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Dogra S, Oneto C, Sherman A, Varughese R, Yuen A, Sherman I, Cohen A, Luo Y, Chen LA. Long-Term Efficacy and Safety of Fecal Microbiota Transplantation for C. difficile Infections Across Academic and Private Clinical Settings. J Clin Gastroenterol 2023; 57:1024-1030. [PMID: 36227005 PMCID: PMC10102254 DOI: 10.1097/mcg.0000000000001778] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2022] [Accepted: 09/05/2022] [Indexed: 12/10/2022]
Abstract
PURPOSE Fecal microbiota transplant (FMT) is increasingly performed for Clostridioides difficile infection (CDI), although long-term efficacy and safety data are limited and are focused on results from academic medical centers rather than private settings where most patients receive care. METHODS Medical records of 165 patients who received FMTs for CDI were reviewed from an academic medical center and an adjacent, unaffiliated private practice. Of these patients, 68 also completed a survey regarding their long-term disease course and interval health. RESULTS CDI resolution occurred in 81.3% (100/123) at the academic center and 95.2% (40/42) in the private setting. Private practice patients were more likely to present with recurrent, rather than refractory, CDI (92.9% vs. 66.7% P <0.001). Those from the academic center were more likely to have comorbid IBD, recent hospitalization, recent proton pump inhibitor use, ongoing immunosuppression, and inpatient FMT (all P values <0.05).Among surveyed patients, 29.4% developed interval comorbidities or changes to pre-existing conditions after a median follow-up of 33.7 months (IQR 13.2 to 44.3 mo). Of 30 patients requiring subsequent antibiotics, 13.3% suffered CDI relapse. All subjects who had initially responded to FMT but had a subsequent CDI (17.9%, 10/56) responded to another FMT. CONCLUSIONS In a real-world setting, patients who underwent FMT at academic centers differed significantly in clinical characteristics from those treated at a private practice. In both settings, FMT is an effective treatment for CDI not responding to standard therapies, even after subsequent antibiotic use. New diagnoses following FMT, however, are common and merit further exploration.
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Affiliation(s)
- Siddhant Dogra
- Division of Gastroenterology, Department of Medicine, NYU Grossman School of Medicine, New York, New York, USA
| | - Caterina Oneto
- Manhattan Clinical Research, LLC, New York, New York, USA
| | - Alex Sherman
- Manhattan Clinical Research, LLC, New York, New York, USA
| | | | - Alexa Yuen
- Division of Gastroenterology, Department of Medicine, NYU Grossman School of Medicine, New York, New York, USA
| | - Isabel Sherman
- Manhattan Clinical Research, LLC, New York, New York, USA
| | - Avi Cohen
- Manhattan Clinical Research, LLC, New York, New York, USA
| | - Yuying Luo
- Division of Gastroenterology, Department of Medicine, NYU Grossman School of Medicine, New York, New York, USA
| | - Lea Ann Chen
- Division of Gastroenterology, Department of Medicine, NYU Grossman School of Medicine, New York, New York, USA
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Giraudeau B, Caille A, Eldridge SM, Weijer C, Zwarenstein M, Taljaard M. Heterogeneity in pragmatic randomised trials: sources and management. BMC Med 2022; 20:372. [PMID: 36303153 PMCID: PMC9615398 DOI: 10.1186/s12916-022-02569-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2022] [Accepted: 09/14/2022] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Pragmatic trials aim to generate evidence to directly inform patient, caregiver and health-system manager policies and decisions. Heterogeneity in patient characteristics contributes to heterogeneity in their response to the intervention. However, there are many other sources of heterogeneity in outcomes. Based on the expertise and judgements of the authors, we identify different sources of clinical and methodological heterogeneity, which translate into heterogeneity in patient responses-some we consider as desirable and some as undesirable. For each of them, we discuss and, using real-world trial examples, illustrate how heterogeneity should be managed over the whole course of the trial. MAIN TEXT Heterogeneity in centres and patients should be welcomed rather than limited. Interventions can be flexible or tailored and control interventions are expected to reflect usual care, avoiding use of a placebo. Co-interventions should be allowed; adherence should not be enforced. All these elements introduce heterogeneity in interventions (experimental or control), which has to be welcomed because it mimics reality. Outcomes should be objective and possibly routinely collected; standardised assessment, blinding and adjudication should be avoided as much as possible because this is not how assessment would be done outside a trial setting. The statistical analysis strategy must be guided by the objective to inform decision-making, thus favouring the intention-to-treat principle. Pragmatic trials should consider including process analyses to inform an understanding of the trial results. Needed data to conduct these analyses should be collected unobtrusively. Finally, ethical principles must be respected, even though this may seem to conflict with goals of pragmatism; consent procedures could be incorporated in the flow of care.
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Affiliation(s)
- Bruno Giraudeau
- Université de Tours, Université de Nantes, INSERM, SPHERE U1246, 2 Bd Tonnellé, 37044, Tours cedex 9, France.
