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Gore JL, Follmer K, Reynolds J, Nash M, Anderson CB, Catto JWF, Chamie K, Daneshmand S, Dickstein R, Garg T, Gilbert SM, Guzzo TJ, Kamat AM, Kates MR, Lane BR, Lotan Y, Mansour AM, Master VA, Montgomery JS, Morris DS, Nepple KG, O'Neil BB, Patel S, Pohar K, Porten SP, Riggs SB, Sankin A, Scarpato KR, Shore ND, Steinberg GD, Strope SA, Taylor JM, Comstock BA, Kessler LG, Wolff EM, Smith AB. Interruptions in bladder cancer care during the COVID-19 public health emergency. Urol Oncol 2024; 42:116.e17-116.e21. [PMID: 38087711 DOI: 10.1016/j.urolonc.2023.11.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Revised: 10/19/2023] [Accepted: 11/10/2023] [Indexed: 03/23/2024]
Abstract
BACKGROUND Academic and community urology centers participating in a pragmatic clinical trial in non-muscle-invasive bladder cancer completed monthly surveys assessing restrictions in aspects of bladder cancer care due to the COVID-19 Public Health Emergency. Our objective was to describe pandemic-related restrictions on bladder cancer care. METHODS We invited 32 sites participating in a multicenter pragmatic bladder cancer trial to complete monthly surveys distributed through REDCap beginning in May 2020. These surveys queried sites on whether they were experiencing restrictions in the use of elective surgery, transurethral resection of bladder tumors (TURBT), radical cystectomy, office cystoscopy, and intravesical bacillus Calmette-Guerin (BCG) availability. Responses were collated with descriptive statistics. RESULTS Of 32 eligible sites, 21 sites had at least a 50% monthly response rate over the study period and were included in the analysis. Elective surgery was paused at 76% of sites in May 2020, 48% of sites in January 2021, and 52% of sites in January 2022. Over those same periods, coinciding with COVID-19 incidence waves, TURBT was restricted at 10%, 14%, and 14% of sites, respectively, radical cystectomy was restricted at 10%, 14%, and 19% of sites, respectively, and cystoscopy was restricted at 33%, 0%, and 10% of sites, respectively. CONCLUSIONS Bladder cancer care was minimally restricted compared with more pronounced restrictions seen in general elective surgeries during the COVID-19 pandemic.
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Affiliation(s)
- John L Gore
- Department of Urology, University of Washington, Seattle, WA.
| | - Kristin Follmer
- Department of Urology, University of Washington, Seattle, WA
| | - Jason Reynolds
- Department of Urology, University of Washington, Seattle, WA
| | - Michael Nash
- Department of Biostatistics, University of Washington, Seattle, WA
| | | | - James W F Catto
- Department of Urology, Sheffield Teaching Hospitals NHS (National Health Service) Foundation Trust, Sheffield, United Kingdom
| | - Karim Chamie
- Department of Urology, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Siamak Daneshmand
- Department of Urology, Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Rian Dickstein
- University of Maryland Medical Center, Baltimore Washington Medical Center, Glen Burnie, MD; Chesapeake Urology, Baltimore, MD
| | - Tullika Garg
- Department of Urology, Penn State Milton S. Hershey Medical Center, Hershey, PA
| | - Scott M Gilbert
- Division of Genitourinary Oncology, H.Lee Moffitt Cancer Center and Research Institute, Tampa FL
| | - Thomas J Guzzo
- Division of Urology, Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Ashish M Kamat
- Department of Urology, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Max R Kates
- Brady Urological Institute, Johns Hopkins Medical Institutions, Baltimore, MD; Johns Hopkins Greenberg Bladder Cancer Institute, Baltimore, MD
| | - Brian R Lane
- Division of Urology, Spectrum Health, Grand Rapids, MI
| | - Yair Lotan
- Department of Urology, University of Texas Southwestern Medical Center, Dallas, TX
| | - Ahmed M Mansour
- Department of Urology, University of Texas Health, San Antonio, TX
| | - Viraj A Master
- Department of Urology and Winship Cancer Institute, Emory University, Atlanta, GA
| | | | | | | | - Brock B O'Neil
- Division of Urology, Huntsman Cancer Institute, University of Utah, Salt Lake City, UT
| | - Sanjay Patel
- Department of Urology, University of Oklahoma, Oklahoma City, OK
| | - Kamal Pohar
- Department of Urology, The Ohio State University, Columbus, OH
| | - Sima P Porten
- Department of Urology, UCSF School of Medicine, San Francisco, CA
| | - Stephen B Riggs
- Department of Urology, Levine Cancer Institute, Atrium Health, Charlotte, NC
| | | | - Kristen R Scarpato
- Department of Urology, Vanderbilt University Medical Center, Nashville, TN
| | - Neal D Shore
- Carolina Urologic Research Center, Myrtle Beach, SC
| | - Gary D Steinberg
- Department of Urology, Rush University Medical Center, Chicago, IL
| | | | - Jennifer M Taylor
- Michael E. DeBakey VAMC, Scott Department of Urology, Baylor College of Medicine, Houston, TX
| | - Bryan A Comstock
- Department of Biostatistics, University of Washington, Seattle, WA
| | - Larry G Kessler
- Department of Health Systems and Population Health, School of Public Health, University of Washington, Seattle, WA
| | - Erika M Wolff
- Department of Urology, University of Washington, Seattle, WA
| | - Angela B Smith
- Department of Urology, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC
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Huelster HL, Mason NT, Davaro F, Naqvi SMH, Kim Y, Gilbert SM. Cost-Utility of Initial Management of High-grade T1 Bladder Cancer with Intravesical BCG vs Immediate Radical Cystectomy. Urology 2024:S0090-4295(24)00126-2. [PMID: 38467285 DOI: 10.1016/j.urology.2024.02.033] [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: 11/29/2023] [Revised: 01/27/2024] [Accepted: 02/21/2024] [Indexed: 03/13/2024]
Abstract
OBJECTIVES To compare the cost-utility of initial management of high-grade T1 non-muscle invasive bladder cancer (HGT1 NMIBC) with intravesical BCG versus immediate radical cystectomy. High risk NMIBC patients may climb a costly ladder of treatments, culminating in radical cystectomy for oncologic or symptomatic benefit in up to one-third. This high healthcare resource utilization presents a challenging dilemma in balancing sufficiently aggressive management with cost, toxicity, and quality-of-life. METHODS Cost-utility of initially managing HGT1 with intravesical BCG and early radical cystectomy with ileal conduit urinary diversion was compared using decision-analytic Markov models. Five-year oncologic outcomes, adverse event rates, and published utility values were extracted from literature. Costs were calculated from a US Medicare perspective in 2021 US dollars. Sensitivity analysis identified drivers of cost and break-even points for recurrence and progression. RESULTS Mean costs were $26,093 for intravesical BCG and $39,720 for immediate radical cystectomy, though cystectomy generated a gain of 2.2 QALYs compared to intravesical BCG. Immediate cystectomy was a more cost-effective management strategy for HGT1 NMIBC with an ICER of $7120/QALY. The costs associated with cystectomy, TURBT, and BCG toxicity had the greatest impact on ICER. One-way sensitivity analysis demonstrated that intravesical BCG became a cost-effective management strategy if the five-year recurrence rate of HG T1 was less than 56% or the five-year progression rate to MIBC was less than 4%. CONCLUSIONS At current prices, treatment of high-grade T1 NMIBC with early radical cystectomy is more cost-effective management strategy than initial treatment with intravesical BCG.
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Affiliation(s)
- Heather L Huelster
- Department of Genitourinary Oncology, H Lee Moffitt Cancer Center and Research Institute, Tampa, FL, 33612, USA; Department of Urology, Indiana University Health, Indianapolis, IN 46202, USA.
| | - Neil T Mason
- Department of Individualized Cancer Medicine, H Lee Moffitt Cancer Center and Research Institute, Tampa, FL 33612, USA
| | - Facundo Davaro
- Department of Genitourinary Oncology, H Lee Moffitt Cancer Center and Research Institute, Tampa, FL, 33612, USA
| | | | - Youngchul Kim
- Department of Biostatistics, H Lee Moffitt Cancer Center and Research Institute, Tampa, FL 33612, USA
| | - Scott M Gilbert
- Department of Genitourinary Oncology, H Lee Moffitt Cancer Center and Research Institute, Tampa, FL, 33612, USA
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Grassauer J, Schmidt J, Cowan A, Gilbert SM, Chakiryan NH. Downstaging and Survival Associated with Neoadjuvant Immunotherapy Before Radical Cystectomy for Muscle-invasive Bladder Cancer. Eur Urol Oncol 2024; 7:139-146. [PMID: 37453853 DOI: 10.1016/j.euo.2023.06.005] [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: 01/31/2023] [Revised: 06/11/2023] [Accepted: 06/14/2023] [Indexed: 07/18/2023]
Abstract
BACKGROUND Neoadjuvant cisplatin-containing chemotherapy before radical cystectomy is the standard of care for patients with localized muscle-invasive bladder cancer (MIBC). However, a large proportion of patients are ineligible for cisplatin. Single-arm phase 2 neoadjuvant immunotherapy trials have reported promising tumor response rates, but interpretation is limited owing to lack of a comparator arm. OBJECTIVE To compare rates of pathologic downstaging and overall survival between patients receiving neoadjuvant immunotherapy (NAI), neoadjuvant chemotherapy (NAC), or no neoadjuvant therapy (NNAT). DESIGN, SETTING, AND PARTICIPANTS We identified 18 483 patients in the National Cancer Data Base who were diagnosed with clinically localized MIBC and underwent radical cystectomy from 2014 to 2019. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS Nearest-neighbor propensity-score caliper matching was used to create three demographically similar and equally sized cohorts stratified by NAT receipt. Logistic regression was used to examine the association of treatment received with pathologic downstaging to pT0N0 and pT < 2N0. Cox proportional-hazards regression was used to assess the association of treatment received with overall survival (OS). RESULTS AND LIMITATIONS Propensity score matching yielded three equally sized cohorts without significant differences in baseline characteristics (n = 840). The NAI group had a higher rate of pathologic downstaging to pT0N0 than the NNAT group and a similar rate to the NAC group (NNAT 6.7% vs NAC 26.4%, odds ratio 5.0, 95% confidence interval [CI] 2.9-8.3; NAI 22.5%, odds ratio 4.0, 95% CI 2.4-7.1). The NAI group had better OS than the NNAT group and similar OS to the NAC group (NAC: hazard ratio 0.62, 95% CI 0.42-0.92; NAI: hazard ratio 0.68, 95% CI 0.46-0.97, with NNAT as the reference). The primary limitation is selection bias from confounding by clinical indication. CONCLUSIONS NAI is a promising alternative to NAC for patients with clinically localized MIBC, as evidenced by similar pathologic downstaging rates and OS benefits in comparison to no NAT. Phase 3 trials should be conducted to test the noninferiority of NAI to NAC. PATIENT SUMMARY We compared outcomes for patients with muscle-invasive bladder cancer according to whether they received chemotherapy, immunotherapy, or no medical therapy before surgical removal of their bladder. We found that preoperative immunotherapy improved patient survival and regression of the cancer stage in comparison to no medical therapy, similar to the outcomes seen with preoperative chemotherapy. Randomized clinical trials are needed to confirm these findings.
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Affiliation(s)
- Jacob Grassauer
- Department of Urology, Oregon Health & Science University, Portland, OR, USA
| | - Jackson Schmidt
- Department of Urology, Oregon Health & Science University, Portland, OR, USA.
| | - Andrew Cowan
- Department of Urology, Oregon Health & Science University, Portland, OR, USA
| | - Scott M Gilbert
- Department of Genitourinary Oncology, Moffitt Cancer Center, Tampa, FL, USA
| | - Nicholas H Chakiryan
- Department of Urology, Oregon Health & Science University, Portland, OR, USA; Department of Urology, Portland VA Medical Center, Portland, OR, USA; Translational Oncology Program, Knight Cancer Institute, Portland, OR, USA
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Li R, Nocera L, Rose KM, Raggi D, Naidu S, Mercinelli C, Cigliola A, Tateo V, Patanè D, Grass GD, Gilbert SM, Sexton WJ, Bandini M, Moschini M, Briganti A, Montorsi F, Spiess PE, Necchi A. Comparative Effectiveness of Neoadjuvant Pembrolizumab Versus Cisplatin-based Chemotherapy or Upfront Radical Cystectomy in Patients with Muscle-invasive Urothelial Bladder Cancer. Eur Urol Oncol 2024:S2588-9311(23)00296-1. [PMID: 38184473 DOI: 10.1016/j.euo.2023.12.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Revised: 11/21/2023] [Accepted: 12/23/2023] [Indexed: 01/08/2024]
Abstract
BACKGROUND Recent progresses in the use of immune checkpoint inhibitor (ICI) have challenged the therapeutic standards in patients with muscle-invasive urothelial bladder carcinoma (MIBC). OBJECTIVE To compare neoadjuvant pembrolizumab followed by radical cystectomy (RC) versus neoadjuvant chemotherapy (NAC) and RC or upfront RC, according to cisplatin eligibility. DESIGN, SETTING, AND PARTICIPANTS We conducted two separate analyses for cisplatin-eligible and cisplatin-ineligible cT2-4N0M0 MIBC patients. We used a propensity score adjustment that relied on inverse probability of treatment-weighting (IPTW). INTERVENTION Pembrolizumab within the PURE-01 trial, and NAC and RC or upfront RC from a high-volume tertiary care referral center. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS The primary endpoint in both analyses was event-free survival (EFS), defined as freedom from recurrence, and/or death from any cause indexed from the date of treatment initiation or RC. The secondary endpoints included EFS in propensity score-matched patients, pathologic response rate, and recurrence-free survival (RFS) after RC. RESULTS AND LIMITATIONS A total of 458 patients who underwent RC, with or without NAC, at Moffitt Cancer Center between October 2005 and October 2020, and 146 patients enrolled in PURE-01 were analyzed. In cisplatin-ineligible patients, EFS was superior in those receiving pembrolizumab (p < 0.001). The estimated 3-yr EFS was 77.8% (95% confidence interval [CI]: 63.5-95.2) for pembrolizumab and RC, and 36.1% (95% CI: 28.6-45.5) for upfront RC. EFS remained superior in those receiving neoadjuvant ICI (NICI) following IPTW (p < 0.001). In cisplatin-eligible patients, EFS was superior in those receiving pembrolizumab and RC (p < 0.001). The estimated 3-yr EFS was 86.9% (95% CI: 80.9-93.3) for pembrolizumab and 63.5% (95% CI: 56.5-71.4) for NAC. EFS remained superior in those receiving NICI following IPTW (p < 0.001). Pathologic responses and RFS in pembrolizumab-treated patients were also superior to those in NAC-treated patients. Results are limited by the retrospective nature of the study. CONCLUSIONS In the first ever reported comprehensive comparison of outcomes between neoadjuvant ICI and NAC, followed by RC, or upfront RC, we report increased responses and improved oncologic outcomes with neoadjuvant ICI in patients with MIBC. PATIENT SUMMARY We compared the results obtained from the use of pembrolizumab and radical cystectomy with standard-of-care treatments in patients with bladder carcinoma infiltrating the muscle layer. We reported increased response and survival rates possibilities with the use of immunotherapy, anticipating the possibility to set new therapeutic standards in these patients, pending the results of ongoing randomized studies.
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Affiliation(s)
- Roger Li
- Department of Genitourinary Oncology, Moffitt Cancer Center, Tampa, FL, USA.
| | - Luigi Nocera
- Department of Urology, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Kyle M Rose
- Department of Genitourinary Oncology, Moffitt Cancer Center, Tampa, FL, USA
| | - Daniele Raggi
- Department of Medical Oncology, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Shreyas Naidu
- Department of Genitourinary Oncology, Moffitt Cancer Center, Tampa, FL, USA
| | - Chiara Mercinelli
- Department of Medical Oncology, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Antonio Cigliola
- Department of Medical Oncology, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Valentina Tateo
- Department of Medical Oncology, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Damiano Patanè
- Department of Medical Oncology, IRCCS Ospedale San Raffaele, Milan, Italy
| | - G Daniel Grass
- Department of Genitourinary Oncology, Moffitt Cancer Center, Tampa, FL, USA
| | - Scott M Gilbert
- Department of Genitourinary Oncology, Moffitt Cancer Center, Tampa, FL, USA
| | - Wade J Sexton
- Department of Genitourinary Oncology, Moffitt Cancer Center, Tampa, FL, USA
| | - Marco Bandini
- Department of Urology, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Marco Moschini
- Department of Urology, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Alberto Briganti
- Department of Urology, IRCCS Ospedale San Raffaele, Milan, Italy; Department of Medical Oncology, IRCCS Ospedale San Raffaele, Milan, Italy; Vita-Salute San Raffaele University, Milan, Italy
| | - Francesco Montorsi
- Department of Urology, IRCCS Ospedale San Raffaele, Milan, Italy; Vita-Salute San Raffaele University, Milan, Italy
| | - Philippe E Spiess
- Department of Genitourinary Oncology, Moffitt Cancer Center, Tampa, FL, USA
| | - Andrea Necchi
- Department of Genitourinary Oncology, Moffitt Cancer Center, Tampa, FL, USA; Vita-Salute San Raffaele University, Milan, Italy
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Gore JL, Wolff EM, Comstock BA, Follmer KM, Nash MG, Basu A, Chisolm S, MacLean DB, Lee JR, Lotan Y, Porten SP, Steinberg GD, Chang SS, Gilbert SM, Kessler LG, Smith AB. Protocol of the Comparison of Intravesical Therapy and Surgery as Treatment Options (CISTO) study: a pragmatic, prospective multicenter observational cohort study of recurrent high-grade non-muscle invasive bladder cancer. BMC Cancer 2023; 23:1127. [PMID: 37980511 PMCID: PMC10657633 DOI: 10.1186/s12885-023-11605-8] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Accepted: 11/02/2023] [Indexed: 11/20/2023] Open
Abstract
BACKGROUND Bladder cancer poses a significant public health burden, with high recurrence and progression rates in patients with non-muscle-invasive bladder cancer (NMIBC). Current treatment options include bladder-sparing therapies (BST) and radical cystectomy, both with associated risks and benefits. However, evidence supporting optimal management decisions for patients with recurrent high-grade NMIBC remains limited, leading to uncertainty for patients and clinicians. The CISTO (Comparison of Intravesical Therapy and Surgery as Treatment Options) Study aims to address this critical knowledge gap by comparing outcomes between patients undergoing BST and radical cystectomy. METHODS The CISTO Study is a pragmatic, prospective observational cohort trial across 36 academic and community urology practices in the US. The study will enroll 572 patients with a diagnosis of recurrent high-grade NMIBC who select management with either BST or radical cystectomy. The primary outcome is health-related quality of life (QOL) at 12 months as measured with the EORTC-QLQ-C30. Secondary outcomes include bladder cancer-specific QOL, progression-free survival, cancer-specific survival, and financial toxicity. The study will also assess patient preferences for treatment outcomes. Statistical analyses will employ targeted maximum likelihood estimation (TMLE) to address treatment selection bias and confounding by indication. DISCUSSION The CISTO Study is powered to detect clinically important differences in QOL and cancer-specific survival between the two treatment approaches. By including a diverse patient population, the study also aims to assess outcomes across the following patient characteristics: age, gender, race, burden of comorbid health conditions, cancer severity, caregiver status, social determinants of health, and rurality. Treatment outcomes may also vary by patient preferences, health literacy, and baseline QOL. The CISTO Study will fill a crucial evidence gap in the management of recurrent high-grade NMIBC, providing evidence-based guidance for patients and clinicians in choosing between BST and radical cystectomy. The CISTO study will provide an evidence-based approach to identifying the right treatment for the right patient at the right time in the challenging clinical setting of recurrent high-grade NMIBC. TRIAL REGISTRATION ClinicalTrials.gov, NCT03933826. Registered on May 1, 2019.
