1
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Lee KM, Nelson TJ, Bryant A, Teerlink CC, Gulati R, Pagadala MS, Tcheandjieu C, Pridgen KM, DuVall SL, Yamoah K, Vassy JL, Seibert TM, Hauger RL, Rose BS, Lynch JA. Genetic risk and likelihood of prostate cancer detection on first biopsy by ancestry. J Natl Cancer Inst 2024; 116:753-757. [PMID: 38212986 DOI: 10.1093/jnci/djae002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Revised: 11/03/2023] [Accepted: 12/23/2023] [Indexed: 01/13/2024] Open
Abstract
Despite differences in prostate cancer risk across ancestry groups, relative performance of prostate cancer genetic risks scores (GRS) for positive biopsy prediction in different ancestry groups is unknown. This cross-sectional retrospective analysis examines the association between a polygenic hazard score (PHS290) and risk of prostate cancer diagnosis upon first biopsy in male veterans using 2-sided tests. Our analysis included 36 717 veterans (10 297 of African ancestry). Unadjusted rates of positive first prostate biopsy increased with higher genetic risk (low risk: 34%, high risk: 58%; P < .001). Among men of African ancestry, higher genetic risk was associated with increased prostate cancer detection on first biopsy (odds ratio = 2.18, 95% confidence interval = 1.93 to 2.47), but the effect was stronger among men of European descent (odds ratio = 3.89, 95% confidence interval = 3.62 to 4.18). These findings suggest that incorporating genetic risk into prediction models could better personalize biopsy decisions, although further study is needed to achieve equitable genetic risk stratification among ancestry groups.
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Affiliation(s)
- Kyung Min Lee
- VA Informatics and Computing Infrastructure, VA Salt Lake City Health Care System, Salt Lake City, UT, USA
| | - Tyler J Nelson
- VA Informatics and Computing Infrastructure, VA Salt Lake City Health Care System, Salt Lake City, UT, USA
| | - Alex Bryant
- Department of Radiation Oncology, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, MI, USA
- Department of Radiation Oncology, University of Michigan, Ann Arbor, MI, USA
| | - Craig C Teerlink
- VA Informatics and Computing Infrastructure, VA Salt Lake City Health Care System, Salt Lake City, UT, USA
- Department of Internal Medicine, School of Medicine, University of Utah, Salt Lake City, UT, USA
| | - Roman Gulati
- Division of Public Health Sciences, Fred Hutchinson Cancer Center, Seattle, Washington, USA
| | - Meghana S Pagadala
- VA San Diego Healthcare System, San Diego, CA, USA
- Medical Scientist Training Program, University of California San Diego, La Jolla, CA, USA
- Biomedical Science Program, University of California San Diego, La Jolla, CA, USA
| | - Catherine Tcheandjieu
- VA Palo Alto Health Care System, Palo Alto, CA, USA
- Gladstone Institute of Data Science and Biotechnology, Gladstone Institutes, San Francisco, CA, USA
- Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, CA, USA
| | - Kathryn M Pridgen
- VA Informatics and Computing Infrastructure, VA Salt Lake City Health Care System, Salt Lake City, UT, USA
- Department of Internal Medicine, School of Medicine, University of Utah, Salt Lake City, UT, USA
| | - Scott L DuVall
- VA Informatics and Computing Infrastructure, VA Salt Lake City Health Care System, Salt Lake City, UT, USA
- Department of Internal Medicine, School of Medicine, University of Utah, Salt Lake City, UT, USA
| | - Kosj Yamoah
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center, Tampa, FL, USA
- James A. Haley Veterans' Hospital, Tampa, FL, USA
| | - Jason L Vassy
- Section of General Internal Medicine, VA Boston Healthcare System, Boston, MA, USA
- Department of Medicine, Harvard Medical School, Boston, MA, USA
- Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Tyler M Seibert
- VA San Diego Healthcare System, San Diego, CA, USA
- Department of Radiation Medicine and Applied Sciences, University of California, San Diego, La Jolla, CA, USA
- Department of Radiology, University of California San Diego, La Jolla, CA, USA
- Department of Bioengineering, University of California San Diego, La Jolla, CA, USA
| | - Richard L Hauger
- VA San Diego Healthcare System, San Diego, CA, USA
- Center for Behavior Genetics of Aging, University of California San Diego, La Jolla, CA, USA
- Department of Psychiatry, University of California San Diego, La Jolla, CA, USA
| | - Brent S Rose
- VA San Diego Healthcare System, San Diego, CA, USA
- Department of Radiation Medicine and Applied Sciences, University of California, San Diego, La Jolla, CA, USA
| | - Julie A Lynch
- VA Informatics and Computing Infrastructure, VA Salt Lake City Health Care System, Salt Lake City, UT, USA
- Department of Internal Medicine, School of Medicine, University of Utah, Salt Lake City, UT, USA
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2
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Lange JM, Gogebakan KC, Gulati R, Etzioni R. Projecting the impact of multi-cancer early detection on late-stage incidence using multi-state disease modeling. Cancer Epidemiol Biomarkers Prev 2024:741914. [PMID: 38506751 DOI: 10.1158/1055-9965.epi-23-1470] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Revised: 01/29/2024] [Accepted: 03/18/2024] [Indexed: 03/21/2024] Open
Abstract
BACKGROUND Downstaging- reduction in late-stage incidence-has been proposed as an endpoint in randomized trials of multi-cancer early detection (MCED) tests. How downstaging depends on test performance and follow-up has been studied for some cancers but is understudied for cancers without existing screening and for MCED tests that include these cancer types. METHODS We develop a model for cancer natural history that can be fit to registry incidence patterns under minimal inputs and can be estimated for solid cancers without existing screening. Fitted models are combined to project downstaging in MCED trials given sensitivity for early- and late-stage cancers. We fit models for 12 cancers using incidence data from the Surveillance, Epidemiology, and End Results program and project downstaging in a simulated trial under variable preclinical latencies and test sensitivities. RESULTS A proof-of-principle lung cancer model approximated downstaging in the National Lung Screening Trial. Given published stage-specific sensitivities for 12 cancers, we projected downstaging ranging 21%-43% across plausible preclinical latencies in a hypothetical 3-screen MCED trial. Late-stage incidence reductions manifest soon after screening begins. Downstaging increases with longer early-stage latency or higher early-stage test sensitivity. CONCLUSION Even short-term MCED trials could produce substantial downstaging given adequate early-stage test sensitivity. IMPACT Modeling the natural histories of cancers without existing screening facilitates analysis of novel MCED products and trial designs. The framework informs expectations of MCED impact on disease stage at diagnosis and could serve as a building block for designing trials with late-stage incidence as the primary endpoint.
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Affiliation(s)
- Jane M Lange
- Oregon Health and Science University Hospital, Portland, Oregon, United States
| | | | - Roman Gulati
- Fred Hutchinson Cancer Center, Seattle, WA, United States
| | - Ruth Etzioni
- Fred Hutchinson Cancer Center, Seattle, WA, United States
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3
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Caruana M, Gulati R, Etzioni R, Barratt A, Armstrong BK, Chiam K, Nair-Shalliker V, Luo Q, Bang A, Grogan P, Smith DP, O'Connell DL, Canfell K. Benefits and harms of prostate specific antigen testing according to Australian guidelines. Int J Cancer 2024; 154:648-658. [PMID: 37819139 DOI: 10.1002/ijc.34731] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Revised: 06/24/2023] [Accepted: 07/06/2023] [Indexed: 10/13/2023]
Abstract
Guidelines for prostate specific antigen (PSA) testing in Australia recommend that men at average risk of prostate cancer who have been informed of the benefits and harms, and who decide to undergo regular testing, should be offered testing every 2 years from 50 to 69 years. This study aimed to estimate the benefits and harms of regular testing in this context. We constructed Policy1-Prostate, a discrete event microsimulation platform of the natural history of prostate cancer and prostate cancer survival, and PSA testing patterns and subsequent management in Australia. The model was calibrated to pre-PSA (before 1985) prostate cancer incidence and mortality and validated against incidence and mortality trends from 1985 to 2011 and international trials. The model predictions were concordant with trials and Australian observed incidence and mortality data from 1985 to 2011. Out of 1000 men who choose to test according to the guidelines, 36 [21-41] men will die from prostate cancer and 126 [119-133] men will be diagnosed with prostate cancer, compared with 50 [47-54] and 94 [90-98] men who do not test, respectively. During the 20 years of active PSA testing, 32.3% [25.6%-38.8%] of all PSA-test detected cancers are overdiagnosed cases that is, 30 [21-42] out of 94 [83-107] PSA-test detected cancers. Australian men choosing to test with PSA every two years from 50 to 69 will reduce their risk of ever dying from prostate cancer and incur a risk of overdiagnosis: for every man who avoids dying from prostate cancer, two will be overdiagnosed with prostate cancer between 50 and 69 years of age. Australian men, with health professionals, can use these results to inform decision-making about PSA testing.
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Affiliation(s)
- Michael Caruana
- The Daffodil Centre, The University of Sydney, A Joint Venture with Cancer Council NSW, Sydney, New South Wales, Australia
| | - Roman Gulati
- Program in Biostatistics, Division of Public Health Sciences, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA
| | - Ruth Etzioni
- Program in Biostatistics, Division of Public Health Sciences, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA
| | - Alexandra Barratt
- Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Bruce K Armstrong
- School of Public Health, University of Sydney, Sydney, New South Wales, Australia
- School of Population and Global Health, University of Western Australia, Sydney, New South Wales, Australia
| | - Karen Chiam
- The Daffodil Centre, The University of Sydney, A Joint Venture with Cancer Council NSW, Sydney, New South Wales, Australia
| | - Visalini Nair-Shalliker
- The Daffodil Centre, The University of Sydney, A Joint Venture with Cancer Council NSW, Sydney, New South Wales, Australia
| | - Qingwei Luo
- The Daffodil Centre, The University of Sydney, A Joint Venture with Cancer Council NSW, Sydney, New South Wales, Australia
| | - Albert Bang
- The Daffodil Centre, The University of Sydney, A Joint Venture with Cancer Council NSW, Sydney, New South Wales, Australia
| | - Paul Grogan
- The Daffodil Centre, The University of Sydney, A Joint Venture with Cancer Council NSW, Sydney, New South Wales, Australia
| | - David P Smith
- The Daffodil Centre, The University of Sydney, A Joint Venture with Cancer Council NSW, Sydney, New South Wales, Australia
| | - Dianne L O'Connell
- The Daffodil Centre, The University of Sydney, A Joint Venture with Cancer Council NSW, Sydney, New South Wales, Australia
- School of Medicine and Public Health, University of Newcastle, Newcastle, New South Wales, Australia
| | - Karen Canfell
- The Daffodil Centre, The University of Sydney, A Joint Venture with Cancer Council NSW, Sydney, New South Wales, Australia
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4
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Etzioni R, Gulati R, Patriotis C, Rutter C, Zheng Y, Srivastava S, Feng Z. Revisiting the standard blueprint for biomarker development to address emerging cancer early detection technologies. J Natl Cancer Inst 2024; 116:189-193. [PMID: 37941446 PMCID: PMC10852609 DOI: 10.1093/jnci/djad227] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Revised: 06/07/2023] [Accepted: 10/25/2023] [Indexed: 11/10/2023] Open
Abstract
Novel liquid biopsy technologies are creating a watershed moment in cancer early detection. Evidence supporting population screening is nascent, but a rush to market the new tests is prompting cancer early detection researchers to revisit the standard blueprint that the Early Detection Research Network established to evaluate novel screening biomarkers. In this commentary, we review the Early Detection Research Network's Phases of Biomarker Development (PBD) for rigorous evaluation of novel early detection biomarkers and discuss both hazards and opportunities involved in expedited evaluation. According to the PBD, for a biomarker-based test to be considered for population screening, 1) test sensitivity in a prospective screening setting must be adequate, 2) the shift to early curable stages must be meaningful, and 3) any stage shift must translate into clinically significant mortality benefit. In the past, determining mortality benefit has required lengthy randomized screening trials, but interest is growing in expedited trial designs with shorter-term endpoints. Whether and how best to use such endpoints in a manner that retains the rigor of the PBD remains to be determined. We discuss how computational disease modeling can be harnessed to learn about screening impact and meet the needs of the moment.
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Affiliation(s)
- Ruth Etzioni
- Division of Public Health Sciences, Fred Hutchinson Cancer Center, Seattle, WA, USA
| | - Roman Gulati
- Division of Public Health Sciences, Fred Hutchinson Cancer Center, Seattle, WA, USA
| | - Christos Patriotis
- Division of Cancer Prevention, National Cancer Institute, Bethesda, MD, USA
| | - Carolyn Rutter
- Division of Public Health Sciences, Fred Hutchinson Cancer Center, Seattle, WA, USA
| | - Yingye Zheng
- Division of Public Health Sciences, Fred Hutchinson Cancer Center, Seattle, WA, USA
| | - Sudhir Srivastava
- Division of Cancer Prevention, National Cancer Institute, Bethesda, MD, USA
| | - Ziding Feng
- Division of Public Health Sciences, Fred Hutchinson Cancer Center, Seattle, WA, USA
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5
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Kensler KH, Johnson R, Morley F, Albrair M, Dickerman BA, Gulati R, Holt SK, Iyer HS, Kibel AS, Lee JR, Preston MA, Vassy JL, Wolff EM, Nyame YA, Etzioni R, Rebbeck TR. Prostate cancer screening in African American men: a review of the evidence. J Natl Cancer Inst 2024; 116:34-52. [PMID: 37713266 PMCID: PMC10777677 DOI: 10.1093/jnci/djad193] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Revised: 08/25/2023] [Accepted: 08/30/2023] [Indexed: 09/16/2023] Open
Abstract
BACKGROUND Prostate cancer is the most diagnosed cancer in African American men, yet prostate cancer screening regimens in this group are poorly guided by existing evidence, given underrepresentation of African American men in prostate cancer screening trials. It is critical to optimize prostate cancer screening and early detection in this high-risk group because underdiagnosis may lead to later-stage cancers at diagnosis and higher mortality while overdiagnosis may lead to unnecessary treatment. METHODS We performed a review of the literature related to prostate cancer screening and early detection specific to African American men to summarize the existing evidence available to guide health-care practice. RESULTS Limited evidence from observational and modeling studies suggests that African American men should be screened for prostate cancer. Consideration should be given to initiating screening of African American men at younger ages (eg, 45-50 years) and at more frequent intervals relative to other racial groups in the United States. Screening intervals can be optimized by using a baseline prostate-specific antigen measurement in midlife. Finally, no evidence has indicated that African American men would benefit from screening beyond 75 years of age; in fact, this group may experience higher rates of overdiagnosis at older ages. CONCLUSIONS The evidence base for prostate cancer screening in African American men is limited by the lack of large, randomized studies. Our literature search supported the need for African American men to be screened for prostate cancer, for initiating screening at younger ages (45-50 years), and perhaps screening at more frequent intervals relative to men of other racial groups in the United States.
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Affiliation(s)
- Kevin H Kensler
- Department of Population Health Sciences, Weill Cornell Medical Center, New York, NY, USA
| | - Roman Johnson
- Center for Global Health, Massachusetts General Hospital, Boston, MA, USA
| | - Faith Morley
- Department of Population Health Sciences, Weill Cornell Medical Center, New York, NY, USA
| | - Mohamed Albrair
- Department of Global Health, University of Washington, Seattle, WA, USA
- Division of Public Health Sciences, Fred Hutchinson Cancer Center, Seattle, WA, USA
| | - Barbra A Dickerman
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Roman Gulati
- Division of Public Health Sciences, Fred Hutchinson Cancer Center, Seattle, WA, USA
| | - Sarah K Holt
- Department of Urology, University of Washington, Seattle, WA, USA
| | - Hari S Iyer
- Section of Cancer Epidemiology and Health Outcomes, Rutgers Cancer Institute of New Jersey, New Brunswick, NJ, USA
| | - Adam S Kibel
- Department of Urology, Brigham and Women’s Hospital, Boston, MA, USA
| | - Jenney R Lee
- Department of Urology, University of Washington, Seattle, WA, USA
| | - Mark A Preston
- Department of Urology, Brigham and Women’s Hospital, Boston, MA, USA
| | - Jason L Vassy
- VA Boston Healthcare System, Boston, MA, USA
- Division of General Internal Medicine and Primary Care, Department of Medicine, Brigham and Women’s Hospital, Boston, MA, USA
| | - Erika M Wolff
- Department of Urology, University of Washington, Seattle, WA, USA
| | - Yaw A Nyame
- Division of Public Health Sciences, Fred Hutchinson Cancer Center, Seattle, WA, USA
- Department of Urology, University of Washington, Seattle, WA, USA
| | - Ruth Etzioni
- Division of Public Health Sciences, Fred Hutchinson Cancer Center, Seattle, WA, USA
| | - Timothy R Rebbeck
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, USA
- Division of Population Sciences, Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
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6
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Patel RA, Sayar E, Coleman I, Roudier MP, Hanratty B, Low JY, Jaiswal N, Ajkunic A, Dumpit R, Ercan C, Salama N, O’Brien VP, Isaacs WB, Epstein JI, De Marzo AM, Trock BJ, Luo J, Brennen WN, Tretiakova M, Vakar-Lopez F, True LD, Goodrich DW, Corey E, Morrissey C, Nelson PS, Hurley PJ, Gulati R, Haffner MC. Characterization of HOXB13 expression patterns in localized and metastatic castration-resistant prostate cancer. J Pathol 2024; 262:105-120. [PMID: 37850574 PMCID: PMC10871027 DOI: 10.1002/path.6216] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Revised: 08/16/2023] [Accepted: 09/08/2023] [Indexed: 10/19/2023]
Abstract
HOXB13 is a key lineage homeobox transcription factor that plays a critical role in the differentiation of the prostate gland. Several studies have suggested that HOXB13 alterations may be involved in prostate cancer development and progression. Despite its potential biological relevance, little is known about the expression of HOXB13 across the disease spectrum of prostate cancer. To this end, we validated a HOXB13 antibody using genetic controls and investigated HOXB13 protein expression in murine and human developing prostates, localized prostate cancers, and metastatic castration-resistant prostate cancers. We observed that HOXB13 expression increases during later stages of murine prostate development. All localized prostate cancers showed HOXB13 protein expression. Interestingly, lower HOXB13 expression levels were observed in higher-grade tumors, although no significant association between HOXB13 expression and recurrence or disease-specific survival was found. In advanced metastatic prostate cancers, HOXB13 expression was retained in the majority of tumors. While we observed lower levels of HOXB13 protein and mRNA levels in tumors with evidence of lineage plasticity, 84% of androgen receptor-negative castration-resistant prostate cancers and neuroendocrine prostate cancers (NEPCs) retained detectable levels of HOXB13. Notably, the reduced expression observed in NEPCs was associated with a gain of HOXB13 gene body CpG methylation. In comparison to the commonly used prostate lineage marker NKX3.1, HOXB13 showed greater sensitivity in detecting advanced metastatic prostate cancers. Additionally, in a cohort of 837 patients, 383 with prostatic and 454 with non-prostatic tumors, we found that HOXB13 immunohistochemistry had a 97% sensitivity and 99% specificity for prostatic origin. Taken together, our studies provide valuable insight into the expression pattern of HOXB13 during prostate development and cancer progression. Furthermore, our findings support the utility of HOXB13 as a diagnostic biomarker for prostate cancer, particularly to confirm the prostatic origin of advanced metastatic castration-resistant tumors. © 2023 The Pathological Society of Great Britain and Ireland.
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Affiliation(s)
- Radhika A. Patel
- Division of Human Biology, Fred Hutchinson Cancer Center, Seattle, WA, USA
| | - Erolcan Sayar
- Division of Human Biology, Fred Hutchinson Cancer Center, Seattle, WA, USA
| | - Ilsa Coleman
- Division of Human Biology, Fred Hutchinson Cancer Center, Seattle, WA, USA
| | | | - Brian Hanratty
- Division of Human Biology, Fred Hutchinson Cancer Center, Seattle, WA, USA
| | - Jin-Yih Low
- Division of Human Biology, Fred Hutchinson Cancer Center, Seattle, WA, USA
| | - Neha Jaiswal
- Department of Pharmacology and Therapeutics, Roswell Park Comprehensive Cancer Center, Buffalo, NY, USA
| | - Azra Ajkunic
- Division of Human Biology, Fred Hutchinson Cancer Center, Seattle, WA, USA
| | - Ruth Dumpit
- Division of Human Biology, Fred Hutchinson Cancer Center, Seattle, WA, USA
| | - Caner Ercan
- Institute of Pathology and Medical Genetics, University Hospital Basel, Basel, Switzerland
| | - Nina Salama
- Division of Human Biology, Fred Hutchinson Cancer Center, Seattle, WA, USA
| | - Valerie P. O’Brien
- Division of Human Biology, Fred Hutchinson Cancer Center, Seattle, WA, USA
| | - William B. Isaacs
- Department of Urology, Johns Hopkins University School of Medicine, MD, Baltimore, USA
- Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, MD, Baltimore, USA
| | - Jonathan I. Epstein
- Department of Urology, Johns Hopkins University School of Medicine, MD, Baltimore, USA
- Department of Pathology, Johns Hopkins University School of Medicine, MD, Baltimore, USA
- Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, MD, Baltimore, USA
| | - Angelo M. De Marzo
- Department of Urology, Johns Hopkins University School of Medicine, MD, Baltimore, USA
- Department of Pathology, Johns Hopkins University School of Medicine, MD, Baltimore, USA
- Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, MD, Baltimore, USA
| | - Bruce J. Trock
- Department of Urology, Johns Hopkins University School of Medicine, MD, Baltimore, USA
- Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, MD, Baltimore, USA
| | - Jun Luo
- Department of Urology, Johns Hopkins University School of Medicine, MD, Baltimore, USA
- Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, MD, Baltimore, USA
| | - W Nathaniel Brennen
- Department of Urology, Johns Hopkins University School of Medicine, MD, Baltimore, USA
- Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, MD, Baltimore, USA
| | - Maria Tretiakova
- Department of Laboratory Medicine and Pathology, University of Washington, Seattle, WA, USA
| | - Funda Vakar-Lopez
- Department of Laboratory Medicine and Pathology, University of Washington, Seattle, WA, USA
| | - Lawrence D. True
- Department of Laboratory Medicine and Pathology, University of Washington, Seattle, WA, USA
| | - David W. Goodrich
- Department of Pharmacology and Therapeutics, Roswell Park Comprehensive Cancer Center, Buffalo, NY, USA
| | - Eva Corey
- Department of Urology, University of Washington, Seattle, WA, USA
| | - Colm Morrissey
- Department of Urology, University of Washington, Seattle, WA, USA
| | - Peter S. Nelson
- Division of Human Biology, Fred Hutchinson Cancer Center, Seattle, WA, USA
- Department of Laboratory Medicine and Pathology, University of Washington, Seattle, WA, USA
- Division of Clinical Research, Fred Hutchinson Cancer Center, Seattle, WA, USA
| | - Paula J. Hurley
- Departments of Medicine and Urology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Roman Gulati
- Division of Public Health Sciences, Fred Hutchinson Cancer Center, Seattle, WA, USA
| | - Michael C. Haffner
- Division of Human Biology, Fred Hutchinson Cancer Center, Seattle, WA, USA
- Department of Laboratory Medicine and Pathology, University of Washington, Seattle, WA, USA
- Division of Clinical Research, Fred Hutchinson Cancer Center, Seattle, WA, USA
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7
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Ajkunic A, Sayar E, Roudier MP, Patel RA, Coleman IM, De Sarkar N, Hanratty B, Adil M, Zhao J, Zaidi S, True LD, Sperger JM, Cheng HH, Yu EY, Montgomery RB, Hawley JE, Ha G, Lee JK, Harmon SA, Corey E, Lang JM, Sawyers CL, Morrissey C, Schweizer MT, Gulati R, Nelson PS, Haffner MC. ASSESSMENT OF CELL SURFACE TARGETS IN METASTATIC PROSTATE CANCER: EXPRESSION LANDSCAPE AND MOLECULAR CORRELATES. Res Sq 2023:rs.3.rs-3745991. [PMID: 38196594 PMCID: PMC10775381 DOI: 10.21203/rs.3.rs-3745991/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/11/2024]
Abstract
Therapeutic approaches targeting proteins on the surface of cancer cells have emerged as an important strategy for precision oncology. To fully capitalize on the potential impact of drugs targeting surface proteins, detailed knowledge about the expression patterns of the target proteins in tumor tissues is required. In castration-resistant prostate cancer (CRPC), agents targeting prostate-specific membrane antigen (PSMA) have demonstrated clinical activity. However, PSMA expression is lost in a significant number of CRPC tumors, and the identification of additional cell surface targets is necessary in order to develop new therapeutic approaches. Here, we performed a comprehensive analysis of the expression and co-expression patterns of trophoblast cell-surface antigen 2 (TROP2), delta-like ligand 3 (DLL3), and carcinoembryonic antigen-related cell adhesion molecule 5 (CEACAM5) in CRPC samples from a rapid autopsy cohort. We show that DLL3 and CEACAM5 exhibit the highest expression in neuroendocrine prostate cancer (NEPC), while TROP2 is expressed across different CRPC molecular subtypes, except for NEPC. We observed variable intra-tumoral and inter-tumoral heterogeneity and no dominant metastatic site predilections for TROP2, DLL3, and CEACAM5. We further show that AR amplifications were associated with higher expression of PSMA and TROP2 but lower DLL3 and CEACAM5 levels. Conversely, PSMA and TROP2 expression was lower in RB1-altered tumors. In addition to genomic alterations, we demonstrate a tight correlation between epigenetic states, particularly histone H3 lysine 27 methylation (H3K27me3) at the transcriptional start site and gene body of TACSTD2 (encoding TROP2), DLL3, and CEACAM5, and their respective protein expression in CRPC patient-derived xenografts. Collectively, these findings provide novel insights into the patterns and determinants of expression of TROP2, DLL3, and CEACAM5 with important implications for the clinical development of cell surface targeting agents in CRPC.