- INSERM CIC1415, CHRU de Tours, Tours, France.
| | - Agnès Caille
- Université de Tours, Université de Nantes, INSERM, SPHERE U1246, 2 Bd Tonnellé, 37044, Tours cedex 9, France
- INSERM CIC1415, CHRU de Tours, Tours, France
| | - Sandra M Eldridge
- Centre for Primary Care and Public Health, Queen Mary University of London, 58 Turner Street, London, E1 2AB, UK
| | - Charles Weijer
- Departments of Medicine and Philosophy, Western University, Stevenson Hall 4130, 1151 Richmond Street, London, ON, N6A 5B7, Canada
| | - Merrick Zwarenstein
- Centre for Studies in Family Medicine, Department of Family Medicine Schulich School of Medicine & Dentistry Western University, 1151 Richmond Street, London, ON, N6A 3K7, Canada
| | - Monica Taljaard
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, The Ottawa Hospital, Civic Campus, 1053 Carling Avenue, Ottawa, Ontario, K1Y 4E9, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Canada
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Gong IY, Yan AT, Earle CC, Trudeau ME, Eisen A, Chan KKW. Comparison of outcomes in a population-based cohort of metastatic breast cancer patients receiving anti-HER2 therapy with clinical trial outcomes. Breast Cancer Res Treat 2020; 181:155-165. [PMID: 32236828 DOI: 10.1007/s10549-020-05614-5] [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: 01/20/2020] [Accepted: 03/23/2020] [Indexed: 12/17/2022]
Abstract
PURPOSE Little data exist for comparing cardiac safety and survival outcomes of trastuzumab/pertuzumab or ado-T emtansine (TDM1) in metastatic breast cancer (MBC) patients enrolled in randomized clinical trial (RCT) vs the real-world. METHODS This was a retrospective population-based cohort of all patients with MBC treated with trastuzumab/pertuzumab or TDM1 (2012-2017) in Ontario, Canada. Outcomes were incident heart failure (HF) and overall survival (OS). RCT data were obtained from digitizing survival curves and compared with cohort data using Kaplan-Meier analysis. Age-based comparison of outcomes was conducted for patients ≥ 65 years old vs younger than 65. RESULTS The two cohorts composed of 833 and 397 patients treated with trastuzumab/pertuzumab and TDM1, of whom 5.5% and 7.6% had baseline HF, respectively. Incident HF following trastuzumab/pertuzumab or TDM1 was low (trastuzumab/pertuzumab 1.8 events/100 person years; TDM1 0.02 events/100 person years). The median OS was 39.2 and 56.4 months in the trastuzumab/pertuzumab population-based cohort and CLEOPATRA, respectively. The median OS was 15.4 and 30.9 months in the TDM1 population-based cohort and EMILIA, respectively. Cohort OS was significantly worse than RCT OS (trastuzumab/pertuzumab HR 1.67, 95% CI 1.37-2.03, p < 0.0001; TDM1 HR 2.80, 95% CI 2.27-3.44, p < 0.0001). Older patients had worse OS than younger patients for trastuzumab/pertuzumab (HR 1.60, 95% CI 1.19-2.16, p = 0.0018), but not for TDM1 (HR 1.16, 95% CI 0.81-1.66, p = 0.43). CONCLUSION HF incidence during trastuzumab/pertuzumab or TDM1 therapy in this real-world cohort was low. Survival in this cohort was worse compared to RCT, suggesting that recruitment of patients similar to the real-world population is required.
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Affiliation(s)
- Inna Y Gong
- Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Andrew T Yan
- Department of Medicine, University of Toronto, Toronto, ON, Canada.,St. Michael's Hospital, Toronto, ON, Canada
| | - Craig C Earle
- Department of Medicine, University of Toronto, Toronto, ON, Canada.,Institute for Clinical Evaluative Sciences, Toronto, ON, Canada.,Sunnybrook Health Sciences Centre, Toronto, ON, Canada.,Ontario Institute for Cancer Research, Toronto, ON, Canada
| | - Maureen E Trudeau
- Department of Medicine, University of Toronto, Toronto, ON, Canada.,Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Andrea Eisen
- Department of Medicine, University of Toronto, Toronto, ON, Canada.,Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Kelvin K W Chan
- Department of Medicine, University of Toronto, Toronto, ON, Canada. .,Sunnybrook Health Sciences Centre, Toronto, ON, Canada. .,Cancer Care Ontario, Toronto, Canada. .,Canadian Centre for Applied Research in Cancer Control, Vancouver, Canada. .,Sunnybrook Odette Cancer Centre, University of Toronto, T-Wing, 2075 Bayview Avenue, T2-058, Toronto, ON, M2N3E6, Canada.
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Park EM, Stephenson EM, Moore CW, Deal AM, Muriel AC. Parental psychological distress and cancer stage: a comparison of adults with metastatic and non-metastatic cancer. Support Care Cancer 2018; 27:2443-2451. [PMID: 30368671 DOI: 10.1007/s00520-018-4518-1] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2018] [Accepted: 10/16/2018] [Indexed: 10/28/2022]
Abstract
PURPOSE Parents with cancer have unique and often under-recognized psychological distress about the impact of their illness on their children. Relatively little is known about how parenting concerns may differ among patients by cancer stage. METHODS This is a secondary data analysis of 203 adults with cancer who had children < 18 years old from two geographically distinct areas. We used an analysis of covariance to estimate the mean differences in PCQ, depression symptom severity and anxiety symptom severity (Hospital Anxiety and Depression Scale, HADS) scores between participants with metastatic and non-metastatic disease, and Pearson's correlation coefficients to assess associations between HADS and PCQ scores by cancer stage. RESULTS Seventy-two percent of participants (n = 146) had metastatic solid tumor cancer. In adjusted analyses, mean PCQ scores did not significantly differ between parents with metastatic and non-metastatic disease (2.0 vs. 2.2, p = 0.06). Differences in mean PCQ scores were driven by a single question concerning the impact of death on children (2.3 vs. 2.9, p = 0.004). Mean HADS scores did not significantly differ between groups, although PCQ scores explained a greater amount of variance in HADS scores for the metastatic group as compared to the non-metastatic group. CONCLUSIONS With the exception of concerns about death, intensity of parenting concerns, as measured by the PCQ, was similar between parents with metastatic and non-metastatic cancer. However, parenting concerns may be more strongly linked to overall psychological distress in patients with metastatic disease. Further research is needed to clarify how parenting concerns uniquely relate to advanced stage illness.
