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Rothrock RJ, Ozair A, Avendano MC, Herrera S, Appel H, Ramos S, Starosciak AK, Leon-Ariza DS, Rubens M, McDermott MW, Ahluwalia MS, Mehta MP, Kotecha RR. Prophylactic Radiotherapy Of MInimally Symptomatic Spinal Disease (PROMISSeD): study protocol for a randomized controlled trial. Trials 2024; 25:41. [PMID: 38217032 PMCID: PMC10785467 DOI: 10.1186/s13063-023-07850-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2023] [Accepted: 12/03/2023] [Indexed: 01/14/2024] Open
Abstract
BACKGROUND Early palliative/pre-emptive intervention improves clinical outcomes and quality of life for patients with metastatic cancer. A previous signal-seeking randomized controlled trial (RCT) demonstrated that early upfront radiotherapy to asymptomatic or minimally symptomatic high-risk osseous metastases led to reduction in skeletal-related events (SREs), a benefit driven primarily by subgroup of high-risk spine metastasis. The current RCT aims to determine whether early palliative/pre-emptive radiotherapy in patients with high-risk, asymptomatic or minimally symptomatic spine metastases will lead to fewer SREs within 1 year. METHODS This is a single-center, parallel-arm, in-progress RCT in adults (≥ 18 years) with ECOG performance status 0-2 and asymptomatic or minimally symptomatic (not requiring opioids) high-risk spine metastases from histologically confirmed solid tumor malignancies with > 5 sites of metastatic disease on cross-sectional imaging. High-risk spine metastases are defined by the following: (a) bulkiest disease sites ≥ 2 cm; (b) junctional disease (occiput to C2, C7-T1, T12-L2, L5-S1); (c) posterior element involvement; or (d) vertebral body compression deformity > 50%. Patients are randomized 1:1 to receive either standard-of-care systemic therapy (arm 1) or upfront, early radiotherapy to ≤ 5 high-risk spine lesions plus standard-of-care systemic therapy (arm 2), in the form of 20-30 Gy of radiation in 2-10 fractions. The primary endpoint is SRE, a composite outcome including spinal fracture, spinal cord compression, need for palliative radiotherapy, interventional procedures, or spinal surgery. Secondary endpoints include (1) surrogates of health care cost, including the number and duration of SRE-related hospitalizations; (2) overall survival; (3) pain-free survival; and (4) quality of life. Study instruments will be captured pre-treatment, at baseline, during treatment, and at 1, 3, 6, 12, and 24 months post-treatment. The trial aims to accrue 74 patients over 2 years to achieve > 80% power in detecting difference using two-sample proportion test with alpha < 0.05. DISCUSSION The results of this RCT will demonstrate the value, if any, of early radiotherapy for high-risk spine metastases. The trial has received IRB approval, funding, and prospective registration (NCT05534321) and has been open to accrual since August 19, 2022. If positive, the trial will expand the scope and utility of spine radiotherapy. TRIAL REGISTRATION ClinicalTrials.Gov NCT05534321 . Registered September 9, 2022. TRIAL STATUS Version 2.0 of the protocol (2021-KOT-002), revised last on September 2, 2022, was approved by the WCG institutional review board (Study Number 1337188, IRB tracking number 20223735). The trial was first posted on ClinicalTrials.Gov on September 9, 2022 (NCT05534321). Patient enrollment commenced on August 19, 2022, and is expected to be completed in 2 years, likely by August 2024.
