treatment resistance in aggressive lymphomas using ctDNA. Blood Cancer Discov 2020. [DOI: 10.1158/2643-3249.lymphoma20-ia42] [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: 11/16/2022] Open
Abstract
Abstract
A significant proportion of diffuse large B-cell lymphoma (DLBCL) patients treated with immunochemotherapy containing rituximab (R-CHOP) exhibit either primary or acquired treatment resistance. The advancement of therapeutics in the relapse setting has likely been encumbered by our limited understanding of the molecular features that underlie resistance to R-CHOP. Unfortunately, our knowledge of DLBCL genetics is mostly limited to analyses conducted on diagnostic tissue biopsies, which have not been exposed to the selective pressures imposed by therapy. Identifying genetic alterations that contribute to treatment resistance may reveal additional treatment options and lead to biomarkers allowing patients to be paired with appropriate treatments. Genetic subgroups are gaining popularity as a new strategy to implement precision medicine in DLBCL (1). The relevance of these and other biomarkers in the relapse setting remains unclear due to limited genetic exploration of relapsed and refractory DLBCL (rrDLBCL). Progress has been limited, in part, by the requirement of tissue biopsies collected after relapse. It is well established that quantitative genomic techniques such as digital PCR and targeted sequencing can be used to determine the proportion of tumor DNA in plasma from lymphoma patients (2). With a sufficiently broad panel, sequencing affords additional opportunities including the ability to identify subclonal structure and population dynamics over time. This presentation will discuss our recent analysis of a large collection of ctDNA primarily comprising DLBCL patients on various clinical trials (3). Targeted sequencing of these samples and comparison to exome data from a meta-cohort of previously characterized untreated DLBCL biopsies revealed six genes significantly enriched for mutations upon relapse. We found both TP53 and KMT2D were mutated in the majority of rrDLBCLs, and these mutations persisted in the dominant clone following relapse, suggesting a role in primary treatment resistance. By inferring subclonal dynamics, we observed recurrent patterns of clonal expansion and contraction following rituximab-based therapy, with MS4A1 mutations representing the only example of consistent clonal expansion. MS4A1 missense mutations within the transmembrane domains led to loss of CD20 expression in vitro, and patient tumors harboring these mutations lacked CD20 protein expression. Our analysis nominates TP53 and KMT2D mutation status as novel prognostic factors that may facilitate the identification of high-risk patients prior to therapy. Moreover, we have demonstrated the potential to identify tumors with loss of CD20 surface expression stemming from MS4A1 mutations. Implementation of noninvasive assays to detect such features of acquired treatment resistance may allow timely transition to more effective treatment regimens. In certain scenarios whole-exome sequencing (WES) or whole-genome sequencing (WGS) can be successfully applied to ctDNA, thereby allowing the identification of mutations, structural variation, and copy number changes. Low-pass sequencing of shotgun libraries can also be used to ascertain course estimates of ctDNA levels as well as the copy number landscape (4). Given the importance of copy number and structural alterations in the inference of genetic subgroups, these methods may allow the exploration of these groups and their stability over time. Through a series of illustrative examples, this presentation will explore the benefits of each of these techniques in the study of tumor evolution and acquired treatment resistance in DLBCL.
References: 1. Morin RD, Scott DW. DLBCL subclassification: Divide and conquer? Blood 2020;135:1722–4. 2. Rossi D et al. The development of liquid biopsy for research and clinical practice in lymphomas: Report of the 15-ICML workshop on ctDNA. Hematol Oncol 2020;38:34–7. 3. Rushton CK et al. Genetic and evolutionary patterns of treatment resistance in relapsed B-cell lymphoma. Blood Adv 2020;4:2886–98. 4. Adalsteinsson VA et al. Scalable whole-exome sequencing of cell-free DNA reveals high concordance with metastatic tumors. Nat Commun 2017;8:1324.
Citation Format: Nicole Thomas, Laura K. Hilton, Neil Michaud, Kevin Bushell, Ryan Rys, Michael Jain, Lois Shepherd, Marco A. Marra, John Kuruvilla, Michael Crump, Koren Mann, Sarit Assouline, Christian Steidl, Mark S. Cragg, David W. Scott, Nathalie Johnson, Ryan D. Morin, Christopher K. Rushton, Sarah E. Arthur, Miguel Alcaide, Matthew Cheung, Aixiang Jiang, Krysta M. Coyle, Kirstie L. S. Cleary. Detecting and quantifying mutations associated with treatment resistance in aggressive lymphomas using ctDNA [abstract]. In: Proceedings of the AACR Virtual Meeting: Advances in Malignant Lymphoma; 2020 Aug 17-19. Philadelphia (PA): AACR; Blood Cancer Discov 2020;1(3_Suppl):Abstract nr IA42.
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Affiliation(s)
| | | | | | | | - Ryan Rys
- 3McGill University, Montreal, QC, Canada,
| | | | | | | | | | - Michael Crump
- 7Princess Margaret Cancer Centre, Toronto, ON, Canada,
| | - Koren Mann
- 3McGill University, Montreal, QC, Canada,
| | | | | | - Mark S. Cragg
- 8University of Southampton, Southampton, United Kingdom
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19
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Trevena H, Munn E, King L, Thomas M, Shepherd L, Cranney L, Crino M, O'Connell T, Cobcroft M. Healthy choices in New South Wales health facilities for staff and visitors: a policy evaluation. Eur J Public Health 2020. [DOI: 10.1093/eurpub/ckaa165.1143] [Citation(s) in RCA: 1] [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: 11/12/2022] Open
Abstract
Abstract
Issue
Obesity and its determinants are risk factors for most leading causes of chronic diseases. In New South Wales (NSW), Australia, 1 in 2 adults and more than 1 in 5 children are above a healthy weight. As a key symbolic part of a suite of health eating policies, the NSW Ministry of Health implemented a Healthy Food and Drink in NSW Health facilities for Staff and Visitors Framework (Framework) across 18 Local Health Districts (LHDs). Many countries are grappling to understand the effectiveness of obesity prevention policies. Description 2: This policy evaluation synthesised evaluation study findings and internal records to assess the effectiveness of the Framework in achieving implementation targets: a) the removal of sugar-sweetened drinks (SSDs) from sale (Dec 2017), b) implementation of 12 food-based practices (Dec 2018).
Results
The overall implementation package was appropriate for the large, geographically dispersed, decentralised health system (160 health facilities; 927 food outlets;76 retailers) and variable retail arrangements. The Ministry provided LHDs with overall direction, phasing, and monitoring; the LHDs had local leadership, governance, cross-functional support and autonomy to implement in a way to suit them. Accountability and pace of implementation was driven most notably by monitoring and reporting using an electronic tool (PHIMS-N), and a 'network of practice' that was pivotal to problem solving. SSDs were removed from 96% (n = 606) of applicable food outlets; overall average achievement of all practices was high at 82% (22.4 SD). Nine in 10 (92%) consumers support the Framework, and retailers are accepting of its targets. Lessons: This was the right policy at the right time, with well-orchestrated implementation. Annual monitoring and reporting enabled by PHIMS-N is unique in this type of policy implementation and essential for tracking progress, informing decision making, and ensuring accountability.
Key messages
Implementation of the Framework has resulted in the removal of SSDs from sale, increased availability of healthier foods and decreased unhealthy foods as measured by 12 food-based practices. The Framework is feasible and effective in influencing retail practices in health facilities, has high consumer support for its goals, and overall acceptability and adoption amongst retailers.
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Affiliation(s)
- H Trevena
- School of Public Health, The University of Sydney, Sydney, Australia
| | - E Munn
- Food Policy Unit, NSW Ministry of Health, Sydney, Australia
| | - L King
- School of Public Health, The University of Sydney, Sydney, Australia
| | - M Thomas
- School of Public Health, The University of Sydney, Sydney, Australia
| | - L Shepherd
- School of Public Health, The University of Sydney, Sydney, Australia
| | - L Cranney
- School of Public Health, The University of Sydney, Sydney, Australia
| | - M Crino
- School of Public Health, The University of Sydney, Sydney, Australia
- Food Policy Unit, NSW Ministry of Health, Sydney, Australia
| | - T O'Connell
- Food Policy Unit, NSW Ministry of Health, Sydney, Australia
| | - M Cobcroft
- Food Policy Unit, NSW Ministry of Health, Sydney, Australia
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20
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Lankes HA, Watson MA, Jordan RC, Ramirez NC, Wistuba II, Shepherd L, Lubensky IA, Makhlouf H. Abstract PO-065: National Clinical Trials Network biobanking during the COVID-19 pandemic. Clin Cancer Res 2020. [DOI: 10.1158/1557-3265.covid-19-po-065] [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: 11/16/2022]
Abstract
Abstract
The National Cancer Institute (NCI) has a large portfolio of ongoing cancer clinical trials that involve biospecimen collection and are supported by the NCI-funded National Clinical Trials Network (NCTN) Biospecimen Banks located across the United States and Canada. At the start of the COVID-19 pandemic, NCTN biobanks rapidly responded to staffing consequences of state- and institution-issued stay-at-home orders. Many of the NCTN biobanks were deemed essential by their institutions, allowing for limited and/or socially distanced operations. NCTN biobanks quickly worked with NCI and their respective groups to advise participating sites of changes to usual biospecimen collection procedures in order to accommodate limited staffing at the biobanks. In many instances, participating sites were navigating their own institutional process change due to the pandemic. NCTN cancer clinical trials experienced an approximate 40% decrease in enrollment from March 11 to May 19, 2020, compared to the same time frame in 2019. Likewise, NCTN biobanks saw an approximate 40% and 60% decrease in biospecimen receipt and distribution, respectively. The decrease in biospecimen receipt was likely due to two factors: (1) participating site COVID-19 policies limiting patient enrollment on NCI cancer clinical trials and/or biospecimen collection for those trials, and (2) NCTN biobank requests for participating sites to hold nonurgent and/or nonmandatory biospecimens during the initial phase of the pandemic. Decrease in biospecimen distributions was mainly due to receiving laboratory closures as dictated by their institutional COVID-19 policies. On May 20, 2020, all states had begun initial reopening phases to some extent. At this time, several, but not all, NCTN biobanks had begun measured return to full operations, following institutional guidance. NCTN biobanks are making numerous considerations toward returning to full operations and will continue to work with NCI and their respective groups to responsibly collect and distribute biospecimens collected during the COVID-19 pandemic. Likely, some patients enrolled on NCTN cancer clinical trials may have had clinical or subclinical COVID-19 at the time of biospecimen collection. Additionally, biospecimens will be collected on two recently activated NCI COVID-19 studies: (1) the NCI COVID-19 in Cancer Patients Study (NCCAPS): A Longitudinal Natural History Study (NCT04387656), and (2) a tocilizumab treatment trial for COVID-19-related acute respiratory distress syndrome in cancer patients (NCT04370834). Retrospective annotation of these biospecimens may provide a unique resource for translational research efforts and will also be a needed caveat for interpreting biomarker studies conducted using these biospecimens, as the impact of COVID-19 on various biomarkers is currently unknown.
Citation Format: Heather A. Lankes, Mark A. Watson, Richard C. Jordan, Nilsa C. Ramirez, Ignacio I. Wistuba, Lois Shepherd, Irina A. Lubensky, Hala Makhlouf. National Clinical Trials Network biobanking during the COVID-19 pandemic [abstract]. In: Proceedings of the AACR Virtual Meeting: COVID-19 and Cancer; 2020 Jul 20-22. Philadelphia (PA): AACR; Clin Cancer Res 2020;26(18_Suppl):Abstract nr PO-065.
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Affiliation(s)
| | - Mark A. Watson
- 2Washington University School of Medicine in St. Louis, St. Louis, MO,
| | | | | | | | - Lois Shepherd
- 6Queen's University School of Medicine Cancer Research Institute, Kingston, ON, Canada,
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21
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Moku P, Shepherd L, Ali SM, Leitzel K, Parulekar WR, Zhu L, Virk S, Nomikos D, Aparicio S, Gelmon K, Drabick J, Cream L, Halstead ES, Umstead TM, Mckeone D, Polimera H, Maddukuri A, Ali A, Nagabhairu V, Poulose J, Pancholy N, Spiegel H, Chen BE, Lipton A. Higher serum PD-L1 level predicts increased overall survival with lapatinib versus trastuzumab in the CCTG MA.31 phase 3 trial. Cancer 2020; 126:4859-4866. [PMID: 32910476 DOI: 10.1002/cncr.33149] [Citation(s) in RCA: 4] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Revised: 05/18/2020] [Accepted: 06/26/2020] [Indexed: 11/08/2022]
Abstract
BACKGROUND The purpose of this retrospective biomarker study of the Canadian Cancer Trials Group (CCTG) MA.31 randomized phase 3 trial (lapatinib vs trastuzumab) of HER2-positive metastatic breast cancer (MBC) was to evaluate the prognostic and predictive biomarker utility of pretreatment serum programmed death ligand 1 (PD-L1) levels. METHODS CCTG MA.31 accrued 652 HER2-positive patients; 387 had serum available (185 in the trastuzumab arm and 202 in the lapatinib arm). The Ella immunoassay platform (ProteinSimple, San Jose, California) was used to quantitate serum PD-L1 levels. Stepwise forward Cox multivariable analyses were performed for progression-free survival and overall survival (OS). RESULTS In the whole trial population, continuous pretreatment serum PD-L1 levels were not associated with OS. However, within the trastuzumab arm, a higher continuous pretreatment serum PD-L1 level was significant for shorter OS (hazard ratio [HR], 3.85; P = .04), but within the lapatinib arm, pretreatment serum PD-L1 was not associated with OS (P = .37). In the whole trial, in a multivariable analysis for OS, serum PD-L1 (median cut point) remained a significant independent covariate (HR, 2.38; P = .001). There was a significant interaction between treatment arm and continuous serum PD-L1 (bootstrap method; P = .0025): at or above 214.2 pg/mL (the 89th percentile), serum PD-L1 was associated with significantly shorter OS with trastuzumab treatment versus lapatinib treatment. CONCLUSIONS In the CCTG MA.31 trial, serum PD-L1 was a significant predictive factor: a higher pretreatment serum PD-L1 level was associated with shorter OS with trastuzumab treatment but with longer OS with lapatinib treatment. Immune evasion may decrease the effectiveness of trastuzumab therapy. Further evaluation of elevated serum PD-L1 in advanced breast cancer is warranted to identify patients with HER2-positive MBC who may benefit from novel immune-targeted therapies in addition to trastuzumab.
