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Childs S, Nindra U, Yoon R, Haider S, Hong M, Roohullah A, Cooper A, Wilkinson K, Chua W, Pal A. Comparison of Prognostic Scores in Early Phase Clinical Trials: A 10-year Single Centre Australian Experience. Anticancer Res 2024; 44:2095-2102. [PMID: 38677731 DOI: 10.21873/anticanres.17014] [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: 02/10/2024] [Revised: 02/29/2024] [Accepted: 03/01/2024] [Indexed: 04/29/2024]
Abstract
BACKGROUND/AIM Early phase clinical trials (EPCTs) assess the tolerability of novel anti-cancer therapeutics in patients with advanced malignancy. Patient selection is important given the modest clinical benefit and time commitments for trials. Prognostic scores have been developed to facilitate identification of high-risk patients. This study aimed to compare five prognostic scores to predict survival for patients on an EPCT. PATIENTS AND METHODS We performed a retrospective review of patients enrolled in EPCT at Liverpool Hospital, Sydney, from 2013 to 2023. Demographic, biochemical, and survival data were collected from electronic medical records. The score from five prognostic scoring systems (Royal Marsden hospital, MD Anderson Cancer centre, Gustave Roussy Immune, MD Anderson Immune Checkpoint Inhibitor and Princess Margaret Hospital Index) were calculated. Overall survival was measured using the Kaplan-Meier method and predictive discrimination was assessed using Harrell's c-index. RESULTS A total of 218 patients across 36 EPCTs were included. The median overall survival was 9.8 months with 22% of patients dying in less than 90 days. Seventeen to thirty-four percent of patients were categorised as high-risk. The MDACC score obtained the highest predictability for overall survival for the whole cohort (c-index=0.67, 95%CI=0.62-0.72) and the immunotherapy-based cohort (c-index= 0.65, 95%CI=0.59-0.71). However, all scores performed similarly with a significant overlap in the confidence intervals. CONCLUSION Our retrospective audit confirms the utility of prognostic scores to predict survival in an Australian EPCT cohort, with similar predictive discrimination across various scoring systems. Integration of these prognostic tools into EPCT screening processes may optimise benefits and reduce risks associated with EPCTs.
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Affiliation(s)
- Sarah Childs
- Department of Medical Oncology, Liverpool Hospital, Liverpool, Australia;
| | - Udit Nindra
- Department of Medical Oncology, Liverpool Hospital, Liverpool, Australia
- Ingham Institute for Applied Medical Research, Liverpool, Australia
- Western Sydney University, Sydney, Australia
| | - Robert Yoon
- Department of Medical Oncology, Liverpool Hospital, Liverpool, Australia
- Ingham Institute for Applied Medical Research, Liverpool, Australia
- Western Sydney University, Sydney, Australia
- Department of Medical Oncology, Macarthur Cancer Therapy Centre, Campbelltown Hospital, Campbelltown, Australia
| | - Sana Haider
- Ingham Institute for Applied Medical Research, Liverpool, Australia
- Western Sydney University, Sydney, Australia
- Department of Medical Oncology, Northern Cancer Service, Tasmania, Australia
| | - Martin Hong
- Department of Medical Oncology, Liverpool Hospital, Liverpool, Australia
- Ingham Institute for Applied Medical Research, Liverpool, Australia
- Western Sydney University, Sydney, Australia
| | - Aflah Roohullah
- Department of Medical Oncology, Liverpool Hospital, Liverpool, Australia
- Ingham Institute for Applied Medical Research, Liverpool, Australia
- Western Sydney University, Sydney, Australia
- Department of Medical Oncology, Macarthur Cancer Therapy Centre, Campbelltown Hospital, Campbelltown, Australia
| | - Adam Cooper
- Department of Medical Oncology, Liverpool Hospital, Liverpool, Australia
- Ingham Institute for Applied Medical Research, Liverpool, Australia
- Western Sydney University, Sydney, Australia
| | - Kate Wilkinson
- Department of Medical Oncology, Liverpool Hospital, Liverpool, Australia
- Ingham Institute for Applied Medical Research, Liverpool, Australia
- Western Sydney University, Sydney, Australia
| | - Wei Chua
- Department of Medical Oncology, Liverpool Hospital, Liverpool, Australia
- Ingham Institute for Applied Medical Research, Liverpool, Australia
- Western Sydney University, Sydney, Australia
| | - Abhijit Pal
- Department of Medical Oncology, Liverpool Hospital, Liverpool, Australia
- Department of Medical Oncology, Bankstown-Lidcombe Hospital, Bankstown, Australia
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Nindra U, Childs S, Yoon R, Haider S, Hong M, Roohullah A, Cooper A, Wilkinson K, Pal A, Chua W. Survival outcomes in older adults undergoing early phase clinical trials. J Geriatr Oncol 2024; 15:101743. [PMID: 38461116 DOI: 10.1016/j.jgo.2024.101743] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2024] [Revised: 02/05/2024] [Accepted: 03/04/2024] [Indexed: 03/11/2024]
Affiliation(s)
- Udit Nindra
- Department of Medical Oncology, Liverpool Hospital, Liverpool, NSW, Australia; Ingham Institute for Applied Medical Research, Liverpool, Australia; Western Sydney University, Sydney, Australia.
| | - Sarah Childs
- Department of Medical Oncology, Liverpool Hospital, Liverpool, NSW, Australia
| | - Robert Yoon
- Department of Medical Oncology, Liverpool Hospital, Liverpool, NSW, Australia; Ingham Institute for Applied Medical Research, Liverpool, Australia; Western Sydney University, Sydney, Australia; Department of Medical Oncology, Macarthur Cancer Therapy Centre, Campbelltown Hospital, Campbelltown, NSW, Australia
| | - Sana Haider
- Ingham Institute for Applied Medical Research, Liverpool, Australia; Western Sydney University, Sydney, Australia; Department of Medical Oncology, Northern Cancer Service, Tasmania, Australia
| | - Martin Hong
- Department of Medical Oncology, Liverpool Hospital, Liverpool, NSW, Australia; Ingham Institute for Applied Medical Research, Liverpool, Australia; Western Sydney University, Sydney, Australia
| | - Aflah Roohullah
- Department of Medical Oncology, Liverpool Hospital, Liverpool, NSW, Australia; Ingham Institute for Applied Medical Research, Liverpool, Australia; Western Sydney University, Sydney, Australia; Department of Medical Oncology, Macarthur Cancer Therapy Centre, Campbelltown Hospital, Campbelltown, NSW, Australia
| | - Adam Cooper
- Department of Medical Oncology, Liverpool Hospital, Liverpool, NSW, Australia; Ingham Institute for Applied Medical Research, Liverpool, Australia; Western Sydney University, Sydney, Australia; Department of Medical Oncology, Macarthur Cancer Therapy Centre, Campbelltown Hospital, Campbelltown, NSW, Australia
| | - Kate Wilkinson
- Department of Medical Oncology, Liverpool Hospital, Liverpool, NSW, Australia; Ingham Institute for Applied Medical Research, Liverpool, Australia; Western Sydney University, Sydney, Australia
| | - Abhijit Pal
- Department of Medical Oncology, Liverpool Hospital, Liverpool, NSW, Australia; Department of Medical Oncology, Bankstown-Lidcombe Hospital, Bankstown, NSW, Australia
| | - Wei Chua
- Department of Medical Oncology, Liverpool Hospital, Liverpool, NSW, Australia; Ingham Institute for Applied Medical Research, Liverpool, Australia; Western Sydney University, Sydney, Australia
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Nindra U, Lin P, Becker T, Roberts TL, Chua W. Current state of theranostics in metastatic castrate-resistant prostate cancer. J Med Imaging Radiat Oncol 2024. [PMID: 38632711 DOI: 10.1111/1754-9485.13658] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2023] [Accepted: 04/05/2024] [Indexed: 04/19/2024]
Abstract
Prostate cancer remains one of the leading causes of cancer-related death in the world. There have been significant advances in chemotherapy, hormonal therapy and targeted therapy options for patients with castrate-resistant disease. However, these systemic treatments are often associated with unwanted toxicities. Targeted therapy with radiopharmaceuticals has become of key interest to limit systemic toxicity and provides a more precision oncology approach to treatment. Strontium-89, Samarium-153 EDTMP and Radium-223 have been trialled with mixed results. Strontium-89 and Samarium-153 EDTMP have shown benefits in palliating metastatic bone pain but with no impact on survival outcomes. Early therapeutic radiopharmaceuticals targeting PSMA that were developed were beta-emitting agents, but recently alpha-emitting agents are being investigated as potentially superior options. Radium-223 is the first alpha-particle emitter therapeutic agent approved by the FDA, with phase III trial evidence showing benefits in overall survival and delay in symptomatic skeletal events for patients. Recently, 177-Lutetium-PSMA-617 has demonstrated significant survival advantages in pre-treated metastatic castrate-resistant cancer patients in a number of phase II and III studies. Furthermore, 225-Actinium-PSMA-617 also showed promise even in patients pre-treated with 177-Lutetium-PSMA-617. Hence, there has been an explosion of radiopharmaceutical treatment options for patients with prostate cancer. This review explores past and current theranostic capacities in the radiopharmaceutical treatment of metastatic castrate-resistant prostate cancer.
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Affiliation(s)
- Udit Nindra
- Department of Medical Oncology, Liverpool Hospital, Sydney, New South Wales, Australia
- Ingham Institute for Applied Medical Research, Sydney, New South Wales, Australia
- Western Sydney University, Sydney, New South Wales, Australia
| | - Peter Lin
- Ingham Institute for Applied Medical Research, Sydney, New South Wales, Australia
- Western Sydney University, Sydney, New South Wales, Australia
- Department of Nuclear Medicine, Liverpool Hospital, Sydney, New South Wales, Australia
| | - Therese Becker
- Ingham Institute for Applied Medical Research, Sydney, New South Wales, Australia
- Western Sydney University, Sydney, New South Wales, Australia
- University of New South Wales, Sydney, New South Wales, Australia
| | - Tara L Roberts
- Ingham Institute for Applied Medical Research, Sydney, New South Wales, Australia
- Western Sydney University, Sydney, New South Wales, Australia
- University of New South Wales, Sydney, New South Wales, Australia
| | - Wei Chua
- Department of Medical Oncology, Liverpool Hospital, Sydney, New South Wales, Australia
- Ingham Institute for Applied Medical Research, Sydney, New South Wales, Australia
- Western Sydney University, Sydney, New South Wales, Australia
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Nindra U, Pal A, Bray V, Yip PY, Tognela A, Roberts TL, Becker TM, Williamson J, Farzin M, Li JJ, Lea V, Hagelamin A, Ng W, Wang B, Lee CS, Chua W. Utility of multigene panel next-generation sequencing in routine clinical practice for identifying genomic alterations in newly diagnosed metastatic nonsmall cell lung cancer. Intern Med J 2024; 54:596-601. [PMID: 37713593 DOI: 10.1111/imj.16224] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [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: 01/19/2023] [Accepted: 08/17/2023] [Indexed: 09/17/2023]
Abstract
BACKGROUND The standard of care in newly diagnosed metastatic non-small cell lung cancer (NSCLC) is to test for aberrations in three genes for driver mutations - ALK, ROS1 and epidermal growth factor receptor (EGFR) - and also for immunohistochemistry to be performed for programmed death-ligand 1 expression level. Next-generation sequencing (NGS), with or without RNA fusion testing, is increasingly used in standard clinical practice to identify patients with potentially actionable mutations. Stratification of NGS mutation tiers is currently based on the European Society of Medical Oncology Scale for Clinical Actionability of Molecular Targets (ESCAT) Tiers I-V and X. AIM Our aim was to analyse NSCLC tumour samples for the prevalence of Tiers I-V mutations to establish guidance for current and novel treatments in patients with metastatic disease. METHODS NGS was performed employing the Oncomine Precision Assay (without RNA fusion testing) that interrogates DNA hotspot variants across 45 genes to screen 210 NSCLC tissue samples obtained across six Sydney hospitals between June 2021 and March 2022. RESULTS In our cohort, 161 of 210 (77%) had at least one gene mutation identified, with 41 of 210 (20%) having two or more concurrent mutations. Tier I mutations included 42 of 210 (20%) EGFR mutations (EIA) and five of 210 (3%) MET exon 14 skipping mutations (EIB). Non-Tier I variants included 22 of 210 (11%) KRAS G12C hotspot mutations (EIIB), with a further 47 of 210 (22%) having non-G12C KRAS (EX) mutations. NGS testing revealed an additional 15% of cases with Tier II ESCAT mutations in NSCLC. Forty-six percent of patients also demonstrated potential Tier III and IV mutations that are currently under investigation in early-phase clinical trials. CONCLUSIONS In addition to identifying patients with genomic alterations suitable for clinically proven standard-of-care therapeutic options, the 45-gene NGS panel has significant potential in identifying potentially actionable non-Tier 1 mutations that may become future standard clinical practice in NSCLC.
