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Hu M, Ding Y, Zhang H, Guo W, Li Y, Jin Z, Qu C, Xia F. Body mass index-associated responses to an ABVD-like regimen in newly-diagnosed patients with Hodgkin lymphoma. Front Pharmacol 2023; 14:1195907. [PMID: 37680722 PMCID: PMC10482088 DOI: 10.3389/fphar.2023.1195907] [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: 03/29/2023] [Accepted: 08/11/2023] [Indexed: 09/09/2023] Open
Abstract
Background: The role of body mass index (BMI) in the treatment outcomes of lymphoma patients is controversial. While investigating the efficacy of ABVD-like regimen in Hodgkin lymphoma (HL) patients, we observed that obese patients had poor responses. To better understand this clinical phenomenon, we evaluated the effect of BMI on responses to ABVD-like chemotherapy in HL patients. Methods: This retrospective cohort study evaluated the clinical outcomes of all 67 patients with confirmed HL who were treated at the First Affiliated Hospital of Soochow University from November 2016 to March 2023 with an ABVD-like regimen as first-line chemotherapy. Baseline patient characteristics and clinical outcomes were compared across different BMI categories. The primary end-point was the overall response rate defined as the proportion of the HL patients who achieved complete response or partial response. The additional end-points included progression-free survival and overall survival. Results: The median age of the HL patients was 31 years old. Of the patients, 10.4% were obese, and 17.9% patients were overweight. Interim and end-term response evaluations revealed overall response rates of 98.5% and 83.6%, respectively. The proportion of patients with potential poor prognostic factors (IPS risk factors) did not differ significantly in the responders versus non-responders. However, non-responders had a higher average BMI when compared with responders (p = 0.002). Poor overall response rates in higher BMI patients indeed manifested with shorter progression free survival (p = 0.013). The minimum relative dose of the ABVD-like regimen in the overweight and obese groups was significantly lower than in the normal weight group (p < 0.001). Conclusion: Our analyses show that >80% of newly-diagnosed HL patients responded to the ABVD-like regimen. We find that being obese or overweight at the time of diagnosis correlated with a poorer overall response rate and that BMI was an independent risk factor in HL patients treated with the ABVD-like regimen. Lower doses of ABVD-like regimen contributed to the discrepant findings of responses in the high BMI groups. These findings indicate that newly-diagnosed, obese HL patients receiving an ABVD-like regimen require personalized treatment.
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Affiliation(s)
- Min Hu
- Department of Pharmacy, The First Affiliated Hospital of Soochow University, Suzhou, China
- Department of Pharmacy, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yiduo Ding
- Department of Pharmacy, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Haizhou Zhang
- Department of Pharmacy, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Wei Guo
- Department of Pharmacy, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yun Li
- Department of Pharmacy, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Zhengming Jin
- Department of Hematology, Collaborative Innovation Center of Hematology, Institute of Blood and Marrow Transplantation, The First Affiliated Hospital of Soochow University, Jiangsu Institute of Hematology, Suzhou, China
| | - Changju Qu
- Department of Hematology, Collaborative Innovation Center of Hematology, Institute of Blood and Marrow Transplantation, The First Affiliated Hospital of Soochow University, Jiangsu Institute of Hematology, Suzhou, China
| | - Fan Xia
- Department of Pharmacy, The First Affiliated Hospital of Soochow University, Suzhou, China
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Rinaldi I, Sari RM, Tedhy VU, Winston K. Leukapheresis Does Not Improve Early Survival Outcome of Acute Myeloid Leukemia with Leukostasis Patients - A Dual-Center Retrospective Cohort Study. J Blood Med 2021; 12:623-633. [PMID: 34290537 PMCID: PMC8286962 DOI: 10.2147/jbm.s312140] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2021] [Accepted: 06/30/2021] [Indexed: 01/12/2023] Open
Abstract
Introduction Leukostasis is a medical emergency with high mortality which often occurs in acute myeloid leukemia patients with hyperleukocytosis. One of the therapies that can be used for leukostasis in acute myeloid leukemia is leukapheresis. However, whether leukapheresis can provide better survival benefit when compared with patients not receiving leukapheresis is still unclear. Hence, we aimed to evaluate the effect of chemotherapy plus leukapheresis combination versus chemotherapy only on 28-day survival of acute myeloid leukemia patients with leukostasis. Methods This study was a dual-center retrospective cohort using secondary data from medical records collected from November 2018 to March 2019. Inclusion criteria were adult patients aged 18 years old or above, diagnosed with acute leukemia with hyperleukocytosis status defined by WBC count greater than 100,000/uL, and with symptoms of leukostasis. One-month survival analysis was conducted using Kaplan–Meier curve method. Univariate and multivariate analyses were then conducted using Cox proportional hazards model to obtain value of hazard ratio (HR) with a 95% confidence interval (CI). Results A total of 38 patients were obtained for analysis. The median overall survival was 25 days (95% CI: 17.001–32.999 days) in the chemotherapy only group and 20 days (95% CI: 1.497–38.503) in the chemotherapy with leukapheresis group. The use of leukapheresis did not affect 28-day survival (HR: 1.140; 95% CI: 0.396–3.283; p value: 0.809) and 7-day survival (HR: 1.073; 95% CI: 0.277–4.152; p value: 0.919). In the multivariate analysis, age ≥60 years, blast percentage ≥90%, creatinine ≥1.4 mg/dL, and presence of disseminated intravascular coagulation were associated with worse 28-day survival. Conclusion AML patients with leukostasis who received both chemotherapy and leukapheresis did not have better 28-day survival and 7-day survival when compared with patients receiving chemotherapy only. Old age, high blast percentage, high creatinine, and presence of disseminated intravascular coagulation were prognostic factors for worse 28-day survival.
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Affiliation(s)
- Ikhwan Rinaldi
- Division of Hematology and Medical Oncology, Department of Internal Medicine, Cipto Mangunkusumo National General Hospital, Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia
| | - Resti Mulya Sari
- Division of Hematology and Medical Oncology, Department of Internal Medicine, Dharmais National Cancer Hospital, Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia
| | | | - Kevin Winston
- Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia
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Khouri J, Rybicki L, Majhail NS, Kalaycio M, Pohlman B, Hill B, Jagadeesh D, Dean R, Hamilton B, Sobecks R, Koo A, Liu H. Body mass index does not impact hematopoietic progenitor cell mobilization for autologous hematopoietic cell transplantation. J Clin Apher 2019; 34:638-645. [PMID: 31381194 DOI: 10.1002/jca.21739] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2019] [Revised: 06/14/2019] [Accepted: 07/16/2019] [Indexed: 02/04/2023]
Abstract
BACKGROUND Obesity has implications for hematopoietic progenitor cell (HPC) mobilization, chemotherapy administration, and medication dosing. We analyzed the impact of obesity on HPC mobilization as well as key outcomes that are associated with cell dose in autologous hematopoietic cell transplantation (AHCT) recipients. METHODS We conducted a retrospective cohort study on 556 consecutive eligible AHCT recipients at our institution from 1/2004 to 12/2009. Patients were categorized into four groups based on the body mass index (BMI): underweight (BMI < 18.5), normal (18.5-24.9), overweight (25.0-29.9), or obese (≥30.0). Primary endpoints of interest included HPC mobilization, neutrophil and platelet recovery, hospital stay and survival. RESULTS The diagnoses were mostly non-Hodgkin lymphoma, multiple myeloma, and Hodgkin lymphoma. The majority of the patients had received three or less prior chemotherapy regimens and had not received prior radiation therapy. Most patients had chemosensitive disease at time of transplant. For HPC mobilization regimen, 68% received chemotherapy and G-CSF, 32% received G-CSF alone. Busuflan/etoposide/cyclophosphamide, melphalan, and busulfan/cyclophosphamide were used for conditioning. Obesity did not correlate with HPC mobilization and had no association with neutrophil or platelet recovery, or length of transplant hospitalization. On multivariable analysis, obese patients demonstrated better survival than those who were not obese. CONCLUSION Obese AHCT recipients had similar rates of HPC mobilization, neutrophil and platelet engraftment and length of transplant hospitalization, and experienced better survival compared with recipients with lower BMI. High BMI by itself should not be considered as a contraindication to AHCT.
