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Franco S, Khan T, Dinner S, Karmali R, Melody M. Dosing of 7 + 3 induction chemotherapy in a patient with acute myeloid leukemia (AML) and morbid obesity. J Oncol Pharm Pract 2024; 30:945-949. [PMID: 38509800 DOI: 10.1177/10781552241240444] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/22/2024]
Abstract
INTRODUCTION Traditional chemotherapy dosing is based on body surface area (BSA) using standard formulas, which can pose challenges in dosing patients at body weight extremes. Studies suggest that chemotherapy dosing according to actual body weight does not increase toxicity in obese patients and current guidelines recommend full weight-based dosing of chemotherapy regardless of body mass index (BMI). However, the dosing of anthracyclines in obese patients can be challenging given limitations in maximum cumulative dosage, particularly in those at very extreme BMI. In this case, we highlight the difficulties of dosing anthracycline-based induction chemotherapy in a patient with newly diagnosed acute myeloid leukemia (AML) and BMI >90 kg/m2. CASE REPORT A 40-year-old female with morbid obesity is diagnosed with AML (nucleophosmin 1 (NPMI) and isocitrate dehydrogenase-2 mutated, FMS-like tyrosine kinase 3-Internal tandem duplication negative). MANAGEMENT AND OUTCOME The patient was initiated on induction therapy with 7 + 3 with dose capping of BSA at 2.75 m2 (cytarabine 200 mg/m2 continuous infusion over 24 h for 7 days, plus daunorubicin 60 mg/m2 slow intravenous push for 3 days), followed by two cycles of high-dose cytarabine consolidation therapy using actual BSA. The patient achieved morphologic complete remission; however, measurable residual disease testing for NPM1 remained positive after induction therapy. DISCUSSION This case suggests that dose capping of anthracyclines in the treatment of newly diagnosed AML may be an effective and safe treatment alternative in those with extreme BMI elevations beyond what has been studied in the literature. Given the increasing incidence of morbid obesity, further studies are needed to confirm appropriate dosing of anthracycline-based regimens at upper BMI extremes (>60 kg/m2).
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Affiliation(s)
- Stephanie Franco
- Department of Internal Medicine, Northwestern Medicine, Chicago, IL, USA
| | - Talha Khan
- Robert H. Lurie Comprehensive Cancer Center, Department of Pharmacy, Chicago, IL, USA
| | - Shira Dinner
- Robert H. Lurie Comprehensive Cancer Center, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Reem Karmali
- Robert H. Lurie Comprehensive Cancer Center, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Megan Melody
- Robert H. Lurie Comprehensive Cancer Center, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
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Sano H, Fukushima K, Yano M, Osone S, Kato Y, Hasegawa D, Miyamura T, Iwamoto S, Takahashi H, Terui K, Tawa A, Tomizawa D. Analysis of overweight/obese pediatric patients with acute myeloid leukemia: a report from the Japanese Pediatric Leukemia/Lymphoma Study Group AML-05 study. Int J Hematol 2024; 119:745-754. [PMID: 38460081 DOI: 10.1007/s12185-024-03745-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Revised: 02/20/2024] [Accepted: 03/05/2024] [Indexed: 03/11/2024]
Abstract
The dosage of chemotherapy drugs for overweight/obese children with acute myeloid leukemia (AML) has been empirically reduced based on ideal body weight (BW) in Japan to reduce the risk of adverse events. We investigated the associations between pre-therapeutic body mass index (BMI) and clinical outcomes among children with AML. A total of 280 children were divided into two groups based on the World Health Organization Child Growth Standards: a healthy-weight group (n = 254), and an overweight/obese group (n = 26). If BW exceeded 1.2 times the standard BW of Japanese children, the dosage of chemotherapy drugs was calculated using 1.2 times the standard BW. The dosage of chemotherapy drugs was reduced during at least one chemotherapy cycle in 24 of 26 patients (92.3%) in the overweight/obese group, compared with zero patients in the healthy-weight group. Overall/event-free survival, cumulative incidence of relapse, and treatment-related mortality (TRM) did not differ between the overweight/obese and healthy weight groups. However, the frequency of bacteremia was higher in the overweight/obese group (80.8 vs. 52.4%, P = 0.006). This indicates that TRM may increase when chemotherapy drug dosage is not corrected in overweight/obese patients. Drug reduction is a potential treatment strategy.
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Affiliation(s)
- Hirozumi Sano
- Department of Hematology/Oncology for Children and Adolescents, Sapporo Hokuyu Hospital, Higashi-Sapporo 6-6, Shiroishi-ku, Sapporo, 003-0006, Japan.
| | | | - Michihiro Yano
- Department of Pediatrics, Akita University Graduate School of Medicine, Akita, Japan
| | - Shinya Osone
- Department of Pediatrics, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Yoko Kato
- Department of Pediatrics, The Jikei University School of Medicine, Tokyo, Japan
| | - Daiichiro Hasegawa
- Department of Hematology/Oncology, Kobe Children's Hospital, Kobe, Japan
| | - Takako Miyamura
- Department of Pediatrics, Osaka University Graduate School of Medicine, Suita, Japan
| | | | | | - Kiminori Terui
- Department of Pediatrics, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - Akio Tawa
- Higashiosaka Aramoto Heiwa Clinic, Higashiosaka, Japan
| | - Daisuke Tomizawa
- Division of Leukemia and Lymphoma, Children's Cancer Center, National Center for Child Health and Development, Tokyo, Japan
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Cheng H, Sun Y, Zhang X, Chen Z, Shao L, Liu J, Wang D, Chen Y, Wang X, Chen W, Sang W, Qi K, Li Z, Sun C, Shi M, Qiao J, Wu Q, Zeng L, Zheng J, Xu K, Cao J. Complex association of body mass index and outcomes in patients with relapsed and refractory multiple myeloma treated with CAR-T cell immunotherapy. Cytotherapy 2024:S1465-3249(24)00572-3. [PMID: 38625072 DOI: 10.1016/j.jcyt.2024.03.481] [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: 10/22/2023] [Revised: 03/07/2024] [Accepted: 03/22/2024] [Indexed: 04/17/2024]
Abstract
BACKGROUND AIMS Chimeric antigen receptor-T (CAR-T) cells have exhibited remarkable efficacy in treating refractory or relapsed multiple myeloma (R/R MM). Although obesity has a favorable value in enhancing the response to immunotherapy, less is known about its predictive value regarding the efficacy and prognosis of CAR-T cell immunotherapy. METHODS We conducted a retrospective study of 111 patients with R/R MM who underwent CAR-T cell treatment. Using the body mass index (BMI) classification, the patients were divided into a normal-weight group (73/111) and an overweight group (38/111). We investigated the effect of BMI on CAR-T cell therapy outcomes in patients with R/R MM. RESULTS The objective remission rates after CAR-T cell infusion were 94.7% and 89.0% in the overweight and normal-weight groups, respectively. The duration of response and overall survival were not significant difference between BMI groups. Compared to normal-weight patients, overweight patients had an improved median progression-free survival. There was no significant difference in cytokine release syndrome and immune effector cell-associated neurotoxicity syndrome between the subgroups. In terms of hematological toxicity, the erythrocyte, hemoglobin, platelet, leukocyte and neutrophil recovery was accelerated in the overweight group. Fewer patients in the overweight group displayed moderate percent CD4 and CD4/CD8 ratios compared to the normal-weight group. Furthermore, the percent CD4 ratios were positively correlated with the levels of cytokines [interleukin-2 (IL-2) (day 14), interferon gamma (IFN-γ) (day 7) and tumor necrosis factor alpha (TNF-α) (days 14 and 21)] after cells infusion. On the other hand, BMI was positively associated with the levels of IFN-γ (day 7) and TNF-α (days 14 and 21) after CAR-T cells infusion. CONCLUSIONS Overall, this study highlights the potential beneficial effect of a higher BMI on CAR-T cell therapy outcomes.
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Affiliation(s)
- Hai Cheng
- Department of Hematology, The Affiliated Hospital of Xuzhou Medical University, Xuzhou, China
| | - Yingjun Sun
- Department of Hematology, The Affiliated Hospital of Xuzhou Medical University, Xuzhou, China
| | - Xiaoxue Zhang
- Department of Hematology, The Affiliated Hospital of Xuzhou Medical University, Xuzhou, China
| | - Zihan Chen
- Department of Hematology, The Affiliated Hospital of Xuzhou Medical University, Xuzhou, China
| | - Lingyan Shao
- Department of Hematology, The Affiliated Hospital of Xuzhou Medical University, Xuzhou, China
| | - Jiaying Liu
- Department of Hematology, The Affiliated Hospital of Xuzhou Medical University, Xuzhou, China
| | - Dandan Wang
- Department of Hematology, The Affiliated Hospital of Xuzhou Medical University, Xuzhou, China
| | - Yegan Chen
- Department of Hematology, The Affiliated Hospital of Xuzhou Medical University, Xuzhou, China
| | - Xue Wang
- Department of Hematology, The Affiliated Hospital of Xuzhou Medical University, Xuzhou, China
| | - Wei Chen
- Department of Hematology, The Affiliated Hospital of Xuzhou Medical University, Xuzhou, China
| | - Wei Sang
- Department of Hematology, The Affiliated Hospital of Xuzhou Medical University, Xuzhou, China
| | - Kunming Qi
- Department of Hematology, The Affiliated Hospital of Xuzhou Medical University, Xuzhou, China
| | - Zhenyu Li
- Department of Hematology, The Affiliated Hospital of Xuzhou Medical University, Xuzhou, China
| | - Cai Sun
- Department of Hematology, The Affiliated Hospital of Xuzhou Medical University, Xuzhou, China
| | - Ming Shi
- Cancer Institute, Xuzhou Medical University, Xuzhou, China
| | - Jianlin Qiao
- Jiangsu Bone Marrow Stem Cell Institute, Xuzhou, China
| | - Qingyun Wu
- Jiangsu Bone Marrow Stem Cell Institute, Xuzhou, China
| | - Lingyu Zeng
- Jiangsu Bone Marrow Stem Cell Institute, Xuzhou, China
| | - Junnian Zheng
- Cancer Institute, Xuzhou Medical University, Xuzhou, China
| | - Kailin Xu
- Department of Hematology, The Affiliated Hospital of Xuzhou Medical University, Xuzhou, China.
| | - Jiang Cao
- Department of Hematology, The Affiliated Hospital of Xuzhou Medical University, Xuzhou, China.
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Shimony S, Flamand Y, Valtis YK, Place AE, Silverman LB, Vrooman LM, Brunner AM, Sallan SE, Stone RM, Wadleigh M, Neuberg DS, DeAngelo DJ, Luskin MR. Effect of BMI on toxicities and survival among adolescents and young adults treated on DFCI Consortium ALL trials. Blood Adv 2023; 7:5234-5245. [PMID: 37432068 PMCID: PMC10500474 DOI: 10.1182/bloodadvances.2023009976] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Revised: 04/24/2023] [Accepted: 05/16/2023] [Indexed: 07/12/2023] Open
Abstract
Adolescent and young adults (AYAs) with acute lymphoblastic leukemia (ALL) treated with asparaginase-containing pediatric regimens are commonly overweight or obese. We studied the association of body mass index (BMI) on outcomes of 388 AYAs aged 15 to 50 years treated on Dana-Farber Cancer Institute (DFCI) consortium regimens (2008-2021). BMI was normal in 207 (53.3%) and overweight/obese in 181 (46.7%). Patients who were overweight or obese experienced higher nonrelapse mortality (NRM; 4-year, 11.7% vs 2.8%, P = .006), worse event-free survival (4-year, 63% vs 77%, P = .003), and worse overall survival (OS; 4-year, 64% vs 83%, P = .0001). Because younger (aged 15-29 years) AYAs more frequently had a normal BMI (79% vs 20%, P < .0001), we conducted separate analyses in each BMI group. We found excellent OS among younger and older (30-50 years) AYAs with normal BMI (4-year OS, 83% vs 85%, P = .89). Conversely, in AYAs who were overweight/obese, worse outcomes were seen in older AYAs (4-year OS, 55% vs 73%, P = .023). Regarding toxicity, AYAs who were overweight/obese experienced higher rates of grade 3/4 hepatotoxicity and hyperglycemia (60.7% vs 42.2%, P = .0005, and 36.4% vs 24.4%, P = .014, respectively) but had comparable rates of hypertriglyceridemia (29.5% vs 24.4%, P = .29). In a multivariable analysis, higher BMI was associated with worse OS, hypertriglyceridemia was associated with improved OS, and age was not associated with OS. In conclusion, among AYAs treated on DFCI Consortium ALL regimens, elevated BMI was associated with increased toxicity, increased NRM, and decreased OS. The deleterious effect of elevated BMI was more pronounced in older AYAs.
