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Patel TA, Jain B, Vapiwala N, Chino F, Tringale KR, Mahal BA, Yamoah K, McBride SN, Lam MB, Hubbard A, Nguyen PL, Dee EC. Trends in Utilization and Medicare Spending on Short-Course Radiation Therapy for Breast and Prostate Cancer: An Episode-Based Analysis From 2015 to 2019. Int J Radiat Oncol Biol Phys 2024; 119:17-22. [PMID: 38072324 DOI: 10.1016/j.ijrobp.2023.11.043] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Revised: 11/16/2023] [Accepted: 11/22/2023] [Indexed: 01/18/2024]
Abstract
PURPOSE Evidence supports the value of shorter, similarly efficacious, and potentially more cost-effective hypofractionated radiation therapy (RT) regimens in many clinical scenarios for breast cancer (BC) and prostate cancer (PC). However, practice patterns vary considerably. We used the most recent Centers for Medicare and Medicaid Services data to assess trends in RT cost and practice patterns among episodes of BC and PC. METHODS AND MATERIALS We performed a retrospective cohort analysis of all external beam RT episodes for BC and PC from 2015 to 2019 to assess predictors of short-course RT (SCRT) use and calculated spending differences. Multivariable logistic regression defined adjusted odds ratios of receipt of SCRT over longer-course RT (LCRT) by treatment modality, age, year of diagnosis, type of practice, and the interaction between year and treatment setting. Medicare spending was evaluated using multivariable linear regression controlling for duration of RT regimen (SCRT vs LCRT) in addition to the above covariables. RESULTS Of 143,729 BC episodes and 114,214 PC episodes, 63,623 (44.27%) and 25,955 (22.72%) were SCRT regimens, respectively. Median total spending for SCRT regimens among BC episodes was $9418 (interquartile range [IQR], $7966-$10,983) versus $13,602 (IQR, $11,814-$15,499) for LCRT. Among PC episodes, median total spending was $6924 (IQR, $4,509-$12,905) for stereotactic body RT, $18,768 (IQR, $15,421-$20,740) for moderate hypofractionation, and $27,319 (IQR, $25,446-$29,421) for LCRT. On logistic regression, receipt of SCRT was associated with older age among both BC and PC episodes as well as treatment at hospital-affiliated over freestanding sites (P < .001 for all). CONCLUSIONS In this evaluation of BC and PC RT episodes from 2015 to 2019, we found that shorter-course RT resulted in lower costs than longer-course RT. SCRT was also more common in hospital-affiliated sites. Future research focusing on potential payment incentives encouraging SCRT when clinically appropriate in the 2 most common cancers treated with RT will be valuable as the field continues to prospectively evaluate cost-effective hypofractionation in other disease sites.
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Affiliation(s)
- Tej A Patel
- Department of Healthcare Management and Policy, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Bhav Jain
- Department of Health Policy, Stanford University School of Medicine, Stanford, California
| | - Neha Vapiwala
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Fumiko Chino
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Kathryn R Tringale
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York; Department of Radiation Medicine and Applied Sciences, University of California, San Diego, School of Medicine, San Diego, California
| | - Brandon A Mahal
- Department of Radiation Oncology, Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, Florida
| | - Kosj Yamoah
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, Florida
| | - Sean N McBride
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Miranda B Lam
- Department of Radiation Oncology, Dana-Farber Cancer Institute/Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Anne Hubbard
- Department of Health Policy, American Society for Radiation Oncology, Arlington, Virgnia
| | - Paul L Nguyen
- Department of Radiation Oncology, Dana-Farber Cancer Institute/Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Edward Christopher Dee
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York.
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Kazzi B, Mankuzhy NP, Swami N, Jain B, Patel TA, Chan JSK, Lam MB, Tian S, Dee EC. Surgical Resection Delays among Patients with Stage 1 Lung Cancer: A Study with Disaggregated Ethnic Groups. Ann Surg Oncol 2024; 31:2818-2823. [PMID: 38282026 DOI: 10.1245/s10434-024-14952-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Accepted: 01/09/2024] [Indexed: 01/30/2024]
Affiliation(s)
- Bahaa Kazzi
- Hope Clinic of the Emory Vaccine Center, Emory University School of Medicine Decatur, Atlanta, GA, USA
| | - Nikhil P Mankuzhy
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Nishwant Swami
- Department of Internal Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Bhav Jain
- Department of Health Policy, Stanford University School of Medicine, Stanford, CA, USA
| | - Tej A Patel
- Department of Healthcare Management and Policy, University of Pennsylvania, Philadelphia, PA, USA
| | - Jeffrey Shi Kai Chan
- Cardio-Oncology Research Unit, Cardiovascular Analytics Group, UK-China Collaboration, Hong Kong, China
| | - Miranda B Lam
- Department of Radiation Oncology, Brigham and Women's Hospital, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Sibo Tian
- Department of Radiation Oncology, Winship Cancer Institute, Atlanta, GA, USA
| | - Edward Christopher Dee
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
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Ranganathan S, Dee EC, Debnath N, Patel TA, Jain B, Murthy V. Access and barriers to genomic classifiers for breast cancer and prostate cancer in India. Int J Cancer 2024; 154:1335-1339. [PMID: 37962056 DOI: 10.1002/ijc.34784] [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: 05/16/2023] [Revised: 09/25/2023] [Accepted: 10/10/2023] [Indexed: 11/15/2023]
Abstract
The incidence of cancer in general, including breast and prostate cancer specifically, is increasing in India. Breast and prostate cancers have genomic classifiers developed to guide therapy decisions. However, these genomic classifiers are often inaccessible in India due to high cost. These classifiers may also be less suitable to the Indian population, as data primarily from patients in wealthy Western countries were used in developing these genomic classifiers. In addition to the limitations in using these existing genomic classifiers, developing and validating new genomic classifiers for breast and prostate cancer in India is challenging due to the heterogeneity in the Indian population. However, there are steps that can be taken to address the various barriers that currently exist for accurate, accessible genomic classifiers for cancer in India.
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Affiliation(s)
| | - Edward Christopher Dee
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Neha Debnath
- Department of Medicine, Icahn School of Medicine at Mount Sinai (Morningside/West), New York, New York, USA
| | - Tej A Patel
- Department of Healthcare Management & Policy, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Bhav Jain
- Department of Health Policy, Stanford University School of Medicine, Stanford, California, USA
| | - Vedang Murthy
- Department of Radiation Oncology, ACTREC, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, India
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Dee EC, Swami N, Kazzi B, Lapen K, Franco I, Jain B, Patel TA, Mahal BA, Rimner A, Wu A, Iyengar P, Li B, Florez N, Gomez DR. Disparities in Stage at Presentation Among Hispanic and Latinx Patients With Non-Small-Cell Lung Cancer in the United States. JCO Oncol Pract 2024; 20:525-537. [PMID: 38252900 DOI: 10.1200/op.23.00474] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2023] [Revised: 10/12/2023] [Accepted: 11/02/2023] [Indexed: 01/24/2024] Open
Abstract
PURPOSE Hispanic and Latinx people in the United States are the fastest-growing ethnic group. However, previous studies in non-small-cell lung cancer (NSCLC) often analyze these diverse communities in aggregate. We aimed to identify differences in NSCLC stage at diagnosis in the US population, focusing on disaggregated Hispanic/Latinx individuals. METHODS Data from the National Cancer Database from 2004 to 2018 identified patients with primary NSCLC. Individuals were disaggregated by racial and ethnic subgroup and Hispanic country of origin. Ordinal logistic regression adjusting for age, facility type, income, educational attainment, comorbidity index, insurance, and year of diagnosis was used to create adjusted odds ratios (aORs), with higher odds representing diagnosis at later-stage NSCLC. RESULTS Of 1,565,159 patients with NSCLC, 46,616 were Hispanic/Latinx (3.0%). When analyzed in the setting of race and ethnicity, Hispanic patients were more likely to be diagnosed with metastatic disease compared with non-Hispanic White (NHW) patients: 47.0% for Hispanic Black, 46.0% Hispanic White, and 44.3% of Hispanic other patients versus 39.1% of non-Hispanic White patients (P < .001 for all). By country of origin, 51.4% of Mexican, 41.7% of Puerto Rican, 44.6% of Cuban, 50.8% of South or Central American, 48.4% of Dominican, and 45.6% of other Hispanic patients were diagnosed with metastatic disease, compared with 39.1% of NHWs. Conversely, 20.2% of Mexican, 26.9% of Puerto Rican, 24.2% of Cuban, 22.5% of South or Central American, 23.7% of Dominican, and 24.5% of other Hispanic patients were diagnosed with stage I disease, compared with 30.0% of NHWs. All Hispanic groups were more likely to present with later-stage NSCLC than NHW patients (greatest odds for Mexican patients, aOR, 1.44; P < .001). CONCLUSION Hispanic/Latinx patients with non-small-cell lung cancer were more likely to be diagnosed with advanced disease compared with NHWs. Disparities persisted upon disaggregation by both race and country of origin, with over half of Mexican patients with metastatic disease at diagnosis. Disparities among Hispanic/Latinx groups by race and by country of origin highlight the shortcomings of treating these groups as a monolith and underscore the need for disaggregated research and targeted interventions.