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Affiliation(s)
- Eliza M Park
- Department of Psychiatry, University of North Carolina, 170 Manning Drive, CB #7305, Chapel Hill, NC, 27599, USA. .,Department of Medicine, University of North Carolina, Chapel Hill, NC, USA. .,Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC, USA.
| | | | - Cynthia W Moore
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA
| | - Allison M Deal
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC, USA
| | - Anna C Muriel
- Department of Psychosocial Oncology and Palliative Care, Dana Farber Cancer Institute, Boston, MA, USA
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Presley CJ, Tang D, Soulos PR, Chiang AC, Longtine JA, Adelson KB, Herbst RS, Zhu W, Nussbaum NC, Sorg RA, Agarwala V, Abernethy AP, Gross CP. Association of Broad-Based Genomic Sequencing With Survival Among Patients With Advanced Non-Small Cell Lung Cancer in the Community Oncology Setting. JAMA 2018; 320:469-477. [PMID: 30088010 PMCID: PMC6142984 DOI: 10.1001/jama.2018.9824] [Citation(s) in RCA: 103] [Impact Index Per Article: 17.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
IMPORTANCE Broad-based genomic sequencing is being used more frequently for patients with advanced non-small cell lung cancer (NSCLC). However, little is known about the association between broad-based genomic sequencing and treatment selection or survival among patients with advanced NSCLC in a community oncology setting. OBJECTIVE To compare clinical outcomes between patients with advanced NSCLC who received broad-based genomic sequencing vs a control group of patients who received routine testing for EGFR mutations and/or ALK rearrangements alone. DESIGN, SETTING, AND PARTICIPANTS Retrospective cohort study of patients with chart-confirmed advanced NSCLC between January 1, 2011, and July 31, 2016, and who received care at 1 of 191 oncology practices across the United States using the Flatiron Health Database. Patients were diagnosed with stage IIIB/IV or unresectable nonsquamous NSCLC who received at least 1 line of antineoplastic treatment. EXPOSURES Receipt of either broad-based genomic sequencing or routine testing (EGFR and/or ALK only). Broad-based genomic sequencing included any multigene panel sequencing assay examining more than 30 genes prior to third-line treatment. MAIN OUTCOMES AND MEASURES Primary outcomes were 12-month mortality and overall survival from the start of first-line treatment. Secondary outcomes included frequency of genetic alterations and treatments received. RESULTS Among 5688 individuals with advanced NSCLC (median age, 67 years [interquartile range, 41-85], 63.6% white, 80% with a history of smoking); 875 (15.4%) received broad-based genomic sequencing and 4813 (84.6%) received routine testing. Among patients who received broad-based genomic sequencing, 4.5% received targeted treatment based on testing results, 9.8% received routine EGFR/ALK targeted treatment, and 85.1% received no targeted treatment. Unadjusted mortality rates at 12 months were 49.2% for patients undergoing broad-based genomic sequencing and 35.9% for patients undergoing routine testing. Using an instrumental variable analysis, there was no significant association between broad-based genomic sequencing and 12-month mortality (predicted probability of death at 12 months, 41.1% for broad-based genomic sequencing vs 44.4% for routine testing; difference -3.6% [95% CI, -18.4% to 11.1%]; P = .63). The results were consistent in the propensity score-matched survival analysis (42.0% vs 45.1%; hazard ratio, 0.92 [95% CI, 0.73 to 1.11]; P = .40) vs unmatched cohort (hazard ratio, 0.69 [95% CI, 0.62 to 0.77]; log-rank P < .001). CONCLUSIONS AND RELEVANCE Among patients with advanced non-small cell lung cancer receiving care in the community oncology setting, broad-based genomic sequencing directly informed treatment in a minority of patients and was not independently associated with better survival.
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Affiliation(s)
| | - Daiwei Tang
- Yale School of Public Health, New Haven, Connecticut
| | | | | | | | | | | | - Weiwei Zhu
- Yale School of Medicine, New Haven, Connecticut
| | - Nathan C. Nussbaum
- Flatiron Health, New York, New York
- New York University School of Medicine, New York
| | | | - Vineeta Agarwala
- Flatiron Health, New York, New York
- Stanford University School of Medicine, Stanford, California
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van de Wal M, van Oort I, Schouten J, Thewes B, Gielissen M, Prins J. Fear of cancer recurrence in prostate cancer survivors. Acta Oncol 2016; 55:821-7. [PMID: 26935517 DOI: 10.3109/0284186x.2016.1150607] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Background High fear of cancer recurrence (FCR) is an understudied topic in prostate cancer (PCa) survivors. This study aimed to detect the prevalence, consequences and characteristics associated with high FCR in PCa survivors. Material and methods This cross-sectional study included patients diagnosed with localized PCa and treated with curative radical prostatectomy between 1992 and 2012. We administered the Cancer Worry Scale (CWS) to assess FCR severity (primary outcome measure). Secondary outcomes included distress, quality of life (QOL), post-traumatic symptoms, and multidimensional aspects of FCR. χ(2)-tests, t-tests and Pearson's correlations examined the relationship between FCR and medical/demographic characteristics. MANOVA analyses and χ2-tests identified differences between PCa survivors with high and low FCR. Results Two hundred eighty-three PCa survivors (median age of 70.0 years) completed the questionnaires a median time of 7.1 years after surgery. About a third (36%) of all PCa survivors experienced high FCR. High FCR was associated with lower QOL, more physical problems, higher distress and more post-traumatic stress symptoms. PCa survivors with high FCR reported disease-related triggers (especially medical examinations), felt helpless and experienced problems in social relationships. High FCR was associated with a younger age and having received adjuvant radiotherapy. Conclusions Results illustrate that FCR is a significant problem in PCa survivors. Younger men and those treated with adjuvant radiotherapy are especially at risk. Those with high FCR experience worse QOL and higher symptom burden. Health care providers should pay specific attention to this problem and provide appropriate psychosocial care when needed.
