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Daamen LA, Parikh PJ, Hall WA. The Use of MR-Guided Radiation Therapy for Pancreatic Cancer. Semin Radiat Oncol 2024; 34:23-35. [PMID: 38105090 DOI: 10.1016/j.semradonc.2023.10.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2023]
Abstract
The introduction of online adaptive magnetic resonance (MR)-guided radiation therapy (RT) has enabled safe treatment of pancreatic cancer with ablative doses. The aim of this review is to provide a comprehensive overview of the current literature on the use and clinical outcomes of MR-guided RT for treatment of pancreatic cancer. Relevant outcomes included toxicity, tumor response, survival and quality of life. The results of these studies support further investigation of the effectiveness of ablative MR-guided SBRT as a low-toxic, minimally-invasive therapy for localized pancreatic cancer in prospective clinical trials.
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Affiliation(s)
- Lois A Daamen
- Imaging & Oncology Division, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Parag J Parikh
- Department of Radiation Oncology, Henry Ford Medical Center, Henry Ford Health System, Detroit, MI
| | - William A Hall
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, WI.
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2
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Augustinus S, van Laarhoven HWM, Cirkel GA, de Groot JWB, Groot Koerkamp B, Macarulla T, Melisi D, O’Reilly EM, van Santvoort HC, Mackay TM, Besselink MG, Wilmink JW. Timing of Initiation of Palliative Chemotherapy in Asymptomatic Patients with Metastatic Pancreatic Cancer: An International Expert Survey and Case-Vignette Study. Cancers (Basel) 2023; 15:5603. [PMID: 38067306 PMCID: PMC10705283 DOI: 10.3390/cancers15235603] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Revised: 11/17/2023] [Accepted: 11/20/2023] [Indexed: 02/15/2024] Open
Abstract
Background: The use of imaging, in general, and during follow-up after resection of pancreatic cancer, is increasing. Consequently, the number of asymptomatic patients diagnosed with metastatic pancreatic cancer (mPDAC) is increasing. In these patients, palliative systemic therapy is the only tumor-directed treatment option; hence, it is often immediately initiated. However, delaying therapy in asymptomatic palliative patients may preserve quality of life and avoid therapy-related toxicity, but the impact on survival is unknown. This study aimed to gain insight into the current perspectives and clinical decision=making of experts regarding the timing of treatment initiation of patients with asymptomatic mPDAC. Methods: An online survey (13 questions, 9 case-vignettes) was sent to all first and last authors of published clinical trials on mPDAC over the past 10 years and medical oncologists of the Dutch Pancreatic Cancer Group. Inter-rater variability was determined using the Kappa Light test. Differences in the preferred timing of treatment initiation among countries, continents, and years of experience were analyzed using Fisher's exact test. Results: Overall, 78 of 291 (27%) medical oncologists from 15 countries responded (62% from Europe, 23% from North America, and 15% from Asia-Pacific). The majority of respondents (63%) preferred the immediate initiation of chemotherapy following diagnosis. In 3/9 case-vignettes, delayed treatment was favored in specific clinical contexts (i.e., patient with only one small lung metastasis, significant comorbidities, and higher age). A significant degree of inter-rater variability was present within 7/9 case-vignettes. The recommended timing of treatment initiation differed between continents for 2/9 case-vignettes (22%), in 7/9 (77.9%) comparing the Netherlands with other countries, and based on years of experience for 5/9 (56%). Conclusions: Although the response rate was limited, in asymptomatic patients with mPDAC, immediate treatment is most often preferred. Delaying treatment until symptoms occur is considered in patients with limited metastatic disease, more comorbidities, and higher age.
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Affiliation(s)
- Simone Augustinus
- Department of Surgery, Location University of Amsterdam, Amsterdam University Medical Center, 1105 Amsterdam, The Netherlands; (S.A.); (M.G.B.)
- Cancer Center Amsterdam, 1105 Amsterdam, The Netherlands
| | - Hanneke W. M. van Laarhoven
- Cancer Center Amsterdam, 1105 Amsterdam, The Netherlands
- Department of Medical Oncology, Location University of Amsterdam, Amsterdam University Medical Center, 1105 Amsterdam, The Netherlands
| | - Geert A. Cirkel
- Department of Medical Oncology, University Medical Center Utrecht, Utrecht University, 3584 Utrecht, The Netherlands
| | | | - Bas Groot Koerkamp
- Department of Surgery, Erasmus MC Cancer Institute, 3015 Rotterdam, The Netherlands
| | - Teresa Macarulla
- Department of Medical Oncology, Vall d’Hebron Unveristy Hospital, Vall d’Hebron Institute of Oncology (VHIO), 08035 Barcelona, Spain
| | - Davide Melisi
- Digestive Molecular Clinical Oncology Unit, Univeristy of Verona, 37134 Verona, Italy
| | - Eileen M. O’Reilly
- Department of Medical Oncology, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA
| | - Hjalmar C. van Santvoort
- Department of Surgery, Regional Academic Cancer Center Utrecht, UMC Utrecht Cancer Center, St. Antonius Hospital Nieuwegein, Utrecht University, 3584 Utrech, The Netherlands
| | - Tara M. Mackay
- Department of Surgery, Location University of Amsterdam, Amsterdam University Medical Center, 1105 Amsterdam, The Netherlands; (S.A.); (M.G.B.)
- Cancer Center Amsterdam, 1105 Amsterdam, The Netherlands
| | - Marc G. Besselink
- Department of Surgery, Location University of Amsterdam, Amsterdam University Medical Center, 1105 Amsterdam, The Netherlands; (S.A.); (M.G.B.)