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Affiliation(s)
| | - Nishwant Swami
- University of Massachusetts Chan Medical School, Worcester, MA
- Department of Internal Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Bahaa Kazzi
- The Hope Clinic of the Emory Vaccine Center, Division of Infectious Diseases, Department of Medicine, Emory University, Decatur, GA
| | - Kaitlyn Lapen
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Idalid Franco
- Department of Radiation Oncology, Brigham and Women's Hospital, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA
| | - Bhav Jain
- Stanford School of Medicine, Palo Alto, CA
| | - Tej A Patel
- University of Pennsylvania, Philadelphia, PA
| | - Brandon A Mahal
- Department of Radiation Oncology, University of Miami/Sylvester Cancer Center, Miami, FL
| | - Andreas Rimner
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Abraham Wu
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Puneeth Iyengar
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
- Department of Radiation Oncology, Druckenmiller Center for Lung Cancer Research, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Bob Li
- Department of Medical Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Narjust Florez
- Department of Medical Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Daniel R Gomez
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
- Department of Radiation Oncology, Druckenmiller Center for Lung Cancer Research, Memorial Sloan Kettering Cancer Center, New York, NY
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Patel TA, Jain B, Cho HL, Corti C, Vapiwala N, Chino F, Leeman JE, Dee EC. Second Malignancy Probabilities in Patients With Breast Cancer Treated With Conventional Versus Hypofractionated External Beam Radiation Therapy in the Adjuvant Setting. Clin Oncol (R Coll Radiol) 2024; 36:183-192. [PMID: 38184401 DOI: 10.1016/j.clon.2023.12.002] [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: 06/12/2023] [Revised: 10/12/2023] [Accepted: 12/05/2023] [Indexed: 01/08/2024]
Abstract
AIMS For women with breast cancer, seminal studies have shown that adjuvant hypofractionated external beam radiation therapy (hEBRT) maintains similar outcomes and may reduce overall costs compared with conventionally fractionated external beam radiation therapy (cEBRT). However, it is unclear whether hEBRT may be associated with differential risk of development of radiation-induced second malignancies compared with cEBRT. Because the occurrence of second malignancies is small, large databases may improve our understanding of the relative risk of second malignancies between hEBRT and cEBRT. MATERIALS AND METHODS Using the National Cancer Database, we carried out a retrospective cohort analysis of women diagnosed with non-metastatic, stage 0-III breast cancer from 2004 to 2017. All patients had a lumpectomy or mastectomy and a follow-up time of at least 60 months after diagnosis. The probability of second malignancies in women receiving adjuvant cEBRT or hEBRT was compared using multivariable logistic regression adjusting for sociodemographic, geographical, clinical and treatment factors, allowing for relative (but not absolute) comparison of second malignancy risk. Temporal sensitivity analyses stratified by year of diagnosis and length of follow-up time were also conducted. RESULTS Of the 125 228 women in our study, 115 576 (92.3%) received cEBRT and 9652 (7.71%) received hEBRT. The median age of the cohort was 60 (interquartile range 51-68) years at diagnosis and the median follow-up time was 99.61 (interquartile range 77.5-128.49) months. Upon adjusting for sociodemographic and clinical factors, patients who received hEBRT had no difference in relative risk than patients who received cEBRT (odds ratio 0.937, 95% confidence interval 0.869-1.010, P = 0.091). In analyses stratified by year of diagnosis, and stratified by length of follow-up, there was no difference in second malignancy probability between patients who completed hEBRT and patients who completed cEBRT. CONCLUSIONS In this analysis of over 120 000 women with non-metastatic breast cancer, hEBRT was not associated with different odds of developing second malignancies compared with cEBRT. Our findings may inform patient counselling in the choice of radiation regimens for breast cancer and further support the safety of hypofractionated regimens for breast cancer.
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Affiliation(s)
- T A Patel
- University of Pennsylvania, Philadelphia, PA, USA
| | - B Jain
- Stanford School of Medicine, Stanford, CA, USA
| | - H L Cho
- Department of Internal Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - C Corti
- Breast Oncology Program, Dana-Farber Cancer Centre, Boston, MA, USA; Harvard Medical School, Boston, MA, USA; Division of New Drugs and Early Drug Development for Innovative Therapies, European Institute of Oncology, IRCCS, Milan, Italy; Department of Oncology and Hematology-Oncology (DIPO), University of Milan, Milan, Italy
| | - N Vapiwala
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA, USA
| | - F Chino
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - J E Leeman
- Department of Radiation Oncology, Dana-Farber Cancer Institute/Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
| | - E C Dee
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
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Fung V, Price M, Cheng D, Patel TA, Yang Z, Hsu J, Alegria M, Newhouse JP. Associations Between Annual Medicare Part D Low-Income Subsidy Loss and Prescription Drug Spending and Use. JAMA Health Forum 2024; 5:e235152. [PMID: 38306091 PMCID: PMC10837747 DOI: 10.1001/jamahealthforum.2023.5152] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2024] Open
Abstract
Importance The Medicare Part D Low Income Subsidy (LIS) program provides millions of beneficiaries with drug plan premium and cost-sharing assistance. The extent to which LIS recipients experience subsidy losses with annual redetermination cycles and the resulting associations with prescription drug affordability and use are unknown. Objective To examine how frequently annual LIS benefits are lost among Medicare Part D beneficiaries and how this is associated with prescription drug use and out-of-pocket costs. Design, Setting, and Participants In this cohort study of Medicare Part D beneficiaries from 2007 to 2018, annual changes in LIS recipients among those automatically deemed eligible (eg, due to dual eligibility for Medicare and Medicaid) and nondeemed beneficiaries who must apply for LIS benefits were analyzed using Medicare enrollment and Part D event data. Subsidy losses were classified in 4 groups: temporary losses (<1 year); extended losses (≥1 year); subsidy reductions (change to partial LIS); and disenrollment from Medicare Part D after subsidy loss. Temporary losses could more likely represent subsidy losses among eligible beneficiaries. Multinomial logit models were used to examine associations between beneficiary characteristics and subsidy loss; linear regression models were used to compare changes in prescription drug cost and use in the months after subsidy losses vs before. Analyses were conducted between November 2022 and November 2023. Exposure Subsidy loss at the beginning of each year among subsidy recipients in December of the prior year. Main Outcomes and Measures The main outcomes were out-of-pocket costs and prescription drug fills overall and for 4 classes: antidiabetes, antilipid, antidepressant, and antipsychotic drugs. Results In 2008, 731 070 full LIS beneficiaries (17%) were not deemed automatically eligible (39% were aged <65 years; 59% were female). Nearly all beneficiaries deemed automatically eligible (≥99%) retained the subsidy annually from 2007 to 2018, compared with 78% to 84% of nondeemed beneficiaries. Among nondeemed beneficiaries, disabled individuals younger than 65 years and racial and ethnic minority groups were more likely to have temporary subsidy losses vs none. Temporary losses were associated with an average 700% increase in out-of-pocket drug costs (+$52.72/mo [95% CI, 52.52-52.92]) and 15% reductions in prescription fills (-0.58 fills/mo [95% CI, -0.59 to -0.57]) overall. Similar changes were found for antidiabetes, antilipid, antidepressant, and antipsychotic prescription drug classes. Beneficiaries who retained their subsidy had few changes. Conclusions and Relevance The conclusions of this cohort study suggest that efforts to help eligible beneficiaries retain Medicare Part D subsidies could improve drug affordability, treatment adherence, and reduce disparities in medication access.
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Affiliation(s)
- Vicki Fung
- Massachusetts General Hospital, Boston
- Harvard Medical School, Boston, Massachusetts
| | | | - David Cheng
- Massachusetts General Hospital, Boston
- Harvard Medical School, Boston, Massachusetts
| | - Tej A Patel
- Massachusetts General Hospital, Boston
- University of Pennsylvania, Philadelphia
| | | | - John Hsu
- Massachusetts General Hospital, Boston
- Harvard Medical School, Boston, Massachusetts
| | - Margarita Alegria
- Massachusetts General Hospital, Boston
- Harvard Medical School, Boston, Massachusetts
| | - Joseph P Newhouse
- Harvard Medical School, Boston, Massachusetts
- Harvard T.H. Chan School of Public Health, Boston, Massachusetts
- Harvard Kennedy School, Cambridge, Massachusetts
- National Bureau of Economic Research, Cambridge, Massachusetts
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Mathew A, Jain B, Patel TA, Hammond A, Dee EC, Chino F. Trends in Location of Death for Individuals With Ovarian Cancer in the United States. Obstet Gynecol 2024; 143:101-103. [PMID: 37944156 PMCID: PMC10842215 DOI: 10.1097/aog.0000000000005439] [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: 06/21/2023] [Accepted: 10/02/2023] [Indexed: 11/12/2023]
Abstract
Using the publicly available Centers for Disease Control and Prevention's WONDER (Wide-ranging Online Data for Epidemiologic Research) database from 2003 to 2019, we evaluated associations between decedent characteristics and location of death for patients with ovarian malignancy. We found that Black, Native American, Asian American, and Hispanic patients were more likely to die in hospitals than White patients, despite an overall reduction in hospital deaths and an overall increase in hospice facility deaths. Additionally, patients with lesser educational attainment were more likely to die in nursing facilities and less likely to die in hospice facilities. Although there may be some contribution from cultural preferences, these findings may represent disparities in access to palliative care affecting people with cancer from racial and ethnic minoritized groups.