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Affiliation(s)
- Udit Nindra
- Department of Medical Oncology, Liverpool Hospital, Sydney, New South Wales, Australia
- Department of Medical Oncology, Macarthur Cancer Therapy Centre, Campbelltown Hospital, Sydney, New South Wales, Australia
- Department of Medical Oncology, Bankstown-Lidcombe Hospital, Sydney, New South Wales, Australia
- Ingham Institute for Applied Medical Research, Sydney, New South Wales, Australia
| | - Abhijit Pal
- Department of Medical Oncology, Liverpool Hospital, Sydney, New South Wales, Australia
- Department of Medical Oncology, Bankstown-Lidcombe Hospital, Sydney, New South Wales, Australia
| | - Victoria Bray
- Department of Medical Oncology, Liverpool Hospital, Sydney, New South Wales, Australia
| | - Po Y Yip
- Department of Medical Oncology, Macarthur Cancer Therapy Centre, Campbelltown Hospital, Sydney, New South Wales, Australia
- Department of Medical Oncology, Bankstown-Lidcombe Hospital, Sydney, New South Wales, Australia
- Discipline of Pathology, School of Medicine, Western Sydney University, Sydney, New South Wales, Australia
| | - Annette Tognela
- Department of Medical Oncology, Macarthur Cancer Therapy Centre, Campbelltown Hospital, Sydney, New South Wales, Australia
| | - Tara L Roberts
- Department of Medical Oncology, Bankstown-Lidcombe Hospital, Sydney, New South Wales, Australia
- Discipline of Pathology, School of Medicine, Western Sydney University, Sydney, New South Wales, Australia
- South Western Clinical School, University of New South Wales, Sydney, New South Wales, Australia
| | - Therese M Becker
- Department of Medical Oncology, Bankstown-Lidcombe Hospital, Sydney, New South Wales, Australia
- Discipline of Pathology, School of Medicine, Western Sydney University, Sydney, New South Wales, Australia
- South Western Clinical School, University of New South Wales, Sydney, New South Wales, Australia
| | - Jonathon Williamson
- Department of Respiratory Medicine, Liverpool Hospital, Sydney, New South Wales, Australia
| | - Mahtab Farzin
- Department of Anatomical Pathology, Liverpool Hospital, Sydney, New South Wales, Australia
| | - Jing J Li
- Department of Anatomical Pathology, Liverpool Hospital, Sydney, New South Wales, Australia
| | - Vivienne Lea
- Department of Anatomical Pathology, Liverpool Hospital, Sydney, New South Wales, Australia
| | - Abeer Hagelamin
- Department of Anatomical Pathology, Liverpool Hospital, Sydney, New South Wales, Australia
| | - Weng Ng
- Department of Medical Oncology, Liverpool Hospital, Sydney, New South Wales, Australia
- Ingham Institute for Applied Medical Research, Sydney, New South Wales, Australia
- Discipline of Pathology, School of Medicine, Western Sydney University, Sydney, New South Wales, Australia
- South Western Clinical School, University of New South Wales, Sydney, New South Wales, Australia
| | - Bin Wang
- Department of Anatomical Pathology, Liverpool Hospital, Sydney, New South Wales, Australia
| | - C Soon Lee
- Ingham Institute for Applied Medical Research, Sydney, New South Wales, Australia
- Discipline of Pathology, School of Medicine, Western Sydney University, Sydney, New South Wales, Australia
- South Western Clinical School, University of New South Wales, Sydney, New South Wales, Australia
- Department of Anatomical Pathology, Liverpool Hospital, Sydney, New South Wales, Australia
| | - Wei Chua
- Department of Medical Oncology, Liverpool Hospital, Sydney, New South Wales, Australia
- Ingham Institute for Applied Medical Research, Sydney, New South Wales, Australia
- Discipline of Pathology, School of Medicine, Western Sydney University, Sydney, New South Wales, Australia
- South Western Clinical School, University of New South Wales, Sydney, New South Wales, Australia
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Nindra U, Shivasabesan G, Mellor R, Chua W, Ng W, Karikios D, Richards B, Liu J. Evaluating Systemic Burnout in Medical Oncology Through a National Oncology Mentorship Program. JCO Oncol Pract 2024; 20:549-557. [PMID: 38290086 DOI: 10.1200/op.23.00469] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Revised: 10/14/2023] [Accepted: 12/01/2023] [Indexed: 02/01/2024] Open
Abstract
PURPOSE Mentorship has a positive influence on trainee skills and well-being. A 2022 Pilot Mentorship Program in New South Wales involving 40 participants revealed high burnout rates in Medical Oncology trainees. As part of an Australia-wide inaugural National Oncology Mentorship Program in 2023 (NOMP23), a national survey was undertaken to assess the prevalence of burnout, anxiety, depression, professional fulfilment, and drivers of distress in the Australian medical oncology workforce. METHODS NOMP23 is a 1-year prospective cohort study that recruited medical oncology trainees and consultants using e-mail correspondence between February and March 2023. Each participant completed a baseline survey which included the Maslach Burnout Index (MBI), Stanford Professional Fulfilment Index, and Patient Health Questionnaire-4 for anxiety and depression. RESULTS One hundred and twelve participants (56 mentors, 56 mentees) were enrolled in NOMP23, of which 86 (77%) completed the baseline survey. MBI results at baseline demonstrated that 77% of consultants and 82% of trainees experienced burnout in the past 12 months. Professional fulfilment was noted to be <5% in our cohort. Screening rates of anxiety and depression in trainees were 32% and 16%, respectively, compared with 7% and 2% for consultants. When assessing reasons for workplace stress, two thirds stated that heavy patient load contributed to stress, while almost three quarters attributed a heavy administrative load. Lack of supervision was a key stressor for trainees (39%), as was lack of support from the training college (58%). CONCLUSION Trainees and consultant medical oncologists demonstrate high rates of burnout and low professional fulfilment. The NOMP23 program has identified a number of key stress factors driving burnout and demonstrated concerning levels of anxiety and depression. Ongoing mentorship and other well-being initiatives are needed to address these issues.
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Affiliation(s)
- Udit Nindra
- Department of Medical Oncology, Liverpool Hospital, Liverpool, Australia
- School of Medicine, Western Sydney University, Sydney, Australia
- Ingham Institute for Applied Medical Research, Liverpool, Australia
| | - Gowri Shivasabesan
- Department of Medical Oncology, Liverpool Hospital, Liverpool, Australia
| | - Rhiannon Mellor
- Department of Medical Oncology, Chris O'Brien Lifehouse, Sydney, Australia
- Garvan Institute of Applied Medical Research, Sydney, Australia
- School of Medicine and Health, University of New South Wales, Sydney, Australia
| | - Wei Chua
- Department of Medical Oncology, Liverpool Hospital, Liverpool, Australia
- School of Medicine, Western Sydney University, Sydney, Australia
- Ingham Institute for Applied Medical Research, Liverpool, Australia
| | - Weng Ng
- Department of Medical Oncology, Liverpool Hospital, Liverpool, Australia
- School of Medicine, Western Sydney University, Sydney, Australia
- Ingham Institute for Applied Medical Research, Liverpool, Australia
| | - Deme Karikios
- School of Medicine, University of Sydney, Sydney, Australia
- Department of Medical Oncology, Nepean Hospital, Sydney, Australia
| | - Bethan Richards
- Department of Rheumatology, Royal Prince Alfred Hospital, Sydney, Australia
- Institute of Musculoskeletal Health, Sydney Local Health District, Sydney, Australia
| | - Jia Liu
- Garvan Institute of Applied Medical Research, Sydney, Australia
- School of Medicine, University of Sydney, Sydney, Australia
- The Kinghorn Cancer Centre, St Vincent's Hospital, Sydney Australia
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McNamee N, Harvey C, Gray L, Khoo T, Lingam L, Zhang B, Nindra U, Yip PY, Pal A, Clay T, Arulananda S, Itchins M, Pavlakis N, Kao S, Bowyer S, Chin V, Warburton L, Pires da Silva I, John T, Solomon B, Alexander M, Nagrial A. Brief Report: Real-World Toxicity and Survival of Combination Immunotherapy in Pleural Mesothelioma-RIOMeso. J Thorac Oncol 2024; 19:636-642. [PMID: 38036250 DOI: 10.1016/j.jtho.2023.11.014] [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: 09/28/2023] [Revised: 11/03/2023] [Accepted: 11/09/2023] [Indexed: 12/02/2023]
Abstract
BACKGROUND Australia has one of the highest rates of asbestos-associated diseases. Mesothelioma remains an area of unmet need with a 5-year overall survival of 10%. First-line immunotherapy with ipilimumab and nivolumab is now a standard of care for unresectable pleural mesothelioma following the CheckMate 743 trial, with supportive data from the later line single-arm MAPS2 trial. RIOMeso evaluates survival and toxicity of this regimen in real-world practice. METHODS Demographic and clinicopathologic data of Australian patients treated with ipilimumab and nivolumab in first- and subsequent-line settings for pleural mesothelioma were collected retrospectively. Survival was reported using the Kaplan-Meier method and compared between subgroups with the log-rank test. Toxicity was investigator assessed using Common Terminology Criteria for Adverse Events version 5.0. RESULTS A total of 119 patients were identified from 11 centers. The median age was 72 years, 83% were male, 92% had Eastern Cooperative Oncology Group less than or equal to 1, 50% were past or current smokers, and 78% had known asbestos exposure. In addition, 50% were epithelioid, 19% sarcomatoid, 14% biphasic, and 17% unavailable. Ipilimumab and nivolumab were used first line in 75% of patients. Median overall survival (mOS) was 14.5 months (95% confidence interval [CI]: 13.0-not reached [NR]) for the entire cohort. For patients treated first line, mOS was 14.5 months (95% CI: 12.5-NR) and in second- or later-line patients was 15.4 months (95% CI: 11.2-NR). There was no statistically significant difference in mOS for epithelioid patients compared with nonepithelioid (19.1 mo [95% CI: 15.4-NR] versus 13.0 mo [95% CI: 9.7-NR], respectively, p = 0.064). Furthermore, 24% of the patients had a Common Terminology Criteria for Adverse Events grade greater than or equal to 3 adverse events, including three treatment-related deaths. Colitis was the most frequent adverse event. CONCLUSIONS Combination immunotherapy in real-world practice has poorer survival outcomes and seems more toxic compared with clinical trial data. This is the first detailed report of real-world survival and toxicity outcomes using ipilimumab and nivolumab treatment of pleural mesothelioma.
