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Ng IKS, Tan LF, Kumarakulasinghe NB, Goh WGW, Ngiam N, Teo DB. Providing family updates: a primer for the medical trainee. Postgrad Med J 2024; 100:344-349. [PMID: 38272463 DOI: 10.1093/postmj/qgad143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2023] [Revised: 12/12/2023] [Accepted: 12/18/2023] [Indexed: 01/27/2024]
Abstract
Providing family updates is a common clinical task for medical trainees and practitioners working in hospital settings. Good clinical communication skills are essential in clinical care as it is associated with improved patient satisfaction, understanding of condition, treatment adherence, and better overall clinical outcomes. Moreover, poor communications are often the source of medical complaints. However, while patient-centred communication skills training has generally been incorporated into clinical education, there hitherto remains inadequate training on clinical communications with patients' families, which carry different nuances. In recent years, it is increasingly recognized that familial involvement in the care of hospitalized patients leads to better clinical and psychological outcomes. In fact, in Asian populations with more collectivistic cultures, families are generally highly involved in patient care and decision-making. Therefore, effective clinical communications and regular provision of family updates are essential to build therapeutic rapport, facilitate familial involvement in patient care, and also provide a more holistic understanding of the patient's background and psychosocial set-up. In this article, we herein describe a seven-step understand the clinical context, gather perspectives, deliver medical information, address questions, concerns and expectations, provide tentative plans, demonstrate empathy, postcommunication reflections model as a practical guide for medical trainees and practitioners in provision of structured and effective family updates in their clinical practice.
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Affiliation(s)
- Isaac K S Ng
- Department of Medicine, National University Hospital, Singapore 119228, Singapore
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore 117597, Singapore
| | - Li Feng Tan
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore 117597, Singapore
- Healthy Ageing Programme, Alexandra Hospital, Singapore 159964, Singapore
| | - Nesaretnam Barr Kumarakulasinghe
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore 117597, Singapore
- Department of Haematology-Oncology, National University Cancer Institute of Singapore, Singapore 119228, Singapore
| | - Wilson G W Goh
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore 117597, Singapore
- Division of Infectious Diseases, Department of Medicine, National University Hospital, Singapore 119228, Singapore
| | - Nicola Ngiam
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore 117597, Singapore
- Khoo Teck Puat-National University Children's Medical Institute, National University Hospital, Singapore 119074, Singapore
| | - Desmond B Teo
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore 117597, Singapore
- Fast and Chronic Programmes, Alexandra Hospital, Singapore 159964, Singapore
- Division of Advanced Internal Medicine, Department of Medicine, National University Hospital, Singapore 119228, Singapore
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Hallinan JTPD, Zhu L, Zhang W, Ge S, Muhamat Nor FE, Ong HY, Eide SE, Cheng AJL, Kuah T, Lim DSW, Low XZ, Yeong KY, AlMuhaish MI, Alsooreti A, Kumarakulasinghe NB, Teo EC, Yap QV, Chan YH, Lin S, Tan JH, Kumar N, Vellayappan BA, Ooi BC, Quek ST, Makmur A. Deep learning assessment compared to radiologist reporting for metastatic spinal cord compression on CT. Front Oncol 2023; 13:1151073. [PMID: 37213273 PMCID: PMC10193838 DOI: 10.3389/fonc.2023.1151073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Accepted: 03/16/2023] [Indexed: 05/23/2023] Open
Abstract
Introduction Metastatic spinal cord compression (MSCC) is a disastrous complication of advanced malignancy. A deep learning (DL) algorithm for MSCC classification on CT could expedite timely diagnosis. In this study, we externally test a DL algorithm for MSCC classification on CT and compare with radiologist assessment. Methods Retrospective collection of CT and corresponding MRI from patients with suspected MSCC was conducted from September 2007 to September 2020. Exclusion criteria were scans with instrumentation, no intravenous contrast, motion artefacts and non-thoracic coverage. Internal CT dataset split was 84% for training/validation and 16% for testing. An external test set was also utilised. Internal training/validation sets were labelled by radiologists with spine imaging specialization (6 and 11-years post-board certification) and were used to further develop a DL algorithm for MSCC classification. The spine imaging specialist (11-years expertise) labelled the test sets (reference standard). For evaluation of DL algorithm performance, internal and external test data were independently reviewed by four radiologists: two spine specialists (Rad1 and Rad2, 7 and 5-years post-board certification, respectively) and two oncological imaging specialists (Rad3 and Rad4, 3 and 5-years post-board certification, respectively). DL model performance was also compared against the CT report issued by the radiologist in a real clinical setting. Inter-rater agreement (Gwet's kappa) and sensitivity/specificity/AUCs were calculated. Results Overall, 420 CT scans were evaluated (225 patients, mean age=60 ± 11.9[SD]); 354(84%) CTs for training/validation and 66(16%) CTs for internal testing. The DL algorithm showed high inter-rater agreement for three-class MSCC grading with kappas of 0.872 (p<0.001) and 0.844 (p<0.001) on internal and external testing, respectively. On internal testing DL algorithm inter-rater agreement (κ=0.872) was superior to Rad 2 (κ=0.795) and Rad 3 (κ=0.724) (both p<0.001). DL algorithm kappa of 0.844 on external testing was superior to Rad 3 (κ=0.721) (p<0.001). CT report classification of high-grade MSCC disease was poor with only slight inter-rater agreement (κ=0.027) and low sensitivity (44.0), relative to the DL algorithm with almost-perfect inter-rater agreement (κ=0.813) and high sensitivity (94.0) (p<0.001). Conclusion Deep learning algorithm for metastatic spinal cord compression on CT showed superior performance to the CT report issued by experienced radiologists and could aid earlier diagnosis.
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Affiliation(s)
- James Thomas Patrick Decourcy Hallinan
- Department of Diagnostic Imaging, National University Hospital, Singapore, Singapore
- Department of Diagnostic Radiology, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- *Correspondence: James Thomas Patrick Decourcy Hallinan,
| | - Lei Zhu
- Department of Computer Science, School of Computing, National University of Singapore, Singapore, Singapore
| | - Wenqiao Zhang
- Department of Computer Science, School of Computing, National University of Singapore, Singapore, Singapore
| | - Shuliang Ge
- Department of Diagnostic Imaging, National University Hospital, Singapore, Singapore
| | - Faimee Erwan Muhamat Nor
- Department of Diagnostic Imaging, National University Hospital, Singapore, Singapore
- Department of Diagnostic Radiology, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Han Yang Ong
- Department of Diagnostic Imaging, National University Hospital, Singapore, Singapore
- Department of Diagnostic Radiology, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Sterling Ellis Eide
- Department of Diagnostic Imaging, National University Hospital, Singapore, Singapore
- Department of Diagnostic Radiology, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Amanda J. L. Cheng
- Department of Diagnostic Imaging, National University Hospital, Singapore, Singapore
- Department of Diagnostic Radiology, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Tricia Kuah
- Department of Diagnostic Imaging, National University Hospital, Singapore, Singapore
| | - Desmond Shi Wei Lim
- Department of Diagnostic Imaging, National University Hospital, Singapore, Singapore
| | - Xi Zhen Low
- Department of Diagnostic Imaging, National University Hospital, Singapore, Singapore
| | - Kuan Yuen Yeong
- Department of Radiology, Ng Teng Fong General Hospital, Singapore, Singapore
| | - Mona I. AlMuhaish
- Department of Diagnostic Imaging, National University Hospital, Singapore, Singapore
- Department of Radiology, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
| | - Ahmed Mohamed Alsooreti
- Department of Diagnostic Imaging, National University Hospital, Singapore, Singapore
- Department of Diagnostic Imaging, Salmaniya Medical Complex, Manama, Bahrain
| | | | - Ee Chin Teo
- Department of Diagnostic Imaging, National University Hospital, Singapore, Singapore
| | - Qai Ven Yap
- Biostatistics Unit, Yong Loo Lin School of Medicine, Singapore, Singapore
| | - Yiong Huak Chan
- Biostatistics Unit, Yong Loo Lin School of Medicine, Singapore, Singapore
| | - Shuxun Lin
- Division of Spine Surgery, Department of Orthopaedic Surgery, Ng Teng Fong General Hospital, Singapore, Singapore
| | - Jiong Hao Tan
- University Spine Centre, Department of Orthopaedic Surgery, National University Health System, Singapore, Singapore
| | - Naresh Kumar
- University Spine Centre, Department of Orthopaedic Surgery, National University Health System, Singapore, Singapore
| | - Balamurugan A. Vellayappan
- Department of Radiation Oncology, National University Cancer Institute Singapore, National University Hospital, Singapore, Singapore
| | - Beng Chin Ooi
- Department of Computer Science, School of Computing, National University of Singapore, Singapore, Singapore
| | - Swee Tian Quek
- Department of Diagnostic Imaging, National University Hospital, Singapore, Singapore
- Department of Diagnostic Radiology, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Andrew Makmur
- Department of Diagnostic Imaging, National University Hospital, Singapore, Singapore
- Department of Diagnostic Radiology, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
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Hallinan JTPD, Ge S, Zhu L, Zhang W, Lim YT, Thian YL, Jagmohan P, Kuah T, Lim DSW, Low XZ, Teo EC, Barr Kumarakulasinghe N, Yap QV, Chan YH, Tan JH, Kumar N, Vellayappan BA, Ooi BC, Quek ST, Makmur A. Diagnostic Accuracy of CT for Metastatic Epidural Spinal Cord Compression. Cancers (Basel) 2022; 14:cancers14174231. [PMID: 36077767 PMCID: PMC9454807 DOI: 10.3390/cancers14174231] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Revised: 08/23/2022] [Accepted: 08/25/2022] [Indexed: 11/16/2022] Open
Abstract
Background: Early diagnosis of metastatic epidural spinal cord compression (MESCC) is vital to expedite therapy and prevent paralysis. Staging CT is performed routinely in cancer patients and presents an opportunity for earlier diagnosis. Methods: This retrospective study included 123 CT scans from 101 patients who underwent spine MRI within 30 days, excluding 549 CT scans from 216 patients due to CT performed post-MRI, non-contrast CT, or a gap greater than 30 days between modalities. Reference standard MESCC gradings on CT were provided in consensus via two spine radiologists (11 and 7 years of experience) analyzing the MRI scans. CT scans were labeled using the original reports and by three radiologists (3, 13, and 14 years of experience) using dedicated CT windowing. Results: For normal/none versus low/high-grade MESCC per CT scan, all radiologists demonstrated almost perfect agreement with kappa values ranging from 0.866 (95% CI 0.787–0.945) to 0.947 (95% CI 0.899–0.995), compared to slight agreement for the reports (kappa = 0.095, 95%CI −0.098–0.287). Radiologists also showed high sensitivities ranging from 91.51 (95% CI 84.49–96.04) to 98.11 (95% CI 93.35–99.77), compared to 44.34 (95% CI 34.69–54.31) for the reports. Conclusion: Dedicated radiologist review for MESCC on CT showed high interobserver agreement and sensitivity compared to the current standard of care.