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Affiliation(s)
- Marieke van de Wal
- Department of Medical Psychology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Inge van Oort
- Department of Urology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Joost Schouten
- Department of Urology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Belinda Thewes
- Department of Medical Psychology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Marieke Gielissen
- Department of Medical Psychology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Judith Prins
- Department of Medical Psychology, Radboud University Medical Center, Nijmegen, The Netherlands
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Eaton BR, Pugh SL, Bradley JD, Masters G, Kavadi VS, Narayan S, Nedzi L, Robinson C, Wynn RB, Koprowski C, Johnson DW, Meng J, Curran WJ. Institutional Enrollment and Survival Among NSCLC Patients Receiving Chemoradiation: NRG Oncology Radiation Therapy Oncology Group (RTOG) 0617. J Natl Cancer Inst 2016; 108:djw034. [PMID: 27206636 DOI: 10.1093/jnci/djw034] [Citation(s) in RCA: 77] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2015] [Accepted: 02/09/2016] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND The purpose of this analysis is to evaluate the effect of institutional accrual volume on clinical outcomes among patients receiving chemoradiation for locally advanced non-small cell lung cancer (LA-NSCLC) on a phase III trial. METHODS Patients with LA-NSCLC were randomly assigned to 60 Gy or 74 Gy radiotherapy (RT) with concurrent carboplatin/paclitaxel +/- cetuximab on NRG Oncology RTOG 0617. Participating institutions were categorized as low-volume centers (LVCs) or high-volume centers (HVCs) according to the number of patients accrued (≤3 vs > 3). All statistical tests were two-sided. RESULTS Range of accrual for LVCs (n = 195) vs HVCs (n = 300) was 1 to 3 vs 4 to 18 patients. Baseline characteristics were similar between the two cohorts. Treatment at a HVC was associated with statistically significantly longer overall survival (OS) and progression-free survival (PFS) compared with treatment at a LVC (median OS = 26.2 vs 19.8 months; HR = 0.70, 95% CI = 0.56 to 0.88, P = .002; median PFS: 11.4 vs 9.7 months, HR = 0.80, 95% CI = 0.65-0.99, P = .04). Patients treated at HVCs were more often treated with intensity-modulated RT (54.0% vs 39.5%, P = .002), had a lower esophageal dose (mean = 26.1 vs 28.0 Gy, P = .03), and had a lower heart dose (median = V5 Gy 38.2% vs 54.1%, P = .006; V50 Gy 3.6% vs 7.3%, P < .001). Grade 5 adverse events (AEs) (5.3% vs 9.2%, P = .09) and RT termination because of AEs (1.3% vs 4.1%, P = .07) were less common among patients treated at HVCs. HVC remained independently associated with longer OS (P = .03) when accounting for other factors. CONCLUSION Treatment at institutions with higher clinical trial accrual volume is associated with longer OS among patients with LA-NSCLC participating in a phase III trial.
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Affiliation(s)
- Bree R Eaton
- Winship Cancer Institute of Emory University, Atlanta, GA (BRE, WJCJr); NRG Oncology Statistics and Data Management Center, Philadelphia, PA (SLP); Washington University School of Medicine, St. Louis, MO (JDB, CR); Christiana Care/Helen Graham Medical Center, Newark, DE (GM); USON-Texas Oncology, Sugarland, TX (VSK); Michigan Cancer Research Consortium, Ann Arbor, MI (SN); University of Texas Southwestern Medical School, Dallas, TX (LN); University of Pittsburgh Medical Center, Pittsburgh, PA (RBW); Christiana Care Health System, Wilmington, DE (CK); Florida Radiation Oncology Group, Jacksonville, FL (DWJ); The Ottawa Hospital, Ottawa, ON, Canada (JM)
| | - Stephanie L Pugh
- Winship Cancer Institute of Emory University, Atlanta, GA (BRE, WJCJr); NRG Oncology Statistics and Data Management Center, Philadelphia, PA (SLP); Washington University School of Medicine, St. Louis, MO (JDB, CR); Christiana Care/Helen Graham Medical Center, Newark, DE (GM); USON-Texas Oncology, Sugarland, TX (VSK); Michigan Cancer Research Consortium, Ann Arbor, MI (SN); University of Texas Southwestern Medical School, Dallas, TX (LN); University of Pittsburgh Medical Center, Pittsburgh, PA (RBW); Christiana Care Health System, Wilmington, DE (CK); Florida Radiation Oncology Group, Jacksonville, FL (DWJ); The Ottawa Hospital, Ottawa, ON, Canada (JM)
| | - Jeffrey D Bradley
