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Dong H, Guo H, Du J, Cheng Y, Wang D, Han J, Yuan Z, Yao Z, An R, Wu X, Poulsen KL, Wang Z, Shao S, Fan X, Wang Z, Zhao J. The classification of obesity based on metabolic status redefines the readmission of non-Hodgkin's lymphoma-an observational study. Cancer Metab 2023; 11:24. [PMID: 38057929 DOI: 10.1186/s40170-023-00327-x] [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: 07/02/2023] [Accepted: 11/28/2023] [Indexed: 12/08/2023] Open
Abstract
BACKGROUND The relationship between obesity and non-Hodgkin's lymphoma (NHL) was controversial, which may be due to the crudeness definition of obesity based on body mass index (BMI). As obesity and metabolic abnormalities often coexist, we aimed to explore whether the classification of obesity based on metabolic status can help to evaluate the real impact of obesity on the readmission of NHL. METHODS In this retrospective cohort study, utilizing the 2018 Nationwide Readmissions Database, we identified NHL-related index hospitalizations and followed them for non-elective readmission. The patients with NHL were classified as metabolically healthy non-obese (MHNO) and obese (MHO) and metabolically unhealthy non-obese (MUNO) and obese (MUO). Readmission rates for each phenotype were calculated at 30-day intervals. Multiple COX regression was used to analyze the association of metabolic-defined obesity with 30-day, 90-day, and 180-day readmission rates in patients with NHL. RESULTS There were 22,086 index hospitalizations with NHL included. In the multivariate COX regression, MUNO was associated with increased 30-day (HR = 1.113, 95% CI 1.036-1.195), 90-day (HR = 1.148, 95% CI 1.087-1.213), and 180-day readmission rates (HR = 1.132, 95% CI 1.077-1.189), and MUO was associated with increased 30-day (HR=1.219, 95% CI: 1.081-1.374), 90-day (HR = 1.228, 95% CI 1.118-1.348), and 180-day readmission rates (HR = 1.223, 95% CI 1.124-1.33), while MHO had no associations with readmission rates. CONCLUSIONS The presence of metabolic abnormalities with or without obesity increased the risk of non-selective readmission in patients with NHL. However, obesity alone had no associations with the risk of non-selective readmission, suggesting that interventions for metabolic abnormalities may be more important in reducing readmissions of NHL patients.
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Affiliation(s)
- Hang Dong
- Department of Endocrinology, Shandong Provincial Hospital, Shandong University, Jinan, Shandong, 250021, China
- Key Laboratory of Endocrine Glucose & Lipids Metabolism and Brain Aging, Ministry of Education; Department of Endocrinology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, 250021, China
- Shandong Clinical Research Center of Diabetes and Metabolic Diseases, Jinan, Shandong, 250021, China
- Shandong Institute of Endocrine and Metabolic Diseases, Jinan, Shandong, 250021, China
- "Chuangxin China" Innovation Base of stem cell and Gene Therapy for endocrine Metabolic diseases, Jinan, Shandong, 250021, China
- Shandong Engineering Laboratory of Prevention and Control for Endocrine and Metabolic Diseases, Jinan, Shandong, 250021, China
- Department of Mechanical and Aerospace Engineering, Shandong Engineering Research Center of Stem Cell and Gene Therapy for Endocrine and Metabolic Diseases, Jinan, Shandong, 250021, China
| | - Honglin Guo
- Department of Endocrinology, Shandong Provincial Hospital, Shandong University, Jinan, Shandong, 250021, China
- Key Laboratory of Endocrine Glucose & Lipids Metabolism and Brain Aging, Ministry of Education; Department of Endocrinology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, 250021, China
- Shandong Clinical Research Center of Diabetes and Metabolic Diseases, Jinan, Shandong, 250021, China
- Shandong Institute of Endocrine and Metabolic Diseases, Jinan, Shandong, 250021, China
- "Chuangxin China" Innovation Base of stem cell and Gene Therapy for endocrine Metabolic diseases, Jinan, Shandong, 250021, China
- Shandong Engineering Laboratory of Prevention and Control for Endocrine and Metabolic Diseases, Jinan, Shandong, 250021, China
- Department of Mechanical and Aerospace Engineering, Shandong Engineering Research Center of Stem Cell and Gene Therapy for Endocrine and Metabolic Diseases, Jinan, Shandong, 250021, China
| | - Jing Du
- Department of Endocrinology, Shandong Provincial Hospital, Shandong University, Jinan, Shandong, 250021, China
- Department of Endocrinology, The First Affiliated Hospital of Baotou Medical College, Baotou, 014010, China
- Shandong Clinical Research Center of Diabetes and Metabolic Diseases, Jinan, Shandong, 250021, China
- Shandong Institute of Endocrine and Metabolic Diseases, Jinan, Shandong, 250021, China
- "Chuangxin China" Innovation Base of stem cell and Gene Therapy for endocrine Metabolic diseases, Jinan, Shandong, 250021, China
- Shandong Engineering Laboratory of Prevention and Control for Endocrine and Metabolic Diseases, Jinan, Shandong, 250021, China
- Department of Mechanical and Aerospace Engineering, Shandong Engineering Research Center of Stem Cell and Gene Therapy for Endocrine and Metabolic Diseases, Jinan, Shandong, 250021, China
| | - Yiping Cheng
- Department of Endocrinology, Shandong Provincial Hospital, Shandong University, Jinan, Shandong, 250021, China
- Key Laboratory of Endocrine Glucose & Lipids Metabolism and Brain Aging, Ministry of Education; Department of Endocrinology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, 250021, China
- Shandong Clinical Research Center of Diabetes and Metabolic Diseases, Jinan, Shandong, 250021, China
- Shandong Institute of Endocrine and Metabolic Diseases, Jinan, Shandong, 250021, China
- "Chuangxin China" Innovation Base of stem cell and Gene Therapy for endocrine Metabolic diseases, Jinan, Shandong, 250021, China
- Shandong Engineering Laboratory of Prevention and Control for Endocrine and Metabolic Diseases, Jinan, Shandong, 250021, China
- Department of Mechanical and Aerospace Engineering, Shandong Engineering Research Center of Stem Cell and Gene Therapy for Endocrine and Metabolic Diseases, Jinan, Shandong, 250021, China
