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Pop CT, Gu CS, Vedantham S, Galanaud JP, Kahn SR. Exploring the Villalta scale to capture postthrombotic syndrome using alternative approaches: A subanalysis of the ATTRACT trial. Res Pract Thromb Haemost 2022; 7:100032. [PMID: 36970743 PMCID: PMC10031339 DOI: 10.1016/j.rpth.2022.100032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Revised: 12/02/2022] [Accepted: 12/09/2022] [Indexed: 01/25/2023] Open
Abstract
Background Clinical trials that evaluated interventions to prevent postthrombotic syndrome (PTS) used the Villalta scale (VS) to define PTS, but there is a lack of consistency in its use. Objectives This study aimed to improve the ability to identify patients with clinically meaningful PTS after DVT in participants of the ATTRACT trial. Methods We conducted a post hoc exploratory analysis of 691 patients from the ATTRACT study, a randomized trial evaluating the effectiveness of pharmacomechanical thrombolysis to prevent PTS in proximal deep vein thrombosis. We compared 8 VS approaches to classify patients with or without PTS in terms of their ability to discriminate between those with poorer vs better venous disease-specific quality of life (Venous Insufficiency Epidemiological and Economic Study Quality of Life [VEINES-QOL]) between 6- and 24-months follow-up. The difference in the average area under the fitted curve of VEINES-QOL scores between PTS and no PTS ( Δ A U C ¯ ) were compared among approaches. Results For any PTS (a single VS score ≥5), approaches 1 to 3 had similar Δ A U C ¯ (-21.2, -23.7, -22.0, respectively). Adjusting the VS for contralateral chronic venous insufficiency (CVI) or restricting to patients without baseline CVI (approaches 7 and 8) did not improve Δ A U C ¯ (-13.6, -19.9, respectively; P >.01). For moderate-to-severe PTS (a single VS score ≥10), approaches 5 and 6 requiring 2 positive assessments had greater but not statistically significant Δ A U C ¯ than approach 4, using one single positive assessment (-31.7, -31.0, -25.5, respectively; P >.01). Conclusion A single VS score of ≥ 5 reliably distinguishes patients with clinically meaningful PTS as assessed by impact on QOL and is preferred because of greater convenience (only one assessment needed). Alternative methods to define PTS (ie, adjusting for CVI) do not improve the scale's ability to identify clinically meaningful PTS.
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Rinfret F, Gu CS, Vedantham S, Kahn SR. New and known predictors of the postthrombotic syndrome: A subanalysis of the ATTRACT trial. Res Pract Thromb Haemost 2022; 6:e12796. [PMID: 36051541 PMCID: PMC9424505 DOI: 10.1002/rth2.12796] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Revised: 06/17/2022] [Accepted: 07/26/2022] [Indexed: 11/13/2022] Open
Abstract
Introduction Postthrombotic syndrome (PTS) remains associated with significant clinical and economic burden. This study aimed to investigate known and novel predictors of the development of PTS in participants of the ATTRACT (Acute Venous Thrombosis: Thrombus Removal With Adjunctive Catheter‐Directed Thrombolysis) trial. Methods We used multivariable logistic regression to identify baseline and postbaseline factors that were predictive of the development of PTS during study follow‐up, as defined by a Villalta score of 5 or greater or the development of a venous ulcer from 6 to 24 months after enrollment. Results Among 691 patients in the study cohort (all had proximal deep vein thrombosis [DVT] that extended above the popliteal vein, of which 57% had iliofemoral DVT), 47% developed PTS. Further, we identified that Villalta score at baseline (odds ratio [OR], 1.09 [95% confidence interval [CI], 1.05–1.13] per one‐unit increase) and employment status (unemployed due to disability: OR, 3.31 [95% CI, 1.72–6.35] vs. employed more than 35 hours per week) were predictive of PTS. In terms of postbaseline predictors, leg pain severity at day 10 (OR, 1.28 [95% CI, 1.13–1.45] per 1‐point increase in a 7‐point scale) predicted PTS. Also, patients receiving rivaroxaban on day 10 following randomization had lower rates of PTS (OR, 0.53 [95% CI, 0.33–0.86]) than patients on warfarin. Conclusions Novel predictors for PTS identified in our study include baseline Villalta score, leg pain severity at 10 days, and unemployed due to disability. Our findings also suggest that the initial choice of anticoagulant to treat DVT may have an impact on the development of PTS.
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Affiliation(s)
- Félix Rinfret
- Department of Medicine McGill University Montreal Quebec Canada
| | - Chu-Shu Gu
- Centre for Regulatory Excellence, Statistics and Trials Ottawa Ontario Canada
| | | | - Susan R Kahn
- Department of Medicine McGill University Montreal Quebec Canada.,Centre of Excellence in Thrombosis and Anticoagulation Care Jewish General Hospital Montreal Quebec Canada
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Krzyzanowska MK, Julian JA, Gu CS, Powis M, Li Q, Enright K, Howell D, Earle CC, Gandhi S, Rask S, Brezden-Masley C, Dent S, Hajra L, Freeman O, Spadafora S, Hamm C, Califaretti N, Trudeau M, Levine MN, Amir E, Bordeleau L, Chiarotto JA, Elser C, Husain J, Laferriere N, Rahim Y, Robinson AG, Vandenberg T, Grunfeld E. Remote, proactive, telephone based management of toxicity in outpatients during adjuvant or neoadjuvant chemotherapy for early stage breast cancer: pragmatic, cluster randomised trial. BMJ 2021; 375:e066588. [PMID: 34880055 PMCID: PMC8652580 DOI: 10.1136/bmj-2021-066588] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
OBJECTIVE To evaluate the effectiveness of remote proactive management of toxicities during chemotherapy for early stage breast cancer. DESIGN Pragmatic, cluster randomised trial. SETTING 20 cancer centres in Ontario, Canada, allocated by covariate constrained randomisation to remote management of toxicities or routine care. PARTICIPANTS All patients starting adjuvant or neoadjuvant chemotherapy for early stage breast cancer at each centre. 25 patients from each centre completed patient reported outcome questionnaires. INTERVENTIONS Proactive, standardised, nurse led telephone management of common toxicities at two time points after each chemotherapy cycle. MAIN OUTCOME MEASURES The primary outcome, cluster level mean number of visits to the emergency department or admissions to hospital per patient during the whole course of chemotherapy treatment, was evaluated with routinely available administrative healthcare data. Secondary patient reported outcomes included toxicity, self-efficacy, and quality of life. RESULTS Baseline characteristics of participants were similar in the intervention (n=944) and control arms (n=1214); 22% were older than 65 years. Penetration (that is, the percentage of patients who received the intervention at each centre) was 50-86%. Mean number of visits to the emergency department or admissions to hospital per patient was 0.91 (standard deviation 0.28) in the intervention arm and 0.94 (0.40) in the control arm (P=0.94); 47% (1014 of 2158 patients) had at least one visit to the emergency department or a hospital admission during chemotherapy. Among 580 participants who completed the patient reported outcome questionnaires, at least one grade 3 toxicity was reported by 48% (134 of 278 patients) in the intervention arm and by 58% (163 of 283) in the control arm. No differences in self-efficacy, anxiety, or depression were found. Compared with baseline, the functional assessment of cancer therapy trial outcome index decreased by 6.1 and 9.0 points in the intervention and control participants, respectively. CONCLUSIONS Proactive, telephone based management of toxicities during chemotherapy did not result in fewer visits to the emergency department or hospital admissions. With the rapid rise in remote care because of the covid-19 pandemic, identifying scalable strategies for remote management of patients during cancer treatment is particularly relevant. TRIAL REGISTRATION ClinicalTrials.gov NCT02485678.
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Affiliation(s)
- Monika K Krzyzanowska
- Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
- Institute for Clinical Evaluative Sciences, Toronto, ON, Canada
| | - Jim A Julian
- Ontario Clinical Oncology Group, McMaster University, Hamilton, ON, Canada
| | - Chu-Shu Gu
- Ontario Clinical Oncology Group, McMaster University, Hamilton, ON, Canada
| | - Melanie Powis
- Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
| | - Qing Li
- Institute for Clinical Evaluative Sciences, Toronto, ON, Canada
| | - Katherine Enright
- Trillium Health Partners, Credit Valley Hospital, Mississauga, ON, Canada
| | - Doris Howell
- Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
| | - Craig C Earle
- Institute for Clinical Evaluative Sciences, Toronto, ON, Canada
- Ontario Institute for Cancer Research, Toronto, ON, Canada
| | - Sonal Gandhi
- Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Sara Rask
- Simcoe Muskoka Regional Cancer Program, Royal Victoria Hospital, Barrier, ON, Canada
| | | | - Susan Dent
- Ottawa Hospital Cancer Centre, Ottawa, ON, Canada
| | - Leena Hajra
- Markham Stouffville Hospital, Markham, ON, Canada
| | - Orit Freeman
- Durham Regional Cancer Centre, Oshawa, ON, Canada
| | - Silvana Spadafora
- Algoma District Cancer Programme, Sault Area Hospital, Sault Ste Marie, ON, Canada
| | | | - Nadia Califaretti
- Grand River Hospital's Regional Cancer Centre, Kitchener, ON, Canada
| | - Maureen Trudeau
- Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Mark N Levine
- Ontario Clinical Oncology Group, McMaster University, Hamilton, ON, Canada
- Juravinski Cancer Centre, Hamilton, ON, Canada
| | - Eitan Amir
- Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
| | | | | | - Christine Elser
- Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
| | - Juhi Husain
- Brampton Civic Hospital, Brampton, ON, Canada
| | - Nicole Laferriere
- Regional Cancer Centre Northwest, Thunder Bay Regional Health Sciences Centre, Thunder Bay, ON, Canada
| | - Yasmin Rahim
- Stronach Regional Cancer Centre, Newmarket, ON, Canada
| | | | | | - Eva Grunfeld
- Ontario Institute for Cancer Research, Toronto, ON, Canada
- Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada
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Lee A, Gu CS, Vedantham S, Kearon C, Blostein M, Kahn SR. Performance of two clinical scales to assess quality of life in patients with post-thrombotic syndrome. J Vasc Surg Venous Lymphat Disord 2021; 9:1257-1265.e2. [PMID: 33548557 DOI: 10.1016/j.jvsv.2021.01.017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Accepted: 01/26/2021] [Indexed: 01/22/2023]
Abstract
OBJECTIVE We directly compared the Villalta scale and the Venous Clinical Severity Score (VCSS) to determine which of the two measures would be better at capturing clinically important cases of post-thrombotic syndrome (PTS) and PTS severity compared with patient-reported quality of life (QOL) scores. METHODS We performed a secondary analysis of the ATTRACT (acute venous thrombosis: thrombus removal with adjunctive catheter-directed thrombolysis) trial study population. We calculated the correlations of the Villalta scores and VCSSs with QOL scores (short-form 36-item health survey [SF-36] physical component summary [PCS] and mental component summary [MCS]; and VEINES [venous insufficiency epidemiological and economic study]-QOL/symptom [VEINES-QOL/Sym] questionnaire) at each study visit (6, 12, 18, and 24 months of follow-up). The correlation of the random intercept (mean scores) and random slope (rate of change of the scores) among the Villalta scores, VCSS, and VEINES-QOL/Sym scores was assessed using a multivariate longitudinal model. RESULTS The median correlation between Villalta scores and VCSSs was 0.72. The median correlation between the Villalta scores and VEINES-QOL and VEINES-Sym scores at all follow-up visits was -0.68 and -0.71, respectively. The median correlation between the Villalta scores and SF-36 PCS and MCS scores was -0.51 and -0.31, respectively. For the VCSSs, the median correlation with the VEINES-QOL and VEINES-Sym scores at all follow-up visits was -0.39 and -0.41, respectively. The median correlation between the VCSSs and SF-36 PCS and MCS scores was -0.32 and -0.13, respectively. The correlations between the random effects in the multivariate longitudinal models showed a similar pattern. The effect of covariate adjustment by age, sex, and body mass index was minor. CONCLUSIONS The Villalta scores and VCSSs correlated strongly. The Villalta scale showed a substantially greater correlation with venous disease-specific and general QOL scores compared with the correlation with the VCSS. Our findings suggest that when a single scale is used to assess for clinically meaningful PTS, the Villalta scale will better capture the effects of PTS on patient-reported QOL.
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Affiliation(s)
- Angela Lee
- Division of Experimental Medicine, McGill University, Montreal, Quebec, Canada.
| | - Chu-Shu Gu
- McMaster University Medical Center, Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Suresh Vedantham
- Mallinckrodt Institute of Radiology, Washington University, St. Louis, Mo
| | - Clive Kearon
- Department of Medicine, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Mark Blostein
- Department of Medicine, Faculty of Medicine and Health Sciences, McGill University, Montreal, Quebec, Canada
| | - Susan R Kahn
- Department of Medicine, Faculty of Medicine and Health Sciences, McGill University, Montreal, Quebec, Canada; Lady Davis Institute, Jewish General Hospital, Montreal, Quebec, Canada
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Kearon C, Carrier M, Gu CS, Schulman S, Bates SM, Kahn SR, Chagnon I, Nguyen DT, Wu C, Rudd-Scott L, Julian JA. Rivaroxaban Compared to Placebo for the Treatment of Leg Superficial Vein Thrombosis: A Randomized Trial. Semin Thromb Hemost 2020; 46:977-985. [PMID: 33368114 DOI: 10.1055/s-0040-1718891] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
The role of rivaroxaban in the treatment of leg superficial venous thrombosis (SVT) is uncertain. This article aims to determine if rivaroxaban is an effective and safe treatment for leg SVT. Patients with symptomatic leg SVT of at least 5 cm length were randomized to 45 days of rivaroxaban 10 mg daily or to placebo, and followed for a total of 90 days. Treatment failure (required a nonstudy anticoagulant; had proximal deep vein thrombosis or pulmonary embolism; or had surgery for SVT) at 90 days was the primary efficacy outcome. Secondary efficacy outcomes included leg pain severity, and venous disease-specific and general health-related quality of life over 90 days. Major bleeding at 90 days was the primary safety outcome. Poor enrollment led to the trial being stopped after 85 of the planned 600 patients were randomized to rivaroxaban (n = 43) or placebo (n = 42). One rivaroxaban and five placebo patients had a treatment failure by 90 days (absolute risk reduction = 9.0%, 95% confidence interval: -22 to 5.9%). Leg pain improvement did not differ at 7 (p = 0.16) or 45 days (p = 0.89), but was greater with rivaroxaban at 90 days (p = 0.011). There was no difference in venous disease-specific (p = 0.99) or general health-related (p = 0.37) quality of life over 45 days. There were no major bleeds or deaths in either group. There were no identifiable differences in efficacy or safety between rivaroxaban and placebo in patients with symptomatic SVT but comparisons were undermined by a much smaller than planned sample size (NCT1499953).
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Affiliation(s)
- Clive Kearon
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Marc Carrier
- Department of Medicine, Ottawa Hospital Research Institute at the University of Ottawa, Ottawa, Ontario, Canada
| | - Chu-Shu Gu
- Department of Oncology, McMaster University, Hamilton, Ontario, Canada
| | - Sam Schulman
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada.,Department of Obstetrics and Gynecology, I.M. Sechenov First Moscow State Medical University, Moscow, Russia
| | - Shannon M Bates
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Susan R Kahn
- Department of Medicine, McGill University, Montreal, Quebec, Canada
| | - Isabelle Chagnon
- Department of Medicine, University of Montreal, Montreal, Quebec, Canada
| | - Doan Trang Nguyen
- Department of Medicine, University of Montreal, Montreal, Quebec, Canada
| | - Cynthia Wu
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Lisa Rudd-Scott
- Department of Oncology, McMaster University, Hamilton, Ontario, Canada
| | - Jim A Julian
- Department of Oncology, McMaster University, Hamilton, Ontario, Canada
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Serrano PE, Gu CS, Moulton CA, Gallinger S. Positron Emission Tomography Combined With Computed Tomography vs. No Positron Emission Tomography Combined With Computed Tomography for the Management of Patients With Resectable Colorectal Cancer Liver Metastases and Synchronous Extrahepatic Disease. Am Surg 2020; 87:1431-1437. [PMID: 33345573 DOI: 10.1177/0003134820954834] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
INTRODUCTION Selected patients with colorectal cancer liver metastases (CRLM) and synchronous extrahepatic disease (EHD) are considered for surgery. OBJECTIVES To evaluate the change in surgical management and long-term survival (disease-free survival [DFS] and overall survival [OS]) for patients with CRLM and EHD who undergo positron emission tomography combined with computed tomography (PET-CT) vs no PET-CT. METHODS Patients with CRLM were enrolled in a trial evaluating the effect of PET-CT (vs no PET-CT) on surgical management, DFS, and OS. This is a sub-study of the trial, including only patients with synchronous EHD. Cox proportional hazard models were used to calculate risks for recurrence and death. Survival were described by Kaplan-Meier method and compared with log-rank test. RESULTS Of 25 patients with EHD (PET-CT arm: 14/270 (5%) and no PET-CT arm: 11/134 (8%)), PET-CT changed surgical management in 14%, all of which avoided liver resection due to more extensive disease. Complete metastasectomy was achieved in 36% (5/14) and 72% (8/11), respectively. Respectively, PET-CT vs no PET-CT had statistically similar median DFS, 5.6 months (95% confidence interval (CI) 3.6-18) vs 7.6 months (95% CI 2.9-15) and median OS, 42 months (95% CI 25-48) vs 29 months (95% CI 17-41). EHD was associated with worse DFS (hazard ratio HR = 1.89, 95% CI 1.41-2.52) and OS (HR = 2.47, 95% CI 1.6-3.83). CONCLUSIONS Preoperative PET-CT for the management of resectable CRLM did not improve long-term outcomes among patients who had synchronous EHD; however, it changed surgical management in a relatively significant proportion of patients.
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Affiliation(s)
- Pablo E Serrano
- Department of Surgery, 153004McMaster University, Canada.,Ontario Clinical Oncology Group, McMaster University, Canada
| | - Chu-Shu Gu
- Ontario Clinical Oncology Group, McMaster University, Canada.,Department of Oncology, 152999McMaster University, Canada
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Rabinovich A, Gu CS, Vedantham S, Kearon C, Goldhaber SZ, Gornik HL, Kahn SR. External validation of the SOX-PTS score in a prospective multicenter trial of patients with proximal deep vein thrombosis. J Thromb Haemost 2020; 18:1381-1389. [PMID: 32145144 PMCID: PMC7545582 DOI: 10.1111/jth.14791] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2019] [Revised: 02/23/2020] [Accepted: 02/28/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND Using data from the SOX Trial, we recently developed a clinical prediction model for occurrence of the postthrombotic syndrome (PTS) after proximal deep vein thrombosis (DVT), termed the SOX-PTS score. The score includes anatomical extent of DVT; body mass index; and baseline Villalta score. OBJECTIVE To externally validate the SOX-PTS score. METHODS Logistic regression analysis of data from the ATTRACT Trial that evaluated pharmacomechanical catheter directed thrombolysis in patients with proximal DVT. The primary outcome was the occurrence of PTS (defined as Villalta score ≥ 5) from 6 to 24 months after DVT. Secondary outcomes included moderate-severe PTS (Villalta scale ≥ 10) and severe PTS (Villalta scale ≥ 14). Predictive performance was assessed by discrimination and calibration. An updated score was evaluated in an exploratory analysis. RESULTS Six hundred and ninety-one ATTRACT patients were included, of whom 328 (47%) developed PTS. The c-statistic was 0.63; 95% confidence interval (CI) 0.59-0.67 for PTS. The model's performance appeared to be better for the outcomes moderate to severe PTS and severe PTS (c-statistic 0.67; 95% CI 0.62-0.72 for moderate-severe PTS and 0.70; 0.64-0.77 for severe PTS). An updated model with age as an additional variable performed similarly to the original model. CONCLUSION We externally validated the SOX-PTS score for estimating the risk of developing PTS, moderate to severe PTS, and severe PTS, in patients with proximal DVT. The score may be useful to predict PTS at the time of DVT diagnosis. Further external validation in different patient cohorts is required.
