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Eriksson M, Hayat R, Kinsella E, Lewis K, White DCS, Boyd J, Bullen A, Maclean M, Stoddart A, Phair S, Evans H, Noakes J, Alexander D, Keerie C, Linsley C, Milne G, Norrie J, Farrar N, Realpe AX, Donovan JL, Bunch J, Douthwaite K, Temple S, Hogg J, Scott D, Spallone P, Stuart I, Wardlaw JM, Palmer J, Sakka E, Mukerji N, Cirstea E, Davies S, Giannakaki V, Kadhim A, Kennion O, Islam M, Ferguson L, Prasad M, Bacon A, Richards E, Howe J, Kamara C, Gardner J, Roman M, Sikaonga M, Cahill J, Rossdeutsch A, Cahill V, Hamina I, Chaudhari K, Danciut M, Clarkson E, Bjornson A, Bulters D, Digpal R, Ruiz W, Taylor M, Anyog D, Tluchowska K, Nolasco J, Brooks D, Angelopoulou K, Welch B, Broomes N, Fouyas I, MacRaild A, Kaliaperumal C, Teasdale J, Coakley M, Brennan P, Sokol D, Wiggins A, MacDonald M, Risbridger S, Bhatt P, Irvine J, Majeed S, Williams S, Reid J, Walch A, Muir F, van Beijnum J, Leach P, Hughes T, Makwana M, Hamandi K, McAleer D, Gunning B, Walsh D, Wroe Wright O, Patel S, Gurusinghe N, Raza-Knight S, Cromie TL, Brown A, Raj S, Pennington R, Campbell C, Patel S, Colombo F, Teo M, Wildman J, Smith K, Goff E, Stephens D, Borislavova B, Worner R, Buddha S, Clatworthy P, Edwards R, Clayton E, Coy K, Tucker L, Dymond S, Mallick A, Hodnett R, Spickett-Jones F, Grover P, Banaras A, Tshuma S, Muirhead W, Scott Hill C, Shah R, Doke T, Hall R, Coskuner S, Aslett L, Vindlacheruvu R, Ghosh A, Fitzpatrick T, Harris L, Hayton T, Whitehouse A, McDarby A, Hancox R, Auyeung CK, Nair R, Thomas R, McLachlan H, Kountourgioti A, Orjales G, Kruczynski J, Hunter S, Bohnacker N, Marimon R, Parker L, Raha O, Sharma P, Uff C, Boyapati G, Papadopoulos M, Kearney S, Visagan R, Bosetta E, Asif H, Helmy A, Chapas L, Tarantino S, Caldwell K, Guilfoyle M, Agarwal S, Brown D, Holland S, Tajsic T, Fletcher C, Sebyatki A, Ushewokunze S, Ali S, Preston J, Chambers C, Patel M, Holsgrove D, McLaughlan D, Marsden T, Colombo F, Cawley K, Raffalli H, Lee S, Israni A, Dore R, Anderson T, Hennigan D, Mayor S, Glover S, Chavredakis E, Brown D, Sokratous G, Williamson J, Stoneley C, Brodbelt A, Farah JO, Illingworth S, Konteas AB, Davies D, Owen C, Kerr L, Hall P, Al-Shahi Salman R, Forsyth L, Lewis SC, Loan JJM, Neilson AR, Stephen J, Kitchen N, Harkness KA, Hutchinson PJA, Mallucci C, Wade J, White PM. Medical management and surgery versus medical management alone for symptomatic cerebral cavernous malformation (CARE): a feasibility study and randomised, open, pragmatic, pilot phase trial. Lancet Neurol 2024:S1474-4422(24)00096-6. [PMID: 38643777 DOI: 10.1016/s1474-4422(24)00096-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2024] [Revised: 03/01/2024] [Accepted: 03/04/2024] [Indexed: 04/23/2024]
Abstract
BACKGROUND The highest priority uncertainty for people with symptomatic cerebral cavernous malformation is whether to have medical management and surgery or medical management alone. We conducted a pilot phase randomised controlled trial to assess the feasibility of addressing this uncertainty in a definitive trial. METHODS The CARE pilot trial was a prospective, randomised, open-label, assessor-blinded, parallel-group trial at neuroscience centres in the UK and Ireland. We aimed to recruit 60 people of any age, sex, and ethnicity who had mental capacity, were resident in the UK or Ireland, and had a symptomatic cerebral cavernous malformation. Computerised, web-based randomisation assigned participants (1:1) to medical management and surgery (neurosurgical resection or stereotactic radiosurgery) or medical management alone, stratified by the neurosurgeon's and participant's consensus about the intended type of surgery before randomisation. Assignment was open to investigators, participants, and carers, but not clinical outcome event adjudicators. Feasibility outcomes included site engagement, recruitment, choice of surgical management, retention, adherence, data quality, clinical outcome event rate, and protocol implementation. The primary clinical outcome was symptomatic intracranial haemorrhage or new persistent or progressive non-haemorrhagic focal neurological deficit due to cerebral cavernous malformation or surgery during at least 6 months of follow-up. We analysed data from all randomly assigned participants according to assigned management. This trial is registered with ISRCTN (ISRCTN41647111) and has been completed. FINDINGS Between Sept 27, 2021, and April 28, 2023, 28 (70%) of 40 sites took part, at which investigators screened 511 patients, of whom 322 (63%) were eligible, 202 were approached for recruitment, and 96 had collective uncertainty with their neurosurgeon about whether to have surgery for a symptomatic cerebral cavernous malformation. 72 (22%) of 322 eligible patients were randomly assigned (mean recruitment rate 0·2 [SD 0·25] participants per site per month) at a median of 287 (IQR 67-591) days since the most recent symptomatic presentation. Participants' median age was 50·6 (IQR 38·6-59·2) years, 68 (94%) of 72 participants were adults, 41 (57%) were female, 66 (92%) were White, 56 (78%) had a previous intracranial haemorrhage, and 28 (39%) had a previous epileptic seizure. The intended type of surgery before randomisation was neurosurgical resection for 19 (26%) of 72, stereotactic radiosurgery for 44 (61%), and no preference for nine (13%). Baseline clinical and imaging data were complete for all participants. 36 participants were randomly assigned to medical management and surgery (12 to neurosurgical resection and 24 to stereotactic radiosurgery) and 36 to medical management alone. Three (4%) of 72 participants withdrew, one was lost to follow-up, and one declined face-to-face follow-up, leaving 67 (93%) retained at 6-months' clinical follow-up. 61 (91%) of 67 participants with follow-up adhered to the assigned management strategy. The primary clinical outcome occurred in two (6%) of 33 participants randomly assigned to medical management and surgery (8·0%, 95% CI 2·0-32·1 per year) and in two (6%) of 34 participants randomly assigned to medical management alone (7·5%, 1·9-30·1 per year). Investigators reported no deaths, no serious adverse events, one protocol violation, and 61 protocol deviations. INTERPRETATION This pilot phase trial exceeded its recruitment target, but a definitive trial will require extensive international engagement. FUNDING National Institute for Health and Care Research.
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Phillips I, Deans M, Walton A, Vallet M, Mencnarowksi J, McMillan D, Peacock C, Hall P, O'Brien F, Stares M, Mackean M, Plant T, Grecian R, Allan L, Petrie R, Blues D, Haddad S, Barrie C. Early prehabilitation reduces admissions and time in hospital in patients with newly diagnosed lung cancer. BMJ Support Palliat Care 2024:spcare-2024-004869. [PMID: 38631891 DOI: 10.1136/spcare-2024-004869] [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: 03/07/2024] [Accepted: 03/12/2024] [Indexed: 04/19/2024]
Abstract
OBJECTIVES Lung cancer is the leading cause of cancer death in the UK. Prehabilitation aims to maximise patient fitness and minimise the negative impact of anticancer treatment. What constitutes prehabilitation before non-surgical anticancer treatment is not well established. We present data from a pilot project of Early prehabilitation In lung Cancer. METHODS All new patients with likely advanced lung cancer were offered prehabilitation at respiratory clinic, if fit for further investigation. Prehabilitation included assessment and appropriate intervention from a consultant in palliative medicine, registered dietitian and rehabilitation physiotherapist. Four objective endpoints were identified, namely admissions to hospital, time spent in the hospital, treatment rates and overall survival. Outcomes were to be compared with 178 prehab eligible historical controls diagnosed from 2019 to 2021. RESULTS From July 2021 to June 2023, 65 patients underwent prehabilitation and 72% of patients underwent all 3 interventions. 54 patients had a stage 3 or 4 lung cancer. In the prehab group, fewer patients attended Accident and Emergency (31.5 vs 37.4 attendances per 100 patients) and fewer were admitted (51.9 vs 67.9) when compared with historical controls. Those receiving prehab spent a lot less time in the hospital (129.7 vs 543.5 days per 100 patients) with shorter admissions (2.5 vs 8 days). Systemic anticancer treatment rates increased in the short term but were broadly similar overall. Median survival was higher in the prehabilitation group (0.73 vs 0.41 years, p=0.046). CONCLUSIONS Early prehabilitation appears to reduce time spent in the hospital. It may improve survival. Further work is required to understand its full effect on treatment rates.
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Affiliation(s)
- Iain Phillips
- Edinburgh Cancer Centre, Western General Hospital, Edinburgh, Scotland, UK
- Edinburgh University, Edinburgh, UK
| | - Maria Deans
- Cancer Information Team, Western General Hospital, Edinburgh, UK
| | - Abi Walton
- Edinburgh Cancer Centre, Western General Hospital, Edinburgh, Scotland, UK
- St Johns Hospital, Livingston, UK
| | | | | | | | | | | | | | | | - Melanie Mackean
- Edinburgh Cancer Centre, Western General Hospital, Edinburgh, Scotland, UK
| | | | | | - Lindsey Allan
- Department of Nutrition and Dietetics, Royal Surrey County Hospital NHS Foundation Trust, Guildford, UK
| | - Rebecca Petrie
- Edinburgh Cancer Centre, Western General Hospital, Edinburgh, Scotland, UK
| | - Duncan Blues
- Edinburgh Cancer Centre, Western General Hospital, Edinburgh, Scotland, UK
| | - Suraiya Haddad
- Edinburgh Cancer Centre, Western General Hospital, Edinburgh, Scotland, UK
| | - Colin Barrie
- Edinburgh Cancer Centre, Western General Hospital, Edinburgh, Scotland, UK
- St Johns Hospital, Livingston, UK
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Coakley M, Villacampa G, Sritharan P, Swift C, Dunne K, Kilburn L, Goddard K, Pipinikas C, Rojas P, Emmett W, Hall P, Harper-Wynne C, Hickish T, Macpherson I, Okines A, Wardley A, Wheatley D, Waters S, Palmieri C, Winter M, Cutts RJ, Garcia-Murillas I, Bliss J, Turner NC. Comparison of Circulating Tumor DNA Assays for Molecular Residual Disease Detection in Early-Stage Triple-Negative Breast Cancer. Clin Cancer Res 2024; 30:895-903. [PMID: 38078899 PMCID: PMC10870111 DOI: 10.1158/1078-0432.ccr-23-2326] [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: 08/11/2023] [Revised: 10/16/2023] [Accepted: 12/06/2023] [Indexed: 02/17/2024]
Abstract
PURPOSE Detection of circulating tumor DNA (ctDNA) in patients who have completed treatment for early-stage breast cancer is associated with a high risk of relapse, yet the optimal assay for ctDNA detection is unknown. EXPERIMENTAL DESIGN The cTRAK-TN clinical trial prospectively used tumor-informed digital PCR (dPCR) assays for ctDNA molecular residual disease (MRD) detection in early-stage triple-negative breast cancer. We compared tumor-informed dPCR assays with tumor-informed personalized multimutation sequencing assays in 141 patients from cTRAK-TN. RESULTS MRD was first detected by personalized sequencing in 47.9% of patients, 0% first detected by dPCR, and 52.1% with both assays simultaneously (P < 0.001; Fisher exact test). The median lead time from ctDNA detection to relapse was 6.1 months with personalized sequencing and 3.9 months with dPCR (P = 0.004, mixed-effects Cox model). Detection of MRD at the first time point was associated with a shorter time to relapse compared with detection at subsequent time points (median lead time 4.2 vs. 7.1 months; P = 0.02). CONCLUSIONS Personalized multimutation sequencing assays have potential clinically important improvements in clinical outcome in the early detection of MRD.
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Affiliation(s)
- Maria Coakley
- Breast Cancer Now Research Centre, The Institute of Cancer Research, London, United Kingdom
| | - Guillermo Villacampa
- Clinical Trials and Statistics Unit, The Institute of Cancer Research, London, United Kingdom
| | - Prithika Sritharan
- Breast Cancer Now Research Centre, The Institute of Cancer Research, London, United Kingdom
| | - Claire Swift
- Ralph Lauren Centre for Breast Cancer Research, London, United Kingdom
| | - Kathryn Dunne
- Ralph Lauren Centre for Breast Cancer Research, London, United Kingdom
| | - Lucy Kilburn
- Clinical Trials and Statistics Unit, The Institute of Cancer Research, London, United Kingdom
| | - Katie Goddard
- Clinical Trials and Statistics Unit, The Institute of Cancer Research, London, United Kingdom
| | | | - Patricia Rojas
- NeoGenomics Ltd, Glenn Berge Building, Babraham Research Park, Cambridge, United Kingdom
| | - Warren Emmett
- NeoGenomics Ltd, Glenn Berge Building, Babraham Research Park, Cambridge, United Kingdom
| | - Peter Hall
- University of Edinburgh, Edinburgh, United Kingdom
| | | | - Tamas Hickish
- University Hospitals Dorset NHS Foundation Trust, Bournemouth, United Kingdom
| | | | - Alicia Okines
- Breast Unit, Royal Marsden Hospital, London, United Kingdom
| | - Andrew Wardley
- Outreach Research & Innovation Group Ltd, Manchester, United Kingdom
| | | | - Simon Waters
- Velindre Cancer Centre, Velindre University NHS Trust, Cardiff, United Kingdom
| | - Carlo Palmieri
- Clatterbridge Cancer Centre NHS Foundation Trust, Liverpool, United Kingdom
| | - Matthew Winter
- Weston Park Cancer Centre, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, United Kingdom
| | - Rosalind J. Cutts
- Breast Cancer Now Research Centre, The Institute of Cancer Research, London, United Kingdom
| | - Isaac Garcia-Murillas
- Breast Cancer Now Research Centre, The Institute of Cancer Research, London, United Kingdom
| | - Judith Bliss
- Clinical Trials and Statistics Unit, The Institute of Cancer Research, London, United Kingdom
| | - Nicholas C. Turner
- Breast Cancer Now Research Centre, The Institute of Cancer Research, London, United Kingdom
- Ralph Lauren Centre for Breast Cancer Research, London, United Kingdom
- Breast Unit, Royal Marsden Hospital, London, United Kingdom
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Diernberger K, Clausen E, Murray G, Wee B, Kaasa S, Hall P, Fallon M. Cancer pain assessment and management: does an institutional approach individualise and reduce cost of care? BMJ Support Palliat Care 2024; 13:e1258-e1264. [PMID: 37236649 PMCID: PMC10850828 DOI: 10.1136/spcare-2022-003547] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Accepted: 01/13/2023] [Indexed: 05/28/2023]
Abstract
OBJECTIVES To understand individual prescribing and associated costs in patients managed with the Edinburgh Pain Assessment and management Tool (EPAT). METHODS The EPAT study was a two-arm parallel group cluster randomised (1:1) trial, including 19 UK cancer centres. Study outcome assessments, including pain levels, analgesia and non-pharmacological and anaesthetic interventions, collected at baseline, 3-5 days and, if applicable, 7-10 days after admission. Costs calculated for inpatient length of stay (LoS), medications and complex pain interventions. Analysis accounted for the clustered nature of the trial design. In this post-hoc analysis, healthcare utilisation and costs are presented descriptively. PARTICIPANTS 10 centres randomised to EPAT (487 patients) and 9 (449 patients) to usual care (UC). MAIN OUTCOME MEASURES Pharmacological and non-pharmacological management, complex pain interventions, length of hospital stay and costs related to these outcomes. RESULTS The mean per patient hospital cost was £3866 with EPAT and £4194 with UC, reflecting a mean LoS of 2.9 days and 3.1 days, respectively. Costs were lower for non-opioids, Non-steroidal anti-inflammatories (NSAIDs) and opioids but slightly higher for adjuvants with EPAT than with UC. The mean per-patient opioid costs were £17.90 (EPAT) and £25.80 (UC). Mean per patient costs of all medication were £36 (EPAT) and £40 (UC).Complex pain intervention costs were £117 with EPAT per patient and £90 with UC. Overall mean cost per patient was £4018.3 (95% CI 3698.9 to 4337.8) with EPAT and £4323.8 (95% CI 4060.0 to 4587.7) with UC. CONCLUSIONS EPAT facilitated personalised medicine and may result in less opioids, more specific treatments, improved pain outcomes and cost savings.
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Affiliation(s)
| | - Eleanor Clausen
- The International Spine Centre, Adelaide, South Australia, Australia
| | - Gordon Murray
- Public Health Sciences, University of Edinburgh, Edinburgh, UK
| | - Bee Wee
- University of Oxford, Oxford, UK
| | - Stein Kaasa
- University of Oslo Faculty of Medicine, Oslo, Norway
| | - Peter Hall
- University of Edinburgh Western General Hospital, Edinburgh, UK
| | - Marie Fallon
- Department of Palliative Medicine, Western General Hospital, University of Edinburgh, Edinburgh, UK
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Phillips I, Petrie R, Allan L, Hall P, Walton A, McMillan D, Peacock C, Primrose L, Vallet M, Mencnarowksi J, MacDonald N, Mackean M, Barrie C. Early prehabilitation in suspected locally advanced and metastatic lung cancer. BMJ Support Palliat Care 2024; 13:e908-e911. [PMID: 37495261 DOI: 10.1136/spcare-2023-004349] [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: 05/01/2023] [Accepted: 07/03/2023] [Indexed: 07/28/2023]
Abstract
OBJECTIVES The most common treatment for locally advanced and metastatic lung cancer is best supportive care. Patients with lung cancer are often comorbid with a high symptom burden. We wanted to assess whether early prehabilitation was feasible in patients with likely lung cancer. METHODS Patients were offered prehabilitation if they were attending the new patient respiratory clinic, had a CT scan suggesting stage III or IV lung cancer and undergoing further investigations. Patients receiving palliative care were ineligible. All prehabilitation patients were referred to a palliative medicine physician, registered dietitian and rehabilitation physiotherapist. RESULTS 50 patients underwent prehabilitation between June 2021 and August 2022. The median age was 72 years (range 54-89 years). 48 patients had lung cancer. 84% of patients attended all three interventions.Half of the palliative care consultations focused on pain. Half of the patients seen had a change in medication. 25% of patients' weights were stable, 32% required a food-first strategy and 33% required oral nutritional supplements. 57% of patients discussed managing breathlessness with the physiotherapist. CONCLUSIONS Early prehabilitation is feasible alongside the investigation of locally advanced and metastatic lung cancer. Further work will aim to assess its impact on admission to the hospital, survival and treatment rates.
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Affiliation(s)
- Iain Phillips
- Edinburgh Cancer Centre, Western General Hospital, Edinburgh, UK
| | - Rebecca Petrie
- Edinburgh Cancer Centre, Western General Hospital, Edinburgh, UK
| | - Lindsey Allan
- Department of Nutrition and Dietetics, Royal Surrey County Hospital NHS Foundation Trust, Guildford, UK
| | - Peter Hall
- Edinburgh Cancer Centre, Western General Hospital, Edinburgh, UK
| | - Abi Walton
- Oncology department, St Johns Hospital, Livingston, UK
| | | | | | | | - Mahéva Vallet
- Edinburgh Cancer Centre, Western General Hospital, Edinburgh, UK
| | | | | | - Melanie Mackean
- Edinburgh Cancer Centre, Western General Hospital, Edinburgh, UK
| | - Colin Barrie
- Edinburgh Cancer Centre, Western General Hospital, Edinburgh, UK
- Oncology department, St Johns Hospital, Livingston, UK
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Davey-Young J, Hasan F, Tennakoon R, Rozik P, Moore H, Hall P, Cozma E, Genereaux J, Hoffman KS, Chan PP, Lowe TM, Brandl CJ, O’Donoghue P. Mistranslating the genetic code with leucine in yeast and mammalian cells. RNA Biol 2024; 21:1-23. [PMID: 38629491 PMCID: PMC11028032 DOI: 10.1080/15476286.2024.2340297] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/03/2024] [Indexed: 04/19/2024] Open
Abstract
Translation fidelity relies on accurate aminoacylation of transfer RNAs (tRNAs) by aminoacyl-tRNA synthetases (AARSs). AARSs specific for alanine (Ala), leucine (Leu), serine, and pyrrolysine do not recognize the anticodon bases. Single nucleotide anticodon variants in their cognate tRNAs can lead to mistranslation. Human genomes include both rare and more common mistranslating tRNA variants. We investigated three rare human tRNALeu variants that mis-incorporate Leu at phenylalanine or tryptophan codons. Expression of each tRNALeu anticodon variant in neuroblastoma cells caused defects in fluorescent protein production without significantly increased cytotoxicity under normal conditions or in the context of proteasome inhibition. Using tRNA sequencing and mass spectrometry we confirmed that each tRNALeu variant was expressed and generated mistranslation with Leu. To probe the flexibility of the entire genetic code towards Leu mis-incorporation, we created 64 yeast strains to express all possible tRNALeu anticodon variants in a doxycycline-inducible system. While some variants showed mild or no growth defects, many anticodon variants, enriched with G/C at positions 35 and 36, including those replacing Leu for proline, arginine, alanine, or glycine, caused dramatic reductions in growth. Differential phenotypic defects were observed for tRNALeu mutants with synonymous anticodons and for different tRNALeu isoacceptors with the same anticodon. A comparison to tRNAAla anticodon variants demonstrates that Ala mis-incorporation is more tolerable than Leu at nearly every codon. The data show that the nature of the amino acid substitution, the tRNA gene, and the anticodon are each important factors that influence the ability of cells to tolerate mistranslating tRNAs.