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Affiliation(s)
- James Thomas Patrick Decourcy Hallinan
- Department of Diagnostic Imaging, National University Hospital, 5 Lower Kent Ridge Rd, Singapore 119074, Singapore
- Department of Diagnostic Radiology, Yong Loo Lin School of Medicine, National University of Singapore, 10 Medical Drive, Singapore 117597, Singapore
- Correspondence:
| | - Shuliang Ge
- Department of Diagnostic Imaging, National University Hospital, 5 Lower Kent Ridge Rd, Singapore 119074, Singapore
- Department of Diagnostic Radiology, Yong Loo Lin School of Medicine, National University of Singapore, 10 Medical Drive, Singapore 117597, Singapore
| | - Lei Zhu
- Department of Computer Science, School of Computing, National University of Singapore, 13 Computing Drive, Singapore 117417, Singapore
| | - Wenqiao Zhang
- Department of Computer Science, School of Computing, National University of Singapore, 13 Computing Drive, Singapore 117417, Singapore
| | - Yi Ting Lim
- Department of Diagnostic Imaging, National University Hospital, 5 Lower Kent Ridge Rd, Singapore 119074, Singapore
- Department of Diagnostic Radiology, Yong Loo Lin School of Medicine, National University of Singapore, 10 Medical Drive, Singapore 117597, Singapore
| | - Yee Liang Thian
- Department of Diagnostic Imaging, National University Hospital, 5 Lower Kent Ridge Rd, Singapore 119074, Singapore
- Department of Diagnostic Radiology, Yong Loo Lin School of Medicine, National University of Singapore, 10 Medical Drive, Singapore 117597, Singapore
| | - Pooja Jagmohan
- Department of Diagnostic Imaging, National University Hospital, 5 Lower Kent Ridge Rd, Singapore 119074, Singapore
- Department of Diagnostic Radiology, Yong Loo Lin School of Medicine, National University of Singapore, 10 Medical Drive, Singapore 117597, Singapore
| | - Tricia Kuah
- Department of Diagnostic Imaging, National University Hospital, 5 Lower Kent Ridge Rd, Singapore 119074, Singapore
| | - Desmond Shi Wei Lim
- Department of Diagnostic Imaging, National University Hospital, 5 Lower Kent Ridge Rd, Singapore 119074, Singapore
| | - Xi Zhen Low
- Department of Diagnostic Imaging, National University Hospital, 5 Lower Kent Ridge Rd, Singapore 119074, Singapore
| | - Ee Chin Teo
- Department of Diagnostic Imaging, National University Hospital, 5 Lower Kent Ridge Rd, Singapore 119074, Singapore
| | - Nesaretnam Barr Kumarakulasinghe
- National University Cancer Institute, NUH Medical Centre (NUHMC), Levels 8–10, 5 Lower Kent Ridge Road, Singapore 119074, Singapore
| | - Qai Ven Yap
- Biostatistics Unit, Yong Loo Lin School of Medicine, 10 Medical Drive, Singapore 117597, Singapore
| | - Yiong Huak Chan
- Biostatistics Unit, Yong Loo Lin School of Medicine, 10 Medical Drive, Singapore 117597, Singapore
| | - Jiong Hao Tan
- University Spine Centre, Department of Orthopaedic Surgery, National University Health System, 1E, Lower Kent Ridge Road, Singapore 119228, Singapore
| | - Naresh Kumar
- University Spine Centre, Department of Orthopaedic Surgery, National University Health System, 1E, Lower Kent Ridge Road, Singapore 119228, Singapore
| | - Balamurugan A. Vellayappan
- Department of Radiation Oncology, National University Cancer Institute Singapore, National University Hospital, Singapore 119074, Singapore
| | - Beng Chin Ooi
- Department of Computer Science, School of Computing, National University of Singapore, 13 Computing Drive, Singapore 117417, Singapore
| | - Swee Tian Quek
- Department of Diagnostic Imaging, National University Hospital, 5 Lower Kent Ridge Rd, Singapore 119074, Singapore
- Department of Diagnostic Radiology, Yong Loo Lin School of Medicine, National University of Singapore, 10 Medical Drive, Singapore 117597, Singapore
| | - Andrew Makmur
- Department of Diagnostic Imaging, National University Hospital, 5 Lower Kent Ridge Rd, Singapore 119074, Singapore
- Department of Diagnostic Radiology, Yong Loo Lin School of Medicine, National University of Singapore, 10 Medical Drive, Singapore 117597, Singapore
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Sooi K, Low JL, Miow QH, Kumarakulasinghe NB, Sundar R, Huang Y. Pan-immune-inflammation value as a predictive biomarker for survival in advanced non-small cell lung cancer patients treated with immunotherapy. J Clin Oncol 2022. [DOI: 10.1200/jco.2022.40.16_suppl.e21095] [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
e21095 Background: It is well known that chronic inflammation can enable immune escape by suppressing immune surveillance. This promotes cancer growth and development, which forms the basis of immune checkpoint inhibitors use. Pan-Immune-Inflammation Value (PIV), a type of immune-inflammatory biomarker, has shown predictive value in various cancer patient populations (colorectal, melanoma, breast, oesophagus, ALK-positive lung cancer) and patients with ANCA-associated vasculitis. We aimed to evaluate the role of PIV as a predictive biomarker in advanced non-small cell lung cancer (NSCLC), whereby immune checkpoint inhibitor therapy is frequently used. Methods: We conducted a retrospective review of advanced NSCLC patients who received immunotherapy in the National University Hospital, Singapore between January 2015 and January 2022. PIV was calculated as: (neutrophil count × platelet count × monocyte count)/lymphocyte count, with the median value used to distinguish between high and low PIV. Kaplan–Meier method and Cox proportional hazards regression models were used for survival analyses. Results: 203 patients were included in the study. The median age was 63, 70% were males, 76% were Chinese, 83% had ECOG Performance Status ≤1 and 70% had adenocarcinoma histology. The immunotherapy agents used were Pembrolizumab (82%), Nivolumab (13%) and Atezolizumab (5%). Chemotherapy was given in conjunction with immunotherapy in 37% of the population. The median PIV value derived was 790 and patients with a low baseline PIV experienced better progression-free survival (PFS) and overall survival (OS). The median PFS was 249 days in PIV-low vs 145 days in PIV-high cohorts (hazard ratio for progression or death from any cause [HR] 0.58, 95% Confidence Interval [CI] 0.40-0.86, p < 0.01) and the median OS was 794 days in PIV-low vs 420 days in PIV-high cohorts (HR 0.69, 95% CI 0.49-0.96, p = 0.03). Patients who had higher PIV, ECOG performance status ≥2, liver metastases, immunotherapy exposure in 2nd line or later, use of immunotherapy alone without chemotherapy had worse OS in univariate analysis, but only PIV (HR = 1.61, 95% CI 1.08-2.40, p < 0.02) was an independent prognostic factor in multivariate analysis. Amongst the patients with known PD-L1 status (n = 158), univariate analysis showed that PD-L1 ≥1 and PD-L1 ≥50 were not prognostic for OS whereas PIV remained an independent prognostic factor in both univariate and multivariate analyses. Conclusions: PIV appears to be a strong predictor of survival outcomes for patients with advanced NSCLC receiving immunotherapy as part of their cancer treatment. Prospective clinical trials are required to validate the predictive value of PIV in NSCLC patients receiving immunotherapy, as well as evaluating PIV’s performance against PD-L1.
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Affiliation(s)
- Kenneth Sooi
- National University Health System, Singapore, Singapore
| | | | - Qing Hao Miow
- Department of Haematology-Oncology, National University Cancer Institute, Singapore, Singapore
| | | | - Raghav Sundar
- National University Health System, Singapore, Singapore
| | - Yiqing Huang
- Department of Haematology Oncology, National University Cancer Institute Singapore, Singapore, Singapore
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Hallinan JTPD, Zhu L, Zhang W, Lim DSW, Baskar S, Low XZ, Yeong KY, Teo EC, Kumarakulasinghe NB, Yap QV, Chan YH, Lin S, Tan JH, Kumar N, Vellayappan BA, Ooi BC, Quek ST, Makmur A. Deep Learning Model for Classifying Metastatic Epidural Spinal Cord Compression on MRI. Front Oncol 2022; 12:849447. [PMID: 35600347 PMCID: PMC9114468 DOI: 10.3389/fonc.2022.849447] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Accepted: 03/18/2022] [Indexed: 11/13/2022] Open
Abstract
Background Metastatic epidural spinal cord compression (MESCC) is a devastating complication of advanced cancer. A deep learning (DL) model for automated MESCC classification on MRI could aid earlier diagnosis and referral. Purpose To develop a DL model for automated classification of MESCC on MRI. Materials and Methods Patients with known MESCC diagnosed on MRI between September 2007 and September 2017 were eligible. MRI studies with instrumentation, suboptimal image quality, and non-thoracic regions were excluded. Axial T2-weighted images were utilized. The internal dataset split was 82% and 18% for training/validation and test sets, respectively. External testing was also performed. Internal training/validation data were labeled using the Bilsky MESCC classification by a musculoskeletal radiologist (10-year experience) and a neuroradiologist (5-year experience). These labels were used to train a DL model utilizing a prototypical convolutional neural network. Internal and external test sets were labeled by the musculoskeletal radiologist as the reference standard. For assessment of DL model performance and interobserver variability, test sets were labeled independently by the neuroradiologist (5-year experience), a spine surgeon (5-year experience), and a radiation oncologist (11-year experience). Inter-rater agreement (Gwet’s kappa) and sensitivity/specificity were calculated. Results Overall, 215 MRI spine studies were analyzed [164 patients, mean age = 62 ± 12(SD)] with 177 (82%) for training/validation and 38 (18%) for internal testing. For internal testing, the DL model and specialists all showed almost perfect agreement (kappas = 0.92–0.98, p < 0.001) for dichotomous Bilsky classification (low versus high grade) compared to the reference standard. Similar performance was seen for external testing on a set of 32 MRI spines with the DL model and specialists all showing almost perfect agreement (kappas = 0.94–0.95, p < 0.001) compared to the reference standard. Conclusion A DL model showed comparable agreement to a subspecialist radiologist and clinical specialists for the classification of malignant epidural spinal cord compression and could optimize earlier diagnosis and surgical referral.
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Affiliation(s)
- James Thomas Patrick Decourcy Hallinan
- Department of Diagnostic Imaging, National University Hospital, Singapore, Singapore.,Department of Diagnostic Radiology, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Lei Zhu
- NUS Graduate School, Integrative Sciences and Engineering Programme, National University of Singapore, Singapore, Singapore
| | - Wenqiao Zhang
- Department of Computer Science, School of Computing, National University of Singapore, Singapore, Singapore
| | - Desmond Shi Wei Lim
- Department of Diagnostic Imaging, National University Hospital, Singapore, Singapore.,Department of Diagnostic Radiology, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Sangeetha Baskar
- Department of Diagnostic Imaging, National University Hospital, Singapore, Singapore
| | - Xi Zhen Low
- Department of Diagnostic Imaging, National University Hospital, Singapore, Singapore.,Department of Diagnostic Radiology, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Kuan Yuen Yeong
- Department of Radiology, Ng Teng Fong General Hospital, Singapore, Singapore
| | - Ee Chin Teo
- Department of Diagnostic Imaging, National University Hospital, Singapore, Singapore
| | | | - Qai Ven Yap
- Biostatistics Unit, Yong Loo Lin School of Medicine, Singapore, Singapore
| | - Yiong Huak Chan
- Biostatistics Unit, Yong Loo Lin School of Medicine, Singapore, Singapore
| | - Shuxun Lin
- Division of Spine Surgery, Department of Orthopaedic Surgery, Ng Teng Fong General Hospital, Singapore, Singapore
| | - Jiong Hao Tan
- University Spine Centre, Department of Orthopaedic Surgery, National University Health System, Singapore, Singapore
| | - Naresh Kumar
- University Spine Centre, Department of Orthopaedic Surgery, National University Health System, Singapore, Singapore
| | - Balamurugan A Vellayappan
- Department of Radiation Oncology, National University Cancer Institute Singapore, National University Hospital, Singapore, Singapore
| | - Beng Chin Ooi
- Department of Computer Science, School of Computing, National University of Singapore, Singapore, Singapore
| | - Swee Tian Quek
- Department of Diagnostic Imaging, National University Hospital, Singapore, Singapore.,Department of Diagnostic Radiology, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Andrew Makmur
- Department of Diagnostic Imaging, National University Hospital, Singapore, Singapore.,Department of Diagnostic Radiology, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
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Malhotra C, Bundoc F, Chaudhry I, Teo I, Ozdemir S, Finkelstein E, Dent RA, Kumarakulasinghe NB, Cheung YB, Malhotra R, Kanesvaran R, Yee ACP, Chan N, Wu HY, Chin SM, Allyn HYM, Yang GM, Neo PSH, Harding R, Heng LL. A prospective cohort study assessing aggressive interventions at the end-of-life among patients with solid metastatic cancer. Palliat Care 2022; 21:73. [PMID: 35578270 PMCID: PMC9109395 DOI: 10.1186/s12904-022-00970-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2021] [Accepted: 04/12/2022] [Indexed: 01/08/2023] Open
Abstract
Background Many patients with a solid metastatic cancer are treated aggressively during their last month of life. Using data from a large prospective cohort study of patients with an advanced cancer, we aimed to assess the number and predictors of aggressive interventions during last month of life among patients with solid metastatic cancer and its association with bereaved caregivers’ outcomes. Methods We used data of 345 deceased patients from a prospective cohort study of 600 patients. We surveyed patients every 3 months until death for their physical, psychological and functional health, end-of-life care preference and palliative care use. We surveyed their bereaved caregivers 8 weeks after patients’ death regarding their preparedness about patient’s death, regret about patient’s end-of-life care and mood over the last week. Patient data was merged with medical records to assess aggressive interventions received including hospital death and use of anti-cancer treatment, more than 14 days in hospital, more than one hospital admission, more than one emergency room visit and at least one intensive care unit admission, all within the last month of life. Results 69% of patients received at least one aggressive intervention during last month of life. Patients hospitalized during the last 2–12 months of life, male patients, Buddhist or Taoist, and with breast or respiratory cancer received more aggressive interventions in last month of life. Patients with worse functional health prior to their last month of life received fewer aggressive interventions in last month of life. Bereaved caregivers of patients receiving more aggressive interventions reported feeling less prepared for patients’ death. Conclusion Findings suggest that intervening early in the sub-group of patients with history of hospitalization prior to their last month may reduce number of aggressive interventions during last month of life and ultimately positively influence caregivers’ preparedness for death during the bereavement phase. Trial registration NCT02850640. Supplementary Information The online version contains supplementary material available at 10.1186/s12904-022-00970-z.