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Affiliation(s)
- Shai Shimony
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
- Hematology Department, Rabin Medical Center and Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Yael Flamand
- Department of Data Science, Dana-Farber Cancer Institute, Boston, MA
| | - Yannis K. Valtis
- Department of Medicine, Memorial Sloan Kettering Cancer Institute, New York, NY
| | - Andrew E. Place
- Department of Pediatric Oncology, Dana-Farber Cancer Institute and Boston Children’s Hospital, Boston, MA
| | - Lewis B. Silverman
- Department of Pediatric Oncology, Dana-Farber Cancer Institute and Boston Children’s Hospital, Boston, MA
| | - Lynda M. Vrooman
- Department of Pediatric Oncology, Dana-Farber Cancer Institute and Boston Children’s Hospital, Boston, MA
| | - Andrew M. Brunner
- Leukemia Department, Hematology/Oncology, Massachusetts General Hospital, Boston, MA
| | - Stephen E. Sallan
- Department of Pediatric Oncology, Dana-Farber Cancer Institute and Boston Children’s Hospital, Boston, MA
| | - Richard M. Stone
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
| | - Martha Wadleigh
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
| | - Donna S. Neuberg
- Department of Data Science, Dana-Farber Cancer Institute, Boston, MA
| | - Daniel J. DeAngelo
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
| | - Marlise R. Luskin
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
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Nyrop KA, Monaco J, Vohra S, Deal AM, Wood WA, Shachar SS, Dees EC, Kimmick GG, Speca JC, Muss HB. Body mass index and patient-reported function, quality of life and treatment toxicity in women receiving adjuvant chemotherapy for breast cancer. Support Care Cancer 2023; 31:196. [PMID: 36859693 DOI: 10.1007/s00520-023-07637-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Accepted: 02/08/2023] [Indexed: 03/03/2023]
Abstract
BACKGROUND This study investigates whether high body mass index (BMI) in women diagnosed with early breast cancer (BC) is associated with patient-reported symptom severity during chemotherapy. METHODS Women with Stage I-III BC completed toxicity reports for 17 side effects throughout regularly scheduled chemotherapy infusions. Toxicity reports were compared in women with obesity (BMI > = 30) versus no obesity (BMI < 30). Fisher's exact tests and 2-sample t-tests compared baseline patient characteristics. Risk ratios (RR) for women with obesity as compared to no obesity were estimated for individual symptoms that were patient-rated as moderate, severe or very severe (MSVS) severity, adjusting for marital status and race. RESULTS In a sample of 286 patients, Black women comprised 23% of the sample. The obesity rate was 76% among Black patients and 31% among White patients (p < .0001). Women with obesity rated an average of 6.9 side effects (standard deviation, SD 4.2) as MSVS vs 5.5 side effects (SD 3.7) among women with no obesity (p = .003). In adjusted analysis, women with obesity had significantly greater risk for MSVS fatigue (RR 1.18, 95% CI 1.01-1.36), dyspnea (RR 1.71, 95% CI 1.09-2.69), arthralgia (RR 1.47, 95% CI 1.10-1.97), peripheral neuropathy (RR 1.45, 95% CI 1.01-2.08), edema of limbs (RR 1.84, 95% CI 1.18-2.88), and abdominal pain (RR 1.75, 95% CI 1.07-2.87). There were no inter-group differences in BC stage or phenotype, chemotherapy treatment modifications, or hospitalizations. CONCLUSIONS Among women with early BC, patients with obesity reported higher chemotherapy toxicity as compared to patients without obesity; however, this did not result in differences in treatment completion.
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Affiliation(s)
- Kirsten A Nyrop
- School of Medicine, Department of Medicine, University of North Carolina at Chapel Hill, 170 Manning Drive, Campus Box 7305, Chapel Hill, NC, 27599-7305, USA.
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, 170 Manning Drive, Campus Box 7305, Chapel Hill, NC, 27599-7305, USA.
| | - Jane Monaco
- Gillings School of Global Public Health, Department of Biostatistics, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Sanah Vohra
- Gillings School of Global Public Health, Department of Biostatistics, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Allison M Deal
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, 170 Manning Drive, Campus Box 7305, Chapel Hill, NC, 27599-7305, USA
| | - William A Wood
- School of Medicine, Department of Medicine, University of North Carolina at Chapel Hill, 170 Manning Drive, Campus Box 7305, Chapel Hill, NC, 27599-7305, USA
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, 170 Manning Drive, Campus Box 7305, Chapel Hill, NC, 27599-7305, USA
| | | | - E Claire Dees
- School of Medicine, Department of Medicine, University of North Carolina at Chapel Hill, 170 Manning Drive, Campus Box 7305, Chapel Hill, NC, 27599-7305, USA
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, 170 Manning Drive, Campus Box 7305, Chapel Hill, NC, 27599-7305, USA
| | | | - JoEllen C Speca
- School of Medicine, Department of Medicine, University of North Carolina at Chapel Hill, 170 Manning Drive, Campus Box 7305, Chapel Hill, NC, 27599-7305, USA
| | - Hyman B Muss
- School of Medicine, Department of Medicine, University of North Carolina at Chapel Hill, 170 Manning Drive, Campus Box 7305, Chapel Hill, NC, 27599-7305, USA
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, 170 Manning Drive, Campus Box 7305, Chapel Hill, NC, 27599-7305, USA
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Lomma C, Chih H, Chan A. Adjuvant Dose Dense Chemotherapy in patients with obesity: short-term toxicities and breast cancer outcome. Clin Breast Cancer 2023:S1526-8209(23)00077-0. [PMID: 37169686 DOI: 10.1016/j.clbc.2023.03.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Revised: 02/03/2023] [Accepted: 03/19/2023] [Indexed: 04/03/2023]
Abstract
BACKGROUND Dose dense adjuvant chemotherapy is associated with improved outcomes in breast cancer compared to standard dosing. Despite current guidelines recommending that chemotherapy is dosed according to actual body weight, reviews have shown patients with obesity often receive a capped chemotherapy dose. The latter is commonly undertaken as clinicians have concerns that adverse events are more frequent if full doses are administered. This study assessed surgical, radiotherapy and chemotherapy related adverse events between patients with and without obesity receiving dose dense adjuvant chemotherapy for breast cancer. MATERIALS AND METHODS A retrospective review of prospective collected data for patients receiving adjuvant chemotherapy from 30 April 2018 from a single institution was analyzed. Data collected included demographic data, height, weight, pathological information, comorbidities, surgical, radiotherapy chemotherapy treatment, and toxicity. Primary outcomes were surgical complications at 30 days, radiotherapy skin toxicity at 30 days and chemotherapy side-effects. Secondary outcomes were rates of recurrence and time to recurrence. RESULTS A total of 280 patients were included in the analysis: 55 obese and 225 nonobese. Obese status was associated with higher rates of grade >2 skin toxicity and this difference was significant after adjusting for age, comorbidity and radiotherapy field (P = .017). Obese status was not associated with higher rates of surgical or chemotherapy related adverse events. All patients regardless of obese status received adequate dose intensity with similar rates of recurrence and time to recurrence. CONCLUSION Patients with obesity who receive dose dense adjuvant chemotherapy do not experience higher rates of surgical or chemotherapy related adverse events although they do experience higher rates of grade >2 radiotherapy related skin toxicity. This supports the use of dose dense chemotherapy being based on actual body weight in patients with obesity.
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Petrella F, Manganaro L, Rizzo S. Editorial: State of the art body composition profiling: Advances in imaging modalities and patient outcomes. Front Oncol 2022; 12:1096671. [PMID: 36544701 PMCID: PMC9761766 DOI: 10.3389/fonc.2022.1096671] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2022] [Accepted: 11/22/2022] [Indexed: 12/09/2022] Open
Affiliation(s)
- Francesco Petrella
- Department of Thoracic Surgery, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) European Institute of Oncology, Milan, Italy,Department of Oncology and Hemato-oncology, University of Milan, Milan, Italy,*Correspondence: Francesco Petrella, ;;
| | - Lucia Manganaro
- Department of Radiological, Oncological and Pathological Sciences, University of Rome Sapienza, Rome, Italy
| | - Stefania Rizzo
- Istituto di Imaging della Svizzera Italiana (IIMSI), Ente Ospedaliero Cantonale (EOC), Lugano, Switzerland,Facoltà di Scienze Biomediche, Università della Svizzera italiana (USI), Lugano, Switzerland
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Arafat Y, Loft M, Cao K, Reid F, Kosmider S, Lee M, Gibbs P, Faragher IG, Yeung JM. Current colorectal cancer chemotherapy dosing limitations and novel assessments to personalize treatments. ANZ J Surg 2022; 92:2784-2785. [PMID: 36398349 PMCID: PMC9827998 DOI: 10.1111/ans.18046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2022] [Accepted: 09/02/2022] [Indexed: 11/19/2022]
Affiliation(s)
- Yasser Arafat
- Department of Colorectal SurgeryWestern HealthMelbourneVictoriaAustralia,Western PrecinctThe University of MelbourneMelbourneVictoriaAustralia
| | - Matthew Loft
- Western PrecinctThe University of MelbourneMelbourneVictoriaAustralia,Department of OncologyWestern HealthMelbourneVictoriaAustralia
| | - Ke Cao
- Western PrecinctThe University of MelbourneMelbourneVictoriaAustralia
| | - Fiona Reid
- Department of Colorectal SurgeryWestern HealthMelbourneVictoriaAustralia,Western PrecinctThe University of MelbourneMelbourneVictoriaAustralia
| | | | - Margret Lee
- Department of OncologyWestern HealthMelbourneVictoriaAustralia,Personalised Oncology DivisionWalter and Eliza Hall Institute of Medical ResearchMelbourneVictoriaAustralia,Consultant Department of Medical OncologyEastern HealthMelbourneVictoriaAustralia
| | - Peter Gibbs
- Western PrecinctThe University of MelbourneMelbourneVictoriaAustralia,Department of OncologyWestern HealthMelbourneVictoriaAustralia,Personalised Oncology DivisionWalter and Eliza Hall Institute of Medical ResearchMelbourneVictoriaAustralia
| | - Ian G. Faragher
- Department of Colorectal SurgeryWestern HealthMelbourneVictoriaAustralia,Western PrecinctThe University of MelbourneMelbourneVictoriaAustralia
| | - Justin M Yeung
- Department of Colorectal SurgeryWestern HealthMelbourneVictoriaAustralia,Western PrecinctThe University of MelbourneMelbourneVictoriaAustralia
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Njoku K, Barr CE, Crosbie EJ. Current and Emerging Prognostic Biomarkers in Endometrial Cancer. Front Oncol 2022; 12:890908. [PMID: 35530346 PMCID: PMC9072738 DOI: 10.3389/fonc.2022.890908] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Accepted: 03/28/2022] [Indexed: 12/19/2022] Open
Abstract
Endometrial cancer is the most common gynaecological malignancy in high income countries and its incidence is rising. Whilst most women with endometrial cancer are diagnosed with highly curable disease and have good outcomes, a significant minority present with adverse clinico-pathological characteristics that herald a poor prognosis. Prognostic biomarkers that reliably select those at greatest risk of disease recurrence and death can guide management strategies to ensure that patients receive appropriate evidence-based and personalised care. The Cancer Genome Atlas substantially advanced our understanding of the molecular diversity of endometrial cancer and informed the development of simplified, pragmatic and cost-effective classifiers with prognostic implications and potential for clinical translation. Several blood-based biomarkers including proteins, metabolites, circulating tumour cells, circulating tumour DNA and inflammatory parameters have also shown promise for endometrial cancer risk assessment. This review provides an update on the established and emerging prognostic biomarkers in endometrial cancer.
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Affiliation(s)
- Kelechi Njoku
- Division of Cancer Sciences, University of Manchester, Manchester, United Kingdom
- Stoller Biomarker Discovery Centre, University of Manchester, Manchester, United Kingdom
- Department of Obstetrics and Gynaecology, St Mary’s Hospital, Manchester, University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, United Kingdom
| | - Chloe E. Barr
- Division of Cancer Sciences, University of Manchester, Manchester, United Kingdom
- Department of Obstetrics and Gynaecology, St Mary’s Hospital, Manchester, University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, United Kingdom
| | - Emma J. Crosbie
- Division of Cancer Sciences, University of Manchester, Manchester, United Kingdom
- Department of Obstetrics and Gynaecology, St Mary’s Hospital, Manchester, University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, United Kingdom
- *Correspondence: Emma J. Crosbie,
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Del Grande M, Rizzo S, Nicolino GM, Colombo I, Rossi L, Manganaro L, Del Grande F. Computed Tomography-Based Body Composition in Patients With Ovarian Cancer: Association With Chemotoxicity and Prognosis. Front Oncol 2021; 11:718815. [PMID: 34868915 PMCID: PMC8634936 DOI: 10.3389/fonc.2021.718815] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Accepted: 10/26/2021] [Indexed: 01/06/2023] Open
Abstract
Purpose To assess the association between computed tomography (CT)-derived quantitative measures of body composition profiling and chemotherapy-related complications, in terms of dose reduction, premature discontinuation of chemotherapy, and cycle delays in patients with ovarian cancer. Secondary purposes were to evaluate associations between sarcopenia and survival, and to evaluate differences in body composition profiling at baseline and after neoadjuvant chemotherapy. Materials and Methods The study population was retrospectively selected from a database of patients with newly diagnosed ovarian cancer (any stage) referred to our Institution between Feb 2011 and Mar 2020. Clinical data were recorded, and CT images at the level of the 3rd lumbar vertebra were stored. By using specific software, skeletal muscle area (SMA), subcutaneous adipose tissue (SAT), visceral adipose tissue (VAT), and skeletal muscle density (SMD) were extracted. Skeletal muscle index (SMI) was then calculated. Statistical analysis was performed by logistic regression models to identify body composition features predictive of dose reduction, premature end of chemotherapy, and cycle delays. Kaplan-Meier analyses were performed to assess overall survival (OS) and progression-free survival (PFS). The log-rank test was used to determine differences in OS and PFS between sarcopenic and non-sarcopenic patients. Wilcoxon test was performed to compare body composition features before and after neoadjuvant chemotherapy (NACT). Results Sixty-nine patients were included. A significant association was found between VAT and cycle delays (OR = 1.01, z = 2.01, 95% CI: 1.00–1.02, p < 0.05), between SMA and early discontinuation of chemotherapy (OR = 1.03, z = 2.10, 95% CI: 1.00–1.05, p < 0.05), and between mean SMD and cycle delays (OR = 0.92, z = −2.70, 95%CI: 0.87–0.98, p < 0.01). No significant difference emerged for OS in sarcopenic and non-sarcopenic patients, nor in CT body composition features before and after NACT. Conclusions In ovarian cancer patients, CT-derived body composition profiling might predict the risk of chemotoxicity. In particular, VAT and SMD are associated with chemotherapy cycle delays, and SMA with early discontinuation of chemotherapy.