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Affiliation(s)
- Azra Ajkunic
- Division of Human Biology, Fred Hutchinson Cancer Center, Seattle, WA, USA
| | - Erolcan Sayar
- Division of Human Biology, Fred Hutchinson Cancer Center, Seattle, WA, USA
| | | | - Radhika A Patel
- Division of Human Biology, Fred Hutchinson Cancer Center, Seattle, WA, USA
| | - Ilsa M Coleman
- Division of Human Biology, Fred Hutchinson Cancer Center, Seattle, WA, USA
| | - Navonil De Sarkar
- Division of Human Biology, Fred Hutchinson Cancer Center, Seattle, WA, USA
- Medical College of Wisconsin Cancer Center, Milwaukee, WI, USA
- Department of Pathology, Medical College of Wisconsin, WI, USA
| | - Brian Hanratty
- Division of Human Biology, Fred Hutchinson Cancer Center, Seattle, WA, USA
| | - Mohamed Adil
- Division of Human Biology, Fred Hutchinson Cancer Center, Seattle, WA, USA
| | - Jimmy Zhao
- Human Oncology and Pathogenesis Program, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Samir Zaidi
- Human Oncology and Pathogenesis Program, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Lawrence D True
- Department of Laboratory Medicine and Pathology, University of Washington, Seattle, WA, USA
| | | | - Heather H Cheng
- Division of Clinical Research, Fred Hutchinson Cancer Center, Seattle, WA, USA
- Division of Hematology and Oncology, Department of Medicine, University of Washington, Seattle, WA, USA
| | - Evan Y Yu
- Division of Clinical Research, Fred Hutchinson Cancer Center, Seattle, WA, USA
- Division of Hematology and Oncology, Department of Medicine, University of Washington, Seattle, WA, USA
| | - Robert B Montgomery
- Division of Clinical Research, Fred Hutchinson Cancer Center, Seattle, WA, USA
- Division of Hematology and Oncology, Department of Medicine, University of Washington, Seattle, WA, USA
| | - Jessica E Hawley
- Division of Clinical Research, Fred Hutchinson Cancer Center, Seattle, WA, USA
- Division of Hematology and Oncology, Department of Medicine, University of Washington, Seattle, WA, USA
| | - Gavin Ha
- Division of Human Biology, Fred Hutchinson Cancer Center, Seattle, WA, USA
- Public Health Sciences Division, Fred Hutchinson Cancer Center, Seattle, WA, USA
- Department of Genome Sciences, University of Washington, Seattle, WA, USA
| | - John K Lee
- Division of Human Biology, Fred Hutchinson Cancer Center, Seattle, WA, USA
- Division of Clinical Research, Fred Hutchinson Cancer Center, Seattle, WA, USA
- Division of Hematology and Oncology, Department of Medicine, University of Washington, Seattle, WA, USA
| | - Stephanie A Harmon
- Artificial Intelligence Resource, Molecular Imaging Branch, NCI, NIH, Bethesda, MD, USA
| | - Eva Corey
- Department of Urology, University of Washington, Seattle, WA, USA
| | | | - Charles L Sawyers
- Human Oncology and Pathogenesis Program, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Howard Hughes Medical Institute, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Colm Morrissey
- Department of Urology, University of Washington, Seattle, WA, USA
| | - Michael T Schweizer
- Division of Clinical Research, Fred Hutchinson Cancer Center, Seattle, WA, USA
- Division of Hematology and Oncology, Department of Medicine, University of Washington, Seattle, WA, USA
| | - Roman Gulati
- Public Health Sciences Division, Fred Hutchinson Cancer Center, Seattle, WA, USA
| | - Peter S Nelson
- Division of Human Biology, Fred Hutchinson Cancer Center, Seattle, WA, USA
- Department of Urology, University of Washington, Seattle, WA, USA
- Department of Laboratory Medicine and Pathology, University of Washington, Seattle, WA, USA
- Division of Clinical Research, Fred Hutchinson Cancer Center, Seattle, WA, USA
- Division of Hematology and Oncology, Department of Medicine, University of Washington, Seattle, WA, USA
| | - Michael C Haffner
- Division of Human Biology, Fred Hutchinson Cancer Center, Seattle, WA, USA
- Department of Laboratory Medicine and Pathology, University of Washington, Seattle, WA, USA
- Division of Clinical Research, Fred Hutchinson Cancer Center, Seattle, WA, USA
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8
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Park J, Lim F, Prest M, Ferris JS, Aziz Z, Agyekum A, Wagner S, Gulati R, Hur C. Quantifying the potential benefits of early detection for pancreatic cancer through a counterfactual simulation modeling analysis. Sci Rep 2023; 13:20028. [PMID: 37973858 PMCID: PMC10654404 DOI: 10.1038/s41598-023-46751-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Accepted: 11/04/2023] [Indexed: 11/19/2023] Open
Abstract
The benefits of cancer early detection depend on various factors, including cancer type, screening method performance, stage at diagnosis, and subsequent treatment. Although numerous studies have evaluated the effectiveness of screening interventions for identifying cancer at earlier stages, there is no quantitative analysis that studies the optimal early detection time interval that results in the greatest mortality benefit; such data could serve as a target and benchmark for cancer early detection strategies. In this study, we focus on pancreatic ductal adenocarcinoma (PDAC), a cancer known for its lack of early symptoms. Consequently, it is most often detected at late stages when the 5-year survival rate is only 3%. We developed a PDAC population model that simulates an individual patient's age and stage at diagnosis, while replicating overall US cancer incidence and mortality rates. The model includes "cancer sojourn time," serving as a proxy for the speed of cancer progression, with shorter times indicating rapid progression and longer times indicating slower progression. In our PDAC model, our hypothesis was that earlier cancer detection, potentially through a hypothetical screening intervention in the counterfactual analysis, would yield reduced mortality as compared to a no-screening group. We found that the benefits of early detection, such as increased life-years gained, are greater when the sojourn time is shorter, reaching their maximum when identification is made 4-6 years prior to clinical diagnosis (e.g., when a symptomatic diagnosis is made). However, when early detection occurs even earlier, for example 6-10 years prior to clinical diagnosis, the benefits significantly diminish for shorter sojourn time cancers, and level off for longer sojourn time cancers. Our study clarifies the potential benefits of PDAC early detection that explicitly incorporates individual patient heterogeneity in cancer progression and identifies quantitative benchmarks for future interventions.
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Affiliation(s)
- Jiheum Park
- Department of Medicine, Columbia University Irving Medical Center, New York, NY, 10032, USA.
| | - Francesca Lim
- Department of Medicine, Columbia University Irving Medical Center, New York, NY, 10032, USA
| | - Matthew Prest
- Department of Medicine, Columbia University Irving Medical Center, New York, NY, 10032, USA
| | - Jennifer S Ferris
- Department of Medicine, Columbia University Irving Medical Center, New York, NY, 10032, USA
| | - Zainab Aziz
- Department of Medicine, Columbia University Irving Medical Center, New York, NY, 10032, USA
| | - Alice Agyekum
- Department of Medicine, Columbia University Irving Medical Center, New York, NY, 10032, USA
| | - Sophie Wagner
- Department of Medicine, Columbia University Irving Medical Center, New York, NY, 10032, USA
| | - Roman Gulati
- Division of Public Health Sciences, Fred Hutchinson Cancer Center, Seattle, WA, 98109, USA
| | - Chin Hur
- Department of Medicine, Columbia University Irving Medical Center, New York, NY, 10032, USA.
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9
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Gulati R, Nyame YA, Lange JM, Shoag JE, Tsodikov A, Etzioni R. Racial disparities in prostate cancer mortality: a model-based decomposition of contributing factors. J Natl Cancer Inst Monogr 2023; 2023:212-218. [PMID: 37947332 PMCID: PMC10637024 DOI: 10.1093/jncimonographs/lgad018] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Revised: 05/22/2023] [Accepted: 06/27/2023] [Indexed: 11/12/2023] Open
Abstract
To investigate the relative contributions of natural history and clinical interventions to racial disparities in prostate cancer mortality in the United States, we extended a model that was previously calibrated to Surveillance, Epidemiology, and End Results (SEER) incidence rates for the general population and for Black men. The extended model integrated SEER data on curative treatment frequencies and cancer-specific survival. Starting with the model for all men, we replaced up to 9 components with corresponding components for Black men, projecting age-standardized mortality rates for ages 40-84 years at each step. Based on projections in 2019, the increased frequency of developing disease, more aggressive tumor features, and worse cancer-specific survival in Black men diagnosed at local-regional and distant stages explained 38%, 34%, 22%, and 8% of the modeled disparity in mortality. Our results point to intensified screening and improved care in Black men as priority areas to achieve greater equity.
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Affiliation(s)
- Roman Gulati
- Division of Public Health Sciences, Biostatistics Program, Fred Hutchinson Cancer Center, Seattle, WA, USA
| | - Yaw A Nyame
- Division of Public Health Sciences, Biostatistics Program, Fred Hutchinson Cancer Center, Seattle, WA, USA
- Department of Urology, University of Washington Medical Center, Seattle, WA, USA
| | - Jane M Lange
- Division of Public Health Sciences, Biostatistics Program, Fred Hutchinson Cancer Center, Seattle, WA, USA
- Cancer Early Detection Advanced Research Center, Knight Cancer Institute, Oregon Health & Science University, Portland, OR, USA
| | - Jonathan E Shoag
- Department of Urology, University Hospitals Cleveland Medical Center, Case Western Reserve University School of Medicine, Cleveland, OH, USA
- Department of Urology, Weill Cornell Medicine, New York, NY, USA
| | - Alex Tsodikov
- Department of Biostatistics, University of Michigan, Ann Arbor, MI, USA
| | - Ruth Etzioni
- Division of Public Health Sciences, Biostatistics Program, Fred Hutchinson Cancer Center, Seattle, WA, USA
- Cancer Early Detection Advanced Research Center, Knight Cancer Institute, Oregon Health & Science University, Portland, OR, USA
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10
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Owens L, Gogebakan KC, Menon U, Gulati R, Weiss NS, Etzioni R. Short-term Endpoints for Cancer Screening Trials: Does Tumor Subtype Matter? Cancer Epidemiol Biomarkers Prev 2023; 32:741-743. [PMID: 37259797 PMCID: PMC10335323 DOI: 10.1158/1055-9965.epi-22-1307] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Revised: 02/13/2023] [Accepted: 03/16/2023] [Indexed: 06/02/2023] Open
Abstract
Multicancer early detection tests are precipitating a reexamination of potential short-term endpoints for cancer screening trials. A reduction in advanced stage incidence is a prime candidate, and stage-shift models that substitute early-stage for late-stage survival have been used to predict mortality reduction due to screening. However, standard stage-shift models often ignore prognostic subtypes, effectively implying that cancers detected early also have an associated subtype shift. To illustrate the differences between mortality predictions from stage-shift models that ignore versus preserve prognostic subtype, we use ovarian cancer partitioned by histologic subtype and prostate cancer partitioned by grade. We infer general conditions under which stage-shift models that preserve prognostic subtype are likely to predict mortality reductions that differ from those that ignore subtype and examine the implications for short-term endpoints based on stage in cancer screening trials.
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Affiliation(s)
- Lukas Owens
- Division of Public Health Sciences, Fred Hutchinson Cancer Center
| | | | - Usha Menon
- Institute of Clinical Trials and Methodology, University College London
| | - Roman Gulati
- Division of Public Health Sciences, Fred Hutchinson Cancer Center
| | - Noel S Weiss
- Department of Epidemiology, University of Washington
| | - Ruth Etzioni
- Division of Public Health Sciences, Fred Hutchinson Cancer Center
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11
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Bhatia V, Kamat NV, Pariva TE, Wu LT, Tsao A, Sasaki K, Sun H, Javier G, Nutt S, Coleman I, Hitchcock L, Zhang A, Rudoy D, Gulati R, Patel RA, Roudier MP, True LD, Srivastava S, Morrissey CM, Haffner MC, Nelson PS, Priceman SJ, Ishihara J, Lee JK. Targeting advanced prostate cancer with STEAP1 chimeric antigen receptor T cell and tumor-localized IL-12 immunotherapy. Nat Commun 2023; 14:2041. [PMID: 37041154 PMCID: PMC10090190 DOI: 10.1038/s41467-023-37874-2] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Accepted: 04/04/2023] [Indexed: 04/13/2023] Open
Abstract
Six transmembrane epithelial antigen of the prostate 1 (STEAP1) is a cell surface antigen for therapeutic targeting in prostate cancer. Here, we report broad expression of STEAP1 relative to prostate-specific membrane antigen (PSMA) in lethal metastatic prostate cancers and the development of a STEAP1-directed chimeric antigen receptor (CAR) T cell therapy. STEAP1 CAR T cells demonstrate reactivity in low antigen density, antitumor activity across metastatic prostate cancer models, and safety in a human STEAP1 knock-in mouse model. STEAP1 antigen escape is a recurrent mechanism of treatment resistance and is associated with diminished tumor antigen processing and presentation. The application of tumor-localized interleukin-12 (IL-12) therapy in the form of a collagen binding domain (CBD)-IL-12 fusion protein combined with STEAP1 CAR T cell therapy enhances antitumor efficacy by remodeling the immunologically cold tumor microenvironment of prostate cancer and combating STEAP1 antigen escape through the engagement of host immunity and epitope spreading.
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Affiliation(s)
- Vipul Bhatia
- Human Biology Division, Fred Hutchinson Cancer Center, 1100 Fairview Ave N, Seattle, WA, 98109, USA
| | - Nikhil V Kamat
- Division of Medical Oncology, University of Washington, 1959 NE Pacific Street, Seattle, WA, 98195, USA
| | - Tiffany E Pariva
- Human Biology Division, Fred Hutchinson Cancer Center, 1100 Fairview Ave N, Seattle, WA, 98109, USA
| | - Li-Ting Wu
- Human Biology Division, Fred Hutchinson Cancer Center, 1100 Fairview Ave N, Seattle, WA, 98109, USA
| | - Annabelle Tsao
- Human Biology Division, Fred Hutchinson Cancer Center, 1100 Fairview Ave N, Seattle, WA, 98109, USA
| | - Koichi Sasaki
- Department of Bioengineering, Imperial College London, 86 Wood Lane, London, W12 0BZ, UK
| | - Huiyun Sun
- Human Biology Division, Fred Hutchinson Cancer Center, 1100 Fairview Ave N, Seattle, WA, 98109, USA
| | - Gerardo Javier
- Human Biology Division, Fred Hutchinson Cancer Center, 1100 Fairview Ave N, Seattle, WA, 98109, USA
| | - Sam Nutt
- Human Biology Division, Fred Hutchinson Cancer Center, 1100 Fairview Ave N, Seattle, WA, 98109, USA
| | - Ilsa Coleman
- Human Biology Division, Fred Hutchinson Cancer Center, 1100 Fairview Ave N, Seattle, WA, 98109, USA
| | - Lauren Hitchcock
- Human Biology Division, Fred Hutchinson Cancer Center, 1100 Fairview Ave N, Seattle, WA, 98109, USA
| | - Ailin Zhang
- Human Biology Division, Fred Hutchinson Cancer Center, 1100 Fairview Ave N, Seattle, WA, 98109, USA
| | - Dmytro Rudoy
- Human Biology Division, Fred Hutchinson Cancer Center, 1100 Fairview Ave N, Seattle, WA, 98109, USA
| | - Roman Gulati
- Public Health Sciences Division, Fred Hutchinson Cancer Center, 1100 Fairview Ave N, Seattle, WA, 98109, USA
| | - Radhika A Patel
- Human Biology Division, Fred Hutchinson Cancer Center, 1100 Fairview Ave N, Seattle, WA, 98109, USA
| | - Martine P Roudier
- Department of Urology, University of Washington, 1959 NE Pacific Street, Seattle, WA, 98195, USA
| | - Lawrence D True
- Department of Pathology and Laboratory Medicine, University of Washington, 1959 NE Pacific Street, Seattle, WA, 98195, USA
| | - Shivani Srivastava
- Human Biology Division, Fred Hutchinson Cancer Center, 1100 Fairview Ave N, Seattle, WA, 98109, USA
| | - Colm M Morrissey
- Department of Urology, University of Washington, 1959 NE Pacific Street, Seattle, WA, 98195, USA
| | - Michael C Haffner
- Human Biology Division, Fred Hutchinson Cancer Center, 1100 Fairview Ave N, Seattle, WA, 98109, USA
- Department of Pathology and Laboratory Medicine, University of Washington, 1959 NE Pacific Street, Seattle, WA, 98195, USA
- Clinical Research Division, Fred Hutchinson Cancer Center, 1100 Fairview Ave N, Seattle, WA, 98109, USA
| | - Peter S Nelson
- Human Biology Division, Fred Hutchinson Cancer Center, 1100 Fairview Ave N, Seattle, WA, 98109, USA
- Division of Medical Oncology, University of Washington, 1959 NE Pacific Street, Seattle, WA, 98195, USA
- Public Health Sciences Division, Fred Hutchinson Cancer Center, 1100 Fairview Ave N, Seattle, WA, 98109, USA
- Department of Urology, University of Washington, 1959 NE Pacific Street, Seattle, WA, 98195, USA
- Department of Pathology and Laboratory Medicine, University of Washington, 1959 NE Pacific Street, Seattle, WA, 98195, USA
- Clinical Research Division, Fred Hutchinson Cancer Center, 1100 Fairview Ave N, Seattle, WA, 98109, USA
| | - Saul J Priceman
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope, 1500 East Duarte Road, Duarte, CA, 91010, USA
- Department of Immuno-Oncology, Beckman Research Institute of City of Hope, 1500 East Duarte Road, Duarte, CA, 91010, USA
| | - Jun Ishihara
- Department of Bioengineering, Imperial College London, 86 Wood Lane, London, W12 0BZ, UK.
| | - John K Lee
- Human Biology Division, Fred Hutchinson Cancer Center, 1100 Fairview Ave N, Seattle, WA, 98109, USA.
- Division of Medical Oncology, University of Washington, 1959 NE Pacific Street, Seattle, WA, 98195, USA.
- Department of Pathology and Laboratory Medicine, University of Washington, 1959 NE Pacific Street, Seattle, WA, 98195, USA.
- Clinical Research Division, Fred Hutchinson Cancer Center, 1100 Fairview Ave N, Seattle, WA, 98109, USA.
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12
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Sayar E, Patel RA, Coleman IM, Roudier MP, Zhang A, Mustafi P, Low JY, Hanratty B, Ang LS, Bhatia V, Adil M, Bakbak H, Quigley DA, Schweizer MT, Hawley JE, Kollath L, True LD, Feng FY, Bander NH, Corey E, Lee JK, Morrissey C, Gulati R, Nelson PS, Haffner MC. Reversible epigenetic alterations mediate PSMA expression heterogeneity in advanced metastatic prostate cancer. JCI Insight 2023; 8:e162907. [PMID: 36821396 PMCID: PMC10132157 DOI: 10.1172/jci.insight.162907] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Accepted: 02/21/2023] [Indexed: 02/24/2023] Open
Abstract
Prostate-specific membrane antigen (PSMA) is an important cell surface target in prostate cancer. There are limited data on the heterogeneity of PSMA tissue expression in metastatic castration-resistant prostate cancer (mCRPC). Furthermore, the mechanisms regulating PSMA expression (encoded by the FOLH1 gene) are not well understood. Here, we demonstrate that PSMA expression is heterogeneous across different metastatic sites and molecular subtypes of mCRPC. In a rapid autopsy cohort in which multiple metastatic sites per patient were sampled, we found that 13 of 52 (25%) cases had no detectable PSMA and 23 of 52 (44%) cases showed heterogeneous PSMA expression across individual metastases, with 33 (63%) cases harboring at least 1 PSMA-negative site. PSMA-negative tumors displayed distinct transcriptional profiles with expression of druggable targets such as MUC1. Loss of PSMA was associated with epigenetic changes of the FOLH1 locus, including gain of CpG methylation and loss of histone 3 lysine 27 (H3K27) acetylation. Treatment with histone deacetylase (HDAC) inhibitors reversed this epigenetic repression and restored PSMA expression in vitro and in vivo. Collectively, these data provide insights into the expression patterns and regulation of PSMA in mCRPC and suggest that epigenetic therapies - in particular, HDAC inhibitors - can be used to augment PSMA levels.
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Affiliation(s)
- Erolcan Sayar
- Division of Human Biology, Fred Hutchinson Cancer Center, Seattle, Washington, USA
| | - Radhika A. Patel
- Division of Human Biology, Fred Hutchinson Cancer Center, Seattle, Washington, USA
| | - Ilsa M. Coleman
- Division of Human Biology, Fred Hutchinson Cancer Center, Seattle, Washington, USA
| | - Martine P. Roudier
- Department of Urology, University of Washington (UW), Seattle, Washington, USA
| | - Ailin Zhang
- Division of Human Biology, Fred Hutchinson Cancer Center, Seattle, Washington, USA
| | - Pallabi Mustafi
- Division of Human Biology, Fred Hutchinson Cancer Center, Seattle, Washington, USA
| | - Jin-Yih Low
- Division of Human Biology, Fred Hutchinson Cancer Center, Seattle, Washington, USA
| | - Brian Hanratty
- Division of Human Biology, Fred Hutchinson Cancer Center, Seattle, Washington, USA
| | - Lisa S. Ang
- Division of Human Biology, Fred Hutchinson Cancer Center, Seattle, Washington, USA
| | - Vipul Bhatia
- Division of Human Biology, Fred Hutchinson Cancer Center, Seattle, Washington, USA
| | - Mohamed Adil
- Division of Human Biology, Fred Hutchinson Cancer Center, Seattle, Washington, USA
| | - Hasim Bakbak
- Division of Human Biology, Fred Hutchinson Cancer Center, Seattle, Washington, USA
| | - David A. Quigley
- UCSF Helen Diller Family Comprehensive Cancer Center, San Francisco, California, USA
| | - Michael T. Schweizer
- Division of Medical Oncology, Department of Medicine, UW, Seattle, Washington, USA
- Division of Clinical Research, Fred Hutchinson Cancer Center, Seattle, Washington, USA
| | - Jessica E. Hawley
- Division of Medical Oncology, Department of Medicine, UW, Seattle, Washington, USA
- Division of Clinical Research, Fred Hutchinson Cancer Center, Seattle, Washington, USA
| | - Lori Kollath
- Department of Urology, University of Washington (UW), Seattle, Washington, USA
| | - Lawrence D. True
- Department of Laboratory Medicine and Pathology, UW, Seattle, Washington, USA
| | - Felix Y. Feng
- UCSF Helen Diller Family Comprehensive Cancer Center, San Francisco, California, USA
| | - Neil H. Bander
- Department of Urology, Weill Cornell Medicine, New York, New York, USA
| | - Eva Corey
- Department of Urology, University of Washington (UW), Seattle, Washington, USA
| | - John K. Lee
- Division of Human Biology, Fred Hutchinson Cancer Center, Seattle, Washington, USA
- Department of Urology, Weill Cornell Medicine, New York, New York, USA
| | - Colm Morrissey
- Department of Urology, University of Washington (UW), Seattle, Washington, USA
| | - Roman Gulati
- Division of Public Health Sciences, Fred Hutchinson Cancer Center, Seattle, Washington, USA
| | - Peter S. Nelson
- Division of Human Biology, Fred Hutchinson Cancer Center, Seattle, Washington, USA
- Department of Urology, University of Washington (UW), Seattle, Washington, USA
- Division of Medical Oncology, Department of Medicine, UW, Seattle, Washington, USA
- Division of Clinical Research, Fred Hutchinson Cancer Center, Seattle, Washington, USA
- Department of Laboratory Medicine and Pathology, UW, Seattle, Washington, USA
| | - Michael C. Haffner
- Division of Human Biology, Fred Hutchinson Cancer Center, Seattle, Washington, USA
- Division of Clinical Research, Fred Hutchinson Cancer Center, Seattle, Washington, USA
- Department of Laboratory Medicine and Pathology, UW, Seattle, Washington, USA
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13
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Schweizer MT, Gulati R, Yezefski T, Cheng HH, Mostaghel E, Haffner MC, Patel RA, De Sarkar N, Ha G, Dumpit R, Woo B, Lin A, Panlasigui P, McDonald N, Lai M, Nega K, Hammond J, Grivas P, Hsieh A, Montgomery B, Nelson PS, Yu EY. Bipolar androgen therapy plus olaparib in men with metastatic castration-resistant prostate cancer. Prostate Cancer Prostatic Dis 2023; 26:194-200. [PMID: 36564459 PMCID: PMC10286318 DOI: 10.1038/s41391-022-00636-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Revised: 12/07/2022] [Accepted: 12/13/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND Bipolar androgen therapy (BAT) results in rapid fluctuation of testosterone (T) between near-castrate and supraphysiological levels and has shown promise in metastatic castration-resistant prostate cancer (mCRPC). Its clinical effects may be mediated through induction of DNA damage, and preclinical studies suggest synergy with PARP inhibitors. PATIENTS AND METHODS This was a single-center, Phase II trial testing olaparib plus BAT (T cypionate/enanthate 400 mg every 28 days) with ongoing androgen deprivation. Planned recruitment was 30 subjects (equal proportions with/without homologous recombination repair [HRR] gene mutations) with mCRPC post abiraterone and/or enzalutamide. The primary objective was to determine PSA50 response (PSA decline ≥50% from baseline) rate at 12-weeks. The primary analysis utilized the entire (intent-to-treat [ITT]) cohort, with those dropping out early counted as non-responders. Secondary/exploratory analyses were in those treated beyond 12-weeks (response-evaluable cohort). RESULTS Thirty-six patients enrolled and 6 discontinued prior to response assessment. In the ITT cohort, PSA50 response rate at 12-weeks was 11/36 (31%; 95% CI 17-48%), and 16/36 (44%, 95% CI 28-62%) had a PSA50 response at any time on-study. After a median follow-up of 19 months, the median clinical/radiographic progression-free survival in the ITT cohort was 13.0 months (95% CI 7-17). Clinical outcomes were similar regardless of HRR gene mutational status. CONCLUSIONS BAT plus olaparib is associated with high response rates and long PFS. Clinical benefit was observed regardless of HRR gene mutational status.