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Affiliation(s)
- Nicholas McNamee
- The Kinghorn Cancer Centre, St. Vincent's Hospital, Sydney, Australia; Crown Princess Mary Cancer Centre, Westmead Hospital, Sydney, Australia; Garvan Institute of Medical Research, Sydney, Australia.
| | - Catriona Harvey
- Crown Princess Mary Cancer Centre, Westmead Hospital, Sydney, Australia
| | - Lauren Gray
- Crown Princess Mary Cancer Centre, Westmead Hospital, Sydney, Australia
| | - Trisha Khoo
- Sir Charles Gairdner Hospital, Perth, Australia
| | | | | | | | - Po Yee Yip
- Campbelltown Hospital, Sydney, Australia
| | | | - Timothy Clay
- St. John of God Subiaco Hospital, Perth, Australia; Edith Cowan University, Perth, Australia
| | - Surein Arulananda
- Monash Health, Melbourne, Australia; Monash University, Melbourne, Australia
| | - Malinda Itchins
- Royal North Shore Hospital, Sydney, Australia; University of Sydney, Sydney, Australia
| | - Nick Pavlakis
- Royal North Shore Hospital, Sydney, Australia; University of Sydney, Sydney, Australia
| | - Steven Kao
- Chris O'Brien Lifehouse, Sydney, Australia; University of Sydney, Sydney, Australia
| | - Samantha Bowyer
- Sir Charles Gairdner Hospital, Perth, Australia; University of Western Australia, Perth, Australia
| | - Venessa Chin
- The Kinghorn Cancer Centre, St. Vincent's Hospital, Sydney, Australia; Garvan Institute of Medical Research, Sydney, Australia; University of New South Wales, Sydney, Australia
| | - Lydia Warburton
- Fiona Stanley Hospital, Perth, Australia; Edith Cowan University, Perth, Australia
| | - Inês Pires da Silva
- University of Sydney, Sydney, Australia; Blacktown Hospital, Sydney, Australia
| | - Thomas John
- Peter MacCallum Cancer Centre, Melbourne, Australia; University of Melbourne, Melbourne, Australia
| | - Benjamin Solomon
- Peter MacCallum Cancer Centre, Melbourne, Australia; University of Melbourne, Melbourne, Australia
| | - Marliese Alexander
- Peter MacCallum Cancer Centre, Melbourne, Australia; University of Melbourne, Melbourne, Australia
| | - Adnan Nagrial
- Crown Princess Mary Cancer Centre, Westmead Hospital, Sydney, Australia; University of Sydney, Sydney, Australia; Blacktown Hospital, Sydney, Australia
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Stevens S, Nindra U, Shahnam A, Wei J, Bray V, Pal A, Yip PY, Linton A, Blinman P, Nagrial A, Lee J, Boyer M, Kao S. Real world efficacy and toxicity of consolidation durvalumab following chemoradiotherapy in older Australian patients with unresectable stage III non-small cell lung cancer. J Geriatr Oncol 2024; 15:101705. [PMID: 38290173 DOI: 10.1016/j.jgo.2024.101705] [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: 07/31/2023] [Revised: 11/29/2023] [Accepted: 01/10/2024] [Indexed: 02/01/2024]
Abstract
INTRODUCTION Consolidation durvalumab following platinum-based chemoradiotherapy (CRT) significantly improved overall survival for patients with unresectable stage III non-small cell lung cancer (NSCLC) in the PACIFIC trial. However, older patients were underrepresented in PACIFIC, and subsequent analyses suggested trends toward poorer survival and increased toxicity in patients aged ≥70 years old. We assessed the effectiveness and safety of consolidation durvalumab following CRT in older Australian patients with unresectable stage III NSCLC. MATERIALS AND METHODS This retrospective observational study was conducted across seven sites in Sydney, Australia between January 2018 and September 2021. All adult patients with unresectable stage III NSCLC who received platinum-based chemoradiotherapy followed by at least one cycle of consolidation durvalumab were included. Older patients were defined as being ≥70 years old. RESULTS Of 152 patients included in the analysis, 42.8% (n = 67) patients were 70 years or older. Median follow-up was 26.1 months. The two-year overall survival and median PFS was similar between older and younger patients. At two years, 74.8% (95% confidence interval [CI]: 65.4-84.2%) of patients <70 years old and 65.2% (95% CI: 53.4-77.0%) of older patients were alive (p = 0.07; hazard ratio [HR] 1.64, 95% CI: 0.95-2.81). Median progression-free survival (PFS) in patients <70 years was 30.3 months (95% CI: 22.2-38.4 months) compared with 26.7 months (95% CI: 12.8-40.6 months) in older patients (p = 0.22; HR 1.46, 95% CI: 0.80-2.65). Toxicity was also similar, with 11.5% of patients <70 years old and 18.5% of older patients experiencing grade 3-4 adverse events (AEs; p = 0.23); 16.1% and 24.6% of the patients, respectively, discontinued treatment due to toxicity (p = 0.19). Grade 3-4 AEs and treatment discontinuation were associated with Charlson Comorbidity Index >5 (p = 0.011) and chronic obstructive pulmonary disease diagnosis at presentation (p = 0.002), respectively. DISCUSSION Older Australian patients receiving consolidation durvalumab following CRT experienced comparable outcomes to their younger peers. Comorbidity burden may be more important determinants of treatment tolerance than chronological age.
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Affiliation(s)
- Samuel Stevens
- Department of Medical Oncology, Chris O'Brien Lifehouse, Sydney, 119-143 Missenden Road, Camperdown, NSW 2050, Australia; Department of Medical Oncology, Concord Cancer Centre, Concord Repatriation General Hospital, Sydney, Hospital Road, Concord, NSW 2139, Australia; School of Medicine, The University of Sydney, Camperdown, NSW 2006, Australia.
| | - Udit Nindra
- Department of Medical Oncology, Liverpool Hospital, Sydney, Cnr Elizabeth and Goulburn Street, Liverpool, NSW 2170, Australia; School of Medicine, University of New South Wales, Level 2, AGSM Building, Gate 11 Botany Street, Kensington, NSW 2052, Australia
| | - Adel Shahnam
- Department of Medical Oncology, Crown Princess Margaret Cancer Centre, Westmead Hospital, Sydney, Cnr Hawkesbury and Darcy Road, Westmead, NSW, Australia, 2145
| | - Joe Wei
- Department of Medical Oncology, Crown Princess Margaret Cancer Centre, Westmead Hospital, Sydney, Cnr Hawkesbury and Darcy Road, Westmead, NSW, Australia, 2145; School of Medicine, The University of Sydney, Camperdown, NSW 2006, Australia
| | - Victoria Bray
- Department of Medical Oncology, Liverpool Hospital, Sydney, Cnr Elizabeth and Goulburn Street, Liverpool, NSW 2170, Australia
| | - Abhijit Pal
- Department of Medical Oncology, Liverpool Hospital, Sydney, Cnr Elizabeth and Goulburn Street, Liverpool, NSW 2170, Australia; Department of Medical Oncology, Bankstown-Lidcombe Hospital, Sydney, Eldrige Road, Bankstown, NSW 2200, Australia
| | - Po Yee Yip
- Department of Medical Oncology, Macarthur Cancer Therapy Centre, Campbelltown Hospital, Sydney, Therry Road, Campbelltown, NSW 2560, Australia
| | - Anthony Linton
- Department of Medical Oncology, Concord Cancer Centre, Concord Repatriation General Hospital, Sydney, Hospital Road, Concord, NSW 2139, Australia; School of Medicine, The University of Sydney, Camperdown, NSW 2006, Australia
| | - Prunella Blinman
- Department of Medical Oncology, Concord Cancer Centre, Concord Repatriation General Hospital, Sydney, Hospital Road, Concord, NSW 2139, Australia; School of Medicine, The University of Sydney, Camperdown, NSW 2006, Australia
| | - Adnan Nagrial
- Department of Medical Oncology, Crown Princess Margaret Cancer Centre, Westmead Hospital, Sydney, Cnr Hawkesbury and Darcy Road, Westmead, NSW, Australia, 2145; Department of Medical Oncology, Blacktown Cancer and Haematology Centre, Blacktown Hospital, Sydney, 18 Blacktown Road, Blacktown, NSW 2148, Australia; School of Medicine, The University of Sydney, Camperdown, NSW 2006, Australia
| | - Jenny Lee
- Department of Medical Oncology, Chris O'Brien Lifehouse, Sydney, 119-143 Missenden Road, Camperdown, NSW 2050, Australia; Macquarie Medical School, Macquarie University, Wallumattagal Campus, Macquarie, NSW 2109, Australia
| | - Michael Boyer
- Department of Medical Oncology, Chris O'Brien Lifehouse, Sydney, 119-143 Missenden Road, Camperdown, NSW 2050, Australia; School of Medicine, The University of Sydney, Camperdown, NSW 2006, Australia
| | - Steven Kao
- Department of Medical Oncology, Chris O'Brien Lifehouse, Sydney, 119-143 Missenden Road, Camperdown, NSW 2050, Australia; School of Medicine, The University of Sydney, Camperdown, NSW 2006, Australia
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Shahnam A, Hitchen N, Nindra U, Manoharan S, Desai J, Tran B, Solomon B, Luen SJ, Hui R, Hopkins AM, Sorich MJ. Objective response rate and progression-free survival as surrogates for overall survival treatment effect: A meta-analysis across diverse tumour groups and contemporary therapies. Eur J Cancer 2024; 198:113503. [PMID: 38134560 DOI: 10.1016/j.ejca.2023.113503] [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: 09/27/2023] [Revised: 12/06/2023] [Accepted: 12/14/2023] [Indexed: 12/24/2023]
Abstract
BACKGROUND Overall survival (OS) results from randomized control trials (RCT) provide the strongest evidence for efficacy of anti-cancer treatments but can take a considerable amount of time to mature. Progression free survival (PFS) and objective response rate (ORR) are used as an early surrogate of OS treatment effect however their validity remains unclear. Our study aims to comprehensively evaluate ORR and PFS as surrogates for OS treatment effect across tumor groups and treatment types. MATERIAL AND METHODS Phase 3 RCTs in solid malignancies that reported OS/PFS and ORR published between 1st of January 2010 and 30th of June 2022 were evaluated. The relationship of surrogate endpoints and OS treatment effect was assessed via weighted linear regression. The coefficient of determination (R2) quantified the fit of the regression model. RESULTS 675 phase 3 RCT comprising of 350 112 patients were analysed. ORR (R2 of 0.10) and PFS (R2 of 0.38) were poor surrogate markers of OS treatment effect. The strength of surrogacy differed within treatment and tumour groups. PFS had the highest R2 for chemotherapy (0.56) and lowest for targeted therapy (0.40). PFS had the highest level of surrogacy for melanoma (R2 = 0.72) and pancreatic cancer (R2 = 0.70) compared to other tumour groups. Importantly ORR and PFS were also poorly correlated to each other (R2 = 0.33). CONCLUSIONS ORR and PFS were poor trial-level surrogate markers of OS. The surrogacy performance of ORR and PFS differed by treatment and malignancy sub-type.