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Affiliation(s)
- John L Gore
- Department of Urology, University of Washington, Seattle, WA, USA.
| | - Erika M Wolff
- Department of Urology, University of Washington, Seattle, WA, USA
| | - Bryan A Comstock
- Department of Biostatistics, University of Washington, Seattle, WA, USA
| | | | - Michael G Nash
- Department of Biostatistics, University of Washington, Seattle, WA, USA
| | - Anirban Basu
- Departments of Pharmacy, Health Services, and Economics, University of Washington, Seattle, WA, USA
| | | | | | - Jenney R Lee
- Department of Urology, University of Washington, Seattle, WA, USA
| | - Yair Lotan
- Department of Urology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Sima P Porten
- Department of Urology, UCSF School of Medicine, San Francisco, CA, USA
| | - Gary D Steinberg
- Department of Urology, Rush University Medical Center, Chicago, IL, USA
| | - Sam S Chang
- Department of Urology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Scott M Gilbert
- Department of Genitourinary Oncology, H. Lee Moffit Cancer Center and Research Institute, Tampa, FL, USA
| | - Larry G Kessler
- Department of Health Systems and Population Health, School of Public Health, University of Washington, Seattle, WA, USA
| | - Angela B Smith
- Department of Urology, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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Amorrortu RP, Zhao Y, Keenan RJ, Gilbert SM, Rollison DE. Factors Associated with Self-reported COVID-19 Infection and Hospitalization among Patients Seeking Care at a Comprehensive Cancer Center. J Racial Ethn Health Disparities 2023:10.1007/s40615-023-01855-4. [PMID: 37917235 DOI: 10.1007/s40615-023-01855-4] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Revised: 10/23/2023] [Accepted: 10/27/2023] [Indexed: 11/04/2023]
Abstract
BACKGROUND COVID-19 infection severity differs by race and ethnicity, but its long-term effect on cancer-related outcomes is unknown. Therefore, information on COVID-19 history is critical to ascertain among new cancer patients in order to advance research on its impact on cancer outcomes and potentially related health disparities. METHODS A cross-sectional study was conducted among 16,025 new patients seeking care at Moffitt Cancer Center (MCC) between 2021 and 2022. Patient self-reported histories of COVID-19 infection and other pre-existing health conditions were obtained from electronic questionnaires administered to all new MCC patients. Associations between demographics and COVID-19 infection and hospitalization were examined. RESULTS A total of 1,971 patients (12.3%) reported ever having COVID-19. Self-reported COVID-19 history was significantly more prevalent in Hispanic vs. non-Hispanic patients (OR = 1.24, 1.05-1.45) and less prevalent in Asian versus White patients (OR = 0.49, 95% 0.33-0.70). Among patients who ever had COVID-19, 10.6% reported a COVID-19-related hospitalization. Males had higher odds of a COVID-19 related hospitalization than females (OR = 1.50, 95% CI = 1.09-2.05), as did Black/African American patients (OR = 2.11, 95% CI = 1.18-3.60) and patients of races other than Black/African American and Asian (OR = 2.61, 95% CI = 1.43-4.54) compared to White patients. Hispanic patients also experienced higher odds of hospitalization (OR = 2.06, 95% CI-1.29- 3.23) compared with non-Hispanic patients of all races in a sensitivity analysis that combined race/ethnicity. Pre-existing lung and breathing problems were associated with higher odds of being hospitalized with COVID-19 (OR = 2.38, 95% CI = 1.61-3.48), but these and other health conditions did not explain the observed associations between race and COVID-19 hospitalization. CONCLUSIONS Higher rates of COVID-19 hospitalization were observed among patients identifying as Black/African American or Hispanic independent of pre-existing health conditions. Future studies evaluating long-term effects of COVID-19 should carefully examine potential racial/ethnic disparities in cancer outcomes.
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Affiliation(s)
- Rossybelle P Amorrortu
- Department of Cancer Epidemiology, Moffitt Cancer Center, 12902 Magnolia Drive, CSB 8th 8108, Tampa, FL, 33612, USA
| | - Yayi Zhao
- Department of Cancer Epidemiology, Moffitt Cancer Center, 12902 Magnolia Drive, CSB 8th 8108, Tampa, FL, 33612, USA
| | - Robert J Keenan
- Department of Thoracic Oncology, Moffitt Cancer Center, Tampa, FL, USA
| | - Scott M Gilbert
- Department of Health Outcomes and Behavior, Moffitt Cancer Center, Tampa, FL, USA
- Department of Genitourinary Oncology, Moffitt Cancer Center, Tampa, FL, USA
| | - Dana E Rollison
- Department of Cancer Epidemiology, Moffitt Cancer Center, 12902 Magnolia Drive, CSB 8th 8108, Tampa, FL, 33612, USA.
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Li R, Naidu S, Fan W, Rose K, Huelster H, Grass GD, Vosoughi A, Dhillon J, Kim Y, Gupta S, Jain RK, Zhang J, Zemp L, Yu A, Poch MA, Spiess PE, Pow-Sang J, Gilbert SM, Sexton WJ. Effectiveness of perioperative chemotherapy and radical cystectomy in treating bladder cancer. Urol Oncol 2023; 41:457.e17-457.e24. [PMID: 37880002 DOI: 10.1016/j.urolonc.2023.09.017] [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: 03/05/2023] [Revised: 09/04/2023] [Accepted: 09/26/2023] [Indexed: 10/27/2023]
Abstract
BACKGROUND Despite abundant evidence supporting the use of perioperative chemotherapy from clinical trials, no study to date has comprehensively evaluated its use in the treatment of muscle-invasive bladder cancer (MIBC) in the real-world setting. Little is known regarding the impact of pretreatment disease stage and real-world factors such as patient comorbidities preventing timely completion of therapy on its effectiveness. This study aims to assess the usage of perioperative chemotherapy and examines its impact on pathologic downstaging rates and recurrence free survival in patients undergoing radical cystectomy. METHODS A retrospective review was conducted in 805 patients with muscle invasive bladder cancer undergoing radical cystectomy with no perioperative chemotherapy, 761 with presurgical chemotherapy followed by radical cystectomy, and 134 radical cystectomy followed by adjuvant chemotherapy. Relevant clinicopathologic features were reviewed. Recurrence-free survival and Overall Survival probability estimates were calculated using the Kaplan-Meier method and compared using the Log-rank or Gehan-Breslow tests. The prognostic effects of presurgical chemotherapy and adjuvant chemotherapy regimens were evaluated by estimating hazard ratio and 95% confidence interval from an adjusted Cox proportional hazards model. Statistical tests were 2-sided, and significance was defined as P-value < 0.05. RESULTS In this contemporary, real-world cohort, 5-yr RFS was found to be 65.6% in pT0, 59.1%in pT2, and 10.8% in pN+ patients. Presurgical chemotherapy increased pathologic downstaging rates from 27.5% to 41.1% in patients with ≥cT2 BCa. Stratified by clinical T-stage, only cT2 patients derived recurrence-free survival (Median 45.3 months vs. 29.0 months, P < 0.01) and overall survival (Median 62.3 months vs. 41.9 months, P < 0.001) benefits. In patients with adverse pathologic features (≥pT3 or pN+), adjuvant chemotherapy improved recurrence-free survival (Median 22.8 months vs. 10.0 months, P < 0.0001) and overall survival (Median OS 32.4 months vs. 16.3 months, P < 0.0001). CONCLUSIONS We report real-world outcomes from a large cohort of muscle-invasive bladder cancer patients undergoing surgical treatment with/out perioperative chemotherapy. Pathologic response rates to pre-surgical chemotherapy were modest and led to clinical benefit only in cT2 patients. Adjuvant chemotherapy provided survival benefit for pathologically advanced MIBC patients irrespective of pT/N staging.
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Affiliation(s)
- Roger Li
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center, Tampa, FL; Department of Immunology, H. Lee Moffitt Cancer Center, Tampa, FL.
| | - Shreyas Naidu
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center, Tampa, FL; Department of Immunology, H. Lee Moffitt Cancer Center, Tampa, FL
| | - Wenyi Fan
- Biostatistics and Bioinformatics Shared Resource, H. Lee Moffitt Cancer Center, Tampa, FL
| | - Kyle Rose
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center, Tampa, FL
| | - Heather Huelster
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center, Tampa, FL
| | - George Daniel Grass
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center, Tampa, FL
| | - Aram Vosoughi
- Department of Pathology, H. Lee Moffitt Cancer Center, Tampa, FL
| | - Jasreman Dhillon
- Department of Pathology, H. Lee Moffitt Cancer Center, Tampa, FL
| | - Youngchul Kim
- Biostatistics and Bioinformatics Shared Resource, H. Lee Moffitt Cancer Center, Tampa, FL
| | - Shilpa Gupta
- Cleveland Clinic Taussig Cancer Institute, Cleveland, OH
| | - Rohit K Jain
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center, Tampa, FL
| | - Jingsong Zhang
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center, Tampa, FL
| | - Logan Zemp
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center, Tampa, FL
| | - Alice Yu
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center, Tampa, FL
| | - Michael A Poch
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center, Tampa, FL
| | - Philippe E Spiess
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center, Tampa, FL
| | - Julio Pow-Sang
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center, Tampa, FL
| | - Scott M Gilbert
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center, Tampa, FL
| | - Wade J Sexton
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center, Tampa, FL
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8
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Li R, Sexton WJ, Dhillon J, Berglund A, Naidu S, Borjas G, Rose K, Kim Y, Wang X, Conejo-Garcia JR, Jain RK, Poch MA, Spiess PE, Pow-Sang J, Gilbert SM, Zhang J. A Phase II Study of Durvalumab for Bacillus Calmette-Guerin (BCG) Unresponsive Urothelial Carcinoma In Situ of the Bladder. Clin Cancer Res 2023; 29:3875-3881. [PMID: 37505486 DOI: 10.1158/1078-0432.ccr-23-0354] [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: 02/04/2023] [Revised: 05/04/2023] [Accepted: 07/26/2023] [Indexed: 07/29/2023]
Abstract
PURPOSE Immune checkpoint blockade holds promise for treating bacillus Calmette-Guerin (BCG)-unresponsive non-muscle-invasive bladder cancer (NMIBC). In this phase II study, we investigated the safety and efficacy of durvalumab, a human IgG1 monoclonal antibody, against BCG-unresponsive carcinoma in situ (CIS). PATIENTS AND METHODS Patients with BCG-unresponsive CIS-containing NMIBC received durvalumab IV at 1,500 mg every 4 weeks for up to 12 months. The primary endpoint was complete response (CR) rate at month 6, defined by negative cystoscopy, urine cytology, and absence of high-grade recurrence on bladder mapping biopsy. The null hypothesis specified a CR rate of 18% and alternative hypothesis of 40%. According to the Simon two-stage design, if ≤3/13 patients achieved CR during stage 1, the trial is stopped due to futility. RESULTS Between March 8, 2017, and January 24, 2020, 17 patients were accrued whereas 4 withdrew from study treatment after bladder biopsy at month 3 was positive for CIS. Two of 17 (12%) achieved a CR at month 6, with duration of response of 10 and 18 months, respectively. A single grade 3 lipase elevation was attributed to durvalumab, and immune-related adverse events were observed in 7/17 (41%) patients. Only 1/17 patients had high programmed death-ligand 1 expression pretreatment. On RNA sequencing, complement activation genes were elevated posttreatment, along with enrichment of tumor-associated macrophage signature. CONCLUSIONS Durvalumab monotherapy conferred minimal efficacy in treating BCG-unresponsive CIS of the bladder, with 6-month CR of 12%. Complement activation is a potential mechanism behind treatment resistance.
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Affiliation(s)
- Roger Li
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center, Tampa, Florida
- Department of Immunology, H. Lee Moffitt Cancer Center, Tampa, Florida
| | - Wade J Sexton
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center, Tampa, Florida
| | - Jasreman Dhillon
- Department of Pathology, H. Lee Moffitt Cancer Center, Tampa, Florida
| | - Anders Berglund
- Department of Biostatistics/Bioinformatics, H. Lee Moffitt Cancer Center, Tampa, Florida
| | - Shreyas Naidu
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center, Tampa, Florida
- Department of Immunology, H. Lee Moffitt Cancer Center, Tampa, Florida
| | - Gustavo Borjas
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center, Tampa, Florida
- Department of Immunology, H. Lee Moffitt Cancer Center, Tampa, Florida
| | - Kyle Rose
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center, Tampa, Florida
| | - Youngchul Kim
- Department of Biostatistics/Bioinformatics, H. Lee Moffitt Cancer Center, Tampa, Florida
| | - Xuefeng Wang
- Department of Biostatistics/Bioinformatics, H. Lee Moffitt Cancer Center, Tampa, Florida
| | | | - Rohit K Jain
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center, Tampa, Florida
| | - Michael A Poch
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center, Tampa, Florida
| | - Philippe E Spiess
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center, Tampa, Florida
| | - Julio Pow-Sang
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center, Tampa, Florida
| | - Scott M Gilbert
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center, Tampa, Florida
| | - Jingsong Zhang
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center, Tampa, Florida
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9
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Oh N, Nakashima J, Chadha JS, Kish JA, Manley B, Pow-Sang J, Yu A, Zhang J, Spiess P, Chatwal MS, Jain R, Zemp LW, Poch M, Sexton WJ, Li R, Gilbert SM, Johnstone PAS, Torres-Roca JF, Yamoah K, Grass D. An Analysis of Patients Treated with Stereotactic Body Radiotherapy for Metastatic Urinary Tract Tumors to Identify Predictors of Response. Int J Radiat Oncol Biol Phys 2023; 117:e424-e425. [PMID: 37785392 DOI: 10.1016/j.ijrobp.2023.06.1583] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/04/2023]
Abstract
PURPOSE/OBJECTIVE(S) To identify selection criteria linked to outcomes in patients treated with stereotactic body radiotherapy (SBRT) for metastatic tumors of the urinary tract (UT). MATERIALS/METHODS Single institution retrospective analysis of SBRT treated patients for oligometastatic/progressive UT tumors from 2006-2022. Charts were queried for M1 status at diagnosis or during disease course, treatment details (surgery, SBRT, systemic therapy), metabolic status (diabetes [DM], BMI) and outcomes. A linear quadratic formula was used to calculate the biologically effective dose (BED) using an α/β of 10 for tumor. Descriptive statistics portrayed the cohort, and analyses were done at patient and site level. Time-to-event analyses, including overall survival (OS) and progression-free survival (PFS) from SBRT, were assessed by the Kaplan-Meier method. Cox regression was used for univariable (UVA) and multivariable analyses (MVA) to identify predictors of outcomes. RESULTS A total of 35 patients were treated at 44 metastatic sites, including: bone (25%), node (36.4%), lung (20.5%), soft tissue (13.6%) and liver (4.5%). Most were male (74.3%) with a median age of 70 (range: 51-89), without DM (60%) having a median BMI of 29.8, and ECOG <2 (97.1%) at time of SBRT. Six (17.1%) patients were M1 at diagnosis. Of the 29 non-M1 patients, 86.2% received definitive local therapy (LT), 58.6% had at least T3/N+ disease, 75.8% received systemic therapy with a median of 2 agents (range: 1-6) prior to SBRT. Sixteen (45.7%) received immunotherapy (IO) with most receiving this before (75%) and after (56.2%) SBRT. Six patients had positive PD-L1 status (n = 10). The median RT dose, fractionation and BED was 40 Gy (range: 14-46), 5 fractions, and 72 (range: 28-132), respectively. At a median follow-up of 34.8, the median OS was 18.4 m (range: 9.3-27.4) with a 2-year OS of 35.9%. At patient level, 62.8% recurred after SBRT. The median PFS after SBRT was 5.3 m (range: 1.8-8.7) with a 2-yr PFS of 29.3%. Patient-level PFS was improved with LT (6.7 vs 1.4 m; p = 0.001) and DM (NR vs 2.9 m; p = 0.015), whereas improved OS was related with LT (18.9 vs 6.6 m; p = 0.03), DM (p = 0.04), ECOG (p = 0.004), and no relapse after SBRT (NR vs 9.8 m; p <0.001). Exposure to < 3 systemic agents prior to SBRT portended better PFS (6.7 vs 2.6 m; p = 0.04) without any impact by IO. At site level, 20.4% of sites had local relapse with 4 being the first event. Site was related with PFS (p = 0.009) with order of increased relapse risk being liver > bone > soft tissue > node > lung. No dosimetric feature was related with recurrence risk. On MVA, both DM (p = 0.02) and LT (p = 0.002) were predictive for PFS. Only recurrence after SBRT predicted for OS on MVA (HR: 6.7, 95% CI: 1.4-31; p = 0.014). In the IO subset, median PFS was 5.3 m and OS was 9.4 m, with no difference seen with IO-SBRT sequence or PDL1 status. CONCLUSION Optimized selection criteria for metastasis-directed therapy in patients with UT tumors is unclear, notably with IO. Future studies may benefit by assessing circulating tumor markers prior to SBRT.