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Affiliation(s)
- Maria Del Grande
- Service of Medical Oncology, Oncology Institute of Southern Switzerland, Ente Ospedaliero Cantonale (EOC), Bellinzona, Switzerland
| | - Stefania Rizzo
- Istituto di Imaging della Svizzera Italiana (IIMSI), Ente Ospedaliero Cantonale, Lugano, Switzerland.,Facoltà di Scienze Biomediche, Università della Svizzera Italiana, Lugano, Switzerland
| | | | - Ilaria Colombo
- Service of Medical Oncology, Oncology Institute of Southern Switzerland, Ente Ospedaliero Cantonale (EOC), Bellinzona, Switzerland
| | - Lorenzo Rossi
- Service of Medical Oncology, Oncology Institute of Southern Switzerland, Ente Ospedaliero Cantonale (EOC), Bellinzona, Switzerland
| | - Lucia Manganaro
- Department of Radiological, Oncological and Pathological Sciences, University of Rome Sapienza, Rome, Italy
| | - Filippo Del Grande
- Istituto di Imaging della Svizzera Italiana (IIMSI), Ente Ospedaliero Cantonale, Lugano, Switzerland.,Facoltà di Scienze Biomediche, Università della Svizzera Italiana, Lugano, Switzerland
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11
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Njoku K, Barr CE, Hotchkies L, Quille N, Wan YL, Crosbie EJ. Impact of socio-economic deprivation on endometrial cancer survival in the North West of England: a prospective database analysis. BJOG 2021; 128:1215-1224. [PMID: 33289967 PMCID: PMC8248174 DOI: 10.1111/1471-0528.16618] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/25/2020] [Indexed: 02/06/2023]
Abstract
OBJECTIVE To assess the impact of socio-economic deprivation on endometrial cancer survival. DESIGN Single-centre prospective database study. SETTING North West England. POPULATION Women with endometrial cancer treated between 2010 and 2015. METHODS Areal-level socio-economic status, using the English indices of multiple deprivation from residential postcodes, was analysed in relation to survival using Kaplan-Meier estimation and multivariable Cox regression. MAIN OUTCOME MEASURES Overall survival, cancer-specific survival and patterns and rates of recurrence. RESULTS A total of 539 women, with a median age of 66 years (interquartile range, IQR 56-73 years) and a body mass index (BMI) of 32 kg/m2 (IQR 26-39 kg/m2 ), were included in the analysis. Women in the most deprived social group were younger (median 64 years, IQR 55-72 years) and more obese (median 34 kg/m2 , IQR 28-42 kg/m2 ) than women in the least deprived group (median age 68 years, IQR 60-74 years; BMI 29 kg/m2 , IQR 25-36 kg/m2 ; P = 0.002 and <0.001, respectively). There were no differences in endometrial cancer type, stage or grade between social groups. There was no difference in recurrence rates, however, women in the middle and most deprived social groups were more likely to present with distant/metastatic recurrence (80.6 and 79.2%, respectively) than women in the least deprived group (43.5%, P < 0.001). Women in the middle and most deprived groups had a two-fold (adjusted hazard ratio, HR = 2.00, 95% CI 1.07-3.73, P = 0.030) and 53% (adjusted HR = 1.53, 95% CI 0.77-3.04, P = 0.221) increase in cancer-specific mortality compared with women in the least deprived group. There were no differences in overall survival. CONCLUSIONS We found that socio-economically deprived women with endometrial cancer were more likely to develop fatal recurrence. Larger studies are needed to confirm these findings and to identify modifiable contributing factors. TWEETABLE ABSTRACT Socio-economic deprivation is linked to an increased risk of death from endometrial cancer in the North West of England.
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Affiliation(s)
- K Njoku
- Division of Cancer SciencesSchool of Medical SciencesFaculty of Biology, Medicine and HealthSt Mary’s HospitalUniversity of ManchesterManchesterUK
- Division of Cancer SciencesFaculty of Biology, Medicine and HealthStoller Biomarker Discovery CentreUniversity of ManchesterManchesterUK
- Department of Obstetrics and GynaecologyManchester University NHS Foundation TrustManchester Academic Health Science CentreManchesterUK
| | - CE Barr
- Division of Cancer SciencesSchool of Medical SciencesFaculty of Biology, Medicine and HealthSt Mary’s HospitalUniversity of ManchesterManchesterUK
- Department of Obstetrics and GynaecologyManchester University NHS Foundation TrustManchester Academic Health Science CentreManchesterUK
| | - L Hotchkies
- Division of Cancer SciencesSchool of Medical SciencesFaculty of Biology, Medicine and HealthSt Mary’s HospitalUniversity of ManchesterManchesterUK
| | - N Quille
- Division of Cancer SciencesSchool of Medical SciencesFaculty of Biology, Medicine and HealthSt Mary’s HospitalUniversity of ManchesterManchesterUK
| | - YL Wan
- Division of Cancer SciencesSchool of Medical SciencesFaculty of Biology, Medicine and HealthSt Mary’s HospitalUniversity of ManchesterManchesterUK
- Department of Obstetrics and GynaecologyManchester University NHS Foundation TrustManchester Academic Health Science CentreManchesterUK
| | - EJ Crosbie
- Division of Cancer SciencesSchool of Medical SciencesFaculty of Biology, Medicine and HealthSt Mary’s HospitalUniversity of ManchesterManchesterUK
- Department of Obstetrics and GynaecologyManchester University NHS Foundation TrustManchester Academic Health Science CentreManchesterUK
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12
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Kristensen D, Nielsen LB, Roug AS, Kristensen TCC, Heath A, Jacobsen LH, Nørgaard JM, Jepsen LØ, Schöllkopf C, Theilgaard-Mönch K, Severinsen MT. The prognostic impact of anthropometrics in acute myeloid leukemia treated with intensive chemotherapy - A Danish nationwide cohort study. Leuk Res 2021; 106:106567. [PMID: 33865033 DOI: 10.1016/j.leukres.2021.106567] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Revised: 03/16/2021] [Accepted: 03/18/2021] [Indexed: 01/22/2023]
Affiliation(s)
- Daniel Kristensen
- Department of Hematology, Clinical Cancer Research Center, Aalborg University Hospital, Aalborg, Denmark; Clinical Cancer Research Center, Aalborg University Hospital, Aalborg, Denmark.
| | - Lars Børty Nielsen
- Department of Hematology, Clinical Cancer Research Center, Aalborg University Hospital, Aalborg, Denmark
| | - Anne Stidsholt Roug
- Department of Hematology, Clinical Cancer Research Center, Aalborg University Hospital, Aalborg, Denmark; Clinical Cancer Research Center, Aalborg University Hospital, Aalborg, Denmark; Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | | | - Astrid Heath
- Department of Hematology, Clinical Cancer Research Center, Aalborg University Hospital, Aalborg, Denmark
| | - Lasse Hjort Jacobsen
- Department of Hematology, Clinical Cancer Research Center, Aalborg University Hospital, Aalborg, Denmark; Clinical Cancer Research Center, Aalborg University Hospital, Aalborg, Denmark; Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | | | | | | | - Kim Theilgaard-Mönch
- Department of Hematology, Rigshospitalet, Copenhagen University Hospital, Denmark
| | - Marianne Tang Severinsen
- Department of Hematology, Clinical Cancer Research Center, Aalborg University Hospital, Aalborg, Denmark; Clinical Cancer Research Center, Aalborg University Hospital, Aalborg, Denmark; Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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13
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Yang R, Younis M, Joseph K, Ghosh S, Nijjar T, Severin D, Tankel K, Tamhane Y, Fairchild A, Spratlin J, Mulder K, Usmani N. Impact of dose-capping chemotherapy in concurrent chemoradiotherapy in rectal cancer patients. J Oncol Pharm Pract 2020; 27:1596-1603. [PMID: 33023385 DOI: 10.1177/1078155220962192] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
INTRODUCTION The study evaluated the effect of chemotherapy dose-capping on disease recurrence, toxicity and survival of rectal cancer patients treated with chemoradiotherapy (CRT). METHODS 601 consecutive rectal cancer patients treated with concurrent CRT were retrospectively analysed. Dose-capped patients were defined as having a body surface area (BSA) ≥2.0 m2 and who received <95% full weight-based chemotherapy dose. Binary logistic regression was used to study the factors associated with the outcome variables (capped vs. uncapped). Kaplan-Meier estimation evaluated significant predictors of survival. RESULTS The median follow-up time was 7.54 years. The rate of disease recurrence was significantly higher in dose-capped patients (35%) compared to those without dose-capping (24%, P = 0.016). The adjusted odds ratio for dose-capped patients experiencing recurrence was 1.64 compared to uncapped patients (95% CI, 1.10-2.43). Overall, dose-capped patients were less likely to experience significant toxicity requiring dose reduction and/or treatment break when compared to uncapped patients (15% and 28% respectively, P = 0.008).There was significant differences in PFS between capped and uncapped group (77% vs. 85%; P = 0.017). The 5-year OS in the capped group was 75.0%, and 80% in the uncapped group (P = 0.149). CONCLUSIONS Rectal cancer patients treated with dose-capped CRT were at increased risk of disease recurrence. Patients dosed by actual BSA did experience excessive toxicity compared to dose-capped group. We recommend that chemotherapy dose-capping based on BSA should not be practiced in rectal cancer patients undergoing CRT.
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Affiliation(s)
- Ran Yang
- Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Moftah Younis
- Division of Radiation Oncology, Faculty of Medicine and Dentistry, University of Alberta and Cross Cancer Institute, Edmonton, AB, Canada
| | - Kurian Joseph
- Division of Radiation Oncology, Faculty of Medicine and Dentistry, University of Alberta and Cross Cancer Institute, Edmonton, AB, Canada
| | - Sunita Ghosh
- Division of Medical Oncology, Faculty of Medicine and Dentistry, University of Alberta and Cross Cancer Institute, Edmonton, AB, Canada
| | - Tirath Nijjar
- Division of Radiation Oncology, Faculty of Medicine and Dentistry, University of Alberta and Cross Cancer Institute, Edmonton, AB, Canada
| | - Diane Severin
- Division of Radiation Oncology, Faculty of Medicine and Dentistry, University of Alberta and Cross Cancer Institute, Edmonton, AB, Canada
| | - Keith Tankel
- Division of Radiation Oncology, Faculty of Medicine and Dentistry, University of Alberta and Cross Cancer Institute, Edmonton, AB, Canada
| | - Yash Tamhane
- Division of Radiation Oncology, Faculty of Medicine and Dentistry, University of Alberta and Cross Cancer Institute, Edmonton, AB, Canada
| | - Alysa Fairchild
- Division of Radiation Oncology, Faculty of Medicine and Dentistry, University of Alberta and Cross Cancer Institute, Edmonton, AB, Canada
| | - Jennifer Spratlin
- Division of Medical Oncology, Faculty of Medicine and Dentistry, University of Alberta and Cross Cancer Institute, Edmonton, AB, Canada
| | - Karen Mulder
- Division of Medical Oncology, Faculty of Medicine and Dentistry, University of Alberta and Cross Cancer Institute, Edmonton, AB, Canada
| | - Nawaid Usmani
- Division of Radiation Oncology, Faculty of Medicine and Dentistry, University of Alberta and Cross Cancer Institute, Edmonton, AB, Canada
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14
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Slawinski CGV, Barriuso J, Guo H, Renehan AG. Obesity and Cancer Treatment Outcomes: Interpreting the Complex Evidence. Clin Oncol (R Coll Radiol) 2020; 32:591-608. [PMID: 32595101 DOI: 10.1016/j.clon.2020.05.004] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2019] [Revised: 03/17/2020] [Accepted: 05/07/2020] [Indexed: 02/06/2023]
Abstract
A wealth of epidemiological evidence, combined with plausible biological mechanisms, present a convincing argument for a causal relationship between excess adiposity, commonly approximated as body mass index (BMI, kg/m2), and incident cancer risk. Beyond this relationship, there are a number of challenges posed in the context of interpreting whether being overweight (BMI 25.0-29.9 kg/m2) or obese (BMI ≥ 30.0 kg/m2) adversely influences disease progression, cancer mortality and survival. Elevated BMI (≥ 25.0 kg/m2) may influence treatment selection of, for example, the approach to surgery; the choice of chemotherapy dosing; the inclusion of patients into randomised clinical trials. Furthermore, the technical challenges posed by an elevated BMI may adversely affect surgical outcomes, for example, morbidity (increasing the risk of surgical site infections), reduced lymph node harvest (and subsequent risk of under-staging and under-treatment) and increased risk of margin positivity. Suboptimal chemotherapy dosing, associated with capping chemotherapy in obese patients as an attempt to avoid excess toxicity, might be a driver of poor prognostic outcomes. By contrast, the efficacy of immune checkpoint inhibition may be enhanced in patients who are obese, although in turn, this observation might be due to reverse causality. So, a central research question is whether being overweight or obese adversely affects outcomes either directly through effects of cancer biology or whether adverse outcomes are mediated through indirect pathways. A further dimension to this complex relationship is the obesity paradox, a phenomenon where being overweight or obese is associated with improved survival where the reverse is expected. In this overview, we describe a framework for evaluating methodological problems such as selection bias, confounding and reverse causality, which may contribute to spurious interpretations. Future studies will need to focus on prospective studies with well-considered methodology in order to improve the interpretation of causality.
