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Liang K, Feliciano JL, Marrone KA, Murray JC, Hann CL, Anagnostou V, Tackett SA, Shin EJ, Hales RK, Voong KR, Battafarano RJ, Yang SC, Broderick SR, Ha JS, Forde PM, Brahmer JR, Lam VK. Clinical features and outcomes of advanced HER2+ esophageal/GEJ cancer with brain metastasis. ESMO Open 2024; 9:102199. [PMID: 38071928 PMCID: PMC10837776 DOI: 10.1016/j.esmoop.2023.102199] [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: 06/13/2023] [Revised: 10/30/2023] [Accepted: 11/15/2023] [Indexed: 01/26/2024] Open
Abstract
BACKGROUND Brain metastasis (BRM) is uncommon in gastroesophageal cancer. As such, clinicopathologic and molecular determinants of BRM and impact on clinical outcome remain incompletely understood. METHODS We retrospectively analyzed clinicopathologic data from advanced esophageal/gastroesophageal junction (E/GEJ) patients at Johns Hopkins from 2003 to 2021. We investigated the association between several clinical and molecular features and the occurrence of BRM, with particular focus on human epidermal growth factor receptor 2 (HER2) overexpression. Survival outcomes and time to BRM onset were also evaluated. RESULTS We included 515 patients with advanced E/GEJ cancer. Tumors were 78.3% esophageal primary, 82.9% adenocarcinoma, 31.0% HER2 positive. Cumulative incidence of BRM in the overall cohort and within HER2+ subgroup was 13.8% and 24.3%, respectively. HER2 overexpression was associated with increased risk of BRM [odds ratio 2.45; 95% confidence interval (CI) 1.10-5.46]. On initial presentation with BRM, 50.7% had a solitary brain lesion and 11.3% were asymptomatic. HER2+ status was associated with longer median time to onset of BRM (14.0 versus 6.3 months, P < 0.01), improved median progression free survival on first-line systemic therapy (hazard ratio 0.35, 95% CI 0.16-0.80), and improved median overall survival (hazard ratio 0.20, 95% CI 0.08-0.54) in patients with BRM. CONCLUSION HER2 overexpression identifies a gastroesophageal cancer molecular subtype that is significantly associated with increased risk of BRM, though with later onset of BRM and improved survival likely reflecting the impact of central nervous system-penetrant HER2-directed therapy. The prevalence of asymptomatic and solitary brain lesions suggests that brain surveillance for HER2+ patients warrants prospective investigation.
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Affiliation(s)
- K Liang
- The Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, USA
| | - J L Feliciano
- The Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, USA
| | - K A Marrone
- The Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, USA
| | - J C Murray
- The Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, USA
| | - C L Hann
- The Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, USA
| | - V Anagnostou
- The Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, USA
| | - S A Tackett
- Department of Medicine, Biostatistics, Epidemiology and Data Management (BEAD) Core, Johns Hopkins University School of Medicine, Baltimore, USA
| | - E J Shin
- Department of Gastroenterology & Hepatology, Johns Hopkins University School of Medicine, Baltimore, USA
| | - R K Hales
- The Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, USA; Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, USA
| | - K R Voong
- The Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, USA; Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, USA
| | - R J Battafarano
- The Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, USA
| | - S C Yang
- The Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, USA
| | - S R Broderick
- The Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, USA
| | - J S Ha
- The Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, USA
| | - P M Forde
- The Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, USA
| | - J R Brahmer
- The Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, USA
| | - V K Lam
- The Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, USA.