| | - Dawei Wang
- Department of Endocrinology, Shandong Provincial Hospital, Shandong University, Jinan, Shandong, 250021, China
- Key Laboratory of Endocrine Glucose & Lipids Metabolism and Brain Aging, Ministry of Education; Department of Endocrinology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, 250021, China
- Shandong Clinical Research Center of Diabetes and Metabolic Diseases, Jinan, Shandong, 250021, China
- Shandong Institute of Endocrine and Metabolic Diseases, Jinan, Shandong, 250021, China
- "Chuangxin China" Innovation Base of stem cell and Gene Therapy for endocrine Metabolic diseases, Jinan, Shandong, 250021, China
- Shandong Engineering Laboratory of Prevention and Control for Endocrine and Metabolic Diseases, Jinan, Shandong, 250021, China
- Department of Mechanical and Aerospace Engineering, Shandong Engineering Research Center of Stem Cell and Gene Therapy for Endocrine and Metabolic Diseases, Jinan, Shandong, 250021, China
| | - Junming Han
- Key Laboratory of Endocrine Glucose & Lipids Metabolism and Brain Aging, Ministry of Education; Department of Endocrinology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, 250021, China
- Shandong Clinical Research Center of Diabetes and Metabolic Diseases, Jinan, Shandong, 250021, China
- Shandong Institute of Endocrine and Metabolic Diseases, Jinan, Shandong, 250021, China
- "Chuangxin China" Innovation Base of stem cell and Gene Therapy for endocrine Metabolic diseases, Jinan, Shandong, 250021, China
- Shandong Engineering Laboratory of Prevention and Control for Endocrine and Metabolic Diseases, Jinan, Shandong, 250021, China
- Department of Mechanical and Aerospace Engineering, Shandong Engineering Research Center of Stem Cell and Gene Therapy for Endocrine and Metabolic Diseases, Jinan, Shandong, 250021, China
| | - Zinuo Yuan
- Department of Endocrinology, Shandong Provincial Hospital, Shandong University, Jinan, Shandong, 250021, China
- Key Laboratory of Endocrine Glucose & Lipids Metabolism and Brain Aging, Ministry of Education; Department of Endocrinology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, 250021, China
- Shandong Clinical Research Center of Diabetes and Metabolic Diseases, Jinan, Shandong, 250021, China
- Shandong Institute of Endocrine and Metabolic Diseases, Jinan, Shandong, 250021, China
- "Chuangxin China" Innovation Base of stem cell and Gene Therapy for endocrine Metabolic diseases, Jinan, Shandong, 250021, China
- Shandong Engineering Laboratory of Prevention and Control for Endocrine and Metabolic Diseases, Jinan, Shandong, 250021, China
- Department of Mechanical and Aerospace Engineering, Shandong Engineering Research Center of Stem Cell and Gene Therapy for Endocrine and Metabolic Diseases, Jinan, Shandong, 250021, China
| | - Zhenyu Yao
- Key Laboratory of Endocrine Glucose & Lipids Metabolism and Brain Aging, Ministry of Education; Department of Endocrinology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, 250021, China
- Shandong Clinical Research Center of Diabetes and Metabolic Diseases, Jinan, Shandong, 250021, China
- Shandong Institute of Endocrine and Metabolic Diseases, Jinan, Shandong, 250021, China
- "Chuangxin China" Innovation Base of stem cell and Gene Therapy for endocrine Metabolic diseases, Jinan, Shandong, 250021, China
- Shandong Engineering Laboratory of Prevention and Control for Endocrine and Metabolic Diseases, Jinan, Shandong, 250021, China
- Department of Mechanical and Aerospace Engineering, Shandong Engineering Research Center of Stem Cell and Gene Therapy for Endocrine and Metabolic Diseases, Jinan, Shandong, 250021, China
| | - Ran An
- Department of Mechanical and Aerospace Engineering, Case Western Reserve University, Cleveland, OH, USA
| | - Xiaoqin Wu
- Department of Integrative Biology and Pharmacology, McGovern Medical School at UTHealth, Houston, TX, USA
| | - Kyle L Poulsen
- Department of Anesthesiology, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Zhixiang Wang
- Department of Endocrinology, Shandong Provincial Hospital, Shandong University, Jinan, Shandong, 250021, China
- Key Laboratory of Endocrine Glucose & Lipids Metabolism and Brain Aging, Ministry of Education; Department of Endocrinology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, 250021, China
- Shandong Clinical Research Center of Diabetes and Metabolic Diseases, Jinan, Shandong, 250021, China
- Shandong Institute of Endocrine and Metabolic Diseases, Jinan, Shandong, 250021, China
- "Chuangxin China" Innovation Base of stem cell and Gene Therapy for endocrine Metabolic diseases, Jinan, Shandong, 250021, China
- Shandong Engineering Laboratory of Prevention and Control for Endocrine and Metabolic Diseases, Jinan, Shandong, 250021, China
- Department of Mechanical and Aerospace Engineering, Shandong Engineering Research Center of Stem Cell and Gene Therapy for Endocrine and Metabolic Diseases, Jinan, Shandong, 250021, China
| | - Shanshan Shao
- Department of Endocrinology, Shandong Provincial Hospital, Shandong University, Jinan, Shandong, 250021, China
- Key Laboratory of Endocrine Glucose & Lipids Metabolism and Brain Aging, Ministry of Education; Department of Endocrinology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, 250021, China
- Shandong Clinical Research Center of Diabetes and Metabolic Diseases, Jinan, Shandong, 250021, China
- Shandong Institute of Endocrine and Metabolic Diseases, Jinan, Shandong, 250021, China
- "Chuangxin China" Innovation Base of stem cell and Gene Therapy for endocrine Metabolic diseases, Jinan, Shandong, 250021, China
- Shandong Engineering Laboratory of Prevention and Control for Endocrine and Metabolic Diseases, Jinan, Shandong, 250021, China
- Department of Mechanical and Aerospace Engineering, Shandong Engineering Research Center of Stem Cell and Gene Therapy for Endocrine and Metabolic Diseases, Jinan, Shandong, 250021, China
| | - Xiude Fan
- Key Laboratory of Endocrine Glucose & Lipids Metabolism and Brain Aging, Ministry of Education; Department of Endocrinology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, 250021, China.
