Percutaneous Coronary Intervention in Patients With Gynecological Cancer: Machine Learning-Augmented Propensity Score Mortality and Cost Analysis for 383,760 Patients

Background

Despite the growing number of patients with both coronary artery disease and gynecological cancer, there are no nationally representative studies of mortality and cost effectiveness for percutaneous coronary interventions (PCI) and this cancer type.

Methods

Backward propagation neural network machine learning supported and propensity score adjusted multivariable regression was conducted for the above outcomes in this case-control study of the 2016 National Inpatient Sample (NIS), the United States' largest all-payer hospitalized dataset. Regression models were fully adjusted for age, race, income, geographic region, cancer metastases, mortality risk, and the likelihood of undergoing PCI (and also with length of stay [LOS] for cost). Analyses were also adjusted for the complex survey design to produce nationally representative estimates. Centers for Disease Control and Prevention (CDC)-based cost effectiveness ratio (CER) analysis was performed.

Results

Of the 30,195,722 hospitalized patients meeting criteria, 1.27% had gynecological cancer of whom 0.02% underwent PCI including 0.04% with metastases. In propensity score adjusted regression among all patients, the interaction of PCI and gynecological cancer (vs. not having PCI) significantly reduced mortality (OR 0.53, 95%CI 0.36–0.77; p = 0.001) while increasing LOS (Beta 1.16 days, 95%CI 0.57–1.75; p < 0.001) and total cost (Beta $31,035.46, 95%CI 26758.86–35312.06; p < 0.001). Among gynecological cancer patients, mortality was significantly reduced by PCI (OR 0.58, 95%CI 0.39–0.85; p = 0.006) and being in East North Central, West North Central, South Atlantic, and Mountain regions (all p < 0.03) compared to New England. PCI reduced mortality but not significantly for metastatic patients (OR 0.74, 95%CI 0.32–1.71; p = 0.481). Eighteen extra gynecological cancer patients' lives were saved with PCI for a net national cost of $3.18 billion and a CER of $176.50 million per averted death.

Conclusion

This large propensity score analysis suggests that PCI may cost inefficiently reduce mortality for gynecological cancer patients, amid income and geographic disparities in outcomes.

Trends in hospitalized patients with cancer and stress cardiomyopathy

Introduction

Although cardiovascular disease (CVD) and cancer remain the top two causes of death worldwide, novel therapeutics have resulted in a decreased mortality rate in both groups. Accordingly, there has been a heightened awareness of patients with cancer experiencing stress cardiomyopathy (SC). In patients with cancer, the emotional stress of the diagnosis of cancer is compounded by the physical stress of treatments such as surgery, chemotherapy, immunotherapy, and radiotherapy. Previous studies have shown that SC in patients with cancer is associated with higher odds of in-hospital mortality when compared to patients with SC alone. No studies have examined the differences between patients with active cancer and SC compared to patients with active cancer without SC.

Purpose

To explore the unique impact that a diagnosis of SC has on patients with specific types of cancer, so that clinicians may recognize these phenomena and reduce morbidity associated with this disease.

Methods

We queried the 2016 United States National Inpatient Sample, which is the largest publicly available all-payer inpatient healthcare database, to identify demographic characteristics and outcomes in patients with active cancer and SC.

Results

Of 30,195,722 adult hospitalized patients, 4,719,591 (15.63%) had active cancer of whom 568,239 (12.04%) had SC. Among patients with active cancer, patients with SC versus those without SC were significantly more likely to have the following characteristics: female sex, white race, commercial insurance, hypertension, anemia, thrombocytopenia, and coagulation disorder (p<0.003 for all variables). The five most common primary malignancies in patients with SC were breast (13.4%), lung (10.2%), skin (9.5%), colon (8.1%), and leukemia (4.8%) (Figure 1).

In machine learning-augmented propensity score-adjusted multivariable regression fully adjusting for age, race, income, and presence of metastases, the only primary malignancies that significantly increased the likelihood of SC were lung cancer (OR 1.25; p=0.003) and breast cancer (OR 1.81; p<0.001) (Table 1). In separate regression, neither SC alone nor having both SC and cancer was significantly associated with mortality. The presence of concomitant SC and breast cancer was significantly associated with reduced mortality (OR 0.48; p=0.032).

