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Im A, Pusic I, Onstad L, Kitko CL, Hamilton BK, Alousi AM, Flowers ME, Sarantopoulos S, Carpenter P, White J, Arai S, El Jurdi N, Chen G, Cutler C, Lee S, Pidala J. Patient-reported treatment response in chronic graft- versus-host disease. Haematologica 2024; 109:143-150. [PMID: 37226713 PMCID: PMC10772515 DOI: 10.3324/haematol.2023.282734] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Accepted: 05/17/2023] [Indexed: 05/26/2023] Open
Abstract
Chronic graft-versus-host disease (GvHD) treatment response is assessed using National Institutes of Health (NIH) Consensus Criteria in clinical trials, and by clinician assessment in routine practice. Patient-reported treatment response is central to the experience of chronic GvHD manifestations as well as treatment benefit and toxicity, but how they correlate with clinician- or NIH-responses has not been well-studied. We aimed to characterize 6-month patientreported response, determine associated chronic GvHD baseline organ features and changes, and evaluate which patientreported quality of life and chronic GvHD symptom burden measures correlated with patient-reported response. From two nationally representative Chronic GVHD Consortium prospective observational studies, 382 subjects were included in this analysis. Patient and clinician responses were categorized as improved (completely gone, very much better, moderately better, a little better) versus not improved (about the same, a little worse, moderately worse, very much worse). At six months, 270 (71%) patients perceived chronic GvHD improvement, while 112 (29%) perceived no improvement. Patient-reported response had limited correlation with either clinician-reported (kappa 0.37) or NIH chronic GvHD response criteria (kappa 0.18). Notably, patient-reported response at six months was significantly associated with subsequent failure-free survival. In multivariate analysis, NIH responses in eye, mouth, and lung had significant association with 6-month patient-reported response, as well as a change in Short Form 36 general health and role physical domains and Lee Symptom Score skin and eye changes. Based on these findings, patient-reported responses should be considered as an important complementary endpoint in chronic GvHD clinical trials and drug development.
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Affiliation(s)
- Annie Im
- University of Pittsburgh/UPMC Hillman Cancer Center, Pittsburgh, PA
| | - Iskra Pusic
- Division of Medicine and Oncology, Washington University, Saint Louis, Missouri
| | - Lynn Onstad
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Carrie L Kitko
- Pediatric Blood and Marrow Transplantation Program, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Betty K Hamilton
- Blood and Marrow Transplantation, Department of Hematology and Medical Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH
| | - Amin M Alousi
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Mary E Flowers
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Stefanie Sarantopoulos
- Division of Hematological Malignancies and Cellular Therapy, Duke University Department of Medicine, Duke Cancer Institute, Durham, North Carolina
| | - Paul Carpenter
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Jennifer White
- Leukemia/Bone Marrow Transplant Program of British Columbia, British Columbia Cancer Agency, Vancouver, BC
| | - Sally Arai
- Department of Medicine, Division of Blood and Marrow Transplantation, Stanford University School of Medicine, Stanford, CA
| | - Najla El Jurdi
- Division of Hematology, Oncology and Transplantation, University of Minnesota Medical Center, Minneapolis, MN
| | - George Chen
- Department of Medicine, Roswell Park Comprehensive Cancer Center, Buffalo, NY
| | - Corey Cutler
- Division of Stem Cell Transplantation and Cellular Therapy, Dana-Farber Cancer Institute, Boston, MA
| | - Stephanie Lee
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Joseph Pidala
- Blood and Marrow Transplantation and Cellular Immunotherapy, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL.
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2
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Vigorito AC, Miranda ECM, Colturato VAR, Funke VAM, Fatobene G, Mariano L, Macedo MCMDA, Ribeiro LB, Daudt LE, Moreira MCR, Bonfim C, Colella MP, Seber A, Rodrigues M, Duarte FB, Martin PJ, Flowers MED. Chronic graft-versus-host-disease treatment in Brazil: analyses of failure-free survival. Transplant Cell Ther 2023; 29:276.e1-276.e7. [PMID: 36646321 DOI: 10.1016/j.jtct.2023.01.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2022] [Revised: 01/05/2023] [Accepted: 01/06/2023] [Indexed: 01/15/2023]
Abstract
Failure-free survival (FFS), defined as the absence of new systemic treatment, recurrence of original malignancy and mortality not associated with recurrence after allogeneic hematopoietic stem cell transplantation (HCT), is a robust clinical measure to interpret results of initial systemic treatment of chronic graft-versus-host disease (cGVHD). We evaluate FFS after initial treatment of cGVHD in a mixed-race cohort from a resource-constrained country. This retrospective study included 354 consecutive patients after their first HCT between January 2014 and August 2020, who received initial systemic treatment for moderate or severe cGVHD at 13 Brazilian centers. Cox regression models were used to identify risk factors for treatment failure. The overall median follow-up among survivors was 28 months (range 1-71) after initial treatment. FFS was 89% at 6 months, 71% at 1 year and 52% at 2 years. New systemic treatment was the major cause of failure. In multivariable models, prior grades II-IV acute GVHD, a National Institutes of Health severity score of 3 in liver, gastrointestinal tract or lung involvement, and onset of initial treatment of cGVHD within 12 months after transplantation were all associated with an increased risk of treatment failure. Our results could serve as a benchmark for the design of future clinical trials evaluating initial treatment of cGVHD in resource-constrained locations.
