Integrative Bioinformatics-Gene Network Approach Reveals Linkage between Estrogenic Endocrine Disruptors and Vascular Remodeling in Peripheral Arterial Disease

Vascular diseases, including peripheral arterial disease (PAD), pulmonary arterial hypertension, and atherosclerosis, significantly impact global health due to their intricate relationship with vascular remodeling. This process, characterized by structural alterations in resistance vessels, is a hallmark of heightened vascular resistance seen in these disorders. The influence of environmental estrogenic endocrine disruptors (EEDs) on the vasculature suggests a potential exacerbation of these alterations. Our study employs an integrative approach, combining data mining with bioinformatics, to unravel the interactions between EEDs and vascular remodeling genes in the context of PAD. We explore the molecular dynamics by which EED exposure may alter vascular function in PAD patients. The investigation highlights the profound effect of EEDs on pivotal genes such as ID3, LY6E, FOS, PTP4A1, NAMPT, GADD45A, PDGF-BB, and NFKB, all of which play significant roles in PAD pathophysiology. The insights gained from our study enhance the understanding of genomic alterations induced by EEDs in vascular remodeling processes. Such knowledge is invaluable for developing strategies to prevent and manage vascular diseases, potentially mitigating the impact of harmful environmental pollutants like EEDs on conditions such as PAD.

The impact of COVID-19 on patients diagnosed with melanoma, breast, and colorectal cancer

BACKGROUND

The COVID-19 pandemic impacted healthcare resource allocation and utilization of preventative medical services. It is unknown if there is resultant stage migration of melanoma, breast, and colorectal cancer when comparing extended time periods before and after the pandemic onset.

METHODS

A retrospective cohort study of melanoma, breast, and colorectal cancer patients was completed. Clinical and pathological staging was compared utilizing 12 and 22-month timeframes before and after the pandemic outbreak.

RESULTS

Between the 22-month pre- and post-COVID-19 groups, breast cancer clinical stage T2 significantly increased, and pathological stage 2 decreased. Colorectal cancer clinical stage T1 decreased, stage T4 increased, and stage 0 decreased in the 22-month groups. In the 12-month groups, melanoma clinical stage T1 increased, and colorectal cancer clinical stage N2 increased.

CONCLUSIONS

Evaluating extended timeframes beyond the immediate pre- and post-COVID-19 period revealed significant increases in clinical staging of breast and colorectal cancer, suggesting advanced disease is becoming more evident as time progresses.

Development of a Cancer Rehabilitation Dashboard to Collect Data on Physical Function in Cancer Patients and Survivors

OBJECTIVE

The aim of the study is to describe the development of a cancer rehabilitation dashboard that collects data on physical function for cancer survivors in a cancer institute.

METHODS

This project was conducted at the Miami Cancer Institute. The cancer rehabilitation dashboard was developed by a team of physicians, biostatistician, and medical informatics teams to record, report and track the physical function of cancer survivors. A multimodal approach to the measurement of physical function was used and included the Patient-Reported Outcome Measurement Information System-Physical Function short form, Patient-Reported Outcome Measurement Information System-Fatigue short form, Timed Up and Go Test, Sit-to-Stand Test in 30-sec test, four-stage balance test, and grip strength. To develop this system, a Cerner Power Form was developed based on the physical function data. To display the data, a dedicated flowsheet was developed and placed within the Oncology Viewpoint in Cerner Millennium. Thus, from inside any patient record, the flowsheet could easily be accessed by providers without leaving normal clinician workflows. Using native functionality, the data can also be shown in graphical format to facilitate dialog with patients and oncology teams. All patient data from the Cerner Power Form discrete task assays were integrated into an existing Oncology Data Warehouse for all patients. The data elements in the Cerner Power Form were identified in the electronic medical record system, loaded into the Oncology Data Warehouse, and related to the other source systems to develop reports and data visualizations such as the cancer rehabilitation dashboard. The cancer rehabilitation dashboard allows visualization of numerous parameters of physical function in cancer survivors evaluated and treated and their change over time. Rendered in Tableau, the cancer rehabilitation dashboard acts as a centralized, interactive data source to analyze and connect clinicians to near real-time data.

RESULTS

The cancer rehabilitation dashboard was successfully developed and implemented into a cancer rehabilitation practice in a cancer institute and used to collect and track physical function data for cancer survivors receiving treatment and cancer survivors. This information has been used to direct the treatment plan and educate individual patients about the impact of the cancer and its treatment on physical function as well as oncology teams in a cancer institute.

CONCLUSIONS

The cancer rehabilitation dashboard provides an insight into the physical function of cancer survivors receiving treatment and cancer survivors using both self-reported and objective metrics. It can be customized to suit the interests of clinicians and researchers wishing to improve the quality of life of this population.

Gender Differences in Hospital Outcomes among COVID-19 Hospitalizations

OBJECTIVES

Many epidemiological studies have shown that coronavirus disease 2019 (COVID-19) disproportionately affects males, compared with females, although other studies show that there were no such differences. The aim of the present study was to assess differences in the prevalence of hospitalizations and in-hospital outcomes between the sexes, using a larger administrative database.

METHODS

We used the 2020 California State Inpatient Database for this retrospective analysis. International Classification of Diseases, Tenth Revision, Clinical Modification diagnosis code U07.1 was used to identify COVID-19 hospitalizations. These hospitalizations were subsequently stratified by male and female sex. Diagnosis and procedures were identified using the International Classification of Diseases, Tenth Revision, Clinical Modification codes. The primary outcome of the study was hospitalization rate, and secondary outcomes were in-hospital mortality, prolonged length of stay, vasopressor use, mechanical ventilation, and intensive care unit (ICU) admission.

RESULTS

There were 95,180 COVID-19 hospitalizations among patients 18 years and older, 52,465 (55.1%) of which were among men and 42,715 (44.9%) were among women. In-hospital mortality (12.4% vs 10.1%), prolonged length of hospital stays (30.6% vs 25.8%), vasopressor use (2.6% vs 1.6%), mechanical ventilation (11.8% vs 8.0%), and ICU admission rates (11.4% versus 7.8%) were significantly higher among male compared with female hospitalizations. Conditional logistic regression analysis showed that the odds of mortality (odds ratio [OR] 1.38, 95% confidence interval [CI] 1.38-1.44), hospital lengths of stay (OR 1.35, 95% CI 1.31-1.39), vasopressor use (OR 1.59, 95% CI 1.51-1.66), mechanical ventilation (OR 1.62, 95% CI 1.47-1.78), and ICU admission rates (OR 1.58, 95% CI 1.51-1.66) were significantly higher among male hospitalizations.

CONCLUSION

Our findings show that male sex is an independent and strong risk factor associated with COVID-19 severity.

Hospital Outcomes in Patients With Pulmonary Hypertension With Atrial Fibrillation in the United States

In this study, using a large database, we examined the association between atrial fibrillation (AF) in hospitalized patients with pulmonary hypertension (PH) and in-hospital mortality and other adverse hospital outcomes. This study was a retrospective analysis of the United States National (Nationwide) Inpatient Sample from 2005 to 2014. All hospitalizations for patients diagnosed with primary PH and over the age of 65 years were included and then grouped based on the presence AF. The outcomes were in-hospital mortality rate, hospital length of stay, and hospitalization costs. Weighted regression analyses were performed to find the association between AF and outcomes. Of the 5,428,332 hospitalizations with PH, 2,531,075 (46.6%) had concomitant AF. The Cox proportional regression analysis showed that in patients with PE, all-cause mortality (hazard ratio 1.35, confidence interval [CI] 1.15 to 1.55) was significantly higher in patients with AF than those without AF. In addition, PH hospitalizations with AF had a longer hospital length of stay (β coefficient 1.74, 95% CI 1.58 to 1.83) and higher hospitalization cost (β coefficient 1.33, 95% CI 1.12 to 1.42). In patients aged over 65 years admitted for PH, the presence of AF was very frequent and worsened the prognosis. In conclusion, to improve patient outcomes and decrease hospital burden, it is important to consider AF during risk stratification for patients with PH to provide timely and prompt interventions. An interdisciplinary approach to treatment should be used to account for the burden of co-morbidities in this population.

Prophylactic Radiotherapy Of MInimally Symptomatic Spinal Disease (PROMISSeD): study protocol for a randomized controlled trial

BACKGROUND

Early palliative/pre-emptive intervention improves clinical outcomes and quality of life for patients with metastatic cancer. A previous signal-seeking randomized controlled trial (RCT) demonstrated that early upfront radiotherapy to asymptomatic or minimally symptomatic high-risk osseous metastases led to reduction in skeletal-related events (SREs), a benefit driven primarily by subgroup of high-risk spine metastasis. The current RCT aims to determine whether early palliative/pre-emptive radiotherapy in patients with high-risk, asymptomatic or minimally symptomatic spine metastases will lead to fewer SREs within 1 year.

METHODS

This is a single-center, parallel-arm, in-progress RCT in adults (≥ 18 years) with ECOG performance status 0-2 and asymptomatic or minimally symptomatic (not requiring opioids) high-risk spine metastases from histologically confirmed solid tumor malignancies with > 5 sites of metastatic disease on cross-sectional imaging. High-risk spine metastases are defined by the following: (a) bulkiest disease sites ≥ 2 cm; (b) junctional disease (occiput to C2, C7-T1, T12-L2, L5-S1); (c) posterior element involvement; or (d) vertebral body compression deformity > 50%. Patients are randomized 1:1 to receive either standard-of-care systemic therapy (arm 1) or upfront, early radiotherapy to ≤ 5 high-risk spine lesions plus standard-of-care systemic therapy (arm 2), in the form of 20-30 Gy of radiation in 2-10 fractions. The primary endpoint is SRE, a composite outcome including spinal fracture, spinal cord compression, need for palliative radiotherapy, interventional procedures, or spinal surgery. Secondary endpoints include (1) surrogates of health care cost, including the number and duration of SRE-related hospitalizations; (2) overall survival; (3) pain-free survival; and (4) quality of life. Study instruments will be captured pre-treatment, at baseline, during treatment, and at 1, 3, 6, 12, and 24 months post-treatment. The trial aims to accrue 74 patients over 2 years to achieve > 80% power in detecting difference using two-sample proportion test with alpha < 0.05.