Conclusion

In patients with active cancer, SC was not associated with in-hospital mortality. In addition, patients with both SC and breast cancer had significantly reduced mortality when compared to all patients with cancer. Further investigation will be necessary to confirm these findings and determine the possible protective factors in patients with SC and breast cancer. Furthermore, clinicians should be aware, early during hospitalization, of the increased likelihood of SC in patients with lung cancer and breast cancer, in order to reduce morbidity associated with these diagnoses.

Funding Acknowledgement

Type of funding sources: None.

Stress cardiomyopathy in hospitalized patients with cancer: machine learning analysis by primary malignancy type

Aims

Previous studies have shown that patients with stress (Takotsubo) cardiomyopathy (SC) and cancer have higher in‐hospital mortality than patients with SC alone. No studies have examined outcomes in patients with active cancer and SC compared to patients with active cancer without SC. We aimed to assess the potential association between primary malignancy type and SC and their shared interaction with inpatient mortality.

Methods and results

We analysed SC by primary malignancy type with propensity score adjusted multivariable regression and machine learning analysis using the 2016 United States National Inpatient Sample. Of 30 195 722 adult hospitalized patients, 4 719 591 had active cancer, of whom 568 239 had SC. The mean age of patients with cancer and SC was 69.1, of which 74.7% were women. Among patients with cancer, those with SC were more likely to be female and have white race, Medicare insurance, hypertension, heart failure with reduced ejection fraction, obesity, cerebrovascular disease, anaemia, and chronic obstructive pulmonary disease (P < 0.003 for all). In machine learning‐augmented, propensity score multivariable regression adjusted for age, race, and income, only lung cancer [OR 1.25; 95% CI: 1.08–1.46; P = 0.003] and breast cancer [OR 1.81; 95% CI: 1.62–2.02; P < 0.001] were associated with a significantly increased likelihood of SC. Neither SC alone nor having both SC and cancer was significantly associated with in‐hospital mortality. The presence of concomitant SC and breast cancer was significantly associated with reduced mortality (OR 0.48; 95% CI: 0.25–0.94; P = 0.032).

Conclusions

This analysis demonstrates that primary malignancy type influences the likelihood of developing SC. Further studies will be necessary to delineate characteristics in patients with lung cancer and breast cancer which contribute to development of SC. Additional investigation should confirm lower mortality in patients with SC and breast cancer and determine possible explanations and protective factors.

Schistosomiasis and liver disease: Learning from the past to understand the present

To diagnose schistosomiasis, past medical history review should include recent travel to or from an endemic area, a history of elevated liver enzymes as well as contact with contaminated sources of water or farm animals.

P3629Invasive versus medical management of non-ST elevation myocardial infarction in cancer patients: knowledge is bliss

Background

Cancer patients with non-ST elevation myocardial infarction (NSTEMI) frequently present with comorbidities (e.g., anaemia, thrombocytopenia) that discourage invasive treatment.

Purpose

To compare outcomes of cancer patients with NSTEMI treated with optimal medical therapy (OMT) + percutaneous coronary intervention (PCI) versus OMT alone and to identify variables associated with overall survival (OS).

Methods

All cancer patients diagnosed with NSTEMI between March 2016 and December 2018 at our institution were included. Patients were classified based on treatment of NSTEMI into 2 groups: invasive strategy or OMT alone. The invasive group was further classified into early (PCI≤72 hours since presentation) or delayed strategy (PCI>72 hours). Clinical and laboratory data, oncologic history, major adverse cardiovascular events, and survival were collected. Univariate Cox proportional hazards regression analyses were conducted to identify variables associated with OS.

Results

We included 201 patients with a mean age of 68±11 years, 136 (68%) of which were women. Median OS was 13 months. Factors influencing OS are presented in Table I. Patients receiving PCI had better OS compared to patients treated with OMT only (Figure 1, p<0.0001). Procedure-related complications were non-fatal and present in 2 (1.85%) cases.