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Affiliation(s)
- Afonso Celso Vigorito
- Hospital das Clínicas/Hemocentro da Universidade Estadual de Campinas, Campinas, SP, Brasil
| | | | | | | | | | - Livia Mariano
- Laboratório de Investigação Médica, Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
| | | | | | - Liane Esteves Daudt
- Hospital de Clínicas de Porto Alegre e Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brasil
| | | | - Carmem Bonfim
- Instituto de Pesq0uisa Pele Pequeno Príncipe, Hospital Pequeno Príncipe, Curitiba, PR, Brasil
| | - Marcos Paulo Colella
- Hospital das Clínicas/Hemocentro da Universidade Estadual de Campinas, Campinas, SP, Brasil
| | | | | | - Fernando Barroso Duarte
- Hospital Universitário Walter Cantidio, Universidade Federal do Ceará, Fortaleza, CE, Brasil
| | - Paul J Martin
- Clinical Research Division, Fred Hutchinson Cancer Research Center and the Department of Medicine, University of Washington School of Medicine, Seattle, WA, USA
| | - Mary E D Flowers
- Clinical Research Division, Fred Hutchinson Cancer Research Center and the Department of Medicine, University of Washington School of Medicine, Seattle, WA, USA.
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- Hospital das Clínicas/Hemocentro da Universidade Estadual de Campinas, Campinas, SP, Brasil
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3
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Longitudinal Analysis of Infrared Meibography in Patients Undergoing Hematopoietic Stem Cell Transplantation. Cornea 2020; 39:812-817. [DOI: 10.1097/ico.0000000000002271] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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4
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Martin PJ, Storer BE, Palmer J, Jagasia MH, Chen GL, Broady R, Arora M, Pidala JA, Hamilton BK, Lee SJ. Organ Changes Associated with Provider-Assessed Responses in Patients with Chronic Graft-versus-Host Disease. Biol Blood Marrow Transplant 2019; 25:1869-1874. [PMID: 31085305 PMCID: PMC6755054 DOI: 10.1016/j.bbmt.2019.05.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2019] [Revised: 05/06/2019] [Accepted: 05/06/2019] [Indexed: 12/21/2022]
Abstract
Assessments of overall improvement and worsening of chronic graft-versus-host disease (GVHD) manifestations by the algorithm recommended by National Institutes of Health (NIH) response criteria do not align closely with those reported by providers, particularly when patients have mixed responses with improvement in some manifestations but worsening in others. To elucidate the changes that influence provider assessment of response, we used logistic regression to generate an overall change index based on specific manifestations of chronic GVHD measured at baseline and 6 months later. We hypothesized that this overall change index would correlate strongly with overall improvement as determined by providers. The analysis included 488 patients from 2 prospective observational studies who were randomly assigned in a 3:2 ratio to discovery and replication cohorts. Changes in bilirubin and scores of the lower gastrointestinal tract, mouth, joint/fascia, lung, and skin were correlated with provider-assessed improvement, suggesting that the main NIH response measures capture relevant information. Conversely, changes in the eye, esophagus, and upper gastrointestinal tract did not correlate with provider-assessed response, suggesting that these scales could be modified or dropped from the NIH response assessment. The area under the receiver operator characteristic curve in the replication cohort was 0.72, indicating that the scoring algorithm for overall change based on NIH response measures is not well calibrated with provider-assessed response.
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Affiliation(s)
- Paul J Martin
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, Washington; Department of Medicine, University of Washington, Seattle, Washington.
| | - Barry E Storer
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, Washington
| | | | - Madan H Jagasia
- Division of Hematology/Oncology, Vanderbilt-Ingram Cancer Center, Nashville, Tennessee
| | - George L Chen
- Department of Medicine, Roswell Park Cancer Institute, Buffalo, New York
| | - Raewyn Broady
- Leukemia/Bone Marrow Transplant Program of British Columbia, BC Cancer Agency, Vancouver, British Columbia, Canada
| | - Mukta Arora
- Hematology, Oncology and Transplantation, University of Minnesota, Minneapolis, Minnesota
| | - Joseph A Pidala
- Blood and Marrow Transplantation, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Betty K Hamilton
- Blood and Marrow Transplantation, Department of Hematology and Medical Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio
| | - Stephanie J Lee
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, Washington; Department of Medicine, University of Washington, Seattle, Washington
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5
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Tkaczyk ER, Coco JR, Wang J, Chen F, Ye C, Jagasia MH, Dawant BM, Fabbri D. Crowdsourcing to delineate skin affected by chronic graft-vs-host disease. Skin Res Technol 2019; 25:572-577. [PMID: 30786065 DOI: 10.1111/srt.12688] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2018] [Revised: 01/05/2019] [Accepted: 01/12/2019] [Indexed: 11/27/2022]
Abstract
BACKGROUND Estimating the extent of affected skin is an important unmet clinical need both for research and practical management in many diseases. In particular, cutaneous burden of chronic graft-vs-host disease (cGVHD) is a primary outcome in many trials. Despite advances in artificial intelligence and 3D photography, progress toward reliable automated techniques is hindered by limited expert time to delineate cGVHD patient images. Crowdsourcing may have potential to provide the requisite expert-level data. MATERIALS AND METHODS Forty-one three-dimensional photographs of three cutaneous cGVHD patients were delineated by a board-certified dermatologist. 410 two-dimensional projections of the raw photos were each annotated by seven crowd workers, whose consensus performance was compared to the expert. RESULTS The consensus delineation by four of seven crowd workers achieved the highest agreement with the expert, measured by a median Dice index of 0.7551 across all 410 images, outperforming even the best worker from the crowd (Dice index 0.7216). For their internal agreement, crowd workers achieved a median Fleiss's kappa of 0.4140 across the images. The time a worker spent marking an image had only weak correlation with the surface area marked, and very low correlation with accuracy. Percent of pixels selected by the consensus exhibited good correlation (Pearson R = 0.81) with the patient's affected surface area. CONCLUSION Crowdsourcing may be an efficient method for obtaining demarcations of affected skin, on par with expert performance. Crowdsourced data generally agreed with the current clinical standard of percent body surface area to assess cGVHD severity in the skin.