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Affiliation(s)
- Josephine Davey-Young
- Department of Biochemistry, The University of Western Ontario, London, Ontario, Canada
| | - Farah Hasan
- Department of Biochemistry, The University of Western Ontario, London, Ontario, Canada
| | - Rasangi Tennakoon
- Department of Biochemistry, The University of Western Ontario, London, Ontario, Canada
| | - Peter Rozik
- Department of Biochemistry, The University of Western Ontario, London, Ontario, Canada
| | - Henry Moore
- Department of Biomolecular Engineering, Baskin School of Engineering & UCSC Genomics Institute, University of California Santa Cruz, Santa Cruz, CA, USA
| | - Peter Hall
- Department of Biochemistry, The University of Western Ontario, London, Ontario, Canada
| | - Ecaterina Cozma
- Department of Biochemistry, The University of Western Ontario, London, Ontario, Canada
| | - Julie Genereaux
- Department of Biochemistry, The University of Western Ontario, London, Ontario, Canada
| | | | - Patricia P. Chan
- Department of Biomolecular Engineering, Baskin School of Engineering & UCSC Genomics Institute, University of California Santa Cruz, Santa Cruz, CA, USA
| | - Todd M. Lowe
- Department of Biomolecular Engineering, Baskin School of Engineering & UCSC Genomics Institute, University of California Santa Cruz, Santa Cruz, CA, USA
| | - Christopher J. Brandl
- Department of Biochemistry, The University of Western Ontario, London, Ontario, Canada
| | - Patrick O’Donoghue
- Department of Biochemistry, The University of Western Ontario, London, Ontario, Canada
- Department of Chemistry, The University of Western Ontario, London, Ontario, Canada
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Lim HF, Sharma A, Gallagher C, Hall P. Value of ultrasound in assessing response to neoadjuvant chemotherapy in breast cancer. Clin Radiol 2023; 78:912-918. [PMID: 37734976 DOI: 10.1016/j.crad.2023.07.010] [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: 05/23/2023] [Revised: 07/12/2023] [Accepted: 07/17/2023] [Indexed: 09/23/2023]
Abstract
AIM To analyse the utility of ultrasound in assessing response to neoadjuvant chemotherapy (NAC) and predicting residual cancer burden (RCB) index and pathological complete response (pCR) MATERIALS AND METHODS: This was a retrospective study with 417 patients over 7 years. The difference in longest diameter (LD) of the index lesion from baseline to end, baseline to mid, and mid to end was evaluated with respect to RCB class using logistic regression and ordered logistic regression. RESULTS Change in LD measurements from baseline to end, baseline to mid, and mid to end of chemotherapy as a predictor of RCB class show a negative relationship with a statistically significant association. This would suggest that a smaller change in LD measurements would be associated with an eventual higher RCB class. Change in LD measurements from baseline to end and baseline to mid chemotherapy as a predictor of pCR class show a negative relationship with a statistically significant association (p<0.05). This similarly indicates an inversely proportional relationship between changes in LD measurements and RCB class 0 for baseline to end and baseline to mid. CONCLUSION This study has shown significance in reducing LD measurements on ultrasound as a predictor of PCR and RCB class. This adds weight to the current practice of using ultrasound at the start, mid and end of chemotherapy cycles to monitor NACT responses.
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Affiliation(s)
- H F Lim
- Department of Radiology, Western General Hospital, Crewe Rd S, Edinburgh EH4 2XU, UK.
| | - A Sharma
- Department of Radiology, Western General Hospital, Crewe Rd S, Edinburgh EH4 2XU, UK
| | - C Gallagher
- Department of Oncology, Western General Hospital, Crewe Rd S, Edinburgh EH4 2XU, UK
| | - P Hall
- Department of Oncology, Western General Hospital, Crewe Rd S, Edinburgh EH4 2XU, UK
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Henriksen PA, Hall P, MacPherson IR, Joshi SS, Singh T, Maclean M, Lewis S, Rodriguez A, Fletcher A, Everett RJ, Stavert H, Broom A, Eddie L, Primrose L, McVicars H, McKay P, Borley A, Rowntree C, Lord S, Collins G, Radford J, Guppy A, Williams MC, Japp A, Payne JR, Newby DE, Mills NL, Oikonomidou O, Lang NN. Multicenter, Prospective, Randomized Controlled Trial of High-Sensitivity Cardiac Troponin I-Guided Combination Angiotensin Receptor Blockade and Beta-Blocker Therapy to Prevent Anthracycline Cardiotoxicity: The Cardiac CARE Trial. Circulation 2023; 148:1680-1690. [PMID: 37746692 PMCID: PMC10655910 DOI: 10.1161/circulationaha.123.064274] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2023] [Accepted: 08/24/2023] [Indexed: 09/26/2023]
Abstract
BACKGROUND Anthracycline-induced cardiotoxicity has a variable incidence, and the development of left ventricular dysfunction is preceded by elevations in cardiac troponin concentrations. Beta-adrenergic receptor blocker and renin-angiotensin system inhibitor therapies have been associated with modest cardioprotective effects in unselected patients receiving anthracycline chemotherapy. METHODS In a multicenter, prospective, randomized, open-label, blinded end-point trial, patients with breast cancer and non-Hodgkin lymphoma receiving anthracycline chemotherapy underwent serial high-sensitivity cardiac troponin testing and cardiac magnetic resonance imaging before and 6 months after anthracycline treatment. Patients at high risk of cardiotoxicity (cardiac troponin I concentrations in the upper tertile during chemotherapy) were randomized to standard care plus cardioprotection (combination carvedilol and candesartan therapy) or standard care alone. The primary outcome was adjusted change in left ventricular ejection fraction at 6 months. In low-risk nonrandomized patients with cardiac troponin I concentrations in the lower 2 tertiles, we hypothesized the absence of a 6-month change in left ventricular ejection fraction and tested for equivalence of ±2%. RESULTS Between October 2017 and June 2021, 175 patients (mean age, 53 years; 87% female; 71% with breast cancer) were recruited. Patients randomized to cardioprotection (n=29) or standard care (n=28) had left ventricular ejection fractions of 69.4±7.4% and 69.1±6.1% at baseline and 65.7±6.6% and 64.9±5.9% 6 months after completion of chemotherapy, respectively. After adjustment for age, pretreatment left ventricular ejection fraction, and planned anthracycline dose, the estimated mean difference in 6-month left ventricular ejection fraction between the cardioprotection and standard care groups was -0.37% (95% CI, -3.59% to 2.85%; P=0.82). In low-risk nonrandomized patients, baseline and 6-month left ventricular ejection fractions were 69.3±5.7% and 66.4±6.3%, respectively: estimated mean difference, 2.87% (95% CI, 1.63%-4.10%; P=0.92, not equivalent). CONCLUSIONS Combination candesartan and carvedilol therapy had no demonstrable cardioprotective effect in patients receiving anthracycline-based chemotherapy with high-risk on-treatment cardiac troponin I concentrations. Low-risk nonrandomized patients had similar declines in left ventricular ejection fraction, bringing into question the utility of routine cardiac troponin monitoring. Furthermore, the modest declines in left ventricular ejection fraction suggest that the value and clinical impact of early cardioprotection therapy need to be better defined in patients receiving high-dose anthracycline. REGISTRATION URL: https://doi.org; Unique identifier: 10.1186/ISRCTN24439460. URL: https://www.clinicaltrialsregister.eu/ctr-search/search; Unique identifier: 2017-000896-99.
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Affiliation(s)
- Peter A. Henriksen
- BHF Centre for Cardiovascular Science (P.A.H., S.S.J., T.S., A.F., R.J.E., M.C.W., A.J., D.E.N., N.L.M.), University of Edinburgh, UK
| | - Peter Hall
- MRC Institute Genetics and Molecular Medicine, (P.H., H.S., L.P., H.M., O.O.), University of Edinburgh, UK
- Cancer Research UK, Edinburgh Centre, UK (P.H., H.S., L.P., H.M., O.O.)
| | | | - Shruti S. Joshi
- BHF Centre for Cardiovascular Science (P.A.H., S.S.J., T.S., A.F., R.J.E., M.C.W., A.J., D.E.N., N.L.M.), University of Edinburgh, UK
| | - Trisha Singh
- BHF Centre for Cardiovascular Science (P.A.H., S.S.J., T.S., A.F., R.J.E., M.C.W., A.J., D.E.N., N.L.M.), University of Edinburgh, UK
| | - Morag Maclean
- Edinburgh Clinical Trials Unit, Usher Institute (M.M., S.L., A.R.), University of Edinburgh, UK
| | - Steff Lewis
- Edinburgh Clinical Trials Unit, Usher Institute (M.M., S.L., A.R.), University of Edinburgh, UK
| | - Aryelly Rodriguez
- Edinburgh Clinical Trials Unit, Usher Institute (M.M., S.L., A.R.), University of Edinburgh, UK
| | - Alex Fletcher
- BHF Centre for Cardiovascular Science (P.A.H., S.S.J., T.S., A.F., R.J.E., M.C.W., A.J., D.E.N., N.L.M.), University of Edinburgh, UK
- Department of Child Health, University of Glasgow, School of Medicine and Dentistry, UK (A.F.)
| | - Russell J. Everett
- BHF Centre for Cardiovascular Science (P.A.H., S.S.J., T.S., A.F., R.J.E., M.C.W., A.J., D.E.N., N.L.M.), University of Edinburgh, UK
| | - Harriet Stavert
- MRC Institute Genetics and Molecular Medicine, (P.H., H.S., L.P., H.M., O.O.), University of Edinburgh, UK
- Cancer Research UK, Edinburgh Centre, UK (P.H., H.S., L.P., H.M., O.O.)
| | - Angus Broom
- Department of Haematology, Western General Hospital, Edinburgh, UK (A.B., L.E.)
| | - Lois Eddie
- Department of Haematology, Western General Hospital, Edinburgh, UK (A.B., L.E.)
| | - Lorraine Primrose
- MRC Institute Genetics and Molecular Medicine, (P.H., H.S., L.P., H.M., O.O.), University of Edinburgh, UK
- Cancer Research UK, Edinburgh Centre, UK (P.H., H.S., L.P., H.M., O.O.)
| | - Heather McVicars
- MRC Institute Genetics and Molecular Medicine, (P.H., H.S., L.P., H.M., O.O.), University of Edinburgh, UK
- Cancer Research UK, Edinburgh Centre, UK (P.H., H.S., L.P., H.M., O.O.)
| | - Pam McKay
- Department of Haematology, Beatson Oncology Centre, Glasgow, UK (P.M.)
| | - Annabel Borley
- Velindre Cancer Centre, Velindre University NHS Trust, Cardiff, UK (A.B.)
| | | | - Simon Lord
- Department of Oncology, University of Oxford, UK (S.L.)
| | - Graham Collins
- Oxford Cancer and Hematology Centre, Churchill Hospital, UK (G.C.)
| | - John Radford
- University of Manchester and Christie NHS Foundation, UK (J.R.)
| | - Amy Guppy
- Mount Vernon Cancer Centre, Middlesex, UK (A.G.)
| | - Michelle C. Williams
- BHF Centre for Cardiovascular Science (P.A.H., S.S.J., T.S., A.F., R.J.E., M.C.W., A.J., D.E.N., N.L.M.), University of Edinburgh, UK
| | - Alan Japp
- BHF Centre for Cardiovascular Science (P.A.H., S.S.J., T.S., A.F., R.J.E., M.C.W., A.J., D.E.N., N.L.M.), University of Edinburgh, UK
| | - John R. Payne
- Scottish National Advanced Heart Failure Service, Golden Jubilee National Hospital, Glasgow, UK (J.R.P.)
| | - David E. Newby
- BHF Centre for Cardiovascular Science (P.A.H., S.S.J., T.S., A.F., R.J.E., M.C.W., A.J., D.E.N., N.L.M.), University of Edinburgh, UK
| | - Nicholas L. Mills
- BHF Centre for Cardiovascular Science (P.A.H., S.S.J., T.S., A.F., R.J.E., M.C.W., A.J., D.E.N., N.L.M.), University of Edinburgh, UK
- Usher Institute (N.L.M.), University of Edinburgh, UK
| | - Olga Oikonomidou
- MRC Institute Genetics and Molecular Medicine, (P.H., H.S., L.P., H.M., O.O.), University of Edinburgh, UK
- Cancer Research UK, Edinburgh Centre, UK (P.H., H.S., L.P., H.M., O.O.)
| | - Ninian N. Lang
- School of Cardiovascular and Metabolic Health, University of Glasgow, UK (N.N.L.)
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9
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Liu XC, Wu YC, Hall P. Painterly Style Transfer With Learned Brush Strokes. IEEE Trans Vis Comput Graph 2023; PP:1-12. [PMID: 37966930 DOI: 10.1109/tvcg.2023.3332950] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2023]
Abstract
Real-world paintings are made, by artists, using brush strokes as the rendering primitive to depict semantic content. The bulk of the Neural Style Transfer (NST) is known transferring style using texture patches, not strokes. The output looks like the content image, but some are traced over using the style texture: it does not look painterly. We adopt a very different approach that uses strokes. Our contribution is to analyse paintings to learn stroke families-that is, distributions of strokes based on their shape (a dot, straight lines, curved arcs, etc.). When synthesising a new output, these distributions are sampled to ensure the output is painted with the correct style of stroke. Consequently, our output looks more "painterly" than NST output based on texture. Furthermore, where strokes are placed is an important contributing factor in determining output quality, and we have also addressed this aspect. Humans place strokes to emphasize salient semantically meaningful image content. Conventional NST uses a content loss premised on filter responses that is agnostic to salience. We show that replacing that loss with one based on the language-image model benefits the output through greater emphasis of salient content.
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10
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Solaymani S, Villamor G, Dunningham A, Hall P. The relationship between energy and non-energy factors and CO 2 emissions in New Zealand. Environ Sci Pollut Res Int 2023; 30:104270-104283. [PMID: 37700128 DOI: 10.1007/s11356-023-29784-z] [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: 02/06/2023] [Accepted: 09/04/2023] [Indexed: 09/14/2023]
Abstract
The use of renewable energy as a fuel source and expansion of forest areas are the best ways for reducing CO2 emissions. This study aims to examine the effects of forest plantation area, renewable energies, real gross domestic product (GDP), and technological innovation on CO2 emissions in 9 regions of New Zealand between 2006 and 2019. For this purpose, it employs a pooled mean group methodology. Investigating the regional impacts of various variables, especially the forest area, on CO2 emissions is the main contribution of this study. The results suggest that planted forest areas can reduce CO2 emissions in the long run, but its impact in the short run is not significant. Non-renewable energy consumption is the major contributor to CO2 emissions in both the short and long run. While technological innovation and renewable energy consumption appear effective in reducing carbon emissions in the short term, they still contribute to increased CO2 emissions in the long term. At the regional level, we found that the forest plantation areas in Manawatu-Whanganui and Gisborne are important regions for reducing CO2 emissions. By taking account of these results, New Zealand should take swift action to properly manage and increase the current level of forest areas and if applicable expand them. It also needs to improve the current level of use of renewable energy to achieve its abatement goals.
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Affiliation(s)
- Saeed Solaymani
- Scion (New Zealand Forest Research Institute Ltd), Titokorangi Drive (Formerly Longmile Road), 3046, Rotorua, New Zealand.
- Department of Economics, Faculty of Administration and Economics, Arak University, 38156879, Arak, Iran.
| | - Grace Villamor
- Scion (New Zealand Forest Research Institute Ltd), Titokorangi Drive (Formerly Longmile Road), 3046, Rotorua, New Zealand
| | - Andrew Dunningham
- Scion (New Zealand Forest Research Institute Ltd), Titokorangi Drive (Formerly Longmile Road), 3046, Rotorua, New Zealand
| | - Peter Hall
- Scion (New Zealand Forest Research Institute Ltd), Titokorangi Drive (Formerly Longmile Road), 3046, Rotorua, New Zealand
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11
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Grevot A, Boisclair J, Guffroy M, Hall P, Pohlmeyer-Esch G, Jacobsen M, Bach U, Frisk AL, Dybdal N, Palazzi X. Toxicologic Pathology Forum Opinion Piece: Use of Virtual Control Groups in Nonclinical Toxicity Studies: The Anatomic Pathology Perspective. Toxicol Pathol 2023; 51:390-396. [PMID: 38293937 DOI: 10.1177/01926233231224805] [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] [Indexed: 02/01/2024]
Abstract
In the last decade, numerous initiatives have emerged worldwide to reduce the use of animals in drug development, including more recently the introduction of Virtual Control Groups (VCGs) concept for nonclinical toxicity studies. Although replacement of concurrent controls (CCs) by virtual controls (VCs) represents an exciting opportunity, there are associated challenges that will be discussed in this paper with a more specific focus on anatomic pathology. Coordinated efforts will be needed from toxicologists, clinical and anatomic pathologists, and regulators to support approaches that will facilitate a staggered implementation of VCGs in nonclinical toxicity studies. Notably, the authors believe that a validated database for VC animals will need to include histopathology (digital) slides for microscopic assessment. Ultimately, the most important step lies in the validation of the concept by performing VCG and the full control group in parallel for studies of varying duration over a reasonable timespan to confirm there are no differences in outcomes (dual study design). The authors also discuss a hybrid approach, whereby control groups comprised both concurrent and VCs to demonstrate proof-of-concept. Once confidence is established by sponsors and regulators, VCs have the potential to replace some or all CC animals.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Noel Dybdal
- Genentech Inc., South San Francisco, California, USA
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12
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Date K, Williams B, Cohen J, Chaudhuri N, Bajwah S, Pearson M, Higginson I, Norrie J, Keerie C, Tuck S, Hall P, Currow D, Fallon M, Johnson M. Modified-release morphine or placebo for chronic breathlessness: the MABEL trial protocol. ERJ Open Res 2023; 9:00167-2023. [PMID: 37583966 PMCID: PMC10423982 DOI: 10.1183/23120541.00167-2023] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Accepted: 05/13/2023] [Indexed: 08/17/2023] Open
Abstract
Chronic breathlessness, a persistent and disabling symptom despite optimal treatment of underlying causes, is a frightening symptom with serious and widespread impact on patients and their carers. Clinical guidelines support the use of morphine for the relief of chronic breathlessness in common long-term conditions, but questions remain around clinical effectiveness, safety and longer term (>7 days) administration. This trial will evaluate the effectiveness of low-dose oral modified-release morphine in chronic breathlessness. This is a multicentre, parallel group, double-blind, randomised, placebo-controlled trial. Participants (n=158) will be opioid-naïve with chronic breathlessness due to heart or lung disease, cancer or post-coronavirus disease 2019. Participants will be randomised 1:1 to 5 mg oral modified-release morphine/placebo twice daily and docusate/placebo 100 mg twice daily for 56 days. Non-responders at Day 7 will dose escalate to 10 mg morphine/placebo twice daily at Day 15. The primary end-point (Day 28) measure will be worst breathlessness severity (previous 24 h). Secondary outcome measures include worst cough, distress, pain, functional status, physical activity, quality of life, and early identification and management of morphine-related side-effects. At Day 56, participants may opt to take open-label, oral modified-release morphine as part of usual care and complete quarterly breathlessness and toxicity questionnaires. The study is powered to be able to reject the null hypothesis and an embedded normalisation process theory-informed qualitative substudy will explore the adoption of morphine as a first-line pharmacological treatment for chronic breathlessness in clinical practice if effective.
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Affiliation(s)
- Kathryn Date
- Hull Health Trials Unit, Hull York Medical School, University of Hull, Hull, UK
| | - Bronwen Williams
- Hull Health Trials Unit, Hull York Medical School, University of Hull, Hull, UK
| | - Judith Cohen
- Hull Health Trials Unit, Hull York Medical School, University of Hull, Hull, UK
| | | | - Sabrina Bajwah
- Cicely Saunders Institute, King's College London, London, UK
| | - Mark Pearson
- Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, Hull, UK
| | - Irene Higginson
- Cicely Saunders Institute, King's College London, London, UK
| | - John Norrie
- Edinburgh Clinical Trials Unit, Usher Institute, University of Edinburgh, Edinburgh, UK
| | - Catriona Keerie
- Edinburgh Clinical Trials Unit, Usher Institute, University of Edinburgh, Edinburgh, UK
| | - Sharon Tuck
- Edinburgh Clinical Trials Unit, Usher Institute, University of Edinburgh, Edinburgh, UK
| | - Peter Hall
- Edinburgh Clinical Trials Unit, Usher Institute, University of Edinburgh, Edinburgh, UK
| | - David Currow
- Faculty of Science, Medicine and Health, University of Wollongong, Wollongong, Australia
| | - Marie Fallon
- Edinburgh Cancer Research Centre (IGMM), University of Edinburgh, Edinburgh, UK
| | - Miriam Johnson
- Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, Hull, UK
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13
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Hall P, Howell S, Venkitaraman R, Thomson A, Raja F, King J, Michie C, Khan S, Brunt A, Gahir D, McAdam K, Cooner J, Kane N. P084 Socioeconomic Outcomes With Ribociclib in Patients With HR+, HER2– Advanced Breast Cancer (ABC) in UK Real-world Settings. Breast 2023. [DOI: 10.1016/s0960-9776(23)00201-1] [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: 03/18/2023] Open
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14
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Jadva V, Jones C, Hall P, Imrie S, Golombok S. 'I know it's not normal but it's normal to me, and that's all that matters': experiences of young adults conceived through egg donation, sperm donation, and surrogacy. Hum Reprod 2023; 38:908-916. [PMID: 36921279 PMCID: PMC10152165 DOI: 10.1093/humrep/dead048] [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: 07/15/2022] [Revised: 02/10/2023] [Indexed: 03/17/2023] Open
Abstract
STUDY QUESTION What are thoughts and feelings of young adults born following egg donation, sperm donation, and surrogacy? SUMMARY ANSWER Young adults felt either unconcerned or positive about the method of their conception. WHAT IS KNOWN ALREADY Much of what we know about adults born to heterosexual couples following anonymous donation has come from samples of donor conceived people who had found out about their origins during adulthood. There have been no studies of how young adults born through surrogacy feel about their conception and towards their surrogate. STUDY DESIGN, SIZE, DURATION Thirty-five young adults were interviewed as part of the seventh phase of a larger multi-method, multi-informant longitudinal study of assisted conception families in the UK. Adults were conceived using either egg donation, sperm donation, gestational surrogacy, or genetic surrogacy and were raised in households headed by heterosexual couples. PARTICIPANTS/MATERIALS, SETTING, METHODS Participants had a mean age of 20 years and were born following traditional surrogacy (n = 10), gestational surrogacy (n = 5), egg donation (n = 11), or sperm donation (n = 9). All young adults born following sperm donation and most (n = 10) born from egg donation had an anonymous donor. In all surrogacy arrangements, the parents had met the surrogate prior to treatment. The majority of young adults were told about their conception by the age of 4 years. Participants were interviewed over the internet using a semi-structured interview. Interviews were transcribed verbatim and analysed using qualitative content analysis to understand young adults' thoughts and experiences related to their conception and whether they were interested in meeting their donor or surrogate. MAIN RESULTS AND THE ROLE OF CHANCE Fourteen (40%) young adults felt their conception made them feel special or unique, with the remainder feeling either neutral or unconcerned (n = 21, 60%). A higher proportion of young adults conceived using egg donation (n = 8, 73%) felt unique/special compared to young adults born following sperm donation and surrogacy. For 10 of the young adults, their feelings about their conception had changed over time, with most becoming more positive (n = 9, 26%). For most young adults (n = 22, 63%), conception was rarely or infrequently discussed with others. However, when it was, these conversations were largely conducted with ease. Most (n = 25, 71%) did not know other individuals born through the same method of conception as themselves, and the vast majority (n = 34, 97%) were not members of any support groups. For the 25 young adults not in contact with their donor or surrogate, 11 wished to meet them, 8 did not want to have contact, and 6 were unsure. Young adults in contact with their donor or surrogate had varying levels of closeness to them. Only one young adult had searched for the identity of their donor. LIMITATIONS, REASONS FOR CAUTION Of the 47 young adults invited to participate in the present study, 35 agreed to take part resulting in a response rate of 74%. It is therefore not known how those who did not take part felt about their conception. Given that the families reported here had been taking part in this longitudinal study from when the target child was aged 1 year, they may have been more likely to discuss the child's conception than other families. The study also utilized self-report measures, which may have been prone to social desirability, with donor conceived young adults wanting to present their experiences in a positive light. WIDER IMPLICATIONS OF THE FINDINGS The findings suggest that young adults born through surrogacy and donor conception do not feel negatively about their birth and this may be a consequence of the young age at which they found out about their conception. Although some young adults said they wished to meet their donor, this did not necessarily mean they were actively searching for them. STUDY FUNDING/COMPETING INTEREST(S) The study was funded by the Wellcome Trust [grant number 208013/Z/17/Z]. The authors have no conflicts of interest to declare. TRIAL REGISTRATION NUMBER N/A.