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Sundar R, Barr Kumarakulasinghe N, Huak Chan Y, Yoshida K, Yoshikawa T, Miyagi Y, Rino Y, Masuda M, Guan J, Sakamoto J, Tanaka S, Tan ALK, Hoppe MM, Jeyasekharan AD, Ng CCY, De Simone M, Grabsch HI, Lee J, Oshima T, Tsuburaya A, Tan P. Machine-learning model derived gene signature predictive of paclitaxel survival benefit in gastric cancer: results from the randomised phase III SAMIT trial. Gut 2022; 71:676-685. [PMID: 33980610 PMCID: PMC8921574 DOI: 10.1136/gutjnl-2021-324060] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Revised: 04/26/2021] [Accepted: 04/29/2021] [Indexed: 12/17/2022]
Abstract
OBJECTIVE To date, there are no predictive biomarkers to guide selection of patients with gastric cancer (GC) who benefit from paclitaxel. Stomach cancer Adjuvant Multi-Institutional group Trial (SAMIT) was a 2×2 factorial randomised phase III study in which patients with GC were randomised to Pac-S-1 (paclitaxel +S-1), Pac-UFT (paclitaxel +UFT), S-1 alone or UFT alone after curative surgery. DESIGN The primary objective of this study was to identify a gene signature that predicts survival benefit from paclitaxel chemotherapy in GC patients. SAMIT GC samples were profiled using a customised 476 gene NanoString panel. A random forest machine-learning model was applied on the NanoString profiles to develop a gene signature. An independent cohort of metastatic patients with GC treated with paclitaxel and ramucirumab (Pac-Ram) served as an external validation cohort. RESULTS From the SAMIT trial 499 samples were analysed in this study. From the Pac-S-1 training cohort, the random forest model generated a 19-gene signature assigning patients to two groups: Pac-Sensitive and Pac-Resistant. In the Pac-UFT validation cohort, Pac-Sensitive patients exhibited a significant improvement in disease free survival (DFS): 3-year DFS 66% vs 40% (HR 0.44, p=0.0029). There was no survival difference between Pac-Sensitive and Pac-Resistant in the UFT or S-1 alone arms, test of interaction p<0.001. In the external Pac-Ram validation cohort, the signature predicted benefit for Pac-Sensitive (median PFS 147 days vs 112 days, HR 0.48, p=0.022). CONCLUSION Using machine-learning techniques on one of the largest GC trials (SAMIT), we identify a gene signature representing the first predictive biomarker for paclitaxel benefit. TRIAL REGISTRATION NUMBER UMIN Clinical Trials Registry: C000000082 (SAMIT); ClinicalTrials.gov identifier, 02628951 (South Korean trial).
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Affiliation(s)
- Raghav Sundar
- Department of Haematology-Oncology, National University Cancer Institute Singapore, National University Hospital, Singapore,Yong Loo Lin School of Medicine, National University of Singapore, Singapore,Program in Cancer and Stem Cell Biology, Duke-NUS Medical School, Singapore,The N.1 Institute for Health, National University of Singapore, Singapore
| | | | - Yiong Huak Chan
- Biostatistics Unit, Yong Loo Lin School of Medicine, National University Singapore, Singapore
| | - Kazuhiro Yoshida
- Department of Surgical Oncology, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Takaki Yoshikawa
- Department of Gastric Surgery, National Cancer Center Hospital, Tokyo, Japan
| | - Yohei Miyagi
- Kanagawa Cancer Center Research Institute, Yokohama, Japan
| | - Yasushi Rino
- Department of Surgery, Yokohama City University, Yokohama, Japan
| | - Munetaka Masuda
- Department of Surgery, Yokohama City University, Yokohama, Japan
| | - Jia Guan
- Department of Clinical Biostatistics, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | | | - Shiro Tanaka
- Department of Clinical Biostatistics, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Angie Lay-Keng Tan
- Program in Cancer and Stem Cell Biology, Duke-NUS Medical School, Singapore
| | - Michal Marek Hoppe
- Cancer Science Institute of Singapore, National University of Singapore, Singapore
| | - Anand D. Jeyasekharan
- Department of Haematology-Oncology, National University Cancer Institute Singapore, National University Hospital, Singapore,Cancer Science Institute of Singapore, National University of Singapore, Singapore
| | - Cedric Chuan Young Ng
- Laboratory of Cancer Epigenome, Department of Medical Sciences, National Cancer Centre Singapore, Singapore
| | | | - Heike I. Grabsch
- Department of Pathology, GROW - School for Oncology and Developmental Biology, Maastricht University Medical Center+, Maastricht, The Netherlands,Division of Pathology and Data Analytics, Leeds Institute of Medical Research at St James's, University of Leeds, Leeds, UK
| | - Jeeyun Lee
- Department of Medicine, Division of Hematology-Oncology, Samsung Medical Center, Gangnam-gu, Republic of Korea
| | - Takashi Oshima
- Department of Gastrointestinal Surgery, Kanagawa Cancer Center, Yokohama, Japan
| | | | - Patrick Tan
- Program in Cancer and Stem Cell Biology, Duke-NUS Medical School, Singapore .,Cancer Science Institute of Singapore, National University of Singapore, Singapore.,Genome Institute of Singapore, Singapore.,SingHealth/Duke-NUS Institute of Precision Medicine, National Heart Centre Singapore, Singapore.,Department of Physiology, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
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8
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Wong A, Vellayappan B, Cheng L, Zhao JJ, Muthu V, Asokumaran Y, Low JL, Lee M, Huang YQ, Kumarakulasinghe NB, Ngoi N, Leong CN, Chua W, Thian YL. Atypical Response Patterns in Renal Cell Carcinoma Treated with Immune Checkpoint Inhibitors-Navigating the Radiologic Potpourri. Cancers (Basel) 2021; 13:1689. [PMID: 33918397 PMCID: PMC8038243 DOI: 10.3390/cancers13071689] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Revised: 03/23/2021] [Accepted: 03/31/2021] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Atypical response patterns have been a topic of increasing relevance since the advent of immune checkpoint inhibitors (ICIs), challenging the traditional RECIST (Response Evaluation Criteria in Solid Tumors) method of tumor response assessment. Newer immune-related response criteria can allow for the evolution of radiologic pseudoprogression, but still fail to capture the full range of atypical response patterns encountered in clinical reporting. METHODS We did a detailed lesion-by-lesion analysis of the serial imaging of 46 renal cell carcinoma (RCC) patients treated with ICIs with the aim of capturing the full range of radiologic behaviour. RESULTS Atypical response patterns observed included pseudoprogression (n = 15; 32.6%), serial pseudoprogression (n = 4; 8.7%), dissociated response (n = 22; 47.8%), abscopal response (n = 9; 19.6%), late response (n = 5; 10.9%), and durable response after cessation of immunotherapy (n = 2; 4.3%). Twenty-four of 46 patients (52.2%) had at least one atypical response pattern and 18 patients (39.1%) had multiple atypical response patterns. CONCLUSIONS There is a high incidence of atypical response patterns in RCC patients receiving ICIs and the study contributes to the growing literature on the abscopal effect. The recognition of these interesting and overlapping radiologic patterns challenges the oncologist to tweak treatment options such that the clinical benefits of ICIs are potentially maximized.
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Affiliation(s)
- Alvin Wong
- Department of Haematology-Oncology, National University Cancer Institute, Singapore 119228, Singapore; (V.M.); (Y.A.); (J.-L.L.); (M.L.); (Y.-Q.H.); (N.B.K.); (N.N.)
| | - Balamurugan Vellayappan
- Department of Radiation Oncology, National University Cancer Institute, Singapore 119228, Singapore; (B.V.); (C.-N.L.)
| | - Lenith Cheng
- Department of Diagnostic Imaging, National University Hospital, Singapore 119228, Singapore; (L.C.); (W.C.); (Y.-L.T.)
| | - Joseph J. Zhao
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore 117597, Singapore;
| | - Vaishnavi Muthu
- Department of Haematology-Oncology, National University Cancer Institute, Singapore 119228, Singapore; (V.M.); (Y.A.); (J.-L.L.); (M.L.); (Y.-Q.H.); (N.B.K.); (N.N.)
| | - Yugarajah Asokumaran
- Department of Haematology-Oncology, National University Cancer Institute, Singapore 119228, Singapore; (V.M.); (Y.A.); (J.-L.L.); (M.L.); (Y.-Q.H.); (N.B.K.); (N.N.)
| | - Jia-Li Low
- Department of Haematology-Oncology, National University Cancer Institute, Singapore 119228, Singapore; (V.M.); (Y.A.); (J.-L.L.); (M.L.); (Y.-Q.H.); (N.B.K.); (N.N.)
| | - Matilda Lee
- Department of Haematology-Oncology, National University Cancer Institute, Singapore 119228, Singapore; (V.M.); (Y.A.); (J.-L.L.); (M.L.); (Y.-Q.H.); (N.B.K.); (N.N.)
| | - Yi-Qing Huang
- Department of Haematology-Oncology, National University Cancer Institute, Singapore 119228, Singapore; (V.M.); (Y.A.); (J.-L.L.); (M.L.); (Y.-Q.H.); (N.B.K.); (N.N.)
| | - Nesaretnam Barr Kumarakulasinghe
- Department of Haematology-Oncology, National University Cancer Institute, Singapore 119228, Singapore; (V.M.); (Y.A.); (J.-L.L.); (M.L.); (Y.-Q.H.); (N.B.K.); (N.N.)
| | - Natalie Ngoi
- Department of Haematology-Oncology, National University Cancer Institute, Singapore 119228, Singapore; (V.M.); (Y.A.); (J.-L.L.); (M.L.); (Y.-Q.H.); (N.B.K.); (N.N.)
| | - Cheng-Nang Leong
- Department of Radiation Oncology, National University Cancer Institute, Singapore 119228, Singapore; (B.V.); (C.-N.L.)
| | - Wynne Chua
- Department of Diagnostic Imaging, National University Hospital, Singapore 119228, Singapore; (L.C.); (W.C.); (Y.-L.T.)
| | - Yee-Liang Thian
- Department of Diagnostic Imaging, National University Hospital, Singapore 119228, Singapore; (L.C.); (W.C.); (Y.-L.T.)
