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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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van Lieshout R, Tick LW, de Beer F, Koene HR, Regelink JC, Westerweel PE, de Witte MA, Beckers EAM, Schouten HC, Beijer S. Medical nutrition therapy during intensive remission-induction treatment and hematopoietic stem cell transplantation in acute myeloid leukemia patients: Hematologists' experiences and perspectives. Clin Nutr ESPEN 2023; 57:399-409. [PMID: 37739686 DOI: 10.1016/j.clnesp.2023.07.015] [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: 01/23/2023] [Revised: 05/09/2023] [Accepted: 07/11/2023] [Indexed: 09/24/2023]
Abstract
BACKGROUND & AIMS The European Societies for Clinical Nutrition and Metabolism (ESPEN) and Blood and Marrow Transplantation (EBMT) recommend enteral nutrition (EN) as the first-choice medical nutrition therapy in acute myeloid leukemia (AML) patients undergoing intensive treatments, including high-dose remission-induction chemotherapy and hematopoietic stem cell transplantation (HSCT). However, parenteral nutrition (PN) remains the preferred method of nutrition support in current clinical practice. The aim of this qualitative study was to gain insight into hematologists' experiences and perspectives regarding the choice and ESPEN/EBMT recommendations on EN versus PN. METHODS Online semi-structured interviews were conducted with one hematologist from each of the 21 hospitals offering intensive AML treatments in the Netherlands, using Microsoft Teams. Interviews were audio-recorded, transcribed verbatim and thematically analyzed using Atlas. ti. One hundred nineteen hematologists working in the same hospitals were invited to complete a short online questionnaire survey (SurveyMonkey®) regarding their knowledge and opinion on the ESPEN/EBMT guidelines recommending EN over PN during intensive AML treatments. The results of this survey are presented in a descriptive way. RESULTS Fifty-nine hematologists participated in this study (42% overall response rate), of which 21 in the semi-structured interviews (response rate 100%) and 38 in the online survey (response rate 32%). Hematologists considered medical nutrition therapy important for prevention and treatment of malnutrition and associated adverse outcomes in AML patients undergoing intensive remission-induction treatment and HSCT. However, opposed to the ESPEN/EBMT guidelines, the vast majority of hematologists were hesitant or reluctant to use EN instead of PN as the first-choice medical nutrition therapy in these patients. The most frequently cited barriers to use EN were the expected low feasibility and tolerance of EN, feeding tube-related discomfort and bleeding risk, and patient refusal. Other barriers to follow the guidelines on EN were related to personal factors, including hematologists' knowledge (lack of awareness and familiarity) and attitude (lack of agreement, outcome expectancy, experience, success, motivation, and learning culture), guideline-related factors (lack of evidence and applicability), and external factors (lack of collaboration and resources). Facilitators included strategies for nutrition education and dissemination of nutritional guidelines, interprofessional and patient collaboration, availability of feeding tubes that can be inserted without endoscopy and stronger scientific evidence. CONCLUSIONS Hematologists recognized the importance of medical nutrition therapy for reducing malnutrition and related negative outcomes during intensive AML treatments. However, contrary to the ESPEN/EBMT guidelines, they preferred PN instead of EN as the medical nutrition therapy of first choice. To reduce compliance barriers, interventions should focus on improving hematologists' knowledge of medical nutrition therapy and dietary guidelines, enhancing success rates of EN by adequately triaging patients eligible for EN and inserting duodenal feeding tubes using an electromagnetic sensing device without endoscopy, developing decision aids and multidisciplinary guidelines and care pathways. Furthermore, future trials should focus on the feasibility and benefits of EN versus PN both during remission-induction treatment and HSCT.
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Affiliation(s)
- Rianne van Lieshout
- Department of Dietetics and Nutrition, Maxima MC, De Run 4600, Veldhoven, 5504 DB, The Netherlands.