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Affiliation(s)
- Eric R Tkaczyk
- Department of Veterans Affairs, Tennessee Valley Health System, Nashville, Tennessee.,Department of Dermatology, Vanderbilt Cutaneous Imaging Clinic, Vanderbilt University Medical Center, Nashville, Tennessee.,Department of Biomedical Engineering, Vanderbilt University, Nashville, Tennessee
| | - Joseph R Coco
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Jianing Wang
- Department of Electrical Engineering and Computer Science, Vanderbilt University, Nashville, Tennessee
| | - Fuyao Chen
- Department of Veterans Affairs, Tennessee Valley Health System, Nashville, Tennessee.,Department of Dermatology, Vanderbilt Cutaneous Imaging Clinic, Vanderbilt University Medical Center, Nashville, Tennessee.,Department of Biomedical Engineering, Vanderbilt University, Nashville, Tennessee
| | - Cheng Ye
- Department of Electrical Engineering and Computer Science, Vanderbilt University, Nashville, Tennessee
| | | | - Benoit M Dawant
- Department of Biomedical Engineering, Vanderbilt University, Nashville, Tennessee.,Department of Electrical Engineering and Computer Science, Vanderbilt University, Nashville, Tennessee
| | - Daniel Fabbri
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee.,Department of Electrical Engineering and Computer Science, Vanderbilt University, Nashville, Tennessee
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6
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Atilla E, Atilla PA, Toprak SK, Demirer T. A review of late complications of allogeneic hematopoietic stem cell transplantations. Clin Transplant 2017; 31. [PMID: 28753218 DOI: 10.1111/ctr.13062] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/24/2017] [Indexed: 12/13/2022]
Abstract
Allogeneic hematopoietic stem cell transplantation (allo-HSCT) is an effective and curative treatment of different malignant and non-malignant diseases. Early transplant-related mortality after allo-HSCT has decreased with reduced-intensity conditioning regimens and effective anti-infectious treatments, but late transplant-related mortality is still a problem. Physicians are now paying more attention to late complications that may worsen the quality of life of many transplant recipients. Chronic graft versus host disease (cGVHD) is one of the major causes of late transplant-related mortality after allo-HSCT. This review discusses recent advances that have been made in clinical evaluation and treatment of late transplant-related complications including cGVHD. The different sites of involvement are organs, especially the skin and eye, and the gastrointestinal, endocrinologic, metabolic, renal, cardiologic, pulmonary, connective tissue, and neurological systems. In addition, this review includes infections and secondary malignancies in post-transplant settings that worsen quality of life in long-term follow-ups.
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Affiliation(s)
- Erden Atilla
- Department of Hematology, Ankara University Medical School, Ankara, Turkey
| | - Pinar Ataca Atilla
- Department of Hematology, Ankara University Medical School, Ankara, Turkey
| | | | - Taner Demirer
- Department of Hematology, Ankara University Medical School, Ankara, Turkey
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7
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Yuan A, Chai X, Martins F, Arai S, Arora M, Correa ME, Pidala J, Cutler CS, Lee SJ, Treister NS. Oral chronic GVHD outcomes and resource utilization: a subanalysis from the chronic GVHD consortium. Oral Dis 2015; 22:235-40. [PMID: 26708609 DOI: 10.1111/odi.12429] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2015] [Revised: 11/25/2015] [Accepted: 12/16/2015] [Indexed: 01/03/2023]
Abstract
OBJECTIVES This study evaluated the extent to which oral chronic graft-versus-host disease (cGVHD) consensus assessments are predictive of management across institutions with and without oral medicine (OM) centers, and whether ancillary care guidelines are followed within clinical practice. METHODS Longitudinal oral cGVHD data were abstracted from the cGVHD Consortium, and additional mouth-specific management data were analyzed across five transplant centers. RESULTS Seventy-nine patients with 656 visits were observed for a median of 7.1 months with one visit per follow-up month. Ancillary therapies for oral cGVHD were prescribed for 67% of patients for a median of 0.46 months (per follow-up month) at OM centers and 0.78 months at non-OM centers. Patients treated with ancillary therapy were more likely to have an National Institutes of Health (NIH) mouth score of ≥1 (P < 0.001, odds ratio: 5.1) and mouth pain (P = 0.01, odds ratio: 2.6). The odds ratios of receiving ancillary therapy from OM experts were higher than transplant physicians (53%; P = 0.03). CONCLUSIONS Oral cGVHD consensus assessments corresponding with ancillary therapy use were mouth pain and NIH mouth score, with higher odds ratios of receiving therapy from OM experts. Ancillary care guidelines for oral cGVHD are reflected in academic clinical practice with respect to utilization of recommended prescriptions.