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Affiliation(s)
- Anat Rabinovich
- Thrombosis and Hemostasis unit, Hematology institute, Soroka University Medical Center, Faculty of Health Sciences, Ben Gurion University of the Negev, Beer Sheva, Israel
| | - Chu-Shu Gu
- Department of Oncology, McMaster University, Hamilton, ON, Canada
| | - Suresh Vedantham
- Mallinckrodt Institute of Radiology, Washington University in St. Louis, MO, USA
| | - Clive Kearon
- Thrombosis and Atherosclerosis Research Institute, McMaster University, Hamilton, ON, Canada
| | - Samuel Z. Goldhaber
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, and Harvard Medical School, Boston, MA, USA
| | - Heather L. Gornik
- University Hospitals, Case Western Reserve University, Cleveland Ohio, USA
| | - Susan R. Kahn
- Jewish General Hospital, Lady Davis Institute, Center for Clinical Epidemiology, Montreal, QC, Canada
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Wang J, Griffiths C, Simunovic M, Parpia S, Gu CS, Gafni A, Ruo L, Hallet J, Bogach J, Serrano PE. Simultaneous versus staged resection for synchronous colorectal liver metastases: A population-based cost analysis in Ontario, Canada - Health economic evaluation. Int J Surg 2020; 78:75-82. [PMID: 32335234 DOI: 10.1016/j.ijsu.2020.04.044] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Revised: 04/13/2020] [Accepted: 04/16/2020] [Indexed: 01/02/2023]
Abstract
BACKGROUND Simultaneous compared to staged resection of synchronous colorectal cancer liver metastases is considered safe. We aimed to determine their cost implications. STUDY DESIGN Population-based cohort was generated by linking administrative healthcare datasets in Ontario, Canada (2006-2014). Resection of colorectal cancer and liver metastases within six months was considered synchronous. Cost analysis was performed from the perspective of a third-party payer. Median costs with range were estimated using the log-normal distribution of cost using t-test with a one-year time horizon. RESULTS Among patients undergoing staged resection (n = 678), the estimated median cost was $54,321 CAD (IQR 45,472 to 68,475) and $41,286 CAD (IQR 31,633 to 58,958) for those undergoing simultaneous resection (n = 390), median difference: $13,035 CAD (p < 0.001). Primary cost driver were all costs related to hospitalization for liver and colon resection, which was higher for the staged approach, median difference: $16,346 CAD (p < 0.001). This was mainly due to a longer median length of hospital stay in the staged vs. simultaneous group (11 vs. 8 days, p < 0.001 respectively), which was not attributable to differences in major postoperative complication rates (23% vs. 28%, p = 0.067 respectively). Other costs, including cost of chemotherapy within six months of surgery ($11,681 CAD vs. $8644 CAD, p = 0.074 respectively) and 90-day re-hospitalization cost ($2155 CAD vs. $2931 CAD, p = 0.454 respectively) were similar between groups. CONCLUSION Cost of staged resection of synchronous colorectal cancer liver metastases is significantly higher compared to the simultaneous approach, mostly driven by a longer length of hospital stay despite similar postoperative complication rates.
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Affiliation(s)
- Julian Wang
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON, Canada
| | | | - Marko Simunovic
- Department of Surgery, McMaster University, Hamilton, ON, Canada
| | - Sameer Parpia
- Department of Oncology, McMaster University, Hamilton, ON, Canada
| | - Chu-Shu Gu
- Ontario Clinical Oncology Group, Hamilton Health Sciences, Hamilton, ON, Canada
| | - Amiram Gafni
- Department of Health Research Methods, Evaluation and Impact, McMaster University, Hamilton, ON, Canada
| | - Leyo Ruo
- Department of Surgery, McMaster University, Hamilton, ON, Canada
| | - Julie Hallet
- Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Jessica Bogach
- Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Pablo E Serrano
- Department of Surgery, McMaster University, Hamilton, ON, Canada.
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Lee A, Gu CS, Suresh V, Kearon C, Blostein M, Kahn S. Comparison of Two Clinical Scales to Assess the Post-thrombotic Syndrome: Secondary Analysis of a Multicenter Randomized Trial of Pharmacomechanical Catheter-Directed Thrombolysis for Deep Venous Thrombosis. J Vasc Surg Venous Lymphat Disord 2020. [DOI: 10.1016/j.jvsv.2019.12.012] [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: 11/26/2022]
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10
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Serrano PE, Gu CS, Moulton CA, Husien M, Jalink D, Martel G, Tsang ME, Hallet J, McAlister V, Gallinger S, Levine M. Effect of PET-CT on disease recurrence and management in patients with potentially resectable colorectal cancer liver metastases. Long-term results of a randomized controlled trial. J Surg Oncol 2020; 121:1001-1006. [PMID: 32034769 DOI: 10.1002/jso.25864] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2019] [Accepted: 01/27/2020] [Indexed: 12/22/2022]
Abstract
BACKGROUND Preoperative evaluation of resectable colorectal cancer liver metastases with positron emission tomography (PET) combined with computed tomography (PET-CT) is used extensively. The PETCAM trial evaluated the effect of PET-CT (intervention) vs no PET-CT (control) on surgical management. PET-CT resulted in 8% change in surgical management, therefore, we aimed to compare long-term outcomes (disease-free [DFS], overall survival [OS]). METHODS Trial recruitment (2005-2010) had prospective follow-up until 2013. Events from 2013 to 2017 were collected retrospectively. Survival was described by the Kaplan-Meier method and compared with log-rank test. Oncologic risk factors were calculated using Cox proportional hazard models. RESULTS Among 404 patients randomized, there were no differences in DFS (hazard ratio [HR] = 1.13; 95% confidence interval [CI], 0.89 to 1.43) or OS (HR, 1.02; 95% CI, 0.78-1.32) between groups. For all patients randomized, median DFS (PET-CT vs no PET-CT) was 16 months (95% CI, 13-18) and 15 months (95% CI, 11-22), P = .33. For patients who underwent liver resection (n = 368), DFS (17 vs 16 months, P = .51) and OS (58 months vs 52 months, P = .90) were similar between groups, respectively. Risk factors for DFS and OS were age, tumor size, node-positive disease, extrahepatic metastases and disease-free duration. CONCLUSION Preoperative PET-CT changes surgical management in a small percentage of cases, without effect on recurrence rates or long-term survival.
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Affiliation(s)
- Pablo E Serrano
- Department of Surgery, McMaster University, Hamilton, Ontario.,Ontario Clinical Oncology Group, McMaster University, Hamilton, Ontario
| | - Chu-Shu Gu
- Ontario Clinical Oncology Group, McMaster University, Hamilton, Ontario.,Department of Oncology, McMaster University, Hamilton, Ontario
| | | | | | - Diederick Jalink
- Cancer Centre of Southeastern Ontario at Kingston General Hospital, Kingston, Ontario
| | | | | | - Julie Hallet
- Odette Cancer Centre - Sunnybrook Health Sciences Centre, Toronto, Ontario
| | | | | | - Mark Levine
- Ontario Clinical Oncology Group, McMaster University, Hamilton, Ontario.,Department of Oncology, McMaster University, Hamilton, Ontario
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Kahn SR, Julian JA, Kearon C, Gu CS, Cohen DJ, Magnuson EA, Comerota AJ, Goldhaber SZ, Jaff MR, Razavi MK, Kindzelski AL, Schneider JR, Kim P, Chaer R, Sista AK, McLafferty RB, Kaufman JA, Wible BC, Blinder M, Vedantham S. Quality of life after pharmacomechanical catheter-directed thrombolysis for proximal deep venous thrombosis. J Vasc Surg Venous Lymphat Disord 2020; 8:8-23.e18. [PMID: 31843251 PMCID: PMC7681916 DOI: 10.1016/j.jvsv.2019.03.023] [Citation(s) in RCA: 45] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2018] [Accepted: 03/07/2019] [Indexed: 12/19/2022]
Abstract
BACKGROUND After deep venous thrombosis (DVT), many patients have impaired quality of life (QOL). We aimed to assess whether pharmacomechanical catheter-directed thrombolysis (PCDT) improves short-term or long-term QOL in patients with proximal DVT and whether QOL is related to extent of DVT. METHODS The Acute Venous Thrombosis: Thrombus Removal with Adjunctive Catheter-Directed Thrombolysis (ATTRACT) trial was an assessor-blinded randomized trial that compared PCDT with no PCDT in patients with DVT of the femoral, common femoral, or iliac veins. QOL was assessed at baseline and 1 month, 6 months, 12 months, 18 months, and 24 months using the Venous Insufficiency Epidemiological and Economic Study on Quality of Life/Symptoms (VEINES-QOL/Sym) disease-specific QOL measure and the 36-Item Short Form Health Survey (SF-36) physical component summary (PCS) and mental component summary general QOL measures. Change in QOL scores from baseline to assessment time were compared in the PCDT and no PCDT treatment groups overall and in the iliofemoral DVT and femoral-popliteal DVT subgroups. RESULTS Of 692 ATTRACT patients, 691 were analyzed (mean age, 53 years; 62% male; 57% iliofemoral DVT). VEINES-QOL change scores were greater (ie, better) in PCDT vs no PCDT from baseline to 1 month (difference, 5.7; P = .0006) and from baseline to 6 months (5.1; P = .0029) but not for other intervals. SF-36 PCS change scores were greater in PCDT vs no PCDT from baseline to 1 month (difference, 2.4; P = .01) but not for other intervals. Among iliofemoral DVT patients, VEINES-QOL change scores from baseline to all assessments were greater in the PCDT vs no PCDT group; this was statistically significant in the intention-to-treat analysis at 1 month (difference, 10.0; P < .0001) and 6 months (8.8; P < .0001) and in the per-protocol analysis at 18 months (difference, 5.8; P = .0086) and 24 months (difference, 6.6; P = .0067). SF-36 PCS change scores were greater in PCDT vs no PCDT from baseline to 1 month (difference, 3.2; P = .0010) but not for other intervals. In contrast, in femoral-popliteal DVT patients, change scores from baseline to all assessments were similar in the PCDT and no PCDT groups. CONCLUSIONS Among patients with proximal DVT, PCDT leads to greater improvement in disease-specific QOL than no PCDT at 1 month and 6 months but not later. In patients with iliofemoral DVT, PCDT led to greater improvement in disease-specific QOL during 24 months.
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Affiliation(s)
- Susan R Kahn
- Center for Clinical Epidemiology, Lady Davis Institute, Jewish General Hospital, Montreal, Quebec, Canada.
| | - Jim A Julian
- Department of Oncology, McMaster University, Hamilton, Ontario, Canada; Juravinski Hospital and Cancer Centre, Hamilton, Ontario, Canada
| | - Clive Kearon
- Juravinski Hospital and Cancer Centre, Hamilton, Ontario, Canada; Thrombosis and Atherosclerosis Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Chu-Shu Gu
- Department of Oncology, McMaster University, Hamilton, Ontario, Canada; Juravinski Hospital and Cancer Centre, Hamilton, Ontario, Canada
| | - David J Cohen
- Department of Medicine, University of Missouri-Kansas City, Kansas City, Mo; St. Luke's Mid America Heart Institute, Kansas City, Mo
| | | | - Anthony J Comerota
- Inova Heart and Vascular Institute, Inova Alexandria Hospital, Alexandria, Va
| | - Samuel Z Goldhaber
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, Mass; Harvard Medical School, Boston, Mass
| | - Michael R Jaff
- Harvard Medical School, Boston, Mass; Newton-Wellesley Hospital, Newton, Mass
| | | | - Andrei L Kindzelski
- Division of Blood Diseases and Resources, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Md
| | - Joseph R Schneider
- Vascular Surgery and Interventional Radiology Partners/VSIR, Northwestern Medicine, Chicago, Ill
| | - Paul Kim
- Department of Radiology, Maine Medical Center, Portland, Me
| | - Rabih Chaer
- Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | | | | | - John A Kaufman
- Department of Interventional Radiology, Dotter Interventional Institute, Oregon Health & Science University, Portland
| | - Brandt C Wible
- Department of Radiology, St. Luke's Hospital, Kansas City, Mo
| | - Morey Blinder
- Department of Medicine, Washington University in St. Louis, St. Louis, Mo
| | - Suresh Vedantham
- Mallinckrodt Institute of Radiology, Washington University in St. Louis, St. Louis, Mo
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Comerota AJ, Kearon C, Gu CS, Julian JA, Goldhaber SZ, Kahn SR, Jaff MR, Razavi MK, Kindzelski AL, Bashir R, Patel P, Sharafuddin M, Sichlau MJ, Saad WE, Assi Z, Hofmann LV, Kennedy M, Vedantham S. Endovascular Thrombus Removal for Acute Iliofemoral Deep Vein Thrombosis. Circulation 2019; 139:1162-1173. [PMID: 30586751 DOI: 10.1161/circulationaha.118.037425] [Citation(s) in RCA: 149] [Impact Index Per Article: 29.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
BACKGROUND The ATTRACT trial (Acute Venous Thrombosis: Thrombus Removal with Adjunctive Catheter-Directed Thrombolysis) previously reported that pharmacomechanical catheter-directed thrombolysis (PCDT) did not prevent postthrombotic syndrome (PTS) in patients with acute proximal deep vein thrombosis. In the current analysis, we examine the effect of PCDT in ATTRACT patients with iliofemoral deep vein thrombosis. METHODS Within a large multicenter randomized trial, 391 patients with acute deep vein thrombosis involving the iliac or common femoral veins were randomized to PCDT with anticoagulation versus anticoagulation alone (No-PCDT) and were followed for 24 months to compare short-term and long-term outcomes. RESULTS Between 6 and 24 months, there was no difference in the occurrence of PTS (Villalta scale ≥5 or ulcer: 49% PCDT versus 51% No-PCDT; risk ratio, 0.95; 95% CI, 0.78-1.15; P=0.59). PCDT led to reduced PTS severity as shown by lower mean Villalta and Venous Clinical Severity Scores ( P<0.01 for comparisons at 6, 12, 18, and 24 months), and fewer patients with moderate-or-severe PTS (Villalta scale ≥10 or ulcer: 18% versus 28%; risk ratio, 0.65; 95% CI, 0.45-0.94; P=0.021) or severe PTS (Villalta scale ≥15 or ulcer: 8.7% versus 15%; risk ratio, 0.57; 95% CI, 0.32-1.01; P=0.048; and Venous Clinical Severity Score ≥8: 6.6% versus 14%; risk ratio, 0.46; 95% CI, 0.24-0.87; P=0.013). From baseline, PCDT led to greater reduction in leg pain and swelling ( P<0.01 for comparisons at 10 and 30 days) and greater improvement in venous disease-specific quality of life (Venous Insufficiency Epidemiological and Economic Study Quality of Life unit difference 5.6 through 24 months, P=0.029), but no difference in generic quality of life ( P>0.2 for comparisons of SF-36 mental and physical component summary scores through 24 months). In patients having PCDT versus No-PCDT, major bleeding within 10 days occurred in 1.5% versus 0.5% ( P=0.32), and recurrent venous thromboembolism over 24 months was observed in 13% versus 9.2% ( P=0.21). CONCLUSIONS In patients with acute iliofemoral deep vein thrombosis, PCDT did not influence the occurrence of PTS or recurrent venous thromboembolism. However, PCDT significantly reduced early leg symptoms and, over 24 months, reduced PTS severity scores, reduced the proportion of patients who developed moderate-or-severe PTS, and resulted in greater improvement in venous disease-specific quality of life. CLINICAL TRIAL REGISTRATION URL: https://www.clinicaltrials.gov . Unique identifier: NCT00790335.
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Affiliation(s)
- Anthony J Comerota
- Inova Heart and Vascular Institute, Inova Alexandria Hospital, VA (A.J.C.)
| | - Clive Kearon
- Thrombosis and Atherosclerosis Research Institute (C.K.), McMaster University, Hamilton, ON, Canada.,Juravinski Hospital and Cancer Centre, Hamilton, ON, Canada (C.K., C.-S.G., J.A.J.)
| | - Chu-Shu Gu
- Department of Oncology (C.-S.G., J.A.J.), McMaster University, Hamilton, ON, Canada.,Juravinski Hospital and Cancer Centre, Hamilton, ON, Canada (C.K., C.-S.G., J.A.J.)
| | - Jim A Julian
- Department of Oncology (C.-S.G., J.A.J.), McMaster University, Hamilton, ON, Canada.,Juravinski Hospital and Cancer Centre, Hamilton, ON, Canada (C.K., C.-S.G., J.A.J.)
| | - Samuel Z Goldhaber
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, and Harvard Medical School, Boston, MA (S.Z.G.)
| | - Susan R Kahn
- Jewish General Hospital, Lady Davis Institute, Center for Clinical Epidemiology, Montreal, QC, Canada (S.R.K.)
| | - Michael R Jaff
- Newton-Wellesley Hospital, and Harvard Medical School, Boston, MA (M.R.J.)
| | | | - Andrei L Kindzelski
- National Heart Lung and Blood Institute, National Institutes of Health, Bethesda, MD (A.L.K.)
| | - Riyaz Bashir
- Department of Medicine, Temple University Hospital, Philadelphia, PA (R.B.)
| | - Parag Patel
- Department of Radiology, Medical College of Wisconsin, Milwaukee (P.P.)
| | - Mel Sharafuddin
- Division of Vascular Surgery, University of Iowa, Iowa City (M.S.)
| | - Michael J Sichlau
- Vascular and Interventional Professionals LLC, Hinsdale, IL (M.J.S.)
| | - Wael E Saad
- Department of Radiology, University of Michigan, Ann Arbor (W.E.S.)
| | - Zakaria Assi
- Toledo Radiological Associates, Vascular & Interventional Radiology, OH (Z.A.)
| | | | | | - Suresh Vedantham
- Mallinckrodt Institute of Radiology, Washington University in St. Louis, MO (S.V.)