DISCUSSION

The results of this RCT will demonstrate the value, if any, of early radiotherapy for high-risk spine metastases. The trial has received IRB approval, funding, and prospective registration (NCT05534321) and has been open to accrual since August 19, 2022. If positive, the trial will expand the scope and utility of spine radiotherapy.

TRIAL REGISTRATION

ClinicalTrials.Gov NCT05534321 . Registered September 9, 2022.

TRIAL STATUS

Version 2.0 of the protocol (2021-KOT-002), revised last on September 2, 2022, was approved by the WCG institutional review board (Study Number 1337188, IRB tracking number 20223735). The trial was first posted on ClinicalTrials.Gov on September 9, 2022 (NCT05534321). Patient enrollment commenced on August 19, 2022, and is expected to be completed in 2 years, likely by August 2024.

Prevalence and effects of acute myocardial infarction on hospital outcomes among COVID-19 patients

BACKGROUND

Acute myocardial infarction (AMI) is one of the most lethal complications of COVID-19 hospitalization. In this study, we looked for the occurrence of AMI and its effects on hospital outcomes among COVID-19 patients.

METHODS

Data from the 2020 California State Inpatient Database was used retrospectively. All COVID-19 hospitalizations with age ≥ 18 years were included in the analyses. Adverse hospital outcomes included in-hospital mortality, prolonged length of stay (LOS), vasopressor use, mechanical ventilation, and ICU admission. Prolonged LOS was defined as any hospital LOS ≥ 75th percentile. Multivariate logistic regression analyses were used to understand the strength of associations after adjusting for cofactors.

RESULTS

Our analysis had 94 114 COVID-19 hospitalizations, and 1548 (1.6%) had AMI. Mortality (43.2% vs. 10.8%, P  < 0.001), prolonged LOS (39.9% vs. 28.2%, P  < 0.001), vasopressor use (7.8% vs. 2.1%, P  < 0.001), mechanical ventilation (35.0% vs. 9.7%, P  < 0.001), and ICU admission (33.0% vs. 9.4%, P  < 0.001) were significantly higher among COVID-19 hospitalizations with AMI. The odds of adverse outcomes such as mortality (aOR 3.90, 95% CI: 3.48-4.36), prolonged LOS (aOR 1.23, 95% CI: 1.10-1.37), vasopressor use (aOR 3.71, 95% CI: 3.30-4.17), mechanical ventilation (aOR 2.71, 95% CI: 2.21-3.32), and ICU admission (aOR 3.51, 95% CI: 3.12-3.96) were significantly more among COVID-19 hospitalizations with AMI.

CONCLUSION

Despite the very low prevalence of AMI among COVID-19 hospitalizations, the study showed a substantially greater risk of adverse hospital outcomes and mortality. COVID-19 patients with AMI should be aggressively treated to improve hospital outcomes.

Racial difference in mortality among COVID-19 hospitalizations in California

In the US, racial disparities in hospital outcomes are well documented. We explored whether race was associated with all-cause in-hospital mortality and intensive care unit (ICU) admission among COVID-19 patients in California. This was a retrospective analysis of California State Inpatient Database during 2020. Hospitalizations ≥ 18 years of age for COVID-19 were included. Cox proportional hazards with mixed effects were used for associations between race and in-hospital mortality. Logistic regression was used for the association between race and ICU admission. Among 87,934 COVID-19 hospitalizations, majority were Hispanics (56.5%), followed by White (27.3%), Asian, Pacific Islander, Native American (9.9%), and Black (6.3%). Cox regression showed higher mortality risk among Hispanics, compared to Whites (hazard ratio, 0.91; 95% CI 0.87-0.96), Blacks (hazard ratio, 0.87; 95% CI 0.79-0.94), and Asian, Pacific Islander, Native American (hazard ratio, 0.89; 95% CI 0.83-0.95). Logistic regression showed that the odds of ICU admission were significantly higher among Hispanics, compared to Whites (OR, 1.70; 95% CI 1.67-1.74), Blacks (OR, 1.70; 95% CI 1.64-1.78), and Asian, Pacific Islander, Native American (OR, 1.82; 95% CI 1.76-1.89). We found significant disparities in mortality among COVID-19 hospitalizations in California. Hispanics were the worst affected with the highest mortality and ICU admission rates.

Characterization of Physical Function and Cancer-Related Physical Impairments in Hispanic Women With Breast Cancer: A Descriptive Study

Introduction: This study reports characteristics of Hispanic women with breast cancer with respect to physical function, body mass index (BMI), and depression. Methods: This retrospective study included 322 Hispanic women with breast cancer. Physical function and fatigue were assessed using the Patient Reported Outcomes Measurement System-Physical Function (PROMIS-PF) short form and PROMIS-Fatigue (PROMISE-F) short form. In addition, Timed Up and Go (TUG) test, sit to stand in 30 s (STS30) test, four-stage balance test (4SB), and grip strength (GS) were measured. Depression was identified using Patient Health Questionnaire (PHQ)-2 and extracted from medical chart. Results: Nearly 40.8% were obese, and 20.8% had depression. Compared to normal BMI patients, mean PROMIS-F score was significantly higher among overweight and obese patients. The mean STS30 score was significantly lower in obese patients, compared to normal BMI patients. Regression analysis showed that the odds of depression were higher with increasing TUG and lower PROMIS-F, STS30, and GS. Conclusion: Hispanic women with breast cancer have substantial loss of physical function, and this is exaggerated if they are obese, overweight, or depressed. Clinicians caring for this population should screen them for the presence of loss of physical function, BMI, and depression.

The Impact of Patients' Primary Language on Inpatient Gastrointestinal Bleeding Outcomes

BACKGROUND

The impact of English proficiency on gastrointestinal bleeding (GIB) outcomes remains unclear. In this analysis, we compare inpatient GIB outcomes between patients with English as their primary language (EPL) and those with a primary language other than English (PLOE).

METHODS

Using the 2019 State Inpatient Databases for New Jersey, Maryland, and Michigan, we created an analysis cohort of GIB hospitalizations using International Classification of Diseases, 10th Revision codes. Patients were stratified by primary language (EPL vs PLOE) and type of bleeding (variceal upper GI bleeding [VUGIB], nonvariceal upper GI bleeding [NVUGIB], and lower GI bleeding (LGIB)]. Regression analyses were used to compare mortality, 30-day readmissions, and length of stay. Adjusted odds ratios (aORs) and 95% confidence intervals (CIs) were reported. P < 0.05 was considered statistically significant.

RESULTS

In the cohort, 5.5%-10% of the patients spoke a primary language other than English. Endoscopy utilization was lower among patients with PLOE vs EPL for NVUGIB (17.2% vs 21.2%, P < 0.001) and LGIB (26.3% vs 29.2%, P = 0.027). Patients with PLOE had higher odds of dying of VUGIB (aOR 1.45, 95% CI 1.16-2.48) and LGIB (aOR 1.71, 95% CI 1.22-2.12). Patients with PLOE were also more likely to be readmitted after NVUGIB (aOR 1.75, 95% CI 1.64-1.81). However, after controlling for the percentage of patients with PLOE discharged from each hospital, the disparities in mortality and readmissions were no longer detected.

DISCUSSION

Disparities exist in GIB outcomes among patients with PLOE, but these gaps narrow at hospitals with higher percentages of patients with PLOE. Cultural and linguistic competence may improve outcomes in this vulnerable group.

Association Between Frailty, 30-day Unplanned Readmission and Mortality After Hospitalization for Heart Failure: Results From the Nationwide Readmissions Database

Objectives: This study examined how frailty in traditional risk-adjusted models could improve the predictability of unplanned 30-day readmission and mortality among heart failure patients. Methods: This study was a retrospective analysis of Nationwide Readmissions Database data collected during the years 2010-2018. All patients ≥65 years who had a principal diagnosis of heart failure were included in the analysis. The Johns Hopkins Adjusted Clinical Groups frailty-defining diagnosis indicator was used to identify frail patients. Results: There was a total of 819,854 patients admitted for heart failure during the study period. Among them, 63,302 (7.7%) were frail. In the regression analysis, the risk of all-cause 30-day readmission (OR, 1.18; 95% CI, 1.14-1.22) and in-hospital mortality (OR, 1.52; 95% CI, 1.40-1.66) were higher in patients with frailty. Discussion: Inclusion of frailty in comorbidity-based risk-prediction models significantly improved the predictability of unplanned 30-day readmission and in-hospital mortality.

Healthcare expenditure trends among adult stroke patients in the United States, 2011-2020

BACKGROUND

In the US, between 2018 and 2019, approximately $57 billion were expended on stroke and related conditions. The aim of this study was to understand trends in direct healthcare expenditures among stroke patients using novel cost estimation methods and a nationally representative database.

METHODS

This study was a retrospective analysis of 193,003 adults, ≥18 years of age, using the Medical Expenditure Panel Survey during 2009-2016. Manning and Mullahy's two-part model were used to calculate adjusted mean and incremental medical expenditures after adjusting for covariates.