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Affiliation(s)
- C G V Slawinski
- Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre, University of Manchester, Manchester, UK.
| | - J Barriuso
- Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre, University of Manchester, Manchester, UK
| | - H Guo
- Centre for Biostatistics, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - A G Renehan
- Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre, University of Manchester, Manchester, UK; Colorectal and Peritoneal Oncology Centre, Christie NHS Foundation Trust, Manchester, UK
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15
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Levin G, Meyer R, Dior U, Gilad R, Benshushan A, Shushan A, Rottenstreich A. Outcome of methotrexate treatment for ectopic pregnancies among obese women. J Gynecol Obstet Hum Reprod 2020; 49:101790. [PMID: 32413523 DOI: 10.1016/j.jogoh.2020.101790] [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: 04/02/2020] [Revised: 04/28/2020] [Accepted: 04/29/2020] [Indexed: 10/24/2022]
Abstract
OBJECTIVE Single dose administration of methotrexate (MTX) is considered the first line of treatment in selected patients with an ectopic pregnancy (EP). However, data regarding MTX efficacy among obese patients is limited. We sought to investigate the efficacy of MTX single dose regimen among obese patients MATERIAL AND METHODS: A retrospective cohort study conducted at a gynecology department in a tertiary teaching hospital, between January 2010 and December 2018, including women diagnosed with an EP and treated by a single-dose regimen of MTX. We compared success rate and gestation characteristics between obese and non-obese women. RESULTS Overall, 195 women were treated with single-dose intramuscular MTX for EP during the study period. Of those, 31 women (15.9%) were obese (BMI ≥ 30 kg/m2) and the rest 164 (84.1%) were of normal body weight. Median MTX dosage for the obese group was 95 milligrams (IQR 91-104) vs. 83 milligrams (IQR 78-87) for the non-obese group. Treatment success rate of the overall cohort was 66.6% (130/195) and treatment success rate of single-dose MTX was comparable between the obese and non-obese groups (64.5% vs. 67.0%, p = 0.78). Obese patients were older as compared to non-obese (median age 33 vs. 29, p = 0.03). In multivariate logistic regression analysis, percentage hCG change from day 1 to day 4 was the only factor associated with treatment success (aOR 1.02; 95%CI 1.01, 1.04, p < 0.001). CONCLUSION Single-dose MTX treatment among obese patients diagnosed with ectopic pregnancy led to similar success rates as compared to non-obese patients.
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Affiliation(s)
- Gabriel Levin
- The Department of Obstetrics and Gynecology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Raanan Meyer
- The Department of Obstetrics and Gynecology, the Chaim Sheba Medical Center, Ramat-Gan, Israel.
| | - Uri Dior
- The Department of Obstetrics and Gynecology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Ronit Gilad
- The Department of Obstetrics and Gynecology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Avi Benshushan
- The Department of Obstetrics and Gynecology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Asher Shushan
- The Department of Obstetrics and Gynecology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Amihai Rottenstreich
- The Department of Obstetrics and Gynecology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
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16
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Dhakal P, Lyden E, Lee A, Michalski J, Al-Kadhimi ZS, Maness LJ, Gundabolu K, Bhatt VR. Effects of Obesity on Overall Survival of Adults With Acute Myeloid Leukemia. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2019; 20:e131-e136. [PMID: 32029396 DOI: 10.1016/j.clml.2019.11.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Revised: 10/14/2019] [Accepted: 11/01/2019] [Indexed: 12/23/2022]
Abstract
BACKGROUND The role of obesity in prognosis of acute myeloid leukemia (AML) is debatable. Our retrospective study aimed to determine the effect of obesity on overall survival (OS) in AML. PATIENTS AND METHODS AML patients diagnosed at University of Nebraska Medical Center were divided into 3 groups according to body mass index (BMI): normal (18.5-25 kg/m2) or underweight (< 18.5 kg/m2); overweight (25-30 kg/m2); and obese (≥ 30 kg/m2). Chi-square test, Kruskal-Wallis test, and ANOVA were used to examine the association of BMI with baseline characteristics. Mann-Whitney test was used for pairwise comparisons of hematopoietic cell transplantation (HCT) comorbidity index. Bonferroni correction was used to adjust P values. OS, defined as time from diagnosis to death from any cause, was determined by the Kaplan-Meier method; comparisons of survival curves were done using log-rank test. Cox regression analysis was performed to detect the effect of BMI on OS. RESULTS Of 314 patients, 38% were obese, 68% received intensive chemotherapy, and 30% underwent HCT. Patient characteristics for all BMI groups were similar except greater HCT comorbidity index in obese patients. Actual body weight was used to calculate the chemotherapy dose in 92% of obese patients. The rates of receipt of HCT in normal, overweight, and obese groups were 33%, 32%, and 25%, respectively (P = .6). One-year OS values for normal/underweight, overweight, and obese groups was 42%, 45%, and 39%, respectively (P = .31). On multivariate analysis, obesity was associated with worse OS compared to normal-weight (hazard ratio = 0.6; 95% confidence interval, 0.4-0.9; P = .03) but not overweight patients. CONCLUSION Obesity confers worse prognosis in AML. Differences in OS were not the result of differences in chemotherapy dose or receipt of HCT.
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Affiliation(s)
- Prajwal Dhakal
- Division of Oncology and Hematology, Department of Internal Medicine, University of Nebraska Medical Center, Omaha, NE; Fred and Pamela Buffett Cancer Center, University of Nebraska Medical Center, Omaha, NE.
| | - Elizabeth Lyden
- Department of Biostatics, University of Nebraska Medical Center, Omaha, NE
| | - Andrea Lee
- Division of Oncology and Hematology, Department of Internal Medicine, University of Nebraska Medical Center, Omaha, NE
| | - Joel Michalski
- Division of Oncology and Hematology, Department of Internal Medicine, University of Nebraska Medical Center, Omaha, NE; Fred and Pamela Buffett Cancer Center, University of Nebraska Medical Center, Omaha, NE
| | - Zaid S Al-Kadhimi
- Division of Oncology and Hematology, Department of Internal Medicine, University of Nebraska Medical Center, Omaha, NE; Fred and Pamela Buffett Cancer Center, University of Nebraska Medical Center, Omaha, NE
| | - Lori J Maness
- Division of Oncology and Hematology, Department of Internal Medicine, University of Nebraska Medical Center, Omaha, NE; Fred and Pamela Buffett Cancer Center, University of Nebraska Medical Center, Omaha, NE
| | - Krishna Gundabolu
- Division of Oncology and Hematology, Department of Internal Medicine, University of Nebraska Medical Center, Omaha, NE; Fred and Pamela Buffett Cancer Center, University of Nebraska Medical Center, Omaha, NE
| | - Vijaya Raj Bhatt
- Division of Oncology and Hematology, Department of Internal Medicine, University of Nebraska Medical Center, Omaha, NE; Fred and Pamela Buffett Cancer Center, University of Nebraska Medical Center, Omaha, NE
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17
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Fatal events during clinical trials: an evaluation of deaths during breast cancer studies. Breast Cancer 2019; 26:826-834. [PMID: 31254201 DOI: 10.1007/s12282-019-00990-3] [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: 03/14/2019] [Accepted: 06/14/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND Information on deaths occurring during oncological clinical trials has never been systematically assessed. Here, we examine the incidence of death and the profile of patients who died during randomized clinical breast cancer (BC) trials. METHODS Information on fatal events during German Breast Group (GBG) led BC trials was prospectively captured. Data were derived from the trial databases and death narratives. All deaths were evaluated for possible causes, underlying conditions, treatment relatedness, time point and rate of autopsies. RESULTS From 12/1996 to 01/2017, 23,387 patients were treated within 32 trials. Of those 88 (0.4%) died on therapy within 17 trials. Median age was 64 [range 35-84] years, 63.2% of patients had a body mass index (BMI) ≥ 25 kg/m2; 65.9% 1-3 and 22.7% ≥ 4 comorbidities; 61.4% 1-2 cardiovascular risk factors (CRFs); 26.4% took > 3 drugs; 81.7% had ECOG 0; 50.0% stage III, 76.7% luminal BC. The main causes of death were infection (38.6%; of those, 82.3% sepsis, 17.6% pneumonia), heart failure (14.8%), and pulmonary embolism (13.6%). Fatal events mainly occurred within the first 4 therapy cycles (55.7%), in the investigational arm (66.7%) and under anthracycline-taxane-based chemotherapy (51.1%). A relationship with the treatment was declared in 27.3% of the cases. An autopsy was performed in 13.6% of patients. CONCLUSIONS Death during study treatment was mainly related to infections, and patients with advanced disease, high BMI, underlying comorbidities, CRFs and concomitant medications. If considered for study participation these patients need careful monitoring due to their higher risk for death on study.
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18
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Ross KH, Gogineni K, Subhedar PD, Lin JY, McCullough LE. Obesity and cancer treatment efficacy: Existing challenges and opportunities. Cancer 2019; 125:1588-1592. [PMID: 30633328 DOI: 10.1002/cncr.31976] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2018] [Revised: 12/11/2018] [Accepted: 12/12/2018] [Indexed: 01/22/2023]
Affiliation(s)
- Katherine H Ross
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Keerthi Gogineni
- Department of Medical Oncology, School of Medicine, Emory University, Atlanta, Georgia.,Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Preeti D Subhedar
- Winship Cancer Institute, Emory University, Atlanta, Georgia.,Department of Surgery, School of Medicine, Emory University, Atlanta, Georgia
| | - Jolinta Y Lin
- Winship Cancer Institute, Emory University, Atlanta, Georgia.,Department of Radiation Oncology, School of Medicine, Emory University, Atlanta, Georgia
| | - Lauren E McCullough
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia.,Winship Cancer Institute, Emory University, Atlanta, Georgia
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19
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Hilmi M, Jouinot A, Burns R, Pigneur F, Mounier R, Gondin J, Neuzillet C, Goldwasser F. Body composition and sarcopenia: The next-generation of personalized oncology and pharmacology? Pharmacol Ther 2018; 196:135-159. [PMID: 30521882 DOI: 10.1016/j.pharmthera.2018.12.003] [Citation(s) in RCA: 95] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Body composition has gained increasing attention in oncology in recent years due to fact that sarcopenia has been revealed to be a strong prognostic indicator for survival across multiple stages and cancer types and a predictive factor for toxicity and surgery complications. Accumulating evidence over the last decade has unraveled the "pharmacology" of sarcopenia. Lean body mass may be more relevant to define drug dosing than the "classical" body surface area or flat-fixed dosing in patients with cancer. Since sarcopenia has a major impact on patient survival and quality of life, therapeutic interventions aiming at reducing muscle loss have been developed and are being prospectively evaluated in randomized controlled trials. It is now acknowledged that this supportive care dimension of oncological management is essential to ensure the success of any anticancer treatment. The field of sarcopenia and body composition in cancer is developing quickly, with (i) the newly identified concept of sarcopenic obesity defined as a specific pathophysiological entity, (ii) unsolved issues regarding the best evaluation modalities and cut-off for definition of sarcopenia on imaging, (iii) first results from clinical trials evaluating physical activity, and (iv) emerging body-composition-tailored drug administration schemes. In this context, we propose a comprehensive review providing a panoramic approach of the clinical, pharmacological and therapeutic implications of sarcopenia and body composition in oncology.
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Affiliation(s)
- Marc Hilmi
- Department of Medical Oncology, CAncer Research for PErsonalized Medicine (CARPEM), Paris Centre Teaching Hospitals, Paris Descartes University, USPC, Paris, France
| | - Anne Jouinot
- Department of Medical Oncology, CAncer Research for PErsonalized Medicine (CARPEM), Paris Centre Teaching Hospitals, Paris Descartes University, USPC, Paris, France
| | - Robert Burns
- Department of Radiology, Henri Mondor University Hospital, Créteil, France
| | - Frédéric Pigneur
- Department of Radiology, Henri Mondor University Hospital, Créteil, France
| | - Rémi Mounier
- Institut NeuroMyoGène (INMG) CNRS 5310 - INSERM U1217 - UCBL, Lyon, France
| | - Julien Gondin
- Institut NeuroMyoGène (INMG) CNRS 5310 - INSERM U1217 - UCBL, Lyon, France
| | - Cindy Neuzillet
- Department of Medical Oncology, Curie Institute, Versailles Saint-Quentin University, Saint-Cloud, France, and GERCOR group, Paris, France.
| | - François Goldwasser
- Department of Medical Oncology, CAncer Research for PErsonalized Medicine (CARPEM), Paris Centre Teaching Hospitals, Paris Descartes University, USPC, Paris, France
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20
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Toso E, Peyracchia M, Matta M, D'Ascenzo F, Gaita F, Kornej J, Hindricks G, Jared Bunch T, Saliba W. Incidence of thromboembolic events following atrial fibrillation catheter ablation and rate control strategies according to the kind of oral anticoagulation: A systematic review and meta-analysis. Int J Cardiol 2018; 270:172-179. [PMID: 29945808 DOI: 10.1016/j.ijcard.2018.06.082] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2018] [Revised: 05/28/2018] [Accepted: 06/18/2018] [Indexed: 11/18/2022]
Abstract
INTRODUCTION Anticoagulantion therapy (OAT) represents the cornerstone to reduce thromboembolic events for atrial fibrillation (AF). Recent studies suggest that AF catheter ablation on top of OAT may be useful to further reduce the thromboembolic risk in AF patients. The aim of the present study is to compare the long-term risk of thromboembolic events and treatment-related complications in patients with AF treated by OAT strategies and catheter ablation. METHODS Pubmed, Cochrane and Google Scholar were searched for studies including >500 patients evaluating AF patients treated with OAT (VKA: vitamin K antagonist or DOAC: Direct oral anticoagulants) and/or AF ablation. Pooled incidence of stroke/year was the primary end point, while that of stroke, of all cause bleeding and of major bleeding the secondary ones. All the analyses were stratified according to the CHADS2 score of included patients. RESULTS Overall, 27 studies were selected, including 50,973 patients in the AF catheter ablation group; 281,595 patients in the VKA group; 54,811 patients in the DOAC group. After a mean follow-up of 2.4 (1.5-3.8) years, the overall incidence of stroke and thromboembolic events was 0.63 per 100 patients/year in AF ablation group, 2.09 per 100 patients/year in VKA group and 1.24 per 100 patients/year in DOAC group (p < 0.001). After stratification in 4 groups according to CHADS2 score, the incidence of thromboembolic events remained lower in patients included in the AF ablation, followed by DOAC and VKA respectively (p < 0.001), for each CHADS2 cluster. Both the incidence of all cause bleedings and major bleedings resulted lower in AF ablation group (p < 0.001). The incidence of all-cause mortality in the AF ablation group was significant lower than in the group of OAT (p < 0.0001). CONCLUSION AF catheter ablation significantly reduces the incidence of long-term thromboembolic events compared to both VKA and DOAC. This reduction is maintained in all CHADS2 score clusters and is strengthened by the concomitant reduction in hemorrhagic complications provided by AF ablation.