- Cancer Center Amsterdam, 1105 Amsterdam, The Netherlands
| | - Johanna W. Wilmink
- Cancer Center Amsterdam, 1105 Amsterdam, The Netherlands
- Department of Medical Oncology, Location University of Amsterdam, Amsterdam University Medical Center, 1105 Amsterdam, The Netherlands
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3
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Doppenberg D, Besselink MG, van Eijck CHJ, Intven MPW, Koerkamp BG, Kazemier G, van Laarhoven HWM, Meijerink M, Molenaar IQ, Nuyttens JJME, van Os R, van Santvoort HC, van Tienhoven G, Verkooijen HM, Versteijne E, Wilmink JW, Lagerwaard FJ, Bruynzeel AME. Stereotactic ablative radiotherapy or best supportive care in patients with localized pancreatic cancer not receiving chemotherapy and surgery (PANCOSAR): a nationwide multicenter randomized controlled trial according to a TwiCs design. BMC Cancer 2022; 22:1363. [PMID: 36581914 PMCID: PMC9801528 DOI: 10.1186/s12885-022-10419-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Accepted: 12/06/2022] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Significant comorbidities, advanced age, and a poor performance status prevent surgery and systemic treatment for many patients with localized (non-metastatic) pancreatic ductal adenocarcinoma (PDAC). These patients are currently treated with 'best supportive care'. Therefore, it is desirable to find a treatment option which could improve both disease control and quality of life in these patients. A brief course of high-dose high-precision radiotherapy i.e. stereotactic ablative body radiotherapy (SABR) may be feasible. METHODS A nationwide multicenter trial performed within a previously established large prospective cohort (the Dutch Pancreatic cancer project; PACAP) according to the 'Trial within cohorts' (TwiCs) design. Patients enrolled in the PACAP cohort routinely provide informed consent to answer quality of life questionnaires and to be randomized according to the TwiCs design when eligible for a study. Patients with localized PDAC who are unfit for chemotherapy and surgery or those who refrain from these treatments are eligible. Patients will be randomized between SABR (5 fractions of 8 Gy) with 'best supportive care' and 'best supportive care' only. The primary endpoint is overall survival from randomization. Secondary endpoints include preservation of quality of life (EORTC-QLQ-C30 and -PAN26), NRS pain score response and WHO performance scores at baseline, and, 3, 6 and 12 months. Acute and late toxicity will be scored using CTCAE criteria version 5.0: assessed at baseline, day of last fraction, at 3 and 6 weeks, and 3, 6 and 12 months following SABR. DISCUSSION The PANCOSAR trial studies the added value of SBRT as compared to 'best supportive care' in patients with localized PDAC who are medically unfit to receive chemotherapy and surgery, or refrain from these treatments. This study will assess whether SABR, in comparison to best supportive care, can relieve or delay tumor-related symptoms, enhance quality of life, and extend survival in these patients. TRIAL REGISTRATION Clinical trials, NCT05265663 , Registered March 3 2022, Retrospectively registered.
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Affiliation(s)
- D. Doppenberg
- grid.509540.d0000 0004 6880 3010Amsterdam UMC, Location Vrije Universiteit Amsterdam, Department of Radiation Oncology, Amsterdam, The Netherlands ,grid.7177.60000000084992262Amsterdam UMC, Location University of Amsterdam, Department of Surgery, Amsterdam, The Netherlands ,grid.16872.3a0000 0004 0435 165XCancer Center Amsterdam, Amsterdam, The Netherlands
| | - M. G. Besselink
- grid.7177.60000000084992262Amsterdam UMC, Location University of Amsterdam, Department of Surgery, Amsterdam, The Netherlands ,grid.16872.3a0000 0004 0435 165XCancer Center Amsterdam, Amsterdam, The Netherlands
| | - C. H. J. van Eijck
- grid.508717.c0000 0004 0637 3764Department of Surgery, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - M. P. W. Intven
- grid.5477.10000000120346234Department of Radiation Oncology, Regional Academic Cancer Center Utrecht, University of Utrecht, Utrecht, The Netherlands
| | - B. Groot Koerkamp
- grid.508717.c0000 0004 0637 3764Department of Surgery, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - G. Kazemier
- grid.16872.3a0000 0004 0435 165XCancer Center Amsterdam, Amsterdam, The Netherlands ,grid.509540.d0000 0004 6880 3010Amsterdam UMC, Location Vrije Universiteit Amsterdam, Department of Surgery, Amsterdam, The Netherlands
| | - H. W. M. van Laarhoven
- grid.16872.3a0000 0004 0435 165XCancer Center Amsterdam, Amsterdam, The Netherlands ,grid.7177.60000000084992262Amsterdam UMC, Location University of Amsterdam, Department of Medical Oncology, Amsterdam, The Netherlands
| | - M. Meijerink
- grid.16872.3a0000 0004 0435 165XCancer Center Amsterdam, Amsterdam, The Netherlands ,grid.509540.d0000 0004 6880 3010Amsterdam UMC, Location Vrije Universiteit Amsterdam, Department of Intervention Radiology, Amsterdam, The Netherlands
| | - I. Q. Molenaar
- grid.5477.10000000120346234Department of Surgery, Regional Academic Cancer Center Utrecht, University of Utrecht, Utrecht, The Netherlands