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Affiliation(s)
| | - Bhav Jain
- Stanford University School of Medicine, Stanford, CA
| | | | | | | | - Fumiko Chino
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
- Department of Radiation Oncology, Affordability Working Group, Memorial Sloan Kettering Cancer Center, New York, NY
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Patel TA, Jain B, Raifman J. Revamping Public Health Systems: Lessons Learned From the Tripledemic. Am J Prev Med 2024; 66:185-188. [PMID: 37598983 DOI: 10.1016/j.amepre.2023.08.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2023] [Revised: 08/14/2023] [Accepted: 08/14/2023] [Indexed: 08/22/2023]
Affiliation(s)
- Tej A Patel
- Department of Healthcare Management & Policy, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Bhav Jain
- Department of Health Policy, Stanford University School of Medicine, Stanford, California
| | - Julia Raifman
- Department of Health Law, Policy & Management, Boston University School of Public Health, Boston, Massachusetts.
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Patel TA, Mustak H, Lubbe DE. Tips and tricks for maximising access to the middle cranial fossa using the superior lateral orbital portal. J Laryngol Otol 2023; 137:1401-1405. [PMID: 36503647 DOI: 10.1017/s0022215122002560] [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] [Indexed: 12/14/2022]
Abstract
BACKGROUND Transorbital endoscopic approaches are becoming increasingly popular for skull base pathologies; the superior lateral orbital portal is one such approach to the middle cranial fossa. This paper provides a technical description that maximises the surgical portal and minimises morbidity. TECHNICAL DESCRIPTION A superior lid crease incision is made extending laterally and the orbital rim is exposed. A subperiosteal dissection of the lateral and superior orbit is performed, with elevation of periosteum off Whitnall's tubercle, ligation of the recurrent branch of the middle meningeal artery, and identification of the superior orbital fissure. The lacrimal keyhole is then drilled away. The middle cranial fossa is accessed by drilling posterior to the orbital rim to expose: the temporalis muscle anterior-laterally, the dura of the temporal lobe posterior-laterally, the anterior cranial fossa superiorly and the periorbita medially. CONCLUSION These surgical steps can maximise the surgical portal and minimise morbidity, with avoidance of injury to surrounding structures.
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Affiliation(s)
- T A Patel
- Department of Otolaryngology - Head and Neck Surgery, University of Pittsburgh Medical Centre, Pittsburgh, PA, USA
| | - H Mustak
- Division of Ophthalmology, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa, and Gruute Schuur Hospital, Cape Town, South Africa
| | - D E Lubbe
- Division of Otolaryngology, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa, and Groote Schuur Hospital, Cape Town, South Africa
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Patel TA, Jain B, Vapiwala N, Chino F, Tringale KR, Mahal BA, Yamoah K, McBride S, Hubbard A, Nguyen PL, Dee EC. Trends in Utilization and Medicare Spending on Shorter vs. Longer Radiotherapy Courses for Breast and Prostate Cancer. Int J Radiat Oncol Biol Phys 2023; 117:e614. [PMID: 37785845 DOI: 10.1016/j.ijrobp.2023.06.1990] [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) Evidence based research supports shorter, similarly efficacious, and potentially more cost-effective hypofractionated treatment regimens in many clinical scenarios for breast cancer (BC) and prostate cancer (PC). However, practice patterns of hospital-affiliated and standalone facilities vary considerably. We used the most recent Centers for Medicare and Medicaid Services data to assess trends in radiotherapy (RT) costs and practice patterns among episodes of BC and PC. MATERIALS/METHODS We performed a retrospective cohort analysis of all external beam episodes for BC and PC from 2015-2019. For patients with BC, receipt of shorter-course RT (SCRT) was defined as receiving 11-20 fractions of external beam radiation therapy (including IMRT), and conventional RT as >20 fractions. For patients with PC, SBRT was defined as receipt of <10 fractions and moderate hypofractionation as 10-30 fractions (SCRT defined as SBRT and moderate hypofractionation), and >30 fractions for conventional RT. Total Medicare spending were defined as the sum of winsorized payment for professional and technical services furnished during the episode in 2019 dollars. Multivariable logistic regression defined adjusted odds ratios (ORs) of receipt of SCRT over conventional RT by treatment modality, age, year of diagnosis, type of practice, as well as a time*treatment setting interaction term. Medicare spending was evaluated using multivariable linear regression controlling for duration of RT regimen (SCRT vs conventional) in addition to the covariables above. RESULTS Of 47,283 BC episodes and 45,917 PC episodes, 23,705 (50.13%) and 9,125 (19.87%) were SCRT, respectively. Median total spending for SCRT among BC episodes was $9,324 (IQR, $7,916-$10,921) vs. $13,372 (IQR, $11,511-$15,283) for conventional RT. Among PC episodes, median total spending was $12,917 (IQR, $9,551-$15,271) for SBRT, $18,944 (IQR, $16,530-$20,615) for moderate hypofractionation, and $26,935 (IQR, $25,062-$28,959) for conventional RT. For both cancers, total episode spending was reduced with SCRT utilization [(BC adjusted β, -$4,200; p<0.001), (PC adjusted β, -$8,747; p<0.001)], older age, and non-IMRT-based treatment. On logistic regression, receipt of SCRT was associated with older age among both BC and PC episodes (p<0.001), as well as treatment at hospital-affiliated over freestanding sites [(BC OR [95% CI], 1.41 [1.29-1.54], p<0.001), (PC OR, 1.64 [1.39-1.94], p<0.001)]. CONCLUSION In this evaluation of all BC and PC RT episodes from 2015-2019, we found that shorter-course RT resulted in increased cost-savings vs. conventional RT. SCRT was also more common in hospital-affiliated sites. Further research is needed to devise payment incentives that encourage SCRT when clinically applicable in the two most common sites treated with RT, and to prospectively study cost-effective hypofractionation in other disease sites.
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Affiliation(s)
- T A Patel
- University of Pennsylvania, Philadelphia, PA
| | - B Jain
- Massachusetts Institute of Technology, Cambridge, MA
| | - N Vapiwala
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA
| | - F Chino
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - K R Tringale
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - B A Mahal
- Department of Radiation Oncology, University of Miami/Sylvester Comprehensive Cancer Center, Miami, FL
| | - K Yamoah
- H. Lee Moffitt Cancer Center and Research Institute, Department of Radiation Oncology, Tampa, FL
| | - S McBride
- Memorial Sloan Kettering Cancer Center, New York, NY
| | - A Hubbard
- American Society for Radiation Oncology, Arlington, VA
| | - P L Nguyen
- Brigham and Women's Hospital/Dana-Farber Cancer Institute, Boston, MA
| | - E C Dee
- Memorial Sloan Kettering Cancer Center, New York, NY
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Patel TA, Dee EC, Jain B, Vapiwala N, Fayanju O, Santos P. Disparities in Breast-Conserving Therapy vs. Mastectomy among Asian American and Pacific Islander Women. Int J Radiat Oncol Biol Phys 2023; 117:e198-e199. [PMID: 37784843 DOI: 10.1016/j.ijrobp.2023.06.1071] [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) Multiple randomized trials support the use of breast-conserving therapy (BCT), defined as lumpectomy followed by adjuvant radiotherapy, as an alternative to mastectomy for definitive treatment of early-stage (T1-2N0) breast cancer. However, data suggest that Asian American, Native Hawaiian, and Pacific Islander (AANHPI) may undergo mastectomy at higher rates than BCT and may experience barriers to receipt of BCT. The purpose of this study was to examine BCT utilization by disaggregated AANHPI groups to identify differences in receipt of mastectomy versus BCT. MATERIALS/METHODS The 2004-2017 National Cancer Database was queried to identify women age ≥18 years old diagnosed with cT1-2N0M0 breast cancer treated with either BCT or mastectomy without post-mastectomy radiation therapy. Women were classified based on self-reported race. Multivariable logistic regression defined adjusted odds ratios (OR) assessing the association between race and receipt of BCT versus mastectomy for all patients and separately by cT1-2 stage. All models were adjusted for relevant sociodemographic and clinical factors. RESULTS Of 794,403 women with cT1-2N0M0 breast cancer, 239,801 (30%) received mastectomy and 554,602 (70%) received BCT. After adjusting for clinical and sociodemographic factors, AANHPI women had greater odds of receiving mastectomy over BCT, compared to White women (OR [95% CI], 1.35 [1.30-1.39]; p<0.001). In contrast, Black women were less likely than White women to receive mastectomy (0.86 [0.84-0.87]; p<0.001). Upon disaggregation, Chinese, Japanese, Filipino, Korean, Vietnamese, and Asian Indian & Pakistani women were more likely to receive mastectomy over BCT compared to White women (p<0.001 for all). Treatment at academic (1.30 [1.27-1.32]), integrated (1.24 [1.21-1.27]), and comprehensive community cancer centers (1.15 [1.13-1.17]) were all associated with greater odds of mastectomy compared to treatment at community cancer programs (all p<0.001). Greater distance from treatment facility (≥50 mi. vs. 0 to <10 mi. [reference], OR 1.50 [1.47-1.53]) and cT2 disease (1.85 [1.82-1.87]) were also associated with greater odds of receiving mastectomy (all p<0.001). CONCLUSION In this evaluation of women with early-stage breast cancer, women from several AANHPI groups were more likely to receive mastectomy (as opposed to BCT) compared to White women. While sociocultural preferences, differences in access to and interest in reconstruction, as well as prevalent tumor-to-breast ratios may partially explain the disparities, collectively our data suggest an ongoing need for greater patient involvement in shared-decision making, particularly in vulnerable and understudied Asian populations.