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Affiliation(s)
- Jack Khouri
- Blood & Marrow Transplant Program, Taussig Cancer Center, Cleveland Clinic, Cleveland, Ohio.,Therapeutic Apheresis, Taussig Cancer Center, Cleveland Clinic, Cleveland, Ohio
| | - Lisa Rybicki
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio
| | - Navneet S Majhail
- Blood & Marrow Transplant Program, Taussig Cancer Center, Cleveland Clinic, Cleveland, Ohio
| | - Matt Kalaycio
- Blood & Marrow Transplant Program, Taussig Cancer Center, Cleveland Clinic, Cleveland, Ohio
| | - Brad Pohlman
- Blood & Marrow Transplant Program, Taussig Cancer Center, Cleveland Clinic, Cleveland, Ohio
| | - Brian Hill
- Blood & Marrow Transplant Program, Taussig Cancer Center, Cleveland Clinic, Cleveland, Ohio
| | - Deepa Jagadeesh
- Blood & Marrow Transplant Program, Taussig Cancer Center, Cleveland Clinic, Cleveland, Ohio
| | - Robert Dean
- Blood & Marrow Transplant Program, Taussig Cancer Center, Cleveland Clinic, Cleveland, Ohio
| | - Betty Hamilton
- Blood & Marrow Transplant Program, Taussig Cancer Center, Cleveland Clinic, Cleveland, Ohio
| | - Ronald Sobecks
- Blood & Marrow Transplant Program, Taussig Cancer Center, Cleveland Clinic, Cleveland, Ohio
| | - Anna Koo
- Therapeutic Apheresis, Taussig Cancer Center, Cleveland Clinic, Cleveland, Ohio
| | - Hien Liu
- Department of Blood and Marrow Transplant and Cellular Immunotherapy, Moffitt Cancer Center, Tampa, Florida
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Hytting-Andreasen R, Balk-Møller E, Hartmann B, Pedersen J, Windeløv JA, Holst JJ, Kissow H. Endogenous glucagon-like peptide- 1 and 2 are essential for regeneration after acute intestinal injury in mice. PLoS One 2018; 13:e0198046. [PMID: 29864142 PMCID: PMC5986149 DOI: 10.1371/journal.pone.0198046] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2018] [Accepted: 05/12/2018] [Indexed: 12/15/2022] Open
Abstract
Objective Mucositis is a side effect of chemotherapy seen in the digestive tract, with symptoms including pain, diarrhoea, inflammation and ulcerations. Our aim was to investigate whether endogenous glucagon-like peptide -1 and -2 (GLP-1 and GLP-2) are implicated in intestinal healing after chemotherapy-induced mucositis. Design We used a transgenic mouse model Tg(GCG.DTR)(Tg) expressing the human diphtheria toxin receptor in the proglucagon-producing cells. Injections with diphtheria toxin ablated the GLP-1 and GLP-2 producing L-cells in Tg mice with no effect in wild-type (WT) mice. Mice were injected with 5-fluorouracil or saline and received vehicle, exendin-4, teduglutide (gly2-GLP-2), or exendin-4/teduglutide in combination. The endpoints were body weight change, small intestinal weight, morphology, histological scoring of mucositis and myeloperoxidase levels. Results Ablation of L-cells led to impaired GLP-2 secretion; increased loss of body weight; lower small intestinal weight; lower crypt depth, villus height and mucosal area; and increased the mucositis severity score in mice given 5-fluorouracil. WT mice showed compensatory hyperproliferation as a sign of regeneration in the recovery phase. Co-treatment with exendin-4 and teduglutide rescued the body weight of the Tg mice and led to a hyperproliferation in the small intestine, whereas single treatment was less effective. Conclusion The ablation of L-cells leads to severe mucositis and insufficient intestinal healing, shown by severe body weight loss and lack of compensatory hyperproliferation in the recovery phase. Co-treatment with exendin-4 and teduglutide could prevent this. Because both peptides were needed, we can conclude that both GLP-1 and GLP-2 are essential for intestinal healing in mice.
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Affiliation(s)
- Rasmus Hytting-Andreasen
- Department of Biomedical Sciences, University of Copenhagen, Copenhagen, Denmark
- NNF Center of Basic Metabolic Research, University of Copenhagen, Copenhagen, Denmark
| | - Emilie Balk-Møller
- Department of Biomedical Sciences, University of Copenhagen, Copenhagen, Denmark
- NNF Center of Basic Metabolic Research, University of Copenhagen, Copenhagen, Denmark
| | - Bolette Hartmann
- Department of Biomedical Sciences, University of Copenhagen, Copenhagen, Denmark
- NNF Center of Basic Metabolic Research, University of Copenhagen, Copenhagen, Denmark
| | - Jens Pedersen
- Department of Biomedical Sciences, University of Copenhagen, Copenhagen, Denmark
- NNF Center of Basic Metabolic Research, University of Copenhagen, Copenhagen, Denmark
| | - Johanne Agerlin Windeløv
- Department of Biomedical Sciences, University of Copenhagen, Copenhagen, Denmark
- NNF Center of Basic Metabolic Research, University of Copenhagen, Copenhagen, Denmark
| | - Jens Juul Holst
- Department of Biomedical Sciences, University of Copenhagen, Copenhagen, Denmark
- NNF Center of Basic Metabolic Research, University of Copenhagen, Copenhagen, Denmark
| | - Hannelouise Kissow
- Department of Biomedical Sciences, University of Copenhagen, Copenhagen, Denmark
- NNF Center of Basic Metabolic Research, University of Copenhagen, Copenhagen, Denmark
- * E-mail:
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Shultes KC, Arp C, Stockerl-Goldstein K, Trinkaus K, DeFrates S. Impact of Dose-Adjusted Melphalan in Obese Patients Undergoing Autologous Stem Cell Transplantation. Biol Blood Marrow Transplant 2017; 24:687-693. [PMID: 29225163 DOI: 10.1016/j.bbmt.2017.11.041] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2017] [Accepted: 11/30/2017] [Indexed: 12/21/2022]
Abstract
Limited guidance exists for dosing melphalan for autologous stem cell transplantation (ASCT) in the obese patient population, because the current literature reports conflicting clinical outcomes between obese and nonobese patients. In 2014, the American Society for Blood and Marrow Transplantation published conditioning chemotherapy dosing guidelines for obese patients and recommended dosing of melphalan using actual body weight (ABW) in the body surface area calculation. The practice at Barnes-Jewish Hospital has consistently been to dose melphalan using adjusted body weight (AdBW), with a 20% correction when a patient weighs ≥120% of his or her ideal body weight (IBW). The purpose of this study was to compare outcomes of melphalan ASCT in patients with multiple myeloma between obese (≥120% IBW) and nonobese (<120% IBW) populations. This retrospective, single-center study included adult patients with multiple myeloma undergoing first ASCT with melphalan conditioning between January 2009 and December 2012. Patient demographic data, transplantation characteristics, and clinical outcomes were collected. The primary outcome was 3-year event-free survival (EFS). Secondary outcomes included response at 100 days post-transplantation, 3-year overall survival, treatment-related mortality (TRM), time to neutrophil engraftment, and hospital length of stay (LOS). To ensure that melphalan dosage adjustment in the obese population did not impact efficacy, the primary outcome was assessed using a noninferiority design, with a predetermined noninferiority margin of 7%. Assuming a 70% 3-year EFS in the nonobese population, a noninferiority margin of 7%, a power of 80%, and an α value of .05, an analysis of 280 patients was required. A total of 270 patients, including 171 (63%) obese patients and 99 (37%) nonobese patients, met our inclusion criteria. Baseline characteristics were well matched between the 2 cohorts, including high-risk cytogenetics, disease severity at diagnosis, and use of maintenance therapy, with the only detectable differences related to weight itself. The 3-year EFS was 41% for the total cohort, with fewer events occurring in the obese cohort compared with the nonobese cohort (51% versus 40%; P = .0025). The 95% lower confidence limit established noninferiority. High-risk cytogenetics, disease severity at diagnosis, and therapy response pre- and post-ASCT were all associated with significantly shorter EFS. No between-group differences in TRM, time to engraftment, or hospital LOS were noted. This retrospective, single-center study found that using AdBW to dose melphalan in obese patients was not inferior to the nonobese population in terms of 3-year EFS. This study adds to the limited evidence on melphalan dosing and suggests that transplantation efficacy is not affected by AdBW dosing in obese patients. Further studies are needed to provide additional insight into the pharmacokinetic differences and best dosing practices for obese patients.