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Affiliation(s)
- N Oh
- University of South Florida Morsani College of Medicine, Tampa, FL
| | - J Nakashima
- H. Lee Moffitt Cancer Center and Research Institute, Department of Radiation Oncology, Tampa, FL
| | - J S Chadha
- H. Lee Moffitt Cancer Center and Research Institute, Department of Genitourinary Oncology, Tampa, FL
| | - J A Kish
- H. Lee Moffitt Cancer Center and Research Institute, Department of Genitourinary Oncology, Tampa, FL
| | - B Manley
- H. Lee Moffitt Cancer Center and Research Institute, Department of Genitourinary Oncology, Tampa, FL
| | - J Pow-Sang
- H. Lee Moffitt Cancer Center and Research Institute, Department of Genitourinary Oncology, Tampa, FL
| | - A Yu
- H. Lee Moffitt Cancer Center and Research Institute, Department of Genitourinary Oncology, Tampa, FL
| | - J Zhang
- H. Lee Moffitt Cancer Center and Research Institute, Department of Genitourinary Oncology, Tampa, FL
| | - P Spiess
- H. Lee Moffitt Cancer Center and Research Institute, Department of Genitourinary Oncology, Tampa, FL
| | - M S Chatwal
- H. Lee Moffitt Cancer Center and Research Institute, Department of Genitourinary Oncology, Tampa, FL
| | - R Jain
- H. Lee Moffitt Cancer Center and Research Institute, Department of Genitourinary Oncology, Tampa, FL
| | - L W Zemp
- H. Lee Moffitt Cancer Center and Research Institute, Department of Genitourinary Oncology, Tampa, FL
| | - M Poch
- H. Lee Moffitt Cancer Center and Research Institute, Department of Genitourinary Oncology, Tampa, FL
| | - W J Sexton
- H. Lee Moffitt Cancer Center and Research Institute, Department of Genitourinary Oncology, Tampa, FL
| | - R Li
- H. Lee Moffitt Cancer Center and Research Institute, Department of Genitourinary Oncology, Tampa, FL
| | - S M Gilbert
- H. Lee Moffitt Cancer Center and Research Institute, Department of Genitourinary Oncology, Tampa, FL
| | - P A S Johnstone
- H. Lee Moffitt Cancer Center and Research Institute, Department of Radiation Oncology, Tampa, FL
| | - J F Torres-Roca
- H. Lee Moffitt Cancer Center and Research Institute, Department of Radiation Oncology, Tampa, FL
| | - K Yamoah
- H. Lee Moffitt Cancer Center and Research Institute, Department of Radiation Oncology, Tampa, FL
| | - D Grass
- H. Lee Moffitt Cancer Center and Research Institute, Department of Radiation Oncology, Tampa, FL
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10
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Retzloff A, Li R, Gilbert SM, Dohm AE, Sexton WJ, Poch M, Zemp LW, Pow-Sang J, Jain R, Chatwal MS, Dhillon J, Yamoah K, Fernandez DC, Johnstone PAS, Spiess P, Grass D. Multidisciplinary Management of Primary Urethral Cancer with Radiotherapy. Int J Radiat Oncol Biol Phys 2023; 117:e431-e432. [PMID: 37785408 DOI: 10.1016/j.ijrobp.2023.06.1597] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/04/2023]
Abstract
PURPOSE/OBJECTIVE(S) Primary urethral cancer (PUC) is a rare form of genitourinary malignancy with a paucity of data to guide management. We analyzed PUC patients for clinicopathologic characteristics and treatment approach (radiotherapy [RT] with/without consolidative surgery) to identify predictors of outcome and RT response. MATERIALS/METHODS We conducted a single-institution retrospective review of patients treated with RT for PUC between 2002 to 2020. Each patient underwent multidisciplinary evaluation (including cystoscopy) as well as imaging to confirm tumor origin in the urethra. The linear quadratic formula was used to calculate the biologically effective dose (BED) using an α/β of 10 for tumor. Descriptive statistics were used to characterize the cohort. Fisher's Exact test was used to compare groups. Time-to-event analyses was conducted with the Kaplan-Meier method; outcomes included overall survival (OS) and time to recurrence (TTR) from diagnosis. Cox regression analysis assessed predictors of outcomes. RESULTS A total of 17 patients were identified for analysis. Median age was 63 years (range: 34-86); the majority were female (76.5%) and white (82.4%). Tumors were localized in the proximal (n = 6) or distal (n = 11) urethra. Histology included urothelial (11.8%), squamous (35.3%), adenocarcinoma (29.4%) and mixed (23.5%). Ten patients (58.8%) had cT3 or higher disease with 10 being cN0 (58.8%), 1 cN1 (5.9%), 5 cN2 (29.4%) and 1 cNx (5.9%). Median tumor size was 4.8 cm (range: 0.5-12 cm). The majority (88.2%) were treated with definitive chemoRT with 70.5% receiving platinum therapy. Median RT dose was 59.4 Gy (range: 39.6-70.2) with a median of 30 fractions. One patient underwent upfront cystourethrectomy and 6 (35.3%) underwent consolidative surgery at a median of 2.3 months after RT. Five patients (29.4%) had a complete response (CR) and 70.6% had a partial response (PR) to RT. Of the 7 patients who underwent surgical resection the final pathology was ypTis (28.5%), ypT1 (14.2%), ypT2 (14.2%), ypT4 (28.5%) and pT2 (14.2%). A median of 16 lymph nodes were removed with 1 patient having pN2 and all others pN0. Four patients (66.6%) were downstaged by chemoRT prior to surgery. At a median follow-up time of 8.4 years, the median OS was 37.9 months (range: 23.2-52.7), which was associated with a 5-year OS of 37.2%. Twelve (70.5%) patients recurred with a median TTR of 6.3 months (range 4.8-7.7). No demographics, staging methods, or tumor characteristics were associated with OS or TTR. Urothelial histology was associated with CR following chemoRT (p = 0.02). RT dose (continuous) was associated with OS (p = 0.018) as well as a BED (HR: 0.90, 95% CI: 0.84-0.97; p = 0.01). A BED > 55 Gy was associated with improved median OS (56.4 vs 9.13 months, p = 0.006). CONCLUSION Analysis of PUC patients treated with multimodal therapy found higher rates of CR in patients with urothelial histology and increased OS in patients treated with a BED > 55 Gy. Neoadjuvant chemoRT may downstage disease prior to surgical extirpation.
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Affiliation(s)
- A Retzloff
- USF Health Morsani College of Medicine, Tampa, FL
| | - R Li
- H. Lee Moffitt Cancer Center and Research Institute, Department of Genitourinary Oncology, Tampa, FL
| | - S M Gilbert
- H. Lee Moffitt Cancer Center and Research Institute, Department of Genitourinary Oncology, Tampa, FL
| | - A E Dohm
- H. Lee Moffitt Cancer Center and Research Institute, Department of Radiation Oncology, Tampa, FL
| | - W J Sexton
- H. Lee Moffitt Cancer Center and Research Institute, Department of Genitourinary Oncology, Tampa, FL
| | - M Poch
- H. Lee Moffitt Cancer Center and Research Institute, Department of Genitourinary Oncology, Tampa, FL
| | - L W Zemp
- H. Lee Moffitt Cancer Center and Research Institute, Department of Genitourinary Oncology, Tampa, FL
| | - J Pow-Sang
- H. Lee Moffitt Cancer Center and Research Institute, Department of Genitourinary Oncology, Tampa, FL
| | - R Jain
- H. Lee Moffitt Cancer Center and Research Institute, Department of Genitourinary Oncology, Tampa, FL
| | - M S Chatwal
- H. Lee Moffitt Cancer Center and Research Institute, Department of Genitourinary Oncology, Tampa, FL
| | - J Dhillon
- H. Lee Moffitt Cancer Center and Research Institute, Department of Anatomic Pathology, Tampa, FL
| | - K Yamoah
- H. Lee Moffitt Cancer Center and Research Institute, Department of Radiation Oncology, Tampa, FL
| | - D C Fernandez
- H. Lee Moffitt Cancer Center and Research Institute, Department of Radiation Oncology, Tampa, FL
| | - P A S Johnstone
- H. Lee Moffitt Cancer Center and Research Institute, Department of Radiation Oncology, Tampa, FL
| | - P Spiess
- H. Lee Moffitt Cancer Center and Research Institute, Department of Genitourinary Oncology, Tampa, FL
| | - D Grass
- H. Lee Moffitt Cancer Center and Research Institute, Department of Radiation Oncology, Tampa, FL
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11
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Rollison DE, Gonzalez BD, Turner K, Jim HSL, Zhao Y, Amorrortu RP, Howard R, Ghia KM, Ngo B, Reisman P, Moore C, Perkins R, Keenan RJ, Sallman DA, Naso CM, Robinson EJ, Vadaparampil ST, Simmons VN, Schabath MB, Gilbert SM. Examining disparities in large-scale patient-reported data capture using digital tools among cancer patients at clinical intake. Cancer Med 2023; 12:19033-19046. [PMID: 37596773 PMCID: PMC10557830 DOI: 10.1002/cam4.6459] [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: 06/05/2023] [Revised: 07/19/2023] [Accepted: 08/06/2023] [Indexed: 08/20/2023] Open
Abstract
BACKGROUND Patient-reported data can improve quality of healthcare delivery and patient outcomes. Moffitt Cancer Center ("Moffitt") administers the Electronic Patient Questionnaire (EPQ) to collect data on demographics, including sexual orientation and gender identity (SOGI), medical history, cancer risk factors, and quality of life. Here we investigated differences in EPQ completion by demographic and cancer characteristics. METHODS An analysis including 146,142 new adult patients at Moffitt in 2009-2020 was conducted using scheduling, EPQ and cancer registry data. EPQ completion was described by calendar year and demographics. Logistic regression was used to estimate associations between demographic/cancer characteristics and EPQ completion. More recently collected information on SOGI were described. RESULTS Patient portal usage (81%) and EPQ completion rates (79%) were consistently high since 2014. Among patients in the cancer registry, females were more likely to complete the EPQ than males (odds ratio [OR] = 1.17, 95% confidence interval [CI] = 1.14-1.20). Patients ages 18-64 years were more likely to complete the EPQ than patients aged ≥65. Lower EPQ completion rates were observed among Black or African American patients (OR = 0.59, 95% CI = 0.56-0.63) as compared to Whites and among patients whose preferred language was Spanish (OR = 0.40, 95% CI = 0.36-0.44) or another language as compared to English. Furthermore, patients with localized (OR = 1.16, 95% CI = 1.12-1.19) or regional (OR = 1.16, 95% CI = 1.12-1.20) cancer were more likely to complete the EPQ compared to those with metastatic disease. Less than 3% of patients self-identified as being lesbian, gay, or bisexual and <0.1% self-identified as transgender, genderqueer, or other. CONCLUSIONS EPQ completion rates differed across demographics highlighting opportunities for targeted process improvement. Healthcare organizations should evaluate data acquisition methods to identify potential disparities in data completeness that can impact quality of clinical care and generalizability of self-reported data.
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Affiliation(s)
- Dana E. Rollison
- Department of Cancer EpidemiologyMoffitt Cancer CenterTampaFloridaUSA
| | - Brian D. Gonzalez
- Department of Health Outcomes and BehaviorMoffitt Cancer CenterTampaFloridaUSA
| | - Kea Turner
- Department of Health Outcomes and BehaviorMoffitt Cancer CenterTampaFloridaUSA
| | - Heather S. L. Jim
- Department of Health Outcomes and BehaviorMoffitt Cancer CenterTampaFloridaUSA
| | - Yayi Zhao
- Department of Cancer EpidemiologyMoffitt Cancer CenterTampaFloridaUSA
| | | | - Rachel Howard
- Department of Health InformaticsMoffitt Cancer CenterTampaFloridaUSA
| | - Kavita M. Ghia
- Collaborative Data Services Core, Moffitt Cancer CenterTampaFloridaUSA
| | - Bryan Ngo
- Department of Business Intelligence and AnalyticsMoffitt Cancer CenterTampaFloridaUSA
| | - Phillip Reisman
- Department of Health InformaticsMoffitt Cancer CenterTampaFloridaUSA
| | - Colin Moore
- Department of Clinical InformaticsMoffitt Cancer CenterTampaFloridaUSA
| | - Randa Perkins
- Department of Clinical InformaticsMoffitt Cancer CenterTampaFloridaUSA
| | - Robert J. Keenan
- Department of Thoracic OncologyMoffitt Cancer CenterTampaFloridaUSA
| | - David A. Sallman
- Department of Malignant HematologyMoffitt Cancer CenterTampaFloridaUSA
| | - Cristina M. Naso
- Department of Virtual HealthMoffitt Cancer CenterTampaFloridaUSA
| | - Edmondo J. Robinson
- Center for Digital HealthMoffitt Cancer CenterTampaFloridaUSA
- Department of Internal and Hospital MedicineMoffitt Cancer CenterTampaFloridaUSA
| | | | - Vani N. Simmons
- Department of Health Outcomes and BehaviorMoffitt Cancer CenterTampaFloridaUSA
| | | | - Scott M. Gilbert
- Department of Health Outcomes and BehaviorMoffitt Cancer CenterTampaFloridaUSA
- Department of Genitourinary OncologyMoffitt Cancer CenterTampaFloridaUSA
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12
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Davaro F, Davaro E, Rose K, Murthy P, Huelster H, Naidu S, Camperlengo L, Grass GD, Vosoughi A, Chumbalkar V, Jain RK, Zemp L, Yu A, Poch MA, Spiess PE, Gilbert SM, Sexton WJ, Li R. Impact of surgical margin and extent of lymphadenectomy on oncologic outcomes in plasmacytoid urothelial carcinoma. Urol Oncol 2023; 41:389.e7-389.e13. [PMID: 36959058 DOI: 10.1016/j.urolonc.2023.02.003] [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: 01/04/2023] [Revised: 02/03/2023] [Accepted: 02/18/2023] [Indexed: 03/25/2023]
Abstract
OBJECTIVE Guideline recommendations disagree on template boundaries for pelvic lymph node dissection (PLND) in conventional urothelial carcinoma. Less is known about PLND in variant histology. We aimed to analyze the role of LND in plasmacytoid urothelial carcinoma (PUC). METHODS A retrospective review of patients with cTanyNanyM0 PUC who underwent radical cystectomy (RC) with PLND was performed from 2012 to 2022. Lymph node count (LNC) was a surrogate for extent of lymph node dissection and dichotomized based on maximally selected rank statistics. Multivariable cox hazard regression analysis (MVA) for overall survival (OS) corrected for age, perioperative chemotherapy, soft tissue margin status, and stage ≥pT3 and/or pN+ was performed. Disease free survival (DFS) and OS were estimated using Kaplan-Meier (KM) analysis. RESULTS Sixty-seven patients with median age of 71, who were 79.1% male were included. Neoadjuvant and adjuvant chemotherapy were administered in 61.2% and 19.4% of patients, respectively. At RC, 70.1% were ≥pT3. Median LNC was 22 (IQR 14-27) with 43.3% of patients being pN+. Calculated optimal-LNC cut point for DFS and OS was 19. Grouping by optimal (≥20) vs. suboptimal-LNC (<20), no significant clinicodemographic differences were found. Optimal-LNC provided improved DFS (P = 0.05) and OS (P = 0.02). Optimal-LNC (HR 0.47, 0.24-0.93 CI 95%, P = 0.03) and negative soft tissue margin (HR 0.38, 0.19-0.76 CI 95%, P = 0.01) was associated with improved OS on MVA. Receipt of perioperative chemotherapy did not improve OS (P = 0.46). CONCLUSION In PUC, complete surgical extirpation achieving negative soft tissue margins and removing ≥20 lymph should be prioritized if operative intervention is pursued.
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Affiliation(s)
- Facundo Davaro
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center, Tampa, FL
| | - Elizabeth Davaro
- Department of Pathology, H. Lee Moffitt Cancer Center, Tampa, FL
| | - Kyle Rose
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center, Tampa, FL
| | - Prithvi Murthy
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center, Tampa, FL
| | - Heather Huelster
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center, Tampa, FL
| | - Shreyas Naidu
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center, Tampa, FL; Department of Immunology, H. Lee Moffitt Cancer Center, Tampa, FL
| | - Lucia Camperlengo
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center, Tampa, FL
| | | | - Aram Vosoughi
- Department of Pathology, H. Lee Moffitt Cancer Center, Tampa, FL
| | | | - Rohit K Jain
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center, Tampa, FL
| | - Logan Zemp
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center, Tampa, FL
| | - Alice Yu
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center, Tampa, FL
| | - Michael A Poch
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center, Tampa, FL
| | - Philippe E Spiess
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center, Tampa, FL
| | - Scott M Gilbert
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center, Tampa, FL
| | - Wade J Sexton
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center, Tampa, FL
| | - Roger Li
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center, Tampa, FL.
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13
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Hugar LA, Geiss C, Chavez MN, Gore LR, Thirlwell S, Reblin M, Gilbert SM. Exploring knowledge, perspectives, and misperceptions of palliative care: A mixed methods analysis. Urol Oncol 2023; 41:327.e19-327.e26. [PMID: 37225636 DOI: 10.1016/j.urolonc.2023.03.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Revised: 03/14/2023] [Accepted: 03/24/2023] [Indexed: 05/26/2023]
Abstract
OBJECTIVES To better understand palliative care knowledge and beliefs of patients with stage II or greater bladder cancer and their caregivers. SUBJECTS AND METHODS Participants were primarily patients diagnosed with muscle-invasive or locally advanced bladder cancer. All were encouraged to enroll with a caregiver (defined as the individual who most closely assists with a patient's care). Participants completed a survey and semistructured interview. Applied thematic analysis techniques were used to analyze the interview data. In total, we recruited 16 dyads, 11 patients who participated alone, and 1 caregiver who participated alone. RESULTS Patients and caregivers had high levels of palliative care knowledge and there was no difference in baseline knowledge. Palliative care receptivity was also high, with most participants stating that they would be "very likely" to consider palliative care for themselves or a loved one. However, based on the analysis of multiple-choice palliative care questions and interview transcripts, many participants lacked a nuanced understanding of palliative care and harbored many common misconceptions of the basic tenants. Five main themes emerged related to palliative care: (1) Participants have a general lack of awareness of it, (2) Participants associate it with hospice and death, (3) Participants view it as primarily emotional or psychological support, (4) Participants believe it is for patients without a strong support system, and (5) Participants believe it is for people who have "given up." CONCLUSIONS High educational attainment and baseline palliative care knowledge did not preclude the most common misperceptions related to palliative care. These study results indicate that patients need clearer counseling regarding the definition, goals, benefits, and availability of palliative care.