- Winship Cancer Institute of Emory University, Atlanta, GA (BRE, WJCJr); NRG Oncology Statistics and Data Management Center, Philadelphia, PA (SLP); Washington University School of Medicine, St. Louis, MO (JDB, CR); Christiana Care/Helen Graham Medical Center, Newark, DE (GM); USON-Texas Oncology, Sugarland, TX (VSK); Michigan Cancer Research Consortium, Ann Arbor, MI (SN); University of Texas Southwestern Medical School, Dallas, TX (LN); University of Pittsburgh Medical Center, Pittsburgh, PA (RBW); Christiana Care Health System, Wilmington, DE (CK); Florida Radiation Oncology Group, Jacksonville, FL (DWJ); The Ottawa Hospital, Ottawa, ON, Canada (JM)
| | - Greg Masters
- Winship Cancer Institute of Emory University, Atlanta, GA (BRE, WJCJr); NRG Oncology Statistics and Data Management Center, Philadelphia, PA (SLP); Washington University School of Medicine, St. Louis, MO (JDB, CR); Christiana Care/Helen Graham Medical Center, Newark, DE (GM); USON-Texas Oncology, Sugarland, TX (VSK); Michigan Cancer Research Consortium, Ann Arbor, MI (SN); University of Texas Southwestern Medical School, Dallas, TX (LN); University of Pittsburgh Medical Center, Pittsburgh, PA (RBW); Christiana Care Health System, Wilmington, DE (CK); Florida Radiation Oncology Group, Jacksonville, FL (DWJ); The Ottawa Hospital, Ottawa, ON, Canada (JM)
| | - Vivek S Kavadi
- Winship Cancer Institute of Emory University, Atlanta, GA (BRE, WJCJr); NRG Oncology Statistics and Data Management Center, Philadelphia, PA (SLP); Washington University School of Medicine, St. Louis, MO (JDB, CR); Christiana Care/Helen Graham Medical Center, Newark, DE (GM); USON-Texas Oncology, Sugarland, TX (VSK); Michigan Cancer Research Consortium, Ann Arbor, MI (SN); University of Texas Southwestern Medical School, Dallas, TX (LN); University of Pittsburgh Medical Center, Pittsburgh, PA (RBW); Christiana Care Health System, Wilmington, DE (CK); Florida Radiation Oncology Group, Jacksonville, FL (DWJ); The Ottawa Hospital, Ottawa, ON, Canada (JM)
| | - Samir Narayan
- Winship Cancer Institute of Emory University, Atlanta, GA (BRE, WJCJr); NRG Oncology Statistics and Data Management Center, Philadelphia, PA (SLP); Washington University School of Medicine, St. Louis, MO (JDB, CR); Christiana Care/Helen Graham Medical Center, Newark, DE (GM); USON-Texas Oncology, Sugarland, TX (VSK); Michigan Cancer Research Consortium, Ann Arbor, MI (SN); University of Texas Southwestern Medical School, Dallas, TX (LN); University of Pittsburgh Medical Center, Pittsburgh, PA (RBW); Christiana Care Health System, Wilmington, DE (CK); Florida Radiation Oncology Group, Jacksonville, FL (DWJ); The Ottawa Hospital, Ottawa, ON, Canada (JM)
| | - Lucien Nedzi
- Winship Cancer Institute of Emory University, Atlanta, GA (BRE, WJCJr); NRG Oncology Statistics and Data Management Center, Philadelphia, PA (SLP); Washington University School of Medicine, St. Louis, MO (JDB, CR); Christiana Care/Helen Graham Medical Center, Newark, DE (GM); USON-Texas Oncology, Sugarland, TX (VSK); Michigan Cancer Research Consortium, Ann Arbor, MI (SN); University of Texas Southwestern Medical School, Dallas, TX (LN); University of Pittsburgh Medical Center, Pittsburgh, PA (RBW); Christiana Care Health System, Wilmington, DE (CK); Florida Radiation Oncology Group, Jacksonville, FL (DWJ); The Ottawa Hospital, Ottawa, ON, Canada (JM)
| | - Cliff Robinson
- Winship Cancer Institute of Emory University, Atlanta, GA (BRE, WJCJr); NRG Oncology Statistics and Data Management Center, Philadelphia, PA (SLP); Washington University School of Medicine, St. Louis, MO (JDB, CR); Christiana Care/Helen Graham Medical Center, Newark, DE (GM); USON-Texas Oncology, Sugarland, TX (VSK); Michigan Cancer Research Consortium, Ann Arbor, MI (SN); University of Texas Southwestern Medical School, Dallas, TX (LN); University of Pittsburgh Medical Center, Pittsburgh, PA (RBW); Christiana Care Health System, Wilmington, DE (CK); Florida Radiation Oncology Group, Jacksonville, FL (DWJ); The Ottawa Hospital, Ottawa, ON, Canada (JM)
| | - Raymond B Wynn
- Winship Cancer Institute of Emory University, Atlanta, GA (BRE, WJCJr); NRG Oncology Statistics and Data Management Center, Philadelphia, PA (SLP); Washington University School of Medicine, St. Louis, MO (JDB, CR); Christiana Care/Helen Graham Medical Center, Newark, DE (GM); USON-Texas Oncology, Sugarland, TX (VSK); Michigan Cancer Research Consortium, Ann Arbor, MI (SN); University of Texas Southwestern Medical School, Dallas, TX (LN); University of Pittsburgh Medical Center, Pittsburgh, PA (RBW); Christiana Care Health System, Wilmington, DE (CK); Florida Radiation Oncology Group, Jacksonville, FL (DWJ); The Ottawa Hospital, Ottawa, ON, Canada (JM)
| | - Christopher Koprowski