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Affiliation(s)
- Prashanth Moku
- Penn State Hershey Medical Center, Hershey, Pennsylvania
| | - Lois Shepherd
- Canadian Cancer Trials Group, Queen's University, Kingston, Ontario, Canada
| | - Suhail M Ali
- Penn State Hershey Medical Center, Hershey, Pennsylvania.,Lebanon VA Medical Center, Lebanon, Pennsylvania
| | - Kim Leitzel
- Penn State Hershey Medical Center, Hershey, Pennsylvania
| | - Wendy R Parulekar
- Canadian Cancer Trials Group, Queen's University, Kingston, Ontario, Canada
| | - Liting Zhu
- Canadian Cancer Trials Group, Queen's University, Kingston, Ontario, Canada
| | - Shakeel Virk
- Canadian Cancer Trials Group, Queen's University, Kingston, Ontario, Canada
| | - Dora Nomikos
- Canadian Cancer Trials Group, Queen's University, Kingston, Ontario, Canada
| | - Samuel Aparicio
- British Columbia Cancer Agency, Vancouver, British Columbia, Canada
| | - Karen Gelmon
- British Columbia Cancer Agency, Vancouver, British Columbia, Canada
| | - Joe Drabick
- Penn State Hershey Medical Center, Hershey, Pennsylvania
| | - Leah Cream
- Penn State Hershey Medical Center, Hershey, Pennsylvania
| | | | - Todd M Umstead
- Penn State Hershey Medical Center, Hershey, Pennsylvania
| | - Dan Mckeone
- Penn State Hershey Medical Center, Hershey, Pennsylvania
| | - Hyma Polimera
- Penn State Hershey Medical Center, Hershey, Pennsylvania
| | | | - Aamnah Ali
- Penn State Hershey Medical Center, Hershey, Pennsylvania
| | | | - Joyson Poulose
- Penn State Hershey Medical Center, Hershey, Pennsylvania
| | - Neha Pancholy
- Penn State Hershey Medical Center, Hershey, Pennsylvania
| | | | - Bingshu E Chen
- Canadian Cancer Trials Group, Queen's University, Kingston, Ontario, Canada
| | - Allan Lipton
- Penn State Hershey Medical Center, Hershey, Pennsylvania
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22
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Rushton CK, Arthur SE, Alcaide M, Cheung M, Jiang A, Coyle KM, Cleary KLS, Thomas N, Hilton LK, Michaud N, Daigle S, Davidson J, Bushell K, Yu S, Rys RN, Jain M, Shepherd L, Marra MA, Kuruvilla J, Crump M, Mann K, Assouline S, Connors JM, Steidl C, Cragg MS, Scott DW, Johnson NA, Morin RD. Genetic and evolutionary patterns of treatment resistance in relapsed B-cell lymphoma. Blood Adv 2020; 4:2886-2898. [PMID: 32589730 PMCID: PMC7362366 DOI: 10.1182/bloodadvances.2020001696] [Citation(s) in RCA: 54] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Accepted: 05/14/2020] [Indexed: 12/20/2022] Open
Abstract
Diffuse large B-cell lymphoma (DLBCL) patients are typically treated with immunochemotherapy containing rituximab (rituximab, cyclophosphamide, hydroxydaunorubicin-vincristine (Oncovin), and prednisone [R-CHOP]); however, prognosis is extremely poor if R-CHOP fails. To identify genetic mechanisms contributing to primary or acquired R-CHOP resistance, we performed target-panel sequencing of 135 relapsed/refractory DLBCLs (rrDLBCLs), primarily comprising circulating tumor DNA from patients on clinical trials. Comparison with a metacohort of 1670 diagnostic DLBCLs identified 6 genes significantly enriched for mutations upon relapse. TP53 and KMT2D were mutated in the majority of rrDLBCLs, and these mutations remained clonally persistent throughout treatment in paired diagnostic-relapse samples, suggesting a role in primary treatment resistance. Nonsense and missense mutations affecting MS4A1, which encodes CD20, are exceedingly rare in diagnostic samples but show recurrent patterns of clonal expansion following rituximab-based therapy. MS4A1 missense mutations within the transmembrane domains lead to loss of CD20 in vitro, and patient tumors harboring these mutations lacked CD20 protein expression. In a time series from a patient treated with multiple rounds of therapy, tumor heterogeneity and minor MS4A1-harboring subclones contributed to rapid disease recurrence, with MS4A1 mutations as founding events for these subclones. TP53 and KMT2D mutation status, in combination with other prognostic factors, may be used to identify high-risk patients prior to R-CHOP for posttreatment monitoring. Using liquid biopsies, we show the potential to identify tumors with loss of CD20 surface expression stemming from MS4A1 mutations. Implementation of noninvasive assays to detect such features of acquired treatment resistance may allow timely transition to more effective treatment regimens.
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Affiliation(s)
- Christopher K Rushton
- Department of Molecular Biology and Biochemistry, Simon Fraser University, Burnaby, BC, Canada
| | - Sarah E Arthur
- Department of Molecular Biology and Biochemistry, Simon Fraser University, Burnaby, BC, Canada
- Centre for Lymphoid Cancer, BC Cancer, Vancouver, BC, Canada
| | - Miguel Alcaide
- Department of Molecular Biology and Biochemistry, Simon Fraser University, Burnaby, BC, Canada
| | - Matthew Cheung
- Department of Molecular Biology and Biochemistry, Simon Fraser University, Burnaby, BC, Canada
| | - Aixiang Jiang
- Department of Molecular Biology and Biochemistry, Simon Fraser University, Burnaby, BC, Canada
- Centre for Lymphoid Cancer, BC Cancer, Vancouver, BC, Canada
| | - Krysta M Coyle
- Department of Molecular Biology and Biochemistry, Simon Fraser University, Burnaby, BC, Canada
| | - Kirstie L S Cleary
- Faculty of Medicine, University of Southampton, Southampton, United Kingdom
| | - Nicole Thomas
- Department of Molecular Biology and Biochemistry, Simon Fraser University, Burnaby, BC, Canada
| | - Laura K Hilton
- Department of Molecular Biology and Biochemistry, Simon Fraser University, Burnaby, BC, Canada
| | | | | | - Jordan Davidson
- Department of Molecular Biology and Biochemistry, Simon Fraser University, Burnaby, BC, Canada
| | - Kevin Bushell
- Department of Molecular Biology and Biochemistry, Simon Fraser University, Burnaby, BC, Canada
| | - Stephen Yu
- Department of Molecular Biology and Biochemistry, Simon Fraser University, Burnaby, BC, Canada
| | | | - Michael Jain
- Department of Blood and Marrow Transplant and Cellular Immunotherapy, Moffitt Cancer Center, Tampa, FL
| | - Lois Shepherd
- Canadian Cancer Trials Group, Queen's University, Kingston, ON, Canada
| | - Marco A Marra
- Genome Sciences Centre, BC Cancer, Vancouver, BC, Canada
| | - John Kuruvilla
- Princess Margaret Cancer Centre, Toronto, ON, Canada; and
| | - Michael Crump
- Princess Margaret Cancer Centre, Toronto, ON, Canada; and
| | - Koren Mann
- Lady Davis Institute for Medical Research
- Jewish General Hospital, Montreal, QC, Canada
| | | | | | | | - Mark S Cragg
- Faculty of Medicine, University of Southampton, Southampton, United Kingdom
| | - David W Scott
- Centre for Lymphoid Cancer, BC Cancer, Vancouver, BC, Canada
| | | | - Ryan D Morin
- Department of Molecular Biology and Biochemistry, Simon Fraser University, Burnaby, BC, Canada
- Genome Sciences Centre, BC Cancer, Vancouver, BC, Canada
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Callum J, Farkouh ME, Scales DC, Heddle NM, Crowther M, Rao V, Hucke HP, Carroll J, Grewal D, Brar S, Bussières J, Grocott H, Harle C, Pavenski K, Rochon A, Saha T, Shepherd L, Syed S, Tran D, Wong D, Zeller M, Karkouti K. Effect of Fibrinogen Concentrate vs Cryoprecipitate on Blood Component Transfusion After Cardiac Surgery: The FIBRES Randomized Clinical Trial. JAMA 2019; 322:1966-1976. [PMID: 31634905 PMCID: PMC6822637 DOI: 10.1001/jama.2019.17312] [Citation(s) in RCA: 85] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
IMPORTANCE Excessive bleeding is a common complication of cardiac surgery. An important cause of bleeding is acquired hypofibrinogenemia (fibrinogen level <1.5-2.0 g/L), for which guidelines recommend fibrinogen replacement with cryoprecipitate or fibrinogen concentrate. The 2 products have important differences, but comparative clinical data are lacking. OBJECTIVE To determine if fibrinogen concentrate is noninferior to cryoprecipitate for treatment of bleeding related to hypofibrinogenemia after cardiac surgery. DESIGN, SETTING, AND PARTICIPANTS Randomized clinical trial at 11 Canadian hospitals enrolling adult patients experiencing clinically significant bleeding and hypofibrinogenemia after cardiac surgery (from February 10, 2017, to November 1, 2018). Final 28-day follow-up visit was completed on November 28, 2018. INTERVENTIONS Fibrinogen concentrate (4 g; n = 415) or cryoprecipitate (10 units; n = 412) for each ordered dose within 24 hours after cardiopulmonary bypass. MAIN OUTCOMES AND MEASURES Primary outcome was blood components (red blood cells, platelets, plasma) administered during 24 hours post bypass. A 2-sample, 1-sided test for the ratio of the mean number of units was conducted to evaluate noninferiority (threshold for noninferiority ratio, <1.2). RESULTS Of 827 randomized patients, 735 (372 fibrinogen concentrate, 363 cryoprecipitate) were treated and included in the primary analysis (median age, 64 [interquartile range, 53-72] years; 30% women; 72% underwent complex operations; 95% moderate to severe bleeding; and pretreatment fibrinogen level, 1.6 [interquartile range, 1.3-1.9] g/L). The trial met the a priori stopping criterion for noninferiority at the interim analysis after 827 of planned 1200 patients were randomized. Mean 24-hour postbypass allogeneic transfusions were 16.3 (95% CI, 14.9 to 17.8) units in the fibrinogen concentrate group and 17.0 (95% CI, 15.6 to 18.6) units in the cryoprecipitate group (ratio, 0.96 [1-sided 97.5% CI, -∞ to 1.09; P < .001 for noninferiority] [2-sided 95% CI, 0.84 to 1.09; P = .50 for superiority]). Thromboembolic events occurred in 26 patients (7.0%) in the fibrinogen concentrate group and 35 patients (9.6%) in the cryoprecipitate group. CONCLUSIONS AND RELEVANCE In patients undergoing cardiac surgery who develop clinically significant bleeding and hypofibrinogenemia after cardiopulmonary bypass, fibrinogen concentrate is noninferior to cryoprecipitate with regard to number of blood components transfused in a 24-hour period post bypass. Use of fibrinogen concentrate may be considered for management of bleeding in patients with acquired hypofibrinogenemia in cardiac surgery. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT03037424.
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Affiliation(s)
- Jeannie Callum
- Department of Laboratory Medicine and Molecular Diagnostics, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
- Laboratory Medicine Program, University Health Network, Toronto, Ontario, Canada
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada
| | - Michael E. Farkouh
- Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada
- Heart and Stroke Richard Lewar Centre, University of Toronto, Toronto, Ontario, Canada
| | - Damon C. Scales
- Interdepartmental Division of Critical Care, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Sunnybrook Research Institute, Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Nancy M. Heddle
- Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Mark Crowther
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Vivek Rao
- Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada
- University Health Network, Division of Cardiovascular Surgery, Toronto General Hospital, Toronto, Ontario, Canada
- University of Toronto, Toronto, Ontario, Canada
| | | | - Jo Carroll
- Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada
- University of Toronto, Toronto, Ontario, Canada
- Department of Anesthesia and Pain Management, Sinai Health System, Women’s College Hospital, University Health Network, Toronto, Ontario, Canada
| | - Deep Grewal
- Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada
- University of Toronto, Toronto, Ontario, Canada
- Department of Anesthesia and Pain Management, Sinai Health System, Women’s College Hospital, University Health Network, Toronto, Ontario, Canada
| | - Sukhpal Brar
- Department of Anesthesiology, Pharmacology and Therapeutics; University of British Columbia, Vancouver, Canada
- Royal Columbian Hospital, Vancouver, British Columbia, Canada
| | - Jean Bussières
- Anesthesiology Department, Institut universitaire de cardiologie et de pneumologie de Québec-Université Laval, Québec City, Québec, Canada
| | - Hilary Grocott
- Departments of Anesthesiology, Perioperative and Pain Medicine, and Surgery, University of Manitoba, Winnipeg, Canada
| | - Christopher Harle
- Department of Anesthesia and Perioperative Medicine, Western University, London, Ontario, Canada
| | - Katerina Pavenski
- St Michael’s Hospital, Division of Transfusion Medicine, Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada
| | - Antoine Rochon
- Department of Anesthesiology, Montréal Heart Institute, Université de Montréal, Montréal, Québec, Canada
| | - Tarit Saha
- Department of Anesthesiology and Perioperative Medicine; Kingston General Hospital, Queen’s University, Kingston, Ontario, Canada
| | - Lois Shepherd
- Department of Pathology and Molecular Medicine, Kingston Health Science Center, Queen’s University, Kingston, Ontario, Canada
| | - Summer Syed
- Department of Anesthesiology; Hamilton Health Sciences Corporation, McMaster University, Hamilton, Ontario, Canada
| | - Diem Tran
- University of Ottawa Heart Institute, Division of Cardiac Anesthesiology and Critical Care, Department of Anesthesia and Pain Medicine, University of Ottawa School of Epidemiology and Public Health, Ottawa, Ontario, Canada
| | - Daniel Wong
- Cardiac Surgery, Royal Columbian Hospital, University of British Columbia, Vancouver, Canada
| | - Michelle Zeller
- McMaster Centre for Transfusion Research, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Keyvan Karkouti
- Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada
- Interdepartmental Division of Critical Care, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Anesthesia and Pain Management, Sinai Health System, Women’s College Hospital, University Health Network, Toronto, Ontario, Canada
- Department of Anesthesia and Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada
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Monteith B, Venner C, Reece D, Kew A, Lalancette M, Garland J, Shepherd L, McDonald G, Gul E, Pater J, Hay A. Unusual Carfilzomib Toxicity: Three Cases of Drug-induced Thrombotic Microangiopathy (TMA) after Treatment with High-dose weekly Carfilzomib, Cyclophosphamide, and Dexamethasone (wCCD). Clinical Lymphoma Myeloma and Leukemia 2019. [DOI: 10.1016/j.clml.2019.09.449] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Chen D, Shepherd L, Muse E, Johnston A. What Medical Students Teach: The Healing Skill of Being a Team Player. Hastings Cent Rep 2019; 49:38-47. [DOI: 10.1002/hast.1055] [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: 11/07/2022]
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Rushton C, Alcaide M, Cheung M, Thomas N, Arthur S, Michaud N, Daigle S, Davidson J, Bushell K, Yu S, Jain M, Shepherd L, Crump M, Mann K, Kuruvilla J, Assouline S, Johnson N, Scott D, Morin R. IDENTIFYING MUTATIONS ENRICHED IN RELAPSED-REFRACTORY DLBCL TO DERIVE GENETIC FACTORS UNDERLYING TREATMENT RESISTANCE. Hematol Oncol 2019. [DOI: 10.1002/hon.4_2629] [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: 11/07/2022]
Affiliation(s)
- C. Rushton
- Molecular Biology and Biochemistry; Simon Fraser University; Burnaby Canada
| | - M. Alcaide
- Molecular Biology and Biochemistry; Simon Fraser University; Burnaby Canada
| | - M. Cheung
- Molecular Biology and Biochemistry; Simon Fraser University; Burnaby Canada
| | - N. Thomas
- Molecular Biology and Biochemistry; Simon Fraser University; Burnaby Canada