RESULTS

The mean (Standard Deviation) direct annual healthcare expenditure among stroke patients was $16,979.0 ($16,222.0- $17,736.0) and was nearly 3 times greater than non-stroke participants which were $5,039.7 ($4,951.0-$5,128.5) and were mainly spent on inpatient services, prescription medications, and office-based visits. Stroke patients had an additional healthcare expenditure of $4096.0 (3543.9, 4648.1) per person per year, compared to participants without stroke after adjusting for covariates (P<0.001). The total mean annual direct healthcare expenditure for stroke survivors increased from $16,142.0 (15,017.0-17,267.0) in 2007-2008 to $16,979.0 (16,222.0-17,736.0) in 2015-2016.

CONCLUSION

Our study showed that stroke survivors had significantly greater healthcare expenses, compared to non-stroke individuals, mainly due to higher expenditures on inpatient services, prescription drugs, and office visits. These findings are concerning because the prevalence of stroke is projected to increase due to aging population and increased survival rates.

Characterization of Large Brain Metastases with 18F-Fluciclovine PET/CT Treated with Staged Stereotactic Radiosurgery (SSRS): Phase 1 Proof-of-Concept Interim Analysis

PURPOSE/OBJECTIVE(S)

Single-session stereotactic radiosurgery (SRS) for large brain metastases (>2cm) results in modest local control. Temporally staged SRS (SSRS), whereby 2 stages of SRS are delivered over a time interval of several weeks, is a novel strategy associated with improved control rates and acceptable radiation necrosis rates. Biomarkers for response are lacking. Here, we report interim results of a phase 1, proof-of-concept study (NCT04689048) to assess the potential clinical utility of amino acid radiotracer 18F-fluciclovine PET/CT as a functional integral biomarker for patients with large brain metastases treated with SSRS.

MATERIALS/METHODS

Patients with previously untreated large brain metastases (≥1 lesion; >2cm) underwent a baseline (pre-treatment) 18F-fluciclovine PET/CT and contrast-enhanced treatment planning brain MRI immediately before first SSRS (15 Gy), an interim PET/CT + MRI (4 weeks after the 1st SSRS, immediately prior the 2nd SSRS [15 Gy]), and post-treatment PET/CT + MRI (8 weeks after 2nd SSRS). This interim analysis reviewed the imaging characteristics from static PET images acquired 10-25 minutes after 18F-fluciclovine injection, for the first 7 enrolled patients who completed baseline imaging and 5 who completed the entire treatment course.

RESULTS

Seven patients completed baseline imaging and were treated with SSRS for 9 protocol-eligible target lesions, and an additional 25 bystander lesions were treated with SRS. The median age was 72 years and 57% were female. All lesions > 5 mm exhibited baseline increased 18F-fluciclovine uptake compared to the normal contralateral brain. The median baseline target lesion diameters and volumes were 2.16 cm (1.76-3.22 cm) and 4.71cc (2.24-10.21 cc). The median baseline SUVmax, SUVpeak, and SUVmean values were 5.78 (2.16-8.79), 3.33 (0.5-2.72), and 1.75 (1.22-5.16), respectively. The median relative reduction in diameter and volume were both 2% (-13% to 23% and -30% to 60%, respectively) at the interim scans, and at the first follow-up were 30% (-0.2% to 44%) and 43% (-13% to 94%), respectively. Corresponding median relative reduction values for SUVmax, SUVpeak, and SUVmean at interim scans were 20% (-174%-73%), 9% (-99% to 75%), and 14% (-36% to 69%), and at first follow-up 59% (21% to 87%), 41% (-11% to 86%), and 21% (-44% to 79%), respectively. Bystander lesions (< 2 cm) treated with SRS had a median baseline lesion diameter and volume of 0.5 cm (Range: 0.20-1.64 cm) and 0.06 cc (Range: 0.01-1.94 cc). Corresponding median reductions for SUVmax were 5% at interim and 63% at follow-up scans.

CONCLUSION

This proof-of-concept interim study reports baseline 18F-fluciclovine metrics for patients with brain metastases of varying lesion diameters and volumes. Target lesions appear to demonstrate interval reduction in PET metrics after SSRS, more than dimensional measurements alone.

Adverse Outcomes in Hospitalizations for Amyloid-Related Heart Failure

Transthyretin amyloid cardiomyopathy is being increasingly recognized as an important cause of heart failure (HF). In this study, we looked at adverse outcomes in hospitalizations with amyloid-related HF. This study was a retrospective analysis of the National Inpatient Sample data, collected from 2016 to 2019. Patients ≥41 years of age and admitted for HF were included in the study. In these hospitalizations, amyloid-related HF was identified through the International Classification of Diseases, Tenth Revision, Clinical Modification codes for amyloidosis. The primary outcome of the study was in-hospital mortality, whereas secondary outcomes were prolonged length of stay, mechanical ventilation, mechanical circulatory support, vasopressors use, and dispositions other than home. From 2016 to 2019, there were 4,705,274 HF hospitalizations, of which 16,955 (0.4%) had amyloid cardiomyopathy. In all HF hospitalizations, amyloid-related increased from 0.26% in 2016 to 0.46% in 2019 (relative increase, 76.9%, P for trend <0.001). Amyloid-related HF hospitalizations were more common in older, male, and Black patients. The odds of in-hospital mortality (odds ratio [OR], 1.29; 95% confidence interval [CI]: 1.11 to 1.38), prolonged hospital length (OR, 1.61; 95% CI: 1.49 to 1.73) and vasopressors use (OR, 1.59; 95% CI: 1.23 to 2.05) were significantly higher for amyloid-related hospitalizations. Amyloid-related HF hospitalizations are increasing substantially and are associated with adverse hospital outcomes. These hospitalizations were disproportionately higher for older, male, and Black patients. Amyloid-related HF is rare and underdiagnosed yet has several adverse outcomes. Hence, healthcare providers should be watchful of this condition for early identification and prompt management.

Effect of Frailty on Hospital Outcomes Among Pediatric Cancer Patients in the United States: Results From the National Inpatient Sample

BACKGROUND

Studies on frailty among pediatric patients with cancer are scarce. In this study, we sought to understand the effects of frailty on hospital outcomes in pediatric patients with cancer.

METHODS

This retrospective study used data collected and stored in the Nationwide Inpatient Sample (NIS) between 2005 and 2014. These were hospitalized patients and hence represented the sickest group of patients. Frailty was measured using the frailty definition diagnostic indicator by Johns Hopkins Adjusted Clinical Groups.

RESULTS

Of 187,835 pediatric cancer hospitalizations included in this analysis, 11,497 (6.1%) were frail. The average hospitalization costs were $86,910 among frail and $40,358 for nonfrail patients. In propensity score matching analysis, the odds of in-hospital mortality (odds ratio, 2.08; 95% CI, 1.71-2.52) and length of stay (odds ratio, 3.76; 95% CI, 3.46-4.09) were significantly greater for frail patients. The findings of our study suggest that frailty is a crucial clinical factor to be considered when treating pediatric cancer patients in a hospital setting.

CONCLUSIONS

These findings highlight the need for further research on frailty-based risk stratification and individualized interventions that could improve outcomes in frail pediatric cancer patients. The adaptation and validation of a frailty-defining diagnostic tool in the pediatric population is a high priority in the field.

Comparison of Inpatient Outcomes Between HIV Positive and Negative Hospitalizations for Autologous Stem Cell Transplant Treatment among Lymphoid Malignancies

BACKGROUND

Comorbidity burden is higher among people living with HIV (PLWH). In addition, they experience adverse effects associated with antiretrovirals. In this study we looked for differences in adverse hospital outcomes between those with and without HIV among hospitalizations for autologous stem cell transplantations (ASCTs) for lymphoid malignancies.

MATERIALS AND METHODS

The current study was a retrospective analysis using the National Inpatient Sample (NIS) database, for the years 2005 to 2014. Adult hospitalizations ≥18 years of age, for ASCTs were included for the analysis, and were stratified into those with and without HIV. The primary outcome variables were in-hospital mortality, prolonged length of stay, and adverse dispositions.

RESULTS

We included a total of 117,686 ASCT hospitalizations, of which, 468 (0.4%) were HIV positive. Among HIV-positive hospitalizations, there were 251 (53.4%), non-Hodgkin lymphoma, 128 (27.4%), Hodgkin lymphoma, and 89 (19.2%) multiple myeloma cases. Only half of the PLWH among Black population received ASCT, compared to Whites (26.8% vs. 54.8%). Regression analyses showed that the odds of in-hospital mortality (OR, 0.77; 95% CI, 0.13-4.44), prolonged length of stay (OR, 1.18; 95% CI, 0.67-2.11), and dispositions other than home (OR, 1.26; 95% CI, 0.61-2.59) did not differ significantly between 2 groups.

DISCUSSION

We found that adverse hospital outcomes did not differ between those with and without HIV among hospitalized autologous stem cell transplant recipients. However, the rates of ASCT were substantially lower among Black PLWH. New interventions and approaches should be developed to improve ASCT rates among HIV positive racial minorities.

A nationwide study of liver disease hospitalizations during the coronavirus pandemic in the United States

BACKGROUND AND AIM

The impact of the Coronavirus disease-2019 (COVID-19) pandemic on patients with liver disease is not well described at the population level in the United States. We used the largest, nationwide inpatient dataset to describe inpatient liver disease outcomes in the United States during the first year of the pandemic (2020) using 2018 and 2019 as comparator years.

METHODS

Using the National Inpatient Sample (2018-2020), we explored year-to-year and 2020 month-to-month trends in hospitalizations, length of stay, and inpatient mortality for liver-related complications including cirrhosis, alcohol-associated liver disease (ALD) and alcoholic hepatitis using regression modeling. We reported relative change (RC) in the study period.