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Affiliation(s)
- A Yuan
- Division of Oral Medicine, Brigham and Women's Hospital, Boston, MA, USA.,Department of Oral Medicine, Infection and Immunity, Harvard School of Dental Medicine, Boston, MA, USA
| | - X Chai
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - F Martins
- Department of Oral Pathology and Oral Diagnosis, University of São Paulo School of Dentistry, São Paulo, Brazil
| | - S Arai
- Division of Blood and Marrow Transplantation, Stanford University Medical Center, Stanford, CA, USA
| | - M Arora
- Department of Medicine, University of Minnesota, Boston, MA, USA
| | - M E Correa
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA.,Oral Medicine Ambulatory, Bone Marrow Transplantation Unit, Hematology and Blood Transfusion Center, State University of Campinas (UNICAMP), Campinas, SP, Brazil
| | - J Pidala
- Department of Blood and Marrow Transplantation, Moffitt Cancer Center, Tampa, FL, USA
| | - C S Cutler
- Division of Hematologic Malignancies, Dana-Farber Cancer Institute, Boston, MA, USA
| | - S J Lee
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - N S Treister
- Division of Oral Medicine, Brigham and Women's Hospital, Boston, MA, USA.,Department of Oral Medicine, Infection and Immunity, Harvard School of Dental Medicine, Boston, MA, USA
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8
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Predictors of survival, nonrelapse mortality, and failure-free survival in patients treated for chronic graft-versus-host disease. Blood 2015; 127:160-6. [PMID: 26527676 DOI: 10.1182/blood-2015-08-662874] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2015] [Accepted: 10/02/2015] [Indexed: 12/24/2022] Open
Abstract
Chronic graft-versus-host disease (GVHD) is a pleotropic syndrome that lacks validated methods of measuring response in clinical trials, although several end points have been proposed. To investigate the prognostic significance of these proposed end points, such as the 2005 National Institutes of Health (NIH) response measures, 2014 NIH response measures, clinician-reported response, and patient-reported response, we tested their ability to predict subsequent overall survival (OS), nonrelapse mortality (NRM), and failure-free survival (FFS). Patients (n = 575) were enrolled on a prospective chronic GVHD observational trial. At 6 months, clinician-reported response (P = .004) and 2014 NIH-calculated response (P = .001) correlated with subsequent FFS, and clinician-reported response predicted OS (P = .007). Multivariate models were used to identify changes in organ involvement, laboratory values, and patient-reported outcomes that were associated with long-term outcomes. At 6 months, a change in the 2005 NIH 0 to 3 clinician-reported skin score and 0 to 10 patient-reported itching score predicted subsequent FFS. Change in the Lee skin symptom score and Functional Assessment of Cancer Therapy-Bone Marrow Transplant score predicted subsequent OS. Change in the Lee skin symptom score predicted subsequent NRM. This study provides evidence that clinician-reported response and patient-reported outcomes are predictive of long-term survival. The trial was registered at www.clinicaltrials.gov as #NCT00637689.
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9
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Arai S, Pidala J, Pusic I, Chai X, Jaglowski S, Khera N, Palmer J, Chen GL, Jagasia MH, Mayer SA, Wood WA, Green M, Hyun TS, Inamoto Y, Storer BE, Miklos DB, Shulman HM, Martin PJ, Sarantopoulos S, Lee SJ, Flowers MED. A Randomized Phase II Crossover Study of Imatinib or Rituximab for Cutaneous Sclerosis after Hematopoietic Cell Transplantation. Clin Cancer Res 2015; 22:319-27. [PMID: 26378033 DOI: 10.1158/1078-0432.ccr-15-1443] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2015] [Accepted: 08/21/2015] [Indexed: 12/14/2022]
Abstract
PURPOSE Cutaneous sclerosis occurs in 20% of patients with chronic graft-versus-host disease (GVHD) and can compromise mobility and quality of life. EXPERIMENTAL DESIGN We conducted a prospective, multicenter, randomized, two-arm phase II crossover trial of imatinib (200 mg daily) or rituximab (375 mg/m(2) i.v. weekly × 4 doses, repeatable after 3 months) for treatment of cutaneous sclerosis diagnosed within 18 months (NCT01309997). The primary endpoint was significant clinical response (SCR) at 6 months, defined as quantitative improvement in skin sclerosis or joint range of motion. Treatment success was defined as SCR at 6 months without crossover, recurrent malignancy or death. Secondary endpoints included changes of B-cell profiles in blood (BAFF levels and cellular subsets), patient-reported outcomes, and histopathology between responders and nonresponders with each therapy. RESULTS SCR was observed in 9 of 35 [26%; 95% confidence interval (CI); 13%-43%] participants randomized to imatinib and 10 of 37 (27%; 95% CI, 14%-44%) randomized to rituximab. Six (17%; 95% CI, 7%-34%) patients in the imatinib arm and 5 (14%; 95% CI, 5%-29%) in the rituximab arm had treatment success. Higher percentages of activated B cells (CD27(+)) were seen at enrollment in rituximab-treated patients who had treatment success (P = 0.01), but not in imatinib-treated patients. CONCLUSIONS These results support the need for more effective therapies for cutaneous sclerosis and suggest that activated B cells define a subgroup of patients with cutaneous sclerosis who are more likely to respond to rituximab.