- Shandong Clinical Research Center of Diabetes and Metabolic Diseases, Jinan, Shandong, 250021, China.
- Shandong Institute of Endocrine and Metabolic Diseases, Jinan, Shandong, 250021, China.
- "Chuangxin China" Innovation Base of stem cell and Gene Therapy for endocrine Metabolic diseases, Jinan, Shandong, 250021, China.
- Shandong Engineering Laboratory of Prevention and Control for Endocrine and Metabolic Diseases, Jinan, Shandong, 250021, China.
- Department of Mechanical and Aerospace Engineering, Shandong Engineering Research Center of Stem Cell and Gene Therapy for Endocrine and Metabolic Diseases, Jinan, Shandong, 250021, China.
| | - Zhen Wang
- Key Laboratory of Endocrine Glucose & Lipids Metabolism and Brain Aging, Ministry of Education; Department of Endocrinology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, 250021, China.
- Shandong Clinical Research Center of Diabetes and Metabolic Diseases, Jinan, Shandong, 250021, China.
- Shandong Institute of Endocrine and Metabolic Diseases, Jinan, Shandong, 250021, China.
- "Chuangxin China" Innovation Base of stem cell and Gene Therapy for endocrine Metabolic diseases, Jinan, Shandong, 250021, China.
- Shandong Engineering Laboratory of Prevention and Control for Endocrine and Metabolic Diseases, Jinan, Shandong, 250021, China.
- Department of Mechanical and Aerospace Engineering, Shandong Engineering Research Center of Stem Cell and Gene Therapy for Endocrine and Metabolic Diseases, Jinan, Shandong, 250021, China.
| | - Jiajun Zhao
- Key Laboratory of Endocrine Glucose & Lipids Metabolism and Brain Aging, Ministry of Education; Department of Endocrinology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, 250021, China.
- Shandong Clinical Research Center of Diabetes and Metabolic Diseases, Jinan, Shandong, 250021, China.
- Shandong Institute of Endocrine and Metabolic Diseases, Jinan, Shandong, 250021, China.
- "Chuangxin China" Innovation Base of stem cell and Gene Therapy for endocrine Metabolic diseases, Jinan, Shandong, 250021, China.
- Shandong Engineering Laboratory of Prevention and Control for Endocrine and Metabolic Diseases, Jinan, Shandong, 250021, China.
- Department of Mechanical and Aerospace Engineering, Shandong Engineering Research Center of Stem Cell and Gene Therapy for Endocrine and Metabolic Diseases, Jinan, Shandong, 250021, China.
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2
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Enßle JC, Wolf S, Scheich S, Weber S, Kramer M, Ruhnke L, Schliemann C, Mikesch JH, Krause S, Sauer T, Hanoun M, Reinhardt HC, Kraus S, Kaufmann M, Hänel M, Fransecky L, Burchert A, Neubauer A, Crysandt M, Jost E, Niemann D, Schäfer-Eckart K, Held G, Kaiser U, Wass M, Schaich M, Müller-Tidow C, Platzbecker U, Baldus CD, Bornhäuser M, Röllig C, Serve H, Steffen B. Impact of BMI on patient outcome in acute myeloid leukaemia patients receiving intensive induction therapy: a real-world registry experience. Br J Cancer 2023; 129:1126-1133. [PMID: 37542108 PMCID: PMC10539505 DOI: 10.1038/s41416-023-02362-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Revised: 06/06/2023] [Accepted: 07/05/2023] [Indexed: 08/06/2023] Open
Abstract
BACKGROUND Acute myeloid leukaemia (AML) is treated with intensive induction chemotherapy (IT) in medically fit patients. In general, obesity was identified as a risk factor for all-cause mortality, and there is an ongoing debate on its impact on outcome and optimal dosing strategy in obese AML patients. METHODS We conducted a registry study screening 7632 patients and assessed the impact of obesity in 1677 equally IT treated, newly diagnosed AML patients on the outcome (OS, EFS, CR1), comorbidities, toxicities and used dosing strategies. RESULTS Obese patients (BMI ≥ 30) displayed a significant inferior median OS (29.44 vs. 47.94 months, P = 0.015) and CR1 rate (78.7% vs. 84.3%, P = 0.015) without differences in median EFS (7.8 vs. 9.89 months, P = 0.3) compared to non-obese patients (BMI < 30). The effect was predominantly observed in older (≥60 years) patients. Obesity was identified as an independent risk factor for death, and obese patients demonstrated higher rates of cardiovascular or metabolic comorbidities. No differences for OS, EFS, CR1 or treatment-related toxicities were observed by stratification according to used dosing strategy or dose reduction. CONCLUSIONS In conclusion, this study identifies obesity as an independent risk factor for worse OS in older AML patients undergoing curative IT most likely due to obesity-related comorbidities and not to dosing strategy.