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Affiliation(s)
| | - Christopher Arp
- Department of Pharmacy, Carolinas Medical Center, Charlotte, North Carolina
| | - Keith Stockerl-Goldstein
- Department of Medicine, Bone Marrow Transplantation and Leukemia, Washington University School of Medicine, St. Louis, Missouri
| | - Kathryn Trinkaus
- Biostatistics Shared Resource, Siteman Cancer Center, Washington University School of Medicine, St. Louis, Missouri
| | - Sean DeFrates
- Department of Pharmacy, Northwestern Memorial Hospital, Chicago, Illinois
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Xiong Y, Fukuda T, Knibbe CAJ, Vinks AA. Drug Dosing in Obese Children: Challenges and Evidence-Based Strategies. Pediatr Clin North Am 2017; 64:1417-1438. [PMID: 29173794 DOI: 10.1016/j.pcl.2017.08.011] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
With the alarming increase of obesity in children, pediatricians are increasingly being confronted with difficult dosing decisions. Many drug labels do not provide specific dosing instructions for children who are obese. In this article, we describe the physiologic parameters altered by obesity and their influences on drug disposition and effect. We review the principles of allometry, and the key pharmacokinetic parameters that can be used to derive age appropriate dosing regimens. Last, we illustrate how appropriate weight descriptors can be selected, and how important PK parameters can be extrapolated for dosing in obese children when pediatric pharmacokinetic information is available.
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Affiliation(s)
- Ye Xiong
- Division of Clinical Pharmacology, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, MLC 6018, Cincinnati, OH 45229-3039, USA
| | - Tsuyoshi Fukuda
- Division of Clinical Pharmacology, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, MLC 6018, Cincinnati, OH 45229-3039, USA; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Catherijne A J Knibbe
- Department of Clinical Pharmacy, St Antonius Hospital, PO Box 2500, Nieuwegein 3430 EM, The Netherlands; Division of Pharmacology, Leiden Academic Center for Drug Research, Faculty of Science, Leiden University, PO Box 9502, 2300 RA, Leiden, The Netherlands
| | - Alexander A Vinks
- Division of Clinical Pharmacology, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, MLC 6018, Cincinnati, OH 45229-3039, USA; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA.
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BEAM conditioning is well-tolerated and yields similar survival in obese and non-obese patients with lymphoma: no requirement for weight-based dose modifications. Bone Marrow Transplant 2017; 52:491-493. [PMID: 28067889 PMCID: PMC5332312 DOI: 10.1038/bmt.2016.316] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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Castillo JJ, Mulkey F, Geyer S, Kolitz JE, Blum W, Powell BL, George SL, Larson RA, Stone RM. Relationship between obesity and clinical outcome in adults with acute myeloid leukemia: A pooled analysis from four CALGB (alliance) clinical trials. Am J Hematol 2016; 91:199-204. [PMID: 26526191 DOI: 10.1002/ajh.24230] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2015] [Revised: 10/19/2015] [Accepted: 10/30/2015] [Indexed: 01/28/2023]
Abstract
Obesity has been previously suggested as an adverse prognostic marker in patients with acute leukemia. To evaluate the relationship between obesity and clinical outcome, disease-free survival (DFS) and overall survival (OS), in patients with acute myelogenous leukemia (AML), including acute promyelocytic leukemia (APL), we performed a pooled analysis of four CALGB (Alliance) clinical trials. Our study included 446 patients with APL from CALGB 9710, and 1,648 patients between 18 and 60 years of age with non-APL AML from CALGB 9621, 10503, and 19808. Obesity was defined as BMI ≥30 kg/m(2). Multivariate Cox proportional-hazard regression models were fitted for DFS and OS. Obesity was seen in 50% and 38% of APL and non-APL AML patients, respectively. In APL patients, obesity was associated with worse DFS (HR 1.53, 95% CI 1.03-2.27; P = 0.04) and OS (HR 1.72, 95% CI 1.15-2.58; P = 0.01) after adjusting for age, sex, performance status, race, ethnicity, treatment arm and baseline white blood cell count. Obesity was not significantly associated with DFS or OS in the non-APL AML patients. In conclusion, our study indicates that obesity has significant prognostic value for DFS and OS in APL patients, but not for non-APL AML patients.
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Affiliation(s)
- Jorge J. Castillo
- Division of Hematologic Malignancies; Dana-Farber Cancer Institute, Harvard Medical School; Boston Massachusetts
| | - Flora Mulkey
- Alliance Statistics and Data Center, Duke University; Durham North Carolina
| | - Susan Geyer
- Health Informatics Institute, University of South Florida; Tampa Florida
| | | | - William Blum
- Division of Hematology; The Ohio State University Comprehensive Cancer Center; Columbus Ohio
| | - Bayard L. Powell
- Section on Hematology and Oncology; Comprehensive Cancer Center of Wake Forest University; Winston-Salem North Carolina
| | - Stephen L. George
- Alliance Statistics and Data Center, Duke University; Durham North Carolina
| | - Richard A. Larson
- Section of Hematology and Oncology; Comprehensive Cancer Center, University of Chicago; Chicago Illinois
| | - Richard M. Stone
- Division of Hematologic Malignancies; Dana-Farber Cancer Institute, Harvard Medical School; Boston Massachusetts
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Shem-Tov N, Labopin M, Moukhtari L, Ciceri F, Esteve J, Giebel S, Gorin NC, Schmid C, Shimoni A, Nagler A, Mohty M. Chemotherapy dose adjustment for obese patients undergoing hematopoietic stem cell transplantation: a survey on behalf of the Acute Leukemia Working Party of the European Society for Blood and Marrow Transplantation. Oncologist 2014; 20:50-5. [PMID: 25480827 DOI: 10.1634/theoncologist.2014-0187] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Appropriate chemotherapy dosing for obese patients with malignant diseases is a significant challenge because limiting chemotherapy doses in these patients may negatively influence outcome. There is a paucity of information addressing high-dose chemotherapy in obese patients undergoing hematopoietic stem cell transplantation (HSCT). METHODS The Acute Leukemia Working Party of the European Society for Blood and Marrow Transplantation (EBMT) designed an electronic survey to assess current practice of dose adjustment of chemotherapy in obese patients undergoing HSCT. RESULTS A total of 56 EBMT centers from 27 countries responded to the online survey. Overall, 45 centers declared that they routinely adjust chemotherapy doses for obese patients (80.5%), and only 11 (19.5%) declared they do not adjust dose. Among the former group, most used body mass index as the parameter for defining obesity (28 centers, 62%). The method for determining the weight for chemotherapy calculation was actual body weight (ABW) in 16 centers, ideal body weight (IBW) in 10 centers, IBW plus 25% of the difference between IBW and ABW in 16 centers, and other methods for the rest. Among centers that used dose adjustment, 44% also capped the dose at 2 m(2) for a chemotherapy dose based on body surface area (BSA), whereas 56% did not cap. Interestingly, most of the centers (9 of 11) that did not adjust dose for weight also did not cap the BSA at 2 m(2). CONCLUSION This EBMT survey revealed large diversity among transplant centers regarding dose-adjustment practice for high-dose conditioning chemotherapy. Our next step is to analyze outcomes of transplantation according to dose-adjustment practice and, subsequently, to formulate a methodology for future prospective studies.