RESULTS

Decompensated cirrhosis hospitalizations decreased in 2020 compared with 2019 (RC: -2.7%, P < 0.001) while all-cause mortality increased by 15.5% (P < 0.001). Hospitalizations for ALD increased compared with pre-pandemic years (RC: 9.2%, P < 0.001) with a corresponding increase in mortality in 2020 (RC 25.2%, P = 0.002). We observed an increase in liver transplant surgery mortality during the peak months of the pandemic. Importantly, mortality from COVID-19 was higher among patients with decompensated cirrhosis (adjusted odds ratio [OR] 1.72, 95% confidence interval [CI] [1.53-1.94]), Native Americans (OR 1.76, 95% CI [1.53-2.02]), and patients from lower socioeconomic groups.

CONCLUSIONS

Cirrhosis hospitalizations decreased in 2020 compared with pre-pandemic years but were associated with higher all-cause mortality rates particularly in the peak months of the COVID-19 pandemic. In-hospital COVID-19 mortality was higher among Native Americans, patients with decompensated cirrhosis, chronic illnesses, and those from lower socioeconomic groups.

A63 TRENDS AND OUTCOMES OF LIVER DISEASE HOSPITALIZATIONS DURING THE CORONAVIRUS PANDEMIC IN THE UNITED STATES: A NATIONWIDE POPULATION-LEVEL ANALYSIS

Background

The impact of the Coronavirus disease-2019 (COVID-19) pandemic on patients with liver disease is not well described at the population level in the United States.

Purpose

We used the largest, nationwide inpatient dataset to describe inpatient liver disease outcomes in the United States during the first year of the pandemic (2020) using 2018 and 2019 as comparator years.

Method

Using the National Inpatient Sample (2018-2020), we explored year-to-year and 2020 month-to-month trends in hospitalizations, length of stay, and inpatient mortality for liver-related indications including compensated cirrhosis, decompensated cirrhosis, alcohol-associated liver disease (ALD), alcohol-associated hepatitis (AH), hepatocellular carcinoma (HCC), and variceal upper gastrointestinal bleeding (VUGIB) using regression modeling. We also looked at the impact of the COVID-19 pandemic on liver transplantation rates. A p-value <0.05 was considered statistically significant.

Result(s)

Hospitalizations for both compensated and decompensated cirrhosis decreased in 2020 compared to 2019 (relative change [RC] of 1.5%, p <0.001, Table 1). Interestingly, hospitalizations for ALD and AH increased in 2020 compared to pre-pandemic years (ALD RC=15.5% and AH RC 17.0%; p<0.001). Despite the decrease in cirrhosis hospitalizations in 2020, all-cause inpatient mortality among patients with compensated cirrhosis increased from 30,135 in 2019 to 35,220 in 2020 (p<0.001) and from 22,850 in 2019 to 26,390 in 2020 among patients with decompensated cirrhosis (p<0.001). This was accompanied by a 27.8% increase in mortality for ALD (p=0.004) in comparison to pre-pandemic years. Corresponding to the peaks of the pandemic, we observed the fewest cirrhosis hospitalizations in April and December 2020 (Table 2), however, these months had the highest observed mortality rates (p-trend ≤ 0.004). Reassuringly, liver transplantation rates were not significantly impacted by the COVID-19 pandemic (p=0.51).

Image

Conclusion(s)

Cirrhosis hospitalizations, in general, decreased in 2020 compared to pre-pandemic years but were associated with higher all-cause mortality rates particularly in the peak months of the COVID-19 pandemic (April and December 2020) possibly reflecting COVID-19 specific mortality. Alcoholic liver disease admissions also increased during the pandemic while liver transplantation rates were not significant impacted.

Please acknowledge all funding agencies by checking the applicable boxes below

None

Disclosure of Interest

None Declared

Abstract P6-08-11: Hyperglycemia in Hispanic MBC patients treated with alpelisib: single institution retrospective study

Background: PIK3CA mutations are found in up to 40% of hormone receptor positive (HR+), human epidermal growth factor receptor 2 negative (HER2-) metastatic breast cancers (MBC). Alpelisib is an orally bioavailable PIK3CA inhibitor approved in combination with fulvestrant based on the SOLAR-1 study. However, uptake has been limited due to toxicity concerns, most commonly hyperglycemia (grade ≥3 was 37% in SOLAR-1 and 28% in the BYLieve study, which evaluated alpelisib after progression on a CDK 4/6 inhibitor). Patients with uncontrolled type 2 diabetes (T2DM) were excluded from both studies [defined as fasting plasma glucose (FPG) level &gt;140 mg per deciliter, or a glycosylated hemoglobin (HgbA1C) level of &gt;6.4%]. Of note, both trials enrolled a majority of non-Hispanic White (NHW) patients. Disparities regarding prevalence of diabetes has been reported among Hispanics (H). The Centers for Disease Control and Prevention reports that H are more likely to have T2DM than NHW (approximately 17% vs 8% respectively). Our study aims to characterize the incidence and management of hyperglycemia in H MBC patients treated with alpelisib. Methods: A retrospective chart review was performed to include patients with HR+ HER2- MBC with a documented PIK3CA mutation treated with alpelisib in combination with fulvestrant at Miami Cancer Institute from 2019-2022. Patients were identified using pharmacy records and the COTA real-world database (RWD, an analytics platform enabling investigation of longitudinal RWD). Cases were excluded where the start date was unclear, or treatment was given for a diagnosis other than breast cancer. Based on available data in the medical record, patients were categorized as H or NH. Descriptive statistics were used to describe variables in both groups of patients. Results: Of 46 patients identified, 34 were included in the final analysis (17 H and 17 NH). The median age was 63 y (range 32-87). The most common PIK3CA mutation identified was H1047R (41.2% of H and 23.5% of NH; p &gt; 0.05). Starting body mass index (BMI) was higher in H compared to NH (29.9 vs 24.8; p &lt; 0.05). Starting FPG was the same for both groups (115 mg/dL), and within the first two weeks on treatment the highest FPG was higher in H vs NH (250 mg/dL vs 157 mg/dL; p &gt; 0.05). H also had the highest peak glucose when compared to NH (333.8 mg/dL vs 217.8 mg/dL; p &lt; 0.05). Furthermore, by the end of treatment H had a higher FBG than NH (247.4 mg/dL vs 118.0 mg/dL; p &lt; 0.05). Overall, any grade hyperglycemia occurred in 70.6% (82.4% H, 58.8% NH; p &gt; 0.05, with high rates of grade 3/4 hyperglycemia in both groups (53% H 41% NH; p &gt; 0.05). A higher percentage of H patients required more than one anti-hyperglycemic medication as compared to NH (41% vs 12%; p &gt; 0.05). Hispanics time on treatment was shorter compared to NH (151 vs 240 days; p &gt; 0. 05). Disease progression was the most frequent reason for treatment discontinuation in both groups 52.9%. However, more H patients discontinued alpelisib due to hyperglycemia (23.5% vs 5.9%; p &gt; 0.31). Conclusions: Despite starting treatment with similar FPG levels, H had a higher peak plasma glucose level compared to NH. Although not statistically significant, likely due to a small sample size, the rates of hyperglycemia within two weeks of treatment was higher in H than NH. Furthermore, H required the use of more antiglycemic medications and had higher discontinuation rates. Therefore, there is a heightened need to increase education and awareness of glucose monitoring in H during treatment with alpelisib. Further prospective studies are warranted to better define the optimal management of hyperglycemia in H patients.

Citation Format: Yolcar Chamorro, Reshma Mahtani, Shanada Monestime, Manmeet Ahluwalia, Muni Rubens, Natasha Harpalani, Ana Sandoval-Leon. Hyperglycemia in Hispanic MBC patients treated with alpelisib: single institution retrospective study [abstract]. In: Proceedings of the 2022 San Antonio Breast Cancer Symposium; 2022 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2023;83(5 Suppl):Abstract nr P6-08-11.

The impact of the Coronavirus disease 2019 on hospitalizations for coronary artery revascularization: results from California State Inpatient Database

BACKGROUND

Coronavirus disease 2019 (COVID-19) outbreak has negatively impacted routine cardiovascular care. In this study, we assessed the impact of COVID-19 pandemic on percutaneous coronary artery intervention (PCI) and coronary artery bypass grafting (CABG) hospitalizations and outcomes using a large database.

METHODS

The current study was a retrospective analysis of California State Inpatient Database (SID) during March-December of 2019 and 2020. All adult hospitalizations for coronary artery revascularization were included for the analysis. ICD-10-CM diagnosis and procedure codes were used for identifying hospitalizations and procedures. The primary outcome was inhospital mortality, and secondary outcomes were hospital length of stay, stroke, acute kidney injury, and mechanical ventilation. Propensity score match analysis was done to compare adverse clinical outcomes.

RESULTS

PCI hospitalizations (relative decrease, 15.0%, P for trend <0.001) and CABG hospitalizations (relative decrease, 16.4%, P for trend <0.001) decreased from 2019 to 2020, while viral pneumonia hospitalizations increased (relative increase, 1751.6%, P for trend <0.001). Monthly PCI and CABG hospitalization showed decreasing trends from January 2019 to December 2020. Propensity score match analysis showed that the odds of inhospital mortality (OR, 1.12; 95% CI, 1.01-1.24), acute kidney injury (OR, 1.12; 95% CI, 1.06-1.17), and ARDS (OR, 1.89; 95% CI, 1.18-3.01) were higher among patients who received PCI in 2020.

CONCLUSION

Results of our study indicate that initiatives such as encouraging patients to receive treatments and controlling the spread of COVID-19 should be instituted to improve PCI and CABG hospitalizations.