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Affiliation(s)
- Robert J Rothrock
- Office 1R203, Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL, 33176, USA
- Herbert Wertheim College of Medicine, Florida International University, Miami, FL, USA
- Miami Neuroscience Institute, Baptist Health South Florida, Miami, FL, USA
| | - Ahmad Ozair
- Office 1R203, Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL, 33176, USA
- Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - Maria C Avendano
- Office 1R203, Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL, 33176, USA
| | - Susana Herrera
- Office 1R203, Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL, 33176, USA
| | - Haley Appel
- Office 1R203, Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL, 33176, USA
| | - Suyen Ramos
- Office 1R203, Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL, 33176, USA
| | - Amy K Starosciak
- Office 1R203, Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL, 33176, USA
- Herbert Wertheim College of Medicine, Florida International University, Miami, FL, USA
| | - Daniel S Leon-Ariza
- Office 1R203, Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL, 33176, USA
| | - Muni Rubens
- Office 1R203, Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL, 33176, USA
| | - Michael W McDermott
- Herbert Wertheim College of Medicine, Florida International University, Miami, FL, USA
- Miami Neuroscience Institute, Baptist Health South Florida, Miami, FL, USA
| | - Manmeet S Ahluwalia
- Office 1R203, Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL, 33176, USA
- Herbert Wertheim College of Medicine, Florida International University, Miami, FL, USA
| | - Minesh P Mehta
- Office 1R203, Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL, 33176, USA
- Herbert Wertheim College of Medicine, Florida International University, Miami, FL, USA
| | - Rupesh R Kotecha
- Office 1R203, Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL, 33176, USA.
- Herbert Wertheim College of Medicine, Florida International University, Miami, FL, USA.
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Tatineni V, O'Shea PJ, Saxena S, Khosla AA, Ozair A, Kotecha RR, Jia X, Rauf Y, Murphy ES, Chao ST, Suh JH, Peereboom DM, Ahluwalia MS. Combination of EGFR-Directed Tyrosine Kinase Inhibitors (EGFR-TKI) with Radiotherapy in Brain Metastases from Non-Small Cell Lung Cancer: A 2010-2019 Retrospective Cohort Study. Cancers (Basel) 2023; 15:cancers15113015. [PMID: 37296975 DOI: 10.3390/cancers15113015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Revised: 05/17/2023] [Accepted: 05/22/2023] [Indexed: 06/12/2023] Open
Abstract
INTRODUCTION Traditionally, brain metastases have been treated with stereotactic radiosurgery (SRS), whole-brain radiation (WBRT), and/or surgical resection. Non-small cell lung cancers (NSCLC), over half of which carry EGFR mutations, are the leading cause of brain metastases. EGFR-directed tyrosine kinase inhibitors (TKI) have shown promise in NSCLC; but their utility in NSCLC brain metastases (NSCLCBM) remains unclear. This work sought to investigate whether combining EGFR-TKI with WBRT and/or SRS improves overall survival (OS) in NSCLCBM. METHODS A retrospective review of NSCLCBM patients diagnosed during 2010-2019 at a tertiary-care US center was performed and reported following the 'strengthening the reporting of observational studies in epidemiology' (STROBE) guidelines. Data regarding socio-demographic and histopathological characteristics, molecular attributes, treatment strategies, and clinical outcomes were collected. Concurrent therapy was defined as the combination of EGFR-TKI and radiotherapy given within 28 days of each other. RESULTS A total of 239 patients with EGFR mutations were included. Of these, 32 patients had been treated with WBRT only, 51 patients received SRS only, 36 patients received SRS and WBRT only, 18 were given EGFR-TKI and SRS, and 29 were given EGFR-TKI and WBRT. Median OS for the WBRT-only group was 3.23 months, for SRS + WBRT it was 3.17 months, for EGFR-TKI + WBRT 15.50 months, for SRS only 21.73 months, and for EGFR-TKI + SRS 23.63 months. Multivariable analysis demonstrated significantly higher OS in the SRS-only group (HR = 0.38, 95% CI 0.17-0.84, p = 0.017) compared to the WBRT reference group. There were no significant differences in overall survival for the SRS + WBRT combination cohort (HR = 1.30, 95% CI = 0.60, 2.82, p = 0.50), EGFR-TKIs and WBRT combination cohort (HR = 0.93, 95% CI = 0.41, 2.08, p = 0.85), or the EGFR-TKI + SRS cohort (HR = 0.46, 95% CI = 0.20, 1.09, p = 0.07). CONCLUSIONS NSCLCBM patients treated with SRS had a significantly higher OS compared to patients treated with WBRT-only. While sample-size limitations and investigator-associated selection bias may limit the generalizability of these results, phase II/III clinicals trials are warranted to investigate synergistic efficacy of EGFR-TKI and SRS.