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Affiliation(s)
- Lee A Hugar
- Lexington Urology, Lexington Medical Center, West Columbia, SC.
| | - Carley Geiss
- Participant Research, Interventions, and Measurement (PRISM) Core, H. Lee Moffitt Cancer Center, Tampa, FL
| | - Melody N Chavez
- Participant Research, Interventions, and Measurement (PRISM) Core, H. Lee Moffitt Cancer Center, Tampa, FL
| | - L Robert Gore
- Biostatistics and Bioinformatics Shared Resource, H. Lee Moffitt Cancer Center, Tampa, FL
| | | | - Majia Reblin
- University of Vermont College of Medicine, Burlington, VT
| | - Scott M Gilbert
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center, Tampa, FL
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14
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Mason NT, Joshi VB, Adashek JJ, Kim Y, Shah SS, Schneider AM, Chadha J, Jim HSL, Byrne MM, Gilbert SM, Manley BJ, Spiess PE, Chahoud J. Cost Effectiveness of Treatment Sequences in Advanced Renal Cell Carcinoma. Eur Urol Oncol 2023; 6:331-338. [PMID: 36797084 DOI: 10.1016/j.euo.2023.01.011] [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: 10/03/2022] [Revised: 01/13/2023] [Accepted: 01/31/2023] [Indexed: 02/16/2023]
Abstract
BACKGROUND The treatment landscape for metastatic renal cell carcinoma (mRCC) has significantly evolved in recent years. Without direct comparator trials, factors such as cost effectiveness (CE) are important to guide decision-making. OBJECTIVE To assess the CE of guideline-recommended approved first- and second-line treatment regimens. DESIGN, SETTING, AND PARTICIPANTS A comprehensive Markov model was developed to analyze the CE of the five current National Comprehensive Cancer Network-recommended first-line therapies with appropriate second-line therapy for patient cohorts with International Metastatic RCC Database Consortium favorable and intermediate/poor risk. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS Life years, quality-adjusted life years (QALYs), and total accumulated costs were estimated using a willingness-to-pay threshold of $150 000 per QALY. One-way and probabilistic sensitivity analyses were performed. RESULTS AND LIMITATIONS In patients with favorable risk, pembrolizumab + lenvatinib followed by cabozantinib added $32 935 in costs and yielded 0.28 QALYs, resulting in an incremental CE ratio (ICER) of $117 625 per QALY in comparison to pembrolizumab + axitinib followed by cabozantinib. In patients with intermediate/poor risk, nivolumab + ipilimumab followed by cabozantinib added $2252 in costs and yielded 0.60 QALYs compared to cabozantinib followed by nivolumab, yielding an ICER of $4184. Limitations include differences in median follow-up duration between treatments. CONCLUSIONS Pembrolizumab + lenvatinib followed by cabozantinib, and pembrolizumab + axitinib followed by cabozantinib were cost-effective treatment sequences for patients with favorable-risk mRCC. Nivolumab +ipilimumab followed by cabozantinib was the most cost-effective treatment sequence for patients with intermediate-/poor-risk mRCC, dominating all preferred treatments. PATIENT SUMMARY Because new treatments for kidney cancer have not been compared head to head, comparison of their cost and efficacy can help in making decisions about the best treatments to use first. Our model showed that patients with a favorable risk profile are most likely to benefit from pembrolizumab and lenvatinib or axitinib followed by cabozantinib, while patients with an intermediate or poor risk profile will probably benefit most from nivolumab and ipilimumab followed by cabozantinib.
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Affiliation(s)
- Neil T Mason
- Department of Individualized Cancer Medicine, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL, USA
| | - Vidhu B Joshi
- Villanova University Charles Widger School of Law, Villanova, PA, USA
| | - Jacob J Adashek
- Department of Internal Medicine, University of South Florida, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL, USA
| | - Youngchul Kim
- Biostatistics and Bioinformatics, H. Lee Moffitt Cancer Center, Tampa, FL, USA
| | - Savan S Shah
- Department of Medical Oncology, H. Lee Moffitt Cancer Center & Research Institute, University of South Florida, Tampa, FL, USA
| | - Amy M Schneider
- Department of Pharmacy, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL, USA
| | - Juskaran Chadha
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL, USA
| | - Heather S L Jim
- Department of Health Outcomes and Behavior, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Margaret M Byrne
- Department of Health Outcomes and Behavior, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Scott M Gilbert
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL, USA
| | - Brandon J Manley
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL, USA
| | - Philippe E Spiess
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL, USA
| | - Jad Chahoud
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL, USA.
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15
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Gilbert SM. Will Patient-Reported Outcomes Be the Key to Demonstrating the Value of Robotic Cystectomy? Data Are Accumulating but Clarity Is Not. J Urol 2023; 209:833-835. [PMID: 36893473 DOI: 10.1097/ju.0000000000003424] [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: 03/11/2023]
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16
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Huelster HL, Zemp L, Turner K, Gonzalez BD, Jim H, Gore LR, Gilbert SM. Mobile Postoperative Symptom Intervention Tool and Biometric Monitoring After Radical Cystectomy: Pilot Study Evaluating Feasibility, Usability, and Potential Utility. J Urol 2023; 209:410-421. [PMID: 36350586 PMCID: PMC10316518 DOI: 10.1097/ju.0000000000003048] [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: 06/15/2022] [Accepted: 10/25/2022] [Indexed: 11/11/2022]
Abstract
PURPOSE Mobile health technology and integration of patient-reported outcome measures into clinical interventions have the potential to transform patient care. Though patient-reported outcome measure management has been shown to improve outcomes in ambulatory care settings, few studies have examined remote patient-reported outcome measure assessment after major cancer surgery. MATERIALS AND METHODS A multiphased feasibility and usability study was designed. A mobile app-based postoperative symptom intervention tool was developed and evaluated by a focus group of bladder cancer patients and caregivers. Patients were prospectively accrued prior to cystectomy and asked to complete the daily mobile postoperative symptom intervention tool and wear biometric monitoring devices for 30 days post discharge. Retention, postoperative symptom intervention tool completion, and usability were assessed. Exploratory analysis of daily symptoms and patient-generated health information correlated signals with postsurgical complications and hospital readmission. RESULTS Fifteen patients with a median age of 72 years completed 78% of daily surveys over the 30-day recovery period. Average time to complete the postoperative symptom intervention tool was 152 seconds. All patients agreed that the daily survey was easy to use, and most reported it would be a better way to communicate with the care team about symptoms than calling the clinic. Frequency and severity of patient-reported symptoms appeared to cluster prior to or at the time of complication or unplanned health care encounters on visual-analogue mapping. CONCLUSIONS Using smartphone and wearable technology to capture patient-reported symptoms and biometric data is feasible and rated as highly usable by bladder cancer patients after cystectomy. Symptom scores may signal developing complications and help clinicians identify postsurgical patients who may benefit from intervention.
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Affiliation(s)
- Heather L Huelster
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Logan Zemp
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Kea Turner
- Department of Health Outcomes and Behavior, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Brian D Gonzalez
- Department of Health Outcomes and Behavior, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Heather Jim
- Department of Health Outcomes and Behavior, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - L Robert Gore
- Department of Biostatistics and Bioinformatics, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Scott M Gilbert
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
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17
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Filippou P, Hugar LA, Louwers R, Pomper A, Chisolm S, Smith AB, Gore JL, Gilbert SM. Palliative care knowledge, attitudes, and experiences amongst patients with bladder cancer and their caregivers. Urol Oncol 2023; 41:108.e1-108.e9. [PMID: 36529652 DOI: 10.1016/j.urolonc.2022.10.013] [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: 06/14/2022] [Revised: 10/02/2022] [Accepted: 10/13/2022] [Indexed: 12/23/2022]
Abstract
OBJECTIVES Palliative care is underutilized amongst patients with bladder cancer despite guideline recommendations and known benefits. In order to uncover potential access barriers, we sought to describe patient and caregiver knowledge, attitudes and experiences surrounding palliative care. METHODS We surveyed 272 patients with bladder cancer and their caregivers through the Bladder Cancer Advocacy Network Patient Survey Network. In addition to collecting demographic, socioeconomic, and clinical characteristics, previously studied and validated questionnaires on palliative care knowledge and beliefs were administered. Patients and caregivers were also queried regarding their experiences with palliative care consultation. RESULTS Survey respondents demonstrated highly accurate knowledge of palliative care services. Attitudes and beliefs surrounding palliative care were overall positive. Caregivers demonstrated better knowledge and more positive beliefs of palliative care compared to patients. Despite an overall positive sentiment toward palliative care, only 9% of the cohort had palliative care consultation as part of their cancer treatment plan. Most patients with muscle-invasive or metastatic bladder cancer wished that palliative care had been discussed by their providers. CONCLUSIONS A subset of bladder cancer patients possess accurate knowledge and positive beliefs of palliative care. Palliative care is infrequently discussed during the treatment of bladder cancer, with patients and their caregivers expressing desire for palliative care to be discussed more often. Provider education surrounding palliative care services is imperative to improving access for bladder cancer patients and caregivers.
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Affiliation(s)
| | - Lee A Hugar
- Division of Genitourinary Oncology, H.Lee Moffitt Cancer Center and Research Institute, Tampa FL
| | - Renata Louwers
- Bladder Cancer Advocacy Network, Bethesda, Maryland, USA
| | - Ann Pomper
- Bladder Cancer Advocacy Network, Bethesda, Maryland, USA
| | | | - Angela B Smith
- Department of Urology, University of North Carolina at Chapel Hill, Chapel Hill NC
| | - John L Gore
- Department of Urology, University of Washington, Seattle WA
| | - Scott M Gilbert
- Division of Genitourinary Oncology, H.Lee Moffitt Cancer Center and Research Institute, Tampa FL
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18
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Turner K, Stover AM, Tometich DB, Geiss C, Mason A, Nguyen OT, Hume E, McCormick R, Powell S, Hallanger-Johnson J, Patel KB, Kirtane KS, Jammigumpula N, Moore C, Perkins R, Rollison DE, Jim HSL, Oswald LB, Crowder S, Gonzalez BD, Robinson E, Tabriz AA, Islam JY, Gilbert SM. Oncology Providers' and Professionals' Experiences With Suicide Risk Screening Among Patients With Head and Neck Cancer: A Qualitative Study. JCO Oncol Pract 2022:OP2200433. [PMID: 36395441 DOI: 10.1200/op.22.00433] [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: 11/18/2022] Open
Abstract
PURPOSE There has been limited study of the implementation of suicide risk screening for patients with head and neck cancer (HNC) as a part of routine care. To address this gap, this study assessed oncology providers' and professionals' perspectives about barriers and facilitators of implementing a suicide risk screening among patients with HNC. MATERIALS AND METHODS All patients with HNC with an in-person visit completed a suicide risk screening on an electronic tablet. Patients reporting passive death wish were then screened for active suicidal ideation and referred for appropriate intervention. Interviews were conducted with 25 oncology providers and professionals who played a key role in implementation including nurses, medical assistants, patient access representatives, advanced practice providers, physicians, social workers, and informatics staff. The interview guide was based on the Consolidated Framework for Implementation Research. Interviews were transcribed and analyzed for themes. RESULTS Participants identified multilevel implementation barriers, such as intervention level (eg, patient difficulty with using a tablet), process level (eg, limited nursing engagement), organizational level (eg, limited clinic Wi-Fi connectivity), and individual level (eg, low clinician self-efficacy for interpreting and acting upon patient-reported outcome scores). Participants noted facilitators, such as effective care coordination across nursing and social work staff and the opportunity for patients to be screened multiple times. Participants recommended strengthening patient and clinician education and providing patients with other modalities for data entry (eg, desktop computer in the waiting room). CONCLUSION Participants identified important intervention modifications that may be needed to optimize suicide risk screening in cancer care settings.
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Affiliation(s)
- Kea Turner
- Department of Health Outcomes and Behavior, Moffitt Cancer Center, Tampa, FL.,Department of Gastrointestinal Oncology, Moffitt Cancer Center, Tampa, FL.,Department of Oncological Sciences, University of South Florida, Tampa, FL
| | - Angela M Stover
- Department of Health Policy and Management, UNC Chapel Hill, Chapel Hill, NC.,Lineberger Comprehensive Cancer Center, UNC Chapel Hill, Chapel Hill, NC
| | - Danielle B Tometich
- Department of Health Outcomes and Behavior, Moffitt Cancer Center, Tampa, FL
| | - Carley Geiss
- Participant Research, Interventions, and Measurement Core, Moffitt Cancer Center, Tampa, FL
| | - Arianna Mason
- Participant Research, Interventions, and Measurement Core, Moffitt Cancer Center, Tampa, FL
| | - Oliver T Nguyen
- Department of Health Outcomes and Behavior, Moffitt Cancer Center, Tampa, FL
| | - Emma Hume
- Department of Health Outcomes and Behavior, Moffitt Cancer Center, Tampa, FL
| | - Rachael McCormick
- Department of Health Outcomes and Behavior, Moffitt Cancer Center, Tampa, FL
| | - Sean Powell
- Department of Social Work, Moffitt Cancer Center, Tampa, FL
| | | | - Krupal B Patel
- Department of Head and Neck-Endocrine Oncology, Moffitt Cancer Center, Tampa, FL
| | - Kedar S Kirtane
- Department of Head and Neck-Endocrine Oncology, Moffitt Cancer Center, Tampa, FL
| | - Neelima Jammigumpula
- Department of Clinical Informatics, Center for Digital Health, Moffitt Cancer Center, Tampa, FL
| | - Colin Moore
- Department of Clinical Informatics, Center for Digital Health, Moffitt Cancer Center, Tampa, FL.,Department of Malignant Hematology, Moffitt Cancer Center, Tampa, FL
| | - Randa Perkins
- Department of Clinical Informatics, Center for Digital Health, Moffitt Cancer Center, Tampa, FL.,Department of Internal and Hospital Medicine, Moffitt Cancer Center, Tampa, FL
| | - Dana E Rollison
- Department of Cancer Epidemiology, Moffitt Cancer Center, Tampa, FL
| | - Heather S L Jim
- Department of Health Outcomes and Behavior, Moffitt Cancer Center, Tampa, FL.,Department of Oncological Sciences, University of South Florida, Tampa, FL
| | - Laura B Oswald
- Department of Health Outcomes and Behavior, Moffitt Cancer Center, Tampa, FL.,Department of Oncological Sciences, University of South Florida, Tampa, FL
| | - Sylvia Crowder
- Department of Health Outcomes and Behavior, Moffitt Cancer Center, Tampa, FL.,Department of Oncological Sciences, University of South Florida, Tampa, FL
| | - Brian D Gonzalez
- Department of Health Outcomes and Behavior, Moffitt Cancer Center, Tampa, FL.,Department of Oncological Sciences, University of South Florida, Tampa, FL
| | - Edmondo Robinson
- Department of Clinical Informatics, Center for Digital Health, Moffitt Cancer Center, Tampa, FL.,Department of Internal and Hospital Medicine, Moffitt Cancer Center, Tampa, FL
| | - Amir Alishahi Tabriz
- Department of Health Outcomes and Behavior, Moffitt Cancer Center, Tampa, FL.,Department of Oncological Sciences, University of South Florida, Tampa, FL
| | - Jessica Y Islam
- Department of Cancer Epidemiology, Moffitt Cancer Center, Tampa, FL
| | - Scott M Gilbert
- Department of Genitourinary Oncology, Moffitt Cancer Center, Tampa, FL
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19
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Affiliation(s)
- Lee A. Hugar
- Moffitt Cancer Center and Research Institute, Tampa, Florida
| | | | - Roger Li
- Moffitt Cancer Center and Research Institute, Tampa, Florida
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20
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Chakiryan NH, Gore LR, Reich RR, Dunn RL, Jiang DD, Gillis KA, Green E, Hajiran A, Hugar L, Zemp L, Zhang J, Jain RK, Chahoud J, Spiess PE, Manley BJ, Sexton WJ, Hollenbeck BK, Gilbert SM. Survival Outcomes Associated With Cytoreductive Nephrectomy in Patients With Metastatic Clear Cell Renal Cell Carcinoma. JAMA Netw Open 2022; 5:e2212347. [PMID: 35576003 PMCID: PMC9112069 DOI: 10.1001/jamanetworkopen.2022.12347] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
IMPORTANCE Level I evidence has failed to demonstrate an overall survival (OS) advantage for cytoreductive nephrectomy in patients with metastatic clear cell renal cell carcinoma (ccRCC) in the modern era, which is at odds with observational studies reporting a marked OS benefit associated with these operations. These observational studies were not designed to adjust for unmeasured confounding. OBJECTIVE To assess whether cytoreductive nephrectomy is associated with improved OS in patients with metastatic ccRCC. DESIGN, SETTING, AND PARTICIPANTS This cohort study identified patients with metastatic ccRCC in the National Cancer Database from January 1, 2006, to December 31, 2016, who received systemic targeted therapy. The analysis was finalized on July 23, 2021. EXPOSURES Receipt of cytoreductive nephrectomy. MAIN OUTCOMES AND MEASURES The primary outcome was OS from the date of diagnosis to death or censoring at last follow-up. Distance from the patients' zip code of residence to the treating facility was identified as a valid instrument and was used in a 2-stage residual inclusion instrumental variable analysis. Conventional adjustments for selection bias, multivariable Cox proportional hazards regression, and propensity score matching were performed for comparison. Measured covariates adjusted for in all analyses included age, sex, race, Charlson-Deyo score, facility type, year of diagnosis, clinical T stage, and clinical N stage. RESULTS The final study population included 12 766 patients (median age, 63 years; IQR, 56-70 years; 8744 [68%] male; 11 206 [88%] White). Cytoreductive nephrectomy was performed in 5005 patients (39%). Conventional adjustments for selection bias demonstrated a significant OS benefit associated with cytoreductive nephrectomy (multivariable Cox proportional hazards regression: hazard ratio [HR], 0.49; 95% CI, 0.47-0.51; propensity score matching: HR, 0.48; 95% CI, 0.46-0.50). Instrumental variable estimates did not demonstrate an association between cytoreductive nephrectomy and OS (HR, 0.92; 95% CI, 0.78-1.09). CONCLUSIONS AND RELEVANCE Instrumental variable analysis did not demonstrate a survival advantage associated with cytoreductive nephrectomy for patients with metastatic ccRCC. This discrepancy likely reflects the fact that surgical indication for cytoreductive nephrectomy is primarily driven by factors that are not commonly measured or available in observational data sets.