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9
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Zhao JJ, Kumarakulasinghe NB, Muthu V, Lee M, Walsh R, Low JL, Choo J, Tan HL, Chong WQ, Ang Y, Chan G, Yong WP, Huang Y, Ngoi N, Wong A. Low-Dose Nivolumab in Renal Cell Carcinoma: A Real-World Experience. Oncology 2021; 99:192-202. [PMID: 33440374 DOI: 10.1159/000512000] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Accepted: 09/23/2020] [Indexed: 11/19/2022]
Abstract
BACKGROUND The approved doses of the single agent nivolumab - an anti-programmed cell death protein 1 (PD-1) monoclonal antibody - for renal cell carcinoma (RCC) are 3 mg/kg and a 240-mg flat dose, despite efficacy shown at lower doses in earlier CheckMate trials. In view of financial constraints, the minimum dose of nivolumab required for efficacy remains a critical area of inquiry. METHODS A retrospective review of RCC patients receiving single-agent anti-PD-1 treatment was conducted. Using the median cutoff of the maximum dose per body weight received, we investigated the effect of lower dosages on overall survival (OS), progression-free survival (PFS), objective response rate (ORR), and immune-related adverse event-free survival (irAE-FS). Survival analysis was made by Kaplan-Meier, by uni- and multivariable Cox models, and by modeling the statistical interaction between dosages and survival. RESULTS 32 patients were recruited: 8 patients (25%) receiving first-line treatment and 24 (75%) receiving second-line treatment and beyond. A median split at 2.15 mg/kg yielded 16 patients in both the lower-dose (LD) and the higher-dose (HD) cohort. Hazard ratios (HRs) demonstrated no difference in OS after adjustment for gender (HR = 0.22, 95% CI 0.05-1.05, p = 0.054; favoring LD), as well as in PFS after adjustment for gender and concurrent radiation therapy (HR = 0.58, 95% CI 0.25-1.34, p = 0.210; favoring LD). No differences in ORR were observed (50.0 vs. 43.8%, p = 1.00, in the LD and the HD cohort, respectively). Immune-related phenomena were observed in the LD group, including pseudoprogression and increased all-grade immune-related toxicities (irAE-FS: HR = 1.72, 95% CI 0.48-6.14, p = 0.293; favoring HD). Iterative dichotomization of dosages showed no dose-OS or dose-irAE-FS relationship. CONCLUSION Our study suggests no apparent reduction in efficacy when using a low-dosage nivolumab regimen.
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Affiliation(s)
- Joseph J Zhao
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore,
| | - Nesaretnam Barr Kumarakulasinghe
- Department of Haematology-Oncology, National University Cancer Institute, Singapore, Singapore.,Department of Learning, Informatics, Management and Ethics (LIME), Karolinska Institutet, Stockholm, Sweden
| | - Vaishnavi Muthu
- Department of Haematology-Oncology, National University Cancer Institute, Singapore, Singapore
| | - Matilda Lee
- Department of Haematology-Oncology, National University Cancer Institute, Singapore, Singapore
| | - Robert Walsh
- Department of Haematology-Oncology, National University Cancer Institute, Singapore, Singapore
| | - Jia Li Low
- Department of Haematology-Oncology, National University Cancer Institute, Singapore, Singapore
| | - Joan Choo
- Department of Haematology-Oncology, National University Cancer Institute, Singapore, Singapore
| | - Hon Lyn Tan
- Department of Haematology-Oncology, National University Cancer Institute, Singapore, Singapore
| | - Wan Qin Chong
- Department of Haematology-Oncology, National University Cancer Institute, Singapore, Singapore
| | - Yvonne Ang
- Department of Haematology-Oncology, National University Cancer Institute, Singapore, Singapore
| | - Gloria Chan
- Department of Haematology-Oncology, National University Cancer Institute, Singapore, Singapore
| | - Wei Peng Yong
- Department of Haematology-Oncology, National University Cancer Institute, Singapore, Singapore
| | - Yiqing Huang
- Department of Haematology-Oncology, National University Cancer Institute, Singapore, Singapore
| | - Natalie Ngoi
- Department of Haematology-Oncology, National University Cancer Institute, Singapore, Singapore
| | - Alvin Wong
- Department of Haematology-Oncology, National University Cancer Institute, Singapore, Singapore
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10
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Ngoi NYL, Heong V, Tang JI, Choo BA, Kumarakulasinghe NB, Lim D, Low M, Lim SE, Lim YW, Leong YH, Tseng M, Tong PSY, Ilancheran A, Low JJH, Ng J, Thian YL, Koh V, Tan DSP. Phase 1 Study of Low-Dose Fractionated Whole Abdominal Radiation Therapy in Combination With Weekly Paclitaxel for Platinum-Resistant Ovarian Cancer (GCGS-01). Int J Radiat Oncol Biol Phys 2020; 109:701-711. [PMID: 33045316 DOI: 10.1016/j.ijrobp.2020.09.059] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Revised: 09/24/2020] [Accepted: 09/30/2020] [Indexed: 12/24/2022]
Abstract
PURPOSE Low-dose fractionated whole abdominal radiation therapy (LDFWART) has synergistic activity with paclitaxel in preclinical models. The aim of this phase 1 trial was to determine the recommended phase 2 dose and preliminary activity of weekly paclitaxel (wP) concurrent with LDFWART in patients with platinum-resistant ovarian cancer (PROC). METHODS AND MATERIALS Patients were enrolled at de-escalating dose levels of wP (part A), starting at 80 mg/m2, concurrent with fixed-dose LDFWART delivered in 60 cGy fractions twice-daily, 2 days per week, for 6 continuous weeks. After completing the 6-week course of wP + LDFWART, patients received wP until disease progression. Dose-limiting toxicity was evaluated during the first 3 weeks of wP + LDFWART. At wP (80 mg/m2) + LDFWART, no dose-limiting toxicities were observed; this was the established maximum tolerated dose. The trial was expanded (part B) with 7 additional patients with platinum-resistant, high-grade serous ovarian cancer to confirm toxicity and activity. RESULTS A total of 10 heavily pretreated patients were recruited (3 patients to part A, 7 patients to part B). They had received a median of 5 prior lines of therapy, and 70% of patients had received prior wP; 60% of patients completed 6 weeks of wP + LDFWART. Common related grade ≥3 adverse events were neutropenia (60%) and anemia (30%). Median progression-free survival was 3.2 months, and overall survival was 13.5 months. Of patients evaluable for response, 33% (3 of 9) achieved confirmed biochemical response (CA125 decrease >50% from baseline), 11% (1) achieved a partial response, and 5 patients had stable disease, giving a disease control rate of 66.7% (6 of 9). Four patients had durable disease control of ≥12 weeks, completing 12 to 21 weeks of wP. CONCLUSIONS The recommended phase 2 dose of wP + LDFWART for 6 weeks is 80 mg/m2. Encouraging efficacy in heavily pretreated PROC patients was observed, suggesting that further development of this therapeutic strategy in PROC should be considered.
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Affiliation(s)
- Natalie Y L Ngoi
- Department of Haematology-Oncology, National University Cancer Institute, Singapore
| | - Valerie Heong
- Department of Medical Oncology, Tan Tock Seng Hospital, Singapore
| | - Johann I Tang
- Department of Radiation Oncology, National University Cancer Institute, Singapore
| | - Bok Ai Choo
- Department of Radiation Oncology, National University Cancer Institute, Singapore
| | | | - Diana Lim
- Department of Pathology, National University Health System, Singapore
| | - Mellisa Low
- Department of Haematology-Oncology, National University Cancer Institute, Singapore
| | - Siew Eng Lim
- Department of Haematology-Oncology, National University Cancer Institute, Singapore
| | - Yi Wan Lim
- Department of Haematology-Oncology, National University Cancer Institute, Singapore
| | - Yiat Horng Leong
- Department of Radiation Oncology, National University Cancer Institute, Singapore
| | - Michelle Tseng
- Department of Radiation Oncology, National University Cancer Institute, Singapore
| | - Pearl S Y Tong
- Division of Gynaecologic-Oncology, Department of Obstetrics and Gynaecology, National University Health System, Singapore
| | - Arunachalam Ilancheran
- Division of Gynaecologic-Oncology, Department of Obstetrics and Gynaecology, National University Health System, Singapore
| | - Jeffrey J H Low
- Division of Gynaecologic-Oncology, Department of Obstetrics and Gynaecology, National University Health System, Singapore
| | - Joseph Ng
- Division of Gynaecologic-Oncology, Department of Obstetrics and Gynaecology, National University Health System, Singapore
| | - Yee Liang Thian
- Department of Diagnostic Imaging, National University Health System, Singapore
| | - Vicky Koh
- Department of Radiation Oncology, National University Cancer Institute, Singapore
| | - David S P Tan
- Department of Haematology-Oncology, National University Cancer Institute, Singapore; Cancer Science Institute, National University of Singapore, Singapore; Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore.
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11
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Chong WQ, Lim CM, Sinha AK, Tan CS, Chan GHJ, Huang Y, Kumarakulasinghe NB, Sundar R, Jeyasekharan AD, Loh WS, Tay JK, Yadav K, Wang L, Wong AL, Kong LR, Soo RA, Lau JA, Soon YY, Goh RM, Ho FCH, Chong SM, Lee SC, Loh KS, Tai BC, Lim YC, Goh BC. Integration of Antiangiogenic Therapy with Cisplatin and Gemcitabine Chemotherapy in Patients with Nasopharyngeal Carcinoma. Clin Cancer Res 2020; 26:5320-5328. [PMID: 32816944 DOI: 10.1158/1078-0432.ccr-20-1727] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Revised: 06/26/2020] [Accepted: 08/04/2020] [Indexed: 12/08/2022]
Abstract
PURPOSE Induction cisplatin and gemcitabine chemotherapy is a standard treatment for locally advanced nasopharyngeal carcinoma (NPC). Inhibition of VEGF axis has been shown to promote maturation of microvasculature and improve perfusion. We conducted a four-arm study to assess the effect of two doses of either sunitinib or bevacizumab with chemotherapy in NPC. PATIENTS AND METHODS Patients with treatment-naïve locally advanced NPC were treated with three cycles of 3-weekly cisplatin and gemcitabine preceded by 1 week of anti-VEGF therapy for each cycle, followed by standard concurrent chemoradiation: arm A patients received 7 days of 12.5 mg/day sunitinib; arm B 7 days of 25 mg/day sunitinib; arm C bevacizumab 7.5 mg/kg infusion; arm D bevacizumab 2.5 mg/kg infusion. Patients with metastatic NPC were treated with up to six cycles of similar treatment without concurrent chemoradiation. RESULTS Complete metabolic response (mCR) by whole body 18FDG PET was highest in arm C (significant difference in four groups Fisher exact test P = 0.001; type 1 error = 0.05), with 42% mCR (95% confidence interval, 18-67) and 3-year relapse-free survival of 88% in patients with locally advanced NPC. Significant increase in pericyte coverage signifying microvascular maturation and increased immune cell infiltration was observed in posttreatment tumor biopsies in Arm C. Myelosuppression was more profound in sunitinib containing arms, and tolerability was established in arm C where hypertension was the most significant toxicity. CONCLUSIONS Bevacizumab 7.5 mg/kg with cisplatin and gemcitabine was well tolerated. Promising tumor response was observed and supported mechanistically by positive effects on tumor perfusion and immune cell trafficking into the tumor.