| | - J. J. M. E. Nuyttens
- grid.508717.c0000 0004 0637 3764Department of Radiation Oncology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - R. van Os
- grid.509540.d0000 0004 6880 3010Amsterdam UMC, Location Vrije Universiteit Amsterdam, Department of Radiation Oncology, Amsterdam, The Netherlands
| | - H. C. van Santvoort
- grid.5477.10000000120346234Department of Surgery, Regional Academic Cancer Center Utrecht, University of Utrecht, Utrecht, The Netherlands
| | - G. van Tienhoven
- grid.509540.d0000 0004 6880 3010Amsterdam UMC, Location Vrije Universiteit Amsterdam, Department of Radiation Oncology, Amsterdam, The Netherlands ,grid.16872.3a0000 0004 0435 165XCancer Center Amsterdam, Amsterdam, The Netherlands
| | - H. M. Verkooijen
- grid.5477.10000000120346234Department of Surgery, Regional Academic Cancer Center Utrecht, University of Utrecht, Utrecht, The Netherlands
| | - E. Versteijne
- grid.509540.d0000 0004 6880 3010Amsterdam UMC, Location Vrije Universiteit Amsterdam, Department of Radiation Oncology, Amsterdam, The Netherlands ,grid.16872.3a0000 0004 0435 165XCancer Center Amsterdam, Amsterdam, The Netherlands
| | - J. W. Wilmink
- grid.16872.3a0000 0004 0435 165XCancer Center Amsterdam, Amsterdam, The Netherlands ,grid.7177.60000000084992262Amsterdam UMC, Location University of Amsterdam, Department of Medical Oncology, Amsterdam, The Netherlands
| | - F. J. Lagerwaard
- grid.509540.d0000 0004 6880 3010Amsterdam UMC, Location Vrije Universiteit Amsterdam, Department of Radiation Oncology, Amsterdam, The Netherlands ,grid.16872.3a0000 0004 0435 165XCancer Center Amsterdam, Amsterdam, The Netherlands
| | - A. M. E. Bruynzeel
- grid.509540.d0000 0004 6880 3010Amsterdam UMC, Location Vrije Universiteit Amsterdam, Department of Radiation Oncology, Amsterdam, The Netherlands ,grid.16872.3a0000 0004 0435 165XCancer Center Amsterdam, Amsterdam, The Netherlands
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Logan K, Pearson F, Kenny RP, Pandanaboyana S, Sharp L. Are older patients less likely to be treated for pancreatic cancer? A systematic review and meta-analysis. Cancer Epidemiol 2022; 80:102215. [PMID: 35901624 DOI: 10.1016/j.canep.2022.102215] [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: 02/18/2022] [Revised: 06/28/2022] [Accepted: 07/08/2022] [Indexed: 11/27/2022]
Abstract
Pancreatic cancer is the seventh commonest cause of cancer-related death worldwide. Although prognosis is poor, both surgery and adjuvant chemotherapy improve survival. However, it has been suggested that not all pancreatic cancer patients who may benefit from treatment receive it. This systematic review and meta-analysis investigated the existence of age-related inequalities in receipt of first-line pancreatic cancer treatment. Medline, Embase, Cochrane Library and grey literature were searched for population-based studies investigating treatment receipt, reported by age, for patients with primary pancreatic cancer from inception until 4th June 2020, and updated 5th August 2021. Studies from countries with universal healthcare were included, to minimise influence of health system-related economic factors. A modified version of the Newcastle-Ottawa Scale was used to assess risk of bias. Random-effects meta-analysis was undertaken comparing likelihood of treatment receipt in older versus younger patients. Sensitivity and subgroup analyses were conducted. Eighteen papers were included; 12 independent populations were eligible for meta-analysis. In most studies, < 10% of older patients were treated. Older age (generally ≥65) was significantly associated with reduced receipt of any treatment (OR=0.14, 95% CI 0.10-0.21, n = 12 studies), surgery (OR=0.15, 95% CI 0.09-0.24, n = 9 studies) and chemotherapy as a primary treatment (OR=0.13, 95% CI 0.07-0.24, n = 5 studies). The effect of age was independent of methodological quality, patient population or time-period of patient diagnosis and remained in studies with confounder adjustment. The mean quality score of included studies was 6/8. Inequalities in receipt of healthcare interventions across social groups is a recognised concern internationally. This review shows that older age is significantly, and consistently, associated with non-receipt of treatment in pancreatic cancer. However, there are risks and side-effects associated with pancreatic cancer treatment. Further research on what influences patient and professional treatment decision-making is required to better understand these apparent inequalities.
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Affiliation(s)
- Kirsty Logan
- Faculty of Medical Sciences, Newcastle University, Newcastle, United Kingdom
| | - Fiona Pearson
- Population Health Sciences Institute, Newcastle University, Newcastle, United Kingdom
| | - Ryan Pw Kenny
- Population Health Sciences Institute, Newcastle University, Newcastle, United Kingdom
| | - Sanjay Pandanaboyana
- Faculty of Medical Sciences, Newcastle University, Newcastle, United Kingdom; HPB and Transplant Unit, Freeman Hospital, Newcastle Upon Tyne, United Kingdom
| | - Linda Sharp
- Population Health Sciences Institute, Newcastle University, Newcastle, United Kingdom.