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Affiliation(s)
- Julius C Enßle
- Department of Medicine II, Hematology and Oncology, University Hospital Frankfurt, Goethe-University, Frankfurt am Main, Germany
| | - Sebastian Wolf
- Department of Medicine II, Hematology and Oncology, University Hospital Frankfurt, Goethe-University, Frankfurt am Main, Germany
| | - Sebastian Scheich
- Department of Medicine II, Hematology and Oncology, University Hospital Frankfurt, Goethe-University, Frankfurt am Main, Germany
| | - Sarah Weber
- Department of Medicine II, Hematology and Oncology, University Hospital Frankfurt, Goethe-University, Frankfurt am Main, Germany
| | - Michael Kramer
- Department of Internal Medicine I, University Hospital Dresden, Dresden, Germany
| | - Leo Ruhnke
- Department of Internal Medicine I, University Hospital Dresden, Dresden, Germany
| | | | | | - Stefan Krause
- Department of Hematology and Medical Oncology, University Hospital Erlangen, Erlangen, Germany
| | - Tim Sauer
- Department of Medicine V, Hematology, Oncology and Rheumatology, University Hospital Heidelberg, Heidelberg, Germany
| | - Maher Hanoun
- Department of Hematology and Stem Cell Transplantation, University Hospital Essen, Essen, Germany
| | - Hans Christian Reinhardt
- Department of Hematology and Stem Cell Transplantation, University Hospital Essen, Essen, Germany
| | - Sabrina Kraus
- Department of Internal Medicine II, University Hospital Würzburg, Würzburg, Germany
| | - Martin Kaufmann
- Department of Hematology, Oncology and Palliative Medicine, Robert-Bosch-Hospital, Stuttgart, Germany
| | - Mathias Hänel
- Department of Internal Medicine III, Chemnitz Hospital, Chemnitz, Germany
| | - Lars Fransecky
- Department of Internal Medicine II, University Hospital Schleswig-Holstein, Kiel, Germany
| | - Andreas Burchert
- Department of Hematology, Oncology and Immunology, University Hospital Marburg, Marburg, Germany
| | - Andreas Neubauer
- Department of Hematology, Oncology and Immunology, University Hospital Marburg, Marburg, Germany
| | - Martina Crysandt
- Department of Internal Medicine IV, University Hospital RWTH Aachen, Aachen, Germany
| | - Edgar Jost
- Department of Internal Medicine IV, University Hospital RWTH Aachen, Aachen, Germany
| | - Dirk Niemann
- Department of Hematology/Oncology and Palliative Medicine, Ev. Stift St. Martin, Koblenz, Germany
| | - Kerstin Schäfer-Eckart
- Department of Internal Medicine 5, Hospital Nürnberg, Paracelsus Medizinische Privatuniversität, Nürnberg, Germany
| | - Gerhard Held
- Department of Internal Medicine I, Westpfalz Klinik, Kaiserslautern, Germany
| | - Ulrich Kaiser
- Department of Hematology and Oncology, St. Bernward Hospital, Hildesheim, Germany
| | - Maxi Wass
- Department of Internal Medicine IV, University Hospital Halle (Saale), Halle (Saale), Germany
| | - Markus Schaich
- Department of Hematology, Oncology and Palliative Medicine, Rems-Murr-Kliniken, Winnenden, Germany
| | - Carsten Müller-Tidow
- Department of Medicine V, Hematology, Oncology and Rheumatology, University Hospital Heidelberg, Heidelberg, Germany
| | - Uwe Platzbecker
- Department for Internal Medicine I, University Hospital Leipzig, Leipzig, Germany
| | - Claudia D Baldus
- Department of Internal Medicine II, University Hospital Schleswig-Holstein, Kiel, Germany
| | - Martin Bornhäuser
- Department of Internal Medicine I, University Hospital Dresden, Dresden, Germany
| | - Christoph Röllig
- Department of Internal Medicine I, University Hospital Dresden, Dresden, Germany
| | - Hubert Serve
- Department of Medicine II, Hematology and Oncology, University Hospital Frankfurt, Goethe-University, Frankfurt am Main, Germany
| | - Björn Steffen
- Department of Medicine II, Hematology and Oncology, University Hospital Frankfurt, Goethe-University, Frankfurt am Main, Germany.
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Nitsche LJ, Mukherjee S, Cheruvu K, Krabak C, Rachala R, Ratnakaram K, Sharma P, Singh M, Yendamuri S. Exploring the Impact of the Obesity Paradox on Lung Cancer and Other Malignancies. Cancers (Basel) 2022; 14:cancers14061440. [PMID: 35326592 PMCID: PMC8946288 DOI: 10.3390/cancers14061440] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2021] [Revised: 03/01/2022] [Accepted: 03/09/2022] [Indexed: 02/06/2023] Open
Abstract
Simple Summary Studies have shown that obesity is associated with many adverse health effects, including worse cancer outcomes. Many studies paradoxically suggest a survival benefit for obesity in treatment outcomes of cancers such as non-small-cell lung cancer. This relationship is not seen in animal models. We hypothesize that this relationship is secondary to suboptimal quantification of adiposity, enhanced immunotherapy response, and variables such as sex, medications, and smoking status. There are many ways to measure and classify adiposity, but the ability to distinguish abdominal obesity is likely key in predicting accurate prognosis. There are many ways obesity impacts cancer treatment course from diagnosis to survivorship. In this paper, we aim to analyze the factors contributing to the obesity paradox and its effect on lung cancer. This can aid the treatment and prognosis of lung cancer and may support further research into obesity-specific impacts on this malignancy. Abstract There is a paradoxical relationship between obesity, as measured by BMI, and many types of cancer, including non-small-cell lung cancer. Obese non-small-cell lung cancer patients have been shown to fare better than their non-obese counterparts. To analyze the multifaceted effects of obesity on oncologic outcomes, we reviewed the literature on the obesity paradox, methods to measure adiposity, the obesity-related derangements in immunology and metabolism, and the oncologic impact of confounding variables such as gender, smoking, and concomitant medications such as statins and metformin. We analyzed how these aspects may contribute to the obesity paradox and cancer outcomes with a focus on lung cancer. We concluded that the use of BMI to measure adiposity is limited and should be replaced by a method that can differentiate abdominal obesity. We also concluded that the concomitant metabolic and immunologic derangements caused by obesity contribute to the obesity paradox. Medications, gender, and smoking are additional variables that impact oncologic outcomes, and further research needs to be performed to solidify the mechanisms.