Table I Covariate Hazard Ratio (95% confidence interval) p-value Early invasive treatment (≤72 hours) 0.327 (0.207–0.516) <0.0001 Delayed invasive treatment (>72 hours) 0.496 (0.252–0.977) 0.0426 Presenting symptom: chest pain 0.406 (0.254–0.649) 0.0002 Presenting symptom: others 1.869 (1.223–2.855) 0.0039 Single agent antiplatelet therapy 0.434 (0.263–0.716) 0.0011 Dual agent antiplatelet therapy 0.294 (0.174–0.496) <0.0001 Statins 0.440 (0.276–0.703) 0.0006 Active cancer 4.487 (1.646–12.234) 0.0033 Prior chemotherapy 2.312 (1.328–4.023) 0.0030 Prior chest radiation 1.752 (1.065–2.884) 0.0272 Active chemotherapy 1.931 (1.271–2.934) 0.0021

Figure 1

Conclusions

An invasive management of NSTEMI in cancer patients, especially within 72 hours, appears to be associated with improved OS. Patients presenting with symptoms other than chest pain were less likely to undergo PCI and had worse outcomes. Active cancer, a history of chest radiation, and active or prior chemotherapy were also associated with decreased OS.

Acknowledgement/Funding

None

Predictors of mortality following cardiac surgery for carcinoid heart disease

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Background: Carcinoid Heart Disease (CHD) complicates 50% of carcinoid syndrome cases and represents a major cause of mortality in these patients. Surgery continues to be the only strategy to improve survival in CHD. We aimed to evaluate predictors of mortality following surgery for CHD. Methods: We retrospectively analyzed patients with CHD and a history of valve surgery presenting at a tertiary cancer center between November 2005 and March 2018. Data regarding symptoms, clinical findings, and CHD treatment were collected. Overall survival (OS, time interval from heart surgery to death) was calculated. Univariate Cox proportional hazards regression analyses were conducted to identify variables that were associated with OS. Results: We identified 25 patients with CHD who underwent surgical replacement with bioprosthetic valves: 10 (40%) the tricuspid valve (TV), 11 (44%) TV and pulmonary valve (PV), 3 (12%) TV, PV, and aortic valve, and 1 (4%) all 4 valves. Among them, 19 (76%) survived at least 12 months after the surgery. Clinical factors associated with decreased OS are presented in Table 1. Conclusions: OS following surgery is dictated by the severity of CHD at the time of surgery. Worse outcomes are predicted by a history of congestive heart failure, the number of symptoms, and ascites. Better selection criteria are needed in order to choose the candidates for surgery who will benefit the most. [Table: see text]

Enormous haemangioma of the liver

Haemangiomas are the most common benign tumours of the liver. Their origin lies in the proliferation of the vascular endothelium. Their growth mechanism is by dilation. They are considered giant when they exceed 5 cm at their greatest diameter. Very uncommon presentations surpass 15 cm; these are known as enormous haemangiomas. We present a case of a 54-year-old woman with an enormous haemangioma of 30 cm in diameter. A mass was present in her right upper quadrant along with dull abdominal pain for several years. It is unknown for how long the tumour had been developing. She underwent surgical management due to evident mass effect. Clinicians should be aware of the importance of early diagnosis in these types of tumours. Its erratic growth pattern, mass effect-related complications and the capacity of producing haematological abnormalities makes it an entity to be considered.

Impact of cardiopulmonary resuscitation (CPR) on the survival of patients with cancer: DNR before or after cardiac arrest?

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Background: Cardiopulmonary resuscitation (CPR) after cardiac arrest in cancer patients is associated with lower survival rates when compared to non-cancer patients. The quality of life of those who survive after CPR to be discharged is often diminished. Among these patients there is a high likelihood of changing their code status to DNR. Methods: Our study determines the overall survival rate, the survival to discharge rate, and the DNR change rate postcode among cancer patients who underwent CPR in our cancer center. Data was analyzed retrospectively from electronic records of cancer patients who had cardiac arrest and underwent CPR between April 2017 and March 2018 at a tertiary cancer center. The end points included the overall survival immediately after CPR, the survival rate at 24h, the survival to discharge rate, and the DNR change rate postcode. Results: Between 2017 and 2018, a total of 396 codes were registered in cancer patients in our center, out of which 53% had cardiopulmonary arrest as trigger event. In more than 90% of the patients, average chest compression rate, average compression rate, average compression depth, and overall compression in the targeted zone were obtained, meeting all the required criteria to deliver high-quality CPR. Overall survival rate in cancer patients was 79% after CPR efforts. The survival rate at 24h was 48%, while the rate of survival to discharge was 17%. 64% of the patients changed their code status to DNR in critical care settings. Conclusions: The prognosis remains poor for cancer patients undergoing CPR. A significant proportion of patients who survive CPR will become DNR postcode. Physicians should effectively and honestly engage in discussing end of life matters with their cancer patients.