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Affiliation(s)
- Vineeth Tatineni
- Rosa Ella Burkhart Brain Tumor and Neuro-Oncology Center, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH 44106, USA
| | - Patrick J O'Shea
- Rosa Ella Burkhart Brain Tumor and Neuro-Oncology Center, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH 44106, USA
- Case Western Reserve University School of Medicine, Cleveland, OH 44106, USA
| | - Shreya Saxena
- Miami Cancer Institute, Baptist Health South Florida, Miami, FL 33176, USA
| | - Atulya A Khosla
- Miami Cancer Institute, Baptist Health South Florida, Miami, FL 33176, USA
| | - Ahmad Ozair
- Miami Cancer Institute, Baptist Health South Florida, Miami, FL 33176, USA
| | - Rupesh R Kotecha
- Miami Cancer Institute, Baptist Health South Florida, Miami, FL 33176, USA
| | - Xuefei Jia
- Rosa Ella Burkhart Brain Tumor and Neuro-Oncology Center, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH 44106, USA
| | - Yasmeen Rauf
- Rosa Ella Burkhart Brain Tumor and Neuro-Oncology Center, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH 44106, USA
- Department of Medical Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH 44106, USA
- Division of Neuro-Oncology, University of North Carolina, Chapel Hill, NC 27599, USA
| | - Erin S Murphy
- Rosa Ella Burkhart Brain Tumor and Neuro-Oncology Center, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH 44106, USA
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH 44106, USA
| | - Samuel T Chao
- Rosa Ella Burkhart Brain Tumor and Neuro-Oncology Center, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH 44106, USA
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH 44106, USA
| | - John H Suh
- Rosa Ella Burkhart Brain Tumor and Neuro-Oncology Center, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH 44106, USA
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH 44106, USA
| | - David M Peereboom
- Rosa Ella Burkhart Brain Tumor and Neuro-Oncology Center, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH 44106, USA
- Department of Medical Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH 44106, USA
| | - Manmeet S Ahluwalia
- Miami Cancer Institute, Baptist Health South Florida, Miami, FL 33176, USA
- Herbert Wertheim College of Medicine, Florida International University, Miami, FL 33199, USA
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Ozair A, Bhat V, Alisch RS, Khosla AA, Kotecha RR, Odia Y, McDermott MW, Ahluwalia MS. DNA Methylation and Histone Modification in Low-Grade Gliomas: Current Understanding and Potential Clinical Targets. Cancers (Basel) 2023; 15:cancers15041342. [PMID: 36831683 PMCID: PMC9954183 DOI: 10.3390/cancers15041342] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Revised: 02/02/2023] [Accepted: 02/14/2023] [Indexed: 02/22/2023] Open
Abstract
Gliomas, the most common type of malignant primary brain tumor, were conventionally classified through WHO Grades I-IV (now 1-4), with low-grade gliomas being entities belonging to Grades 1 or 2. While the focus of the WHO Classification for Central Nervous System (CNS) tumors had historically been on histopathological attributes, the recently released fifth edition of the classification (WHO CNS5) characterizes brain tumors, including gliomas, using an integration of histological and molecular features, including their epigenetic changes such as histone methylation, DNA methylation, and histone acetylation, which are increasingly being used for the classification of low-grade gliomas. This review describes the current understanding of the role of DNA methylation, demethylation, and histone modification in pathogenesis, clinical behavior, and outcomes of brain tumors, in particular of low-grade gliomas. The review also highlights potential diagnostic and/or therapeutic targets in associated cellular biomolecules, structures, and processes. Targeting of MGMT promoter methylation, TET-hTDG-BER pathway, association of G-CIMP with key gene mutations, PARP inhibition, IDH and 2-HG-associated processes, TERT mutation and ARL9-associated pathways, DNA Methyltransferase (DNMT) inhibition, Histone Deacetylase (HDAC) inhibition, BET inhibition, CpG site DNA methylation signatures, along with others, present exciting avenues for translational research. This review also summarizes the current clinical trial landscape associated with the therapeutic utility of epigenetics in low-grade gliomas. Much of the evidence currently remains restricted to preclinical studies, warranting further investigation to demonstrate true clinical utility.