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Affiliation(s)
- Michael T Schweizer
- Department of Medicine, University of Washington, Seattle, WA, USA.
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, WA, USA.
| | - Roman Gulati
- Public Health Sciences Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Todd Yezefski
- Department of Medicine, University of Washington, Seattle, WA, USA
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, WA, USA
| | - Heather H Cheng
- Department of Medicine, University of Washington, Seattle, WA, USA
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, WA, USA
| | - Elahe Mostaghel
- Department of Medicine, University of Washington, Seattle, WA, USA
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, WA, USA
- VA Puget Sound Health Care System, Seattle, WA, USA
| | - Michael C Haffner
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, WA, USA
- Human Biology Division, Fred Hutchinson Cancer Center, Seattle, WA, USA
- Department of Laboratory Medicine and Pathology, University of Washington, Seattle, WA, USA
| | - Radhika A Patel
- Human Biology Division, Fred Hutchinson Cancer Center, Seattle, WA, USA
| | - Navonil De Sarkar
- Human Biology Division, Fred Hutchinson Cancer Center, Seattle, WA, USA
| | - Gavin Ha
- Public Health Sciences Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
- Human Biology Division, Fred Hutchinson Cancer Center, Seattle, WA, USA
| | - Ruth Dumpit
- Human Biology Division, Fred Hutchinson Cancer Center, Seattle, WA, USA
| | - Brianna Woo
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, WA, USA
| | - Aaron Lin
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, WA, USA
| | - Patrick Panlasigui
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, WA, USA
| | - Nerina McDonald
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, WA, USA
| | - Michael Lai
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, WA, USA
| | - Katie Nega
- Department of Medicine, University of Washington, Seattle, WA, USA
| | - Jeannette Hammond
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, WA, USA
| | - Petros Grivas
- Department of Medicine, University of Washington, Seattle, WA, USA
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, WA, USA
| | - Andrew Hsieh
- Department of Medicine, University of Washington, Seattle, WA, USA
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, WA, USA
- Human Biology Division, Fred Hutchinson Cancer Center, Seattle, WA, USA
| | - Bruce Montgomery
- Department of Medicine, University of Washington, Seattle, WA, USA
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, WA, USA
- VA Puget Sound Health Care System, Seattle, WA, USA
| | - Peter S Nelson
- Department of Medicine, University of Washington, Seattle, WA, USA
- Human Biology Division, Fred Hutchinson Cancer Center, Seattle, WA, USA
| | - Evan Y Yu
- Department of Medicine, University of Washington, Seattle, WA, USA
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, WA, USA
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14
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Schweizer MT, True L, Gulati R, Zhao Y, Ellis W, Schade G, Montgomery B, Goyal S, Nega K, Hakansson AK, Liu Y, Davicioni E, Pienta K, Nelson PS, Lin D, Wright J. Reply by Authors. J Urol 2023; 209:362-363. [PMID: 36621992 DOI: 10.1097/ju.0000000000003038.02] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Affiliation(s)
- Michael T Schweizer
- Department of Medicine, University of Washington, Seattle, Washington.,Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Lawrence True
- Department of Pathology, University of Washington, Seattle, Washington
| | - Roman Gulati
- Public Health Sciences Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Yibai Zhao
- Public Health Sciences Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - William Ellis
- Department of Urology, University of Washington, Seattle, Washington
| | - George Schade
- Department of Urology, University of Washington, Seattle, Washington
| | - Bruce Montgomery
- Department of Medicine, University of Washington, Seattle, Washington.,Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington.,VA Puget Sound Health Care System and Prostate Cancer Foundation POPCAP Network, Seattle, Washington
| | - Sonia Goyal
- Department of Medicine, University of Washington, Seattle, Washington
| | - Katie Nega
- Department of Medicine, University of Washington, Seattle, Washington
| | | | - Yang Liu
- Veracyte, Inc., San Francisco, California
| | | | - Kenneth Pienta
- The James Buchanan Brady Urological Institute, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Peter S Nelson
- Department of Medicine, University of Washington, Seattle, Washington.,Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington.,Division of Human Biology, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Daniel Lin
- Department of Urology, University of Washington, Seattle, Washington
| | - Jonathan Wright
- Department of Urology, University of Washington, Seattle, Washington
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15
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Schweizer MT, True L, Gulati R, Zhao Y, Ellis W, Schade G, Montgomery B, Goyal S, Nega K, Hakansson AK, Liu Y, Davicioni E, Pienta K, Nelson PS, Lin D, Wright J. Pathological Effects of Apalutamide in Lower-risk Prostate Cancer: Results From a Phase II Clinical Trial. J Urol 2023; 209:354-363. [PMID: 36621991 PMCID: PMC9833838 DOI: 10.1097/ju.0000000000003038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
PURPOSE Active surveillance is a safe and effective strategy for men with lower-risk prostate cancer who want to avoid local therapy; however, many patients on active surveillance progress to active treatment (eg, prostatectomy or radiation). We hypothesized that apalutamide would decrease active surveillance attrition rates through downstaging low-grade tumors. MATERIALS AND METHODS This was an open-label, single-arm, phase II study testing 90 days of oral apalutamide 240 mg daily in men with low- to intermediate-risk prostate cancer on active surveillance. The primary objective was to determine the percentage of patients with a negative biopsy immediately following treatment. Secondary objectives were to assess long-term clinical outcomes, quality of life, safety, and biomarkers of response/resistance. RESULTS Twenty-three patients enrolled and 22 completed 90 days of apalutamide with post-treatment biopsy. Fifteen (65%) had Grade Group 1 disease, and all others had Grade Group 2 disease. Seven (30%) had favorable- to intermediate-risk disease. Of 22 evaluable patients, 13 (59%) had no residual cancer on post-treatment biopsy. The median time to first positive biopsy was 364 days (95% CI: 91-742 days). The impact of apalutamide on quality of life was minimal and transient. Decipher risk classifier revealed a greater number of negative post-treatment biopsies in those with higher baseline genomic risk score (P = .01). CONCLUSIONS The negative repeat biopsy rate following 90 days of apalutamide was high in men with prostate cancer followed on active surveillance. Apalutamide was safe, well tolerated, and had minimal impact on quality of life. Randomized studies evaluating the effects of apalutamide in men enrolled on active surveillance are warranted.
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Affiliation(s)
- Michael T Schweizer
- Department of Medicine, University of Washington, Seattle, Washington
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Lawrence True
- Department of Pathology, University of Washington, Seattle, Washington
| | - Roman Gulati
- Public Health Sciences Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Yibai Zhao
- Public Health Sciences Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - William Ellis
- Department of Urology, University of Washington, Seattle, Washington
| | - George Schade
- Department of Urology, University of Washington, Seattle, Washington
| | - Bruce Montgomery
- Department of Medicine, University of Washington, Seattle, Washington
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
- VA Puget Sound Health Care System and Prostate Cancer Foundation POPCAP Network, Seattle, Washington
| | - Sonia Goyal
- Department of Medicine, University of Washington, Seattle, Washington
| | - Katie Nega
- Department of Medicine, University of Washington, Seattle, Washington
| | | | - Yang Liu
- Veracyte, Inc., San Francisco, California
| | | | - Kenneth Pienta
- The James Buchanan Brady Urological Institute, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Peter S Nelson
- Department of Medicine, University of Washington, Seattle, Washington
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
- Division of Human Biology, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Daniel Lin
- Department of Urology, University of Washington, Seattle, Washington
| | - Jonathan Wright
- Department of Urology, University of Washington, Seattle, Washington
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16
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Cheng HH, Sokolova AO, Gulati R, Bowen D, Knerr SA, Klemfuss N, Grivas P, Hsieh A, Lee JK, Schweizer MT, Yezefski T, Zhou A, Yu EY, Nelson PS, Montgomery B. Internet-Based Germline Genetic Testing for Men With Metastatic Prostate Cancer. JCO Precis Oncol 2023; 7:e2200104. [PMID: 36623239 PMCID: PMC9928882 DOI: 10.1200/po.22.00104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
PURPOSE Germline mutations in DNA repair genes are present in approximately 10% of men with metastatic prostate cancer (mPC), and guidelines recommend genetic germline testing. Notable barriers exist, including access to genetic counseling, insurance coverage, and out-of-pocket costs. The GENTleMEN study was designed to determine the feasibility of an Internet-based, patient-driven germline genetic testing approach for men with mPC. PATIENTS AND METHODS In this prospective cohort study, men with mPC provided informed consent via an Internet-based platform and completed a questionnaire including demographics and family cancer history. Supporting medical data were also collected. Genetic testing was performed using the Color Genomics 30-gene targeted panel of cancer predisposition genes on a mailed saliva sample. Men whose test results identified a germline pathogenic or likely pathogenic variant received results by phone or telehealth genetic counseling; other participants received results by email with an option for phone-based or telehealth genetic counseling. RESULTS As of August 18, 2021, 816 eligible men were consented, of whom 68% (551) completed genetic testing, and 8.7% (48 of 551) were found to carry a pathogenic or likely pathogenic variant in a germline DNA repair gene: CHEK2 (17), BRCA2 (15), ATM (6), NBN1 (3), BRCA1 (2), PALB2 (2), PMS2 (2), and MSH6 (1). Participants were more likely to complete the testing process if they were non-Hispanic White, married, highly educated, or from a higher-income bracket. CONCLUSION Here, we show the feasibility of delivering germline (inherited) genetic testing by a voluntary, patient-driven, Internet-based platform to men with mPC. Preliminary results show rates of germline DNA repair mutations, consistent with other cohorts. Although feasible for some, reduced steps for participation, more dedicated diverse outreach and participant support, and identification and addressing of additional barriers is needed to ensure equitable access and optimization.
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Affiliation(s)
- Heather H. Cheng
- University of Washington, Seattle, WA
- Fred Hutchinson Cancer Center, Seattle, WA
- Heather H. Cheng, MD, PhD, Division of Medical Oncology, University of Washington, Fred Hutchinson Cancer Center, 825 Eastlake Ave. E., Seattle, WA 98109; e-mail:
| | | | | | | | | | | | - Petros Grivas
- University of Washington, Seattle, WA
- Fred Hutchinson Cancer Center, Seattle, WA
| | - Andrew Hsieh
- University of Washington, Seattle, WA
- Fred Hutchinson Cancer Center, Seattle, WA
| | - John K. Lee
- University of Washington, Seattle, WA
- Fred Hutchinson Cancer Center, Seattle, WA
| | | | - Todd Yezefski
- University of Washington, Seattle, WA
- Fred Hutchinson Cancer Center, Seattle, WA
| | | | - Evan Y. Yu
- University of Washington, Seattle, WA
- Fred Hutchinson Cancer Center, Seattle, WA
| | - Peter S. Nelson
- University of Washington, Seattle, WA
- Fred Hutchinson Cancer Center, Seattle, WA
| | - Bruce Montgomery
- University of Washington, Seattle, WA
- Fred Hutchinson Cancer Center, Seattle, WA
- Veterans Affairs Puget Sound Health Care System, Seattle, WA
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17
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Etzioni R, Gulati R, Owens L, Lange J, Ryser MD. Abstract IA018: Opportunity for interception as a driver of benefit in cancer early detection: implications for multi-cancer early detection testing. Cancer Prev Res (Phila) 2023. [DOI: 10.1158/1940-6215.precprev22-ia018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Abstract
Early detection cannot succeed unless there is adequate opportunity for cancer to be diagnosed and intercepted within its early preclinical phase. An understanding of opportunity for early detection and interception is therefore critical in predicting potential mortality reduction due to screening. Opportunity is not directly observable but may be learned using data from prospectively screened cohorts and populations. In this presentation I will share a history of methods for learning about early detection opportunity and will present examples of how we have built on this work to study opportunity for early detection in prostate and breast cancer. I will describe a generic model of how opportunity and sensitivity combine to produce stage shift and mortality reduction and will briefly explore whether a lack of opportunity may have been behind the results of the UCKCTOCS trial. I will use this learning to motivate why I believe a prospective study to investigate opportunity for multi-cancer detection and interception is warranted before or alongside ongoing and planned screening trials. This work in in collaboration with Roman Gulat i and Lukas Owens (Fred Hutch), Jane Lange (OHSU) and Marc Ryser (Duke University). We acknowledge funding from the National Cancer Institute and collaboration with and data from the Breast Cancer Surveillance Consortium
Citation Format: Ruth Etzioni, Roman Gulati, Lukas Owens, Jane Lange, Marc D. Ryser. Opportunity for interception as a driver of benefit in cancer early detection: implications for multi-cancer early detection testing. [abstract]. In: Proceedings of the AACR Special Conference: Precision Prevention, Early Detection, and Interception of Cancer; 2022 Nov 17-19; Austin, TX. Philadelphia (PA): AACR; Can Prev Res 2023;16(1 Suppl): Abstract nr IA018.
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Affiliation(s)
| | | | | | - Jane Lange
- 2Oregon Health Sciences University, Portland, OR,
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18
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19
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Keeney E, Sanghera S, Martin RM, Gulati R, Wiklund F, Walsh EI, Donovan JL, Hamdy F, Neal DE, Lane JA, Turner EL, Thom H, Clements MS. Cost-Effectiveness Analysis of Prostate Cancer Screening in the UK: A Decision Model Analysis Based on the CAP Trial. Pharmacoeconomics 2022; 40:1207-1220. [PMID: 36201131 PMCID: PMC9674711 DOI: 10.1007/s40273-022-01191-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 09/05/2022] [Indexed: 06/12/2023]
Abstract
BACKGROUND AND OBJECTIVE Most guidelines in the UK, Europe and North America do not recommend organised population-wide screening for prostate cancer. Prostate-specific antigen-based screening can reduce prostate cancer-specific mortality, but there are concerns about overdiagnosis, overtreatment and economic value. The aim was therefore to assess the cost effectiveness of eight potential screening strategies in the UK. METHODS We used a cost-utility analysis with an individual-based simulation model. The model was calibrated to data from the 10-year follow-up of the Cluster Randomised Trial of PSA Testing for Prostate Cancer (CAP). Treatment effects were modelled using data from the Prostate Testing for Cancer and Treatment (ProtecT) trial. The participants were a hypothetical population of 10 million men in the UK followed from age 30 years to death. The strategies were: no screening; five age-based screening strategies; adaptive screening, where men with an initial prostate-specific antigen level of < 1.5 ng/mL are screened every 6 years and those above this level are screened every 4 years; and two polygenic risk-stratified screening strategies. We assumed the use of pre-biopsy multi-parametric magnetic resonance imaging for men with prostate-specific antigen ≥ 3 ng/mL and combined transrectal ultrasound-guided and targeted biopsies. The main outcome measures were projected lifetime costs and quality-adjusted life-years from a National Health Service perspective. RESULTS All screening strategies increased costs compared with no screening, with the majority also increasing quality-adjusted life-years. At willingness-to-pay thresholds of £20,000 or £30,000 per quality-adjusted life-year gained, a once-off screening at age 50 years was optimal, although this was sensitive to the utility estimates used. Although the polygenic risk-stratified screening strategies were not on the cost-effectiveness frontier, there was evidence to suggest that they were less cost ineffective than the alternative age-based strategies. CONCLUSIONS Of the prostate-specific antigen-based strategies compared, only a once-off screening at age 50 years was potentially cost effective at current UK willingness-to-pay thresholds. An additional follow-up of CAP to 15 years may reduce uncertainty about the cost effectiveness of the screening strategies.
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Affiliation(s)
- Edna Keeney
- Department of Population Health Sciences, Health Economics Bristol, Population Health Sciences, Bristol Medical School, University of Bristol, 1-5 Whiteladies Road, Bristol, BS8 1NU, UK.
| | - Sabina Sanghera
- Department of Population Health Sciences, Health Economics Bristol, Population Health Sciences, Bristol Medical School, University of Bristol, 1-5 Whiteladies Road, Bristol, BS8 1NU, UK
| | - Richard M Martin
- Department of Population Health Sciences, Health Economics Bristol, Population Health Sciences, Bristol Medical School, University of Bristol, 1-5 Whiteladies Road, Bristol, BS8 1NU, UK
- NIHR Bristol Biomedical Research Centre at University Hospitals Bristol and Weston NHS Foundation Trust and the University of Bristol, Bristol, UK
| | - Roman Gulati
- Division of Public Health Sciences, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Fredrik Wiklund
- Department of Medical Epidemiology and Biostatistics, Karolinska Institute, Stockholm, Sweden
| | - Eleanor I Walsh
- Department of Population Health Sciences, Health Economics Bristol, Population Health Sciences, Bristol Medical School, University of Bristol, 1-5 Whiteladies Road, Bristol, BS8 1NU, UK
| | - Jenny L Donovan
- Department of Population Health Sciences, Health Economics Bristol, Population Health Sciences, Bristol Medical School, University of Bristol, 1-5 Whiteladies Road, Bristol, BS8 1NU, UK
| | - Freddie Hamdy
- Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
| | - David E Neal
- Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
| | - J Athene Lane
- Department of Population Health Sciences, Health Economics Bristol, Population Health Sciences, Bristol Medical School, University of Bristol, 1-5 Whiteladies Road, Bristol, BS8 1NU, UK
| | - Emma L Turner
- Department of Population Health Sciences, Health Economics Bristol, Population Health Sciences, Bristol Medical School, University of Bristol, 1-5 Whiteladies Road, Bristol, BS8 1NU, UK
| | - Howard Thom
- Department of Population Health Sciences, Health Economics Bristol, Population Health Sciences, Bristol Medical School, University of Bristol, 1-5 Whiteladies Road, Bristol, BS8 1NU, UK
| | - Mark S Clements
- Department of Medical Epidemiology and Biostatistics, Karolinska Institute, Stockholm, Sweden
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20
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Bakbak H, Sayar E, Kaur HB, Salles DC, Patel RA, Hicks J, Lotan TL, De Marzo AM, Gulati R, Epstein JI, Haffner MC. Clonal relationships of adjacent Gleason pattern 3 and Gleason pattern 5 lesions in Gleason Scores 3+5=8 and 5+3=8. Hum Pathol 2022; 130:18-24. [PMID: 36309296 PMCID: PMC10542864 DOI: 10.1016/j.humpath.2022.10.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Revised: 10/13/2022] [Accepted: 10/20/2022] [Indexed: 11/04/2022]
Abstract
Genomic studies have demonstrated a high level of intra-tumoral heterogeneity in prostate cancer. There is strong evidence suggesting that individual tumor foci can arise as genetically distinct, clonally independent lesions. However, recent studies have also demonstrated that adjacent Gleason pattern (GP) 3 and GP4 lesions can originate from the same clone but follow divergent genetic and morphologic evolution. The clonal relationship of adjacent GP3 and GP5 lesions has thus far not been investigated. Here we analyzed a cohort of 14 cases-11 biopsy and 3 radical prostatectomy specimens-with a Gleason score of 3 + 5 = 8 or 5 + 3 = 8 present in the same biopsy or in a single dominant tumor nodule at radical prostatectomy. Clonal and subclonal relationships between GP3 and GP5 lesions were assessed using genetically validated immunohistochemical assays for ERG, PTEN, and P53. 9/14 (64%) cases showed ERG reactivity in both GP3 and GP5 lesions. Only 1/14 (7%) cases showed a discordant pattern with ERG staining present only in GP3. PTEN expression was lost in 2/14 (14%) cases with perfect concordance between GP5 and GP3. P53 nuclear reactivity was present in 1/14 (7%) case in both GP5 and GP3. This study provides first evidence that the majority of adjacent GP3 and GP5 lesions share driver alterations and are clonally related. In addition, we observed a lower-than-expected rate of PTEN loss in GP5 in the context of Gleason score 3 + 5 = 8 or 5 + 3 = 8 tumors.
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Affiliation(s)
- Hasim Bakbak
- Division of Human Biology, Fred Hutchinson Cancer Research Center, Seattle, 98109, WA, USA
| | - Erolcan Sayar
- Division of Human Biology, Fred Hutchinson Cancer Research Center, Seattle, 98109, WA, USA
| | - Harsimar B Kaur
- Department of Oncology, The Johns Hopkins University School of Medicine, Baltimore, 21287, MD, USA
| | - Daniela C Salles
- Department of Oncology, The Johns Hopkins University School of Medicine, Baltimore, 21287, MD, USA
| | - Radhika A Patel
- Division of Human Biology, Fred Hutchinson Cancer Research Center, Seattle, 98109, WA, USA
| | - Jessica Hicks
- Department of Pathology, The Johns Hopkins University School of Medicine, Baltimore, 21287, MD, USA
| | - Tamara L Lotan
- Department of Pathology, The Johns Hopkins University School of Medicine, Baltimore, 21287, MD, USA; Department of Oncology, The Johns Hopkins University School of Medicine, Baltimore, 21287, MD, USA; Department of Urology, The Johns Hopkins University School of Medicine, Baltimore, 21287, MD, USA
| | - Angelo M De Marzo
- Department of Pathology, The Johns Hopkins University School of Medicine, Baltimore, 21287, MD, USA; Department of Oncology, The Johns Hopkins University School of Medicine, Baltimore, 21287, MD, USA; Department of Urology, The Johns Hopkins University School of Medicine, Baltimore, 21287, MD, USA
| | - Roman Gulati
- Division of Public Health Sciences, Fred Hutchinson Cancer Research Center, Seattle, 98109, WA, USA
| | - Jonathan I Epstein
- Department of Pathology, The Johns Hopkins University School of Medicine, Baltimore, 21287, MD, USA; Department of Oncology, The Johns Hopkins University School of Medicine, Baltimore, 21287, MD, USA; Department of Urology, The Johns Hopkins University School of Medicine, Baltimore, 21287, MD, USA.
| | - Michael C Haffner
- Division of Human Biology, Fred Hutchinson Cancer Research Center, Seattle, 98109, WA, USA; Department of Pathology, The Johns Hopkins University School of Medicine, Baltimore, 21287, MD, USA; Division of Clinical Research, Fred Hutchinson Cancer Research Center, Seattle, 98109, WA, USA; Department of Laboratory Medicine and Pathology, University of Washington, Seattle, 98195, WA, USA.
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21
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De Michieli L, Knott J, Attia Z, Ola O, Akula A, Mehta R, Dworak M, Lobo R, Hodge D, Tak T, Cagin C, Friedman P, Gulati R, Jaffe A, Sandoval Y. Artificial intelligence-enabled electrocardiographic algorithm for the detection of left ventricular dysfunction in emergency department patients undergoing high-sensitivity cardiac troponin T. Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehac544.1330] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Background
Artificial intelligence-augmented electrocardiogram (AI-ECG) algorithms have been developed from the standard 12-lead ECG and validated for the recognition of left ventricular systolic dysfunction (LVSD), defined as LV ejection fraction (LVEF)≤35%. Whether AI-ECG facilitates identification of LVSD and is associated with adverse outcomes in emergency department (ED) patients undergoing high-sensitivity cardiac troponin (hs-cTnT) testing is uncertain.