| | - S. Arthur
- Molecular Biology and Biochemistry; Simon Fraser University; Burnaby Canada
| | | | | | - J. Davidson
- Molecular Biology and Biochemistry; Simon Fraser University; Burnaby Canada
| | - K. Bushell
- Molecular Biology and Biochemistry; Simon Fraser University; Burnaby Canada
| | - S. Yu
- Molecular Biology and Biochemistry; Simon Fraser University; Burnaby Canada
| | - M. Jain
- Department of Medical Oncology and Hematology; Princess Margaret Cancer Centre; Toronto Canada
| | - L. Shepherd
- Canada Cancer Trials Group; Queen's University; Kingston Canada
| | - M. Crump
- Department of Medical Oncology and Hematology; Princess Margaret Cancer Centre; Toronto Canada
| | - K. Mann
- Department of Medicine; McGill University; Montreal Canada
| | - J. Kuruvilla
- Department of Medical Oncology and Hematology; Princess Margaret Cancer Centre; Toronto Canada
| | - S. Assouline
- Department of Oncology; McGill University; Montreal Canada
| | - N. Johnson
- Department of Medicine; McGill University; Montreal Canada
| | - D.W. Scott
- Genome Sciences Centre; BC Cancer; Vancouver Canada
| | - R.D. Morin
- Molecular Biology and Biochemistry; Simon Fraser University; Burnaby Canada
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Lamarche MC, Hammond DE, Hopman WM, Sirosky‐Yanyk A, Shepherd L, Bhella SD. Can we transfuse wisely in patients undergoing chemotherapy for acute leukemia or autologous stem cell transplantation? Transfusion 2019; 59:2308-2315. [DOI: 10.1111/trf.15335] [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] [Received: 09/13/2018] [Revised: 04/01/2019] [Accepted: 04/05/2019] [Indexed: 01/11/2023]
Affiliation(s)
- Michelle C. Lamarche
- Department of Medicine, Division of General Internal MedicineQueen's University Kingston Ontario Canada
| | - Danielle E. Hammond
- Department of Medicine, Division of HematologyQueen's University Kingston Ontario Canada
| | - Wilma M. Hopman
- Kingston General Hospital Research Institute, and Department of Public Health SciencesQueen's University Kingston Ontario Canada
| | - Angela Sirosky‐Yanyk
- Department of Pathology and Molecular MedicineQueen's University Kingston Ontario Canada
| | - Lois Shepherd
- Department of Pathology and Molecular MedicineQueen's University Kingston Ontario Canada
| | - Sita D. Bhella
- Department of Medicine, Division of HematologyQueen's University Kingston Ontario Canada
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Mumtaz S, Batchford C, Shepherd L. Postoperative care advice: who cares? Br Dent J 2019; 226:471. [PMID: 30979977 DOI: 10.1038/s41415-019-0217-7] [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: 11/09/2022]
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Gray R, Bradley R, Braybrooke J, Liu Z, Peto R, Davies L, Dodwell D, McGale P, Pan H, Taylor C, Barlow W, Bliss J, Bruzzi P, Cameron D, Fountzilas G, Loibl S, Mackey J, Martin M, Del Mastro L, Möbus V, Nekljudova V, De Placido S, Swain S, Untch M, Pritchard KI, Bergh J, Norton L, Boddington C, Burrett J, Clarke M, Davies C, Duane F, Evans V, Gettins L, Godwin J, Hills R, James S, Liu H, MacKinnon E, Mannu G, McHugh T, Morris P, Read S, Wang Y, Wang Z, Fasching P, Harbeck N, Piedbois P, Gnant M, Steger G, Di Leo A, Dolci S, Francis P, Larsimont D, Nogaret JM, Philippson C, Piccart M, Linn S, Peer P, Tjan-Heijnen V, Vliek S, Mackey J, Slamon D, Bartlett J, Bramwell VH, Chen B, Chia S, Gelmon K, Goss P, Levine M, Parulekar W, Pater J, Rakovitch E, Shepherd L, Tu D, Whelan T, Berry D, Broadwater G, Cirrincione C, Muss H, Weiss R, Shan Y, Shao YF, Wang X, Xu B, Zhao DB, Bartelink H, Bijker N, Bogaerts J, Cardoso F, Cufer T, Julien JP, Poortmans P, Rutgers E, van de Velde C, Carrasco E, Segui MA, Blohmer JU, Costa S, Gerber B, Jackisch C, von Minckwitz G, Giuliano M, De Laurentiis M, Bamia C, Koliou GA, Mavroudis D, A'Hern R, Ellis P, Kilburn L, Morden J, Yarnold J, Sadoon M, Tulusan AH, Anderson S, Bass G, Costantino J, Dignam J, Fisher B, Geyer C, Mamounas EP, Paik S, Redmond C, Wickerham DL, Venturini M, Bighin C, Pastorino S, Pronzato P, Sertoli MR, Foukakis T, Albain K, Arriagada R, Bergsten Nordström E, Boccardo F, Brain E, Carey L, Coates A, Coleman R, Correa C, Cuzick J, Davidson N, Dowsett M, Ewertz M, Forbes J, Gelber R, Goldhirsch A, Goodwin P, Hayes D, Hill C, Ingle J, Jagsi R, Janni W, Mukai H, Ohashi Y, Pierce L, Raina V, Ravdin P, Rea D, Regan M, Robertson J, Sparano J, Tutt A, Viale G, Wilcken N, Wolmark N, Wood W, Zambetti M. Increasing the dose intensity of chemotherapy by more frequent administration or sequential scheduling: a patient-level meta-analysis of 37 298 women with early breast cancer in 26 randomised trials. Lancet 2019; 393:1440-1452. [PMID: 30739743 PMCID: PMC6451189 DOI: 10.1016/s0140-6736(18)33137-4] [Citation(s) in RCA: 202] [Impact Index Per Article: 40.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2018] [Revised: 11/11/2018] [Accepted: 11/29/2018] [Indexed: 12/15/2022]
Abstract
BACKGROUND Increasing the dose intensity of cytotoxic therapy by shortening the intervals between cycles, or by giving individual drugs sequentially at full dose rather than in lower-dose concurrent treatment schedules, might enhance efficacy. METHODS To clarify the relative benefits and risks of dose-intense and standard-schedule chemotherapy in early breast cancer, we did an individual patient-level meta-analysis of trials comparing 2-weekly versus standard 3-weekly schedules, and of trials comparing sequential versus concurrent administration of anthracycline and taxane chemotherapy. The primary outcomes were recurrence and breast cancer mortality. Standard intention-to-treat log-rank analyses, stratified by age, nodal status, and trial, yielded dose-intense versus standard-schedule first-event rate ratios (RRs). FINDINGS Individual patient data were provided for 26 of 33 relevant trials identified, comprising 37 298 (93%) of 40 070 women randomised. Most women were aged younger than 70 years and had node-positive disease. Total cytotoxic drug usage was broadly comparable in the two treatment arms; colony-stimulating factor was generally used in the more dose-intense arm. Combining data from all 26 trials, fewer breast cancer recurrences were seen with dose-intense than with standard-schedule chemotherapy (10-year recurrence risk 28·0% vs 31·4%; RR 0·86, 95% CI 0·82-0·89; p<0·0001). 10-year breast cancer mortality was similarly reduced (18·9% vs 21·3%; RR 0·87, 95% CI 0·83-0·92; p<0·0001), as was all-cause mortality (22·1% vs 24·8%; RR 0·87, 95% CI 0·83-0·91; p<0·0001). Death without recurrence was, if anything, lower with dose-intense than with standard-schedule chemotherapy (10-year risk 4·1% vs 4·6%; RR 0·88, 95% CI 0·78-0·99; p=0·034). Recurrence reductions were similar in the seven trials (n=10 004) that compared 2-weekly chemotherapy with the same chemotherapy given 3-weekly (10-year risk 24·0% vs 28·3%; RR 0·83, 95% CI 0·76-0·91; p<0·0001), in the six trials (n=11 028) of sequential versus concurrent anthracycline plus taxane chemotherapy (28·1% vs 31·3%; RR 0·87, 95% CI 0·80-0·94; p=0·0006), and in the six trials (n=6532) testing both shorter intervals and sequential administration (30·4% vs 35·0%; RR 0·82, 95% CI 0·74-0·90; p<0·0001). The proportional reductions in recurrence with dose-intense chemotherapy were similar and highly significant (p<0·0001) in oestrogen receptor (ER)-positive and ER-negative disease and did not differ significantly by other patient or tumour characteristics. INTERPRETATION Increasing the dose intensity of adjuvant chemotherapy by shortening the interval between treatment cycles, or by giving individual drugs sequentially rather than giving the same drugs concurrently, moderately reduces the 10-year risk of recurrence and death from breast cancer without increasing mortality from other causes. FUNDING Cancer Research UK, Medical Research Council.
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Ethier JL, Parulekar W, Shepherd L, Summers L, Strasser-Weippl K, Tu D, Amir E. Abstract P4-14-03: Influence of competing risks of death on the interpretation of adjuvant endocrine therapy trials for breast cancer. Cancer Res 2019. [DOI: 10.1158/1538-7445.sabcs18-p4-14-03] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
Background: Early stage, hormone sensitive breast cancer is associated generally with a good prognosis, with only a minority of patients expected to die of breast cancer. Death from causes other than breast cancer can dilute the patients at risk of breast cancer events and result in over-estimation of risk of recurrence and consequently the benefit from breast cancer therapy, a so-called immortal time bias. The MA.17R trial (Goss et al 2016) evaluated the role of extending adjuvant treatment with letrozole from 5 to 10 years. Here we determine the effect of analyzing the MA.17R trial using methods accounting for competing risks.
Methods: We compared conventional and competing risk methods for disease-free survival (DFS) and for distant recurrence-free survival (DRFS). In Kaplan-Meier analyses death from any cause was considered an event while cumulative incidence functions (CIFs) assumed death without recurrence to be a competing risk. The complement of the survival function (one minus the survival function) was used to estimate incidence of the primary event of interest. This was compared to estimates obtained using CIFs accounting for the occurrence of competing events.
Results: Non-breast cancer death was the most common event defining DFS and DRFS. Over the course of follow-up, there was increasing discrepancy between the risk of disease recurrence measured using Kaplan-Meier and CIF. Among letrozole treated patients the estimated distant recurrence at 5 years of follow-up was 5.4% using CIF and 9.6% using Kaplan-Meier. At 10 years of follow-up, the estimated distant recurrence was 8.4% using CIF and 20.0% using Kaplan-Meier. Similar results were observed for the placebo group (8.5% vs 12.1% at 5 years and 14.8% vs 27.3% at 10 years), and in patients with baseline cardiovascular disease (see Table). Benefit from letrozole on DFS and DRFS was greater when accounting for competing risk (hazard ratio [HR] for DFS 0.66, 95%CI 0.48-0.90; DFRS HR 0.75, 0.50-1.14) compared to the conventional method (DFS HR 0.79, 0.62-0.99; DRFS HR 0.91, 0.70-1.18). In women with baseline cardiovascular risk, the benefits of extended adjuvant letrozole when considering competing risk (DFS HR 0.38, 0.16-0.89; DRFS HR 0.46, 0.16-1.35) were also greater than those observed in the conventional analysis (DFS HR 0.55, 0.32-0.93; DRFS HR 0.59, 0.33-1.04). Treatment with extended letrozole did not influence non-breast cancer death in women who died with disease recurrence (HR 1.06, 0.74 -1.50) or in those with competing risk or censored from the analysis (HR 1.05, 0.73 -1.49).
Conclusion: Over the course of follow-up, estimates of DFS and DRFS differ increasingly if measured using Kaplan-Meier or CIF, with CIF estimates of risk being substantially lower. Using a competing risk model, the reduction in distant recurrence at 8 years with extended letrozole is less than 1%. Additional competing risk analyses of the MA.17 (Goss 2006) and MA.27 (Goss 2013) trials are ongoing.
Cumulative incidence of disease recurrence in patients with baseline cardiovascular riskTime (years)CIF (%)1-KM (%)Letrozole11.51.534.46.555.813.8Placebo13.53.538.311.8512.520.3
Citation Format: Ethier J-L, Parulekar W, Shepherd L, Summers L, Strasser-Weippl K, Tu D, Amir E. Influence of competing risks of death on the interpretation of adjuvant endocrine therapy trials for breast cancer [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P4-14-03.
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Affiliation(s)
- J-L Ethier
- Cancer Centre of Southeastern Ontario, Kingston, ON, Canada; Canadian Cancer Trials Group, Kingston, ON, Canada; Center for Oncology, Hematology and Palliative Care, Wilhelminen Hospital, Vienna, Austria; Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - W Parulekar
- Cancer Centre of Southeastern Ontario, Kingston, ON, Canada; Canadian Cancer Trials Group, Kingston, ON, Canada; Center for Oncology, Hematology and Palliative Care, Wilhelminen Hospital, Vienna, Austria; Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - L Shepherd
- Cancer Centre of Southeastern Ontario, Kingston, ON, Canada; Canadian Cancer Trials Group, Kingston, ON, Canada; Center for Oncology, Hematology and Palliative Care, Wilhelminen Hospital, Vienna, Austria; Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - L Summers
- Cancer Centre of Southeastern Ontario, Kingston, ON, Canada; Canadian Cancer Trials Group, Kingston, ON, Canada; Center for Oncology, Hematology and Palliative Care, Wilhelminen Hospital, Vienna, Austria; Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - K Strasser-Weippl
- Cancer Centre of Southeastern Ontario, Kingston, ON, Canada; Canadian Cancer Trials Group, Kingston, ON, Canada; Center for Oncology, Hematology and Palliative Care, Wilhelminen Hospital, Vienna, Austria; Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - D Tu
- Cancer Centre of Southeastern Ontario, Kingston, ON, Canada; Canadian Cancer Trials Group, Kingston, ON, Canada; Center for Oncology, Hematology and Palliative Care, Wilhelminen Hospital, Vienna, Austria; Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - E Amir
- Cancer Centre of Southeastern Ontario, Kingston, ON, Canada; Canadian Cancer Trials Group, Kingston, ON, Canada; Center for Oncology, Hematology and Palliative Care, Wilhelminen Hospital, Vienna, Austria; Princess Margaret Cancer Centre, Toronto, ON, Canada
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Shepherd L, Macklin R. Erosion of informed consent in U.S. research. Bioethics 2019; 33:4-12. [PMID: 30474129 DOI: 10.1111/bioe.12532] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/13/2017] [Revised: 07/25/2018] [Accepted: 08/25/2018] [Indexed: 06/09/2023]
Abstract
This paper evaluates four recent randomized clinical trials in which the informed consent of participants was either not sought at all, or else was conducted with critical information missing from the consent documents. As these studies have been taking place, various proposals to conduct randomized clinical trials without consent have been appearing in the medical literature. Some of the explanations offered for why it is appropriate to bypass consent or disclosure requirements appear to represent a fundamental misunderstanding of applicable government regulations and even the research enterprise. Others are the result of conceptual disagreements about the importance and application of traditional research ethics norms to 'comparative effectiveness research' and modern research environments. Common among these explanations, however, is a failure to appreciate when a research intervention, rather than merely an observation or review of data, is taking place. Review committees and investigators are failing to see, or choosing to ignore, interventions in the lives of research subjects. When these studies have come to light, government agencies with oversight authority have done little or backed down. Prestigious medical journals have published research results knowing that the required consent was not obtained, or they have stood by the published studies even after the inadequacy of consent is discovered. This article critically examines this erosion of consent in theory and practice and calls for restoring the requirement of informed consent to its proper place as a priority in human subjects research.