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Affiliation(s)
- Lindsay Joyce Nitsche
- Department of Thoracic Surgery, Roswell Park Comprehensive Cancer Center, Elm and Carlton Streets, Buffalo, NY 14263, USA; (L.J.N.); (K.C.); (C.K.); (R.R.); (K.R.); (P.S.); (M.S.)
| | - Sarbajit Mukherjee
- Department of Medicine, Roswell Park Comprehensive Cancer Center, Elm and Carlton Streets, Buffalo, NY 14263, USA;
| | - Kareena Cheruvu
- Department of Thoracic Surgery, Roswell Park Comprehensive Cancer Center, Elm and Carlton Streets, Buffalo, NY 14263, USA; (L.J.N.); (K.C.); (C.K.); (R.R.); (K.R.); (P.S.); (M.S.)
| | - Cathleen Krabak
- Department of Thoracic Surgery, Roswell Park Comprehensive Cancer Center, Elm and Carlton Streets, Buffalo, NY 14263, USA; (L.J.N.); (K.C.); (C.K.); (R.R.); (K.R.); (P.S.); (M.S.)
| | - Rohit Rachala
- Department of Thoracic Surgery, Roswell Park Comprehensive Cancer Center, Elm and Carlton Streets, Buffalo, NY 14263, USA; (L.J.N.); (K.C.); (C.K.); (R.R.); (K.R.); (P.S.); (M.S.)
| | - Kalyan Ratnakaram
- Department of Thoracic Surgery, Roswell Park Comprehensive Cancer Center, Elm and Carlton Streets, Buffalo, NY 14263, USA; (L.J.N.); (K.C.); (C.K.); (R.R.); (K.R.); (P.S.); (M.S.)
| | - Priyanka Sharma
- Department of Thoracic Surgery, Roswell Park Comprehensive Cancer Center, Elm and Carlton Streets, Buffalo, NY 14263, USA; (L.J.N.); (K.C.); (C.K.); (R.R.); (K.R.); (P.S.); (M.S.)
| | - Maddy Singh
- Department of Thoracic Surgery, Roswell Park Comprehensive Cancer Center, Elm and Carlton Streets, Buffalo, NY 14263, USA; (L.J.N.); (K.C.); (C.K.); (R.R.); (K.R.); (P.S.); (M.S.)
| | - Sai Yendamuri
- Department of Thoracic Surgery, Roswell Park Comprehensive Cancer Center, Elm and Carlton Streets, Buffalo, NY 14263, USA; (L.J.N.); (K.C.); (C.K.); (R.R.); (K.R.); (P.S.); (M.S.)
- Correspondence: ; Tel.: +1-716-8458675
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4
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Griggs JJ, Bohlke K, Balaban EP, Dignam JJ, Hall ET, Harvey RD, Hecht DP, Klute KA, Morrison VA, Pini TM, Rosner GL, Runowicz CD, Shayne M, Sparreboom A, Turner S, Zarwan C, Lyman GH. Appropriate Systemic Therapy Dosing for Obese Adult Patients With Cancer: ASCO Guideline Update. J Clin Oncol 2021; 39:2037-2048. [PMID: 33939491 DOI: 10.1200/jco.21.00471] [Citation(s) in RCA: 46] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
PURPOSE To provide recommendations for appropriate dosing of systemic antineoplastic agents in obese adults with cancer. METHODS A systematic review of the literature collected evidence regarding dosing of chemotherapy, immunotherapy, and targeted therapies in obese adults with cancer. PubMed and the Cochrane Library were searched for randomized controlled trials, meta-analyses, or cohort studies published from November 1, 2010, through March 27, 2020. ASCO convened an Expert Panel to review the evidence and formulate recommendations. RESULTS Sixty studies, primarily retrospective, were included in the review. Overall, the evidence supported previous findings that obese adult patients tolerate full, body-size-based dosing of chemotherapy as well as nonobese patients. Fewer studies have addressed the dosing of targeted therapies and immunotherapies in relation to safety and efficacy in obese patients. RECOMMENDATIONS The Panel continues to recommend that full, weight-based cytotoxic chemotherapy doses be used to treat obese adults with cancer. New to this version of the guideline, the Panel also recommends that full, approved doses of immunotherapy and targeted therapies be offered to obese adults with cancer. In the event of toxicity, the consensus of the Panel is that dose modifications of systemic antineoplastic therapies should be handled similarly for obese and nonobese patients. Important areas for future research include the impact of sarcopenia and other measures of body composition on optimal antineoplastic dosing, and more customized dosing based on pharmacokinetic or pharmacogenetic factors.Additional information is available at www.asco.org/supportive-care-guidelines.