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Affiliation(s)
- Adel Shahnam
- Department of Medical Oncology, Peter McCallum Cancer Centre, Melbourne, VIC, Australia.
| | - Nadia Hitchen
- Department of Medical Oncology, Peter McCallum Cancer Centre, Melbourne, VIC, Australia
| | - Udit Nindra
- Department of Medical Oncology, Liverpool Hospital, Sydney, New South Wales, Australia
| | - Sathya Manoharan
- Department of Medical Oncology, Peter McCallum Cancer Centre, Melbourne, VIC, Australia
| | - Jayesh Desai
- Department of Medical Oncology, Peter McCallum Cancer Centre, Melbourne, VIC, Australia; Sir Peter MacCallum Department of Oncology, The University of Melbourne, Melbourne, Australia
| | - Ben Tran
- Department of Medical Oncology, Peter McCallum Cancer Centre, Melbourne, VIC, Australia; Sir Peter MacCallum Department of Oncology, The University of Melbourne, Melbourne, Australia
| | - Benjamin Solomon
- Department of Medical Oncology, Peter McCallum Cancer Centre, Melbourne, VIC, Australia; Sir Peter MacCallum Department of Oncology, The University of Melbourne, Melbourne, Australia
| | - Stephen J Luen
- Department of Medical Oncology, Peter McCallum Cancer Centre, Melbourne, VIC, Australia; Sir Peter MacCallum Department of Oncology, The University of Melbourne, Melbourne, Australia
| | - Rina Hui
- The Centre of Cancer Medicine, University Hong Kong, Hong Kong
| | - Ashley M Hopkins
- College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia
| | - Michael J Sorich
- College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia
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9
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Nindra U, Bray V, Karikios D, Shafiei M, Subramaniam S, Ding P, Kao S, Pal A. Variations in patterns of prescribing durvalumab in stage III lung cancer: a survey of Australian Medical Oncologists. Oncology 2024:000535855. [PMID: 38232722 DOI: 10.1159/000535855] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2023] [Accepted: 12/13/2023] [Indexed: 01/19/2024]
Abstract
BACKGROUND Local Australian guidelines for the optimal management of stage III unresectable NSCLC are lacking. The American Society of Clinical Oncology (ASCO) guidelines recommend consolidation durvalumab for all patients with unresectable stage III NSCLC irrespective of their PD-L1 expression or driver mutation status. The European Society of Medical Oncology (ESMO) differs, with consolidation durvalumab only recommended in those patients whose tumours express PD-L1. METHODS Due to differing global guidelines we conducted an Australia and New Zealand wide survey of medical oncologists specialising in thoracic cancer to determine the variations in patterns of prescribing durvalumab in stage III unresectable NSCLC. This survey was done electronically and sponsored by the Thoracic Oncology Group of Australia (TOGA). RESULTS Thirty-two medical oncologists completed the survey. In patients with EGFR¬-mutated stage III unresectable NSCLC, 6% of respondents stated that they prescribed durvalumab for all patients, whilst an additional 6% strongly recommended treatment. Fourty-four percent suggested little benefit of consolidation durvalumab in this cohort, with an additional 19% advocating for observation only. In patients with PD-L1 negative (0%) stage III unresectable NSCLC, 13% of respondents prescribed durvalumab for all patients, whilst an additional 56% strongly recommended treatment. Interestingly, 18%, 10% and 10% of prescribers discussed self-funded oral tyrosine kinase inhibitor (TKI) therapy in patients with EGFR, ALK or ROS-1 mutated NSCLC respectively as a substitute for consolidation durvalumab. CONCLUSION Overall, the clinical practice of Australian and New Zealand Medical Oncologists is variable, but remains consistent with either the ASCO or ESMO guidelines. Local practice guidelines are required to ensure consistency in prescribing patterns across Australia, as well as providing evidence for self-funded treatments outside standard of care.
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10
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Shahnam A, Nindra U, Desai J, Hui R, Buyse M, Hopkins AM, Sorich MJ. Time to deterioration of patient-reported outcomes as a surrogate of overall survival: a meta-analysis. J Natl Cancer Inst 2023; 115:1475-1482. [PMID: 37540222 DOI: 10.1093/jnci/djad152] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Revised: 07/06/2023] [Accepted: 07/31/2023] [Indexed: 08/05/2023] Open
Abstract
BACKGROUND Overall survival is the optimal marker of treatment efficacy in randomized clinical trials (RCTs) but can take considerable time to mature. Progression-free survival (PFS) has served as an early surrogate of overall survival but is imperfect. Time to deterioration in quality of life (QOL) measures could be a surrogate for overall survival. METHODS Phase 3 RCTs in solid malignancies that reported overall survival, PFS, and time to deterioration in QOL or physical function published between January 1, 2010, and June 30, 2022, were evaluated. Weighted regression analysis was used to assess the relationship between PFS, time to deterioration in QOL, and time to deterioration in physical function with overall survival. The coefficient of determination (R2) was used to quantify surrogacy. RESULTS In total, 138 phase 3 RCTs were included. Of these, 47 trials evaluated immune checkpoint inhibitors and 91 investigated non-immune checkpoint inhibitor agents. Time to deterioration in QOL (137 RCTs) and time to deterioration in physical function (75 RCTs) performed similarly to PFS as surrogates for overall survival (R2 = 0.18 vs R2 = 0.19 and R2 = 0.10 vs R2 = 0.09, respectively). For immune checkpoint inhibitor studies, time to deterioration in physical function had a higher association with overall survival than with PFS (R2 = 0.38 vs R2 = 0.19), and PFS and time to deterioration in physical function did not correlate with each other (R2 = 0). When time to deterioration in physical function and PFS are used together, the coefficient of determination increased (R2 = 0.57). CONCLUSIONS Time to deterioration in physical function appears to be an overall survival surrogate measure of particular importance for immune checkpoint inhibitor treatment efficacy. The combination of time to deterioration in physical function with PFS may enable better prediction of overall survival treatment benefit in RCTs of immune checkpoint inhibitors than either PFS or time to deterioration in physical function alone.
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Affiliation(s)
- Adel Shahnam
- Department of Medical Oncology, Peter McCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Udit Nindra
- Department of Medical Oncology, Liverpool Hospital, Sydney, New South Wales, Australia
| | - Jayesh Desai
- Department of Medical Oncology, Peter McCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Rina Hui
- Centre of Cancer Medicine, University of Hong Kong, Hong Kong
| | - Marc Buyse
- International Drug Development Institute, Brussels, Belgium
| | - Ashley M Hopkins
- College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia
| | - Michael J Sorich
- College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia
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11
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Nindra U, Shivasabesan G, Childs S, Yoon R, Haider S, Hong M, Cooper A, Roohullah A, Wilkinson K, Pal A, Chua W. Time toxicity associated with early phase clinical trial participation. ESMO Open 2023; 8:102046. [PMID: 37979324 PMCID: PMC10774969 DOI: 10.1016/j.esmoop.2023.102046] [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: 08/25/2023] [Revised: 09/27/2023] [Accepted: 09/28/2023] [Indexed: 11/20/2023] Open
Abstract
BACKGROUND Early phase cancer clinical trials (EPCTs) involve experimental drugs being used for the first time in humans. These studies are designed for dose determination and safety, and represent the most time intensive of all clinical trials for both clinicians and patients. We sought to quantify the amount of patient time consumed through EPCT participation. PATIENTS AND METHODS A retrospective audit of patients treated in the EPCT unit at Liverpool Hospital, Sydney was carried out from 2013 to 2023. We defined 'time toxicity' (TT) as a composite measure where time-toxic days were considered days with any health care system contact, including clinic visits, infusions, procedures or blood work. RESULTS A total of 219 patients across 36 EPCTs were included. The median age was 65 years (range 31-81 years). Patients spent a median of 29% (range 4%-100%) of their days in direct contact with the health care system during their study. Protocol-specified visits accounted for the greatest contribution to total TT in 101 (46%) patients. In 7% (n = 16) of patients, unscheduled visits due to either adverse events or cancer-related symptoms accounted for the greatest TT. TT reduced as patients completed additional cycles of treatment. Patients who completed >10 cycles spent 14% of their days interacting with health care systems compared with 35% for those who completed ≤2 cycles. No statistically significant difference in TT was noted between dose-expansion and dose-escalation studies or trials focusing on immune-oncology versus targeted therapy. CONCLUSIONS Our study is the first to report TT in EPCTs with an extended follow-up. Clinicians should be aware of TT when discussing risks and benefits. TT also may not be the appropriate term when describing the time patients invest during EPCTs. Toxicity implies a negative impact, but for many patients, trial participation would be seen as positive. There should be efforts to streamline health care visits to limit TT in EPCTs.
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Affiliation(s)
- U Nindra
- Department of Medical Oncology, Liverpool Hospital, Liverpool; Ingham Institute for Applied Medical Research, Liverpool; School of Medicine, Western Sydney University, Sydney.
| | - G Shivasabesan
- Department of Medical Oncology, Liverpool Hospital, Liverpool
| | - S Childs
- Department of Medical Oncology, Liverpool Hospital, Liverpool
| | - R Yoon
- Department of Medical Oncology, Liverpool Hospital, Liverpool; Ingham Institute for Applied Medical Research, Liverpool; School of Medicine, Western Sydney University, Sydney; Department of Medical Oncology, Macarthur Cancer Therapy Centre, Campbelltown Hospital, Campbelltown
| | - S Haider
- Ingham Institute for Applied Medical Research, Liverpool; School of Medicine, Western Sydney University, Sydney; Department of Medical Oncology, Northern Cancer Service, Burnie
| | - M Hong
- Department of Medical Oncology, Liverpool Hospital, Liverpool; Ingham Institute for Applied Medical Research, Liverpool; School of Medicine, Western Sydney University, Sydney
| | - A Cooper
- Department of Medical Oncology, Liverpool Hospital, Liverpool; Ingham Institute for Applied Medical Research, Liverpool; School of Medicine, Western Sydney University, Sydney
| | - A Roohullah
- Department of Medical Oncology, Liverpool Hospital, Liverpool; Ingham Institute for Applied Medical Research, Liverpool; School of Medicine, Western Sydney University, Sydney; Department of Medical Oncology, Macarthur Cancer Therapy Centre, Campbelltown Hospital, Campbelltown
| | - K Wilkinson
- Department of Medical Oncology, Liverpool Hospital, Liverpool; Ingham Institute for Applied Medical Research, Liverpool; School of Medicine, Western Sydney University, Sydney
| | - A Pal
- Department of Medical Oncology, Liverpool Hospital, Liverpool; Department of Medical Oncology, Bankstown-Lidcombe Hospital, Bankstown, Australia
| | - W Chua
- Department of Medical Oncology, Liverpool Hospital, Liverpool; Ingham Institute for Applied Medical Research, Liverpool; School of Medicine, Western Sydney University, Sydney
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Nindra U, Pal A, Lea V, Lim SHS, Wilkinson K, Asghari R, Roberts TL, Becker TM, Farzin M, Rutland T, Lee M, MacKenzie S, Ng W, Wang B, Lee CS, Chua W. Multigene panel next generation sequencing in metastatic colorectal cancer in an Australian population. PLoS One 2023; 18:e0292087. [PMID: 37796807 PMCID: PMC10553362 DOI: 10.1371/journal.pone.0292087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2023] [Accepted: 09/12/2023] [Indexed: 10/07/2023] Open
Abstract
BACKGROUND Next generation sequencing (NGS) is increasingly used in standard clinical practice to identify patients with potentially actionable mutations. Stratification of NGS mutation tiers is currently based on the European Society of Medical Oncology (ESMO) Scale for Clinical Actionability of Molecular Targets (ESCAT[E]) Tier I-V & X. Allele frequency is also increasingly recognised as an important prognostic tool in advanced cancer. The aim of this study was to determine the genomic mutations in metastatic colorectal cancer (CRC) in an Australian multicultural population and their influence on survival outcomes. METHODS Next generation sequencing with the 50-gene panel Oncomine Precision Assay™ was used on 180 CRC tissue samples obtained across six Sydney hospitals between June 2021 and March 2022. RESULTS From 180 samples, 147 (82%) had at least one gene mutation identified with 68 (38%) having two or more concurrent mutations. Tier I variants included RAS wild-type [EI] in 73 (41%) and BRAF V600E [EIA] in 27 (15%). Non-tier I variants include 2 (1%) ERBB2 amplification [EIIB], 26 (15%) PIK3CA hotspot mutations [EIIIA] and 9 (5%) MET focal amplifications [EIIIA]. NGS testing revealed an additional 22% of cases with Tier II & III mutations. 43% of patients also presented with potentially actionable Tier III & IV mutations. Patients with concurrent TP53 and RAS mutations had significantly reduced overall survival (6.1 months versus 21.1 months, p <0.01). High KRAS allele frequency, as defined by those with over 20% variant allele frequency (VAF), also demonstrated reduced overall survival (12.1 months versus 42.9 months, p = 0.04). CONCLUSIONS In addition to identifying patients with genomic alterations suitable for clinically proven standard of care therapeutic options, the 50 gene NGS panel has significant potential in identifying potentially actionable non-tier 1 mutations and therefore may become future standard clinical practice.