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Affiliation(s)
- V Jadva
- Centre for Family Research, University of Cambridge, Cambridge, UK.,Institute for Women's Health, University College London, London, UK.,Institute for Women's Health, Faculty of Population Health Sciences, University College London, London, UK
| | - C Jones
- Social, Genetic & Developmental Psychiatry Centre, King's College London, London, UK
| | - P Hall
- Centre for Family Research, University of Cambridge, Cambridge, UK
| | - S Imrie
- Centre for Family Research, University of Cambridge, Cambridge, UK.,Murray Edwards College, University of Cambridge, Cambridge, UK
| | - S Golombok
- Centre for Family Research, University of Cambridge, Cambridge, UK
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15
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Stares M, Lewis G, Vallet M, Killean A, Tramonti G, Patrizio A, Mackean M, Harrow S, Barrie C, MacLennan K, Campbell S, Evans T, Tufail A, Hall P, Phillips I. Real-World Impact of SABR on Stage I Non-Small-Cell Lung Cancer Outcomes at a Scottish Cancer Centre. Cancers (Basel) 2023; 15:cancers15051431. [PMID: 36900224 PMCID: PMC10000454 DOI: 10.3390/cancers15051431] [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] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Revised: 02/09/2023] [Accepted: 02/20/2023] [Indexed: 03/06/2023] Open
Abstract
INTRODUCTION Stereotactic ablative body radiotherapy (SABR) offers patients with stage I non-small-cell lung cancer (NSCLC) a safe, effective radical therapy option. The impact of introducing SABR at a Scottish regional cancer centre was studied. METHODS The Edinburgh Cancer Centre Lung Cancer Database was assessed. Treatment patterns and outcomes were compared across treatment groups (no radical therapy (NRT), conventional radical radiotherapy (CRRT), SABR and surgery) and across three time periods reflecting the availability of SABR (A, January 2012/2013 (pre-SABR); B, 2014/2016 (introduction of SABR); C, 2017/2019, (SABR established)). RESULTS 1143 patients with stage I NSCLC were identified. Treatment was NRT in 361 (32%), CRRT in 182 (16%), SABR in 132 (12%) and surgery in 468 (41%) patients. Age, performance status, and comorbidities correlated with treatment choice. The median survival increased from 32.5 months in time period A to 38.8 months in period B to 48.8 months in time period C. The greatest improvement in survival was seen in patients treated with surgery between time periods A and C (HR 0.69 (95% CI 0.56-0.86), p < 0.001). The proportion of patients receiving a radical therapy rose between time periods A and C in younger (age ≤ 65, 65-74 and 75-84 years), fitter (PS 0 and 1), and less comorbid patients (CCI 0 and 1-2), but fell in other patient groups. CONCLUSIONS The introduction and establishment of SABR for stage I NSCLC has improved survival outcomes in Southeast Scotland. Increasing SABR utilisation appears to have enhanced the selection of surgical patients and increased the proportion of patients receiving a radical therapy.
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Affiliation(s)
- Mark Stares
- Edinburgh Cancer Centre, NHS Lothian, Western General Hospital, Crewe Road South, Edinburgh EH4 2XU, UK
- Cancer Research UK Edinburgh Centre, Institute of Genetics and Cancer, Western General Hospital, University of Edinburgh, Crewe Road South, Edinburgh EH4 2XR, UK
- Correspondence: ; Tel.: +44-1315371000
| | - Georgina Lewis
- Cancer Research UK Edinburgh Centre, Institute of Genetics and Cancer, Western General Hospital, University of Edinburgh, Crewe Road South, Edinburgh EH4 2XR, UK
| | - Maheva Vallet
- Cancer Research UK Edinburgh Centre, Institute of Genetics and Cancer, Western General Hospital, University of Edinburgh, Crewe Road South, Edinburgh EH4 2XR, UK
| | - Angus Killean
- Edinburgh Cancer Centre, NHS Lothian, Western General Hospital, Crewe Road South, Edinburgh EH4 2XU, UK
- Cancer Research UK Edinburgh Centre, Institute of Genetics and Cancer, Western General Hospital, University of Edinburgh, Crewe Road South, Edinburgh EH4 2XR, UK
| | - Giovanni Tramonti
- Cancer Research UK Edinburgh Centre, Institute of Genetics and Cancer, Western General Hospital, University of Edinburgh, Crewe Road South, Edinburgh EH4 2XR, UK
| | - Ailsa Patrizio
- Edinburgh Cancer Centre, NHS Lothian, Western General Hospital, Crewe Road South, Edinburgh EH4 2XU, UK
| | - Melanie Mackean
- Edinburgh Cancer Centre, NHS Lothian, Western General Hospital, Crewe Road South, Edinburgh EH4 2XU, UK
| | - Stephen Harrow
- Edinburgh Cancer Centre, NHS Lothian, Western General Hospital, Crewe Road South, Edinburgh EH4 2XU, UK
| | - Colin Barrie
- Edinburgh Cancer Centre, NHS Lothian, Western General Hospital, Crewe Road South, Edinburgh EH4 2XU, UK
| | - Kirsty MacLennan
- Edinburgh Cancer Centre, NHS Lothian, Western General Hospital, Crewe Road South, Edinburgh EH4 2XU, UK
| | - Sorcha Campbell
- Edinburgh Cancer Centre, NHS Lothian, Western General Hospital, Crewe Road South, Edinburgh EH4 2XU, UK
| | - Tamasin Evans
- Edinburgh Cancer Centre, NHS Lothian, Western General Hospital, Crewe Road South, Edinburgh EH4 2XU, UK
| | - Aisha Tufail
- Edinburgh Cancer Centre, NHS Lothian, Western General Hospital, Crewe Road South, Edinburgh EH4 2XU, UK
| | - Edinburgh Cancer Informatics Programme
- Cancer Research UK Edinburgh Centre, Institute of Genetics and Cancer, Western General Hospital, University of Edinburgh, Crewe Road South, Edinburgh EH4 2XR, UK
| | - Peter Hall
- Edinburgh Cancer Centre, NHS Lothian, Western General Hospital, Crewe Road South, Edinburgh EH4 2XU, UK
- Cancer Research UK Edinburgh Centre, Institute of Genetics and Cancer, Western General Hospital, University of Edinburgh, Crewe Road South, Edinburgh EH4 2XR, UK
| | - Iain Phillips
- Edinburgh Cancer Centre, NHS Lothian, Western General Hospital, Crewe Road South, Edinburgh EH4 2XU, UK
- Cancer Research UK Edinburgh Centre, Institute of Genetics and Cancer, Western General Hospital, University of Edinburgh, Crewe Road South, Edinburgh EH4 2XR, UK
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16
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Cafferkey J, Ferguson A, Grahamslaw J, Oatey K, Norrie J, Lone N, Walsh T, Horner D, Appelboam A, Hall P, Skipworth R, Bell D, Rooney K, Shankar-Hari M, Corfield A, Gray A. Albumin versus balanced crystalloid for resuscitation in the treatment of sepsis: A protocol for a randomised controlled feasibility study, "ABC-Sepsis". J Intensive Care Soc 2023; 24:78-84. [PMID: 36860553 PMCID: PMC9157259 DOI: 10.1177/17511437221103692] [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] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Background Patients presenting with suspected sepsis to secondary care often require fluid resuscitation to correct hypovolaemia and/or septic shock. Existing evidence signals, but does not demonstrate, a benefit for regimes including albumin over balanced crystalloid alone. However, interventions may be started too late, missing a critical resuscitation window. Methods ABC Sepsis is a currently recruiting randomised controlled feasibility trial comparing 5% human albumin solution (HAS) with balanced crystalloid for fluid resuscitation in patients with suspected sepsis. This multicentre trial is recruiting adult patients within 12 hours of presentation to secondary care with suspected community acquired sepsis, with a National Early Warning Score ≥5, who require intravenous fluid resuscitation. Participants are randomised to 5% HAS or balanced crystalloid as the sole resuscitation fluid for the first 6 hours. Objectives Primary objectives are feasibility of recruitment to the study and 30-day mortality between groups. Secondary objectives include in-hospital and 90-day mortality, adherence to trial protocol, quality of life measurement and secondary care costs. Discussion This trial aims to determine the feasibility of conducting a trial to address the current uncertainty around optimal fluid resuscitation of patients with suspected sepsis. Understanding the feasibility of delivering a definitive study will be dependent on how the study team are able to negotiate clinician choice, Emergency Department pressures and participant acceptability, as well as whether any clinical signal of benefit is detected.
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Affiliation(s)
- John Cafferkey
- Emergency Medicine Research Group
Edinburgh (EMERGE), Department of Emergency Medicine, Royal Infirmary of
Edinburgh, Edinburgh, UK
| | - Andrew Ferguson
- Emergency Medicine Research Group
Edinburgh (EMERGE), Department of Emergency Medicine, Royal Infirmary of
Edinburgh, Edinburgh, UK
| | - Julia Grahamslaw
- Emergency Medicine Research Group
Edinburgh (EMERGE), Department of Emergency Medicine, Royal Infirmary of
Edinburgh, Edinburgh, UK
| | - Katherine Oatey
- Edinburgh Clinical Trials Unit,
Usher Institute, University of Edinburgh, Edinburgh, UK
| | - John Norrie
- Department of Critical Care, Royal
Infirmary of Edinburgh, Usher Institute, University of
Edinburgh, Edinburgh, UK
| | - Nazir Lone
- Department of Critical Care, Royal
Infirmary of Edinburgh, Usher Institute, University of
Edinburgh, Edinburgh, UK
| | - Timothy Walsh
- Department of Critical Care, Royal
Infirmary of Edinburgh, Usher Institute, University of
Edinburgh, Edinburgh, UK
| | - Daniel Horner
- Emergency Department, Salford Royal NHS Foundation
Trust, Salford, UK,Division of Infection, Immunity and
Respiratory Medicine, University of
Manchester, Manchester, UK
| | - Andy Appelboam
- Academic Department of Emergency
Medicine Exeter (ACADEMEx), Royal Devon and Exeter Hospital NHS
Foundation Trust, Exeter Devon
| | - Peter Hall
- Edinburgh Cancer Research Centre, University of Edinburgh, Edinburgh, UK
| | | | - Derek Bell
- Department of Acute Medicine, Chelsea and Westminster
Campus, Imperial College London, London
| | | | - Manu Shankar-Hari
- The Queen’s Medical Research
Institute, Edinburgh BioQuarter, Centre for
Inflammation Research, University of Edinburgh, UK
| | - Alasdair Corfield
- Emergency Department, Royal Alexandra
Hospital, NHS Greater Glasgow and Clyde, UK
| | - Alasdair Gray
- Emergency Medicine Research Group
Edinburgh (EMERGE), Department of Emergency Medicine, Royal Infirmary of
Edinburgh, Edinburgh, UK,Acute Care Edinburgh, Centre for
Population and Health Sciences, Usher Institute, University of
Edinburgh, Edinburgh UK,Professor Alasdair Gray, Emergency Medicine
Research Group Edinburgh (EMERGE), Department of Emergency Medicine, Royal
Infirmary of Edinburgh, Edinburgh EH16 4SA, UK.
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Turner NC, Swift C, Jenkins B, Kilburn L, Coakley M, Beaney M, Fox L, Goddard K, Garcia-Murillas I, Proszek P, Hall P, Harper-Wynne C, Hickish T, Kernaghan S, Macpherson IR, Okines AFC, Palmieri C, Perry S, Randle K, Snowdon C, Stobart H, Wardley AM, Wheatley D, Waters S, Winter MC, Hubank M, Allen SD, Bliss JM. Results of the c-TRAK TN trial: a clinical trial utilising ctDNA mutation tracking to detect molecular residual disease and trigger intervention in patients with moderate- and high-risk early-stage triple-negative breast cancer. Ann Oncol 2023; 34:200-211. [PMID: 36423745 DOI: 10.1016/j.annonc.2022.11.005] [Citation(s) in RCA: 33] [Impact Index Per Article: 33.0] [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: 07/14/2022] [Revised: 11/04/2022] [Accepted: 11/08/2022] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Post-treatment detection of circulating tumour DNA (ctDNA) in early-stage triple-negative breast cancer (TNBC) patients predicts high risk of relapse. c-TRAK TN assessed the utility of prospective ctDNA surveillance in TNBC and the activity of pembrolizumab in patients with ctDNA detected [ctDNA positive (ctDNA+)]. PATIENTS AND METHODS c-TRAK TN, a multicentre phase II trial, with integrated prospective ctDNA surveillance by digital PCR, enrolled patients with early-stage TNBC and residual disease following neoadjuvant chemotherapy, or stage II/III with adjuvant chemotherapy. ctDNA surveillance comprised three-monthly blood sampling to 12 months (18 months if samples were missed due to coronavirus disease), and ctDNA+ patients were randomised 2 : 1 to intervention : observation. ctDNA results were blinded unless patients were allocated to intervention, when staging scans were done and those free of recurrence were offered pembrolizumab. A protocol amendment (16 September 2020) closed the observation group; all subsequent ctDNA+ patients were allocated to intervention. Co-primary endpoints were (i) ctDNA detection rate and (ii) sustained ctDNA clearance rate on pembrolizumab (NCT03145961). RESULTS Two hundred and eight patients registered between 30 January 2018 and 06 December 2019, 185 had tumour sequenced, 171 (92.4%) had trackable mutations, and 161 entered ctDNA surveillance. Rate of ctDNA detection by 12 months was 27.3% (44/161, 95% confidence interval 20.6% to 34.9%). Seven patients relapsed without prior ctDNA detection. Forty-five patients entered the therapeutic component (intervention n = 31; observation n = 14; one observation patient was re-allocated to intervention following protocol amendment). Of patients allocated to intervention, 72% (23/32) had metastases on staging at the time of ctDNA+, and 4 patients declined pembrolizumab. Of the five patients who commenced pembrolizumab, none achieved sustained ctDNA clearance. CONCLUSIONS c-TRAK TN is the first prospective study to assess whether ctDNA assays have clinical utility in guiding therapy in TNBC. Patients had a high rate of metastatic disease on ctDNA detection. Findings have implications for future trial design, emphasising the importance of commencing ctDNA testing early, with more sensitive and/or frequent ctDNA testing regimes.
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Affiliation(s)
- N C Turner
- Breast Cancer Now Research Centre, The Institute of Cancer Research, London, UK; Breast Unit, The Royal Marsden Hospital, London, UK.
| | - C Swift
- The Institute of Cancer Research, London, UK; The Royal Marsden NHS Foundation Trust, Sutton, Surrey, UK
| | - B Jenkins
- Clinical Trials and Statistics Unit, The Institute of Cancer Research, London, UK
| | - L Kilburn
- Clinical Trials and Statistics Unit, The Institute of Cancer Research, London, UK
| | - M Coakley
- The Institute of Cancer Research, London, UK; The Royal Marsden NHS Foundation Trust, Sutton, Surrey, UK
| | - M Beaney
- The Institute of Cancer Research, London, UK
| | - L Fox
- Clinical Trials and Statistics Unit, The Institute of Cancer Research, London, UK
| | - K Goddard
- Clinical Trials and Statistics Unit, The Institute of Cancer Research, London, UK
| | | | - P Proszek
- NIHR Centre for Molecular Pathology, Royal Marsden Hospital, London, UK
| | - P Hall
- University of Edinburgh, Edinburgh, UK
| | - C Harper-Wynne
- Maidstone Hospital, Maidstone and Tunbridge Wells NHS Trust, Maidstone, UK
| | - T Hickish
- University Hospitals Dorset NHS Foundation Trust, Bournemouth, UK
| | - S Kernaghan
- Clinical Trials and Statistics Unit, The Institute of Cancer Research, London, UK
| | | | - A F C Okines
- Breast Unit, The Royal Marsden Hospital, London, UK
| | - C Palmieri
- Clatterbridge Cancer Centre NHS Trust, Liverpool, Wirral, UK
| | - S Perry
- Clinical Trials and Statistics Unit, The Institute of Cancer Research, London, UK
| | - K Randle
- Independent Cancer Patients' Voice, London, UK
| | - C Snowdon
- Clinical Trials and Statistics Unit, The Institute of Cancer Research, London, UK
| | - H Stobart
- Independent Cancer Patients' Voice, London, UK
| | - A M Wardley
- Outreach Research & Innovation Group Ltd, Manchester, UK
| | - D Wheatley
- Royal Cornwall Hospitals NHS Trust, Truro, UK
| | - S Waters
- Velindre Cancer Centre, Velindre University NHS Trust, Cardiff, UK
| | - M C Winter
- Sheffield Teaching Hospitals NHS Foundation Trust, Weston Park Hospital, Sheffield, UK
| | - M Hubank
- The Institute of Cancer Research, London, UK; The Royal Marsden NHS Foundation Trust, Sutton, Surrey, UK
| | - S D Allen
- The Royal Marsden NHS Foundation Trust, Sutton, Surrey, UK
| | - J M Bliss
- Clinical Trials and Statistics Unit, The Institute of Cancer Research, London, UK
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Platt JR, Todd OM, Hall P, Craig Z, Quyn A, Seymour M, Braun M, Roodhart J, Punt C, Christou N, Taieb J, Karoui M, Brown J, Cairns DA, Morton D, Gilbert A, Seligmann JF. FOxTROT2: innovative trial design to evaluate the role of neoadjuvant chemotherapy for treating locally advanced colon cancer in older adults or those with frailty. ESMO Open 2023; 8:100642. [PMID: 36549127 PMCID: PMC9800329 DOI: 10.1016/j.esmoop.2022.100642] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2022] [Revised: 10/19/2022] [Accepted: 10/21/2022] [Indexed: 12/24/2022] Open
Abstract
Treating older adults with cancer is increasingly important in modern oncology practice. However, we currently lack the high-quality evidence needed to guide optimal management of this heterogeneous group. Principally, historic under-recruitment of older adults to clinical trials limits our understanding of how existing evidence can be applied to this group. Such uncertainty is particularly prevalent in the management of colon cancer (CC). With CC being most common in older adults, many patients also suffer from frailty, which is recognised as being strongly associated with poor clinical outcomes. Conducting clinical trials in older adults presents several major challenges, many of which impact the clinical relevance of results to a real-world population. When considering this heterogeneous group, it may be difficult to define the target population, recruit participants effectively, choose an appropriate trial design, and ensure participants remain engaged with the trial during follow-up. Furthermore, after overcoming these challenges, clinical trials tend to enrol highly selected patient cohorts that comprise only the fittest older patients, which are not representative of the wider population. FOxTROT1 was the first phase III randomised controlled trial to illustrate the benefit of neoadjuvant chemotherapy (NAC) in the treatment of CC. Patients receiving NAC had greater 2-year disease-free survival compared to those proceeding straight to surgery. Outcomes for older adults in FOxTROT1 were similarly impressive when compared to their younger counterparts. Yet, this group inevitably represents a fitter subgroup of the older patient population. FOxTROT2 has been designed to investigate NAC in a full range of older adults with CC, including those with frailty. In this review, we describe the key challenges to conducting a robust clinical trial in this heterogeneous patient group, highlight our strategies for overcoming these challenges in FOxTROT2, and explain how we hope to provide clarity on the optimal treatment of CC in older adults.