| | - Lidwine W Tick
- Department of Internal Medicine, Maxima MC, De Run 4600, Veldhoven, 5504 DB, The Netherlands
| | - Fenne de Beer
- Department of Dietetics and Nutrition, Maxima MC, De Run 4600, Veldhoven, 5504 DB, The Netherlands
| | - Harry R Koene
- Department of Internal Medicine, Sint Antonius Hospital, Koekoekslaan 1, Nieuwegein, 3435 CM, The Netherlands
| | - Josien C Regelink
- Department of Internal Medicine, Meander Medical Center, Maatweg 3, Amersfoort, 3813 TZ, The Netherlands
| | - Peter E Westerweel
- Department of Internal Medicine, Albert Schweitzer Hospital, Albert Schweitzerplaats 25, Dordrecht, 3318 AT, The Netherlands
| | - Moniek A de Witte
- Department of Internal Medicine, University Medical Center Utrecht, Division Hematology, Heidelberglaan 100, Utrecht, 3584 CX, The Netherlands
| | - Erik A M Beckers
- Department of Internal Medicine, Division Hematology, P. Debyelaan 25, Maastricht University Medical Center, Maastricht, 6229 HX, The Netherlands
| | - Harry C Schouten
- Department of Internal Medicine, Division Hematology, P. Debyelaan 25, Maastricht University Medical Center, Maastricht, 6229 HX, The Netherlands
| | - Sandra Beijer
- Department of Research and Development, Netherlands Comprehensive Cancer Organization, Godebaldkwartier 419, Utrecht, 3511 DT, The Netherlands
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Griggs JJ, Bohlke K, Balaban EP, Dignam JJ, Hall ET, Harvey RD, Hecht DP, Klute KA, Morrison VA, Pini TM, Rosner GL, Runowicz CD, Shayne M, Sparreboom A, Turner S, Zarwan C, Lyman GH. Appropriate Systemic Therapy Dosing for Obese Adult Patients With Cancer: ASCO Guideline Update. J Clin Oncol 2021; 39:2037-2048. [PMID: 33939491 DOI: 10.1200/jco.21.00471] [Citation(s) in RCA: 54] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
PURPOSE To provide recommendations for appropriate dosing of systemic antineoplastic agents in obese adults with cancer. METHODS A systematic review of the literature collected evidence regarding dosing of chemotherapy, immunotherapy, and targeted therapies in obese adults with cancer. PubMed and the Cochrane Library were searched for randomized controlled trials, meta-analyses, or cohort studies published from November 1, 2010, through March 27, 2020. ASCO convened an Expert Panel to review the evidence and formulate recommendations. RESULTS Sixty studies, primarily retrospective, were included in the review. Overall, the evidence supported previous findings that obese adult patients tolerate full, body-size-based dosing of chemotherapy as well as nonobese patients. Fewer studies have addressed the dosing of targeted therapies and immunotherapies in relation to safety and efficacy in obese patients. RECOMMENDATIONS The Panel continues to recommend that full, weight-based cytotoxic chemotherapy doses be used to treat obese adults with cancer. New to this version of the guideline, the Panel also recommends that full, approved doses of immunotherapy and targeted therapies be offered to obese adults with cancer. In the event of toxicity, the consensus of the Panel is that dose modifications of systemic antineoplastic therapies should be handled similarly for obese and nonobese patients. Important areas for future research include the impact of sarcopenia and other measures of body composition on optimal antineoplastic dosing, and more customized dosing based on pharmacokinetic or pharmacogenetic factors.Additional information is available at www.asco.org/supportive-care-guidelines.
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Affiliation(s)
| | - Kari Bohlke
- American Society of Clinical Oncology, Alexandria, VA
| | | | | | - Evan T Hall
- Fred Hutchinson Cancer Research Center and University of Washington, Seattle, WA
| | | | - Diane P Hecht
- University of Texas MD Anderson Cancer Center, Houston, TX
| | | | - Vicki A Morrison
- University of Minnesota Hennepin County Medical Center, Minneapolis, MN
| | | | | | - Carolyn D Runowicz
- Herbert Wertheim College of Medicine, Florida International University, Miami, FL
| | | | | | | | | | - Gary H Lyman
- Fred Hutchinson Cancer Research Center and University of Washington, Seattle, WA
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Chester R, Das AAK, Medlock J, Nees D, Allsup DJ, Madden LA, Paunov VN. Removal of Human Leukemic Cells from Peripheral Blood Mononuclear Cells by Cell Recognition Chromatography with Size Matched Particle Imprints. ACS APPLIED BIO MATERIALS 2020; 3:789-800. [DOI: 10.1021/acsabm.9b00770] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Rosie Chester
- Department of Chemistry and Biochemistry, University of Hull, Cottingham Road, Hull, HU67RX, U.K