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Affiliation(s)
- Ahmad Ozair
- Miami Cancer Institute, Baptist Health South Florida, Miami, FL 33176, USA
- Faculty of Medicine, King George’s Medical University, Lucknow 226003, India
| | - Vivek Bhat
- St. John’s Medical College, Bangalore 560034, India
| | - Reid S. Alisch
- Department of Neurosurgery, University of Wisconsin-Madison, Madison, WI 53792, USA
| | - Atulya A. Khosla
- Miami Cancer Institute, Baptist Health South Florida, Miami, FL 33176, USA
| | - Rupesh R. Kotecha
- Miami Cancer Institute, Baptist Health South Florida, Miami, FL 33176, USA
- Herbert Wertheim College of Medicine, Florida International University, Miami, FL 33199, USA
| | - Yazmin Odia
- Miami Cancer Institute, Baptist Health South Florida, Miami, FL 33176, USA
- Herbert Wertheim College of Medicine, Florida International University, Miami, FL 33199, USA
| | - Michael W. McDermott
- Herbert Wertheim College of Medicine, Florida International University, Miami, FL 33199, USA
- Miami Neuroscience Institute, Baptist Health South Florida, Miami, FL 33176, USA
- Correspondence: (M.W.M.); (M.S.A.)
| | - Manmeet S. Ahluwalia
- Miami Cancer Institute, Baptist Health South Florida, Miami, FL 33176, USA
- Miami Neuroscience Institute, Baptist Health South Florida, Miami, FL 33176, USA
- Correspondence: (M.W.M.); (M.S.A.)
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Abstract
Brain metastases occur in almost one-third of adult patients with solid tumor malignancies and lead to considerable patient morbidity and mortality. The rising incidence of brain metastases has been ascribed to the development of better imaging and screening techniques and the formulation of better systemic therapies. Until recently, the multimodal management of brain metastases focused primarily on the utilization of neurosurgical techniques, with varying combinations of whole-brain radiation therapy and stereotactic radio-surgical procedures. Over the past 2 decades, in particular, the increment in knowledge pertaining to molecular genetics and the pathogenesis of brain metastases has led to significant developments in targeted therapies and immunotherapies. This review article highlights the recent updates in the management of brain metastases with an emphasis on novel systemic therapies.
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Affiliation(s)
- Karanvir Singh
- Division of Medical Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL, 33176, USA
| | - Shreya Saxena
- Division of Medical Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL, 33176, USA
| | - Atulya A Khosla
- Division of Medical Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL, 33176, USA
| | - Michael W McDermott
- Division of Neurosurgery, Miami Neuroscience Institute, Baptist Health South Florida, Miami, FL, 33176, USA
- Herbert Wertheim College of Medicine, Florida International University, Miami, FL, 33199, USA
| | - Rupesh R Kotecha
- Division of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL, 33176, USA
- Herbert Wertheim College of Medicine, Florida International University, Miami, FL, 33199, USA
| | - Manmeet S Ahluwalia
- Division of Medical Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL, 33176, USA.
- Herbert Wertheim College of Medicine, Florida International University, Miami, FL, 33199, USA.
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Kotecha RR, Mehta MP. Optimizing the radiotherapy treatment planning process for glioblastoma. Neurooncol Pract 2022; 9:351-353. [DOI: 10.1093/nop/npac051] [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: 11/14/2022] Open
Affiliation(s)
- Rupesh R Kotecha
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida , Miami, Florida , USA
- Herbert Wertheim College of Medicine, Florida International University , Miami, Florida , USA
| | - Minesh P Mehta
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida , Miami, Florida , USA
- Herbert Wertheim College of Medicine, Florida International University , Miami, Florida , USA