Stress-Induced Cardiomyopathy in Cancer Patients

Takotsubo syndrome, also known as stress-induced cardiomyopathy (SC), is underrecognized in cancer patients. This study aims to investigate the incidence, natural history, and triggers of SC in cancer patients and its impact on cancer therapy and overall survival. A total of 30 subjects fulfilled the diagnostic criteria for SC at MD Anderson Cancer Center over a 6-year period. Clinical presentation, electrocardiogram, laboratory data, and transthoracic echocardiogram results registered during the acute phase and follow-up were collected. All patients underwent coronary angiography. The most frequent presenting symptoms were chest pain in 63.3% of the patients and shortness of breath/dyspnea on exertion in 27% of the patients. T-wave inversion was a more common electrocardiographic presentation (60%) than ST elevation (13.3%). The median and interquartile range of peak creatine kinase MB fraction, troponin I, and brain natriuretic peptide were creatine kinase MB fraction 8.9, 4.6 to 21.1; troponin I 1.31, 0.7 to 3.3; and brain natriuretic peptide 1,124, 453.5 to 2,369.5. The most common complication of SC was cardiogenic shock requiring inotropic agents (20%). Of the 21 patients who required ongoing cancer treatment, 16 were able to resume chemotherapy, 5 underwent surgery, and 4 received radiation treatment. Median time to resume cancer treatment was 20 days after SC. None of the patients experienced recurrence of SC and other cardiac events. In conclusion, SC should be considered in the differential diagnosis of cancer patients who present with chest pain and ECG findings characteristic of acute coronary syndrome. Most of these patients normalize ejection fraction and may resume cancer therapy early.

Midcavitary Tako-Tsubo syndrome in cancer patients

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Background:Variants of the classic Tako-tsubo syndrome or stress induced cardiomyopathy (SC) includes mid ventricular or basal left ventricular wall motion abnormalities. Midcavitary dyskinesia and ballooning is considered a unique presentation, and there is no published data showing midcavitary involvement in cancer patients. Methods: All cancer patients who fulfilled the diagnostic criteria for SC at MD Anderson Cancer Center over a 6–year period were included in the study. We selected and retrospectively reviewed the medical records of 8 patients who had midcavitary SC. Clinical presentation, ECG, laboratory data, transthoracic echocardiogram and left ventriculography results were reviewed. Results: Out of30 cancer patients who fulfilled the diagnostic criteria for SC, 8 patients (26.7%) (4 females, 4 men, mean age 57.37 yo) had midcavitary SC. 62,5 % patients were diagnosed with a solid malignancy. Trigger factors for midcavitary SC were: systemic infection (3 patients with neutropenia), emotional stress (2 patients), chemotherapy (1 patient undergoing treatment with Ibrutinib), and surgical interventions (3 patients). Clinical presentation included chest pain (37.5%), shortness of breath (50%) and non specific symptoms (12.5%). T wave inversion was the most common electrocardiographic presentation (37.5 %), followed by ST elevation (25 %). All patients had changes of the cardiac biomarkers (BNP mean 2224. 4 pg/dl, TN I mean 2. 8 ng/dl, CK-MB mean 14 ng/dl) and significant LV dysfunction (LVEF < 50%). All patients underwent coronary angiography which showed no obstructive CAD; left ventriculography identified basilar and apical hyperkinesis and midventricular hypokinesia. Cancer therapy was interrupted; aspirin and beta blockers were initiated in all patients. The most common complications of midcavitary SC were: respiratory failure requiring intubation (37, 5%), pulmonary edema (25%), and hypotension (25%). No cardiac deaths were registered. None of the patients experienced recurrence of SC. Conclusions: Mid cavitary SC remains a rare entity, and raises further questions about the causal association between the mid cavitary involvement and cancer, and its impact on cancer therapy and overall survival in this cohort of patients.

