Precision needle-punch tumor enrichment from paraffin blocks improves the detection of clinically actionable genomic alterations and biomarkers

Background

While many molecular assays can detect mutations at low tumor purity and variant allele frequencies, complex biomarkers such as tumor mutational burden (TMB), microsatellite instability (MSI), and genomic loss of heterozygosity (gLOH) require higher tumor purity for accurate measurement. Scalable, quality-controlled, tissue-conserving methods to increase tumor nuclei percentage (TN%) from tumor specimens are needed for complex biomarkers and hence necessary to maximize patient matching to approved therapies or clinical trial enrollment. We evaluated the clinical utility and performance of precision needle-punch enrichment (NPE) compared with traditional razor blade macroenrichment of tumor specimens on molecular testing success.

Methods

Pathologist-directed NPE was performed manually on formalin-fixed, paraffin embedded (FFPE) blocks. Quality control of target capture region and quantity of residual tumor in each tissue block was determined via a post-enrichment histologic slide recut. Resultant tumor purity and biomarker status were determined by the computational analysis pipeline component of the FDA-approved next-generation sequencing (NGS) assay, FoundationOne®CDx. Following NPE implementation for real-world clinical samples, assay performance and biomarker (MSI, TMB, gLOH) detection were analyzed.

Results

In real-world clinical samples, enrichment rate via NPE was increased to ~50% over a 2.5-year period, exceeding the prior use of razor blade macro-enrichment (<30% of cases) prior to NPE implementation due to proven efficacy in generating high quality molecular results from marginal samples and the ease of use for both pathologist and histotechnologists. NPE was associated with lower test failures, higher computational tumor purity, and higher rates of successful TMB, MSI and gLOH determination when stratified by pre-enriched (incipient) tumor nuclei percentage. In addition, challenging cases in which tumor content was initially insufficient for testing were salvaged for analysis of biomarker status, gene amplification/deletion, and confident mutant or wild-type gene status determination.

Conclusions

Pathologist-directed precision enrichment from tissue blocks (aka NPE) increases tumor purity, and consequently, yields a greater number of successful tests and complex biomarker determinations. Moreover, this process is rapid, safe, inexpensive, scalable, and conserves patient surgical pathology material. NPE may constitute best practice with respect to enriching tumor cells from low-purity specimens for biomarker detection in molecular laboratories.

Oncogenic Drivers and Therapeutic Vulnerabilities in KRAS Wild-Type Pancreatic Cancer

PURPOSE

Approximately 8% to 10% of pancreatic ductal adenocarcinomas (PDAC) do not harbor mutations in KRAS. Understanding the unique molecular and clinical features of this subset of pancreatic cancer is important to guide patient stratification for clinical trials of molecularly targeted agents.

EXPERIMENTAL DESIGN

We analyzed a single-institution cohort of 795 exocrine pancreatic cancer cases (including 785 PDAC cases) with a targeted multigene sequencing panel and identified 73 patients (9.2%) with KRAS wild-type (WT) pancreatic cancer.

RESULTS

Overall, 43.8% (32/73) of KRAS WT cases had evidence of an alternative driver of the MAPK pathway, including BRAF mutations and in-frame deletions and receptor tyrosine kinase fusions. Conversely, 56.2% of cases did not harbor a clear MAPK driver alteration, but 29.3% of these MAPK-negative KRAS WT cases (12/41) demonstrated activating alterations in other oncogenic drivers, such as GNAS, MYC, PIK3CA, and CTNNB1. We demonstrate potent efficacy of pan-RAF and MEK inhibition in patient-derived organoid models carrying BRAF in-frame deletions. Moreover, we demonstrate durable clinical benefit of targeted therapy in a patient harboring a KRAS WT tumor with a ROS1 fusion. Clinically, patients with KRAS WT tumors were significantly younger in age of onset (median age: 62.6 vs. 65.7 years; P = 0.037). SMAD4 mutations were associated with a particularly poor prognosis in KRAS WT cases.

CONCLUSIONS

This study defines the genomic underpinnings of KRAS WT pancreatic cancer and highlights potential therapeutic avenues for future investigation in molecularly directed clinical trials. See related commentary by Kato et al., p. 4527.

Potential pathogenic germline variant reporting from tumor comprehensive genomic profiling complements classic approaches to germline testing

Existing guidance regarding clinically informed germline testing for patients with cancer is effective for evaluation of classic hereditary cancer syndromes and established gene/cancer type associations. However, current screening methods may miss patients with rare, reduced penetrance, or otherwise occult hereditary risk. Secondary finding of suspected germline variants that may confer inherited cancer risk via tumor comprehensive genomic profiling (CGP) has the potential to help address these limitations. However, reporting practices for secondary finding of germline variants are inconsistent, necessitating solutions for transparent and coherent communication of these potentially important findings. A workflow for improved confidence detection and clear reporting of potential pathogenic germline variants (PPGV) in select cancer susceptibility genes (CSG) was applied to a research dataset from real-world clinical tumor CGP of > 125,000 patients with advanced cancer. The presence and patterns of PPGVs identified across tumor types was assessed with a focus on scenarios in which traditional clinical germline evaluation may have been insufficient to capture genetic risk. PPGVs were identified in 9.7% of tumor CGP cases using tissue- and liquid-based assays across a broad range of cancer types, including in a number of "off-tumor" contexts. Overall, PPGVs were identified in a similar proportion of cancers with National Comprehensive Cancer Network (NCCN) recommendations for germline testing regardless of family history (11%) as in all other cancer types (9%). These findings suggest that tumor CGP can serve as a tool that is complementary to traditional germline genetic evaluation in helping to ascertain inherited susceptibility in patients with advanced cancer.

Abstract 305: POLE-specific variant classification strategy is critical for identifying patients who may benefit from immunotherapy

BACKGROUND: Pathogenic POLE exonuclease domain mutations (pPOLE) undermine mismatch error correction during DNA replication, causing somatic ultramutation and response to immunotherapy. We examined the pan-cancer landscape of POLE mutations and applied a POLE-specific variant classification model.

METHODS: Comprehensive genomic profiling was performed during clinical care. Mutational signature calling was performed via decomposition using the 96-feature single-base substitution COSMIC reference signatures. A POLE-specific classification model encompassing mutation position in the exonuclease domain, TMB, presence of POLE signature, absence of other signatures, germline frequency, and other features was applied to identify pPOLE mutations causative of ultramutation.

RESULTS: POLE mutation status was evaluated in 458,437 samples (425,520 tissue biopsies (TB) and 32,917 liquid biopsies (LB)). One or more POLE alterations, including pathogenic alterations and variants of unknown significance (VUS), were detected in 3.8% of samples. 19,470 total alterations were identified, 84.8% of which were missense substitutions. Application of the POLE-specific classification model identified 35 unique pathogenic variants, many of which were VUS prior to this study. 749 samples harbored a pPOLE, more than half (56.6%) of which were either p.P286R (n=245) or p.V411L (n=179). pPOLE were found in 1.4% (199/13,688) of endometrial cancers (EC) and 0.5% (270/55,981) of colorectal cancers (CRC) and were rarer in a long tail of other malignancies. The overall pPOLE rate was significantly lower in LB than TB (0.02% vs 0.17%, P&lt;0.001) in the context of different clinical ordering patterns for EC (0.9% of LB cohort vs 3.1% of TB cohort; P&lt;0.001) and CRC (7.5% of LB cohort vs 12.6% of TB cohort; P&lt;0.001). Median TB TMB for pPOLE+ samples was 157.5 mut/mb, compared to 3.5 for the cohort overall (P&lt;0.001). Similarly in LB, median pPOLE+ bTMB was 165.6 vs 2.5 overall (P&lt;0.001). MSI-H or an MMR-associated signature was found in 17.5% of samples with pPOLE, most commonly in neurologic malignancies (75%, 27/36). Median TMB of samples with both pPOLE and MMRD was 2.4-fold higher than those with pPOLE alone (337.6 vs 139.4; P&lt;0.001). Notably, 6.8% of pPOLE+ cases had TMB&lt;10, which was associated median pPOLE VAF of 3.5%, compared with 25.7% among pPOLE samples with TMB≥10 (P&lt;0.001). This pattern suggests that TMB is underestimated when tumor purity is near the limit of detection for the assay.

CONCLUSIONS: pPOLE were seen in both TB and LB across cancer types. The high rate of passenger mutations underscores the utility of this POLE-specific variant classification model. Because TMB can be underestimated when tumor purity is near the limit of detection for the assay, accurate detection and classification of pPOLE is critical for identifying patients who may benefit from immunotherapy.

Citation Format: Rachel B. Keller, James Haberberger, Tyler Janovitz, Alexa B. Schrock, Hanna Tukachinsky, Lei Zhong, Douglas A. Mata, Lyle V. Lopez, Zoe Fleischmann, Radwa Sharaf, Ethan S. Sokol, Garrett M. Frampton, Nimesh R. Patel, Douglas I. Lin, Geoff R. Oxnard, Erik A. Williams, Julia A. Elvin, Brennan Decker. POLE-specific variant classification strategy is critical for identifying patients who may benefit from immunotherapy [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2023; Part 1 (Regular and Invited Abstracts); 2023 Apr 14-19; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2023;83(7_Suppl):Abstract nr 305.

Programmatic Precision Oncology Decision Support for Patients With Gastrointestinal Cancer

PURPOSE

With the growing number of available targeted therapeutics and molecular biomarkers, the optimal care of patients with cancer now depends on a comprehensive understanding of the rapidly evolving landscape of precision oncology, which can be challenging for oncologists to navigate alone.