- Winship Cancer Institute of Emory University, Atlanta, GA (BRE, WJCJr); NRG Oncology Statistics and Data Management Center, Philadelphia, PA (SLP); Washington University School of Medicine, St. Louis, MO (JDB, CR); Christiana Care/Helen Graham Medical Center, Newark, DE (GM); USON-Texas Oncology, Sugarland, TX (VSK); Michigan Cancer Research Consortium, Ann Arbor, MI (SN); University of Texas Southwestern Medical School, Dallas, TX (LN); University of Pittsburgh Medical Center, Pittsburgh, PA (RBW); Christiana Care Health System, Wilmington, DE (CK); Florida Radiation Oncology Group, Jacksonville, FL (DWJ); The Ottawa Hospital, Ottawa, ON, Canada (JM)
| | - Douglas W Johnson
- Winship Cancer Institute of Emory University, Atlanta, GA (BRE, WJCJr); NRG Oncology Statistics and Data Management Center, Philadelphia, PA (SLP); Washington University School of Medicine, St. Louis, MO (JDB, CR); Christiana Care/Helen Graham Medical Center, Newark, DE (GM); USON-Texas Oncology, Sugarland, TX (VSK); Michigan Cancer Research Consortium, Ann Arbor, MI (SN); University of Texas Southwestern Medical School, Dallas, TX (LN); University of Pittsburgh Medical Center, Pittsburgh, PA (RBW); Christiana Care Health System, Wilmington, DE (CK); Florida Radiation Oncology Group, Jacksonville, FL (DWJ); The Ottawa Hospital, Ottawa, ON, Canada (JM)
| | - Joanne Meng
- Winship Cancer Institute of Emory University, Atlanta, GA (BRE, WJCJr); NRG Oncology Statistics and Data Management Center, Philadelphia, PA (SLP); Washington University School of Medicine, St. Louis, MO (JDB, CR); Christiana Care/Helen Graham Medical Center, Newark, DE (GM); USON-Texas Oncology, Sugarland, TX (VSK); Michigan Cancer Research Consortium, Ann Arbor, MI (SN); University of Texas Southwestern Medical School, Dallas, TX (LN); University of Pittsburgh Medical Center, Pittsburgh, PA (RBW); Christiana Care Health System, Wilmington, DE (CK); Florida Radiation Oncology Group, Jacksonville, FL (DWJ); The Ottawa Hospital, Ottawa, ON, Canada (JM)
| | - Walter J Curran
- Winship Cancer Institute of Emory University, Atlanta, GA (BRE, WJCJr); NRG Oncology Statistics and Data Management Center, Philadelphia, PA (SLP); Washington University School of Medicine, St. Louis, MO (JDB, CR); Christiana Care/Helen Graham Medical Center, Newark, DE (GM); USON-Texas Oncology, Sugarland, TX (VSK); Michigan Cancer Research Consortium, Ann Arbor, MI (SN); University of Texas Southwestern Medical School, Dallas, TX (LN); University of Pittsburgh Medical Center, Pittsburgh, PA (RBW); Christiana Care Health System, Wilmington, DE (CK); Florida Radiation Oncology Group, Jacksonville, FL (DWJ); The Ottawa Hospital, Ottawa, ON, Canada (JM)
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Bhatt VR, Dhakal P, Dahal S, Giri S, Pathak R, Bociek RG, Silberstein PT, Armitage JO. Demographic and other characteristics of nodal non-Hodgkin's lymphoma managed in academic versus non-academic centers. Ther Adv Hematol 2015; 6:223-7. [PMID: 26425335 DOI: 10.1177/2040620715592568] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Cancer therapy and outcomes are known to be affected by various demographic features and hospital types. We aimed to identify the characteristics of non-Hodgkin's lymphoma (NHL) patients associated with receipt of care at academic centers. METHOD This is a retrospective study of all patients diagnosed with nodal NHL between 2000 and 2011 in the National Cancer Database (NCDB), who received the diagnosis, and all or part of their initial therapy in the reporting hospital (n = 243,436). Characteristics of patients receiving care in academic versus nonacademic centers were compared using the Chi-square test. RESULTS Approximately 27% received care in academic centers. Patients receiving care in nonacademic centers, compared with academic centers, were more likely to be ⩾60 years (69% versus 58%, p < .0001), White (89% versus 80%, p < .0001) and have lower educational attainment (>12% without high school diploma: 72% versus 69%, p < .0001) and economic status (household income <$49,000: 66% versus 61%, p < 0.0001). Patients receiving care in nonacademic centers were less likely to travel ⩾25 miles (21% versus 26%, p < 0.0001). White patients, compared with non-Whites, were more likely to be ⩾60 years (70% versus <50%, p < 0.0001), which probably explains less care in academic centers. CONCLUSIONS Patients ⩾60 years and those with poorer educational attainment and economic status were less likely to receive care in academic centers. Care in academic centers required a longer commute. Elderly patients frequently have inferior outcomes and may benefit from clinical trials with novel agents and expertise at academic centers.