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Affiliation(s)
- Sally Arai
- Department of Medicine/Division of Blood and Marrow Transplant, Stanford University School of Medicine, Stanford, California
| | - Joseph Pidala
- Blood and Marrow Transplantation, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Iskra Pusic
- Division of Oncology, Section of Bone Marrow Transplantation, Washington University School of Medicine, St. Louis, Missouri
| | - Xiaoyu Chai
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Samantha Jaglowski
- Division of Hematology, Internal Medicine, Ohio State University, Columbus, Ohio
| | - Nandita Khera
- Division of Hematology/Oncology, Mayo Clinic, Scottsdale, Arizona
| | - Jeanne Palmer
- Division of Hematology/Oncology, Mayo Clinic, Scottsdale, Arizona
| | - George L Chen
- Department of Medicine/Division of Blood and Marrow Transplant, Stanford University School of Medicine, Stanford, California
| | - Madan H Jagasia
- Department of Hematology and Oncology, Vanderbilt University Medical Center, Nashville, Tennessee
| | | | - William A Wood
- Department of Hematology/Oncology, University of North Carolina, Chapel Hill, North Carolina
| | - Michael Green
- Division of Hematologic Malignancies and Cellular Therapy, Department of Medicine, Duke Cancer Institute, Duke University, Durham, North Carolina
| | - Teresa S Hyun
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Yoshihiro Inamoto
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Barry E Storer
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - David B Miklos
- Department of Medicine/Division of Blood and Marrow Transplant, Stanford University School of Medicine, Stanford, California
| | - Howard M Shulman
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Paul J Martin
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Stefanie Sarantopoulos
- Division of Hematologic Malignancies and Cellular Therapy, Department of Medicine, Duke Cancer Institute, Duke University, Durham, North Carolina
| | - Stephanie J Lee
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Mary E D Flowers
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington.
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10
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Martin PJ, Lee SJ, Przepiorka D, Horowitz MM, Koreth J, Vogelsang GB, Walker I, Carpenter PA, Griffith LM, Akpek G, Mohty M, Wolff D, Pavletic SZ, Cutler CS. National Institutes of Health Consensus Development Project on Criteria for Clinical Trials in Chronic Graft-versus-Host Disease: VI. The 2014 Clinical Trial Design Working Group Report. Biol Blood Marrow Transplant 2015; 21:1343-59. [PMID: 25985921 PMCID: PMC4506719 DOI: 10.1016/j.bbmt.2015.05.004] [Citation(s) in RCA: 80] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2015] [Accepted: 05/05/2015] [Indexed: 10/23/2022]
Abstract
Treatment of chronic graft-versus-host disease is intended to produce a sustainable benefit by reducing symptom burden, controlling objective manifestations of disease activity, preventing damage and impairment, and improving overall survival without causing disproportionate harms related to the treatment itself. Successful management can control the disease until systemic treatment is no longer needed. The complexity of the disease, the extended duration of follow-up needed to observe disease resolution and withdrawal of immunosuppressive treatment, and the lack of fully developed shorter term endpoints impede progress in the field. Identification and characterization of primary endpoints demonstrating clinical benefit without requiring years of follow-up is urgently needed, with the understanding that clinical benefit encompasses not only the self-evident benefit of the primary endpoint but also any other associated benefits. This report discusses regulatory considerations, eligibility criteria, the value of controlled trial designs, the merits of proposed primary endpoints, and key considerations elaborated from experience and progress during the past decade. The report concludes by mapping an overall approach that could support and lead to maximally informative clinical trials, especially those that seek to demonstrate clinical benefit along a pathway to regulatory review and approval.
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Affiliation(s)
- Paul J Martin
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington.