METHODS

We developed and implemented a precision oncology decision support system, GI TARGET, (Gastrointestinal Treatment Assistance Regarding Genomic Evaluation of Tumors) within the Gastrointestinal Cancer Center at the Dana-Farber Cancer Institute. With a multidisciplinary team, we systematically reviewed tumor molecular profiling for GI tumors and provided molecularly informed clinical recommendations, which included identifying appropriate clinical trials aided by the computational matching platform MatchMiner, suggesting targeted therapy options on or off the US Food and Drug Administration-approved label, and consideration of additional or orthogonal molecular testing.

RESULTS

We reviewed genomic data and provided clinical recommendations for 506 patients with GI cancer who underwent tumor molecular profiling between January and June 2019 and determined follow-up using the electronic health record. Summary reports were provided to 19 medical oncologists for patients with colorectal (n = 198, 39%), pancreatic (n = 124, 24%), esophagogastric (n = 67, 13%), biliary (n = 40, 8%), and other GI cancers. We recommended ≥ 1 precision medicine clinical trial for 80% (406 of 506) of patients, leading to 24 enrollments. We recommended on-label and off-label targeted therapies for 6% (28 of 506) and 25% (125 of 506) of patients, respectively. Recommendations for additional or orthogonal testing were made for 42% (211 of 506) of patients.

CONCLUSION

The integration of precision medicine in routine cancer care through a dedicated multidisciplinary molecular tumor board is scalable and sustainable, and implementation of precision oncology recommendations has clinical utility for patients with cancer.

Abstract A001: Clinical-genomic analysis of KRAS wild-type pancreatic cancer confirms alternative targetable drivers and provides insight for age and risk related clinical stratification

Approximately 8-10% of pancreatic cancers do not harbor mutations in KRAS. Understanding the unique molecular and clinical features of this subset of pancreatic cancer (PC) is important to guide patient stratification for clinical trials of molecularly targeted agents. To this end we investigated a cohort of 795 PC patients from Dana-Farber Cancer Institute who had undergone somatic genomic characterization with OncoPanel, a targeted next-generation sequencing panel with coverage of more than 400 cancer-associated genes. A total of 9.2% (73/795) of cases in our cohort were KRAS WT. The KRAS WT cohort was statistically enriched for MSI-H PC and acinar cell carcinomas (p = 0.0035, p &lt; 0.0001 respectively). Actionable alterations in alternative MAPK drivers were identified in 44% (32/73) of KRAS WT cases. BRAF alterations accounted for 56% (18/32) of detected alternative MAPK drivers, the majority of which (72%) were Class II which exhibit dimer-dependent constitutive activity. Receptor Tyrosine Kinase (RTK) fusion events in BRAF, NTRK1, NRG1, NTRK3, ROS1, and FGFR2 accounted for 25% (8/32) of detected alternative MAPK drivers in KRAS WT tumors. BRAF in-frame deletions showed increased sensitivity to dual pan-RAF and MEK inhibition in organoid models and one patient with a ROS1 fusion received prolonged clinical benefit from targeted therapy. In addition to alternative MAPK drivers, mutations in GNAS (p = 0.0014) and ARID2 (p = 0.045) were significantly enriched in KRAS WT PC, whereas TP53 mutations were significantly less frequent in KRAS WT cases. Interestingly, although not statistically significant, rates of mutation in the other canonical tumor suppressor genes (CDKN2A, SMAD4) were also lower in KRAS WT PC. Clinically, KRAS Mutant (MUT) PC were associated with a decreased overall survival (OS) compared to the KRAS WT cohort [median OS 17.5 vs 24.0 months, HR 1.38, p = 0.036], however this relationship was no longer significant after accounting for other clinical factors. For patients with KRAS WT PC, those with SMAD4 alterations had a significantly decreased OS (HR 6.24, p &lt; 0.001), whereas presence of TP53 or CDKN2A mutations had no significant impact. Lastly, we found that KRAS WT PC was associated with a younger age of onset. Interestingly, we noted that KRAS WT PC patients with a younger age of onset had tumors with few oncogenic alterations whereas no such association was seen in KRAS MUT patients. Validation of this finding in a separate dataset is required and is currently ongoing. In summary, our clinical and genomic characterization of KRAS WT PC identifies a high prevalence of alternative MAPK drivers that are amenable to targeted therapies. Our cohort also recapitulates the previously reported clinical characteristics of KRAS WT PC and identifies the presence of SMAD4 alterations as significantly associated with decreased overall survival in KRAS WT PC. Additional analysis from multiple sources will be critical to risk stratify these patients further and to validate age-related findings.

Citation Format: Harshabad Singh, Rachel B. Keller, Kevin S. Kapner, Julien Dilly, Srivatsan Raghavan, Chen Yuan, Eizabeth Cohen, Michael Tolstorukov, Emma Hill, Elizabeth Andrews, Lauren K. Brais, Annacarolina Da Silva, Kimberly Perez, Douglas A. Rubinson, Benjamin L. Schlechter, Michael H. Rosenthal, Jason L. Hornick, Valentina Nardi, Yvonne Li, Hersh Gupta, Andrew Cherniack, Mathew L. Meyerson, James M. Cleary, Jonathan A. Nowak, Brian M. Wolpin, Andrew A. Aguirre. Clinical-genomic analysis of KRAS wild-type pancreatic cancer confirms alternative targetable drivers and provides insight for age and risk related clinical stratification [abstract]. In: Proceedings of the AACR Special Conference on Pancreatic Cancer; 2022 Sep 13-16; Boston, MA. Philadelphia (PA): AACR; Cancer Res 2022;82(22 Suppl):Abstract nr A001.

MatchMiner: an open-source platform for cancer precision medicine

Widespread, comprehensive sequencing of patient tumors has facilitated the usage of precision medicine (PM) drugs to target specific genomic alterations. Therapeutic clinical trials are necessary to test new PM drugs to advance precision medicine, however, the abundance of patient sequencing data coupled with complex clinical trial eligibility has made it challenging to match patients to PM trials. To facilitate enrollment onto PM trials, we developed MatchMiner, an open-source platform to computationally match genomically profiled cancer patients to PM trials. Here, we describe MatchMiner’s capabilities, outline its deployment at Dana-Farber Cancer Institute (DFCI), and characterize its impact on PM trial enrollment. MatchMiner’s primary goals are to facilitate PM trial options for all patients and accelerate trial enrollment onto PM trials. MatchMiner can help clinicians find trial options for an individual patient or provide trial teams with candidate patients matching their trial’s eligibility criteria. From March 2016 through March 2021, we curated 354 PM trials containing a broad range of genomic and clinical eligibility criteria and MatchMiner facilitated 166 trial consents (MatchMiner consents, MMC) for 159 patients. To quantify MatchMiner’s impact on trial consent, we measured time from genomic sequencing report date to trial consent date for the 166 MMC compared to trial consents not facilitated by MatchMiner (non-MMC). We found MMC consented to trials 55 days (22%) earlier than non-MMC. MatchMiner has enabled our clinicians to match patients to PM trials and accelerated the trial enrollment process.

Biallelic variants in MESD, which encodes a WNT-signaling-related protein, in four new families with recessively inherited osteogenesis imperfecta

The bone disorder osteogenesis imperfecta (OI) is genetically heterogeneous. Most affected individuals have an autosomal dominant disorder caused by heterozygous variants in either of the type I collagen genes (COL1A1 or COL1A2). To date, two reports have linked Mesoderm Development LRP Chaperone (MESD) to autosomal recessive OI type XX. Four different biallelic pathogenic variants in MESD were shown to cause a progressively deforming phenotype, associated with recurrent fractures and oligodontia in five individuals in five families. Recently, compound heterozygosity for a frameshift predicted to lead to a premature termination codon in exon 2 of the 3-exon gene and a second frameshift in the terminal exon in MESD were detected in three stillbirths in one family with severe OI consistent with the neonatal lethal phenotype. We have identified four additional individuals from four independent families with biallelic variants in MESD: the earlier reported c.632dupA (p.Lys212Glufs∗19) and c.676C>T (p.Arg226∗)-which are associated with a severe form of OI-and one new pathogenic variant, c.603-606delTAAA (p.Asn201Lysfs∗15), which causes a neonatal lethal form of OI. MESD acts in the WNT signaling pathway, where it is thought to play a role in the folding of the WNT co-receptors low-density lipoprotein receptor-related proteins 5 and 6 (LRP5/LRP6) and in chaperoning their transit to the cell surface. Our report broadens the phenotypic and genetic spectrum of MESD-related OI, provides additional insight into the pathogenic pathways, and underscores the necessity of MESD for normal WNT signaling in bone formation.

FGFR2 Extracellular Domain In-Frame Deletions are Therapeutically Targetable Genomic Alterations that Function as Oncogenic Drivers in Cholangiocarcinoma

We conducted next generation DNA sequencing on 335 biliary tract cancers and characterized the genomic landscape by anatomic site within the biliary tree. In addition to frequent FGFR2 fusions among patients with intrahepatic cholangiocarcinoma (IHCC), we identified FGFR2 extracellular domain in-frame deletions (EIDs) in 5 of 178 (2.8%) patients with IHCC, including two patients with FGFR2 p.H167_N173del. Expression of this FGFR2 EID in NIH3T3 cells resulted in constitutive FGFR2 activation, oncogenic transformation, and sensitivity to FGFR inhibitors. Three patients with FGFR2 EIDs were treated with Debio 1347, an oral FGFR-1/2/3 inhibitor, and all showed partial responses. One patient developed an acquired L618F FGFR2 kinase domain mutation at disease progression and experienced a further partial response for 17 months to an irreversible FGFR2 inhibitor, futibatinib. Together, these findings reveal FGFR2 EIDs as an alternative mechanism of FGFR2 activation in IHCC that predict sensitivity to FGFR inhibitors in the clinic.