| | - Anupam A. K. Das
- Department of Chemistry and Biochemistry, University of Hull, Cottingham Road, Hull, HU67RX, U.K
| | - Jevan Medlock
- Department of Chemistry and Biochemistry, University of Hull, Cottingham Road, Hull, HU67RX, U.K
| | - Dieter Nees
- Joanneum Research FmbH, Leonhardstrasse 59, 8010 Graz, Austria
| | - David J. Allsup
- Hull York Medical School, University of Hull, Cottingham Road, Hull, HU67RX, U.K
| | - Leigh A. Madden
- Department of Biomedical Sciences, University of Hull, Cottingham Road, Hull, HU67RX, U.K
| | - Vesselin N. Paunov
- Department of Chemistry and Biochemistry, University of Hull, Cottingham Road, Hull, HU67RX, U.K
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Berger K, Schopohl D, Bollig A, Strobach D, Rieger C, Rublee D, Ostermann H. Burden of Oral Mucositis: A Systematic Review and Implications for Future Research. Oncol Res Treat 2018; 41:399-405. [PMID: 29734184 DOI: 10.1159/000487085] [Citation(s) in RCA: 47] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2017] [Accepted: 01/22/2018] [Indexed: 12/31/2022]
Abstract
BACKGROUND Surprisingly little is known about the burden of oral mucositis (OM). We provide a systematic review of studies on the burden of OM (incidence, economic impact, health-related quality of life (HRQoL)). METHODS Systematic literature searches were made in BIOSIS, EMBASE, and MEDLINE. Inclusion criteria were studies on OM in hematology/oncology patients of ≥ 18 years, journal articles, English language, and published between 2000 and 2016; OM treatment studies were excluded. Quality assessment was performed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. RESULTS We screened 4,996 hits, and identified 68 studies of which 13 were without transparency on OM grading. The evidence level of 65 studies was rated 'low' or 'very low' in 58.5%, 'moderate' in 20% and 'high' in 21.5%. Mean value of incidence (7 studies) was 83.5% for all grades of OM with hematopoietic stem cell transplantation. OM incidence for all grades in head and neck cancer patients was 59.4-100%. Considering the economic impact, 16 studies showed highly variable numbers. HRQoL was measured in 16 studies using 13 different instruments. Statistically significant changes in HRQoL scores were demonstrated. CONCLUSION OM is common, burdensome, costly and imposes major reductions in HRQoL. However, from a quality standpoint, the level of current evidence in OM is disappointing. The field needs continued attention to address methodological challenges.
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Deluche E, Girault S, Jesus P, Monzat S, Turlure P, Leobon S, Abraham J, Daly N, Dauriac O, Bordessoule D. Assessment of the nutritional status of adult patients with acute myeloid leukemia during induction chemotherapy. Nutrition 2017; 41:120-125. [DOI: 10.1016/j.nut.2017.04.011] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2016] [Revised: 04/10/2017] [Accepted: 04/22/2017] [Indexed: 12/18/2022]
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Cahu X, Carré M, Recher C, Pigneux A, Hunault-Berger M, Vey N, Chevallier P, Delaunay J, Gyan E, Lioure B, Bonmati C, Himberlin C, Hicheri Y, Guillerm G, Didier B, Larosa F, Ojeda-Uribe M, Bernard M, Bene MC, Ifrah N, Cahn JY. Impact of body-surface area on patients’ outcome in younger adults with acute myeloid leukemia. Eur J Haematol 2017; 98:443-449. [DOI: 10.1111/ejh.12850] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/19/2017] [Indexed: 12/20/2022]
Affiliation(s)
- Xavier Cahu
- Department of Hematology; Hôpital Pontchaillou; CHU; Rennes France
| | - Martin Carré
- Department of Hematology; CHU Grenoble Alpes; La Tronche France
| | - Christian Recher
- Department of Hematology; CHU de Toulouse; Centre de Recherches en Cancerologie de Toulouse; Universite Paul Sabatier; Toulouse France
| | - Arnaud Pigneux
- Department of Hematology; CHU Bordeaux; Université Bordeaux; Bordeaux France
| | | | - Norbert Vey
- Department of Hematology; Institut Paoli-Calmettes; Marseille France
| | | | - Jacques Delaunay
- Department of Hematology; Centre Catherine de Sienne; Nantes France
| | - Emmanuel Gyan
- Department of Hematology and Cell Therapy; UMR CNRS 7292; Centre Hospitalier Universitaire; Tours France
| | - Bruno Lioure
- Department of Hematology; Hopitaux Universitaires de Strasbourg; Strasbourg France
| | - Caroline Bonmati
- Department of Hematology; CHU Vandoeuvre-les-Nancy; Nancy France
| | | | - Yosr Hicheri
- Department of Hematology; CHU Montpellier; Montpellier France
| | | | - Bouscary Didier
- Department of Hematology; Hôpital Cochin; AP-HP; Paris France
| | | | - Mario Ojeda-Uribe
- Department of Hematology; Centre Hospitalier Mulhouse; Mulhouse France