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Affiliation(s)
- Udit Nindra
- Department of Medical Oncology, Liverpool Hospital, Liverpool, New South Wales, Australia
- Department of Medical Oncology, Macarthur Cancer Therapy Centre, Campbelltown Hospital, Campbelltown, New South Wales, Australia
- Department of Medical Oncology, Bankstown-Lidcombe Hospital, Bankstown, New South Wales, Australia
- Ingham Institute for Applied Medical Research, Liverpool, Australia
- School of Medicine, Western Sydney University, Sydney, Australia
| | - Abhijit Pal
- Department of Medical Oncology, Liverpool Hospital, Liverpool, New South Wales, Australia
- Department of Medical Oncology, Bankstown-Lidcombe Hospital, Bankstown, New South Wales, Australia
- Ingham Institute for Applied Medical Research, Liverpool, Australia
| | - Vivienne Lea
- Department of Anatomical Pathology, Liverpool Hospital, Liverpool, Sydney, Australia
| | - Stephanie Hui-Su Lim
- Department of Medical Oncology, Macarthur Cancer Therapy Centre, Campbelltown Hospital, Campbelltown, New South Wales, Australia
- Ingham Institute for Applied Medical Research, Liverpool, Australia
- School of Medicine, Western Sydney University, Sydney, Australia
| | - Kate Wilkinson
- Department of Medical Oncology, Liverpool Hospital, Liverpool, New South Wales, Australia
| | - Ray Asghari
- Department of Medical Oncology, Bankstown-Lidcombe Hospital, Bankstown, New South Wales, Australia
| | - Tara L. Roberts
- Ingham Institute for Applied Medical Research, Liverpool, Australia
- School of Medicine, Western Sydney University, Sydney, Australia
- South Western Clinical School, University of New South Wales, Sydney, Australia
| | - Therese M. Becker
- Ingham Institute for Applied Medical Research, Liverpool, Australia
- School of Medicine, Western Sydney University, Sydney, Australia
- South Western Clinical School, University of New South Wales, Sydney, Australia
| | - Mahtab Farzin
- Department of Anatomical Pathology, Liverpool Hospital, Liverpool, Sydney, Australia
| | - Tristan Rutland
- School of Medicine, Western Sydney University, Sydney, Australia
- Department of Anatomical Pathology, Liverpool Hospital, Liverpool, Sydney, Australia
| | - Mark Lee
- South Western Clinical School, University of New South Wales, Sydney, Australia
| | - Scott MacKenzie
- School of Medicine, Western Sydney University, Sydney, Australia
| | - Weng Ng
- Department of Medical Oncology, Liverpool Hospital, Liverpool, New South Wales, Australia
- Ingham Institute for Applied Medical Research, Liverpool, Australia
- School of Medicine, Western Sydney University, Sydney, Australia
- South Western Clinical School, University of New South Wales, Sydney, Australia
| | - Bin Wang
- Department of Anatomical Pathology, Liverpool Hospital, Liverpool, Sydney, Australia
| | - C. Soon Lee
- Department of Medical Oncology, Bankstown-Lidcombe Hospital, Bankstown, New South Wales, Australia
- School of Medicine, Western Sydney University, Sydney, Australia
- Department of Anatomical Pathology, Liverpool Hospital, Liverpool, Sydney, Australia
- South Western Clinical School, University of New South Wales, Sydney, Australia
| | - Wei Chua
- Department of Medical Oncology, Liverpool Hospital, Liverpool, New South Wales, Australia
- Ingham Institute for Applied Medical Research, Liverpool, Australia
- School of Medicine, Western Sydney University, Sydney, Australia
- South Western Clinical School, University of New South Wales, Sydney, Australia
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McNamee N, Nindra U, Shahnam A, Yoon R, Asghari R, Ng W, Karikios D, Wong M. Haematological and nutritional prognostic biomarkers for patients receiving CROSS or FLOT. J Gastrointest Oncol 2023; 14:494-503. [PMID: 37201072 PMCID: PMC10186526 DOI: 10.21037/jgo-22-886] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Accepted: 02/10/2023] [Indexed: 10/20/2023] Open
Abstract
BACKGROUND Neoadjuvant carboplatin and paclitaxel with radiotherapy (CROSS) and perioperative docetaxel, oxaliplatin, calcium folinate and fluorouracil (FLOT) are widely used for gastric (GC), gastro-oesophageal junction (GOJ) and oesophageal cancers (OC). Prognostic and predictive markers for response and survival outcomes are lacking. This study evaluates dynamic neutrophil-lymphocyte ratios (NLR), platelet-lymphocyte ratios (PLR), albumin and body mass index (BMI) as predictors of survival, response and toxicity. METHODS This multi-centre retrospective observational study across 5 Sydney hospitals included patients receiving CROSS or FLOT from 2015 to 2021. Haematological results and BMI were recorded at baseline and pre-operatively, and after adjuvant treatment for FLOT. Toxicities were also recorded. An NLR ≥2 and PLR ≥200 was used to stratify patients. Univariate and multivariate analyses were performed to determine predictors of overall survival (OS), disease free survival (DFS), rates of pathological complete response (pCR) and toxicity. RESULTS One hundred sixty-eight patients were included (95 FLOT, 73 FLOT). A baseline NLR ≥2 was predictive for worse DFS (HR 2.78, 95% CI: 1.41-5.50, P<0.01) and OS (HR 2.90, 95% CI: 1.48-5.67, P<0.01). Sustained elevation in NLR was predictive for DFS (HR 1.54, 95% CI: 1.08-2.17, P=0.01) and OS (HR 1.65, 95% CI: 1.17-2.33, P<0.01). An NLR ≥2 correlated with worse pCR rates (16% for NLR ≥2, 48% for NLR <2, P=0.04). A baseline serum albumin <33 was predictive of worse DFS and OS with a HR of 6.17 (P=0.01) and 4.66 (P=0.01) respectively. Baseline PLR, BMI, and dynamic changes in these markers were not associated with DFS, OS or pCR rates. There was no association of the aforementioned variables with toxicity. CONCLUSIONS This demonstrates that a high inflammatory state represented by an NLR ≥2, both at baseline and sustained, is prognostic and predictive of response in patients receiving FLOT or CROSS. Baseline hypoalbuminaemia is predictive of poorer outcomes.
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Affiliation(s)
- Nicholas McNamee
- Department of Medical Oncology, Westmead Hospital, Sydney, Australia
| | - Udit Nindra
- Department of Medical Oncology, Liverpool Hospital, Sydney, Australia
| | - Adel Shahnam
- Department of Medical Oncology, Westmead Hospital, Sydney, Australia
| | - Robert Yoon
- Department of Medical Oncology, Liverpool Hospital, Sydney, Australia
| | - Ray Asghari
- Department of Medical Oncology, Bankstown-Lidcombe Hospital, Sydney, Australia
| | - Weng Ng
- Department of Medical Oncology, Liverpool Hospital, Sydney, Australia
| | - Deme Karikios
- Department of Medical Oncology, Nepean Hospital, Sydney, Australia
| | - Mark Wong
- Department of Medical Oncology, Westmead Hospital, Sydney, Australia
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14
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Nindra U, Hurwitz J, Forstner D, Chin V, Gallagher R, Liu J. A systematic review of neoadjuvant and definitive immunotherapy in locally advanced head and neck squamous cell carcinoma. Cancer Med 2023. [PMID: 36934434 DOI: 10.1002/cam4.5815] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2023] [Revised: 02/28/2023] [Accepted: 03/06/2023] [Indexed: 03/20/2023] Open
Abstract
BACKGROUND Patients with locally advanced head and neck squamous cell carcinoma (HNSCC) require multi-modality treatment. Immune checkpoint inhibitors (ICIs) are now standard of care in management of recurrent/metastatic HNSCC. However, its role in the definitive and neoadjuvant setting remains unclear. METHODS A literature search was conducted that included all articles investigating ICI in untreated locally advanced (LA) HNSCC. Data was extracted and summarised and rated for quality using the Cochrane risk of bias tool. RESULTS Of 1086 records, 29 met the final inclusion criteria. In both concurrent and neoadjuvant settings, the addition of ICI was safe and did not delay surgery or reduce chemoradiotherapy completion. In the concurrent setting, although ICI use demonstrates objective responses in all published trials, there has not yet been published data to with PFS or OS benefit. In the neoadjuvant setting, combination ICI resulted in superior major pathological response rates compared to ICI monotherapy without a significant increase adverse event profiles, but its value in improving survival is not clear. ICI efficacy appears to be affected by tumour characteristics, in particular PD-L1 combined positive score, HPV status and the tumour microenvironment. CONCLUSIONS There is significant heterogeneity of ICI use in untreated LA HNSCC with multiple definitive concurrent and neoadjuvant protocols used. Resultantly, conclusions regarding the survival benefits of adding ICI to standard-of-care regimens cannot be made. Further trials and translational studies are required to elucidate optimal ICI sequencing in the definitive setting as well as better define populations more suited for neoadjuvant protocols.