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Affiliation(s)
- Lois Shepherd
- Biomedical Ethics and Humanities, University of Virginia School of Medicine, Charlottesville, Virginia
| | - Ruth Macklin
- Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, New York
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Robertson B, Parker M, Shepherd L, Panieri E, Cairncross L, Malherbe F, Ross IL, Omar F, Hunter A. Nodal disease predicts recurrence whereas other traditional factors affect survival in a cohort of South African patients with differentiated thyroid carcinoma. Cancers Head Neck 2018; 3:10. [PMID: 31093363 PMCID: PMC6460678 DOI: 10.1186/s41199-018-0037-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/17/2018] [Accepted: 10/31/2018] [Indexed: 11/21/2022]
Abstract
Background and aim Information on patients with differentiated thyroid carcinoma in South Africa is limited. The objective of this study was to review demographics and tumour characteristics in a cohort of patients with differentiated thyroid carcinoma, presenting to Groote Schuur Hospital and evaluate risk factors for recurrence and survival. Patients and methodology Retrospective demographic and clinical data were collected on all patients referred between January 2003 and December 2013. Prognostic factors for recurrence free survival and cancer specific survival were assessed using univariate and multivariate analyses. Results The total number of patients was 231.The median age at presentation was 44 years and 82% were female patients. The pathological sub-types were papillary (60.6%), follicular (38.9%) and poorly differentiated (0.5%). Total thyroidectomy was performed in 191 patients and 30 patients required neck dissections. A total of 171 (74%) patients received 131Iodine. The recurrence free and cause specific survival rates at 10 years were 83 and 91%, respectively. Nodal disease at presentation was the only significant risk factor for recurrence (p < 0.001) on multivariate analysis. Significant risk factors for cause specific mortality were age ≥ 45 years (p = 0.006), follicular pathology (p = 0.004), extra-thyroid extension (p = 0.013) and residual tumour (p = 0.004). Conclusions Consistent with international trends, patients with differentiated thyroid carcinoma treated at Groote Schuur Hospital had a favourable prognosis. The known risk factors associated with recurrence and survival in this South African cohort were consistent with those reported in developed countries.
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Affiliation(s)
- B Robertson
- Department of Radiation Oncology, Cape Town, South Africa.,2Groote Schuur Hospital, Cape Town, South Africa.,3University of Cape Town, Cape Town, South Africa
| | - M Parker
- Department of Radiation Oncology, Cape Town, South Africa.,3University of Cape Town, Cape Town, South Africa
| | - L Shepherd
- Department of Radiation Oncology, Cape Town, South Africa.,2Groote Schuur Hospital, Cape Town, South Africa.,3University of Cape Town, Cape Town, South Africa
| | - E Panieri
- 2Groote Schuur Hospital, Cape Town, South Africa.,3University of Cape Town, Cape Town, South Africa.,Department of Surgery, Cape Town, South Africa
| | - L Cairncross
- 2Groote Schuur Hospital, Cape Town, South Africa.,3University of Cape Town, Cape Town, South Africa.,Department of Surgery, Cape Town, South Africa
| | - F Malherbe
- 2Groote Schuur Hospital, Cape Town, South Africa.,3University of Cape Town, Cape Town, South Africa.,Department of Surgery, Cape Town, South Africa
| | - I L Ross
- 5Department of Medicine, Cape Town, South Africa.,2Groote Schuur Hospital, Cape Town, South Africa.,3University of Cape Town, Cape Town, South Africa
| | - F Omar
- Division of Chemical Pathology, Cape Town, South Africa.,3University of Cape Town, Cape Town, South Africa
| | - A Hunter
- Department of Radiation Oncology, Cape Town, South Africa.,2Groote Schuur Hospital, Cape Town, South Africa.,3University of Cape Town, Cape Town, South Africa
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Shepherd L, Turner HD. The Over-Medicalization and Corrupted Medicalization of Abortion and its Effect on Women Living in Poverty. J Law Med Ethics 2018; 46:672-679. [PMID: 30336084 DOI: 10.1177/1073110518804222] [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] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
Many current abortion regulations represent an over-medicalization of abortion or a corruption of abortion's true medical nature, with disproportionate consequences to women with lower incomes and lesser means. This article explores the effects of unnecessary and harmful abortion restrictions on women living in poverty. A brief summary of the major abortion rights cases explains how the Constitution, as currently interpreted, vests the government and sometimes the medical profession with the power to protect women's health, rather than granting this power to women themselves. The article then argues for a new approach for protecting women's health and respecting their dignity by reframing reproductive rights as health rights that women themselves can assert.
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Affiliation(s)
- Lois Shepherd
- Lois Shepherd, J.D., is the Peter A. Wallenborn, Jr. and Dolly F. Wallenborn Professor of Biomedical Ethics, Professor of Public Health Sciences, Professor of Law, University of Virginia. Hilary D. Turner, J.D., graduated from University of Virginia in 2018
| | - Hilary D Turner
- Lois Shepherd, J.D., is the Peter A. Wallenborn, Jr. and Dolly F. Wallenborn Professor of Biomedical Ethics, Professor of Public Health Sciences, Professor of Law, University of Virginia. Hilary D. Turner, J.D., graduated from University of Virginia in 2018
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Affiliation(s)
- Lois Shepherd
- Lois Shepherd, J.D., is the Peter A. Wallenborn, Jr. and Dolly F. Wallenborn Professor of Biomedical Ethics, Professor of Public Health Sciences, and Professor of Law at the University of Virginia. Robin Fretwell Wilson, J.D., is the Roger and Stephany Joslin Professor of Law and the Director of the Epstein Health Law and Policy Program at the University of Illinois College of Law
| | - Robin Fretwell Wilson
- Lois Shepherd, J.D., is the Peter A. Wallenborn, Jr. and Dolly F. Wallenborn Professor of Biomedical Ethics, Professor of Public Health Sciences, and Professor of Law at the University of Virginia. Robin Fretwell Wilson, J.D., is the Roger and Stephany Joslin Professor of Law and the Director of the Epstein Health Law and Policy Program at the University of Illinois College of Law
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Shepherd L, Marshall MF. Blanket Bans on Therapeutic Abortion and the Responsibilities of Hospitals as Moral Communities. Am J Bioeth 2018; 18:55-57. [PMID: 30040578 DOI: 10.1080/15265161.2018.1478046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
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Spears M, Kornaga E, Lyttle N, Liao L, Bayani J, Quintayo MA, Yao CQ, D'Costa A, Boutros PC, Twelves CJ, Pritchard KI, Levine MN, Nielsen TO, Shepherd L, Bartlett JMS. Abstract P2-10-01: Validation that a histone gene signature predicts anthracycline response in early breast cancer. Cancer Res 2018. [DOI: 10.1158/1538-7445.sabcs17-p2-10-01] [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: 11/16/2022]
Abstract
Abstract
Background: The use of anthracycline-based chemotherapies has improved overall and disease free survival in breast cancer. However, anthracyclines can have significant toxicities including cardiotoxicity and leukemia. It is, therefore, imperative to identify those patients who will benefit from adjuvant anthracycline treatment and patients who could be spared unnecessary toxicities and be considered for alternative adjuvant therapy. Previous work performed by our laboratory identified a histone gene expression signature as a predictive marker of anthracycline benefit in the BR9601 clinical trial. In this study we validate the 18 histone gene signature in the MA.5 clinical trial and examine the role of the signature in individual intrinsic subtypes of breast cancer.
Methods We analysed the CCTG MA.5 clinical trial in a prospectively planned retrospective biomarker approach to validate this signature and tested the role of intrinsic subtyping as predictive markers of anthracycline benefit. RNA was extracted from patients in the MA.5 adjuvant trial evaluating the addition of epirubicin (E) to CMF and analysed using NanoString technology. Log-rank analyses validated the predictive values of the signature on distant relapse-free survival (DRFS). Cox-regression models tested independent predictive value on DRFS in the presence of treatment, age, tumour size, nodal status, HER2, ER status and grade, and treatment by marker interactions.
Results Analysis of the MA.5 clinical cohort revealed that patients whose tumour had low histone gene signature expression experienced increased DRFS (HR: 0.54, 95% CI 0.38-0.76, p=0.001) when treated with CEF compared with patients treated with CMF alone. Conversely, there was no apparent benefit of CEF vs CMF in patients with high histone gene expression signature (HR: 1.01, 95%CI 0.66-1.55, p=0.963). After multivariate analysis and adjustment for HER2, nodal status, age, grade and ER, the treatment by marker interaction for the gene signature was 0.54 (95%CI 0.31-0.94, p=0.030) for DRFS.
The predictive impact of the histone signature was independent of intrinsic subtype.
Conclusion The histone gene expression signature is an independent predictor of anthracycline benefit and could be a potential candidate diagnostic assay for patients with early breast cancer.
Citation Format: Spears M, Kornaga E, Lyttle N, Liao L, Bayani J, Quintayo M-A, Yao CQ, D'Costa A, Boutros PC, Twelves CJ, Pritchard KI, Levine MN, Nielsen TO, Shepherd L, Bartlett JMS. Validation that a histone gene signature predicts anthracycline response in early breast cancer [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P2-10-01.
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Affiliation(s)
- M Spears
- Ontario Institute for Cancer Research, Toronto, ON, Canada; University of Toronto, Toronto, ON, Canada; Tom Baker Cancer Centre, Calgary, AB, Canada; Leeds Institute of Cancer and Pathology and Cancer Research UK Centre, Leeds, United Kingdom; Suunybrook Odette Cancer Centre, Toronto, ON, Canada; McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada; University of British Columbia, Vancouver, BC, Canada; Canadian Clinical Trials Group, Kingston, ON, Canada; Edinburgh Cancer Research UK Centre, Edinburgh, United Kingdom
| | - E Kornaga
- Ontario Institute for Cancer Research, Toronto, ON, Canada; University of Toronto, Toronto, ON, Canada; Tom Baker Cancer Centre, Calgary, AB, Canada; Leeds Institute of Cancer and Pathology and Cancer Research UK Centre, Leeds, United Kingdom; Suunybrook Odette Cancer Centre, Toronto, ON, Canada; McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada; University of British Columbia, Vancouver, BC, Canada; Canadian Clinical Trials Group, Kingston, ON, Canada; Edinburgh Cancer Research UK Centre, Edinburgh, United Kingdom
| | - N Lyttle
- Ontario Institute for Cancer Research, Toronto, ON, Canada; University of Toronto, Toronto, ON, Canada; Tom Baker Cancer Centre, Calgary, AB, Canada; Leeds Institute of Cancer and Pathology and Cancer Research UK Centre, Leeds, United Kingdom; Suunybrook Odette Cancer Centre, Toronto, ON, Canada; McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada; University of British Columbia, Vancouver, BC, Canada; Canadian Clinical Trials Group, Kingston, ON, Canada; Edinburgh Cancer Research UK Centre, Edinburgh, United Kingdom
| | - L Liao
- Ontario Institute for Cancer Research, Toronto, ON, Canada; University of Toronto, Toronto, ON, Canada; Tom Baker Cancer Centre, Calgary, AB, Canada; Leeds Institute of Cancer and Pathology and Cancer Research UK Centre, Leeds, United Kingdom; Suunybrook Odette Cancer Centre, Toronto, ON, Canada; McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada; University of British Columbia, Vancouver, BC, Canada; Canadian Clinical Trials Group, Kingston, ON, Canada; Edinburgh Cancer Research UK Centre, Edinburgh, United Kingdom
| | - J Bayani
- Ontario Institute for Cancer Research, Toronto, ON, Canada; University of Toronto, Toronto, ON, Canada; Tom Baker Cancer Centre, Calgary, AB, Canada; Leeds Institute of Cancer and Pathology and Cancer Research UK Centre, Leeds, United Kingdom; Suunybrook Odette Cancer Centre, Toronto, ON, Canada; McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada; University of British Columbia, Vancouver, BC, Canada; Canadian Clinical Trials Group, Kingston, ON, Canada; Edinburgh Cancer Research UK Centre, Edinburgh, United Kingdom
| | - M-A Quintayo
- Ontario Institute for Cancer Research, Toronto, ON, Canada; University of Toronto, Toronto, ON, Canada; Tom Baker Cancer Centre, Calgary, AB, Canada; Leeds Institute of Cancer and Pathology and Cancer Research UK Centre, Leeds, United Kingdom; Suunybrook Odette Cancer Centre, Toronto, ON, Canada; McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada; University of British Columbia, Vancouver, BC, Canada; Canadian Clinical Trials Group, Kingston, ON, Canada; Edinburgh Cancer Research UK Centre, Edinburgh, United Kingdom
| | - CQ Yao
- Ontario Institute for Cancer Research, Toronto, ON, Canada; University of Toronto, Toronto, ON, Canada; Tom Baker Cancer Centre, Calgary, AB, Canada; Leeds Institute of Cancer and Pathology and Cancer Research UK Centre, Leeds, United Kingdom; Suunybrook Odette Cancer Centre, Toronto, ON, Canada; McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada; University of British Columbia, Vancouver, BC, Canada; Canadian Clinical Trials Group, Kingston, ON, Canada; Edinburgh Cancer Research UK Centre, Edinburgh, United Kingdom
| | - A D'Costa
- Ontario Institute for Cancer Research, Toronto, ON, Canada; University of Toronto, Toronto, ON, Canada; Tom Baker Cancer Centre, Calgary, AB, Canada; Leeds Institute of Cancer and Pathology and Cancer Research UK Centre, Leeds, United Kingdom; Suunybrook Odette Cancer Centre, Toronto, ON, Canada; McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada; University of British Columbia, Vancouver, BC, Canada; Canadian Clinical Trials Group, Kingston, ON, Canada; Edinburgh Cancer Research UK Centre, Edinburgh, United Kingdom
| | - PC Boutros
- Ontario Institute for Cancer Research, Toronto, ON, Canada; University of Toronto, Toronto, ON, Canada; Tom Baker Cancer Centre, Calgary, AB, Canada; Leeds Institute of Cancer and Pathology and Cancer Research UK Centre, Leeds, United Kingdom; Suunybrook Odette Cancer Centre, Toronto, ON, Canada; McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada; University of British Columbia, Vancouver, BC, Canada; Canadian Clinical Trials Group, Kingston, ON, Canada; Edinburgh Cancer Research UK Centre, Edinburgh, United Kingdom
| | - CJ Twelves
- Ontario Institute for Cancer Research, Toronto, ON, Canada; University of Toronto, Toronto, ON, Canada; Tom Baker Cancer Centre, Calgary, AB, Canada; Leeds Institute of Cancer and Pathology and Cancer Research UK Centre, Leeds, United Kingdom; Suunybrook Odette Cancer Centre, Toronto, ON, Canada; McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada; University of British Columbia, Vancouver, BC, Canada; Canadian Clinical Trials Group, Kingston, ON, Canada; Edinburgh Cancer Research UK Centre, Edinburgh, United Kingdom
| | - KI Pritchard
- Ontario Institute for Cancer Research, Toronto, ON, Canada; University of Toronto, Toronto, ON, Canada; Tom Baker Cancer Centre, Calgary, AB, Canada; Leeds Institute of Cancer and Pathology and Cancer Research UK Centre, Leeds, United Kingdom; Suunybrook Odette Cancer Centre, Toronto, ON, Canada; McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada; University of British Columbia, Vancouver, BC, Canada; Canadian Clinical Trials Group, Kingston, ON, Canada; Edinburgh Cancer Research UK Centre, Edinburgh, United Kingdom
| | - MN Levine
- Ontario Institute for Cancer Research, Toronto, ON, Canada; University of Toronto, Toronto, ON, Canada; Tom Baker Cancer Centre, Calgary, AB, Canada; Leeds Institute of Cancer and Pathology and Cancer Research UK Centre, Leeds, United Kingdom; Suunybrook Odette Cancer Centre, Toronto, ON, Canada; McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada; University of British Columbia, Vancouver, BC, Canada; Canadian Clinical Trials Group, Kingston, ON, Canada; Edinburgh Cancer Research UK Centre, Edinburgh, United Kingdom
| | - TO Nielsen
- Ontario Institute for Cancer Research, Toronto, ON, Canada; University of Toronto, Toronto, ON, Canada; Tom Baker Cancer Centre, Calgary, AB, Canada; Leeds Institute of Cancer and Pathology and Cancer Research UK Centre, Leeds, United Kingdom; Suunybrook Odette Cancer Centre, Toronto, ON, Canada; McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada; University of British Columbia, Vancouver, BC, Canada; Canadian Clinical Trials Group, Kingston, ON, Canada; Edinburgh Cancer Research UK Centre, Edinburgh, United Kingdom
| | - L Shepherd
- Ontario Institute for Cancer Research, Toronto, ON, Canada; University of Toronto, Toronto, ON, Canada; Tom Baker Cancer Centre, Calgary, AB, Canada; Leeds Institute of Cancer and Pathology and Cancer Research UK Centre, Leeds, United Kingdom; Suunybrook Odette Cancer Centre, Toronto, ON, Canada; McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada; University of British Columbia, Vancouver, BC, Canada; Canadian Clinical Trials Group, Kingston, ON, Canada; Edinburgh Cancer Research UK Centre, Edinburgh, United Kingdom
| | - JMS Bartlett
- Ontario Institute for Cancer Research, Toronto, ON, Canada; University of Toronto, Toronto, ON, Canada; Tom Baker Cancer Centre, Calgary, AB, Canada; Leeds Institute of Cancer and Pathology and Cancer Research UK Centre, Leeds, United Kingdom; Suunybrook Odette Cancer Centre, Toronto, ON, Canada; McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada; University of British Columbia, Vancouver, BC, Canada; Canadian Clinical Trials Group, Kingston, ON, Canada; Edinburgh Cancer Research UK Centre, Edinburgh, United Kingdom
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Spears M, Kalatskaya I, Trinh QM, Liao L, Chong TM, Crozier C, Dion D, Heisler L, Timms L, Stein LD, Pritchard KI, Levine MN, Shepherd L, Twelves CJ, Bartlett JMS. Abstract P2-10-04: Targeted sequencing in early breast cancer: Identification of novel candidate mutations predictive of anthracycline benefit. Cancer Res 2018. [DOI: 10.1158/1538-7445.sabcs17-p2-10-04] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
Background The use of chemotherapies such as anthracyclines and taxanes have improved overall and disease free survival in breast cancer. For all patients, anthracyclines can have significant toxicities including cardiotoxicity and leukemia. It is therefore essential to select the subset of patients who will receive the optimal overall benefit from anthracycline therapy and to identify molecular pathways driving resistance. To fully understand the impact of mutations in the context of current breast cancer therapy, requires a comprehensive mapping of key molecular events in the context of treatment. We sequenced 101 genes, that were prioritized based on not only gene frequency, but also taking into account the importance of amino acid substitution, type of mutation and network connectivity, in 692 primary tumours to both identify driver genes and pathway cassettes and to understand their clinical significance in response to anthracycline treatment.