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Luo J, Wu S, Rizvi H, Zhang Q, Egger JV, Osorio JC, Schoenfeld AJ, Plodkowski AJ, Ginsberg MS, Callahan MK, Maher C, Shoushtari AN, Postow MA, Voss MH, Kotecha RR, Gupta A, Raja R, Kris MG, Hellmann MD. Deciphering radiological stable disease to immune checkpoint inhibitors. Ann Oncol 2022; 33:824-835. [PMID: 35533926 PMCID: PMC10001430 DOI: 10.1016/j.annonc.2022.04.450] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [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: 11/18/2021] [Revised: 04/17/2022] [Accepted: 04/19/2022] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND 'Stable disease (SD)' as per RECIST is a common but ambiguous outcome in patients receiving immune checkpoint inhibitors (ICIs). This study aimed to characterize SD and identify the subset of patients with SD who are benefiting from treatment. Understanding SD would facilitate drug development and improve precision in correlative research. PATIENTS AND METHODS A systematic review was carried out to characterize SD in ICI trials. SD and objective response were compared to proliferation index using The Cancer Genome Atlas gene expression data. To identify a subgroup of SD with outcomes mirroring responders, we examined a discovery cohort of non-small-cell lung cancer (NSCLC). Serial cutpoints of two variables, % best overall response and progression-free survival (PFS), were tested to define a subgroup of patients with SD with similar survival as responders. Results were then tested in external validation cohorts. RESULTS Among trials of ICIs (59 studies, 14 280 patients), SD ranged from 16% to 42% in different tumor types and was associated with disease-specific proliferation index (ρ = -0.75, P = 0.03), a proxy of tumor kinetics, rather than relative response to ICIs. In a discovery cohort of NSCLC [1220 patients, 313 (26%) with SD to ICIs], PFS ranged widely in SD (0.2-49 months, median 4.9 months). The subset with PFS >6 months and no tumor growth mirrored partial response (PR) minor (overall survival hazard ratio 1.0) and was proposed as the definition of SD responder. This definition was confirmed in two validation cohorts from trials of NSCLC treated with durvalumab and found to apply in tumor types treated with immunotherapy in which depth and duration of benefit were correlated. CONCLUSIONS RECIST-defined SD to immunotherapy is common, heterogeneous, and may largely reflect tumor growth rate rather than ICI response. In patients with NSCLC and SD to ICIs, PFS >6 months and no tumor growth may be considered 'SD responders'. This definition may improve the efficiency of and insight derivable from clinical and translational research.
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Affiliation(s)
- J Luo
- Thoracic Oncology Service, Memorial Sloan Kettering Cancer Center, New York, USA; Lowe Center for Thoracic Oncology, Dana-Farber Cancer Institute, Boston, USA; Department of Medicine, Harvard Medical School, Boston, USA
| | - S Wu
- Translational Medicine Oncology, AstraZeneca, Gaithersburg, USA
| | - H Rizvi
- Druckenmiller Center for Lung Cancer Research, Memorial Sloan Kettering Cancer Center, New York, USA
| | - Q Zhang
- Translational Medicine Oncology, AstraZeneca, Gaithersburg, USA
| | - J V Egger
- Druckenmiller Center for Lung Cancer Research, Memorial Sloan Kettering Cancer Center, New York, USA
| | - J C Osorio
- Thoracic Oncology Service, Memorial Sloan Kettering Cancer Center, New York, USA
| | - A J Schoenfeld
- Thoracic Oncology Service, Memorial Sloan Kettering Cancer Center, New York, USA; Department of Medicine, Weill Cornell Medical Center, New York, USA
| | - A J Plodkowski
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, USA
| | - M S Ginsberg
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, USA
| | - M K Callahan
- Department of Medicine, Weill Cornell Medical Center, New York, USA; Parker Institute for Cancer Immunotherapy at Memorial Sloan Kettering Cancer Center, New York, USA; Melanoma Service, Memorial Sloan Kettering Cancer Center, New York, USA
| | - C Maher
- Melanoma Service, Memorial Sloan Kettering Cancer Center, New York, USA
| | - A N Shoushtari
- Department of Medicine, Weill Cornell Medical Center, New York, USA; Melanoma Service, Memorial Sloan Kettering Cancer Center, New York, USA
| | - M A Postow
- Department of Medicine, Weill Cornell Medical Center, New York, USA; Melanoma Service, Memorial Sloan Kettering Cancer Center, New York, USA
| | - M H Voss
- Department of Medicine, Weill Cornell Medical Center, New York, USA; Genitourinary Oncology Service, Memorial Sloan Kettering Cancer Center, New York, USA
| | - R R Kotecha
- Department of Medicine, Weill Cornell Medical Center, New York, USA; Genitourinary Oncology Service, Memorial Sloan Kettering Cancer Center, New York, USA
| | - A Gupta
- Global Medicines Development, AstraZeneca, Gaithersburg, USA
| | - R Raja
- Translational Medicine Oncology, AstraZeneca, Gaithersburg, USA
| | - M G Kris
- Thoracic Oncology Service, Memorial Sloan Kettering Cancer Center, New York, USA; Department of Medicine, Weill Cornell Medical Center, New York, USA
| | - M D Hellmann
- Thoracic Oncology Service, Memorial Sloan Kettering Cancer Center, New York, USA; Department of Medicine, Weill Cornell Medical Center, New York, USA; Parker Institute for Cancer Immunotherapy at Memorial Sloan Kettering Cancer Center, New York, USA.