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Affiliation(s)
- Udit Nindra
- Department of Medical Oncology, Liverpool Hospital, Sydney, New South Wales, Australia.,Department of Medical Oncology, Campbelltown Hospital, Sydney, New South Wales, Australia
| | - Joshua Hurwitz
- The Kinghorn Cancer Centre, St Vincent's Hospital, Darlinghurst, New South Wales, Australia
| | - Dion Forstner
- The Kinghorn Cancer Centre, St Vincent's Hospital, Darlinghurst, New South Wales, Australia.,The University of New South Wales, Kensington, New South Wales, Australia.,GenesisCare, Darlinghurst, New South Wales, Australia
| | - Venessa Chin
- The Kinghorn Cancer Centre, St Vincent's Hospital, Darlinghurst, New South Wales, Australia.,The University of New South Wales, Kensington, New South Wales, Australia.,The Garvan Institute of Research, Camperdown, New South Wales, Australia
| | - Richard Gallagher
- The Kinghorn Cancer Centre, St Vincent's Hospital, Darlinghurst, New South Wales, Australia.,The University of New South Wales, Kensington, New South Wales, Australia.,The University of Sydney, Camperdown, New South Wales, Australia
| | - Jia Liu
- The Kinghorn Cancer Centre, St Vincent's Hospital, Darlinghurst, New South Wales, Australia.,The University of New South Wales, Kensington, New South Wales, Australia.,The University of Sydney, Camperdown, New South Wales, Australia
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15
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Nindra U, Pal A, Lee CS. Precision medicine in Australia: now is the time to get it right. Med J Aust 2023; 218:330. [PMID: 36924108 DOI: 10.5694/mja2.51887] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Revised: 02/21/2023] [Accepted: 03/02/2023] [Indexed: 03/18/2023]
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16
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Nindra U, Shahnam A, Stevens S, Pal A, Nagrial A, Lee J, Yip PY, Adam T, Boyer M, Kao S, Bray V. Influence of EGFR mutation status and PD-L1 expression in stage III unresectable non-small cell lung cancer treated with chemoradiation and consolidation durvalumab. Asia Pac J Clin Oncol 2023. [PMID: 36855021 DOI: 10.1111/ajco.13940] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Revised: 12/28/2022] [Accepted: 01/04/2023] [Indexed: 03/02/2023]
Abstract
BACKGROUND Consolidation durvalumab after concurrent chemoradiation is the standard of care for unresectable stage III non-small cell lung cancer (NSCLC) based on the PACIFIC trial. However, there have been reports in the literature suggesting the efficacy of the treatment differs in patients whose tumors harbor epidermal growth factor receptor (EGFR) mutations and in those with low programed death ligand-1 (PD-L1) expression. This study describes the survival outcomes for patients with unresectable stage III NSCLC treated with chemoradiation followed by durvalumab with a specific focus on EGFR mutation status and PD-L1 expression. METHODS This retrospective observational study was conducted across six sites in Greater Sydney, Australia. It included all patients diagnosed with unresectable stage III NSCLC treated with chemoradiation and who received at least one cycle of durvalumab between January 2018 and September 2021. Patients were stratified according to EGFR mutation status and PD-L1 tumor proportion score (TPS) of 1%. RESULTS Of the 145 patients included in the analysis, 15/145 (10%) patients harbored an EGFR mutation and 61/145 (42%) patients had PD-L1 TPS of <1%. At a median follow-up of 15.1 months from the start of durvalumab, median progression-free survival (PFS) in EGFR mutant versus wild-type patients was 7.5 and 33.9 months, respectively (hazard ratio [HR]: 2.7; 95% confidence intervals [95% CI] 1.2-5.7; p = .01). Overall survival (OS) was not different between EGFR mutant and wild-type patients. There was no statistically significant difference in PFS (HR .7, 95% CI .4-1.7, p = .43) or OS (HR .5, 95% CI .4-4.7, p = .16) between patients with PD-L1 TPS of <1% versus PD-L1 TPS of ≥1%. CONCLUSIONS Our data adds to the growing evidence that suggests consolidation durvalumab after definitive chemoradiation may not be as efficacious in patients with EGFR-mutant tumors compared with EGFR wild-type NSCLC.
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Affiliation(s)
- Udit Nindra
- Department of Medical Oncology, Liverpool Hospital, Liverpool, Australia
| | - Adel Shahnam
- Department of Medical Oncology, Westmead Hospital, Sydney, Australia
| | - Samuel Stevens
- Department of Medical Oncology, Chris O'Brien Lifehouse, Sydney, Australia
| | - Abhijit Pal
- Department of Medical Oncology, Liverpool Hospital, Liverpool, Australia
| | - Adnan Nagrial
- Department of Medical Oncology, Westmead Hospital, Sydney, Australia
| | - Jenny Lee
- Department of Medical Oncology, Chris O'Brien Lifehouse, Sydney, Australia
- Department of Clinical Medicine, Macquarie University, Sydney, Australia
| | - Po Yee Yip
- Department of Medical Oncology, Macarthur Cancer Therapy Centre, Campbelltown Hospital, Campbelltown, Australia
- School of Medicine, Western Sydney University, Sydney, Australia
| | - Tamiem Adam
- Department of Medical Oncology, Bankstown-Lidcombe Hospital, Sydney, Australia
| | - Michael Boyer
- Department of Medical Oncology, Chris O'Brien Lifehouse, Sydney, Australia
- Sydney Medical School, The University of Sydney, Sydney, Australia
| | - Steven Kao
- Department of Medical Oncology, Chris O'Brien Lifehouse, Sydney, Australia
- Sydney Medical School, The University of Sydney, Sydney, Australia
| | - Victoria Bray
- Department of Medical Oncology, Liverpool Hospital, Liverpool, Australia
- Department of Medical Oncology, Bankstown-Lidcombe Hospital, Sydney, Australia
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Nindra U, Hong JH, Balakrishnar B, Pal A, Chua W. Review of Toxicities of PARP Inhibitors in Metastatic Castrate Resistant Prostate Cancer. Clin Genitourin Cancer 2023; 21:183-193. [PMID: 35927195 DOI: 10.1016/j.clgc.2022.07.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2022] [Revised: 07/07/2022] [Accepted: 07/09/2022] [Indexed: 02/01/2023]
Abstract
There is emerging evidence for the use of poly (ADP-ribose) polymerase inhibitors (PARPi) in patients with mCRPC with patients harboring germline or somatic mutations deriving clinical benefit. However, the toxicity profile of PARPi in mCRPC is not well established. In March 2022 a literature search was conducted across 4 databases - Medline, PubMed, Cochrane Library and Embase. In total, 14 relevant studies were identified cumulating in 2066 patients that were treated with PARPi. The overall ORR to PARPi alone or in combination with other therapy was 37% (246/666). In 5trials that investigated PARPi alone, the ORR was 39% (141/361). Treatment emergent adverse events (TEAEs) of any grade were reported in 96% (1034/1080) in PARPi treatment arms. TEAEs of grade >= 3 were reported in 57% (611/1080). 45% (457/1006) experienced treatment interruption whilst 31% (310/989) required dose reductions. 11% (114/1006) of patients had their treatment discontinued directly as the result of toxicity associated with the trial medications. The most common hematological toxicity was anemia, reported in 490/1160 (42%) patients. and lowered white blood cell count were the next 2most common toxicities, reported in 186/655 (28%) and 133/729 (18%) respectively. The 3most common non-hematological toxicities reported were nausea, fatigue and anorexia reported in 440/1013 (43%), 340/1013 (34%) and 274/1013 (27%) patients respectively. Overall, TRAEs associated with individual PARPi are still emerging with hematological toxicities being most apparent. Further toxicities will be informed from future clinical trials to allow improved treatment selection, education and management of toxicities in prostate cancer.
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Affiliation(s)
- Udit Nindra
- Department of Medical Oncology, Liverpool Hospital, Sydney, NSW, Australia; School of Medicine, University of New South Wales, Sydney, NSW, Australia.
| | - Jun Hee Hong
- Department of Medical Oncology, Liverpool Hospital, Sydney, NSW, Australia; School of Medicine, University of New South Wales, Sydney, NSW, Australia
| | | | - Abhijit Pal
- Department of Medical Oncology, Liverpool Hospital, Sydney, NSW, Australia; School of Medicine, University of New South Wales, Sydney, NSW, Australia
| | - Wei Chua
- Department of Medical Oncology, Liverpool Hospital, Sydney, NSW, Australia; School of Medicine, University of New South Wales, Sydney, NSW, Australia; School of Medicine, Western Sydney University, Sydney, NSW, Australia; Ingham Institute for Applied Medical Research, Sydney, NSW, Australia
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18
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Shahnam A, Nindra U, McNamee N, Yoon R, Asghari R, Ng W, Karikios D, Wong M. Real-World Outcomes of FLOT versus CROSS Regimens for Patients with Oesophagogastric Cancers. Gastrointest Tumors 2023; 10:19-28. [PMID: 37901653 PMCID: PMC10601866 DOI: 10.1159/000531536] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2022] [Accepted: 06/07/2023] [Indexed: 10/31/2023] Open
Abstract
Introduction Treatment of oesophageal (OC), gastro-oesophageal junction (GOJ), and gastric cancer (GC) includes either neoadjuvant Chemoradiotherapy for Oesophageal Cancer Followed by Surgery Study (CROSS) for OC or GOJ or perioperative 5-fluorouracil, leucovorin, oxaliplatin, and docetaxel (FLOT) for OC, GOJ, and GC adenocarcinomas. This study aims to describe the real-world outcomes of patients with GC, GOJ, and OC treated with FLOT or CROSS and identify variables associated with efficacy through exploratory analysis. We also aimed to evaluate the comparison of FLOT and CROSS for the treatment of OC and GOJ adenocarcinomas. Methods This is a retrospective observational study of patients with locally advanced OC, GOJ, or GC treated with FLOT or CROSS between January 2015 and June 2021 in 5 cancer centres across Sydney, Australia. Long-rank test was used to compare survival estimated between subgroups. Hazard ratios for univariate and multivariate analyses were estimated with Cox proportional regression. Results The study included 168 patients. The 24-month relapse-free survival (RFS) and overall survival (OS) for FLOT were 59% and 69%, respectively. The median RFS was 29.6 months and median OS was not reached. For CROSS, the 24-month RFS and OS were 55% and 63% with a median RFS and OS of 28.5 and 40.2 months, respectively. There was no difference in OS and RFS between the treatments. FLOT was less tolerable than CROSS with more dose reductions, treatment discontinuation, and clinically relevant grade 3 and 4 toxicity. Neutrophil lymphocyte ratio was associated with survival for both treatments. Conclusion Similar efficacy outcomes were seen in this real-world population compared to the clinical trials for FLOT and CROSS.
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Affiliation(s)
- Adel Shahnam
- Department of Medical Oncology, Westmead Hospital and Blacktown Hospital, Sydney, NSW, Australia
| | - Udit Nindra
- Department of Medical Oncology, Liverpool Hospital, Sydney, NSW, Australia
| | - Nicholas McNamee
- Department of Medical Oncology, Westmead Hospital and Blacktown Hospital, Sydney, NSW, Australia
| | - Robert Yoon
- Department of Medical Oncology, Liverpool Hospital, Sydney, NSW, Australia
| | - Ray Asghari
- Department of Medical Oncology, Bankstown-Lidcombe Hospital, Sydney, NSW, Australia
| | - Weng Ng
- Department of Medical Oncology, Liverpool Hospital, Sydney, NSW, Australia
| | - Deme Karikios
- Department of Medical Oncology, Nepean Hospital, Sydney, NSW, Australia
| | - Mark Wong
- Department of Medical Oncology, Westmead Hospital and Blacktown Hospital, Sydney, NSW, Australia
- Clinical Associate Professor, Macquarie University, Sydney, NSW, Australia
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Hong JH, Nindra U, Nguyen R, Gassner P, Balakrishnar B, Rutland T. A Rare Case of Castrate-Resistant Prostate Adenocarcinoma with a Unilateral Testicular Metastasis Mimicking a Primary Testicular Tumour. Case Rep Oncol 2022; 15:1055-1062. [PMID: 36605230 PMCID: PMC9808135 DOI: 10.1159/000525842] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Accepted: 06/27/2022] [Indexed: 11/17/2022] Open
Abstract
Prostate adenocarcinoma with testicular metastasis is rare, present in up to 4% of autopsy diagnoses, and presents symptomatically in less than 0.5% of cases. We report an unusual case of a 55-year-old male who developed a symptomatic testicular metastasis from primary prostate cancer 4 years after initial diagnosis of metastatic castrate-sensitive prostate cancer with nodal and bone-only involvement. The patient had orchidectomy, histologically confirming the metastasis and revealing sparing of the spermatic cord. Prior treatment for his metastatic castrate-sensitive prostate cancer had included androgen deprivation therapy and upfront docetaxel chemotherapy. He had received palliative radiotherapy for symptomatic bone metastasis and managed on enzalutamide for castrate-resistant disease for the preceding 22 months with ongoing PSA response at the time of diagnosis of new testicular metastasis, with a further significant PSA response following his "testicular metastasectomy." At the time of diagnosis of testicular metastasis, he did not have any evidence of other visceral metastases, and his metastatic disease otherwise remained radiologically stable. We describe his disease course, treatment and outline the rare nature of his case of testicular metastasis from prostate cancer.