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Affiliation(s)
- Noga Shem-Tov
- Division of Hematology and Bone Marrow Transplantation, Chaim Sheba Medical Center, Tel-Hashomer, Israel; EBMT Acute Leukemia Working Party and Registry, Department of Hematology and Cell Therapy, Hospital Saint-Antoine, Paris University, Paris, France; San Raffaele Telethon Institute for Gene Therapy (TIGET), San Raffaele Scientific Institute, Milan, Italy; Hematology Department, IDIBAPS, Hospital Clínic, Barcelona, Spain; Department of Bone Marrow Transplantation and Onco-Hematology, Maria Sklodowska-Curie Memorial Cancer Center and Institute of Oncology, Gliwice Branch, Gliwice, Poland; Department of Hematology and Oncology, Klinikum Augsburg, Ludwing-Maximilinas-Universitat Munich, Germany
| | - Myriam Labopin
- Division of Hematology and Bone Marrow Transplantation, Chaim Sheba Medical Center, Tel-Hashomer, Israel; EBMT Acute Leukemia Working Party and Registry, Department of Hematology and Cell Therapy, Hospital Saint-Antoine, Paris University, Paris, France; San Raffaele Telethon Institute for Gene Therapy (TIGET), San Raffaele Scientific Institute, Milan, Italy; Hematology Department, IDIBAPS, Hospital Clínic, Barcelona, Spain; Department of Bone Marrow Transplantation and Onco-Hematology, Maria Sklodowska-Curie Memorial Cancer Center and Institute of Oncology, Gliwice Branch, Gliwice, Poland; Department of Hematology and Oncology, Klinikum Augsburg, Ludwing-Maximilinas-Universitat Munich, Germany
| | - Leila Moukhtari
- Division of Hematology and Bone Marrow Transplantation, Chaim Sheba Medical Center, Tel-Hashomer, Israel; EBMT Acute Leukemia Working Party and Registry, Department of Hematology and Cell Therapy, Hospital Saint-Antoine, Paris University, Paris, France; San Raffaele Telethon Institute for Gene Therapy (TIGET), San Raffaele Scientific Institute, Milan, Italy; Hematology Department, IDIBAPS, Hospital Clínic, Barcelona, Spain; Department of Bone Marrow Transplantation and Onco-Hematology, Maria Sklodowska-Curie Memorial Cancer Center and Institute of Oncology, Gliwice Branch, Gliwice, Poland; Department of Hematology and Oncology, Klinikum Augsburg, Ludwing-Maximilinas-Universitat Munich, Germany
| | - Fabio Ciceri
- Division of Hematology and Bone Marrow Transplantation, Chaim Sheba Medical Center, Tel-Hashomer, Israel; EBMT Acute Leukemia Working Party and Registry, Department of Hematology and Cell Therapy, Hospital Saint-Antoine, Paris University, Paris, France; San Raffaele Telethon Institute for Gene Therapy (TIGET), San Raffaele Scientific Institute, Milan, Italy; Hematology Department, IDIBAPS, Hospital Clínic, Barcelona, Spain; Department of Bone Marrow Transplantation and Onco-Hematology, Maria Sklodowska-Curie Memorial Cancer Center and Institute of Oncology, Gliwice Branch, Gliwice, Poland; Department of Hematology and Oncology, Klinikum Augsburg, Ludwing-Maximilinas-Universitat Munich, Germany
| | - Jordi Esteve
- Division of Hematology and Bone Marrow Transplantation, Chaim Sheba Medical Center, Tel-Hashomer, Israel; EBMT Acute Leukemia Working Party and Registry, Department of Hematology and Cell Therapy, Hospital Saint-Antoine, Paris University, Paris, France; San Raffaele Telethon Institute for Gene Therapy (TIGET), San Raffaele Scientific Institute, Milan, Italy; Hematology Department, IDIBAPS, Hospital Clínic, Barcelona, Spain; Department of Bone Marrow Transplantation and Onco-Hematology, Maria Sklodowska-Curie Memorial Cancer Center and Institute of Oncology, Gliwice Branch, Gliwice, Poland; Department of Hematology and Oncology, Klinikum Augsburg, Ludwing-Maximilinas-Universitat Munich, Germany
| | - Sebastian Giebel
- Division of Hematology and Bone Marrow Transplantation, Chaim Sheba Medical Center, Tel-Hashomer, Israel; EBMT Acute Leukemia Working Party and Registry, Department of Hematology and Cell Therapy, Hospital Saint-Antoine, Paris University, Paris, France; San Raffaele Telethon Institute for Gene Therapy (TIGET), San Raffaele Scientific Institute, Milan, Italy; Hematology Department, IDIBAPS, Hospital Clínic, Barcelona, Spain; Department of Bone Marrow Transplantation and Onco-Hematology, Maria Sklodowska-Curie Memorial Cancer Center and Institute of Oncology, Gliwice Branch, Gliwice, Poland; Department of Hematology and Oncology, Klinikum Augsburg, Ludwing-Maximilinas-Universitat Munich, Germany
| | - Norbert-Claude Gorin
- Division of Hematology and Bone Marrow Transplantation, Chaim Sheba Medical Center, Tel-Hashomer, Israel; EBMT Acute Leukemia Working Party and Registry, Department of Hematology and Cell Therapy, Hospital Saint-Antoine, Paris University, Paris, France; San Raffaele Telethon Institute for Gene Therapy (TIGET), San Raffaele Scientific Institute, Milan, Italy; Hematology Department, IDIBAPS, Hospital Clínic, Barcelona, Spain; Department of Bone Marrow Transplantation and Onco-Hematology, Maria Sklodowska-Curie Memorial Cancer Center and Institute of Oncology, Gliwice Branch, Gliwice, Poland; Department of Hematology and Oncology, Klinikum Augsburg, Ludwing-Maximilinas-Universitat Munich, Germany
| | - Christopher Schmid
- Division of Hematology and Bone Marrow Transplantation, Chaim Sheba Medical Center, Tel-Hashomer, Israel; EBMT Acute Leukemia Working Party and Registry, Department of Hematology and Cell Therapy, Hospital Saint-Antoine, Paris University, Paris, France; San Raffaele Telethon Institute for Gene Therapy (TIGET), San Raffaele Scientific Institute, Milan, Italy; Hematology Department, IDIBAPS, Hospital Clínic, Barcelona, Spain; Department of Bone Marrow Transplantation and Onco-Hematology, Maria Sklodowska-Curie Memorial Cancer Center and Institute of Oncology, Gliwice Branch, Gliwice, Poland; Department of Hematology and Oncology, Klinikum Augsburg, Ludwing-Maximilinas-Universitat Munich, Germany
| | - Avichai Shimoni
- Division of Hematology and Bone Marrow Transplantation, Chaim Sheba Medical Center, Tel-Hashomer, Israel; EBMT Acute Leukemia Working Party and Registry, Department of Hematology and Cell Therapy, Hospital Saint-Antoine, Paris University, Paris, France; San Raffaele Telethon Institute for Gene Therapy (TIGET), San Raffaele Scientific Institute, Milan, Italy; Hematology Department, IDIBAPS, Hospital Clínic, Barcelona, Spain; Department of Bone Marrow Transplantation and Onco-Hematology, Maria Sklodowska-Curie Memorial Cancer Center and Institute of Oncology, Gliwice Branch, Gliwice, Poland; Department of Hematology and Oncology, Klinikum Augsburg, Ludwing-Maximilinas-Universitat Munich, Germany
| | - Arnon Nagler
- Division of Hematology and Bone Marrow Transplantation, Chaim Sheba Medical Center, Tel-Hashomer, Israel; EBMT Acute Leukemia Working Party and Registry, Department of Hematology and Cell Therapy, Hospital Saint-Antoine, Paris University, Paris, France; San Raffaele Telethon Institute for Gene Therapy (TIGET), San Raffaele Scientific Institute, Milan, Italy; Hematology Department, IDIBAPS, Hospital Clínic, Barcelona, Spain; Department of Bone Marrow Transplantation and Onco-Hematology, Maria Sklodowska-Curie Memorial Cancer Center and Institute of Oncology, Gliwice Branch, Gliwice, Poland; Department of Hematology and Oncology, Klinikum Augsburg, Ludwing-Maximilinas-Universitat Munich, Germany
| | - Mohamad Mohty
- Division of Hematology and Bone Marrow Transplantation, Chaim Sheba Medical Center, Tel-Hashomer, Israel; EBMT Acute Leukemia Working Party and Registry, Department of Hematology and Cell Therapy, Hospital Saint-Antoine, Paris University, Paris, France; San Raffaele Telethon Institute for Gene Therapy (TIGET), San Raffaele Scientific Institute, Milan, Italy; Hematology Department, IDIBAPS, Hospital Clínic, Barcelona, Spain; Department of Bone Marrow Transplantation and Onco-Hematology, Maria Sklodowska-Curie Memorial Cancer Center and Institute of Oncology, Gliwice Branch, Gliwice, Poland; Department of Hematology and Oncology, Klinikum Augsburg, Ludwing-Maximilinas-Universitat Munich, Germany
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10
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Hunter MR, Sabo RT, McCarty JM, Newland AM. Effectiveness and toxicity of high-dose cyclophosphamide in obese versus non-obese patients receiving allogeneic hematopoietic stem cell transplant. J Oncol Pharm Pract 2014; 22:54-9. [PMID: 25245037 DOI: 10.1177/1078155214549617] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
PURPOSE To determine if there is a difference in toxicity and effectiveness between obese and non-obese patients who receive high-dose cyclophosphamide (Cy) prior to allogeneic hematopoietic stem cell transplant (allo-HCT). METHODS Patients were included in this study if they were at least 18 years of age and received high-dose Cy in combination with total body irradiation (CyTBI) or busulfan (BuCy) prior to allo-HCT between 1 January 2008 and 29 February 2012. The primary endpoint was the difference in overall toxicity between obese and non-obese patients. Secondary objectives examined differences in effectiveness between groups assessed by relapse at day +100, relapse at 1 year, death at 1 year, chimerisms at days +30, +60, and +90, and incidence of acute graft versus host disease (aGVHD). RESULTS Sixty-one patients met the inclusion criteria, 28 obese and 33 non-obese. Overall toxicity was greater in obese patients compared to non-obese patients (82% vs. 52%, OR 4.3 [95% CI 1.3-14.1]; p = 0.01), which was driven by a greater incidence of renal dysfunction (79% vs. 48%, OR 3.9 [95% CI 1.3-12.1]; p = 0.02). There were no differences in rates of grade 3 or 4 toxicity, hepatic dysfunction, or any measure of effectiveness between groups. CONCLUSION Obese patients receiving high-dose Cy and allo-HCT are at increased risk for toxicity, although there appears to be no difference in the rate of relapse or survival between obese and non-obese patients.