| | - Marc Bernard
- Department of Hematology; Hôpital Pontchaillou; CHU; Rennes France
| | | | | | - Jean-Yves Cahn
- Department of Hematology; CHU Grenoble Alpes; La Tronche France
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Tavitian S, Denis A, Vergez F, Berard E, Sarry A, Huynh A, Delabesse E, Luquet I, Huguet F, Récher C, Bertoli S. Impact of obesity in favorable-risk AML patients receiving intensive chemotherapy. Am J Hematol 2016; 91:193-8. [PMID: 26509505 DOI: 10.1002/ajh.24228] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2015] [Revised: 10/22/2015] [Accepted: 10/26/2015] [Indexed: 12/25/2022]
Abstract
We assessed the influence of obesity on the characteristics and prognosis of acute myeloid leukemia (AML). Indeed, safety of intensive chemotherapy and outcome of obese AML patients in a real-life setting are poorly described, and chemotherapy dosing remains challenging. We included 619 consecutive genetically-defined cases of AML treated with intensive chemotherapy between 2004 and 2012. In this cohort, 93 patients (15%) were classified in the obese category according to WHO classification; 59% of them received capped doses of chemotherapy because of a body surface area above 2 m(2) . Obese patients were older and presented more often with cardiovascular comorbidities. Although obese patients had more frequently de novo AML, main characteristics of AML including white blood cell count, karyotype and mutations were well-balanced between obese and non-obese patients. After induction chemotherapy, early death and complete remission rates were similar. Overall (OS), event-free (EFS) and disease-free (DFS) survival were not significantly different compared to non-obese patients. However, in the European LeukemiaNet (ELN) favorable subgroup, obese patients had lower median OS, EFS and DFS than non-obese patients (18.4, 16.8 and 17.2 vs. 43.6, 31.8 and 29.7 months, respectively) and obesity showed a significant impact on OS (OR 2.54; P = 0.02) in multivariate models. Although we did not find any significant impact of obesity on outcome in the whole series, this study suggests that special efforts for chemotherapy dose optimization are needed in the ELN favorable subgroup since dose capping may be deleterious.
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Affiliation(s)
- Suzanne Tavitian
- Service d'hématologie, Institut Universitaire du Cancer de Toulouse Oncopole, Centre Hospitalier Universitaire de Toulouse; Toulouse France
- Université Toulouse III Paul Sabatier; Toulouse France
| | - Amélia Denis
- Cancer Research Center of Toulouse (CRCT), UMR1037 INSERM, ERL5294 CNRS; Toulouse France
- COREVIH Ile-de-France Centre, Hôpital Pitié-Salpêtrière; Paris France
| | - François Vergez
- Cancer Research Center of Toulouse (CRCT), UMR1037 INSERM, ERL5294 CNRS; Toulouse France
- Laboratoire d'hématologie, Institut Universitaire du Cancer de Toulouse Oncopole; Toulouse France
| | - Emilie Berard
- Service d'epidémiologie, Centre Hospitalier Universitaire de Toulouse; Toulouse France
- UMR 1027, INSERM-Université de Toulouse III; Toulouse France
| | - Audrey Sarry
- Service d'hématologie, Institut Universitaire du Cancer de Toulouse Oncopole, Centre Hospitalier Universitaire de Toulouse; Toulouse France
| | - Anne Huynh
- Service d'hématologie, Institut Universitaire du Cancer de Toulouse Oncopole, Centre Hospitalier Universitaire de Toulouse; Toulouse France
| | - Eric Delabesse
- Université Toulouse III Paul Sabatier; Toulouse France
- Cancer Research Center of Toulouse (CRCT), UMR1037 INSERM, ERL5294 CNRS; Toulouse France
- Laboratoire d'hématologie, Institut Universitaire du Cancer de Toulouse Oncopole; Toulouse France
| | - Isabelle Luquet
- Laboratoire d'hématologie, Institut Universitaire du Cancer de Toulouse Oncopole; Toulouse France
| | - Françoise Huguet
- Service d'hématologie, Institut Universitaire du Cancer de Toulouse Oncopole, Centre Hospitalier Universitaire de Toulouse; Toulouse France
| | - Christian Récher
- Service d'hématologie, Institut Universitaire du Cancer de Toulouse Oncopole, Centre Hospitalier Universitaire de Toulouse; Toulouse France
- Université Toulouse III Paul Sabatier; Toulouse France
- Cancer Research Center of Toulouse (CRCT), UMR1037 INSERM, ERL5294 CNRS; Toulouse France
| | - Sarah Bertoli
- Service d'hématologie, Institut Universitaire du Cancer de Toulouse Oncopole, Centre Hospitalier Universitaire de Toulouse; Toulouse France
- Université Toulouse III Paul Sabatier; Toulouse France
- Cancer Research Center of Toulouse (CRCT), UMR1037 INSERM, ERL5294 CNRS; Toulouse France
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