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Affiliation(s)
- Wan Qin Chong
- Department of Haematology-Oncology, National University Cancer Institute, Singapore
| | - Chwee Ming Lim
- Department of Otolaryngology - Head and Neck Surgery, National University of Singapore, Singapore
| | - Arvind Kumar Sinha
- Department of Diagnostic Imaging, National University Health System, Singapore
| | - Chee Seng Tan
- Department of Haematology-Oncology, National University Cancer Institute, Singapore
| | - Gloria Hui Jia Chan
- Department of Haematology-Oncology, National University Cancer Institute, Singapore
| | - Yiqing Huang
- Department of Haematology-Oncology, National University Cancer Institute, Singapore
| | | | - Raghav Sundar
- Department of Haematology-Oncology, National University Cancer Institute, Singapore
| | - Anand D Jeyasekharan
- Department of Haematology-Oncology, National University Cancer Institute, Singapore.,Cancer Science Institute of Singapore, NUS, Singapore
| | - Woei Shyang Loh
- Department of Otolaryngology - Head and Neck Surgery, National University of Singapore, Singapore
| | - Joshua K Tay
- Department of Otolaryngology - Head and Neck Surgery, National University of Singapore, Singapore
| | - Kritika Yadav
- Cancer Science Institute of Singapore, NUS, Singapore
| | - Lingzhi Wang
- Cancer Science Institute of Singapore, NUS, Singapore.,Department of Pharmacology, National University of Singapore, Singapore
| | - Andrea L Wong
- Department of Haematology-Oncology, National University Cancer Institute, Singapore.,Cancer Science Institute of Singapore, NUS, Singapore
| | - Li Ren Kong
- Cancer Science Institute of Singapore, NUS, Singapore
| | - Ross Andrew Soo
- Department of Haematology-Oncology, National University Cancer Institute, Singapore.,Cancer Science Institute of Singapore, NUS, Singapore
| | | | - Yu Yang Soon
- Department of Radiation Oncology, National University Cancer Institute, Singapore
| | - Robby Miguel Goh
- Department of Haematology-Oncology, National University Cancer Institute, Singapore
| | - Francis Cho Hao Ho
- Department of Radiation Oncology, National University Cancer Institute, Singapore
| | - Siew Meng Chong
- Department of Pathology, National University of Singapore, Singapore
| | - Soo Chin Lee
- Department of Haematology-Oncology, National University Cancer Institute, Singapore.,Cancer Science Institute of Singapore, NUS, Singapore
| | - Kwok Seng Loh
- Department of Otolaryngology - Head and Neck Surgery, National University of Singapore, Singapore
| | - Bee Choo Tai
- School of Public Health, National University of Singapore, Singapore
| | - Yaw Chyn Lim
- Department of Pathology, National University of Singapore, Singapore.,Department of Physiology, National University of Singapore, Singapore
| | - Boon Cher Goh
- Department of Haematology-Oncology, National University Cancer Institute, Singapore. .,Cancer Science Institute of Singapore, NUS, Singapore.,Department of Pharmacology, National University of Singapore, Singapore
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12
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Ng IK, Kumarakulasinghe NB, Syn NL, Soo RA. Development, internal validation and calibration of a risk score to predict survival in patients with EGFR-mutant non-small cell lung cancer. J Clin Pathol 2020; 74:116-122. [PMID: 32576630 DOI: 10.1136/jclinpath-2020-206754] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Revised: 05/26/2020] [Accepted: 05/27/2020] [Indexed: 11/04/2022]
Abstract
AIMS EGFR tyrosine kinase inhibitors (TKIs) are first-line molecularly targeted therapies in patients with advanced non-small cell lung cancer (NSCLC) who carry sensitising EGFR mutations, due to its superior survival outcomes compared with conventional chemotherapy regimens. In this study, we sought to identify clinical, immune and biochemical variables with prognostic significance in this patient subgroup and incorporate them into a nomogram-based risk score. METHODS A total of 199 patients with EGFR mutation-positive, advanced NSCLC (defined as stage IV at initial diagnosis or incurable disease recurrence) treated with first-line EGFR TKI therapy were retrospectively profiled. Univariable and multivariable survival analyses were conducted, with variables from the multivariable model with the highest Harrell's Concordance (C) Index selected for inclusion in the subsequent survival nomogram. Internal validation and internal calibration of our prognostic nomogram were also performed. RESULTS Serum lactate dehydrogenase (LDH) and lung/pleural metastasis were independent predictors of unfavourable overall survival in all three multivariable models. A survival nomogram was generated based on the multivariable model with the highest Harrell's C Index, incorporating the following 11 variables: white cell count, haemoglobin, LDH, neutrophil/lymphocyte ratio, ethnicity (Chinese vs non-Chinese), Karnofsky-Performance Status (score of '90-100' or '70-80' vs '0-60'), Charlson Comorbidity Index (≥3, or 2, or 1 vs 0), neurological symptoms, brain, lung/pleural and adrenal metastases. CONCLUSION We identified serum LDH as an independent predictor of unfavourable clinical outcomes in patients with advanced, EGFR mutation-positive NSCLC. We further developed a robust nomogram-based risk score that incorporates clinical, biochemical and immune variables that can provide more targeted prognostication and management in this patient subgroup.
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Affiliation(s)
- Isaac Ks Ng
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | | | - Nicholas L Syn
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Ross Andrew Soo
- Department of Hematology-Oncology, National University Cancer Institute, Singapore
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13
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Lee SC, Shimasaki N, Lim JSJ, Wong A, Yadav K, Yong WP, Tan LK, Koh LP, Poon MLM, Tan SH, Ow SGW, Bharwani L, Yap YS, Foo MZQ, Coustan-Smith E, Sundar R, Tan HL, Chong WQ, Kumarakulasinghe NB, Lieow JLM, Koe PJX, Goh BC, Campana D. Phase I Trial of Expanded, Activated Autologous NK-cell Infusions with Trastuzumab in Patients with HER2-positive Cancers. Clin Cancer Res 2020; 26:4494-4502. [PMID: 32522887 DOI: 10.1158/1078-0432.ccr-20-0768] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Revised: 04/30/2020] [Accepted: 06/05/2020] [Indexed: 11/16/2022]
Abstract
PURPOSE Natural killer (NK) cells exert antibody-dependent cell cytotoxicity (ADCC). We infused expanded, activated autologous NK cells to potentiate trastuzumab-mediated ADCC in patients with HER2-positive malignancies. PATIENTS AND METHODS In a phase I trial, patients with treatment-refractory HER2-positive solid tumors received trastuzumab, with or without bevacizumab, and autologous NK cells expanded by 10-day coculture with K562-mb15-41BBL cells. Primary objectives included safety and recommended phase II dose determination; secondary objectives included monitoring NK-cell activity and RECIST antitumor efficacy. RESULTS In 60 cultures with cells from 31 subjects, median NK-cell expansion from peripheral blood was 340-fold (range, 91-603). NK cells expressed high levels of CD16, the mediator of ADCC, and exerted powerful killing of trastuzumab-targeted cells. In the 22 subjects enrolled in phase I dose escalation, trastuzumab plus NK cells were well tolerated; MTD was not reached. Phase IB (n = 9) included multiple cycles of NK cells (1 × 107/kg) and addition of bevacizumab. Although no objective response was observed, 6 of 19 subjects who received at least 1 × 107/kg NK cells at cycle 1 had stable disease for ≥6 months (median, 8.8 months; range 6.0-12.0). One patient, the only one with the high-affinity F158V CD16 variant, had a partial response. Peripheral blood NK cells progressively downregulated CD16 postinfusion; paired tumor biopsies showed increased NK cells, lymphocytic infiltrates, and apoptosis posttreatment. CONCLUSIONS NK-cell therapy in combination with trastuzumab was well tolerated, with target engagement and preliminary antitumor activity, supporting continued assessment of this approach in phase II trials.
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Affiliation(s)
- Soo-Chin Lee
- Department of Hematology-Oncology, National University Cancer Institute, Singapore. .,Experimental Therapeutics Programme, Cancer Science Institute, Singapore
| | - Noriko Shimasaki
- Department of Paediatrics, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Joline S J Lim
- Department of Hematology-Oncology, National University Cancer Institute, Singapore.,Experimental Therapeutics Programme, Cancer Science Institute, Singapore
| | - Andrea Wong
- Department of Hematology-Oncology, National University Cancer Institute, Singapore.,Experimental Therapeutics Programme, Cancer Science Institute, Singapore
| | - Kritika Yadav
- Experimental Therapeutics Programme, Cancer Science Institute, Singapore
| | - Wei Peng Yong
- Department of Hematology-Oncology, National University Cancer Institute, Singapore.,Experimental Therapeutics Programme, Cancer Science Institute, Singapore
| | - Lip Kun Tan
- Department of Hematology-Oncology, National University Cancer Institute, Singapore
| | - Liang Piu Koh
- Department of Hematology-Oncology, National University Cancer Institute, Singapore
| | - Michelle L M Poon
- Department of Hematology-Oncology, National University Cancer Institute, Singapore
| | | | - Samuel G W Ow
- Department of Hematology-Oncology, National University Cancer Institute, Singapore
| | - Lavina Bharwani
- Department of Medical Oncology, Tan Tock Seng Hospital, Singapore
| | - Yoon Sim Yap
- Department of Medical Oncology, National Cancer Centre, Singapore
| | - Mabel Z Q Foo
- Experimental Therapeutics Programme, Cancer Science Institute, Singapore
| | - Elaine Coustan-Smith
- Department of Paediatrics, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Raghav Sundar
- Department of Hematology-Oncology, National University Cancer Institute, Singapore
| | - Hon Lyn Tan
- Department of Hematology-Oncology, National University Cancer Institute, Singapore
| | - Wan Qin Chong
- Department of Hematology-Oncology, National University Cancer Institute, Singapore
| | | | - Jedidah L M Lieow
- Department of Hematology-Oncology, National University Cancer Institute, Singapore
| | - Priscillia J X Koe
- Department of Hematology-Oncology, National University Cancer Institute, Singapore
| | - Boon Cher Goh
- Department of Hematology-Oncology, National University Cancer Institute, Singapore.,Experimental Therapeutics Programme, Cancer Science Institute, Singapore
| | - Dario Campana
- Department of Paediatrics, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
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14
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Teo I, Baid D, Ozdemir S, Malhotra C, Singh R, Harding R, Malhotra R, Yang MG, Neo SHS, Cheung YB, Neo PSH, Kanesvaran R, Kumarakulasinghe NB, Lee LH, Koh GCH, Finkelstein EA. Family caregivers of advanced cancer patients: self-perceived competency and meaning-making. BMJ Support Palliat Care 2019; 10:435-442. [PMID: 31806656 DOI: 10.1136/bmjspcare-2019-001979] [Citation(s) in RCA: 9] [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: 07/22/2019] [Revised: 10/03/2019] [Accepted: 11/10/2019] [Indexed: 11/04/2022]
Abstract
BACKGROUND Family caregivers of patients with advanced cancer have been reported to provide long hours of care and be at risk for poor psychological outcomes. Although research has focused on the nature of caregiving burden, little attention has been paid to identifying protective factors that improve caregiver psychological outcomes. AIM We examined the relationship between caregivers' time spent caregiving and the following psychological outcomes: anxiety, depression and caregiving esteem. Subsequently, we explored the main and moderating effects of caregiver-perceived self-competency and sense of meaning on caregiver psychological outcomes. DESIGN/PARTICIPANTS Cross-sectional analysis was conducted using the baseline data from an ongoing cohort study. Family caregivers of advanced cancer patients (n=287) were recruited from two tertiary hospitals in Singapore. RESULTS Time spent caregiving was not significantly associated with caregiver anxiety, depression or caregiving esteem. However, significant main effects of self-competency on anxiety and caregiving esteem; and sense of meaning on anxiety, depression and caregiving esteem were observed. Moderator analyses further indicated that self-competency attenuated the positive relationship between time spent caregiving and anxiety, while sense of meaning attenuated the negative relationship between time spent caregiving and caregiving esteem. CONCLUSION Greater perceived self-competency and sense of meaning are related to better caregiver psychological outcomes, and protect caregivers from worsening outcomes as caregiving hours increase. Our findings suggest that screening caregivers for distress is an important part of care, and that supportive interventions for caregivers should aim to enhance their perceived caregiving competencies and the ability to make meaning of their caregiving role.