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Affiliation(s)
- J R Platt
- Department of Oncology, Leeds Institute of Medical Research at St James's, University of Leeds, Leeds. https://twitter.com/Jplatt_19
| | - O M Todd
- Academic Unit for Ageing and Stroke Research, University of Leeds, Leeds. https://twitter.com/ToddOly
| | - P Hall
- University of Edinburgh Cancer Research Centre, Edinburgh
| | - Z Craig
- Leeds Cancer Research UK Clinical Trials Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds
| | - A Quyn
- The John Goligher Colorectal Surgery Unit, St James's University Hospital, The Leeds Teaching Hospitals NHS Trust, Leeds
| | - M Seymour
- Department of Oncology, Leeds Institute of Medical Research at St James's, University of Leeds, Leeds
| | - M Braun
- Department of Medical Oncology, The Christie NHS Foundation Trust, Manchester; School of Medical Sciences, University of Manchester, Manchester, UK
| | - J Roodhart
- Department of Medical Oncology, University Medical Center Utrecht, Utrecht University, Utrecht
| | - C Punt
- Department of Epidemiology, Julius Center for Health Sciences and Primary Care, University Medical Center, Utrecht University, Utrecht, The Netherlands
| | - N Christou
- Department of Digestive Surgery, University Hospital of Limoges, Limoges. https://twitter.com/CNikinc
| | - J Taieb
- Department of Gastroenterology and Digestive Oncology, Georges Pompidou European Hospital, Assistance publique-Hôpitaux de Paris, Sorbonne Paris Cité, University Paris-Cité (Paris Descartes), Paris
| | - M Karoui
- Department of Digestive and Oncological Surgery, Georges Pompidou European Hospital, Assistance publique-Hôpitaux de Paris, Paris Cité University, Paris, France
| | - J Brown
- Leeds Cancer Research UK Clinical Trials Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds
| | - D A Cairns
- Leeds Cancer Research UK Clinical Trials Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds. https://twitter.com/kennycairns
| | - D Morton
- Institute of Cancer and Genomic Medicine, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - A Gilbert
- Department of Oncology, Leeds Institute of Medical Research at St James's, University of Leeds, Leeds
| | - J F Seligmann
- Department of Oncology, Leeds Institute of Medical Research at St James's, University of Leeds, Leeds.
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Reid EA, Abathun E, Diribi J, Mamo Y, Wondemagegnhu T, Hall P, Fallon M, Grant L. Early palliative care in newly diagnosed cancer in Ethiopia: feasibility randomised controlled trial and cost analysis. BMJ Support Palliat Care 2022:spcare-2022-003996. [PMID: 36414402 DOI: 10.1136/spcare-2022-003996] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Accepted: 11/02/2022] [Indexed: 11/23/2022]
Abstract
OBJECTIVES Globally, cancer deaths are rising. In low-and-middle-income countries, there is a gap in access to palliative care (PC). We designed a feasibility trial to study the initiation of early PC in patients with cancer in Addis Ababa, Ethiopia. METHODS A randomised controlled trial (RCT) of standard cancer care versus standard cancer care plus in-home PC was conducted. Follow-up was at 8 and 12 weeks. Primary outcomes were: (1) feasibility, (2) patient-reported PC outcomes (African Palliative Care Association Palliative Outcome Scale (APCA POS)), and (3) costs. RESULTS Of 95 adults randomised (mean age 49.5 years; 66% female), 27 completed 3 study visits. Of these, 89% had stage III or IV disease. Recruitment was feasible, but attrition was high. APCA POS use was feasible, with significant within-arm improvements: 24% versus 18% reduction (p<0.0002, p<0.0025) in PC versus standard care, respectively. Standard care subjects reported higher out-of-pocket payments (5810 Ethiopian birr) (ETB) and lost wages of informal caregivers (74 900 ETB), multiple times an average Ethiopian salary (3696 ETB). CONCLUSION It is feasible to conduct an RCT of early PC for patients with cancer in Ethiopia. Retention was the biggest challenge. This study revealed opportunities to improve care, and important feasibility results to inform future, larger scale PC research in Ethiopia and beyond.
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Affiliation(s)
- Eleanor Anderson Reid
- Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut, USA
- Usher Institute, Center for Population Health Sciences, University of Edinburgh Division of Medical and Radiological Sciences, Edinburgh, UK
| | | | - Jilcha Diribi
- Department of Oncology, Addis Ababa College of Health Sciences School of Medicine, Addis Ababa, Ethiopia
| | | | - Tigeneh Wondemagegnhu
- Department of Oncology, Addis Ababa College of Health Sciences School of Medicine, Addis Ababa, Ethiopia
| | - Peter Hall
- Department of Oncology, University of Edinburgh Western General Hospital, Edinburgh, UK
| | - Marie Fallon
- Palliative Medicine, University of Edinburgh Western General Hospital, Edinburgh, UK
| | - Liz Grant
- Programme Director Global Health: Non Communicable Diseases, University of Edinburgh Global Health Academy, Edinburgh, UK
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Lemmon E, Connearn E, Hall P, Morris E. Successful public and patient involvement in bowel cancer research using linked administrative health data. Int J Popul Data Sci 2022. [PMCID: PMC9644930 DOI: 10.23889/ijpds.v7i3.2014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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Lemmon E, Birch R, Hall P, Morris E, Downing A. Analytical considerations when using the Scottish and English Cancer Registries for applied research: the case of colorectal cancer. Int J Popul Data Sci 2022. [DOI: 10.23889/ijpds.v7i3.2049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/15/2022] Open
Abstract
In this paper, we carry out a retrospective analysis of the Scottish and English cancer registries for the case of colorectal cancer. We aim to assess the comparability of variable coding between the datasets and create derived variables and open access code for use by researchers working with linked Scottish and English cancer registry data.
We bring together the national data dictionaries for the Scottish and English cancer registries and define a list of targeted variables. We establish the consistency of variable coding across the two registries, identifying fully complete, near complete, partial, composite and impossible matched variables. In the case of near complete, partial and composite matches, we create derived variables between the two registries. We liaise with NHS staff working within the retrospective registry teams to validate the derivations. Finally, we produce corresponding documentation for the dissemination and preservation of final data items.
We considered 63 variables for analysis. Preliminary results show that there is a high degree of similarity between the Scottish and English cancer registries. In particular, 82% of variables were fully, nearly or partially matched, with the remaining 12% and 6% composite matches and impossible matches respectively. The session with the respective cancer registry teams will take place in May 2022. At which point we will present our existing results and seek their input into the final derived data items. Following this, we will publish documentation detailing the derived variables and associated code, to be made available to other researchers working with the Scottish and English cancer registries.
This study provides a useful starting point for any researchers seeking to use the linked Scottish and English cancer registry data for applied research. Whilst our analysis has focused on colorectal cancer, the majority of variables are applicable for any cancer. Future research should extend this work to include staging variables for other cancers.
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Lemmon E, Rutherford A, Hall P, Bell D, Henderson D, Downing A, Clark S. The use of social care services by individuals aged 50 and over diagnosed with colorectal cancer in Scotland: a linked data study. Int J Popul Data Sci 2022. [DOI: 10.23889/ijpds.v7i3.2017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/15/2022] Open
Abstract
The objective of this paper is to explore how a colorectal cancer (CRC) diagnosis influences an individual’s use of social care services in Scotland. In particular, we aim to compare this use to individual’s diagnosed with other cancers and to those without a cancer diagnosis.
We use a linked health and social care dataset of the Scottish population aged 50 and over in the financial year 2015/16. Our approach involves several methods to estimate the effect of a CRC diagnosis on social care use. Firstly, we conduct difference in means tests. Secondly, we estimate two-part models of the utilisation of social care for the CRC, other cancer and non-cancer groups. Lastly, we use propensity score matching. Models are estimated for those diagnosed during 2015/16 and for those diagnosed during 2015/16 or with an historical diagnosis.
Preliminary results reveal that the likelihood of receipt of social care services is higher for those diagnosed with CRC compared to those without a cancer diagnosis. Further, individuals with a non-CRC cancer diagnosis are more likely to receive social care services compared to those without a cancer diagnosis, but they are less likely to receive social care compared to those with a CRC diagnosis. Further, the likelihood of care receipt for the CRC and other cancer group increases as the number of years since a cancer diagnosis increases. In terms of the number of services received, CRC patients and those with other types of cancer receive fewer services when compared to those without a cancer diagnosis.
Our paper has demonstrated that a CRC diagnosis has a significant impact on an individual’s use of social care services. However, conditional on receiving social care, the number of services received is lower for individuals with CRC. Further research is required to understand whether the needs of those individuals are being met.
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23
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Henriksen PA, Hall P, Oikonomidou O, MacPherson IR, Maclean M, Lewis S, McVicars H, Broom A, Scott F, McKay P, Borley A, Rowntree C, Lord S, Collins G, Radford J, Guppy A, Payne JR, Newby DE, Mills NL, Lang NN. Rationale and Design of the Cardiac CARE Trial: A Randomized Trial of Troponin-Guided Neurohormonal Blockade for the Prevention of Anthracycline Cardiotoxicity. Circ Heart Fail 2022; 15:e009445. [PMID: 35766037 DOI: 10.1161/circheartfailure.121.009445] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Anthracyclines are effective cytotoxic drugs used in the treatment of breast cancer and lymphoma but are associated with myocardial injury, left ventricular dysfunction, and heart failure. Anthracycline-induced cardiotoxicity is highly variable in severity and without a proven therapeutic intervention. β-Adrenergic receptor blockers and renin-angiotensin-system inhibitor therapies have been associated with modest cardioprotective effects in unselected patients. METHODS The Cardiac CARE trial is a multicentre prospective randomized open-label blinded end point trial of combination β-adrenergic receptor blocker and renin-angiotensin-system inhibitor therapy in patients with breast cancer and non-Hodgkin lymphoma receiving anthracycline chemotherapy that is associated with myocardial injury. Patients at higher risk of cardiotoxicity with plasma high-sensitivity cTnI (cardiac troponin I) concentrations in the upper tertile at the end of chemotherapy are randomized to standard of care plus combination candesartan and carvedilol therapy or standard of care alone. All patients undergo cardiac magnetic resonance imaging before and 6 months after anthracycline treatment. The primary end point is the change in left ventricular ejection fraction at 6 months after chemotherapy. In low-risk nonrandomized patients, left ventricular ejection fraction before and 6 months after anthracycline will be compared with define the specificity of the high-sensitivity cTnI assay for identifying low-risk participants who do not develop left ventricular systolic dysfunction. DISCUSSION Cardiac CARE will examine whether cardiac biomarker monitoring identifies patients at risk of left ventricular dysfunction following anthracycline chemotherapy and whether troponin-guided treatment with combination candesartan and carvedilol therapy prevents the development of left ventricular dysfunction in these high-risk patients.
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Affiliation(s)
- Peter A Henriksen
- BHF Centre for Cardiovascular Science (P.A.H., D.E.N., N.L.M.), University of Edinburgh, United Kingdom
| | - Peter Hall
- Cancer Research UK, Edinburgh Centre, MRC Institute Genetics and Molecular Medicine (P.H., O.O., H.M.), University of Edinburgh, United Kingdom
| | - Olga Oikonomidou
- Cancer Research UK, Edinburgh Centre, MRC Institute Genetics and Molecular Medicine (P.H., O.O., H.M.), University of Edinburgh, United Kingdom
| | - Iain R MacPherson
- Institute of Cancer Sciences (I.R.M.), University of Glasgow, United Kingdom
| | - Morag Maclean
- Edinburgh Clinical Trials Unit (M.M., S. Lewis), University of Edinburgh, United Kingdom
| | - Steff Lewis
- Edinburgh Clinical Trials Unit (M.M., S. Lewis), University of Edinburgh, United Kingdom
| | - Heather McVicars
- Cancer Research UK, Edinburgh Centre, MRC Institute Genetics and Molecular Medicine (P.H., O.O., H.M.), University of Edinburgh, United Kingdom
| | - Angus Broom
- Department of Haematology, Western General Hospital, Edinburgh, United Kingdom (A. Broom, F.S.)
| | - Fiona Scott
- Department of Haematology, Western General Hospital, Edinburgh, United Kingdom (A. Broom, F.S.)
| | - Pam McKay
- Department of Haematology, Beatson Oncology Centre, Glasgow, United Kingdom (P.M.)
| | - Annabel Borley
- Velindre Cancer Centre, Velindre University NHS Trust, Cardiff, United Kingdom (A. Borley)
| | - Clare Rowntree
- University Hospital of Wales, Cardiff, United Kingdom (C.R.)
| | - Simon Lord
- Department of Oncology, University of Oxford, United Kingdom (S. Lord)
| | - Graham Collins
- Oxford Cancer and Hematology Centre, Churchill Hospital, United Kingdom (G.C.)
| | - John Radford
- University of Manchester and Christie NHS Foundation, United Kingdom (J.R.)
| | - Amy Guppy
- Mount Vernon Cancer Centre, Middlesex, United Kingdom (A.G.)
| | - John R Payne
- Scottish National Advanced Heart Failure Service, Golden Jubilee National Hospital, Glasgow, United Kingdom (J.R.P.)
| | - David E Newby
- BHF Centre for Cardiovascular Science (P.A.H., D.E.N., N.L.M.), University of Edinburgh, United Kingdom
| | - Nick L Mills
- BHF Centre for Cardiovascular Science (P.A.H., D.E.N., N.L.M.), University of Edinburgh, United Kingdom
| | - Ninian N Lang
- Institute of Cardiovascular and Medical Sciences (N.N.L.), University of Glasgow, United Kingdom
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Peters A, Marashi H, Jordan LB, Hannington L, Vallet M, Cartwright D, Yi-Soh F, Makaranka S, Urquhart G, Hall P, Elsberger B. Steroid receptor positivity and tumour type are influencing Oncotype DX recurrence score and subsequent treatment delivery in Scotland. European Journal of Surgical Oncology 2022. [DOI: 10.1016/j.ejso.2022.03.221] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Pearce J, Swinson D, Cairns D, Nair S, Baxter M, Petty R, Seymour M, Hall P, Velikova G. Frailty and treatment outcome in advanced gastro-oesophageal cancer: An exploratory analysis of the GO2 trial. J Geriatr Oncol 2022; 13:287-293. [PMID: 34955446 PMCID: PMC8986151 DOI: 10.1016/j.jgo.2021.12.009] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2021] [Revised: 11/12/2021] [Accepted: 12/08/2021] [Indexed: 11/16/2022]
Abstract
INTRODUCTION Research into the optimal management of frail patients with cancer is limited and treatment decision-making in this cohort can be difficult. A number of measures have been developed to assess frailty, but few studies explore the correlation between frailty measures and cancer treatment outcomes. METHODS This retrospective cohort study is an exploratory analysis of the GO2 randomised controlled trial. GO2 recruited both older and frail younger patients commencing first-line palliative chemotherapy for advanced gastro-oesophageal (aGO) cancer. This analysis aims to explore the correlation between baseline frailty and treatment outcome. Baseline frailty measures were derived from clinical data and included ECOG Performance Status (PS), the GO2 Frailty Score (GO2FS), Geriatric-8 (G8), Cancer and Aging Research Group (CARG) toxicity score and a 'modified' Rockwood Clinical Frailty Scale (mCFS). Novel patient-centred composite measure Overall Treatment Utility (OTU) was the primary endpoint. Ordinal logistic regression was undertaken to give odds ratios for poor vs good/intermediate OTU. Secondary endpoints were progression-free and overall survival. Models were adjusted for age, sex, histology, metastases, Trastuzumab and renal/hepatic function. RESULTS In GO2, 514 patients were randomised between three chemotherapy dose-levels; all of these patients were assessed for OTU and are included in this analysis. Worse GO2FS, mCFS and G8 scores all had a statistically significant association with poor (vs good/intermediate) OTU, progression and death, which persisted after adjustment. Adjusted odds ratios for poor OTU amongst those with the worst GO2FS and mCFS and best G8 scores were as follows: 1.85 (95% confidence interval [CI] 1.20-2.88) for GO2FS ≥3 ('severely frail'), 1.72 (1.19-2.50) for mCFS 5+ ('frail') and 0.57 (0.32-1.00) for G8 > 14 ('normal'). Worse ECOG PS and CARG scores did not have a statistically significant association with poor OTU/progression/death. CONCLUSION In this study, frailty identified via GO2FS, mCFS and G8 conveyed a statistically significant increased risk of worse treatment outcome in older and frail younger patients with aGO cancer. Frailty assessment provides information over and above PS and should be integrated alongside routine assessments in research and clinical practice. In the absence of prospective data, frailty measures can be derived retrospectively to build the evidence base around optimal care of frailer patients.
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Affiliation(s)
- Jessica Pearce
- Leeds Institute of Medical Research at St James', University of Leeds, Woodhouse, Leeds, LS2 9JT, UK; Leeds Teaching Hospitals NHS Trust, Beckett Street, Leeds LS9 7TF, UK.
| | - Daniel Swinson
- Leeds Teaching Hospitals NHS Trust, Beckett Street, Leeds LS9 7TF, UK
| | - David Cairns
- Leeds Cancer Research UK Clinical Trials Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds LS2 9JT, UK
| | - Sherena Nair
- Leeds Teaching Hospitals NHS Trust, Beckett Street, Leeds LS9 7TF, UK
| | - Mark Baxter
- Division of Molecular and Clinical Medicine, Ninewells Hospital and Medical School, University of Dundee, Nethergate, Dundee DD1 4HN, UK
| | - Russell Petty
- Tayside Cancer Centre, Ninewells Hospital and Medical School, NHS Tayside, James Arrott Dr, Dundee DD2 1SG, UK
| | - Matt Seymour
- Leeds Institute of Medical Research at St James', University of Leeds, Woodhouse, Leeds, LS2 9JT, UK; Leeds Teaching Hospitals NHS Trust, Beckett Street, Leeds LS9 7TF, UK
| | - Peter Hall
- Cancer Research UK Edinburgh Centre, MRC Institute of Genetics & Molecular Medicine, The University of Edinburgh, Western General Hospital, Crewe Road South, Edinburgh EH4 2XR, UK
| | - Galina Velikova
- Leeds Institute of Medical Research at St James', University of Leeds, Woodhouse, Leeds, LS2 9JT, UK; Leeds Teaching Hospitals NHS Trust, Beckett Street, Leeds LS9 7TF, UK
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Reid E, Abathun E, Diribi J, Mamo Y, Wondemagegnhu T, Hall P, Fallon M, Grant L. Early integrated palliative care in patients newly diagnosed with cancer in Ethiopia: a randomised controlled trial and cost–consequence analysis. Lancet Glob Health 2022. [DOI: 10.1016/s2214-109x(22)00142-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Macpherson I, McIntosh S, Kilburn L, Tovey H, Kernaghan S, Goddard K, Bhattacharya I, Boyd C, Coles C, Kirwan C, Mackenzie M, O’Brien C, Ring A, Snowdon C, Stobart H, Wheatley D, Wardley A, Shaaban A, Hall P, Cameron D, Bliss J. Abstract OT2-05-01: The HER2-RADiCAL study (Response ADaptive CAre pLan) - Tailoring treatment for HER2 positive early breast cancer. Cancer Res 2022. [DOI: 10.1158/1538-7445.sabcs21-ot2-05-01] [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 presence or absence of residual disease following neoadjuvant systemic anti-cancer therapy (neoSACT) for HER2-positive early breast cancer (HER2+ EBC) provides powerful prognostic information that may guide subsequent adjuvant treatment for the individual patient. Pathological complete response (pCR) following neoSACT identifies a population with excellent outcomes in whom the balance of toxicity associated with the current treatment pathway may be disproportionate to the absolute clinical benefit. Aims HER2-RADiCAL seeks to reduce the burden of toxicity and healthcare costs of treating HER2+ EBC by testing the hypothesis that pCR can be used as a functional response biomarker to select patients who can safely receive less intensive therapy, including avoiding anthracyclines, with minimal or no loss of efficacy in the population. Trial design and eligibility criteria HER2-RADiCAL is a response-directed interventional cohort (single-arm) study embedded within a real-world data driven clinical pathway model. Participants will be registered within 6 weeks of completion of breast cancer surgery. The main eligibility criteria include clinical stage T1N1 or T2N0-1 at diagnosis and locally-determined pCR (ypT0/Tis ypN0) after standard of care taxane-based (non-anthracycline) neoadjuvant chemotherapy, trastuzumab and pertuzumab. After registration participants will continue to receive trastuzumab to complete a total of 9 cycles including those (neo-)adjuvant cycles administered prior to study entry. Participants will receive no further pertuzumab nor any adjuvant chemotherapy. Statistical methods The primary clinical endpoint is relapse free interval. Recruitment of 720 participants over 3 years will provide 90% power to exclude an event rate >6.5% at 3 years. Secondary endpoints include relapse-free survival, invasive breast cancer-free survival, invasive disease-free survival, distant recurrence-free interval, breast cancer-free interval, treatment pathway adherence and cost-effectiveness. Real-world data driven clinical pathway model Health economic modelling will compare the protocol-driven study cohort with two comparator pathways: a non-response adapted maximum therapy pathway (the standard clinical pathway prior to the study) and a real-world representative pathway taken from 4-nation UK National Health Service data at the beginning and end of the study. Patient and public involvement Patient advocates have shaped the research by confirming that the main outcomes being evaluated are important to patients and that the interventional cohort design, with power to exclude an absolute risk of recurrence outwith a 2-3% margin of historical control data, is acceptable and preferable to a randomised controlled trial, which would take longer to get answers and need many more patients to be included. They have been involved in protocol design, including methodology, sample collection and patient follow-up, and their input has shaped the patient information materials and consent forms. Patient advocates will have an ongoing key role in overseeing the progress of the study as members of the Trial Management Group, and they will also have an important role in communicating the study results to patients and the public. Current status HER2-RADiCAL is planned to open at ~40 UK sites commencing in September 2021.
Citation Format: Iain Macpherson, Stuart McIntosh, Lucy Kilburn, Holly Tovey, Sarah Kernaghan, Katie Goddard, Indrani Bhattacharya, Clinton Boyd, Charlotte Coles, Cliona Kirwan, Mairead Mackenzie, Ciara O’Brien, Alistair Ring, Claire Snowdon, Hilary Stobart, Duncan Wheatley, Andrew Wardley, Abeer Shaaban, Peter Hall, David Cameron, Judith Bliss. The HER2-RADiCAL study (Response ADaptive CAre pLan) - Tailoring treatment for HER2 positive early breast cancer [abstract]. In: Proceedings of the 2021 San Antonio Breast Cancer Symposium; 2021 Dec 7-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2022;82(4 Suppl):Abstract nr OT2-05-01.