Purpose
To investigate the diagnostic and prognostic performance of AI-ECG in ED patients undergoing hs-cTnT measurement.
Methods
Observational US cohort study of ED patients undergoing hs-cTnT measurement. Cases with hs-cTnT increases >sex-specific 99th percentiles were adjudicated following the Fourth Universal Definition of Myocardial Infarction (MI). Post-discharge major adverse cardiac events (MACE) included death, MI, heart failure (HF) hospitalization, stroke or transient ischemic attack, and new onset atrial fibrillation/flutter during 2-years follow-up. The AI-ECG network output, which is a continuous number between 0–1, that provides a probability of LVSD, was obtained for each patient from the first ECG during the index presentation. An AI-ECG threshold of ≥0.256 indicates a positive screen that correlates with a high probability of LVSD.
Results
Among 1977 patients, 1729 (87%) had a negative AI-ECG screen, while 248 (13%) had a positive AI-ECG screen. Patients with a positive AI-ECG screen were older and had more comorbidities. As compared to patients with hs-cTnT≤99th percentile in whom AI-ECG was positive in 5.8%, those with hs-cTnT>99th percentile had a positive AI-ECG in 22% of cases (p<0.0001). Based on adjudicated diagnoses, the frequency of a positive AI-ECG was 20% in myocardial injury, 38% in type 1 MI, and 20% in type 2 MI. At 2-years follow-up, as compared to patients with a negative AI-ECG, those with a positive AI-ECG had a higher risk for MACE (48% vs. 21%, p<0.0001, adjusted HR 1.39, 95% CI 1.11–1.75) (Figure 1), mainly because of more deaths (43% vs. 30%, p=0.004) and HF hospitalizations (36% vs. 13%, p<0.0001). A positive AI-ECG was associated with a higher risk for MACE (60% vs. 41%, p<0.0001, adjusted HR 1.30, 95% CI 1.02–1.64) in those with hs-cTnT increases >99th percentile, but not in those without hs-cTnT increases. Among patients with an echocardiogram during index presentation or within 30-days (n=452), the diagnostic accuracy of AI-ECG for LVEF ≤35% was 81.4% (95% CI 77.5, 84.9) with a negative predictive value of 96.5% (95% CI 94.0, 98.2). A normal LVEF (>50%) was observed in 87% of those with a negative AI ECG, whereas in those with a positive AI-ECG LVEF was reduced (<50%) in 60%.
Conclusions
Among ED patients evaluated with hs-cTnT, a positive AI-ECG screen for LVSD identifies patients at high risk of MACE. These findings are largely because of more deaths and HF hospitalizations in those with hs-cTnT increases >sex-specific 99th percentiles.
Funding Acknowledgement
Type of funding sources: None.
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Affiliation(s)
| | - J Knott
- Mayo Clinic , Rochester , United States of America
| | - Z Attia
- Mayo Clinic , Rochester , United States of America
| | - O Ola
- Franciscan Skemp Healthcare Mayo Health System , La Crosse , United States of America
| | - A Akula
- Franciscan Skemp Healthcare Mayo Health System , La Crosse , United States of America
| | - R Mehta
- Mayo Clinic , Rochester , United States of America
| | - M Dworak
- Franciscan Skemp Healthcare Mayo Health System , La Crosse , United States of America
| | - R Lobo
- Mayo Clinic , Rochester , United States of America
| | - D Hodge
- Mayo Clinic , Jacksonville , United States of America
| | - T Tak
- Franciscan Skemp Healthcare Mayo Health System , La Crosse , United States of America
| | - C Cagin
- Franciscan Skemp Healthcare Mayo Health System , La Crosse , United States of America
| | - P Friedman
- Mayo Clinic , Rochester , United States of America
| | - R Gulati
- Mayo Clinic , Rochester , United States of America
| | - A Jaffe
- Mayo Clinic , Rochester , United States of America
| | - Y Sandoval
- Mayo Clinic , Rochester , United States of America
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22
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Naser J, Gochanour BR, Scott CG, Luis SA, Greason KL, Crestanello JA, Gulati R, Eleid MF, Nkomo VT, Pislaru SV. The use of warfarin as part of antithrombotic strategy after transcutaneous aortic valve replacement is not associated with better medium-term outcomes. Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehac544.2705] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background
Bioprosthetic valve thrombosis is currently a well-recognized cause of bioprosthetic valve dysfunction. It was found to be associated with accelerated degeneration of the bioprosthesis with higher rates of valve re-replacement, even after treatment with anticoagulation. We hypothesized that the use of warfarin for three months after transcatheter aortic valve replacement (TAVR) protects against accelerated valve degeneration and is therefore associated with better outcomes compared to dual antiplatelet therapy (DAPT).
Methods
Consecutive adult patients who underwent TAVR in our clinic between 2012 and 2019 were identified retrospectively. Patients with atrial fibrillation were excluded. Subsequently, patients who received DAPT were propensity matched to up to 2 patients who received three months of warfarin as part of their anti-thrombotic regimen. Matching was performed for variables that were significantly different at baseline between the two groups and included diabetes mellitus, prior myocardial infarctions, chronic lung disease, peripheral arterial disease, hemoglobin at time of TAVR, kidney function [creatinine>2], use of angiotensin-converting enzyme inhibitors / angiotensin II receptor blockers, beta blockers, the Society of Thoracic Surgeons (STS) score [STS ≥8, STS 4–8, STS<4], and valve size. The two groups were then compared for outcomes of ischemic stroke, death, valve re-replacement/intervention, the composite endpoint of the aforementioned three outcomes, as well as the three-month outcome of hemorrhagic strokes. Kaplan Meier was used for outcome analysis, and discharge date was considered time zero. Patients who had their anti-thrombotic therapy interrupted were censored at that time point.
Results
A total of 1,373 patients who underwent TAVR were identified. Of these, 576 patients with atrial fibrillation were excluded. Baseline characteristics were compared between 633 patients who received three months of warfarin and 164 patients who received DAPT after TAVR. After matching the two groups, 435 patients were included in the final analysis [warfarin in 281, DAPT in 154; median time to last follow up 2.61 years], Table 1. There was no difference in matched (Figure 1) or unmatched analysis (not shown) in outcomes of ischemic stroke, death, valve re-replacement/intervention, their composite endpoint, or hemorrhagic strokes (p>0.05 for all).
Conclusion
Antithrombotic regimen including three months of warfarin after TAVR was not associated with better outcomes of ischemic strokes, deaths, and valve re-replacement/intervention or with increased risk of hemorrhagic strokes compared to DAPT.
Funding Acknowledgement
Type of funding sources: None.
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Affiliation(s)
- J Naser
- Mayo Clinic , Rochester , United States of America
| | | | - C G Scott
- Mayo Clinic , Rochester , United States of America
| | - S A Luis
- Mayo Clinic , Rochester , United States of America
| | - K L Greason
- Mayo Clinic , Rochester , United States of America
| | | | - R Gulati
- Mayo Clinic , Rochester , United States of America
| | - M F Eleid
- Mayo Clinic , Rochester , United States of America
| | - V T Nkomo
- Mayo Clinic , Rochester , United States of America
| | - S V Pislaru
- Mayo Clinic , Rochester , United States of America
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23
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Owens L, Gulati R, Etzioni R. Stage Shift as an Endpoint in Cancer Screening Trials: Implications for Evaluating Multicancer Early Detection Tests. Cancer Epidemiol Biomarkers Prev 2022; 31:1298-1304. [PMID: 35477176 PMCID: PMC9250620 DOI: 10.1158/1055-9965.epi-22-0024] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Revised: 03/30/2022] [Accepted: 04/14/2022] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND Disease-specific mortality is a consensus endpoint in cancer screening trials. New liquid biopsy-based screening tests, including multi-cancer early detection (MCED) tests, are creating a need to reduce the typically lengthy screening trial process. Endpoints based on the reduction in late-stage disease (stage shift) have been proposed but it is unclear how well they predict the impact of screening on disease-specific mortality across a variety of cancers potentially detectable by MCED tests. METHODS We develop a mathematical formulation relating the reduction in late-stage cancer to the expected reduction in disease-specific mortality if cases diagnosed early via screening receive a corresponding shift in mortality. We investigate the similarity between the expected mortality reduction and the observed mortality reduction in published trials of screening for breast, lung, ovarian, and prostate cancer. RESULTS The expected mortality reduction for a given stage shift varies significantly depending on cancer- and stage-specific survival distributions, with some cancer types showing little possibility for mortality improvement even under substantial stage shift. The expected mortality reduction fails to consistently match the mortality outcomes of published trials. CONCLUSIONS In MCED, any mortality benefit is likely to vary substantially across target cancers. Stage shift does not appear to be a reliable basis for inference about mortality reduction across cancers potentially detectable by MCED tests. IMPACT Stage shift may be an appealing endpoint for evaluation of cancer screening tests but it appears to be an unreliable predictor of mortality benefit; furthermore, the same stage shift can mean different things for different cancers.
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Affiliation(s)
- Lukas Owens
- Program in Biostatistics, Division of Public Health Sciences, Fred Hutchinson Cancer Research Center
| | - Roman Gulati
- Program in Biostatistics, Division of Public Health Sciences, Fred Hutchinson Cancer Research Center
| | - Ruth Etzioni
- Program in Biostatistics, Division of Public Health Sciences, Fred Hutchinson Cancer Research Center
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Kouli O, Murray V, Bhatia S, Cambridge WA, Kawka M, Shafi S, Knight SR, Kamarajah SK, McLean KA, Glasbey JC, Khaw RA, Ahmed W, Akhbari M, Baker D, Borakati A, Mills E, Thavayogan R, Yasin I, Raubenheimer K, Ridley W, Sarrami M, Zhang G, Egoroff N, Pockney P, Richards T, Bhangu A, Creagh-Brown B, Edwards M, Harrison EM, Lee M, Nepogodiev D, Pinkney T, Pearse R, Smart N, Vohra R, Sohrabi C, Jamieson A, Nguyen M, Rahman A, English C, Tincknell L, Kakodkar P, Kwek I, Punjabi N, Burns J, Varghese S, Erotocritou M, McGuckin S, Vayalapra S, Dominguez E, Moneim J, Salehi M, Tan HL, Yoong A, Zhu L, Seale B, Nowinka Z, Patel N, Chrisp B, Harris J, Maleyko I, Muneeb F, Gough M, James CE, Skan O, Chowdhury A, Rebuffa N, Khan H, Down B, Fatimah Hussain Q, Adams M, Bailey A, Cullen G, Fu YXJ, McClement B, Taylor A, Aitken S, Bachelet B, Brousse de Gersigny J, Chang C, Khehra B, Lahoud N, Lee Solano M, Louca M, Rozenbroek P, Rozitis E, Agbinya N, Anderson E, Arwi G, Barry I, Batchelor C, Chong T, Choo LY, Clark L, Daniels M, Goh J, Handa A, Hanna J, Huynh L, Jeon A, Kanbour A, Lee A, Lee J, Lee T, Leigh J, Ly D, McGregor F, Moss J, Nejatian M, O'Loughlin E, Ramos I, Sanchez B, Shrivathsa A, Sincari A, Sobhi S, Swart R, Trimboli J, Wignall P, Bourke E, Chong A, Clayton S, Dawson A, Hardy E, Iqbal R, Le L, Mao S, Marinelli I, Metcalfe H, Panicker D, R HH, Ridgway S, Tan HH, Thong S, Van M, Woon S, Woon-Shoo-Tong XS, Yu S, Ali K, Chee J, Chiu C, Chow YW, Duller A, Nagappan P, Ng S, Selvanathan M, Sheridan C, Temple M, Do JE, Dudi-Venkata NN, Humphries E, Li L, Mansour LT, Massy-Westropp C, Fang B, Farbood K, Hong H, Huang Y, Joan M, Koh C, Liu YHA, Mahajan T, Muller E, Park R, Tanudisastro M, Wu JJG, Chopra P, Giang S, Radcliffe S, Thach P, Wallace D, Wilkes A, Chinta SH, Li J, Phan J, Rahman F, Segaran A, Shannon J, Zhang M, Adams N, Bonte A, Choudhry A, Colterjohn N, Croyle JA, Donohue J, Feighery A, Keane A, McNamara D, Munir K, Roche D, Sabnani R, Seligman D, Sharma S, Stickney Z, Suchy H, Tan R, Yordi S, Ahmed I, Aranha M, El Sabawy D, Garwood P, Harnett M, Holohan R, Howard R, Kayyal Y, Krakoski N, Lupo M, McGilberry W, Nepon H, Scoleri Y, Urbina C, Ahmad Fuad MF, Ahmed O, Jaswantlal D, Kelly E, Khan MHT, Naidu D, Neo WX, O'Neill R, Sugrue M, Abbas JD, Abdul-Fattah S, Azlan A, Barry K, Idris NS, Kaka N, Mc Dermott D, Mohammad Nasir MN, Mozo M, Rehal A, Shaikh Yousef M, Wong RH, Curran E, Gardner M, Hogan A, Julka R, Lasser G, Ní Chorráin N, Ting J, Browne R, George S, Janjua Z, Leung Shing V, Megally M, Murphy S, Ravenscroft L, Vedadi A, Vyas V, Bryan A, Sheikh A, Ubhi J, Vannelli K, Vawda A, Adeusi L, Doherty C, Fitzgerald C, Gallagher H, Gill P, Hamza H, Hogan M, Kelly S, Larry J, Lynch P, Mazeni NA, O'Connell R, O'Loghlin R, Singh K, Abbas Syed R, Ali A, Alkandari B, Arnold A, Arora E, Azam R, Breathnach C, Cheema J, Compton M, Curran S, Elliott JA, Jayasamraj O, Mohammed N, Noone A, Pal A, Pandey S, Quinn P, Sheridan R, Siew L, Tan EP, Tio SW, Toh VTR, Walsh M, Yap C, Yassa J, Young T, Agarwal N, Almoosawy SA, Bowen K, Bruce D, Connachan R, Cook A, Daniell A, Elliott M, Fung HKF, Irving A, Laurie S, Lee YJ, Lim ZX, Maddineni S, McClenaghan RE, Muthuganesan V, Ravichandran P, Roberts N, Shaji S, Solt S, Toshney E, Arnold C, Baker O, Belais F, Bojanic C, Byrne M, Chau CYC, De Soysa S, Eldridge M, Fairey M, Fearnhead N, Guéroult A, Ho JSY, Joshi K, Kadiyala N, Khalid S, Khan F, Kumar K, Lewis E, Magee J, Manetta-Jones D, Mann S, McKeown L, Mitrofan C, Mohamed T, Monnickendam A, Ng AYKC, Ortu A, Patel M, Pope T, Pressling S, Purohit K, Saji S, Shah Foridi J, Shah R, Siddiqui SS, Surman K, Utukuri M, Varghese A, Williams CYK, Yang JJ, Billson E, Cheah E, Holmes P, Hussain S, Murdock D, Nicholls A, Patel P, Ramana G, Saleki M, Spence H, Thomas D, Yu C, Abousamra M, Brown C, Conti I, Donnelly A, Durand M, French N, Goan R, O'Kane E, Rubinchik P, Gardiner H, Kempf B, Lai YL, Matthews H, Minford E, Rafferty C, Reid C, Sheridan N, Al Bahri T, Bhoombla N, Rao BM, Titu L, Chatha S, Field C, Gandhi T, Gulati R, Jha R, Jones Sam MT, Karim S, Patel R, Saunders M, Sharma K, Abid S, Heath E, Kurup D, Patel A, Ali M, Cresswell B, Felstead D, Jennings K, Kaluarachchi T, Lazzereschi L, Mayson H, Miah JE, Reinders B, Rosser A, Thomas C, Williams H, Al-Hamid Z, Alsadoun L, Chlubek M, Fernando P, Gaunt E, Gercek Y, Maniar R, Ma R, Matson M, Moore S, Morris A, Nagappan PG, Ratnayake M, Rockall L, Shallcross O, Sinha A, Tan KE, Virdee S, Wenlock R, Donnelly HA, Ghazal R, Hughes I, Liu X, McFadden M, Misbert E, Mogey P, O'Hara A, Peace C, Rainey C, Raja P, Salem M, Salmon J, Tan CH, Alves D, Bahl S, Baker C, Coulthurst J, Koysombat K, Linn T, Rai P, Sharma A, Shergill A, Ahmed M, Ahmed S, Belk LH, Choudhry H, Cummings D, Dixon Y, Dobinson C, Edwards J, Flint J, Franco Da Silva C, Gallie R, Gardener M, Glover T, Greasley M, Hatab A, Howells R, Hussey T, Khan A, Mann A, Morrison H, Ng A, Osmond R, Padmakumar N, Pervaiz F, Prince R, Qureshi A, Sawhney R, Sigurdson B, Stephenson L, Vora K, Zacken A, Cope P, Di Traglia R, Ferarrio I, Hackett N, Healicon R, Horseman L, Lam LI, Meerdink M, Menham D, Murphy R, Nimmo I, Ramaesh A, Rees J, Soame R, Dilaver N, Adebambo D, Brown E, Burt J, Foster K, Kaliyappan L, Knight P, Politis A, Richardson E, Townsend J, Abdi M, Ball M, Easby S, Gill N, Ho E, Iqbal H, Matthews M, Nubi S, Nwokocha JO, Okafor I, Perry G, Sinartio B, Vanukuru N, Walkley D, Welch T, Yates J, Yeshitila N, Bryans K, Campbell B, Gray C, Keys R, Macartney M, Chamberlain G, Khatri A, Kucheria A, Lee STP, Reese G, Roy choudhury J, Tan WYR, Teh JJ, Ting A, Kazi S, Kontovounisios C, Vutipongsatorn K, Amarnath T, Balasubramanian N, Bassett E, Gurung P, Lim J, Panjikkaran A, Sanalla A, Alkoot M, Bacigalupo V, Eardley N, Horton M, Hurry A, Isti C, Maskell P, Nursiah K, Punn G, Salih H, Epanomeritakis E, Foulkes A, Henderson R, Johnston E, McCullough H, McLarnon M, Morrison E, Cheung A, Cho SH, Eriksson F, Hedges J, Low Z, May C, Musto L, Nagi S, Nur S, Salau E, Shabbir S, Thomas MC, Uthayanan L, Vig S, Zaheer M, Zeng G, Ashcroft-Quinn S, Brown R, Hayes J, McConville R, French R, Gilliam A, Sheetal S, Shehzad MU, Bani W, Christie I, Franklyn J, Khan M, Russell J, Smolarek S, Varadarassou R, Ahmed SK, Narayanaswamy S, Sealy J, Shah M, Dodhia V, Manukyan A, O'Hare R, Orbell J, Chung I, Forenc K, Gupta A, Agarwal A, Al Dabbagh A, Bennewith R, Bottomley J, Chu TSM, Chu YYA, Doherty W, Evans B, Hainsworth P, Hosfield T, Li CH, McCullagh I, Mehta A, Thaker A, Thompson B, Virdi A, Walker H, Wilkins E, Dixon C, Hassan MR, Lotca N, Tong KS, Batchelor-Parry H, Chaudhari S, Harris T, Hooper J, Johnson C, Mulvihill C, Nayler J, Olutobi O, Piramanayagam B, Stones K, Sussman M, Weaver C, Alam F, Al Rawi M, Andrew F, Arrayeh A, Azizan N, Hassan A, Iqbal Z, John I, Jones M, Kalake O, Keast M, Nicholas J, Patil A, Powell K, Roberts P, Sabri A, Segue AK, Shah A, Shaik Mohamed SA, Shehadeh A, Shenoy S, Tong A, Upcott M, Vijayasingam D, Anarfi S, Dauncey J, Devindaran A, Havalda P, Komninos G, Mwendwa E, Norman C, Richards J, Urquhart A, Allan J, Cahya E, Hunt H, McWhirter C, Norton R, Roxburgh C, Tan JY, Ali Butt S, Hansdot S, Haq I, Mootien A, Sanchez I, Vainas T, Deliyannis E, Tan M, Vipond M, Chittoor Satish NN, Dattani A, De Carvalho L, Gaston-Grubb M, Karunanithy L, Lowe B, Pace C, Raju K, Roope J, Taylor C, Youssef H, Munro T, Thorn C, Wong KHF, Yunus A, Chawla S, Datta A, Dinesh AA, Field D, Georgi T, Gwozdz A, Hamstead E, Howard N, Isleyen N, Jackson N, Kingdon J, Sagoo KS, Schizas A, Yin L, Aung E, Aung YY, Franklin S, Han SM, Kim WC, Martin Segura A, Rossi M, Ross T, Tirimanna R, Wang B, Zakieh O, Ben-Arzi H, Flach A, Jackson E, Magers S, Olu abara C, Rogers E, Sugden K, Tan H, Veliah S, Walton U, Asif A, Bharwada Y, Bowley D, Broekhuizen A, Cooper L, Evans N, Girdlestone H, Ling C, Mann H, Mehmood N, Mulvenna CL, Rainer N, Trout I, Gujjuri R, Jeyaraman D, Leong E, Singh D, Smith E, Anderton J, Barabas M, Goyal S, Howard D, Joshi A, Mitchell D, Weatherby T, Badminton R, Bird R, Burtle D, Choi NY, Devalia K, Farr E, Fischer F, Fish J, Gunn F, Jacobs D, Johnston P, Kalakoutas A, Lau E, Loo YNAF, Louden H, Makariou N, Mohammadi K, Nayab Y, Ruhomaun S, Ryliskyte R, Saeed M, Shinde P, Sudul M, Theodoropoulou K, Valadao-Spoorenberg J, Vlachou F, Arshad SR, Janmohamed AM, Noor M, Oyerinde O, Saha A, Syed Y, Watkinson W, Ahmadi H, Akintunde A, Alsaady A, Bradley J, Brothwood D, Burton M, Higgs M, Hoyle C, Katsura C, Lathan R, Louani A, Mandalia R, Prihartadi AS, Qaddoura B, Sandland-Taylor L, Thadani S, Thompson A, Walshaw J, Teo S, Ali S, Bawa JH, Fox S, Gargan K, Haider SA, Hanna N, Hatoum A, Khan Z, Krzak AM, Li T, Pitt J, Tan GJS, Ullah Z, Wilson E, Cleaver J, Colman J, Copeland L, Coulson A, Davis P, Faisal H, Hassan F, Hughes JT, Jabr Y, Mahmoud Ali F, Nahaboo Solim ZN, Sangheli A, Shaya S, Thompson R, Cornwall H, De Andres Crespo M, Fay E, Findlay J, Groves E, Jones O, Killen A, Millo J, Thomas S, Ward J, Wilkins M, Zaki F, Zilber E, Bhavra K, Bilolikar A, Charalambous M, Elawad A, Eleni A, Fawdon R, Gibbins A, Livingstone D, Mala D, Oke SE, Padmakumar D, Patsalides MA, Payne D, Ralphs C, Roney A, Sardar N, Stefanova K, Surti F, Timms R, Tosney G, Bannister J, Clement NS, Cullimore V, Kamal F, Lendor J, McKay J, Mcswiggan J, Minhas N, Seneviratne K, Simeen S, Valverde J, Watson N, Bloom I, Dinh TH, Hirniak J, Joseph R, Kansagra M, Lai CKN, Melamed N, Patel J, Randev J, Sedighi T, Shurovi B, Sodhi J, Vadgama N, Abdulla S, Adabavazeh B, Champion A, Chennupati R, Chu K, Devi S, Haji A, Schulz J, Testa F, Davies P, Gurung B, Howell S, Modi P, Pervaiz A, Zahid M, Abdolrazaghi S, Abi Aoun R, Anjum Z, Bawa G, Bhardwaj R, Brown S, Enver M, Gill D, Gopikrishna D, Gurung D, Kanwal A, Kaushal P, Khanna A, Lovell E, McEvoy C, Mirza M, Nabeel S, Naseem S, Pandya K, Perkins R, Pulakal R, Ray M, Reay C, Reilly S, Round A, Seehra J, Shakeel NM, Singh B, Vijay Sukhnani M, Brown L, Desai B, Elzanati H, Godhaniya J, Kavanagh E, Kent J, Kishor A, Liu A, Norwood M, Shaari N, Wood C, Wood M, Brown A, Chellapuri A, Ferriman A, Ghosh I, Kulkarni N, Noton T, Pinto A, Rajesh S, Varghese B, Wenban C, Aly R, Barciela C, Brookes T, Corrin E, Goldsworthy M, Mohamed Azhar MS, Moore J, Nakhuda S, Ng D, Pillay S, Port S, Abdullah M, Akinyemi J, Islam S, Kale A, Lewis A, Manjunath T, McCabe H, Misra S, Stubley T, Tam JP, Waraich N, Chaora T, Ford C, Osinkolu I, Pong G, Rai J, Risquet R, Ainsworth J, Ayandokun P, Barham E, Barrett G, Barry J, Bisson E, Bridges I, Burke D, Cann J, Cloney M, Coates S, Cripps P, Davies C, Francis N, Green S, Handley G, Hathaway D, Hurt L, Jenkins S, Johnston C, Khadka A, McGee U, Morris D, Murray R, Norbury C, Pierrepont Z, Richards C, Ross O, Ruddy A, Salmon C, Shield M, Soanes K, Spencer N, Taverner S, Williams C, Wills-Wood W, Woodward S, Chow J, Fan J, Guest O, Hunter I, Moon WY, Arthur-Quarm S, Edwards P, Hamlyn V, McEneaney L, N D G, Pranoy S, Ting M, Abada S, Alawattegama LH, Ashok A, Carey C, Gogna A, Haglund C, Hurley P, Leelo N, Liu B, Mannan F, Paramjothy K, Ramlogan