Prevalence and trends of perioperative major adverse cardiovascular and cerebrovascular events during cancer surgeries

Major adverse cardiovascular and cerebrovascular events (MACCE) is an important cause of morbidity and mortality during perioperative period. In this study, we looked for national trends in perioperative MACCE and its components as well as cancer types associated with high rates of perioperative MACCE during major cancer surgeries. This study was a retrospective analysis of the National Inpatient Sample, 2005-2014. Hospitalizations for surgeries of prostate, bladder, esophagus, pancreas, lung, liver, colorectal, and breast among patients 40 years and greater were included in the analysis. MACCE was defined as a composite measure that included in-hospital all-cause mortality, acute myocardial infarction (AMI), and ischemic stroke. A total of 2,854,810 hospitalizations for major surgeries were included in this study. Of these, 67,316 (2.4%) had perioperative MACCE. Trends of perioperative MACCE showed that it decreased significantly for AMI, death and any MACCE, while stroke did not significantly change during the study period. Logistic regression analysis for perioperative MACCE by cancer types showed that surgeries for esophagus, pancreas, lung, liver, and colorectal cancers had significantly greater odds for perioperative MACCE. The surgeries identified to have greater risks for MACCE in this study could be risk stratified for better informed decision-making and management.

Racial disparities in clinical presentation, surgical procedures, and hospital outcomes among patients with hepatocellular carcinoma in the United States

BACKGROUND

Hepatocellular carcinoma (HCC) is one of the leading causes of cancer-related deaths in the United States (US), with substantial disparities observed in cancer incidence and survival among racial groups. This study provides analyses on race and ethnicity disparities for patients with HCC.

METHODS

This is a cross-sectional analysis of data from the National Inpatient Sample (NIS) between 2011 and 2016, utilizing the STROBE guidelines. Multivariate logistic regression analyses were used to examine the risk-adjusted associations between race and pre-treatment clinical presentation, surgical procedure allocation, and post-treatment hospital outcomes. All clinical parameters were identified using ICD-9-CM and ICD-10-CM diagnosis and procedure codes.

RESULTS

83,876 weighted HCC hospitalizations were reported during the study period. Patient demographics were divided according to NIS racial/ethnic categorization, which includes Caucasian (57.3%), African American (16.9%), Hispanic (15.7%), Asian or Pacific Islanders (9.3%), and Native American (0.8%). Association between greater odds of hospitalization and Elixhauser Comorbidity Index > 4 was significantly higher among Native Americans (aOR=1.79; 95% CI: 1.23-2.73), African Americans (aOR=1.24; 95% CI: 1.12-1.38), and Hispanics (aOR=1.11; 95% CI, 1.01-1.24). Risk-adjusted association between race and receipt of surgical procedures demonstrated that the odds of having surgery was significantly lower for African Americans (aOR=0.64; 95% CI: 0.55-0.73) and Hispanics (aOR=0.70; 95% CI: 0.59-0.82), while significantly higher for Asians/Pacific Islanders (aOR=1.36; 95% CI: 1.28-1.63). Post-operative complications were significantly lower for African Americans (aOR=0.68; 95% CI: 0.55-0.86) while the odds of in-hospital mortality were significantly higher for African Americans (aOR=1.28; 95% CI: 1.11-1.49) and Asians/Pacific Islanders (aOR=1.26; 95% CI: 1.13-1.62).

CONCLUSIONS

After controlling for potential confounders, there were significant racial disparities in pre-treatment presentations, surgical procedure allocations, and post-treatment outcomes among patients with HCC. Further studies are needed to determine the underlying factors for these disparities to develop targeted interventions to reduce these disparities of care.

Trends in gastrointestinal disease hospitalizations and outcomes during the first year of the coronavirus pandemic

BACKGROUND

The impact of the coronavirus on hospitalizations for gastrointestinal (GI) disease, particularly at a population level is understudied.

AIM

To investigate trends in hospitalizations, inpatient endoscopy resource utilization, and outcomes during the first year of the coronavirus pandemic and subsequent lockdowns.

METHODS

Using the California State Inpatient Database for 2018-2020, we explored year-to-year and 2020 month-to-month trends in hospitalizations, length of stay, and inpatient mortality (all-cause & viral pneumonia-specific) for common inpatient GI diagnoses including acute pancreatitis, diverticulitis, cholelithiasis, non-infectious gastroenteritis, upper and lower GI bleeding (LGIB), Clostridium difficile, viral gastroenteritis, inflammatory bowel disease, and acute cholangitis.

RESULTS

Disease-specific hospitalizations decreased for all included conditions except nonvariceal upper GI bleeding (NVUGIB), LGIB, and ulcerative colitis (UC) (ptrend < 0.0001). All-cause inpatient mortality was higher in 2020 vs 2019, for acute pancreatitis (P = 0.029), diverticulitis (P = 0.04), NVUGIB (P = 0.003), and Crohn’s disease (P = 0.004). In 2020, hospitalization rates were lowest in April, November, and December. There was no significant corresponding increase in inpatient mortality except in UC (ptrend = 0.048). Viral pneumonia and viral pneumonia complicated by respiratory failure increased (P < 0.001) among GI hospitalizations. Endoscopy utilization within 24 h of admission was unchanged for GI emergencies except NVUGIB (P < 0.001).

CONCLUSION

Our findings suggest that hospitalization rates for common GI conditions significantly declined in California during the COVID pandemic, particularly in April, November and December 2020. All-cause mortality was significantly higher among acute pancreatitis, diverticulitis, NVUGIB, and Crohn’s disease hospitalizations. Emergency endoscopy rates were mostly comparable between 2020 and 2019.

Multi-Institutional Outcomes of Patients Aged 75 years and Older With Pancreatic Ductal Adenocarcinoma Treated With 5-Fraction Ablative Stereotactic Magnetic Resonance Image-Guided Adaptive Radiation Therapy (A-SMART)

PURPOSE

Treatment options for pancreatic ductal adenocarcinoma (PDAC) are commonly limited for patients with advanced age due to medical comorbidities and/or poor performance status. These patients may not be candidates for more aggressive chemotherapy regimens and/or surgical resection leaving few, if any, other effective treatments. Ablative stereotactic MRI-guided adaptive radiation therapy (A-SMART) is both efficacious and safe for PDAC and can achieve excellent long-term local control, however, the appropriateness of A-SMART for elderly patients with inoperable PDAC is not well understood.

METHODS

A retrospective analysis was performed of inoperable non-metastatic PDAC patients aged 75 years or older treated on the MRIdian Linac at 2 institutions. Clinical outcomes of interest included overall survival (OS), progression-free survival (PFS), distant metastasis-free survival (DMFS), and locoregional (LRC). Toxicity was graded according to Common Terminology Criteria for Adverse Events (CTCAE, v5).

RESULTS

A total of 49 patients were evaluated with a median age of 81 years (range, 75-91) and a median follow-up of 14 months from diagnosis. PDAC was classified as locally advanced (46.9%), borderline resectable (36.7%), or medically inoperable (16.3%). Neoadjuvant chemotherapy was delivered to 84% of patients and all received A-SMART to a median 50 Gy (range, 40-50 Gy) in 5 fractions. 1 Year LRC, PFS, and OS were 88.9%, 53.8%, and 78.9%, respectively. Nine patients (18%) had resection after A-SMART and benefited from PFS improvement (26 vs 6 months, P = .01). ECOG PS <2 was the only predictor of improved OS on multivariate analysis. Acute and late grade 3 + toxicity rates were 8.2% and 4.1%, respectively.

CONCLUSIONS

A-SMART is associated with encouraging LRC and OS in elderly patients with initially inoperable PDAC. This novel non-invasive treatment strategy appears to be well-tolerated in patients with advanced age and should be considered in this population that has limited treatment options.

Recent Trends in Diabetes-Associated Hospitalizations in the United States

The purpose of this study was to examine trends in diabetes-related hospitalizations over the period 2010 to 2019 using Nationwide Inpatient Sample (NIS) to facilitate informed policies regarding diabetes-related prevention and management. Between 2010 and 2019, there were 304 million hospitalizations above 18 years of age, of which 78 million were diabetes-associated hospitalizations. The overall population-adjusted diabetes hospitalizations significantly increased from 3079.0 to 3280.8 per 100,000 US population (relative increase, 6.6%, Ptrend < 0.028). Age-stratified analysis showed that hospitalizations significantly increased for 18−29 years (relative increase, 7.8%, Ptrend < 0.001) while age- and gender-stratified analysis showed that diabetes hospitalization significantly increased for 18−29-year males (relative increase, 18.1%, Ptrend < 0.001). Total hospitalization charge increased from 97.5 billion USD in 2010 to 132.0 billion USD in 2019 (relative increase, 35.4%, Ptrend < 0.001). Our study’s findings suggest that diabetes-associated hospitalizations will continue to increase in the future because recent evidence indicates a reappearance of diabetes complications. It is important to screen, prevent, and control diabetes at a younger age based on the trends observed in our study.

Hospital outcomes of patients receiving catheter ablation of atrial fibrillation, left atrial appendage closure, or both

BACKGROUND

Catheter ablation (CA) and left atrial appendage closure (LAAC) require transseptal access; combining both in a single procedure may have advantages. However, the safety of this approach has not been extensively studied. The objective of this study was to compare in hospital outcomes among patients receiving CA, LAAC, and combination of both treatments on the same day.

METHODS

We conducted a retrospective cohort analysis of the National Inpatient Sample database. The primary outcome was the presence of major adverse cardiovascular and cerebrovascular events (MACCE) during index hospitalization. Secondary outcomes included stroke, pericardial effusion, pericardiocentesis, and bleeding.