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Voong KR, Shokek OB, Hill C, Hu C, Hales RK, Greco SC, Meyer JJ, Wright JL, Lowe K, McNutt TR, Narang A, PhD CS, Lee SM. Improving Cancer Care by Incorporating the Patient's Voice in Symptom Management (IMPROVE): A Multicenter-Prospective Pilot Study. Int J Radiat Oncol Biol Phys 2023; 117:e264-e265. [PMID: 37785007 DOI: 10.1016/j.ijrobp.2023.06.1222] [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: 10/04/2023]
Abstract
PURPOSE/OBJECTIVE(S) IMPROVE is a prospective multicenter pilot study. It evaluates whether routine physician review of patient-reported outcomes measures (PROMs) during radiotherapy alters physicians' perception of cancer patients' treatment-related toxicity and influences symptom management. MATERIALS/METHODS We are enrolling patients with thoracic or gastrointestinal cancers amenable to conventional-fractionated radiotherapy. Patients may receive concurrent chemotherapy. Patients report (1) symptoms, using PRO-CTCAE measures, (2) the most burdensome symptom, and (3) how symptoms interfere with daily activities. Patients complete the measures before seeing their physician during each on-treatment visit. During weekly visits and before reviewing the patient's PROMs, physicians rate the symptom burden for each patient from 0 to 10, using available clinical data. These data include vital signs, lab work, physical exams, nursing assessments, and physicians' clinical judgment. After reviewing the patients' PROMs, physicians re-rate each patient's symptom burden and report any changes in recommended interventions. Changes could include (1) additional counseling, (2) new medications or interventions, (3) referrals to other services, or (4) further testing or evaluation. After each patient's course of radiotherapy, providers complete a Clinician Feedback Form about the impact of PROM review on symptom perception and management during treatment. This study commenced November 11, 2020 at a multi-site tertiary academic cancer center (using electronic or paper questionnaires) and July 21, 2021 at a multi-site community cancer center (using paper forms). RESULTS To be determined. CONCLUSION To be determined.
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Affiliation(s)
- K R Voong
- Johns Hopkins University, Baltimore, MD
| | - O B Shokek
- Wellspan York Cancer Center, York, PA, United States
| | - C Hill
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, MD
| | - C Hu
- Johns Hopkins Medicine Sidney Kimmel Comprehensive Cancer Center, Baltimore, MD
| | - R K Hales
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, MD
| | - S C Greco
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, MD
| | - J J Meyer
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, MD
| | - J L Wright
- Johns Hopkins Medicine, Department of Radiation Oncology, Baltimore, MD
| | - K Lowe
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, MD
| | - T R McNutt
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, MD
| | - A Narang
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, MD
| | - C Snyder PhD
- Johns Hopkins University School of Medicine, Baltimore, MD
| | - S M Lee
- Department of Biostatistics, Columbia University School of Medicine, New York, NY
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Chang L, Song D, Hales RK, Viswanathan AN, Wright JL. Quantifying Value in an Iterative Disease-Site Specific Peer Review System. Int J Radiat Oncol Biol Phys 2023; 117:e369-e370. [PMID: 37785261 DOI: 10.1016/j.ijrobp.2023.06.2468] [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: 10/04/2023]
Abstract
PURPOSE/OBJECTIVE(S) To assess the greatest impact of peer review on treatment planning and plan modification in two disease-site specific peer review groups to improve quality assurance workflow. MATERIALS/METHODS We implemented an iterative peer review checklist tool and treatment planning registry to document recommendations and time spent in breast and thoracic disease-site specific peer review. Plan review included discussion of the clinical scenario, radiation dose/fractionation, prescription, organs at risk and target volumes, planning metrics including dose volume histogram and patient setup. Pre-treatment (Pre-tx) review of volumes and plans occurred prior to treatment start for definitive plans of ≤five fractions or using protons, and cases were re-reviewed in subsequent sessions to complete checklist items as needed. Reviews were graded as follows: discussion (no required changes), minor recommendations (changes recommended at attending discretion) and major recommendations (changes required). Students t-test and chi-squared analysis were used to identify statistical significance. RESULTS We identified 723 peer reviews over a 3-month period: 275 thoracic reviews of 195 unique patients (32% reviewed ≥twice), and 448 breast reviews of 273 unique patients (48% reviewed ≥twice, most commonly for a boost plan). On average, pre-tx review doubled the amount of time spent per case, (4:47min versus 2:03min, p<0.01) and resulted in significantly more discussion (29.3% vs 9.3%, p<0.01), minor changes recommended (13.2% versus 4.8%, p<0.01) and plan revision (19.2% versus 2.4%, p<0.01). Thoracic pre-tx reviews were twice as long as breast (5:43min versus 3:00min, p<0.01), and had a greater proportion of cases prompting discussion (26.7% vs 13.2%, p<0.01) and minor changes recommended (12.8% vs 6.3%, p<0.01). No time difference was found in regular review (2:19min vs 1:58 min, p = 0.09). The most frequent discussion/recommendation topics also varied by group with planning metrics in thoracic cases (14.9%) and setup imaging including PORT films and electron setup (5.1%) in breast (Table). CONCLUSION Iterative plan review with pre-review for selected cases encouraged educational discussion and plan revision, with notable variability by disease site. Thoracic cases required longer review time and had more frequent plan change recommendations likely reflecting differences in case complexity. In contrast, setup imaging in breast cases, which are more commonly 3D or electron-based, more frequently warranted discussion/revision and should be considered within the peer review paradigm.