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Affiliation(s)
- Jun Hee Hong
- Department of Medical Oncology, Liverpool Hospital, Sydney, NSW, Australia
| | - Udit Nindra
- Department of Medical Oncology, Liverpool Hospital, Sydney, NSW, Australia
| | - Rebecca Nguyen
- Department of Medical Oncology, Liverpool Hospital, Sydney, NSW, Australia
| | - Paul Gassner
- Department of Urology, Liverpool Hospital, Sydney, NSW, Australia
| | | | - Tristan Rutland
- Department of Anatomical Pathology, Liverpool Hospital, Sydney, NSW, Australia
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Nindra U, Shahnam A, Stevens S, Pal A, Nagrial A, Lee J, Yip PY, Adam T, Boyer M, Kao S, Bray V. Elevated neutrophil-to-lymphocyte ratio (NLR) is associated with poorer progression-free survival in unresectable stage III NSCLC treated with consolidation durvalumab. Thorac Cancer 2022; 13:3058-3062. [PMID: 36111516 PMCID: PMC9626316 DOI: 10.1111/1759-7714.14646] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [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: 07/03/2022] [Revised: 08/24/2022] [Accepted: 08/25/2022] [Indexed: 01/07/2023] Open
Abstract
Sustained elevation in neutrophil-to-lymphocyte ratio (NLR) after initial chemoradiotherapy (CRT) has been shown to correlate with worse prognosis in a number of solid organ malignancies. Here, we conducted a retrospective observational cohort study involving six sites across Sydney, Australia, including all patients with unresectable stage III NSCLC treated with CRT and consolidation durvalumab between January 2018 and September 2021. Patients had NLR collected prior to CRT and prior to cycle one of durvalumab. We used an NLR value of 3 to stratify patients into high and low groups. Patients with sustained NLR were defined as those with values ≥3 at both timepoints. A total of 145 patients were included in the study. The median age of patients was 66 years with median follow-up of 15.1 months. The median PFS was 17.6 months in the pre-CRT NLR high cohort and not reached (NR) in the pre-CRT NLR low cohort (HR 1.99; p = 0.01). The median OS was 35.5 months in the high pre-CRT NLR cohort compared with 42.0 months in the low pre-CRT NLR cohort (HR 2.62; 95% CI: 1.23-5.56, p < 0.01). Median PFS for sustained NLR elevation was 17.1 months versus NR (HR 1.5; p < 0.01). Pre-CRT NLR and sustained NLR remained independently prognostic for PFS on multivariate analysis (p = 0.04, p = 0.01) respectively. Pre-CRT NLR and sustained NLR is associated with worse PFS outcomes in unresectable stage III NSCLC treated with CRT and durvalumab. Pre-CRT NLR is also associated with worse OS.
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Affiliation(s)
- Udit Nindra
- Department of Medical OncologyLiverpool HospitalSydneyAustralia
| | - Adel Shahnam
- Department of Medical OncologyWestmead HospitalSydneyAustralia
| | - Samuel Stevens
- Department of Medical OncologyChris O'Brien LifehouseSydneyAustralia
| | - Abhijit Pal
- Department of Medical OncologyLiverpool HospitalSydneyAustralia
| | - Adnan Nagrial
- Department of Medical OncologyWestmead HospitalSydneyAustralia,Sydney Medical SchoolThe University of SydneySydneyAustralia
| | - Jenny Lee
- Department of Medical OncologyChris O'Brien LifehouseSydneyAustralia,Department of Clinical MedicineMacquarie UniversitySydneyAustralia
| | - Po Yee Yip
- Department of Medical OncologyMacarthur Cancer Therapy Center, Campbelltown HospitalSydneyAustralia,School of MedicineWestern Sydney UniversitySydneyAustralia
| | - Tamiem Adam
- Department of Medical OncologyBankstown‐Lidcombe HospitalSydneyAustralia
| | - Michael Boyer
- Department of Medical OncologyChris O'Brien LifehouseSydneyAustralia,Sydney Medical SchoolThe University of SydneySydneyAustralia
| | - Steven Kao
- Department of Medical OncologyChris O'Brien LifehouseSydneyAustralia,Sydney Medical SchoolThe University of SydneySydneyAustralia
| | - Victoria Bray
- Department of Medical OncologyLiverpool HospitalSydneyAustralia,Department of Medical OncologyBankstown‐Lidcombe HospitalSydneyAustralia
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Nindra U, Shahnam A, Stevens SX, Pal A, Yip PY, Adam T, Lee JHJ, Boyer MJ, Nagrial A, Kao SCH, Bray VJ. The prognostic influence of neutrophil to lymphocyte ratio (NLR) and platelet to lymphocyte ratio (PLR) in stage III non-small cell lung cancer (NSCLC) treated with consolidation durvalumab. J Clin Oncol 2022. [DOI: 10.1200/jco.2022.40.16_suppl.e18773] [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
e18773 Background: The neutrophil to lymphocyte ratio (NLR) and platelet to lymphocyte ratio (PLR) has been of prognostic interest in lung cancer. Sustained NLR and PLR after initial chemoradiotherapy (CRT) has been shown to correlate with worse prognosis in other solid organ malignancies. This study aims to add to the available evidence by describing the survival outcomes for patients with stage III NSCLC who are treated with consolidation Durvalumab when stratified by baseline or sustained NLR and PLR. Methods: We conducted a retrospective observational cohort study involving 6 sites across Sydney, Australia, including all patients diagnosed with stage III NSCLC treated with chemoradiation (CRT) and at least one cycle of durvalumab between January 2018 to September 2021. Patients had NLR and PLR collected prior to their first treatment of CRT and prior to their first treatment with Durvalumab. We used NLR and PLR values of 3 and 185 respectively to stratify patients into high and low groups. Patients with sustained NLR or PLR were defined as those with values > = 3 or > = 185 at both pre-CRT and pre-Durvalumab time points. Results: 148 patients were included in the study. The median follow-up from the start of Durvalumab was 15.1 months. The median age was 66 years. 61% (n = 90) of patients were male. The median PFS was 17.6 months in the pre-CRT NLR high cohort and not reached in the pre-CRT NLR low cohort (HR 1.99; 95% CI 1.16 – 3.41; p = 0.01). Median OS was 35.5 months versus 42.0 months in high and low pre-CRT NLR groups respectively (HR 2.62; 95% CI 1.23 – 5.56; p < 0.01). The median PFS was 19.9 months in the pre-CRT high PLR cohort versus and not reached in the pre-CRT low PLR cohort (HR 1.98; 95% CI 1.15 – 3.42; p = 0.02). The median OS was 39.9 months versus 42.0 months in high and low pre-CRT PLR groups respectively (HR 2.29; 95% CI 1.08– 4.88; p = 0.03). Median PFS for sustained NLR elevation was 17.1 months versus NR (HR 1.5, 95% CI 1.1 – 2.2, p < 0.01). Similarly median PFS for sustained PLR elevation was 16.6 months versus NR (HR 1.7, 95% CI 1.1 – 2.4, p < 0.01). Conclusions: Pre-CRT NLR and pre-CRT PLR are associated with OS and PFS outcomes in stage III unresectable NSCLC treated with CRT and Durvalumab. Those with sustained NLR or sustained PLR also have worse progression free survival outcomes.
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Affiliation(s)
| | | | | | - Abhijit Pal
- Royal Prince Alfred Hospital, Sydney, United Kingdom
| | - Po Yee Yip
- Macarthur Cancer Therapy Centre, Sydney, Australia
| | | | - Jenny HJ Lee
- Westmead Hospital Cancer Care, Sydney, Australia
| | - Michael J. Boyer
- Department of Medical Oncology, Chris O'Brien Lifehouse, Camperdown, Australia
| | | | - Steven Chuan-Hao Kao
- Chris O’Brien Life House, School of Medicine, University of Sydney, Sydney, NSW, Australia
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22
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Nindra U, Stevens SX, Shahnam A, Pal A, Adam T, Yip PY, Lee JHJ, Boyer MJ, Nagrial A, Kao SCH, Bray VJ. The influence of EGFR mutation status and PD-L1 expression in stage III unresectable non-small cell lung cancer treated with chemoradiation and consolidation durvalumab. J Clin Oncol 2022. [DOI: 10.1200/jco.2022.40.16_suppl.e18810] [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
e18810 Background: The PACIFIC trial established concurrent chemoradiation followed by one year of consolidation durvalumab as the standard of care for unresectable stage III non-small cell lung cancer (NSCLC). However, the data to support the use of durvalumab in patients with EGFR mutations and low PD-L1 expression is less clear. This study adds to the available evidence by describing the survival outcomes for patients with stage III unresectable NSCLC treated with chemoradiation followed by durvalumab with a focus on their EGFR mutation and PD-L1 status. Methods: This retrospective observational study was conducted at six sites across Sydney, Australia. It included patients diagnosed with unresectable stage III NSCLC treated with chemoradiation and at least one cycle of durvalumab between January 2018 to September 2021. Patients were stratified into EGFR wild-type and mutated tumours and PD-L1 tumour proportional score (TPS) greater than or less than 1%. Survival analyses were supplemented with cox proportional hazards regression models which estimated HRs for PFS in treatment group comparisons. The proportional hazards assumption was confirmed for all cox models. All statistical analysis was done using R version 4.1.1. Results: 146 patients were included in the analysis. The median follow-up from the start of Durvalumab was 15.1 months. The median age was 66 years in the EGFR mutated and 65 years in the EGFR wild-type cohorts. 61% (n = 89) of patients were male. 10% (n = 15) of patients had EGFR mutation. 42% (n = 61) of patients had a PD-L1 TPS of < 1%. PD-L1 expression was similar in both cohorts with 47% (n = 7) of EGFR mutated patients having PD-L1 TPS of < 1% compared with 45% (n = 59) in the wild-type group. The median progression-free survival (PFS) was 7.5 months for EGFR mutated patients versus 33.9 months for EGFR wild- type patients (HR: 2.7; 95% CI: 1.2 – 5.7; p = 0.01). There was no statistically significant difference in either PFS (HR 0.7, 95% CI 0.4 – 1.7, p = 0.43) or OS (HR 0.5, 95% CI 0.4 – 4.7, p = 0.16) for patients with PD-L1 TPS of < 1% compared with PD-L1 TPS of > 1%. Conclusions: Our data adds to the growing evidence that suggests consolidation durvalumab after definitive chemoradiation may not be as efficacious in patients with EGFR-mutated tumours. PD-L1 TPS did not affect survival outcomes.