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Affiliation(s)
| | - Kari Bohlke
- American Society of Clinical Oncology, Alexandria, VA
| | | | | | - Evan T Hall
- Fred Hutchinson Cancer Research Center and University of Washington, Seattle, WA
| | | | - Diane P Hecht
- University of Texas MD Anderson Cancer Center, Houston, TX
| | | | - Vicki A Morrison
- University of Minnesota Hennepin County Medical Center, Minneapolis, MN
| | | | | | - Carolyn D Runowicz
- Herbert Wertheim College of Medicine, Florida International University, Miami, FL
| | | | | | | | | | - Gary H Lyman
- Fred Hutchinson Cancer Research Center and University of Washington, Seattle, WA
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5
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Sallustio BC, Boddy AV. Is there scope for better individualisation of anthracycline cancer chemotherapy? Br J Clin Pharmacol 2020; 87:295-305. [PMID: 33118175 DOI: 10.1111/bcp.14628] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Revised: 10/13/2020] [Accepted: 10/17/2020] [Indexed: 12/11/2022] Open
Abstract
Anthracyclines are used to treat solid and haematological cancers, particularly breast cancers, lymphomas and childhood cancers. Myelosuppression and cardiotoxicity are the primary toxicities that limit treatment duration and/or intensity. Cardiotoxicity, particularly heart failure, is a leading cause of morbidity and mortality in cancer survivors. Cumulative anthracycline dose is a significant predictor of cardiotoxicity risk, suggesting a role for anthracycline pharmacokinetic variability. Population pharmacokinetic modelling in children has shown that doxorubicin clearance in the very young is significantly lower than in older children, potentially contributing to their higher risk of cardiotoxicity. A model of doxorubicin clearance based on body surface area and age offers a patient-centred dose-adjustment strategy that may replace the current disparate initial-dose selection tools, providing a rational way to compensate for pharmacokinetic variability in children aged <7 years. Population pharmacokinetic models in adults have not adequately addressed older ages, obesity, hepatic and renal dysfunction, and potential drug-drug interactions to enable clinical application. Although candidate gene and genome-wide association studies have investigated relationships between genetic variability and anthracycline pharmacokinetics or clinical outcomes, there have been few clinically significant reproducible associations. Precision-dosing of anthracyclines is currently hindered by lack of clinically useful pharmacokinetic targets and models that predict cumulative anthracycline exposures. Combined with known risk factors for cardiotoxicity, the use of advanced echocardiography and biomarkers, future validated pharmacokinetic targets and predictive models could facilitate anthracycline precision dosing that truly maximises efficacy and provides individualised early intervention with cardioprotective therapies in patients at risk of cardiotoxicity.
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Affiliation(s)
- Benedetta C Sallustio
- Department of Clinical Pharmacology, Basil Hetzel Institute for Translational Health Research, The Queen Elizabeth Hospital, Woodville South, SA, Australia.,Discipline of Pharmacology, Adelaide Medical School, The University of Adelaide, Adelaide, SA, Australia
| | - Alan V Boddy
- School of Pharmacy and Medical Sciences and UniSA Cancer Research Institute, University of South Australia, Adelaide, SA, Australia
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6
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Saini M, Ghosh S, Kumar V, Roy P, Sadhu KK. Selective Release of Doxorubicin from Cucurbit[8]uril Stabilized Gold Supra-Pyramid Host at pH of Small Intestine. Chemistry 2020; 26:15150-15158. [PMID: 32463129 DOI: 10.1002/chem.202002048] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Indexed: 12/14/2022]
Abstract
Gold supra-pyramid structures were obtained by the addition of acidic solution of cucurbit[8]uril (CB[8]) to an aqueous solution of citrate stabilized gold nanoparticles (AuNP). The reaction resulted in the precipitation of supra-pyramid from the solution after just 1 min of shaking. Microscopic images confirmed formation of the supra-pyramid. The stepwise structural transformation towards the supra-pyramid was examined with variable concentrations of CB[8] to AuNP solution. Anionic counter parts of these acids (Br- , NO3 - , SO4 2- and Cl- ) controlled the size of the synthesized supra-pyramids. These supra-pyramid hosts showed uptake of three anticancer drugs: oral drugs etoposide, prednisolone and intravenous drug doxorubicin. Releases of drugs from these hosts were emulated at acidic stomach pH, basic small intestinal pH and in the presence of human serum albumin (HSA). The specific release of doxorubicin was confirmed at small intestinal pH 7.4. Poor release of drugs in presence of CB[8] specific guest 1-adamantanamine confirmed the role of the supra-pyramid as the exclusive host. The release of doxorubicin from the supra-pyramid at pH 7.4 was confirmed by fluorescence microscopic imaging with prostate cancer DU-145 cell line.
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Affiliation(s)
- Meenaxi Saini
- Department of Chemistry, Indian Institution of Technology Roorkee, Roorkee, 247667, Uttarakhand, India
| | - Souvik Ghosh
- Department of Biotechnology, Indian Institution of Technology Roorkee, Roorkee, 247667, Uttarakhand, India
| | - Viney Kumar
- Department of Biotechnology, Indian Institution of Technology Roorkee, Roorkee, 247667, Uttarakhand, India
| | - Partha Roy
- Department of Biotechnology, Indian Institution of Technology Roorkee, Roorkee, 247667, Uttarakhand, India
| | - Kalyan K Sadhu
- Department of Chemistry, Indian Institution of Technology Roorkee, Roorkee, 247667, Uttarakhand, India
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7
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Wang Z, Luo S, Zhao X. The Prognostic Impact of Body Mass Index in Patients with Diffuse Large B-Cell Lymphoma: A Meta-Analysis. Nutr Cancer 2020; 73:2336-2346. [PMID: 32964748 DOI: 10.1080/01635581.2020.1823437] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
OBJECTIVE Some studies on the relation between body mass index (BMI) and outcome of diffuse large B-cell lymphoma (DLBCL) remain controversial. We performed a meta-analysis to evaluate the overall survival (OS) and progression-free survival (PFS) of DLBCL in overweight (≥25 to <30 kg/m2), obese (≥30 kg/m2) and underweight (<18.5 kg/m2) individuals compared with normal weight patients (≥18.5 to <25 kg/m2). METHODS PubMed, Web of Science, EMBASE and the Cochrane Library databases were searched to identify relevant studies before February 20, 2020. The summary hazard ratio (HR) and 95% confidence interval (CI) were used for analyzing survival outcomes. RESULTS Fourteen articles involving 8,753 subjects were included. The pooled analysis indicated that OS of overweight group (HR = 0.86, 95% CI: 0.78-0.95, P = 0.002) was better than of normal weight group, but no association was found in obese patients (HR = 1.11, 95% CI: 0.81-1.53, P = 0.501). Similarly, obese and overweight status had no significant impact on PFS in DLBCL. Underweight patients had poorer OS (HR = 1.99, 95% CI: 1.45-2.74, P < 0.001) and PFS (HR = 1.78, 95% CI: 1.12-2.83, P = 0.014) compared with normal weight group. CONCLUSION Overweight patients have a better survival than normal weight patients, while underweight patients have a poorer survival in DLBCL.