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5
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Mowbray NG, Griffiths R, Akbari A, Hutchings H, Jenkins G, Al-Sarireh B. The Impact of a Centralised Pancreatic Cancer Service: a Case Study of Wales, UK. J Gastrointest Surg 2022; 26:367-375. [PMID: 34506014 DOI: 10.1007/s11605-020-04612-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Accepted: 04/11/2020] [Indexed: 01/31/2023]
Abstract
INTRODUCTION The centralisation of pancreatic cancer (PC) services still varies worldwide. This study aimed to assess the impact that a centralisation has had on patients in South Wales, UK. METHODS A retrospective cohort analysis of patients in South Wales, UK, with PC prior to (2004-2009), and after (2010-2014) the formation of a specialist centre. Patients were identified using record linkage of electronic health records. RESULTS The overall survival (OS) of all 3413 patients with PC increased from a median (IQR) 10 weeks (3-31) to 11 weeks (4-35), p = 0.038, after centralisation. The OS of patients undergoing surgical resection or chemotherapy alone did not improve (93 weeks (39-203) vs. 90 weeks (50-95), p = 0.764 and 33 weeks (20-57) vs. 33 weeks (19-58), p = 0.793). Surgical resection and chemotherapy rates increased (6.1% vs. 9.2%, p < 0.001 and 19.7% vs. 27.0%, p < 0.001). The 30-day mortality rate trended downwards (7.2% vs. 3.6%, p = 0.186). The percentage of patients who received no treatment reduced (75.2% vs. 69.6%, p < 0.001). CONCLUSION The centralisation of PC services in South Wales is associated with a small increase in OS and a larger increase in PC treatment utilisation. It is concerning that many patients still fail to receive any treatments.
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Affiliation(s)
- Nicholas G Mowbray
- Swansea University Medical School, Swansea, SA2 8QA, UK. .,Morriston Hospital, Swansea Bay University Health Board, Swansea, SA6 6NL, UK.
| | - Rowena Griffiths
- Swansea University Medical School, Swansea, SA2 8QA, UK.,Health Data Research UK, Swansea University, Swansea, SA2 8PP, UK
| | - Ashley Akbari
- Swansea University Medical School, Swansea, SA2 8QA, UK.,Health Data Research UK, Swansea University, Swansea, SA2 8PP, UK
| | | | | | - Bilal Al-Sarireh
- Swansea University Medical School, Swansea, SA2 8QA, UK.,Morriston Hospital, Swansea Bay University Health Board, Swansea, SA6 6NL, UK
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6
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Partelli S, Sclafani F, Barbu ST, Beishon M, Bonomo P, Braz G, de Braud F, Brunner T, Cavestro GM, Crul M, Trill MD, Ferollà P, Herrmann K, Karamitopoulou E, Neuzillet C, Orsi F, Seppänen H, Torchio M, Valenti D, Zamboni G, Zins M, Costa A, Poortmans P. European Cancer Organisation Essential Requirements for Quality Cancer Care (ERQCC): Pancreatic Cancer. Cancer Treat Rev 2021; 99:102208. [PMID: 34238640 DOI: 10.1016/j.ctrv.2021.102208] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Revised: 04/07/2021] [Accepted: 04/09/2021] [Indexed: 12/14/2022]
Abstract
European Cancer Organisation Essential Requirements for Quality Cancer Care (ERQCC) are written by experts representing all disciplines involved in cancer care in Europe. They give patients, health professionals, managers and policymakers a guide to essential care throughout the patient journey. Pancreatic cancer is an increasing cause of cancer mortality and has wide variation in treatment and care in Europe. It is a major healthcare burden and has complex diagnosis and treatment challenges. Care must be carried out only in pancreatic cancer units or centres that have a core multidisciplinary team (MDT) and an extended team of health professionals detailed here. Such units are far from universal in European countries. To meet European aspirations for comprehensive cancer control, healthcare organisations must consider the requirements in this paper, paying particular attention to multidisciplinarity and patient-centred pathways from diagnosis, to treatment, to survivorship.
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Affiliation(s)
- Stefano Partelli
- European Society of Surgical Oncology (ESSO); IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Francesco Sclafani
- European Organisation for Research and Treatment of Cancer (EORTC); Institut Jules Bordet, Brussels, Belgium
| | - Sorin Traian Barbu
- Pancreatic Cancer Europe (PCE); Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Marc Beishon
- Cancer World, European School of Oncology (ESO), Milan, Italy
| | - Pierluigi Bonomo
- Flims Alumni Club (FAC); Careggi University Hospital, Florence, Italy
| | - Graça Braz
- European Oncology Nursing Society (EONS); Portuguese Oncology Institute, Porto, Portugal
| | - Filippo de Braud
- Organisation of European Cancer Institutes (OECI); IRCCS Foundation National Cancer Institute of Milan, Milan, Italy
| | - Thomas Brunner
- European Society for Radiotherapy and Oncology (ESTRO); Otto von Guericke University, Magdeburg, Germany
| | - Giulia Martina Cavestro
- European Hereditary Tumour Group (EHTG); IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Mirjam Crul
- European Society of Oncology Pharmacy (ESOP); Amsterdam University Medical Centre, Netherlands
| | - Maria Die Trill
- International Psycho-Oncology Society (IPOS); ATRIUM: Psycho-Oncology & Clinical Psychology, Madrid, Spain
| | - Piero Ferollà
- International Neuroendocrine Cancer Alliance (INCA); Umbria Regional Cancer Network, Perugia, Italy
| | - Ken Herrmann
- European Association of Nuclear Medicine (EANM); University Hospital Essen, Essen, Germany
| | - Eva Karamitopoulou
- European Society of Pathology (ESP); Institute of Pathology, University of Bern, Bern, Switzerland
| | - Cindy Neuzillet
- International Society of Geriatric Oncology (SIOG), Institut Curie, Saint-Cloud, France
| | - Franco Orsi
- Cardiovascular and Interventional Radiological Society of Europe (CIRSE); European Institute of Oncology, Milan, Italy
| | - Hanna Seppänen
- Association of European Cancer Leagues (ECL); Helsinki University Hospital, Helsinki, Finland
| | - Martina Torchio
- Organisation of European Cancer Institutes (OECI); IRCCS Foundation National Cancer Institute of Milan, Milan, Italy
| | - Danila Valenti
- European Association for Palliative Care (EAPC); Palliative Care Network, AUSL Bologna, Bologna, Italy
| | - Giulia Zamboni
- European Society of Oncologic Imaging (ESOI); University Hospital Verona, Verona, Italy
| | - Marc Zins
- European Society of Radiology (ESR); Groupe hospitalier Paris Saint-Joseph, Paris, France
| | | | - Philip Poortmans
- European Cancer Organisation (ECCO); Iridium Kankernetwerk and University of Antwerp, Wilrijk-Antwerp, Belgium
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7