RESULTS

A total of 69,285 hospitalizations with AF were included in the analysis, of which 71.7% received LAAC, 27.8% received CA, and 0.5% received combination of both treatments on the same day. MACEE (OR, 1.63; 95% CI, 0.39-6.70), stroke (OR, 2.98; 95% CI, 0.55-16.01), pericardial effusion (OR, 0.33; 95% CI, 0.07-1.41), pericardiocentesis (OR, 1.00; 95% CI, 0.25-3.86), and bleeding (OR, 3.25; 95% CI, 0.87-12.07) did not differ significantly between CA and combination treatment. Similarly, MACCE (OR, 1.11; 95% CI, 0.28-4.41), stroke (OR, 1.03; 95% CI, 0.24-4.35), pericardial effusion (OR, 0.45; 95% CI, 0.11-1.90), pericardiocentesis (OR, 0.63; 95% CI, 0.14-2.83), and bleeding (OR, 2.04; 95% CI, 0.65-6.39) did not differ significantly between LAAC and combination treatment.

CONCLUSIONS

The combined approach is infrequently used in clinical practice (< 1%). However, major life-threatening adverse events did not differ between CA and LAAC when performed in isolation or combined in a single procedural stage on the same day.

Hospital Outcomes Among COVID-19 Hospitalizations With Myocarditis from the California State Inpatient Database

Many case reports have indicated that myocarditis could be a prognostic factor for predicting morbidity and mortality among patients with COVID-19. In this study, using a large database we examined the association between myocarditis among COVID-19 hospitalizations and in-hospital mortality and other adverse hospital outcomes. The present study was a retrospective analysis of data collected in the California State Inpatient Database during 2020. All hospitalizations for COVID-19 were included in the analysis and grouped into those with and without myocarditis. The outcomes were in-hospital mortality, cardiac arrest, cardiogenic shock, mechanical ventilation, and acute respiratory distress syndrome. Propensity score matching, followed by conditional logistic regression, was performed to find the association between myocarditis and outcomes. Among 164,417 COVID-19 hospitalizations, 578 (0.4%) were with myocarditis. After propensity score matching, the rate of in-hospital mortality was significantly higher among COVID-19 hospitalizations with myocarditis (30.0% vs 17.5%, p <0.001). Survival analysis with log-rank test showed that 30-day survival rates were significantly lower among those with myocarditis (39.5% vs 46.3%, p <0.001). Conditional logistic regression analysis showed that the odds of cardiac arrest (odds ratio [OR] 1.90, 95% confidence interval [CI] 1.16 to 3.14), cardiogenic shock (OR 4.13, 95% CI 2.14 to 7.99), mechanical ventilation (OR 3.30, 95% CI 2.47 to 4.41), and acute respiratory distress syndrome (OR 2.49, 95% CI 1.70 to 3.66) were significantly higher among those with myocarditis. Myocarditis was associated with greater rates of in-hospital mortality and adverse hospital outcomes among patients with COVID-19, and early suspicion is important for prompt diagnosis and management.

Hospital Outcomes among COVID-19 Hospitalizations with Acute Ischemic Stroke: Cross-Sectional Study Results from California State Inpatient Database

Coronavirus disease 2019 (COVID-19) could be a risk factor for acute ischemic stroke (AIS) due to the altered coagulation process and hyperinflammation. This study examined the risk factors, clinical profile, and hospital outcomes of COVID-19 hospitalizations with AIS. This study was a retrospective analysis of data from California State Inpatient Database (SID) during 2019 and 2020. COVID-19 hospitalizations with age ≥ 18 years during 2020 and a historical cohort without COVID-19 from 2019 were included in the analysis. The primary outcomes studied were in-hospital mortality and discharge to destinations other than home. There were 91,420 COVID-19 hospitalizations, of which, 1027 (1.1%) had AIS. The historical control cohort included 58,083 AIS hospitalizations without COVID-19. Conditional logistic regression analysis showed that the odds of in-hospital mortality, discharge to destinations other than home, DVT, pulmonary embolism, septic shock, and mechanical ventilation were significantly higher among COVID-19 hospitalizations with AIS, compared to those without AIS. The odds of in-hospital mortality, DVT, pulmonary embolism, septic shock, mechanical ventilation, and respiratory failure were significantly higher among COVID-19 hospitalizations with AIS, compared to AIS hospitalizations without COVID-19. Although the prevalence of AIS was low among COVID-19 hospitalizations, it was associated with higher mortality and greater rates of discharges to destinations other than home.

SPIN-01 RADIATION THERAPY ALONE VERSUS RADIATION THERAPY PLUS RADIOFREQUENCY ABLATION/VERTEBRAL AUGMENTATION FOR SPINE METASTASIS: TRIAL IN PROGRESS

BACKGROUND

Spine metastases are a common occurrence in cancer patients and result in pain, neurologic deficits, decline in performance status, disability, inferior quality of life (QOL), and reduction in ability to receive cancer-directed therapies. Conventional external beam radiation therapy (EBRT) is associated with modest rates of pain relief, high rates of disease recurrence, low response rates for those with radioresistant histologies, and limited improvement in neurologic deficits. The addition of radiofrequency ablation/percutaneous vertebral augmentation (RFA/PVA) to index sites together with EBRT may improve pain response rates and corresponding quality of life.

METHODS/DESIGN

This is a single-center, prospective, randomized, controlled trial in patients with spine metastases from T5-L5, stratified according to tumor type (radioresistant vs. radiosensitive) in which patients in each stratum are randomized in a 2:1 ratio to either RFA/PVA and EBRT or EBRT alone. All patients are treated with EBRT to a dose of 20-30 Gy in 5-10 fractions. The target parameters are measured and recorded at the baseline clinic visit, and daily at home with collection of weekly measurements at 1, 2, and 3 weeks after treatment, and at 3, 6, 12, and 24 months following treatment with imaging and QOL assessments.

DISCUSSION

The primary objective of this randomized trial is to determine whether RFA/PVA in addition to EBRT improves pain control compared to palliative EBRT alone for patients with spine metastases, defined as complete or partial pain relief (measured using the Numerical Rating Pain Scale [NRPS]) at 3 months. Secondary objectives include determining whether combined modality treatment improves the rapidity of pain response, duration of pain response, patient reported pain impact, health utility, and overall QOL. The results from this study will be used to allow for comparisons to alternative treatment approaches. This trial was activated 5/2020 and is open to accrual.

Management and Outcomes of ST-Segment Elevation Myocardial Infarction in Hospitalized Frail Patients in the United States

Cardiovascular diseases and frailty are common conditions of aging populations and often coexist. In this study, we examined the in-hospital management, outcomes, and resource use of frail patients hospitalized for ST-segment elevation myocardial infarction (STEMI). This was a retrospective analysis of the 2005-2014 data from the Nationwide Inpatient Sample. Patients were classified into to versus 'nonfrail' using the Johns Hopkins Adjusted Clinical Groups frailty-defining diagnosis indicator. The primary outcome was STEMI management, whereas secondary outcomes were in-hospital mortality, length of stay, and cost. Outcomes were compared between frail and nonfrail patients using propensity score-matched analysis. There were 1,360,597 STEMI hospitalizations, of which 36,316 (2.7%) were frail. Propensity score-matched analysis showed that in in-hospital management options for STEMI, the odds of overall revascularization (odds ratio [OR], 0.60; 95% confidence interval [CI], 0.55 to 0.65), percutaneous coronary intervention (OR, 0.53; 95% CI, 0.49 to 0.57), and coronary angiography (OR, 0.59; 95% CI, 0.55 to 0.64) were significantly lower for frail patients. The odds of receiving coronary artery bypass grafting (OR, 1.66; 95% CI, 1.48 to 1.86) and overall hemodynamic support (OR, 1.26; 95% CI, 1.15 to 1.39) were significantly higher for frail patients. In-hospital mortality (18.7% vs 8.2%, p <0.001), length of stay (7.7 vs 3.7 days, p <0.001) and costs ($90,060 vs $63,507, p <0.001) were significantly higher in frail patients. Our findings suggest that collaborative efforts by cardiologists and cardiovascular surgeons for identifying frailty in patients with STEMI and incorporating frailty in risk estimation measures may improve management strategies, resource use and optimize patient outcomes.

Impact of Frailty on Hospital Outcomes Among Patients with Lymphoid Malignancies Receiving Autologous Hematopoietic Stem Cell Transplantation in the United States

BACKGROUND

Frailty could affect outcomes of autologous hematopoietic stem cell transplantation (aHSCT). This study sought to examine the effects of frailty on hospital outcomes among patients with non-Hodgkin lymphoma (NHL), Hodgkin lymphoma (HL), and multiple myeloma (MM) who received aHSCT.

MATERIALS AND METHODS

This study was a retrospective analysis of Nationwide Inpatient Sample database, 2005 to 2014. Outcome variables were in-hospital mortality, prolonged length of stay and hospitalization cost. Frail patients were defined using the Johns Hopkins Adjusted Clinical Groups frailty-defining diagnosis indicator.

RESULTS

There were 20,573 NHL, 8,974 HL, and 40,750 MM patients. Among them, 5.5% NHL, 3.8% HL, and 4.8% MM patients were frail. Among patients with NHL, there were significant associations between frailty and in-hospital mortality (Odds Ratio [OR], 4.04, 95% CI: 2.11-7.76), and prolonged length of stay (OR, 2.32, 95% CI: 1.56-3.46). Similarly, among HL, there were significant associations between frailty and in-hospital mortality (OR, 1.82, 95% CI: 1.43-2.76), and prolonged length of stay (OR, 1.55, 95% CI: 1.34-2.84). Likewise, for MM, there were significant associations between frailty and in-hospital mortality (OR, 4.28, 95% CI: 2.16-8.48), and prolonged length of stay (OR, 3.00, 95% CI: 2.00-4.51). These associations remained significant after stratifying by age and comorbidities. Significant differences were observed in hospitalization cost between frail and non-frail patients.