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Affiliation(s)
- Elisabetta Toso
- Division of Cardiology, Department of Medical Sciences, Città della salute e della scienza, University of Turin, Turin, Italy.
| | - Mattia Peyracchia
- Division of Cardiology, Department of Medical Sciences, Città della salute e della scienza, University of Turin, Turin, Italy
| | - Mario Matta
- Division of Cardiology, Department of Medical Sciences, Città della salute e della scienza, University of Turin, Turin, Italy
| | - Fabrizio D'Ascenzo
- Division of Cardiology, Department of Medical Sciences, Città della salute e della scienza, University of Turin, Turin, Italy.
| | - Fiorenzo Gaita
- Division of Cardiology, Department of Medical Sciences, Città della salute e della scienza, University of Turin, Turin, Italy.
| | - Jelena Kornej
- Department of Electrophysiology, Heart Center Leipzig, University of Leipzig, Germany
| | - Gerhard Hindricks
- Department of Electrophysiology, Heart Center Leipzig, University of Leipzig, Germany
| | - Thomas Jared Bunch
- Heart Rhythm Services, Intermountain Medical Center Heart Institute, Murray, UT, USA
| | - Walid Saliba
- Translational Epidemiology Unit, Department of Community Medicine and Epidemiology, Carmel Medical Center, Haifa, Israel
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Moore AH, Trentham-Dietz A, Burns M, Gangnon RE, Greenberg CC, Vanness DJ, Hampton J, Wu XC, Anderson RT, Lipscomb J, Kimmick GG, Cress R, Wilson JF, Sabatino SA, Fleming ST. Obesity and mortality after locoregional breast cancer diagnosis. Breast Cancer Res Treat 2018; 172:647-657. [PMID: 30159788 DOI: 10.1007/s10549-018-4932-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2018] [Accepted: 08/20/2018] [Indexed: 12/01/2022]
Abstract
PURPOSE Higher mortality after a breast cancer diagnosis has been observed among women who are obese. We investigated the relationships between body mass index (BMI) and all-cause or breast cancer-specific mortality after a diagnosis of locoregional breast cancer. METHODS Women diagnosed in 2004 with AJCC Stage I, II, or III breast cancer (n = 5394) were identified from a population-based National Program of Cancer Registries (NPCR) patterns of care study (POC-BP) drawing from registries in seven U.S. states. Differences in overall and breast cancer-specific mortality were investigated using Cox proportional hazards regression models adjusting for demographic and clinical covariates, including age- and stage-based subgroup analyses. RESULTS In women 70 or older, higher BMI was associated with lower overall mortality (HR for a 5 kg/m2 difference in BMI = 0.85, 95% CI 0.75-0.95). There was no significant association between BMI and overall mortality for women under 70. BMI was not associated with breast cancer death in the full sample, but among women with Stage I disease; those in the highest BMI category had significantly higher breast cancer mortality (HR for BMI ≥ 35 kg/m2 vs. 18.5-24.9 kg/m2 = 4.74, 95% CI 1.78-12.59). CONCLUSIONS Contrary to our hypothesis, greater BMI was not associated with higher overall mortality. Among older women, BMI was inversely related to overall mortality, with a null association among younger women. Higher BMI was associated with breast cancer mortality among women with Stage I disease, but not among women with more advanced disease.
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Affiliation(s)
- A Holliston Moore
- Department of Population Health Sciences, University of Wisconsin, Madison, WI, USA. .,University of Wisconsin, 307 WARF Building, 610 Walnut St, Madison, WI, 53726, USA. .,Smith Cardiovascular Research Building, University of California San Francisco, 555 Mission Bay Blvd S, Suite 161, San Francisco, CA, 94158, USA.
| | - Amy Trentham-Dietz
- Department of Population Health Sciences, University of Wisconsin, Madison, WI, USA.,University of Wisconsin Paul P. Carbone Comprehensive Cancer Center, Madison, WI, USA
| | - Marguerite Burns
- Department of Population Health Sciences, University of Wisconsin, Madison, WI, USA
| | - Ronald E Gangnon
- Department of Population Health Sciences, University of Wisconsin, Madison, WI, USA.,Department of Biostatistics and Medical Informatics, University of Wisconsin, Madison, WI, USA
| | - Caprice C Greenberg
- Department of Surgery, University of Wisconsin, Madison, WI, USA.,University of Wisconsin Paul P. Carbone Comprehensive Cancer Center, Madison, WI, USA
| | - David J Vanness
- Department of Health Policy and Administration, The Pennsylvania State University, University Park, PA, USA
| | - John Hampton
- University of Wisconsin Paul P. Carbone Comprehensive Cancer Center, Madison, WI, USA
| | - Xiao-Cheng Wu
- Louisiana State University Health Sciences Center, New Orleans, LA, USA
| | - Roger T Anderson
- University of Virginia School of Medicine, Charlottesville, VA, USA
| | - Joseph Lipscomb
- Rollins School of Public Health and Winship Cancer Institute, Emory University, Atlanta, GA, USA
| | | | - Rosemary Cress
- Public Health Institute, Cancer Registry of Greater California, Sacramento, USA
| | | | | | - Steven T Fleming
- University of Kentucky College of Public Health, Lexington, KY, USA
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22
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Abstract
High BMI is associated with an increased risk of breast cancer in post-menopausal women but poorer outcomes in all age groups. The underlying mechanism is likely to be multi-factorial. Patients with a high BMI may present later due to body habitus. Some studies have also indicated an increased incidence of biologically adverse features, including a higher frequency of oestrogen receptor (ER negative) tumours, in obese patients. Obese patients have a higher frequency of surgical complications, potentially delaying systemic therapies, and reports suggest that chemotherapy and endocrine therapy are less effective in patients with BMI ≥30 kg/m2.High BMI is generally interpreted as excess adiposity and a World Cancer Research Fund report judged that the associations between BMI and incidence of breast cancer were due to body fatness. However, BMI cannot distinguish lean mass from fat mass, or characterise body fat distribution. Most chemotherapy drugs are dosed according to calculated body surface area (BSA). Patients with a similar BSA or BMI may have wide variations in their distribution of adipose tissue and skeletal muscle (body composition); however, few studies have looked at the effect of this on chemotherapy tolerance or effectiveness. Finally, adjuvant treatments for breast cancer can themselves result in body composition changes.Research is required to fully understand the biological mechanisms by which obesity influences cancer behaviour and the impact of obesity on treatment effectiveness and tolerance so that specific management strategies can be developed to improve the prognosis of this patient group.
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23
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Jin WH, Mellon EA, Frakes JM, Murimwa GZ, Hodul PJ, Pimiento JM, Malafa MP, Hoffe SE. Impact of sarcopenia in borderline resectable and locally advanced pancreatic cancer patients receiving stereotactic body radiation therapy. J Gastrointest Oncol 2018; 9:24-34. [PMID: 29564168 DOI: 10.21037/jgo.2017.09.13] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Background Total psoas area (TPA), a marker of sarcopenia, has been used as an independent predictor of clinical outcomes in gastrointestinal (GI) cancers as a proxy for frailty and nutritional status. Our study aimed to evaluate whether TPA, in contrast to traditional measurements of nutrition like body mass index (BMI) and body surface area (BSA), was predictive of outcomes in borderline resectable pancreatic cancer (BRPC) and locally advanced pancreatic cancer (LAPC) patients receiving stereotactic body radiation therapy (SBRT). Methods Retrospective analysis of an institutional review board approved database of 222 BRPC and LAPC treated with SBRT from 2009-2016 yielded 183 patients that met our selection criteria of pre-SBRT computed tomography (CT) imaging with an identifiable L4 vertebra. Once the L4 vertebral level was identified, the bilateral psoas muscles were manually contoured. This area was normalized by patient height, with units described in mm2/m2. Receiver operating characteristic (ROC) curves were generated for TPA, BMI, and BSA to elicit clinically relevant cutoffs. Regression and Kaplan-Meier analyses were used to correlate toxicity with survival functions. Results Low TPA (OR =1.903, P=0.036) was predictive of acute toxicities, and only TPA was predictive of Grade 3 or higher acute toxicities (OR =10.24, P=0.007). Both findings were independent of tumor resectability. Pain (P=0.003), fatigue (P=0.040), and nausea (P=0.039) were significantly associated with low TPA. No association was identified between any measurement of nutritional status and the development of late toxicities, overall survival, local progression or local recurrence. However, BRPC patients survived longer (median =21.98 months) than their LAPC (median =16.2 months) counterparts (P=0.002), independent of nutritional status. Conclusions TPA measurement is readily available and more specific than BMI or BSA as a predictor of acute radiotoxic complications following SBRT in BRPC/LAPC patients. A TPA of <500 mm2/m2 is a clinically relevant cutoff that can direct physicians to address expected complications of pain, fatigue, and nausea. However, tumor resectability remains as the only predictor of overall survival in this cohort.
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Affiliation(s)
- William H Jin
- University of South Florida Morsani College of Medicine, Tampa, FL, USA.,Moffitt Cancer Center, Tampa, FL, USA
| | | | | | - Gilbert Z Murimwa
- University of South Florida Morsani College of Medicine, Tampa, FL, USA.,Moffitt Cancer Center, Tampa, FL, USA
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24
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Creation and evaluation of a cancer chemotherapy order review guide for use at a community hospital. J Oncol Pharm Pract 2017; 25:25-43. [DOI: 10.1177/1078155217726162] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The proper evaluation of cancer chemotherapy orders is necessary for patients to receive safe and effective treatment. The chemotherapy treatment setting is evolving resulting in hospital pharmacists without extensive oncology training or experience now being responsible for evaluation of chemotherapy orders. The primary objective was to create a step-by-step chemotherapy order evaluation guide with a detailed explanation for each step. The secondary objective was to evaluate non-oncology trained pharmacists' ability to accurately review simulated chemotherapy orders post-education using the guide. A two-page chemotherapy order evaluation guide was created based on an accepted method of chemotherapy order review consisting of the following eight steps: regimen verification, clinical trial protocol verification, body surface area calculation, dose calculation, laboratory values, emesis prophylaxis, adjunctive or supportive care measures, and pharmacy labels. A literature search was performed for each step. A detailed explanation for each step was written as a separate component from the guide to encompass the literature search information and current guidelines in a more comprehensive manner. Non-oncology trained community hospital pharmacists were educated on use of the guide for approximately 30 min. The guide was evaluated using timed simulated chemotherapy orders pre- and post-education consisting of a general chemotherapy order and a carboplatin dosing order. Nineteen pharmacists were tested with simulated chemotherapy orders. A significant difference was detected between the pre- and post-education for both the general chemotherapy (p = 0.00032) order and carboplatin dosing order (p = 0.031).
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25
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Xu X, Zhang Q, Hu G, Zhuang Q, Xing C, Shi Y, Liang B, Shen Z, Jiang S, Yu K, Feng J. Effect of initial body mass index on survival outcome of patients with myelodysplastic syndrome: a single-center retrospective study. Leuk Lymphoma 2017; 59:129-137. [PMID: 28573898 DOI: 10.1080/10428194.2017.1330477] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
- Xi Xu
- Division of Hematology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, PR China
| | - Qianying Zhang
- Division of Hematology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, PR China
| | - Gang Hu
- Division of Hematology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, PR China
| | - Qiang Zhuang
- Division of Hematology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, PR China
| | - Chongyun Xing
- Division of Hematology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, PR China
| | - Yifen Shi
- Division of Hematology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, PR China
| | - Bin Liang
- Division of Hematology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, PR China
| | - Zhijian Shen
- Division of Hematology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, PR China
| | - Songfu Jiang
- Division of Hematology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, PR China
| | - Kang Yu
- Division of Hematology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, PR China
| | - Jianhua Feng
- Division of Hematology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, PR China
- Division of Pediatric Hematology-Oncology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, PR China
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26
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Farr A, Stolz M, Baumann L, Bago-Horvath Z, Oppolzer E, Pfeiler G, Seifert M, Singer CF. The effect of obesity on pathological complete response and survival in breast cancer patients receiving uncapped doses of neoadjuvant anthracycline-taxane-based chemotherapy. Breast 2017; 33:153-158. [DOI: 10.1016/j.breast.2017.04.001] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2017] [Revised: 04/03/2017] [Accepted: 04/04/2017] [Indexed: 11/16/2022] Open
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27
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Renehan AG, Harvie M, Cutress RI, Leitzmann M, Pischon T, Howell S, Howell A. How to Manage the Obese Patient With Cancer. J Clin Oncol 2016; 34:4284-4294. [DOI: 10.1200/jco.2016.69.1899] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Purpose Obesity (body mass index [BMI] ≥ 30 kg/m2) is common among patients with cancer. We reviewed management issues in the obese patient with cancer, focusing on how obesity influences treatment selection (including chemotherapy dosing), affects chemotherapy toxicity and surgical complications, and might be a treatment effect modifier. Methods The majority of evidence is drawn from observational studies and secondary analyses of trial data, typically analyzed in N × 3 BMI categories (normal weight, overweight, and obese) matrix structures. We propose a methodological framework for interpretation focusing on sample size and composition, nonlinearity, and unmeasured confounding. Results There is a common perception that obesity is associated with increased treatment-related toxicity. Accordingly, cytotoxic chemotherapy dose reduction is common in patients with elevated BMI. Contrary to this, there is some evidence that full dosing in obese patients does not result in increased toxicity. However, these data are from a limited number of regimens, and fail to fully capture cytotoxic drug pharmacodynamics and pharmacokinetic variability in obese patients. Among patients undergoing surgery, there is evidence that elevated BMI is associated with increased perioperative mortality and increased rates of infectious complications. A novel finding is that these relationships hold after surgery for malignancy, but not for benign indications. There are biologic plausibilities that obesity might be an effect modifier of treatment, but supporting evidence from clinical studies is inconsistent. Conclusion In line with the ASCO 2012 guidelines, chemotherapy dosing is probably best performed using actual body weight in obese patients. However, specific regimens known to be associated with increased toxicity in this group should be used with caution. There is no guidance on dose for obese patients treated with biologic agents. Currently, there are no specific recommendations for the surgical management of the obese patient with cancer.