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Affiliation(s)
- Irene Teo
- Lien Centre for Palliative Care, Duke-NUS Medical School, Singapore .,Division of Supportive and Palliative Care, National Cancer Centre Singapore, Singapore.,Program in Health Services & Systems Research, Duke-NUS Medical School, Singapore
| | - Drishti Baid
- Lien Centre for Palliative Care, Duke-NUS Medical School, Singapore
| | - Semra Ozdemir
- Lien Centre for Palliative Care, Duke-NUS Medical School, Singapore.,Program in Health Services & Systems Research, Duke-NUS Medical School, Singapore
| | - Chetna Malhotra
- Lien Centre for Palliative Care, Duke-NUS Medical School, Singapore.,Program in Health Services & Systems Research, Duke-NUS Medical School, Singapore
| | - Ratna Singh
- Lien Centre for Palliative Care, Duke-NUS Medical School, Singapore
| | - Richard Harding
- Department of Palliative Care and Policy, King's College London, London, UK
| | - Rahul Malhotra
- Program in Health Services & Systems Research, Duke-NUS Medical School, Singapore.,Centre for Aging Research and Education, Duke-NUS Medical School, Singapore
| | - Meijuan Grace Yang
- Lien Centre for Palliative Care, Duke-NUS Medical School, Singapore.,Division of Supportive and Palliative Care, National Cancer Centre Singapore, Singapore
| | - Shirlyn Hui-Shan Neo
- Division of Supportive and Palliative Care, National Cancer Centre Singapore, Singapore
| | - Yin Bun Cheung
- Program in Health Services & Systems Research, Duke-NUS Medical School, Singapore.,Centre for Quantitative Medicine, Duke-NUS Medical School, Singapore.,Center for Child Health Research, Tampere University, Tampere, Pirkanmaa, Finland
| | - Patricia Soek Hui Neo
- Division of Supportive and Palliative Care, National Cancer Centre Singapore, Singapore
| | | | | | - Lai Heng Lee
- Department of Haematology, Singapore General Hospital, Singapore
| | - Gerald Choon Huat Koh
- Program in Health Services & Systems Research, Duke-NUS Medical School, Singapore.,Saw Swee Hock School of Public Health, National University of Singapore, Singapore
| | - Eric A Finkelstein
- Lien Centre for Palliative Care, Duke-NUS Medical School, Singapore.,Program in Health Services & Systems Research, Duke-NUS Medical School, Singapore
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15
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Malhotra C, Kanesvaran R, Barr Kumarakulasinghe N, Tan SH, Xiang L, Tulsky JA, Pollak KI. Oncologist-patient-caregiver decision-making discussions in the context of advanced cancer in an Asian setting. Health Expect 2019; 23:220-228. [PMID: 31682064 PMCID: PMC6978867 DOI: 10.1111/hex.12994] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [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: 07/09/2019] [Revised: 09/24/2019] [Accepted: 10/09/2019] [Indexed: 11/30/2022] Open
Abstract
Objective Patient involvement in treatment decisions is recommended in clinician‐patient encounters. Little is known about how oncologists engage patients in shared decision making in non‐Western countries. We assessed the prevalence of shared decision making among Singaporean oncologists and analysed how they discussed prognosis. Methods We audio‐recorded 100 consultations between advanced cancer patients and their oncologists. We developed a coding system to assess oncologist encouragement of patient participation in decision making and disclosure of an explicit prognosis. We assessed patient and oncologist characteristics that predicted these behaviours. Results Forty‐one consultations involved treatment discussions. Oncologists almost always listed more than one treatment option (90%). They also checked patient understanding (34%), discussed pros and cons (34%) and addressed uncertainty (29%). Oncologists discussed prognosis mostly qualitatively (34%) rather than explicitly (17%). They were more likely to give an explicit prognosis when patients/caregivers asked questions related to prognosis. Conclusion Oncologists in our sample engaged their patients in decision making. They have areas in which they can improve to involve patients at a deeper level to ensure shared decision making. Findings will be used to develop an intervention targeting oncologists and patients to promote patient involvement in decision making.
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Affiliation(s)
- Chetna Malhotra
- Lien Centre for Palliative Care, Duke-NUS Medical School, Singapore, Singapore
| | | | | | - Sing-Huang Tan
- OncoCare Cancer Centre, Gleneagles Medical Centre, Singapore, Singapore
| | - Ling Xiang
- Lien Centre for Palliative Care, Duke-NUS Medical School, Singapore, Singapore
| | - James A Tulsky
- Dana-Farber Cancer Institute, Boston, MA, USA.,Brigham and Women's Hospital, Boston, MA, USA
| | - Kathryn I Pollak
- Cancer Control and Population Sciences, Duke University, Durham, NC, USA.,Population Health Sciences, Duke University, Durham, NC, USA
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16
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Saei A, Palafox M, Benoukraf T, Kumari N, Jaynes PW, Iyengar PV, Muñoz-Couselo E, Nuciforo P, Cortés J, Nötzel C, Kumarakulasinghe NB, Richard JLC, Bin Adam Isa ZF, Pang B, Guzman M, Siqin Z, Yang H, Tam WL, Serra V, Eichhorn PJA. Loss of USP28-mediated BRAF degradation drives resistance to RAF cancer therapies. J Exp Med 2018; 215:1913-1928. [PMID: 29880484 PMCID: PMC6028519 DOI: 10.1084/jem.20171960] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2017] [Revised: 03/09/2018] [Accepted: 05/09/2018] [Indexed: 11/04/2022] Open
Abstract
RAF kinase inhibitors are clinically active in patients with BRAF (V600E) mutant melanoma. However, rarely do tumors regress completely, with the majority of responses being short-lived. This is partially mediated through the loss of negative feedback loops after MAPK inhibition and reactivation of upstream signaling. Here, we demonstrate that the deubiquitinating enzyme USP28 functions through a feedback loop to destabilize RAF family members. Loss of USP28 stabilizes BRAF enhancing downstream MAPK activation and promotes resistance to RAF inhibitor therapy in culture and in vivo models. Importantly, we demonstrate that USP28 is deleted in a proportion of melanoma patients and may act as a biomarker for response to BRAF inhibitor therapy in patients. Furthermore, we identify Rigosertib as a possible therapeutic strategy for USP28-depleted tumors. Our results show that loss of USP28 enhances MAPK activity through the stabilization of RAF family members and is a key factor in BRAF inhibitor resistance.
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Affiliation(s)
- Azad Saei
- Genome Institute of Singapore, A*STAR, Singapore, Singapore.,Department of Biochemistry, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Marta Palafox
- Vall d'Hebron Institute of Oncology (VHIO), Barcelona, Spain
| | - Touati Benoukraf
- Cancer Science Institute of Singapore, National University of Singapore, Singapore
| | - Nishi Kumari
- Department of Biochemistry, Yong Loo Lin School of Medicine, National University of Singapore, Singapore.,Cancer Science Institute of Singapore, National University of Singapore, Singapore
| | | | | | | | - Paolo Nuciforo
- Vall d'Hebron Institute of Oncology (VHIO), Barcelona, Spain
| | - Javier Cortés
- Vall d'Hebron Institute of Oncology (VHIO), Barcelona, Spain.,Cancer Ramon y Cajal University Hospital, Madrid, Spain.,IOB Institute of Oncology, Quironsalud group, Madrid & Barcelona, Spain
| | - Christopher Nötzel
- Cancer Science Institute of Singapore, National University of Singapore, Singapore
| | - Nesaretnam Barr Kumarakulasinghe
- Department of Hematology-Oncology, National University Cancer Institute, Singapore, National University Health System, Singapore, Singapore
| | | | | | - Brendan Pang
- Cancer Science Institute of Singapore, National University of Singapore, Singapore
| | - Marta Guzman
- Vall d'Hebron Institute of Oncology (VHIO), Barcelona, Spain
| | - Zhou Siqin
- Cancer Science Institute of Singapore, National University of Singapore, Singapore
| | - Henry Yang
- Cancer Science Institute of Singapore, National University of Singapore, Singapore
| | - Wai Leong Tam
- Genome Institute of Singapore, A*STAR, Singapore, Singapore.,Cancer Science Institute of Singapore, National University of Singapore, Singapore
| | - Violeta Serra
- Vall d'Hebron Institute of Oncology (VHIO), Barcelona, Spain
| | - Pieter Johan Adam Eichhorn
- Cancer Science Institute of Singapore, National University of Singapore, Singapore .,Department of Pharmacology, Yong Loo Lin School of Medicine, National University of Singapore, Singapore.,School of Pharmacy and Biomedical Sciences, Curtin University, Perth, Australia
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17
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Sundar R, Bandla A, Tan S, Kumarakulasinghe NB, Huang Y, Ang S, Hairom Z, Lim JSJ, Wong ASC, Chan GHJ, Ngoi N, Ang E, Chan A, Lee SC, Thakor N, Wilder-Smith E. Cryocompression for enhanced limb hypothermia in preventing paclitaxel-induced peripheral neuropathy. J Clin Oncol 2018. [DOI: 10.1200/jco.2018.36.15_suppl.10095] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [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)
- Raghav Sundar
- National University Health System, Singapore, Singapore
| | | | - Stacey Tan
- National University of Singapore, Singapore, Singapore
| | - Nesaretnam Barr Kumarakulasinghe
- Department of Haematology-Oncology, National University Cancer Institute, National University Health System, Singapore, Singapore
| | - Yiqing Huang
- National University Cancer Institute Singapore, National University Hospital, Singapore, Singapore
| | - Sally Ang
- National University Health System, Singapore, Singapore
| | | | | | | | | | - Natalie Ngoi
- Department of Haematology-Oncology, National University Cancer Institute, Singapore, Singapore, Singapore
| | - Emily Ang
- National University Health System, Singapore, Singapore
| | - Amanda Chan
- National University Health System, Singapore, Singapore
| | - Soo-Chin Lee
- National University Cancer Institute Singapore, Singapore, Singapore
| | - Nitish Thakor
- National University of Singapore, Singapore, Singapore
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18
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Kumarakulasinghe NB, Syn N, Soon YY, Asmat A, Zheng H, Loy EY, Pang B, Soo RA. EGFR kinase inhibitors and gastric acid suppressants in EGFR-mutant NSCLC: a retrospective database analysis of potential drug interaction. Oncotarget 2018; 7:85542-85550. [PMID: 27907909 PMCID: PMC5356756 DOI: 10.18632/oncotarget.13458] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2016] [Accepted: 10/27/2016] [Indexed: 11/25/2022] Open
Abstract
Background Erlotinib and gefitinib are weak base drugs whose absorption and clinical efficacy may be impaired by concomitant gastric acid suppressive (AS) therapy, yet proton pump inhibitors (PPIs) and histamine-2 receptor antagonists (H2As) are widely indicated in non-small cell lung cancer (NSCLC) patients for the prevention and treatment of erlotinib-induced gastrointestinal injury and corticosteroid-associated gastric irritation. We assessed the clinical relevance of this potential drug-drug interaction (DDI) in a retrospective cohort of EGFR-mutant NSCLC patients. Results The AS usage rate was 35%. In the overall cohort, AS users did not experience poorer OS (HR: 1.47, 95% CI: 0.92 – 2.35, P = 0.10; median, 11.4 versus 17.5 months) or PFS (HR = 1.37, 95% CI: 0.89 – 2.12, P = 0.16; median, 7.6 versus 8.7 months) compared with non-users in multivariate Cox regression analysis. However, subgroup analyses indicated that AS usage was associated with significantly poorer OS and PFS in patients who had fewer or milder comorbidities (Charlson comorbidity index ≤ 2), those with Karnofsky performance status < 90, and never-smokers. Materials and Methods A retrospective database analysis of 157 patients given erlotinib or gefitinib for EGFR-mutant advanced NSCLC from two institutions was conducted. Patients were classified as AS-users if the periods of AS and anti-EGFR therapy overlapped by ≥ 30%. Overall survival (OS) and progression-free survival (PFS) were assessed according to AS usage. Conclusions Concomitant AS therapy did not have an adverse impact on OS and/or PFS in the overall cohort. Our subgroup findings should be regarded exploratory and require replication in a large prospective cohort.