| | - Stephanie J Lee
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Donna Przepiorka
- Center for Drug Evaluation Research, US Food and Drug Administration, Silver Spring, Maryland
| | - Mary M Horowitz
- Division of Hematology and Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - John Koreth
- Division of Hematologic Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Georgia B Vogelsang
- Department of Oncology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Irwin Walker
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Paul A Carpenter
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Linda M Griffith
- Division of Allergy, Immunology and Transplantation, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland
| | - Gorgun Akpek
- Stem Cell Transplant Program, Banner MD Anderson Cancer Center, Gilbert, Arizona
| | - Mohamad Mohty
- Clinical Hematology and Cellular Therapy Department, Hôpital Saint-Antoine, University Pierre & Marie Curie, INSERM U938, Paris, France
| | - Daniel Wolff
- Department of Internal Medicine III, University of Regensburg, Regensburg, Germany
| | - Steven Z Pavletic
- Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, Maryland
| | - Corey S Cutler
- Division of Hematologic Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
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11
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Flowers MED, Martin PJ. How we treat chronic graft-versus-host disease. Blood 2015; 125:606-15. [PMID: 25398933 PMCID: PMC4304105 DOI: 10.1182/blood-2014-08-551994] [Citation(s) in RCA: 219] [Impact Index Per Article: 24.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2014] [Accepted: 11/06/2014] [Indexed: 02/07/2023] Open
Abstract
Chronic graft-versus-host disease (GVHD) remains a common and potentially life-threatening complication of allogeneic hematopoietic stem cell transplantation (HCT). The 2-year cumulative incidence of chronic GVHD requiring systemic treatment is ~30% to 40% by National Institutes of Health criteria. The risk of chronic GVHD is higher and the duration of treatment is longer after HCT with mobilized blood cells than with marrow cells. Clinical manifestations can impair activities of daily living and often linger for years. Hematology and oncology specialists who refer patients to centers for HCT are often subsequently involved in the management of chronic GVHD when patients return to their care after HCT. Treatment of these patients can be optimized under shared care arrangements that enable referring physicians to manage long-term administration of immunosuppressive medications and supportive care with guidance from transplant center experts. Keys to successful collaborative management include early recognition in making the diagnosis of chronic GVHD, comprehensive evaluation at the onset and periodically during the course of the disease, prompt institution of systemic and topical treatment, appropriate monitoring of the response, calibration of treatment intensity over time in order to avoid overtreatment or undertreatment, and the use of supportive care to prevent complications and disability.
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Affiliation(s)
- Mary E D Flowers
- Clinical Research Division, Fred Hutchinson Cancer Research Center and Department of Medicine, University of Washington, Seattle, WA
| | - Paul J Martin
- Clinical Research Division, Fred Hutchinson Cancer Research Center and Department of Medicine, University of Washington, Seattle, WA
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13
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Abstract
Chronic graft-versus-host disease (GVHD) is a frequent and potentially life-threatening complication of allogeneic hematopoietic stem cell transplantation. Increased transplantation of older patients and the more frequent use of unrelated donors has led to increased numbers of patients with this painful complication. Recent advances have been made in understanding the pathophysiology of chronic GVHD and in establishing precise criteria for diagnosis and classification of disease manifestations. These advances will hopefully pave the way for improving both the prophylaxis and treatment of chronic GVHD.
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Abstract
Chronic graft-versus-host disease (GVHD) is a frequent and potentially life-threatening complication of allogeneic hematopoietic stem cell transplantation. Increased transplantation of older patients and the more frequent use of unrelated donors has led to increased numbers of patients with this painful complication. Recent advances have been made in understanding the pathophysiology of chronic GVHD and in establishing precise criteria for diagnosis and classification of disease manifestations. These advances will hopefully pave the way for improving both the prophylaxis and treatment of chronic GVHD.
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Saillard C, Crocchiolo R, Furst S, El-Cheikh J, Castagna L, Signori A, Oudin C, Faucher C, Lemarie C, Chabannon C, Granata A, Blaise D. National Institutes of Health classification for chronic graft-versus-host disease predicts outcome of allo-hematopoietic stem cell transplant after fludarabine-busulfan-antithymocyte globulin conditioning regimen. Leuk Lymphoma 2014; 55:1106-12. [PMID: 23822538 DOI: 10.3109/10428194.2013.820285] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Abstract In 2005, the National Institutes of Health (NIH) proposed standard criteria for diagnosis, organ scoring and global assessment of chronic graft-versus-host disease (cGvHD) severity. We retrospectively reclassified cGvHD with NIH criteria in a monocentric cohort of 130 consecutive adult patients with hematological malignancies presenting cGvHD after receiving allo-hematopoietic stem cell transplant (HSCT) with a fludarabine-busulfan-antithymocyte globulin (ATG) conditioning regimen, among 313 consecutive HSCT recipients. We compared NIH and Seattle classifications to correlate severity and outcome. The follow up range was effectively 2-120 months. Forty-four percent developed Seattle-defined cGvHD (22% limited, 78% extensive forms). Using NIH criteria, there were 23%, 40% and 37% mild, moderate and severe forms, respectively, and 58%, 32% and 8% classic cGvHD, late acute GvHD and overlap syndrome. Five-year overall survival was 55% (49-61), and cumulative incidences of non-relapse mortality (NRM) and relapse/progression at 2 years were 19% (14-23) and 19% (14-24). NIH mild and moderate forms were associated with better survival compared to severe cGvHD (hazard ratio [HR] = 3.28, 95% confidence interval [CI]: 1.38-7.82, p = 0.007), due to higher NRM among patients with severe cGvHD (HR = 3.04, 95% CI: 1.05-8.78, p = 0.04) but comparable relapse risk (p = NS). In conclusion, the NIH classification appears to be more accurate in predicting outcome mostly by the reclassification of old-defined extensive forms into NIH-defined moderate or severe.