Molecular Characterization and Therapeutic Targeting of Colorectal Cancers Harboring Receptor Tyrosine Kinase Fusions

PURPOSE

Receptor tyrosine kinase fusions in colorectal cancers are rare, but potentially therapeutically relevant. We describe clinical, molecular, and pathologic attributes of RTK fusion-associated colorectal cancer.

EXPERIMENTAL DESIGN

We identified all cases with RTK fusions in patients with colorectal cancer seen at Dana-Farber Cancer Institute (Boston, MA) who underwent OncoPanel testing between 2013 and 2018. Clinical, histologic, and molecular features were extracted from the patient charts and molecular testing results.

RESULTS

We identified 12 driver oncogenic fusions in various RTKs. These fusions occurred exclusively in BRAF and RAS wild-type tumors and were enriched in right-sided and mismatch repair-deficient (MMR-D) colorectal cancers. All of the MMR-D colorectal cancers with RTK fusions were found in tumors with acquired MMR-D due to MLH1 promoter hypermethylation and one was associated with a sessile serrated polyp. Molecular profiles of MMR-D colorectal cancer with RTK fusions largely resembled BRAF V600E-mutated MMR-D colorectal cancer, rather than those secondary to Lynch syndrome. We describe two patients with fusion-associated microsatellite stable (MSS) colorectal cancer who derived clinical benefit from therapeutic targeting of their translocation. The first harbored an ALK-CAD fusion and received sequential crizotinib and alectinib therapy for a total of 7.5 months until developing an ALK L1196Q gatekeeper mutation. The second patient, whose tumor contained an ROS1-GOPC fusion, continues to benefit from entrectinib after 9 months of therapy.

CONCLUSIONS

RTK fusions in colorectal cancer are a rare, but important disease subgroup that occurs in RAS and BRAF wild-type tumors. Despite enrichment in acquired MMR-D tumors, RTK fusions also occur in MSS colorectal cancer and provide an important therapeutic target.

Abstract 3382: MatchMiner: An open-source computational platform for genomically-driven matching of cancer patients to precision medicine clinical trials

To facilitate interpretation of complex tumor sequencing data and clinical trial genomic eligibility criteria, we developed MatchMiner, an open-source platform to computationally match cancer patients to precision medicine clinical trials based on clinical and genomic features. MatchMiner supports two distinct workflows: (1) patient-centric mode, in which an oncologist can find clinical trial matches for a specific patient, and (2) trial-centric mode, in which a clinical trial investigator can identify and recruit patients for a specific trial.

MatchMiner has been operational at Dana-Farber Cancer Institute since early 2017. There are currently 275+ trials curated in the system and genomic data from 26,000+ patients. Over 80% of living patients match to at least one open clinical trial, with an average of 6 trial matches per patient. At least 98 patients have enrolled on a clinical trial as a result of MatchMiner.

To enable computational matching, we developed clinical trial markup language (CTML), a structured format to encode detailed information about a trial. CTML utilizes boolean logic to define clinical (e.g. cancer type), demographic (e.g. age) and genomic (e.g. specific mutations, copy number alterations, structural variants or mutational signatures) eligibility, which can be applied to individual arms of a trial.

MatchMiner is an open-source two-tier web application with a Python-based REST API server and an AngularJS front-end. MatchMiner utilizes Security Assertion Markup Language (SAML)-based authentication and is fully HIPAA-compliant when hosted behind a secure institutional firewall. MatchMiner ingests clinical and genomic data, and connects to existing clinical systems, including clinical trial management systems for real-time trial status.

We recently refactored the core matching algorithm (the matchengine), which improves upon the original matchengine in several ways: (1) increased granularity in reporting the reason for a match; (2) can match all patients/trials or individual patients/trials; (3) easily extensible to match based on additional data types.

The MatchMiner open-source software package is available through GitHub (https://github.com/dfci/matchminer). We are committed to supporting MatchMiner as an open-source software; to our knowledge, at least five cancer centers are implementing MatchMiner at their own institutions.

In summary, we have defined a standard for encoding clinical trial information in a structured and computable form, and we have developed an open-source computational trial matching platform to support patient-specific trial identification as well as trial-specific patient recruitment. We are actively collaborating with clinical groups at Dana-Farber Cancer Institute and other institutions to understand the role of MatchMiner in their clinical workflows, and we are committed to continuing to evolve MatchMiner to meet clinical needs.

Citation Format: Tali Mazor, Rachel B. Keller, Priti Kumai, James Lindsay, Eric Marriott, Andrea Ovalle, Ethan Siegel, Joyce Yu, Michael Hassett, Ethan Cerami. MatchMiner: An open-source computational platform for genomically-driven matching of cancer patients to precision medicine clinical trials [abstract]. In: Proceedings of the Annual Meeting of the American Association for Cancer Research 2020; 2020 Apr 27-28 and Jun 22-24. Philadelphia (PA): AACR; Cancer Res 2020;80(16 Suppl):Abstract nr 3382.

Abstract C130: Precision oncology decision support within the Gastrointestinal Cancer Center at Dana-Farber Cancer Institute (GI TARGET)

Precision oncology is fast becoming the new paradigm for cancer treatment. This approach involves molecular profiling of patient tumors and tailoring of a treatment regimen based on the unique combination of targetable alterations identified therein. At Dana-Farber Cancer Institute (DFCI), over 24,000 patient tumors have been sequenced using the NGS platform OncoPanel since 2013. OncoPanel is a comprehensive genomic characterization of a tumor and it can be time-consuming to discern those alterations that are interesting from an academic or research perspective from those that can be leveraged to direct patient care. To address this issue, the GI TARGET (Treatment Assistance Regarding Genomic Evaluation of Tumors) project was initiated to provide decision support for oncologists within the DFCI Gastrointestinal Cancer Center (GCC). GI TARGET is a collaboration between the DFCI GCC, the Brigham & Women’s Hospital (BWH) Center for Advanced Molecular Diagnostics (CAMD), and the DFCI Knowledge Systems Group, developers of the precision medicine clinical trial matching platform MatchMiner. Report generation involves review of OncoPanel data in the context of patient clinical history via one of two workflows; complex genomic cases are reviewed in a weekly Molecular Tumor Board comprised of oncologists, molecular pathologists, a PhD-level Clinical Genomics Scientist, and representatives from the MatchMiner team, while ‘simple’ genomic cases are reviewed by both an oncologist and a PhD-level Clinical Genomics Scientist. Since the launch of the project in January 2018, we have signed out over 1000 GI TARGET reports. We are assessing the utility of these reports using a number of metrics including clinical trial enrollment tracking via MatchMiner, follow-up on recommendations via chart abstraction, and oncologist feedback. The aims of GI TARGET are 1) to reduce the burden of genomic analysis on the treating oncologist by providing expert-led deep review of OncoPanel and exploration of associated therapy/additional patient care considerations, 2) to support clinical trial enrollment by matching the results of somatic testing with ongoing clinical studies, and 3) to provide an example framework for how precision oncology can be incorporated into standard clinical cancer care, which may be helpful to guide efforts in other care settings, particularly in community hospitals where the vast majority (an estimated 80%-85%) of cancer patients in the United States receive their care.

Citation Format: Rachel B Keller, Tali Mazor, Marios Giannakis, Jonathan Nowak, Lynette Sholl, Andrew Aguirre, Adam Bass, Nilay Sethi, Ankur Nagaraja, Lauren Brais, Emma Reilly, Ethan Cerami, Brian Wolpin. Precision oncology decision support within the Gastrointestinal Cancer Center at Dana-Farber Cancer Institute (GI TARGET) [abstract]. In: Proceedings of the AACR-NCI-EORTC International Conference on Molecular Targets and Cancer Therapeutics; 2019 Oct 26-30; Boston, MA. Philadelphia (PA): AACR; Mol Cancer Ther 2019;18(12 Suppl):Abstract nr C130. doi:10.1158/1535-7163.TARG-19-C130

Abstract A024: MatchMiner: An open-source computational platform for genomically-driven matching of cancer patients to precision medicine clinical trials

To facilitate interpretation of complex tumor sequencing data and clinical trial genomic eligibility criteria, we developed MatchMiner, an open-source platform to computationally match cancer patients to precision medicine clinical trials based on clinical and genomic features. MatchMiner supports two distinct workflows: (1) a patient-centric mode, in which an oncologist can find clinical trial matches for a specific patient, and (2) a trial-centric mode, in which a clinical trial investigator can identify and recruit patients for a specific trial. MatchMiner has been operational at Dana-Farber Cancer Institute since early 2017. There are currently 250+ trials curated in the system and genomic data from 24,000+ patients. Over 82% of living patients match to at least one open clinical trial, with an average of 6 trial matches per patient. At least 85 patients have enrolled on a clinical trial as a result of MatchMiner. The MatchMiner open-source software package is available through GitHub (https://github.com/dfci/matchminer). MatchMiner is a two-tier web application with a Python-based REST application programming interface (API) server and an AngularJS front-end. MatchMiner utilizes Security Assertion Markup Language (SAML)-based authentication and, when hosted behind a secure institutional firewall, is fully HIPAA-compliant. MatchMiner can connect to existing clinical systems, including clinical trial management systems for real-time trial status. To enable computational matching to clinical trials, we developed clinical trial markup language (CTML), a structured format to encode detailed information about a trial. CTML utilizes boolean logic to define clinical (e.g. cancer type), demographic (e.g. age) and genomic (e.g. specific mutations, copy number alterations, structural variants or mutational signatures) eligibility, which can be applied to individual arms of a trial. We recently refactored the core matching algorithm (the matchengine), which improves upon the original matchengine in several ways. While the original matchengine reported the reason for a patient-trial match, the refactored matchengine provides additional, more granular details. In addition, the original matchengine ran at the cohort level, matching all patients to all trials, whereas the refactored matchengine can also run against individual patients or trials, speeding up the matching process. The refactored matchengine is also easily extensible to match based on additional data types. In summary, we have defined a standard for encoding clinical trial information in a structured and computable form, and we have developed an open-source computational trial matching platform to support patient-specific trial identification as well as trial-specific patient recruitment. We are actively collaborating with clinical groups at Dana-Farber Cancer Institute to understand the role of MatchMiner in their clinical workflows, and we are committed to continuing to evolve MatchMiner to meet clinical needs.