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Affiliation(s)
| | | | - Lucy Kilburn
- Clinical Trials and Statistics Unit at The Institute of Cancer Research, London, United Kingdom
| | - Holly Tovey
- Clinical Trials and Statistics Unit at The Institute of Cancer Research, London, United Kingdom
| | - Sarah Kernaghan
- Clinical Trials and Statistics Unit at The Institute of Cancer Research, London, United Kingdom
| | - Katie Goddard
- Clinical Trials and Statistics Unit at The Institute of Cancer Research, London, United Kingdom
| | | | - Clinton Boyd
- Belfast Health and Social Care Trust, Belfast, United Kingdom
| | - Charlotte Coles
- Department of Oncology, University of Cambridge, Cambridge, United Kingdom
| | - Cliona Kirwan
- The Christie NHS Foundation Trust, Manchester, United Kingdom
| | | | - Ciara O’Brien
- The Christie NHS Foundation Trust, Manchester, United Kingdom
| | - Alistair Ring
- The Royal Marsden NHS Foundation Trust, Sutton, United Kingdom
| | - Claire Snowdon
- Clinical Trials and Statistics Unit at The Institute of Cancer Research, London, United Kingdom
| | - Hilary Stobart
- Independent Cancer Patients' Voice, London, United Kingdom
| | | | - Andrew Wardley
- Outreach Research & Innovation Group and AstraZeneca, Manchester, United Kingdom
| | - Abeer Shaaban
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| | - Peter Hall
- The University of Edinburgh, Edinburgh, United Kingdom
| | - David Cameron
- The University of Edinburgh, Edinburgh, United Kingdom
| | - Judith Bliss
- Clinical Trials and Statistics Unit at The Institute of Cancer Research, London, United Kingdom
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Yau C, Osdoit M, van der Noordaa M, Shad S, Wei J, de Croze D, Hamy AS, Laé M, Reyal F, Sonke GS, Steenbruggen TG, van Seijen M, Wesseling J, Martín M, Del Monte-Millán M, López-Tarruella S, Boughey JC, Goetz MP, Hoskin T, Gould R, Valero V, Edge SB, Abraham JE, Bartlett JMS, Caldas C, Dunn J, Earl H, Hayward L, Hiller L, Provenzano E, Sammut SJ, Thomas JS, Cameron D, Graham A, Hall P, Mackintosh L, Fan F, Godwin AK, Schwensen K, Sharma P, DeMichele AM, Cole K, Pusztai L, Kim MO, van 't Veer LJ, Esserman LJ, Symmans WF. Residual cancer burden after neoadjuvant chemotherapy and long-term survival outcomes in breast cancer: a multicentre pooled analysis of 5161 patients. Lancet Oncol 2022; 23:149-160. [PMID: 34902335 PMCID: PMC9455620 DOI: 10.1016/s1470-2045(21)00589-1] [Citation(s) in RCA: 140] [Impact Index Per Article: 70.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Revised: 10/06/2021] [Accepted: 10/07/2021] [Indexed: 12/14/2022]
Abstract
BACKGROUND Previous studies have independently validated the prognostic relevance of residual cancer burden (RCB) after neoadjuvant chemotherapy. We used results from several independent cohorts in a pooled patient-level analysis to evaluate the relationship of RCB with long-term prognosis across different phenotypic subtypes of breast cancer, to assess generalisability in a broad range of practice settings. METHODS In this pooled analysis, 12 institutes and trials in Europe and the USA were identified by personal communications with site investigators. We obtained participant-level RCB results, and data on clinical and pathological stage, tumour subtype and grade, and treatment and follow-up in November, 2019, from patients (aged ≥18 years) with primary stage I-III breast cancer treated with neoadjuvant chemotherapy followed by surgery. We assessed the association between the continuous RCB score and the primary study outcome, event-free survival, using mixed-effects Cox models with the incorporation of random RCB and cohort effects to account for between-study heterogeneity, and stratification to account for differences in baseline hazard across cancer subtypes defined by hormone receptor status and HER2 status. The association was further evaluated within each breast cancer subtype in multivariable analyses incorporating random RCB and cohort effects and adjustments for age and pretreatment clinical T category, nodal status, and tumour grade. Kaplan-Meier estimates of event-free survival at 3, 5, and 10 years were computed for each RCB class within each subtype. FINDINGS We analysed participant-level data from 5161 patients treated with neoadjuvant chemotherapy between Sept 12, 1994, and Feb 11, 2019. Median age was 49 years (IQR 20-80). 1164 event-free survival events occurred during follow-up (median follow-up 56 months [IQR 0-186]). RCB score was prognostic within each breast cancer subtype, with higher RCB score significantly associated with worse event-free survival. The univariable hazard ratio (HR) associated with one unit increase in RCB ranged from 1·55 (95% CI 1·41-1·71) for hormone receptor-positive, HER2-negative patients to 2·16 (1·79-2·61) for the hormone receptor-negative, HER2-positive group (with or without HER2-targeted therapy; p<0·0001 for all subtypes). RCB score remained prognostic for event-free survival in multivariable models adjusted for age, grade, T category, and nodal status at baseline: the adjusted HR ranged from 1·52 (1·36-1·69) in the hormone receptor-positive, HER2-negative group to 2·09 (1·73-2·53) in the hormone receptor-negative, HER2-positive group (p<0·0001 for all subtypes). INTERPRETATION RCB score and class were independently prognostic in all subtypes of breast cancer, and generalisable to multiple practice settings. Although variability in hormone receptor subtype definitions and treatment across patients are likely to affect prognostic performance, the association we observed between RCB and a patient's residual risk suggests that prospective evaluation of RCB could be considered to become part of standard pathology reporting after neoadjuvant therapy. FUNDING National Cancer Institute at the US National Institutes of Health.
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Affiliation(s)
- Christina Yau
- Department of Surgery, University of California, San Francisco, San Francisco, CA, USA.
| | - Marie Osdoit
- Department of Surgery, University of California, San Francisco, San Francisco, CA, USA; Department of Surgery, Institut Curie, Paris, France
| | | | - Sonal Shad
- Department of Surgery, University of California, San Francisco, San Francisco, CA, USA
| | - Jane Wei
- Department of Surgery, University of California, San Francisco, San Francisco, CA, USA
| | - Diane de Croze
- Department of Tumor Biology, Institut Curie, Paris, France
| | | | - Marick Laé
- Department of Tumor Biology, Institut Curie, Paris, France; Department of Pathology, Université de Rouen Normandie, Rouen, France
| | - Fabien Reyal
- Department of Surgery, Institut Curie, Paris, France
| | - Gabe S Sonke
- Department of Medical Oncology, Netherlands Cancer Institute, Amsterdam, Netherlands
| | - Tessa G Steenbruggen
- Department of Medical Oncology, Netherlands Cancer Institute, Amsterdam, Netherlands
| | - Maartje van Seijen
- Department of Pathology, Netherlands Cancer Institute, Amsterdam, Netherlands
| | - Jelle Wesseling
- Department of Pathology, Netherlands Cancer Institute, Amsterdam, Netherlands
| | - Miguel Martín
- Department of Medical Oncology, Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
| | - Maria Del Monte-Millán
- Department of Medical Oncology, Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
| | - Sara López-Tarruella
- Department of Medical Oncology, Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
| | | | | | - Tanya Hoskin
- Department of Health Sciences Research, Mayo Clinic, Rochester, MN, USA
| | - Rebekah Gould
- Department of Pathology and Translational Molecular Pathology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Vicente Valero
- Department of Breast Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Stephen B Edge
- Department of Surgical Oncology, Roswell Park Cancer Institute, Buffalo, NY, USA
| | - Jean E Abraham
- Department of Oncology, University of Cambridge, Cambridge, UK
| | - John M S Bartlett
- Diagnostic Development Program, Ontario Institute for Cancer Research, Toronto, Canada; Deanery of Molecular, Genetic and Population Health Sciences, Edinburgh Cancer Research Centre, Edinburgh, UK; Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada
| | - Carlos Caldas
- Department of Oncology, University of Cambridge, Cambridge, UK
| | - Janet Dunn
- Warwick Clinical Trials Unit, University of Warwick, Coventry, UK
| | - Helena Earl
- Department of Oncology, University of Cambridge, Cambridge, UK
| | - Larry Hayward
- Department of Oncology, Western General Hospital, Edinburgh, UK
| | - Louise Hiller
- Warwick Clinical Trials Unit, University of Warwick, Coventry, UK
| | - Elena Provenzano
- Department of Histopathology, University of Cambridge, Cambridge, UK
| | | | - Jeremy S Thomas
- Department of Pathology, Western General Hospital, Edinburgh, UK
| | - David Cameron
- Department of Oncology, Western General Hospital, Edinburgh, UK
| | - Ashley Graham
- Department of Pathology, Western General Hospital, Edinburgh, UK
| | - Peter Hall
- Department of Oncology, Western General Hospital, Edinburgh, UK
| | - Lorna Mackintosh
- Department of Pathology, Western General Hospital, Edinburgh, UK
| | - Fang Fan
- Department of Pathology and Laboratory Medicine, University of Kansas Medical Center, Kansas City, KS, USA
| | - Andrew K Godwin
- Department of Pathology and Laboratory Medicine, University of Kansas Medical Center, Kansas City, KS, USA
| | - Kelsey Schwensen
- Department of Medical Oncology, University of Kansas Medical Center, Kansas City, KS, USA
| | - Priyanka Sharma
- Department of Medical Oncology, University of Kansas Medical Center, Kansas City, KS, USA
| | - Angela M DeMichele
- Department of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Kimberly Cole
- Department of Pathology, Yale University, New Haven, CT, USA
| | - Lajos Pusztai
- Department of Medical Oncology, Yale University, New Haven, CT, USA
| | - Mi-Ok Kim
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, CA, USA
| | - Laura J van 't Veer
- Department of Laboratory Medicine, University of California, San Francisco, San Francisco, CA, USA
| | - Laura J Esserman
- Department of Surgery, University of California, San Francisco, San Francisco, CA, USA
| | - W Fraser Symmans
- Department of Pathology and Translational Molecular Pathology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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Berdunov V, Millen S, Paramore A, Hall P, Perren T, Brown R, Griffin J, Reynia S, Fryer N, Longworth L. Cost-effectiveness analysis of the Oncotype DX Breast Recurrence Score test in node-positive early breast cancer. J Med Econ 2022; 25:591-604. [PMID: 35416089 DOI: 10.1080/13696998.2022.2066399] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
AIMS Given the high rate of adverse events and high cost of adjuvant chemotherapy, it is optimal to avoid its use when endocrine therapy is equally effective at preventing distant recurrence of early breast cancer. The Oncotype DX test is a predictive and prognostic multigene assay used to guide adjuvant chemotherapy decisions in early breast cancer based on a Recurrence Score (RS) result. A model-based cost-effectiveness analysis compared the Oncotype DX test to clinical risk tools alone for HR+/HER2- node-positive (1-3 axillary lymph nodes) early breast cancer patients based on results from the RxPONDER trial. MATERIALS AND METHODS A decision-tree and Markov model was developed in Microsoft Excel. Distributions of patients and distant recurrence probabilities with endocrine and chemo-endocrine therapy were derived from the RxPONDER trial, TransATAC and SWOG-8814. Chemotherapy assignment data were obtained from the Clalit registry. The cost of adjuvant chemotherapy was based on the distribution of treatments used in the UK combined with published drug unit costs in the UK. The cost of distant recurrence and health state utility values were obtained from literature. RESULTS The Oncotype DX test was found to be more effective (with an estimated 0.02 additional QALYs) at a lower estimated cost (-£989) compared to clinical risk tools alone. The results did not substantially change with more conservative clinical and cost scenarios. The RxPONDER trial was restricted to RS 0-25, and data synthesis with other studies was required to inform the analysis, which increased uncertainty. CONCLUSIONS The Oncotype DX test is highly likely to be cost-effective in node-positive early breast cancer. The results were driven by reduction in the use of chemotherapy with consequence avoidance of the costs and harmful effects of chemotherapy. Targeted treatment of a minority (11%) of women with RS 26-100 who benefit from chemotherapy reduced cost and improved survival.
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Affiliation(s)
| | | | | | - Peter Hall
- Edinburgh Cancer Research Centre, University of Edinburgh, Edinburgh, UK
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Hall CC, Skipworth RJ, Blackwood H, Brown D, Cook J, Diernberger K, Dixon E, Gibson V, Graham C, Hall P, Haraldsdottir E, Hopkinson J, Lloyd A, Maddocks M, Norris L, Tuck S, Fallon MT, Laird BJ. A randomized, feasibility trial of an exercise and nutrition-based rehabilitation programme (ENeRgy) in people with cancer. J Cachexia Sarcopenia Muscle 2021; 12:2034-2044. [PMID: 34612012 PMCID: PMC8718057 DOI: 10.1002/jcsm.12806] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Revised: 08/03/2021] [Accepted: 08/23/2021] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Despite rehabilitation being increasingly advocated for people living with incurable cancer, there is limited evidence supporting efficacy or component parts. The progressive decline in function and nutritional in this population would support an approach that targets these factors. This trial aimed to assess the feasibility of an exercise and nutrition based rehabilitation programme in people with incurable cancer. METHODS We randomized community dwelling adults with incurable cancer to either a personalized exercise and nutrition based programme (experimental arm) or standard care (control arm) for 8 weeks. Endpoints included feasibility, quality of life, physical activity (step count), and body weight. Qualitative and health economic analyses were also included. RESULTS Forty-five patients were recruited (23 experimental arm, 22 control arm). There were 26 men (58%), and the median age was 78 years (IQR 69-84). At baseline, the median BMI was 26 kg/m2 (IQR: 22-29), and median weight loss in the previous 6 months was 5% (IQR: -12% to 0%). Adherence to the experimental arm was >80% in 16/21 (76%) patients. There was no statistically significant difference in the following between trial arms: step count - median % change from baseline to endpoint, per trial arm (experimental -18.5% [IQR: -61 to 65], control 5% [IQR: -32 to 50], P = 0.548); weight - median % change from baseline to endpoint, per trial arm (experimental 1%[IQR: -3 to 3], control -0.5% [IQR: -3 to 1], P = 0.184); overall quality of life - median % change from baseline to endpoint, per trial arm (experimental 0% [IQR: -20 to 19], control 0% [IQR: -23 to 33], P = 0.846). Qualitative findings observed themes of capability, opportunity, and motivation amongst patients in the experimental arm. The mean incremental cost of the experimental arm versus control was £-319.51 [CI -7593.53 to 6581.91], suggesting the experimental arm was less costly. CONCLUSIONS An exercise and nutritional rehabilitation intervention is feasible and has potential benefits for people with incurable cancer. A larger trial is now warranted to test the efficacy of this approach.
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Affiliation(s)
- Charlie C. Hall
- St Columba's HospiceEdinburghUK
- Institute of Genetics and CancerUniversity of EdinburghEdinburghUK
| | | | | | | | | | - Katharina Diernberger
- Institute of Genetics and CancerUniversity of EdinburghEdinburghUK
- Edinburgh Clinical Trials UnitUniversity of EdinburghEdinburghUK
| | - Elizabeth Dixon
- Southampton Clinical Trials UnitUniversity of SouthamptonSouthamptonUK
| | | | - Catriona Graham
- Edinburgh Clinical Research FacilityUniversity of EdinburghEdinburghUK
| | - Peter Hall
- Institute of Genetics and CancerUniversity of EdinburghEdinburghUK
- Edinburgh Clinical Trials UnitUniversity of EdinburghEdinburghUK
| | | | | | | | - Matthew Maddocks
- Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, Kings CollegeLondonUK
| | - Lucy Norris
- Institute of Genetics and CancerUniversity of EdinburghEdinburghUK
| | - Sharon Tuck
- Edinburgh Clinical Trials UnitUniversity of EdinburghEdinburghUK
| | - Marie T. Fallon
- Institute of Genetics and CancerUniversity of EdinburghEdinburghUK
| | - Barry J.A. Laird
- St Columba's HospiceEdinburghUK
- Institute of Genetics and CancerUniversity of EdinburghEdinburghUK
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Pearce J, Swinson D, Cairns D, Nair S, Baxter M, Petty R, Seymour M, Hall P, Velikova G. Frailty and treatment outcome in advanced gastro-oesophageal cancer: an exploratory analysis of the GO2 trial. J Geriatr Oncol 2021. [DOI: 10.1016/s1879-4068(21)00394-5] [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: 11/17/2022]
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Aftimos P, Oliveira M, Irrthum A, Fumagalli D, Sotiriou C, Gal-Yam EN, Robson ME, Ndozeng J, Di Leo A, Ciruelos EM, de Azambuja E, Viale G, Scheepers ED, Curigliano G, Bliss JM, Reis-Filho JS, Colleoni M, Balic M, Cardoso F, Albanell J, Duhem C, Marreaud S, Romagnoli D, Rojas B, Gombos A, Wildiers H, Guerrero-Zotano A, Hall P, Bonetti A, Larsson KF, Degiorgis M, Khodaverdi S, Greil R, Sverrisdóttir Á, Paoli M, Seyll E, Loibl S, Linderholm B, Zoppoli G, Davidson NE, Johannsson OT, Bedard PL, Loi S, Knox S, Cameron DA, Harbeck N, Montoya ML, Brandão M, Vingiani A, Caballero C, Hilbers FS, Yates LR, Benelli M, Venet D, Piccart MJ. Genomic and Transcriptomic Analyses of Breast Cancer Primaries and Matched Metastases in AURORA, the Breast International Group (BIG) Molecular Screening Initiative. Cancer Discov 2021; 11:2796-2811. [PMID: 34183353 PMCID: PMC9414283 DOI: 10.1158/2159-8290.cd-20-1647] [Citation(s) in RCA: 68] [Impact Index Per Article: 22.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Revised: 04/05/2021] [Accepted: 06/11/2021] [Indexed: 02/01/2023]
Abstract
AURORA aims to study the processes of relapse in metastatic breast cancer (MBC) by performing multi-omics profiling on paired primary tumors and early-course metastases. Among 381 patients (primary tumor and metastasis pairs: 252 targeted gene sequencing, 152 RNA sequencing, 67 single nucleotide polymorphism arrays), we found a driver role for GATA1 and MEN1 somatic mutations. Metastases were enriched in ESR1, PTEN, CDH1, PIK3CA, and RB1 mutations; MDM4 and MYC amplifications; and ARID1A deletions. An increase in clonality was observed in driver genes such as ERBB2 and RB1. Intrinsic subtype switching occurred in 36% of cases. Luminal A/B to HER2-enriched switching was associated with TP53 and/or PIK3CA mutations. Metastases had lower immune score and increased immune-permissive cells. High tumor mutational burden correlated to shorter time to relapse in HR+/HER2- cancers. ESCAT tier I/II alterations were detected in 51% of patients and matched therapy was used in 7%. Integration of multi-omics analyses in clinical practice could affect treatment strategies in MBC. SIGNIFICANCE: The AURORA program, through the genomic and transcriptomic analyses of matched primary and metastatic samples from 381 patients with breast cancer, coupled with prospectively collected clinical data, identified genomic alterations enriched in metastases and prognostic biomarkers. ESCAT tier I/II alterations were detected in more than half of the patients.This article is highlighted in the In This Issue feature, p. 2659.
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Affiliation(s)
- Philippe Aftimos
- Institut Jules Bordet - Université Libre de Bruxelles, Brussels, Belgium
| | - Mafalda Oliveira
- Medical Oncology Department, Vall d'Hebron University Hospital, Barcelona, Spain
| | | | | | - Christos Sotiriou
- Institut Jules Bordet - Université Libre de Bruxelles, Brussels, Belgium
| | | | - Mark E Robson
- Memorial Sloan Kettering Cancer Center, New York, New York
| | - Justin Ndozeng
- Institut Jules Bordet - Université Libre de Bruxelles, Brussels, Belgium
| | | | | | | | - Giuseppe Viale
- IEO, Istituto Europeo di Oncologia, IRCCS, and University of Milan, Milan, Italy
| | | | - Giuseppe Curigliano
- IEO, Istituto Europeo di Oncologia, IRCCS, and University of Milan, Milan, Italy
| | - Judith M Bliss
- The Institute of Cancer Research, London, United Kingdom
| | | | - Marco Colleoni
- IEO, Istituto Europeo di Oncologia, IRCCS, and University of Milan, Milan, Italy
| | | | - Fatima Cardoso
- Breast Unit, Champalimaud Clinical Center/Champalimaud Foundation, Lisbon, Portugal
| | - Joan Albanell
- Hospital del Mar - CIBERONC; IMIM, Barcelona; Pompeu Fabra University, Barcelona, Spain
| | - Caroline Duhem
- Centre Hospitalier Luxembourg, Luxembourg City, Luxembourg
| | | | | | - Beatriz Rojas
- CIOCC (Centro Integral Oncologico "Clara Campal"), Madrid, Spain
| | - Andrea Gombos
- Institut Jules Bordet - Université Libre de Bruxelles, Brussels, Belgium
| | | | | | - Peter Hall
- University of Edinburgh Cancer Research Centre, Edinburgh, United Kingdom
| | - Andrea Bonetti
- Department of Oncology AZIENDA ULSS 9 Verona, Verona, Italy
| | | | | | - Silvia Khodaverdi
- Sana Klinikum Offenbach, Klinik für Gynaekologie und Geburtshilfe, Offenbach, Germany
| | - Richard Greil
- Paracelsus Medical University Salzburg, Salzburg Cancer Research Institute-CCCIT and Cancer Cluster Salzburg, Salzburg, Austria
| | | | | | - Ethel Seyll
- Institut Jules Bordet - Université Libre de Bruxelles, Brussels, Belgium
| | | | | | - Gabriele Zoppoli
- Università degli Studi di Genova and IRCCS Ospedale Policlinico San Martino, San Martino, Italy
| | - Nancy E Davidson
- Fred Hutchinson Cancer Research Center and University of Washington, Seattle, Washington
| | | | | | - Sherene Loi
- Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Susan Knox
- Europa Donna- The European Breast Cancer Coalition, Milan, Italy
| | - David A Cameron
- University of Edinburgh Cancer Research Centre, Edinburgh, United Kingdom
| | - Nadia Harbeck
- Breast Center, LMU University Hospital, Munich, Germany, and West German Study Group, Moenchengladbach, Germany
| | | | - Mariana Brandão
- Institut Jules Bordet - Université Libre de Bruxelles, Brussels, Belgium
| | - Andrea Vingiani
- Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | | | | | - Lucy R Yates
- Wellcome Trust Sanger Institute, London, United Kingdom
| | | | - David Venet
- Institut Jules Bordet - Université Libre de Bruxelles, Brussels, Belgium
| | - Martine J Piccart
- Institut Jules Bordet - Université Libre de Bruxelles, Brussels, Belgium.