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Affiliation(s)
- Colombe Saillard
- Hematology Department, Institut Paoli-Calmettes , Marseille , France
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Inamoto Y, Jagasia M, Wood WA, Pidala J, Palmer J, Khera N, Weisdorf D, Carpenter PA, Flowers MED, Jacobsohn D, Martin PJ, Lee SJ, Pavletic SZ. Investigator feedback about the 2005 NIH diagnostic and scoring criteria for chronic GVHD. Bone Marrow Transplant 2014; 49:532-8. [PMID: 24464142 PMCID: PMC3975688 DOI: 10.1038/bmt.2013.225] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2013] [Revised: 10/20/2013] [Accepted: 12/01/2013] [Indexed: 12/31/2022]
Abstract
The 2005 National Institutes of Health (NIH) consensus criteria for chronic graft-versus-host disease (cGVHD) have set standards for reporting. Many questions, however, have arisen regarding implementation and utilization. To identify perceived areas of controversy, we conducted an international survey on diagnosis and scoring of cGVHD. Agreement was observed for 50% to 83% of the 72 questions in 7 topic areas. There was agreement in the need for modifying criteria in 6 situations: 2 or more distinctive manifestations should be enough to diagnose cGVHD, symptoms not due to cGVHD should be scored differently, active disease and fixed deficits should be distinguished, a minimum threshold body surface area of hidebound skin involvement should be required for a skin score 3, asymptomatic oral lichenoid changes should be considered a score 1, and lung biopsy should be unnecessary to diagnose cGVHD in a patient with bronchiolitis obliterans as the only manifestation. The survey also identified 26 points of controversy. Whenever possible, studies should be conducted to confirm the appropriateness of any revisions. In cases where data are not available, clarification of the NIH recommendations by consensus is necessary. This survey should inform future research in the field and revisions of the current consensus criteria.
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Affiliation(s)
- Y Inamoto
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - M Jagasia
- Hematology and Stem Cell Transplant Program, Vanderbilt University Medical Center, Nashville, TN, USA
| | - W A Wood
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - J Pidala
- Blood and Marrow Transplantation, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - J Palmer
- Division of Hematology/Oncology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - N Khera
- Division of Hematology/Oncology, Mayo Clinic Arizona, Scottsdale, AZ, USA
| | - D Weisdorf
- Blood and Marrow Transplant Program, University of Minnesota Medical Center, Minneapolis, MN, USA
| | - P A Carpenter
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - M E D Flowers
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - D Jacobsohn
- Division of Blood and Marrow Transplantation, Center for Cancer and Blood Disorders, Children's National Medical Center, Washington, DC, USA
| | - P J Martin
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - S J Lee
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
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Abstract
There are no validated biomarkers for chronic GVHD (cGVHD). We used a protein microarray and subsequent sequential enzyme-linked immunosorbent assay to compare 17 patients with treatment-refractory de novo-onset cGVHD and 18 time-matched control patients without acute or chronic GVHD to identify 5 candidate proteins that distinguished cGVHD from no cGVHD: CXCL9, IL2Rα, elafin, CD13, and BAFF. We then assessed the discriminatory value of each protein individually and in composite panels in a validation cohort (n = 109). CXCL9 was found to have the highest discriminatory value with an area under the receiver operating characteristic curve of 0.83 (95% confidence interval, 0.74-0.91). CXCL9 plasma concentrations above the median were associated with a higher frequency of cGVHD even after adjustment for other factors related to developing cGVHD including age, diagnosis, donor source, and degree of HLA matching (71% vs 20%; P < .001). A separate validation cohort from a different transplant center (n = 211) confirmed that CXCL9 plasma concentrations above the median were associated with more frequent newly diagnosed cGVHD after adjusting for the aforementioned factors (84% vs 60%; P = .001). Our results confirm that CXCL9 is elevated in patients with newly diagnosed cGVHD.
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Cheville AL, Basford JR, Dos Santos K, Kroenke K. Symptom burden and comorbidities impact the consistency of responses on patient-reported functional outcomes. Arch Phys Med Rehabil 2013; 95:79-86. [PMID: 23988394 DOI: 10.1016/j.apmr.2013.08.009] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2013] [Revised: 07/22/2013] [Accepted: 08/11/2013] [Indexed: 01/11/2023]
Abstract
OBJECTIVE To assess the influence of symptom intensity, mood, and comorbidities on patient-clinician agreement and the consistency of responses to functional patient-reported outcomes (PROs). DESIGN Two data sources were used. The first, a cross-sectional database of patients with breast cancer who completed functional PROs and were administered the FIM, was used to examine whether average pain intensity (as measured with an 11-point numeric rating scale [NRS]) and Rand Mental Health inventory scores differed among those rating their functional independence as different than clinicians. The second, a longitudinal database of 311 adults with late-stage lung cancer who completed the Activity Measure for Post Acute Care Computer Adaptive Test (AM PAC CAT) with differences between their expected and actual responses as reflected in their AM PAC CAT SEs. SETTING Two tertiary medical centers. PARTICIPANTS Data source #1, 163 women with stage IV breast cancer; data source #2, 311 adults with late-stage lung cancer. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Data source #1, FIM, pain NRS, Older Americans Resource Study activities of daily living subscale, Physical Function-10, Mental Health Inventory-17. Data source #2, AM PAC CAT and NRS symptom ratings. RESULTS Pain intensity was significantly higher when clinicians and patients disagreed regarding a patient's independence in the ability to transfer (NRS pain severity, 3.78 vs 2.40; P=.014), groom (3.71 vs 2.36, P=.009), bathe (3.76 vs 2.40, P=.016), and dress (3.09 vs 2.44, P=.034). The magnitude of AM PAC CAT SEs was significantly associated with the severity of participants' pain, dyspnea, and fatigue, as well as the presence of musculoskeletal disorders and coronary artery disease. Neither mood nor emotional distress was associated with clinician-patient agreement or AM PAC CAT SE. CONCLUSIONS Pain intensity is associated with disagreement between patients and clinicians about the patient's level of functioning. Moreover, physical symptoms (pain, dyspnea, fatigue) as well as specific medical comorbidities (musculoskeletal disorders, coronary artery disease), but not mood, are associated with inconsistency in patients' assessment of their functional abilities.