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Affiliation(s)
| | | | | | - Abhijit Pal
- Royal Prince Alfred Hospital, Sydney, United Kingdom
| | | | - Po Yee Yip
- Macarthur Cancer Therapy Centre, Sydney, Australia
| | - Jenny HJ Lee
- Westmead Hospital Cancer Care, Sydney, Australia
| | - Michael J. Boyer
- Department of Medical Oncology, Chris O'Brien Lifehouse, Camperdown, Australia
| | | | - Steven Chuan-Hao Kao
- Chris O’Brien Life House, School of Medicine, University of Sydney, Sydney, NSW, Australia
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23
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Stevens SX, Nindra U, Shahnam A, Bray VJ, Yip PY, Adam T, Lee JHJ, Boyer MJ, Nagrial A, Kao SCH. Effect of delayed consolidation durvalumab and timing of treatment on survival outcomes in patients (pts) with unresectable stage III non-small cell lung cancer (NSCLC) treated with chemoradiotherapy (CRT). J Clin Oncol 2022. [DOI: 10.1200/jco.2022.40.16_suppl.e18809] [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
e18809 Background: Consolidation treatment with durvalumab following CRT is now standard of care for pts with unresectable stage III NSCLC. In PACIFIC, durvalumab was administered within 42 days of completing CRT. There has also been recent interest in whether the time-of-day immunotherapy is given impacts on outcomes. In practice, many pts experience delays to consolidation immunotherapy, and the timing of infusions is variable. We investigated the effect of treatment delays and time-of-treatment on survival outcomes in a real-world setting. Materials & Methods: A retrospective observational study was conducted with patients treated with consolidation durvalumab following concurrent platinum-based CRT for unresectable stage III NSCLC in 6 centres across Sydney, Australia between January 2018 and September 2021. The primary outcomes were overall survival (OS) and progression-free survival (PFS) based on RECIST v1.1, from completion of radiotherapy. We collected treatment initiation and completion dates as well the administration time of durvalumab. In the time-of-treatment analysis, pts were stratified into median time of treatment either before or after 12.00pm. Survival was estimated using Kaplan-Meier and Cox-proportional hazard models. Results: 145 pts were included in the study. Median age was 67 years. 62.3% of pts were male, 84.9% were smokers, and 57.5% had adenocarcinoma. The median time between completion of CRT and commencement of durvalumab was 59 days (11-187 days). 71.2% (n = 102) of pts experienced a treatment delay. Over a median follow-up of 18.9 months, median PFS was 33.9 months in pts treated within 42 days of CRT and 25.6 months in pts treated beyond 42 days of CRT (HR 0.97; 95% CI 0.46-2.06; p = 0.815). Median OS was not reached in either group but no difference in OS was observed in the two cohorts (HR 1.07; 95% CI 0.39-2.96; p = 0.88). Median timing of treatment did not affect outcomes for either PFS (HR 1.07; 95% CI 0.50-1.71; p = 0.80) or OS (HR 1.01; 95% CI 0.44-2.31; p = 0.91). Conclusions: No difference in survival outcomes was seen between patients who had received durvalumab 42 days after CRT compared to within 42 days. The median timing of treatment did not appear to impact outcomes in our cohort.
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Affiliation(s)
| | | | | | | | - Po Yee Yip
- Macarthur Cancer Therapy Centre, Sydney, Australia
| | | | - Jenny HJ Lee
- Westmead Hospital Cancer Care, Sydney, Australia
| | - Michael J. Boyer
- Department of Medical Oncology, Chris O'Brien Lifehouse, Camperdown, Australia
| | | | - Steven Chuan-Hao Kao
- Chris O’Brien Life House, School of Medicine, University of Sydney, Sydney, NSW, Australia
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Nindra U, Nguyen K, Hong J, Bray V, Moylan E. Concurrent Paraneoplastic Dermatomyositis and Acquired C1 Esterase Inhibitor Deficiency in Primary Laryngeal Small Cell Carcinoma. Case Rep Oncol 2021; 14:1806-1813. [PMID: 35111013 PMCID: PMC8787545 DOI: 10.1159/000520383] [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] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Accepted: 10/21/2021] [Indexed: 11/23/2022] Open
Abstract
Small cell carcinoma is associated with a number of paraneoplastic syndromes. We report a case of a 42-year-old female who presented with primary laryngeal small cell carcinoma associated with concurrent paraneoplastic dermatomyositis and paraneoplastic angioedema secondary to acquired C1 esterase inhibitor deficiency. The patient required extensive treatment for her dermatomyositis including high-dose corticosteroid therapy and intravenous immunoglobulin followed by steroid-sparing disease-modifying immunosuppression. Her angioedema also required multiple lines of therapy including bradykinin inhibitors and human recombinant C1 esterase. We believe this is the first reported case of either of these paraneoplastic syndromes arising from an extrapulmonary small cell carcinoma and highlights the difficulty of its initial diagnosis as well as concurrent management.
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Affiliation(s)
- Udit Nindra
- Medical Oncology Department, Liverpool Hospital, Liverpool, New South Wales, Australia
- School of Medicine, University of New South Wales, Kensington, New South Wales, Australia
- *Udit Nindra,
| | - Katie Nguyen
- Medical Oncology Department, Liverpool Hospital, Liverpool, New South Wales, Australia
| | - JunHee Hong
- Medical Oncology Department, Liverpool Hospital, Liverpool, New South Wales, Australia
- School of Medicine, University of New South Wales, Kensington, New South Wales, Australia
| | - Victoria Bray
- Medical Oncology Department, Liverpool Hospital, Liverpool, New South Wales, Australia
| | - Eugene Moylan
- Medical Oncology Department, Liverpool Hospital, Liverpool, New South Wales, Australia
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Nindra U, Shahnam A, Mahon KL. Review of systemic chemotherapy in unresectable colorectal peritoneal carcinomatosis. Asia Pac J Clin Oncol 2021; 18:7-12. [PMID: 33609014 DOI: 10.1111/ajco.13552] [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] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Accepted: 12/02/2020] [Indexed: 01/02/2023]
Abstract
Colorectal cancer remains the third most common malignancy in Australia with the peritoneum being the second most common metastatic site. Colorectal peritoneal carcinomatosis (CPC) can be treated with cytoreductive surgery and hyperthermic intraperitoneal chemotherapy but this is only limited to a small subset of patients. Those with inoperable disease have a particularly poor prognosis. While the ideal systemic regimen has not been defined, 5-fluorouracil-based chemotherapy regimens appear to provide overall and progression free survival benefits. The role of targeted agents such as bevacizumab (vascular endothelial growth factor inhibitor) or cetuximab (epidermal growth factor inhibitor) in the setting of CPC is still evolving. Currently, retrospective analyses have shown promising results for the use of bevacizumab in addition to systemic chemotherapy but similar results have not been seen with cetuximab or panitumumab. However, there is significant heterogeneity in the trial data, lack of prospective randomized controlled trials and demonstrated treatment variability based on age and tumour characteristics. This review summarises the current literature in regard to treatment in the unresectable CPC setting as well as discussing issues with the current data and highlighting the need for further trials.
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Affiliation(s)
- Udit Nindra
- Royal Prince Alfred Hospital, Sydney, Australia.,Chris O'Brien Lifehouse, Sydney, Australia
| | - Adel Shahnam
- Royal Prince Alfred Hospital, Sydney, Australia.,Chris O'Brien Lifehouse, Sydney, Australia
| | - Kate L Mahon
- Chris O'Brien Lifehouse, Sydney, Australia.,Garvan Institute of Medical Research, Sydney, Australia.,University of NSW, Sydney, Australia.,University of Sydney, Sydney, Australia
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Nindra U, Wonson TM, Fuller K. 028 Delayed CT imaging leading to delays in acute stroke management in regional australia. J Neurol Neurosurg Psychiatry 2019. [DOI: 10.1136/jnnp-2019-anzan.27] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
IntroductionUrgent CT imaging is crucial for acute stroke management to allow for timely thrombolysis and early referral to a peripheral endovascular thrombectomy (ECR) service. Delays in CT imaging are suspected to correlate with lengthening door-to-needle time (DNT) and arrival-to-referral time (ART) in regional Australia.Methods and resultsWe retrospectively analysed 656 acute stroke admissions between 2016 and 2018 to determine mean DNT and ART in addition to influencing factors such as age, gender, onset to arrival time & baseline National Institute of Health Stroke Scale (NIHSS) score. Over 3 years, 70 patients underwent thrombolysis and 56 ECR. The mean DNT was 108 minutes with mean arrival to CT time of 30 minutes. Multiple linear regression displayed a positive correlation between arrival to CT time and DNT (p<0.01). For every 10-minute delay in CT imaging, there was a 6-minute delay in DNT (95% CI 2 – 11 minutes). The mean ART was 150 minutes. A positive correlation was again seen between ART and arrival to CT Time (p=0.02). For every 10-minute delay in CT imaging, there was a 9-minute delay in ART (95% CI 1 – 16 minutes).ConclusionsIt is known that early initiation of both thrombolysis and ECR are associated with positive patient outcomes. There is a need to reduce time taken to complete CT imaging in regional Australia, as it is clearly shown to be associated with lengthened time for treatment initiation and timely referral. Reduction in this arrival to CT time will likely improve patient outcomes.
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Nindra U, Wonson TM, Fuller K. 029 Time equals brain – retrospective analysis of thrombolysis in regional australia to determine factors which influence door to needle time. J Neurol Neurosurg Psychiatry 2019. [DOI: 10.1136/jnnp-2019-anzan.28] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
IntroductionMinimising delay in thrombolysis is a key outcome in acute stroke care.MethodsA 3 year retrospective cohort analysis of all acute stroke admissions in Wollongong Hospital, a major regional referral centre in New South Wales, was completed to determine the causes of in-hospital delays for thrombolysis. Data collected included age, baseline National Institute of Health Stroke Scale (NIHSS) score, onset time, arrival time, CT imaging & reporting time and outcomes of the event.ResultsFrom 656 admissions, 70 cases of thrombolysis were recorded 56 cases of endovascular thrombectomy. The mean time from onset to arrival was 85 minutes, from arrival to CT was 31 minutes and from door to needle time (DNT) was 108 minutes. Multiple regression analysis revealed a an inverse linear association between onset to arrival time and DNT. Age, stroke severity and gender were not shown to impact treatment times. The results showed that there was a paradoxical association between arrival time and DNT. The cause for this was not clearly identified but similar to previous studies is likely to be contributed by a lack of urgency when initiating management.1 2ConclusionFor every 30-minute delay in hospital arrival, there was a 13- minute reduction in DNT. In light of this, education trials to promote ‘time equals brain’ understanding amongst stroke first responders is being implemented to aim to reduce DNT to less than 80 minutes. The results of this are anticipated to be available in mid 2019.ReferencesAlbers GW, Bates VE, Clark WM. Intravenous tissue-type plasminogen activator for treatment of acute stroke: The Standard Treatment with Alteplase to Reverse Stroke (STARS) Study. Journal of the American Medical Association 2000; 283:1145–1150.Romano JG, Muller N, Merino JG, Forteza AM, Koch S, Rabinstein AA. In-hospital delays to stroke thrombolysis: paradoxical effct of early arrival. Neurological Research 2007;29:664–666.
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