Citation Format: Tali Mazor, Rachel B Keller, Priti Kumari, James Lindsay, Eric Marriott, Andrea Ovalle, Ethan Siegel, Elizabeth H Williams, Joyce Yu, Michael Hassett, Ethan Cerami. MatchMiner: An open-source computational platform for genomically-driven matching of cancer patients to precision medicine clinical trials [abstract]. In: Proceedings of the AACR-NCI-EORTC International Conference on Molecular Targets and Cancer Therapeutics; 2019 Oct 26-30; Boston, MA. Philadelphia (PA): AACR; Mol Cancer Ther 2019;18(12 Suppl):Abstract nr A024. doi:10.1158/1535-7163.TARG-19-A024

Monoallelic and biallelic CREB3L1 variant causes mild and severe osteogenesis imperfecta, respectively

Purpose

Osteogenesis imperfecta (OI) is a heritable skeletal dysplasia. Dominant pathogenic variants in COL1A1 and COL1A2 explain the majority of OI cases. At least fifteen additional genes have been identified, but still do not account for all OI phenotypes that present. We sought the genetic cause of mild and lethal OI phenotypes in an unsolved family.

Methods

We performed exome sequencing on seven members of the family, both affected and unaffected.

Results

We identified a variant in Cyclic AMP Responsive Element Binding Protein 3-Like 1 (CREB3L1) in a consanguineous family. The variant caused a prenatal/perinatal lethal OI in homozygotes, similar to that seen in OI type II as a result of mutations in type I collagen genes, and a mild phenotype (fractures, blue sclerae) in multiple heterozygous family members. CREB3L1 encodes Old Astrocyte Specifically-Induced Substance (OASIS), an ER stress transducer. The variant disrupts a DNA-binding site and prevents OASIS from acting on its transcriptional targets including SEC24D, which encodes a component of the coat protein II (COPII) complex.

Conclusion

This report confirms that CREB3L1 is an OI-related gene and suggests the pathogenic mechanism of CREB3L1-associated OI involves the altered regulation of proteins involved in cellular secretion.

Endothelial and circulating C19MC microRNAs are biomarkers of infantile hemangioma

Infantile hemangioma (IH) is the most common vascular tumor of infancy, and it uniquely regresses in response to oral propranolol. MicroRNAs (miRNAs) have emerged as key regulators of vascular development and are dysregulated in many disease processes, but the role of miRNAs in IH growth has not been investigated. We report expression of C19MC, a primate-specific megacluster of miRNAs expressed in placenta with rare expression in postnatal tissues, in glucose transporter 1-expressing (GLUT-1-expressing) IH endothelial cells and in the plasma of children with IH. Tissue or circulating C19MC miRNAs were not detectable in patients having 9 other types of vascular anomalies or unaffected children, identifying C19MC miRNAs as the first circulating biomarkers of IH. Levels of circulating C19MC miRNAs correlated with IH tumor size and propranolol treatment response, and IH tissue from children treated with propranolol or from children with partially involuted tumors contained lower levels of C19MC miRNAs than untreated, proliferative tumors, implicating C19MC miRNAs as potential drivers of IH pathogenesis. Detection of C19MC miRNAs in the circulation of infants with IH may provide a specific and noninvasive means of IH diagnosis and identification of candidates for propranolol therapy as well as a means to monitor treatment response.

Methylation status of the chromosome arm 19q MicroRNA cluster in sporadic and androgenetic-Biparental mosaicism-associated hepatic mesenchymal hamartoma

The C19MC gene on chromosome band 19q13.4 encodes a cluster of 46 microRNAs; those microRNAs are normally only expressed from the paternal allele and in the placenta. Placental expression correlates with selective demethylation of the paternal C19MC promoter, in contrast to methylation of both maternal and paternal alleles in nonplacental tissues. Prior investigations demonstrated "ectopic" activation of this gene in most hepatic mesenchymal hamartomas, including sporadic tumors and others with androgenetic-biparental mosaicism (subset of cells are diploid, but contain only paternally derived chromosomes). In the present investigation of C19MC promoter methylation status in a series of 14 mesenchymal hamartomas, a demethylated allele was identified in 6 tumors, including all 4 with androgenetic-biparental mosaicism. Conversely, only methylated alleles were cloned from sporadic hamartomas, including 3 tumors with chromosomal rearrangements thought likely to activate C19MC expression independent of the native promoter. In conjunction with published data, the findings suggest multiple molecular mechanisms for C19MC activation in hepatic mesenchymal hamartoma, including the existence of a normal placental imprinting pattern in mesenchymal cells in a subset of cases. Some or all of the latter hamartomas may result from placental "grafting," a hypothesis supported by endothelial expression of the placental vascular marker, glucose transporter-1, in 1 of the 6 cases with a demethylated allele.

CTC1 Mutations in a patient with dyskeratosis congenita

Dyskeratosis congenita (DC) is a rare inherited bone marrow failure syndrome caused by mutations in seven genes involved in telomere biology, with approximately 50% of cases remaining genetically uncharacterized. We report a patient with classic DC carrying a compound heterozygous mutation in the CTC1 (conserved telomere maintenance component 1) gene, which has recently implicated in the pleiotropic syndrome Coats plus. This report confirms a molecular link between DC and Coats plus and expands the genotype-phenotype complexity observed in telomere-related genetic disorders.

Surgical and nonsurgical management of sciatica secondary to a lumbar disc herniation: five-year outcomes from the Maine Lumbar Spine Study

STUDY DESIGN

A prospective cohort study.

OBJECTIVE

To assess 5-year outcomes for patients with sciatica caused by a lumbar disc herniation treated surgically or nonsurgically.

SUMMARY OF BACKGROUND DATA

There is limited knowledge about long-term treatment outcomes of sciatica caused by a lumbar disc herniation, particularly the relative benefits of surgical and conservative therapy in contemporary clinical practice.

METHODS

Eligible, consenting patients recruited from the practices of orthopedic surgeons, neurosurgeons, and occupational medicine physicians throughout Maine had baseline interviews with mailed follow-up questionnaires at 3, 6, and 12 months and annually thereafter. Clinical data were obtained at baseline from a physician questionnaire. Outcomes included patient-reported symptoms of leg and back pain, functional status, satisfaction, and employment and compensation status.

RESULTS

Of 507 patients initially enrolled, 5-year outcomes were available for 402 (79.3%) patients: 220 (80%) treated surgically and 182 (78.4%) treated nonsurgically. Surgically treated patients had worse baseline symptoms and functional status than those initially treated nonsurgically. By 5 years 19% of surgical patients had undergone at least one additional lumbar spine operation, and 16% of nonsurgical patients had opted for at least one lumbar spine operation. Overall, patients treated initially with surgery reported better outcomes. At the 5-year follow-up, 70% of patients initially treated surgically reported improvement in their predominant symptom (back or leg pain) versus 56% of those initially treated nonsurgically (P < 0.001). Similarly, a larger proportion of surgical patients reported satisfaction with their current status (63% vs. 46%, P < 0.001). These differences persisted after adjustment for other determinants of outcome. The relative advantage of surgery was greatest early in follow-up and narrowed over 5 years. There was no difference in the proportion of patients receiving disability compensation at the 5-year follow-up. The least symptomatic patients at baseline did well regardless of initial treatment, although function improved more in the surgical group.

CONCLUSIONS

For patients with moderate or severe sciatica, surgical treatment was associated with greater improvement than nonsurgical treatment at 5 years. However, patients treated surgically were as likely to be receiving disability compensation, and the relative benefit of surgery decreased over time.

Predictors of outcomes of carpal tunnel release

OBJECTIVE

To identify factors that are predictive of the outcomes of greatest importance to patients-i.e., symptom relief, functional improvement, and satisfaction with the outcomes of surgery-following carpal tunnel release.

METHODS

We analyzed data from the Maine Carpal Tunnel Study, a community-based study of the outcomes of treatment for carpal tunnel syndrome. In a cohort of patients who underwent carpal tunnel release, a preoperative physical examination was performed and questionnaires were completed preoperatively and at 6, 18, and 30 months postoperatively. The questionnaires assessed symptom severity, upper extremity functional limitations, mental health, general physical health status, the relative severity of individual symptoms, satisfaction with the results of surgery, sociodemographic factors, and for those subjects who were in the workforce, aspects of the work environment. The associations between preoperative factors and the 3 principal outcomes (symptom severity, upper extremity functional limitations, and satisfaction with the results of surgery, all evaluated at 18 months postoperatively) were assessed with bivariate and multivariate linear regression and logistic regression analyses.

RESULTS

Two hundred forty-one subjects were enrolled and 188 (78%) completed followup surveys 18 months postoperatively. Two-thirds of the patients reported being completely or very satisfied with the outcomes of surgery at 6, 18, and 30 months postoperatively. A range of clinical and work-related variables were associated with outcomes. In multivariate analyses, greater preoperative upper extremity functional limitation was predictive of greater functional limitations postoperatively. Worse mental health status was significantly associated with more severe symptoms and lower satisfaction. Alcohol use was also associated with more severe symptoms and lower satisfaction. Among workers, involvement of an attorney was significantly associated with greater functional limitation, more severe symptoms, and lower satisfaction. Recipients of worker's compensation who did not hire an attorney had generally good outcomes. Of note, physical examination parameters were not predictive of the outcomes of surgery.

