Real-world patterns of chemotherapy and immunotherapy utilization at end of life in a large community oncology network

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Background: End-of-life anti-neoplastic treatment does not improve quality of life nor prolong survival of advanced cancer patients. It is also not cost-effective. To-date, there has been little data examining real-world patterns of chemotherapy and immunotherapy treatment at end of life. We investigated use of chemotherapy and/or immunotherapy in the last 14 days of life across a community oncology network of 5 practices, 100 sites of care, and 160 oncology providers. Methods: Using a real-time, network-wide database, we identified patients with solid tumor malignancies who died during an episode of active treatment, defined as having received intravenous (IV) chemotherapy and/or immunotherapy within 90 days of death. We then identified patients in this cohort who received IV chemotherapy and/or IV immunotherapy within 14 days of death (TxEoL). We studied TxEoL patterns by cancer type, treatment type, line of therapy, patient age, patient race, and oncology provider years in practice. Statistical significance was assessed using Pearson’s Chi-squared test. Results: 2,858 qualifying solid tumor cancer patients with dates of death between 1/1/2019 and 5/31/2020 were identified. Observed rates of TxEoL were 16.7% for immunotherapy alone vs. 19.6% for chemotherapy +/- immunotherapy (p = 0.09). We found high variation in TxEoL across 132 oncologists that had 5 or more deceased patients (range: 0% to 50%, mean: 19.2%, median: 19.6%). We found no association of TxEOL with physician years in practice, patient age or race. Rates of TxEoL in the first-line setting were significantly higher than in second-line setting or later (23.3% versus 16.4%, p < 0.01). Patients with head and neck, pancreatic, and hepatobiliary malignancies were the most likely to receive TxEoL, while patients with prostate, brain, and ovarian malignancies were the least likely to receive TxEoL. Conclusions: Our data and method identified wide variation in TxEoL patterns across a large community oncology network, suggesting room for provider-level interventions to improve treatment decisions in patients at high risk of death. Studies within our group, such as examining the impact of palliative care referrals on IV anti-cancer treatment in patients potentially facing end of life, are ongoing.

Clinical pathway creation and adherence at a large hybrid cancer center

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Background: Clinical pathways are valuable in reducing treatment variation, improving outcomes, and reducing costs in an oncology setting. With input of clinical stakeholders at West Cancer Center, we created and implemented a melanoma clinical pathway to improve care and facilitate standardization between melanoma sub-specialists and general oncologists. Retrospective pathway adherence was assessed to inform quality improvement goals. Methods: Using national guidelines and expert literature review, we developed a pathway defining a center-wide algorithmic approach to treat melanoma. Prior adherence to the pathway was retrospectively assessed by evaluating treatment during 1 year across 8 metrics. All patients who received systemic melanoma therapy during the study period at a large cancer center ( > 5000 new patients annually) were included in the assessment. Of the included patients, metric adherence was only measured when applicable. Adherence rates were described for predefined melanoma subspecialists versus predefined general oncologists without a declared subspecialty in melanoma. Significance was assessed with fisher exact test. Results: The following metrics were defined by the expert team as essential components of melanoma pathway; receipt of wide local excision; receipt of sentinel lymph node biopsy; presentation at multidisciplinary conference; molecular profiling before treatment of metastatic disease; treatment with preferred regimens in 1st line, 2nd line, and 3rd line; and clinical trial participation. Ninety patients were evaluated. Conclusions: Most differences in pathway adherence were found to be not significant. Clinical trial accrual was higher among melanoma subspecialists compared to general oncologists. Clinical pathways allow patients treated by general oncologists to benefit from the expertise of subspecialists and improve quality of care.[Table: see text]

Purification and amino acid analysis of a human macrophage cytotoxicity-inducing factor (MCF)

Recently we have described a CD4+ human T-cell hybridoma Ft.F3 (ATCC HB 9713). This hybridoma produces two proteins having molecular weights of 29 kd (P29) and 14.7 kd (P14.7) that function as activators of human monocyte tumor cytotoxicity and interleukin 1 (IL-1) synthesis (macrophage cytotoxicity-inducing factors, MCFs). Both MCF species were purified to apparent homogeneity, as assessed by two-dimensional (2D) gel electrophoresis, by a combination of dye ligand, ion exchange, and hydrophobic interaction chromatography, and sodium dodecyl sulfate polyacrylamide gel electrophoresis (SDS-PAGE). Exhaustive treatment of P29 by endoglycosidase F, performic acid, and 40x molar excess 2-mercaptoethanol failed to generate P14.7 from P29. Antisera raised to P29 recognized only P29 in immunoblots of 2D gels of crude hybridoma supernatant. Amino acid composition analyses of both species are similar but not identical. These MCFs appear to be distinct but possibly related proteins important in the inflammatory response, whereas N-terminal analysis of P29 reveals it to be a previously undescribed cytokine.