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Affiliation(s)
| | - L. Robert Gore
- Department of Biostatistics and Bioinformatics, H. Lee Moffitt Cancer Center, Tampa, Florida
| | - Richard R. Reich
- Department of Biostatistics and Bioinformatics, H. Lee Moffitt Cancer Center, Tampa, Florida
| | - Rodney L. Dunn
- Department of Urology, University of Michigan Medical School, Ann Arbor
| | - Da David Jiang
- Department of Urology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Kyle A. Gillis
- Department of Urology, University of Iowa Hospitals & Clinics, Iowa City
| | - Elizabeth Green
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center, Tampa, Florida
| | - Ali Hajiran
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center, Tampa, Florida
| | - Lee Hugar
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center, Tampa, Florida
| | - Logan Zemp
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center, Tampa, Florida
| | - Jingsong Zhang
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center, Tampa, Florida
| | - Rohit K. Jain
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center, Tampa, Florida
| | - Jad Chahoud
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center, Tampa, Florida
| | - Philippe E. Spiess
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center, Tampa, Florida
| | - Brandon J. Manley
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center, Tampa, Florida
| | - Wade J. Sexton
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center, Tampa, Florida
| | | | - Scott M. Gilbert
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center, Tampa, Florida
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21
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Stetson PD, McCleary NJ, Osterman T, Ramchandran K, Tevaarwerk A, Wong T, Sugalski JM, Akerley W, Mercurio A, Zachariah FJ, Yamzon J, Stillman RC, Gabriel PE, Heinrichs T, Kerrigan K, Patel SB, Gilbert SM, Weiss E. Adoption of Patient-Generated Health Data in Oncology: A Report From the NCCN EHR Oncology Advisory Group. J Natl Compr Canc Netw 2022; 20:jnccn21244. [PMID: 35042190 PMCID: PMC10961646 DOI: 10.6004/jnccn.2021.7088] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Accepted: 09/08/2021] [Indexed: 11/17/2022]
Abstract
BACKGROUND Collecting, monitoring, and responding to patient-generated health data (PGHD) are associated with improved quality of life and patient satisfaction, and possibly with improved patient survival in oncology. However, the current state of adoption, types of PGHD collected, and degree of integration into electronic health records (EHRs) is unknown. METHODS The NCCN EHR Oncology Advisory Group formed a Patient-Reported Outcomes (PRO) Workgroup to perform an assessment and provide recommendations for cancer centers, researchers, and EHR vendors to advance the collection and use of PGHD in oncology. The issues were evaluated via a survey of NCCN Member Institutions. Questions were designed to assess the current state of PGHD collection, including how, what, and where PGHD are collected. Additionally, detailed questions about governance and data integration into EHRs were asked. RESULTS Of 28 Member Institutions surveyed, 23 responded. The collection and use of PGHD is widespread among NCCN Members Institutions (96%). Most centers (90%) embed at least some PGHD into the EHR, although challenges remain, as evidenced by 88% of respondents reporting the use of instruments not integrated. Forty-seven percent of respondents are leveraging PGHD for process automation and adherence to best evidence. Content type and integration touchpoints vary among the members, as well as governance maturity. CONCLUSIONS The reported variability regarding PGHD suggests that it may not yet have reached its full potential for oncology care delivery. As the adoption of PGHD in oncology continues to expand, opportunities exist to enhance their utility. Among the recommendations for cancer centers is establishment of a governance process that includes patients. Researchers should consider determining which PGHD instruments confer the highest value. It is recommended that EHR vendors collaborate with cancer centers to develop solutions for the collection, interpretation, visualization, and use of PGHD.
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Affiliation(s)
| | | | | | | | - Amye Tevaarwerk
- 5University of Wisconsin Carbone Cancer Center, Madison, Wisconsin
| | - Tracy Wong
- 6Seattle Cancer Care Alliance, Seattle, Washington
| | | | - Wallace Akerley
- 8Huntsman Cancer Institute at the University of Utah, Salt Lake City, Utah
| | | | | | | | - Robert C Stillman
- 10The Ohio State University, James Comprehensive Cancer Center, Columbus, Ohio
| | - Peter E Gabriel
- 11Abramson Cancer Center at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Tricia Heinrichs
- 7National Comprehensive Cancer Network, Plymouth Meeting, Pennsylvania
| | - Kathleen Kerrigan
- 8Huntsman Cancer Institute at the University of Utah, Salt Lake City, Utah
| | - Shiven B Patel
- 8Huntsman Cancer Institute at the University of Utah, Salt Lake City, Utah
| | | | - Everett Weiss
- 1Memorial Sloan Kettering Cancer Center, New York, New York
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22
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Chadha J, Adashek JJ, Jim H, Kim Y, Semaan A, Chakiryan NH, Safa H, Hajiran A, Sexton W, Gilbert SM, Manley BJ, Spiess PE, Chahoud J. Evaluation of Patient-Reported Outcomes (PROs) Protocol Content and Reporting for Clinical Trials that Lead to the approval of frontline Immune Checkpoint Blockade Combination for Patients with Advanced Renal Cell Carcinoma - The Patients' Voice or a Missed Opportunity. Clin Genitourin Cancer 2021; 20:e158-e165. [PMID: 34974985 DOI: 10.1016/j.clgc.2021.12.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2021] [Revised: 11/29/2021] [Accepted: 12/03/2021] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Immune checkpoint blockade (ICB) is a rapidly emerging field of oncology that has revolutionized the metastatic renal cell carcinoma (mRCC) treatment. Four recent treatment regimens Nivolumab-Ipilimumab, Pembrolizumab-Axitinib, Nivolumab-Cabozantinib, and Pembrolizumab-Lenvatinib-have demonstrated improved clinical endpoints compared to standard of care and are endorsed by NCCN (2021). However, data on patient-reported outcomes (PROs) for patients receiving these regimens are limited. We conducted a comparative assessment of the quality and standardization of PROs endpoints and data reported for these randomized controlled trials (RCTs). PATIENTS AND METHODS We systematically identified all RCTs evaluating combination ICB for ccRCC. PROs-specific data were abstracted from the final version of 4 RCT protocols, as well as clinical and PROs specific manuscripts published between April 2018 and April 2021. We used 3 previously published guides standardizing PROs research to objectively score the data: (i) 24-point PROEAS; (ii) 12-point SPIRIT-PRO; and (iii) 14-point CONSORT-PRO. RESULTS The CheckMate 214, KEYNOTE 426, CheckMate 9ER, and CLEAR studies had PROEAS scores of 88% (21/24), 37% (9/24), 83% (20/24), and 16% (4/24), respectively, and SPIRIT-PRO scores of 50% (6/12), 75% (9/12), 66% (8/12), and 41% (5/12) respectively. The CONSORT-PRO scores were 86% (12/14) for CheckMate 214 and 43% (6/14) for CheckMate 9ER, but scores were not available for the CLEAR and KEYNOTE 426 studies because of a lack of sufficient data. The average SPIRIT-PRO score across the 4 RCTs was 58%, indicating a reasonable adoption of PROs research in data management and analysis. The CheckMate 214 trial had the longest follow-up and most comprehensive published PROs data. CONCLUSION Our analysis identified the limitations of current PROs data in combination ICB approved for mRCC. This analysis will enable clinicians to better interpret the current PROs results and emphasize the importance of better incorporation of PROs endpoints in future mRCC trial design.
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Affiliation(s)
- Juskaran Chadha
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL
| | - Jacob J Adashek
- Department of Internal Medicine, University of South Florida, Tampa, FL
| | - Heather Jim
- Health Outcomes and Behavior, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL
| | - Youngchul Kim
- Biostatistics and Bioinformatics, H. Lee Moffitt Cancer Center, Tampa, FL
| | - Adele Semaan
- Participant Research, Interventions, and Measurements Core, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL
| | - Nicholas H Chakiryan
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL
| | - Houssein Safa
- Department of Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York
| | - Ali Hajiran
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL
| | - Wade Sexton
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL
| | - Scott M Gilbert
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL
| | - Brandon J Manley
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL
| | - Philippe E Spiess
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL
| | - Jad Chahoud
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL.
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Chakiryan NH, Jiang DD, Gillis KA, Green E, Hajiran A, Hugar L, Zemp L, Zhang J, Jain R, Chahoud J, Li R, Sexton W, Manley BJ, Gilbert SM. Comparative effectiveness analysis of first-line immunotherapy versus chemotherapy in metastatic urothelial carcinoma of the bladder. Urol Oncol 2021; 40:107.e11-107.e17. [PMID: 34426068 DOI: 10.1016/j.urolonc.2021.07.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2021] [Revised: 07/06/2021] [Accepted: 07/29/2021] [Indexed: 11/17/2022]
Abstract
BACKGROUND Clinical trials have not shown a significant overall survival (OS) difference between chemotherapy and immunotherapy as first-line agents in metastatic urothelial carcinoma (UC). However, the generalizability of these findings in a real-world setting has not yet been evaluated in comparative effectiveness studies. OBJECTIVE To assess the effectiveness of first-line immunotherapy compared with chemotherapy regimens on OS in patients with metastatic UC of the bladder. DESIGN, SETTING, AND PARTICIPANTS This retrospective propensity-matched study identified metastatic bladder UC patients in the National Cancer Database from 2014 to 2017 who received either first-line immunotherapy-monotherapy or multi-agent chemotherapy, and who were not treated on a clinical trial protocol. OUTCOME MEASURES AND ANALYSIS The primary outcome was OS from the date of diagnosis to date of death or censoring at last follow-up. Patients were stratified into first-line immunotherapy and chemotherapy treatment groups. After 1:1 nearest-neighbor caliper-matching of propensity scores, the survival analysis was conducted using Cox regression modeling and Kaplan-Meier estimates. RESULTS AND LIMITATIONS A total of 2,796 patients were included in the final study population, and 960 in the matched cohort (480 per treatment group). Utilization of immunotherapy increased over the time period studied as chemotherapy decreased (Immunotherapy: 3%-37%; Chemotherapy: 97%-63%; P < 0.001). In the overall cohort, patients who received first-line immunotherapy were older and more comorbid than those who received first-line chemotherapy (Age: 73 v. 67, respectively, P < 0.001; Charlson-Deyo score ≥2: 17% v. 11.5%, respectively, P < 0.001). In the matched cohort, patients who were treated with first-line immunotherapy had similar OS to those who were treated with first-line chemotherapy (HR: 0.91, 95CI 0.72-1.15). Due to the retrospective nature of the study, interpretation is limited by potential selection bias from unmeasured confounding. CONCLUSIONS AND RELEVANCE Metastatic bladder UC patients who received first-line immunotherapy had similar OS to those who received first-line chemotherapy.
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Affiliation(s)
| | - Da David Jiang
- Department of Urology, Beth Israel Deaconess Medical Center, Boston, MA
| | - Kyle A Gillis
- Department of Urology, University of Iowa Hospitals & Clinics, Iowa City, IA
| | - Elizabeth Green
- Department of Genitourinary Oncology, H Lee Moffitt Cancer Center, Tampa, FL
| | - Ali Hajiran
- Department of Genitourinary Oncology, H Lee Moffitt Cancer Center, Tampa, FL
| | - Lee Hugar
- Department of Genitourinary Oncology, H Lee Moffitt Cancer Center, Tampa, FL
| | - Logan Zemp
- Department of Genitourinary Oncology, H Lee Moffitt Cancer Center, Tampa, FL
| | - Jingsong Zhang
- Department of Genitourinary Oncology, H Lee Moffitt Cancer Center, Tampa, FL
| | - Rohit Jain
- Department of Genitourinary Oncology, H Lee Moffitt Cancer Center, Tampa, FL
| | - Jad Chahoud
- Department of Genitourinary Oncology, H Lee Moffitt Cancer Center, Tampa, FL
| | - Roger Li
- Department of Genitourinary Oncology, H Lee Moffitt Cancer Center, Tampa, FL
| | - Wade Sexton
- Department of Genitourinary Oncology, H Lee Moffitt Cancer Center, Tampa, FL
| | - Brandon J Manley
- Department of Genitourinary Oncology, H Lee Moffitt Cancer Center, Tampa, FL
| | - Scott M Gilbert
- Department of Genitourinary Oncology, H Lee Moffitt Cancer Center, Tampa, FL
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Hajiran A, Azizi M, Aydin AM, Chakiryan NH, Peyton CC, Boulware DC, Manley BJ, Gilbert SM, Sexton WJ. Retroperitoneal Lymph Node Dissection Versus Surveillance for Adult Early Stage Pure Testicular Teratoma: A Nationwide Analysis. Ann Surg Oncol 2021; 28:3648-3655. [PMID: 33689081 PMCID: PMC9801512 DOI: 10.1245/s10434-021-09696-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Accepted: 12/13/2020] [Indexed: 01/01/2023]
Abstract
PURPOSE Following radical orchiectomy, surveillance and primary retroperitoneal lymph node dissection (RPLND) are acceptable options for the management of early stage pure testicular teratoma in adult patients; however, there is no uniform consensus. The aim of this study was to investigate survival outcomes of adults with early stage pure testicular teratoma based on management strategy. METHODS Data was extracted from the National Cancer Database (NCDB) from testicular cancer patients diagnosed with clinical stage (CS) I pure teratoma (pT1-4N0M0S0) between 2004 and 2014. Kaplan-Meier and Cox regression analyses were used to assess clinical outcomes based on management strategy. RESULTS Of the 61,167 patients diagnosed with testicular cancer, 692 (1.1%) had pure teratoma. Only individuals with CS I disease were considered (n = 237). The median age was 28 (23-35) years. Overall, 43 (18%) patients underwent RPLND and 194 (82%) patients were managed with surveillance. There was an increase in surveillance for CS I teratoma during the study period. Increasing distance from residence to treatment facility was an unadjusted predictor for undergoing primary RPLND (p < 0.001). Median follow-up was 54 months and there was no significant difference in overall survival between CS I teratoma patients managed with RPLND and those managed with surveillance (p = 0.13). CONCLUSIONS There has been a trend toward increasing adoption of surveillance for the management of early stage pure testicular teratoma in adults. Our findings suggest that surveillance provides comparable survival outcomes to primary retroperitoneal lymph node dissection in this setting.
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Affiliation(s)
- Ali Hajiran
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL
| | - Mounsif Azizi
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL
| | - Ahmet M. Aydin
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL
| | - Nicholas H. Chakiryan
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL
| | - Charles C. Peyton
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL
| | - David C. Boulware
- Department of Biostatistics, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL
| | - Brandon J. Manley
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL,Department of Integrated Mathematical Oncology, H. Lee Moffitt Cancer Center and Research Institute Center, Tampa, FL
| | - Scott M. Gilbert
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL
| | - Wade J. Sexton
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL
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Patel SY, Kubal TE, Li R, Manley BJ, Gilbert SM, Sexton WJ, Spiess PE, Boulware D, Poch MA. Prevalence of Preoperative Iron Deficiency Anemia: A Case Series Among Patients Undergoing Radical Cystectomy. A A Pract 2021; 15:e01477. [PMID: 33999012 DOI: 10.1213/xaa.0000000000001477] [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: 11/05/2022]
Abstract
Anemia occurs in a significant group of patients with bladder cancer before radical cystectomy. Iron deficiency is a readily identifiable cause of anemia, which can be treated before surgery. The proportion of patients with bladder cancer with iron deficiency anemia is unknown. Laboratory and clinical outcomes were collected on 47 consecutive patients presenting for radical cystectomy. Iron studies found 30% of patients had iron deficiency anemia. These findings present an opportunity to treat anemia before surgery, to reduce blood transfusions during radical cystectomy.
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Affiliation(s)
| | | | - Roger Li
- Department of Genitourinary Oncology
| | | | | | | | | | - David Boulware
- Department of Biostatistics and Bioinformatics, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
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26
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Chakiryan NH, Jiang DD, Gillis KA, Green E, Hajiran A, Hugar L, Zemp L, Zhang J, Jain RK, Chahoud J, Spiess PE, Sexton W, Gilbert SM, Manley BJ. Real-World Survival Outcomes Associated With First-Line Immunotherapy, Targeted Therapy, and Combination Therapy for Metastatic Clear Cell Renal Cell Carcinoma. JAMA Netw Open 2021; 4:e2111329. [PMID: 34032854 PMCID: PMC8150693 DOI: 10.1001/jamanetworkopen.2021.11329] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
IMPORTANCE Clinical trials have shown an overall survival (OS) benefit associated with first-line immunotherapy (IT) and combination targeted therapy (TT) and IT regimens compared with TT among patients with metastatic clear cell renal cell carcinoma (RCC). Generalizability of these findings in a real-world cohort outside of a clinical trial setting is unclear. OBJECTIVE To assess the association of first-line TT, IT, and combination TT and IT regimens with OS in a real-world cohort of patients with metastatic clear cell RCC. DESIGN, SETTING, AND PARTICIPANTS This retrospective propensity-matched cohort study identified 5872 patients with metastatic clear cell RCC in the National Cancer Database from January 1, 2015, to December 31, 2017, who received first-line TT, IT, or combination TT and IT and were not treated on a clinical trial protocol. Patients were stratified by first-line systemic treatment. Statistical analysis was conducted from October 1 to December 1, 2020. MAIN OUTCOMES AND MEASURES The primary outcome was OS from the date of diagnosis to death or censoring at last follow-up. After 1:1:1 nearest-neighbor caliper matching of propensity scores, survival analyses were conducted using Cox proportional hazards regression and Kaplan-Meier estimates. RESULTS The final study population included 5872 patients (TT group: n = 4755 [81%]; 3332 men [70%]; median age, 64 years [interquartile range, 57-71 years]; IT group: n = 638 [11%]; 475 men [74%]; median age, 61 years [interquartile range, 54-69 years]; and combination TT and IT group: n = 479 [8%]; 321 men [67%]; median age, 62 years [interquartile range, 55-69 years]), and the matched cohort included 1437 patients (479 per treatment group). Patients in the IT and combination TT and IT groups were younger than those in the TT group, had fewer comorbid conditions (Charlson-Deyo score of 0, 480 of 638 [75%] in the TT group, 356 of 479 [74%] in the IT group, and 3273 of 4755 [69%] in the combination TT and IT group), and were more often treated at academic centers (315 of 638 [49%], 216 of 479 [45%], and 1935 of 4755 [41%], respectively). Both first-line IT and combination TT and IT were associated with improved OS compared with first-line TT for patients with metastatic clear cell RCC (IT group: hazard ratio [HR], 0.60 [95% CI, 0.48-0.75]; P < .001; combination TT and IT group: HR, 0.74 [95% CI, 0.60-0.91]; P = .005). No survival difference was seen between the IT and combination TT and IT groups (combination TT and IT: HR, 1.24 [95% CI, 0.98-1.56]; P = .08). CONCLUSIONS AND RELEVANCE This study suggests that both first-line IT and combination TT and IT were associated with improved OS compared with first-line TT for patients with metastatic clear cell RCC. These findings are similar to those identified in recently reported clinical trials, lending confidence to the broader applicability of these findings outside of a clinical trial setting.