CONCLUSION

The outcomes of carpal tunnel release in community-based practices are excellent. Predictors of the outcomes of surgery are disease-specific and generic clinical factors as well as work-related factors. The strongest predictors of less favorable outcomes are worse scores on patient-reported measures of upper extremity functional limitation and mental health status, alcohol use, and the involvement of an attorney. Clinicians should carefully evaluate patients' functional status, mental health status, health habits, and attorney involvement prior to performing carpal tunnel release, and discuss with patients the prognostic implications of these parameters.

Surgical and nonsurgical management of lumbar spinal stenosis: four-year outcomes from the maine lumbar spine study

STUDY DESIGN

A prospective cohort study of patients with lumbar spinal stenosis recruited from the practices of orthopedic surgeons and neurosurgeons throughout Maine.

OBJECTIVE

To assess 4-year outcomes for patients with lumbar spinal stenosis treated surgically or nonsurgically.

SUMMARY OF BACKGROUND DATA

Surgery for lumbar spinal stenosis has increased dramatically despite the lack of randomized trials comparing surgical with nonsurgical treatments. Long-term evaluation of surgical series has documented deterioration in initial symptomatic improvement, but few studies have compared long-term outcomes of surgical and nonsurgical treatment.

METHODS

Eligible, consenting patients had baseline interviews with mailed follow-up questionnaires at 3, 6, and 12 months, then annually thereafter. Clinical data were obtained at baseline from a physician questionnaire. Outcomes included patient-reported symptoms of leg and back pain, functional status, and satisfaction.

RESULTS

Of 148 patients with lumbar spinal stenosis initially enrolled, 4-year outcomes were available on 119 patients (80.4%): 67 of 81 (83%) treated surgically and 52 of 67 (78%) treated nonsurgically. The surgically treated patients had more severe symptoms and worse functional status at baseline and better outcomes at 4-year evaluation than the nonsurgically treated patients. After 4 years, 70% of the surgically treated and 52% of the nonsurgically treated patients reported that their predominant symptom, either leg or back pain, was better (P = 0.05). Satisfaction of patients with their current state at 4 years was reported by 63% of the surgically treated and 42% of the nonsurgically treated patients (P = 0.04). Surgical treatment remained a significant determinant of 4-year satisfaction, even after adjustment for other independent predictors (P = 0.001). For the nonsurgically treated patients, there was no significant change in outcomes over 4 years, whereas the initial improvement seen in the surgically treated patients modestly decreased over the subsequent 4 years.

CONCLUSIONS

For the patients with severe lumbar spinal stenosis, surgical treatment was associated with greater improvement in patient-reported outcomes than nonsurgical treatment at 4-year evaluation, even after adjustment for differences in baseline characteristics among treatment groups. The relative benefit of surgery declined over time but remained superior to nonsurgical treatment. Outcomes for the nonsurgically treated patients improved modestly and remained stable over 4 years. Determining whether outcomes continue to converge will require longer-term evaluation.

Long-term disability and return to work among patients who have a herniated lumbar disc: the effect of disability compensation

BACKGROUND

Low-back problems are one of the most frequent reasons for disability compensation claims by workers. However, the effect of Workers' Compensation status on the long-term outcome for workers with sciatica has not been studied in detail, to our knowledge. Therefore, we believe that it is important to describe the long-term outcomes for patients who have herniation of a lumbar disc and sciatica according to the Workers' Compensation status at the time of the preoperative consultation.

METHODS

We conducted a prospective, observational study of patients who had sciatica and were seeking care from specialist physicians in community-based practices throughout Maine. Among 440 eligible patients, 199 were receiving Workers' Compensation at the time of entry into the study (baseline) and 241 were not. Three hundred and twenty-six patients (74 percent) completed questionnaires at the time of a four-year follow-up. The outcomes that we assessed included disability compensation and work status as well as relief from symptoms, functional status, and quality of life.

RESULTS

Patients who were receiving Workers' Compensation at baseline were more likely to be young, male, and employed as laborers. They reported worse functional status; however, the clinical findings for these patients were similar to those for patients who were not receiving Workers' Compensation. Patients who had been receiving Workers' Compensation at baseline were more likely to be receiving disability benefits at the time of the four-year follow-up compared with those who had not (27 percent of 133 compared with 7 percent of 189; p<0.001); however, they were only slightly less likely to be working at the time of the four-year follow-up (80 percent of 133 compared with 87 percent of 190; p = 0.09). Operative management did not influence these comparisons, but it decreased symptoms and improved functional status. Patients who had been receiving Workers' Compensation at baseline also had significantly less relief from symptoms and improvement in quality of life than patients who had not been receiving Workers' Compensation (all p<0.001). In multivariate models, Workers' Compensation status at baseline was an independent predictor of whether the patient would be receiving disability benefits after four years (odds ratio, 3.5; 95 percent confidence interval, 1.7 to 7.6) but was not an independent predictor of whether the patient would be working on a job for pay at the time of the four-year follow-up (odds ratio, 0.6; 95 percent confidence interval, 0.3 to 1.2).

CONCLUSIONS

Even after adjustment for the initial treatment of the sciatica and for other clinical factors, patients who had been receiving Workers' Compensation at baseline were more likely to be receiving disability benefits and were less likely to report relief from symptoms and improvement in quality of life at the time of the four-year follow-up than patients who had not been receiving Workers' Compensation at baseline. Nonetheless, most patients returned to work regardless of their initial disability status, and those who had been receiving Workers' Compensation at baseline were only slightly less likely to be working after four years. Whether or not they had been receiving Workers' Compensation at baseline, patients who had been managed with an operation reported greater relief from symptoms and improvement in functional status at the time of the four-year follow-up compared with patients who had been managed nonoperatively, even though the outcomes with regard to disability and work status in these two groups were comparable.

The relation between expectations and outcomes in surgery for sciatica

OBJECTIVE

To describe the expectations that patients and their physicians have for outcomes after surgical treatment for sciatica and to examine the associations between expectations and outcomes.

DESIGN

Prospective cohort study.

SETTING/PATIENTS

We recruited 273 patients, from the offices of orthopedic surgeons, neurosurgeons, and occupational medicine physicians in Maine, who had diskectomy for sciatica.

MEASUREMENTS AND MAIN RESULTS

Patients' and physicians' expectations were measured before surgery. Satisfaction with care and changes in symptoms and functional status were measured 12 months after surgery. More patients who expected a shorter recovery tJgie after surgery were "delighted," "pleased," or "mostly satisfied" with their outcomes 12 months after surgery than patients who expected a longer recovery tJgie (odds ratio [OR] 2.2; 95% confidence interval [CI] 1.1, 4.4). Also, more patients who preferred surgery after learning that sciatica could get better without surgery had good symptom scores 12 months after surgery than patients who did not prefer surgery (OR 2.9; 95% CI 1.2, 7.0). When physicians predicted a "great deal of Jgiprovement" after surgery, 39% of patients were not satisfied with their outcomes and 25% said their symptoms had not Jgiproved.

CONCLUSIONS

More patients with favorable expectations about surgery had good outcomes than patients with unfavorable expectations. Physicians' expectations were overly optJgiistic. Patient expectations appear to be Jgiportant predictors of outcomes, and eliciting them may help physicians identify patients more likely to benefit from diskectomy for sciatica.

Relationship between rates and outcomes of operative treatment for lumbar disc herniation and spinal stenosis

BACKGROUND

Population-based variations in rates of operations for the treatment of lumbar disc herniation and spinal stenosis are well known. This variability may occur in part because of differences in the threshold at which physicians recommend an operation, reflecting uncertainty about the optimum use of an operative procedure. To the best of our knowledge, no previous reports have indicated whether differences in population-based rates of operative treatment are associated with patient outcomes.

METHODS

The Maine Lumbar Spine Study is an ongoing prospective study of 655 patients who had a herniated lumbar disc or spinal stenosis. The patients were enrolled by their physicians, who provided baseline demographic and treatment-related data. The patients completed baseline and follow-up questionnaires that focused on symptoms, function, satisfaction, and quality of life. Small-area variation analysis was used to develop three distinct so-called spine service areas in Maine. The outcomes (usually at four years; minimum, two years) were compared among these areas, in which a total of 250 patients had been managed operatively and had answered questionnaires.

RESULTS

Population-based rates of operative treatment derived from statewide data that had been collected over five years in the state of Maine ranged from 38 percent below to 72 percent above the average rate in the state (a greater than fourfold difference). The outcomes for the patients who had been managed by surgeons in the lowest-rate area were superior to those for the patients in the two higher-rate areas. Seventy-nine percent (fifty-seven) of seventy-two patients in the lowest-rate area had marked or complete relief of pain in the lower extremity compared with 60 percent (eighteen) of thirty patients in the highest-rate area. The improvements in the Roland disability score (p < or = 0.01), quality of life (p < or = 0.01), and satisfaction (p < or = 0.05) were significantly greater among the patients in the lowest-rate area. The patients in the higher-rate areas generally had less severe symptoms and findings at baseline than those in the lowest-rate area did.

CONCLUSIONS

Higher population-based rates of elective spinal operations may be associated with inferior outcomes. This variability is possibly related to differences in physicians' preferences with regard to recommending an operation and in their criteria for the selection of patients. Physicians cannot assume that their outcomes will be the same as those of others, and therefore they need to evaluate their own results.

Physician partnering in Maine: an update from the Maine Medical Assessment Foundation

BACKGROUND

The Maine Medical Assessment Foundation (MMAF) has involved the participation of hundreds of physicians in study groups to analyze data on small-area variation and assess physician decision-making patterns. In 1991 the MMAF model was replicated across a tri-state area (Maine, New Hampshire, and Vermont) in an effort called the Outcomes Dissemination Project.