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Affiliation(s)
- T A Patel
- University of Pennsylvania, Philadelphia, PA
| | - E C Dee
- Memorial Sloan Kettering Cancer Center, New York, NY
| | - B Jain
- Massachusetts Institute of Technology, Cambridge, MA
| | - N Vapiwala
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA
| | - O Fayanju
- Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - P Santos
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
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Jain B, Bajaj SS, Patel TA, Vapiwala N, Lam MB, Mahal BA, Muralidhar V, Amen TB, Nguyen PL, Sanford NN, Dee EC. Colon Cancer Disparities in Stage at Presentation and Time to Surgery for Asian Americans, Native Hawaiians, and Pacific Islanders: A Study with Disaggregated Ethnic Groups. Ann Surg Oncol 2023; 30:5495-5505. [PMID: 37017832 PMCID: PMC10075171 DOI: 10.1245/s10434-023-13339-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [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: 07/19/2022] [Accepted: 02/19/2023] [Indexed: 04/06/2023]
Abstract
BACKGROUND Vast differences in barriers to care exist among Asian American, Native Hawaiian, and Pacific Islander (AANHPI) groups and may manifest as disparities in stage at presentation and access to treatment. Thus, we characterized AANHPI patients with stage 0-IV colon cancer and examined differences in (1) stage at presentation and (2) time to surgery relative to white patients. PATIENTS AND METHODS We assessed all patients in the National Cancer Database (NCDB) with stage 0-IV colon cancer from 2004 to 2016 who identified as white, Chinese, Japanese, Filipino, Native Hawaiian, Korean, Vietnamese, Laotian, Hmong, Kampuchean, Thai, Asian Indian or Pakistani, and Pacific Islander. Multivariable ordinal logistic regression defined adjusted odds ratios (AORs), with 95% confidence intervals (CI), of (1) patients presenting with advanced stage colon cancer and (2) patients with stage 0-III colon cancer receiving surgery at ≥ 60 days versus 30-59 days versus < 30 days postdiagnosis, adjusting for sociodemographic/clinical factors. RESULTS Among 694,876 patients, Japanese [AOR 1.08 (95% CI 1.01-1.15), p < 0.05], Filipino [AOR 1.17 (95% CI 1.09-1.25), p < 0.001], Korean [AOR 1.09 (95% CI 1.01-1.18), p < 0.05], Laotian [AOR 1.51 (95% CI 1.17-1.95), p < 0.01], Kampuchean [AOR 1.33 (95% CI 1.04-1.70), p < 0.01], Thai [AOR 1.60 (95% CI 1.22-2.10), p = 0.001], and Pacific Islander [AOR 1.41 (95% CI 1.20-1.67), p < 0.001] patients were more likely to present with more advanced colon cancer compared with white patients. Chinese [AOR 1.27 (95% CI 1.17-1.38), p < 0.001], Japanese [AOR 1.23 (95% CI 1.10-1.37], p < 0.001], Filipino [AOR 1.36 (95% CI 1.22-1.52), p < 0.001], Korean [AOR 1.16 (95% CI 1.02-1.32), p < 0.05], and Vietnamese [AOR 1.55 (95% CI 1.36-1.77), p < 0.001] patients were more likely to experience greater time to surgery than white patients. Disparities persisted when comparing among AANHPI subgroups. CONCLUSIONS Our findings reveal key disparities in stage at presentation and time to surgery by race/ethnicity among AANHPI subgroups. Heterogeneity upon disaggregation underscores the importance of examining and addressing access barriers and clinical disparities.
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Affiliation(s)
- Bhav Jain
- Massachusetts Institute of Technology, Cambridge, MA, USA
| | | | - Tej A Patel
- University of Pennsylvania, Philadelphia, PA, USA
| | - Neha Vapiwala
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA, USA
| | - Miranda B Lam
- Department of Health Policy and Management, Harvard T. H. Chan School of Public Health, Boston, MA, USA
- Department of Radiation Oncology, Brigham and Women's Hospital/Dana Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
| | - Brandon A Mahal
- Department of Radiation Oncology, University of Miami/Sylvester Comprehensive Cancer Center, Miami, FL, USA
| | - Vinayak Muralidhar
- Department of Radiation Oncology, Brigham and Women's Hospital/Dana Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
- Kaiser Permanente Northwest, Portland, OR, USA
| | - Troy B Amen
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY, USA
| | - Paul L Nguyen
- Department of Radiation Oncology, Brigham and Women's Hospital/Dana Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
| | - Nina N Sanford
- Department of Radiation Oncology, University of Texas Southwestern, Dallas, TX, USA.
| | - Edward Christopher Dee
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
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13
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Patel TA, Lubbe D. How we do it: using the nasion as a landmark for identifying the anterior ethmoidal artery. J Laryngol Otol 2023; 137:1054-1057. [PMID: 36503555 DOI: 10.1017/s0022215122002523] [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] [Indexed: 12/14/2022]
Abstract
BACKGROUND In severe refractory epistaxis, the anterior ethmoidal artery may need to be ligated. Previously described endonasal or transorbital approaches are not always effective, or they have suboptimal aesthetic outcomes. This paper describes a safe and effective surgical technique, with a consistent landmark allowing quick identification. TECHNICAL DESCRIPTION A transcaruncular incision is made, oriented medially in the direction of the medial orbital wall towards the level of the nasion. Once onto bone, a subperiosteal plane is developed and an endoscope is used to dissect posteriorly at the level of the nasion, until the anterior ethmoidal artery is identified, and subsequently ligated. CONCLUSION The nasion is an easy, constant landmark to use for ligation of the anterior ethmoidal artery in refractory epistaxis. The traditional method of identifying the anterior ethmoidal artery is not applicable or constant enough for use during the transorbital approach. The described technique avoids injury to surrounding structures and has a satisfactory aesthetic outcome.
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Affiliation(s)
- T A Patel
- Department of Otolaryngology - Head and Neck Surgery, University of Pittsburgh Medical Centre, Pittsburgh, PA, USA
| | - D Lubbe
- Division of Otolaryngology, Faculty of Health Services, University of Cape Town, Cape Town, South Africa, and Groote Schuur Hospital, Cape Town, South Africa
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14
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Patel TA, Jain B, Eala MAB, Manlongat KD, Vapiwala N, Celi LA, Dee EC. Disparities in Receipt of Mental Health Services and Mental Distress Among Patients with Chronic Obstructive Pulmonary Disease. J Gen Intern Med 2023; 38:2849-2851. [PMID: 37349638 PMCID: PMC10506969 DOI: 10.1007/s11606-023-08273-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Accepted: 06/09/2023] [Indexed: 06/24/2023]
Affiliation(s)
- Tej A Patel
- University of Pennsylvania, Philadelphia, PA, USA
| | - Bhav Jain
- Massachusetts Institute of Technology, Cambridge, MA, USA
| | - Michelle Ann B Eala
- College of Medicine, University of the Philippines, Manila, Philippines
- Department of Radiation Oncology, University of California Los Angeles, Los Angeles, CA, USA
| | | | - Neha Vapiwala
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA, USA
| | - Leo Anthony Celi
- Harvard Medical School, Boston, MA, USA.
- Laboratory for Computational Physiology, Massachusetts Institute of Technology, Cambridge, MA, USA.
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA.
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA, USA.
| | - Edward Christopher Dee
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
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15
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Jain B, Bajaj SS, Patel TA, Vapiwala N, Lam MB, Mahal BA, Muralidhar V, Amen TB, Nguyen PL, Sanford NN, Dee EC. ASO Visual Abstract: Colon Cancer Disparities in Stage at Presentation and Time to Surgery for Asian Americans, Native Hawaiians, and Pacific Islanders: A Study with Disaggregated Ethnic Groups. Ann Surg Oncol 2023; 30:5509-5510. [PMID: 37330450 DOI: 10.1245/s10434-023-13699-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/19/2023]
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16
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Patel TA, Jain B, Dee EC, Gomez SL, Vapiwala N, Chino F, Fayanju OM. Delays in Time to Surgery Among Asian and Pacific Islander Women with Breast Cancer. Ann Surg Oncol 2023; 30:5337-5340. [PMID: 37365415 PMCID: PMC10869161 DOI: 10.1245/s10434-023-13806-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Accepted: 06/12/2023] [Indexed: 06/28/2023]
Affiliation(s)
- Tej A Patel
- University of Pennsylvania, Philadelphia, PA, USA
| | - Bhav Jain
- Massachusetts Institute of Technology, Cambridge, MA, USA
| | - Edward Christopher Dee
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Scarlett Lin Gomez
- Department of Epidemiology & Biostatistics, University of California San Francisco, San Francisco, CA, USA
| | - Neha Vapiwala
- Department of Radiation Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Fumiko Chino
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Oluwadamilola M Fayanju
- Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
- Rena Rowan Breast Center, Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA, USA.