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Ledesma Vicioso N, Lin D, Gomez DR, Yang JT, Lee NY, Rimner A, Yamada Y, Zelefsky MJ, Kalman NS, Rutter CE, Kotecha RR, Mehta MP, Panoff JE, Chuong MD, Salner AL, Ostroff JS, Diamond LC, Mathis NJ, Cahlon O, Pfister DG, Zhang Z, Chino F, Tsai J, Gillespie EF. Implementation Strategies to Increase Clinical Trial Enrollment in a Community-Academic Partnership and Impact on Hispanic Representation: An Interrupted Time Series Analysis. JCO Oncol Pract 2022; 18:e780-e785. [PMID: 35544650 PMCID: PMC10166438 DOI: 10.1200/op.22.00037] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [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
PURPOSE Community-academic partnerships have the potential to improve access to clinical trials for under-represented minority patients who more often receive cancer treatment in community settings. In 2017, the Memorial Sloan Kettering (MSK) Cancer Center began opening investigator-initiated clinical trials in radiation oncology in targeted community-based partner sites with a high potential to improve diverse population accrual. This study evaluates the effectiveness of a set of implementation strategies for increasing overall community-based enrollment and the resulting proportional enrollment of Hispanic patients on trials on the basis of availability in community-based partner sites. METHODS An interrupted time series analysis evaluating implementation strategies was conducted from April 2018 to September 2021. Descriptive analysis ofHispanic enrollment on investigator-initiated randomized therapeutic radiation trials open at community-based sites was compared with those open only at themain academic center. RESULTS Overall, 84 patients were enrolled in clinical trials in the MSK Alliance, of which 48 (56%) identified as Hispanic. The quarterly patient enrollment pre- vs postimplementation increased from 1.39 (95% CI, -3.67 to 6.46) to 9.42 (95% CI, 2.05 to 16.78; P5 .017). In the investigator-initiated randomized therapeutic radiation trials open in the MSK Alliance, Hispanic representation was 11.5% and 35.9% in twometastatic trials and 14.2% in a proton versus photon trial. Inmatched trials open only at the main academic center, Hispanic representation was 5.6%, 6.0%, and 4.0%, respectively. CONCLUSION A combination of practice-level and physician-level strategies implemented at community-based partner sites was associated with increased clinical trial enrollment, which translated to improved Hispanic representation. This supports the role Q:2 of strategic community-academic partnerships in addressing disparities in clinical trial enrollment.