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Affiliation(s)
- Zanzan Wang
- Department of Hematology, Zhejiang University School of Medicine Second Affiliated Hospital, Hangzhou, China
| | - Shuna Luo
- Department of Hematology, Zhejiang University School of Medicine Fourth Affiliated Hospital, Yiwu, China
| | - Xiaoying Zhao
- Department of Hematology, Zhejiang University School of Medicine Second Affiliated Hospital, Hangzhou, China
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8
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Fürstenau M, Hopfinger G, Robrecht S, Fink AM, Al-Sawaf O, Langerbeins P, Cramer P, Tresckow JV, Maurer C, Kutsch N, Hoechstetter M, Dreyling M, Lange E, Kneba M, Stilgenbauer S, Döhner H, Hensel M, Kiehl MG, Jaeger U, Wendtner CM, Goede V, Fischer K, von Bergwelt-Baildon M, Eichhorst B, Hallek M, Theurich S. Influence of obesity and gender on treatment outcomes in patients with chronic lymphocytic leukemia (CLL) undergoing rituximab-based chemoimmunotherapy. Leukemia 2019; 34:1177-1181. [PMID: 31728057 DOI: 10.1038/s41375-019-0630-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2019] [Revised: 10/14/2019] [Accepted: 11/03/2019] [Indexed: 11/09/2022]
Affiliation(s)
- Moritz Fürstenau
- Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, German CLL Study Group, CECAD Cluster of Excellence, University of Cologne, Cologne, Germany.
| | - Georg Hopfinger
- Department of Internal Medicine I, Bone Marrow Transplantation, Medical University of Vienna, Vienna, Austria
| | - Sandra Robrecht
- Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, German CLL Study Group, CECAD Cluster of Excellence, University of Cologne, Cologne, Germany
| | - Anna-Maria Fink
- Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, German CLL Study Group, CECAD Cluster of Excellence, University of Cologne, Cologne, Germany
| | - Othman Al-Sawaf
- Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, German CLL Study Group, CECAD Cluster of Excellence, University of Cologne, Cologne, Germany
| | - Petra Langerbeins
- Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, German CLL Study Group, CECAD Cluster of Excellence, University of Cologne, Cologne, Germany
| | - Paula Cramer
- Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, German CLL Study Group, CECAD Cluster of Excellence, University of Cologne, Cologne, Germany
| | - Julia Von Tresckow
- Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, German CLL Study Group, CECAD Cluster of Excellence, University of Cologne, Cologne, Germany
| | - Christian Maurer
- Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, German CLL Study Group, CECAD Cluster of Excellence, University of Cologne, Cologne, Germany
| | - Nadine Kutsch
- Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, German CLL Study Group, CECAD Cluster of Excellence, University of Cologne, Cologne, Germany
| | - Manuela Hoechstetter
- Department of Hematology, Oncology, Immunology, Palliative Care, Infectious Diseases and Tropical Medicine, München Klinik Schwabing, Munich, Germany
| | - Martin Dreyling
- Department of Medicine III, University Hospital, Ludwig-Maximilians-Universität (LMU) München, Munich, Germany
| | | | - Michael Kneba
- Department II of Internal Medicine, University of Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - Stephan Stilgenbauer
- Department of Internal Medicine III, University Hospital Ulm, Ulm, Germany.,Department of Hematology, Oncology and Rheumatology and José Carreras Center for Immuno and Gene Therapy, Saarland University Medical School, Homburg/Saar, Germany
| | - Hartmut Döhner
- Department of Internal Medicine III, University Hospital Ulm, Ulm, Germany
| | | | - Michael G Kiehl
- Department of Internal Medicine, Frankfurt (Oder) General Hospital, Frankfurt/Oder, Germany
| | - Ulrich Jaeger
- Department of Medicine I, Clinical Division of Hematology and Hemostaseology and Comprehensive Cancer Center (CCC), Medical University of Vienna, Vienna, Austria
| | - Clemens-Martin Wendtner
- Department of Hematology, Oncology, Immunology, Palliative Care, Infectious Diseases and Tropical Medicine, München Klinik Schwabing, Munich, Germany
| | - Valentin Goede
- Oncogeriatric Unit, Department of Geriatric Medicine, St. Marien Hospital, Cologne, Germany
| | - Kirsten Fischer
- Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, German CLL Study Group, CECAD Cluster of Excellence, University of Cologne, Cologne, Germany
| | | | - Barbara Eichhorst
- Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, German CLL Study Group, CECAD Cluster of Excellence, University of Cologne, Cologne, Germany
| | - Michael Hallek
- Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, German CLL Study Group, CECAD Cluster of Excellence, University of Cologne, Cologne, Germany
| | - Sebastian Theurich
- Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, German CLL Study Group, CECAD Cluster of Excellence, University of Cologne, Cologne, Germany. .,Department of Medicine III, University Hospital, Ludwig-Maximilians-Universität (LMU) München, Munich, Germany. .,Gene Center, Cancer- and Immunometabolism Research Group, Ludwig-Maximilians-Universität (LMU) München, Munich, Germany.