- Penn Center for Cancer Care Innovation (PC3I), Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA, USA.
- Leonard Davis Institute of Health Economics (LDI), University of Pennsylvania, Philadelphia, PA, USA.
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17
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Jain B, Bajaj SS, Patel TA, Vapiwala N, Lam MB, Mahal BA, Muralidhar V, Amen TB, Nguyen PL, Sanford NN, Dee EC. ASO Author Reflections: Colon Cancer Disparities in Stage at Presentation and Time to Surgery for Asian Americans, Native Hawaiians, and Pacific Islanders. Ann Surg Oncol 2023; 30:5506-5508. [PMID: 37120487 DOI: 10.1245/s10434-023-13560-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Accepted: 04/12/2023] [Indexed: 05/01/2023]
Affiliation(s)
- Bhav Jain
- Massachusetts Institute of Technology, Cambridge, MA, USA
| | | | - Tej A Patel
- University of Pennsylvania, Philadelphia, PA, USA
| | - Neha Vapiwala
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA, USA
| | - Miranda B Lam
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA, USA
- Department of Radiation Oncology, Brigham and Women's Hospital/Dana Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
| | - Brandon A Mahal
- Sylvester Comprehensive Cancer Center, University of Miami, Miami, FL, USA
| | - Vinayak Muralidhar
- Department of Radiation Oncology, Brigham and Women's Hospital/Dana Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
- Kaiser Permanente Northwest, Portland, OR, USA
| | - Troy B Amen
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY, USA
| | - Paul L Nguyen
- Department of Radiation Oncology, Brigham and Women's Hospital/Dana Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
| | - Nina N Sanford
- Department of Radiation Oncology, University of Texas Southwestern, Dallas, TX, USA.
| | - Edward Christopher Dee
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
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18
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Patel TA, Dee EC, Jain B, Vapiwala N, Santos PMG, Fayanju OM. Disparities in Breast-Conserving Therapy Versus Mastectomy Among Asian American and Pacific Islander Women. Ann Surg Oncol 2023; 30:3894-3897. [PMID: 37014557 PMCID: PMC10431949 DOI: 10.1245/s10434-023-13315-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2022] [Accepted: 02/20/2023] [Indexed: 04/05/2023]
Affiliation(s)
- Tej A Patel
- University of Pennsylvania, Philadelphia, PA, USA
| | - Edward Christopher Dee
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Bhav Jain
- Massachusetts Institute of Technology, Cambridge, MA, USA
| | - Neha Vapiwala
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA, USA
| | - Patricia Mae G Santos
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
| | - Oluwadamilola M Fayanju
- Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
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19
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Ranganathan S, Tomar V, Chino F, Jain B, Patel TA, Dee EC, Mathew A. A burden shared: the financial, psychological, and health-related consequences borne by family members and caregivers of people with cancer in India. Support Care Cancer 2023; 31:420. [PMID: 37354234 DOI: 10.1007/s00520-023-07886-1] [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: 02/12/2023] [Accepted: 06/13/2023] [Indexed: 06/26/2023]
Abstract
In India, approximately 1.4 million new cases of cancer are recorded annually, with 26.7 million people living with cancer in 2021. Providing care for family members with cancer impacts caregivers' health and financial resources. Effects on caregivers' health and financial resources, understood as family and caregiver "financial toxicity" of cancer, are important to explore in the Indian context, where family members often serve as caregivers, in light of cultural attitudes towards family. This is reinforced by other structural issues such as grave disparities in socioeconomic status, barriers in access to care, and limited access to supportive care services for many patients. Effects on family caregivers' financial resources are particularly prevalent in India given the increased dependency on out-of-pocket financing for healthcare, disparate access to insurance coverage, and limitations in public expenditure on healthcare. In this paper, we explore family and caregiver financial toxicity of cancer in the Indian context, highlighting the multiple psychosocial aspects through which these factors may play out. We suggest steps forward, including future directions in (1) health services research, (2) community-level interventions, and (3) policy changes. We underscore that multidisciplinary and multi-sectoral efforts are needed to study and address family and caregiver financial toxicity in India.
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Affiliation(s)
| | | | - Fumiko Chino
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Department of Radiation Oncology and Affordability Working Group, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Bhav Jain
- Massachusetts Institute of Technology, Cambridge, MA, USA
| | - Tej A Patel
- University of Pennsylvania, Philadelphia, PA, USA
| | - Edward Christopher Dee
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
| | - Aju Mathew
- Department of Oncology, MOSC Medical College, Ernakulam, Kerala, 682311, India
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20
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Patel TA, Jain B, Rahim F, Palakodeti S. Spending It Forward: Integrated Public Health Investments Are Vital to the Pandemic Response. J Public Health Manag Pract 2023; 29:430-432. [PMID: 37071037 DOI: 10.1097/phh.0000000000001739] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/19/2023]
Affiliation(s)
- Tej A Patel
- University of Pennsylvania, Philadelphia, Pennsylvania (Mr Patel); Massachusetts Institute of Technology, Cambridge, Massachusetts (Mr Jain); Duke University, Durham, North Carolina (Mr Rahim); and Case Western Reserve University, Cleveland, Ohio (Dr Palakodeti)
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21
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Patel TA, Ting FIL, Jain B, Eala MAB, Jacomina LE, Mejia MBA, Dee EC. Epistemic equity in oncology: Opportunities to leverage patient-centric implementation in clinical trial design. Cancer 2023; 129:1313-1315. [PMID: 36755299 DOI: 10.1002/cncr.34674] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/10/2023]
Affiliation(s)
- Tej A Patel
- University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Frederic Ivan L Ting
- Department of Clinical Sciences, College of Medicine, University of St. La Salle, Bacolod, Philippines.,Division of Oncology, Department of Medicine, Corazon Locsin Montelibano Memorial Regional Hospital, Bacolod, Philippines.,Division of Oncology, Department of Internal Medicine, Dr. Pablo O. Torre Memorial Hospital, Bacolod, Philippines
| | - Bhav Jain
- Harvard-MIT Division of Health Sciences and Technology, Massachusetts Institute of Technology, Cambridge, Massachusetts, USA
| | - Michelle Ann B Eala
- College of Medicine, University of the Philippines, Manila, Philippines.,Department of Radiation Oncology, University of California Los Angeles, Los Angeles, California, USA
| | - Luisa E Jacomina
- Department of Radiation Oncology, Benavides Cancer Institute, University of Santo Tomas Hospital, Manila, Philippines
| | - Michael Benedict A Mejia
- Department of Radiation Oncology, Benavides Cancer Institute, University of Santo Tomas Hospital, Manila, Philippines
| | - Edward Christopher Dee
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York, USA
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22
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Patel TA, Jain B, Parikh RB. The Enhancing Oncology Model: Leveraging improvement science to increase health equity in value-based care. J Natl Cancer Inst 2023; 115:125-130. [PMID: 36245086 PMCID: PMC9905958 DOI: 10.1093/jnci/djac194] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2022] [Revised: 09/27/2022] [Accepted: 10/06/2022] [Indexed: 11/12/2022] Open
Abstract
The Oncology Care Model (OCM), launched in 2016 by the Centers for Medicare and Medicaid Services, was the first demonstration of value-based payment in oncology. Although the OCM delivered mixed results in terms of quality of care and total episode costs, the model had no statistically significant impact on remediating racial, ethnic, and socioeconomic disparities among beneficiaries. These deficits have been prominent in other aspects of US healthcare, and as a result, the Institute for Healthcare Improvement has advocated for stakeholders to leverage improvement science, an applied science that focuses on implementing rapid cycles for change, to identify and overcome barriers to health equity. With the announcement of the new Enhancing Oncology Model, a continuation of the OCM's efforts in introducing value to cancer care for episodes surrounding chemotherapy administration, both policymakers and providers must apply tenets of improvement science and make eliminating disparities in alternative payment models a forefront objective. In this commentary, we discuss previous inequities in alternative payment models, the role that improvement science plays in addressing health-care disparities, and steps that stakeholders can take to maximize equitable outcomes in the Enhancing Oncology Model.
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Affiliation(s)
- Tej A Patel
- Department of Health Care Management, University of Pennsylvania, Philadelphia, PA, USA
| | - Bhav Jain
- Harvard-MIT Division of Health Sciences and Technology, Massachusetts Institute of Technology, Cambridge, MA, USA
| | - Ravi B Parikh
- Perelman School of Medicine, Department of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, USA
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Creamer SL, Patel TA, Ensor JE, Rodriguez AA, Niravath PA, Darcourt JG, Kaklamani VG, Meisel JL, Li X, Zhao J, Kuhn JG, Rosato RR, Qian W, Belcheva A, Boone T, Chang J. Abstract P6-17-26: Care 001: multi-center randomized open-label phase II trial of neoadjuvant trastuzumab emtansine (T-DM1) in combination with lapatinib and nab-paclitaxel compared with paclitaxel, trastuzumab and pertuzumab in HER2-neu over-expressed breast cancer patients (TEAL study). Cancer Res 2019. [DOI: 10.1158/1538-7445.sabcs18-p6-17-26] [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: We conducted a multicenter, randomized open-label phase II neoadjuvant study of trastuzumab-emtansine (T-DM1), Lapatinib (L) and Nab Paclitaxel (Nab-P) compared to standard of care (SOC) Paclitaxel (Pac), Trastuzumab (T), and Pertuzumab (P) in patients with HER2 over-expressed breast cancer.