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Wang J, Parpia S, Gu CS, Gafni A, Serrano Aybar PE, Griffiths C, Simunovic M. Cost Analysis of Simultaneous vs Staged Resection of Colorectal Cancer Liver Metastases: A Population Based Study. J Am Coll Surg 2019. [DOI: 10.1016/j.jamcollsurg.2019.08.136] [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: 11/28/2022]
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Kearon C, Gu CS, Julian J, Goldhaber S, Comerota A, Gornik H, Murphy T, Lewis L, Kahn S, Kindzelski A, Slater D, Geary R, Winokur R, Natarajan K, Dietzek A, Leung D, Kim S, Vedantham S. Pharmacomechanical Catheter-Directed Thrombolysis in Acute Femoral–Popliteal Deep Vein Thrombosis: Analysis from a Stratified Randomized Trial. Thromb Haemost 2019; 119:633-644. [DOI: 10.1055/s-0039-1677795] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Background and Objectives The Acute Venous Thrombosis: Thrombus Removal with Adjunctive Catheter-Directed Thrombolysis (ATTRACT) trial reported that pharmacomechanical catheter-directed thrombolysis (PCDT) did not reduce post-thrombotic syndrome (PTS), but reduced moderate-to-severe PTS and the severity of PTS symptoms. In this analysis, we examine the effect of PCDT in patients with femoral–popliteal deep vein thrombosis (DVT) (without involvement of more proximal veins).
Patients and Methods Within the ATTRACT trial, 300 patients had DVT involving the femoral vein without involvement of the common femoral or iliac veins and were randomized to receive PCDT with anticoagulation or anticoagulation alone (no PCDT). Patients were followed for 24 months.
Results From 6 to 24 months, between the PCDT versus no PCDT arms, there was: no difference in any PTS (Villalta scale ≥ 5: risk ratio [RR] = 0.97; 95% confidence interval [CI], 0.75–1.24); moderate-or-severe PTS (Villalta scale ≥ 10: RR = 0.93; 95% CI, 0.57–1.52); severity of PTS scores; or general or disease-specific quality of life (p > 0.5 for all comparisons). From baseline to both 10 and 30 days, there was no difference in improvement of leg pain or swelling between treatment arms. From baseline to 10 days, major bleeding occurred in three versus none (p = 0.06) and any bleeding occurred in eight versus two (p = 0.032) PCDT versus no PCDT patients. Over 24 months, recurrent venous thromboembolism occurred in 16 PCDT and 12 no PCDT patients (p = 0.24).
Conclusion In patients with femoral–popliteal DVT, PCDT did not improve short- or long-term efficacy outcomes, but it increased bleeding. Therefore, PCDT should not be used as initial treatment of femoral–popliteal DVT. (NCT00790335).
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Affiliation(s)
- Clive Kearon
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Chu-Shu Gu
- Department of Oncology, McMaster University, Hamilton, Ontario, Canada
| | - Jim Julian
- Department of Oncology, McMaster University, Hamilton, Ontario, Canada
| | - Samuel Goldhaber
- Department of Medicine, Harvard Medical School, Boston, Massachusetts, United States
| | - Anthony Comerota
- Inova Alexandria Health Care, Alexandria, Virginia, United States
| | - Heather Gornik
- Department of Medicine, Cleveland Clinic, Cleveland, Ohio, United States
| | - Timothy Murphy
- Department of Diagnostic Imaging, Brown University, Providence, Rhode Island, United States
| | - Laurence Lewis
- Department of Medicine, Washington University in St. Louis, St. Louis, Missouri, United States
| | - Susan Kahn
- Department of Medicine, McGill University, Montreal, Quebec, Canada
| | - Andrei Kindzelski
- Division of Blood Diseases & Resources, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland, United States
| | - Dennis Slater
- Eastern Connecticut Hematology and Oncology Associates, Norwich, Connecticut, United States
| | - Randolph Geary
- Department of Vascular and Endovascular Surgery, Wake Forest School of Medicine, Wake Forest University, Winston-Salem, North Carolina, United States
| | - Ronald Winokur
- Department of Radiology, Weill Cornell Medicine, New York, New York, United States
| | | | - Alan Dietzek
- Department of Surgery, University of Vermont College of Medicine, University of Vermont, Burlington, Vermont, United States
| | - Daniel Leung
- Department of Radiology, Christiana Care Health Services, Edgemoor, Delaware, United States
| | - Stanley Kim
- Division of Vascular Surgery, Central DuPage Hospital, Winfield, Illinois, United States
| | - Suresh Vedantham
- Department of Radiology, Washington University in St. Louis, St. Louis, Missouri, United States
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Yuan F, Gafni A, Gu CS, Serrano PE. Does giving pasireotide to patients undergoing pancreaticoduodenectomy always pay for itself? Eur Surg 2018. [DOI: 10.1007/s10353-018-0563-8] [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: 10/27/2022]
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Elit LM, Fyles AW, Gu CS, Pond GR, D’Souza D, Samant R, Anthes M, Thomas G, Filion M, Arsenault J, Dayes I, Whelan TJ, Gulenchyn KY, Metser U, Dhamanaskar K, Levine MN. Effect of Positron Emission Tomography Imaging in Women With Locally Advanced Cervical Cancer: A Randomized Clinical Trial. JAMA Netw Open 2018; 1:e182081. [PMID: 30646153 PMCID: PMC6324512 DOI: 10.1001/jamanetworkopen.2018.2081] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE In women with locally advanced cancer of the cervix (LACC), staging defines disease extent and guides therapy. Currently, undetected disease outside the radiation field can result in undertreatment or, if disease is disseminated, overtreatment. OBJECTIVE To determine whether adding fludeoxyglucose F 18 positron emission tomography-computed tomography (PET-CT) to conventional staging with CT of the abdomen and pelvis affects therapy received in women with LACC. DESIGN, SETTING, AND PARTICIPANTS A randomized clinical trial was conducted. Women with newly diagnosed histologically confirmed International Federation of Gynecology and Obstetrics stage IB to IVA carcinoma of the cervix who were candidates for chemotherapy and radiation therapy (CRT) were allocated 2:1 to PET-CT plus CT of the abdomen and pelvis or CT alone. Enrollment occurred between April 2010 and June 2014 at 6 regional cancer centers in Ontario, Canada. The PET-CT scanners were at 6 associated academic institutions. The median follow-up at the time of the analysis was 3 years. The analysis was conducted on March 30, 2017. INTERVENTIONS Patients received either PET-CT plus CT of the abdomen and pelvis or CT of the abdomen and pelvis. MAIN OUTCOMES AND MEASURES Treatment delivered, defined as standard pelvic CRT vs more extensive CRT, ie, extended field radiotherapy or therapy with palliative intent. RESULTS One hundred seventy-one patients were allocated to PET-CT (n = 113) or CT (n = 58). The trial stopped early before the planned target of 288 was reached because of low recruitment. Mean (SD) age was 48.1 (11.2) years in the PET-CT group vs 48.9 (12.7) years in the CT group. In the 112 patients who received PET-CT, 68 (60.7%) received standard pelvic CRT, 38 (33.9%) more extensive CRT, and 6 (5.4%) palliative treatment. The corresponding data for the 56 patients who received CT alone were 42 (75.0%), 11 (19.6%), and 3 (5.4%). Overall, 44 patients (39.3%) in the PET-CT group received more extensive CRT or palliative treatment compared with 14 patients (25.0%) in the CT group (odds ratio, 2.05; 95% CI, 0.96-4.37; P = .06). Twenty-four patients in the PET-CT group (21.4%) received extended field radiotherapy to para-aortic nodes and 14 (12.5%) to common iliac nodes compared with 8 (14.3%) and 3 (5.4%), respectively, in the CT group (odds ratio, 1.64; 95% CI, 0.68-3.92; P = .27). CONCLUSIONS AND RELEVANCE There was a trend for more extensive CRT with PET-CT, but the difference was not significant because the trial was underpowered. This trial provides information on the utility of PET-CT for staging in LACC. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT00895349.
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Affiliation(s)
- Lorraine M. Elit
- Juravinski Cancer Centre, Department of Obstetrics & Gynecology, McMaster University, Hamilton, Ontario, Canada
| | - Anthony W. Fyles
- Princess Margaret Cancer Centre, Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada
| | - Chu-Shu Gu
- Ontario Clinical Oncology Group, Department of Oncology, McMaster University, Hamilton, Ontario, Canada
| | - Gregory R. Pond
- Ontario Clinical Oncology Group, Department of Oncology, McMaster University, Hamilton, Ontario, Canada
| | - David D’Souza
- London Regional Cancer Centre, Department of Oncology, University of Western Ontario, London, Ontario, Canada
| | - Rajiv Samant
- Ottawa Hospital Cancer Centre, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Margaret Anthes
- Thunder Bay Regional Cancer Centre, Thunder Bay, Ontario, Canada
| | - Gillian Thomas
- Odette Sunnybrook Cancer Centre, Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada
| | - Marc Filion
- Ontario Clinical Oncology Group, Department of Oncology, McMaster University, Hamilton, Ontario, Canada
| | - Julie Arsenault
- Juravinski Cancer Centre, Department of Oncology, McMaster University, Hamilton, Ontario, Canada
| | - Ian Dayes
- Juravinski Cancer Centre, Department of Oncology, McMaster University, Hamilton, Ontario, Canada
| | - Timothy J. Whelan
- Juravinski Cancer Centre, Department of Oncology, McMaster University, Hamilton, Ontario, Canada
| | - Karen Y. Gulenchyn
- Hamilton Health Sciences, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- Hamilton Health Sciences, Department of Radiology, McMaster University, Hamilton, Ontario, Canada
| | - Ur Metser
- Princess Margaret Hospital, Department of Medical Imaging, University of Toronto, Toronto, Ontario, Canada
| | - Kavita Dhamanaskar
- Hamilton Health Sciences, Department of Radiology, McMaster University, Hamilton, Ontario, Canada
| | - Mark N. Levine
- Ontario Clinical Oncology Group, Department of Oncology, McMaster University, Hamilton, Ontario, Canada
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Serrano Aybar PE, Gu CS, Husien M, Jalink D, Martel G, Tsang ME, Hallet JI, Gallinger S, Ritter A, McAlister V, Sela N, Solomon H, Beyfuss K, Li C, Lee E, Moulton CA, Levine MN. Effect of PET-CT on disease recurrence and its management in patients with potentially resectable colorectal cancer liver metastases. The long-term results of a randomized controlled trial (PET-CT Imaging prior to liver resection for colorectal adenocarcinoma metastases). J Clin Oncol 2018. [DOI: 10.1200/jco.2018.36.15_suppl.3527] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
| | - Chu-Shu Gu
- Ontario Clinical Oncology Group, McMaster University, Hamilton, ON, Canada
| | - Mohamed Husien
- Grand River Regional Cancer Centre, Kitchener, ON, Canada
| | | | | | | | | | | | | | | | | | | | | | | | - Erika Lee
- McMaster University, Hamilton, ON, Canada
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Serrano Aybar PE, Gu CS, Husien M, Jalink D, Martel G, Tsang ME, Hallet JI, Gallinger S, Ritter A, McAlister V, Sela N, Solomon H, Beyfuss K, Li C, Lee E, Moulton C, Levine MN. Effect of PET-CT on disease recurrence and its management in patients with potentially resectable colorectal cancer liver metastases: The long-term results of a randomized control trial. J Clin Oncol 2018. [DOI: 10.1200/jco.2018.36.4_suppl.562] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
562 Background: The PETCAM randomized trial evaluated the effect of preoperative PET-CT (vs. no PET-CT) on surgical management in patients with colorectal cancer liver metastases. In this study, 8% of patients had a change in surgical management, including a higher proportion of major liver resections in the PET-CT arm. The current study compares the intervention groups for 5-year disease free (DFS) and overall survival (OS), and evaluated their long-term clinical course, i.e. sites of recurrence and management of disease recurrence. Methods: Recruitment to the trial occurred between 2005-2010, with last follow-up in 2013. Data on recurrence, management of recurrence and mortality from 2013-2017 was collected from patient’s charts. Recurrences according to site and management were described. Cox proportional Hazard Models were used to calculate the risk for recurrence and death. OS was calculated with Kaplan-Meir method and compared with log-rank test. Results: At 5 years, 157 of 404 (39%) patients were still alive and 19 patients were lost to follow-up. Median follow-up is 4.2 years. There were no differences in DFS (HR: 1.12, 95%CI: 0.88-1.42) or OS (HR: 0.97, 95%CI: 0.74-1.28) between groups. The median DFS for the 372 patients who had surgery was 17 months, 95%CI: 14.7-19.4. Risks factors for recurrence were: extrahepatic disease, liver tumour size, and nodal stage. The median OS for all patients was 50 months, 95%CI: 43.5-64.3. Risks factors for death also included age and prior use of chemotherapy. During the follow-up period, 287/404, 71% patients recurred (mostly liver and lung); 137 (48%) were treated solely with chemotherapy and 35% were treated with surgery with curative intent. Of these, the majority recurred (109/116, 94%). The median OS following first recurrence was 27.5 months, 95%CI: 23-30. Conclusions: PET-CT did not improve DFS or OS. Survival following liver resection is similar to previous reports, however most patients experience disease recurrence. A substantial proportion of patients who recur undergo surgery, however it is likely that they will recur again.
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Affiliation(s)
| | - Chu-Shu Gu
- Ontario Clinical Oncology Group, McMaster University, Hamilton, ON, Canada
| | - Mohamed Husien
- Grand River Regional Cancer Centre, Kitchener, ON, Canada
| | | | | | | | | | | | | | | | | | | | | | | | - Erika Lee
- McMaster University, Hamilton, ON, Canada
| | - Carolanne Moulton
- Toronto General Hospital, University Health Network, Toronto, ON, Canada
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Vedantham S, Goldhaber SZ, Julian JA, Kahn SR, Jaff MR, Cohen DJ, Magnuson E, Razavi MK, Comerota AJ, Gornik HL, Murphy TP, Lewis L, Duncan JR, Nieters P, Derfler MC, Filion M, Gu CS, Kee S, Schneider J, Saad N, Blinder M, Moll S, Sacks D, Lin J, Rundback J, Garcia M, Razdan R, VanderWoude E, Marques V, Kearon C. Pharmacomechanical Catheter-Directed Thrombolysis for Deep-Vein Thrombosis. N Engl J Med 2017; 377:2240-2252. [PMID: 29211671 PMCID: PMC5763501 DOI: 10.1056/nejmoa1615066] [Citation(s) in RCA: 439] [Impact Index Per Article: 62.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND The post-thrombotic syndrome frequently develops in patients with proximal deep-vein thrombosis despite treatment with anticoagulant therapy. Pharmacomechanical catheter-directed thrombolysis (hereafter "pharmacomechanical thrombolysis") rapidly removes thrombus and is hypothesized to reduce the risk of the post-thrombotic syndrome. METHODS We randomly assigned 692 patients with acute proximal deep-vein thrombosis to receive either anticoagulation alone (control group) or anticoagulation plus pharmacomechanical thrombolysis (catheter-mediated or device-mediated intrathrombus delivery of recombinant tissue plasminogen activator and thrombus aspiration or maceration, with or without stenting). The primary outcome was development of the post-thrombotic syndrome between 6 and 24 months of follow-up. RESULTS Between 6 and 24 months, there was no significant between-group difference in the percentage of patients with the post-thrombotic syndrome (47% in the pharmacomechanical-thrombolysis group and 48% in the control group; risk ratio, 0.96; 95% confidence interval [CI], 0.82 to 1.11; P=0.56). Pharmacomechanical thrombolysis led to more major bleeding events within 10 days (1.7% vs. 0.3% of patients, P=0.049), but no significant difference in recurrent venous thromboembolism was seen over the 24-month follow-up period (12% in the pharmacomechanical-thrombolysis group and 8% in the control group, P=0.09). Moderate-to-severe post-thrombotic syndrome occurred in 18% of patients in the pharmacomechanical-thrombolysis group versus 24% of those in the control group (risk ratio, 0.73; 95% CI, 0.54 to 0.98; P=0.04). Severity scores for the post-thrombotic syndrome were lower in the pharmacomechanical-thrombolysis group than in the control group at 6, 12, 18, and 24 months of follow-up (P<0.01 for the comparison of the Villalta scores at each time point), but the improvement in quality of life from baseline to 24 months did not differ significantly between the treatment groups. CONCLUSIONS Among patients with acute proximal deep-vein thrombosis, the addition of pharmacomechanical catheter-directed thrombolysis to anticoagulation did not result in a lower risk of the post-thrombotic syndrome but did result in a higher risk of major bleeding. (Funded by the National Heart, Lung, and Blood Institute and others; ATTRACT ClinicalTrials.gov number, NCT00790335 .).