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Affiliation(s)
- Vijaya Raj Bhatt
- Department of Internal Medicine, Division of Hematology-Oncology, University of Nebraska Medical Center, 987680 Nebraska Medical Center, Omaha, NE 68198-7680, USA
| | - Prajwal Dhakal
- Department of Medicine, Institute of Medicine, Tribhuvan University, Maharajgunj, Kathmandu, Nepal
| | - Sumit Dahal
- Department of Internal Medicine, Interfaith Medical Center, NY, USA
| | - Smith Giri
- Department of Medicine, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Ranjan Pathak
- Department of Medicine, Reading Health System, Reading, PA, USA
| | - R Gregory Bociek
- Department of Internal Medicine, Division of Hematology-Oncology, University of Nebraska Medical Center, Omaha, NE, USA
| | - Peter T Silberstein
- Department of Internal Medicine, Division of Hematology-Oncology, Creighton University Medical Center, Omaha, NE, USA
| | - James O Armitage
- Department of Internal Medicine, Division of Hematology-Oncology, University of Nebraska Medical Center, Omaha, NE, USA
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Reynolds CH, Patel JD, Garon EB, Olsen MR, Bonomi P, Govindan R, Pennella EJ, Liu J, Guba SC, Li S, Spigel DR, Hermann RC, Socinski MA, Obasaju CK. Exploratory Subset Analysis of African Americans From the PointBreak Study: Pemetrexed-Carboplatin-Bevacizumab Followed by Maintenance Pemetrexed-Bevacizumab Versus Paclitaxel-Carboplatin-Bevacizumab Followed by Maintenance Bevacizumab in Patients With Stage IIIB/IV Nonsquamous Non-Small-Cell Lung Cancer. Clin Lung Cancer 2014; 16:200-8. [PMID: 25516338 DOI: 10.1016/j.cllc.2014.11.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2014] [Revised: 11/09/2014] [Accepted: 11/11/2014] [Indexed: 10/24/2022]
Abstract
INTRODUCTION African Americans have a greater incidence of lung cancer than whites and have been underrepresented in clinical trials. In the PointBreak trial (pemetrexed-carboplatin-bevacizumab and maintenance pemetrexed-bevacizumab [PemCBev] vs. paclitaxel-carboplatin-bevacizumab and maintenance bevacizumab [PacCBev]), 10% of the patients were African American. PointBreak had negative findings; PemCBev did not demonstrate superior overall survival (OS). MATERIALS AND METHODS PointBreak subgroup efficacy and safety data were retrospectively analyzed: African Americans versus whites for PemCBev; PemCBev versus PacCBev in African Americans; and academic versus community settings for African Americans. Hazard ratios (HRs) and P values were derived from a multivariate Cox proportional hazards model after adjusting for covariates. RESULTS Of 939 intent-to-treat (ITT) patients, 94 were African American and 805 were white. African-American enrollment was uniform across the study sites (median, 1 African American per site). In the PemCBev arm, OS (HR, 1.125; P = .525), progression-free survival (PFS) (HR, 1.229; P = .251), response (P = .607), and toxicity profiles were similar in African Americans versus whites. For African Americans, OS (HR, 1.375; P = .209), PFS (HR, 0.902; P = .670), response (P = 1.000), and toxicity profiles were similar in the PemCBev versus PacCBev arm. For African Americans, no significant differences were seen in OS (HR, 0.661; P = .191) or PFS (HR, 0.969; P = .915) in academic versus community practice settings. CONCLUSION In the PemCBev arm, this exploratory analysis showed no significant differences between African Americans and whites for the efficacy outcomes or toxicity profiles. Consistent with the ITT population negative trial result, for African Americans, the median OS was not superior for either arm. For African Americans, PFS and OS were similar in the academic and community settings. Additional outcomes data for African Americans should be collected in lung cancer studies.
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Affiliation(s)
| | - Jyoti D Patel
- Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Edward B Garon
- University of California, Los Angeles, David Geffen School of Medicine, Translational Research in Oncology-United States, Los Angeles, CA
| | | | | | | | | | | | | | - Shi Li
- Eli Lilly and Company, Indianapolis, IN
| | - David R Spigel
- Sarah Cannon Research Institute, Nashville, TN and Tennessee Oncology, PLLC, Nashville, TN
| | | | - Mark A Socinski
- Division of Hematology/Oncology, University of Pittsburgh Cancer Institute, Pittsburgh, PA
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Patterns of chemotherapy, toxicity, and short-term outcomes for older women receiving adjuvant trastuzumab-based therapy. Breast Cancer Res Treat 2014; 145:491-501. [PMID: 24756187 DOI: 10.1007/s10549-014-2968-9] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2014] [Accepted: 04/12/2014] [Indexed: 10/25/2022]
Abstract
Limited data are available regarding patterns of chemotherapy receipt and treatment-related toxicities for older women receiving adjuvant trastuzumab-based therapy. We used surveillance, epidemiology and end results (SEER)-Medicare data to identify patients ≥66 years with stage I-III breast cancer treated during 2005-2009, who received trastuzumab-based therapy. We examined patterns of chemotherapy receipt, and using multivariable logistic regression, we examined associations of age and comorbidity with non-standard chemotherapy. In propensity-weighted cohorts of women receiving standard and non-standard trastuzumab-based therapy, we also examined rates of (1) hospital events during the first 6 months of chemotherapy and (2) short-term survival. Among 2,106 women, 29.7 % were aged ≥76 and 66 % had a comorbidity score = 0. Overall, 31.3 % of women received non-standard chemotherapy. Compared to patients aged 66-70, older patients more often received non-standard chemotherapy [adjusted odds ratio (OR) = 4.1, 95 % confidence interval (CI) = 3.40-4.92 (ages 76-80); OR = 15.3, 95 %CI = 9.92-23.67 (age ≥ 80)]. However, comorbidity was not associated with receipt of non-standard chemotherapy. After propensity score adjustment, hospitalizations were more frequent in the standard (vs. non-standard) group (adjusted OR = 1.7, 95 % CI = 1.29-2.24). With a median follow-up of 2.8 years, 276 deaths occurred; the adjusted hazard ratio (HR) for death was lower in standard versus non-standard treated women (HR = 0.69, 95 % CI = 0.52-0.91). Among a population-based cohort of older women receiving trastuzumab, nearly one-third received non-standard chemotherapy, with the highest rates among the oldest women. Non-standard chemotherapy was associated with fewer toxicity-related hospitalizations but worse survival. Further exploration of treatment toxicities and outcomes for older women with HER2-positive breast cancer is warranted.