Methods: Patients in the experimental arm received a biologic window of targeted therapies alone for 6 weeks (T-DM1 and L) followed by T-DM1 3.0 mg/kg Q3W, L 750mg oral daily and Nab-P 80 mg/m2 weekly (QW) X 12 weeks. Patients in SOC arm received targeted therapies alone for 6 weeks (T and P) followed by Pac 80mg/m2QW, T 2mg/kg QW, and P 420mg Q3W X 12 weeks. The primary objective was to evaluate the proportion of patients with residual cancer burden (RCB) 0 or 1. Key secondary objectives included correlative assessments of PIK3CA mutations, PTEN expression, and HER2 subtypes which are being reported.
Results: Thirty of the 33 enrolled patients were evaluable. Patient demographics were well balanced. HER2 subtypes and altered PIK3CA (low PTEN or PIK3CA mutations) pathway were not statistically different between both arms. We have previously reported that all patients achieved RCB 0 & I in the T-DM1, L and Nab-P arm, compared to SOC (100% vs. 62.5%, p 0.0035). In the SOC arm, the 6 week change in tumor size on breast MRI during targeted biologic window treatment is significantly different between the responders and non-responders based on two-sided Wilcoxon rank-sum test (p =0.0065). Consistent with literature, among ER positive patients treated with SOC, PTEN low expressers were less likely to respond (0%, 0 of 2) than PTEN high expressers (67%, 2 of 3). In the experimental arm, all patients responded regardless of PTEN. There was only 1 PIK3CA mutation on the experimental arm where all responded.
Table 1:Breast MRI Tumor Size Standard of Care ArmResponseNMeanStandard Deviation95% CL MeanMinimumMaximumNo6-0.13330.4457-0.60110.3344-1.00.3Yes52.58001.88330.24154.91850.24.9Sixteen patients total were present in standard of care arm but 5 had incomplete imaging data.
Conclusions: TDM1 plus L and Nab-P therapy was well tolerated with noteworthy responses in all patients, including in PTEN low expressers. Change in tumor size at 6 weeks of biologic therapies was significant between responders and non-responders and can be evaluated as a surrogate for future studies.
Citation Format: Creamer SL, Patel TA, Ensor JE, Rodriguez AA, Niravath PA, Darcourt JG, Kaklamani VG, Meisel JL, Li X, Zhao J, Kuhn JG, Rosato RR, Qian W, Belcheva A, Boone T, Chang J. Care 001: multi-center randomized open-label phase II trial of neoadjuvant trastuzumab emtansine (T-DM1) in combination with lapatinib and nab-paclitaxel compared with paclitaxel, trastuzumab and pertuzumab in HER2-neu over-expressed breast cancer patients (TEAL study) [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P6-17-26.
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Affiliation(s)
- SL Creamer
- Houston Methodist Cancer Center, Houston, TX; Houston Methodist Research Institute, Houston, TX; The University of Texas Health Science Center, San Antonio, TX; Winship Cancer Institute Emory University School of Medicine, Atlanta, GA; Affiliated Hospital of Qingdao University, Qingdao, China
| | - TA Patel
- Houston Methodist Cancer Center, Houston, TX; Houston Methodist Research Institute, Houston, TX; The University of Texas Health Science Center, San Antonio, TX; Winship Cancer Institute Emory University School of Medicine, Atlanta, GA; Affiliated Hospital of Qingdao University, Qingdao, China
| | - JE Ensor
- Houston Methodist Cancer Center, Houston, TX; Houston Methodist Research Institute, Houston, TX; The University of Texas Health Science Center, San Antonio, TX; Winship Cancer Institute Emory University School of Medicine, Atlanta, GA; Affiliated Hospital of Qingdao University, Qingdao, China
| | - AA Rodriguez
- Houston Methodist Cancer Center, Houston, TX; Houston Methodist Research Institute, Houston, TX; The University of Texas Health Science Center, San Antonio, TX; Winship Cancer Institute Emory University School of Medicine, Atlanta, GA; Affiliated Hospital of Qingdao University, Qingdao, China
| | - PA Niravath
- Houston Methodist Cancer Center, Houston, TX; Houston Methodist Research Institute, Houston, TX; The University of Texas Health Science Center, San Antonio, TX; Winship Cancer Institute Emory University School of Medicine, Atlanta, GA; Affiliated Hospital of Qingdao University, Qingdao, China
| | - JG Darcourt
- Houston Methodist Cancer Center, Houston, TX; Houston Methodist Research Institute, Houston, TX; The University of Texas Health Science Center, San Antonio, TX; Winship Cancer Institute Emory University School of Medicine, Atlanta, GA; Affiliated Hospital of Qingdao University, Qingdao, China
| | - VG Kaklamani
- Houston Methodist Cancer Center, Houston, TX; Houston Methodist Research Institute, Houston, TX; The University of Texas Health Science Center, San Antonio, TX; Winship Cancer Institute Emory University School of Medicine, Atlanta, GA; Affiliated Hospital of Qingdao University, Qingdao, China
| | - JL Meisel
- Houston Methodist Cancer Center, Houston, TX; Houston Methodist Research Institute, Houston, TX; The University of Texas Health Science Center, San Antonio, TX; Winship Cancer Institute Emory University School of Medicine, Atlanta, GA; Affiliated Hospital of Qingdao University, Qingdao, China
| | - X Li
- Houston Methodist Cancer Center, Houston, TX; Houston Methodist Research Institute, Houston, TX; The University of Texas Health Science Center, San Antonio, TX; Winship Cancer Institute Emory University School of Medicine, Atlanta, GA; Affiliated Hospital of Qingdao University, Qingdao, China
| | - J Zhao
- Houston Methodist Cancer Center, Houston, TX; Houston Methodist Research Institute, Houston, TX; The University of Texas Health Science Center, San Antonio, TX; Winship Cancer Institute Emory University School of Medicine, Atlanta, GA; Affiliated Hospital of Qingdao University, Qingdao, China
| | - JG Kuhn
- Houston Methodist Cancer Center, Houston, TX; Houston Methodist Research Institute, Houston, TX; The University of Texas Health Science Center, San Antonio, TX; Winship Cancer Institute Emory University School of Medicine, Atlanta, GA; Affiliated Hospital of Qingdao University, Qingdao, China
| | - RR Rosato
- Houston Methodist Cancer Center, Houston, TX; Houston Methodist Research Institute, Houston, TX; The University of Texas Health Science Center, San Antonio, TX; Winship Cancer Institute Emory University School of Medicine, Atlanta, GA; Affiliated Hospital of Qingdao University, Qingdao, China
| | - W Qian
- Houston Methodist Cancer Center, Houston, TX; Houston Methodist Research Institute, Houston, TX; The University of Texas Health Science Center, San Antonio, TX; Winship Cancer Institute Emory University School of Medicine, Atlanta, GA; Affiliated Hospital of Qingdao University, Qingdao, China
| | - A Belcheva
- Houston Methodist Cancer Center, Houston, TX; Houston Methodist Research Institute, Houston, TX; The University of Texas Health Science Center, San Antonio, TX; Winship Cancer Institute Emory University School of Medicine, Atlanta, GA; Affiliated Hospital of Qingdao University, Qingdao, China
| | - T Boone
- Houston Methodist Cancer Center, Houston, TX; Houston Methodist Research Institute, Houston, TX; The University of Texas Health Science Center, San Antonio, TX; Winship Cancer Institute Emory University School of Medicine, Atlanta, GA; Affiliated Hospital of Qingdao University, Qingdao, China
| | - J Chang
- Houston Methodist Cancer Center, Houston, TX; Houston Methodist Research Institute, Houston, TX; The University of Texas Health Science Center, San Antonio, TX; Winship Cancer Institute Emory University School of Medicine, Atlanta, GA; Affiliated Hospital of Qingdao University, Qingdao, China
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Stubbins RE, Cheng TH, Yu X, Puppala M, Chen S, Valdivia Y Alvarado M, Niravath PA, Chang JC, Wong ST, Patel TA. Abstract P5-13-03: The use of a behavior-modification clinical solution application to improve breast cancer survivors' accountability and health outcomes. Cancer Res 2018. [DOI: 10.1158/1538-7445.sabcs17-p5-13-03] [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: Studies have demonstrated that obesity increases the risk of breast cancer recurrence and death in survivors but only 34% of breast cancer survivors engage in the recommended level of physical activity. This low percentage is related to a lack of accountability and motivation. We hypothesize that using a mobile application (app) incorporating the concept of cognitive-behavioral therapy and dietary and physical activity recommendations will improve breast cancer survivors' accountability and help them reach their personalized health goals; specifically with diet and exercise. Methods: We have created an app, METHODIST HOSPITAL CANCER HEALTH APPLICATION (MOCHA) for the purpose of patient self-reinforcement through the daily accounting of activity and nutrition as well as group feedback and direct interaction with clinical dietician. To test the MOCHA app's feasibility, we enrolled 33 breast cancer survivors with a body mass index (BMI) over 25 who were at least 6 months post active treatment (surgery, chemotherapy, or radiation) for a 4 week feasibility trial. During these 4 weeks, the users used the app to track wellness (mood, sleep or pain), diet (calorie intake) and exercise (walking or steps). Our primary objective was to demonstrate adherence, defined as the number of days recorded on MOCHA during week 2 and 3 of the 4 week study period (14 days). A registered dietitian assigned personalized goals for each user and monitored their usage of the app and followed the progress of their goals. Additionally, the dietitian sent daily push notifications to encourage the user to stay on track. Results: Our results suggests a correlation between utilization of the app and achievement of the goals of weight loss and increased motivation to exercise. The average number of daily uses of the app was approximately 3.76 (0-12) and 50% of enrolled users lost average of 2.14 lbs (0-6lbs) weight during this short 4 week study; preliminary correlation analysis suggest a correlation coefficient of -0.42 between these two variables. This is noteworthy as traditionally we would expect weight increase in this group of users. Our secondary objective was to determine MOCHA's usability using System Usability Scale (SUS) scale. Our average score on the SUS scale is 77%, which is above average. Lastly, users have stated that access to the dietitian in the app improves their food choices and accountability. Conclusion: This study provides essential data that emphasizes the importance of using technology to improve patients' goal adherence by providing real-time feedback and accountability with their healthcare team. Most health mobile apps focus on data acquisition but without the engagement of the health care team, this aspect differentiates MOCHA from the other apps. Our future directions will focus on using our MOCHA app in breast cancer survivors in a long term behavior modification study.