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Affiliation(s)
- Suresh Vedantham
- From the Washington University School of Medicine, St. Louis (S.V., L.L., J.R.D., P.N., M.C.D., N.S., M.B.); Brigham and Women's Hospital, Harvard Medical School (S.Z.G.), and Massachusetts General Hospital, Harvard Medical School (M.R.J.) - all in Boston; McMaster University, Hamilton, ON (J.A.J., M.F., C.-S.G., C.K.), and McGill University, Jewish General Hospital, Montreal (S.R.K.) - all in Canada; the University of Missouri, St. Luke's Mid America Heart Institute, Kansas City (D.J.C., E.M.); St. Joseph's Vascular Institute, Orange (M.K.R.), and University of California, Los Angeles, Los Angeles (S.K.) - both in California; University of Michigan, Ann Arbor (A.J.C.); Cleveland Clinic Heart and Vascular Institute, Cleveland (H.L.G.); Rhode Island Hospital, Brown University, Providence (T.P.M.); Central DuPage Hospital, Winfield, IL (J.S.); University of North Carolina, Chapel Hill (S.M.); Reading Hospital, Reading, PA (D.S.); Henry Ford Hospital, Detroit (J.L.); Holy Name Hospital, Teaneck, NJ (J.R.); Christiana Care Hospital, Newark, DE (M.G.); St. Elizabeth's Regional Medical Center, Lincoln, NE (R.R., E.V.); and Pepin Heart Center, Tampa, FL (V.M.)
| | - Samuel Z Goldhaber
- From the Washington University School of Medicine, St. Louis (S.V., L.L., J.R.D., P.N., M.C.D., N.S., M.B.); Brigham and Women's Hospital, Harvard Medical School (S.Z.G.), and Massachusetts General Hospital, Harvard Medical School (M.R.J.) - all in Boston; McMaster University, Hamilton, ON (J.A.J., M.F., C.-S.G., C.K.), and McGill University, Jewish General Hospital, Montreal (S.R.K.) - all in Canada; the University of Missouri, St. Luke's Mid America Heart Institute, Kansas City (D.J.C., E.M.); St. Joseph's Vascular Institute, Orange (M.K.R.), and University of California, Los Angeles, Los Angeles (S.K.) - both in California; University of Michigan, Ann Arbor (A.J.C.); Cleveland Clinic Heart and Vascular Institute, Cleveland (H.L.G.); Rhode Island Hospital, Brown University, Providence (T.P.M.); Central DuPage Hospital, Winfield, IL (J.S.); University of North Carolina, Chapel Hill (S.M.); Reading Hospital, Reading, PA (D.S.); Henry Ford Hospital, Detroit (J.L.); Holy Name Hospital, Teaneck, NJ (J.R.); Christiana Care Hospital, Newark, DE (M.G.); St. Elizabeth's Regional Medical Center, Lincoln, NE (R.R., E.V.); and Pepin Heart Center, Tampa, FL (V.M.)
| | - Jim A Julian
- From the Washington University School of Medicine, St. Louis (S.V., L.L., J.R.D., P.N., M.C.D., N.S., M.B.); Brigham and Women's Hospital, Harvard Medical School (S.Z.G.), and Massachusetts General Hospital, Harvard Medical School (M.R.J.) - all in Boston; McMaster University, Hamilton, ON (J.A.J., M.F., C.-S.G., C.K.), and McGill University, Jewish General Hospital, Montreal (S.R.K.) - all in Canada; the University of Missouri, St. Luke's Mid America Heart Institute, Kansas City (D.J.C., E.M.); St. Joseph's Vascular Institute, Orange (M.K.R.), and University of California, Los Angeles, Los Angeles (S.K.) - both in California; University of Michigan, Ann Arbor (A.J.C.); Cleveland Clinic Heart and Vascular Institute, Cleveland (H.L.G.); Rhode Island Hospital, Brown University, Providence (T.P.M.); Central DuPage Hospital, Winfield, IL (J.S.); University of North Carolina, Chapel Hill (S.M.); Reading Hospital, Reading, PA (D.S.); Henry Ford Hospital, Detroit (J.L.); Holy Name Hospital, Teaneck, NJ (J.R.); Christiana Care Hospital, Newark, DE (M.G.); St. Elizabeth's Regional Medical Center, Lincoln, NE (R.R., E.V.); and Pepin Heart Center, Tampa, FL (V.M.)
| | - Susan R Kahn
- From the Washington University School of Medicine, St. Louis (S.V., L.L., J.R.D., P.N., M.C.D., N.S., M.B.); Brigham and Women's Hospital, Harvard Medical School (S.Z.G.), and Massachusetts General Hospital, Harvard Medical School (M.R.J.) - all in Boston; McMaster University, Hamilton, ON (J.A.J., M.F., C.-S.G., C.K.), and McGill University, Jewish General Hospital, Montreal (S.R.K.) - all in Canada; the University of Missouri, St. Luke's Mid America Heart Institute, Kansas City (D.J.C., E.M.); St. Joseph's Vascular Institute, Orange (M.K.R.), and University of California, Los Angeles, Los Angeles (S.K.) - both in California; University of Michigan, Ann Arbor (A.J.C.); Cleveland Clinic Heart and Vascular Institute, Cleveland (H.L.G.); Rhode Island Hospital, Brown University, Providence (T.P.M.); Central DuPage Hospital, Winfield, IL (J.S.); University of North Carolina, Chapel Hill (S.M.); Reading Hospital, Reading, PA (D.S.); Henry Ford Hospital, Detroit (J.L.); Holy Name Hospital, Teaneck, NJ (J.R.); Christiana Care Hospital, Newark, DE (M.G.); St. Elizabeth's Regional Medical Center, Lincoln, NE (R.R., E.V.); and Pepin Heart Center, Tampa, FL (V.M.)
| | - Michael R Jaff
- From the Washington University School of Medicine, St. Louis (S.V., L.L., J.R.D., P.N., M.C.D., N.S., M.B.); Brigham and Women's Hospital, Harvard Medical School (S.Z.G.), and Massachusetts General Hospital, Harvard Medical School (M.R.J.) - all in Boston; McMaster University, Hamilton, ON (J.A.J., M.F., C.-S.G., C.K.), and McGill University, Jewish General Hospital, Montreal (S.R.K.) - all in Canada; the University of Missouri, St. Luke's Mid America Heart Institute, Kansas City (D.J.C., E.M.); St. Joseph's Vascular Institute, Orange (M.K.R.), and University of California, Los Angeles, Los Angeles (S.K.) - both in California; University of Michigan, Ann Arbor (A.J.C.); Cleveland Clinic Heart and Vascular Institute, Cleveland (H.L.G.); Rhode Island Hospital, Brown University, Providence (T.P.M.); Central DuPage Hospital, Winfield, IL (J.S.); University of North Carolina, Chapel Hill (S.M.); Reading Hospital, Reading, PA (D.S.); Henry Ford Hospital, Detroit (J.L.); Holy Name Hospital, Teaneck, NJ (J.R.); Christiana Care Hospital, Newark, DE (M.G.); St. Elizabeth's Regional Medical Center, Lincoln, NE (R.R., E.V.); and Pepin Heart Center, Tampa, FL (V.M.)
| | - David J Cohen
- From the Washington University School of Medicine, St. Louis (S.V., L.L., J.R.D., P.N., M.C.D., N.S., M.B.); Brigham and Women's Hospital, Harvard Medical School (S.Z.G.), and Massachusetts General Hospital, Harvard Medical School (M.R.J.) - all in Boston; McMaster University, Hamilton, ON (J.A.J., M.F., C.-S.G., C.K.), and McGill University, Jewish General Hospital, Montreal (S.R.K.) - all in Canada; the University of Missouri, St. Luke's Mid America Heart Institute, Kansas City (D.J.C., E.M.); St. Joseph's Vascular Institute, Orange (M.K.R.), and University of California, Los Angeles, Los Angeles (S.K.) - both in California; University of Michigan, Ann Arbor (A.J.C.); Cleveland Clinic Heart and Vascular Institute, Cleveland (H.L.G.); Rhode Island Hospital, Brown University, Providence (T.P.M.); Central DuPage Hospital, Winfield, IL (J.S.); University of North Carolina, Chapel Hill (S.M.); Reading Hospital, Reading, PA (D.S.); Henry Ford Hospital, Detroit (J.L.); Holy Name Hospital, Teaneck, NJ (J.R.); Christiana Care Hospital, Newark, DE (M.G.); St. Elizabeth's Regional Medical Center, Lincoln, NE (R.R., E.V.); and Pepin Heart Center, Tampa, FL (V.M.)
| | - Elizabeth Magnuson
- From the Washington University School of Medicine, St. Louis (S.V., L.L., J.R.D., P.N., M.C.D., N.S., M.B.); Brigham and Women's Hospital, Harvard Medical School (S.Z.G.), and Massachusetts General Hospital, Harvard Medical School (M.R.J.) - all in Boston; McMaster University, Hamilton, ON (J.A.J., M.F., C.-S.G., C.K.), and McGill University, Jewish General Hospital, Montreal (S.R.K.) - all in Canada; the University of Missouri, St. Luke's Mid America Heart Institute, Kansas City (D.J.C., E.M.); St. Joseph's Vascular Institute, Orange (M.K.R.), and University of California, Los Angeles, Los Angeles (S.K.) - both in California; University of Michigan, Ann Arbor (A.J.C.); Cleveland Clinic Heart and Vascular Institute, Cleveland (H.L.G.); Rhode Island Hospital, Brown University, Providence (T.P.M.); Central DuPage Hospital, Winfield, IL (J.S.); University of North Carolina, Chapel Hill (S.M.); Reading Hospital, Reading, PA (D.S.); Henry Ford Hospital, Detroit (J.L.); Holy Name Hospital, Teaneck, NJ (J.R.); Christiana Care Hospital, Newark, DE (M.G.); St. Elizabeth's Regional Medical Center, Lincoln, NE (R.R., E.V.); and Pepin Heart Center, Tampa, FL (V.M.)
| | - Mahmood K Razavi
- From the Washington University School of Medicine, St. Louis (S.V., L.L., J.R.D., P.N., M.C.D., N.S., M.B.); Brigham and Women's Hospital, Harvard Medical School (S.Z.G.), and Massachusetts General Hospital, Harvard Medical School (M.R.J.) - all in Boston; McMaster University, Hamilton, ON (J.A.J., M.F., C.-S.G., C.K.), and McGill University, Jewish General Hospital, Montreal (S.R.K.) - all in Canada; the University of Missouri, St. Luke's Mid America Heart Institute, Kansas City (D.J.C., E.M.); St. Joseph's Vascular Institute, Orange (M.K.R.), and University of California, Los Angeles, Los Angeles (S.K.) - both in California; University of Michigan, Ann Arbor (A.J.C.); Cleveland Clinic Heart and Vascular Institute, Cleveland (H.L.G.); Rhode Island Hospital, Brown University, Providence (T.P.M.); Central DuPage Hospital, Winfield, IL (J.S.); University of North Carolina, Chapel Hill (S.M.); Reading Hospital, Reading, PA (D.S.); Henry Ford Hospital, Detroit (J.L.); Holy Name Hospital, Teaneck, NJ (J.R.); Christiana Care Hospital, Newark, DE (M.G.); St. Elizabeth's Regional Medical Center, Lincoln, NE (R.R., E.V.); and Pepin Heart Center, Tampa, FL (V.M.)
| | - Anthony J Comerota
- From the Washington University School of Medicine, St. Louis (S.V., L.L., J.R.D., P.N., M.C.D., N.S., M.B.); Brigham and Women's Hospital, Harvard Medical School (S.Z.G.), and Massachusetts General Hospital, Harvard Medical School (M.R.J.) - all in Boston; McMaster University, Hamilton, ON (J.A.J., M.F., C.-S.G., C.K.), and McGill University, Jewish General Hospital, Montreal (S.R.K.) - all in Canada; the University of Missouri, St. Luke's Mid America Heart Institute, Kansas City (D.J.C., E.M.); St. Joseph's Vascular Institute, Orange (M.K.R.), and University of California, Los Angeles, Los Angeles (S.K.) - both in California; University of Michigan, Ann Arbor (A.J.C.); Cleveland Clinic Heart and Vascular Institute, Cleveland (H.L.G.); Rhode Island Hospital, Brown University, Providence (T.P.M.); Central DuPage Hospital, Winfield, IL (J.S.); University of North Carolina, Chapel Hill (S.M.); Reading Hospital, Reading, PA (D.S.); Henry Ford Hospital, Detroit (J.L.); Holy Name Hospital, Teaneck, NJ (J.R.); Christiana Care Hospital, Newark, DE (M.G.); St. Elizabeth's Regional Medical Center, Lincoln, NE (R.R., E.V.); and Pepin Heart Center, Tampa, FL (V.M.)
| | - Heather L Gornik
- From the Washington University School of Medicine, St. Louis (S.V., L.L., J.R.D., P.N., M.C.D., N.S., M.B.); Brigham and Women's Hospital, Harvard Medical School (S.Z.G.), and Massachusetts General Hospital, Harvard Medical School (M.R.J.) - all in Boston; McMaster University, Hamilton, ON (J.A.J., M.F., C.-S.G., C.K.), and McGill University, Jewish General Hospital, Montreal (S.R.K.) - all in Canada; the University of Missouri, St. Luke's Mid America Heart Institute, Kansas City (D.J.C., E.M.); St. Joseph's Vascular Institute, Orange (M.K.R.), and University of California, Los Angeles, Los Angeles (S.K.) - both in California; University of Michigan, Ann Arbor (A.J.C.); Cleveland Clinic Heart and Vascular Institute, Cleveland (H.L.G.); Rhode Island Hospital, Brown University, Providence (T.P.M.); Central DuPage Hospital, Winfield, IL (J.S.); University of North Carolina, Chapel Hill (S.M.); Reading Hospital, Reading, PA (D.S.); Henry Ford Hospital, Detroit (J.L.); Holy Name Hospital, Teaneck, NJ (J.R.); Christiana Care Hospital, Newark, DE (M.G.); St. Elizabeth's Regional Medical Center, Lincoln, NE (R.R., E.V.); and Pepin Heart Center, Tampa, FL (V.M.)
| | - Timothy P Murphy
- From the Washington University School of Medicine, St. Louis (S.V., L.L., J.R.D., P.N., M.C.D., N.S., M.B.); Brigham and Women's Hospital, Harvard Medical School (S.Z.G.), and Massachusetts General Hospital, Harvard Medical School (M.R.J.) - all in Boston; McMaster University, Hamilton, ON (J.A.J., M.F., C.-S.G., C.K.), and McGill University, Jewish General Hospital, Montreal (S.R.K.) - all in Canada; the University of Missouri, St. Luke's Mid America Heart Institute, Kansas City (D.J.C., E.M.); St. Joseph's Vascular Institute, Orange (M.K.R.), and University of California, Los Angeles, Los Angeles (S.K.) - both in California; University of Michigan, Ann Arbor (A.J.C.); Cleveland Clinic Heart and Vascular Institute, Cleveland (H.L.G.); Rhode Island Hospital, Brown University, Providence (T.P.M.); Central DuPage Hospital, Winfield, IL (J.S.); University of North Carolina, Chapel Hill (S.M.); Reading Hospital, Reading, PA (D.S.); Henry Ford Hospital, Detroit (J.L.); Holy Name Hospital, Teaneck, NJ (J.R.); Christiana Care Hospital, Newark, DE (M.G.); St. Elizabeth's Regional Medical Center, Lincoln, NE (R.R., E.V.); and Pepin Heart Center, Tampa, FL (V.M.)
| | - Lawrence Lewis
- From the Washington University School of Medicine, St. Louis (S.V., L.L., J.R.D., P.N., M.C.D., N.S., M.B.); Brigham and Women's Hospital, Harvard Medical School (S.Z.G.), and Massachusetts General Hospital, Harvard Medical School (M.R.J.) - all in Boston; McMaster University, Hamilton, ON (J.A.J., M.F., C.-S.G., C.K.), and McGill University, Jewish General Hospital, Montreal (S.R.K.) - all in Canada; the University of Missouri, St. Luke's Mid America Heart Institute, Kansas City (D.J.C., E.M.); St. Joseph's Vascular Institute, Orange (M.K.R.), and University of California, Los Angeles, Los Angeles (S.K.) - both in California; University of Michigan, Ann Arbor (A.J.C.); Cleveland Clinic Heart and Vascular Institute, Cleveland (H.L.G.); Rhode Island Hospital, Brown University, Providence (T.P.M.); Central DuPage Hospital, Winfield, IL (J.S.); University of North Carolina, Chapel Hill (S.M.); Reading Hospital, Reading, PA (D.S.); Henry Ford Hospital, Detroit (J.L.); Holy Name Hospital, Teaneck, NJ (J.R.); Christiana Care Hospital, Newark, DE (M.G.); St. Elizabeth's Regional Medical Center, Lincoln, NE (R.R., E.V.); and Pepin Heart Center, Tampa, FL (V.M.)
| | - James R Duncan
- From the Washington University School of Medicine, St. Louis (S.V., L.L., J.R.D., P.N., M.C.D., N.S., M.B.); Brigham and Women's Hospital, Harvard Medical School (S.Z.G.), and Massachusetts General Hospital, Harvard Medical School (M.R.J.) - all in Boston; McMaster University, Hamilton, ON (J.A.J., M.F., C.-S.G., C.K.), and McGill University, Jewish General Hospital, Montreal (S.R.K.) - all in Canada; the University of Missouri, St. Luke's Mid America Heart Institute, Kansas City (D.J.C., E.M.); St. Joseph's Vascular Institute, Orange (M.K.R.), and University of California, Los Angeles, Los Angeles (S.K.) - both in California; University of Michigan, Ann Arbor (A.J.C.); Cleveland Clinic Heart and Vascular Institute, Cleveland (H.L.G.); Rhode Island Hospital, Brown University, Providence (T.P.M.); Central DuPage Hospital, Winfield, IL (J.S.); University of North Carolina, Chapel Hill (S.M.); Reading Hospital, Reading, PA (D.S.); Henry Ford Hospital, Detroit (J.L.); Holy Name Hospital, Teaneck, NJ (J.R.); Christiana Care Hospital, Newark, DE (M.G.); St. Elizabeth's Regional Medical Center, Lincoln, NE (R.R., E.V.); and Pepin Heart Center, Tampa, FL (V.M.)
| | - Patricia Nieters
- From the Washington University School of Medicine, St. Louis (S.V., L.L., J.R.D., P.N., M.C.D., N.S., M.B.); Brigham and Women's Hospital, Harvard Medical School (S.Z.G.), and Massachusetts General Hospital, Harvard Medical School (M.R.J.) - all in Boston; McMaster University, Hamilton, ON (J.A.J., M.F., C.-S.G., C.K.), and McGill University, Jewish General Hospital, Montreal (S.R.K.) - all in Canada; the University of Missouri, St. Luke's Mid America Heart Institute, Kansas City (D.J.C., E.M.); St. Joseph's Vascular Institute, Orange (M.K.R.), and University of California, Los Angeles, Los Angeles (S.K.) - both in California; University of Michigan, Ann Arbor (A.J.C.); Cleveland Clinic Heart and Vascular Institute, Cleveland (H.L.G.); Rhode Island Hospital, Brown University, Providence (T.P.M.); Central DuPage Hospital, Winfield, IL (J.S.); University of North Carolina, Chapel Hill (S.M.); Reading Hospital, Reading, PA (D.S.); Henry Ford Hospital, Detroit (J.L.); Holy Name Hospital, Teaneck, NJ (J.R.); Christiana Care Hospital, Newark, DE (M.G.); St. Elizabeth's Regional Medical Center, Lincoln, NE (R.R., E.V.); and Pepin Heart Center, Tampa, FL (V.M.)
| | - Mary C Derfler
- From the Washington University School of Medicine, St. Louis (S.V., L.L., J.R.D., P.N., M.C.D., N.S., M.B.); Brigham and Women's Hospital, Harvard Medical School (S.Z.G.), and Massachusetts General Hospital, Harvard Medical School (M.R.J.) - all in Boston; McMaster University, Hamilton, ON (J.A.J., M.F., C.-S.G., C.K.), and McGill University, Jewish General Hospital, Montreal (S.R.K.) - all in Canada; the University of Missouri, St. Luke's Mid America Heart Institute, Kansas City (D.J.C., E.M.); St. Joseph's Vascular Institute, Orange (M.K.R.), and University of California, Los Angeles, Los Angeles (S.K.) - both in California; University of Michigan, Ann Arbor (A.J.C.); Cleveland Clinic Heart and Vascular Institute, Cleveland (H.L.G.); Rhode Island Hospital, Brown University, Providence (T.P.M.); Central DuPage Hospital, Winfield, IL (J.S.); University of North Carolina, Chapel Hill (S.M.); Reading Hospital, Reading, PA (D.S.); Henry Ford Hospital, Detroit (J.L.); Holy Name Hospital, Teaneck, NJ (J.R.); Christiana Care Hospital, Newark, DE (M.G.); St. Elizabeth's Regional Medical Center, Lincoln, NE (R.R., E.V.); and Pepin Heart Center, Tampa, FL (V.M.)