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Abstract
GOALS To evaluate differences in metrics of quality and site performance in academic and community sites participating in a multicenter study. BACKGROUND In the Individualized Dosing Efficacy Versus Flat Dosing to Assess Optimal Pegylated Interferon Therapy study, the participation of 76 academic-based and 42 community-based US centers provided an opportunity to evaluate various metrics of quality and site performance. STUDY A secondary data analysis of the Individualized Dosing Efficacy Versus Flat Dosing to Assess Optimal Pegylated Interferon Therapy study was performed. There were 3070 treatment-naive, hepatitis C virus genotype 1 infected patients were included. We retrospectively evaluated rates of screen failure, completion, and discontinuation of treatment and follow-up, treatment adherence, and virologic response by site type. RESULTS Of the patients screened, 63% and 37% were in academic and community centers, respectively. Screen failure rates were similar (30% to 32%). End-of-treatment response, relapse, and sustained virologic response (SVR) rates in academic and community centers did not differ. SVR was achieved in 40% of patients at academic sites and 39% at community sites. Adherence to ≥80% of peginterferon-α and ribavirin dosing for ≥80% assigned duration was also similar (46% in academic and 47% in community centers). In both academic and community centers, 54% of patients completed treatment; there were similar discontinuation rates for treatment failure and adverse events. CONCLUSIONS There were no significant differences in adherence, adverse events, rates of discontinuation, on-treatment virologic response, and SVR when comparing academic and community sites. The performance of academic-based and experienced community-based sites in clinical trials is largely similar for the treatment of chronic hepatitis C.
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Landrum MB, Keating NL, Lamont EB, Bozeman SR, Krasnow SH, Shulman L, Brown JR, Earle CC, Rabin M, McNeil BJ. Survival of older patients with cancer in the Veterans Health Administration versus fee-for-service Medicare. J Clin Oncol 2012; 30:1072-9. [PMID: 22393093 PMCID: PMC3341151 DOI: 10.1200/jco.2011.35.6758] [Citation(s) in RCA: 61] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2011] [Accepted: 12/20/2011] [Indexed: 11/20/2022] Open
Abstract
PURPOSE The Veterans Health Administration (VHA) provides high-quality preventive chronic care and cancer care, but few studies have documented improved patient outcomes that result from this high-quality care. We compared the survival rates of older patients with cancer in the VHA and fee-for-service (FFS) Medicare and examined whether differences in the stage at diagnosis, receipt of guideline-recommended therapies, and unmeasured characteristics explain survival differences. PATIENTS AND METHODS We used propensity-score methods to compare all-cause and cancer-specific survival rates for men older than age 65 years who were diagnosed or received their first course of treatment for colorectal, lung, lymphoma, or multiple myeloma in VHA hospitals from 2001 to 2004 to similar FFS-Medicare enrollees diagnosed in Surveillance, Epidemiology, and End Results (SEER) areas in the same time frame. We examined the role of unmeasured factors by using sensitivity analyses. RESULTS VHA patients versus similar FFS SEER-Medicare patients had higher survival rates of colon cancer (adjusted hazard ratio [HR], 0.87; 95% CI, 0.82 to 0.93) and non-small-cell lung cancer (NSCLC; HR, 0.91; 95% CI, 0.88 to 0.95) and similar survival rates of rectal cancer (HR, 1.05; 95% CI, 0.95 to 1.16), small-cell lung cancer (HR, 0.99; 95% CI, 0.93 to 1.05), diffuse large-B-cell lymphoma (HR, 1.02; 95% CI, 0.89 to 1.18), and multiple myeloma (HR, 0.92; 95% CI, 0.83 to 1.03). The diagnosis of VHA patients at earlier stages explained much of the survival advantages for colon cancer and NSCLC. Sensitivity analyses suggested that additional adjustment for the severity of comorbid disease or performance status could have substantial effects on estimated differences. CONCLUSION The survival rate for older men with cancer in the VHA was better than or equivalent to the survival rate for similar FFS-Medicare beneficiaries. The VHA provision of high-quality care, particularly preventive care, can result in improved patient outcomes.
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Al-Refaie WB, Vickers SM. Are cancer trials valid and useful for the general surgeon and surgical oncologist? Adv Surg 2012; 46:269-281. [PMID: 22873045 DOI: 10.1016/j.yasu.2012.05.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
Cancer trials represent a rigorous and clear approach to testing whether an intervention or treatment will alter the outcomes of individuals with cancer in an experimental manner that is beyond the level of observational studies. As such, they remain useful and valid to the day-to-day practice of general surgeons and surgical oncologists. However, the shortcomings of current cancer clinical trials need to be recognized, especially when less than 1% of adults persons with cancer participate in cancer clinical trials, thus leaving the ability to generalize these trials to patients and their surgeons in the real-world setting an open question. Moving forward, physicians, payers, professional societies, advocates, the NCI, and other stakeholders need to develop broader cancer trials to benefit the millions of patients with cancer in the United States.
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Affiliation(s)
- Waddah B Al-Refaie
- Department of Surgery, Surgical Outcomes Research Center, University of Minnesota and Minneapolis VAMC, MMC# 195, 420 Delaware Street Southeast, Minneapolis, MN 55455, USA.
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Barr LH, Crofton J, Annie Lin YH. A Community Hospital Clinical Trials Program: Infrastructure for Growth. Surg Oncol Clin N Am 2011; 20:447-53, vii- viii. [DOI: 10.1016/j.soc.2011.01.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Al-Refaie WB, Pisters PWPT, Rothenberger DA. Surgical Oncology Trials and Surgeons in the Real World! Ann Surg Oncol 2010; 17:1727-8. [DOI: 10.1245/s10434-010-1069-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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