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Affiliation(s)
- Andrew G. Renehan
- Andrew G. Renehan, Sacha Howell, and Anthony Howell, University of Manchester; Michelle Harvie and Anthony Howell, University Hospital of South Manchester NHS Foundation Trust, Manchester; Ramsey I. Cutress, University Hospitals Southampton; Ramsey I. Cutress, University of Southampton, Southampton, United Kingdom; Michael Leitzmann, University of Regensburg, Regensburg; and Tobias Pischon, Max Delbrück Center for Molecular Medicine (MDC), Berlin-Buch, Germany
| | - Michelle Harvie
- Andrew G. Renehan, Sacha Howell, and Anthony Howell, University of Manchester; Michelle Harvie and Anthony Howell, University Hospital of South Manchester NHS Foundation Trust, Manchester; Ramsey I. Cutress, University Hospitals Southampton; Ramsey I. Cutress, University of Southampton, Southampton, United Kingdom; Michael Leitzmann, University of Regensburg, Regensburg; and Tobias Pischon, Max Delbrück Center for Molecular Medicine (MDC), Berlin-Buch, Germany
| | - Ramsey I. Cutress
- Andrew G. Renehan, Sacha Howell, and Anthony Howell, University of Manchester; Michelle Harvie and Anthony Howell, University Hospital of South Manchester NHS Foundation Trust, Manchester; Ramsey I. Cutress, University Hospitals Southampton; Ramsey I. Cutress, University of Southampton, Southampton, United Kingdom; Michael Leitzmann, University of Regensburg, Regensburg; and Tobias Pischon, Max Delbrück Center for Molecular Medicine (MDC), Berlin-Buch, Germany
| | - Michael Leitzmann
- Andrew G. Renehan, Sacha Howell, and Anthony Howell, University of Manchester; Michelle Harvie and Anthony Howell, University Hospital of South Manchester NHS Foundation Trust, Manchester; Ramsey I. Cutress, University Hospitals Southampton; Ramsey I. Cutress, University of Southampton, Southampton, United Kingdom; Michael Leitzmann, University of Regensburg, Regensburg; and Tobias Pischon, Max Delbrück Center for Molecular Medicine (MDC), Berlin-Buch, Germany
| | - Tobias Pischon
- Andrew G. Renehan, Sacha Howell, and Anthony Howell, University of Manchester; Michelle Harvie and Anthony Howell, University Hospital of South Manchester NHS Foundation Trust, Manchester; Ramsey I. Cutress, University Hospitals Southampton; Ramsey I. Cutress, University of Southampton, Southampton, United Kingdom; Michael Leitzmann, University of Regensburg, Regensburg; and Tobias Pischon, Max Delbrück Center for Molecular Medicine (MDC), Berlin-Buch, Germany
| | - Sacha Howell
- Andrew G. Renehan, Sacha Howell, and Anthony Howell, University of Manchester; Michelle Harvie and Anthony Howell, University Hospital of South Manchester NHS Foundation Trust, Manchester; Ramsey I. Cutress, University Hospitals Southampton; Ramsey I. Cutress, University of Southampton, Southampton, United Kingdom; Michael Leitzmann, University of Regensburg, Regensburg; and Tobias Pischon, Max Delbrück Center for Molecular Medicine (MDC), Berlin-Buch, Germany
| | - Anthony Howell
- Andrew G. Renehan, Sacha Howell, and Anthony Howell, University of Manchester; Michelle Harvie and Anthony Howell, University Hospital of South Manchester NHS Foundation Trust, Manchester; Ramsey I. Cutress, University Hospitals Southampton; Ramsey I. Cutress, University of Southampton, Southampton, United Kingdom; Michael Leitzmann, University of Regensburg, Regensburg; and Tobias Pischon, Max Delbrück Center for Molecular Medicine (MDC), Berlin-Buch, Germany
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Machado KK, Fader AN. Approaches to Morbidly Obese Women with Gynecologic Cancer. CURRENT OBSTETRICS AND GYNECOLOGY REPORTS 2016. [DOI: 10.1007/s13669-016-0181-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Abstract
Measures of body weight and anthropometrics such as body mass index (BMI) are commonly used to assess nutritional status in clinical conditions including cancer. Extensive research has evaluated associations between body weight and prognosis in ovarian cancer patients, yet little is known about the potential impact of body composition (fat mass (FM) and fat-free mass (FFM)) in these patients. Thus, the purpose of this publication was to review the literature (using PubMed and EMBASE) evaluating the impact of body weight and particularly body composition on surgical complications, morbidity, chemotherapy dosing and toxicity (as predictors of prognosis), and survival in ovarian cancer patients. Body weight is rarely associated with intra-operative complications, but obesity predicts higher rates of venous thromboembolism and wound complications post-operatively in ovarian cancer patients. Low levels of FM and FFM are superior predictors of length of hospital stay compared to measures of body weight alone, but the role of body composition on other surgical morbidities is unknown. Obesity complicates chemotherapy dosing due to altered pharmacokinetics, imprecise dosing strategies, and wide variability in FM and FFM. Measurement of body composition has the potential to reduce toxicity if the results are incorporated into chemotherapy dosing calculations. Some findings suggest that excess body weight adversely affects survival, while others find no such association. Limited studies indicate that FM is a better predictor of survival than body weight in ovarian cancer patients, but the direction of this relationship has not been determined. In conclusion, body composition as an indicator of nutritional status is a better prognostic tool than body weight or BMI alone in ovarian cancer patients.
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30
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Furlanetto J, Eiermann W, Marmé F, Reimer T, Reinisch M, Schmatloch S, Stickeler E, Thomssen C, Untch M, Denkert C, von Minckwitz G, Lederer B, Nekljudova V, Weber K, Loibl S, Möbus V. Higher rate of severe toxicities in obese patients receiving dose-dense (dd) chemotherapy according to unadjusted body surface area: results of the prospectively randomized GAIN study. Ann Oncol 2016; 27:2053-2059. [DOI: 10.1093/annonc/mdw315] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2016] [Accepted: 07/28/2016] [Indexed: 12/14/2022] Open
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Elevated expression of chemokine C-C ligand 2 in stroma is associated with recurrent basal-like breast cancers. Mod Pathol 2016; 29:810-23. [PMID: 27125354 DOI: 10.1038/modpathol.2016.78] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2015] [Revised: 03/10/2016] [Accepted: 03/12/2016] [Indexed: 12/31/2022]
Abstract
Despite advances in treatment, up to 30% of breast cancer patients experience disease recurrence accompanied by more aggressive disease and poorer prognosis. Treatment of breast cancer is complicated by the presence of multiple breast cancer subtypes, including: luminal, Her2 overexpressing, and aggressive basal-like breast cancers. Identifying new biomarkers specific to breast cancer subtypes could enhance the prediction of patient prognosis and contribute to improved treatment strategies. The microenvironment influences breast cancer progression through expression of growth factors, angiogenic factors and other soluble proteins. In particular, chemokine C-C ligand 2 (CCL2) regulates macrophage recruitment to primary tumors and signals to cancer cells to promote breast tumor progression. Here we employed a software-based approach to evaluate the prognostic significance of CCL2 protein expression in breast cancer subtypes in relation to its expression in the epithelium or stroma or in relation to fibroblast-specific protein 1 (Fsp1), a mesenchymal marker. Immunohistochemistry analysis of tissue microarrays revealed that CCL2 significantly correlated with Fsp1 expression in the stroma and tumor epithelium of invasive ductal carcinoma. In the overall cohort of invasive ductal carcinomas (n=427), CCL2 and Fsp1 expression in whole tissues, stroma and epithelium were inversely associated with cancer stage and tumor size. When factoring in molecular subtype, stromal CCL2 was observed to be most highly expressed in basal-like breast cancers. By Cox regression modeling, stromal CCL2, but not epithelial CCL2, expression was significantly associated with decreased recurrence-free survival. Furthermore, stromal CCL2 (HR=7.51 P=0.007) was associated with a greater hazard than cancer stage (HR=2.45, P=0.048) in multivariate analysis. These studies indicate that stromal CCL2 is associated with decreased recurrence-free survival in patients with basal-like breast cancer, with important implications on the use of stromal markers for predicting patient prognosis.
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33
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Karatas F, Erdem GU, Sahin S, Aytekin A, Yuce D, Sever AR, Babacan T, Ates O, Ozisik Y, Altundag K. Obesity is an independent prognostic factor of decreased pathological complete response to neoadjuvant chemotherapy in breast cancer patients. Breast 2016; 32:237-244. [PMID: 27318645 DOI: 10.1016/j.breast.2016.05.013] [Citation(s) in RCA: 59] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2016] [Revised: 05/25/2016] [Accepted: 05/31/2016] [Indexed: 11/30/2022] Open
Abstract
PURPOSE The relation between higher body mass index (BMI) and pathological complete response (pCR) to neoadjuvant chemotherapy (NAC) in breast cancer (BC) is a controversial issue according to the data of Western and Asian patients. The aim of this study is to evaluate BMI and pCR to NAC and discuss the importance of pCR outcomes in Turkish BC patients as a bridging country between Europe and Asia. PATIENTS AND METHODS Of the 4423 BC patients diagnosed between the years 1994 and 2015 in Hacettepe University Cancer Institute, 295 female patients with stage II and III BC were enrolled in the study. Three different group divisions were done according to patients' BMI as normal or underweight (N/U) patients (BMI <25 kg/m2), overweight (OW) patients (BMI = 25-29.9 kg/m2) and obese (OB) patients (BMI ≥30 kg/m2). BC subtypes were defined as luminal-like (ER/PR-positive and HER2-negative), HER2/luminal (ER/PR-positive and HER2-positive), HER2-type (ER/PR-negative and HER2-positive), and triple-negative (TNBC; ER/PR- and HER2-negative). The analysis of overall survival (OS) and recurrence-free survival (RFS) was performed according to Kaplan-Meier method. The Log-rank test was used to compare the subgroup analysis and logistic regression analysis to determine the independent prognostic factors. RESULTS In this study, a total number of 93 (31.5%) patients were N/U, 107 (36.3%) patients were OW and 95 (32.2%) patients were OB. Among groups, except for the age, no baseline clinicopathological differences were found. In 70 (23.7%) patients, pCR was achieved. pCR rates in N/U, OW and OB were 31.2%, 22.4%, and 17.9% respectively, showing a considerable trend towards significance (P = 0.09 in chi-square test). In the multivariate logistic regression analysis, obesity was an independent adverse prognostic feature on pCR to NAC compared to N/U patients (OR, 0.34; 95% CI, 0.13 to 0.85, P = 0.02). The recurrence rates were slightly increased with the increase of BMI (N/U = 24.7%, OW = 29.0% and OB = 40%; P = 0.06 respectively). Median RFS was significantly higher in N/U group compared to OB patients (150 vs. 76 months respectively, P = 0.03) and was also higher in pCR group compared to non-pCR patients (151 vs. 77 months P = 0.004). Median OS was significantly higher in N/U patients compared to OB patients (N/U = not reached, OW = 211 and OB = 114 months; P = 0.01) and was also higher in pCR group compared to non-pCR patients (not reached vs. 211 months P = 0.04). In Cox regression analysis; pCR, histopathological grade and TNBC were found as independent prognostic factors on OS (HR, 0.29; 95% CI, 0.11 to 0.79, P = 0.015, HR, 2.09; 95% CI, 1.14 to 3.83, P = 0.017, HR, 1.95; 95% CI, 1.01 to 3.77, P = 0.046, respectively). CONCLUSION It was observed that obesity was an important independent prognostic factor which has an adverse effect on pCR. Moreover it causes decreasing RFS and OS in BC patients who had received NAC. The probability of inefficient treatment in obese patients should be considered.
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Affiliation(s)
- Fatih Karatas
- Diskapi Yildirim Beyazit Education and Training Hospital, Department of Medical Oncology, Ankara, Turkey
| | - Gokmen Umut Erdem
- Ankara Numune Education and Training Hospital, Department of Medical Oncology, Ankara, Turkey
| | - Suleyman Sahin
- Diskapi Yildirim Beyazit Education and Training Hospital, Department of Medical Oncology, Ankara, Turkey
| | - Aydin Aytekin
- Gazi University Faculty of Medicine, Department of Medical Oncology, Ankara, Turkey
| | - Deniz Yuce
- Hacettepe University Faculty of Medicine, Department of Preventive Oncology, Ankara, Turkey
| | - Ali R Sever
- Hacettepe University Faculty of Medicine, Department of Radiology, Ankara, Turkey
| | - Taner Babacan
- Hacettepe University Faculty of Medicine, Department of Medical Oncology, Ankara, Turkey
| | - Ozturk Ates
- Hacettepe University Faculty of Medicine, Department of Medical Oncology, Ankara, Turkey
| | - Yavuz Ozisik
- Hacettepe University Faculty of Medicine, Department of Medical Oncology, Ankara, Turkey
| | - Kadri Altundag
- Hacettepe University Faculty of Medicine, Department of Medical Oncology, Ankara, Turkey.