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Affiliation(s)
| | - Nicholas Syn
- Department of Haematology-Oncology, National University Cancer Institute, Singapore.,Cancer Science Institute of Singapore, National University of Singapore, Singapore.,Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Yu Yang Soon
- Department of Radiation Oncology, National University Cancer Institute, Singapore
| | - Atasha Asmat
- Department of General Surgery, Tan Tock Seng Hospital, Singapore
| | - Huili Zheng
- National Registry of Diseases Office, Health Promotion Board, Singapore
| | - En Yun Loy
- National Registry of Diseases Office, Health Promotion Board, Singapore
| | - Brendan Pang
- Cancer Science Institute of Singapore, National University of Singapore, Singapore.,Department of Pathology, National University Health System, Singapore
| | - Ross Andrew Soo
- Department of Haematology-Oncology, National University Cancer Institute, Singapore.,Cancer Science Institute of Singapore, National University of Singapore, Singapore
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19
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Tan CS, Kumarakulasinghe NB, Huang YQ, Ang YLE, Choo JRE, Goh BC, Soo RA. Third generation EGFR TKIs: current data and future directions. Mol Cancer 2018; 17:29. [PMID: 29455654 PMCID: PMC5817792 DOI: 10.1186/s12943-018-0778-0] [Citation(s) in RCA: 165] [Impact Index Per Article: 27.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2017] [Accepted: 02/01/2018] [Indexed: 12/16/2022] Open
Abstract
Acquired T790 M mutation is the commonest cause of resistance for advanced non-small cell lung cancer (NSCLC) epidermal growth factor receptor (EGFR) mutant patients who had progressed after first line EGFR TKI (tyrosine kinase inhibitor). Several third generation EGFR TKIs which are EGFR mutant selective and wild-type (WT) sparing were developed to treat these patients with T790 M acquired resistant mutation. Osimertinib is one of the third generation EGFR TKIs and is currently the most advanced in clinical development. Unfortunately, despite good initial response, patients who was treated with third generation EGFR TKI would develop acquired resistance and several mechanisms had been identified and the commonest being C797S mutation at exon 20. Several novel treatment options were being developed for patients who had progressed on third generation EGFR TKI but they are still in the early phase of development. Osimertinib under FLAURA study had been shown to have better progression-free survival over first generation EGFR TKI in the first line setting and likely will become the new standard of care.
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Affiliation(s)
- Chee-Seng Tan
- Department of Haematology-Oncology, National University Cancer Institute of Singapore, National University Health System, 1E Kent Ridge Road, NUHS Tower Block, Level 7, Singapore, 119228, Singapore
| | - Nesaretnam Barr Kumarakulasinghe
- Department of Haematology-Oncology, National University Cancer Institute of Singapore, National University Health System, 1E Kent Ridge Road, NUHS Tower Block, Level 7, Singapore, 119228, Singapore
| | - Yi-Qing Huang
- Department of Haematology-Oncology, National University Cancer Institute of Singapore, National University Health System, 1E Kent Ridge Road, NUHS Tower Block, Level 7, Singapore, 119228, Singapore
| | - Yvonne Li En Ang
- Department of Haematology-Oncology, National University Cancer Institute of Singapore, National University Health System, 1E Kent Ridge Road, NUHS Tower Block, Level 7, Singapore, 119228, Singapore
| | - Joan Rou-En Choo
- Department of Haematology-Oncology, National University Cancer Institute of Singapore, National University Health System, 1E Kent Ridge Road, NUHS Tower Block, Level 7, Singapore, 119228, Singapore
| | - Boon-Cher Goh
- Department of Haematology-Oncology, National University Cancer Institute of Singapore, National University Health System, 1E Kent Ridge Road, NUHS Tower Block, Level 7, Singapore, 119228, Singapore.,Cancer Science Institute of Singapore, National University of Singapore, Singapore, Singapore.,Department of Pharmacology, Yong Loo Lin School of Medicine, National University Health System, Singapore, Singapore
| | - Ross A Soo
- Department of Haematology-Oncology, National University Cancer Institute of Singapore, National University Health System, 1E Kent Ridge Road, NUHS Tower Block, Level 7, Singapore, 119228, Singapore. .,Cancer Science Institute of Singapore, National University of Singapore, Singapore, Singapore. .,School of Surgery, The University of Western Australia, Perth, Australia.
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20
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Walsh RJ, Lee SC, Seng KY, Wang LZ, Ho GF, Ow SGW, Kumarakulasinghe NB, Sundar R, Lee XW, Yap HL, Jeyasekharan AD, Pang A, Ho J, Tan CS, Lim YW, Malik RA, Wan Ishak WZ, Goh BC, Tai BC, Wong ALA. Prospective study of UDP-glucuronosyltransferase (UGT) 2B17 genotype and exemestane (Exe) pharmacokinetics (PK) and pharmacodynamics (PD) in Asian, hormone receptor (HR) positive, metastatic breast cancer (MBC) patients. J Clin Oncol 2017. [DOI: 10.1200/jco.2017.35.15_suppl.1056] [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
1056 Background: The active metabolite of Exe, 17-dihydroexemestane (17DhExe), is glucuronidated by UGT2B17 to inactive exemestane-17-O-glucuronide (Exe17- O-glu). UGT2B17*2/*2null genotype is 7 times more common in Asians than Caucasians and leads to reduced Exe glucuronidation in vitro. We studied Exe PK and PD in MBC patients genotyped for UGT2B17. Methods: Eligible patients (HR+ MBC; ≥1 line of endocrine therapy) received Exe 25mg OD till progression. UGBT2B17 genotype was correlated with day 29 (D29) steady-state PK (Exe and metabolites), change in PD biomarkers (estrone and androstenedione) at D29 vs baseline (BL), objective response rate (ORR) [sum of complete and partial responses], and clinical benefit rate (CBR) [response or stable disease ≥ 24 weeks]. Results: In 64 patients enrolled, CBR was 25%; ORR was 3%. Frequencies of UGT2B17*2/*2, UGT2B17*1/*2 and UGT2B17*1/*1 were 72%, 26% and 2%, respectively. PD and PK data were available for 54 and 53 patients respectively. Mean Exe17- O-glu AUC and Cmax were significantly lower, and mean 17DhExe Cmax numerically higher in patients with UGT2B17*2/*2 vs other genotypes (Table 1). 17DhExe Cmax was higher in patients with clinical benefit vs none (5.6 vs 3.8 ng/ml, p=0.02). Frequency of desired PD effect (rise in androstenedione and fall in estrone at D29 vs BL) was 22%. Exe plasma active index (PAI) [Table 1] was higher in patients with a fall in D29 estrone vs those without (14.7 vs 9.5, p=0.05). Conclusions: UGT2B17 genotype affects Exe PK and may have significant PD correlates. Larger studies to examine effects on clinical treatment efficacy are needed. Clinical trial information: NCT01655004. [Table: see text]
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Affiliation(s)
- Robert John Walsh
- Department of Haematology-Oncology, National University Cancer Institute, National University Health System, Singapore, Singapore
| | - Soo Chin Lee
- Department of Haematology-Oncology, National University Cancer Institute, National University Health System, Singapore, Singapore
| | - Kok Yong Seng
- Department of Pharmacology, National University Singapore, Singapore, Singapore
| | - Ling-Zhi Wang
- Cancer Science Institute of Singapore, National University of Singapore, Singapore, Singapore
| | - Gwo Fuang Ho
- Department of Clinical Oncology, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Samuel Guan Wei Ow
- Department of Haematology-Oncology, National University Cancer Institute, National University Health System, Singapore, Singapore
| | - Nesaretnam Barr Kumarakulasinghe
- Department of Haematology-Oncology, National University Cancer Institute, National University Health System, Singapore, Singapore
| | - Raghav Sundar
- Department of Haematology-Oncology, National University Cancer Institute, National University Health System, Singapore, Singapore
| | - Xiao Wen Lee
- Cancer Science Institute of Singapore, National University of Singapore, Singapore, Singapore
| | - Hui-Ling Yap
- Cancer Science Institute of Singapore, National University of Singapore, Singapore, Singapore
| | - Anand Devaprasath Jeyasekharan
- Department of Haematology-Oncology, National University Cancer Institute, National University Health System, Singapore, Singapore
| | - Angela Pang
- Department of Haematology-Oncology, National University Cancer Institute, National University Health System, Singapore, Singapore
| | - Jingshan Ho
- Department of Haematology-Oncology, National University Cancer Institute, National University Health System, Singapore, Singapore
| | - Chee Seng Tan
- Department of Haematology-Oncology, National University Cancer Institute, National University Health System, Singapore, Singapore
| | - Yi Wan Lim
- Department of Haematology-Oncology, National University Cancer Institute, National University Health System, Singapore, Singapore
| | - Rozita Abdul Malik
- Department of Clinical Oncology, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Wan Zamaniah Wan Ishak
- Department of Clinical Oncology, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Boon Cher Goh
- Department of Haematology-Oncology, National University Cancer Institute, National University Health System, Singapore, Singapore
| | - Bee Choo Tai
- Saw Swee Hock School of Public Health, National University Health System, Singapore, Singapore
| | - Andrea Li Ann Wong
- Department of Haematology-Oncology, National University Cancer Institute, National University Health System, Singapore, Singapore
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21
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Sundar R, Bandla A, Tan SSH, Liao LD, Kumarakulasinghe NB, Jeyasekharan AD, Ow SGW, Ho J, Tan DSP, Lim JSJ, Vijayan J, Therimadasamy AK, Hairom Z, Ang E, Ang S, Thakor NV, Lee SC, Wilder-Smith EPV. Limb Hypothermia for Preventing Paclitaxel-Induced Peripheral Neuropathy in Breast Cancer Patients: A Pilot Study. Front Oncol 2017; 6:274. [PMID: 28119855 PMCID: PMC5222823 DOI: 10.3389/fonc.2016.00274] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2016] [Accepted: 12/23/2016] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Peripheral neuropathy (PN) due to paclitaxel is a common dose-limiting toxicity with no effective prevention or treatment. We hypothesize that continuous-flow limb hypothermia can reduce paclitaxel-induced PN. PATIENTS AND METHODS An internally controlled pilot trial was conducted to investigate the neuroprotective effect of continuous-flow limb hypothermia in breast cancer patients receiving weekly paclitaxel. Patients underwent limb hypothermia of one limb for a duration of 3 h with every paclitaxel infusion, with the contralateral limb used as control. PN was primarily assessed using nerve conduction studies (NCSs) before the start of chemotherapy, and after 1, 3, and 6 months. Skin temperature and tolerability to hypothermia were monitored using validated scores. RESULTS Twenty patients underwent a total of 218 cycles of continuous-flow limb hypothermia at a coolant temperature of 22°C. Continuous-flow limb hypothermia achieved mean skin temperature reduction of 1.5 ± 0.7°C and was well tolerated, with no premature termination of cooling due to intolerance. Grade 3 PN occurred in 2 patients (10%), grade 2 in 2 (10%), and grade 1 in 12 (60%). Significant correlation was observed between amount of skin cooling and motor nerve amplitude preservation at 6 months (p < 0.0005). Sensory velocity and amplitude in the cooled limbs were less preserved than in the control limbs, but the difference did not attain statistical significance. One patient with a history of diabetes mellitus had significant preservation of compound muscle action potential in the cooled limb on NCS analysis. CONCLUSION This study suggests that continuous limb hypothermia accompanying paclitaxel infusion may reduce paclitaxel-induced PN and have therapeutic potential in select patients and warrants further investigation. The method is safe and well tolerated.