Tako-tsubo syndrome and use of paclitaxel

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Background: Vasospasm and arrhythmias are the main cardiac toxic effects of cancer treatment with Paclitaxel. Chemotherapy induced stress cardiomyopathy (SC) (Tako-tsubo syndrome) has been linked to antineoplastic agents associated with abnormal vasoreactivity. We aimed to identify if there is a causal relationship between SC and Paclitaxel administration. Methods: All cancer patients who fulfilled the diagnostic criteria for SC at MD Anderson Cancer Center over a 6–year period were included in the study. We selected and retrospectively reviewed the medical records of all the patients who had chemotherapy induced SC. Clinical presentation, ECG, laboratory data, transthoracic echocardiogram and coronary angiography results were reviewed. Results: Out of30 patients who fulfilled the diagnostic criteria for SC, 5 patients (16.6%) had SC triggered by chemotherapy. Three patients (2 females, 1 male, mean age 71.3 yo) had Paclitaxel induced SC (60%); two patients received a combination of Paclitaxel and Carboplatin for ovarian cancer, and one patient had combination of Paclitaxel and Cyclophosphamide for prostate cancer. Two patients had cardiac manifestations in the first day of Paclitaxel administration. All three patients presented with chest pain; T wave inversion was the main finding on the electrocardiography. All patients had changes in the cardiac biomarkers (BNP mean 1459.7 pg/dl, TN I mean 1.36 ng/dl, CK-MB mean 8.6 ng/dl) and significant LV dysfunction (LVEF < 50%). Characteristic apical ballooning pattern was identified in all cases from left ventriculogram. Chemotherapy was interrupted ; aspirin and beta blockers were initiated in all patients. Two patients were rechallenged with chemotherapy after 10 days, respectively 20 days after SC. None of the patients experienced recurrence of SC, nor arrhythmias while on aspirin and beta blockers. Conclusions: To our knowledge there are no published data on the association of Paclitaxel administration and SC. In cancer patients who develop acute chest pain after administration of Paclitaxel, evaluation for SC is important to exclude NSTEMI diagnosis, which can impact further cancer therapy. Cancer patients with SC whom have complete recovery may early resume cancer therapy.

Ischemic Heart Disease: Special Considerations in Cardio-Oncology

OPINION STATEMENT

The interplay and balance between the competing morbidity and mortality of cardiovascular diseases and cancer have a significant impact on both short- and long-term health outcomes of patients who survived cancer or are being treated for cancer. Ischemic heart disease in patients with cancer or caused by cancer therapy is a clinical problem of emerging importance. Prompt recognition and optimum management of ischemic heart disease mean that patients with cancer can successfully receive therapies to treat their malignancy and reduce morbidity and mortality due to cardiovascular disease. In this sense, the presence of cancer and cancer-related comorbidities (e.g., thrombocytopenia, propensity to bleed, thrombotic status) substantially complicates the management of cardiovascular diseases in cancer patients. In this review, we will summarize the current state of knowledge on the management strategies for ischemic disease in patients with cancer, focusing on the challenges encountered when addressing these complexities.

[Colonic Crohn's disease, the total form]

A rectocolic localisation of the Crohn disease, total form-ulcero-granulomatous rectocolitis, which started an a colitic chronic syndrome with secondary anemia, is described. The radiological investigation shows aspects characteristic of the ulcero-granulomatous colitis (disappearance of the haustra coli and a relative stenosis of the sigmoid) (fig. 1 and 2). The biopsy from the superior mucous membrane of the rectum disclose an inflammatory chronic granulomatous process. A temporary derivative right subangulocolic transverse-right paraumbilical anus is performed (Iliescu). The biopsy from the colic wall at the level of the derivative anus shows the same inflammatory granulomatous chronic process. A medical treatment with salazopyrine and cortisone is carried ou for 6 months. Favourable course. Reexamined radiologically, the patient shows a quasi-complete stenosis of the left colic border and of the transverse up to the derivative anus (fig. 3 and 4). After one year of medical treatment, the problem will be contemplated of the eventual reestablishment of the transit by shunting only to the right colon and the superior rectum, the only areas spared for the moment by the cicatricial stenosis (fig. 5). The coding of the medical and surgical treatment in the extensive forms of the colic Crohn disease is discussed in the light of the world medical literature.

[Pyoroplasty with "cruciform" incision of the pylorus]

In cases when the pylorus area is significantly modified by the presence of the ulcerative lesions, frequently associated with hypertrophy of the pyloric sphincter, which does not allow to carry out in satisfactory conditions pyloroplasty of the Heinecke-Mikulicz type, the author introduces an improvement of the above mentioned technique by adding anterior sphincterectomy, obtained by a "cross like" incision of the pylorus. The final suture of the pyloroplasty is exclusively of the transversal type, in a single or in a double layer, when the lumina of the pylorus allows for such a suture.