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Affiliation(s)
- L Chang
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, MD
| | - D Song
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, MD
| | - R K Hales
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, MD
| | - A N Viswanathan
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, MD
| | - J L Wright
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, MD
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Hazell SZ, Fu W, Hu C, Voong KR, Lee B, Peterson V, Feliciano JL, Nicholas LH, McNutt TR, Han P, Hales RK. Financial toxicity in lung cancer: an assessment of magnitude, perception, and impact on quality of life. Ann Oncol 2021; 31:96-102. [PMID: 31912803 DOI: 10.1016/j.annonc.2019.10.006] [Citation(s) in RCA: 51] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2019] [Revised: 09/29/2019] [Accepted: 10/08/2019] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Advances in lung cancer therapy have resulted in improved clinical outcomes. Unfortunately, advances can come at a financial cost to patients and their families that poses a significant risk to overall quality of life (QoL). Financial distress has been shown to be associated with increased symptom burden and decreased treatment compliance but the magnitude of financial distress is not well characterized in lung cancer populations. PATIENTS AND METHODS Patients with stage II-IV newly diagnosed lung cancer and starting first-line therapy were recruited at a tertiary academic institution between July 2018 and April 2019. The comprehensive score for financial toxicity (COST) was used to assess financial toxicity and the Functional Assessment of Cancer Therapy-Lung (FACT-L) was used to assess QoL. Associations between financial toxicity and baseline variables were assessed using multivariable linear regression and correlations were assessed using the Pearson correlation. RESULTS In this study, 143 consecutive patients were approached and 91.6% agreed to participate (N = 131). The median age was 65 years (35-90); 52.7% were male (n = 69), and 75.6% were white (n = 99). The inability to afford basic necessities and having <1 month of savings was associated with increased financial toxicity (P < 0.001) after adjusting for other factors such as age, race, insurance, and income. There was also a trend toward increased financial toxicity among those who were employed but on sick leave (P = 0.06). Increased financial toxicity was correlated with a decrease in QoL (correlation coefficient 0.41, P < 0.001). Patients' anticipated out-of-pocket (OOP) expenses for the upcoming 6 months ranged from $0 to $50 000 (median $2150). However, there was no correlation between anticipated OOP expenses and either financial toxicity or QoL. CONCLUSIONS These data identify key factors for identifying at-risk patients and builds a framework for exploring the benefit of financial counseling interventions, which may improve QoL and oncologic outcomes.
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Affiliation(s)
- S Z Hazell
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, USA
| | - W Fu
- Division of Biostatistics and Bioinformatics, Johns Hopkins University School of Medicine, Baltimore, USA
| | - C Hu
- Division of Biostatistics and Bioinformatics, Johns Hopkins University School of Medicine, Baltimore, USA
| | - K R Voong
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, USA
| | - B Lee
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, USA
| | - V Peterson
- Department of Medical Oncology, Johns Hopkins University School of Medicine, Baltimore, USA
| | - J L Feliciano
- Department of Medical Oncology, Johns Hopkins University School of Medicine, Baltimore, USA
| | - L H Nicholas
- Bloomberg School of Public Health, Johns Hopkins University, Baltimore, USA
| | - T R McNutt
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, USA
| | - P Han
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, USA
| | - R K Hales
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, USA.