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Affiliation(s)
- Raghav Sundar
- Department of Haematology-Oncology, National University Health System , Singapore , Singapore
| | - Aishwarya Bandla
- Singapore Institute for Neurotechnology, National University of Singapore, Singapore, Singapore; Department of Biomedical Engineering, National University of Singapore, Singapore, Singapore
| | - Stacey Sze Hui Tan
- Singapore Institute for Neurotechnology, National University of Singapore , Singapore , Singapore
| | - Lun-De Liao
- Singapore Institute for Neurotechnology, National University of Singapore, Singapore, Singapore; Institute of Biomedical Engineering and Nanomedicine, National Health Research Institutes, Zhunan Township, Taiwan
| | | | - Anand D Jeyasekharan
- Department of Haematology-Oncology, National University Health System , Singapore , Singapore
| | - Samuel Guan Wei Ow
- Department of Haematology-Oncology, National University Health System , Singapore , Singapore
| | - Jingshan Ho
- Department of Haematology-Oncology, National University Health System , Singapore , Singapore
| | - David Shao Peng Tan
- Department of Haematology-Oncology, National University Health System , Singapore , Singapore
| | - Joline Si Jing Lim
- Department of Haematology-Oncology, National University Health System , Singapore , Singapore
| | - Joy Vijayan
- Department of Medicine, National University Health System , Singapore , Singapore
| | | | - Zarinah Hairom
- National University Cancer Institute, National University Health System , Singapore , Singapore
| | - Emily Ang
- National University Cancer Institute, National University Health System , Singapore , Singapore
| | - Sally Ang
- Department of Haematology-Oncology, National University Health System , Singapore , Singapore
| | - Nitish V Thakor
- Singapore Institute for Neurotechnology, National University of Singapore, Singapore, Singapore; Department of Biomedical Engineering, National University of Singapore, Singapore, Singapore; Department of Biomedical Engineering, Johns Hopkins University, Baltimore, MD, USA
| | - Soo-Chin Lee
- Department of Haematology-Oncology, National University Health System, Singapore, Singapore; Cancer Science Institute of Singapore, National University of Singapore, Singapore, Singapore
| | - Einar P V Wilder-Smith
- Singapore Institute for Neurotechnology, National University of Singapore, Singapore, Singapore; Department of Medicine, National University Health System, Singapore, Singapore; Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
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22
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Sundar R, Jeyasekharan AD, Pang B, Soong RCT, Kumarakulasinghe NB, Ow SGW, Ho J, Lim JSJ, Tan DSP, Wilder-Smith EPV, Bandla A, Tan SSH, Asuncion BR, Fazreen Z, Hoppe MM, Putti TC, Poh LM, Goh BC, Lee SC. Low Levels of NDRG1 in Nerve Tissue Are Predictive of Severe Paclitaxel-Induced Neuropathy. PLoS One 2016; 11:e0164319. [PMID: 27716814 PMCID: PMC5055363 DOI: 10.1371/journal.pone.0164319] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2016] [Accepted: 09/22/2016] [Indexed: 11/23/2022] Open
Abstract
Introduction Sensory peripheral neuropathy caused by paclitaxel is a common and dose limiting toxicity, for which there are currently no validated predictive biomarkers. We investigated the relationship between the Charcot-Marie-Tooth protein NDRG1 and paclitaxel-induced neuropathy. Methods/Materials Archived mammary tissue specimen blocks of breast cancer patients who received weekly paclitaxel in a single centre were retrieved and NDRG1 immunohistochemistry was performed on normal nerve tissue found within the sample. The mean nerve NDRG1 score was defined by an algorithm based on intensity of staining and percentage of stained nerve bundles. NDRG1 scores were correlated with paclitaxel induced neuropathy Results 111 patients were studied. 17 of 111 (15%) developed severe paclitaxel-induced neuropathy. The mean nerve NDRG1 expression score was 5.4 in patients with severe neuropathy versus 7.7 in those without severe neuropathy (p = 0.0019). A Receiver operating characteristic (ROC) curve analysis of the mean nerve NDRG1 score revealed an area under the curve of 0.74 (p = 0.0013) for the identification of severe neuropathy, with a score of 7 being most discriminative. 13/54 (24%) subjects with an NDRG1 score < = 7 developed severe neuropathy, compared to only 4/57 (7%) in those with a score >7 (p = 0.017). Conclusion Low NDRG1 expression in nerve tissue present within samples of surgical resection may identify subjects at risk for severe paclitaxel-induced neuropathy. Since nerve biopsies are not routinely feasible for patients undergoing chemotherapy for early breast cancer, this promising biomarker strategy is compatible with current clinical workflow.
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Affiliation(s)
- Raghav Sundar
- Department of Haematology-Oncology, National University Cancer Institute, Singapore, National University Health System, Singapore, Singapore
| | - Anand D. Jeyasekharan
- Department of Haematology-Oncology, National University Cancer Institute, Singapore, National University Health System, Singapore, Singapore
- Cancer Science Institute of Singapore, National University of Singapore, Singapore, Singapore
| | - Brendan Pang
- Cancer Science Institute of Singapore, National University of Singapore, Singapore, Singapore
- Department of Pathology, National University Health System, Singapore, Singapore
| | - Richie Chuan Teck Soong
- Cancer Science Institute of Singapore, National University of Singapore, Singapore, Singapore
- Department of Pathology, National University Health System, Singapore, Singapore
| | - Nesaretnam Barr Kumarakulasinghe
- Department of Haematology-Oncology, National University Cancer Institute, Singapore, National University Health System, Singapore, Singapore
| | - Samuel Guan Wei Ow
- Department of Haematology-Oncology, National University Cancer Institute, Singapore, National University Health System, Singapore, Singapore
| | - Jingshan Ho
- Department of Haematology-Oncology, National University Cancer Institute, Singapore, National University Health System, Singapore, Singapore
| | - Joline Si Jing Lim
- Department of Haematology-Oncology, National University Cancer Institute, Singapore, National University Health System, Singapore, Singapore
| | - David Shao Peng Tan
- Department of Haematology-Oncology, National University Cancer Institute, Singapore, National University Health System, Singapore, Singapore
| | - Einar P. V. Wilder-Smith
- Singapore Institute for Neurotechnology (SINAPSE), National University of Singapore, Singapore, Singapore
- Department of Medicine, National University Health System, Singapore, Singapore
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Aishwarya Bandla
- Singapore Institute for Neurotechnology (SINAPSE), National University of Singapore, Singapore, Singapore
- Department of Biomedical Engineering, National University of Singapore, Singapore, Singapore
| | - Stacey Sze Hui Tan
- Singapore Institute for Neurotechnology (SINAPSE), National University of Singapore, Singapore, Singapore
| | | | - Zul Fazreen
- Cancer Science Institute of Singapore, National University of Singapore, Singapore, Singapore
| | - Michal Marek Hoppe
- Cancer Science Institute of Singapore, National University of Singapore, Singapore, Singapore
| | | | - Lay Mui Poh
- Department of Pharmacy, National University Cancer Institute Singapore, National University Health System, Singapore, Singapore
| | - Boon Cher Goh
- Department of Haematology-Oncology, National University Cancer Institute, Singapore, National University Health System, Singapore, Singapore
- Cancer Science Institute of Singapore, National University of Singapore, Singapore, Singapore
| | - Soo-Chin Lee
- Department of Haematology-Oncology, National University Cancer Institute, Singapore, National University Health System, Singapore, Singapore
- Cancer Science Institute of Singapore, National University of Singapore, Singapore, Singapore
- * E-mail:
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23
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Sundar R, Bandla A, Tan S, Kumarakulasinghe NB, Jeyasekharan AD, Ow SGW, Ho J, Tan DSP, Lim JSJ, Vijayan J, Hairom Z, Ang S, Liao LD, Lee SC, Thakor N, Wilder-Smith E. The role of limb hypothermia in preventing paclitaxel-induced peripheral neuropathy. J Clin Oncol 2016. [DOI: 10.1200/jco.2016.34.15_suppl.e21696] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [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)
- Raghav Sundar
- National University Cancer Institute, National University Health System, Singapore, Singapore, Singapore
| | | | - Stacey Tan
- National University of Singapore, Singapore, Singapore
| | | | | | - Samuel Guan Wei Ow
- National University Cancer Institute, National University Health System, Singapore, Singapore, Singapore
| | - Jingshan Ho
- National University Cancer Institute, Singapore, Singapore, Singapore
| | - David Shao Peng Tan
- National University Cancer Institute, Singapore (NCIS), Singapore, Singapore
| | | | - Joy Vijayan
- National University Health System, Singapore, Singapore
| | | | - Sally Ang
- National University Health System, Singapore, Singapore
| | - Lun-De Liao
- National University of Singapore, Singapore, Singapore
| | - Soo-Chin Lee
- National University Cancer Institute, National University Health System, Singapore, Singapore, Singapore
| | - Nitish Thakor
- National University of Singapore, Singapore, Singapore
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24
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Ang YL, Soo RA, Ho GF, Sundar R, Tan SH, Lim JSJ, Yong WP, Chong WQ, Ho J, Kumarakulasinghe NB, Aung MI, Koh E, Ramlee M, Phyu PS, Kyin L, Goh BC, Lee SC. A phase II randomized study of docetaxel +/- low-dose, short course sunitinib in advanced solid tumours. J Clin Oncol 2016. [DOI: 10.1200/jco.2016.34.15_suppl.e14124] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [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)
| | - Ross A. Soo
- National University Cancer Institute, National University Health System, Singapore, Singapore, Singapore
| | - Gwo Fuang Ho
- University Malaya Medical Center, Kuala Lumpur, Malaysia
| | - Raghav Sundar
- National University Cancer Institute, National University Health System, Singapore, Singapore, Singapore
| | - Sing Huang Tan
- National University Hospital National University Cancer Institute of Singapore, Singapore, Singapore
| | | | - Wei-Peng Yong
- National University Cancer Institute, National University Health System, Singapore, Singapore, Singapore
| | - Wan Qin Chong
- National University Cancer Institute, National University Health System, Singapore, Singapore, Singapore
| | - Jingshan Ho
- National University Cancer Institute, Singapore, Singapore, Singapore
| | | | - May Ingyin Aung
- National University Hospital Singapore, Singapore, Singapore
| | - Esther Koh
- National University Hospital Singapore, Singapore, Singapore
| | - Mira Ramlee
- University Malaya Medical Center, Kuala Lumpur, Malaysia
| | - Pyar Soe Phyu
- Department of Haematology-Oncology, National University Cancer Institute, Singapore, Singapore
| | - Lily Kyin
- National University Hospital Singapore, Singapore, Singapore
| | - Boon Cher Goh
- National University Hospital Singapore, Singapore, Singapore
| | - Soo-Chin Lee
- National University Cancer Institute, National University Health System, Singapore, Singapore, Singapore
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25
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Kumarakulasinghe NB, van Zanwijk N, Soo RA. Molecular targeted therapy in the treatment of advanced stage non-small cell lung cancer (NSCLC). Respirology 2015; 20:370-8. [PMID: 25689095 DOI: 10.1111/resp.12490] [Citation(s) in RCA: 105] [Impact Index Per Article: 11.7] [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: 11/24/2014] [Accepted: 12/07/2014] [Indexed: 12/14/2022]
Abstract
Historically, patients with advanced stage non-small cell lung cancer (NSCLC) were treated with chemotherapy alone, but a therapeutic plateau has been reached. Advances in the understanding of molecular genetics have led to the recognition of multiple molecularly distinct subsets of NSCLC. This in turn has led to the development of rationally directed molecular targeted therapy, leading to improved clinical outcomes. Tumour genotyping for EGFR mutations and ALK rearrangement has meant chemotherapy is no longer given automatically as first-line treatment but reserved for when patients do not have a 'druggable' driver oncogene. In this review, we will address the current status of clinically relevant driver mutations and emerging new molecular subsets in lung adenocarcinoma and squamous cell carcinoma, and the role of targeted therapy and mechanisms of acquired resistance to targeted therapy.
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