Methods We performed targeted sequencing in patients from the BR9601 (n=374) and CCTG MA.5 (n=703) clinical trials. The BR9601 and MA.5 clinical trials examined the effectiveness of combination chemotherapy consisting of CMF (cyclophosphamide, methotrexate and 5-fluorouracil) with or without epirubicin. DNA was extracted, samples were sequenced using AmpliSeq Technology adapted to Illumina and somatic mutations were called using a novel mutation calling pipeline (ISOWN). A priori analyses were performed using distant recurrence free survival (DRFS) as the primary endpoint.
Results: In 692 successfully analysed samples 509 (73.6%) samples exhibited at least one single nucleotide mutation (range 0-54). 94/101 genes were mutated in at least one patient. Only variants in PIK3CA, TP53, CDH1, TLE6, MLL3 and USH2A were detected in 5% or more of samples. TSC22D1, RB1 and ZNF565 were associated with increased risk of distant relapse in multivariate analyses corrected for clinic-pathological variables. No single genes were predictive of anthracycline treatment compared to CMF in multivariate analyses corrected for clinic-pathological variables. Signaling cassettes/modules were designed based on the pathway database, Reactome. Within the signaling cassettes one module was predictive of anthracycline failure. Patients with one or more mutations in this module had an increased risk of distant relapse (HR 0.52, 95% CI 0.29-0.95, p=0.034) when treated with an anthracycline containing chemotherapy regimen compared to CMF (HR 1.34 95% CI 1.05-1.72, p=0.019).
Conclusions: We successfully performed a signaling pathway-based targeted sequencing analysis within predefined signaling modules. We identified a single signaling cassette linked to anthracycline resistance in early breast cancer. However, further work to validate this study in a separate clinical trial is warranted.
Citation Format: Spears M, Kalatskaya I, Trinh QM, Liao L, Chong TM, Crozier C, Dion D, Heisler L, Timms L, Stein LD, Pritchard KI, Levine MN, Shepherd L, Twelves CJ, Bartlett JMS. Targeted sequencing in early breast cancer: Identification of novel candidate mutations predictive of anthracycline benefit [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P2-10-04.
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Affiliation(s)
- M Spears
- Ontario Institute for Cancer Research, Toronto, ON, Canada; University of Toronto, Toronto, ON, Canada; Sunnybrook Odette Cancer, Toronto, ON, Canada; McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada; Canadian Cancer Trials Group, Kingston, ON, Canada; Leeds Institute of Cancer and Pathology and Cancer Research UK Centre, Leeds, United Kingdom; Edinburgh Cancer Research UK Centre, Edinburgh, United Kingdom
| | - I Kalatskaya
- Ontario Institute for Cancer Research, Toronto, ON, Canada; University of Toronto, Toronto, ON, Canada; Sunnybrook Odette Cancer, Toronto, ON, Canada; McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada; Canadian Cancer Trials Group, Kingston, ON, Canada; Leeds Institute of Cancer and Pathology and Cancer Research UK Centre, Leeds, United Kingdom; Edinburgh Cancer Research UK Centre, Edinburgh, United Kingdom
| | - QM Trinh
- Ontario Institute for Cancer Research, Toronto, ON, Canada; University of Toronto, Toronto, ON, Canada; Sunnybrook Odette Cancer, Toronto, ON, Canada; McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada; Canadian Cancer Trials Group, Kingston, ON, Canada; Leeds Institute of Cancer and Pathology and Cancer Research UK Centre, Leeds, United Kingdom; Edinburgh Cancer Research UK Centre, Edinburgh, United Kingdom
| | - L Liao
- Ontario Institute for Cancer Research, Toronto, ON, Canada; University of Toronto, Toronto, ON, Canada; Sunnybrook Odette Cancer, Toronto, ON, Canada; McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada; Canadian Cancer Trials Group, Kingston, ON, Canada; Leeds Institute of Cancer and Pathology and Cancer Research UK Centre, Leeds, United Kingdom; Edinburgh Cancer Research UK Centre, Edinburgh, United Kingdom
| | - TM Chong
- Ontario Institute for Cancer Research, Toronto, ON, Canada; University of Toronto, Toronto, ON, Canada; Sunnybrook Odette Cancer, Toronto, ON, Canada; McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada; Canadian Cancer Trials Group, Kingston, ON, Canada; Leeds Institute of Cancer and Pathology and Cancer Research UK Centre, Leeds, United Kingdom; Edinburgh Cancer Research UK Centre, Edinburgh, United Kingdom
| | - C Crozier
- Ontario Institute for Cancer Research, Toronto, ON, Canada; University of Toronto, Toronto, ON, Canada; Sunnybrook Odette Cancer, Toronto, ON, Canada; McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada; Canadian Cancer Trials Group, Kingston, ON, Canada; Leeds Institute of Cancer and Pathology and Cancer Research UK Centre, Leeds, United Kingdom; Edinburgh Cancer Research UK Centre, Edinburgh, United Kingdom
| | - D Dion
- Ontario Institute for Cancer Research, Toronto, ON, Canada; University of Toronto, Toronto, ON, Canada; Sunnybrook Odette Cancer, Toronto, ON, Canada; McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada; Canadian Cancer Trials Group, Kingston, ON, Canada; Leeds Institute of Cancer and Pathology and Cancer Research UK Centre, Leeds, United Kingdom; Edinburgh Cancer Research UK Centre, Edinburgh, United Kingdom
| | - L Heisler
- Ontario Institute for Cancer Research, Toronto, ON, Canada; University of Toronto, Toronto, ON, Canada; Sunnybrook Odette Cancer, Toronto, ON, Canada; McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada; Canadian Cancer Trials Group, Kingston, ON, Canada; Leeds Institute of Cancer and Pathology and Cancer Research UK Centre, Leeds, United Kingdom; Edinburgh Cancer Research UK Centre, Edinburgh, United Kingdom
| | - L Timms
- Ontario Institute for Cancer Research, Toronto, ON, Canada; University of Toronto, Toronto, ON, Canada; Sunnybrook Odette Cancer, Toronto, ON, Canada; McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada; Canadian Cancer Trials Group, Kingston, ON, Canada; Leeds Institute of Cancer and Pathology and Cancer Research UK Centre, Leeds, United Kingdom; Edinburgh Cancer Research UK Centre, Edinburgh, United Kingdom
| | - LD Stein
- Ontario Institute for Cancer Research, Toronto, ON, Canada; University of Toronto, Toronto, ON, Canada; Sunnybrook Odette Cancer, Toronto, ON, Canada; McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada; Canadian Cancer Trials Group, Kingston, ON, Canada; Leeds Institute of Cancer and Pathology and Cancer Research UK Centre, Leeds, United Kingdom; Edinburgh Cancer Research UK Centre, Edinburgh, United Kingdom
| | - KI Pritchard
- Ontario Institute for Cancer Research, Toronto, ON, Canada; University of Toronto, Toronto, ON, Canada; Sunnybrook Odette Cancer, Toronto, ON, Canada; McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada; Canadian Cancer Trials Group, Kingston, ON, Canada; Leeds Institute of Cancer and Pathology and Cancer Research UK Centre, Leeds, United Kingdom; Edinburgh Cancer Research UK Centre, Edinburgh, United Kingdom
| | - MN Levine
- Ontario Institute for Cancer Research, Toronto, ON, Canada; University of Toronto, Toronto, ON, Canada; Sunnybrook Odette Cancer, Toronto, ON, Canada; McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada; Canadian Cancer Trials Group, Kingston, ON, Canada; Leeds Institute of Cancer and Pathology and Cancer Research UK Centre, Leeds, United Kingdom; Edinburgh Cancer Research UK Centre, Edinburgh, United Kingdom
| | - L Shepherd
- Ontario Institute for Cancer Research, Toronto, ON, Canada; University of Toronto, Toronto, ON, Canada; Sunnybrook Odette Cancer, Toronto, ON, Canada; McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada; Canadian Cancer Trials Group, Kingston, ON, Canada; Leeds Institute of Cancer and Pathology and Cancer Research UK Centre, Leeds, United Kingdom; Edinburgh Cancer Research UK Centre, Edinburgh, United Kingdom
| | - CJ Twelves
- Ontario Institute for Cancer Research, Toronto, ON, Canada; University of Toronto, Toronto, ON, Canada; Sunnybrook Odette Cancer, Toronto, ON, Canada; McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada; Canadian Cancer Trials Group, Kingston, ON, Canada; Leeds Institute of Cancer and Pathology and Cancer Research UK Centre, Leeds, United Kingdom; Edinburgh Cancer Research UK Centre, Edinburgh, United Kingdom
| | - JMS Bartlett
- Ontario Institute for Cancer Research, Toronto, ON, Canada; University of Toronto, Toronto, ON, Canada; Sunnybrook Odette Cancer, Toronto, ON, Canada; McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada; Canadian Cancer Trials Group, Kingston, ON, Canada; Leeds Institute of Cancer and Pathology and Cancer Research UK Centre, Leeds, United Kingdom; Edinburgh Cancer Research UK Centre, Edinburgh, United Kingdom
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Liu S, Chen B, Burugu S, Leung S, Gao D, Virk S, Kos Z, Parulekar WR, Shepherd L, Gelmon KA, Nielsen TO. Role of Cytotoxic Tumor-Infiltrating Lymphocytes in Predicting Outcomes in Metastatic HER2-Positive Breast Cancer: A Secondary Analysis of a Randomized Clinical Trial. JAMA Oncol 2017; 3:e172085. [PMID: 28750133 DOI: 10.1001/jamaoncol.2017.2085] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Importance Accumulating evidence indicates that tumor-infiltrating lymphocytes (TILs) are associated with clinical outcomes and may predict the efficacy of chemotherapy and human epidermal growth factor receptor 2 (HER2, encoded by the gene ERBB2)-targeted therapy in patients with HER2-positive breast cancer. Objective To investigate the role of TILs, particularly cytotoxic CD8+ T cells, in the prediction of outcomes in patients with HER2-positive metastatic breast cancer randomized to an antibody-based (trastuzumab) vs a small molecule-based (lapatinib) anti-HER2 therapy. Design, Setting, and Participants The Canadian Cancer Trials Group MA.31 phase 3 clinical trial accrued patients from 21 countries and randomized 652 with HER2-positive metastatic breast cancer to receive trastuzumab or lapatinib, in combination with a taxane, from January 17, 2008, through December 1, 2011. Patients had received no prior chemotherapy or HER2-targeted therapy in the metastatic setting. The median follow-up was 21.5 months (interquartile range, 14.3-31.0). The tumor tissue collected for primary diagnosis was used in this ad hoc substudy. Sections were scored for TILs on hematoxylin-eosin (H&E)-stained sections, and immunohistochemical analysis was performed to assess CD8, FOXP3, CD56, and programmed cell death protein 1 (PD-1) expression on stromal (sTILs) and intratumoral TILs. Data were analyzed from July 15, 2015, through July 27, 2016. Interventions Treatment with trastuzumab or lapatinib in combination with taxane chemotherapy (paclitaxel or docetaxel) for 24 weeks. Main Outcomes and Measures Prognostic effects of biomarkers were evaluated for progression-free survival by stratified univariate log-rank test with Kaplan-Meier curves and by multivariate Cox proportional hazards regression; predictive effects were examined with a test of interaction between treatment allocation and biomarker classification. Results Of the 647 treated women (mean [SD] age, 55.0 [10.8] years), 614 had tumor tissue samples scored for H&E sTILs and 427 for CD8 biomarker assessments. Overall H&E sTIL counts of greater than 5% (high) were present in 215 cases (35%) but did not show significant prognostic or predictive effects. Univariate stratified analyses detected a significant predictive effect on risk for progression with lapatinib compared with trastuzumab among patients with low CD8+ sTIL counts (observed hazard ratio, 2.94; 95% CI, 1.40-6.17; P = .003) and among those with high CD8+ sTIL counts (observed hazard ratio, 1.36; 95% CI, 1.05-1.75; P = .02), confirmed in stepwise multivariate analysis (interaction P = .04). Other immunohistochemistry biomarkers were not associated with prognostic or predictive effects. Conclusions and Relevance In this secondary analysis of a phase 3 randomized clinical trial, a low level of preexisting cytotoxic sTILs predicted the most benefit from an antibody- vs a small molecule-based drug against the same target. Trial Registration clinicaltrials.gov Identifier: NCT00667251.