CONCLUSION

Among patients with lymphoid malignancies undergoing HSCT, frailty was associated with greater in-hospital mortality, longer length of stay, and higher hospitalization costs. Comprehensive health status assessments for identifying and managing frail patients in this population could improve patient outcomes.

Induction Chemotherapy and Ablative Stereotactic Magnetic Resonance Image-Guided Adaptive Radiation Therapy for Inoperable Pancreas Cancer

Background

Radiation therapy (RT) dose for inoperable pancreatic ductal adenocarcinoma (PDAC) has historically been non-ablative to avoid injuring gastrointestinal (GI) organs at risk (OARs). Accruing data suggest that dose escalation, in select patients, may significantly improve clinical outcomes. Early results of ablative stereotactic magnetic resonance image-guided adaptive radiation therapy (A-SMART) have been encouraging, although long-term outcomes are not well understood.

Methods

A single institution retrospective analysis was performed of inoperable non-metastatic PDAC patients who received induction chemotherapy then 5-fraction A-SMART on a 0.35T-MR Linac from 2018-2021.

Results

Sixty-two patients were evaluated with a median age of 66 years (range 35-91) and nearly all achieved Eastern Cooperative Oncology Group (ECOG) performance status 0-1 (96.8%). Locally advanced disease was common (72.6%), otherwise borderline resectable (22.6%), or medically inoperable (4.8%). All received induction chemotherapy for a median 4.2 months (range, 0.2-13.3) most commonly FOLFIRINOX (n=43; 69.4%). Median prescribed dose was 50 Gy (range 40-50); median biologically effective dose (BED₁₀) was 100 Gy₁₀. The median local control (LC), progression-free survival (PFS), and overall survival (OS) from diagnosis were not reached, 20 months, and 23 months, respectively. Also, 2-year LC, PFS, and OS were 68.8%, 40.0%, and 45.5%, respectively. Acute and late grade 3+ toxicity rates were 4.8% and 4.8%, respectively.

Conclusions

To our knowledge, this is the largest series of induction chemotherapy followed by ablative 5-fraction SMART delivered on an MR Linac for inoperable PDAC. The potential for this novel treatment strategy is to achieve long-term LC and OS, compared to chemotherapy alone, and warrants prospective evaluation.

Effect of frailty on hospital outcomes among patients with cancer in the United States: Results from the National Inpatient Sample

INTRODUCTION

To understand the effects of frailty on hospital outcomes such as in-hospital mortality, length of stay, and healthcare cost among patients with cancer using a nationally representative database.

MATERIALS AND METHODS

This study was a retrospective observational analysis of Nationwide Inpatient Sample (NIS) data collected during 2005-2014. Participants included adult patients with cancer ≥45 years identified by International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes. 'Frail' versus 'non-frail' hospitalizations were determined using the Johns Hopkins Adjusted Clinical Groups (ACG) frailty-defining diagnosis indicator. Main outcome measures were in-hospital mortality, hospital length of stay, and hospitalization cost. We defined prolonged length of stay as hospital stay ≥75th percentile of the study sample. Propensity score match analysis was done to examine whether frailty was associated with length of stay and in-hospital mortality.

RESULTS

There were 10,463,083 cancer hospitalizations during 2005-2014, of which 1,022,777 (9.8%) were frail. Patients having length of stay ≥8 days were significantly higher among frail group, compared to non-frail group (53.3% versus 25.3%, P < 0.001). Similarly, unadjusted mortality (12.0% versus 5.3%, P < 0.001) and hospitalization costs ($29,726 versus $18,595, P < 0.001) were significantly higher for frail patients. Nearly $28 billion was expended on hospitalization of frail patients with cancer during the study period. In propensity score match analysis, the odds of in-hospital mortality (odds ratio [OR], 1.54; 95% confidence interval [CI], 1.50-1.58) and length of stay (OR, 2.23; 95% CI, 2.18-2.27) were significantly greater for frail patients.

DISCUSSION

Frailty was associated with adverse hospital outcomes such as increased length of stay, mortality, and hospitalization cost among all cancer types. Our findings could be valuable for frailty-based risk stratification of patients with cancer. Concerted efforts by the physiatrists, oncologists, and surgeons towards identifying frailty and incorporating it in risk estimation measures could help in optimizing management strategies for cancer.

Pembrolizumab activity in patients with Fanconi anemia repair pathway competent and deficient tumors

Background

Given the observed antitumor activity of immune-checkpoint-inhibitors in patients with mismatch-repair deficient (MSI-H) tumors, we hypothesized that deficiency in homologous-recombination-repair (HRR) can also influence susceptibility.

Methods

Patients with disease progression on standard of care and for whom pembrolizumab had no FDA approved indication received pembrolizumab. Patients with MSI-H tumors were excluded. Objectives included immune-related objective response rate (iORR), progression-free survival (PFS) and 20-weeks-PFS. Pembrolizumab was given every 3 weeks and scans performed every six. We evaluated a triple-stain (FANCD2foci/DAPI/Ki67) functional assay of the Fanconi Anemia (FA) pathway: FATSI, in treated patients’ archived tumors. The two-stage sample size of 20/39 patients evaluated an expected iORR≥20% in the whole population vs. the null hypothesis of an iORR≤5%, based on an assumed iORR≥40% in patients with functional FA deficiency, and < 10% in patients with intact HRR. An expansion cohort of MSI stable endometrial cancer (MS-EC) followed. Exploratory stool microbiome analyses in selected patients were performed.

Results

Fifty-two patients (45F,7M;50-evaluable) were enrolled. For the 39 in the two-stage cohort, response evaluation showed 2CR,5PR,11SD,21PD (iORR-18%). FATSI tumor analyses showed 29 competent (+) and 10 deficient (−). 2PR,9SD,17PD,1NE occurred among the FATSI+ (iORR-7%) and 2CR,3PR,2SD,3PD among the FATSI(−) patients (iORR-50%). mPFS and 20w-PFS were 43 days and 21% in FATSI+, versus 202 days and 70% in FATSI(−) patients. One PR occurred in the MS-EC expansion cohort.

Conclusions

Pembrolizumab has meaningful antitumor activity in malignancies with no current FDA approved indications and FA functional deficiency. The results support further evaluation of FATSI as a discriminatory biomarker for population-selected studies.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40364-022-00386-0.

Dedicated isotropic 3-D T1 SPACE sequence imaging for radiosurgery planning improves brain metastases detection and reduces the risk of intracranial relapse

BACKGROUND

Stereotactic radiosurgery (SRS) is increasingly used for brain metastases (BM) patients, but distant intracranial failure (DIF) remains the principal disadvantage of this focal therapeutic approach. The objective of this study was to determine if dedicated SRS imaging would improve lesion detection and reduce DIF.

METHODS

Between 02/2020 and 01/2021, SRS patients at a tertiary care institution underwent dedicated treatment planning MRIs of the brain including MPRAGE and SPACE post-contrast sequences. DIF was calculated using the Kaplan-Meier method; comparisons were made to a historical consecutive cohort treated using MPRAGE alone (02/2019-01/2020).

RESULTS

134 patients underwent 171 SRS courses for 821 BM imaged with both MPRAGE and SPACE (primary cohort). MPRAGE sequence evaluation alone detected 679 lesions. With neuroradiologists evaluating SPACE and MPRAGE, an additional 108 lesions were identified (p<0.001). Upon multidisciplinary review, 34 additional lesions were identified. Compared to the historical cohort (103 patients, 135 SRS courses, 479 BM), the primary cohort had improved median time to DIF (13.5 vs. 5.1 months, p=0.004). The benefit was even more pronounced for patients treated for their first SRS course (18.4 vs. 6.3 months, p=0.001). SRS using MPRAGE and SPACE was associated with a 60% reduction in risk of DIF compared to the historical cohort (HR: 0.40; 95%CI: 0.28-0.57, p<0.001).

CONCLUSIONS

Among BM patients treated with SRS, a treatment planning SPACE sequence in addition to MPRAGE substantially improved lesion detection and was associated with a statistically significant and clinically meaningful prolongation in time to DIF, especially for patients undergoing their first SRS course.

Abstract 52: Application Of Machine Learning In Predicting Clinical Adverse Events After Transcatheter Aortic Valve Replacement Procedure: Insights From A Systematic Review And Meta-analysis Of Studies

Objective: Identifying patients at high risk of AE after TAVR is essential to prolong their survival. Current prediction models for AE after TAVR suffer from a lack of accuracy and external validation. Modern ML approaches can account for higher-dimensional relationships among variables, potentially improving the prediction of outcomes. We performed a systematic review and meta-analysis to estimate the discriminative ability of recently developed ML-based models, which predict various AE after TAVR.

Methods: We searched Pubmed, Google Scholar, and Web of Science for studies (Jan 2019 to Jan 2022) that used ML approaches to predict AE after TAVR. Inputs in the meta-analysis were study-reported c-index values and 95% CI. Subgroup analyses separated models by outcome (mortality or clinical AE). Combined effect sizes using a random-effects model, test for heterogeneity, and Egger’s test to assess publication bias were considered.

Results: Eight studies were included in the systematic review (patients = 26,023; outcomes = 1,014), of which five models had sufficient data for the meta-analysis. The number of features included in each model ranged from 6 to 107. The two most common models were random forest (n=2) and logistic regression (n=2). The most common outcome was mortality (n=5). The meta-analysis showed that models predicting mortality performed better (0.90; 95% CI: 0.81, 1.01) than models predicting clinical AE (0.80; 95% CI: 0.79, 0.95). The combined mean c-index was 0.87 (95% CI: 0.79-0.95). Test of heterogeneity showed high variation among studies ( I 2 =98.5%). Egger’s test did not indicate publication bias ( β = 1.48; 95% CI: –18.14, 21.09, p = 0.848).