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Li W, Wang X, Yang Y, Zhao L, Lin D, Wang J, Zhu Y, Chen C, Liu Z, Wu X, Zhang X, Wang R, Li R, Ting DSW, Huang W, Lin H. The associations of population mobility in HIV disease severity and mortality rate in China. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:315. [PMID: 33708942 PMCID: PMC7944320 DOI: 10.21037/atm-20-4514] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Background Human immunodeficiency virus (HIV) infection has become a chronic disease and attracted public attention globally. Population migration was considered hindering the control and management of HIV infection, but limited studies have explored how population mobility could influence the development of HIV-related complications and overall prognosis. Methods We enrolled hospitalized HIV patients in this cross-sectional study between January 1, 2006, and December 31, 2016. We extracted demographic, hospitalization, and patient diagnosis data. Patients were divided into three groups according to the population type: (I) resident of Guangzhou City (local resident); (II) migrant outside of Guangzhou City but within Guangdong Province (migrant within the province); and (III) migrant outside of Guangdong Province (migrant outside the province). To represent the prognosis of HIV, in-hospital death was defined as the worst outcome, whereas vision-related events were considered moderate-to-severe complications. Logistic regression models were used to analyze factors influencing the prognosis of HIV. Results Eight thousand and six hundred thirty-one inpatients (14,954 cases) were enrolled. The overall mortality was 7.9%, decreasing from 21.5% in 2006 to 3.8% in 2016. The prevalence of vision-related events was 14.4% between 2015 and 2016. Compared to local patients, migrant patients (within and outside the province) were younger, had significantly less access to health insurance, fewer hospitalization admissions, longer hospital stays, and a higher proportion of physical work (P<0.01). Furthermore, they had a higher prevalence of vision-related events (16.2% and 17.4% in migrant patients within the province and outside the province, respectively vs. 9.5%) and infectious diseases, but lower in-hospital mortality (5.9% and 7.0% vs. 12.3%) than local patients. Migrants correlated negatively with in-hospital death [odds ratio (OR) 95% CI, 0.37 (0.29–0.48) and 0.52 (0.40–0.68)] but correlated positively with vision-related events [OR (95% CI), 2.08 (1.54–2.80) and 2.03 (1.47–2.80)]. Conclusions Migrant patients have significantly poorer access to health insurance, with an increased risk of developing moderate-to-severe HIV infection but a decreased risk of in-hospital death, indicating a trend toward withdrawing treatment in migrant patients when they have advanced diseases. Managements such as optimizing access to health insurance and improving follow-up visits for HIV infection should be considered in the context of the population mobility of HIV patients.
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Affiliation(s)
- Wangting Li
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangzhou, China
| | - Xiaoli Wang
- Guangzhou Eighth People's Hospital, Guangzhou Medical University, Guangzhou, China
| | - Yahan Yang
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangzhou, China
| | - Lanqin Zhao
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangzhou, China
| | - Duoru Lin
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangzhou, China
| | - Jinghui Wang
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangzhou, China
| | - Yi Zhu
- Department of Molecular and Cellular Pharmacology, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Chuan Chen
- Department of Molecular and Cellular Pharmacology, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Zhenzhen Liu
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangzhou, China
| | - Xiaohang Wu
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangzhou, China
| | - Xiayin Zhang
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangzhou, China
| | - Ruixin Wang
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangzhou, China
| | - Ruiyang Li
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangzhou, China
| | - Daniel Shu Wei Ting
- Singapore National Eye Centre, Duke-NUS Medical School, Singapore, Singapore
| | - Wenyong Huang
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangzhou, China
| | - Haotian Lin
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangzhou, China.,Center of Precision Medicine, Sun Yat-sen University, Guangzhou, China
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8
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Observational Study of Clinical Practice in Patients with Pancreatic Adenocarcinoma in Greece. JOURNAL OF ONCOLOGY 2020; 2020:5304516. [PMID: 33014051 PMCID: PMC7520678 DOI: 10.1155/2020/5304516] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/17/2020] [Revised: 08/14/2020] [Accepted: 09/07/2020] [Indexed: 11/21/2022]
Abstract
Background During the last decade, significant improvement was made in systemic therapy of pancreatic adenocarcinoma (PAC). The impact of this progress in everyday clinical practice has not been fully described yet. The aim of the study was to investigate the pattern followed by Greek Medical Oncologists regarding the treatment of patients with PAC. Methods This observational, noninterventional multicenter study recorded clinical data from the files of 200 active patients (alive and under treatment or follow-up) for a two-year period (November 2015 until November 2017) from 20 oncology centers around Greece. Results In total, 51 (25.5%) patients underwent radical surgical resection of PAC, and 40 (78.4%) of them received adjuvant and 1 (2.0%) neoadjuvant chemotherapy. The median time to recurrence was 7.9 months, and median overall survival (OS), 20.2 months. First-line chemotherapy was administered to 193 (96.5%) patients. The majority of patients were treated with the combination of nab-paclitaxel-gemcitabine (NPG), 5-fluorouracil, leucovorin, irinotecan, oxaliplatin (FOLFIRINOX), or gemcitabine monotherapy. Of them, 39.5% responded to the treatment. Median OS and PFS were 14.1 months and 7.0 months, respectively. Second-line treatment was administered to 112 patients. The majority received NPG, FOLFIRINOX/capecitabine, oxaliplatin, irinotecan (CAPOXIRI), or 5-fluorouracil, leucovorin, oxaliplatin (FOLFOX)/capecitabine, oxaliplatin (CAPOX). Median OS with second-line treatment was 8.6 months, and median PFS, 5.5 months. The most common chemotherapy sequences were NPG as first-line followed by FOLFIRINOX/CAPOXIRI as second-line, NPG followed by FOLFOX/CAPOX, NPG followed by other regimens, and FOLFIRINOX/CAPOXIRI followed by NPG. Conclusion This study described the significant improvement in prognosis of PAC patients receiving palliative chemotherapy and the relatively high rate of receipt of second-line chemotherapy, according to real-world data. However, due to the nonrandomized nature of the study, any comparison between different chemotherapy regimens should be regarded with caution.