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9
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Scheich S, Enßle JC, Mücke VT, Acker F, Aspacher L, Wolf S, Wilke AC, Weber S, Brunnberg U, Serve H, Steffen B. Obesity is associated with an impaired survival in lymphoma patients undergoing autologous stem cell transplantation. PLoS One 2019; 14:e0225035. [PMID: 31703102 PMCID: PMC6839865 DOI: 10.1371/journal.pone.0225035] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2019] [Accepted: 10/28/2019] [Indexed: 12/13/2022] Open
Abstract
Autologous hematopoietic stem cell transplantation (auto-HSCT) provides a potentially curative treatment option for relapsed and refractory lymphomas. Obesity displays an emerging epidemic risk factor for global mortality and is associated with an increased mortality in cancer patients. To date, the impact of obesity on the outcome of lymphoma patients undergoing auto-HSCT is understudied. We conducted a retrospective single-center study assessing 119 lymphoma patients who underwent auto-HSCT. Overall survival (OS) served as the primary endpoint whereas progression free survival (PFS), cumulative incidence of non-relapse related mortality (NRM) and cumulative incidence of relapse were analyzed as secondary endpoints. Obese patients (Body mass index, BMI≥30) had significantly lower OS (45.3% vs. 77.9%; p = 0.005) and PFS (29.8% vs. 67.2%; p<0.001) compared to non-obese patients at 48 months post-transplantation. The cumulative incidence of NRM displayed no significant differences while the cumulative incidence of relapse was significantly increased in patients with BMI≥30 (66.2% vs. 21.5%; p<0.001). Patients with a BMI<25 and overweight patients (BMI 25–30; 76.1% vs. 80.9%; p = 0.585), showed no significant difference in OS, whereas patients with BMI≥30 exhibited significant lower OS when compared to either of both groups (76.1% vs. 45.3%; p = .0.021 and 80.9% vs. 45.3%; p = 0.010). Furthermore, in a multivariate analysis, obesity was identified as an independent risk factor for death (Hazard ratio 2.231; 95% CI 1.024 to 4.860; p = 0.043). Further studies are needed to evaluate the reasons for the higher relapse rate causing higher mortality in obese patients.
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Affiliation(s)
- Sebastian Scheich
- Department of Hematology and Oncology, University Hospital Frankfurt, Frankfurt am Main, Germany
- * E-mail:
| | - Julius C. Enßle
- Department of Hematology and Oncology, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Victoria T. Mücke
- Department of Gastroenterology, Hepatology, Pulmonology and Endocrinology, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Fabian Acker
- Department of Hematology and Oncology, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Lukas Aspacher
- Department of Hematology and Oncology, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Sebastian Wolf
- Department of Hematology and Oncology, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Anne C. Wilke
- Department of Hematology and Oncology, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Sarah Weber
- Department of Hematology and Oncology, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Uta Brunnberg
- Department of Hematology and Oncology, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Hubert Serve
- Department of Hematology and Oncology, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Björn Steffen
- Department of Hematology and Oncology, University Hospital Frankfurt, Frankfurt am Main, Germany
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10
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Coutinho R, Lobato J, Esteves S, Cabeçadas J, Gomes da Silva M. Clinical risk scores do not accurately identify a very high risk population with diffuse large B cell lymphoma-an analysis of 386 Portuguese patients. Ann Hematol 2019; 98:1937-1946. [PMID: 30949752 DOI: 10.1007/s00277-019-03676-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2018] [Accepted: 03/17/2019] [Indexed: 12/24/2022]
Abstract
The identification of high-risk patients deserving alternative first-line treatments to R-CHOP is a research priority in diffuse large B cell lymphoma (DLBCL). Despite the increasing recognition of biological features underlying aggressive behavior, clinical scores remain the basis for prognostic evaluation and treatment stratification in DLBCL. We performed a retrospective analysis of patients with DLBCL uniformly treated with immunochemotherapy with the aim of assessing the discriminative power of the NCCN international prognostic index (IPI) and the GELTAMO-IPI scores in risk group stratification and compared them with the IPI. Additionally, we investigated if bulky disease, gender, beta-2 microglobulin (β2m), body mass index, and B-symptoms have independent prognostic impact. We confirmed the discriminative ability of the three prognostic scores in terms of progression-free survival and overall survival and found that the NCCN-IPI performs better in the identification of a high-risk population compared to the IPI and the GELTAMO scores. In an attempt to improve the prognostic power of the NCCN-IPI we analyzed additional clinical variables. Bulky disease and elevated β2m were found to be independent predictors of prognosis when controlling for the NCCN-IPI risk groups. However, they seem to bring no incremental power to the latter in the identification of poor outcome patients. We support the use of the NCCN-IPI for the clinical identification of high-risk patients in DLBCL. Future studies to unravel the biological heterogeneity within NCCN-IPI groups are needed to improve risk prediction and design targeted therapies for poor prognosis patients.
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Affiliation(s)
- Rita Coutinho
- Department of Hematology, Centro Hospitalar Universitário do Porto, Porto, Portugal.
| | - J Lobato
- Department of Hematology, Instituto Português de Oncologia de Lisboa Francisco Gentil, E.P.E., Lisbon, Portugal
| | - S Esteves
- Clinical Research Unit, Instituto Português de Oncologia de Lisboa Francisco Gentil, E.P.E., Lisbon, Portugal
| | - J Cabeçadas
- Department of Pathology, Instituto Português de Oncologia de Lisboa Francisco Gentil, E.P.E., Lisbon, Portugal
| | - M Gomes da Silva
- Department of Hematology, Instituto Português de Oncologia de Lisboa Francisco Gentil, E.P.E., Lisbon, Portugal
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