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Affiliation(s)
- Shuzhen Liu
- Department of Pathology and Laboratory Medicine, Genetic Pathology Evaluation Centre, University of British Columbia, Vancouver, Canada
| | - Bingshu Chen
- Canadian Cancer Trials Group, Queen's University, Kingston, Ontario, Canada
| | - Samantha Burugu
- Department of Pathology and Laboratory Medicine, Genetic Pathology Evaluation Centre, University of British Columbia, Vancouver, Canada
| | - Samuel Leung
- Department of Pathology and Laboratory Medicine, Genetic Pathology Evaluation Centre, University of British Columbia, Vancouver, Canada
| | - Dongxia Gao
- Department of Pathology and Laboratory Medicine, Genetic Pathology Evaluation Centre, University of British Columbia, Vancouver, Canada
| | - Shakeel Virk
- Canadian Cancer Trials Group, Queen's University, Kingston, Ontario, Canada
| | - Zuzana Kos
- Department of Pathology and Laboratory Medicine, University of Ottawa, The Ottawa Hospital, Ottawa, Canada
| | - Wendy R Parulekar
- Canadian Cancer Trials Group, Queen's University, Kingston, Ontario, Canada
| | - Lois Shepherd
- Canadian Cancer Trials Group, Queen's University, Kingston, Ontario, Canada
| | | | - Torsten O Nielsen
- Department of Pathology and Laboratory Medicine, Genetic Pathology Evaluation Centre, University of British Columbia, Vancouver, Canada
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Bosch M, Akhter A, Chen BE, Mansoor A, Lebrun D, Good D, Crump M, Shepherd L, Scott DW, Stewart DA. A bioclinical prognostic model using MYC and BCL2 predicts outcome in relapsed/refractory diffuse large B-cell lymphoma. Haematologica 2017; 103:288-296. [PMID: 29097500 PMCID: PMC5792273 DOI: 10.3324/haematol.2017.179309] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [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: 08/21/2017] [Accepted: 10/31/2017] [Indexed: 12/14/2022] Open
Abstract
The objective of this study was to create a bioclinical model, based on clinical and molecular predictors of event-free and overall survival for relapsed/refractory diffuse large B-cell lymphoma patients treated on the Canadian Cancer Trials Group (CCTG) LY12 prospective study. In 91 cases, sufficient histologic material was available to create tissue microarrays and perform immunohistochemistry staining for CD10, BCL6, MUM1/IRF4, FOXP1, LMO2, BCL2, MYC, P53 and phosphoSTAT3 (pySTAT3) expression. Sixty-seven cases had material sufficient for fluorescent in situ hybridization (FISH) for MYC and BCL2. In addition, 97 formalin-fixed, paraffin-embedded tissue samples underwent digital gene expression profiling (GEP) to evaluate BCL2, MYC, P53, and STAT3 expression, and to determine cell-of-origin (COO) using the Lymph2Cx assay. No method of determining COO predicted event-free survival (EFS) or overall survival (OS). Factors independently associated with survival outcomes in multivariate analysis included primary refractory disease, elevated serum lactate dehydrogenase (LDH) at relapse, and MYC or BCL2 protein or gene expression. A bioclinical score using these four factors predicted outcome with 3-year EFS for cases with 0–1 vs. 2–4 factors of 55% vs. 16% (P<0.0001), respectively, assessing MYC and BCL2 by immunohistochemistry, 46% vs. 5% (P<0.0001) assessing MYC and BCL2 messenger ribonucleic acid (mRNA) by digital gene expression, and 42% vs. 21% (P=0.079) assessing MYC and BCL2 by FISH. This proposed bioclinical model should be further studied and validated in other datasets, but may discriminate relapsed/refractory diffuse large B-cell lymphoma (DLBCL) patients who could benefit from conventional salvage therapy from others who require novel approaches. The LY12 study; clinicaltrials.gov Identifier: 00078949.
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Affiliation(s)
| | | | - Bingshu E Chen
- Canadian Cancer Trials Group, Queen's University, Kingston, ON, Canada
| | | | - David Lebrun
- Department of Pathology and Molecular Medicine, Queen's University, Kingston, ON, Canada
| | - David Good
- Canadian Cancer Trials Group, Queen's University, Kingston, ON, Canada
| | | | - Lois Shepherd
- Canadian Cancer Trials Group, Queen's University, Kingston, ON, Canada
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Shepherd L, Borges ÁH, Harvey R, Bower M, Grulich A, Silverberg M, Weber J, Ristola M, Viard JP, Bogner JR, Gargalianos-Kakolyris P, Mussini C, Mansinho K, Yust I, Paduta D, Jilich D, Smiatacz T, Radoi R, Tomazic J, Plomgaard P, Frikke-Schmidt R, Lundgren J, Mocroft A. The extent of B-cell activation and dysfunction preceding lymphoma development in HIV-positive people. HIV Med 2017; 19:90-101. [PMID: 28857427 DOI: 10.1111/hiv.12546] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/05/2017] [Indexed: 01/06/2023]
Abstract
OBJECTIVES B-cell dysfunction and activation are thought to contribute to lymphoma development in HIV-positive people; however, the mechanisms are not well understood. We investigated levels of several markers of B-cell dysfunction [free light chain (FLC)-κ, FLC-λ, immunoglobulin G (IgG), IgA, IgM and IgD] prior to lymphoma diagnosis in HIV-positive people. METHODS A nested matched case-control study was carried out within the EuroSIDA cohort, including 73 HIV-positive people with lymphoma and 143 HIV-positive lymphoma-free controls. Markers of B-cell dysfunction were measured in prospectively stored serial plasma samples collected before the diagnosis of lymphoma (or selection date in controls). Marker levels ≤ 2 and > 2 years prior to diagnosis were investigated. RESULTS Two-fold higher levels of FLC-κ [odds ratio (OR) 1.84; 95% confidence interval (CI) 1.19, 2.84], FLC-λ (OR 2.15; 95% CI 1.34, 3.46), IgG (OR 3.05; 95% CI 1.41, 6.59) and IgM (OR 1.46; 95% CI 1.01, 2.11) were associated with increased risk of lymphoma > 2 years prior to diagnosis, but not ≤ 2 years prior. Despite significant associations > 2 years prior to diagnosis, the predictive accuracy of each marker was poor, with FLC-λ emerging as the strongest candidate with a c-statistic of 0.67 (95% CI 0.58, 0.76). CONCLUSIONS FLC-κ, FLC-λ and IgG levels were higher > 2 years before lymphoma diagnosis, suggesting that B-cell dysfunction occurs many years prior to lymphoma development. However, the predictive value of each marker was low and they are unlikely candidates for risk assessment for targeted intervention.
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Affiliation(s)
- L Shepherd
- Research Department of Infection and Population Health, University College London, London, UK
| | - Á H Borges
- Centre of Excellence for Health, Immunity and Infections, Department of Infectious Diseases, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - R Harvey
- Charing Cross Oncology Laboratory and Trophoblastic Disease Centre, Charing Cross Hospital Campus of Imperial College Healthcare National Health Service Trust, London, UK
| | - M Bower
- National Centre for HIV Malignancy, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
| | - A Grulich
- Kirby Institute, The University of New South Wales, Sydney, NSW, Australia
| | - M Silverberg
- Kaiser Permanente Northern California, Oakland, CA, USA
| | - J Weber
- Imperial College London, London, UK
| | - M Ristola
- Division of Infectious Diseases, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - J-P Viard
- AP-HP, Diagnostic & Therapeutic Center, Hotel Dieu Hospital, Paris, France
| | - J R Bogner
- Department of Internal Medicine IV, University of Munich, Munich, Germany
| | - P Gargalianos-Kakolyris
- First Department of Internal Medicine and Infectious Diseases Unit, General Hospital of Athens "G. Gennimatas", Athens, Greece
| | - C Mussini
- Clinic of Infectious and Tropical Diseases, University of Modena and Reggio Emilia, Azienda Policlinico, Modena, Italy
| | - K Mansinho
- Department of Infectious Diseases, Hospital Egas Moniz-CHLO, E.P.E., Lisboa, Portugal
| | - I Yust
- Ichilov Hospital, Tel Aviv, Israel
| | - D Paduta
- Gomel Regional Centre for Hygiene, Gomel, Belarus
| | - D Jilich
- Department of Infectious and Tropical Diseases, First Faculty of Medicine, Charles University, Prague, Czech Republic
| | - T Smiatacz
- Infectious Diseases Department, Medical University of Gdańsk, Gdańsk, Poland
| | - R Radoi
- Clinical Hospital of Infectious and Tropical Diseases 'Dr. Victor Babeş', Bucharest, Romania
| | - J Tomazic
- Department of Infectious Diseases, University Medical Center Ljubljana, Ljubljana, Slovenia
| | - P Plomgaard
- Department of Clinical Biochemistry, Rigshospitalet, Copenhagen, Denmark
| | - R Frikke-Schmidt
- Department of Clinical Biochemistry, Rigshospitalet, Copenhagen, Denmark
| | - J Lundgren
- Centre of Excellence for Health, Immunity and Infections, Department of Infectious Diseases, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - A Mocroft
- Research Department of Infection and Population Health, University College London, London, UK
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Kuruvilla J, Crump M, Villa D, Aslam M, Prica A, Scott D, Abdel-Samad N, Couban S, Doucet S, Dudebout J, Fleury I, Fraser G, Larouche J, Shafey M, Skrabek P, Skamene T, Winch C, Shepherd L, Chen B, Hay A. CANADIAN CANCER TRIALS GROUP (CCTG) LY.17: A RANDOMIZED PHASE II STUDY EVALUATING NOVEL SALVAGE THERAPY PRE-AUTOLOGOUS STEM CELL TRANSPLANT (ASCT) IN RELAPSED/REFRACTORY DIFFUSE LARGE B CELL LYMPHOMA (RR-DLBCL) - OUTCOME OF IBRUTINIB + R-GDP. Hematol Oncol 2017. [DOI: 10.1002/hon.2437_76] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- J. Kuruvilla
- Canadian Cancer Trials Group; CCTG; Kingston Canada
| | - M. Crump
- Canadian Cancer Trials Group; CCTG; Kingston Canada
| | - D. Villa
- Canadian Cancer Trials Group; CCTG; Kingston Canada
| | - M. Aslam
- Canadian Cancer Trials Group; CCTG; Kingston Canada
| | - A. Prica
- Canadian Cancer Trials Group; CCTG; Kingston Canada
| | - D.W. Scott
- Canadian Cancer Trials Group; CCTG; Kingston Canada
| | | | - S. Couban
- Canadian Cancer Trials Group; CCTG; Kingston Canada
| | - S. Doucet
- Canadian Cancer Trials Group; CCTG; Kingston Canada
| | - J. Dudebout
- Canadian Cancer Trials Group; CCTG; Kingston Canada
| | - I. Fleury
- Canadian Cancer Trials Group; CCTG; Kingston Canada
| | - G. Fraser
- Canadian Cancer Trials Group; CCTG; Kingston Canada
| | - J. Larouche
- Canadian Cancer Trials Group; CCTG; Kingston Canada
| | - M. Shafey
- Canadian Cancer Trials Group; CCTG; Kingston Canada
| | - P. Skrabek
- Canadian Cancer Trials Group; CCTG; Kingston Canada
| | - T. Skamene
- Canadian Cancer Trials Group; CCTG; Kingston Canada
| | - C. Winch
- Canadian Cancer Trials Group; CCTG; Kingston Canada
| | - L. Shepherd
- Canadian Cancer Trials Group; CCTG; Kingston Canada
| | - B.E. Chen
- Canadian Cancer Trials Group; CCTG; Kingston Canada
| | - A.E. Hay
- Canadian Cancer Trials Group; CCTG; Kingston Canada
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Cairns J, Ingle J, Dudenkov T, Kalari K, Buzdar A, Kubo M, Robson M, Ellis M, Goss P, Shepherd L, Goetz M, Weinshilboum R, Wang L. Abstract PD1-04: CSMD1 SNPs selectively affect anastrozole response in postmenopausal breast cancer patients. Cancer Res 2017. [DOI: 10.1158/1538-7445.sabcs16-pd1-04] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
BACKGROUND: Based on prospective clinical trials, there is no evidence for differences in efficacy between the 3 aromatase inhibitors (AIs) anastrozole, exemestane, and letrozole. The purpose of this study was to identify germline genetic variants associated with response to AIs and to help identify novel mechanisms associated with drug disease efficacy.
METHODS: A genome-wide association study (GWAS) was performed for 624 patients (Steroids 2015;99:32-38) to identify SNPs associated with estrogen level change in women with estrogen receptor (ER) positive breast cancer treated with anastrozole. Replication of associated SNPs was performed in a GWAS from the MA.27 trial that compared adjuvant anastrozole and exemestane treatment of post-menopausal women with ER+ breast cancer. Functional studies were subsequently performed to determine SNP effects and underlying mechanisms.
RESULTS: Our initial GWAS identified SNPs within CSMD1 that were associated with changes in estrogen levels during anastrozole therapy. An additional SNP in CSMD1 was also associated with breast cancer events in CCTG MA.27. Functionally, we showed that CSMD1 regulates CYP19 expression in a SNP-, and in an anastrozole- dependent fashion. These phenomena were not observed for either letrozole or exemestane. In MA.27, an anastrozole- specific effect was also seen with the minor allele having a protective effect on time to distant metastasis (HR=0.49, p=0.00259), but this was not the case for exemestane (HR=0.71, p=0.111). Our in vitro functional studies indicated that overexpression of CSMD1 sensitized anastrozole or letrozole resistant cells to anastrozole but not to the other two AIs. The SNP in CSMD1 that was associated with increased CSMD1 and CYP19 expression levels increased anastrozole sensitivity, but not letrozole or exemestane in lymphoblastoid cell lines (LCLs) homozygous for either WT or variant CSMD1 SNP genotypes. Based on these observations, we explored whether anastrozole has additional mechanisms beyond its function as a CYP19 inhibitor. Utilizing an estrogen response element (ERE) luciferase reporter assay in a CYP19 CRISPR knockout breast cancer T47D cell line and a surface plasmon resonance (SPR) assay, we found that anastrozole can also function as an ERα agonist, and can bind to, and result in, proteasome dependent ERα degradation, especially in the presence of E2. Treatment of these CYP19 CRISPR knockout cells with anastrozole in the presence of increasing concentrations of E2 results in greater sensitivity compared with anastrozole alone, while the addition of E2, as expected, does not improve letrozole or exemestane sensitivity. These same observations were also seen in letrozole and anastrazole resistant cells.
CONCLUSIONS: Our findings suggest that anastrozole might be more effective than letrozole or exemestane in patients with the CSMD1 SNP. Furthermore, anastrozole can function as an ERα agonist, binding to ERα and resulting in its degradation, especially in the presence of E2. These findings should help to make it possible to develop precision endocrine therapies for women who are candidates for AIs.
Citation Format: Cairns J, Ingle J, Dudenkov T, Kalari K, Buzdar A, Kubo M, Robson M, Ellis M, Goss P, Shepherd L, Goetz M, Weinshilboum R, Wang L. CSMD1 SNPs selectively affect anastrozole response in postmenopausal breast cancer patients [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr PD1-04.