- Breast International Group, Brussels, Belgium
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Al-Shahi Salman R, Keerie C, Stephen J, Lewis S, Norrie J, Dennis MS, Newby DE, Wardlaw JM, Lip GY, Parry-Jones A, White PM, Baigent C, Lasserson D, Oliver C, O'Mahony F, Amoils S, Bamford J, Armitage J, Emberson J, Rinkel GJ, Lowe G, Innes K, Adamczuk K, Dinsmore L, Drever J, Milne G, Walker A, Hutchison A, Williams C, Fraser R, Anderson R, Covil K, Stewart K, Rees J, Hall P, Bullen A, Stoddart A, Moullaali TJ, Palmer J, Sakka E, Perthen J, Lyttle N, Samarasekera N, MacRaild A, Burgess S, Teasdale J, Coakley M, Taylor P, Blair G, Whiteley W, Shenkin S, Clancy U, Macleod M, Sutherland R, Moullaali T, Barugh A, Lerpiniere C, Moreton F, Fethers N, Anjum T, Krishnan M, Slade P, Storton S, Williams M, Davies C, Connor L, Gainard G, Murphy C, Barber M, Esson D, Choulerton J, Shaw L, Lucas S, Hierons S, Avis J, Stone A, Gbadamoshi L, Costa T, Pearce L, Harkness K, Richards E, Howe J, Kamara C, Lindert R, Ali A, Rehan J, Chapman S, Edwards M, Bathula R, Cohen D, Devine J, Mpelembue M, Yesupatham P, Chhabra S, Adewetan G, Ballantine R, Brooks D, Smith G, Rogers G, Marsden S, Clark S, Wilkinson A, Brown E, Stephenson L, Nyo K, Abraham A, Pai Y, Shim G, Baliga V, Nair A, Robinson M, Hawksworth C, Greig J, Alam I, Nortcliffe T, Ramiz R, Shaw R, Parry-Jones A, Lee S, Marsden T, Perez J, Birleson E, Yadava R, Sangombe M, Stafford S, Hughes T, Knibbs L, Morse B, Schwarz S, Jelley B, White S, Richard B, Lawson H, Moseley S, Tayler M, Edwards M, Triscott C, Wallace R, Hall A, Dell A, Rashed K, Board S, Buckley C, Tanate A, Pitt-Kerby T, Beesley K, Perry J, Hellyer C, Guyler P, Menon N, Tysoe S, Prabakaran R, Cooper M, Rajapakse A, Wynter I, Smith S, Weir N, Boxall C, Yates H, Smith S, Crawford P, Marigold J, Smith F, Harvey J, Evans S, Baldwin L, Hammond S, Mudd P, Bowring A, Keenan S, Thorpe K, Haque M, Taaffe J, Temple N, Peachey T, Wells K, Haines F, Butterworth-Cowin N, Horne Z, Licenik R, Boughton H, England T, Hedstrom A, Menezes B, Davies R, Johnson V, Whittingham-Jones S, Werring D, Obarey S, Watchurst C, Ashton A, Feerick S, Francia N, Banaras A, Epstein D, Marinescu M, Williams A, Robinson A, Humphries F, Anwar I, Annamalai A, Crawford S, Collins V, Shepherd L, Siddle E, Penge J, Epstein D, Qureshi S, Krishnamurthy V, Papavasileiou V, Waugh D, Veraque E, Douglas N, Khan N, Ramachandran S, Sommerville P, Rudd A, Kullane S, Bhalla A, Birns J, Ahmed R, Gibbons M, Klamerus E, Cendreda B, Muir K, Day N, Welch A, Smith W, Elliot J, Eltawil S, Mahmood A, Hatherley K, Mitchell S, Bains H, Quinn L, Teal R, Gbinigie I, Harston G, Mathieson P, Ford G, Schulz U, Kennedy J, Nagaratnam K, Bangalore K, Bhupathiraju N, Wharton C, Fotherby K, Nasar A, Stevens A, Willberry A, Evans R, Rai B, Blake C, Thavanesan K, Hann G, Changuion T, Nix S, Whiting A, Dharmasiri M, Mallon L, Keltos M, Smyth N, Eglinton C, Duffy J, Tone E, Sykes L, Porter E, Fitton C, Kirkineziadis N, Cluckie G, Kennedy K, Trippier S, Williams R, Hayter E, Rackie J, Patel B, Rita G, Blight A, Jones V, Zhang L, Choy L, Pereira A, Clarke B, Al-Hussayni S, Dixon L, Young A, Bergin A, Broughton D, Raghunathan S, Jackson B, Appleton J, Wilkes G, Buck A, Richardson C, Clarke J, Fleming L, Squires G, Law Z, Hutchinson C, Cvoro V, Couser M, McGregor A, McAuley S, Pound S, Cochrane P, Holmes C, Murphy P, Devitt N, Osborn M, Steele A, Guthrie LB, Smith E, Hewitt J, Chaston N, Myint M, Smith A, Fairlie L, Davis M, Atkinson B, Woodward S, Hogg V, Fawcett M, Finlay L, Dixit A, Cameron E, Keegan B, Kelly J, Concannon D, Dutta D, Ward D, Glass J, O'Connell S, Ngeh J, O'Kelly A, Williams E, Ragab S, Jenkinson D, Dube J, Gleave L, Leggett J, Kissoon N, Southern L, Naghotra U, Bokhari M, McClelland B, Adie K, Mate A, Harrington F, James A, Swanson E, Chant T, Naccache M, Coutts A, Courtauld G, Whurr S, Webber S, Shead E, Luder R, Bhargava M, Murali E, Cuenoud L, Pasco K, Speirs O, Chapman L, Inskip L, Kavanagh L, Srinivasan M, Motherwell N, Mukherjee I, Tonks L, Donaldson D, Button H, Wilcox R, Hurford F, Logan R, Taylor A, Arden T, Carpenter M, Datta P, Zahoor T, Jackson L, Needle A, Stanners A, Ghouri I, Exley D, Akhtar S, Brooke H, Beadle S, O'Brien E, Francis J, McGee J, Amis E, Mitchell J, Finlay S, Sinha D, Manoczki C, King S, Tarka J, Choudhary S, Premaruban J, Sutton D, Kumar P, Culmsee C, Winckley C, Davies H, Thatcher H, Vasileiadis E, Aweid B, Holden M, Mason C, Hlaing T, Madzamba G, Ingram T, Linforth M, Cullen C, Thomas N, France J, Saulat A, Bhaskaran B, Fitzell P, Horan K, Manyoni C, Garfield-Smith J, Griffin H, Atkins S, Redome J, Muddegowda G, Maguire H, Barry A, Abano N, Varquez R, Hiden J, Lyjko S, Remegoso A, Finney K, Butler A, Strecker M, MaCleod MJ, Irvine J, Nelson S, Guzmangutierrez G, Furnace J, Taylor V, Ramadan H, Storton K, Hassan S, Abdus Sami E, Bellfield R, Stewart K, Quinn O, Patterson C, Emsley H, Gregary B, Ahmed S, Patel S, Raj S, Sultan S, Wright F, Langhorne P, Graham R, Quinn T, McArthur K. Effects of oral anticoagulation for atrial fibrillation after spontaneous intracranial haemorrhage in the UK: a randomised, open-label, assessor-masked, pilot-phase, non-inferiority trial. Lancet Neurol 2021; 20:842-853. [PMID: 34487722 DOI: 10.1016/s1474-4422(21)00264-7] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Revised: 08/03/2021] [Accepted: 08/04/2021] [Indexed: 01/19/2023]
Abstract
BACKGROUND Oral anticoagulation reduces the rate of systemic embolism for patients with atrial fibrillation by two-thirds, but its benefits for patients with previous intracranial haemorrhage are uncertain. In the Start or STop Anticoagulants Randomised Trial (SoSTART), we aimed to establish whether starting is non-inferior to avoiding oral anticoagulation for survivors of intracranial haemorrhage who have atrial fibrillation. METHODS SoSTART was a prospective, randomised, open-label, assessor-masked, parallel-group, pilot phase trial done at 67 hospitals in the UK. We recruited adults (aged ≥18 years) who had survived at least 24 h after symptomatic spontaneous intracranial haemorrhage, had atrial fibrillation, and had a CHA2DS2-VASc score of at least 2. Web-based computerised randomisation incorporating a minimisation algorithm allocated participants (1:1) to start or avoid long-term (≥1 year) full treatment dose open-label oral anticoagulation. The participants assigned to start oral anticoagulation received either a direct oral anticoagulant or vitamin K antagonist, and the group assigned to avoid oral anticoagulation received standard clinical practice (antiplatelet agent or no antithrombotic agent). The primary outcome was recurrent symptomatic spontaneous intracranial haemorrhage, and was adjudicated by an individual masked to treatment allocation. All outcomes were ascertained for at least 1 year after randomisation and assessed in the intention-to-treat population of all randomly assigned participants, using Cox proportional hazards regression adjusted for minimisation covariates. We planned a sample size of 190 participants (one-sided p=0·025, power 90%, allowing for non-adherence) based on a non-inferiority margin of 12% (or adjusted hazard ratio [HR] of 3·2). This trial is registered with ClinicalTrials.gov (NCT03153150) and is complete. FINDINGS Between March 29, 2018, and Feb 27, 2020, consent was obtained at 61 sites for 218 participants, of whom 203 were randomly assigned at a median of 115 days (IQR 49-265) after intracranial haemorrhage onset. 101 were assigned to start and 102 to avoid oral anticoagulation. Participants were followed up for median of 1·2 years (IQR 0·97-1·95; completeness 97·2%). Starting oral anticoagulation was not non-inferior to avoiding oral anticoagulation: eight (8%) of 101 in the start group versus four (4%) of 102 in the avoid group had intracranial haemorrhage recurrences (adjusted HR 2·42 [95% CI 0·72-8·09]; p=0·152). Serious adverse events occurred in 17 (17%) participants in the start group and 15 (15%) in the avoid group. 22 (22%) patients in the start group and 11 (11%) patients in the avoid group died during the study. INTERPRETATION Whether starting oral anticoagulation was non-inferior to avoiding it for people with atrial fibrillation after intracranial haemorrhage was inconclusive, although rates of recurrent intracranial haemorrhage were lower than expected. In view of weak evidence from analyses of three composite secondary outcomes, the possibility that oral anticoagulation might be superior for preventing symptomatic major vascular events should be investigated in adequately powered randomised trials. FUNDING British Heart Foundation, Medical Research Council, Chest Heart & Stroke Scotland.
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Diernberger K, Shinkins B, Hall P, Kaasa S, Fallon M. Incompatible: end-of-life care and health economics. BMJ Support Palliat Care 2021; 11:296-298. [PMID: 33685946 PMCID: PMC8380893 DOI: 10.1136/bmjspcare-2020-002388] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Accepted: 05/12/2020] [Indexed: 11/13/2022]
Affiliation(s)
- Katharina Diernberger
- Cancer Research UK, Institute of Genetics and Molecular Medicine, University of Edinburgh Western General Hospital, Edinburgh, UK
| | - Bethany Shinkins
- Faculty of Medicine and Health, Academic Unit of Health Economics, University of Leeds, Leeds, UK
| | - Peter Hall
- Cancer Research UK, Institute of Genetics and Molecular Medicine, University of Edinburgh Western General Hospital, Edinburgh, UK
| | - Stein Kaasa
- Institute for Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Marie Fallon
- Department of Palliative Medicine, University of Edinburgh, Western General Hospital, Edinburgh, UK
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Lemmon E, Hanna CR, Hall P, Morris EJA. Health economic studies of colorectal cancer and the contribution of administrative data: A systematic review. Eur J Cancer Care (Engl) 2021; 30:e13477. [PMID: 34152043 DOI: 10.1111/ecc.13477] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Revised: 03/23/2021] [Accepted: 05/17/2021] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Several forces are contributing to an increase in the number of people living with and surviving colorectal cancer (CRC). However, due to the lack of available data, little is known about the implications of these forces. In recent years, the use of administrative records to inform research has been increasing. The aim of this paper is to investigate the potential contribution that administrative data could have on the health economic research of CRC. METHODS To achieve this aim, we conducted a systematic review of the health economic CRC literature published in the United Kingdom and Europe within the last decade (2009-2019). RESULTS Thirty-seven relevant studies were identified and divided into economic evaluations, cost of illness studies and cost consequence analyses. CONCLUSIONS The use of administrative data, including cancer registry, screening and hospital records, within the health economic research of CRC is commonplace. However, we found that this data often come from regional databases, which reduces the generalisability of results. Further, administrative data appear less able to contribute towards understanding the wider and indirect costs associated with the disease. We explore several ways in which various sources of administrative data could enhance future research in this area.
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Affiliation(s)
- Elizabeth Lemmon
- Edinburgh Health Economics, University of Edinburgh, Edinburgh, UK
| | - Catherine R Hanna
- CRUK Clinical Trials Unit, Institute of Cancer Sciences, University of Glasgow, Glasgow, UK
| | - Peter Hall
- Edinburgh Cancer Research Centre, University of Edinburgh, Edinburgh, UK
| | - Eva J A Morris
- Nuffield Department of Population Health, University of Oxford, Oxford, UK
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Franks PW, Melén E, Friedman M, Sundström J, Kockum I, Klareskog L, Almqvist C, Bergen SE, Czene K, Hägg S, Hall P, Johnell K, Malarstig A, Catrina A, Hagström H, Benson M, Gustav Smith J, Gomez MF, Orho-Melander M, Jacobsson B, Halfvarson J, Repsilber D, Oresic M, Jern C, Melin B, Ohlsson C, Fall T, Rönnblom L, Wadelius M, Nordmark G, Johansson Å, Rosenquist R, Sullivan PF. Technological readiness and implementation of genomic-driven precision medicine for complex diseases. J Intern Med 2021; 290:602-620. [PMID: 34213793 DOI: 10.1111/joim.13330] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Revised: 03/21/2021] [Accepted: 04/12/2021] [Indexed: 12/20/2022]
Abstract
The fields of human genetics and genomics have generated considerable knowledge about the mechanistic basis of many diseases. Genomic approaches to diagnosis, prognostication, prevention and treatment - genomic-driven precision medicine (GDPM) - may help optimize medical practice. Here, we provide a comprehensive review of GDPM of complex diseases across major medical specialties. We focus on technological readiness: how rapidly a test can be implemented into health care. Although these areas of medicine are diverse, key similarities exist across almost all areas. Many medical areas have, within their standards of care, at least one GDPM test for a genetic variant of strong effect that aids the identification/diagnosis of a more homogeneous subset within a larger disease group or identifies a subset with different therapeutic requirements. However, for almost all complex diseases, the majority of patients do not carry established single-gene mutations with large effects. Thus, research is underway that seeks to determine the polygenic basis of many complex diseases. Nevertheless, most complex diseases are caused by the interplay of genetic, behavioural and environmental risk factors, which will likely necessitate models for prediction and diagnosis that incorporate genetic and non-genetic data.
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Affiliation(s)
- P W Franks
- From the, Department of Clinical Sciences, Lund University Diabetes Center, Lund University, Malmö, Sweden.,Department of Nutrition, Harvard School of Public Health, Boston, MA, USA
| | - E Melén
- Department of Clinical Science and Education Södersjukhuset, Karolinska Institutet, Stockholm, Sweden
| | - M Friedman
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - J Sundström
- Department of Cardiology, Akademiska Sjukhuset, Uppsala, Sweden.,George Institute for Global Health, Camperdown, NSW, Australia.,Medical Sciences, Uppsala University, Uppsala, Sweden
| | - I Kockum
- Center for Molecular Medicine, Karolinska Institutet, Stockholm, Sweden.,Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - L Klareskog
- Center for Molecular Medicine, Karolinska Institutet, Stockholm, Sweden.,Department of Rheumatology, Karolinska Institutet, Stockholm, Sweden
| | - C Almqvist
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - S E Bergen
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - K Czene
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - S Hägg
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - P Hall
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden.,Department of Oncology, Södersjukhuset, Stockholm, Sweden
| | - K Johnell
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - A Malarstig
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden.,Pfizer, Worldwide Research and Development, Stockholm, Sweden
| | - A Catrina
- Department of Medicine, Karolinska Institutet, Stockholm, Sweden
| | - H Hagström
- Department of Medicine, Karolinska Institutet, Stockholm, Sweden.,Division of Hepatology, Department of Upper GI, Karolinska University Hospital, Stockholm, Sweden
| | - M Benson
- Department of Pediatrics, Linkopings Universitet, Linkoping, Sweden.,Division of Ear, Nose and Throat Diseases, Department of Clinical Sciences, Intervention and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden
| | - J Gustav Smith
- Department of Cardiology and Wallenberg Center for Molecular Medicine, Clinical Sciences, Lund University and Skåne University Hospital, Lund, Sweden.,Department of Molecular and Clinical Medicine, Institute of Medicine, Gothenburg University and Sahlgrenska University Hospital, Gothenburg, Sweden
| | - M F Gomez
- From the, Department of Clinical Sciences, Lund University Diabetes Center, Lund University, Malmö, Sweden
| | - M Orho-Melander
- From the, Department of Clinical Sciences, Lund University Diabetes Center, Lund University, Malmö, Sweden
| | - B Jacobsson
- Division of Health Data and Digitalisation, Norwegian Institute of Public Health, Genetics and Bioinformatics, Oslo, Norway.,Department of Obstetrics and Gynecology, Region Västra Götaland, Sahlgrenska University Hospital, Gothenburg, Sweden.,Department of Obstetrics and Gynecology, Institute of Clinical Sciences, University of Gothenburg, Gothenburg, Sweden
| | - J Halfvarson
- School of Medical Sciences, Örebro University, Örebro, Sweden
| | - D Repsilber
- Functional Bioinformatics, Örebro University, Örebro, Sweden
| | - M Oresic
- School of Medical Sciences, Örebro University, Örebro, Sweden.,Turku Bioscience Centre, University of Turku and Åbo Akademi University, Turku, FI, Finland
| | - C Jern
- Department of Clinical Genetics and Genomics, Region Västra Götaland, Sahlgrenska University Hospital, Gothenburg, Sweden.,Department of Laboratory Medicine, Institute of Biomedicine, University of Gothenburg, Gothenburg, Sweden
| | - B Melin
- Department of Radiation Sciences, Oncology, Umeå Universitet, Umeå, Sweden
| | - C Ohlsson
- Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, Sahlgrenska Osteoporosis Centre, CBAR, University of Gothenburg, Gothenburg, Sweden.,Department of Drug Treatment, Region Västra Götaland, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - T Fall
- Department of Medical Sciences, Molecular Epidemiology, Uppsala University, Uppsala, Sweden
| | - L Rönnblom
- Department of Medical Sciences, Rheumatology & Science for Life Laboratory, Uppsala University, Uppsala, Sweden
| | - M Wadelius
- Department of Medical Sciences, Clinical Pharmacogenomics & Science for Life Laboratory, Uppsala University, Uppsala, Sweden
| | - G Nordmark
- Department of Medical Sciences, Rheumatology & Science for Life Laboratory, Uppsala University, Uppsala, Sweden
| | - Å Johansson
- Institute for Immunology, Genetics, and Pathology, Uppsala University, Uppsala, Sweden
| | - R Rosenquist
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - P F Sullivan
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden.,Department of Genetics, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.,Department of Psychiatry, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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Coudé Adam H, Docherty Skogh AC, Edsander Nord Å, Schultz I, Gahm J, Hall P, Frisell J, Halle M, de Boniface J. Survival in breast cancer patients with a delayed DIEP flap breast reconstruction after adjustment for socioeconomic status and comorbidity. Breast 2021; 59:383-392. [PMID: 34438278 PMCID: PMC8390766 DOI: 10.1016/j.breast.2021.07.001] [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] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2021] [Revised: 06/15/2021] [Accepted: 07/03/2021] [Indexed: 12/13/2022] Open
Abstract
Purpose Overall survival in breast cancer patients receiving a delayed deep inferior epigastric perforator (DIEP) flap breast reconstruction is better than in those without delayed breast reconstruction. This study aimed at determining the impact of socioeconomic status (SES) and comorbidity on these observations. Materials and methods This matched cohort study included all consecutive women undergoing a delayed DIEP flap reconstruction at Karolinska University Hospital, Sweden, between 1999 and 2013. Controls had not received any delayed breast reconstruction and were relapse-free after a corresponding follow-up interval. Matching was by year of and age at mastectomy, tumour stage and lymph node status. Charlson Comorbidity Index (CCI) and socioeconomic data were obtained from national registers. Associations with breast cancer-specific (BCSS) and overall survival (OS) were investigated by Kaplan-Meier survival estimates and Cox proportional hazard regression analysis. Results Women in the DIEP group (N = 254) more often continued education after primary school (88.6% versus 82.6%, P = 0.026), belonged to the high-income group (76.0% versus 63.1%, P < 0.001), were in a partnership (57.1% versus 55.7%, P = 0.024) and healthier (median CCI 1.00 (range 0–13) versus 2.00 (range 0–16), P = 0.021) than the control group (N = 729). After adjustment for tumour and treatment factors, SES and comorbidity, OS remained significantly better for the DIEP group than the control group (HR 2.27, 95% CI 1.44–3.55). Conclusion Women with a delayed DIEP flap reconstruction are a subgroup of higher socioeconomic status and better health. Higher survival estimates for the DIEP group persisted after adjusting for those differences, suggesting the presence of further unmeasured covariates. Women with a delayed DIEP flap reconstruction have a higher socioeconomic status. They also have less comorbidity than women with no delayed reconstruction. Superior survival in DIEP patients is not eliminated by adjustments for such differences. Unmeasured selection to the reconstructive process may explain observed survival differences.