| | - Marc Filion
- From the Washington University School of Medicine, St. Louis (S.V., L.L., J.R.D., P.N., M.C.D., N.S., M.B.); Brigham and Women's Hospital, Harvard Medical School (S.Z.G.), and Massachusetts General Hospital, Harvard Medical School (M.R.J.) - all in Boston; McMaster University, Hamilton, ON (J.A.J., M.F., C.-S.G., C.K.), and McGill University, Jewish General Hospital, Montreal (S.R.K.) - all in Canada; the University of Missouri, St. Luke's Mid America Heart Institute, Kansas City (D.J.C., E.M.); St. Joseph's Vascular Institute, Orange (M.K.R.), and University of California, Los Angeles, Los Angeles (S.K.) - both in California; University of Michigan, Ann Arbor (A.J.C.); Cleveland Clinic Heart and Vascular Institute, Cleveland (H.L.G.); Rhode Island Hospital, Brown University, Providence (T.P.M.); Central DuPage Hospital, Winfield, IL (J.S.); University of North Carolina, Chapel Hill (S.M.); Reading Hospital, Reading, PA (D.S.); Henry Ford Hospital, Detroit (J.L.); Holy Name Hospital, Teaneck, NJ (J.R.); Christiana Care Hospital, Newark, DE (M.G.); St. Elizabeth's Regional Medical Center, Lincoln, NE (R.R., E.V.); and Pepin Heart Center, Tampa, FL (V.M.)
| | - Chu-Shu Gu
- From the Washington University School of Medicine, St. Louis (S.V., L.L., J.R.D., P.N., M.C.D., N.S., M.B.); Brigham and Women's Hospital, Harvard Medical School (S.Z.G.), and Massachusetts General Hospital, Harvard Medical School (M.R.J.) - all in Boston; McMaster University, Hamilton, ON (J.A.J., M.F., C.-S.G., C.K.), and McGill University, Jewish General Hospital, Montreal (S.R.K.) - all in Canada; the University of Missouri, St. Luke's Mid America Heart Institute, Kansas City (D.J.C., E.M.); St. Joseph's Vascular Institute, Orange (M.K.R.), and University of California, Los Angeles, Los Angeles (S.K.) - both in California; University of Michigan, Ann Arbor (A.J.C.); Cleveland Clinic Heart and Vascular Institute, Cleveland (H.L.G.); Rhode Island Hospital, Brown University, Providence (T.P.M.); Central DuPage Hospital, Winfield, IL (J.S.); University of North Carolina, Chapel Hill (S.M.); Reading Hospital, Reading, PA (D.S.); Henry Ford Hospital, Detroit (J.L.); Holy Name Hospital, Teaneck, NJ (J.R.); Christiana Care Hospital, Newark, DE (M.G.); St. Elizabeth's Regional Medical Center, Lincoln, NE (R.R., E.V.); and Pepin Heart Center, Tampa, FL (V.M.)
| | - Stephen Kee
- From the Washington University School of Medicine, St. Louis (S.V., L.L., J.R.D., P.N., M.C.D., N.S., M.B.); Brigham and Women's Hospital, Harvard Medical School (S.Z.G.), and Massachusetts General Hospital, Harvard Medical School (M.R.J.) - all in Boston; McMaster University, Hamilton, ON (J.A.J., M.F., C.-S.G., C.K.), and McGill University, Jewish General Hospital, Montreal (S.R.K.) - all in Canada; the University of Missouri, St. Luke's Mid America Heart Institute, Kansas City (D.J.C., E.M.); St. Joseph's Vascular Institute, Orange (M.K.R.), and University of California, Los Angeles, Los Angeles (S.K.) - both in California; University of Michigan, Ann Arbor (A.J.C.); Cleveland Clinic Heart and Vascular Institute, Cleveland (H.L.G.); Rhode Island Hospital, Brown University, Providence (T.P.M.); Central DuPage Hospital, Winfield, IL (J.S.); University of North Carolina, Chapel Hill (S.M.); Reading Hospital, Reading, PA (D.S.); Henry Ford Hospital, Detroit (J.L.); Holy Name Hospital, Teaneck, NJ (J.R.); Christiana Care Hospital, Newark, DE (M.G.); St. Elizabeth's Regional Medical Center, Lincoln, NE (R.R., E.V.); and Pepin Heart Center, Tampa, FL (V.M.)
| | - Joseph Schneider
- From the Washington University School of Medicine, St. Louis (S.V., L.L., J.R.D., P.N., M.C.D., N.S., M.B.); Brigham and Women's Hospital, Harvard Medical School (S.Z.G.), and Massachusetts General Hospital, Harvard Medical School (M.R.J.) - all in Boston; McMaster University, Hamilton, ON (J.A.J., M.F., C.-S.G., C.K.), and McGill University, Jewish General Hospital, Montreal (S.R.K.) - all in Canada; the University of Missouri, St. Luke's Mid America Heart Institute, Kansas City (D.J.C., E.M.); St. Joseph's Vascular Institute, Orange (M.K.R.), and University of California, Los Angeles, Los Angeles (S.K.) - both in California; University of Michigan, Ann Arbor (A.J.C.); Cleveland Clinic Heart and Vascular Institute, Cleveland (H.L.G.); Rhode Island Hospital, Brown University, Providence (T.P.M.); Central DuPage Hospital, Winfield, IL (J.S.); University of North Carolina, Chapel Hill (S.M.); Reading Hospital, Reading, PA (D.S.); Henry Ford Hospital, Detroit (J.L.); Holy Name Hospital, Teaneck, NJ (J.R.); Christiana Care Hospital, Newark, DE (M.G.); St. Elizabeth's Regional Medical Center, Lincoln, NE (R.R., E.V.); and Pepin Heart Center, Tampa, FL (V.M.)
| | - Nael Saad
- From the Washington University School of Medicine, St. Louis (S.V., L.L., J.R.D., P.N., M.C.D., N.S., M.B.); Brigham and Women's Hospital, Harvard Medical School (S.Z.G.), and Massachusetts General Hospital, Harvard Medical School (M.R.J.) - all in Boston; McMaster University, Hamilton, ON (J.A.J., M.F., C.-S.G., C.K.), and McGill University, Jewish General Hospital, Montreal (S.R.K.) - all in Canada; the University of Missouri, St. Luke's Mid America Heart Institute, Kansas City (D.J.C., E.M.); St. Joseph's Vascular Institute, Orange (M.K.R.), and University of California, Los Angeles, Los Angeles (S.K.) - both in California; University of Michigan, Ann Arbor (A.J.C.); Cleveland Clinic Heart and Vascular Institute, Cleveland (H.L.G.); Rhode Island Hospital, Brown University, Providence (T.P.M.); Central DuPage Hospital, Winfield, IL (J.S.); University of North Carolina, Chapel Hill (S.M.); Reading Hospital, Reading, PA (D.S.); Henry Ford Hospital, Detroit (J.L.); Holy Name Hospital, Teaneck, NJ (J.R.); Christiana Care Hospital, Newark, DE (M.G.); St. Elizabeth's Regional Medical Center, Lincoln, NE (R.R., E.V.); and Pepin Heart Center, Tampa, FL (V.M.)
| | - Morey Blinder
- From the Washington University School of Medicine, St. Louis (S.V., L.L., J.R.D., P.N., M.C.D., N.S., M.B.); Brigham and Women's Hospital, Harvard Medical School (S.Z.G.), and Massachusetts General Hospital, Harvard Medical School (M.R.J.) - all in Boston; McMaster University, Hamilton, ON (J.A.J., M.F., C.-S.G., C.K.), and McGill University, Jewish General Hospital, Montreal (S.R.K.) - all in Canada; the University of Missouri, St. Luke's Mid America Heart Institute, Kansas City (D.J.C., E.M.); St. Joseph's Vascular Institute, Orange (M.K.R.), and University of California, Los Angeles, Los Angeles (S.K.) - both in California; University of Michigan, Ann Arbor (A.J.C.); Cleveland Clinic Heart and Vascular Institute, Cleveland (H.L.G.); Rhode Island Hospital, Brown University, Providence (T.P.M.); Central DuPage Hospital, Winfield, IL (J.S.); University of North Carolina, Chapel Hill (S.M.); Reading Hospital, Reading, PA (D.S.); Henry Ford Hospital, Detroit (J.L.); Holy Name Hospital, Teaneck, NJ (J.R.); Christiana Care Hospital, Newark, DE (M.G.); St. Elizabeth's Regional Medical Center, Lincoln, NE (R.R., E.V.); and Pepin Heart Center, Tampa, FL (V.M.)
| | - Stephan Moll
- From the Washington University School of Medicine, St. Louis (S.V., L.L., J.R.D., P.N., M.C.D., N.S., M.B.); Brigham and Women's Hospital, Harvard Medical School (S.Z.G.), and Massachusetts General Hospital, Harvard Medical School (M.R.J.) - all in Boston; McMaster University, Hamilton, ON (J.A.J., M.F., C.-S.G., C.K.), and McGill University, Jewish General Hospital, Montreal (S.R.K.) - all in Canada; the University of Missouri, St. Luke's Mid America Heart Institute, Kansas City (D.J.C., E.M.); St. Joseph's Vascular Institute, Orange (M.K.R.), and University of California, Los Angeles, Los Angeles (S.K.) - both in California; University of Michigan, Ann Arbor (A.J.C.); Cleveland Clinic Heart and Vascular Institute, Cleveland (H.L.G.); Rhode Island Hospital, Brown University, Providence (T.P.M.); Central DuPage Hospital, Winfield, IL (J.S.); University of North Carolina, Chapel Hill (S.M.); Reading Hospital, Reading, PA (D.S.); Henry Ford Hospital, Detroit (J.L.); Holy Name Hospital, Teaneck, NJ (J.R.); Christiana Care Hospital, Newark, DE (M.G.); St. Elizabeth's Regional Medical Center, Lincoln, NE (R.R., E.V.); and Pepin Heart Center, Tampa, FL (V.M.)
| | - David Sacks
- From the Washington University School of Medicine, St. Louis (S.V., L.L., J.R.D., P.N., M.C.D., N.S., M.B.); Brigham and Women's Hospital, Harvard Medical School (S.Z.G.), and Massachusetts General Hospital, Harvard Medical School (M.R.J.) - all in Boston; McMaster University, Hamilton, ON (J.A.J., M.F., C.-S.G., C.K.), and McGill University, Jewish General Hospital, Montreal (S.R.K.) - all in Canada; the University of Missouri, St. Luke's Mid America Heart Institute, Kansas City (D.J.C., E.M.); St. Joseph's Vascular Institute, Orange (M.K.R.), and University of California, Los Angeles, Los Angeles (S.K.) - both in California; University of Michigan, Ann Arbor (A.J.C.); Cleveland Clinic Heart and Vascular Institute, Cleveland (H.L.G.); Rhode Island Hospital, Brown University, Providence (T.P.M.); Central DuPage Hospital, Winfield, IL (J.S.); University of North Carolina, Chapel Hill (S.M.); Reading Hospital, Reading, PA (D.S.); Henry Ford Hospital, Detroit (J.L.); Holy Name Hospital, Teaneck, NJ (J.R.); Christiana Care Hospital, Newark, DE (M.G.); St. Elizabeth's Regional Medical Center, Lincoln, NE (R.R., E.V.); and Pepin Heart Center, Tampa, FL (V.M.)
| | - Judith Lin
- From the Washington University School of Medicine, St. Louis (S.V., L.L., J.R.D., P.N., M.C.D., N.S., M.B.); Brigham and Women's Hospital, Harvard Medical School (S.Z.G.), and Massachusetts General Hospital, Harvard Medical School (M.R.J.) - all in Boston; McMaster University, Hamilton, ON (J.A.J., M.F., C.-S.G., C.K.), and McGill University, Jewish General Hospital, Montreal (S.R.K.) - all in Canada; the University of Missouri, St. Luke's Mid America Heart Institute, Kansas City (D.J.C., E.M.); St. Joseph's Vascular Institute, Orange (M.K.R.), and University of California, Los Angeles, Los Angeles (S.K.) - both in California; University of Michigan, Ann Arbor (A.J.C.); Cleveland Clinic Heart and Vascular Institute, Cleveland (H.L.G.); Rhode Island Hospital, Brown University, Providence (T.P.M.); Central DuPage Hospital, Winfield, IL (J.S.); University of North Carolina, Chapel Hill (S.M.); Reading Hospital, Reading, PA (D.S.); Henry Ford Hospital, Detroit (J.L.); Holy Name Hospital, Teaneck, NJ (J.R.); Christiana Care Hospital, Newark, DE (M.G.); St. Elizabeth's Regional Medical Center, Lincoln, NE (R.R., E.V.); and Pepin Heart Center, Tampa, FL (V.M.)
| | - John Rundback
- From the Washington University School of Medicine, St. Louis (S.V., L.L., J.R.D., P.N., M.C.D., N.S., M.B.); Brigham and Women's Hospital, Harvard Medical School (S.Z.G.), and Massachusetts General Hospital, Harvard Medical School (M.R.J.) - all in Boston; McMaster University, Hamilton, ON (J.A.J., M.F., C.-S.G., C.K.), and McGill University, Jewish General Hospital, Montreal (S.R.K.) - all in Canada; the University of Missouri, St. Luke's Mid America Heart Institute, Kansas City (D.J.C., E.M.); St. Joseph's Vascular Institute, Orange (M.K.R.), and University of California, Los Angeles, Los Angeles (S.K.) - both in California; University of Michigan, Ann Arbor (A.J.C.); Cleveland Clinic Heart and Vascular Institute, Cleveland (H.L.G.); Rhode Island Hospital, Brown University, Providence (T.P.M.); Central DuPage Hospital, Winfield, IL (J.S.); University of North Carolina, Chapel Hill (S.M.); Reading Hospital, Reading, PA (D.S.); Henry Ford Hospital, Detroit (J.L.); Holy Name Hospital, Teaneck, NJ (J.R.); Christiana Care Hospital, Newark, DE (M.G.); St. Elizabeth's Regional Medical Center, Lincoln, NE (R.R., E.V.); and Pepin Heart Center, Tampa, FL (V.M.)
| | - Mark Garcia
- From the Washington University School of Medicine, St. Louis (S.V., L.L., J.R.D., P.N., M.C.D., N.S., M.B.); Brigham and Women's Hospital, Harvard Medical School (S.Z.G.), and Massachusetts General Hospital, Harvard Medical School (M.R.J.) - all in Boston; McMaster University, Hamilton, ON (J.A.J., M.F., C.-S.G., C.K.), and McGill University, Jewish General Hospital, Montreal (S.R.K.) - all in Canada; the University of Missouri, St. Luke's Mid America Heart Institute, Kansas City (D.J.C., E.M.); St. Joseph's Vascular Institute, Orange (M.K.R.), and University of California, Los Angeles, Los Angeles (S.K.) - both in California; University of Michigan, Ann Arbor (A.J.C.); Cleveland Clinic Heart and Vascular Institute, Cleveland (H.L.G.); Rhode Island Hospital, Brown University, Providence (T.P.M.); Central DuPage Hospital, Winfield, IL (J.S.); University of North Carolina, Chapel Hill (S.M.); Reading Hospital, Reading, PA (D.S.); Henry Ford Hospital, Detroit (J.L.); Holy Name Hospital, Teaneck, NJ (J.R.); Christiana Care Hospital, Newark, DE (M.G.); St. Elizabeth's Regional Medical Center, Lincoln, NE (R.R., E.V.); and Pepin Heart Center, Tampa, FL (V.M.)
| | - Rahul Razdan
- From the Washington University School of Medicine, St. Louis (S.V., L.L., J.R.D., P.N., M.C.D., N.S., M.B.); Brigham and Women's Hospital, Harvard Medical School (S.Z.G.), and Massachusetts General Hospital, Harvard Medical School (M.R.J.) - all in Boston; McMaster University, Hamilton, ON (J.A.J., M.F., C.-S.G., C.K.), and McGill University, Jewish General Hospital, Montreal (S.R.K.) - all in Canada; the University of Missouri, St. Luke's Mid America Heart Institute, Kansas City (D.J.C., E.M.); St. Joseph's Vascular Institute, Orange (M.K.R.), and University of California, Los Angeles, Los Angeles (S.K.) - both in California; University of Michigan, Ann Arbor (A.J.C.); Cleveland Clinic Heart and Vascular Institute, Cleveland (H.L.G.); Rhode Island Hospital, Brown University, Providence (T.P.M.); Central DuPage Hospital, Winfield, IL (J.S.); University of North Carolina, Chapel Hill (S.M.); Reading Hospital, Reading, PA (D.S.); Henry Ford Hospital, Detroit (J.L.); Holy Name Hospital, Teaneck, NJ (J.R.); Christiana Care Hospital, Newark, DE (M.G.); St. Elizabeth's Regional Medical Center, Lincoln, NE (R.R., E.V.); and Pepin Heart Center, Tampa, FL (V.M.)
| | - Eric VanderWoude
- From the Washington University School of Medicine, St. Louis (S.V., L.L., J.R.D., P.N., M.C.D., N.S., M.B.); Brigham and Women's Hospital, Harvard Medical School (S.Z.G.), and Massachusetts General Hospital, Harvard Medical School (M.R.J.) - all in Boston; McMaster University, Hamilton, ON (J.A.J., M.F., C.-S.G., C.K.), and McGill University, Jewish General Hospital, Montreal (S.R.K.) - all in Canada; the University of Missouri, St. Luke's Mid America Heart Institute, Kansas City (D.J.C., E.M.); St. Joseph's Vascular Institute, Orange (M.K.R.), and University of California, Los Angeles, Los Angeles (S.K.) - both in California; University of Michigan, Ann Arbor (A.J.C.); Cleveland Clinic Heart and Vascular Institute, Cleveland (H.L.G.); Rhode Island Hospital, Brown University, Providence (T.P.M.); Central DuPage Hospital, Winfield, IL (J.S.); University of North Carolina, Chapel Hill (S.M.); Reading Hospital, Reading, PA (D.S.); Henry Ford Hospital, Detroit (J.L.); Holy Name Hospital, Teaneck, NJ (J.R.); Christiana Care Hospital, Newark, DE (M.G.); St. Elizabeth's Regional Medical Center, Lincoln, NE (R.R., E.V.); and Pepin Heart Center, Tampa, FL (V.M.)
| | - Vasco Marques
- From the Washington University School of Medicine, St. Louis (S.V., L.L., J.R.D., P.N., M.C.D., N.S., M.B.); Brigham and Women's Hospital, Harvard Medical School (S.Z.G.), and Massachusetts General Hospital, Harvard Medical School (M.R.J.) - all in Boston; McMaster University, Hamilton, ON (J.A.J., M.F., C.-S.G., C.K.), and McGill University, Jewish General Hospital, Montreal (S.R.K.) - all in Canada; the University of Missouri, St. Luke's Mid America Heart Institute, Kansas City (D.J.C., E.M.); St. Joseph's Vascular Institute, Orange (M.K.R.), and University of California, Los Angeles, Los Angeles (S.K.) - both in California; University of Michigan, Ann Arbor (A.J.C.); Cleveland Clinic Heart and Vascular Institute, Cleveland (H.L.G.); Rhode Island Hospital, Brown University, Providence (T.P.M.); Central DuPage Hospital, Winfield, IL (J.S.); University of North Carolina, Chapel Hill (S.M.); Reading Hospital, Reading, PA (D.S.); Henry Ford Hospital, Detroit (J.L.); Holy Name Hospital, Teaneck, NJ (J.R.); Christiana Care Hospital, Newark, DE (M.G.); St. Elizabeth's Regional Medical Center, Lincoln, NE (R.R., E.V.); and Pepin Heart Center, Tampa, FL (V.M.)
| | - Clive Kearon
- From the Washington University School of Medicine, St. Louis (S.V., L.L., J.R.D., P.N., M.C.D., N.S., M.B.); Brigham and Women's Hospital, Harvard Medical School (S.Z.G.), and Massachusetts General Hospital, Harvard Medical School (M.R.J.) - all in Boston; McMaster University, Hamilton, ON (J.A.J., M.F., C.-S.G., C.K.), and McGill University, Jewish General Hospital, Montreal (S.R.K.) - all in Canada; the University of Missouri, St. Luke's Mid America Heart Institute, Kansas City (D.J.C., E.M.); St. Joseph's Vascular Institute, Orange (M.K.R.), and University of California, Los Angeles, Los Angeles (S.K.) - both in California; University of Michigan, Ann Arbor (A.J.C.); Cleveland Clinic Heart and Vascular Institute, Cleveland (H.L.G.); Rhode Island Hospital, Brown University, Providence (T.P.M.); Central DuPage Hospital, Winfield, IL (J.S.); University of North Carolina, Chapel Hill (S.M.); Reading Hospital, Reading, PA (D.S.); Henry Ford Hospital, Detroit (J.L.); Holy Name Hospital, Teaneck, NJ (J.R.); Christiana Care Hospital, Newark, DE (M.G.); St. Elizabeth's Regional Medical Center, Lincoln, NE (R.R., E.V.); and Pepin Heart Center, Tampa, FL (V.M.)