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Affiliation(s)
- Melissa R Hunter
- Department of Pharmacy Services, Virginia Commonwealth University Health System/Medical College of Virginia Hospitals, Richmond, VA, USA
| | - Roy T Sabo
- Department of Biostatistics, Virginia Commonwealth University School of Medicine, Richmond, VA, USA
| | - John M McCarty
- Bone Marrow Transplant Program, Virginia Commonwealth University Health System/Medical College of Virginia Hospitals; Richmond, VA, USA Hematology-Oncology, Internal Medicine, Virginia Commonwealth University School of Medicine, Richmond, VA, USA
| | - Ashley M Newland
- Department of Pharmacy Services, Virginia Commonwealth University Health System/Medical College of Virginia Hospitals, Richmond, VA, USA Hematology/Oncology, Health System/Medical College of Virginia Hospitals, Virginia Commonwealth University Virginia Commonwealth University School of Pharmacy, Richmond, VA, USA
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11
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Bubalo J, Carpenter PA, Majhail N, Perales MA, Marks DI, Shaughnessy P, Pidala J, Leather HL, Wingard J, Savani BN. Conditioning chemotherapy dose adjustment in obese patients: a review and position statement by the American Society for Blood and Marrow Transplantation practice guideline committee. Biol Blood Marrow Transplant 2014; 20:600-16. [PMID: 24462742 DOI: 10.1016/j.bbmt.2014.01.019] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2014] [Accepted: 01/21/2014] [Indexed: 01/15/2023]
Abstract
Hematopoietic stem cell transplantation (HCT) is a potentially life-saving therapy for patients with malignant and nonmalignant disease states. This article reviews the current published literature on the dosing of pharmacologic agents used for HCT preparative regimens with specific focus on the obese patient population. The review found that dose adjustments for obesity have, to date, been based empirically or extrapolated from published data in the nontransplantation patient population. As a result, the Committee determined that clear standards or dosing guidelines are unable to be made for the obese population because Level I and II evidence are unavailable at this time. Instead, the Committee provides a current published literature review to serve as a platform for conditioning agent dose selection in the setting of obesity. A necessary goal should be to encourage future prospective trials in this patient population because further information is needed to enhance our knowledge of the pharmacokinetics and pharmacodynamics of conditioning agents in the setting of obesity.
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Affiliation(s)
- Joseph Bubalo
- Department of Pharmacy Services, Oregon Health and Science University Hospital, Portland, Oregon.
| | | | - Navneet Majhail
- Blood and Marrow Transplant Program, Cleveland Clinic, Cleveland, Ohio
| | - Miguel-Angel Perales
- Adult Bone Marrow Transplantation Service, Department of Medicine, Memorial Sloan-Kettering Cancer Center, New York, New York; Weill Cornell Medical College, New York, New York
| | - David I Marks
- Bristol Bone Marrow Transplant Unit, University Hospitals Bristol NHS Foundation Trust, Bristol, United Kingdom
| | - Paul Shaughnessy
- Adult Bone Marrow Transplant, Texas Transplant Institute, San Antonio, Texas
| | - Joseph Pidala
- Division of Blood and Marrow Transplantation, Moffitt Cancer Center, Tampa, Florida
| | - Helen L Leather
- Division of Hematology/Oncology, University of Florida Health Cancer Center, Gainesville, Florida
| | - John Wingard
- Division of Hematology/Oncology, University of Florida Health Cancer Center, Gainesville, Florida
| | - Bipin N Savani
- Vanderbilt University Medical Center, Nashville, Tennessee
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12
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Anglada-Martínez H, Riu-Viladoms G, do Pazo-Oubiña F, Molas-Ferrer G, Mangues-Bafalluy I, Codina-Jané C, Creus-Baró N. Dosing of chemotherapy in obese and cachectic patients: results of a national survey. Int J Clin Pharm 2014; 36:589-95. [DOI: 10.1007/s11096-014-9942-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2013] [Accepted: 03/25/2014] [Indexed: 10/25/2022]
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13
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Effect of body mass in children with hematologic malignancies undergoing allogeneic bone marrow transplantation. Blood 2014; 123:3504-11. [PMID: 24711663 DOI: 10.1182/blood-2013-03-490334] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
The rising incidence of pediatric obesity may significantly affect bone marrow transplantation (BMT) outcomes. We analyzed outcomes in 3687 children worldwide who received cyclophosphamide-based BMT regimens for leukemias between 1990 and 2007. Recipients were classified according to age-adjusted body mass index (BMI) percentiles as underweight (UW), at risk of UW (RUW), normal, overweight (OW), or obese (OB). Median age and race were similar in all groups. Sixty-one percent of OB children were from the United States/Canada. Three-year relapse-free and overall survival ranged from 48% to 52% (P = .54) and 55% to 58% (P = .81) across BMI groups. Three-year leukemia relapses were 33%, 33%, 29%, 25%, and 21% in the UW, RUW, normal, OW, and OB groups, respectively (P < .001). Corresponding cumulative incidences for transplant-related mortality (TRM) were 18%, 19%, 21%, 22%, and 28% (P < .01). Multivariate analysis demonstrated a decreased risk of relapse compared with normal BMI (relative risk [RR] = 0.73; P < .01) and a trend toward higher TRM (RR = 1.28; P = .014). BMI in children is not significantly associated with different survival after BMT for hematologic malignancies. Obese children experience less relapse posttransplant compared with children with normal BMI; however, this benefit is offset by excess in TRM.
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14
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Impact of being overweight on outcomes of hematopoietic SCT: a meta-analysis. Bone Marrow Transplant 2013; 49:66-72. [DOI: 10.1038/bmt.2013.128] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2013] [Revised: 07/08/2013] [Accepted: 07/15/2013] [Indexed: 12/11/2022]
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15
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Brunner AM, Sadrzadeh H, Feng Y, Drapkin BJ, Ballen KK, Attar EC, Amrein PC, McAfee SL, Chen YBA, Neuberg DS, Fathi AT. Association between baseline body mass index and overall survival among patients over age 60 with acute myeloid leukemia. Am J Hematol 2013; 88:642-6. [PMID: 23619915 PMCID: PMC4214755 DOI: 10.1002/ajh.23462] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2013] [Revised: 03/21/2013] [Accepted: 04/16/2013] [Indexed: 12/31/2022]
Abstract
Acute myeloid leukemia (AML) is more common and more lethal among patients over the age of 60. Increased body mass index (BMI) has been associated with a higher incidence of various malignancies, including AML. We sought to determine whether patient BMI at the time of AML diagnosis is related to overall survival (OS) among elderly patients. We identified 97 patients with AML diagnosed after the age of 60 and treated with cytarabine-based induction chemotherapy. The median age was 68 years (range 60-87); 52% of patients were male, and our study population was predominantly white (89% of patients). The median OS for all patients was 316 days (95% CI 246-459). The hazard ratio for mortality was increased among patients with a BMI < 25 compared to BMI ≥ 30 (HR 2.14, P = 0.009, 95% CI 1.21-3.77), as well as with older age (HR 1.76, P = 0.015, 95% CI 1.12-2.79) and with secondary versus de novo disease (HR 1.95, P = 0.006, 95% CI 1.21-3.14). After multivariable analysis, we did not find a significant association between OS and other potential confounders such as coronary artery disease or diabetes among these patients. We conclude that increased BMI was independently associated with improved OS among older AML patients at our institution.