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van Walree IC, Bretveld R, van Huis-Tanja LH, Louwers JA, Emmelot-Vonk MH, Hamaker ME. Reasons for guideline non-adherence in older and younger women with advanced stage ovarian cancer. Gynecol Oncol 2020; 157:593-598. [PMID: 32171566 DOI: 10.1016/j.ygyno.2020.03.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2019] [Accepted: 03/03/2020] [Indexed: 10/24/2022]
Abstract
OBJECTIVE This study aims to assess the reasons for guideline non-adherence in women with advanced stage ovarian cancer and whether these reasons differ according to age. METHODS All women diagnosed with advanced stage ovarian cancer, International Federation of Gynecology and Obstetrics (FIGO) IIb-IV, between 2015 and 2018 were selected from the Netherlands Cancer Registry. Treatment patterns and reasons for guideline non-adherence were analyzed according to age groups. RESULTS 4210 women were included, of whom 34%, 33%, 26%, and 8% were aged <65, 65-75, 75-85, and ≥85 years respectively. With advancing age, less women received guideline-adherent treatment (decreasing from 70% to 2% in women aged <65 and ≥85 years respectively) and more women received best supportive care only (ranging from 4% to 69% in women aged <65 and ≥85 years respectively). The most prevalent reasons for guideline non-adherence differed according to age and included patient preference in older women, and functional status and extent of disease in younger women. CONCLUSIONS Most older women did not receive guideline-adherent care and patient preference was the most common reason for this decision. This knowledge provides insight in the current treatment decision-making process and highlights the importance of eliciting patient treatment preferences. Further prospective research is necessary to study the underlying motivation for women to decline guideline care and the extent to which shared decision-making influences treatment choice.
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Affiliation(s)
- I C van Walree
- Department of Internal Medicine, Diakonessenhuis Utrecht, the Netherlands.
| | - R Bretveld
- Netherlands Comprehensive Cancer Organisation, the Netherlands
| | - L H van Huis-Tanja
- Department of Internal Medicine, Diakonessenhuis Utrecht, the Netherlands
| | - J A Louwers
- Department of Gynecology, Diakonessenhuis Utrecht, the Netherlands
| | - M H Emmelot-Vonk
- Department of Geriatric Medicine, University Medical Center, Utrecht, the Netherlands
| | - M E Hamaker
- Department of Geriatric Medicine, Diakonessenhuis Utrecht, the Netherlands
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Zijlstra M, Timmermans M, Fransen H, van der Aa M, Reyners A, Raijmakers N, van de Poll-Franse L. Treatment patterns and associated factors in patients with advanced epithelial ovarian cancer: a population-based study. Int J Gynecol Cancer 2020; 29:1032-1037. [PMID: 31263022 DOI: 10.1136/ijgc-2019-000489] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2019] [Accepted: 05/02/2019] [Indexed: 12/18/2022] Open
Abstract
OBJECTIVES A significant proportion of women with advanced-stage ovarian cancer receive no cancer-directed treatment and limited research has been devoted to this group. This population-based study aimed to gain insight into treatment patterns and trends in patients with advanced epithelial ovarian cancer in the Netherlands and the main reasons for deciding for no cancer-directed treatment. METHODS All patients diagnosed with advanced epithelial ovarian cancer, International Federation of Gynecology and Obstetrics (FIGO) classification IIB-IV, between 2008 and 2016 were identified from the Netherlands Cancer Registry. Trends in the number of patients receiving cancer-directed treatment were analyzed. Multivariable logistic regression analysis was used to identify factors associated with no cancer-directed treatment. The main reasons for no cancer-directed treatment were analyzed. RESULTS A total of 9303 patients were included, of whom 14% (n=1270) received no cancer-directed treatment while 67% (n=6218) received a combination of cytoreductive surgery and chemotherapy. Some 15% (n=1399) received chemotherapy only, and 4.5% (n=416) surgical resection or hormonal therapy only. The proportion of patients receiving no cancer-directed treatment was higher in 2014-2016 (16%, n=496/3175) compared with 2008-2010 (11%, n=349/3057, p<0.001). Associated factors with no cancer-directed treatment were higher age, FIGO stage IV, lower socioeconomic status, co-morbidity, and more recent years of diagnosis (p<0.001). Main reasons for no cancer-directed treatment were patient's choice (40%) and poor condition of the patient (29%). CONCLUSIONS The proportion of patients with advanced epithelial ovarian cancer not receiving cancer-directed treatment has increased in the last decade in the Netherlands. Patient's choice was the main reason for the decision to undergo no cancer-directed treatment, which indicates patient involvement in the decision-making process. The second most common reason for no cancer-directed treatment was poor condition of the patient, which might indicate careful selection of patients for treatment. Decision-making regarding treatment is well-considered, but more insight is needed, especially from the patient's perspective.