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Affiliation(s)
| | | | - Katiuska Dos Santos
- Department of Physical Medicine and Rehabilitation, Mayo Clinic, Rochester, MN
| | - Kurt Kroenke
- Regenstrief Institute, Inc, Indianapolis, IN; Indiana University Center for Health Services and Outcomes, Indianapolis, IN
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Treister N, Chai X, Kurland B, Pavletic S, Weisdorf D, Pidala J, Palmer J, Martin P, Inamoto Y, Arora M, Flowers M, Jacobsohn D, Jagasia M, Arai S, Lee SJ, Cutler C. Measurement of oral chronic GVHD: results from the Chronic GVHD Consortium. Bone Marrow Transplant 2013; 48:1123-8. [PMID: 23353804 DOI: 10.1038/bmt.2012.285] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2012] [Revised: 12/06/2012] [Accepted: 12/20/2012] [Indexed: 11/09/2022]
Abstract
Oral chronic GVHD (cGVHD) is a serious complication of alloSCT. Scales and instruments to measure oral cGVHD activity and severity have not been prospectively validated. The objective of this study was to describe the characteristics of oral cGVHD and determine the measures most sensitive to change. Patients enrolled in the cGVHD Consortium with oral involvement were included. Clinicians scored oral changes according to the National Institutes of Health (NIH) criteria, and patients completed symptom and quality-of-life measures at each visit. Both rated change on an eight-point scale. Of the 458 participants, 72% (n=331) had objective oral involvement at enrollment. Lichenoid change was the most common feature (n=293; 89%). At visits where oral change could be assessed, 50% of clinicians and 56% of patients reported improvement, with worsening reported in 4-5% for both the groups (weighted kappa=0.41). Multivariable regression modeling suggested that the measurement changes most predictive of perceived change by clinicians and patients were erythema and lichenoid, NIH severity and symptom scores. Oral cGVHD is common and associated with a range of signs and symptoms. Measurement of erythema and lichenoid changes and symptoms may adequately capture the activity of oral cGVHD in clinical trials but require prospective validation.
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Affiliation(s)
- N Treister
- Division of Oral Medicine and Dentistry, Brigham and Women's Hospital, Boston, MA 02115, USA.
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Failure-free survival after second-line systemic treatment of chronic graft-versus-host disease. Blood 2013; 121:2340-6. [PMID: 23321253 DOI: 10.1182/blood-2012-11-465583] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
This study attempted to characterize causes of treatment failure, identify associated prognostic factors, and develop shorter-term end points for trials testing investigational products or regimens for second-line systemic treatment of chronic graft-versus-host disease (GVHD). The study cohort (312 patients) received second-line systemic treatment of chronic GVHD. The primary end point was failure-free survival (FFS) defined by the absence of third-line treatment, nonrelapse mortality, and recurrent malignancy during second-line treatment. Treatment change was the major cause of treatment failure. FFS was 56% at 6 months after second-line treatment. Lower steroid doses at 6 months correlated with subsequent withdrawal of immunosuppressive treatment. Multivariate analysis showed that high-risk disease at transplantation, lower gastrointestinal involvement at second-line treatment, and severe NIH global score at second-line treatment were associated with increased risks of treatment failure. These three factors were used to define risk groups, and success rates at 6 months were calculated for each risk group either without or with various steroid dose limits at 6 months as an additional criterion of success. These success rates could be used as the basis for a clinically relevant and efficient shorter-term end point in clinical studies that evaluate agents for second-line systemic treatment of chronic GVHD.
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Chao N. You Cannot Improve What You Do Not Measure. Biol Blood Marrow Transplant 2012; 18:1467-8. [DOI: 10.1016/j.bbmt.2012.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2012] [Accepted: 07/02/2012] [Indexed: 10/28/2022]
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The adult respiratory distress syndrome. Clinical features, factors influencing prognosis and principles of management. Chest 1971; 128:130-7. [PMID: 4937358 DOI: 10.1182/blood-2016-02-702852] [Citation(s) in RCA: 152] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2016] [Accepted: 03/29/2016] [Indexed: 12/14/2022] Open
Abstract
Key Points
Low-dose IL-2 is efficacious in steroid-refractory cGVHD, with objective responses in >50% of patients, and durable disease control. IL-2 initiation earlier after cGVHD onset, prior to severe impairment of Treg:Tcon ratios, improves likelihood of clinical response.
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