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Affiliation(s)
- Nicholas H. Chakiryan
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Da David Jiang
- Department of Urology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Kyle A. Gillis
- Department of Urology, University of Iowa Hospitals & Clinics, Iowa City
| | - Elizabeth Green
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Ali Hajiran
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Lee Hugar
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Logan Zemp
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Jingsong Zhang
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Rohit K. Jain
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Jad Chahoud
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Philippe E. Spiess
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Wade Sexton
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Scott M. Gilbert
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Brandon J. Manley
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
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27
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Patel SY, Trona N, Alford B, Laborde JM, Kim Y, Li R, Manley BJ, Gilbert SM, Sexton WJ, Spiess PE, Poch MA. Preoperative immunonutrition and carbohydrate loading associated with improved bowel function after radical cystectomy. Nutr Clin Pract 2021; 37:176-182. [PMID: 33900647 DOI: 10.1002/ncp.10661] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
BACKGROUND Preoperative malnourishment has been consistently associated with poor outcomes after radical cystectomy and other major abdominal surgeries. Most enhanced recovery after surgery (ERAS) studies have examined preoperative nutrition and its relationship to outcomes after gastrointestinal surgery. Although numerous studies have demonstrated the benefits of using an ERAS protocol, this study in unique in comparing 2 ERAS protocols, with and without a nutrition component. METHODS A formalized preoperative nutrition protocol (PNP) recommending use of preoperative immunonutrition and carbohydrate drink was introduced in June 2018. A total of 78 consecutive patients who drank both beverages were compared with 92 historical controls. Multivariable logistic regression analyses were sequentially performed to determine if preoperative nutrition was associated with binary outcome variables (30-day complication, infectious complication, and readmission within 30 days). RESULTS The preoperative nutrition group and control group were statistically similar in distribution of age, sex, American Society of Anesthesiologists physical status classification, clinical stage, and body mass index. Return of bowel function was found to occur earlier in the preoperative nutrition group than in the control group (3.12 vs 3.74 days; relative risk, 0.82; CI, 0.73-0.93; P = .0029). Complications within 30 days were similar in both groups (63.6% vs 55.4%; P = 0.36). Infectious complications (42.9% vs 37%; P = .53) and readmission within 30 days (22.1% vs 15.2%; P = .34) were also similar in both groups. CONCLUSIONS Use of a PNP including immunonutrition and carbohydrate drink may be associated with earlier return of bowel function after radical cystectomy.
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Affiliation(s)
- Sephalie Y Patel
- Department of Anesthesiology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida, USA
| | - Nathaniel Trona
- USF Health Morsani College of Medicine, University of South Florida, Tampa, Florida, USA
| | - Brandon Alford
- USF Health Morsani College of Medicine, University of South Florida, Tampa, Florida, USA.,Department of Anesthesiology, University of Tennessee Medical Center, Knoxville, Tennessee, USA
| | - Jose M Laborde
- Department of Biostatistics and Bioinformatics, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida, USA
| | - Youngchul Kim
- Department of Biostatistics and Bioinformatics, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida, USA
| | - Roger Li
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida, USA
| | - Brandon J Manley
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida, USA
| | - Scott M Gilbert
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida, USA
| | - Wade J Sexton
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida, USA
| | - Philippe E Spiess
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida, USA
| | - Michael A Poch
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida, USA
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Abstract
PURPOSE OF REVIEW A number of promising therapies for Bacillus Calmette-Guerin (BCG) unresponsive nonmuscle invasive bladder cancer (NMIBC) are in the pipeline. In this review, we discuss the history of immunotherapy for the treatment of NMIBC and future developments, focusing on novel intravesical treatments. RECENT FINDINGS The term BCG unresponsive NMIBC encompasses patients with both BCG refractory and BCG relapsing disease. This definition was adopted to standardize inclusion criteria for patients enrolling in clinical trials in this setting. A host of intravesical immuno-oncologic therapies that include gene therapies, oncolytic viruses, cell surface molecule delivered immunotoxins, and cytokine driven agonism of cellular immunity, are in various phases of the drug development pipeline. In addition, pembrolizumab, an immune-checkpoint inhibitor, has recently been approved as a treatment option for BCG unresponsive NMIBC. SUMMARY Patients with BCG unresponsive disease face many difficulties. Although radical cystectomy is the most effective treatment option for these patients, it is associated with significant morbidity, difficult recovery challenges, and refusal by many patients. Cancer immunotherapies may provide bladder sparing options for some patients who develop BCG unresponsive disease.
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Affiliation(s)
- Lee A Hugar
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center, Tampa, Florida
| | - Scott M Gilbert
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center, Tampa, Florida
| | - Wade J Sexton
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center, Tampa, Florida
| | - Ashish M Kamat
- Department of Urology, MD Anderson Cancer Center, Houston, Texas, USA
| | - Roger Li
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center, Tampa, Florida
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29
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Safa H, Tamil M, Spiess PE, Manley B, Pow-Sang J, Gilbert SM, Safa F, Gonzalez BD, Oswald LB, Semaan A, Diab A, Chahoud J. Patient-Reported Outcomes in Clinical Trials Leading to Cancer Immunotherapy Drug Approvals From 2011 to 2018: A Systematic Review. J Natl Cancer Inst 2020; 113:532-542. [PMID: 33146385 DOI: 10.1093/jnci/djaa174] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Revised: 09/23/2020] [Accepted: 10/19/2020] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Patient-reported outcomes (PROs) promote patient centeredness in clinical trials; however, in the field of rapidly emerging and clinically impressive immunotherapy, data on PROs are limited. METHODS We systematically identified all immunotherapy approvals from 2011 through 2018 and assessed the analytic tools and reporting quality of associated PRO reports. For randomized clinical trials (RCTs), we developed a novel 24-point scoring scale: the PRO Endpoints Analysis Score based on 24 criteria derived from the recommendations of the Setting International Standards in Analyzing Patient-Reported Outcomes and Quality of Life Endpoints Data Consortium. RESULTS We assessed 44 trial publications supporting 42 immunotherapy approvals. PROs were published for 21 of the 44 (47.7%) trial publications. Twenty-three trials (52.3%) were RCTs and 21 (47.7%) pertained to single-arm trials. The median time between primary clinical outcomes publications and their corresponding secondary PRO publications was 19 months (interquartile range = 9-29 months). Of the 21 PRO reports, 4 (19.0%) reported a specific hypothesis, and most (85.7%) used descriptive statistics. Three (3 of 21 [14.3%]) studies performed a control for type I error. As for RCTs, 14 of 23 (60.9%) published PRO data, including 13 (56.5%) that published a secondary dedicated manuscript. One-half of these 14 trials scored less than 13 points on the 24-point PRO Endpoints Analysis Score. The mean score was 12.71 (range = 5-17, SD = 3.71), and none met all the recommendations of the Setting International Standards in Analyzing Patient-Reported Outcomes and Quality of Life Endpoints Data Consortium. CONCLUSIONS Suboptimal reporting of PROs occurs regularly in cancer immunotherapy trials. Increased efforts are needed to maximize the value of these data in cancer immunotherapy development and approval.
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Affiliation(s)
- Houssein Safa
- Department of Melanoma Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Monica Tamil
- Department of Internal Medicine, The University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Philippe E Spiess
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Brandon Manley
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Julio Pow-Sang
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Scott M Gilbert
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Firas Safa
- John W. Deming Department of Medicine, Section of Hematology and Medical Oncology, Tulane University, New Orleans, LA, USA
| | - Brian D Gonzalez
- Department of Health Outcomes and Behavior, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Laura B Oswald
- Department of Health Outcomes and Behavior, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Adele Semaan
- Participant Research, Interventions, and Measurements Core, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Adi Diab
- Department of Melanoma Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jad Chahoud
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
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30
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Abstract
Our understanding of the mechanism of bacillus Calmette-Guérin (BCG) in controlling urothelial carcinoma is still evolving. Studies have revealed a complex and multifaceted immune response. BCG-elicited adaptive antitumor immunity directed towards tumor antigens could have major implications for trial design.
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Affiliation(s)
- Roger Li
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center, Tampa, FL, USA; Department of Immunology, H. Lee Moffitt Cancer Center, Tampa, FL, USA.
| | - Scott M Gilbert
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center, Tampa, FL, USA
| | - Ashish M Kamat
- Department of Urology, MD Anderson Cancer Center, Houston, TX, USA
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31
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Aydin AM, Gage K, Dhillon J, Cheriyan SK, Poch MA, Manley BJ, Li R, Sexton WJ, Spiess PE, Gilbert SM, Pow-Sang JM. Focal bipolar radiofrequency ablation for localized prostate cancer: Safety and feasibility. Int J Urol 2020; 27:882-889. [PMID: 32767444 DOI: 10.1111/iju.14321] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [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: 02/02/2020] [Accepted: 06/15/2020] [Indexed: 12/26/2022]
Abstract
OBJECTIVES To evaluate the safety and feasibility of focal bipolar radiofrequency ablation in men with localized prostate cancer. METHODS A review of 10 patients treated with a novel bipolar radiofrequency ablation probe integrated in a coil design (Encage; Trod Medical, Bradenton, FL, USA) between 2011 and 2017 in two prospective pilot trials. All men had clinical stage T1c prostate cancer, prostate-specific antigen <10 ng/mL and Gleason score ≤7. Ablation was carried out under general anesthesia, and bipolar probes were inserted transperineally under transrectal ultrasound guidance. Treatment-related adverse events, quality of life and negative biopsy rate were evaluated at 6 months after ablation. The Wilcoxon signed-rank test was used to compare baseline and post-treatment symptom scores. RESULTS The median age was 58 years (range 50-64 years) and the median prostate volume was 49.65 cc (range 21-68 cc). Prostate cancer with a Gleason score of 6 (3 + 3) and 7 (3 + 4) was noted in seven and three patients, respectively. The median number of radiofrequency ablation cycles was 2.5 (range 2-5). All patients were catheter-free and able to void the day of surgery. Within 6 months after ablation, all adverse events were low grade, with the exception of one grade 3 hematuria that required cystoscopy without coagulation. Six months after ablation bowel, urinary and hormonal functions, and overall satisfaction remained stable. Erectile dysfunction occurred in two out of four patients who had normal sexual function before the procedure. Neither urinary incontinence nor urinary infection was noted. CONCLUSIONS This first report on focal bipolar radiofrequency ablation documents a safe and feasible treatment option for selected patients with localized prostate cancer.
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Affiliation(s)
- Ahmet Murat Aydin
- Departments of , Department of , Genitourinary Oncology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, Florida, USA
| | - Kenneth Gage
- Department of , Department of , Diagnostic Imaging, H. Lee Moffitt Cancer Center & Research Institute, Tampa, Florida, USA
| | - Jasreman Dhillon
- Department of , Anatomic Pathology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, Florida, USA
| | - Salim K Cheriyan
- Departments of , Department of , Genitourinary Oncology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, Florida, USA
| | - Michael A Poch
- Departments of , Department of , Genitourinary Oncology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, Florida, USA
| | - Brandon J Manley
- Departments of , Department of , Genitourinary Oncology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, Florida, USA
| | - Roger Li
- Departments of , Department of , Genitourinary Oncology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, Florida, USA
| | - Wade J Sexton
- Departments of , Department of , Genitourinary Oncology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, Florida, USA
| | - Philippe E Spiess
- Departments of , Department of , Genitourinary Oncology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, Florida, USA
| | - Scott M Gilbert
- Departments of , Department of , Genitourinary Oncology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, Florida, USA
| | - Julio M Pow-Sang
- Departments of , Department of , Genitourinary Oncology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, Florida, USA
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Lee CT, Mohamed NE, Pisipati S, Shah QN, Agarwal PK, Downs TM, Droller M, Gilbert SM, Goltz HH, Hall SJ, Hendawi M, Hoffman-Censits J, O’Donnell M, Kaag M, Karsh LI, Kassouf W, Quale DZ, Sagalowsky A, Steinberg GD, Latini DM. Development and evaluation of a bladder Cancer specific survivorship care plan by patients and clinical care providers: a multi-methods approach. BMC Health Serv Res 2020; 20:686. [PMID: 32709234 PMCID: PMC7379822 DOI: 10.1186/s12913-020-05533-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2019] [Accepted: 07/13/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND, CONTEXT AND PURPOSE In spite of the mixed evidence for their impact, survivorship Care Plans (SCPs) are recommended to enhance quality of care for cancer survivors. Data on the feasibility of SCPs in bladder cancer (BC) is sparse. Using a mixed-methods approach, this study describes the iterative development, acceptability and feasibility of BC specific SCP (BC-SCP) in clinical settings. METHODS In Phase I, we developed the BC-SCP. In Phase II, we conducted four focus groups with 19 patients and 15 providers to examine its acceptability and usability challenges. Data analyses using the Atlas.ti program, informed refinement of the BC-SCP. In Phase III, we conducted feasibility testing of the refined BC-SCP with 18 providers from 12 health-centers. An encounter survey was completed after each assessment to examine the feasibility of the BC-SCP. Chi-square and Fisher Exact tests were used for comparative analyses. RESULTS During phase I, we observed high patient and provider acceptability of the BC-SCP and substantial engagement in improving its content, design, and structure. In Phase II, providers completed 59 BC-SCPs. Mean time for BC-SCP completion was 12.3 min. Providers reported that BC-SCP content was clear, did not hamper clinic flow and was readily completed with easy-to-access information. Comparative analyses to examine differences in SCP completion time by patient clinico-demographic characteristics and provider type revealed no significant differences. CONCLUSIONS Our BC-SCP has clinical relevance, and can be used in an active practice setting. However, considerable progress will be necessary to achieve implementation of and sharing the BC-SCP with patients and care providers, particularly within the electronic medical record. In summary, BC-SCPs are essential to improve the follow up care of BC survivors. Clinical resources are required to ensure appropriate implementation of BC-SCPs. TRIAL REGISTRATION Study HUM00056082.
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Affiliation(s)
- Cheryl T. Lee
- Department of Urology, The Ohio State University, Columbus, OH USA
| | - Nihal E. Mohamed
- Department of Urology and Oncological Sciences, Icahn School of Medicine at Mount Sinai, 1 Gustave L Levy Place, New York, NY 10029 USA
| | | | - Qainat N. Shah
- Department of Urology and Oncological Sciences, Icahn School of Medicine at Mount Sinai, 1 Gustave L Levy Place, New York, NY 10029 USA
| | | | | | - Michael Droller
- Department of Urology and Oncological Sciences, Icahn School of Medicine at Mount Sinai, 1 Gustave L Levy Place, New York, NY 10029 USA
| | | | - Heather H. Goltz
- Social Work Program, University of Houston-Downtown, Houston, TX USA
- Section of Infectious Diseases, Baylor College of Medicine, Houston, TX USA
| | - Simon J. Hall
- Smith Institute for Urology, Hofstra School of Medicine/Northwell Health System, Lake Success, NY USA
| | - Mohamed Hendawi
- Department of Urology, The Ohio State University, Columbus, OH USA
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Sessine MS, Weizer A, Kirk PS, Borza T, Jacobs BL, Qin Y, Oerline M, Li B, Modi PK, Lavieri MS, Gilbert SM, Montgomery JS, Hollenbeck BK, Urish K, Helm JE, Skolarus TA. Reframing Financial Incentives Around Reducing Readmission After Radical Cystectomy. Urology 2020; 142:99-105. [PMID: 32413517 DOI: 10.1016/j.urology.2020.03.059] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2019] [Revised: 02/29/2020] [Accepted: 03/29/2020] [Indexed: 01/13/2023]
Abstract
OBJECTIVE To better understand the financial implications of readmission after radical cystectomy, an expensive surgery coupled with a high readmission rate. Currently, whether hospitals benefit financially from readmissions after radical cystectomy remains unclear, and potentially obscures incentives to invest in readmission reduction efforts. MATERIALS AND METHODS Using a 20% sample of national Medicare beneficiaries, we identified 3544 patients undergoing radical cystectomy from January 2010 to November 2014. We compared price-standardized Medicare payments for index admissions and readmissions after surgery. We also examined the variable financial impact of length of stay and the proportion of Medicare payments coming from readmissions based on overall readmission rate. RESULTS Medicare patients readmitted after cystectomy had higher index hospitalization payments ($19,164 readmitted vs $18,146 non-readmitted, P = .03) and an average readmission payment of $7356. Adjusted average Medicare readmission payments and length of stay varied significantly across hospitals, ranging from $2854 to $15,605, and 2.0 to 17.1 days, respectively (both P <.01), with longer length of stay associated with increased payments. After hospitals were divided into quartiles based on overall readmission rates, the percent of payments coming from readmissions ranged from 5% to 13%. CONCLUSION Readmissions following radical cystectomy were associated with increased Medicare payments for the index hospitalization, and the readmission payment, potentially limiting incentives for readmission reduction programs. Our findings highlight opportunities to reframe efforts to support patients, caregivers, and providers through improving the discharge and readmission processes to create a patient-centered experience, rather than for fear of financial penalties.
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Affiliation(s)
- Michael S Sessine
- Dow Division of Health Services Research, Department of Urology, University of Michigan Health System, Ann Arbor, MI
| | - Alon Weizer
- Dow Division of Health Services Research, Department of Urology, University of Michigan Health System, Ann Arbor, MI
| | - Peter S Kirk
- Dow Division of Health Services Research, Department of Urology, University of Michigan Health System, Ann Arbor, MI
| | - Tudor Borza
- Department of Urology, University of Wisconsin School of Medicine and Public Health, Madison, WI; Division of Urology, William S. Middleton Memorial Veterans Hospital, Madison, WI
| | - Bruce L Jacobs
- Department of Urology, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Yongmei Qin
- Dow Division of Health Services Research, Department of Urology, University of Michigan Health System, Ann Arbor, MI
| | - Mary Oerline
- Dow Division of Health Services Research, Department of Urology, University of Michigan Health System, Ann Arbor, MI
| | - Benjamin Li
- Dow Division of Health Services Research, Department of Urology, University of Michigan Health System, Ann Arbor, MI
| | - Parth K Modi
- Dow Division of Health Services Research, Department of Urology, University of Michigan Health System, Ann Arbor, MI
| | - Mariel S Lavieri
- Department of Industrial and Operations Engineering, University of Michigan, Ann Arbor, MI
| | - Scott M Gilbert
- Department of Urology, H. Lee Moffitt Cancer Center, Tampa, FL
| | - Jeffrey S Montgomery
- Dow Division of Health Services Research, Department of Urology, University of Michigan Health System, Ann Arbor, MI
| | - Brent K Hollenbeck
- Dow Division of Health Services Research, Department of Urology, University of Michigan Health System, Ann Arbor, MI
| | - Ken Urish
- Department of Orthopaedic Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Jonathan E Helm
- Department of Operations and Decision Technologies, Kelley School of Business, Indiana University, Bloomington, IN
| | - Ted A Skolarus
- Dow Division of Health Services Research, Department of Urology, University of Michigan Health System, Ann Arbor, MI; VA Health Services Research and Development, Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI.