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Catton CN, Lukka H, Gu CS, Martin JM, Supiot S, Chung PWM, Bauman GS, Bahary JP, Ahmed S, Cheung P, Tai KH, Wu JS, Parliament MB, Tsakiridis T, Corbett TB, Tang C, Dayes IS, Warde P, Craig TK, Julian JA, Levine MN. Randomized Trial of a Hypofractionated Radiation Regimen for the Treatment of Localized Prostate Cancer. J Clin Oncol 2017; 35:1884-1890. [PMID: 28296582 DOI: 10.1200/jco.2016.71.7397] [Citation(s) in RCA: 455] [Impact Index Per Article: 65.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Purpose Men with localized prostate cancer often are treated with external radiotherapy (RT) over 8 to 9 weeks. Hypofractionated RT is given over a shorter time with larger doses per treatment than standard RT. We hypothesized that hypofractionation versus conventional fractionation is similar in efficacy without increased toxicity. Patients and Methods We conducted a multicenter randomized noninferiority trial in intermediate-risk prostate cancer (T1 to 2a, Gleason score ≤ 6, and prostate-specific antigen [PSA] 10.1 to 20 ng/mL; T2b to 2c, Gleason ≤ 6, and PSA ≤ 20 ng/mL; or T1 to 2, Gleason = 7, and PSA ≤ 20 ng/mL). Patients were allocated to conventional RT of 78 Gy in 39 fractions over 8 weeks or to hypofractionated RT of 60 Gy in 20 fractions over 4 weeks. Androgen deprivation was not permitted with therapy. The primary outcome was biochemical-clinical failure (BCF) defined by any of the following: PSA failure (nadir + 2), hormonal intervention, clinical local or distant failure, or death as a result of prostate cancer. The noninferiority margin was 7.5% (hazard ratio, < 1.32). Results Median follow-up was 6.0 years. One hundred nine of 608 patients in the hypofractionated arm versus 117 of 598 in the standard arm experienced BCF. Most of the events were PSA failures. The 5-year BCF disease-free survival was 85% in both arms (hazard ratio [short v standard], 0.96; 90% CI, 0.77 to 1.2). Ten deaths as a result of prostate cancer occurred in the short arm and 12 in the standard arm. No significant differences were detected between arms for grade ≥ 3 late genitourinary and GI toxicity. Conclusion The hypofractionated RT regimen used in this trial was not inferior to conventional RT and was not associated with increased late toxicity. Hypofractionated RT is more convenient for patients and should be considered for intermediate-risk prostate cancer.
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Affiliation(s)
- Charles N Catton
- Charles N. Catton, Peter W.M. Chung, Patrick Cheung, Padraig Warde, and Tim K. Craig, University of Toronto, Toronto; Himu Lukka, Chu-Shu Gu, Theodoros Tsakiridis, Tom B. Corbett, Ian S. Dayes, Jim A. Julian, and Mark N. Levine, McMaster University, Hamilton; Glenn S. Bauman, University of Western Ontario, London, Ontario; Jean-Paul Bahary, University of Montreal, Montreal, Quebec; Shahida Ahmed, University of Manitoba, Winnipeg, Manitoba; Jackson S. Wu, University of Calgary, Calgary; Matthew B. Parliament, University of Alberta, Edmonton, Alberta, Canada; Jarad M. Martin, University of Newcastle, Newcastle, New South Wales; Keen Hun Tai, University of Melbourne, Melbourne, Victoria; Colin Tang, Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia; and Stéphane Supiot, University of Nantes, Nantes, France
| | - Himu Lukka
- Charles N. Catton, Peter W.M. Chung, Patrick Cheung, Padraig Warde, and Tim K. Craig, University of Toronto, Toronto; Himu Lukka, Chu-Shu Gu, Theodoros Tsakiridis, Tom B. Corbett, Ian S. Dayes, Jim A. Julian, and Mark N. Levine, McMaster University, Hamilton; Glenn S. Bauman, University of Western Ontario, London, Ontario; Jean-Paul Bahary, University of Montreal, Montreal, Quebec; Shahida Ahmed, University of Manitoba, Winnipeg, Manitoba; Jackson S. Wu, University of Calgary, Calgary; Matthew B. Parliament, University of Alberta, Edmonton, Alberta, Canada; Jarad M. Martin, University of Newcastle, Newcastle, New South Wales; Keen Hun Tai, University of Melbourne, Melbourne, Victoria; Colin Tang, Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia; and Stéphane Supiot, University of Nantes, Nantes, France
| | - Chu-Shu Gu
- Charles N. Catton, Peter W.M. Chung, Patrick Cheung, Padraig Warde, and Tim K. Craig, University of Toronto, Toronto; Himu Lukka, Chu-Shu Gu, Theodoros Tsakiridis, Tom B. Corbett, Ian S. Dayes, Jim A. Julian, and Mark N. Levine, McMaster University, Hamilton; Glenn S. Bauman, University of Western Ontario, London, Ontario; Jean-Paul Bahary, University of Montreal, Montreal, Quebec; Shahida Ahmed, University of Manitoba, Winnipeg, Manitoba; Jackson S. Wu, University of Calgary, Calgary; Matthew B. Parliament, University of Alberta, Edmonton, Alberta, Canada; Jarad M. Martin, University of Newcastle, Newcastle, New South Wales; Keen Hun Tai, University of Melbourne, Melbourne, Victoria; Colin Tang, Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia; and Stéphane Supiot, University of Nantes, Nantes, France
| | - Jarad M Martin
- Charles N. Catton, Peter W.M. Chung, Patrick Cheung, Padraig Warde, and Tim K. Craig, University of Toronto, Toronto; Himu Lukka, Chu-Shu Gu, Theodoros Tsakiridis, Tom B. Corbett, Ian S. Dayes, Jim A. Julian, and Mark N. Levine, McMaster University, Hamilton; Glenn S. Bauman, University of Western Ontario, London, Ontario; Jean-Paul Bahary, University of Montreal, Montreal, Quebec; Shahida Ahmed, University of Manitoba, Winnipeg, Manitoba; Jackson S. Wu, University of Calgary, Calgary; Matthew B. Parliament, University of Alberta, Edmonton, Alberta, Canada; Jarad M. Martin, University of Newcastle, Newcastle, New South Wales; Keen Hun Tai, University of Melbourne, Melbourne, Victoria; Colin Tang, Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia; and Stéphane Supiot, University of Nantes, Nantes, France
| | - Stéphane Supiot
- Charles N. Catton, Peter W.M. Chung, Patrick Cheung, Padraig Warde, and Tim K. Craig, University of Toronto, Toronto; Himu Lukka, Chu-Shu Gu, Theodoros Tsakiridis, Tom B. Corbett, Ian S. Dayes, Jim A. Julian, and Mark N. Levine, McMaster University, Hamilton; Glenn S. Bauman, University of Western Ontario, London, Ontario; Jean-Paul Bahary, University of Montreal, Montreal, Quebec; Shahida Ahmed, University of Manitoba, Winnipeg, Manitoba; Jackson S. Wu, University of Calgary, Calgary; Matthew B. Parliament, University of Alberta, Edmonton, Alberta, Canada; Jarad M. Martin, University of Newcastle, Newcastle, New South Wales; Keen Hun Tai, University of Melbourne, Melbourne, Victoria; Colin Tang, Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia; and Stéphane Supiot, University of Nantes, Nantes, France
| | - Peter W M Chung
- Charles N. Catton, Peter W.M. Chung, Patrick Cheung, Padraig Warde, and Tim K. Craig, University of Toronto, Toronto; Himu Lukka, Chu-Shu Gu, Theodoros Tsakiridis, Tom B. Corbett, Ian S. Dayes, Jim A. Julian, and Mark N. Levine, McMaster University, Hamilton; Glenn S. Bauman, University of Western Ontario, London, Ontario; Jean-Paul Bahary, University of Montreal, Montreal, Quebec; Shahida Ahmed, University of Manitoba, Winnipeg, Manitoba; Jackson S. Wu, University of Calgary, Calgary; Matthew B. Parliament, University of Alberta, Edmonton, Alberta, Canada; Jarad M. Martin, University of Newcastle, Newcastle, New South Wales; Keen Hun Tai, University of Melbourne, Melbourne, Victoria; Colin Tang, Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia; and Stéphane Supiot, University of Nantes, Nantes, France
| | - Glenn S Bauman
- Charles N. Catton, Peter W.M. Chung, Patrick Cheung, Padraig Warde, and Tim K. Craig, University of Toronto, Toronto; Himu Lukka, Chu-Shu Gu, Theodoros Tsakiridis, Tom B. Corbett, Ian S. Dayes, Jim A. Julian, and Mark N. Levine, McMaster University, Hamilton; Glenn S. Bauman, University of Western Ontario, London, Ontario; Jean-Paul Bahary, University of Montreal, Montreal, Quebec; Shahida Ahmed, University of Manitoba, Winnipeg, Manitoba; Jackson S. Wu, University of Calgary, Calgary; Matthew B. Parliament, University of Alberta, Edmonton, Alberta, Canada; Jarad M. Martin, University of Newcastle, Newcastle, New South Wales; Keen Hun Tai, University of Melbourne, Melbourne, Victoria; Colin Tang, Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia; and Stéphane Supiot, University of Nantes, Nantes, France
| | - Jean-Paul Bahary
- Charles N. Catton, Peter W.M. Chung, Patrick Cheung, Padraig Warde, and Tim K. Craig, University of Toronto, Toronto; Himu Lukka, Chu-Shu Gu, Theodoros Tsakiridis, Tom B. Corbett, Ian S. Dayes, Jim A. Julian, and Mark N. Levine, McMaster University, Hamilton; Glenn S. Bauman, University of Western Ontario, London, Ontario; Jean-Paul Bahary, University of Montreal, Montreal, Quebec; Shahida Ahmed, University of Manitoba, Winnipeg, Manitoba; Jackson S. Wu, University of Calgary, Calgary; Matthew B. Parliament, University of Alberta, Edmonton, Alberta, Canada; Jarad M. Martin, University of Newcastle, Newcastle, New South Wales; Keen Hun Tai, University of Melbourne, Melbourne, Victoria; Colin Tang, Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia; and Stéphane Supiot, University of Nantes, Nantes, France
| | - Shahida Ahmed
- Charles N. Catton, Peter W.M. Chung, Patrick Cheung, Padraig Warde, and Tim K. Craig, University of Toronto, Toronto; Himu Lukka, Chu-Shu Gu, Theodoros Tsakiridis, Tom B. Corbett, Ian S. Dayes, Jim A. Julian, and Mark N. Levine, McMaster University, Hamilton; Glenn S. Bauman, University of Western Ontario, London, Ontario; Jean-Paul Bahary, University of Montreal, Montreal, Quebec; Shahida Ahmed, University of Manitoba, Winnipeg, Manitoba; Jackson S. Wu, University of Calgary, Calgary; Matthew B. Parliament, University of Alberta, Edmonton, Alberta, Canada; Jarad M. Martin, University of Newcastle, Newcastle, New South Wales; Keen Hun Tai, University of Melbourne, Melbourne, Victoria; Colin Tang, Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia; and Stéphane Supiot, University of Nantes, Nantes, France
| | - Patrick Cheung
- Charles N. Catton, Peter W.M. Chung, Patrick Cheung, Padraig Warde, and Tim K. Craig, University of Toronto, Toronto; Himu Lukka, Chu-Shu Gu, Theodoros Tsakiridis, Tom B. Corbett, Ian S. Dayes, Jim A. Julian, and Mark N. Levine, McMaster University, Hamilton; Glenn S. Bauman, University of Western Ontario, London, Ontario; Jean-Paul Bahary, University of Montreal, Montreal, Quebec; Shahida Ahmed, University of Manitoba, Winnipeg, Manitoba; Jackson S. Wu, University of Calgary, Calgary; Matthew B. Parliament, University of Alberta, Edmonton, Alberta, Canada; Jarad M. Martin, University of Newcastle, Newcastle, New South Wales; Keen Hun Tai, University of Melbourne, Melbourne, Victoria; Colin Tang, Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia; and Stéphane Supiot, University of Nantes, Nantes, France
| | - Keen Hun Tai
- Charles N. Catton, Peter W.M. Chung, Patrick Cheung, Padraig Warde, and Tim K. Craig, University of Toronto, Toronto; Himu Lukka, Chu-Shu Gu, Theodoros Tsakiridis, Tom B. Corbett, Ian S. Dayes, Jim A. Julian, and Mark N. Levine, McMaster University, Hamilton; Glenn S. Bauman, University of Western Ontario, London, Ontario; Jean-Paul Bahary, University of Montreal, Montreal, Quebec; Shahida Ahmed, University of Manitoba, Winnipeg, Manitoba; Jackson S. Wu, University of Calgary, Calgary; Matthew B. Parliament, University of Alberta, Edmonton, Alberta, Canada; Jarad M. Martin, University of Newcastle, Newcastle, New South Wales; Keen Hun Tai, University of Melbourne, Melbourne, Victoria; Colin Tang, Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia; and Stéphane Supiot, University of Nantes, Nantes, France
| | - Jackson S Wu
- Charles N. Catton, Peter W.M. Chung, Patrick Cheung, Padraig Warde, and Tim K. Craig, University of Toronto, Toronto; Himu Lukka, Chu-Shu Gu, Theodoros Tsakiridis, Tom B. Corbett, Ian S. Dayes, Jim A. Julian, and Mark N. Levine, McMaster University, Hamilton; Glenn S. Bauman, University of Western Ontario, London, Ontario; Jean-Paul Bahary, University of Montreal, Montreal, Quebec; Shahida Ahmed, University of Manitoba, Winnipeg, Manitoba; Jackson S. Wu, University of Calgary, Calgary; Matthew B. Parliament, University of Alberta, Edmonton, Alberta, Canada; Jarad M. Martin, University of Newcastle, Newcastle, New South Wales; Keen Hun Tai, University of Melbourne, Melbourne, Victoria; Colin Tang, Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia; and Stéphane Supiot, University of Nantes, Nantes, France
| | - Matthew B Parliament
- Charles N. Catton, Peter W.M. Chung, Patrick Cheung, Padraig Warde, and Tim K. Craig, University of Toronto, Toronto; Himu Lukka, Chu-Shu Gu, Theodoros Tsakiridis, Tom B. Corbett, Ian S. Dayes, Jim A. Julian, and Mark N. Levine, McMaster University, Hamilton; Glenn S. Bauman, University of Western Ontario, London, Ontario; Jean-Paul Bahary, University of Montreal, Montreal, Quebec; Shahida Ahmed, University of Manitoba, Winnipeg, Manitoba; Jackson S. Wu, University of Calgary, Calgary; Matthew B. Parliament, University of Alberta, Edmonton, Alberta, Canada; Jarad M. Martin, University of Newcastle, Newcastle, New South Wales; Keen Hun Tai, University of Melbourne, Melbourne, Victoria; Colin Tang, Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia; and Stéphane Supiot, University of Nantes, Nantes, France
| | - Theodoros Tsakiridis
- Charles N. Catton, Peter W.M. Chung, Patrick Cheung, Padraig Warde, and Tim K. Craig, University of Toronto, Toronto; Himu Lukka, Chu-Shu Gu, Theodoros Tsakiridis, Tom B. Corbett, Ian S. Dayes, Jim A. Julian, and Mark N. Levine, McMaster University, Hamilton; Glenn S. Bauman, University of Western Ontario, London, Ontario; Jean-Paul Bahary, University of Montreal, Montreal, Quebec; Shahida Ahmed, University of Manitoba, Winnipeg, Manitoba; Jackson S. Wu, University of Calgary, Calgary; Matthew B. Parliament, University of Alberta, Edmonton, Alberta, Canada; Jarad M. Martin, University of Newcastle, Newcastle, New South Wales; Keen Hun Tai, University of Melbourne, Melbourne, Victoria; Colin Tang, Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia; and Stéphane Supiot, University of Nantes, Nantes, France
| | - Tom B Corbett
- Charles N. Catton, Peter W.M. Chung, Patrick Cheung, Padraig Warde, and Tim K. Craig, University of Toronto, Toronto; Himu Lukka, Chu-Shu Gu, Theodoros Tsakiridis, Tom B. Corbett, Ian S. Dayes, Jim A. Julian, and Mark N. Levine, McMaster University, Hamilton; Glenn S. Bauman, University of Western Ontario, London, Ontario; Jean-Paul Bahary, University of Montreal, Montreal, Quebec; Shahida Ahmed, University of Manitoba, Winnipeg, Manitoba; Jackson S. Wu, University of Calgary, Calgary; Matthew B. Parliament, University of Alberta, Edmonton, Alberta, Canada; Jarad M. Martin, University of Newcastle, Newcastle, New South Wales; Keen Hun Tai, University of Melbourne, Melbourne, Victoria; Colin Tang, Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia; and Stéphane Supiot, University of Nantes, Nantes, France
| | - Colin Tang
- Charles N. Catton, Peter W.M. Chung, Patrick Cheung, Padraig Warde, and Tim K. Craig, University of Toronto, Toronto; Himu Lukka, Chu-Shu Gu, Theodoros Tsakiridis, Tom B. Corbett, Ian S. Dayes, Jim A. Julian, and Mark N. Levine, McMaster University, Hamilton; Glenn S. Bauman, University of Western Ontario, London, Ontario; Jean-Paul Bahary, University of Montreal, Montreal, Quebec; Shahida Ahmed, University of Manitoba, Winnipeg, Manitoba; Jackson S. Wu, University of Calgary, Calgary; Matthew B. Parliament, University of Alberta, Edmonton, Alberta, Canada; Jarad M. Martin, University of Newcastle, Newcastle, New South Wales; Keen Hun Tai, University of Melbourne, Melbourne, Victoria; Colin Tang, Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia; and Stéphane Supiot, University of Nantes, Nantes, France
| | - Ian S Dayes
- Charles N. Catton, Peter W.M. Chung, Patrick Cheung, Padraig Warde, and Tim K. Craig, University of Toronto, Toronto; Himu Lukka, Chu-Shu Gu, Theodoros Tsakiridis, Tom B. Corbett, Ian S. Dayes, Jim A. Julian, and Mark N. Levine, McMaster University, Hamilton; Glenn S. Bauman, University of Western Ontario, London, Ontario; Jean-Paul Bahary, University of Montreal, Montreal, Quebec; Shahida Ahmed, University of Manitoba, Winnipeg, Manitoba; Jackson S. Wu, University of Calgary, Calgary; Matthew B. Parliament, University of Alberta, Edmonton, Alberta, Canada; Jarad M. Martin, University of Newcastle, Newcastle, New South Wales; Keen Hun Tai, University of Melbourne, Melbourne, Victoria; Colin Tang, Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia; and Stéphane Supiot, University of Nantes, Nantes, France
| | - Padraig Warde
- Charles N. Catton, Peter W.M. Chung, Patrick Cheung, Padraig Warde, and Tim K. Craig, University of Toronto, Toronto; Himu Lukka, Chu-Shu Gu, Theodoros Tsakiridis, Tom B. Corbett, Ian S. Dayes, Jim A. Julian, and Mark N. Levine, McMaster University, Hamilton; Glenn S. Bauman, University of Western Ontario, London, Ontario; Jean-Paul Bahary, University of Montreal, Montreal, Quebec; Shahida Ahmed, University of Manitoba, Winnipeg, Manitoba; Jackson S. Wu, University of Calgary, Calgary; Matthew B. Parliament, University of Alberta, Edmonton, Alberta, Canada; Jarad M. Martin, University of Newcastle, Newcastle, New South Wales; Keen Hun Tai, University of Melbourne, Melbourne, Victoria; Colin Tang, Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia; and Stéphane Supiot, University of Nantes, Nantes, France
| | - Tim K Craig
- Charles N. Catton, Peter W.M. Chung, Patrick Cheung, Padraig Warde, and Tim K. Craig, University of Toronto, Toronto; Himu Lukka, Chu-Shu Gu, Theodoros Tsakiridis, Tom B. Corbett, Ian S. Dayes, Jim A. Julian, and Mark N. Levine, McMaster University, Hamilton; Glenn S. Bauman, University of Western Ontario, London, Ontario; Jean-Paul Bahary, University of Montreal, Montreal, Quebec; Shahida Ahmed, University of Manitoba, Winnipeg, Manitoba; Jackson S. Wu, University of Calgary, Calgary; Matthew B. Parliament, University of Alberta, Edmonton, Alberta, Canada; Jarad M. Martin, University of Newcastle, Newcastle, New South Wales; Keen Hun Tai, University of Melbourne, Melbourne, Victoria; Colin Tang, Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia; and Stéphane Supiot, University of Nantes, Nantes, France
| | - Jim A Julian
- Charles N. Catton, Peter W.M. Chung, Patrick Cheung, Padraig Warde, and Tim K. Craig, University of Toronto, Toronto; Himu Lukka, Chu-Shu Gu, Theodoros Tsakiridis, Tom B. Corbett, Ian S. Dayes, Jim A. Julian, and Mark N. Levine, McMaster University, Hamilton; Glenn S. Bauman, University of Western Ontario, London, Ontario; Jean-Paul Bahary, University of Montreal, Montreal, Quebec; Shahida Ahmed, University of Manitoba, Winnipeg, Manitoba; Jackson S. Wu, University of Calgary, Calgary; Matthew B. Parliament, University of Alberta, Edmonton, Alberta, Canada; Jarad M. Martin, University of Newcastle, Newcastle, New South Wales; Keen Hun Tai, University of Melbourne, Melbourne, Victoria; Colin Tang, Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia; and Stéphane Supiot, University of Nantes, Nantes, France
| | - Mark N Levine