Characterization of a human monocyte cytotoxicity-inducing factor (MCF)

Recently, we reported a lymphokine, monocyte cytotoxicity-inducing factor (MCF), which is distinct from interferon-gamma (IFN-gamma). In this report, we provide further characterization of MCF. MCF is inactivated by chymotrypsin, but not trypsin, RNase, or DNase. The production of MCF is abolished in a dose-dependent manner by actinomycin D and is diminished by puromycin, and cycloheximide. Native MCF produced under serum-free conditions demonstrated charge heterogeneity with three species having isoelectric points at 2.7, 5.6, and 6.7 respectively, and two molecular weight species of 29 Kd and 14.7 Kd. MCF-activated monocytes were not only able to lyse both NK sensitive and resistant targets, but also secreted IL 1, but not TNF. In summary, MCF is a lymphokine distinct from TNF, IL 1, IL 2, the IFNs, and the CSFs, which is able to activate monocytes to lyse tumor targets.

Comparison of the electrical properties of neocortical neurones in slices in vitro and in the anaesthetized rat

Because neurones in isolated brain slices are abnormal in several respects, we have compared the electrical properties of neocortical neurones from the anaesthetized rat with neurones from slices of the same area of neocortex in vitro. Resting potentials were not significantly different but there was a small increase in mean spike amplitude and threshold in slices. The most striking observation was a doubling of the mean apparent input resistance (Rin) of neurones in slices (36 M omega cf. 18 M omega in vivo). To assess the extent to which the loss of surface membrane of neurones in slices might contribute to the raised Rin, we estimated the membrane capacity of neurones in the two samples from calculations of the membrane time constants. The mean membrane capacity was significantly lower in neurones from slices, being 2/3 that of the in vivo sample, showing that recordings were indeed mostly from smaller cells in the slices. Possible causes of the difference in mean input resistance not attributable to neuronal size are also discussed.

Identification of a human monocyte cytotoxicity-inducing factor from T cell hybridomas produced from Sezary's cells

Sezary's syndrome is a leukemic proliferation of OKT4+ lymphocytes. Sezary cells were isolated by differential centrifugation and fused to CEM.8azar.C, and HGPRTase-lacking clone of CEM. The hybrid cells were studied for their ability to produce soluble mediators of human monocyte cytotoxicity. The product of a single clone, FtF3, which bore the surface phenotype of Sezary cells, was characterized. Monocyte cytotoxicity-inducing factor (MCF) was found to be stable at pH 2 for 1 hr, unlike IFN-gamma, and was found to be more heat stable as well. Moreover, treatment of MCF with antisera to IFN-gamma, IFN-alpha or a combination of IFN-gamma and IFN-alpha failed to neutralize its biologic activity. MCF binds to matrix gel Red A. MCF eluted from this dye-ligand was found to have an apparent m.w. of 11,500 by gel filtration and 14,700 by SDS-polyacrylamide gel electrophoresis. MCF produced by hybridized Sezary cells appear to be neither IFN-gamma nor an altered molecular form of IFN-gamma, yet is a potent inducer of human monocyte cytotoxicity.

Identification of a human monocyte cytotoxicity-inducing factor from T cell hybridomas produced from Sezary's cells

Sezary's syndrome is a leukemic proliferation of OKT4+ lymphocytes. Sezary cells were isolated by differential centrifugation and fused to CEM.8azar.C, and HGPRTase-lacking clone of CEM. The hybrid cells were studied for their ability to produce soluble mediators of human monocyte cytotoxicity. The product of a single clone, FtF3, which bore the surface phenotype of Sezary cells, was characterized. Monocyte cytotoxicity-inducing factor (MCF) was found to be stable at pH 2 for 1 hr, unlike IFN-gamma, and was found to be more heat stable as well. Moreover, treatment of MCF with antisera to IFN-gamma, IFN-alpha or a combination of IFN-gamma and IFN-alpha failed to neutralize its biologic activity. MCF binds to matrix gel Red A. MCF eluted from this dye-ligand was found to have an apparent m.w. of 11,500 by gel filtration and 14,700 by SDS-polyacrylamide gel electrophoresis. MCF produced by hybridized Sezary cells appear to be neither IFN-gamma nor an altered molecular form of IFN-gamma, yet is a potent inducer of human monocyte cytotoxicity.