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Affiliation(s)
| | | | - Yang Feng
- Dana Farber Cancer Institute, Boston MA
| | | | - Karen K. Ballen
- Massachusetts General Hospital / Harvard Medical School, Boston MA
| | - Eyal C. Attar
- Massachusetts General Hospital / Harvard Medical School, Boston MA
| | - Philip C. Amrein
- Massachusetts General Hospital / Harvard Medical School, Boston MA
| | - Steven L. McAfee
- Massachusetts General Hospital / Harvard Medical School, Boston MA
| | - Yi-Bin A. Chen
- Massachusetts General Hospital / Harvard Medical School, Boston MA
| | | | - Amir T. Fathi
- Massachusetts General Hospital / Harvard Medical School, Boston MA
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16
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Lopes-Serrao MD, Ussery SMG, Hall RG, Shah SR. Evaluation of chemotherapy-induced severe myelosuppression incidence in obese patients with capped dosing. J Oncol Pract 2013; 7:13-7. [PMID: 21532803 DOI: 10.1200/jop.2010.000045] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/21/2010] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Clinicians typically cap an obese patient's chemotherapy regimen as a result of concern for excessive toxicity, without adequate clinical evidence. The purpose of this study was to evaluate the incidence of grade 3 or 4 myelosuppression in obese patients versus nonobese patients with capped dosing on the basis of body surface area (BSA). METHODS A retrospective chart review was conducted comparing obese patients (body mass index [BMI] ≥ 30 kg/m(2)) with capped dosing who received capped chemotherapy doses at a BSA of 2.2 m(2) with nonobese (BMI < 25 kg/m(2)) patients with lung, colorectal, or hormone-refractory prostate cancer. RESULTS Forty-one obese patients with capped dosing and 244 nonobese patients were included. The obese patient group received on average significantly more cycles of chemotherapy (6 v 4 cycles) compared with the nonobese group. The overall incidence of any chemotherapy-related toxicity was 34% in the obese patient group, compared with 42% in the nonobese patient group (P = .356). The incidence of grade 3 or 4 myelosuppression was lower, but not statistically significant, in obese patients with capped dosing compared with the nonobese patient group (22% v 27%; P = .493). CONCLUSIONS Overall, obese patients with capped dosing experienced a lower incidence of severe myelosuppression and tolerated more cycles of chemotherapy compared with nonobese patients. The better tolerability of chemotherapy in obese patients with capped dosing suggests that there is room to increase the dose in obese patients above the nationally recognized BSA cap of 2.0 m(2), especially in early-stage lung or colon cancers in which the intention of treatment is curative.
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Affiliation(s)
- Monique D Lopes-Serrao
- Veterans Affairs North Texas Health Care System; School of Pharmacy, Texas Tech University Health Sciences Center, Dallas, TX
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17
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Myers LC, Sun P, Brennan LL, London WB, Guinan EC. Effect of weight on outcomes of children undergoing hematopoietic cell transplantation. Pediatr Hematol Oncol 2013. [PMID: 23189973 DOI: 10.3109/08880018.2012.743201] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Chemotherapy dosing in hematopoietic cell therapy (HCT) conditioning regimens is based on patient weight. We hypothesized that potential underdosing or overdosing of patients with significant deviation of weight from normal might alter HCT outcomes, such as early mortality, overall or organ-specific toxicity, and/or relapse. We therefore conducted a retrospective analysis of 400 children between the ages of 2 and 18 years who underwent HCT for malignant or nonmalignant disease at Boston Children's Hospital over a 10-year period. Using the Centers for Disease Control and Prevention standard weight classification schema, we found no evidence to suggest a difference in survival or in time to engraftment or in relapse in patients with malignant disease. In the subgroups of patients either receiving autologous HCT or with underlying malignancy, combined overweight and obese patients had a higher rate of any organ, but not organ-specific, Grade 3-5 toxicity compared with the normal weight group. The study was not powered to detect a difference between underweight and normal weight patients. These data suggest that multiple outcome measures over the first year after HCT are unaffected by weight.
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Affiliation(s)
- Laura C Myers
- Department of Internal Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
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18
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De Angel RE, Blando JM, Hogan MG, Sandoval MA, Lansakara-P DSP, Dunlap SM, Hursting SD, Cui Z. Stearoyl gemcitabine nanoparticles overcome obesity-induced cancer cell resistance to gemcitabine in a mouse postmenopausal breast cancer model. Cancer Biol Ther 2013; 14:357-64. [PMID: 23358472 DOI: 10.4161/cbt.23623] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Obesity is associated with increased breast tumor aggressiveness and decreased response to multiple modalities of therapy in postmenopausal women. Delivering cancer chemotherapeutic drugs using nanoparticles has evolved as a promising approach to improve the efficacy of anticancer agents. However, the application of nanoparticles in cancer chemotherapy in the context of obesity has not been studied before. The nucleoside analog gemcitabine is widely used in solid tumor therapy. Previously, we developed a novel stearoyl gemcitabine solid-lipid nanoparticle formulation (GemC18-NPs) and showed that the GemC18-NPs are significantly more effective than gemcitabine in controlling tumor growth in mouse models. In the present study, using ovariectomized diet-induced obese female C57BL/6 mice with orthotopically transplanted MMTV-Wnt-1 mammary tumors as a model of postmenopausal obesity and breast cancer, we discovered that obesity induces tumor cell resistance to gemcitabine. Furthermore, our GemC18-NPs can overcome the obesity-related resistance to gemcitabine chemotherapy. These findings have important clinical implications for cancer chemotherapies involving gemcitabine or other nucleoside analogs in the context of obesity.
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Affiliation(s)
- Rebecca E De Angel
- College of Pharmacy, Pharmaceutics Division, University of Texas at Austin, Austin, TX, USA
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19
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Thompson LA, Lawson AP, Sutphin SD, Steinke D, Adams VR. Description of current practices of empiric chemotherapy dose adjustment in obese adult patients. J Oncol Pract 2011; 6:141-5. [PMID: 20808557 DOI: 10.1200/jop.200016] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/14/2010] [Indexed: 11/20/2022] Open
Abstract
PURPOSE The literature is not clear on the best method to empirically dose chemotherapy in obese adult patients. The purpose of our study was to determine whether a standard of practice existed, characterize current practices of empiric dose adjustment (EDA) in obese adult patients, and identify factors affecting this decision. METHODS An electronic survey was distributed to oncologists and board-certified oncology pharmacists via the Association of Community Cancer Centers and Board of Pharmaceutical Specialties e-mail distribution lists. The survey contained patient scenarios assessing the impact of various factors on EDA of chemotherapy, demographic information, and details of institutional policies. RESULTS Responses were collected from 174 professionals. Pharmacists comprised 95% of respondents. Of these, 50% practiced in academic medical centers, and 19% practiced in institutions with a standard of practice regarding EDA for obesity. The most common methods of EDA were use of an adjusted body weight in the body-surface area (BSA) equation and capping BSA. Factors with the most impact on EDA were curative intent, degree of obesity, type of chemotherapy, and performance status. CONCLUSION There is no standard of practice regarding EDA of chemotherapy in obese adult patients. Although many factors affect this decision, intent of treatment, degree of obesity, performance status, age, and type of medication seem to carry the most weight.
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Affiliation(s)
- Lisa A Thompson
- University of Colorado Denver School of Pharmacy, Aurora, CO; University of Kentucky HealthCare; and Department of Pharmacy Practice and Science, University of Kentucky College of Pharmacy, Lexington, KY
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20
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Vogl DT, Wang T, Pérez WS, Stadtmauer EA, Heitjan DF, Lazarus HM, Kyle RA, Kamble R, Weisdorf D, Roy V, Gibson J, Ballen K, Holmberg L, Bashey A, McCarthy PL, Freytes C, Maharaj D, Maiolino A, Vesole D, Hari P. Effect of obesity on outcomes after autologous hematopoietic stem cell transplantation for multiple myeloma. Biol Blood Marrow Transplant 2011; 17:1765-74. [PMID: 21624486 DOI: 10.1016/j.bbmt.2011.05.005] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2011] [Accepted: 05/02/2011] [Indexed: 12/22/2022]
Abstract
Obesity has implications for chemotherapy dosing and selection of patients for therapy. Autologous hematopoietic stem cell transplant (AutoHCT) improves outcomes for patients with multiple myeloma, but optimal chemotherapy dosing for obese patients is poorly defined. We analyzed the outcomes of 1087 recipients of AutoHCT for myeloma reported to the CIBMTR between 1995 and 2003 who received high-dose melphalan conditioning, with or without total body irradiation (TBI). We categorized patients by body mass index (BMI) as normal, overweight, obese, or severely obese. There was no overall effect of BMI on progression-free survival (PFS), overall survival (OS), progression, or nonrelapse mortality (NRM). In patients receiving melphalan and TBI conditioning, obese and severely obese patients had superior PFS and OS compared with normal and overweight patients, but the clinical significance of this finding is unclear. More obese patients were more likely to receive a reduced dose of melphalan, but there was no evidence that melphalan or TBI dosing variability affected PFS. Therefore, current common strategies of dosing melphalan do not impair outcomes for obese patients, and obesity should not exclude patients from consideration of autologous transplantation. Further research is necessary to optimize dosing of both chemotherapy and radiation in obese patients.