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Gutierrez F, Gonzalez-de-la-Fuente GA, Nazco GJ, Oramas J, Batista N. Hematological toxicity of carboplatin for gynecological cancer according to body mass index. Eur J Clin Pharmacol 2016; 72:1083-9. [PMID: 27287195 DOI: 10.1007/s00228-016-2080-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2016] [Accepted: 06/02/2016] [Indexed: 01/30/2023]
Abstract
PURPOSE The aim of the present study was to analyze how patient weight affects the hematological toxicity of carboplatin and whether this toxicity is more prevalent in overweight patients. METHODS We performed a retrospective 2-year study of patients diagnosed with a gynecological cancer and whose treatment regimen contained carboplatin (AUC dose = 5 or 6) and paclitaxel (dose = 175 mg/m(2)) every 3 weeks (CP scheme). We recorded all severe hematological events (thrombocytopenia, neutropenia, and/or anemia grade III/IV) according to the CTCAE v4.03, as well as treatment modifications and the need for granulocyte colony-stimulating factors (G-CSF) and/or erythropoietin (EPO) or packed red blood cells (PRBC). Patients with a body mass index (BMI) ≥27 kg/m(2) were considered as overweight (OW) and those with a BMI <27 kg/m(2) were considered as normal weight (NW). RESULTS Fifty-two patients met the inclusion criteria (21 patients in the OW group, 31 patients in the NW group). The OW group showed a higher incidence of thrombocytopenia (95% confidence intervals (CI) 1.51-27.72; p < 0.02) and anemia (95% CI 1.06-33.63; p < 0.05). Moreover, this was reflected in a greater number of changes in the usual CP regimen (95% CI 2.19-44.32; p < 0.01). The need for G-CSF and/or EPO/PRBC was also significantly higher in the OW group (95% CI 1.08-12.16; p < 0.04). CONCLUSIONS Carboplatin dosing based on real weight in obese patients resulted in increased hematologic toxicity, mainly thrombocytopenia. Dose adjustment based on other descriptors of weight, such as adjusted weight, may be better tolerated by patients. However, future studies are needed to demonstrate not only better safety of carboplatin but also improved survival rates.
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Affiliation(s)
- Fernando Gutierrez
- , Carretera Ofra S/N La Cuesta, San Cristóbal de La Laguna (Tenerife), 38320, Islas Canarias, Spain.
| | | | - Gloria Julia Nazco
- , Carretera Ofra S/N La Cuesta, San Cristóbal de La Laguna (Tenerife), 38320, Islas Canarias, Spain
| | - Juana Oramas
- , Carretera Ofra S/N La Cuesta, San Cristóbal de La Laguna (Tenerife), 38320, Islas Canarias, Spain
| | - Norberto Batista
- , Carretera Ofra S/N La Cuesta, San Cristóbal de La Laguna (Tenerife), 38320, Islas Canarias, Spain
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Chan H, Jackson S, McLay J, Knox A, Lee J, Wang S, Issa S. Obese non-Hodgkin lymphoma patients tolerate full uncapped doses of chemotherapy with no increase in toxicity, and a similar survival to that seen in nonobese patients. Leuk Lymphoma 2016; 57:2584-92. [DOI: 10.3109/10428194.2016.1151508] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
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Pediatric Obesity: Pharmacokinetics and Implications for Drug Dosing. Clin Ther 2015; 37:1897-923. [DOI: 10.1016/j.clinthera.2015.05.495] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2015] [Revised: 05/14/2015] [Accepted: 05/19/2015] [Indexed: 02/01/2023]
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Huang HL, Lu PH, Yang HC, Lee GD, Li HR, Liao KC. Fiber-optic triggered release of liposome in vivo: implication of personalized chemotherapy. Int J Nanomedicine 2015; 10:5171-84. [PMID: 26316748 PMCID: PMC4542555 DOI: 10.2147/ijn.s85915] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
The aim of this research is to provide proof of principle by applying the fiber-optic triggered release of photo-thermally responsive liposomes embedded with gold nanoparticles (AuNPs) using a 200 μm fiber with 65 mW and 532 nm excitation for topical release in vivo. The tunable delivery function can be paired with an apoptosis biosensor based on the same fiber-optic configuration for providing real-time evaluation of chemotherapy efficacy in vivo to perform as a personalized chemotherapy system. The pattern of topical release triggered by laser excitation conveyed through optical fibers was monitored by the increase in fluorescence resulting from the dilution of self-quenching (75 mM) fluorescein encapsulated in liposomes. In in vitro studies (in 37°C phosphate buffer saline), the AuNP-embedded liposomes showed a more efficient triggered release (74.53%±1.63% in 40 minutes) than traditional temperature-responsive liposomes without AuNPs (14.53%±3.17%) or AuNP-liposomes without excitation (21.92%±2.08%) by spectroscopic measurements. Using the mouse xenograft studies, we first demonstrated that the encapsulation of fluorescein in liposomes resulted in a more substantial content retention (81%) in the tumor than for free fluorophores (14%) at 120 minutes after administration from in vivo fluorescence imaging. Furthermore, the preliminary results also suggested the tunable release capability of the system by demonstrating consecutive triggered releases with fiber-optic guided laser excitation.
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Affiliation(s)
- Huei-Ling Huang
- Graduate Institute of Biomedical Engineering, National Chung Hsing University, Taichung, Taiwan
| | - Pei-Hsuan Lu
- Graduate Institute of Biomedical Engineering, National Chung Hsing University, Taichung, Taiwan
| | - Hung-Chih Yang
- Graduate Institute of Biomedical Engineering, National Chung Hsing University, Taichung, Taiwan
| | - Gi-Da Lee
- Graduate Institute of Biomedical Engineering, National Chung Hsing University, Taichung, Taiwan ; Department of Radiology, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Han-Ru Li
- Graduate Institute of Biomedical Engineering, National Chung Hsing University, Taichung, Taiwan
| | - Kuo-Chih Liao
- Graduate Institute of Biomedical Engineering, National Chung Hsing University, Taichung, Taiwan
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Effect of Initial Body Mass Index on Survival Outcome of Patients With Acute Leukemia: A Single-Center Retrospective Study. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2015; 15 Suppl:S7-13. [DOI: 10.1016/j.clml.2015.02.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/29/2014] [Accepted: 02/03/2015] [Indexed: 11/18/2022]
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Chu MP, McCaw L, Stretch C, Butts C, Hanson J, Kuzma M, Damaraju VL, Baracos VE, Sawyer MB. Development of a new equation to estimate creatinine clearance in cancer patients. Cancer Chemother Pharmacol 2015; 76:117-24. [PMID: 25986679 DOI: 10.1007/s00280-015-2777-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2015] [Accepted: 05/08/2015] [Indexed: 11/25/2022]
Abstract
PURPOSE Determining renal function is important for chemotherapy eligibility and dosing. Measured creatinine clearance (mCrCl) is the gold standard but is cumbersome. Equations estimating CrCl (eCrCl) based on serum creatinine (SCr) produce widely varying estimates. Considering that SCr is derived from skeletal muscle, this study prospectively developed a new eCrCl equation in cancer patients using CT-defined muscle surface area (MSA) and evaluated its utility in a separate, retrospective series. METHODS In a prospective, observational cohort study of cancer patients, mCrCl by 24-h urine collection was correlated with CT-determined MSA to create an equation for eCrCl [muscle surface area (cm(2)) × 42/SCr]. eCrCl by Wright, Cockcroft-Gault (CG), CKD-EPI, MDRD, and MSA was compared to mCrCl to determine fit. MSA-eCrCl was used to simulate carboplatin dosing in a retrospective series of advanced non-small cell lung cancer (NSCLC). RESULTS Prospectively, 22 patients were accrued and evaluable (12 males; median age 69). MSA-eCrCl correlated stronger (r (2) 0.80) than current equations (r (2) 0.47-0.69) with mCrCl. In calculating carboplatin doses for 89 NSCLC patients with MSA and CG-eCrCl, median error of CG-determined carboplatin dose was 5.5 % (range -19.0 to 44.2 %), assuming that MSA was better at estimating CrCl. Forty-two patients (47 %) received doses that varied ≥10 % of what was calculated by MSA. CONCLUSIONS We propose a new formula for eCrCl in patients that appears more accurate than current formulae and may have implications for chemotherapy efficacy and toxicity. Studies to validate this formula are under way.
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Affiliation(s)
- Michael P Chu
- Department of Oncology, Cross Cancer Institute, 11560 University Avenue, Edmonton, AB, T6G 1Z2, Canada,
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Hansen J, Stephan JM, Freesmeier M, Bender D, Button A, Goodheart MJ. The effect of weight-based chemotherapy dosing in a cohort of gynecologic oncology patients. Gynecol Oncol 2015; 138:154-8. [PMID: 25958318 DOI: 10.1016/j.ygyno.2015.04.040] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2015] [Accepted: 04/29/2015] [Indexed: 11/15/2022]
Abstract
OBJECTIVE Many clinicians limit chemotherapy doses based on a maximum body surface area (BSA) of 2m(2). We sought to determine how chemotherapy-related toxicities compared between groups of patients that varied with respect to BSA. We hypothesized that obese patients receiving weight-based (WB) dosing would not have significantly higher chemotherapy-related toxicities than control groups. METHODS We performed a retrospective review of patients with BSA≥2m(2) who received WB chemotherapy for a gynecologic cancer between January and August 2013. Subjects were matched with two controls: patients with BSA<2m(2) who received WB dosing, and patients with BSA≥2m(2) who received capped dosing at BSA=2m(2). Groups were matched for medical co-morbidities and prior cancer treatment. Demographic and clinical information was extracted and analyzed via ANOVA and Fisher's exact test. RESULTS A total of 75 patients were included. The three groups were similar in their medical co-morbidities and prior cancer treatment. When comparing pre- and post-treatment laboratory values, there was no difference in hematologic toxicities. There was no difference between groups with regard to treatment delays, unplanned admissions, transfusions, or dose reductions for toxicity. CONCLUSIONS Gynecologic cancer patients with BSA≥2m(2) treated with WB chemotherapy had no increase in hematologic or non-hematologic toxicities when compared to controls. Consideration should be given to using WB dosing in obese patients with gynecologic malignancies. Further investigation is required to determine the effect of WB dosing on progression-free and overall survival in obese gynecologic cancer patients.
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Affiliation(s)
- Jean Hansen
- Department of Obstetrics and Gynecology, The University of Iowa Hospitals and Clinics, Iowa City, IA 52242, USA
| | - Jean-Marie Stephan
- Department of Obstetrics and Gynecology, The University of Iowa Hospitals and Clinics, Iowa City, IA 52242, USA
| | - Michele Freesmeier
- Department of Obstetrics and Gynecology, The University of Iowa Hospitals and Clinics, Iowa City, IA 52242, USA
| | - David Bender
- Department of Obstetrics and Gynecology, The University of Iowa Hospitals and Clinics, Iowa City, IA 52242, USA
| | - Anna Button
- Department of Biostatistics, The University of Iowa Hospitals and Clinics, Iowa City, IA 52242, USA
| | - Michael J Goodheart
- Department of Obstetrics and Gynecology, The University of Iowa Hospitals and Clinics, Iowa City, IA 52242, USA.
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Horowitz NS, Wright AA. Impact of obesity on chemotherapy management and outcomes in women with gynecologic malignancies. Gynecol Oncol 2015; 138:201-6. [PMID: 25870918 DOI: 10.1016/j.ygyno.2015.04.002] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2015] [Accepted: 04/02/2015] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To describe the effects of obesity on the pharmacokinetics and dosing of chemotherapies and provide recommendations for chemotherapy management in obese women with gynecologic malignancies. METHODS PubMEd and MEDLINE databases were searched for articles published before June 2014. Only English-language articles were considered. 84 manuscripts were reviewed and 66 were included. Search terms included: obesity, overweight, body mass index, body surface area, glomerular filtration rate, chemotherapy, ovarian cancer, endometrial cancer, inflammation, and pharmacokinetics, RESULTS Obese cancer patients have worse clinical outcomes, compared with non-obese patients. This may be because of differences in pharmacokinetics, metabolic dysregulation, or physicians' decisions to reduce chemotherapy dose-intensity during treatment to minimize toxicities. A 2012 American Society of Clinical Oncology Clinical Practice Guideline recommends using actual body weight for chemotherapy dosing in all patients treated with curative intent, irrespective of obesity, to avoid compromising clinical outcomes, including progression free survival (PFS) and overall survival (OS). In women with gynecologic cancers most studies demonstrate no difference in PFS or OS when obese patients receive the same chemotherapy dose intensity as non-obese patients, except perhaps with bevacizumab. CONCLUSIONS Chemotherapy dose-intensity is a critical determinant of cancer outcomes and should be maintained in all patients, irrespective of obesity. Future studies should prospectively examine the impact of obesity on clinical outcomes (adverse events, survival) to improve the care of this growing population of patients who are at risk for inferior clinical outcomes.
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Affiliation(s)
- Neil S Horowitz
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Brigham and Women's Hospital, USA; Division of Medical Oncology, Dana Farber Cancer Institute, USA.
| | - Alexi A Wright
- Division of Medical Oncology, Dana Farber Cancer Institute, USA
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A time to stop, a time to start: high-dose chemotherapy in overweight and obese patients. Bone Marrow Transplant 2015; 50:617-8. [PMID: 25730189 DOI: 10.1038/bmt.2015.26] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
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43
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Outcomes after autologous SCT in lymphoma patients grouped by weight. Bone Marrow Transplant 2015; 50:652-7. [PMID: 25665041 DOI: 10.1038/bmt.2014.327] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2014] [Revised: 12/12/2014] [Accepted: 12/17/2014] [Indexed: 01/09/2023]
Abstract
Obesity continues to be an increasing global health issue contributing to the complexity of chemotherapy dosing in the field of SCT. Investigation into the optimal dosing weight used to calculate chemotherapy doses in obese patients undergoing SCT is limited and inconclusive. Our single-center, retrospective study compared safety and efficacy outcomes by body mass index (BMI) for 476 adult lymphoma patients who underwent auto-SCT with a myeloablative chemotherapeutic regimen of BU, CY and etoposide dosed using adjusted body weight. Three weight groups categorized based on BMI were defined: normal/underweight ⩽24.9 kg/m(2), overweight 25-29.9 kg/m(2) and obese ⩾30 kg/m(2). Severity of mucositis, incidence of secondary malignancy, incidence of bacteremia and median hospital length of stay did not differ among the groups. The median times to absolute neutrophil count and platelet recovery were 10 days (P=0.75) and 14 days (P=0.17), respectively. Obese patients had a lower 100-day mortality compared with other weight groups, although this did not translate into an OS benefit. OS and disease relapse were similar among the groups. Our study demonstrates that use of adjusted body weight to calculate chemotherapy doses does not negatively have an impact on outcomes in obese patients undergoing auto-SCT with BU, CY and etoposide.