K, Raymond-Hayling O, Shanmugarajah A, Solichan D, Wilkinson B, Ahmad NA, Allan D, Amin A, Bakina C, Burns F, Cameron F, Campbell A, Cavanagh S, Chan SMZ, Chapman S, Chong V, Edelsten E, Ekpete O, El Sheikh M, Ghose R, Hassane A, Henderson C, Hilton-Christie S, Husain M, Hussain H, Javid Z, Johnson-Ogbuneke J, Johnston A, Khalil M, Leung TCC, Makin I, Muralidharan V, Naeem M, Patil P, Ravichandran S, Saraeva D, Shankey-Smith W, Sharma N, Swan R, Waudby-West R, Wilkinson A, Wright K, Balasubramanian A, Bhatti S, Chalkley M, Chou WK, Dixon M, Evans L, Fisher K, Gandhi P, Ho S, Lau YB, Lowe S, Meechan C, Murali N, Musonda C, Njoku P, Ochieng L, Pervez MU, Seebah K, Shaikh I, Sikder MA, Vanker R, Alom J, Bajaj V, Coleman O, Finch G, Goss J, Jenkins C, Kontothanassis A, Liew MS, Ng K, Outram M, Shakeel MM, Tawn J, Zuhairy S, Chapple K, Cinnamond A, Coleman S, George HA, Goulder L, Hare N, Hawksley J, Kret A, Luesley A, Mecia L, Porter H, Puddy E, Richardson G, Sohail B, Srikaran V, Tadross D, Tobin J, Tokidis E, Young L, Ashdown T, Bratsos S, Koomson A, Kufuor A, Lim MQ, Shah S, Thorne EPC, Warusavitarne J, Xu S, Abigail S, Ahmed A, Ahmed J, Akmal A, Al-Khafaji M, Amini B, Arshad M, Bogie E, Brazkiewicz M, Carroll M, Chandegra A, Cirelli C, Deng A, Fairclough S, Fung YJ, Gornell C, Green RL, Green SV, Gulamhussein AHM, Isaac AG, Jan R, Jegatheeswaran L, Knee M, Kotecha J, Kotecha S, Maxwell-Armstrong C, McIntyre C, Mendis N, Naing TKP, Oberman J, Ong ZX, Ramalingam A, Saeed Adam A, Tan LL, Towell S, Yadav J, Anandampillai R, Chung S, Hounat A, Ibrahim B, Jeyakumar G, Khalil A, Khan UA, Nair G, Owusu-Ayim M, Wilson M, Kanani A, Kilkelly B, Ogunmwonyi I, Ong L, Samra B, Schomerus L, Shea J, Turner O, Yang Y, Amin M, Blott N, Clark A, Feather A, Forrest M, Hague S, Hamilton K, Higginbotham G, Hope E, Karimian S, Loveday K, Malik H, McKenna O, Noor A, Onsiong C, Patel B, Radcliffe N, Shah P, Tye L, Verma K, Walford R, Yusufi U, Zachariah M, Casey A, Doré C, Fludder V, Fortescue L, Kalapu SS, Karel E, Khera G, Smith C, Appleton B, Ashaye A, Boggon E, Evans A, Faris Mahmood H, Hinchcliffe Z, Marei O, Silva I, Spooner C, Thomas G, Timlin M, Wellington J, Yao SL, Abdelrazek M, Abdelrazik Y, Bee F, Joseph A, Mounce A, Parry G, Vignarajah N, Biddles D, Creissen A, Kolhe S, K T, Lea A, Ledda V, O'Loughlin P, Scanlon J, Shetty N, Weller C, Abdalla M, Adeoye A, Bhatti M, Chadda KR, Chu J, Elhakim H, Foster-Davies H, Rabie M, Tailor B, Webb S, Abdelrahim ASA, Choo SY, Jiwa A, Mangam S, Murray S, Shandramohan A, Aghanenu O, Budd W, Hayre J, Khanom S, Liew ZY, McKinney R, Moody N, Muhammad-Kamal H, Odogwu J, Patel D, Roy C, Sattar Z, Shahrokhi N, Sinha I, Thomson E, Wonga L, Bain J, Khan J, Ricardo D, Bevis R, Cherry C, Darkwa S, Drew W, Griffiths E, Konda N, Madani D, Mak JKC, Meda B, Odunukwe U, Preest G, Raheel F, Rajaseharan A, Ramgopal A, Risbrooke C, Selvaratnam K, Sethunath G, Tabassum R, Taylor J, Thakker A, Wijesingha N, Wybrew R, Yasin T, Ahmed Osman A, Alfadhel S, Carberry E, Chen JY, Drake I, Glen P, Jayasuriya N, Kawar L, Myatt R, Sinan LOH, Siu SSY, Tjen V, Adeboyejo O, Bacon H, Barnes R, Birnie C, D'Cunha Kamath A, Hughes E, Middleton S, Owen R, Schofield E, Short C, Smith R, Wang H, Willett M, Zimmerman M, Balfour J, Chadwick T, Coombe-Jones M, Do Le HP, Faulkner G, Hobson K, Shehata Z, Beattie M, Chmielewski G, Chong C, Donnelly B, Drusch B, Ellis J, Farrelly C, Feyi-Waboso J, Hibell I, Hoade L, Ho C, Jones H, Kodiatt B, Lidder P, Ni Cheallaigh L, Norman R, Patabendi I, Penfold H, Playfair M, Pomeroy S, Ralph C, Rottenburg H, Sebastian J, Sheehan M, Stanley V, Welchman J, Ajdarpasic D, Antypas A, Azouaghe O, Basi S, Bettoli G, Bhattarai S, Bommireddy L, Bourne K, Budding J, Cookey-Bresi R, Cummins T, Davies G, Fabelurin C, Gwilliam R, Hanley J, Hird A, Kruczynska A, Langhorne B, Lund J, Lutchman I, McGuinness R, Neary M, Pampapathi S, Pang E, Podbicanin S, Rai N, Redhouse White G, Sujith J, Thomas P, Walker I, Winterton R, Anderson P, Barrington M, Bhadra K, Clark G, Fowler G, Gibson C, Hudson S, Kaminskaite V, Lawday S, Longshaw A, MacKrill E, McLachlan F, Murdeshwar A, Nieuwoudt R, Parker P, Randall R, Rawlins E, Reeves SA, Rye D, Sirkis T, Sykes B, Ventress N, Wosinska N, Akram B, Burton L, Coombs A, Long R, Magowan D, Ong C, Sethi M, Williams G, Chan C, Chan LH, Fernando D, Gaba F, Khor Z, Les JW, Mak R, Moin S, Ng Kee Kwong KC, Paterson-Brown S, Tew YY, Bardon A, Burrell K, Coldwell C, Costa I, Dexter E, Hardy A, Khojani M, Mazurek J, Raymond T, Reddy V, Reynolds J, Soma A, Agiotakis S, Alsusa H, Desai N, Peristerakis I, Adcock A, Ayub H, Bennett T, Bibi F, Brenac S, Chapman T, Clarke G, Clark F, Galvin C, Gwyn-Jones A, Henry-Blake C, Kerner S, Kiandee M, Lovett A, Pilecka A, Ravindran R, Siddique H, Sikand T, Treadwell K, Akmal K, Apata A, Barton O, Broad G, Darling H, Dhuga Y, Emms L, Habib S, Jain R, Jeater J, Kan CYP, Kathiravelupillai A, Khatkar H, Kirmani S, Kulasabanathan K, Lacey H, Lal K, Manafa C, Mansoor M, McDonald S, Mittal A, Mustoe S, Nottrodt L, Oliver P, Papapetrou I, Pattinson F, Raja M, Reyhani H, Shahmiri A, Small O, Soni U, Aguirrezabala Armbruster B, Bunni J, Hakim MA, Hawkins-Hooker L, Howell KA, Hullait R, Jaskowska A, Ottewell L, Thomas-Jones I, Vasudev A, Clements B, Fenton J, Gill M, Haider S, Lim AJM, Maguire H, McMullan J, Nicoletti J, Samuel S, Unais MA, White N, Yao PC, Yow L, Boyle C, Brady R, Cheekoty P, Cheong J, Chew SJHL, Chow R, Ganewatta Kankanamge D, Mamer L, Mohammed B, Ng Chieng Hin J, Renji Chungath R, Royston A, Sharrad E, Sinclair R, Tingle S, Treherne K, Wyatt F, Maniarasu VS, Moug S, Appanna T, Bucknall T, Hussain F, Owen A, Parry M, Parry R, Sagua N, Spofforth K, Yuen ECT, Bosley N, Hardie W, Moore T, Regas C, Abdel-Khaleq S, Ali N, Bashiti H, Buxton-Hopley R, Constantinides M, D'Afflitto M, Deshpande A, Duque Golding J, Frisira E, Germani Batacchi M, Gomaa A, Hay D, Hutchison R, Iakovou A, Iakovou D, Ismail E, Jefferson S, Jones L, Khouli Y, Knowles C, Mason J, McCaughan R, Moffatt J, Morawala A, Nadir H, Neyroud F, Nikookam Y, Parmar A, Pinto L, Ramamoorthy R, Richards E, Thomson S, Trainer C, Valetopoulou A, Vassiliou A, Wantman A, Wilde S, Dickinson M, Rockall T, Senn D, Wcislo K, Zalmay P, Adelekan K, Allen K, Bajaj M, Gatumbu P, Hang S, Hashmi Y, Kaur T, Kawesha A, Kisiel A, Woodmass M, Adelowo T, Ahari D, Alhwaishel K, Atherton R, Clayton B, Cockroft A, Curtis Lopez C, Hilton M, Ismail N, Kouadria M, Lee L, MacConnachie A, Monks F, Mungroo S, Nikoletopoulou C, Pearce L, Sara X, Shahid A, Suresh G, Wilcha R, Atiyah A, Davies E, Dermanis A, Gibbons H, Hyde A, Lawson A, Lee C, Leung-Tack M, Li Saw Hee J, Mostafa O, Nair D, Pattani N, Plumbley-Jones J, Pufal K, Ramesh P, Sanghera J, Saram S, Scadding S, See S, Stringer H, Torrance A, Vardon H, Wyn-Griffiths F, Brew A, Kaur G, Soni D, Tickle A, Akbar Z, Appleyard T, Figg K, Jayawardena P, Johnson A, Kamran Siddiqui Z, Lacy-Colson J, Oatham R, Rowlands B, Sludden E, Turnbull C, Allin D, Ansar Z, Azeez Z, Dale VH, Garg J, Horner A, Jones S, Knight S, McGregor C, McKenna J, McLelland T, Packham-Smith A, Rowsell K, Spector-Hill I, Adeniken E, Baker J, Bartlett M, Chikomba L, Connell B, Deekonda P, Dhar M, Elmansouri A, Gamage K, Goodhew R, Hanna P, Knight J, Luca A, Maasoumi N, Mahamoud F, Manji S, Marwaha PK, Mason F, Oluboyede A, Pigott L, Razaq AM, Richardson M, Saddaoui I, Wijeyendram P, Yau S, Atkins W, Liang K, Miles N, Praveen B, Ashai S, Braganza J, Common J, Cundy A, Davies R, Guthrie J, Handa I, Iqbal M, Ismail R, Jones C, Jones I, Lee KS, Levene A, Okocha M, Olivier J, Smith A, Subramaniam E, Tandle S, Wang A, Watson A, Wilson C, Chan XHF, Khoo E, Montgomery C, Norris M, Pugalenthi PP, Common T, Cook E, Mistry H, Shinmar HS, Agarwal G, Bandyopadhyay S, Brazier B, Carroll L, Goede A, Harbourne A, Lakhani A, Lami M, Larwood J, Martin J, Merchant J, Pattenden S, Pradhan A, Raafat N, Rothwell E, Shammoon Y, Sudarshan R, Vickers E, Wingfield L, Ashworth I, Azizi S, Bhate R, Chowdhury T, Christou A, Davies L, Dwaraknath M, Farah Y, Garner J, Gureviciute E, Hart E, Jain A, Javid S, Kankam HK, Kaur Toor P, Kaz R, Kermali M, Khan I, Mattson A, McManus A, Murphy M, Nair K, Ngemoh D, Norton E, Olabiran A, Parry L, Payne T, Pillai K, Price S, Punjabi K, Raghunathan A, Ramwell A, Raza M, Ritehnia J, Simpson G, Smith W, Sodeinde S, Studd L, Subramaniam M, Thomas J, Towey S, Tsang E, Tuteja D, Vasani J, Vio M, Badran A, Adams J, Anthony Wilkinson J, Asvandi S, Austin T, Bald A, Bix E, Carrick M, Chander B, Chowdhury S, Cooper Drake B, Crosbie S, D Portela S, Francis D, Gallagher C, Gillespie R, Gravett H, Gupta P, Ilyas C, James G, Johny J, Jones A, Kinder F, MacLeod C, Macrow C, Maqsood-Shah A, Mather J, McCann L, McMahon R, Mitham E, Mohamed M, Munton E, Nightingale K, O'Neill K, Onyemuchara I, Senior R, Shanahan A, Sherlock J, Spyridoulias A, Stavrou C, Stokes D, Tamang R, Taylor E, Trafford C, Uden C, Waddington C, Yassin D, Zaman M, Bangi S, Cheng T, Chew D, Hussain N, Imani-Masouleh S, Mahasivam G, McKnight G, Ng HL, Ota HC, Pasha T, Ravindran W, Shah K, Vishnu K S, Zaman S, Carr W, Cope S, Eagles EJ, Howarth-Maddison M, Li CY, Reed J, Ridge A, Stubbs T, Teasdaled D, Umar R, Worthington J, Dhebri A, Kalenderov R, Alattas A, Arain Z, Bhudia R, Chia D, Daniel S, Dar T, Garland H, Girish M, Hampson A, Kyriacou H, Lehovsky K, Mullins W, Omorphos N, Vasdev N, Venkatesh A, Waldock W, Bhandari A, Brown G, Choa G, Eichenauer CE, Ezennia K, Kidwai Z, Lloyd-Thomas A, Macaskill Stewart A, Massardi C, Sinclair E, Skajaa N, Smith M, Tan I, Afsheen N, Anuar A, Azam Z, Bhatia P, Davies-kelly N, Dickinson S, Elkawafi M, Ganapathy M, Gupta S, Khoury EG, Licudi D, Mehta V, Neequaye S, Nita G, Tay VL, Zhao S, Botsa E, Cuthbert H, Elliott J, Furlepa M, Lehmann J, Mangtani A, Narayan A, Nazarian S, Parmar C, Shah D, Shaw C, Zhao Z, Beck C, Caldwell S, Clements JM, French B, Kenny R, Kirk S, Lindsay J, McClung A, McLaughlin N, Watson S, Whiteside E, Alyacoubi S, Arumugam V, Beg R, Dawas K, Garg S, Lloyd ER, Mahfouz Y, Manobharath N, Moonesinghe R, Morka N, Patel K, Prashar J, Yip S, Adeeko ES, Ajekigbe F, Bhat A, Evans C, Farrugia A, Gurung C, Long T, Malik B, Manirajan S, Newport D, Rayer J, Ridha A, Ross E, Saran T, Sinker A, Waruingi D, Allen R, Al Sadek Y, Alves do Canto Brum H, Asharaf H, Ashman M, Balakumar V, Barrington J, Baskaran R, Berry A, Bhachoo H, Bilal A, Boaden L, Chia WL, Covell G, Crook D, Dadnam F, Davis L, De Berker H, Doyle C, Fox C, Gruffydd-Davies M, Hafouda Y, Hill A, Hubbard E, Hunter A, Inpadhas V, Jamshaid M, Jandu G, Jeyanthi M, Jones T, Kantor C, Kwak SY, Malik N, Matt R, McNulty P, Miles C, Mohomed A, Myat P, Niharika J, Nixon A, O'Reilly D, Parmar K, Pengelly S, Price L, Ramsden M, Turnor R, Wales E, Waring H, Wu M, Yang T, Ye TTS, Zander A, Zeicu C, Bellam S, Francombe J, Kawamoto N, Rahman MR, Sathyanarayana A, Tang HT, Cheung J, Hollingshead J, Page V, Sugarman J, Wong E, Chiong J, Fung E, Kan SY, Kiang J, Kok J, Krahelski O, Liew MY, Lyell B, Sharif Z, Speake D, Alim L, Amakye NY, Chandrasekaran J, Chandratreya N, Drake J, Owoso T, Thu YM, Abou El Ela Bourquin B, Alberts J, Chapman D, Rehnnuma N, Ainsworth K, Carpenter H, Emmanuel T, Fisher T, Gabrel M, Guan Z, Hollows S, Hotouras A, Ip Fung Chun N, Jaffer S, Kallikas G, Kennedy N, Lewinsohn B, Liu FY, Mohammed S, Rutherfurd A, Situ T, Stammer A, Taylor F, Thin N, Urgesi E, Zhang N, Ahmad MA, Bishop A, Bowes A, Dixit A, Glasson R, Hatta S, Hatt K, Larcombe S, Preece J, Riordan E, Fegredo D, Haq MZ, Li C, McCann G, Stewart D, Baraza W, Bhullar D, Burt G, Coyle J, Deans J, Devine A, Hird R, Ikotun O, Manchip G, Ross C, Storey L, Tan WWL, Tse C, Warner C, Whitehead M, Wu F, Court EL, Crisp E, Huttman M, Mayes F, Robertson H, Rosen H, Sandberg C, Smith H, Al Bakry M, Ashwell W, Bajaj S, Bandyopadhyay D, Browlee O, Burway S, Chand CP, Elsayeh K, Elsharkawi A, Evans E, Ferrin S, Fort-Schaale A, Iacob M, I K, Impelliziere Licastro G, Mankoo AS, Olaniyan T, Otun J, Pereira R, Reddy R, Saeed D, Simmonds O, Singhal G, Tron K, Wickstone C, Williams R, Bradshaw E, De Kock Jewell V, Houlden C, Knight C, Metezai H, Mirza-Davies A, Seymour Z, Spink D, Wischhusen S. Evaluation of prognostic risk models for postoperative pulmonary complications in adult patients undergoing major abdominal surgery: a systematic review and international external validation cohort study. Lancet Digit Health 2022; 4:e520-e531. [PMID: 35750401 DOI: 10.1016/s2589-7500(22)00069-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2021] [Revised: 01/07/2022] [Accepted: 04/06/2022] [Indexed: 06/15/2023]
Abstract
BACKGROUND Stratifying risk of postoperative pulmonary complications after major abdominal surgery allows clinicians to modify risk through targeted interventions and enhanced monitoring. In this study, we aimed to identify and validate prognostic models against a new consensus definition of postoperative pulmonary complications. METHODS We did a systematic review and international external validation cohort study. The systematic review was done in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We searched MEDLINE and Embase on March 1, 2020, for articles published in English that reported on risk prediction models for postoperative pulmonary complications following abdominal surgery. External validation of existing models was done within a prospective international cohort study of adult patients (≥18 years) undergoing major abdominal surgery. Data were collected between Jan 1, 2019, and April 30, 2019, in the UK, Ireland, and Australia. Discriminative ability and prognostic accuracy summary statistics were compared between models for the 30-day postoperative pulmonary complication rate as defined by the Standardised Endpoints in Perioperative Medicine Core Outcome Measures in Perioperative and Anaesthetic Care (StEP-COMPAC). Model performance was compared using the area under the receiver operating characteristic curve (AUROCC). FINDINGS In total, we identified 2903 records from our literature search; of which, 2514 (86·6%) unique records were screened, 121 (4·8%) of 2514 full texts were assessed for eligibility, and 29 unique prognostic models were identified. Nine (31·0%) of 29 models had score development reported only, 19 (65·5%) had undergone internal validation, and only four (13·8%) had been externally validated. Data to validate six eligible models were collected in the international external validation cohort study. Data from 11 591 patients were available, with an overall postoperative pulmonary complication rate of 7·8% (n=903). None of the six models showed good discrimination (defined as AUROCC ≥0·70) for identifying postoperative pulmonary complications, with the Assess Respiratory Risk in Surgical Patients in Catalonia score showing the best discrimination (AUROCC 0·700 [95% CI 0·683-0·717]). INTERPRETATION In the pre-COVID-19 pandemic data, variability in the risk of pulmonary complications (StEP-COMPAC definition) following major abdominal surgery was poorly described by existing prognostication tools. To improve surgical safety during the COVID-19 pandemic recovery and beyond, novel risk stratification tools are required. FUNDING British Journal of Surgery Society.
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Sokolova A, Gulati R, Cheng HH, Beer TM, Graff JN, Amador M, Toulouse A, Taylor K, Bailey S, Smith S, Tabatabaei S, Sinit R, Slottke R, Vuky J, Yezefski T, Grivas P, Yu EY, Schweizer MT. Trial in progress: Durvalumab and olaparib for the treatment of prostate cancer in men predicted to have a high neoantigen load. J Clin Oncol 2022. [DOI: 10.1200/jco.2022.40.16_suppl.tps5099] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
TPS5099 Background: Approximately 30% of patients (pts) treated with definitive surgical and/or radiation therapy for localized prostate adenocarcinoma develop biochemical recurrence (BCR). The optimal time to initiate androgen deprivation therapy (ADT) for such patients is controversial and depends on patient and provider preference, absolute PSA value, and PSA doubling time (PSADT), which has been associated with time to metastasis. Because the time from BCR to metastasis can be long in many cases, strategies allowing pts to avoid ADT while extending metastasis-free survival are desirable. Prior studies have shown that a high tumor neoantigen load correlates with response to anti-PD(L)1. We hypothesized that PARP inhibitor-induced genomic instability may sensitize tumors to anti-PD(L)1 through: i) increasing mutational burden and subsequent tumor neoantigen formation, and/or ii) through activation of other immunogenic pathways (e.g. the STING pathway). This trial investigates an ADT-sparing approach for men predicted to have high neoantigen load and who have BCR prostate cancer. Methods: This is a phase 2 clinical trial testing durvalumab (1500 mg IV every 4 weeks) and olaparib (300 mg PO twice a day) (one cycle = 4 weeks) in men with BCR (PSADT≤10 months) whose tumors are predicted to have high neoantigen load based on: biallelic CDK12 mutations (Cohort A), mismatch repair deficiency (MMRd)/high microsatellite instability (MSI-H) (Cohort B), or loss of function mutations in homologous recombination repair (HRR) genes (Cohort C). Cohorts A and B will receive 3 cycles of durvalumab followed by 3 cycles of the combination of durvalumab and olaparib. Given the proven efficacy of olaparib in prostate cancer patient whose tumors posses an HRR gene mutation, Cohort C will receive 6 full cycles of the combination. Ten patients will be enrolled in each cohort (total n = 30) at two collaborating sites. This study was designed to provide preliminary efficacy data across eligible cohorts, with a primary objective of estimating the proportion of pts with an undetectable PSA at 12 months within each cohort. Secondary objectives include safety, proportion of patients with ≥50% decline in PSA from baseline and quality of life measures. Correlative studies will assess blood and tissue molecular biomarkers for association with outcomes. The study is open with two patients enrolled at the time of abstract submission. Clinical trial information: NCT04336943.
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Affiliation(s)
- Alexandra Sokolova
- Oregon Health and Science University Knight Cancer Institute, Portland, OR
| | - Roman Gulati
- Fred Hutchinson Cancer Research Center, Seattle, WA
| | | | - Tomasz M. Beer
- Knight Cancer Institute, Oregon Health & Science University, Portland, OR
| | - Julie N Graff
- VA Portland Health Care System, Portland and Knight Cancer Institute, Oregon Health & Science University, Portland, OR
| | | | | | | | | | - Steven Smith
- Oregon Health & Science University, Portland, OR
| | | | - Ryan Sinit
- Oregon Health & Science University, Portland, OR
| | | | | | | | - Petros Grivas
- University of Washington and Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Evan Y. Yu
- Fred Hutchinson Cancer Research Center and Department of Medicine, Division of Medical Oncology, University of Washington, Seattle, WA
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Basourakos SP, Gulati R, Vince RA, Spratt DE, Lewicki PJ, Hill A, Nyame YA, Cullen J, Markt SC, Barbieri CE, Hu JC, Trapl E, Shoag JE. Harm-to-Benefit of Three Decades of Prostate Cancer Screening in Black Men. NEJM Evid 2022; 1. [PMID: 35721307 PMCID: PMC9202998 DOI: 10.1056/evidoa2200031] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Prostate-specific antigen screening has profoundly affected the epidemiology of prostate cancer in the United States. Persistent racial disparities in outcomes for Black men warrant re-examination of the harms of screening relative to its cancer-specific mortality benefits in this population. METHODS We estimated overdiagnoses and overtreatment of prostate cancer for men of all races and for Black men 50 to 84 years of age until 2016, the most recent year with treatment data available, using excess incidence relative to 1986 based on the Surveillance, Epidemiology, and End Results registry and U.S. Census data as well as an established microsimulation model of prostate cancer natural history. Combining estimates with plausible mortality benefit, we calculated numbers needed to diagnose (NND) and treat (NNT) to prevent one prostate cancer death. RESULTS For men of all races, we estimated 1.5 to 1.9 million (range between estimation approaches) overdiagnosed and 0.9 to 1.5 million overtreated prostate cancers by 2016. Assuming that half of the 270,000 prostate cancer deaths avoided by 2016 were attributable to screening, the NND and the NNT would be 11 to 14 and 7 to 11 for men of all races and 8 to 12 and 5 to 9 for Black men, respectively. Alternative estimates incorporating a lag between incidence and mortality resulted in a NND and a NNT for Black men that reached well into the low single digits. CONCLUSIONS Complementary approaches to quantifying overdiagnosis indicate a harm-benefit tradeoff of prostate-specific antigen screening that is more favorable for Black men than for men of all races considered together. Our findings highlight the need to account for the increased value of screening in Black men in clinical guidelines. (Funded by the Patient-Centered Outcomes Research Institute, the National Cancer Institute, the Bristol Myers Squibb Foundation, and the Damon Runyon Cancer Research Foundation.).