Citation Format: Stubbins RE, Cheng TH, Yu X, Puppala M, Chen S, Valdivia Y Alvarado M, Niravath PA, Chang JC, Wong ST, Patel TA. The use of a behavior-modification clinical solution application to improve breast cancer survivors' accountability and health outcomes [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P5-13-03.
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Affiliation(s)
- RE Stubbins
- Houston Methodist Cancer Center, Houston, TX; Cancer Research Program, Houston Methodist Research Institute, Houston, TX; Houston Methodist Hospital, Houston, TX; Houston Methodist Research Institute, Houston, TX
| | - TH Cheng
- Houston Methodist Cancer Center, Houston, TX; Cancer Research Program, Houston Methodist Research Institute, Houston, TX; Houston Methodist Hospital, Houston, TX; Houston Methodist Research Institute, Houston, TX
| | - X Yu
- Houston Methodist Cancer Center, Houston, TX; Cancer Research Program, Houston Methodist Research Institute, Houston, TX; Houston Methodist Hospital, Houston, TX; Houston Methodist Research Institute, Houston, TX
| | - M Puppala
- Houston Methodist Cancer Center, Houston, TX; Cancer Research Program, Houston Methodist Research Institute, Houston, TX; Houston Methodist Hospital, Houston, TX; Houston Methodist Research Institute, Houston, TX
| | - S Chen
- Houston Methodist Cancer Center, Houston, TX; Cancer Research Program, Houston Methodist Research Institute, Houston, TX; Houston Methodist Hospital, Houston, TX; Houston Methodist Research Institute, Houston, TX
| | - M Valdivia Y Alvarado
- Houston Methodist Cancer Center, Houston, TX; Cancer Research Program, Houston Methodist Research Institute, Houston, TX; Houston Methodist Hospital, Houston, TX; Houston Methodist Research Institute, Houston, TX
| | - PA Niravath
- Houston Methodist Cancer Center, Houston, TX; Cancer Research Program, Houston Methodist Research Institute, Houston, TX; Houston Methodist Hospital, Houston, TX; Houston Methodist Research Institute, Houston, TX
| | - JC Chang
- Houston Methodist Cancer Center, Houston, TX; Cancer Research Program, Houston Methodist Research Institute, Houston, TX; Houston Methodist Hospital, Houston, TX; Houston Methodist Research Institute, Houston, TX
| | - ST Wong
- Houston Methodist Cancer Center, Houston, TX; Cancer Research Program, Houston Methodist Research Institute, Houston, TX; Houston Methodist Hospital, Houston, TX; Houston Methodist Research Institute, Houston, TX
| | - TA Patel
- Houston Methodist Cancer Center, Houston, TX; Cancer Research Program, Houston Methodist Research Institute, Houston, TX; Houston Methodist Hospital, Houston, TX; Houston Methodist Research Institute, Houston, TX
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Patel A, Mukherjee A, Hwang D, Ensor J, Patel TA, Chang JC, Rodriguez AA. Abstract P1-02-06: Serial monitoring of circulating tumor DNA in patients with metastatic breast cancer. Cancer Res 2017. [DOI: 10.1158/1538-7445.sabcs16-p1-02-06] [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: For patients with MBC, there is currently no evidence that changing therapy on the basis of biomarker results improves outcome. Clinical benefit of treatment is defined as complete response, objective response, or stable disease as determined by RECIST criteria on radiological evaluation. Serial measurements of serum biomarkers such as CA2729 and CTCs have proven unsuccessful in predicting clinical benefit. Circulating tumor DNA(ctDNA) has emerged as a potential biomarker that may predict response to therapy or progression of disease. The present retrospective study was conducted to evaluate the relationship between change in ctDNA with clinical benefit determined by clinical and radiological evaluations of patients with MBC patients.
Methods: We conducted a retrospective, single-institutional study to determine if serial monitoring of ctDNA allele frequency levels predict clinical benefit of a treatment. 55 patients with measurable MBC who had serial monitoring of ctDNA between August 2014 and May 2016 were included. The median age was 55.9 (27–94) years). Clinical outcomes were determined as per standard guidelines. The analysis was performed on all cases that had serial measurements of ctDNA with no change in therapy in between and the repeat blood draw was done within 30 days of repeat radiographic evaluation. The dataset contained 125 observations from 48 unique patients. The relationship between the change in ctDNA and clinical benefit was analyzed using a generalized linear model with a random subject effect to account for the intrapatient dependence occurring from obtaining multiple evaluations from the same patient. A logit link function was used akin to logistic regression and a compound symmetric correlation structure was assumed.
Results: 68.8% of the cases were hormone receptor-positive, 18.8% HER2-positive, and 27.1% TNBC. The treatments received were 58.4% hormonal therapy, 31.2% chemotherapy, 26.4% included anti-HER2 therapy, 2 cases were on targeted therapy, and 1 case was not on any treatment. Three patients had stage 4 disease in complete remission. ctDNA analysis was repeated on average 4 days prior to radiological evaluation. The average time between repeat assessments was 108.5 days. 93% of the patients had a genomic alteration detected at some point during their course of disease. The most common mutations detected were TP53 41.7%, PIK3CA 35.4%, ESR1 18.8%, and ERBB2 amplifications 6.3%. A dichotomized change in ctDNA is a significant predictor of clinical benefit (p < 0.0001). The intrapatient correlation is estimated to be 0.273 for the transformed variable. The model yields a predicted probability of clinical benefit of 26.9% when the increase in ctDNA is greater than or equal to 0.5 and when the increase in ctDNA is less than 0.5, the a predicted probability of clinical benefit is 78.4%. The concordance of change in ctDNA and change in CA 27-29 was 76.2%.
Conclusions: Serial evaluation of serum ctDNA may be useful to evaluate molecular response to treatment which may correlate with clinical benefit and potentially guide treatment decisions. Early indication that a chosen therapy is not effective may lead to avoidance of overtreatment and initiation of an alternative regimen. Further, prospective studies are needed.
Citation Format: Patel A, Mukherjee A, Hwang D, Ensor J, Patel TA, Chang JC, Rodriguez AA. Serial monitoring of circulating tumor DNA in patients with metastatic breast cancer [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P1-02-06.
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Affiliation(s)
- A Patel
- Houston Methodist Cancer Center, Houston, TX
| | - A Mukherjee
- Houston Methodist Cancer Center, Houston, TX
| | - D Hwang
- Houston Methodist Cancer Center, Houston, TX
| | - J Ensor
- Houston Methodist Cancer Center, Houston, TX
| | - TA Patel
- Houston Methodist Cancer Center, Houston, TX
| | - JC Chang
- Houston Methodist Cancer Center, Houston, TX
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Liang DH, Patel A, Ensor JE, Patel TA, Chang JC, Rodriguez AA. Abstract P6-03-05: Cell-free DNA as molecular tool for monitoring disease progression and response to therapy in breast cancer patients. Cancer Res 2016. [DOI: 10.1158/1538-7445.sabcs15-p6-03-05] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [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: Identification of cancer-specific genes from breast cancer cells was instrumental in the advancement of targeted breast cancer therapy. However, with genomic heterogeneity within the breast cancer and evolution of cancer over time, genomic sequencing obtained from a single biopsy site may not capture the complete genomic profile. Thus, circulating cell-free DNA (cfDNA), isolated from plasma, is potentially a non-invasive source of identifying cancer-specific genomic alterations and may provide comprehensive genomic data throughout a patient's clinical course as they undergo anti-cancer therapy.