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Affiliation(s)
- J Cairns
- Mayo Clinic, Rochester, MN; The University of Texas MD Anderson Cancer Center, Houston, TX; Riken Center for Integrative Medical Science, Yokohama, Japan; Memorial Sloan Kettering Cancer Center, New York, NY; Baylor Cancer Center, Houston, TX; Massachusetts General Hospital, Boston, MA; NCIC Clinical Trials Group, Kingston, ON, Canada
| | - J Ingle
- Mayo Clinic, Rochester, MN; The University of Texas MD Anderson Cancer Center, Houston, TX; Riken Center for Integrative Medical Science, Yokohama, Japan; Memorial Sloan Kettering Cancer Center, New York, NY; Baylor Cancer Center, Houston, TX; Massachusetts General Hospital, Boston, MA; NCIC Clinical Trials Group, Kingston, ON, Canada
| | - T Dudenkov
- Mayo Clinic, Rochester, MN; The University of Texas MD Anderson Cancer Center, Houston, TX; Riken Center for Integrative Medical Science, Yokohama, Japan; Memorial Sloan Kettering Cancer Center, New York, NY; Baylor Cancer Center, Houston, TX; Massachusetts General Hospital, Boston, MA; NCIC Clinical Trials Group, Kingston, ON, Canada
| | - K Kalari
- Mayo Clinic, Rochester, MN; The University of Texas MD Anderson Cancer Center, Houston, TX; Riken Center for Integrative Medical Science, Yokohama, Japan; Memorial Sloan Kettering Cancer Center, New York, NY; Baylor Cancer Center, Houston, TX; Massachusetts General Hospital, Boston, MA; NCIC Clinical Trials Group, Kingston, ON, Canada
| | - A Buzdar
- Mayo Clinic, Rochester, MN; The University of Texas MD Anderson Cancer Center, Houston, TX; Riken Center for Integrative Medical Science, Yokohama, Japan; Memorial Sloan Kettering Cancer Center, New York, NY; Baylor Cancer Center, Houston, TX; Massachusetts General Hospital, Boston, MA; NCIC Clinical Trials Group, Kingston, ON, Canada
| | - M Kubo
- Mayo Clinic, Rochester, MN; The University of Texas MD Anderson Cancer Center, Houston, TX; Riken Center for Integrative Medical Science, Yokohama, Japan; Memorial Sloan Kettering Cancer Center, New York, NY; Baylor Cancer Center, Houston, TX; Massachusetts General Hospital, Boston, MA; NCIC Clinical Trials Group, Kingston, ON, Canada
| | - M Robson
- Mayo Clinic, Rochester, MN; The University of Texas MD Anderson Cancer Center, Houston, TX; Riken Center for Integrative Medical Science, Yokohama, Japan; Memorial Sloan Kettering Cancer Center, New York, NY; Baylor Cancer Center, Houston, TX; Massachusetts General Hospital, Boston, MA; NCIC Clinical Trials Group, Kingston, ON, Canada
| | - M Ellis
- Mayo Clinic, Rochester, MN; The University of Texas MD Anderson Cancer Center, Houston, TX; Riken Center for Integrative Medical Science, Yokohama, Japan; Memorial Sloan Kettering Cancer Center, New York, NY; Baylor Cancer Center, Houston, TX; Massachusetts General Hospital, Boston, MA; NCIC Clinical Trials Group, Kingston, ON, Canada
| | - P Goss
- Mayo Clinic, Rochester, MN; The University of Texas MD Anderson Cancer Center, Houston, TX; Riken Center for Integrative Medical Science, Yokohama, Japan; Memorial Sloan Kettering Cancer Center, New York, NY; Baylor Cancer Center, Houston, TX; Massachusetts General Hospital, Boston, MA; NCIC Clinical Trials Group, Kingston, ON, Canada
| | - L Shepherd
- Mayo Clinic, Rochester, MN; The University of Texas MD Anderson Cancer Center, Houston, TX; Riken Center for Integrative Medical Science, Yokohama, Japan; Memorial Sloan Kettering Cancer Center, New York, NY; Baylor Cancer Center, Houston, TX; Massachusetts General Hospital, Boston, MA; NCIC Clinical Trials Group, Kingston, ON, Canada
| | - M Goetz
- Mayo Clinic, Rochester, MN; The University of Texas MD Anderson Cancer Center, Houston, TX; Riken Center for Integrative Medical Science, Yokohama, Japan; Memorial Sloan Kettering Cancer Center, New York, NY; Baylor Cancer Center, Houston, TX; Massachusetts General Hospital, Boston, MA; NCIC Clinical Trials Group, Kingston, ON, Canada
| | - R Weinshilboum
- Mayo Clinic, Rochester, MN; The University of Texas MD Anderson Cancer Center, Houston, TX; Riken Center for Integrative Medical Science, Yokohama, Japan; Memorial Sloan Kettering Cancer Center, New York, NY; Baylor Cancer Center, Houston, TX; Massachusetts General Hospital, Boston, MA; NCIC Clinical Trials Group, Kingston, ON, Canada
| | - L Wang
- Mayo Clinic, Rochester, MN; The University of Texas MD Anderson Cancer Center, Houston, TX; Riken Center for Integrative Medical Science, Yokohama, Japan; Memorial Sloan Kettering Cancer Center, New York, NY; Baylor Cancer Center, Houston, TX; Massachusetts General Hospital, Boston, MA; NCIC Clinical Trials Group, Kingston, ON, Canada
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Liu S, Chen B, Burugu S, Leung S, Gao D, Virk S, Kos Z, Parulekar WR, Shepherd L, Gelmon K, Nielsen TO. Abstract P1-09-08: Predictive effect of cytotoxic tumor infiltrating lymphocytes in HER2-positive metastatic breast cancer: A correlative study with CCTG MA.31. Cancer Res 2017. [DOI: 10.1158/1538-7445.sabcs16-p1-09-08] [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: 11/16/2022]
Abstract
Abstract
Background and Objectives: The presence of tumor infiltrating lymphocytes (TILs), particularly CD8+ cytotoxic T-cells, has been associated with improved prognosis in patients with HER2+ breast cancer. Increasing levels of TILs also appear to predict response to adjuvant trastuzumab in early breast cancer, although they did not predict benefit of combined trastuzumab-lapatinib neoadjuvant dual therapy over monotherapy in NeoALLTO. CCTG MA.31 randomized 652 women with HER2+ metastatic breast cancer to treatment with trastuzumab (T) vs. lapatinib (L), in combination with taxane (Tax) chemotherapy for 24 weeks, followed by the same HER2-targeted monotherapy. Final results from MA.31 found trastuzumab was superior to lapatinib for the primary endpoint of progression free survival (PFS): the hazard ratio (HR) for lapatinib to trastuzumab was 1.37 (95% CI, 1.13-1.65). Although both agents block HER2 signaling, trastuzumab has additional mechanisms of action via the immune system. We hypothesized that TIL levels may predict response to HER2-targeted therapy (trastuzumab vs. lapatinib).
Methods: MA.31 included HER2+ metastatic breast cancer patients, median age 55 years, and median follow-up 21.5 months. Overall TILs were counted per published guidelines on the original H&E stained sections used for pathology review at study entry. Immunohistochemistry (IHC) was performed on unstained sections from tissue microarrays or individual formalin-fixed paraffin-embedded blocks to test expression of lymphocyte biomarkers CD8, FOXP3, CD56 and PD-1 on stromal and intra-tumoral TILs (sTILs, iTILs). Statistical analysis was conducted by CCTG for a total of 9 prespecified biomarker tests. Associations of TILs with PFS were evaluated by univariate stratified log-rank test with graphical Kaplan-Meier curves, and by stratified multivariate Cox proportional hazards regression analysis. Predictive effect was examined with a test of interaction between treatment allocation and biomarker classification (high vs. low, using pre-established cutpoints).
Results: Of the 652 cases, 614 had slides for overall TIL assessment and 427 for IHC biomarker assessments. In this correlative study set, superiority of trastuzumab over lapatinib for PFS was confirmed in multivariate analysis (LTax/T vs. TTax/L: HR = 2.55, 95% CI = 1.43-4.55, p = 0.001). TIL counts by H&E were neither prognostic nor predictive in this set of metastatic HER2+ breast cancers. Lymphocyte IHC markers were not prognostic. However, prespecified stratified univariate analysis detected a significantly higher risk for lapatinib over trastuzumab (HR = 2.94, 95% CI = 1.40-6.17, p = 0.003) in patients with low CD8+ sTIL (< 3) than was observed among those with high CD8+ sTIL (HR = 1.36, 95% CI = 1.05-1.75, p = 0.019). This differential effect was confirmed in multivariate analysis (interaction test p = 0.042). The other tested biomarkers did not demonstrate significant predictive effects.
Conclusions: In this correlative study of metastatic HER2+ breast cancer, a low level of pre-existing stromal cytotoxic T cell infiltration predicts women who benefit most from trastuzumab over lapatinib. Overall TIL counts were neither prognostic nor predictive.
Citation Format: Liu S, Chen B, Burugu S, Leung S, Gao D, Virk S, Kos Z, Parulekar WR, Shepherd L, Gelmon K, Nielsen TO. Predictive effect of cytotoxic tumor infiltrating lymphocytes in HER2-positive metastatic breast cancer: A correlative study with CCTG MA.31 [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P1-09-08.
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Affiliation(s)
- S Liu
- University of British Columbia and Vancouver Coastal Health Research Institute; Canadian Cancer Trials Group; University of Ottawa; British Columbia Cancer Agency
| | - B Chen
- University of British Columbia and Vancouver Coastal Health Research Institute; Canadian Cancer Trials Group; University of Ottawa; British Columbia Cancer Agency
| | - S Burugu
- University of British Columbia and Vancouver Coastal Health Research Institute; Canadian Cancer Trials Group; University of Ottawa; British Columbia Cancer Agency
| | - S Leung
- University of British Columbia and Vancouver Coastal Health Research Institute; Canadian Cancer Trials Group; University of Ottawa; British Columbia Cancer Agency
| | - D Gao
- University of British Columbia and Vancouver Coastal Health Research Institute; Canadian Cancer Trials Group; University of Ottawa; British Columbia Cancer Agency
| | - S Virk
- University of British Columbia and Vancouver Coastal Health Research Institute; Canadian Cancer Trials Group; University of Ottawa; British Columbia Cancer Agency
| | - Z Kos
- University of British Columbia and Vancouver Coastal Health Research Institute; Canadian Cancer Trials Group; University of Ottawa; British Columbia Cancer Agency
| | - WR Parulekar
- University of British Columbia and Vancouver Coastal Health Research Institute; Canadian Cancer Trials Group; University of Ottawa; British Columbia Cancer Agency
| | - L Shepherd
- University of British Columbia and Vancouver Coastal Health Research Institute; Canadian Cancer Trials Group; University of Ottawa; British Columbia Cancer Agency
| | - K Gelmon
- University of British Columbia and Vancouver Coastal Health Research Institute; Canadian Cancer Trials Group; University of Ottawa; British Columbia Cancer Agency
| | - TO Nielsen
- University of British Columbia and Vancouver Coastal Health Research Institute; Canadian Cancer Trials Group; University of Ottawa; British Columbia Cancer Agency
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Gurrala R, Lang Z, Shepherd L, Davidson D, Harrison E, McClure M, Kaye S, Toumazou C, Cooke GS. Novel pH sensing semiconductor for point-of-care detection of HIV-1 viremia. Sci Rep 2016; 6:36000. [PMID: 27829667 PMCID: PMC5103182 DOI: 10.1038/srep36000] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2016] [Accepted: 10/11/2016] [Indexed: 11/10/2022] Open
Abstract
The timely detection of viremia in HIV-infected patients receiving antiviral treatment is key to ensuring effective therapy and preventing the emergence of drug resistance. In high HIV burden settings, the cost and complexity of diagnostics limit their availability. We have developed a novel complementary metal-oxide semiconductor (CMOS) chip based, pH-mediated, point-of-care HIV-1 viral load monitoring assay that simultaneously amplifies and detects HIV-1 RNA. A novel low-buffer HIV-1 pH-LAMP (loop-mediated isothermal amplification) assay was optimised and incorporated into a pH sensitive CMOS chip. Screening of 991 clinical samples (164 on the chip) yielded a sensitivity of 95% (in vitro) and 88.8% (on-chip) at >1000 RNA copies/reaction across a broad spectrum of HIV-1 viral clades. Median time to detection was 20.8 minutes in samples with >1000 copies RNA. The sensitivity, specificity and reproducibility are close to that required to produce a point-of-care device which would be of benefit in resource poor regions, and could be performed on an USB stick or similar low power device.
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Affiliation(s)
- R Gurrala
- Division of Infectious Diseases, Imperial College, London, England
| | - Z Lang
- DNA Electronics Ltd, Wood Lane, London, England
| | - L Shepherd
- DNA Electronics Ltd, Wood Lane, London, England
| | - D Davidson
- DNA Electronics Ltd, Wood Lane, London, England
| | - E Harrison
- DNA Electronics Ltd, Wood Lane, London, England
| | - M McClure
- Division of Infectious Diseases, Imperial College, London, England
| | - S Kaye
- Division of Infectious Diseases, Imperial College, London, England
| | - C Toumazou
- DNA Electronics Ltd, Wood Lane, London, England.,Department of Bioengineering, Imperial College, London, England
| | - G S Cooke
- Division of Infectious Diseases, Imperial College, London, England
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Spears M, Yousif F, Lyttle N, Boutros PC, Munro AF, Twelves C, Pritchard KI, Levine MN, Shepherd L, Bartlett JMS. A four gene signature predicts benefit from anthracyclines: evidence from the BR9601 and MA.5 clinical trials. Oncotarget 2016; 6:31693-701. [PMID: 26372731 PMCID: PMC4741633 DOI: 10.18632/oncotarget.5562] [Citation(s) in RCA: 4] [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: 07/20/2015] [Accepted: 08/10/2015] [Indexed: 12/21/2022] Open
Abstract
Chromosome instability (CIN) in solid tumours results in multiple numerical and structural chromosomal aberrations and is associated with poor prognosis in multiple tumour types. Recent evidence demonstrated CEP17 duplication, a CIN marker, is a predictive marker of anthracycline benefit. An analysis of the BR9601 and MA.5 clinical trials was performed to test the role of existing CIN gene expression signatures as predictive markers of anthracycline sensitivity in breast cancer. Univariate analysis demonstrated, high CIN25 expression score was associated with improved distant relapse free survival (DRFS) (HR: 0.74, 95% CI 0.54-0.99, p = 0.046). High tumour CIN70 and CIN25 scores were associated with aggressive clinicopathological phenotype and increased sensitivity to anthracycline therapy compared to low CIN scores. However, in a prospectively planned multivariate analysis only pathological grade, nodal status and tumour size were significant predictors of outcome for CIN25/CIN70. A limited gene signature was generated, patients with low tumour CIN4 scores benefited from anthracycline treatment significantly more than those with high CIN4 scores (HR 0.37, 95% CI 0.20-0.56, p = 0.001). In multivariate analyses the treatment by marker interaction for CIN4/anthracyclines demonstrated hazard ratio of 0.35 (95% CI 0.15-0.80, p = 0.012) for DRFS. This data shows CIN4 is independent predictor of anthracycline benefit for DRFS in breast cancer.