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Affiliation(s)
- Myrte Zijlstra
- Netherlands Comprehensive Cancer Organisation (IKNL), Utrecht, The Netherlands.,Department of Medical Oncology, Maxima Medical Centre, Eindhoven, The Netherlands.,Netherlands Association for Palliative Care (PZNL), Utrecht, The Netherlands
| | - Maite Timmermans
- Netherlands Comprehensive Cancer Organisation (IKNL), Utrecht, The Netherlands.,Department of Gynaecology, Haga Hospital, The Hague, The Netherlands
| | - Heidi Fransen
- Netherlands Comprehensive Cancer Organisation (IKNL), Utrecht, The Netherlands.,Netherlands Association for Palliative Care (PZNL), Utrecht, The Netherlands
| | - Maaike van der Aa
- Netherlands Comprehensive Cancer Organisation (IKNL), Utrecht, The Netherlands
| | - An Reyners
- Department of Medical Oncology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Natasja Raijmakers
- Netherlands Comprehensive Cancer Organisation (IKNL), Utrecht, The Netherlands.,Netherlands Association for Palliative Care (PZNL), Utrecht, The Netherlands
| | - Lonneke van de Poll-Franse
- Netherlands Comprehensive Cancer Organisation (IKNL), Utrecht, The Netherlands.,CoRPS- Center of Research on Psychology in Somatic diseases, Department of Medicaland Clinical Psychology, Tilburg University, Tilburg, The Netherlands.,Division of Psychosocial Research and Epidemiology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
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de la Fuente J, Sharma A, Chari S, Majumder S. Peripheral blood monocyte counts are elevated in the pre-diagnostic phase of pancreatic cancer: A population based study. Pancreatology 2019; 19:1043-1048. [PMID: 31630918 PMCID: PMC7897401 DOI: 10.1016/j.pan.2019.10.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2019] [Revised: 10/09/2019] [Accepted: 10/10/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND Early diagnosis of pancreatic ductal adenocarcinoma (PDAC) is associated with improved outcomes. A biomarker with incremental change in the pre-diagnostic phase of the disease would be valuable for early detection. In our clinical experience, we have observed elevated peripheral blood monocyte (PBM) counts in PDAC patients at diagnosis. In this study, we aimed to compare PBM counts in PDAC cases and healthy controls at diagnosis and in the 2-year pre-diagnostic period. METHODS Using the Rochester Epidemiology Project database, we identified all patients diagnosed with PDAC between 2000 and 2015 (n = 219) and age-and gender-matched disease-free controls (n = 438). PBM counts and temporal trends were analyzed over a 24 month period before PDAC diagnosis. The groups were compared using Fisher's exact test and t-test. RESULTS At diagnosis, compared to controls PDAC cases more often had monocytosis (23% vs 8%; p < 0.001) and higher mean PBM count (x109/L) (0.73 vs 0.59; p < 0.001). In the 2-year pre-diagnostic period, mean PBM counts were significantly higher in PDAC cases in the interval from 6 months to diagnosis (0.69 vs 0.61; p = 0.03). PDAC cases with monocytosis at diagnosis had a significantly lower median survival (1.9 months vs. 7.6 months; p = 0.001). CONCLUSION Monocytosis is more prevalent in PDAC patients at diagnosis compared to controls and is associated with lower median survival. In a subset of patients, PBM count elevation precedes PDAC diagnosis by 6 months. This novel observation can possibly augment strategies for early diagnosis of PDAC but needs further study.
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Affiliation(s)
- Jaime de la Fuente
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Ayush Sharma
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Suresh Chari
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Shounak Majumder
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA.
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Macarulla T, Blanc JF, Wang-Gillam A, Chen LT, Siveke JT, Mirakhur B, Chen J, de Jong FA. Liposomal irinotecan and 5-fluorouracil/leucovorin in older patients with metastatic pancreatic cancer - A subgroup analysis of the pivotal NAPOLI-1 trial. J Geriatr Oncol 2019; 10:427-435. [PMID: 30842038 DOI: 10.1016/j.jgo.2019.02.011] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2018] [Revised: 11/20/2018] [Accepted: 02/19/2019] [Indexed: 01/07/2023]
Abstract
OBJECTIVES Pancreatic cancer is a highly lethal disease predominantly affecting older patients. Characterization of outcomes in these patients may help optimise treatment decisions. The global, phase 3 NAPOLI-1 trial (NCT01494506) demonstrated an overall survival (OS) benefit with liposomal irinotecan and 5-flurouracil/leucovorin (nal-IRI + 5-FU/LV) versus 5-FU/LV. This subgroup analysis explored impact of age on outcomes in NAPOLI-1 patients, and nal-IRI + 5-FU/LV efficacy and safety in older patients. MATERIALS AND METHODS This exploratory, post-hoc analysis of the NAPOLI-1 trial included patients aged ≥eighteen years (no upper limit) with metastatic pancreatic adenocarcinoma that had progressed on gemcitabine-based therapy. Patients were stratified by age (cut-offs at 65, 70, and 75 years); OS and progression-free survival (PFS) were estimated by Kaplan-Meier analysis. RESULTS Of 417 randomized patients, 192 (46%), 110 (26%) and 43 (10%) were aged ≥65, ≥70 and ≥ 75 years, respectively. Mortality risk and risk of disease progression were similar in older and younger patients independent of treatment (HRs for median [m]OS/mPFS comparisons were 0.88/0.95 [<65 versus ≥65 years], 0.89/0.88 [<70 versus ≥70 years] and 1.04/0.98 [<75 versus ≥75 years]; P > .25). Reduced mortality/morbidity risk with nal-IRI + 5-FU/LV in older subgroups was in line with the wider population. No additional toxicities with nal-IRI + 5-FU/LV were observed in older patients: 86% of patients ≥75 years versus 69% <75 years required a dose delay or reduction due to toxicities (43% versus 32% dose reductions). DISCUSSION Results suggest that older patients with metastatic pancreatic adenocarcinoma that progressed on prior gemcitabine-based treatment can benefit from second-line therapy, supporting nal-IRI + 5-FU/LV treatment in older patients.