- Charles N. Catton, Peter W.M. Chung, Patrick Cheung, Padraig Warde, and Tim K. Craig, University of Toronto, Toronto; Himu Lukka, Chu-Shu Gu, Theodoros Tsakiridis, Tom B. Corbett, Ian S. Dayes, Jim A. Julian, and Mark N. Levine, McMaster University, Hamilton; Glenn S. Bauman, University of Western Ontario, London, Ontario; Jean-Paul Bahary, University of Montreal, Montreal, Quebec; Shahida Ahmed, University of Manitoba, Winnipeg, Manitoba; Jackson S. Wu, University of Calgary, Calgary; Matthew B. Parliament, University of Alberta, Edmonton, Alberta, Canada; Jarad M. Martin, University of Newcastle, Newcastle, New South Wales; Keen Hun Tai, University of Melbourne, Melbourne, Victoria; Colin Tang, Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia; and Stéphane Supiot, University of Nantes, Nantes, France
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Serrano PE, Gafni A, Gu CS, Gulenchyn KY, Julian JA, Law C, Hendler AL, Moulton CA, Gallinger S, Levine MN. Positron Emission Tomography–Computed Tomography (PET-CT) Versus No PET-CT in the Management of Potentially Resectable Colorectal Cancer Liver Metastases: Cost Implications of a Randomized Controlled Trial. J Oncol Pract 2016; 12:e765-74. [DOI: 10.1200/jop.2016.011676] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Purpose: To evaluate whether positron emission tomography (PET) combined with computed tomography (PET-CT) is cost saving, or cost neutral, compared with conventional imaging in management of patients with resectable colorectal cancer liver metastases. Methods: Cost evaluation of a randomized trial that compared the effect of PET-CT on surgical management of patients with resectable colorectal cancer liver metastases. Health care use data ≤ 1 year after random assignment was obtained from administrative databases. Cost analysis was undertaken from the perspective of a third-party payer (ie, Ministry of Health). Mean costs with 95% credible intervals (CrI) were estimated by using a Bayesian approach. Results: The estimated mean cost per patient in the 263 patients who underwent PET-CT was $45,454 CAD (range, $1,340 to $181,420) and in the 134 control patients, $40,859 CAD (range, $279 to $293,558), with a net difference of $4,327 CAD (95% CrI, −$2,207 to $10,614). The primary cost driver was hospitalization for liver surgery (difference of $2,997 CAD for PET-CT; 95% CrI, −$2,144 to $8,010), which was mainly a result of a longer length of hospital stay for the PET-CT arm (median, 7 v 6 days; P = .03) and a higher postoperative complication rate (20% v 10%; P = .01). Baseline characteristics were similar between groups, including the number of liver segments involved with cancer, number of segments resected, and type of liver resection performed. No difference in survival was detected between arms. Conclusion: PET-CT was associated with limited clinical benefit and a nonsignificant increased cost. Universal funding of PET-CT in the management of patients with resectable colorectal cancer liver metastases does not seem justified.
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Affiliation(s)
- Pablo E. Serrano
- McMaster University, Hamilton, Ontario; and University of Toronto, Toronto, Ontario, Canada
| | - Amiram Gafni
- McMaster University, Hamilton, Ontario; and University of Toronto, Toronto, Ontario, Canada
| | - Chu-Shu Gu
- McMaster University, Hamilton, Ontario; and University of Toronto, Toronto, Ontario, Canada
| | - Karen Y. Gulenchyn
- McMaster University, Hamilton, Ontario; and University of Toronto, Toronto, Ontario, Canada
| | - Jim A. Julian
- McMaster University, Hamilton, Ontario; and University of Toronto, Toronto, Ontario, Canada
| | - Calvin Law
- McMaster University, Hamilton, Ontario; and University of Toronto, Toronto, Ontario, Canada
| | - Aaron L. Hendler
- McMaster University, Hamilton, Ontario; and University of Toronto, Toronto, Ontario, Canada
| | - Carol-Anne Moulton
- McMaster University, Hamilton, Ontario; and University of Toronto, Toronto, Ontario, Canada
| | - Steven Gallinger
- McMaster University, Hamilton, Ontario; and University of Toronto, Toronto, Ontario, Canada
| | - Mark N. Levine
- McMaster University, Hamilton, Ontario; and University of Toronto, Toronto, Ontario, Canada
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22
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Catton CN, Lukka H, Julian JA, Gu CS, Martin J, Supiot S, Chung PWM, Bauman G, Bahary JP, Ahmed S, Cheung P, Tai KH, Wu J, Parliament M, Levine MN. A randomized trial of a shorter radiation fractionation schedule for the treatment of localized prostate cancer. J Clin Oncol 2016. [DOI: 10.1200/jco.2016.34.15_suppl.5003] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- Charles N Catton
- Department of Radiation Oncology, Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - Himu Lukka
- Juravinski Cancer Centre, Hamilton, ON, Canada
| | - Jim A. Julian
- Ontario Clinical Oncology Group, McMaster University, Hamilton, ON, Canada
| | - Chu-Shu Gu
- Ontario Clinical Oncology Group, McMaster University, Hamilton, ON, Canada
| | - Jarad Martin
- Oncology Research Australia, Toowoomba, Australia
| | - Stéphane Supiot
- Institut de Cancérologie de l'Ouest René Gauducheau, Nantes Saint Herblain, France
| | - Peter W. M. Chung
- Department of Radiation Oncology, Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - Glenn Bauman
- London Regional Cancer Program, London, ON, Canada
| | | | | | | | - Keen Hun Tai
- Peter MacCallum Cancer Centre, East Melbourne, Australia
| | - Jackson Wu
- Tom Baker Cancer Centre, Calgary, AB, Canada
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23
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Serrano Aybar PE, Gafni A, Gu CS, Julian JA, Moulton CA, Gallinger S, Levine MN. PET-CT compared to no PET-CT in the management of potentially resectable colorectal cancer liver metastases: The costs implications of a randomized controlled trial. J Clin Oncol 2016. [DOI: 10.1200/jco.2016.34.4_suppl.296] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
296 Background: PETCAM was a randomized trial evaluating the effect of PET-CT compared to conventional imaging (control) on the surgical management of patients with resectable colorectal cancer liver metastases (CRLM). It concluded that PET-CT did not result in frequent change in surgical management (8·0%, 21/263) with only 2·7% (7/263) avoidance of liver resections. In this study we conducted a cost analysis of these two arms up to one year following randomization. Methods: Health care utilization was collected for all study participants. Unit costs for hospitalization, physician services, chemotherapy and outpatient radiological and endoscopic procedures were obtained from administrative databases. Cost analysis was undertaken from the perspective of a third-party payer (i.e., Ministry of Health). Mean cost with its 95% credible interval was estimated using a Bayesian approach. Results: The estimated mean cost per patient in the PET-CT arm was CAN $45,454 (min-max: 1,340-181,420) and in the control arm, CAN $40,859 (min-max: 279-293,558), with a net difference of CAN $4,327, 95% credible interval -2,207 to 10,614. The primary cost driver was cost of hospitalization for liver surgery (+ $2,997 CAN for the PET-CT arm), mainly due to a longer length of hospital stay for the PET-CT arm compared to control (median 7 days vs. 6 days, P= 0·034) and a higher rate of postoperative complications (52/255, 20% vs. 13/128, 10%, P = 0·014). Baseline characteristics were similar between groups, including a similar number of liver segments involved with cancer, number of segments resected and type of liver resection performed. Conclusions: PET-CT does not appear to provide a significant clinical benefit in the surgical management of patients with resectable CRLM and it is not cost saving compared to control.
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Affiliation(s)
| | | | - Chu-Shu Gu
- Ontario Clinical Oncology Group, McMaster University, Hamilton, ON, Canada
| | - Jim A. Julian
- Ontario Clinical Oncology Group, McMaster University, Hamilton, ON, Canada
| | | | - Steven Gallinger
- Department of Surgery, Toronto General Hospital, University of Toronto, Toronto, ON, Canada
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Elit LM, Fyles AW, Gu CS, Pond GR, D'Souza D, Samant R, Anthes M, Thomas G, Fillion M, Arsenault J, Dayes I, Whelan TJ, Gulenchyn KY, Levine MN. The role of PET-CT in treatment decision making for women with locally advanced cervical cancer. J Clin Oncol 2015. [DOI: 10.1200/jco.2015.33.15_suppl.5523] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
| | | | - Chu-Shu Gu
- Ontario Clinical Oncology Group, McMaster University, Hamilton, ON, Canada
| | | | - David D'Souza
- Department of Radiation Oncology, London Regional Cancer Program, London, ON, Canada
| | - Rajiv Samant
- The Ottawa Hospital Cancer Centre, Ottawa, ON, Canada
| | | | | | - Marc Fillion
- Ontario Clinical Oncology Group, Hamilton, ON, Canada
| | | | - Ian Dayes
- McMaster University, Hamilton, ON, Canada
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Moulton CA, Gu CS, Law CH, Tandan VR, Hart R, Quan D, Fairfull Smith RJ, Jalink DW, Husien M, Serrano PE, Hendler AL, Haider MA, Ruo L, Gulenchyn KY, Finch T, Julian JA, Levine MN, Gallinger S. Effect of PET before liver resection on surgical management for colorectal adenocarcinoma metastases: a randomized clinical trial. JAMA 2014; 311:1863-9. [PMID: 24825641 DOI: 10.1001/jama.2014.3740] [Citation(s) in RCA: 125] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
IMPORTANCE Patients with colorectal cancer with liver metastases undergo hepatic resection with curative intent. Positron emission tomography combined with computed tomography (PET-CT) could help avoid noncurative surgery by identifying patients with occult metastases. OBJECTIVES To determine the effect of preoperative PET-CT vs no PET-CT (control) on the surgical management of patients with resectable metastases and to investigate the effect of PET-CT on survival and the association between the standardized uptake value (ratio of tissue radioactivity to injected radioactivity adjusted by weight) and survival. DESIGN, SETTING, AND PARTICIPANTS A randomized trial of patients older than 18 years with colorectal cancer treated by surgery, with resectable metastases based on CT scans of the chest, abdomen, and pelvis within the previous 30 days, and with a clear colonoscopy within the previous 18 months was conducted between 2005 and 2013, involving 21 surgeons at 9 hospitals in Ontario, Canada, with PET-CT scanners at 5 academic institutions. INTERVENTIONS Patients were randomized using a 2 to 1 ratio to PET-CT or control. MAIN OUTCOMES AND MEASURES The primary outcome was a change in surgical management defined as canceled hepatic surgery, more extensive hepatic surgery, or additional organ surgery based on the PET-CT. Survival was a secondary outcome. RESULTS Of the 263 patients who underwent PET-CT, 21 had a change in surgical management (8.0%; 95% CI, 5.0%-11.9%). Specifically, 7 patients (2.7%) did not undergo laparotomy, 4 (1.5%) had more extensive hepatic surgery, 9 (3.4%) had additional organ surgery (8 of whom had hepatic resection), and the abdominal cavity was opened in 1 patient but hepatic surgery was not performed and the cavity was closed. Liver resection was performed in 91% of patients in the PET-CT group and 92% of the control group. After a median follow-up of 36 months, the estimated mortality rate was 11.13 (95% CI, 8.95-13.68) events/1000 person-months for the PET-CT group and 12.71 (95% CI, 9.40-16.80) events/1000 person-months for the control group. Survival did not differ between the 2 groups (hazard ratio, 0.86 [95% CI, 0.60-1.21]; P = .38). The standardized uptake value was associated with survival (hazard ratio, 1.11 [90% CI, 1.07-1.15] per unit increase; P < .001). The C statistic for the model including the standardized uptake value was 0.62 (95% CI, 0.56-0.68) and without it was 0.50 (95% CI, 0.44-0.56). The difference in C statistics is 0.12 (95% CI, 0.04-0.21). The low C statistic suggests that the standard uptake value is not a strong predictor of overall survival. CONCLUSIONS AND RELEVANCE Among patients with potentially resectable hepatic metastases of colorectal adenocarcinoma, the use of PET-CT compared with CT alone did not result in frequent change in surgical management. These findings raise questions about the value of PET-CT scans in this setting. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00265356.
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Affiliation(s)
| | - Chu-Shu Gu
- McMaster University, Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Calvin H Law
- Sunnybrook Health Sciences Centre and Odette Cancer Centre, Toronto, Ontario, Canada
| | - Ved R Tandan
- McMaster University, Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Richard Hart
- St Joseph's Health Centre, Toronto, Ontario, Canada
| | - Douglas Quan
- London Health Sciences Centre, London, Ontario, Canada
| | | | - Diederick W Jalink
- Cancer Centre of Southeastern Ontario at Kingston General Hospital, Kingston, Canada
| | - Mohamed Husien
- Grand River Regional Cancer Centre, Kitchener, Ontario, Canada
| | | | | | - Masoom A Haider
- Sunnybrook Health Sciences Centre and Odette Cancer Centre, Toronto, Ontario, Canada
| | - Leyo Ruo
- McMaster University, Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Karen Y Gulenchyn
- McMaster University, Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Terri Finch
- McMaster University, Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Jim A Julian
- McMaster University, Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Mark N Levine
- McMaster University, Hamilton Health Sciences, Hamilton, Ontario, Canada
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You JJ, Inculet RI, Dhesy-Thind SK, Chan AM, Freeman M, Cline KJ, Pritchard KI, Dayes IS, Gu CS, Julian JA, Gulenchyn KY, Evans WK, Levine MN. Positron emission tomography/computed tomography (PET/CT) for the diagnosis of recurrent cancer (PETREC): A multicenter, prospective cohort study. J Clin Oncol 2012. [DOI: 10.1200/jco.2012.30.15_suppl.6049] [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: 11/20/2022] Open
Abstract
6049 Background: The clinical utility of PET/CT in patients with suspected cancer recurrence remains unclear. The aim of this multi-center, prospective, comparative effectiveness study is to assess the impact of PET/CT on clinical management of patients with suspected cancer recurrence. Methods: Patients were eligible if cancer recurrence (non-small cell lung, breast, head and neck, ovarian, esophageal, Hodgkin’s or non-Hodgkin’s lymphoma) was clinically suspected, and if conventional imaging (e.g. X-ray, ultrasound, CT, or MRI) was non-diagnostic. As a pre-requisite to PET/CT booking, clinicians were asked at enrolment to indicate their planned management if PET/CT were not available. Patients then underwent 18FDG-PET/CT. Clinicians were then asked to indicate their management plan based on PET/CT findings. Patients were followed up once at 3 months. The primary outcome was change in planned management after PET/CT and was assessed independently and in duplicate by external outcome adjudicators using all available source documents. Results: 101 patients (mean age 64 y, 45% male, median 1.3 y since last treatment) were enrolled from 4 centers in Ontario, Canada between April 2009 and June 2011. Distribution of tumor types was: non-small cell lung (55%), breast (19%), ovarian (10%), esophageal (6%), lymphoma (6%), head and neck (4%). 8 patients did not complete the study (non-adherence to protocol, 2; death, 5; disease progression prior to PET/CT, 1), of whom 2 did not receive PET/CT. PET/CT changed planned management in 52 (53%) patients (Table). At 3 months, planned management was carried out in 46/52 (88%) patients. Conclusions: In patients with suspected cancer recurrence, PET/CT changes planned management from non-treatment to treatment for approximately 1 in every 3 patients (“number needed to scan” = 3) and contributes importantly to clinical management. [Table: see text]
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Affiliation(s)
| | | | | | - Adrien M. Chan
- Thunder Bay Regional Health Sciences Centre, Thunder Bay, ON, Canada
| | | | - Kathryn J. Cline
- Ontario Clinical Oncology Group, McMaster University, Hamilton, ON, Canada
| | | | | | - Chu-Shu Gu
- Ontario Clinical Oncology Group, McMaster University, Hamilton, ON, Canada
| | - Jim A Julian
- Ontario Clinical Oncology Group, McMaster University, Hamilton, ON, Canada
| | | | | | - Mark Norman Levine
- Ontario Clinical Oncology Group, McMaster University, Hamilton, ON, Canada
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Moulton CA, Levine MN, Law C, Hart R, Ruo L, Gu CS, Hendler A, Gulenchyn KY, Haider MA, Marcaccio M, Tandan V, Quan D, Jalink D, Fairfull Smith R, Luu S, Greig PD, Husien M, Finch T, Julian JA, Gallinger S. Survival analysis of PETCAM: A multicenter randomized controlled trial of PET/CT versus no PET/CT for patients with resectable liver colorectal adenocarcinoma metastases. J Clin Oncol 2012. [DOI: 10.1200/jco.2012.30.4_suppl.390] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
390 Background: An increasing proportion of patients with liver CAM are undergoing hepatic resection with curative intent. Detection of occult metastastic disease is important in this setting, and PET/CT is used to identify patients with either inoperable, or limited resectable extrahepatic disease not identified with conventional imaging. We recently reported the results related to the primary objective of PETCAM, a randomized trial for patients with resectable liver CAM, where 7.6% had a change in management based on PET/CT (ASCO 2011). As a secondary objective, we examined whether patients undergoing PET/CT derived a survival benefit, as they may be considered to be better selected. Methods: PETCAM was a multicenter trial with 404 subjects randomized 2:1 to receive PET/CT or no PET/CT once they were assessed by a hepatobiliary surgeon to have resectable CAM. Subjects were followed over 4 years for overall survival (OS). As well as the intervention, we considered the SUV, Fong Score and other baseline factors as predictors for OS. Results: After a median 2.8 years of follow-up, 107 of the 404 (26%) study subjects had died. The 270 PET/CT subjects [and the 245 of these who underwent surgery] showed no statistically significant survival advantage over the 134 No PET/CT subjects [123 who underwent surgery] with a hazard ratio (HR) of 0.85, 95% confidence interval (CI): 0.57 to 1.3; p=0.41 [HR=0.81, 95% CI: 0.52 to 1.3; p=0.34]. Fong score was a strong predictor of OS for all patients (HR=1.4, 95% CI: 1.1 to 1.6), and for those who had surgery (HR=1.4, 95% CI, 1.1 to 1.7). In the PET/CT arm, SUV is strongly predictive of OS [HR per unit SUV increase =1.11, 95% CI: 1.05 to 1.18; p=0.0007. Conclusions: The addition of PET/CT had no effect on improving overall survival for patients who did or did not have hepatic resection for CAM. SUV is strongly predictive of survival for patients who had PET/CT, and Fong score is predictive of survival for all patients. The overall role of PET/CT in patients with resectable CAM appears limited and should be reevaluated in the current era of comparative effectiveness research and health care cost containment.