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Affiliation(s)
- Dan T Vogl
- Abramson Cancer Center, University of Pennsylvania, Philadelphia, Pennsylvania 19104, USA.
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21
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Allogeneic transplant outcomes are not affected by body mass index (BMI) in patients with haematological malignancies. Ann Hematol 2010; 89:1141-5. [DOI: 10.1007/s00277-010-1001-6] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2010] [Accepted: 05/17/2010] [Indexed: 10/19/2022]
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22
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Bremberg ER, Rotstein S, Eksborg S. Treatment modifications of antineoplastic drugs in an oncology day-care unit. Acta Oncol 2009; 46:735-40. [PMID: 17653894 DOI: 10.1080/02841860701373561] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
The frequency of and reasons for treatment modifications related to prescriptions of antineoplastic drugs and to what extent the modifications are performed in accordance with the local treatment protocol were studied at an oncology day-care unit. Ninety-three patients were treated with antineoplastic drugs at the unit during the study period. Their diagnosis included mainly breast- and gastrointestinal tumours. Thirty-eight treatment modifications in relation to the treatment protocol were observed in 31 of 93 patients (33%). Twenty-five of 31 patients were treated with palliative intention (81%). Two treatment modifications of 38 (5%) were in accordance and 21 modifications (55%) were not in accordance with the local treatment protocol. It was not possible to verify whether the remaining 15 modifications (39%) were according to the protocol. Adverse effects were the most common reason specified in the medical file for treatment modification (8 patients; 26%). The reasons for treatment modification were only documented in the medical file for 11 of 31 patients (35%) and only present on the prescription card delivered to the local pharmacy for one of 31 patients (3%). Drug interactions were not considered according to the medical files for any of the 93 patients who were treated at the unit during the study days, and accordingly, no treatment modifications had been performed due to drug interactions. Liver and/or renal function tests were missing in the medical file for four patients treated with drugs for which these tests are crucial. More emphasis should be put on identifying clinically relevant drug interactions between antineoplastic drugs and the patient's regular drugs and also on specifying the reason for modifications in the medical file and on the prescription cards delivered to the local pharmacy. Increased quality assurance of the local treatment protocols is warranted.
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Affiliation(s)
- Eva R Bremberg
- Karolinska Pharmacy, Karolinska University Hospital, Danderyd Hospital, Stockholm, Sweden.
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23
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Sriharsha L, Lipton JH, Pond G, Ma C, Raybardhan S, Messner HA, Seki JT. Examining the safety and efficacy of a chemotherapy dosing method in Allogeneic Stem Cell Transplant patients of extreme body size. J Oncol Pharm Pract 2009; 15:201-10. [DOI: 10.1177/1078155208101960] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background. There is no consensus on a universal dosing method for calculating high-dose chemotherapy in allogeneic Stem Cell Transplant (SCT) patients. The Metropolitan Life (Met-Life) Insurance Company’s weight—height tables have been used to determine body weight for chemotherapy dosing for SCT, however no formal study has been done to determine if the Met-Life weight— height tables can be used for chemotherapy dosing in SCT. We retrospectively studied the use of Met-Life weight—height tables for chemotherapy dosing in SCT. Our goal is to determine if patients with extremes of body size who had undergone an SCT and were dosed according to the Met-Life weight— height tables had an increase of Treatment Related Morbidity (TRM) or mortality or relapse. Patients and Methods. Patients were grouped into three different treatment regimens, cyclophosphamide/TBI, busulphan/cyclophosphamide, and AraC/cyclophosphamide/TBI. Patients in each treatment regimen were further divided into five equal groups based on weight. Treatment related morbidity and mortality was evaluated by comparing the lowest and highest quintiles to the middle quintiles within each treatment regimen. Result. Data from 262 patients was evaluated in this study. Overall, there was not an increase in TRM or mortality or in relapse in patients with extremes of body size. Conclusion. The Met-Life weight—height tables could be used to dose patients undergoing allogeneic SCTs. Additional prospective studies would need to be done comparing other chemotherapy dosing methods with the Met-Life weight—height tables to further validate this conclusion.
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Affiliation(s)
- Lakshmi Sriharsha
- Departments of Pharmacy, University of Toronto, Princess Margaret Hospital, Ontario, Canada
| | - Jeffrey H Lipton
- Medical Oncology and Hematology, University of Toronto, Princess Margaret Hospital, Ontario, Canada
| | - Greg Pond
- Department of Biostatistics University of Toronto, Princess Margaret Hospital, Ontario, Canada
| | - Clement Ma
- Department of Biostatistics University of Toronto, Princess Margaret Hospital, Ontario, Canada
| | - Sumit Raybardhan
- Departments of Pharmacy, University of Toronto, Princess Margaret Hospital, Ontario, Canada
| | - Hans A Messner
- Medical Oncology and Hematology, University of Toronto, Princess Margaret Hospital, Ontario, Canada
| | - Jack T Seki
- Departments of Pharmacy, University of Toronto, Princess Margaret Hospital, Ontario, Canada,
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24
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Bulley S, Gassas A, Dupuis LL, Aplenc R, Beyene J, Greenberg ML, Doyle JJ, Sung L. Inferior outcomes for overweight children undergoing allogeneic stem cell transplantation. Br J Haematol 2007; 140:214-7. [PMID: 18028482 DOI: 10.1111/j.1365-2141.2007.06900.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
This retrospective cohort study aimed at determining whether overweight children undergoing allogeneic stem cell transplantation (SCT) had inferior overall survival compared with children who were not overweight. Children >/=2 years of age who received allogeneic SCT were included. Overweight was defined as a body mass index >/= 95th percentile; 54/325 (17%) children were overweight. Overall survival at 5 years was significantly inferior at 46.6 +/- 7.3% in the overweight group compared with 59.5 +/- 3.2% in the non-overweight group (P = 0.02). Our study demonstrated that overweight children who undergo allogeneic SCT had inferior survival compared with children who were not overweight.
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Affiliation(s)
- Sean Bulley
- Division of Haematology/Oncology and Program in Child Health Evaluative Sciences, The Hospital for Sick Children, Toronto, ON, Canada
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Ritzmo C, Söderhäll S, Karlén J, Nygren H, Eksborg S. Pharmacokinetics of doxorubicin and etoposide in a morbidly obese pediatric patient. Pediatr Hematol Oncol 2007; 24:437-45. [PMID: 17710661 DOI: 10.1080/08880010701451343] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
This case report presents the pharmacokinetics of doxorubicin and etoposide in a 14-year-old morbidly obese (body mass index: 46.3 kg/m2) male patient with Hodgkin disease. Dosing based on an adjusted body surface area resulted in a dose reduction by approximately 25% as compared to dosing based on actual body surface area. Plasma clearance of doxorubicin as well as plasma clearance and elimination rate of etoposide for this patient was comparable to pharmacokinetic data from nonobese pediatric patients. The therapy was well tolerated without any specific toxicity and a complete response was obtained after 2 scheduled courses, with the patient in complete remission 25 months after end of treatment.