THE OUTCOMES DISSEMINATION PROJECT

Five specialty study groups, each meeting three times a year, examined local and national utilization data and guidelines and research findings, participated in outcomes studies and patient education, and disseminated their findings through society presentations and other feedback efforts. Physician surveys indicated that all but one of the study groups were successful in making their existence and activities known to the broader medical community.

PARTNERING WITH PURCHASERS AND MEDICAID

In the "Partnership Projects," the MMAF and relevant study groups, collaborating with a Maine business coalition, analyzed variations in utilization across employers, types of health plans (for example, health maintenance organization, preferred provider organization, fee-for-service), and small areas. Through this process, coalition members learned about small-area analysis and the implications of variations in utilization for cost and quality. The first year of the collaborative projects focused on several issues, including the development and dissemination of a practice guideline for the care of patients with chest pain; the dissemination of a practice guideline for the treatment of patients with acute low back pain; and a project designed to address cesarean section rates.

SUMMARY

Innovative partnerships have been crafted to allow the tenets of the MMAF's working relationships with the medical community to remain intact, ensuring the ongoing interest and cooperation of hundreds of Maine physicians.

Maine Carpal Tunnel Study: small area variations

As is the case for all elective procedures, small area variations occur in rates of surgery for carpal tunnel syndrome. A 1993 analysis of Maine data demonstrates that carpal tunnel release rates across population-based service areas varied 3.5-fold, from 0.82 to 2.87 per thousand. Four areas had rates significantly higher and 2 were significantly lower than the state average of 1.44 per thousand. Among many potential factors influencing variations, physician practice patterns appear to be the major contributor.

Maine Carpal Tunnel Study: outcomes of operative and nonoperative therapy for carpal tunnel syndrome in a community-based cohort

A prospective, community-based, observational study of the outcome of surgical and nonoperative management was conducted. The study included 429 patients with carpal tunnel syndrome recruited in physicians' offices throughout Maine. Patients were assessed at baseline and at 6, 18, and 30 months following presentation using validated scales that measured symptom severity, functional status, and satisfaction. Seventy-seven percent of eligible survivors from the original cohort were monitored for 30 months. Surgically treated patients demonstrated improvements of 1.2 to 1.6 points on the 5-point Symptom Severity and Functional Status scales (23% to 45% improvement in scores), which persisted over the 30-month follow-up period. The nonoperatively managed patients showed little change in clinical status at 6, 18, and 30 months. While workers' compensation recipients had worse outcomes than nonrecipients, 36 of 68 (53%) workers' compensation recipients were completely or very satisfied with the results of the procedure 30 months after surgery. There were no significant differences in outcome between patients treated with endoscopic versus open carpal tunnel release. Among worker's compensation recipients, 12 of 68 (18%) surgical patients and 4 of 32 (13%) nonoperatively treated patients remained out of work because of carpal tunnel syndrome at 30 months. Thus, carpal tunnel surgery offered excellent symptom relief and functional improvement in this prospective community-based sample, irrespective of the surgical approach, even in workers' compensation recipients. Work absence remained high in both surgically and nonoperatively managed workers' compensation recipients.

Prevalence and predictors of long-term work disability due to carpal tunnel syndrome

The objective of this study was to describe patterns and predictors of work absence in the prospective, community-based Maine Carpal Tunnel Study. Three hundred fifteen patients with carpal tunnel syndrome (CTS) were recruited from physicians' offices throughout Maine. The patients completed questionnaires at entry and after 6, 18, and 30 months. The questionnaires included scales measuring symptom severity, functional status, general and mental health status, exposure to physical stressors, work status, and other indicators. The analyses examined univariate and multivariate correlates of work absence. The mean age was 43, 72% of subjects were female, 71% underwent carpal tunnel release, and 45% were receiving Workers' Compensation. Fifty-two percent worked in managerial or technical occupations, 15% in service occupations, and 13% in heavy labor or machine operation. Forty-five percent of patients changed jobs or were absent from work (aside from postoperative recovery) during the 30-month follow-up. In multivariate logistic regression models, correlates of work absence at 18 months included worse functional status of the hand at study entry and at 6-month follow-up, involvement of an attorney at the time of enrollment (P < 0.002 for each), and work absence at 6 months (P = 0.03). Worse upper extremity functional status and having a contested Workers' Compensation claim are critical predictors of work absence and should be principal targets of interventions to reduce work disability in CTS.

Comparative responsiveness of generic versus disease-specific and weighted versus unweighted health status measures in carpal tunnel syndrome

OBJECTIVES

The authors evaluated the relative responsiveness to change of generic versus disease-specific and unweighted versus weighted health status measures in carpal tunnel syndrome (CTS).

METHODS

Data were obtained from 196 subjects followed in a prospective community-based cohort study in Maine who underwent carpal tunnel release (The Maine Carpal Tunnel Syndrome Study). Patients were evaluated before and 6 months after surgery. The disease-specific, unweighted severity score was derived from the validated Carpal Tunnel Syndrome Assessment Questionnaire. Patients were asked to rate the importance of each symptom included in the severity score. Each severity question was weighted by its importance, creating a disease-specific weighted score. Generic instruments were the SF-36, SF-12, and a Quality of Life Rating Scale. Sensitivity to change was calculated with the standardized response mean (SRM, mean change/standard deviation of change) as well as the effect size (ES, mean change/standard deviation of baseline values). The ability of the instruments to distinguish clinically important differences was assessed by correlating the changes in scores with global ratings on satisfaction and perceived improvement as external criteria.

RESULTS

The disease-specific weighted score (SRM: 1.56, ES: 1.99) was more responsive than the unweighted score (SRM: 1.36, ES: 1.57). The Quality of Life Rating Scale, SF-36, and SF-12 subscales were less sensitive to change, with standardized response means and effect sizes that ranged from -0.23 to 0.88. The ability to distinguish clinically important differences was higher for the two disease-specific scales. The coefficients of correlation with the external criteria ranged from 0.50 to 0.56 for the unweighted score and 0.56 to 0.62 for the weighted score and were significantly stronger than the correlations between external measures and the most responsive subscale of the SF-36 (Bodily Pain subscale, r = 0.36). The SF-12 health survey performed as well as the SF-36 in term of responsiveness and ability to distinguish clinically important change.

CONCLUSIONS

Disease-specific measures were superior to generic measures in capturing clinical change after carpal tunnel release, and a weighted score was slightly more responsive than the unweighted score. The SF-12 showed comparable psychometric properties compared with the longer 36-item Short-Form Survey.

Changing physician behavior: the Maine Medical Assessment Foundation

Methods to produce change in physician practice patterns are of increasing importance to payers and regulators as well as to physicians themselves. Because some of the strategies being adopted occur without physician input and participation, they have aroused concern in the medical community. We describe the methods used and results achieved by the Maine Medical Assessment Foundation, a nonprofit education and research organization, that has been active in practice pattern analysis since the late 1970s. The foundation has successfully engaged clinicians in a program of systematic assessment of medical care provided to residents of Maine. Significant change in practice patterns has been documented. Physicians have become active participants in the process of voluntary self-assessment, education, and quality improvement.

Patients' preferences and their relationship with satisfaction following carpal tunnel release

Patients' preferences for specific health outcomes in carpal tunnel syndrome (CTS) and their association with demographic factors and satisfaction with the results of surgery after 6 months were evaluated. Two hundred fifty subjects with CTS and enrolled in a prospective community-based cohort study in Maine completed a preference questionnaire before surgery. Patients were asked to specify the single most important reason they decided to undergo surgery and to rate the importance of improvement in 10 areas, including lessening of specific symptoms and improvement in specific functional states related to CTS. The single most important reason for CTS patients to have surgery was relief of night pain (37%), followed by relief of numbness (21%) and relief of daytime pain (13%). When patients were asked to rate the importance of obtaining relief from specific symptoms and improvement in specific functional states, relief of numbness received the highest rating, with 94% of the patients answering that it was extremely or very important. Workers' compensation recipients, patients with less than a college level of education, and patients with more severe symptoms and functional impairment at baseline assigned higher importance to symptom relief and functional improvement. Controlling for other predictors, higher preference for improved strength was associated with lower satisfaction with the results of the surgery at 6 months. Most CTS patients undergoing surgery have realistic preferences for health outcomes that are influenced by demographic and clinical characteristics; however, physicians should pay attention to unrealistic preferences that might influence patients' satisfaction with surgical results.

Prognostic value of a hand symptom diagram in surgery for carpal tunnel syndrome

OBJECTIVE

To evaluate symptom patterns on a hand diagram as predictors of surgical outcome in carpal tunnel syndrome (CTS).

METHODS

202 patients with CTS enrolled in a prospective, community based cohort study in Maine completed a hand symptom diagram before surgery and at 6 month followup. They were asked to mark on the hand diagram the location of 3 symptoms: pain, numbness/tingling (NT), and "other" symptoms. The diagram was first divided into 6 regions following a standardized procedure. For the 6 regions, symptom patterns were identified separately for each of the 3 symptoms. Outcomes 6 months after surgery were expressed as the percentage of change on the Symptom Severity Scale and Function Status Scale of the Carpal Tunnel Syndrome Assessment Questionnaire, and the satisfaction with the results of the surgery.

RESULTS

Several distinct symptom patterns were associated with the 3 principal outcomes in univariate and multivariate analysis. In linear regression models controlling for the baseline severity of symptoms and function, as well as other predictors, the hand symptom pattern variables accounted for 30, 14, and 24%, respectively, of the total explained variance in satisfaction, symptom severity, and functional status. Patients receiving Workers' Compensation (37% of the cohort) had more wrist pain and NT of the arm, and less pain involving the arm and upper palm. This group also had worse outcomes and were less satisfied with surgery. Drawing expansion was associated with a low score on the SF-36 mental health subscale. However, psychological impairment was not associated with a worse outcome.