Conclusion: Although relatively few studies have applied ML for predicting AE after TAVR, the results are very promising. The time of complex sophisticated models has arrived with improved predictive accuracy through advanced ML methods able to help identify patients who are at risk for clinical AE early in their care.

Abstract 263: Insights From Meta-analysis Of Studies Using Machine Learning To Predict Mortality Or Acute Kidney Injury After Coronary Artery Bypass Graft

Objective: Machine learning (ML) may enhance prediction of outcomes such as mortality or acute kidney injury (AKI) among cardiac patients after coronary artery bypass graft (CABG). In this study, we used meta-analyses of reported ML models to assess what ML has been able to accomplish in this field, by evaluating the model performance in studies with CABG patients.

Methods: We performed a literature search using Google Scholar and included studies that reported AUC and 95% CI for various models in our analysis. In addition, total participants, year of publication, type of analytical method (gradient boosting, random forest, etc.) and type of outcome (mortality or AKI) were extracted. We combined effect sizes using random effects model, and tested for heterogeneity, and publication bias.

Results: 5 models from 5 studies were included in the analysis (patients= 35,152; with outcome mortality =3,080, AKI=933). Combined mean AUC was 0.796 (95% CI: 0.776, 0.815). Test of heterogeneity showed high variation between studies (I 2 = 66.7%). Egger’s test intercept was -1.03 (95% CI: -7.22, 5.17, p > .25) indicating no small study bias. Meta regression showed newer publications had a positive association ( coef = 0.003) and number of variables in the study had a negative association with higher AUC values ( coef = -0.0002). In subgroup analysis, the pooled AUC values for mortality and AKI groups were 0.795 and 0.805 respectively. The highest individual AUC was from ensemble model predicting AKI with AUC 0.84 and lowest was from gradient boosting model predicting mortality with AUC 0.77.

Conclusion: Among the presented models for CABG ensemble methods performed well, but surprisingly methods with lesser number of variables tended to have higher predictive power. In near future, ML-based models may form the basis to build intelligent decision support systems for patient selection and risk stratification prior to CABG and could be applied to other cardiac surgeries.

Abstract 156: Insights From Meta-analysis Of Studies Using Machine Learning To Predict Mortality, Readmission, Or Other Outcomes Among Heart Failure Patients

Developing and implementing analytical models for predicting mortality or readmission related outcomes among heart failure (HF) patients are challenging. In this study, we used meta-analyses of reported predictive models to assess what machine learning (ML) has been able to accomplish in this field, by evaluating the ML model performance for studies in HF.

We performed a literature search using Google Scholar, Web of Science and PubMed. The studies reporting AUC and 95% CI for various models were included. In addition, total participants, year of publication, type of analytical method (logistic regression, RF, etc.) and type of outcome (mortality, readmission, etc.) were extracted. We combined effect sizes using random effects (RF) model, and tested for heterogeneity, and publication bias.

12 studies were included in the analysis (patients= 123,832; AUC=15, with outcome mortality =17,471, readmission=15,703, hospitalization=67,523). Combined mean AUC was 0.77 (95% CI: 0.72, 0.82). Test of heterogeneity showed high variation between studies (I2=98.9%). Egger’s test intercept was 5.2 (95% CI: -4.2, 14.7, p > .25) indicating no small study effects/bias. Meta regression showed newer publications provide better AUC values (p < 0.03). In subgroup analysis, the pooled AUC for readmission, hospitalization, and mortality groups were 0.71, 0.80, and 0.78 respectively. The highest individual AUC was from neural networks (NN) predicting hospitalization with AUC 0.96 and lowest was from RF predicting readmission with AUC 0.65.

Presented models were diverse, ranking in quality from fair to very good, and being varied for different clinical outcomes among HF patients. Situation known from studies using classical statistical methods holds also for methods using ML, with better predictive values for hospitalizations, and lower for other outcomes. Methods using NN and methods using higher numbers of variables performed very well and had highest predictive power.

Obstetric outcomes during delivery hospitalizations among obese pregnant women in the United States

The rates of both maternal and fetal adverse outcomes increase significantly with higher body mass index. The aim of this study was to calculate national estimates of adverse maternal and fetal outcomes and associated hospitalization cost among obese pregnant women using a national database. This study was a retrospective analysis of data retrieved from Nationwide Inpatient Sample database, collected during 2010–2014. The primary outcomes of this study were adverse maternal and fetal outcomes, hospital length of stay, and hospitalization cost. There was a total of 18,687,217 delivery-related hospitalizations, of which 1,048,323 were among obese women. Obese women were more likely to have cesarean deliveries (aOR 1.70, 95% CI 1.62–1.79) and labor inductions (aOR 1.51, 95% CI 1.42–1.60), greater length of stay after cesarean deliveries (aOR 1.14, 95% CI 1.08–1.36) and vaginal deliveries (aOR 1.48, 95% CI 1.23–1.77). They were also more likely to have pregnancy-related hypertension, preeclampsia, gestational diabetes, premature rupture of membranes, chorioamnionitis, venous thromboembolism, excessive fetal growth, and fetal distress. Obese pregnant women had significantly greater risk for adverse obstetrical outcomes, which substantially increased the hospital and economic burden. Risk stratification of pregnant patients based on obesity could also help obstetricians to make better clinical decisions and improve patient outcomes.

Multi-Institutional Outcomes of Stereotactic Magnetic Resonance Image-Guided Adaptive Radiation Therapy (SMART) with a Median Biologically Effective Dose of 100 Gy10 for Non-Bone Oligometastases

Purpose

Randomized data show a survival benefit of stereotactic ablative body radiation therapy in selected patients with oligometastases (OM). Stereotactic magnetic resonance guided adaptive radiation therapy (SMART) may facilitate the delivery of ablative dose for OM lesions, especially those adjacent to historically dose-limiting organs at risk, where conventional approaches preclude ablative dosing.

Methods and Materials

The RSSearch Registry was queried for OM patients (1-5 metastatic lesions) treated with SMART. Freedom from local progression (FFLP), freedom from distant progression (FFDP), progression-free survival (PFS), and overall survival (LS) were estimated using the Kaplan-Meier method. FFLP was evaluated using RECIST 1.1 criteria. Toxicity was evaluated using Common Terminology Criteria for Adverse Events version 4 criteria.

Results

Ninety-six patients with 108 OM lesions were treated on a 0.35 T MR Linac at 2 institutions between 2018 and 2020. SMART was delivered to mostly abdominal or pelvic lymph nodes (48.1%), lung (18.5%), liver and intrahepatic bile ducts (16.7%), and adrenal gland (11.1%). The median prescribed radiation therapy dose was 48.5 Gy (range, 30-60 Gy) in 5 fractions (range, 3-15). The median biologically effective dose corrected using an alpha/beta value of 10 was 100 Gy₁₀ (range, 48-180). No acute or late grade 3+ toxicities were observed with median 10 months (range, 3-25) follow-up. Estimated 1-year FFLP, FFDP, PFS, and OS were 92.3%, 41.1%, 39.3%, and 89.6%, respectively. Median FFDP and PFS were 8.9 months (95% confidence interval, 5.2-12.6 months) and 7.6 months (95% confidence interval, 4.5-10.6 months), respectively.

Conclusions

To our knowledge, this represents the largest analysis of SMART using ablative dosing for non-bone OM. A median prescribed biologically effective dose of 100 Gy₁₀ resulted in excellent early FFLP and no significant toxicity, likely facilitated by continuous intrafraction MR visualization, breath hold delivery, and online adaptive replanning. Additional prospective evaluation of dose-escalated SMART for OM is warranted.

A Brief Overview of Adaptive Designs for Phase I Cancer Trials

Simple Summary

Phase I cancer trials are important for new drug developments to test the safety and optimal dosage of cancer drugs which are usually toxic. Understanding biostatistical methodologies of these designs is important for developing phase I studies that are both safe for the participants and which use optimal dosages for better outcomes. Currently there are several phase I designs that are being refined and modified for better outcomes and newer designs are being continuously developed. In this review article, we described several important phase I study designs to provide a brief overview of existing methods. Our review could be helpful to the research community who intent to have a better and yet a concise summary of existing methods.

Abstract

Phase I studies are used to estimate the dose-toxicity profile of the drugs and to select appropriate doses for successive studies. However, literature on statistical methods used for phase I studies are extensive. The objective of this review is to provide a concise summary of existing and emerging techniques for selecting dosages that are appropriate for phase I cancer trials. Many advanced statistical studies have proposed novel and robust methods for adaptive designs that have shown significant advantages over conventional dose finding methods. An increasing number of phase I cancer trials use adaptive designs, particularly during the early phases of the study. In this review, we described nonparametric and algorithm-based designs such as traditional 3 + 3, accelerated titration, Bayesian algorithm-based design, up-and-down design, and isotonic design. In addition, we also described parametric model-based designs such as continual reassessment method, escalation with overdose control, and Bayesian decision theoretic and optimal design. Ongoing studies have been continuously focusing on improving and refining the existing models as well as developing newer methods. This study would help readers to assimilate core concepts and compare different phase I statistical methods under one banner. Nevertheless, other evolving methods require future reviews.

Dose-Escalated Magnetic Resonance Image–Guided Abdominopelvic Reirradiation With Continuous Intrafraction Visualization, Soft Tissue Tracking, and Automatic Beam Gating

Purpose

Methods and Materials

Results

Conclusions