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Affiliation(s)
- Teresa Macarulla
- Vall d'Hebron University Hospital (HUVH), Vall d'Hebron Institute of Oncology (VHIO), Barcelona, Spain.
| | | | | | - Li-Tzong Chen
- National Institute of Cancer Research, National Health Research Institutes, National Cheng Kung University, Tainan, Taiwan; Department of Internal Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Jens T Siveke
- Division of Solid Tumor Translational Oncology, West German Cancer Center, University Hospital Essen, Essen, Germany; Cancer Consortium (DKTK, partner site Essen), German Cancer Research Center, DKFZ, Heidelberg, Germany
| | - Beloo Mirakhur
- Ipsen Biopharmaceuticals, Inc., Cambridge, MA, United States
| | - Jie Chen
- Shire plc, Cambridge, MA, United States
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Cheng Y, Wang K, Geng L, Sun J, Xu W, Liu D, Gong S, Zhu Y. Identification of candidate diagnostic and prognostic biomarkers for pancreatic carcinoma. EBioMedicine 2019; 40:382-393. [PMID: 30639415 PMCID: PMC6412825 DOI: 10.1016/j.ebiom.2019.01.003] [Citation(s) in RCA: 80] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2018] [Revised: 01/03/2019] [Accepted: 01/04/2019] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Pancreatic carcinoma (PC) is one of the most aggressive cancers affecting human health. It is essential to identify candidate biomarkers for the diagnosis and prognosis of PC. The present study aimed to investigate the diagnosis and prognosis biomarkers of PC. METHODS Differentially expressed genes (DEGs) were identified from the mRNA expression profiles of GSE62452, GSE28735 and GSE16515. Functional analysis and the protein-protein interaction network analysis was performed to explore the biological function of the identified DEGs. Diagnosis markers for PC were identified using ROC curve analysis. Prognosis markers were identified via survival analysis of TCGA data. The protein expression pattern of the identified genes was verified in clinical tissue samples. A retrospective clinical study was performed to evaluate the correlation between the expression of candidate proteins and survival time of patients. Moreover, comprehensive analysis of the combination of multiple genes/proteins for the prognosis prediction of PC was performed using both TCGA data and clinical data. In vitro studies were undertaken to elaborate the potential roles of these biomarkers in clonability and invasion of PC cells. FINDINGS In total, 389 DEGs were identified. These genes were mainly associated with pancreatic secretion, protein digestion and absorption, cytochrome P450 drug metabolism, and energy metabolism pathway. The top 10 genes were filtered out following Fisher's exact test. ROC curve analysis demonstrated that TMPRSS4, SERPINB5, SLC6A14, SCEL, and TNS4 could be used as biomarkers for the diagnosis of PC. Survival analysis of TCGA data and clinical data suggested that TMC7, TMPRSS4, SCEL, SLC2A1, CENPF, SERPINB5 and SLC6A14 can be potential biomarkers for the prognosis of PC. Comprehensive analysis show that a combination of identified genes/proteins can predict the prognosis of PC. Mechanistically, the identified genes attributes to clonability and invasiveness of PC cells. INTERPRETATION We synthesized several sets of public data and preliminarily clarified pathways and functions of PC. Candidate molecular markers were identified for diagnosis and prognosis prediction of PC including a novel gene, TMC7. Moreover, we found that the combination of TMC7, TMPRSS4, SCEL, SLC2A1, CENPF, SERPINB5 and SLC6A14 can serve as a promising indicator of the prognosis of PC patients. The candidate proteins may attribute to clonability and invasiveness of PC cells. This research provides a novel insight into molecular mechanisms as well as diagnostic and prognostic markers of PC. FUND: National Natural Science Foundation of China [No. 81602646 &81802339], Natural Science Foundation of Guangdong Province [No. 2016A030310254] and China Postdoctoral Science Foundation [No. 2016M600648].
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Affiliation(s)
- Yang Cheng
- Liver Tumor Center, Department of Infectious Diseases and Hepatology Unit, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong 510515, China; Digestive Department, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, No.9 Jinsui Road, Guangzhou, Guangdong 510623, China
| | - Kunyuan Wang
- Liver Tumor Center, Department of Infectious Diseases and Hepatology Unit, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong 510515, China
| | - Lanlan Geng
- Digestive Department, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, No.9 Jinsui Road, Guangzhou, Guangdong 510623, China
| | - Jingjing Sun
- Digestive Department, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, No.9 Jinsui Road, Guangzhou, Guangdong 510623, China
| | - Wanfu Xu
- Digestive Department, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, No.9 Jinsui Road, Guangzhou, Guangdong 510623, China
| | - Dingli Liu
- Liver Tumor Center, Department of Infectious Diseases and Hepatology Unit, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong 510515, China
| | - Sitang Gong
- Digestive Department, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, No.9 Jinsui Road, Guangzhou, Guangdong 510623, China.
| | - Yun Zhu
- Liver Tumor Center, Department of Infectious Diseases and Hepatology Unit, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong 510515, China.
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