CONCLUSION

Symptom patterns identified preoperatively with a hand symptom diagram help to predict the outcome of carpal tunnel release.

Do physicians do what they say? The inclination to test and its association with coronary angiography rates

OBJECTIVE

Efforts to evaluate variations in cardiac procedures have focused on patient factors and differences in health care delivery systems. We wanted to assess how physicians' inclination to test patients with coronary artery disease influences utilization patterns.

SETTING AND SUBJECTS

Physicians and the populations of Maine, New Hampshire, and Vermont.

DESIGN

We conducted a survey of 263 family practitioners, internists, and cardiologists residing in 57 hospital service areas in Maine, New Hampshire, and Vermont. Using patient scenarios, we assessed the clinicians' inclinations to test during the evaluation of patients with coronary artery disease. Self-reported testing intensities were used to create three indices: a Catheterization Index, an Imaging Exercise Tolerance Test (ETT) Index, and Nonimaging ETT Index. Using administrative data, age- and gender-adjusted population-based coronary angiography rates were calculated. Physicians were assigned to low (2.9/1,000), average (4.2/1,000), and high (5.8/1,000) coronary angiography rate areas, based on where they practice. Analysis of variance techniques were used to assess the relation of the index scores to the population-based coronary angiography rates and to physician specialties.

RESULTS

There was a positive relationship between the population-based coronary angiography rates and the self-reported scores of the Catheterization Index (p < .005) and the Imaging ETT Index (p = .01), but none was found for the Non-imaging ETT Index (p = .10). These relationships were evident in subanalyses of cardiologists and internists, but not of family practitioners.

CONCLUSIONS

Self-reported testing intensity by physicians is related to the population-based rates of coronary angiography. This relationship cuts across specialties, suggesting that there is a "medical signature" for the evaluation of patients with coronary artery disease.

Predictors of return to work following carpal tunnel release

Little is known about factors that predict return to work following carpal tunnel release. Patients enrolled in a prospective, community-based study of carpal tunnel syndrome in Maine were evaluated with standardized questionnaires preoperatively and 6 months following carpal tunnel release. Univariate and multivariate analyses were performed to identify baseline factors associated with work disability 6 months following surgery. Thirty-one of 135 patients (23%) were out of work because of CTS 6 months following surgery. The predominant preoperative variables associated with work absence due to CTS 6 months postoperatively in logistic regression analyses were Workers' Compensation, work absence preoperatively, and worse mental health status (p < or = 0.01 for each). In analyses that considered postoperative as well as preoperative variables, persistence of symptoms following surgery was the most striking predictor of failure to return to work due to CTS (p < 0.0001). Preoperative correlates of less complete relief of symptoms in multivariate models included involvement of an attorney, milder preoperative symptom severity, preoperative work absence (p < 0.005 for each) and exposure to hand intensive work (p = 0.04). These data indicate that economic and psychosocial variables have a strong influence upon both return to work and the extent of symptom relief 6 months following surgery for carpal tunnel syndrome.

The Quebec Task Force classification for Spinal Disorders and the severity, treatment, and outcomes of sciatica and lumbar spinal stenosis

STUDY DESIGN

A prospective cohort study of patients in Maine with sciatica and lumbar spinal stenosis treated surgically and nonsurgically.

SUMMARY OF BACKGROUND DATA

In 1987, the Quebec Task Force on Spinal Disorders proposed a diagnostic classification to help make clinical decisions, evaluate quality of care, assess prognosis, and conduct research.

OBJECTIVES

To assess the Quebec Task Force classification's ability to stratify patients according to severity and treatment at baseline, and to assess changes over time in health-related quality of life, including symptoms, functional status, and disability.

METHODS

Five hundred sixteen patients participating in the Maine Lumbar Spine Study who completed baseline and 1-year follow-up evaluations were classified successfully according to the Quebec Task Force classification. Patient characteristics and treatments were compared across Quebec Task Force classification categories. Changes in health-related quality of life over 1 year were assessed according to Quebec Task Force classification category and type of treatment.

RESULTS

Among patients with sciatica (n = 370), higher Quebec Task Force classification categories (from 2, pain radiating to the proximal extremity, to 6, sciatica with evidence of nerve root compression) were associated with increased severity of symptoms at baseline. There was no association between Quebec Task Force classification and baseline functional status. Quebec Task Force classification was associated strongly with the likelihood of receiving surgical treatment (P < or = 0.005). Among patients with sciatica treated nonsurgically, improvement at 1 year in back-specific and generic physical function increased with higher Quebec Task Force classification category (P < or = 0.05). Only a nonsignificant trend was observed for surgically treated patients. Patients with lumbar spinal stenosis (Quebec Task Force classification 7, n = 131) had baseline features and outcomes distinct from patients with sciatica.

CONCLUSIONS

For patients with sciatica, the Quebec Task Force classification was highly associated with the severity of symptoms and the probability of subsequent surgical treatment. Nonsurgically treated patients in Quebec Task Force classification categories reflecting nerve root compression had greater improvement than those with pain symptoms alone. Among surgical patients, the Quebec Task Force classification was not associated with outcome. These results provide validation for the classification and its wider adoption. Nonetheless, improved diagnostic classifications are needed to predict outcomes better in patients with sciatica who undergo surgery.

Basic epidemiology of fractures of the upper and lower limb among Americans over 65 years of age

Current knowledge regarding the basic epidemiology of fractures is largely limited to a few fracture sites, notably those of the hip and distal forearm. To clarify the patterns of incidence of limb fractures in the elderly, we used data from a 5% sample of the U.S. Medicare population over age 65 years during the years 1986-1990. We identified incident fractures of the proximal humerus, other parts of the humerus, proximal radius/ ulna, shaft of the radius/ulna, distal radius/ulna, pelvis, hip, other parts of the femur, patella, ankle, and other parts of the tibia/fibula from diagnoses and procedures coded on claims for inpatient services, outpatient facility use, and physician services. We used Poisson regression to investigate the relation between demographic factors and fracture risk at these sites. Fractures at the hip were the most common, accounting for 38% of the fractures identified. The proximal humerus, distal radius/ulna, and ankle also were common fracture sites. A pattern of rapidly rising rates with age was seen for fractures of the pelvis, hip, and other parts of the femur among women. Fractures distal to the elbow or knee, however, had, at most, modest increases in incidence with age over 65 years. For each of the fractures studied, women had higher rates than men of the same race, and whites generally had higher rates than blacks of the same gender. Gender-related differences in risk were larger among whites than among blacks, and racial differences in risk were more marked among women than among men.

The Maine Lumbar Spine Study, Part II. 1-year outcomes of surgical and nonsurgical management of sciatica

STUDY DESIGN

The Maine Lumbar Spine Study is a prospective cohort study of patients recruited from the practices of orthopedic surgeons, neurosurgeons, and occupational medicine physicians throughout Maine.

OBJECTIVE

To assess 1-year outcomes of patients with sciatica believed to be due to a herniated lumbar disc treated surgically or nonsurgically.

SUMMARY OF BACKGROUND DATA

Lumbar spine surgery rates vary by geographic region and may reflect uncertainty about optimal clinical use.

METHODS

Eligible consenting patients participated in a baseline interview performed by study personnel and then were mailed follow-up questionnaires at 3, 6, and 12 months. Clinical data were obtained from a physician questionnaire. Outcomes included patient-reported symptoms of leg and back pain, functional status, disability, quality of life, and satisfaction with care.

RESULTS

Five hundred seven patients with sciatica, 275 treated surgically and 232 treated nonsurgically initially, were enrolled. Surgically treated patients, on average, had more severe symptoms and had more severe physical and imaging findings than nonsurgically treated patients at entry. Although few surgically treated patients had mild symptoms and few nonsurgically treated patients had severe symptoms, about half in each treatment group had symptoms that fell into a moderate category. At the 1-year evaluation, improvement in symptoms, functional status, and disability were found in both treatment groups. However, surgically treated patients reported significantly greater improvement. For the predominant symptom, either back or leg pain, 71% of surgically treated and 43% of nonsurgically treated patients reported definite improvement (P < 0.001). This effect was even greater after adjustment for differences between treatment groups at entry (relative odds of definite improvement, 4.3; P < 0.001). For patients with moderate symptoms and abnormal physical examination findings, surgical treatment also resulted in greater improvement than nonsurgical treatment. However, there was little difference in the employment or workers' compensation status of patients treated surgically versus nonsurgically (5% vs. 7% unemployed at 1-year follow-up if employed at entry [P = 0.68]; 46% vs. 55% receiving workers' compensation at 1-year follow-up if receiving it at entry [P = 0.30] for surgical and nonsurgical management, respectively). For patients with mild symptoms, the benefits of surgical and nonsurgical treatment were similar.

CONCLUSIONS

Although surgically treated patients were on average more symptomatic at entry, there was substantial overlap in symptoms between surgically treated and nonsurgically treated patients. Surgically treated patients with sciatica reported substantially greater improvement at 1-year follow-up. However, employment and compensation outcomes were similar between the two treatment groups, and surgery appeared to provide little advantage for the subset of patients with mild symptoms. These results should be interpreted cautiously, because surgical treatment was not assigned randomly. Long-term follow-up will determine if these differences persist.

The Maine Lumbar Spine Study, Part I. Background and concepts

STUDY DESIGN

This paper describes the background and factors that led to the development and implementation of the Maine Lumbar Spine Study, a prospective cohort study of patients undergoing surgical and nonsurgical treatment of herniated lumbar disc with sciatica and symptomatic spinal stenosis.