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Jim HSL, Hoogland AI, Brownstein NC, Barata A, Dicker AP, Knoop H, Gonzalez BD, Perkins R, Rollison D, Gilbert SM, Nanda R, Berglund A, Mitchell R, Johnstone PAS. Innovations in research and clinical care using patient-generated health data. CA Cancer J Clin 2020; 70:182-199. [PMID: 32311776 PMCID: PMC7488179 DOI: 10.3322/caac.21608] [Citation(s) in RCA: 51] [Impact Index Per Article: 12.8] [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: 12/01/2019] [Revised: 02/24/2020] [Accepted: 02/24/2020] [Indexed: 12/17/2022] Open
Abstract
Patient-generated health data (PGHD), or health-related data gathered from patients to help address a health concern, are used increasingly in oncology to make regulatory decisions and evaluate quality of care. PGHD include self-reported health and treatment histories, patient-reported outcomes (PROs), and biometric sensor data. Advances in wireless technology, smartphones, and the Internet of Things have facilitated new ways to collect PGHD during clinic visits and in daily life. The goal of the current review was to provide an overview of the current clinical, regulatory, technological, and analytic landscape as it relates to PGHD in oncology research and care. The review begins with a rationale for PGHD as described by the US Food and Drug Administration, the Institute of Medicine, and other regulatory and scientific organizations. The evidence base for clinic-based and remote symptom monitoring using PGHD is described, with an emphasis on PROs. An overview is presented of current approaches to digital phenotyping or device-based, real-time assessment of biometric, behavioral, self-report, and performance data. Analytic opportunities regarding PGHD are envisioned in the context of big data and artificial intelligence in medicine. Finally, challenges and solutions for the integration of PGHD into clinical care are presented. The challenges include electronic medical record integration of PROs and biometric data, analysis of large and complex biometric data sets, and potential clinic workflow redesign. In addition, there is currently more limited evidence for the use of biometric data relative to PROs. Despite these challenges, the potential benefits of PGHD make them increasingly likely to be integrated into oncology research and clinical care.
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Affiliation(s)
- Heather S L Jim
- Department of Health Outcomes and Behavior, Moffitt Cancer Center, Tampa, Florida
| | - Aasha I Hoogland
- Department of Health Outcomes and Behavior, Moffitt Cancer Center, Tampa, Florida
| | - Naomi C Brownstein
- Department of Biostatistics and Bioinformatics, Moffitt Cancer Center, Tampa, Florida
| | - Anna Barata
- Department of Health Outcomes and Behavior, Moffitt Cancer Center, Tampa, Florida
| | - Adam P Dicker
- Department of Radiation Oncology, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Hans Knoop
- Department of Medical Psychology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam Public Health Research Institute, Amsterdam, the Netherlands
| | - Brian D Gonzalez
- Department of Health Outcomes and Behavior, Moffitt Cancer Center, Tampa, Florida
| | - Randa Perkins
- Department of Clinical Informatics and Clinical Systems, Moffitt Cancer Center, Tampa, Florida
| | - Dana Rollison
- Department of Cancer Epidemiology, Moffitt Cancer Center, Tampa, Florida
| | - Scott M Gilbert
- Department of Genitourinary Oncology, Moffitt Cancer Center, Tampa, Florida
| | - Ronica Nanda
- Department of Radiation Oncology, Moffitt Cancer Center, Tampa, Florida
- BayCare Health Systems Inc, Morton Plant Hospital, Clearwater, Florida
| | - Anders Berglund
- Department of Biostatistics and Bioinformatics, Moffitt Cancer Center, Tampa, Florida
| | - Ross Mitchell
- Department of Biostatistics and Bioinformatics, Moffitt Cancer Center, Tampa, Florida
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Li R, Sundi D, Zhang J, Kim Y, Sylvester RJ, Spiess PE, Poch MA, Sexton WJ, Black PC, McKiernan JM, Steinberg GD, Kamat AM, Gilbert SM. Systematic Review of the Therapeutic Efficacy of Bladder-preserving Treatments for Non-muscle-invasive Bladder Cancer Following Intravesical Bacillus Calmette-Guérin. Eur Urol 2020; 78:387-399. [PMID: 32143924 DOI: 10.1016/j.eururo.2020.02.012] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [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: 12/23/2019] [Accepted: 02/14/2020] [Indexed: 12/17/2022]
Abstract
CONTEXT There is a critical need for effective bladder-sparing therapies for bacillus Calmette-Guérin (BCG)-unresponsive non-muscle-invasive bladder cancer (NMIBC). Owing to the current lack of effective agents that can be used as a control, the US Food and Drug Administration began to accept single-arm trials for patients with carcinoma in situ (CIS), using complete response rate (CRR) and duration of response as the primary endpoints to support marketing applications. Despite the ensuing growth of clinical trials in this space, no consensus exists on a clinically relevant benchmark for CRR. OBJECTIVE To elucidate the CRR and recurrence-free rate (RFR) using bladder-sparing agents after BCG failure in order to provide a frame of reference for future clinical trial results. EVIDENCE ACQUISITION We performed a systematic review of clinical trials utilizing bladder-sparing therapeutics for NMIBC recurring after intravesical BCG (PROSPERO CRD42019130553). The search was performed in MEDLINE, EMBASE, and Cochrane Library. Relevant studies identified from bibliography search and conference abstracts were searched to complement the systematic review. A total of 42 studies utilizing 24 treatment options and consisting of 2254 patients were included for final analysis. EVIDENCE SYNTHESIS Median CRRs in the treatment of CIS-containing tumors were 26% at 6 mo, 17% at 12 mo, and 8% at 24 mo after treatment. In comparison, median RFRs in the papillary-only studies were 67% at 6 mo, 44% at 12 mo, and 10% at 24 mo. Specifically in the BCG-unresponsive population, 6- and 12-mo CRRs in CIS-containing patients treated with Mycobacterium phlei cell wall-nucleic acid complex were 45% and 27%, respectively, and the median 6-, 12-, and 24-mo disease-free rates in the other studies were 43%, 35%, and 18%, respectively. The median progression-free rate was 91%: 95% in the CIS-containing studies and 89% in studies restricted to papillary-only recurrences. Toxicities of intravesical agents were generally mild, with very few dose limiting toxicities. CONCLUSIONS We demonstrate that, to date, bladder-sparing therapies achieved modest efficacy in patients with NMIBC after BCG. Results from the current study will serve as a frame of reference for emerging trial results in the BCG-unresponsive space. PATIENT SUMMARY In this study, we found that bladder-sparing therapies achieved modest efficacy in patients with non-muscle-invasive bladder cancer after bacillus Calmette-Guérin (BCG). These results will serve to inform future clinical trial results for salvage agents used to treat BCG-unresponsive bladder cancer.
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Affiliation(s)
- Roger Li
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center, Tampa, FL, USA.
| | - Debasish Sundi
- Department of Urology, Ohio State University Comprehensive Cancer Center, Columbus, OH, USA
| | - Jingsong Zhang
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center, Tampa, FL, USA
| | - Youngchul Kim
- Department of Biostatistics and Bioinformatics, Moffitt Cancer Center, Tampa, FL, USA
| | | | - Philippe E Spiess
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center, Tampa, FL, USA
| | - Michael A Poch
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center, Tampa, FL, USA
| | - Wade J Sexton
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center, Tampa, FL, USA
| | - Peter C Black
- Vancouver Prostate Center, Department of Urologic Sciences, University of British Columbia, Vancouver, Canada
| | | | | | - Ashish M Kamat
- Department of Urology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Scott M Gilbert
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center, Tampa, FL, USA
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36
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Peyton CC, Hajiran A, Morgan K, Azizi M, Tang D, Chipollini J, Gilbert SM, Poch M, Sexton WJ, Spiess PE. Urinary leak following partial nephrectomy: a contemporary review of 975 cases. Can J Urol 2020; 27:10118-10124. [PMID: 32065869] [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] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
INTRODUCTION To describe the incidence, contemporary management, risk factors and outcomes of urinary leak following open and robotic partial nephrectomy at a tertiary care, comprehensive cancer center. MATERIALS AND METHODS We reviewed 975 patients who underwent partial nephrectomy at Moffitt Cancer Center from January 2009 to May 2017. Patient demographic, perioperative and follow up data was recorded and compared stratified for postoperative urine leak. Fisher's exact and Wilcoxon sum-rank testing were performed for categorical and continuous variables as indicated. RESULTS Twenty-three of 975 (2.3%) patients experienced a urine leak after partial nephrectomy. Median nephrometry score for urine leak patients was 8 (SD +/- 1.3). Median postoperative days to detection was 3.5 and most leaks were discovered due to high drain output. Operative factors associated with urinary leak included open surgery, estimated blood loss, and not using a sliding-clip renorrhaphy (p < 0.05). Ten (44%) were managed conservatively, 9 (39%) patients required ureteral stent placement, 3 (13%) needed a percutaneous nephrostomy tube, one patient (4%) required percutaneous drainage for urinoma (4%). One patient ultimately failed conservative management and required nephrectomy 45 days after the original surgery. Mean time to stent and drain removal was 40 +/- 17 and 24 +/- 7 days, respectively. Five patients with symptomatic leaks were readmitted with a mean length of stay of 3.2 +/- 1.8 days. CONCLUSIONS The overall incidence of urinary leak after partial nephrectomy remains low regardless of surgical approach. Perioperative characteristics such as tumor complexity and high blood loss, in addition to open surgery and not using a sliding-clip bolstered renorrhaphy are associated with urine leak.
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Affiliation(s)
- Charles C Peyton
- Department of Genitourinary Oncology, Moffitt Cancer Center, Tampa, Florida, USA
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37
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Sexton WJ, Gilbert SM. Focused issue on testicular cancer-forward. Transl Androl Urol 2020; 9:S1-S2. [PMID: 32055479 DOI: 10.21037/tau.2019.12.15] [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: 11/06/2022] Open
Affiliation(s)
- Wade J Sexton
- Department of Genitourinary Oncology, Moffitt Cancer Center, Tampa, FL, USA
| | - Scott M Gilbert
- Department of Genitourinary Oncology, Moffitt Cancer Center, Tampa, FL, USA
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Cheriyan SK, Nicholson M, Aydin AM, Azizi M, Peyton CC, Sexton WJ, Gilbert SM. Current management and management controversies in early- and intermediate-stage of nonseminoma germ cell tumors. Transl Androl Urol 2020; 9:S45-S55. [PMID: 32055485 DOI: 10.21037/tau.2019.05.14] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [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: 11/06/2022] Open
Abstract
Early stage nonseminomatous germ cell tumor (NSGCT) remains a treatable disease, with stage I cancer specific survival exceeding 95%. Using a risk-adapted approach; active surveillance (AS), adjuvant chemotherapy, and retroperitoneal lymph node dissection (RPLND) all options for treatment; with surveillance being increasingly used. With persistently elevated markers (stage IS), chemotherapy remains the hallmark of treatment. Management of stage II NSGCT varies based on status of tumor markers. With negative markers, both induction chemotherapy and upfront RPLND remain options. Management of a residual mass <1 cm after chemotherapy remains controversial, with AS and nerve-sparing RPLND considered options. The development of miR-371a-3p microRNA shows promise a novel biomarker for testicular cancer (GCT). Despite controversies in management, cures for NSGCT are achievable in 95-99% of patients.
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Affiliation(s)
- Salim K Cheriyan
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Marilin Nicholson
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Ahmet M Aydin
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Mounsif Azizi
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Charles C Peyton
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Wade J Sexton
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Scott M Gilbert
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA.,Department of Health Outcomes and Behavior, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
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Azizi M, Aydin AM, Cheriyan SK, Peyton CC, Montanarella M, Gilbert SM, Sexton WJ. Therapeutic strategies for uncommon testis cancer histologies: teratoma with malignant transformation and malignant testicular sex cord stromal tumors. Transl Androl Urol 2020; 9:S91-S103. [PMID: 32055490 DOI: 10.21037/tau.2019.09.08] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [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: 01/14/2023] Open
Abstract
Testicular cancer is the most common solid malignancy in male adolescents and young adults, with germ cell derived seminomas and non-seminomas being by far the most common histologies. Teratoma with somatic-type malignancy is a rare chemo-resistant phenotype of testis cancer associated with poor prognosis in patients with advanced stage disease. Malignant gonadal-stromal tumors comprise 5% of testicular neoplasms and approximately 10% are malignant and considered chemo-radiation resistant. Prognostic factors and treatment strategies for these uncommon histologies are lacking.
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Affiliation(s)
- Mounsif Azizi
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Ahmet M Aydin
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Salim K Cheriyan
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Charles C Peyton
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Matthew Montanarella
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Scott M Gilbert
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA.,Department of Health Outcomes and Behavior, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Wade J Sexton
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
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Azizi M, Peyton CC, Boulware DC, Gilbert SM, Sexton WJ. Primary tumor size thresholds in stage IA testicular seminoma: Implications for adjuvant therapy after orchiectomy and survival. Urol Oncol 2019; 38:7.e9-7.e18. [PMID: 31704139 DOI: 10.1016/j.urolonc.2019.09.022] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2019] [Revised: 09/05/2019] [Accepted: 09/24/2019] [Indexed: 01/03/2023]
Abstract
OBJECTIVES Primary tumor size (PTS) is the main prognostic factor for relapse in clinical stage (CS) IA testicular seminoma (T1N0M0S0) and the 8th edition of the Tumor-Node-Metastasis staging system now subcategorizes pT1 tumors into pT1a and pT1b based on PTS (<3 cm and ≥3 cm, respectively). We attempted to assess PTS as a prognosticator for overall survival (OS) in CS IA seminoma and to evaluate the comparative effectiveness of active surveillance (AS) versus adjuvant therapy (AT) in patients with large primary tumors (LPT). METHODS AND MATERIALS In the National Cancer Database (2004-2014), 2455 (47.7%) and 2685 (52.3%) patients with CS IA seminoma were treated with AS and AT, respectively. AT was defined as the receipt of chemotherapy or radiation within 3 months after orchiectomy. A cut-point analysis was performed to determine the optimal PTS threshold predicting OS at 5 years after orchiectomy. Inverse-probability of treatment weighting (IPTW)-adjusted Kaplan-Meier curves and Cox regression analyses were used to compare OS of patients with LPT (using the optimal PTS cut-point) treated with AS versus AT. RESULTS In adjusted analysis, pathologic T-stage (pT1a vs. pT1b) did not predict OS and no OS benefit was noted in pT1b patients treated with AT. The optimal PTS cut-point was 4.5 cm. In multivariable analysis, patients with LPT (≥4.5 cm) had an increased risk of overall mortality (HR = 1.87, P = 0.003). Kaplan-Meier curves revealed that OS was superior in patients with LPT treated with AT (IPTW-adjusted log-rank P = 0.029). In IPTW-adjusted Cox regression analysis, AT was associated with an OS benefit in patients with LPT (HR = 0.59, 95%CI: 0.39-0.91, P = 0.017). CONCLUSIONS In this National Cancer Database analysis, PTS was a predictor of OS in CS IA seminoma. An OS benefit was noted for individuals with LPT (defined as PTS ≥4.5 cm) managed with AT. These findings may warrant refinement of Tumor-Node-Metastasis staging system.
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Affiliation(s)
- Mounsif Azizi
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL
| | - Charles C Peyton
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL
| | - David C Boulware
- Department of Biostatistics, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL
| | - Scott M Gilbert
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL; Department of Health Outcomes and Behavior, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL
| | - Wade J Sexton
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL.
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Gilbert SM, Sexton WJ. Optimal Management of High-risk Stage I Nonseminoma Germ Cell Tumor: Active Intervention is the Preferred Option. Eur Urol Focus 2019; 5:704-705. [PMID: 31564641 DOI: 10.1016/j.euf.2019.09.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2019] [Accepted: 09/12/2019] [Indexed: 12/01/2022]
Abstract
While there is still debate and uncertainty regarding the best management strategy for clinical stage IB nonseminoma germ cell tumor, adjuvant treatment with chemotherapy or surgery is associated with a markedly lower risk of recurrence for men with high-risk features and provides more definitive disease control and lower overall exposure to chemotherapy for patients who do experience recurrence.
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Affiliation(s)
- Scott M Gilbert
- H. Lee Moffitt Cancer Center & Research Institute, Department of Genitourinary Oncology, Tampa, FL, USA.
| | - Wade J Sexton
- H. Lee Moffitt Cancer Center & Research Institute, Department of Genitourinary Oncology, Tampa, FL, USA
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Kirk PS, Skolarus TA, Jacobs BL, Qin Y, Li B, Sessine M, Liu X, Zhu K, Gilbert SM, Hollenbeck BK, Urish K, Helm J, Lavieri MS, Borza T. Characterising 'bounce-back' readmissions after radical cystectomy. BJU Int 2019; 124:955-961. [PMID: 31313473 DOI: 10.1111/bju.14874] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [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: 01/16/2023]
Abstract
OBJECTIVE To examine predictors of early readmissions after radical cystectomy (RC). Factors associated with preventable readmissions may be most evident in readmissions that occur within 3 days of discharge, commonly termed 'bounce-back' readmissions, and identifying such factors may inform efforts to reduce surgical readmissions. PATIENTS AND METHODS We utilised the Healthcare Cost and Utilization Project's State Inpatient Databases to examine 1867 patients undergoing RC in 2009 and 2010, and identified all patients readmitted within 30 days of discharge. We assessed differences between patients experiencing bounce-back readmission compared to those readmitted 8-30 days after discharge using logistic regression models and also calculated abbreviated LACE scores to assess the utility of common readmissions risk stratification algorithms. RESULTS The 30-day and bounce-back readmission rates were 28.4% and 5.6%, respectively. Although no patient or index hospitalisation characteristics were significantly associated with bounce-back readmissions in adjusted analyses, bounce-back patients did have higher rates of gastrointestinal (14.3% vs 6.7%, P = 0.02) and wound (9.5% vs 3.0%, P < 0.01) diagnoses, as well as increased index and readmission length of stay (5 vs 4 days, P = 0.01). Overall, the median abbreviated LACE score was 7, which fell into the moderate readmission risk category, and no difference was observed between readmitted and non-readmitted patients. CONCLUSION One in five readmissions after RC occurs within 3 days of initial discharge, probably due to factors present at discharge. However, sociodemographic and clinical factors, as well as traditional readmission risk tools were not predictive of this bounce-back. Effective strategies to reduce bounce-back readmission must identify actionable clinical factors prior to discharge.