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Affiliation(s)
- Spyridon P Basourakos
- Department of Urology, New York-Presbyterian Hospital, Weill Cornell Medical Center, New York
| | - Roman Gulati
- Division of Public Health Sciences, Fred Hutchinson Cancer Research Center, Seattle
| | - Randy A Vince
- Department of Urology, University of Michigan, Ann Arbor
| | - Daniel E Spratt
- Department of Radiation Oncology, University Hospitals Seidman Cancer Center, Cleveland.,Case Comprehensive Cancer Center, Case Western Reserve University, Cleveland
| | - Patrick J Lewicki
- Department of Urology, New York-Presbyterian Hospital, Weill Cornell Medical Center, New York
| | - Alexander Hill
- Department of Urology, University Hospitals Cleveland Medical Center, Case Western Reserve University School of Medicine, Cleveland
| | - Yaw A Nyame
- Department of Urology, University of Washington, Seattle
| | - Jennifer Cullen
- Case Comprehensive Cancer Center, Case Western Reserve University, Cleveland.,Department of Population and Quantitative Health Sciences, Case Western Reserve University School of Medicine, Cleveland
| | - Sarah C Markt
- Case Comprehensive Cancer Center, Case Western Reserve University, Cleveland.,Department of Population and Quantitative Health Sciences, Case Western Reserve University School of Medicine, Cleveland
| | - Christopher E Barbieri
- Department of Urology, New York-Presbyterian Hospital, Weill Cornell Medical Center, New York
| | - Jim C Hu
- Department of Urology, New York-Presbyterian Hospital, Weill Cornell Medical Center, New York
| | - Erika Trapl
- Case Comprehensive Cancer Center, Case Western Reserve University, Cleveland.,Department of Population and Quantitative Health Sciences, Case Western Reserve University School of Medicine, Cleveland
| | - Jonathan E Shoag
- Department of Urology, New York-Presbyterian Hospital, Weill Cornell Medical Center, New York.,Case Comprehensive Cancer Center, Case Western Reserve University, Cleveland.,Department of Urology, University Hospitals Cleveland Medical Center, Case Western Reserve University School of Medicine, Cleveland
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27
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Heijnsdijk EAM, Gulati R, Lange JM, Tsodikov A, Roberts R, Etzioni R. Evaluation of Prostate Cancer Screening Strategies in a Low-Resource, High-risk Population in the Bahamas. JAMA Health Forum 2022; 3:e221116. [PMID: 35977253 PMCID: PMC9123504 DOI: 10.1001/jamahealthforum.2022.1116] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Accepted: 03/29/2022] [Indexed: 12/29/2022] Open
Abstract
Importance The benefit of prostate-specific antigen screening may be greatest in high-risk populations, including men of African descent in the Caribbean. However, organized screening may not be sustainable in low- and middle-income countries. Objective To evaluate the expected population outcomes and resource use of conservative prostate-specific antigen screening programs in the Bahamas. Design Setting and Participants Prostate cancer incidence from GLOBOCAN and prostate-specific antigen screening data for 4300 men from the Bahamas were used to recalibrate 2 decision analytical models previously used to study prostate-specific antigen screening for Black men in the United States. Data on age and results obtained from prostate-specific antigen screening tests performed in Nassau from 2004 to 2018 and in Freeport from 2013 to 2018 were used. Data were analyzed from January 15, 2021, to March 23, 2022. Interventions One or 2 screenings for men aged 45 to 60 years and conservative criteria for biopsy (prostate-specific antigen level >10 ng/mL) and curative treatment (Gleason score ≥8) were modeled. Categories of Gleason scores were 6 or lower, 7, and 8 or higher, with higher scores indicating higher risk of cancer progression and death. Main Outcomes and Measures Projected numbers of tests and biopsies, prostate cancer (over)diagnoses, lives saved, and life-years gained owing to screening from 2022 to 2040. Results In this decision analytical modeling study, screening histories from 4300 men (median age, 54 years; range, 13-101 years) tested between 2004 and 2018 at 2 sites in the Bahamas were used to inform the models. Screening once at 60 years of age was projected to involve 40 000 to 42 000 tests (range between models) and prevent 500 to 600 of 10 000 to 14 000 prostate cancer deaths. Screening at 50 and 60 years doubled the number of tests but increased lives saved by only 15% to 16%. Among onetime strategies, screening once at 60 years of age involved the fewest tests per life saved (74-84 tests) and curative treatments per life saved (1.2-2.8 treatments). Conclusions and Relevance The findings of this decision analytical modeling study of prostate cancer screening in the Bahamas suggest that limited screening offered modest benefits that varied with screening ages and number of tests. The results can be combined with data on capacity constraints and evaluated relative to competing national public health priorities.
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Affiliation(s)
- Eveline A. M. Heijnsdijk
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Roman Gulati
- Division of Public Health Sciences, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Jane M. Lange
- Division of Public Health Sciences, Fred Hutchinson Cancer Research Center, Seattle, Washington
- Knight Cancer Institute, School of Medicine, Oregon Health & Science University, Portland
| | - Alex Tsodikov
- School of Public Health, University of Michigan, Ann Arbor
| | - Robin Roberts
- University of The West Indies School of Clinical Medicine and Research, Nassau, The Bahamas
| | - Ruth Etzioni
- Division of Public Health Sciences, Fred Hutchinson Cancer Research Center, Seattle, Washington
- Knight Cancer Institute, School of Medicine, Oregon Health & Science University, Portland
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28
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Maxwell KN, Cheng HH, Powers J, Gulati R, Ledet EM, Morrison C, Le A, Hausler R, Stopfer J, Hyman S, Kohlmann W, Naumer A, Vagher J, Greenberg S, Naylor L, Laurino M, Konnick EQ, Shirts BH, Al-Dubayan SH, Van Allen EM, Nguyen B, Vijai J, Abida W, Carlo M, Dubard-Gault M, Lee DJ, Maese LD, Mandelker D, Montgomery B, Morris MJ, Nicolosi P, Nussbaum RL, Schwartz LE, Stadler Z, Garber JE, Offit K, Schiffman JD, Nelson PS, Sartor O, Walsh MF, Pritchard CC. Inherited TP53 Variants and Risk of Prostate Cancer. Eur Urol 2022; 81:243-250. [PMID: 34863587 PMCID: PMC8891030 DOI: 10.1016/j.eururo.2021.10.036] [Citation(s) in RCA: 38] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2021] [Revised: 09/22/2021] [Accepted: 10/28/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND Inherited germline TP53 pathogenic and likely pathogenic variants (gTP53) cause autosomal dominant multicancer predisposition including Li-Fraumeni syndrome (LFS). However, there is no known association of prostate cancer with gTP53. OBJECTIVE To determine whether gTP53 predisposes to prostate cancer. DESIGN, SETTING, AND PARTICIPANTS This multi-institutional retrospective study characterizes prostate cancer incidence in a cohort of LFS males and gTP53 prevalence in a prostate cancer cohort. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS We evaluated the spectrum of gTP53 variants and clinical features associated with prostate cancer. RESULTS AND LIMITATIONS We identified 31 prostate cancer cases among 163 adult LFS males, including 26 of 54 aged ≥50 yr. Among 117 LFS males without prostate cancer at the time of genetic testing, six were diagnosed with prostate cancer over a median (interquartile range [IQR]) of 3.0 (1.3-7.2) yr of follow-up, a 25-fold increased risk (95% confidence interval [CI] 9.2-55; p < 0.0001). We identified gTP53 in 38 of 6850 males (0.6%) in the prostate cancer cohort, a relative risk 9.1-fold higher than that of population controls (95% CI 6.2-14; p < 0.0001; gnomAD). We observed hotspots at the sites of attenuated variants not associated with classic LFS. Two-thirds of available gTP53 prostate tumors had somatic inactivation of the second TP53 allele. Among gTP53 prostate cancer cases in this study, the median age at diagnosis was 56 (IQR: 51-62) yr, 44% had Gleason ≥8 tumors, and 29% had advanced disease at diagnosis. CONCLUSIONS Complementary analyses of prostate cancer incidence in LFS males and gTP53 prevalence in prostate cancer cohorts suggest that gTP53 predisposes to aggressive prostate cancer. Prostate cancer should be considered as part of LFS screening protocols and TP53 considered in germline prostate cancer susceptibility testing. PATIENT SUMMARY Inherited pathogenic variants in the TP53 gene are likely to predispose men to aggressive prostate cancer.
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Affiliation(s)
- Kara N. Maxwell
- Division of Hematology/Oncology, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA,Department of Genetics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Heather H. Cheng
- Division of Oncology, Department of Medicine, University of Washington, Seattle, WA, USA,Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Jacquelyn Powers
- Division of Hematology/Oncology, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Roman Gulati
- Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Elisa M. Ledet
- Tulane Cancer Center, Tulane Medical School, New Orleans, LA, USA
| | - Casey Morrison
- Department of Pathology and Laboratory Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Anh Le
- Division of Hematology/Oncology, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Ryan Hausler
- Division of Hematology/Oncology, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Jill Stopfer
- Division of Population Sciences, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Sophie Hyman
- Division of Population Sciences, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Wendy Kohlmann
- Huntsman Cancer Institute, University of Utah, Salt Lake City, UT, USA
| | - Anne Naumer
- Huntsman Cancer Institute, University of Utah, Salt Lake City, UT, USA
| | - Jennie Vagher
- Huntsman Cancer Institute, University of Utah, Salt Lake City, UT, USA
| | | | | | | | - Eric Q. Konnick
- Department of Laboratory Medicine and Pathology, University of Washington, Seattle, WA, USA
| | - Brian H. Shirts
- Department of Laboratory Medicine and Pathology, University of Washington, Seattle, WA, USA
| | - Saud H. Al-Dubayan
- Department of Medical Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, USA,Cancer Program, The Broad Institute of MIT and Harvard, Cambridge, MA, USA
| | - Eliezer M. Van Allen
- Department of Medical Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, USA,Cancer Program, The Broad Institute of MIT and Harvard, Cambridge, MA, USA
| | - Bastien Nguyen
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Joseph Vijai
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Wassim Abida
- Division of Solid Tumor Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Maria Carlo
- Division of Solid Tumor Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | | | - Daniel J. Lee
- Department of Surgery, Division of Urology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Luke D. Maese
- Huntsman Cancer Institute, University of Utah, Salt Lake City, UT, USA,Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Diana Mandelker
- Diagnostic Molecular Genetics Laboratory, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Bruce Montgomery
- Division of Oncology, Department of Medicine, University of Washington, Seattle, WA, USA,Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Michael J. Morris
- Division of Solid Tumor Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | | | | | - Lauren E. Schwartz
- Department of Pathology and Laboratory Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Zsofia Stadler
- Division of Solid Tumor Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Judy E. Garber
- Division of Population Sciences, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Kenneth Offit
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Joshua D. Schiffman
- Huntsman Cancer Institute, University of Utah, Salt Lake City, UT, USA,Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, UT, USA,PEEL Therapeutics, Inc., Salt Lake City, UT, USA
| | - Peter S. Nelson
- Fred Hutchinson Cancer Research Center, Seattle, WA, USA,Seattle Cancer Care Alliance, Seattle, WA, USA
| | - Oliver Sartor
- Tulane Cancer Center, Tulane Medical School, New Orleans, LA, USA
| | - Michael F. Walsh
- Division of Solid Tumor Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA,Department of Pediatrics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Colin C. Pritchard
- Department of Laboratory Medicine and Pathology, University of Washington, Seattle, WA, USA,Brotman Baty Institute for Precision Medicine, Seattle, WA, USA,Corresponding author. Department of Laboratory Medicine and Pathology, University of Washington, 1959 NE Pacific Street, Seattle, WA 98195, USA. Tel. +1 (206) 598-6131; Fax: 1 (206) 543-3644. (C.C. Pritchard)
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Schweizer MT, Gulati R, Liu Y, Hakansson AK, Davicioni E, True L, Ellis WJ, Schade G, Montgomery RB, Wadhera S, Nega K, Pienta KJ, Nelson P, Wright JL, Lin DW. Transcriptomic discriminators of response to apalutamide in patients with prostate cancer (PC) on active surveillance (AS). J Clin Oncol 2022. [DOI: 10.1200/jco.2022.40.6_suppl.267] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
267 Background: We previously reported the results of a Phase 2 study showing that a high proportion (59%) of men with PC being followed on AS will have a negative post-treatment biopsy after 90 days of apalutamide (Schweizer, et al. SUO Annual Meeting 2020). In order to identify candidate biomarkers for response, we conducted transcriptional profiling of tumor tissue obtained from men enrolled to the aforementioned trial. Methods: We analyzed FFPE tissue obtained from men enrolled to a Phase II study testing 90-days of apalutamide. Transcript profiles were assessed using Affymetrix Microarrays (Decipher Biosciences, Inc). Differences in signaling pathways were assessed between samples at baseline, day (D) 91 (post-treatment) and at D365. We also assessed differences in signaling pathways between patients that did vs. did not have a response (i.e. negative vs. persistent cancer on surveillance biopsy) at D91, which was the primary endpoint of the study. All comparisons were made using a Wilcoxon signed rank test unless otherwise indicated. Results: Samples from 22 subjects who completed 3-months of apalutamide and subsequently underwent post-treatment biopsy were available for analysis. From 19 Baseline and 15 post-treatment tissue samples, 25 passed pathology quality control (N = 12 at baseline, N = 8 at D91 and N = 5 at D365). Principal component analysis revealed distinct transcriptional profiles between tumor samples analyzed at baseline vs. D91. Surprisingly, D365 specimens still demonstrated a distinct profile compared to both baseline and D91 samples. Pathway analysis revealed up-regulation of angiogenesis signaling at D91 (P < 0.01) and D365 (P = 0.03) compared to baseline. As expected, estrogen (P < 0.01) and androgen receptor (P = 0.02) signaling were significantly lower at D91; however, only estrogen signaling was persistently suppressed at D365 (P = 0.03). Basal pathway signatures and markers associated with inflammatory response were also significantly upregulated at D91. There were no significant differences in Gleason grade group (GG) between responders and non-responders: 8/15 (53%) with GG1 vs. 5/7 (71%) with GG2 (Fisher’s exact P = 0.648). Decipher (P = 0.01) and Cuzick (P = 0.03) risk classifiers revealed an enrichment for responses in those with higher risk disease at baseline. There was also an enrichment for responses in those with higher nucleotide excision repair signature (P = 0.03) and those with signatures associated with TP53 mutations (P = 0.02). Conclusions: We observed significant transcriptional changes following 90 days of apalutamide, with evidence of persistent differences up to one year after enrollment. Higher baseline risk score was associated with improved responses to apalutamide treatment. Prospective studies evaluating the benefit of apalutamide in men on AS with higher risk transcriptional profiles are warranted. Clinical trial information: NCT02721979.
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Affiliation(s)
| | - Roman Gulati
- Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Yang Liu
- GenomeDx Biosciences Inc., San Diego, CA
| | | | | | | | | | | | | | | | | | - Kenneth J. Pienta
- James Buchanan Brady Urological Institute, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Peter Nelson
- Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Jonathan L. Wright
- Department of Urology, University of Washington Medical Center, Seattle, WA
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Sokolova A, Gulati R, Cheng HH, Beer TM, Graff JN, Amador M, Toulouse A, Taylor K, Bailey S, Smith S, Tabatabaei S, Sinit R, Slottke R, Vuky J, Yezefski T, Grivas P, Yu EY, Schweizer MT. Trial in progress: Durvalumab and olaparib for the treatment of prostate cancer in men predicted to have a high neoantigen load. J Clin Oncol 2022. [DOI: 10.1200/jco.2022.40.6_suppl.tps202] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
TPS202 Background: Approximately 30% of patients (pts) treated with definitive surgical and/or radiation therapy for localized prostate adenocarcinoma develop biochemical recurrence (BCR). The optimal time to initiate androgen deprivation therapy (ADT) for such patients is controversial and depends on patient and provider preference, absolute PSA value, and PSA doubling time (PSADT), which has been associated with time to metastasis. Because the time from BCR to metastasis can be long in many cases, strategies allowing pts to avoid ADT while extending metastasis-free survival are desirable. Prior studies have shown that a high tumor neoantigen load correlates with response to anti-PD(L)1. We hypothesized that PARP inhibitor-induced genomic instability may sensitize tumors to anti-PD(L)1 through: i) increasing mutational burden and subsequent tumor neoantigen formation, and/or ii) through activation of other immunogenic pathways (e.g. the STING pathway). This trial investigates an ADT-sparing approach for men predicted to have high neoantigen load and who have BCR prostate cancer. Methods: This is a phase 2 clinical trial testing durvalumab (1500 mg IV every 4 weeks) and olaparib (300 mg PO twice a day) (one cycle = 4 weeks) in men with BCR (PSADT≤10 months) whose tumors are predicted to have high neoantigen load based on: biallelic CDK12 mutations (Cohort A), mismatch repair deficiency (MMRd)/high microsatellite instability (MSI-H) (Cohort B), or loss of function mutations in homologous recombination repair (HRR) genes (Cohort C). Cohorts A and B will receive 3 cycles of durvalumab followed by 3 cycles of the combination of durvalumab and olaparib. Given the proven efficacy of olaparib in prostate cancer patient whose tumors posses an HRR gene mutation, Cohort C will receive 6 full cycles of the combination. Ten patients will be enrolled in each cohort (total n = 30) at two collaborating sites. This study was designed to provide preliminary efficacy data across eligible cohorts, with a primary objective of estimating the proportion of pts with an undetectable PSA at 12 months within each cohort. Secondary objectives include safety, proportion of patients with ≥50% decline in PSA from baseline and quality of life measures. Correlative studies will assess blood and tissue molecular biomarkers for association with outcomes. The study is open with two patients enrolled at the time of abstract submission. Clinical trial information: NCT04336943.
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Affiliation(s)
- Alexandra Sokolova
- Oregon Health and Science University Knight Cancer Institute, Portland, OR
| | - Roman Gulati
- Fred Hutchinson Cancer Research Center, Seattle, WA
| | | | - Tomasz M. Beer
- Knight Cancer Institute, Oregon Health & Science University, Portland, OR
| | | | | | | | | | | | - Steven Smith
- Oregon Health & Science University, Portland, OR
| | | | - Ryan Sinit
- Oregon Health & Science University, Portland, OR
| | | | | | | | - Petros Grivas
- University of Washington and Fred Hutchinson Cancer Research Center, Seattle, WA
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Sokolova AO, Marshall CH, Lozano R, Gulati R, Ledet EM, De Sarkar N, Grivas P, Higano CS, Montgomery B, Nelson PS, Olmos D, Sokolov V, Schweizer MT, Yezefski TA, Yu EY, Paller CJ, Sartor O, Castro E, Antonarakis ES, Cheng HH. Efficacy of systemic therapies in men with metastatic castration resistant prostate cancer harboring germline ATM versus BRCA2 mutations. Prostate 2021; 81:1382-1389. [PMID: 34516663 PMCID: PMC8563438 DOI: 10.1002/pros.24236] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Accepted: 08/30/2021] [Indexed: 11/11/2022]
Abstract
BACKGROUND Among men with metastatic prostate cancer, about 10% have germline alterations in DNA damage response genes. Most studies have examined BRCA2 alone or an aggregate of BRCA1/2 and ATM. Emerging data suggest that ATM mutations may have distinct biology and warrant individual evaluation. The objective of this study is to determine whether response to prostate cancer systemic therapies differs between men with germline mutations in ATM (gATM) and BRCA2 (gBRCA2). METHODS This is an international multicenter retrospective matched cohort study of men with prostate cancer harboring gATM or gBRCA2. PSA50 response (≥50% decline in prostate-specific antigen) was compared using Fisher's exact test. RESULTS AND LIMITATIONS The study included 45 gATM and 45 gBRCA2 patients, matched on stage and year of germline testing. Patients with gATM and gBRCA2 had similar age, Gleason grade, and PSA at diagnosis. We did not observe differences in PSA50 responses to abiraterone, enzalutamide, or docetaxel in metastatic castration resistant prostate cancer between the two groups; however, 0/7 with gATM and 12/14 with gBRCA2 achieved PSA50 response to PARPi (p < .001). Median (95% confidence interval) overall survival from diagnosis to death was 10.9 years (9.5-not reached) versus 9.9 years (7.1-not reached, p = .07) for the gATM and gBRCA2 cohorts, respectively. Limitations include the retrospective design and lack of mutation zygosity data. CONCLUSIONS Conventional therapies can be effective in gATM carriers and should be considered before PARPi, which shows limited efficacy in this group. Men with gATM mutations warrant prioritization for novel treatment strategies.
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Affiliation(s)
| | - Catherine H. Marshall
- Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Rebeca Lozano
- Prostate Cancer Clinical Research Unit, Spanish National Cancer Research Centre (CNIO), Madrid, Spain
- Genitourinary Cancer Traslational Research Group, Instituto de Investigación Biomédica de Málaga, Malaga, Spain
| | - Roman Gulati
- Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | | | | | - Petros Grivas
- University of Washington, Department of Medicine, Division of Medical Oncology, Seattle, WA, USA
- Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Celestia S. Higano
- University of Washington, Department of Medicine, Division of Medical Oncology, Seattle, WA, USA
- Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Bruce Montgomery
- University of Washington, Department of Medicine, Division of Medical Oncology, Seattle, WA, USA
| | - Peter S. Nelson
- University of Washington, Department of Medicine, Division of Medical Oncology, Seattle, WA, USA
- Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - David Olmos
- Prostate Cancer Clinical Research Unit, Spanish National Cancer Research Centre (CNIO), Madrid, Spain
- Genitourinary Cancer Traslational Research Group, Instituto de Investigación Biomédica de Málaga, Malaga, Spain
| | | | - Michael T. Schweizer
- University of Washington, Department of Medicine, Division of Medical Oncology, Seattle, WA, USA
- Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Todd A. Yezefski
- University of Washington, Department of Medicine, Division of Medical Oncology, Seattle, WA, USA
| | - Evan Y. Yu
- University of Washington, Department of Medicine, Division of Medical Oncology, Seattle, WA, USA
- Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Channing J. Paller
- Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Oliver Sartor
- Tulane University School of Medicine, New Orleans, LA, USA
| | - Elena Castro
- Prostate Cancer Clinical Research Unit, Spanish National Cancer Research Centre (CNIO), Madrid, Spain
- Genitourinary Cancer Traslational Research Group, Instituto de Investigación Biomédica de Málaga, Malaga, Spain
- Hospital Universitario Virgen de la Victoria y Regional de Málaga, Spain
| | - Emmanuel S. Antonarakis
- Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Heather H. Cheng
- University of Washington, Department of Medicine, Division of Medical Oncology, Seattle, WA, USA
- Fred Hutchinson Cancer Research Center, Seattle, WA, USA
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Psutka SP, Gulati R, Jewett MAS, Fadaak K, Finelli A, Legere L, Morgan TM, Pierorazio PM, Allaf ME, Herrin J, Lohse CM, Houston Thompson R, Boorjian SA, Atwell TD, Schmit GD, Costello BA, Shah ND, Leibovich BC. A Clinical Decision Aid to Support Personalized Treatment Selection for Patients with Clinical T1 Renal Masses: Results from a Multi-institutional Competing-risks Analysis. Eur Urol 2021; 81:576-585. [PMID: 34862099 DOI: 10.1016/j.eururo.2021.11.002] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Revised: 09/28/2021] [Accepted: 11/01/2021] [Indexed: 12/23/2022]
Abstract
BACKGROUND Personalized treatment for clinical T1 renal cortical masses (RCMs) should take into account competing risks related to tumor and patient characteristics. OBJECTIVE To develop treatment-specific prediction models for cancer-specific mortality (CSM), other-cause mortality (OCM), and 90-d Clavien grade ≥3 complications across radical nephrectomy (RN), partial nephrectomy (PN), thermal ablation (TA), and active surveillance (AS). DESIGN, SETTING, AND PARTICIPANTS Pretreatment clinical and radiological features were collected for consecutive adult patients treated with initial RN, PN, TA, or AS for RCMs at four high-volume referral centers (2000-2019). OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS Prediction models used competing-risks regression for CSM and OCM and logistic regression for 90-d Clavien grade ≥3 complications. Performance was assessed using bootstrap validation. RESULTS AND LIMITATIONS The cohort comprised 5300 patients treated with RN (n = 1277), PN (n = 2967), TA (n = 476), or AS (n = 580). Over median follow-up of 5.2 yr (interquartile range 2.5-8.7), there were 117 CSM, 607 OCM, and 198 complication events. The C index for the predictive models was 0.80 for CSM, 0.77 for OCM, and 0.64 for complications. Predictions from the fitted models are provided in an online calculator (https://small-renal-mass-risk-calculator.fredhutch.org). To illustrate, a hypothetical 74-yr-old male with a 4.5-cm RCM, body mass index of 32 kg/m2, estimated glomerular filtration rate of 50 ml/min, Eastern Cooperative Oncology Group performance status of 3, and Charlson comorbidity index of 3 has predicted 5-yr CSM of 2.9-5.6% across treatments, but 5-yr OCM of 29% and risk of 90-d Clavien grade 3-5 complications of 1.9% for RN, 5.8% for PN, and 3.6% for TA. Limitations include selection bias, heterogeneity in practice across treatment sites and the study time period, and lack of control for surgeon/hospital volume. CONCLUSIONS We present a risk calculator incorporating pretreatment features to estimate treatment-specific competing risks of mortality and complications for use during shared decision-making and personalized treatment selection for RCMs. PATIENT SUMMARY We present a risk calculator that generates personalized estimates of the risks of death from cancer or other causes and of complications for surgical, ablation, and surveillance treatment options for patients with stage 1 kidney tumors.