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Affiliation(s)
- Carina Ritzmo
- Karolinska Pharmacy and Childhood Cancer Research Unit, Department of Woman and Child Health, Karolinska Institutet, Stockholm, Sweden
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26
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Grazziutti ML, Dong L, Miceli MH, Krishna SG, Kiwan E, Syed N, Fassas A, van Rhee F, Klaus H, Barlogie B, Anaissie EJ. Oral mucositis in myeloma patients undergoing melphalan-based autologous stem cell transplantation: incidence, risk factors and a severity predictive model. Bone Marrow Transplant 2006; 38:501-6. [PMID: 16980998 DOI: 10.1038/sj.bmt.1705471] [Citation(s) in RCA: 75] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Melphalan-based autologous stem cell transplant (Mel-ASCT) is a standard therapy for multiple myeloma, but is associated with severe oral mucositis (OM). To identify predictors for severe OM, we studied 381 consecutive newly diagnosed myeloma patients who received Mel-ASCT. Melphalan was given at 200 mg/m2 body surface area (BSA), reduced to 140 mg/m2 for serum creatinine >3 mg/dl. Potential covariates included demographics, pre-transplant serum albumin and renal and liver function tests, and mg/kg melphalan dose received. The BSA dosing resulted in a wide range of melphalan doses given (2.4-6.2 mg/kg). OM developed in 75% of patients and was severe in 21%. Predictors of severe OM in multiple logistic regression analyses were high serum creatinine (odds ratio (OR)=1.581; 95% confidence interval (CI): 1.080-2.313; P=0.018) and high mg/kg melphalan (OR=1.595; 95% CI: 1.065-2.389; P=0.023). An OM prediction model was developed based on these variables. We concluded that BSA dosing of melphalan results in wide variations in the mg/kg dose, and that patients with renal dysfunction who are scheduled to receive a high mg/kg melphalan dose have the greatest risk for severe OM following Mel-ASCT. Pharmacogenomic and pharmacokinetic studies are needed to better understand interpatient variability of melphalan exposure and toxicity.
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Affiliation(s)
- M L Grazziutti
- Myeloma Institute for Research and Therapy, University of Arkansas for Medical Sciences, Little Rock, AR 72205, USA
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27
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Navarro WH, Loberiza FR, Bajorunaite R, van Besien K, Vose JM, Lazarus HM, Rizzo JD. Effect of body mass index on mortality of patients with lymphoma undergoing autologous hematopoietic cell transplantation. Biol Blood Marrow Transplant 2006; 12:541-51. [PMID: 16635789 DOI: 10.1016/j.bbmt.2005.12.033] [Citation(s) in RCA: 76] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2005] [Accepted: 12/11/2005] [Indexed: 01/02/2023]
Abstract
High-dose therapy with autologous hematopoietic cell transplantation (auto-HCT) is frequently used to improve outcomes in lymphoma. However, small studies suggest a survival disadvantage among obese patients. Using a retrospective cohort analysis, we studied the outcomes of 4681 patients undergoing auto-HCT for Hodgkin or non-Hodgkin lymphoma between 1990 and 2000 according to body mass index (BMI). Four groups categorized by BMI were compared by using Cox proportional hazards regression to adjust for other prognostic factors. A total of 1909 patients were categorized as normal weight (BMI 18-25 kg/m2), 121 as underweight (BMI<18 kg/m2), 1725 as overweight (BMI>25-30 kg/m2), and 926 as obese (BMI>30 kg/m2) at the time of HCT. Outcomes evaluated included overall survival, relapse, transplantation-related mortality (TRM), and lymphoma-free survival. TRM was similar among the normal, overweight, and obese groups; the underweight group had a higher risk of TRM (relative risk [RR], 2.46; 95% confidence interval [CI], 1.59-3.82; P<0.0001) compared with the normal-BMI group. No differences in relapse were noted. Overall mortality was higher in the underweight group (RR, 1.48; 95% CI, 1.17-1.88; P=.001) and lower in the overweight (RR, 0.87; 95% CI, 0.79-0.96; P=.004) and obese (RR, 0.76; 95% CI, 0.67-0.86; P<.0001) groups compared with the normal-BMI group. In light of our inability to find differences in survival among overweight, obese, and normal-weight patients, obesity alone should not be viewed as a contraindication to proceeding with auto-HCT for lymphoma when it is otherwise indicated.
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Affiliation(s)
- Willis H Navarro
- University of California, San Francisco, San Francisco, California 94080-4990, and University Hospitals of Cleveland, OH, USA.
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Abstract
Obesity increases morbidity and mortality through its multiple effects on nearly every human system. However, the various aspects of the association between obesity and infection have not been reviewed. Thus, we reviewed the relevant literature focusing on clinical aspects of this association. Obesity has a clear but not yet precisely defined effect on the immune response through a variety of immune mediators, which leads to susceptibility to infections. Data on the incidence and outcome of specific infections, especially community-acquired infections, in obese people are so far limited. The available data suggest that obese people are more likely than people of normal weight to develop infections of various types including postoperative infections and other nosocomial infections, as well to develop serious complications of common infections. Large prospective studies are required to further define the burden of infectious morbidity and mortality conferred by obesity.
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Modesitt SC, van Nagell JR. The impact of obesity on the incidence and treatment of gynecologic cancers: a review. Obstet Gynecol Surv 2006; 60:683-92. [PMID: 16186785 DOI: 10.1097/01.ogx.0000180866.62409.01] [Citation(s) in RCA: 104] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
UNLABELLED Sixty-five percent of the adult population in the United States is overweight and 30% of the population is obese. There is mounting evidence that obesity is a risk factor for gynecologic cancers and may also adversely impact survival. The objectives of this review were to systematically evaluate and discuss the impact of overweight and obesity on endometrial, ovarian, and cervical cancer incidence and to review the data on the impact of obesity on treatment of these same gynecologic cancers. A PUBMED literature search was performed to identify articles in the English language that focused on the impact of obesity on cancer incidence and treatment. References of identified articles were also used to find additional related articles. Obesity profoundly increases the incidence of endometrial cancer, predominantly through the effects of unopposed estrogen. Although the data are less compelling in ovarian and cervical cancer, obesity may modestly increase the incidence of premenopausal ovarian cancer and might potentially increase cervical cancer incidence, perhaps as a result of the impact on glandular cancers or decreased screening compliance. Obese women with cancer have decreased survival; this may be disease-specific, the result of comorbid illnesses, or response to treatment. Obese women have increased surgical complications, may also have increased radiation complications, and there is no current consensus regarding appropriate chemotherapy dosing in the obese patient. Obesity is a serious health problem with significant effects on the incidence and treatment of the gynecologic malignancies. TARGET AUDIENCE Obstetricians & Gynecologists, Family Physicians. LEARNING OBJECTIVES After completion of this article, the reader should be able to summarize the clear evidence that obesity is a risk factor for many cancers, including gynecologic malignancies; describe the role of unopposed estrogen in gynecologic cancers; and explain that obese women overall have a poorer survival rate when afflicted with cancer.
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Affiliation(s)
- Susan C Modesitt
- Gynecologic Oncology Division, Department of Obstetrics and Gynecology, University of Kentucky Chandler Medical Center, Lucille Markey Cancer Center, 800 Rose Street, Lexington, KY 40536-0298, USA.
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Morandi P, Ruffini PA, Benvenuto GM, Raimondi R, Fosser V. Cardiac toxicity of high-dose chemotherapy. Bone Marrow Transplant 2005; 35:323-34. [PMID: 15543194 DOI: 10.1038/sj.bmt.1704763] [Citation(s) in RCA: 116] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Cardiac toxicity is an uncommon but potentially serious complication of high-dose (HD) chemotherapy and little is known about incidence, severity and underlying mechanisms. We have systematically reviewed the literature of the last 30 years to summarize and appraise the published evidence on cardiac toxicity associated with HD chemotherapy. HD cyclophosphamide-containing regimens have been most commonly associated with cardiac toxicity, with a progressively decreasing incidence over time. Dosage, application regimens and coadministration of other chemotherapeutic agents emerged as risk factors. While cardiac toxicity has been rarely associated with other cytotoxic drugs, an unexpected incidence of severe cardiotoxicity resulted from reduced-intensity conditioning regimens containing melphalan and fludarabine. Predictive value of cardiologic examination of patients is limited, and patients with a slight depression of cardiac performance could tolerate HD chemotherapy. Clinical examination, resting electrocardiography and dosage adjustment in overweight patients remain the mainstay of prevention, with bidimensional echocardiography (2D echo) for patients with a history of anthracycline exposure. Strategies to decrease the long-term negative impact of anthracycline administration on cardiac performance are being investigated. New 2D echo-based techniques and circulating markers of cardiac function hold promise for allowing identification of patients at high risk for and early diagnosis of cardiac toxicity.
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Affiliation(s)
- P Morandi
- Divisione Oncologia Medica, Ospedale San Bortolo, Vicenza, Italy.
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