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Affiliation(s)
- Melanie Spears
- Transformative Pathology, Ontario Institute for Cancer Research, MaRS Centre, Toronto, ON, Canada
| | - Fouad Yousif
- Informatics and Bio-Computing, Ontario Institute for Cancer Research, MaRS Centre, Toronto, ON, Canada
| | - Nicola Lyttle
- Transformative Pathology, Ontario Institute for Cancer Research, MaRS Centre, Toronto, ON, Canada
| | - Paul C Boutros
- Informatics and Bio-Computing, Ontario Institute for Cancer Research, MaRS Centre, Toronto, ON, Canada.,Department of Medical Biophysics, University of Toronto, Toronto, ON, Canada.,Department of Pharmacology and Toxicology, University of Toronto, Toronto, ON, Canada
| | - Alison F Munro
- Edinburgh Cancer Research UK Centre, MRC IGMM, University of Edinburgh, Crewe Road South, Edinburgh, UK
| | - Chris Twelves
- Leeds Institute of Cancer and Pathology and Cancer Research UK Centre, St James' University Hospital, Leeds, UK
| | - Kathleen I Pritchard
- Sunnybrook Odette Cancer Centre, Toronto, ON, Canada.,University of Toronto, Toronto, ON, Canada
| | - Mark N Levine
- McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada
| | - Lois Shepherd
- NCIC Clinical Trials Group (NCIC CTG] and Queen's University, Kingston, ON, Canada
| | - John M S Bartlett
- Transformative Pathology, Ontario Institute for Cancer Research, MaRS Centre, Toronto, ON, Canada.,Edinburgh Cancer Research UK Centre, MRC IGMM, University of Edinburgh, Crewe Road South, Edinburgh, UK
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Spears M, Lyttle N, D'Costa A, Chen BE, Yao CQ, Boutros PC, Burnell M, Levine MN, O'Brien P, Shepherd L, Bartlett JMS. A four gene signature of chromosome instability (CIN4) predicts for benefit from taxanes in the NCIC-CTG MA21 clinical trial. Oncotarget 2016; 7:49099-49106. [PMID: 27056899 PMCID: PMC5226493 DOI: 10.18632/oncotarget.8542] [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] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2016] [Accepted: 03/17/2016] [Indexed: 01/26/2023] Open
Abstract
Recent evidence demonstrated CIN4 as a predictive marker of anthracycline benefit in early breast cancer. An analysis of the NCIC CTG MA.21 clinical trial was performed to test the role of existing CIN gene expression signatures as prognostic and predictive markers in the context of taxane based chemotherapy. RNA was extracted from patients in cyclophosphamide, epirubicin and fluorouracil (CEF) and epirubicin, cyclophosphamide and paclitaxel (EC/T) arms of the NCIC CTG MA.21 trial and analysed using NanoString technology. After multivariate analysis both high CIN25 and CIN70 score was significantly associated with an increased in RFS (HR 1.76, 95%CI 1.07-2.86, p=0.0018 and HR 1.59, 95%CI 1.12-2.25, p=0.0096 respectively). Patients whose tumours had low CIN4 gene expression scores were associated with an increase in RFS (HR: 0.64, 95% CI 0.39-1.03, p=0.06) when treated with EC/T compared to patients treated with CEF. In conclusion we have demonstrated CIN25 and CIN70 as prognostic markers in breast cancer and that CIN4 is a potential predictive maker of benefit from taxane treatment.
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Affiliation(s)
- Melanie Spears
- Transformative Pathology, Ontario Institute for Cancer Research, MaRS Centre, Toronto, ON, Canada.,Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, ON, Canada
| | - Nicola Lyttle
- Transformative Pathology, Ontario Institute for Cancer Research, MaRS Centre, Toronto, ON, Canada
| | - Alister D'Costa
- Transformative Pathology, Ontario Institute for Cancer Research, MaRS Centre, Toronto, ON, Canada.,Informatics and Bio-Computing, Ontario Institute for Cancer Research, MaRS Centre, Toronto, ON, Canada
| | - Bingshu E Chen
- NCIC Clinical Trials Group (NCIC CTG) and Queen's University, Kingston, ON, Canada
| | - Cindy Q Yao
- Transformative Pathology, Ontario Institute for Cancer Research, MaRS Centre, Toronto, ON, Canada.,Informatics and Bio-Computing, Ontario Institute for Cancer Research, MaRS Centre, Toronto, ON, Canada
| | - Paul C Boutros
- Informatics and Bio-Computing, Ontario Institute for Cancer Research, MaRS Centre, Toronto, ON, Canada.,Department of Medical Biophysics, University of Toronto, Toronto, ON Canada.,Department of Pharmacology & Toxicology, University of Toronto, Toronto, ON Canada
| | | | - Mark N Levine
- Ontario Clinical Oncology Group, McMaster University, Hamilton, ON, Canada
| | - Patti O'Brien
- NCIC Clinical Trials Group (NCIC CTG) and Queen's University, Kingston, ON, Canada
| | - Lois Shepherd
- NCIC Clinical Trials Group (NCIC CTG) and Queen's University, Kingston, ON, Canada
| | - John M S Bartlett
- Transformative Pathology, Ontario Institute for Cancer Research, MaRS Centre, Toronto, ON, Canada.,Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, ON, Canada.,Edinburgh Cancer Research UK Centre, MRC IGMM, University of Edinburgh, Edinburgh, UK
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48
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Baetz T, Chen BE, Couban S, Tom Kouroukis C, Buckstein R, Kuruvilla J, Howson-Jan K, Szwajcer D, Federico M, Meyer RM, Djurfeldt MS, Hay AE, Shepherd L, Crump M. Effect of the addition of rituximab to salvage chemotherapy prior to autologous stem cell transplant in aggressive CD20+ lymphoma: a cohort comparison from the NCIC Clinical Trials Group Study LY.12<sup/>. Leuk Lymphoma 2016; 58:64-69. [PMID: 27266754 DOI: 10.1080/10428194.2016.1187274] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [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: 10/21/2022]
Abstract
The impact of the addition of rituximab to salvage chemotherapy prior to autologous stem cell transplant (ASCT) was evaluated in a retrospective subgroup analysis of NCIC CTG LY.12. Among 414 patients who relapsed following R-CHOP, 96 received salvage chemotherapy alone [R - cohort]; and 318 received rituximab with chemotherapy [R + cohort] following a protocol amendment. The R-cohort had a higher proportion of patients with PS ≥2 and relapse <1 year after R-CHOP. The response rate (45.6% vs. 25.0%, p = 0.0003), CR/CRu (15.7% vs. 4.2%, p = 0.003) and transplantation rate (51.9% vs. 31.3%, p = 0.0004) was higher in the R + cohort. Event-free (27% vs. 22%, p = 0.0954) and overall survival at four years (43% vs. 31%; p = 0.045) were greater in the R + cohort when the patients with best response SD/PD to R-CHOP were excluded. Addition of rituximab to salvage therapy before ASCT appears to improve the response rate, transplantation rate, and overall survival in patients with CD20+ lymphoma who responded to R-CHOP.
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Affiliation(s)
- Tara Baetz
- a Department of Oncology, Cancer Centre of Southeastern Ontario , Queen's University , Kingston , ON , Canada
| | - Bingshu E Chen
- b Canadian Cancer Trials Group , Cancer Research Institute, Queen's University , Kingston , ON , Canada
| | - Stephen Couban
- c Queen Elizabeth II Heath Sciences Centre , Halifax , NS , Canada
| | - C Tom Kouroukis
- d Department of Oncology , Juravinski Hospital and Cancer Centre , Hamilton , ON , Canada
| | - Rena Buckstein
- e Department of Hematology/Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre , University of Toronto , Toronto , ON , Canada
| | - John Kuruvilla
- f Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre , University of Toronto , Toronto , ON , Canada
| | | | - David Szwajcer
- h Department of Medicine , University of Manitoba , Winnipeg , MB , Canada
| | - Massimo Federico
- i Cattedra Di Oncologia Medica , Università Di Modena E Reggio Emilia , Modena , Italy
| | - Ralph M Meyer
- d Department of Oncology , Juravinski Hospital and Cancer Centre , Hamilton , ON , Canada
| | - Marina S Djurfeldt
- b Canadian Cancer Trials Group , Cancer Research Institute, Queen's University , Kingston , ON , Canada
| | - Annette E Hay
- b Canadian Cancer Trials Group , Cancer Research Institute, Queen's University , Kingston , ON , Canada
| | - Lois Shepherd
- b Canadian Cancer Trials Group , Cancer Research Institute, Queen's University , Kingston , ON , Canada
| | - Michael Crump
- f Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre , University of Toronto , Toronto , ON , Canada
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49
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Liedke PER, Tu D, Shepherd L, Chavarri-Guerra Y, Pritchard KI, Stearns V, Goss PE. New onset vasomotor symptoms but not musculoskeletal symptoms associate with clinical outcomes on extended adjuvant letrozole - Analyses from NCIC CTG MA.17. Breast 2016; 27:99-104. [PMID: 27058233 DOI: 10.1016/j.breast.2016.02.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2015] [Revised: 01/14/2016] [Accepted: 02/22/2016] [Indexed: 11/30/2022] Open
Abstract
PURPOSE New onset symptoms on adjuvant aromatase inhibitors for hormone receptor positive early breast cancer may associate with clinical outcomes. We performed this exploratory analysis of the association of new onset musculoskeletal (MSK) and vasomotor (VM) symptoms with clinical outcomes in the NCIC CTG MA.17 trial 5 years of extended adjuvant endocrine therapy with letrozole after tamoxifen. METHODS Symptoms were collected at baseline, 1, 6, and every 12 months on study. Multivariate Cox Models adjusting for age, nodal status, duration of tamoxifen and prior chemotherapy were used to compare disease-free survival (DFS), distant disease-free survival (DDFS), and overall survival (OS) based on data collected before, and after, the unblinding between women with VM or MSK symptoms and those without. RESULTS Data post-unblinding showed new VM symptoms on extended letrozole significantly improved DFS and DDFS when occurring 1 month (DFS HR 0.52, 95% CI, 0.28-0.96; p = 0.04; DDFS HR 0.49, 95% CI, 0.24-0.99; p = 0.046) and 6 months (DFS HR 0.43, 95% CI, 0.24-0.78; p = 0.006; DDFS HR 0.44, 95% CI, 0.22-0.85; p = 0.02) after treatment initiation. Those with new VM symptoms at 12 months also had a significantly better DFS (HR 0.47, 95% CI 0.26, 0.84; P = 0.01) and a trend in improved DDFS. Only a trend to improved OS was found for those with VM symptoms 6 month after treatment. No significant improvement was found for those with new MSK symptoms at any time point or for any endpoint. CONCLUSIONS New onset VM symptoms with extended letrozole may be useful in predicting treatment benefit.
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Affiliation(s)
- P E R Liedke
- Department of Clinical Oncology, Hospital de Clínicas de Porto Alegre, Porto Alegre, RS, Brazil; Mãe de Deus Cancer Institute, Hospital Mãe de Deus, Porto Alegre, RS, Brazil; Brazilian Breast Cancer Study Group, Porto Alegre, RS, Brazil; Massachusetts General Hospital Cancer Center, Avon International Breast Cancer Research Program, Boston, MA, USA
| | - D Tu
- Canadian Cancer Trials Group, Queen's University, Ontario, Canada
| | - L Shepherd
- Canadian Cancer Trials Group, Queen's University, Ontario, Canada
| | - Y Chavarri-Guerra
- Department of Hematology-Oncology, Instituto Nacional de Ciencias Médicas y Nutrición, Salvador Zubirán, Mexico; Massachusetts General Hospital Cancer Center, Avon International Breast Cancer Research Program, Boston, MA, USA
| | - K I Pritchard
- Canadian Cancer Trials Group, Queen's University, Ontario, Canada; Sunnybrook Odette Cancer Center, University of Toronto, Toronto, ON, Canada
| | - V Stearns
- Kimmel Cancer Center at Johns Hopkins, Breast Cancer Program, Baltimore, MD, USA
| | - P E Goss
- Canadian Cancer Trials Group, Queen's University, Ontario, Canada; Massachusetts General Hospital Cancer Center, Avon International Breast Cancer Research Program, Boston, MA, USA
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50
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Shepherd L, Borges Á, Ledergerber B, Domingo P, Castagna A, Rockstroh J, Knysz B, Tomazic J, Karpov I, Kirk O, Lundgren J, Mocroft A. Infection-related and -unrelated malignancies, HIV and the aging population. HIV Med 2016; 17:590-600. [PMID: 26890156 DOI: 10.1111/hiv.12359] [Citation(s) in RCA: 30] [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] [Accepted: 10/15/2015] [Indexed: 11/28/2022]
Abstract
OBJECTIVES HIV-positive people have increased risk of infection-related malignancies (IRMs) and infection-unrelated malignancies (IURMs). The aim of the study was to determine the impact of aging on future IRM and IURM incidence. METHODS People enrolled in EuroSIDA and followed from the latest of the first visit or 1 January 2001 until the last visit or death were included in the study. Poisson regression was used to investigate the impact of aging on the incidence of IRMs and IURMs, adjusting for demographic, clinical and laboratory confounders. Linear exponential smoothing models forecasted future incidence. RESULTS A total of 15 648 people contributed 95 033 person-years of follow-up, of whom 610 developed 643 malignancies [IRMs: 388 (60%); IURMs: 255 (40%)]. After adjustment, a higher IRM incidence was associated with a lower CD4 count [adjusted incidence rate ratio (aIRR) CD4 count < 200 cells/μL: 3.77; 95% confidence interval (CI) 2.59, 5.51; compared with ≥ 500 cells/μL], independent of age, while a CD4 count < 200 cells/μL was associated with IURMs in people aged < 50 years only (aIRR: 2.51; 95% CI 1.40-4.54). Smoking was associated with IURMs (aIRR: 1.75; 95% CI 1.23, 2.49) compared with never smokers in people aged ≥ 50 years only, and not with IRMs. The incidences of both IURMs and IRMs increased with older age. It was projected that the incidence of IRMs would decrease by 29% over a 5-year period from 3.1 (95% CI 1.5-5.9) per 1000 person-years in 2011, whereas the IURM incidence would increase by 44% from 4.1 (95% CI 2.2-7.2) per 1000 person-years over the same period. CONCLUSIONS Demographic and HIV-related risk factors for IURMs (aging and smoking) and IRMs (immunodeficiency and ongoing viral replication) differ markedly and the contribution from IURMs relative to IRMs will continue to increase as a result of aging of the HIV-infected population, high smoking and lung cancer prevalence and a low prevalence of untreated HIV infection. These findings suggest the need for targeted preventive measures and evaluation of the cost-benefit of screening for IURMs in HIV-infected populations.
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Affiliation(s)
- L Shepherd
- Department of Infection and Population Health, University College London Medical School, London, UK
| | - Áh Borges
- Centre for Health and Infectious Diseases Research (CHIP), Department of Infectious Diseases and Rheumatology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - B Ledergerber
- Division of Infectious Diseases and Hospital Epidemiology, University Hospital Zürich, Zürich, Switzerland
| | | | - A Castagna
- San Raffaele Scientific Institute, Milan, Italy
| | - J Rockstroh
- Department of Medicine I, University Hospital Bonn, Bonn, Germany
| | - B Knysz
- Department of Infectious Diseases, Wroclaw University, Wroclaw, Poland
| | - J Tomazic
- Department of Infectious Diseases, University Clinical Centre Ljubljana, Ljubljana, Slovenia
| | - I Karpov
- Belarus State Medical University, Minsk, Belarus
| | - O Kirk
- Centre for Health and Infectious Diseases Research (CHIP), Department of Infectious Diseases and Rheumatology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - J Lundgren
- Centre for Health and Infectious Diseases Research (CHIP), Department of Infectious Diseases and Rheumatology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - A Mocroft
- Department of Infection and Population Health, University College London Medical School, London, UK
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