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Affiliation(s)
- Sarah P Psutka
- Department of Urology, University of Washington, Seattle, WA, USA.
| | - Roman Gulati
- Division of Public Health Sciences, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Michael A S Jewett
- Departments of Surgery (Urology) and Surgical Oncology, Princess Margaret Cancer Center and University Health Network, University of Toronto, Toronto, Canada
| | - Kamel Fadaak
- Department of Urology, King Fahd Hospital of the University, College of Medicine, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
| | - Antonio Finelli
- Departments of Surgery (Urology) and Surgical Oncology, Princess Margaret Cancer Center and University Health Network, University of Toronto, Toronto, Canada
| | - Laura Legere
- Departments of Surgery (Urology) and Surgical Oncology, Princess Margaret Cancer Center and University Health Network, University of Toronto, Toronto, Canada
| | - Todd M Morgan
- Department of Urology, University of Michigan, Ann Arbor, MI, USA
| | - Phillip M Pierorazio
- Department of Urology, Brady Urological Institute, Department of Urology at Johns Hopkins, Baltimore, MD, USA
| | - Mohamad E Allaf
- Department of Urology, Brady Urological Institute, Department of Urology at Johns Hopkins, Baltimore, MD, USA
| | - Jeph Herrin
- Division of Cardiology, Yale School of Medicine, New Haven, CT, USA; Health Research & Educational Trust, Chicago, IL, USA
| | - Christine M Lohse
- Department of Health Sciences Research, Mayo Clinic, Rochester, MN, USA
| | | | | | | | - Grant D Schmit
- Department of Radiology, Mayo Clinic, Rochester, MN, USA
| | | | - Nilay D Shah
- Department of Health Sciences Research, Mayo Clinic, Rochester, MN, USA
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Hendrix N, Gulati R, Jiao B, Kader AK, Ryan ST, Etzioni R. Clarifying the Trade-Offs of Risk-Stratified Screening for Prostate Cancer: A Cost-Effectiveness Study. Am J Epidemiol 2021; 190:2064-2074. [PMID: 34023874 DOI: 10.1093/aje/kwab155] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2020] [Revised: 05/13/2021] [Accepted: 05/18/2021] [Indexed: 12/18/2022] Open
Abstract
Cancer risk prediction is necessary for precision early detection, which matches screening intensity to risk. However, practical steps for translating risk predictions to risk-stratified screening policies are not well established. We used a validated population prostate-cancer model to simulate the outcomes of strategies that increase intensity for men at high risk and reduce intensity for men at low risk. We defined risk by the Prompt Prostate Genetic Score (PGS) (Stratify Genomics, San Diego, California), a germline genetic test. We first recalibrated the model to reflect the disease incidence observed within risk strata using data from a large prevention trial where some participants were tested with Prompt PGS. We then simulated risk-stratified strategies in a population with the same risk distribution as the trial and evaluated the cost-effectiveness of risk-stratified screening versus universal (risk-agnostic) screening. Prompt PGS risk-adapted screening was more cost-effective when universal screening was conservative. Risk-stratified strategies improved outcomes at a cost of less than $100,000 per quality-adjusted life year compared with biennial screening starting at age 55 years, but risk stratification was not cost-effective compared with biennial screening starting at age 45. Heterogeneity of risk and fraction of the population within each stratum were also important determinants of cost-effectiveness.
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Jiao B, Gulati R, Katki HA, Castle PE, Etzioni R. A Quantitative Framework to Study Potential Benefits and Harms of Multi-Cancer Early Detection Testing. Cancer Epidemiol Biomarkers Prev 2021; 31:38-44. [PMID: 34548329 DOI: 10.1158/1055-9965.epi-21-0380] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Revised: 06/14/2021] [Accepted: 08/26/2021] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Multi-cancer tests offer screening for multiple cancers with one blood draw, but the potential population impact is poorly understood. METHODS We formulate mathematical expressions for expected numbers of: (i) individuals exposed to unnecessary confirmation tests (EUC), (ii) cancers detected (CD), and (iii) lives saved (LS) given test performance, disease incidence and mortality, and mortality reduction. We add colorectal, liver, lung, ovary, and pancreatic cancer to a test for breast cancer, approximating prevalence at ages 50, 60, or 70 using incidence over the next 5 years and mortality using corresponding probabilities of cancer death over 15 years in the Surveillance, Epidemiology, and End Results registry. RESULTS EUC is overwhelmingly determined by specificity. For a given specificity, EUC/CD is most favorable for higher prevalence cancers. Under 99% specificity and sensitivities as published for a 50-cancer test, EUC/CD is 1.1 for breast + lung versus 1.3 for breast + liver at age 50. Under a common mortality reduction associated with screening, EUC/LS is most favorable when the test includes higher mortality cancers (e.g., 19.9 for breast + lung vs. 30.4 for breast + liver at age 50 assuming a common 10% mortality reduction). CONCLUSIONS Published multi-cancer test performance suggests a favorable tradeoff of EUC to CD, yet the full burden of unnecessary confirmations will depend on the posttest work-up protocol. Harm-benefit tradeoffs will be improved if tests prioritize more prevalent and/or lethal cancers for which curative treatments exist. IMPACT The population impact of multi-cancer testing will depend not only on test performance but also on disease characteristics and efficacy of early treatment.See related commentary by Stephen Duffy, p. xxx.
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Affiliation(s)
- Boshen Jiao
- Program in Biostatistics, Division of Public Health Sciences, Fred Hutchinson Cancer Research Center, Seattle, Washington.,The Comparative Health Outcomes, Economics and Policy (CHOICE) Institute, University of Washington, Seattle, Washington
| | - Roman Gulati
- Program in Biostatistics, Division of Public Health Sciences, Fred Hutchinson Cancer Research Center, Seattle, Washington.
| | | | | | - Ruth Etzioni
- Program in Biostatistics, Division of Public Health Sciences, Fred Hutchinson Cancer Research Center, Seattle, Washington
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Etzioni R, Haffner MC, Gulati R. Divining Harm-Benefit Tradeoffs of Magnetic Resonance Imaging-targeted Biopsy. Eur Urol 2021; 80:573-574. [PMID: 34479754 DOI: 10.1016/j.eururo.2021.08.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Accepted: 08/13/2021] [Indexed: 11/30/2022]
Affiliation(s)
- Ruth Etzioni
- Division of Public Health Sciences, Fred Hutchinson Cancer Research Center, Seattle, WA, USA; Department of Biostatistics, University of Washington, Seattle, WA, USA.
| | - Michael C Haffner
- Divisions of Human Biology and Clinical Research, Fred Hutchinson Cancer Research Center, Seattle, WA, USA; Department of Pathology, University of Washington, Seattle, WA, USA
| | - Roman Gulati
- Division of Public Health Sciences, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
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Etzioni R, Gulati R, Weiss NS. Multi-Cancer Early Detection: Learning from the past to Meet the Future. J Natl Cancer Inst 2021; 114:349-352. [PMID: 34450655 DOI: 10.1093/jnci/djab168] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Revised: 06/04/2021] [Accepted: 08/18/2021] [Indexed: 01/08/2023] Open
Abstract
Multi-cancer early detection (MCED) tests may soon be available to screen for many cancers using a single blood test, yet little is known about these tests beyond their diagnostic performance. Taking lessons from the history of cancer early detection, we highlight three factors that influence how performance of early detection tests translates into benefit and benefit-harm tradeoffs: the ability to readily confirm a cancer signal, the population testing strategy, and the natural histories of the targeted cancers. We explain why critical gaps in our current knowledge about each factor prevent reliably projecting the expected clinical impact of MCED testing at this point in time. Our goal is to communicate how much uncertainty there is about the possible effects of MCED tests on population health so that patients, providers, regulatory agencies, and the public are well informed about what is reasonable to expect from this potentially important technological advance. We also urge the community to invest in a coordinated effort to collect data on MCED test dissemination and outcomes so that these can be tracked and studied while the tests are rigorously evaluated for benefit, harm, and cost.
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Affiliation(s)
- Ruth Etzioni
- Division of Public Health Sciences, Fred Hutchinson Cancer Research Center, Seattle, WA, USA.,Department of Biostatistics, University of Washington, Seattle, WA, USA
| | - Roman Gulati
- Division of Public Health Sciences, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Noel S Weiss
- Division of Public Health Sciences, Fred Hutchinson Cancer Research Center, Seattle, WA, USA.,Department of Epidemiology, University of Washington, Seattle, WA, USA
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Affiliation(s)
- Roman Gulati
- Division of Public Health Sciences, Fred Hutchinson Cancer Research Center, Seattle, Washington.
| | - Sigrid V Carlsson
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York; Department of Epidemiology & Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York; Department of Urology, Institute of Clinical Sciences, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
| | - Ruth Etzioni
- Division of Public Health Sciences, Fred Hutchinson Cancer Research Center, Seattle, Washington
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Jiao B, Gulati R, Hendrix N, Gore JL, Rais-Bahrami S, Morgan TM, Etzioni R. Economic Evaluation of Urine-Based or Magnetic Resonance Imaging Reflex Tests in Men With Intermediate Prostate-Specific Antigen Levels in the United States. Value Health 2021; 24:1111-1117. [PMID: 34372976 PMCID: PMC8358184 DOI: 10.1016/j.jval.2021.02.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Revised: 02/03/2021] [Accepted: 02/28/2021] [Indexed: 06/13/2023]
Abstract
OBJECTIVES For men with intermediate prostate-specific antigen (PSA) levels (4-10 ng/mL), urine-based biomarkers and multiparametric magnetic resonance imaging (MRI) are increasingly used as reflex tests before prostate biopsy. We assessed the cost effectiveness of these reflex tests in the United States. METHODS We used an existing microsimulation model of prostate cancer (PCa) progression and survival to predict lifetime outcomes for a hypothetical cohort of 55-year-old men with intermediate PSA levels. Urine-based biomarkers-PCa antigen (PCA3), TMPRSS2:ERG gene fusion (T2:ERG), and the MyProstateScore (MPS) for any PCa and for high-grade (Gleason score ≥7) PCa (MPShg)-were generated using biomarker data from 1112 men presenting for biopsy at 10 United States institutions. MRI results were based on published sensitivity and specificity for high-grade PCa. Costs and utilities were sourced from literature and Medicare reimbursement schedules. Outcome measures included life years, quality-adjusted life years (QALYs), and lifetime medical costs per patient. Incremental cost-effectiveness ratios were empirically calculated on the basis of simulated life histories under different reflex testing strategies. RESULTS Biopsying all men provided the most life years and QALYs, followed by reflex testing using MPShg, MPS, MRI, T2:ERG, PCA3, and biopsying no men (QALY range across strategies 15.98-16.09). Accounting for costs, MRI and MPShg were dominated by other strategies. PCA3, T2:ERG, and MPS were likely to be the most cost-effective strategy at willingness-to-pay thresholds of $100 000/QALY, $125 000/QALY, and $150 000/QALY, respectively. CONCLUSIONS Using PCA3, T2:ERG, or MPS as reflex tests has greater economic value than MRI, biopsying all men, or biopsying no men with intermediate PSA levels.
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Affiliation(s)
- Boshen Jiao
- Division of Public Health Science, Fred Hutchinson Cancer Research Center, Seattle, WA, USA; The Comparative Health Outcomes, Policy, and Economics (CHOICE) Institute, University of Washington, Seattle, WA
| | - Roman Gulati
- Division of Public Health Science, Fred Hutchinson Cancer Research Center, Seattle, WA, USA.
| | - Nathaniel Hendrix
- The Comparative Health Outcomes, Policy, and Economics (CHOICE) Institute, University of Washington, Seattle, WA
| | - John L Gore
- Department of Urology, University of Washington, Seattle, WA, USA
| | - Soroush Rais-Bahrami
- Department of Urology, Department of Radiology, and O'Neal Comprehensive Cancer Center at UAB, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Todd M Morgan
- Department of Urology, University of Michigan, Ann Arbor, MI, USA
| | - Ruth Etzioni
- Division of Public Health Science, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
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Nyquist MD, Corella A, Coleman I, De Sarkar N, Kaipainen A, Ha G, Gulati R, Ang L, Chatterjee P, Lucas J, Pritchard C, Risbridger G, Isaacs J, Montgomery B, Morrissey C, Corey E, Nelson PS. Combined TP53 and RB1 Loss Promotes Prostate Cancer Resistance to a Spectrum of Therapeutics and Confers Vulnerability to Replication Stress. Cell Rep 2021; 31:107669. [PMID: 32460015 DOI: 10.1016/j.celrep.2020.107669] [Citation(s) in RCA: 136] [Impact Index Per Article: 45.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2019] [Revised: 03/22/2020] [Accepted: 04/29/2020] [Indexed: 12/24/2022] Open
Abstract
Prostate cancers (PCs) with loss of the potent tumor suppressors TP53 and RB1 exhibit poor outcomes. TP53 and RB1 also influence cell plasticity and are frequently lost in PCs with neuroendocrine (NE) differentiation. Therapeutic strategies that address these aggressive variant PCs are urgently needed. Using deep genomic profiling of 410 metastatic biopsies, we determine the relationships between combined TP53 and RB1 loss and PC phenotypes. Notably, 40% of TP53/RB1-deficient tumors are classified as AR-active adenocarcinomas, indicating that NE differentiation is not an obligate consequence of TP53/RB1 inactivation. A gene expression signature reflecting TP53/RB1 loss is associated with diminished responses to AR antagonists and reduced survival. These tumors exhibit high proliferation rates and evidence of elevated DNA repair processes. While tumor cells lacking TP53/RB1 are highly resistant to all single-agent therapeutics tested, the combination of PARP and ATR inhibition is found to produce significant responses, reflecting a clinically exploitable vulnerability resulting from replication stress.
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Affiliation(s)
- Michael D Nyquist
- Divisions of Human Biology and Clinical Research, Fred Hutchinson Cancer Research Center, Seattle, WA 98109, USA
| | - Alexandra Corella
- Divisions of Human Biology and Clinical Research, Fred Hutchinson Cancer Research Center, Seattle, WA 98109, USA
| | - Ilsa Coleman
- Divisions of Human Biology and Clinical Research, Fred Hutchinson Cancer Research Center, Seattle, WA 98109, USA
| | - Navonil De Sarkar
- Divisions of Human Biology and Clinical Research, Fred Hutchinson Cancer Research Center, Seattle, WA 98109, USA
| | - Arja Kaipainen
- Divisions of Human Biology and Clinical Research, Fred Hutchinson Cancer Research Center, Seattle, WA 98109, USA
| | - Gavin Ha
- Divisions of Human Biology and Clinical Research, Fred Hutchinson Cancer Research Center, Seattle, WA 98109, USA
| | - Roman Gulati
- Divisions of Human Biology and Clinical Research, Fred Hutchinson Cancer Research Center, Seattle, WA 98109, USA
| | - Lisa Ang
- Divisions of Human Biology and Clinical Research, Fred Hutchinson Cancer Research Center, Seattle, WA 98109, USA
| | - Payel Chatterjee
- Divisions of Human Biology and Clinical Research, Fred Hutchinson Cancer Research Center, Seattle, WA 98109, USA
| | - Jared Lucas
- Divisions of Human Biology and Clinical Research, Fred Hutchinson Cancer Research Center, Seattle, WA 98109, USA
| | - Colin Pritchard
- Department of Laboratory Medicine, University of Washington, Seattle, WA 98195, USA
| | - Gail Risbridger
- Department of Anatomy and Cell Biology, Monash University, Melbourne, VIC 3000, Australia
| | - John Isaacs
- Department of Oncology, Johns Hopkins School of Medicine, Baltimore, MD 21231, USA
| | - Bruce Montgomery
- Department of Medicine, University of Washington, Seattle, WA 98195, USA
| | - Colm Morrissey
- Department of Urology, University of Washington, Seattle, WA 98195, USA
| | - Eva Corey
- Department of Urology, University of Washington, Seattle, WA 98195, USA
| | - Peter S Nelson
- Divisions of Human Biology and Clinical Research, Fred Hutchinson Cancer Research Center, Seattle, WA 98109, USA; Department of Medicine, University of Washington, Seattle, WA 98195, USA; Department of Urology, University of Washington, Seattle, WA 98195, USA.
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40
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Nyame YA, Gulati R, Heijnsdijk EAM, Tsodikov A, Mariotto AB, Gore JL, Etzioni R. The Impact of Intensifying Prostate Cancer Screening in Black Men: A Model-Based Analysis. J Natl Cancer Inst 2021; 113:1336-1342. [PMID: 33963850 DOI: 10.1093/jnci/djab072] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Revised: 02/05/2021] [Accepted: 03/12/2021] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Black men in the United States have markedly higher rates of prostate cancer than the general population. National guidelines for prostate-specific antigen (PSA) screening do not provide clear guidance for this high-risk population. The purpose of this study is to estimate the benefit and harm of intensified PSA screening in Black men. METHODS Two microsimulation models of prostate cancer calibrated to incidence from the Surveillance, Epidemiology, and End Results program among Black men project the impact of different screening strategies (varying screening intervals, starting and stopping ages, and biopsy utilization following an abnormal PSA) on disease-specific mortality and overdiagnosis. Each strategy induces a mean lead time (MLT) for detected cases. A longer MLT reduces mortality according to estimates combining the US and European prostate cancer screening trials but increases overdiagnosis. RESULTS Under historical population screening, Black men had similar MLT to men of all races, and similar mortality reduction (range between models = 21-24% vs. 20-24%) but a higher frequency of overdiagnosis (75-86 vs. 58-60 per 1000 men). Screening Black men aged 40-84 years annually would increase both mortality reduction (29-31%) and overdiagnosis (112-129 per 1000). Restricting screening to age 45-69 years would still achieve substantial mortality reduction (26-29%) with lower overdiagnosis (51-61 per 1000). Increasing biopsy utilization to 100% of abnormal tests would further reduce mortality but substantially increase overdiagnosis. CONCLUSIONS Annual screening in Black men is expected to reduce mortality more than that estimated under historical screening. Limiting screening to men below 70 years is expected to help to reduce overdiagnosis.
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Affiliation(s)
- Yaw A Nyame
- Department of Urology, University of Washington Medical Center, Seattle, WA, USA.,Division of Public Health Sciences, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Roman Gulati
- Division of Public Health Sciences, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | | | - Alex Tsodikov
- School of Public Health, University of Michigan, Ann Arbor, MI, USA
| | - Angela B Mariotto
- Division of Cancer Control and Population Sciences, National Cancer Institute, Bethesda, MD, USA
| | - John L Gore
- Department of Urology, University of Washington Medical Center, Seattle, WA, USA.,Division of Public Health Sciences, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Ruth Etzioni
- Division of Public Health Sciences, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
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41
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Graham LS, True LD, Gulati R, Schade GR, Wright J, Grivas P, Yezefski T, Nega K, Alexander K, Hou WM, Yu EY, Montgomery B, Mostaghel EA, Matsumoto AA, Marck B, Sharifi N, Ellis WJ, Reder NP, Lin DW, Nelson PS, Schweizer MT. Targeting backdoor androgen synthesis through AKR1C3 inhibition: A presurgical hormonal ablative neoadjuvant trial in high-risk localized prostate cancer. Prostate 2021; 81:418-426. [PMID: 33755225 PMCID: PMC8044035 DOI: 10.1002/pros.24118] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Revised: 01/27/2021] [Accepted: 03/09/2021] [Indexed: 12/15/2022]
Abstract
BACKGROUND Localized prostate cancers (PCs) may resist neoadjuvant androgen receptor (AR)-targeted therapies as a result of persistent intraprostatic androgens arising through upregulation of steroidogenic enzymes. Therefore, we sought to evaluate clinical effects of neoadjuvant indomethacin (Indo), which inhibits the steroidogenic enzyme AKR1C3, in addition to combinatorial anti-androgen blockade, in men with high-risk PC undergoing radical prostatectomy (RP). METHODS This was an open label, single-site, Phase II neoadjuvant trial in men with high to very-high-risk PC, as defined by NCCN criteria. Patients received 12 weeks of apalutamide (Apa), abiraterone acetate plus prednisone (AAP), degarelix, and Indo followed by RP. Primary objective was to determine the pathologic complete response (pCR) rate. Secondary objectives included minimal residual disease (MRD) rate, defined as residual cancer burden (RCB) ≤ 0.25cm3 (tumor volume multiplied by tumor cellularity) and elucidation of molecular features of resistance. RESULTS Twenty patients were evaluable for the primary endpoint. Baseline median prostate-specific antigen (PSA) was 10.1 ng/ml, 4 (20%) patients had Gleason grade group (GG) 4 disease and 16 had GG 5 disease. At RP, 1 (5%) patient had pCR and 6 (30%) had MRD. Therapy was well tolerated. Over a median follow-up of 23.8 months, 1 of 7 (14%) men with pathologic response and 6 of 13 (46%) men without pathologic response had a PSA relapse. There was no association between prostate hormone levels or HSD3B1 genotype with pathologic response. CONCLUSIONS In men with high-risk PC, pCR rates remained low even with combinatorial AR-directed therapy, although rates of MRD were higher. Ongoing follow-up is needed to validate clinical outcomes of men who achieve MRD.