OBJECTIVES

To define the factors leading to the study and the methods of designing and implementing a community-based effectiveness study to evaluate the outcomes of herniated lumbar intervertebral disc and spinal stenosis.

SUMMARY OF BACKGROUND DATA

Variations in the utilization of surgery for these conditions and physicians' uncertainty regarding the best way to manage them resulted in support of a community-based study of the effectiveness of treatment alternatives.

METHODS

A prospective cohort design was used. Methods of patient enrollment, data collection, management, and analysis are described. An innovative method of ascertaining the representativeness of the enrolled versus nonenrolled patient population is presented.

RESULTS

The importance of developing community-based networks of physicians is discussed.

CONCLUSIONS

These networks play an important role in analyzing practice pattern variations and in stimulating and participating in effectiveness research. Because effectiveness studies must be conducted at the community level, mechanisms must be developed with which to support and implement these efforts.

The Maine Lumbar Spine Study, Part III. 1-year outcomes of surgical and nonsurgical management of lumbar spinal stenosis

STUDY DESIGN

A prospective cohort study of patients with lumbar spinal stenosis recruited from the practices of orthopedic surgeons and neurosurgeons throughout Maine.

OBJECTIVE

To assess 1-year outcomes of patients with lumbar spinal stenosis treated surgically or nonsurgically.

SUMMARY OF BACKGROUND DATA

No randomized trials and few nonexperimental studies have compared surgical and nonsurgical treatment of patients with lumbar spinal stenosis. The authors' goal was to assess 1-year outcomes of patients with lumbar spinal stenosis treated surgically or nonsurgically.

METHODS

Eligible, consenting patients participated in baseline interviews and were then mailed follow-up questionnaires at 3, 6, and 12 months. Clinical data were obtained from a physician questionnaire. Outcomes included patient-reported symptoms of leg and back pain, functional status, disability, and satisfaction with care.

RESULTS

One hundred forty-eight patients with lumbar spinal stenosis were enrolled, of whom 81 were treated surgically and 67 treated nonsurgically. On average, patients in the surgical group had more severe imaging findings and symptoms and worse functional status than patients in the nonsurgical group at entry. Few patients with mild symptoms were treated surgically, and few patients with severe symptoms were treated nonsurgically. However, of the patients with moderate symptoms, a similar percent were treated surgically or nonsurgically. One year after study entry, 28% of nonsurgically and 55% of surgically treated patients reported definite improvement in their predominant symptoms (P = 0.003). For patients with moderate symptoms, outcomes for surgically treated patients were also improved compared with those of nonsurgically treated patients. Surgical treatment remained a significant determinant of 1-year outcome, even after adjustment for differences between treatment groups at entry (P = 0.05). The maximal benefit of surgery was observed by the time of the first follow-up evaluation, which was at 3 months. Although few nonsurgically treated patients experienced a worsening of their condition, there was little improvement in symptoms and functional status compared with study entry.

CONCLUSIONS

At a 1-year evaluation of patient-reported outcomes, patients with severe lumbar spinal stenosis who were treated surgically had greater improvement than patients treated nonsurgically. Comparisons of outcomes by treatment received must be made cautiously because of differences in baseline characteristics. A determination of whether the outcomes observed persist requires long-term follow-up.

Application of outcomes research in occupational low back pain: the Maine Lumbar Spine Study

Outcomes research represents an expansion of traditional clinical research to include issues of cost and quality of care in usual clinical practice, emphasizing outcomes that matter most to patients. In low back disorders, outcomes research has focused on the lack of reliable information to support much of clinical practice and has demonstrated marked variability in the treatment of these common problems. The Maine Lumbar Spine Study represents an example of an outcomes research study to investigate the treatment of patients with sciatica in usual clinical practice. Because low back symptoms are a frequent cause of occupational disability, Workers' Compensation patients were explicitly oversampled. Baseline features were significantly different in those patients who were receiving Workers' Compensation versus those who were not. Efforts to compare outcomes by disability status need to control for these differences. Whereas most Workers' Compensation patients were still receiving disability compensation regardless of treatment at 6 months, patients who were treated surgically were more likely to have come off disability and returned to work than nonsurgically treated patients. Long-term follow-up is necessary to determine whether these differences persist.

The association between local diagnostic testing intensity and invasive cardiac procedures

OBJECTIVE

To determine the extent to which geographic variation in invasive cardiac procedures can be explained by the variable use of diagnostic testing.

DESIGN

A population-based cohort study using Medicare Part B data (physician services).

SETTING AND SUBJECTS

Procedure data for all Medicare beneficiaries in northern New England.

MAIN OUTCOME MEASURES

Twelve coronary angiography service areas were constructed for Medicare beneficiaries in northern New England. Age- and sex-adjusted utilization rates were developed for three procedure categories: total stress test, coronary angiography, and revascularization. Total stress tests were further stratified into nonimaging and imaging procedures (eg, thallium). Tests performed in follow-up to invasive procedures were excluded (eg, stress test following revascularizations). Linear regression was used to assess the relationship between procedure categories.

RESULTS

A tight positive relationship was found between total stress test rates and the rates of subsequent coronary angiography (R2=0.61, P<.005). Most of the variance was explained by imaging stress tests (R2=0.50, P<.02). A strong relationship was found between coronary angiography and revascularization (R2=0.82, P<.001). Finally, a clear relationship between total stress tests and subsequent revascularizations was also found (R2=0.55, P<.006).

CONCLUSION

The population-based rates of diagnostic testing largely explained the variance associated with subsequent therapeutic interventions. Our results suggest that local testing intensity is an important determinant of the variable use of invasive cardiac procedures.

Workers' compensation recipients with carpal tunnel syndrome: the validity of self-reported health measures

OBJECTIVES

This study compared the reliability, validity, and responsiveness of self-reported measures of health related quality of life in recipients and non-recipients of workers' compensation who have carpal tunnel syndrome.

METHODS

Patients with carpal tunnel syndrome complete questionnaires at study enrollment and 6 months later scales measuring symptom severity functional status, and satisfaction were included. The scales internal consistency, validity, and responsiveness were assessed.

RESULTS

The internal consistencies for each scale were high (Cronbach's alpha .88 to .96) and virtually identical in recipients and nonrecipients of workers' compensation. The correlations between self-reported and objectively measured grip strength were .32 in recipients and .30 in nonrecipients; these correlations were not influenced by whether workers' compensation recipients were out of work. Correlations between changes in scale scores and three indicators of perceived improvement were higher in recipients (.48 to .69) than in nonrecipients (.19 to .41)

CONCLUSIONS

The reliability, validity, and responsiveness of these measures were comparable in nonrecipients and recipients of workers compensation, these data support the use of self-report measures in studies of workers.

Partnering with physicians to achieve quality improvement

BACKGROUND

The Maine Medical Assessment Foundation (MMAF) has successfully involved hundreds of Maine physicians in study groups to analyze data on small-area variation and assess physician decision-making patterns. In 1991 the MMAF model was replicated across a tri-state area (Maine, New Hampshire, Vermont) in an effort called the Outcomes Dissemination Project, which is funded by a five-year grant from the U.S. Agency for Health Care Policy and Research.

THE OUTCOMES DISSEMINATION PROJECT

Five specialty study groups, each meeting three times a year, examine local and national utilization data, examine guidelines and research findings, participate in outcomes studies and patient education, and disseminate their findings through specialty society presentations and other feedback efforts. The MMAF study group process is based on the beliefs that medicine is a subculture with a complex set of professional values, beliefs, socialization processes, and norms, and that quality improvement efforts work best when they are nonpunitive and educational.

ISSUES IN OBTAINING PHYSICIAN INVOLVEMENT

(1) Physicians are willing to change their practices if they are brought into a culturally appropriate improvement program. (2) Related specialties (for example, internists and family practitioners) can often work together effectively on issues of common interest. (3) Involving respected clinical leaders has helped establish the legitimacy of MMAF methods among physicians. (4) Area- and physician-specific data are not made public, so as to build a sense of confidentiality among participants.

CONCLUSIONS

The project continues to function as a powerful education process and serves as a model for replication elsewhere.

Assessing health-related quality of life in patients with sciatica

STUDY DESIGN

This study analyzed health-related quality-of-life measures and other clinical and questionnaire data obtained from the Maine Lumbar Spine Study, a prospective cohort study of persons with low back problems.

OBJECTIVE

For persons with sciatica, back pain-specific and general measures of health-related quality-of-life were compared with regard to internal consistency, construct validity, reproducibility, and responsiveness in detecting small changes over a 3-month period.

SUMMARY OF BACKGROUND DATA

Data were collected from 427 participants with sciatica. Baseline in-person interviews were conducted with surgical and medical patients before treatment and by mail at 3 months.

METHODS

Health-related quality-of-life measures included symptoms (frequency and bothersomeness of pain and sciatica) functional status and well-being (modified back pain-specific Roland scale and Medical Outcomes Study 36-item Short Form Health Survey (SF-36), and disability (bed rest, work loss, and restricted activity days).

RESULTS

Internal consistency of measures was high. Reproducibility was moderate, as expected after a 3-month interval. The SF-36 bodily pain item and the modified Roland measure demonstrated the greatest amount of change and were the most highly associated with self-rated improvement. The specific and generic measures changed in the expected direction, except for general health perceptions, which declined slightly. A high correlation between clinical findings or symptoms and the modified Roland measure, SF-36, and disability days indicated a high degree of construct validity.

CONCLUSIONS

These measures performed well in measuring the health-related quality-of-life of patients with sciatica. The modified Roland and the physical dimension of the SF-36 were the measures most responsive to change over time, suggesting their use in prospective evaluation. Disability day measures, although valuable for assessing the societal impact of dysfunction, were less responsive to changes over this short-term follow-up of 3 months.