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Affiliation(s)
- H Coudé Adam
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden.
| | - A C Docherty Skogh
- Department of Surgery, Breast Cancer Center, South General Hospital, Stockholm, Sweden; Department of Clinical Science and Education, Karolinska Institutet, Stockholm, Sweden
| | - Å Edsander Nord
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden; Department of Reconstructive Plastic Surgery, Karolinska University Hospital, Stockholm, Sweden
| | - I Schultz
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden; Department of Reconstructive Plastic Surgery, Karolinska University Hospital, Stockholm, Sweden
| | - J Gahm
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden; Department of Reconstructive Plastic Surgery, Karolinska University Hospital, Stockholm, Sweden
| | - P Hall
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden; Department of Oncology, South General Hospital, Stockholm, Sweden
| | - J Frisell
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden; Department of Breast and Endocrine Surgery, Karolinska University Hospital, Stockholm, Sweden
| | - M Halle
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden; Department of Reconstructive Plastic Surgery, Karolinska University Hospital, Stockholm, Sweden
| | - J de Boniface
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden; Department of Surgery, Breast Unit, Capio St. Göran's Hospital, Stockholm, Sweden
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Defourny N, Spencer K, Tunstall D, Cosgrove V, Kirkby K, Henry A, Lievens Y, Hall P. OC-0058 Impact of increased hypofractionation on treatment cost. Radiother Oncol 2021. [DOI: 10.1016/s0167-8140(21)06752-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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He W, Eriksson M, Eliasson E, Grassmann F, Bäcklund M, Gabrielson M, Hammarström M, Margolin S, Thorén L, Wengström Y, Borgquist S, Hall P, Czene K. CYP2D6 genotype predicts tamoxifen discontinuation and drug response: a secondary analysis of the KARISMA trial. Ann Oncol 2021; 32:1286-1293. [PMID: 34284099 DOI: 10.1016/j.annonc.2021.07.005] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Revised: 06/17/2021] [Accepted: 07/13/2021] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Guidelines regarding whether tamoxifen should be prescribed based on women's cytochrome P450 2D6 (CYP2D6) genotypes are conflicting and have caused confusion. This study aims to investigate if CYP2D6 metabolizer status is associated with tamoxifen-related endocrine symptoms, tamoxifen discontinuation, and mammographic density change. PATIENTS AND METHODS We used data from 1440 healthy women who participated the KARISMA dose determination trial. Endocrine symptoms were measured using a modified Functional Assessment of Cancer Therapy - Endocrine Symptoms (FACT-ES) questionnaire. Change in mammographic density was measured and used as a proxy for tamoxifen response. Participants were genotyped and categorized as poor, intermediate, normal, or ultrarapid CYP2D6 metabolizers. RESULTS The median endoxifen level per mg oral tamoxifen among poor, intermediate, normal and ultrarapid CYP2D6 metabolizers were 0.18 ng/ml, 0.38 ng/ml, 0.56 ng/ml and 0.67 ng/ml, respectively. Ultrarapid CYP2D6 metabolizers were more likely than other groups to report a clinically relevant change in cold sweats, hot flash, mood swings, being irritable, as well as the overall modified FACT-ES score, after taking tamoxifen. The 6-month tamoxifen discontinuation rates among poor, intermediate, normal, and ultrarapid CYP2D6 metabolizers were 25.7%, 23.6%, 28.6%, and 44.4%, respectively. Among those who continued and finished the 6-month tamoxifen intervention, the mean change in dense area among poor, intermediate, normal, and ultrarapid CYP2D6 metabolizers were -0.8 cm2, -4.5 cm2, -4.1 cm2, and -8.0 cm2 respectively. CONCLUSIONS Poor CYP2D6 metabolizers are likely to experience an impaired response to tamoxifen, measured through mammographic density reduction. In contrast, ultrarapid CYP2D6 metabolizers are at risk for exaggerated response with pronounced adverse effects that may lead to treatment discontinuation.
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Affiliation(s)
- W He
- Chronic Disease Research Institute, The Children's Hospital, and National Clinical Research Center for Child Health, School of Public Health, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, China; Department of Nutrition and Food Hygiene, School of Public Health, Zhejiang University, Hangzhou, Zhejiang, China; Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - M Eriksson
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - E Eliasson
- Department of Laboratory Medicine, Clinical Pharmacology, Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden
| | - F Grassmann
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden; Institute of Medical Sciences, University of Aberdeen, Aberdeen, UK
| | - M Bäcklund
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - M Gabrielson
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - M Hammarström
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - S Margolin
- Department of Oncology, South General Hospital, Stockholm, Sweden; Department of Clinical Science and Education Södersjukhuset, Karolinska Institutet, Stockholm, Sweden
| | - L Thorén
- Department of Oncology, South General Hospital, Stockholm, Sweden; Department of Clinical Science and Education Södersjukhuset, Karolinska Institutet, Stockholm, Sweden
| | - Y Wengström
- Department of Neurobiology, Care Science and Society, Division of Nursing and Theme Cancer, Karolinska University Hospital, Stockholm, Sweden
| | - S Borgquist
- Department of Oncology, Aarhus University Hospital and Aarhus University, Aarhus, Denmark; Department of Clinical Sciences Lund, Oncology, Lund University and Skåne University Hospital, Lund, Sweden
| | - P Hall
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden; Department of Oncology, South General Hospital, Stockholm, Sweden.
| | - K Czene
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
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Downing A, Hall P, Birch R, Lemmon E, Affleck P, Rossington H, Boldison E, Ewart P, Morris EJA. Data Resource Profile: The COloRECTal cancer data repository (CORECT-R). Int J Epidemiol 2021; 50:1418-1418k. [PMID: 34255059 PMCID: PMC8580263 DOI: 10.1093/ije/dyab122] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/27/2021] [Indexed: 11/13/2022] Open
Affiliation(s)
- Amy Downing
- Cancer Epidemiology Group, Leeds Institute of Medical Research at St James's and Leeds Institute for Data Analytics, University of Leeds, Leeds, UK
| | - Peter Hall
- Edinburgh Cancer Research Centre, University of Edinburgh, Western General Hospital, Edinburgh, UK.,Edinburgh Health Economics, University of Edinburgh, NINE BioQuarter, Edinburgh, UK
| | - Rebecca Birch
- Cancer Epidemiology Group, Leeds Institute of Medical Research at St James's and Leeds Institute for Data Analytics, University of Leeds, Leeds, UK
| | - Elizabeth Lemmon
- Edinburgh Health Economics, University of Edinburgh, NINE BioQuarter, Edinburgh, UK
| | - Paul Affleck
- Cancer Epidemiology Group, Leeds Institute of Medical Research at St James's and Leeds Institute for Data Analytics, University of Leeds, Leeds, UK
| | - Hannah Rossington
- Cancer Epidemiology Group, Leeds Institute of Medical Research at St James's and Leeds Institute for Data Analytics, University of Leeds, Leeds, UK
| | - Emily Boldison
- Cancer Epidemiology Group, Leeds Institute of Medical Research at St James's and Leeds Institute for Data Analytics, University of Leeds, Leeds, UK
| | - Paul Ewart
- Cancer Epidemiology Group, Leeds Institute of Medical Research at St James's and Leeds Institute for Data Analytics, University of Leeds, Leeds, UK
| | - Eva J A Morris
- Nuffield Department of Population Health, Big Data Institute, University of Oxford, Oxford, UK
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Holdsworth G, Staley JR, Hall P, van Koeverden I, Vangjeli C, Okoye R, Boyce RW, Turk JR, Armstrong M, Wolfreys A, Pasterkamp G. Sclerostin Downregulation Globally by Naturally Occurring Genetic Variants, or Locally in Atherosclerotic Plaques, Does Not Associate With Cardiovascular Events in Humans. J Bone Miner Res 2021; 36:1326-1339. [PMID: 33784435 PMCID: PMC8360163 DOI: 10.1002/jbmr.4287] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Revised: 03/04/2021] [Accepted: 03/07/2021] [Indexed: 12/13/2022]
Abstract
Inhibition of sclerostin increases bone formation and decreases bone resorption, leading to increased bone mass, bone mineral density, and bone strength and reduced fracture risk. In a clinical study of the sclerostin antibody romosozumab versus alendronate in postmenopausal women (ARCH), an imbalance in adjudicated serious cardiovascular (CV) adverse events driven by an increase in myocardial infarction (MI) and stroke was observed. To explore whether there was a potential mechanistic plausibility that sclerostin expression, or its inhibition, in atherosclerotic (AS) plaques may have contributed to this imbalance, sclerostin was immunostained in human plaques to determine whether it was detected in regions relevant to plaque stability in 94 carotid and 50 femoral AS plaques surgically collected from older female patients (mean age 69.6 ± 10.4 years). Sclerostin staining was absent in most plaques (67%), and when detected, it was of reduced intensity compared with normal aorta and was located in deeper regions of the plaque/wall but was not observed in areas considered relevant to plaque stability (fibrous cap and endothelium). Additionally, genetic variants associated with lifelong reduced sclerostin expression were explored for associations with phenotypes including those related to bone physiology and CV risk factors/events in a population-based phenomewide association study (PheWAS). Natural genetic modulation of sclerostin by variants with a significant positive effect on bone physiology showed no association with lifetime risk of MI or stroke. These data do not support a causal association between the presence of sclerostin, or its inhibition, in the vasculature and increased risk of serious cardiovascular events. © 2021 The Authors. Journal of Bone and Mineral Research published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research (ASBMR).
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Downie S, Cherry J, Hall P, Stillie A, Moran M, Sudlow C, Simpson AHR. Metastatic bone disease: new quality performance indicator development. BMJ Support Palliat Care 2021:bmjspcare-2021-003025. [PMID: 34130998 DOI: 10.1136/bmjspcare-2021-003025] [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: 02/25/2021] [Accepted: 05/28/2021] [Indexed: 11/03/2022]
Abstract
OBJECTIVES Patients with metastatic bone disease (MBD) should receive the same standard of care regardless of which centre they are treated in. The aim was to develop and test a set of quality performance indicators (QPIs) to evaluate care for patients with MBD referred to orthopaedics. METHODS QPIs were adapted from the literature and ranked on feasibility and necessity during a modified RAND/Delphi consensus process. They were then validated and field tested in a retrospective cohort of 108 patients using indicator-specific targets set during consensus. RESULTS 2568 articles including six guidelines were reviewed. 43 quality objectives were extracted and 40 proceeded to expert consensus. After two rounds, 18 QPIs for MBD care were generated, with the following generating the highest consensus: 'Patients with high fracture risk should receive urgent assessment' (combined mean 6.7/7, 95% CI 6.5 to 6.8) and 'preoperative workup should include full blood tests including group and save' (combined mean 6.7/7, 95% CI 6.5 to 6.9). In the pilot test, targets were met for 5/18 QPIs (mean 52%, standard deviation 22%). The median deviation from projected target was -14% (interquartile range -11% to -31%, range -74% to 11%). The highest scoring QPI was 'adults with fractures should have surgery within 7 days' (target 80%:actual 92%). CONCLUSIONS The published evidence and guidelines were adapted into a set of validated QPIs for MBD care which can be used to evaluate variation in care between centres. These QPIs should be correlated with outcome scores to determine whether they can act as predictors of outcome after surgery.
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Affiliation(s)
- Samantha Downie
- Trauma & Orthopaedics, University of Edinburgh, Edinburgh, UK
| | | | - Peter Hall
- University of Edinburgh Western General Hospital, Edinburgh, UK
| | | | | | - Cathie Sudlow
- Department of Clinical Neurosciences, Western General Hospital, Edinburgh, UK
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Giles K, Hall P, Wilson H, Macpherson L, Martin-Hernandez MP, Thompson K, Bailey S. 559 IDENTIFYING PATIENTS WITH MOOD DISORDER FOLLOWING ADMISSION WITH HIP FRACTURE WITH A VIEW TO STARTING TREATMENT & PROVIDE ADVICE. Age Ageing 2021. [DOI: 10.1093/ageing/afab116.21] [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: 11/14/2022] Open
Abstract
Abstract
Introduction
The signs of depression in the elderly often go unnoticed. The MDT at RSCH observed that low mood could negatively impact on patient’s recovery, affecting pain thresholds and leading to poor engagement with rehabilitation. Proactive identification and management of mood disorder is an important part of CGA, but not routinely performed. The aim of this QI project is to improve identification and management of mood disorder in patients over 65 years admitted to RSCH with hip fractures by introducing a standardised assessment tool to guide appropriate interventions.
Method
Notes of patients with hip fracture admitted over a four-month period were retrospectively reviewed to establish if patients were screened for low mood. A mood screening tool, Cornell Score, was chosen and implemented by OT’s and junior doctors over a four-month period. Those identified with depression or probable depression were issued verbal advice, an information leaflet and follow-up arranged.
Results
Ninety-eight patients were included in the retrospective cohort; There was no indication that mood was considered or assessed at any point during admission. During the four-month prospective period, 86 patients (96%) were screened for low mood; 9% had major depression and 16% probable depression. Feedback from our occupational therapists and doctors was positive, with the tool being easy to use in patients with or without cognitive impairment. Much of the assessment could be incorporated into initial assessment or in gaining collateral history. Anecdotally, considering patients psychological well-being had a positive impact on inpatient therapy sessions guided the MDT in supporting the patient appropriately.
Conclusion
Implementation of a standardised and validated mood screening tool enabled us to identify that a quarter (25%) of the patients had, or probably had depression. This allowed us to intervene with simple measures such as verbal advice and an information leaflet and consider pharmacological intervention where appropriate.
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Affiliation(s)
- K Giles
- St Charles Hospital; Royal Surrey Hospital; Royal Surrey Hospital; Royal Surrey Hospital; Royal Surrey Hospital; Royal Surrey Hospital
| | - P Hall
- St Charles Hospital; Royal Surrey Hospital; Royal Surrey Hospital; Royal Surrey Hospital; Royal Surrey Hospital; Royal Surrey Hospital
| | - H Wilson
- St Charles Hospital; Royal Surrey Hospital; Royal Surrey Hospital; Royal Surrey Hospital; Royal Surrey Hospital; Royal Surrey Hospital
| | - L Macpherson
- St Charles Hospital; Royal Surrey Hospital; Royal Surrey Hospital; Royal Surrey Hospital; Royal Surrey Hospital; Royal Surrey Hospital
| | - M P Martin-Hernandez
- St Charles Hospital; Royal Surrey Hospital; Royal Surrey Hospital; Royal Surrey Hospital; Royal Surrey Hospital; Royal Surrey Hospital
| | - K Thompson
- St Charles Hospital; Royal Surrey Hospital; Royal Surrey Hospital; Royal Surrey Hospital; Royal Surrey Hospital; Royal Surrey Hospital
| | - S Bailey
- St Charles Hospital; Royal Surrey Hospital; Royal Surrey Hospital; Royal Surrey Hospital; Royal Surrey Hospital; Royal Surrey Hospital
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Hanna CR, Lemmon E, Ennis H, Jones RJ, Hay J, Halliday R, Clark S, Morris E, Hall P. Creation of the first national linked colorectal cancer dataset in Scotland: prospects for future research and a reflection on lessons learned. Int J Popul Data Sci 2021; 6:1654. [PMID: 34007905 PMCID: PMC8111382 DOI: 10.23889/ijpds.v6i1.1654] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
INTRODUCTION Current understanding of cancer patients, their treatment pathways and outcomes relies mainly on information from clinical trials and prospective research studies representing a selected sub-set of the patient population. Whole-population analysis is necessary if we are to assess the true impact of new interventions or policy in a real-world setting. Accurate measurement of geographic variation in healthcare use and outcomes also relies on population-level data. Routine access to such data offers efficiency in research resource allocation and a basis for policy that addresses inequalities in care provision. OBJECTIVE Acknowledging these benefits, the objective of this project was to create a population level dataset in Scotland of patients with a diagnosis of colorectal cancer (CRC). METHODS This paper describes the process of creating a novel, national dataset in Scotland. RESULTS In total, thirty two separate healthcare administrative datasets have been linked to provide a comprehensive resource to investigate the management pathways and outcomes for patients with CRC in Scotland, as well as the costs of providing CRC treatment. This is the first time that chemotherapy prescribing and national audit datasets have been linked with the Scottish Cancer Registry on a national scale. CONCLUSIONS We describe how the acquired dataset can be used as a research resource and reflect on the data access challenges relating to its creation. Lessons learned from this process and the policy implications for future studies using administrative cancer data are highlighted.
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Affiliation(s)
- Catherine R Hanna
- CRUK Clinical Trials Unit, Institute of Cancer Sciences, University of Glasgow, 1042 Great Western Road, Glasgow, G12 OYN
| | - Elizabeth Lemmon
- Edinburgh Health Economics, University of Edinburgh,NINE BioQuarter 9 Little France Road Edinburgh EH16 4UX
| | - Holly Ennis
- Edinburgh Clinical Trials Unit, Usher Institute, University of Edinburgh, NINE, 9 Little France Road, Edinburgh BioQuarter, Edinburgh EH16 4UX
| | - Robert J Jones
- CRUK Clinical Trials Unit, Institute of Cancer Sciences, University of Glasgow, 1042 Great Western Road, Glasgow, G12 OYN
| | - Joy Hay
- Electronic Data Research and Innovation Service (eDRIS) Public Health Scotland, NINE BioQuarter 9 Little France Road Edinburgh EH16 4UX
| | - Roger Halliday
- University of Glasgow and Chief Statistician, Scottish Government, St Andrew’s house, Regent Road, Edinburgh, EH1 3DG
| | - Steve Clark
- Patient Public Group Member, Bowel Cancer Intelligence (BCI) UK, University of Leeds, LIDA, Worsely Building, Leeds, LS2 9JT
| | - Eva Morris
- Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Big Data Institute, Nuffield Department of Population Health, University of Oxford, Old Road Campus OX3 7LF
| | - Peter Hall
- Edinburgh Cancer Research Centre and Edinburgh Health Economics, University of Edinburgh, Western General Hospital, Crewe Road South, Edinburgh EH4 2XR
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Baxter MA, Murphy J, Cameron D, Jordan J, Crearie C, Lilley C, Sadozye A, Maclean M, Hall P, Phillips A, Greger A, Madeleine J, Petty RD. Correction to: The impact of COVID-19 on systemic anticancer treatment delivery in Scotland. Br J Cancer 2021; 124:1745. [PMID: 33723400 PMCID: PMC7957440 DOI: 10.1038/s41416-021-01298-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Mark A Baxter
- Division of Molecular and Clinical Medicine, Ninewells Hospital and Medical School, University of Dundee, Dundee, UK.,Tayside Cancer Centre, Ninewells Hospital and Medical School, NHS Tayside, Dundee, UK
| | | | - David Cameron
- Edinburgh Cancer Research Centre, University of Edinburgh, Edinburgh, UK.,Edinburgh Cancer Centre, NHS Lothian, Edinburgh, UK
| | | | | | | | | | | | - Peter Hall
- Edinburgh Cancer Research Centre, University of Edinburgh, Edinburgh, UK.,Edinburgh Cancer Centre, NHS Lothian, Edinburgh, UK
| | - Angela Phillips
- Tayside Cancer Centre, Ninewells Hospital and Medical School, NHS Tayside, Dundee, UK
| | | | | | - Russell D Petty
- Division of Molecular and Clinical Medicine, Ninewells Hospital and Medical School, University of Dundee, Dundee, UK. .,Tayside Cancer Centre, Ninewells Hospital and Medical School, NHS Tayside, Dundee, UK.
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Torrance F, Purshouse K, Hall P, Mackean M, Phillips I. MA10.10 Lung Cancer Admission Rates During the COVID-19 Pandemic to a Tertiary Cancer Centre in South East Scotland. J Thorac Oncol 2021. [PMCID: PMC7976859 DOI: 10.1016/j.jtho.2021.01.246] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Oswald AJ, Hall P, Turnbull A, Oikonomidou O. Abstract PS10-55: Palbociclib real-world data in metastatic breast cancer: A multi-site report of survival and adverse events in routine clinical practice in Scotland. Cancer Res 2021. [DOI: 10.1158/1538-7445.sabcs20-ps10-55] [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: Palbociclib, with endocrine therapy, has demonstrated clinical benefit in patients with ER+ve HER2-ve metastatic breast cancer in randomised controlled clinical trials. Further observational data is beneficial to illustrate how these results translate into benefit in routine practice. Furthermore, detecting predictors of response aids clinical decision-making. Our primary aim was to report the survival data and adverse event (AE) rates in a real-life population treated with palbociclib. Secondarily, we aimed to identify predictors of response. Method: We retrospectively analysed 150 patients with metastatic breast cancer treated with palbociclib and endocrine therapy in routine clinical practice, over 3 years in three sites across South East Scotland. Baseline demographics (including disease site, prior treatment, bloods), progression data, AE rates, delays/dose reduction (DR) were recorded. For statistical analysis, we calculated actuarial rates of progression and breast cancer specific survival (BCSS) for the whole cohort. Survival analysis was performed using Kaplan-Meier and cox regression statistics. Statistical associations between variables were analysed by generalised linear models with chi-square statistics. Results: The average patient age was 61.4 years and most were post-menopausal (86.7%). Around two thirds (63.3%) were previously treated adjuvantly and most were performance status 0 (51.3%) or 1 (44.0%). Commonest disease sites were bone (76.0%), liver (46.0%), lung (42.7%) or nodes (36.7%). Patients were prescribed palbociclib with either; aromatase inhibitor (AI) (74.0%) as 1st line or fulvestrant (26.0%) as 2nd line. Standard starting dose was 125mg (87.3%). Rationale for a lower starting dose was mainly due to patient age (78.9%), by physician’s choice.For the whole cohort, the actuarial progression rate at 24 months was 0.45 (95%CI±0.12) and BCSS rate was 0.69 at 24 months (95%CI±0.16). In the AI sub-group (n=111), at 12 months, the actuarial progression rate was 0.26 (95%CI±0.10) and BCSS rate was 0.86 at 12 months (95%CI±0.08). In the fulvestrant sub-group (n=39), the actuarial progression rate was 0.56 (95%CI±0.25) and BCSS was 0.82 (95%CI±0.14) at 12 months. Most common sites of progression were; visceral (84.1%), bone (40.1%), nodal (18.2%) or chest wall (6.8%). less had progressive disease (11.7% vs. 42.8%), compared to the fulvestrant group (n=28). The commonest AE was fatigue. During treatment, 67.1% had grade 3/4 neutropenia. Neutropenic sepsis rates were low (1.3%). Around half (47.9%) required DR, mainly for neutropenia (81.4%). A lower baseline ANC was associated with a lower ANC during cycle 1 (p<0.001) and increased likelihood of DR (p=0.001). Age, disease site and prior chemotherapy did not predict neutropenia. On multivariate analysis for predictors of response, patients were more likely to progress if they had liver involvement (OR 3.5, 95%CI 1.6-7.4, p=0.001) or had previous endocrine therapy in the adjuvant setting (OR 1.74, 95%CI 1.1-2.8, p=0.019). Those who had a DR were significantly less likely to progress (OR 0.23, 95%CI 0.9-0.6, p=0.001). Discussion: Our real-world clinical data of the use of palbociclib illustrates it is an effective therapy in a heterogeneous population, with a progression rate of 45% at 24 months. Neutropenia was common but neutropenic sepsis rates were very low, similarly to the pooled PALOMA safety data. The only predictor of neutropenia was baseline ANC. Those who had prior endocrine therapy or with liver involvement were more likely to progress. Interestingly, those with a DR were significantly less likely to progress. Other observational data has produced mixed results with regard to this relationship and therefore larger studies are needed to validate these findings.