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Affiliation(s)
- Laura S Graham
- Division of Oncology, Department of Medicine, University of Washington, Seattle, Washington, USA
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA
| | - Lawrence D True
- Department of Laboratory Medicine and Pathology, University of Washington, Seattle, Washington, USA
| | - Roman Gulati
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA
| | - George R Schade
- Department of Urology, University of Washington, Seattle, Washington, USA
| | - Jonathan Wright
- Department of Urology, University of Washington, Seattle, Washington, USA
| | - Petros Grivas
- Division of Oncology, Department of Medicine, University of Washington, Seattle, Washington, USA
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA
| | - Todd Yezefski
- Division of Oncology, Department of Medicine, University of Washington, Seattle, Washington, USA
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA
| | - Katie Nega
- Division of Oncology, Department of Medicine, University of Washington, Seattle, Washington, USA
| | - Katerina Alexander
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA
| | - Wen-Min Hou
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA
| | - Evan Y Yu
- Division of Oncology, Department of Medicine, University of Washington, Seattle, Washington, USA
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA
| | - Bruce Montgomery
- Division of Oncology, Department of Medicine, University of Washington, Seattle, Washington, USA
- Geriatric Research Education and Clinical Care, VA Puget Sound Health Care System, Seattle, Washington, USA
| | - Elahe A Mostaghel
- Division of Oncology, Department of Medicine, University of Washington, Seattle, Washington, USA
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA
- Geriatric Research Education and Clinical Care, VA Puget Sound Health Care System, Seattle, Washington, USA
| | - Alvin A Matsumoto
- Geriatric Research Education and Clinical Care, VA Puget Sound Health Care System, Seattle, Washington, USA
| | - Brett Marck
- Geriatric Research Education and Clinical Care, VA Puget Sound Health Care System, Seattle, Washington, USA
| | - Nima Sharifi
- Genitourinary Malignancies Research Center, Cleveland Clinic, Cleveland, Ohio, USA
| | - William J Ellis
- Department of Urology, University of Washington, Seattle, Washington, USA
| | - Nicholas P Reder
- Department of Laboratory Medicine and Pathology, University of Washington, Seattle, Washington, USA
- Department of Mechanical Engineering, University of Washington, Seattle, Washington, USA
| | - Daniel W Lin
- Department of Urology, University of Washington, Seattle, Washington, USA
| | - Peter S Nelson
- Division of Oncology, Department of Medicine, University of Washington, Seattle, Washington, USA
- Division of Human Biology, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA
| | - Michael T Schweizer
- Division of Oncology, Department of Medicine, University of Washington, Seattle, Washington, USA
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA
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42
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Heijnsdijk EAM, Gulati R, Tsodikov A, Lange JM, Mariotto AB, Vickers AJ, Carlsson SV, Etzioni R. Lifetime Benefits and Harms of Prostate-Specific Antigen-Based Risk-Stratified Screening for Prostate Cancer. J Natl Cancer Inst 2021; 112:1013-1020. [PMID: 32067047 PMCID: PMC7566340 DOI: 10.1093/jnci/djaa001] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2019] [Revised: 12/03/2019] [Accepted: 12/12/2019] [Indexed: 12/23/2022] Open
Abstract
Background Studies conducted in Swedish populations have shown that men with lowest prostate-specific antigen (PSA) levels at ages 44–50 years and 60 years have very low risk of future distant metastasis or death from prostate cancer. This study investigates benefits and harms of screening strategies stratified by PSA levels. Methods PSA levels and diagnosis patterns from two microsimulation models of prostate cancer progression, detection, and mortality were compared against results of the Malmö Preventive Project, which stored serum and tracked subsequent prostate cancer diagnoses for 25 years. The models predicted the harms (tests and overdiagnoses) and benefits (lives saved and life-years gained) of PSA-stratified screening strategies compared with biennial screening from age 45 years to age 69 years. Results Compared with biennial screening for ages 45–69 years, lengthening screening intervals for men with PSA less than 1.0 ng/mL at age 45 years led to 46.8–47.0% fewer tests (range between models), 0.9–2.1% fewer overdiagnoses, and 3.1–3.8% fewer lives saved. Stopping screening when PSA was less than 1.0 ng/mL at age 60 years and older led to 12.8–16.0% fewer tests, 5.0–24.0% fewer overdiagnoses, and 5.0–13.1% fewer lives saved. Differences in model results can be partially explained by differences in assumptions about the link between PSA growth and the risk of disease progression. Conclusion Relative to a biennial screening strategy, PSA-stratified screening strategies investigated in this study substantially reduced the testing burden and modestly reduced overdiagnosis while preserving most lives saved. Further research is needed to clarify the link between PSA growth and disease progression.
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Affiliation(s)
- Eveline A M Heijnsdijk
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Roman Gulati
- Division of Public Health Sciences, Fred Hutchinson Cancer Research Institute, Seattle, WA, USA
| | - Alex Tsodikov
- Department of Biostatistics, University of Michigan, Ann Arbor, MI, USA
| | - Jane M Lange
- Division of Public Health Sciences, Fred Hutchinson Cancer Research Institute, Seattle, WA, USA
| | - Angela B Mariotto
- Division of Cancer Control and Population Sciences, National Cancer Institute, Bethesda, MD, USA
| | - Andrew J Vickers
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Sigrid V Carlsson
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA.,Department of Surgery (Urology Service), Memorial Sloan Kettering Cancer Center, New York, NY, USA.,Department of Urology, Institute of Clinical Sciences, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
| | - Ruth Etzioni
- Division of Public Health Sciences, Fred Hutchinson Cancer Research Institute, Seattle, WA, USA
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43
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Fierabracci A, Arena A, Toto F, Gallo N, Puel A, Migaud M, Kumar M, Chengappa KG, Gulati R, Negi VS, Betterle C. Autoimmune polyendocrine syndrome type 1 (APECED) in the Indian population: case report and review of a series of 45 patients. J Endocrinol Invest 2021; 44:661-677. [PMID: 32767280 DOI: 10.1007/s40618-020-01376-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Accepted: 07/26/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND Autoimmune polyendocrinopathy-candidiasis-ectodermal-dystrophy (APECED) or autoimmune polyglandular syndrome type 1 (APS-1) is a rare autosomal recessive genetic disease due to mutations in the AIRE (AutoImmune REgulator) gene. The clinical diagnosis is classically based on the presence of at least two of the three main components: chronic mucocutaneous candidiasis, hypoparathyroidism and primary adrenal insufficiency. Patients often suffer from other endocrine or non-endocrine autoimmune conditions throughout life. APECED etiopathogenesis is mediated by T lymphocytes. Autoantibodies against proteins of the affected organs are found in the serum of APECED patients as well as neutralizing antibodies against cytokines. We report here the clinical and genetic characteristics of 45 Indian APECED patients in comparison to Finnish, Sardinian, Turkish and North/South American cohorts from their published results. We also report a new case of APECED of Indian origin, a 2-year old child suffering from chronic mucocutaneous candidiasis since the age of 8 months, with confirmatory AIRE homozygous mutation c.274C > T (p.R92W). CONCLUSION With the inherent limitations of a retrospective study, analysis of Indian APECED patients suggested that compared to classic criteria, application of Ferre/Lionakis criteria validated in North/South American patients could help in earlier diagnosis in 3 of 8 (37.5%) patients for whom adequate information for evaluation was available.
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Affiliation(s)
- A Fierabracci
- Infectivology and Clinical Trials Research Department, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy.
| | - A Arena
- Infectivology and Clinical Trials Research Department, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - F Toto
- Infectivology and Clinical Trials Research Department, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - N Gallo
- Laboratory Medicine, Department of Medicine (DIMED), University of Padua, Padua, Italy
| | - A Puel
- Laboratory of Human Genetics of Infectious Diseases, INSERM UMR 1163, Imagine Institute, University of Paris, Paris, France
| | - M Migaud
- Laboratory of Human Genetics of Infectious Diseases, INSERM UMR 1163, Imagine Institute, University of Paris, Paris, France
| | - M Kumar
- Department of Clinical Immunology, JIPMER, Pondicherry, India
| | - K G Chengappa
- Department of Clinical Immunology, JIPMER, Pondicherry, India
| | - R Gulati
- Endocrine Unit, Department of Medicine (DIMED), University of Padua, Padua, Italy
| | - V S Negi
- Department of Clinical Immunology, JIPMER, Pondicherry, India
| | - C Betterle
- Endocrine Unit, Department of Medicine (DIMED), University of Padua, Padua, Italy
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44
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Brady L, Kriner M, Coleman I, Morrissey C, Roudier M, True LD, Gulati R, Plymate SR, Zhou Z, Birditt B, Meredith R, Geiss G, Hoang M, Beechem J, Nelson PS. Inter- and intra-tumor heterogeneity of metastatic prostate cancer determined by digital spatial gene expression profiling. Nat Commun 2021; 12:1426. [PMID: 33658518 PMCID: PMC7930198 DOI: 10.1038/s41467-021-21615-4] [Citation(s) in RCA: 123] [Impact Index Per Article: 41.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Accepted: 02/04/2021] [Indexed: 02/08/2023] Open
Abstract
Metastatic prostate cancer (mPC) comprises a spectrum of diverse phenotypes. However, the extent of inter- and intra-tumor heterogeneity is not established. Here we use digital spatial profiling (DSP) technology to quantitate transcript and protein abundance in spatially-distinct regions of mPCs. By assessing multiple discrete areas across multiple metastases, we find a high level of intra-patient homogeneity with respect to tumor phenotype. However, there are notable exceptions including tumors comprised of regions with high and low androgen receptor (AR) and neuroendocrine activity. While the vast majority of metastases examined are devoid of significant inflammatory infiltrates and lack PD1, PD-L1 and CTLA4, the B7-H3/CD276 immune checkpoint protein is highly expressed, particularly in mPCs with high AR activity. Our results demonstrate the utility of DSP for accurately classifying tumor phenotype, assessing tumor heterogeneity, and identifying aspects of tumor biology involving the immunological composition of metastases. The inter- and intra-tumor heterogeneity of metastatic prostate cancer (mPC) is underexplored. Here the authors use Digital Spatial Profiling to study gene and protein expression heterogeneity in 27 mPC patients, finding variation in associated pathways and potential immunotherapy targets.
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Affiliation(s)
- Lauren Brady
- Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | | | - Ilsa Coleman
- Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | | | | | | | - Roman Gulati
- Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Stephen R Plymate
- University of Washington, Seattle, WA, USA.,VAPSHCS-GRECC, Seattle, WA, USA
| | - Zoey Zhou
- NanoString Technologies, Inc., Seattle, WA, USA
| | | | | | - Gary Geiss
- NanoString Technologies, Inc., Seattle, WA, USA
| | | | | | - Peter S Nelson
- Fred Hutchinson Cancer Research Center, Seattle, WA, USA. .,University of Washington, Seattle, WA, USA.
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45
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Lange J, Remmers S, Gulati R, Bill-Axelson A, Johansson JE, Kwiatkowski M, Auvinen A, Hugosson J, Hu JC, Roobol MJ, Carlsson SV, Etzioni R. Impact of cancer screening on metastasis: A prostate cancer case study. J Med Screen 2021; 28:480-487. [PMID: 33563084 DOI: 10.1177/0969141321989738] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Trials of cancer screening present results in terms of deaths prevented, but metastasis is also a key endpoint that screening seeks to prevent. We developed a framework for projecting overall (de novo and progressive) metastases prevented in a screening trial using prostate cancer screening as a case study. METHODS Mechanistic simulation model in which screening shifts a fraction of cases that would be metastatic at diagnosis to being non-metastatic. This shift increases the incidence of non-overdiagnosed, organ-confined cases. We use estimates of the risk of metastatic progression for these cases to project how many progress to metastasis after diagnosis and tally the projected de novo and progressive metastatic cases with and without screening. We use data on stage shift from the European Randomized Study of Screening for Prostate Cancer (ERSPC) and data on the risk of metastatic progression from the Scandinavian Prostate Cancer Group-4 trial. We estimate the relative risk and absolute risk reductions in metastatic disease at diagnosis and compare these with reductions in overall metastases. RESULTS Assuming no effect of screening beyond initial stage shift at diagnosis, the model projects a 43% reduction in metastasis at diagnosis but a 22% reduction in the cumulative probability of metastasis over 12 years in favor of screening. These results are consistent with the empirical findings from the ERSPC. CONCLUSION Any reduction in metastatic disease at diagnosis under screening is likely to be an overly optimistic predictor of the impact of screening on overall metastasis and disease-specific mortality.
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Affiliation(s)
- Jane Lange
- Division of Public Health Sciences, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Sebastiaan Remmers
- Department of Urology, Erasmus University Medical Centre, Rotterdam, the Netherlands
| | - Roman Gulati
- Division of Public Health Sciences, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Anna Bill-Axelson
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Jan-Erik Johansson
- Department of Urology, The School of Health and Medical Sciences Örebro, Örebro, Sweden.,Department of Urology, Örebro University Hospital, Örebro, Sweden
| | - Maciej Kwiatkowski
- Department of Urology, Cantonal Hospital Aarau, Aarau, Switzerland.,Medical Faculty, University of Basel, Basel, Switzerland.,Department of Urology, Academic Hospital Braunschweig, Braunschweig, Germany
| | - Anssi Auvinen
- Faculty of Social Sciences, Tampere University, Tampere, Finland
| | - Jonas Hugosson
- Department of Urology, Institute of Clinical Sciences, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
| | - Jim C Hu
- Department of Urology, New York Presbyterian Hospital, Weill Cornell Medicine, New York, NY, USA
| | - Monique J Roobol
- Department of Urology, Erasmus University Medical Centre, Rotterdam, the Netherlands
| | - Sigrid V Carlsson
- Department of Urology, Institute of Clinical Sciences, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden.,Departments of Surgery (Urology Service) and Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Ruth Etzioni
- Division of Public Health Sciences, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
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46
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Nyame YA, Gulati R, Tsodikov A, Gore JL, Etzioni R. Prostate-Specific Antigen Screening and Recent Increases in Advanced Prostate Cancer. JNCI Cancer Spectr 2020; 5:pkaa098. [PMID: 33442662 PMCID: PMC7791607 DOI: 10.1093/jncics/pkaa098] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Accepted: 10/12/2020] [Indexed: 12/18/2022] Open
Abstract
Recent studies show decreasing prostate-specific antigen utilization and increasing incidence of metastatic prostate cancer in the United States after national recommendations against screening in 2012. Yet, whether the increasing incidence of metastatic prostate cancer is consistent in magnitude with the expected impact of decreased screening is unknown. We compared observed incidence of metastatic prostate cancer from the Surveillance, Epidemiology, and End Results program and published effects of continued historical screening and discontinued screening starting in 2013 projected by 2 models of disease natural history, screening, and diagnosis. The observed rate of new metastatic prostate cancer cases in 2017 was 44%-60% of the projected increase under discontinued screening relative to continued screening. Thus, the observed increase in incident metastatic prostate cancer is consistent with the expected impact of reduced screening. Although this comparison does not establish a causal relationship, it highlights the plausible role of decreased screening in the observed trend.
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Affiliation(s)
- Yaw A Nyame
- Department of Urology, University of Washington Medical Center, Seattle, WA, USA.,Division of Public Health Sciences, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Roman Gulati
- Division of Public Health Sciences, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Alex Tsodikov
- School of Public Health, University of Michigan, Ann Arbor, MI, USA
| | - John L Gore
- Department of Urology, University of Washington Medical Center, Seattle, WA, USA.,Division of Public Health Sciences, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Ruth Etzioni
- Division of Public Health Sciences, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
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47
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Carlson AS, Acevedo RI, Lim DM, Gulati R, Gawne A, Sokolova AO, Cheng HH, Nelson PS, Montgomery RB, Yu EY, Schweizer MT. Impact of mutations in homologous recombination repair genes on treatment outcomes for metastatic castration resistant prostate cancer. PLoS One 2020; 15:e0239686. [PMID: 32997692 PMCID: PMC7526881 DOI: 10.1371/journal.pone.0239686] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Accepted: 08/14/2020] [Indexed: 12/11/2022] Open
Abstract
INTRODUCTION A significant proportion of patients with metastatic castration-resistant prostate cancer (mCRPC) harbor mutations in homologous recombination (HR) repair genes, with some of these mutations associating with increased tumor susceptibility to poly(ADP-ribose) polymerase (PARP) inhibitors and platinum-based chemotherapy. While mutations in some HR repair genes (e.g., BRCA1/2) have been associated with a more aggressive clinical course, prior studies correlating HR mutational status with treatment response to androgen receptor (AR) signaling inhibitors (ARSIs) or taxane-based chemotherapy have yielded conflicting results. METHODS We conducted a single-center retrospective analysis to assess clinical outcomes to conventional, regulatory-approved therapies in mCRPC patients with somatic (monoallelic and biallelic) and/or germline HR repair mutations compared to patients without alterations as determined by clinical-grade next-generation sequencing assays. The primary endpoint was PSA30/PSA50 response, defined as ≥30%/≥50% prostate-specific antigen (PSA) reduction from baseline. Secondary endpoints of PSA progression-free survival (pPFS) and clinical/radiographic progression-free survival (crPFS) were estimated using Kaplan-Meier methods. RESULTS A total of 90 consecutively selected patients were included in this analysis, of which 33 (37%) were identified to have HR repair gene mutations. Age, race, Gleason score, prior surgery, and receipt of prior radiation therapy were comparable between carriers and non-carriers. There was no evidence that PSA30/PSA50 differed by HR gene mutational status. Median pPFS and crPFS ranged 3-14 months across treatment modalities, but there was no evidence either differed by HR gene mutational status (all p>0.05). There was also no difference in outcomes between those with BRCA2 or PALB2 mutations (n = 17) compared to those without HR repair mutations. CONCLUSION HR gene mutational status was associated with comparable clinical outcomes following treatment with ARSIs or taxane-based chemotherapy. Additional prospective studies are needed to confirm these findings.
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Affiliation(s)
| | - Rigo I. Acevedo
- University of Washington, Seattle, WA, United States of America
| | - Daniel M. Lim
- University of Washington, Seattle, WA, United States of America
| | - Roman Gulati
- Division of Public Health Sciences, Fred Hutchinson Cancer Research Center, Seattle, WA, United States of America
| | - Agnes Gawne
- Division of Oncology, University of Washington, Seattle, WA, United States of America
| | - Alexandra O. Sokolova
- Division of Oncology, University of Washington, Seattle, WA, United States of America
- Division of Clinical Research, Fred Hutchinson Cancer Research Center, Seattle, WA, United States of America
| | - Heather H. Cheng
- Division of Oncology, University of Washington, Seattle, WA, United States of America
- Division of Clinical Research, Fred Hutchinson Cancer Research Center, Seattle, WA, United States of America
| | - Peter S. Nelson
- University of Washington, Seattle, WA, United States of America
- Division of Oncology, University of Washington, Seattle, WA, United States of America
- Division of Clinical Research, Fred Hutchinson Cancer Research Center, Seattle, WA, United States of America
- Division of Human Biology, Fred Hutchinson Cancer Research Center, Seattle, WA, United States of America
| | - R. Bruce Montgomery
- Division of Oncology, University of Washington, Seattle, WA, United States of America
- Division of Clinical Research, Fred Hutchinson Cancer Research Center, Seattle, WA, United States of America
| | - Evan Y. Yu
- Division of Oncology, University of Washington, Seattle, WA, United States of America
- Division of Clinical Research, Fred Hutchinson Cancer Research Center, Seattle, WA, United States of America
| | - Michael T. Schweizer
- Division of Oncology, University of Washington, Seattle, WA, United States of America
- Division of Clinical Research, Fred Hutchinson Cancer Research Center, Seattle, WA, United States of America
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Gulati R, Morgan TM, A'mar T, Psutka SP, Tosoian JJ, Etzioni R. Overdiagnosis and Lives Saved by Reflex Testing Men With Intermediate Prostate-Specific Antigen Levels. J Natl Cancer Inst 2020; 112:384-390. [PMID: 31225597 DOI: 10.1093/jnci/djz127] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2019] [Revised: 05/30/2019] [Accepted: 06/13/2019] [Indexed: 01/23/2023] Open
Abstract
BACKGROUND Several prostate cancer (PCa) early-detection biomarkers are available for reflex testing in men with intermediate prostate-specific antigen (PSA) levels. Studies of these biomarkers typically provide information about diagnostic performance but not about overdiagnosis and lives saved, the primary drivers of associated harm and benefit. METHODS We projected overdiagnoses and lives saved using an established microsimulation model of PCa incidence and mortality with screening and treatment efficacy based on randomized trials. We used this framework to evaluate four urinary reflex biomarkers (measured in 1112 men presenting for prostate biopsy at 10 US academic or community clinics) and two hypothetical ideal biomarkers (with 100% sensitivity or specificity for any or for high-grade PCa) at one-time screening tests at ages 55 and 65 years. RESULTS Compared with biopsying all men with elevated PSA, reflex testing reduced overdiagnoses (range across ages and biomarkers = 8.8-60.6%) but also reduced lives saved (by 7.3-64.9%), producing similar overdiagnoses per life saved. The ideal biomarker for high-grade disease improved this ratio (by 35.2% at age 55 years and 42.0% at age 65 years). Results were similar under continued screening for men not diagnosed at age 55 years, but the ideal biomarker for high-grade disease produced smaller incremental improvement. CONCLUSIONS Modeling is a useful tool for projecting the implications of using reflex biomarkers for long-term PCa outcomes. Under simplified conditions, reflex testing with urinary biomarkers is expected to reduce overdiagnoses but also produce commensurate reductions in lives saved. Reflex testing that accurately identifies high-grade PCa could improve the net benefit of screening.
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Affiliation(s)
- Roman Gulati
- Division of Public Health Sciences, Fred Hutchinson Cancer Research Center, Seattle, WA
| | | | - Teresa A'mar
- Division of Public Health Sciences, Fred Hutchinson Cancer Research Center, Seattle, WA.,Department of Urology, University of Michigan, Ann Arbor, MI
| | - Sarah P Psutka
- Department of Urology, University of Washington, Seattle, WA
| | | | - Ruth Etzioni
- Division of Public Health Sciences, Fred Hutchinson Cancer Research Center, Seattle, WA
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Affiliation(s)
- Jonathan E Shoag
- From the Department of Urology, Weill Cornell Medicine, New York (J.E.S., J.C.H.); and the Department of Urology, University of Washington (Y.A.N.), and the Division of Public Health Sciences, Fred Hutchinson Cancer Research Center (Y.A.N., R.G., R.E.) - both in Seattle
| | - Yaw A Nyame
- From the Department of Urology, Weill Cornell Medicine, New York (J.E.S., J.C.H.); and the Department of Urology, University of Washington (Y.A.N.), and the Division of Public Health Sciences, Fred Hutchinson Cancer Research Center (Y.A.N., R.G., R.E.) - both in Seattle
| | - Roman Gulati
- From the Department of Urology, Weill Cornell Medicine, New York (J.E.S., J.C.H.); and the Department of Urology, University of Washington (Y.A.N.), and the Division of Public Health Sciences, Fred Hutchinson Cancer Research Center (Y.A.N., R.G., R.E.) - both in Seattle
| | - Ruth Etzioni
- From the Department of Urology, Weill Cornell Medicine, New York (J.E.S., J.C.H.); and the Department of Urology, University of Washington (Y.A.N.), and the Division of Public Health Sciences, Fred Hutchinson Cancer Research Center (Y.A.N., R.G., R.E.) - both in Seattle
| | - Jim C Hu
- From the Department of Urology, Weill Cornell Medicine, New York (J.E.S., J.C.H.); and the Department of Urology, University of Washington (Y.A.N.), and the Division of Public Health Sciences, Fred Hutchinson Cancer Research Center (Y.A.N., R.G., R.E.) - both in Seattle
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50
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Ryser MD, Weaver DL, Zhao F, Worni M, Grimm LJ, Gulati R, Etzioni R, Hyslop T, Lee SJ, Hwang ES. Cancer Outcomes in DCIS Patients Without Locoregional Treatment. J Natl Cancer Inst 2020; 111:952-960. [PMID: 30759222 PMCID: PMC6748726 DOI: 10.1093/jnci/djy220] [Citation(s) in RCA: 67] [Impact Index Per Article: 16.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2018] [Revised: 10/26/2018] [Accepted: 11/29/2018] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND The vast majority of women diagnosed with ductal carcinoma in situ (DCIS) undergo treatment. Therefore, the risks of invasive progression and competing death in the absence of locoregional therapy are uncertain. METHODS We performed survival analyses of patient-level data from DCIS patients who did not receive definitive surgery or radiation therapy as recorded in the US National Cancer Institute's Surveillance, Epidemiology, and End Results program (1992-2014). Kaplan-Meier curves were used to estimate the net risk of subsequent ipsilateral invasive cancer. The cumulative incidences of ipsilateral invasive cancer, contralateral breast cancer, and death were estimated using competing risk methods. RESULTS A total of 1286 DCIS patients who did not undergo locoregional therapy were identified. Median age at diagnosis was 60 years (inter-quartile range = 51-74 years), with median follow-up of 5.5 years (inter-quartile range = 2.3-10.6 years). Among patients with tumor grade I/II (n = 547), the 10-year net risk of ipsilateral invasive breast cancer was 12.2% (95% confidence interval [CI] = 8.6% to 17.1%) compared with 17.6% (95% CI = 12.1% to 25.2%) among patients with tumor grade III (n = 244) and 10.1% (95% CI = 7.4% to 13.8%) among patients with unknown grade (n = 495). Among all patients, the 10-year cumulative incidences of ipsilateral invasive cancer, contralateral breast cancer, and all-cause mortality were 10.5% (95% CI = 8.5% to 12.4%), 3.9% (95% CI = 2.6% to 5.2%), and 24.1% (95% CI = 21.2% to 26.9%), respectively. CONCLUSION Despite limited data, our findings suggest that DCIS patients without locoregional treatment have a limited risk of invasive progression. Although the cohort is not representative of the general population of patients diagnosed with DCIS, the findings suggest that there may be overtreatment, especially among older patients and patients with elevated comorbidities.
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MESH Headings
- Adult
- Aged
- Aged, 80 and over
- Biomarkers, Tumor
- Breast Neoplasms/epidemiology
- Breast Neoplasms/mortality
- Breast Neoplasms/pathology
- Carcinoma, Intraductal, Noninfiltrating/epidemiology
- Carcinoma, Intraductal, Noninfiltrating/etiology
- Carcinoma, Intraductal, Noninfiltrating/mortality
- Carcinoma, Intraductal, Noninfiltrating/pathology
- Disease Progression
- Female
- Humans
- Middle Aged
- Neoplasm Grading
- Neoplasm Staging
- Prognosis
- SEER Program
- Survival Analysis
- Young Adult
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Affiliation(s)
- Marc D Ryser
- Correspondence to: Marc D. Ryser, PhD, Department of Population Health Sciences and Department of Mathematics, Duke University Medical Center, 215 Morris St., Durham, NC 27701 (e-mail: )
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