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Peric KM, Reeves DJ. Tolerability of induction chemotherapy dosing practices in acute myeloid leukemia patients. Leuk Res 2015; 39:173-6. [DOI: 10.1016/j.leukres.2014.11.024] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2014] [Revised: 11/21/2014] [Accepted: 11/27/2014] [Indexed: 01/07/2023]
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Clemmons AB, Evans S, DeRemer DL, Awan FT. Busulfan dosing (Q6 or Q24) with adjusted or actual body weight, does it matter? J Oncol Pharm Pract 2014; 21:425-32. [PMID: 24986792 DOI: 10.1177/1078155214541571] [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] [Indexed: 11/15/2022]
Abstract
BACKGROUND In hematopoietic stem cell transplantation (HSCT), patients receive individualized treatment planning in conditioning regimens to prevent unwarranted toxicities while maximizing desired outcomes. The dose of a widely studied agent in this setting, busulfan, can be adjusted based on area under the curve (AUC); however, choice of actual body weight (ABW) versus adjusted body weight (DBW) weight to calculate the initial dose may be critical in attaining goal AUC. OBJECTIVE To determine which weight best correlates with achievement of goal AUC for patients receiving busulfan conditioning for HSCT. Secondary objectives include evaluation of AUC results with clinical outcomes such as toxicity and survival. METHODS An institutional review board-approved retrospective analysis was performed on 31 allogeneic HSCT recipients who received intravenous busulfan (Q6H with cyclophosphamide [Bu/Cy] or once daily with fludarabine [Flu/Bu]). RESULTS Eighteen patients received Flu/Bu (50% ABW, 50% DBW) and 13 received Bu/Cy (23% ABW, 77% DBW). Overall, patients dosed by DBW were more likely to undershoot goal AUC (-12.8% vs. +19.5%, p = 0.018) and require dose increases (+20% vs. -19.9%, p = 0.012) versus those dosed by ABW. Subgroup analysis confirmed these results for Bu/Cy (-23.6% vs. +2.2%, p < 0.001 for goal AUC; +36.2% vs. -4.5%, p = 0.008 for busulfan dose increase), but not Flu/Bu (-0.8% vs. +25.3%, p = 0.123 for goal AUC; +3.4% vs. -25.1%, p = 0.174 for busulfan dose increase). Time to engraftment, progression-free survival, and overall survival were not different between dosing groups (p > 0.05). No patient experienced busulfan-related toxicity. CONCLUSIONS Further prospective studies are warranted to elucidate which weight is most likely to achieve goal AUC and subsequent optimal patient outcomes.
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Affiliation(s)
- Amber Bradley Clemmons
- Department of Clinical and Administrative Pharmacy, University of Georgia College of Pharmacy, Augusta, GA, USA Georgia Regents Cancer Center, Augusta, GA, USA
| | - Sarah Evans
- Department of Clinical and Administrative Pharmacy, University of Georgia College of Pharmacy, Augusta, GA, USA
| | - David L DeRemer
- Department of Clinical and Administrative Pharmacy, University of Georgia College of Pharmacy, Augusta, GA, USA Georgia Regents Cancer Center, Augusta, GA, USA
| | - Farrukh T Awan
- Bone Marrow Transplant Program, Division of Hematology, Department of Internal Medicine, The Ohio State University, Columbus, OH, USA
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Olney HJ, Freeman MA, Stewart DA, Mangel JE, White DJ, Elia-Pacitti JO. Prolonged progression-free survival and preserved quality of life in the Canadian prospective study of tositumomab and iodine(131)-tositumomab for previously treated, rituximab-exposed, indolent non-Hodgkin lymphoma. Leuk Lymphoma 2014; 55:2754-60. [PMID: 24528219 DOI: 10.3109/10428194.2014.894190] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Radioimmunotherapy offers a unique treatment modality for indolent non-Hodgkin lymphoma (iNHL). We report 5-year outcomes and quality of life (QoL) in tositumomab and iodine(131)-tositumomab (TST/I(131)-TST) treated patients with iNHL previously treated with rituximab. Ninety-three patients with ≥ 2 lines of therapy, responding to last treatment, were enrolled at 12 Canadian centers. Median age, disease duration and number of prior therapies (#PTx) were 59 years, 4.9 years and 5, respectively. Outcomes were response rate (43.0%), median progression-free survival (mPFS) (12.0 months), 5-year PFS (27%) and median overall survival (OS) (59.8 months). In responders, median response duration and mPFS were not reached. Improvements in QoL were seen by week 7. In univariate and multivariate analyses, hemoglobin, disease bulk and body surface area (BSA) predicted OS, whereas lactate dehydrogenase (LDH), bulk, BSA and #PTx predicted PFS. Most common adverse events (AEs) were fatigue and nausea. Two cases of myelodysplastic syndrome (MDS) were reported. TST/I(131)-TST was associated with durable responses, and prolonged OS and PFS in heavily pretreated iNHL.
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Affiliation(s)
- Harold J Olney
- Centre Hospitalier de l'Université de Montréal , Montreal , Canada
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VOLKOVA EKATERINA, ROBINSON BRIDGETA, WILLIS JINNY, CURRIE MARGARETJ, DACHS GABIU. Marginal effects of glucose, insulin and insulin-like growth factor on chemotherapy response in endothelial and colorectal cancer cells. Oncol Lett 2014; 7:311-320. [PMID: 24396438 PMCID: PMC3881921 DOI: 10.3892/ol.2013.1710] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2013] [Accepted: 10/24/2013] [Indexed: 12/30/2022] Open
Abstract
Resistance to chemotherapy is a major clinical issue for patients with colorectal cancer. Obesity has been associated with a poorer outcome and is a possible mechanism of resistance. The aim of the present study was to investigate the effect of obesity-related factors on the cell response to standard chemotherapy in stromal and colorectal cancer cells. Viability was measured following the treatment of colorectal cancer cell lines (WiDr and SW620) and stromal cells (human microvascular endothelial cells) in vitro with 5-fluorouracil, irinotecan and oxaliplatin under obesity-related conditions [elevated levels of insulin, insulin-like growth factor-1 (IGF-1) and glucose] and compared with non-elevated conditions. Obesity-related conditions alone increased cell viability and in selected cases, accumulation of the transcription factor, hypoxia-inducible factor-1. However, these conditions did not consistently increase resistance to the chemotherapy agents tested. The combination of IGF-1 and extremely low-dose chemotherapy significantly induced cell viability in WiDr colorectal cancer cells. These in vitro results may have clinical importance in an environment of increasing rates of obesity and colorectal cancer, and the frequent under-dosing of obese cancer patients.
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Affiliation(s)
- EKATERINA VOLKOVA
- Mackenzie Cancer Research Group, Department of Pathology, University of Otago Christchurch, Christchurch 8140, New Zealand
| | - BRIDGET A. ROBINSON
- Mackenzie Cancer Research Group, Department of Pathology, University of Otago Christchurch, Christchurch 8140, New Zealand
- Canterbury Regional Cancer and Blood Service, Canterbury District Health Board, Christchurch 8140, New Zealand
| | - JINNY WILLIS
- Lipid and Diabetes Research Group, Christchurch Hospital, Christchurch 8140, New Zealand
| | - MARGARET J. CURRIE
- Mackenzie Cancer Research Group, Department of Pathology, University of Otago Christchurch, Christchurch 8140, New Zealand
| | - GABI U. DACHS
- Mackenzie Cancer Research Group, Department of Pathology, University of Otago Christchurch, Christchurch 8140, New Zealand
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Hourdequin K, Schpero W, McKenna D, Piazik B, Larson R. Toxic effect of chemotherapy dosing using actual body weight in obese versus normal-weight patients: a systematic review and meta-analysis. Ann Oncol 2013; 24:2952-62. [DOI: 10.1093/annonc/mdt294] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
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Pajares B, Pollán M, Martín M, Mackey JR, Lluch A, Gavila J, Vogel C, Ruiz-Borrego M, Calvo L, Pienkowski T, Rodríguez-Lescure Á, Seguí MA, Tredan O, Antón A, Ramos M, Cámara MDC, Rodríguez-Martín C, Carrasco E, Alba E. Obesity and survival in operable breast cancer patients treated with adjuvant anthracyclines and taxanes according to pathological subtypes: a pooled analysis. Breast Cancer Res 2013; 15:R105. [PMID: 24192331 PMCID: PMC3978725 DOI: 10.1186/bcr3572] [Citation(s) in RCA: 66] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2013] [Accepted: 10/16/2013] [Indexed: 01/08/2023] Open
Abstract
INTRODUCTION Obesity is an unfavorable prognostic factor in breast cancer (BC) patients regardless of menopausal status and treatment received. However, the association between obesity and survival outcome by pathological subtype requires further clarification. METHODS We performed a retrospective analysis including 5,683 operable BC patients enrolled in four randomized clinical trials (GEICAM/9906, GEICAM/9805, GEICAM/2003-02, and BCIRG 001) evaluating anthracyclines and taxanes as adjuvant treatments. Our primary aim was to assess the prognostic effect of body mass index (BMI) on disease recurrence, breast cancer mortality (BCM), and overall mortality (OM). A secondary aim was to detect differences of such prognostic effects by subtype. RESULTS Multivariate survival analyses adjusting for age, tumor size, nodal status, menopausal status, surgery type, histological grade, hormone receptor status, human epidermal growth factor receptor 2 (HER2) status, chemotherapy regimen, and under-treatment showed that obese patients (BMI 30.0 to 34.9) had similar prognoses to that of patients with a BMI < 25 (reference group) in terms of recurrence (Hazard Ratio [HR] = 1.08, 95% Confidence Interval [CI] = 0.90 to 1.30), BCM (HR = 1.02, 0.81 to 1.29), and OM (HR = 0.97, 0.78 to 1.19). Patients with severe obesity (BMI ≥ 35) had a significantly increased risk of recurrence (HR = 1.26, 1.00 to 1.59, P = 0.048), BCM (HR = 1.32, 1.00 to 1.74, P = 0.050), and OM (HR = 1.35, 1.06 to 1.71, P = 0.016) compared to our reference group. The prognostic effect of severe obesity did not vary by subtype. CONCLUSIONS Severely obese patients treated with anthracyclines and taxanes present a worse prognosis regarding recurrence, BCM, and OM than patients with BMI < 25. The magnitude of the harmful effect of BMI on survival-related outcomes was similar across subtypes.
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Wenzell CM, Gallagher EM, Earl M, Yeh JY, Kusick KN, Advani AS, Kalaycio ME, Mukherjee S, Tiu RV, Maciejewski JP, Sekeres MA. Outcomes in obese and overweight acute myeloid leukemia patients receiving chemotherapy dosed according to actual body weight. Am J Hematol 2013; 88:906-9. [PMID: 23828018 DOI: 10.1002/ajh.23530] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2013] [Revised: 06/05/2013] [Accepted: 06/28/2013] [Indexed: 11/07/2022]
Abstract
Cytotoxic chemotherapy dosages are traditionally calculated according to body surface area (BSA). No guidelines exist for chemotherapy dosing of acute myeloid leukemia (AML) patients at extremes of weight. We investigated the efficacy and safety of chemotherapy dosed according to BSA based on actual body weight (ABW) among under/normal weight, overweight, and obese AML patients. AML patients (excluding acute promyelocytic leukemia) treated with anthracycline and cytarabine-based remission induction chemotherapy from 2002 to 2009 at Cleveland Clinic were divided into three body mass index (BMI) groups: under/normal weight (BMI ≤ 24.9), overweight (BMI 25.0-29.9), and obese (BMI ≥ 30.0). Among 247 AML patients, 81 (33%) were under/normal weight, 81 (33%) were overweight, and 85 (34%) were obese. Complete remission (CR) rates were similar among these groups (69.1, 79.0, and 76.5%, respectively; P = 0.321), as was median survival (10.7, 16.7, and 14.2 months, respectively, P = 0.352) and 30-day mortality (3.7, 2.5, 7.1%, respectively, P = 0.331). There was no difference among groups in days to neutrophil or platelet recovery, hospitalization days for induction chemotherapy, and bacteremia. After adjustment for confounders (age, sex, BMI, white blood cells, cytogenetic risk, etiology, and bacteremia), overall survival was significantly shorter for normal weight compared to overweight (P = 0.006) and obese (0.038) patients. Response rates and adverse events were not significantly different among AML patients of all weight classes when induction chemotherapy was dosed according to ABW. Induction chemotherapy in these patients can be safely dosed using ABW.
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Affiliation(s)
| | | | - Marc Earl
- Department of Pharmacy; Cleveland Clinic; Cleveland Ohio
| | - Jun-Yen Yeh
- Department of Pharmacy; Cleveland Clinic; Cleveland Ohio
| | | | - Anjali S. Advani
- Leukemia Program; Hematologic Oncology and Blood Disorders; Cleveland Clinic Taussig Cancer Institute; Cleveland Ohio
| | - Matt E. Kalaycio
- Leukemia Program; Hematologic Oncology and Blood Disorders; Cleveland Clinic Taussig Cancer Institute; Cleveland Ohio
| | - Sudipto Mukherjee
- Leukemia Program; Hematologic Oncology and Blood Disorders; Cleveland Clinic Taussig Cancer Institute; Cleveland Ohio
| | - Ramon V. Tiu
- Leukemia Program; Hematologic Oncology and Blood Disorders; Cleveland Clinic Taussig Cancer Institute; Cleveland Ohio
| | - Jaroslaw P. Maciejewski
- Leukemia Program; Hematologic Oncology and Blood Disorders; Cleveland Clinic Taussig Cancer Institute; Cleveland Ohio
| | - Mikkael A. Sekeres
- Leukemia Program; Hematologic Oncology and Blood Disorders; Cleveland Clinic Taussig Cancer Institute; Cleveland Ohio
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