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Affiliation(s)
- Carol-anne Moulton
- Toronto General Hospital, Toronto, ON, Canada; McMaster University, Hamilton, ON, Canada; Sunnybrook Odette Cancer Centre, Toronto, ON, Canada; St. Joseph's Health Centre, Toronto, ON, Canada; McMaster University Medical Centre, Hamilton, ON, Canada; Ontario Clinical Oncology Group, Hamilton, ON, Canada; Mount Sinai Hospital, Toronto, ON, Canada; Hamilton Health Sciences, Hamilton, ON, Canada; Department of Medical Imaging, Princess Margaret Hospital and University of Toronto, Toronto, ON, Canada; St
| | - Mark Norman Levine
- Toronto General Hospital, Toronto, ON, Canada; McMaster University, Hamilton, ON, Canada; Sunnybrook Odette Cancer Centre, Toronto, ON, Canada; St. Joseph's Health Centre, Toronto, ON, Canada; McMaster University Medical Centre, Hamilton, ON, Canada; Ontario Clinical Oncology Group, Hamilton, ON, Canada; Mount Sinai Hospital, Toronto, ON, Canada; Hamilton Health Sciences, Hamilton, ON, Canada; Department of Medical Imaging, Princess Margaret Hospital and University of Toronto, Toronto, ON, Canada; St
| | - Calvin Law
- Toronto General Hospital, Toronto, ON, Canada; McMaster University, Hamilton, ON, Canada; Sunnybrook Odette Cancer Centre, Toronto, ON, Canada; St. Joseph's Health Centre, Toronto, ON, Canada; McMaster University Medical Centre, Hamilton, ON, Canada; Ontario Clinical Oncology Group, Hamilton, ON, Canada; Mount Sinai Hospital, Toronto, ON, Canada; Hamilton Health Sciences, Hamilton, ON, Canada; Department of Medical Imaging, Princess Margaret Hospital and University of Toronto, Toronto, ON, Canada; St
| | - Richard Hart
- Toronto General Hospital, Toronto, ON, Canada; McMaster University, Hamilton, ON, Canada; Sunnybrook Odette Cancer Centre, Toronto, ON, Canada; St. Joseph's Health Centre, Toronto, ON, Canada; McMaster University Medical Centre, Hamilton, ON, Canada; Ontario Clinical Oncology Group, Hamilton, ON, Canada; Mount Sinai Hospital, Toronto, ON, Canada; Hamilton Health Sciences, Hamilton, ON, Canada; Department of Medical Imaging, Princess Margaret Hospital and University of Toronto, Toronto, ON, Canada; St
| | - Leyo Ruo
- Toronto General Hospital, Toronto, ON, Canada; McMaster University, Hamilton, ON, Canada; Sunnybrook Odette Cancer Centre, Toronto, ON, Canada; St. Joseph's Health Centre, Toronto, ON, Canada; McMaster University Medical Centre, Hamilton, ON, Canada; Ontario Clinical Oncology Group, Hamilton, ON, Canada; Mount Sinai Hospital, Toronto, ON, Canada; Hamilton Health Sciences, Hamilton, ON, Canada; Department of Medical Imaging, Princess Margaret Hospital and University of Toronto, Toronto, ON, Canada; St
| | - Chu-Shu Gu
- Toronto General Hospital, Toronto, ON, Canada; McMaster University, Hamilton, ON, Canada; Sunnybrook Odette Cancer Centre, Toronto, ON, Canada; St. Joseph's Health Centre, Toronto, ON, Canada; McMaster University Medical Centre, Hamilton, ON, Canada; Ontario Clinical Oncology Group, Hamilton, ON, Canada; Mount Sinai Hospital, Toronto, ON, Canada; Hamilton Health Sciences, Hamilton, ON, Canada; Department of Medical Imaging, Princess Margaret Hospital and University of Toronto, Toronto, ON, Canada; St
| | - Aaron Hendler
- Toronto General Hospital, Toronto, ON, Canada; McMaster University, Hamilton, ON, Canada; Sunnybrook Odette Cancer Centre, Toronto, ON, Canada; St. Joseph's Health Centre, Toronto, ON, Canada; McMaster University Medical Centre, Hamilton, ON, Canada; Ontario Clinical Oncology Group, Hamilton, ON, Canada; Mount Sinai Hospital, Toronto, ON, Canada; Hamilton Health Sciences, Hamilton, ON, Canada; Department of Medical Imaging, Princess Margaret Hospital and University of Toronto, Toronto, ON, Canada; St
| | - Karen Y. Gulenchyn
- Toronto General Hospital, Toronto, ON, Canada; McMaster University, Hamilton, ON, Canada; Sunnybrook Odette Cancer Centre, Toronto, ON, Canada; St. Joseph's Health Centre, Toronto, ON, Canada; McMaster University Medical Centre, Hamilton, ON, Canada; Ontario Clinical Oncology Group, Hamilton, ON, Canada; Mount Sinai Hospital, Toronto, ON, Canada; Hamilton Health Sciences, Hamilton, ON, Canada; Department of Medical Imaging, Princess Margaret Hospital and University of Toronto, Toronto, ON, Canada; St
| | - Masoom A. Haider
- Toronto General Hospital, Toronto, ON, Canada; McMaster University, Hamilton, ON, Canada; Sunnybrook Odette Cancer Centre, Toronto, ON, Canada; St. Joseph's Health Centre, Toronto, ON, Canada; McMaster University Medical Centre, Hamilton, ON, Canada; Ontario Clinical Oncology Group, Hamilton, ON, Canada; Mount Sinai Hospital, Toronto, ON, Canada; Hamilton Health Sciences, Hamilton, ON, Canada; Department of Medical Imaging, Princess Margaret Hospital and University of Toronto, Toronto, ON, Canada; St
| | - Michael Marcaccio
- Toronto General Hospital, Toronto, ON, Canada; McMaster University, Hamilton, ON, Canada; Sunnybrook Odette Cancer Centre, Toronto, ON, Canada; St. Joseph's Health Centre, Toronto, ON, Canada; McMaster University Medical Centre, Hamilton, ON, Canada; Ontario Clinical Oncology Group, Hamilton, ON, Canada; Mount Sinai Hospital, Toronto, ON, Canada; Hamilton Health Sciences, Hamilton, ON, Canada; Department of Medical Imaging, Princess Margaret Hospital and University of Toronto, Toronto, ON, Canada; St
| | - Ved Tandan
- Toronto General Hospital, Toronto, ON, Canada; McMaster University, Hamilton, ON, Canada; Sunnybrook Odette Cancer Centre, Toronto, ON, Canada; St. Joseph's Health Centre, Toronto, ON, Canada; McMaster University Medical Centre, Hamilton, ON, Canada; Ontario Clinical Oncology Group, Hamilton, ON, Canada; Mount Sinai Hospital, Toronto, ON, Canada; Hamilton Health Sciences, Hamilton, ON, Canada; Department of Medical Imaging, Princess Margaret Hospital and University of Toronto, Toronto, ON, Canada; St
| | - Douglas Quan
- Toronto General Hospital, Toronto, ON, Canada; McMaster University, Hamilton, ON, Canada; Sunnybrook Odette Cancer Centre, Toronto, ON, Canada; St. Joseph's Health Centre, Toronto, ON, Canada; McMaster University Medical Centre, Hamilton, ON, Canada; Ontario Clinical Oncology Group, Hamilton, ON, Canada; Mount Sinai Hospital, Toronto, ON, Canada; Hamilton Health Sciences, Hamilton, ON, Canada; Department of Medical Imaging, Princess Margaret Hospital and University of Toronto, Toronto, ON, Canada; St
| | - Diederick Jalink
- Toronto General Hospital, Toronto, ON, Canada; McMaster University, Hamilton, ON, Canada; Sunnybrook Odette Cancer Centre, Toronto, ON, Canada; St. Joseph's Health Centre, Toronto, ON, Canada; McMaster University Medical Centre, Hamilton, ON, Canada; Ontario Clinical Oncology Group, Hamilton, ON, Canada; Mount Sinai Hospital, Toronto, ON, Canada; Hamilton Health Sciences, Hamilton, ON, Canada; Department of Medical Imaging, Princess Margaret Hospital and University of Toronto, Toronto, ON, Canada; St
| | - Robin Fairfull Smith
- Toronto General Hospital, Toronto, ON, Canada; McMaster University, Hamilton, ON, Canada; Sunnybrook Odette Cancer Centre, Toronto, ON, Canada; St. Joseph's Health Centre, Toronto, ON, Canada; McMaster University Medical Centre, Hamilton, ON, Canada; Ontario Clinical Oncology Group, Hamilton, ON, Canada; Mount Sinai Hospital, Toronto, ON, Canada; Hamilton Health Sciences, Hamilton, ON, Canada; Department of Medical Imaging, Princess Margaret Hospital and University of Toronto, Toronto, ON, Canada; St
| | - Shelly Luu
- Toronto General Hospital, Toronto, ON, Canada; McMaster University, Hamilton, ON, Canada; Sunnybrook Odette Cancer Centre, Toronto, ON, Canada; St. Joseph's Health Centre, Toronto, ON, Canada; McMaster University Medical Centre, Hamilton, ON, Canada; Ontario Clinical Oncology Group, Hamilton, ON, Canada; Mount Sinai Hospital, Toronto, ON, Canada; Hamilton Health Sciences, Hamilton, ON, Canada; Department of Medical Imaging, Princess Margaret Hospital and University of Toronto, Toronto, ON, Canada; St
| | - Paul David Greig
- Toronto General Hospital, Toronto, ON, Canada; McMaster University, Hamilton, ON, Canada; Sunnybrook Odette Cancer Centre, Toronto, ON, Canada; St. Joseph's Health Centre, Toronto, ON, Canada; McMaster University Medical Centre, Hamilton, ON, Canada; Ontario Clinical Oncology Group, Hamilton, ON, Canada; Mount Sinai Hospital, Toronto, ON, Canada; Hamilton Health Sciences, Hamilton, ON, Canada; Department of Medical Imaging, Princess Margaret Hospital and University of Toronto, Toronto, ON, Canada; St
| | - Mohamed Husien
- Toronto General Hospital, Toronto, ON, Canada; McMaster University, Hamilton, ON, Canada; Sunnybrook Odette Cancer Centre, Toronto, ON, Canada; St. Joseph's Health Centre, Toronto, ON, Canada; McMaster University Medical Centre, Hamilton, ON, Canada; Ontario Clinical Oncology Group, Hamilton, ON, Canada; Mount Sinai Hospital, Toronto, ON, Canada; Hamilton Health Sciences, Hamilton, ON, Canada; Department of Medical Imaging, Princess Margaret Hospital and University of Toronto, Toronto, ON, Canada; St
| | - Terri Finch
- Toronto General Hospital, Toronto, ON, Canada; McMaster University, Hamilton, ON, Canada; Sunnybrook Odette Cancer Centre, Toronto, ON, Canada; St. Joseph's Health Centre, Toronto, ON, Canada; McMaster University Medical Centre, Hamilton, ON, Canada; Ontario Clinical Oncology Group, Hamilton, ON, Canada; Mount Sinai Hospital, Toronto, ON, Canada; Hamilton Health Sciences, Hamilton, ON, Canada; Department of Medical Imaging, Princess Margaret Hospital and University of Toronto, Toronto, ON, Canada; St
| | - Jim A Julian
- Toronto General Hospital, Toronto, ON, Canada; McMaster University, Hamilton, ON, Canada; Sunnybrook Odette Cancer Centre, Toronto, ON, Canada; St. Joseph's Health Centre, Toronto, ON, Canada; McMaster University Medical Centre, Hamilton, ON, Canada; Ontario Clinical Oncology Group, Hamilton, ON, Canada; Mount Sinai Hospital, Toronto, ON, Canada; Hamilton Health Sciences, Hamilton, ON, Canada; Department of Medical Imaging, Princess Margaret Hospital and University of Toronto, Toronto, ON, Canada; St
| | - Steven Gallinger
- Toronto General Hospital, Toronto, ON, Canada; McMaster University, Hamilton, ON, Canada; Sunnybrook Odette Cancer Centre, Toronto, ON, Canada; St. Joseph's Health Centre, Toronto, ON, Canada; McMaster University Medical Centre, Hamilton, ON, Canada; Ontario Clinical Oncology Group, Hamilton, ON, Canada; Mount Sinai Hospital, Toronto, ON, Canada; Hamilton Health Sciences, Hamilton, ON, Canada; Department of Medical Imaging, Princess Margaret Hospital and University of Toronto, Toronto, ON, Canada; St
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Elit L, Levine MN, Julian JA, Sellors JW, Lytwyn A, Chong S, Mahony JB, Gu C, Finch T, Zeferino LC. Expectant management versus immediate treatment for low-grade cervical intraepithelial neoplasia. Cancer 2010; 117:1438-45. [DOI: 10.1002/cncr.25635] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2010] [Revised: 08/03/2010] [Accepted: 08/04/2010] [Indexed: 11/10/2022]
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Maziak DE, Darling GE, Inculet RI, Gulenchyn KY, Driedger AA, Ung YC, Miller JD, Gu CS, Cline KJ, Evans WK, Levine MN. Positron emission tomography in staging early lung cancer: a randomized trial. Ann Intern Med 2009; 151:221-8, W-48. [PMID: 19581636 DOI: 10.7326/0003-4819-151-4-200908180-00132] [Citation(s) in RCA: 127] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Among patients with early-stage non-small cell lung cancer (NSCLC), preoperative imaging tests are important in defining surgical candidates. OBJECTIVE To assess whether whole-body positron emission tomography and computed tomography (PET-CT) plus cranial imaging correctly upstages cancer in more patients with NSCLC than does conventional staging plus cranial imaging. DESIGN Randomized clinical trial with recruitment from June 2004 to August 2007. The centralized, computer-generated, variable block size randomization scheme was stratified by treatment center and cancer stage. Participants, health care providers, and outcome assessors were not blinded to imaging modality assignment. SETTING 8 hospitals and 5 PET-CT centers in academic institutions. PATIENTS Eligible patients were older than 18 years; had histologic or cytologic proof of stage I, II, or IIIA NSCLC on the basis of chest radiography and thoracic CT; and had a tumor considered to be resectable. INTERVENTION PET-CT or conventional staging (abdominal CT and bone scan). All patients also had cranial imaging using CT or magnetic resonance imaging. MEASUREMENTS The primary outcome was correct upstaging, thereby avoiding stage-inappropriate surgery. Secondary outcomes were incorrect upstaging and incorrect understaging. RESULTS 170 patients were assigned to PET-CT and 167 to conventional staging. Eight patients (3 who had PET-CT and 5 who had conventional staging) did not have planned surgery. Disease was correctly upstaged in 23 of 167 PET-CT recipients and 11 of 162 conventional staging recipients (13.8% vs. 6.8%; difference, 7.0 percentage points [95% CI, 0.3 to 13.7 percentage points]), thereby sparing these patients from surgery. Disease was incorrectly upstaged in 8 PET-CT recipients and 1 conventional staging recipient (4.8% vs. 0.6%; difference, 4.2 percentage points [CI, 0.5 to 8.6 percentage points]), and it was incorrectly understaged in 25 and 48 patients, respectively (14.9% vs. 29.6%; difference, 14.7 percentage points [CI, 5.7 to 23.4 percentage points]). At 3 years, 52 patients who had PET-CT and 57 patients who had conventional staging had died. LIMITATION The relatively small sample and the fact that some patients did not have planned surgery limited the ability to determine precise differences in clinical outcomes that were attributable to testing strategies. CONCLUSION Preoperative staging with PET-CT and cranial imaging identifies more patients with mediastinal and extrathoracic disease than conventional staging, thereby sparing more patients from stage-inappropriate surgery, but the strategy also incorrectly upstaged disease in more patients.
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Affiliation(s)
- Donna E Maziak
- Ontario Clinical Oncology Group, Hamilton Health Sciences, McMaster University, Hamilton, Ontario, Canada
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