Method: We performed a retrospective chart review of 100 patients with stage 4 or high-risk stage 3 breast cancer who were tested for cfDNA genomic alterations. The most common actionable cancer specific genomic alterations were identified. In 23 patients who also had genomic analysis from tumor DNA (tDNA), an analysis using the Cohen's Kappa statistic was performed to determine the degree of agreement between genomic alterations found in tDNA and cfDNA. The proportion of patients with clinical disease progression between two cohorts determined by change in mutant allele frequency was compared using two-sided Fisher's exact test. Patients who received targeted therapy based on the identified genomic alteration were followed to determine response to therapy.
Results: In cfDNA of 100 breast cancer patients, the most commonly found cancer specific genomic alterations were TP53, PIK3CA, EGFR amplification, and ERBB2 amplification, with incidence rates 27%, 22%, 9%, and 7%, respectively. In tDNA of 23 patients, incidence rates were 65%, 26%, 9%, and 13%. PIK3CA and ERBB2 amplification demonstrated robust agreement between tDNA and cfDNA (Cohen's Kappa= 0.64 and 0.77, respectively). TP53 and EGFR amplification demonstrated poor agreement between tDNA and cfDNA (Cohen's Kappa= 0.18 and 0.33, respectively). There were 22 patients who had baseline and post-therapy mutant allele frequency measurements of TP53 and PIK3CA. Directional change of mutant allele frequency was closely associated with patient's response to therapy (p=0.0017). 8 out of 8 patients (100%) who had progression of disease had increase in mutant allele frequency. 10 out of 14 patients (71%) of patients who responded to therapy had decrease in mutant allele frequency. 6 patients who were found to have ERBB2 amplification were initiated on anti-HER2 cancer therapy. 5 of 6 patients (83%) had clinical response to therapy, while one patient had progression of disease. 3 patients who were found to have EGFR amplification (2 in cfDNA, 1 in tDNA) were initiated on anti-EGFR therapy. 2 of 3 patients (67%) had clinical response to therapy, while one patient had progression of disease.
Conclusion: There is no definite agreement between genomic alterations found in tDNA and those found in cfDNA. Whether this is due to tumor heterogeneity or tumor evolution over time with administration of anti-cancer treatment remains unknown. However, identification of selected cancer specific genomic alterations from cfDNA may be a non-invasive tool to monitor disease progression and response to breast cancer therapy.
Citation Format: Liang DH, Patel A, Ensor JE, Patel TA, Chang JC, Rodriguez AA. Cell-free DNA as molecular tool for monitoring disease progression and response to therapy in breast cancer patients. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P6-03-05.
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Affiliation(s)
- DH Liang
- Houston Methodist Hospital, Houston, TX; Houston Methodist Cancer Center, Houston, TX
| | - A Patel
- Houston Methodist Hospital, Houston, TX; Houston Methodist Cancer Center, Houston, TX
| | - JE Ensor
- Houston Methodist Hospital, Houston, TX; Houston Methodist Cancer Center, Houston, TX
| | - TA Patel
- Houston Methodist Hospital, Houston, TX; Houston Methodist Cancer Center, Houston, TX
| | - JC Chang
- Houston Methodist Hospital, Houston, TX; Houston Methodist Cancer Center, Houston, TX
| | - AA Rodriguez
- Houston Methodist Hospital, Houston, TX; Houston Methodist Cancer Center, Houston, TX
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Patel TA, Smith R, Hopkins S. Ribotyping in the detection of Clostridium difficile outbreaks in a single university hospital. J Hosp Infect 2012; 83:77-9. [PMID: 23158685 DOI: 10.1016/j.jhin.2012.09.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2012] [Accepted: 09/24/2012] [Indexed: 11/19/2022]
Abstract
Clostridium difficile infection (CDI) is the most important bacterial cause of hospital-acquired diarrhoea. Although reports of deaths associated with CDI have been decreasing since a peak in 2007 in England and Northern Ireland, it remains a major cause of morbidity and mortality. The Health Protection Agency's Clostridium difficile Ribotyping Network (CDRN) aims to provide information to help optimize the management of cases of CDI. This study assesses the value of ribotyping to detect outbreaks of potential strains causing severe disease.
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Affiliation(s)
- T A Patel
- Department of Microbiology, Royal Free Hampstead NHS Foundation Trust, London, UK.
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Perez EA, Hillman DW, Dentchev T, Le-Lindqwister NA, Geeraerts LH, Fitch TR, Liu H, Graham DL, Kahanic SP, Gross HM, Patel TA, Palmieri FM, Dueck AC. North Central Cancer Treatment Group (NCCTG) N0432: phase II trial of docetaxel with capecitabine and bevacizumab as first-line chemotherapy for patients with metastatic breast cancer. Ann Oncol 2009; 21:269-274. [PMID: 19901014 DOI: 10.1093/annonc/mdp512] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Docetaxel (T; Taxotere) with capecitabine (X) is active against metastatic breast cancer (MBC); bevacizumab (BV) has demonstrated efficacy with taxanes in the first-line setting. This study was conducted to assess the safety and efficacy of TX-BV in patients with MBC. PATIENTS AND METHODS In this single-arm, multicenter phase II study, patients received first-line bevacizumab 15 mg/kg and docetaxel 75 mg/m(2) on day 1 and capecitabine 825 mg/m(2) twice per day on days 1-14 every 21 days. Primary and secondary end points were tumor response rate (RR), overall survival (OS), progression-free survival (PFS), and toxicity. RESULTS A total of 45 assessable patients received TX-BV for a median of seven cycles. Two complete and 20 partial responses were observed (overall RR 49%); nine patients had stable disease >6 months, for a clinical benefit rate of 69%. Median response duration was 11.8 months. Median OS and PFS were 28.4 and 11.1 months, respectively. Grade 3/4 adverse events included hand-foot syndrome (29%), fatigue (20%), febrile neutropenia (18%), and diarrhea (18%). In cycles 3-10, median dose levels of docetaxel and capecitabine were 60 mg/m(2) and 660 mg/m(2), respectively. CONCLUSION TX-BV demonstrated significant activity; dose modifications were required to manage drug-related toxic effects.
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Affiliation(s)
- E A Perez
- Multidisciplinary Breast Clinic and Breast Cancer Program, Mayo Clinic, Jacksonville, FL.
| | | | | | - N A Le-Lindqwister
- Illinois Oncology Research Association Community Clinical Oncology Program, Peoria, IL
| | - L H Geeraerts
- Community Clinical Oncology Program, MeritCare Hospital, Fargo, ND
| | | | - H Liu
- Mayo Clinic, Rochester, MN
| | | | - S P Kahanic
- Siouxland Hematology-Oncology Associates, Sioux City, IA
| | - H M Gross
- Hematology and Oncology of Dayton, Inc., Dayton, OH, USA
| | - T A Patel
- Multidisciplinary Breast Clinic and Breast Cancer Program, Mayo Clinic, Jacksonville, FL
| | - F M Palmieri
- Multidisciplinary Breast Clinic and Breast Cancer Program, Mayo Clinic, Jacksonville, FL
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Patel TA, Abraham P, Ashar VJ, Bhatia SJ, Anklesaria PS. Gastric bacterial overgrowth accompanies profound acid suppression. Indian J Gastroenterol 1995; 14:134-6. [PMID: 8868355] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Suppression of gastric acid may lead to gastric colonization by aerobic and anaerobic bacteria, and consequent clinical manifestations. The risk is likely to be higher with poor environmental hygiene. AIMS To study the effect of short-term acid suppression with omeprazole on gastric bacterial flora. METHODS Twenty-five ambulatory patients with acid-peptic diseases underwent clinical assessment and gastric juice collection (for pH and culture) prior to start of therapy with 20 mg omeprazole daily, on days 7 and 14 of therapy, and 7 days after omission of therapy (day 21). RESULTS Eighteen patients completed the study. The median gastric pH was 1.8, 7.5, 7.5 and 3.4 on days 0, 7, 14 and 21 respectively. Positive gastric cultures were obtained in 13 of 25, 17 of 21, 18 of 18 and 14 of 18 patients on respective study days, with median colony counts of 1.5 x 10(4), 7.5 x 10(5), 8.7 x 10(7) and 7.3 x 10(4) cfu/mL respectively. Three patients developed self-limiting diarrhea during therapy and two more immediately after discontinuing therapy. CONCLUSIONS Gastric colonization is common with short-term profound acid-suppression, and may cause diarrhea. Acid suppressive therapy should be used with caution especially in patients with poor environmental hygiene.
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Affiliation(s)
- T A Patel
- Department of Gastroenterology, K E M Hospital, Bombay
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Chopra KB, Sawant SS, Patel TA, Banka NH, Chandalia HB. Carotid sinus syndrome associated with carcinoma of the pyriform fossa. J Assoc Physicians India 1992; 40:126-8. [PMID: 1629123] [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: 12/28/2022]
Abstract
A patient who developed syncope due to carotid sinus syndrome is described. The patient was suffering from carcinoma of the pyriform fossa for the past one year and received radiotherapy in the region of the neck for the same. Demand pacing was ineffective in alleviating syncopal episodes. The patient responded to oral administration of an anticholinergic (belladonna) and a sympathomimectic agent (orciprenaline).
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Affiliation(s)
- K B Chopra
- Department of Medicine, Grand Medical College, Bombay
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