Citation Format: Ailsa J Oswald, Peter Hall, Arran Turnbull, Olga Oikonomidou. Palbociclib real-world data in metastatic breast cancer: A multi-site report of survival and adverse events in routine clinical practice in Scotland [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 PS10-55.
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Affiliation(s)
| | - Peter Hall
- University of Edinburgh, Edinburgh, United Kingdom
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van der Noordaa MEM, Yau C, Shad S, Osdoit M, Steenbruggen TG, de Croze D, Hamy AS, Lae M, Reyal F, Del Monte-Millán M, Martin M, Tarruella SL, Boughey JC, Goetz M, Hoskin T, Gould R, Valero V, Sonke G, van Seijen M, Wesseling J, Bartlett J, Edge S, Kim MO, Abraham J, Caldas C, Earl H, Provenzano E, Sammut SJ, Cameron D, Graham A, Hall P, MacKintosh L, Fan F, Godwin AK, Schwensen K, Sharma P, DeMichele A, Dunn J, Hiller L, Hayward L, Thomas J, Cole K, Pusztai L, van 't Veer L, Symmans F, Esserman L. Abstract GS4-07: Assessing prognosis after neoadjuvant therapy: A comparison between anatomic ypAJCC staging, residual cancer burden class and neo-bioscore. Cancer Res 2021. [DOI: 10.1158/1538-7445.sabcs20-gs4-07] [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: Pathologic complete response (pCR) after neoadjuvant chemotherapy (NAC) in patients with breast cancer is associated with improved survival. Further assessment of the extent of residual disease, using the pathological anatomic American Joint Committee on Cancer staging method (ypStage) or the Residual Cancer Burden (RCB) method, have been shown to add prognostic information for patients with residual disease. Neo-Bioscore, an alternate system to classify response to NAC, includes clinical stage at diagnosis and biology and defines eight prognostic groups. The goal of this study was to compared three scoring systems (anatomic ypStage (7th ed), RCB Class and Neo-Bioscore) and assess whether RCB Class and Neo-Bioscore provide additional prognostic value in the context above anatomic ypStage, the most commonly used method for post-neoadjuvant residual disease assessment. Methods: Data from 5161 patients treated with NAC was pooled from 12 sites. Patients without clinical and pathological staging were excluded, as were patients with HER2+ breast cancer who did not receive neoadjuvant HER2-targeted therapy, leaving 3730 for analysis. PCR was defined as no residual invasive tumor in breast and nodes, i.e. RCB-0 or ypT0/Tis and ypN0. Patients with discordant pCR status by RCB Class vs ypStage (n=9) were excluded. Associations between each scoring system and event-free survival (EFS) were evaluated using the log rank test. EFS at 5 years was estimated using the Kaplan Meier method. Associations between Neo-Bioscore and EFS were assessed in the pCR group. For patients with residual disease, we assessed RCB and Neo-Bioscore within each ypStage. Analysis was performed overall and within subtype. Subgroups with <5 patients were excluded from the survival analyses. Results: ypAJCC staging, RCB class and Neo-Bioscore were all associated with EFS in the overall population and within each subtype (log rank p<0.0001). Of note, 13 patients with a Neo-Bioscore of 7 all recurred or died within 19 months of follow-up. Overall, 34% (1264/3721) of patients achieved a pCR. Their Neo-Bioscore ranges from 0-5, where 3% (37/1264) has a Neo-Bioscore of 5 despite achieving pCR. The Neo-Bioscore was not associated with EFS in case of a pCR, with EFS estimates at 5 years of 95%, 94%, 92%, 93%, 90% and 92% for Neo-Bioscores 0-5 respectively. As HR and HER2 status are components of the score, the range of Neo-Bioscore in the pCR group differs by subtype. However, similar to the overall analysis, the Neo-Bioscore was not prognostic within subtypes in case of pCR. Overall, among the patients who did not achieve pCR, both RCB class and Neo-Bioscore were associated with EFS within ypStages I, II and III. However, the ypStage within which RCB and Neo-Bioscore are prognostic is different for each subtype. RCB class was prognostic in ypStage I in both HR+ subtypes: patients with ypStage-I/RCB-I had significantly improved survival compared to patients with ypStage-I/RCB-II (5-year EFS: 100% vs 83% in HR+HER2- and 95% vs 77% in HR+HER2+). In contrast, for patients with triple negative breast cancer, RCB class was prognostic within ypStage II and III. Analysis by clinical stage and the components of the three systems that contribute most to prognosis will be presented. Conclusions: The degree of response to NAC adds important information to pCR versus residual disease. The Neo-Bioscore was not prognostic among patients with pCR, suggesting that clinical stage (including subtype and grade) adds little information in the setting of a pCR. In contrast, both RCB and Neo-Bioscore provide additional prognostic information to the conventional ypAJCC staging among non-pCR patients, suggesting that clinical stage, tumor biology as well as extent of residual disease all contribute to prognosis in the setting of residual disease after NAC.
Citation Format: Marieke EM van der Noordaa, Christina Yau, Sonal Shad, Marie Osdoit, Tessa G Steenbruggen, Diane de Croze, Anne-Sophie Hamy, Marick Lae, Fabien Reyal, Maria Del Monte-Millán, Miguel Martin, Sara Lopez Tarruella, I-SPY 2 TRIAL Consortium, Judy C Boughey, Matthew Goetz, Tanya Hoskin, Rebecca Gould, Vincent Valero, Gabe Sonke, Maartje van Seijen, Jelle Wesseling, John Bartlett, Stephan Edge, Mi-Ok Kim, Jean Abraham, Carlos Caldas, Helena Earl, Elena Provenzano, Stephen-John Sammut, David Cameron, Ashley Graham, Peter Hall, Lorna MacKintosh, Fang Fan, Andrew K Godwin, Kelsey Schwensen, Priyanka Sharma, Angela DeMichele, Janet Dunn, Louise Hiller, Larry Hayward, Jeremy Thomas, Kimberley Cole, Lajos Pusztai, Laura van 't Veer, Fraser Symmans, Laura Esserman. Assessing prognosis after neoadjuvant therapy: A comparison between anatomic ypAJCC staging, residual cancer burden class and neo-bioscore [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 GS4-07.
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Affiliation(s)
| | - Christina Yau
- 1University of California, San Francisco, San Francisco, CA
| | - Sonal Shad
- 1University of California, San Francisco, San Francisco, CA
| | | | | | | | | | | | | | | | - Miguel Martin
- 4Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
| | | | | | | | | | | | | | - Gabe Sonke
- 3Netherlands Cancer Institute, Amsterdam, Netherlands
| | | | | | - John Bartlett
- 7Ontario Institute for Cancer Research, Toronto, ON, Canada
| | - Stephan Edge
- 8Roswell Park Comprehensive Cancer Center, Buffalo, NY
| | - Mi-Ok Kim
- 1University of California, San Francisco, San Francisco, CA
| | - Jean Abraham
- 9University of Cambridge, Cambridge, United Kingdom
| | | | - Helena Earl
- 9University of Cambridge, Cambridge, United Kingdom
| | | | | | - David Cameron
- 10University of Edinburgh, Edinburgh, United Kingdom
| | - Ashley Graham
- 10University of Edinburgh, Edinburgh, United Kingdom
| | - Peter Hall
- 10University of Edinburgh, Edinburgh, United Kingdom
| | | | - Fang Fan
- 11University of Kansas, Kansas City, KS
| | | | | | | | | | - Janet Dunn
- 13University of Warwick, Coventry, United Kingdom
| | | | - Larry Hayward
- 14Western General Hospital, Edinburgh, United Kingdom
| | - Jeremy Thomas
- 14Western General Hospital, Edinburgh, United Kingdom
| | | | | | | | | | - Laura Esserman
- 1University of California, San Francisco, San Francisco, CA
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Schmid P, Abraham J, Chan S, Brunt AM, Nemsadze G, Baird RD, Park YH, Hall P, Perren T, Stein RC, Mangel L, Ferrero JM, Phillips M, Conibear J, Cortes J, Foxley A, de Bruin E, McEwen R, Nikolaou M, Stetson D, Dougherty B, Prendergast A, McLaughlin-Callan M, Burgess M, Lawrence C, Cartwright H, Mousa K, Turner N, Wheatley D. Abstract PD1-11: Mature survival update of the double-blind placebo-controlled randomised phase II PAKT trial of first-line capivasertib plus paclitaxel for metastatic triple-negative breast cancer. Cancer Res 2021. [DOI: 10.1158/1538-7445.sabcs20-pd1-11] [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: 11/16/2022]
Abstract
Abstract
Background: In the PAKT study, addition of the oral AKT inhibitor capivasertib to 1st-line paclitaxel therapy for metastatic TNBC resulted in significantly longer progression-free survival (PFS; primary endpoint; Schmid, J Clin Oncol 2020). The stratified PFS hazard ratio was 0.74 (95% CI, 0.50-1.08; one-sided P=0.06; predefined significance level of 0.10, one-sided; median PFS 5.9 vs 4.2 months with capivasertib vs placebo). Overall survival (OS) results were immature at the primary analysis with 53% of events but suggested long OS with capivasertib (HR, 0.61; 95% CI, 0.37-0.99; two-sided P=0.04). Here we report final results.
Methods: This double-blind, placebo-controlled, randomised phase II trial, recruited women with untreated, metastatic TNBC. Total of 140 patients were randomly assigned (1:1) to paclitaxel 90mg/m2 (days 1, 8, 15) with either capivasertib (400mg twice daily) or placebo (days 2-5, 9-12, 16-19) every 28 days until disease progression or unacceptable toxicity. The primary endpoint was PFS. Secondary endpoints included OS in the ITT population and in patients with and without PIK3CA/AKT1/PTEN-alterations.
Results: With a median F/U of 40.0 months, median OS was longer in the capivasertib arm (19.1 vs 13.5 months, stratified HR 0.70, 95% CI 0.47-1.05, p=0.085). In contrast to the earlier analysis, no meaningful differences were seen in terms of benefit with capivasertib between patients with or without alterations of PIK3CA/AKT1/PTEN. Median OS numerically favoured capivasertib vs placebo both in the PIK3CA/AKT1/PTEN-altered (stratified HR 0.58, 95% CI 0.21-1.58, p=0.290) and PIK3CA/AKT1/PTEN non-altered subgroup (stratified HR 0.74, 95% CI 0.47-1.18, p=0.207). The safety profile of capivasertib plus paclitaxel was unchanged.
Conclusions: Final OS results show a numerical trend favouring capivasertib; effects were observed regardless of PIK3CA/AKT1/PTEN alterations. Consistent with the previously observed PFS benefit, these findings support further evaluation of first-line Capivasertib plus paclitaxel for metastatic TNBC in the ongoing Capitello290 randomised phase III trial in patients with and without PIK3CA/AKT1/PTEN alterations.
Citation Format: Peter Schmid, Jacinta Abraham, Stephen Chan, Adrian Murray Brunt, Gia Nemsadze, Richard D Baird, Yeon Hee Park, Peter Hall, Timothy Perren, Robert C Stein, László Mangel, Jean-Marc Ferrero, Melissa Phillips, John Conibear, Javier Cortes, Andrew Foxley, Elza de Bruin, Robert McEwen, Myria Nikolaou, Daniel Stetson, Brian Dougherty, Aaron Prendergast, Max McLaughlin-Callan, Matthew Burgess, Cheryl Lawrence, Hayley Cartwright, Kelly Mousa, Nicholas Turner, Duncan Wheatley. Mature survival update of the double-blind placebo-controlled randomised phase II PAKT trial of first-line capivasertib plus paclitaxel for metastatic triple-negative breast cancer [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 PD1-11.
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Affiliation(s)
- Peter Schmid
- 1Barts Cancer Institute, StBartholomew’s Hospital, Queen Mary University of London, London, United Kingdom
| | | | - Stephen Chan
- 3Nottingham University Hospitals NHS Trust, London, United Kingdom
| | | | | | - Richard D Baird
- 6Cancer Research UK Cambridge Centre, London, United Kingdom
| | | | - Peter Hall
- 8Edinburgh Cancer Research Centre, University of Edinburgh, Edinburgh, United Kingdom
| | - Timothy Perren
- 9Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom
| | - Robert C Stein
- 10National Institute for Health Research University College London Hospitals Biomedical Research Centre, London, United Kingdom
| | - László Mangel
- 11Medical University of Pécs, Institute of Oncology, Pecs, Hungary
| | - Jean-Marc Ferrero
- 12Department of Medical Oncology, Centre Antoine Lacassagne, Nice, France
| | - Melissa Phillips
- 13Barts Cancer Institute, St Bartholomew’s Hospital, Queen Mary University of London, London, United Kingdom
| | - John Conibear
- 13Barts Cancer Institute, St Bartholomew’s Hospital, Queen Mary University of London, London, United Kingdom
| | | | - Andrew Foxley
- 15IMED Biotech Unit, AstraZeneca, London, United Kingdom
| | - Elza de Bruin
- 15IMED Biotech Unit, AstraZeneca, London, United Kingdom
| | - Robert McEwen
- 15IMED Biotech Unit, AstraZeneca, London, United Kingdom
| | - Myria Nikolaou
- 15IMED Biotech Unit, AstraZeneca, London, United Kingdom
| | - Daniel Stetson
- 15IMED Biotech Unit, AstraZeneca, London, United Kingdom
| | | | - Aaron Prendergast
- 13Barts Cancer Institute, St Bartholomew’s Hospital, Queen Mary University of London, London, United Kingdom
| | - Max McLaughlin-Callan
- 13Barts Cancer Institute, St Bartholomew’s Hospital, Queen Mary University of London, London, United Kingdom
| | - Matthew Burgess
- 13Barts Cancer Institute, St Bartholomew’s Hospital, Queen Mary University of London, London, United Kingdom
| | - Cheryl Lawrence
- 13Barts Cancer Institute, St Bartholomew’s Hospital, Queen Mary University of London, London, United Kingdom
| | - Hayley Cartwright
- 13Barts Cancer Institute, St Bartholomew’s Hospital, Queen Mary University of London, London, United Kingdom
| | - Kelly Mousa
- 13Barts Cancer Institute, St Bartholomew’s Hospital, Queen Mary University of London, London, United Kingdom
| | - Nicholas Turner
- 16Institute of Cancer Research and Royal Marsden Hospital, London, United Kingdom
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Shad S, van der Noordaa M, Osdoit M, de Croze D, Hamy AS, Lae M, Reyal F, Martin M, Del Monte-Millán M, López-Tarruella S, Boughey JC, Goetz MP, Hoskin T, Gould R, Valero V, Sonke G, Steenbruggen TG, van Seijen M, Wesseling J, Bartlett J, Edge S, Kim MO, Abraham J, Caldas C, Earl H, Provenzano E, Sammut SJ, Cameron D, Graham A, Hall P, Mackintosh L, Fang F, Godwin AK, Schwensen K, Sharma P, DeMichele A, Dunn J, Hiller L, Hayward L, Thomas J, Cole K, Pusztai L, Van't Veer L, Symmans F, Esserman L, Yau C. Abstract PD13-02: Site of recurrence after neoadjuvant therapy: A multi-center pooled analysis. Cancer Res 2021. [DOI: 10.1158/1538-7445.sabcs20-pd13-02] [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: Achieving a pathologic complete response (pCR) has been shown on the patient level to predict excellent long-term event-free survival outcomes. Residual cancer burden (RCB) quantifies the extent of residual disease for patients who did not achieve pCR. We have previously observed in the I-SPY 2 TRIAL that while metastatic events outside the central nervous system (CNS) were dramatically reduced in the setting of pCR, the incidence of CNS metastasis remained similar across RCB classes, raising the possibility that these CNS events may be independent of response in the breast. In this study, we evaluate the type and sites of recurrences by RCB in a large pooled dataset, which allows for analysis within subtype, to validate these findings. Methods: 5161 patients pooled across 12 institutions/trials with available RCB and event-free survival (EFS) data were included in this analysis. EFS was calculated as the interval between treatment initiation, and locoregional recurrence, distant recurrence or death from any cause; patients without event are censored at time of last follow-up. The median follow-up is 4.6 years. We summarized the EFS event type, further sub-dividing the distant recurrence events (DR) by their site of relapse (CNS-only, CNS and other sites, Non-CNS). We used a competing risk (Fine-Gray) model to assess which of these site-specific relapses differ between RCB classes and estimated the cumulative incidence of CNS-only and non-CNS events at 5 years. Analyses were performed across the entire study population and within HR/HER2 defined subtypes. Results: Among the 5161 subjects, there were 1164 EFS events, including 92 (7.9%) local recurrences (without distant recurrence and/or death) and 1072 distant recurrence-free survival (DRFS) events. Among the DRFS events, 158 patients died without a distant recurrence. 914 experienced distant recurrences, including 90 (9.8%) with CNS-only, 145 (15.9%) with CNS and other sites, 664 (72.6%) with non-CNS distant recurrence; 15 (1.6%) patients had missing recurrence site information. Table 1 summarizes the cumulative incidence of CNS-only and non-CNS recurrence at 5 years and the proportion of CNS-only recurrences among DR events by RCB class overall and within each HR/HER2 subtypes. The incidence of CNS-only recurrences was low and similar across RCB classes. In contrast, the incidence of non-CNS recurrences increases with increasing RCB. As a result, CNS-only recurrences are proportionally higher within the RCB-0 and RCB-I than in the RCB-II and RCB-III groups, largely because of the low DR event rate and relative low frequency of non-CNS recurrence events within the RCB-0 and RCB-I classes. Overall, 27% of the recurrences in the setting of pCR (RCB-0) are due to CNS-only recurrences.Conclusions: Consistent with previous studies, our large pooled analysis confirmed that CNS-only recurrences are uncommon but appear similar across RCB groups, independent of response, suggesting that the CNS is a treatment sanctuary site. In contrast, non-CNS recurrence rates increase as RCB increases. These findings suggest that inclusion of CNS-only recurrences as an outcome event may impact the association between neoadjuvant therapy response and long-term outcomes in the context of current therapies. Novel therapies that cross the blood brain barrier will be needed to impact CNS recurrence rates.
Table 1: Cumulative Incidence of CNS Only and non-CNS Distant Recurrences at 5 years and proportion of CNS-only events among DR eventsRCB Class0IIIIIIpOverall (5161)N16766622017806Cum. Inc. CNS Only2%2%2%1%0.627Cum. Inc. Non-CNS3%6%16%27%<0.001# CNS-Only / # DR events (%)26/96 (27%)14/74 (19%)39/443 (9%)11/301 (4%)HR-HER2- (1774)N770212590202Cum. Inc. CNS Only2%3%2%4%0.298Cum. Inc. Non-CNS4%11%19%42%<0.001# CNS-Only / # DR events (%)13/50 (26%)6/32 (19%)13/148 (9%)8/111 (7%)HR-HER2+ (572)N3766710029Cum. Inc. CNS Only1%5%5%0%0.022Cum. Inc. Non-CNS2%5%18%38%<0.001# CNS-Only / # DR events (%)4/17 (24%)3/10 (30%)6/31 (19%)0/13 (0%)HR+HER2+ (858)N31317229182Cum. Inc. CNS Only1%1%2%0%0.37Cum. Inc. Non-CNS2%3%15%26%<0.001# CNS-Only / # DR events (%)3/10 (30%)2/16 (12%)7/68 (10%)0/29 (0%)HR+HER2- (1957)N2172111036493Cum. Inc. CNS Only3%2%1%0.2%0.087Cum. Inc. Non-CNS5%4%13%20%<0.001# CNS-Only / # DR events (%)6/19 (32%)3/16 (19%)13/196 (7%)3/148 (2%)
Citation Format: Sonal Shad, Marieke van der Noordaa, Marie Osdoit, Diane de Croze, Anne-Sophie Hamy, Marick Lae, Fabien Reyal, Miguel Martin, María Del Monte-Millán, Sara López-Tarruella, I-SPY 2 TRIAL Consortium, Judy C Boughey, Matthew P Goetz, Tanya Hoskin, Rebekah Gould, Vicente Valero, Gabe Sonke, Tessa G Steenbruggen, Maartje van Seijen, Jelle Wesseling, John Bartlett, Stephen Edge, Mi-Ok Kim, Jean Abraham, Carlos Caldas, Helena Earl, Elena Provenzano, Stephen-John Sammut, David Cameron, Ashley Graham, Peter Hall, Lorna Mackintosh, Fan Fang, Andrew K Godwin, Kelsey Schwensen, Priyanka Sharma, Angela DeMichele, Janet Dunn, Louise Hiller, Larry Hayward, Jeremy Thomas, Kimberly Cole, Lajos Pusztai, Laura Van't Veer, Fraser Symmans, Laura Esserman, Christina Yau. Site of recurrence after neoadjuvant therapy: A multi-center pooled analysis [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 PD13-02.
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Affiliation(s)
- Sonal Shad
- 1University of California, San Francisco, San Francisco, CA
| | | | | | | | | | | | | | - Miguel Martin
- 4Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
| | | | | | | | | | | | | | | | - Gabe Sonke
- 2Netherlands Cancer Institute, Amsterdam, Netherlands
| | | | | | | | - John Bartlett
- 7Ontario Institute for Cancer Research, Toronto, ON, Canada
| | - Stephen Edge
- 8Roswell Park Comprehensive Cancer Center, Buffalo, NY
| | - Mi-Ok Kim
- 1University of California, San Francisco, San Francisco, CA
| | - Jean Abraham
- 9University of Cambridge, Cambridge, United Kingdom
| | | | - Helena Earl
- 9University of Cambridge, Cambridge, United Kingdom
| | | | | | - David Cameron
- 10University of Edinburgh, Edinburgh, United Kingdom
| | - Ashley Graham
- 10University of Edinburgh, Edinburgh, United Kingdom
| | - Peter Hall
- 10University of Edinburgh, Edinburgh, United Kingdom
| | | | - Fan Fang
- 11University of Kansas, Kansas City, KS
| | | | | | | | | | - Janet Dunn
- 13University of Warwick, Coventry, United Kingdom
| | | | - Larry Hayward
- 14Western General Hospital, Edinburgh, United Kingdom
| | - Jeremy Thomas
- 14Western General Hospital, Edinburgh, United Kingdom
| | | | | | | | | | - Laura Esserman
- 1University of California, San Francisco, San Francisco, CA
| | - Christina Yau
- 1University of California, San Francisco, San Francisco, CA
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