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Affiliation(s)
| | - Diana Lin
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Daniel R Gomez
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Jonathan T Yang
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Nancy Y Lee
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Andreas Rimner
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Yoshiya Yamada
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Michael J Zelefsky
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Noah S Kalman
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL
| | | | - Rupesh R Kotecha
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL
| | - Minesh P Mehta
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL
| | - Joseph E Panoff
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL
| | - Michael D Chuong
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL
| | | | - Jamie S Ostroff
- Department of Psychiatry and Behavioral Sciences, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Lisa C Diamond
- Immigrant Health and Cancer Disparities Service, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Noah J Mathis
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Oren Cahlon
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - David G Pfister
- Department of Medical Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Zhigang Zhang
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Fumiko Chino
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Jillian Tsai
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Erin F Gillespie
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
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Shah AY, Kotecha RR, Lemke EA, Chandramohan A, Chaim JL, Msaouel P, Xiao L, Gao J, Campbell MT, Zurita AJ, Wang J, Corn PG, Jonasch E, Motzer RJ, Sharma P, Voss MH, Tannir NM. Outcomes of patients with metastatic clear-cell renal cell carcinoma treated with second-line VEGFR-TKI after first-line immune checkpoint inhibitors. Eur J Cancer 2019; 114:67-75. [PMID: 31075726 DOI: 10.1016/j.ejca.2019.04.003] [Citation(s) in RCA: 81] [Impact Index Per Article: 16.2] [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: 12/19/2018] [Revised: 03/29/2019] [Accepted: 04/02/2019] [Indexed: 01/05/2023]
Abstract
BACKGROUND Immune checkpoint inhibitors (ICIs) are being increasingly utilised in the front-line (1L) setting of metastatic clear-cell renal cell carcinoma (mccRCC). Limited data exist on responses and survival on second-line (2L) vascular endothelial growth factor-receptor tyrosine kinase inhibitor (VEGFR-TKI) therapy after 1L ICI therapy. PATIENTS AND METHODS This is a retrospective study of mccRCC patients treated with 2L VEGFR-TKI after progressive disease (PD) with 1L ICI. Patients were treated at MD Anderson Cancer Center or Memorial Sloan Kettering Cancer Center between December 2015 and February 2018. Objective response was assessed by blinded radiologists' review using Response Evaluation Criteria in Solid Tumours v1.1. Descriptive statistics and Kaplan-Meier method were used. RESULTS Seventy patients were included in the analysis. Median age at mccRCC diagnosis was 59 years; 8 patients (11%) had international metastatic database consortium favourable-risk disease, 48 (69%) had intermediate-risk disease and 14 (20%) had poor-risk disease. As 1L therapy, 12 patients (17%) received anti-programmed death ligand-1 (PD-(L)1) monotherapy with nivolumab or atezolizumab, 33 (47%) received nivolumab plus ipilimumab and 25 (36%) received combination anti-PD-(L)1 plus bevacizumab. 2L TKI therapies included pazopanib, sunitinib, axitinib and cabozantinib. On 2L TKI therapy, one patient (1.5%) achieved a complete response, 27 patients (39.7%) a partial response and 36 patients (52.9%) stable disease. Median progression-free survival (mPFS) was 13.2 months (95% confidence interval: 10.1, NA). Forty-five percent of subjects required a dose reduction, and twenty-seven percent of patients discontinued treatment because of toxicity. CONCLUSIONS In this retrospective study of patients with mccRCC receiving 2L TKI monotherapy after 1L ICI, we observed 2L antitumour activity and tolerance comparable to historical data for 1L TKI.
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Affiliation(s)
- A Y Shah
- Department of Genitourinary Medical Oncology, MD Anderson Cancer Center, Houston, TX, USA.
| | - R R Kotecha
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - E A Lemke
- Department of Genitourinary Medical Oncology, MD Anderson Cancer Center, Houston, TX, USA
| | - A Chandramohan
- Department of Diagnostic Radiology, MD Anderson Cancer Center, Houston, TX, USA
| | - J L Chaim
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - P Msaouel
- Department of Genitourinary Medical Oncology, MD Anderson Cancer Center, Houston, TX, USA
| | - L Xiao
- Department of Biostatistics, MD Anderson Cancer Center, Houston, TX, USA
| | - J Gao
- Department of Genitourinary Medical Oncology, MD Anderson Cancer Center, Houston, TX, USA
| | - M T Campbell
- Department of Genitourinary Medical Oncology, MD Anderson Cancer Center, Houston, TX, USA
| | - A J Zurita
- Department of Genitourinary Medical Oncology, MD Anderson Cancer Center, Houston, TX, USA
| | - J Wang
- Department of Genitourinary Medical Oncology, MD Anderson Cancer Center, Houston, TX, USA
| | - P G Corn
- Department of Genitourinary Medical Oncology, MD Anderson Cancer Center, Houston, TX, USA
| | - E Jonasch
- Department of Genitourinary Medical Oncology, MD Anderson Cancer Center, Houston, TX, USA
| | - R J Motzer
- Genitourinary Oncology Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - P Sharma
- Department of Genitourinary Medical Oncology, MD Anderson Cancer Center, Houston, TX, USA
| | - M H Voss
- Genitourinary Oncology Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - N M Tannir
- Department of Genitourinary Medical Oncology, MD Anderson Cancer Center, Houston, TX, USA
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