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Tran PT, Hales RK, Zeng J, Aziz K, Salih T, Gajula RP, Chettiar S, Gandhi N, Wild AT, Kumar R, Herman JM, Song DY, DeWeese TL. Tissue biomarkers for prostate cancer radiation therapy. Curr Mol Med 2012; 12:772-87. [PMID: 22292443 PMCID: PMC3412203 DOI: 10.2174/156652412800792589] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2011] [Revised: 11/10/2011] [Accepted: 12/20/2011] [Indexed: 12/12/2022]
Abstract
Prostate cancer is the most common cancer and second leading cause of cancer deaths among men in the United States. Most men have localized disease diagnosed following an elevated serum prostate specific antigen test for cancer screening purposes. Standard treatment options consist of surgery or definitive radiation therapy directed by clinical factors that are organized into risk stratification groups. Current clinical risk stratification systems are still insufficient to differentiate lethal from indolent disease. Similarly, a subset of men in poor risk groups need to be identified for more aggressive treatment and enrollment into clinical trials. Furthermore, these clinical tools are very limited in revealing information about the biologic pathways driving these different disease phenotypes and do not offer insights for novel treatments which are needed in men with poor-risk disease. We believe molecular biomarkers may serve to bridge these inadequacies of traditional clinical factors opening the door for personalized treatment approaches that would allow tailoring of treatment options to maximize therapeutic outcome. We review the current state of prognostic and predictive tissue-based molecular biomarkers which can be used to direct localized prostate cancer treatment decisions, specifically those implicated with definitive and salvage radiation therapy.
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Affiliation(s)
- P T Tran
- Department of Radiation Oncology and Molecular Radiation Sciences, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins Medicine, 1550 Orleans Street, CRB2, RM 406, Baltimore, MD 21231, USA.
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Hales RK, Banchereau J, Ribas A, Tarhini AA, Weber JS, Fox BA, Drake CG. Assessing oncologic benefit in clinical trials of immunotherapy agents. Ann Oncol 2010; 21:1944-1951. [PMID: 20237004 DOI: 10.1093/annonc/mdq048] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND USA Food and Drug Administration approval for cancer therapy requires demonstration of patient benefit as a marker of clinical efficacy. Prolonged survival is the gold standard for demonstration of efficacy, but other end points such as antitumor response, progression-free survival, quality of life, or surrogate end points may be used. DESIGN This study was developed based on discussion during a roundtable meeting of experts in the field of immunotherapy. RESULTS In most clinical trials involving cytotoxic agents, response end points use RECIST based on the premise that 'effective' therapy causes tumor destruction, target lesion shrinkage, and prevention of new lesions. However, RECIST may not be appropriate in trials of immunotherapy. Like other targeted agents, immunotherapies may mediate cytostatic rather than direct cytotoxic effects, and these may be difficult to quantify with RECIST. Furthermore, significant time may elapse before clinical effects are quantifiable because of complex response pathways. Effective immunotherapy may even mediate transient lesion growth secondary to immune cell infiltration. CONCLUSIONS RECIST may not be an optimal indicator of clinical benefit in immunotherapy trials. This article discusses alternative clinical trial designs and end points that may be more relevant for immunotherapy trials and may offer more effective prediction of survival in pivotal phase III studies.
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Affiliation(s)
- R K Hales
- Department of Radiation Oncology and Molecular Radiation Sciences, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - J Banchereau
- Baylor Institute for Immunology Research, Dallas, TX
| | - A Ribas
- Division of Hematology-Oncology, University of California Los Angeles, Los Angeles, LA
| | - A A Tarhini
- Department of Medicine, Division of Hematology/Oncology, University of Pittsburgh Cancer Institute, Pittsburgh, PA
| | - J S Weber
- Department of Cutaneous Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL
| | - B A Fox
- Earle A. Chiles Research Institute, Providence Cancer Center and Oregon Health and Science University, Portland, ME, USA
| | - C G Drake
- Department of Radiation Oncology and Molecular Radiation Sciences, The Johns Hopkins University School of Medicine, Baltimore, MD.
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