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Affiliation(s)
- Peter S Kirk
- Dow Division of Health Services Research, Department of Urology, University of Michigan Health System, Ann Arbor, MI, USA
| | - Ted A Skolarus
- Dow Division of Health Services Research, Department of Urology, University of Michigan Health System, Ann Arbor, MI, USA.,VA Health Services Research and Development, Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
| | - Bruce L Jacobs
- Department of Urology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Yongmei Qin
- Dow Division of Health Services Research, Department of Urology, University of Michigan Health System, Ann Arbor, MI, USA
| | - Benjamin Li
- Dow Division of Health Services Research, Department of Urology, University of Michigan Health System, Ann Arbor, MI, USA
| | - Michael Sessine
- Dow Division of Health Services Research, Department of Urology, University of Michigan Health System, Ann Arbor, MI, USA
| | - Xiang Liu
- Department of Industrial and Operations Engineering, University of Michigan, Ann Arbor, MI, USA
| | - Kevin Zhu
- Dow Division of Health Services Research, Department of Urology, University of Michigan Health System, Ann Arbor, MI, USA
| | - Scott M Gilbert
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Brent K Hollenbeck
- Dow Division of Health Services Research, Department of Urology, University of Michigan Health System, Ann Arbor, MI, USA
| | - Ken Urish
- Department of Orthopaedic Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Jonathan Helm
- Department of Operations and Decision Technologies, Kelley School of Business, Indiana University, Bloomington, IN, USA
| | - Mariel S Lavieri
- Department of Industrial and Operations Engineering, University of Michigan, Ann Arbor, MI, USA
| | - Tudor Borza
- Department of Urology, University of Wisconsin, Madison, WI, USA
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Coba GA, Zaman S, Teer JK, Robinson T, Li R, Zhang J, Knepper TC, Spiess PE, Sexton W, Smith MA, Fishman MN, Pow-Sang JM, Poch MA, Gilbert SM, Magliocco AM, Boyle TA, Manley BJ. Abstract 2632: Increased recurrence and clinical grade in renal cell carcinomas associated with novel EGFR splice variants. Cancer Res 2019. [DOI: 10.1158/1538-7445.am2019-2632] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
Background: It is well established that alterations of epidermal growth factor receptor (EGFR) are associated with the development and progression of epithelial tumors across several cancer types. Alternative splicing and alterations of EGFR splice sites can cause translational changes and EGFR alterations have historically demonstrated associations with clinical and therapeutic outcomes in lung cancer.
Objectives: To evaluate the prevalence and clinical significance of recently identified novel ΔEGFR-TKF splice variant in 102 renal cell carcinoma (RCC) tumors
Methods: The majority of the RCC samples were RNA sequenced through the Orien AVATAR™ pipeline, and 7 additional cases were analyzed through Moffitt STAR™. Moffitt STAR™ and AVATAR™ are next generation targeted sequencing assay that include both DNA and RNA analyses. Frequency tables were generated using the data collected. The Grehan-Breslow-Wilcoxon test was used to compare recurrence free survival (RFS) due to the higher weight given to survival difference at earlier time points. The rationale being that the majority of recurrence events occurred earlier than 25 months in EGFR ≥5% cases and 50 months in the EGFR <5% cases compared to the follow-up times of 75 months and 125 months in the study cohort.
Results: We identified a EGFR gene splice variant, predominantly c.2470-188_c.2470-2, between exons 20 and 21 in RCCs subjected to the sequencing assay. Of 1075 solid tumors analyzed, the presence of the EGFR gene splice variant was observed, in any amount, within 74 of 102 RCC cases (72.5%), with the only exceptions being one multiple myeloma and sarcoma case. Using an EGFR slice variant cutoff of ≥5%, 33 of 102 (32.4%) RCC were chosen to be further investigated. Upon further analysis, 32 EGFR slice variant tumors were clear cell RCC, while 1 was papillary type II RCC. Thirty cases involving ≥5% slice variants were clinically staged revealed 6 T1, 8 T2, and 16 T3/4 cases compared to tumors with <5% of the splice variants which were staged 28 T1, 10 T2, 21 T3/4, and 8 Tx (p=.011). The RFS curve trended to worse outcomes for patients with ≥5% EGFR splice variants compared to <5% EGFR splice variants (p=.0315). All variants were identified at the RNA level without obvious corresponding DNA alterations. There was an average of 106 unique reads (average of 7.7% of all reads) for these cases supporting this variant.
Conclusion: EGFR splice variants in RCC are a relatively frequent and specific molecular alteration. This novel splice variant may prove to be significant as a druggable target or as part of a kidney cancer screening protocol.
Citation Format: George A. Coba, Saif Zaman, Jamie K. Teer, Timothy Robinson, Roger Li, Jingsong Zhang, Todd C. Knepper, Philippe E. Spiess, Wade Sexton, Matthew A. Smith, Mayer N. Fishman, Julio M. Pow-Sang, Michael A. Poch, Scott M. Gilbert, Anthony M. Magliocco, Theresa A. Boyle, Brandon J. Manley. Increased recurrence and clinical grade in renal cell carcinomas associated with novel EGFR splice variants [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2019; 2019 Mar 29-Apr 3; Atlanta, GA. Philadelphia (PA): AACR; Cancer Res 2019;79(13 Suppl):Abstract nr 2632.
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Affiliation(s)
- George A. Coba
- H. Lee Moffitt Cancer Center & Research Institute, Temple Terrace, FL
| | - Saif Zaman
- H. Lee Moffitt Cancer Center & Research Institute, Temple Terrace, FL
| | - Jamie K. Teer
- H. Lee Moffitt Cancer Center & Research Institute, Temple Terrace, FL
| | - Timothy Robinson
- H. Lee Moffitt Cancer Center & Research Institute, Temple Terrace, FL
| | - Roger Li
- H. Lee Moffitt Cancer Center & Research Institute, Temple Terrace, FL
| | - Jingsong Zhang
- H. Lee Moffitt Cancer Center & Research Institute, Temple Terrace, FL
| | - Todd C. Knepper
- H. Lee Moffitt Cancer Center & Research Institute, Temple Terrace, FL
| | | | - Wade Sexton
- H. Lee Moffitt Cancer Center & Research Institute, Temple Terrace, FL
| | - Matthew A. Smith
- H. Lee Moffitt Cancer Center & Research Institute, Temple Terrace, FL
| | - Mayer N. Fishman
- H. Lee Moffitt Cancer Center & Research Institute, Temple Terrace, FL
| | - Julio M. Pow-Sang
- H. Lee Moffitt Cancer Center & Research Institute, Temple Terrace, FL
| | - Michael A. Poch
- H. Lee Moffitt Cancer Center & Research Institute, Temple Terrace, FL
| | - Scott M. Gilbert
- H. Lee Moffitt Cancer Center & Research Institute, Temple Terrace, FL
| | | | - Theresa A. Boyle
- H. Lee Moffitt Cancer Center & Research Institute, Temple Terrace, FL
| | - Brandon J. Manley
- H. Lee Moffitt Cancer Center & Research Institute, Temple Terrace, FL
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Li R, Spiess PE, Gilbert SM, Necchi A. Towards Personalized Neoadjuvant Therapy for Muscle-invasive Bladder Cancer. Eur Urol 2019; 76:4-6. [DOI: 10.1016/j.eururo.2019.02.027] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2019] [Accepted: 02/20/2019] [Indexed: 01/18/2023]
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Peyton CC, Henriksen C, Reich RR, Azizi M, Gilbert SM. Estimating Minimally Important Differences for the Bladder Cancer Index Using Distribution and Anchor Based Approaches. J Urol 2019; 201:709-714. [PMID: 30342063 DOI: 10.1016/j.juro.2018.10.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
PURPOSE The BCI (Bladder Cancer Index) is a validated, condition specific health questionnaire assessing urinary, bowel and sexual function and quality of life among patients with bladder cancer. We aimed to establish minimally important difference score thresholds that signal clinical importance. MATERIALS AND METHODS For 1 year after surgery we followed a prospective cohort of 150 patients who underwent radical cystectomy between 2013 and 2016. Usable data on 138 patients were analyzed. The BCI and the Medical Outcomes Study SF-36 (36-Item Short Form Health Survey) questionnaires were completed prior to cystectomy, and 3, 6 and 12 months postoperatively. Distribution based, minimally important differences were estimated at ⅓ and ½ SD for each index domain across time points. Changes in index domain scores anchored to changes in a SF-36 overall health assessment question were used to estimate anchor based, minimally important differences. Pooled averages are reported between time points and methods. RESULTS The distribution based, minimally important difference of ⅓ SDs for urinary, bowel and sexual domains ranged between 5.3 and 7.3, 4.6 and 5.6, and 6.0 and 8.9 points, respectively. Ranges of ½ SDs were 8.8 and 10.9, 6.8 and 8.4, and 8.9 and 13.5 points, respectively. The anchor based approach resulted in minimally important difference estimates of 6.2, 7.3 and 6.8 points, respectively. Aggregated results across the 2 approaches resulted in minimally important differences of 6 to 9, 5 to 8 and 7 to 11 points for urinary, bowel and sexual domains, respectively. CONCLUSIONS Using 2 independent approaches to our knowledge we established the first minimally important difference estimates for the BCI. Defining patient reported outcome thresholds is important to interpret changes or differences in BCI scores.
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Affiliation(s)
| | - Carl Henriksen
- University of Florida, School of Medicine , Gainesville , FL
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Kwan ML, Leo MC, Danforth KN, Weinmann S, Lee VS, Munneke JR, Bulkley JE, Rosetti MO, Yi DK, Banegas MP, Wagner MD, Williams SG, Aaronson DS, Grant M, Krouse RS, Gilbert SM, McMullen CK. Factors That Influence Selectionof Urinary Diversion Among Bladder Cancer Patients in 3 Community-based Integrated Health Care Systems. Urology 2019; 125:222-229. [PMID: 30471370 PMCID: PMC6389399 DOI: 10.1016/j.urology.2018.09.037] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [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: 09/26/2018] [Revised: 10/06/2018] [Accepted: 11/15/2018] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To assess the relative contributions of patient and surgeon factors for predicting selection of ileal conduit (IC), neobladder (NB), or continent pouch (CP) urinary diversions (UD) for patients diagnosed with muscle-invasive/high-risk nonmuscle invasive bladder cancer. This information is needed to enhance research comparing cancer survivors' outcomes across different surgical treatment options. METHODS Bladder cancer patients' age ≥21 years with cystectomy/UD performed from January 2010 to June 2015 in 3 Kaiser Permanente regions were included. All patient and surgeon data were obtained from electronic health records. A mixed effects logistic regression model was used treating surgeon as a random effect and region as a fixed effect. RESULTS Of 991 eligible patients, 794 (80%) received IC. One hundred sixty-nine surgeons performed the surgeries and accounted for a sizeable proportion of the variability in patient receipt of UD (intraclass correlation coefficient = 0.26). The multilevel model with only patient factors showed good fit (area under the curve = 0.93, Hosmer-Lemeshow test P = .44), and older age, female sex, estimated glomerular filtration rate <45, 4+ comorbidity index score, and stage III/IV tumors were associated with higher odds of receiving an IC vs neobladder/continent pouch. However, including surgeon factors (annual cystectomy volume, specialty training, clinical tenure) had no association (P = .29). CONCLUSION In this community setting, patient factors were major predictors of UD received. Surgeons also played a substantial role, yet clinical training and experience were not major predictors. Surgeon factors such as beliefs about UD options and outcomes should be explored.
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Affiliation(s)
| | - Michael C Leo
- Kaiser Permanente Center for Health Research, Portland, OR
| | - Kim N Danforth
- Kaiser Permanente Department of Research & Evaluation, Pasadena, CA
| | | | | | | | | | | | - David K Yi
- Kaiser Permanente Department of Research & Evaluation, Pasadena, CA
| | | | - Matthew D Wagner
- Department of Urology, Kaiser Permanente Sunnyside Medical Center, Clackamas, OR
| | - Stephen G Williams
- Department of Urology, Kaiser Permanente Riverside Medical Center, Riverside, CA
| | - David S Aaronson
- Department of Urology, Kaiser Permanente Oakland Medical Center, Oakland, CA
| | | | - Robert S Krouse
- University of Pennsylvania School of Medicine, University & Woodland Aves., Philadelphia, PA
| | - Scott M Gilbert
- H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL
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Gilbert SM. EDITORIAL COMMENT. Urology 2019; 125:152-153. [PMID: 30798964 DOI: 10.1016/j.urology.2018.11.040] [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: 09/04/2018] [Accepted: 11/11/2018] [Indexed: 11/16/2022]
Affiliation(s)
- Scott M Gilbert
- Department of Genitourinary Oncology, Department of Health Outcomes and Behavior, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL
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McMullen CK, Kwan ML, Colwell JC, Munneke JR, Davis JV, Firemark A, Brooks N, Grant M, Gilbert SM, Altschuler A. Recovering from Cystectomy: Patient Perspectives. Bladder Cancer 2019; 5:51-61. [PMID: 30854413 PMCID: PMC6401661 DOI: 10.3233/blc-180202] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background: Bladder cancer patients who undergo cystectomy and urinary diversion face functional and quality-of-life challenges. Little is known about these patients’ experiences during decision-making, surgery, and recovery, or how they vary by treatment setting. Objective: To learn about patients’ experiences with treatment choice, surgical care, and recovery across health settings. Understanding patient experiences is essential to closing care gaps and developing patient-reported measures. Methods: We conducted focus groups with cystectomy patients and family caregivers at a large comprehensive health care system (N = 32 patients) and an NCI-designated comprehensive cancer center (N = 25 patients and 5 caregivers). Using standard qualitative methods, we identified themes that are not well-represented in existing research. Results: Across both systems, patients described variable experiences in decision-making about their cystectomy and urinary diversion. Some felt overwhelmed by information; others felt poorly informed. Many found self-care equipment challenging; many felt they knew little about what to expect regarding chemotherapy, recovery, and transitioning home. At times, health care personnel could not help manage patients’ ostomies or catheterization equipment. Our study also contributes a grounded theoretical framework for describing meaningful domains of patient experience with cystectomy and urinary diversion. We identified a common trajectory that includes decision-making, surgery and post-operative recovery, mastery of self-care, and reintegration. Conclusions: Patients with radical cystectomy and urinary diversion report a wide variety of experiences not captured by quantitative measures. These findings demonstrate that many cystectomy patients could benefit from additional post-operative support. We offer a framework to measure patient-centered domains in future research.
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Affiliation(s)
| | - Marilyn L Kwan
- Division of Research, Kaiser Permanente, Oakland, CA, USA
| | | | | | - James V Davis
- Center for Health Research, Kaiser Permanente, Portland, OR, USA
| | - Alison Firemark
- Center for Health Research, Kaiser Permanente, Portland, OR, USA
| | - Neon Brooks
- Center for Health Research, Kaiser Permanente, Portland, OR, USA
| | | | - Scott M Gilbert
- Moffitt Cancer Center and Research Institute, Tampa, FL, USA
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Gilbert SM. WITHDRAWN: Knowledge Gained: Patient-Reported Outcomes Associated with NMIBC. Urology 2018:S0090-4295(18)31317-7. [PMID: 30578791 DOI: 10.1016/j.urology.2018.12.006] [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: 11/16/2018] [Revised: 11/16/2018] [Accepted: 12/11/2018] [Indexed: 10/27/2022]
Affiliation(s)
- Scott M Gilbert
- Department of Genitourinary Oncology, Department of Health Outcomes and Behavior, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL.
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Chipollini J, Alford B, Boulware DC, Forget P, Gilbert SM, Lockhart JL, Pow-Sang JM, Sexton WJ, Spiess PE, Poch MA, Patel SY. Epidural anesthesia and cancer outcomes in bladder cancer patients: is it the technique or the medication? A matched-cohort analysis from a tertiary referral center. BMC Anesthesiol 2018; 18:157. [PMID: 30390636 PMCID: PMC6215353 DOI: 10.1186/s12871-018-0622-5] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2018] [Accepted: 10/19/2018] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND The perioperative period can be a critical period with long-term implications on cancer-related outcomes. In this study, we evaluate the influence of regional anesthesia on cancer-specific outcomes in a radical cystectomy (RC) cohort of patients. METHODS We performed a retrospective analysis of patients with clinically-nonmetastatic urothelial carcinoma of the bladder who underwent RC at our institution from 2008 to 2012. Patients were retrospectively registered and stratified based on two anesthetic techniques: perioperative epidural analgesia with general anesthesia (epidural) versus general anesthesia alone (GA). Epidural patients received a sufentanil-based regimen (median intraoperative sufentanil dose 50 mcg (45,85). Propensity-score was used to make 1:1 case-control matching. Cumulative risk of recurrence with competing risks was calculated based on anesthetic technique. Kaplan-Meier curves were used to compare recurrence-free (RFS) and cancer-specific survival (CSS). Univariable and multivariable analyses were performed with Cox proportional hazard regression models for RFS and CSS. RESULTS Only patients with complete data on anesthetic technique were included. Out of 439 patients, 215-pair samples with complete follow-up were included in the analysis. Median follow-up was 41.4 months (range: 0.20-101). Patients with epidurals received higher median total intravenous morphine equivalents (ivMEQ) versus those in the GA group (75 (11-235) vs. 50 ivMEQ (7-277), p < 0.0001). Cumulative risk of recurrence at two years was 25.2% (19.6, 31.2) for epidural patients vs. 20.0% (15.0, 25.7) for GA patients (Gray test p = 0.0508). Epidural analgesic technique was a significant predictor of worse RFS (adjusted HR = 1.67, 1.14-2.45; p = 0.009) and CSS (HR = 1.53, 1.04-2.25; p = 0.030) on multivariable analyses. CONCLUSIONS Epidural anesthesia using sufentanil was associated with worse recurrence and disease-free survival in bladder cancer patients treated with surgery. This may be due use of epidural sufentanil or due to the increased total morphine equivalents patient received as a consequence of this drug.
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Affiliation(s)
- Juan Chipollini
- Department of Genitourinary Oncology, Moffitt Cancer Center, 12902 Magnolia Drive, Tampa, FL, 33612, USA
| | - Brandon Alford
- Morsani College of Medicine, University of South Florida, 12901 Bruce B. Downs Blvd, Tampa, FL, 33612, USA
| | - David C Boulware
- Department of Biostatistics and Bioinformatics, Moffitt Cancer Center, 12902 Magnolia Drive, Tampa, FL, 33612, USA
| | - Patrice Forget
- Department of Anesthesiology, Vrije Universiteit Brussel (VUB), Universitair Ziekenhuis, Laarbeeklaan 101, 1090, Brussels, Belgium
| | - Scott M Gilbert
- Department of Genitourinary Oncology, Moffitt Cancer Center, 12902 Magnolia Drive, Tampa, FL, 33612, USA
| | - Jorge L Lockhart
- Department of Genitourinary Oncology, Moffitt Cancer Center, 12902 Magnolia Drive, Tampa, FL, 33612, USA
| | - Julio M Pow-Sang
- Department of Genitourinary Oncology, Moffitt Cancer Center, 12902 Magnolia Drive, Tampa, FL, 33612, USA
| | - Wade J Sexton
- Department of Genitourinary Oncology, Moffitt Cancer Center, 12902 Magnolia Drive, Tampa, FL, 33612, USA
| | - Philippe E Spiess
- Department of Genitourinary Oncology, Moffitt Cancer Center, 12902 Magnolia Drive, Tampa, FL, 33612, USA
| | - Michael A Poch
- Department of Genitourinary Oncology, Moffitt Cancer Center, 12902 Magnolia Drive, Tampa, FL, 33612, USA
| | - Sephalie Y Patel
- Department of Anesthesiology, Moffitt Cancer Center, 12902 Magnolia Drive, Tampa, FL, 33612, USA.
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