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Mara A, Rader R, Bylund C, Eggly S, Weiss E, Szumita L, Sitlinger A, Friedman D. QIM23-139: Creating a Fellowship Curriculum: Clinical Trial Patient Conversations. J Natl Compr Canc Netw 2023. [DOI: 10.6004/jnccn.2022.7195] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/03/2023]
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Artese AL, Sitlinger A, MacDonald G, Deal MA, Hanson ED, Pieper CF, Weinberg JB, Brander DM, Bartlett DB. Effects of high-intensity interval training on health-related quality of life in chronic lymphocytic leukemia: A pilot study. J Geriatr Oncol 2023; 14:101373. [PMID: 36096873 DOI: 10.1016/j.jgo.2022.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Revised: 08/24/2022] [Accepted: 09/02/2022] [Indexed: 11/15/2022]
Abstract
INTRODUCTION Chronic lymphocytic leukemia (CLL) is the most common incurable leukemia/lymphoma in the United States. Individuals with CLL are at risk for disability, frailty, and cancer-specific complications that negatively affect health-related quality of life (HRQOL). High-intensity interval training (HIIT) and resistance training (RT) are safe and feasible for individuals with chronic diseases and when combined, they may be beneficial for reducing cancer-related fatigue, symptom burden, and global quality of life. However, no studies have examined the impact of HIIT or RT on HRQOL in CLL. The purpose of this study was to investigate the effects of a 12-week HIIT and RT (HIIT+RT) intervention on HRQOL in adults with treatment naïve CLL. MATERIALS AND METHODS Changes in HRQOL was a secondary outcome in this pilot study. Individuals with CLL (63.9 ± 8.5 yrs) were non-randomly assigned to 12 weeks of HIIT+RT or a control group. The HIIT+RT protocol consisted of three 30-min sessions/week of HIIT and two sessions/week of RT. The control group maintained usual daily activities. We assessed pre and post HRQOL using the Functional Assessment of Cancer Therapy-Lymphoma (FACT-Lym) questionnaire with domains of physical (PWB), social (SWB), emotional (EWB), functional (FWB), and general (FACT-G) well-being as well as a lymphoma-specific subscale (LymS). We used a two-way mixed analysis of variance to assess changes in HRQOL. We calculated effect size (ES) using Cohen's d. RESULTS Fifteen participants (HIIT+RT: n = 9; Control: n = 6) completed the study and questionnaire. Scores for FWB improved following HIIT+RT (21.7 ± 3.4 to 23.9 ± 3.2; ES = 1.38) compared to controls (25.7 ± 2.2 to 25.7 ± 2.3). The HIIT+RT group experienced clinically meaningful improvements in total FACT-Lym, FWB, FACT-G, and LymS. The control group had clinically meaningful changes only in LymS. DISCUSSION The large effect sizes and clinically meaningful improvements associated with 12 weeks of HIIT+RT support the potential benefits of this type of exercise program for FWB, lymphoma-specific symptoms, and general well-being in CLL. A future randomized trial with an adequately powered sample size is needed to evaluate these findings. TRIAL REGISTRATION NCT04950452.
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Affiliation(s)
- Ashley L Artese
- Duke University Aging Center, Duke University School of Medicine, Durham, NC, USA; Duke Molecular Physiology Institute, Duke University School of Medicine, Durham, NC, USA
| | - Andrea Sitlinger
- Hematologic Malignancies and Cellular Therapies, Duke University School of Medicine, Durham, NC, USA.
| | - Grace MacDonald
- Duke Molecular Physiology Institute, Duke University School of Medicine, Durham, NC, USA; Division of Medical Oncology, Duke University School of Medicine, Durham, NC, USA
| | - Michael A Deal
- Duke Molecular Physiology Institute, Duke University School of Medicine, Durham, NC, USA; Division of Medical Oncology, Duke University School of Medicine, Durham, NC, USA
| | - Erik D Hanson
- Department of Exercise & Sport Science, University of North Carolina, Chapel Hill, NC, USA
| | - Carl F Pieper
- Duke University Aging Center, Duke University School of Medicine, Durham, NC, USA
| | - J Brice Weinberg
- Division of Hematology, Duke University School of Medicine and VA Medical Center, Durham, NC, USA
| | - Danielle M Brander
- Hematologic Malignancies and Cellular Therapies, Duke University School of Medicine, Durham, NC, USA
| | - David B Bartlett
- Duke University Aging Center, Duke University School of Medicine, Durham, NC, USA; Duke Molecular Physiology Institute, Duke University School of Medicine, Durham, NC, USA; Division of Medical Oncology, Duke University School of Medicine, Durham, NC, USA; School of Bioscience and Medicine, University of Surrey, Guildford, UK.
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Artese AL, Sitlinger A, MacDonald G, Deal MA, Hanson ED, Pieper CF, Weinberg JB, Brander DM, Bartlett DB. Quality Of Life Changes Following High-intensity Interval Training In Older Adults With Chronic Lymphocytic Leukemia. Med Sci Sports Exerc 2022. [DOI: 10.1249/01.mss.0000877004.38963.34] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Sitlinger A, Deal MA, Garcia E, Connelly M, Thompson D, Stewart T, Macdonald G, Hanson ED, Neely M, Neely B, Artese A, Weinberg JB, Brander D, Bartlett DB. Associations of clinical and circulating metabolic biomarkers with low physical fitness and function in adults with chronic lymphocytic leukemia. Front Oncol 2022; 12:933619. [PMID: 35992862 PMCID: PMC9381973 DOI: 10.3389/fonc.2022.933619] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2022] [Accepted: 07/04/2022] [Indexed: 11/18/2022] Open
Abstract
Many patients with chronic lymphocytic leukemia (CLL) experience physical dysfunction and low overall fitness. It remains unknown what factors drive CLL physical dysfunction. We assessed physical function and metabolic lipoprotein panels in 106 patients with CLL. In univariate analyses of clinical factors, a longer time since diagnosis was associated with a higher likelihood of dysfunctional aerobic fitness (OR = 3.56, 95% CI: 1.37–9.22; p = 0.002) and physical performance (SPPB: OR = 2.03, 95% CI: 1.20–3.44; p = 0.004). Having received treatment was associated with a higher likelihood of dysfunctional aerobic fitness (OR = 1.57, 95% CI: 1.02–2.40; p = 0.036), SPPB (OR = 1.85, 95% CI: 1.13–3.03; p = 0.011) and grip strength (OR = 1.67, 95% CI: 1.10–2.55; p = 0.015). We found that several small HDL particle parameters, higher levels of citrate (OR = 2.01, 95% CI: 1.22–3.31; p = 0.030), and lower levels of hemoglobin (OR = 0.50, 95% CI: 0.31–0.82; p = 0.030) were associated with a higher likelihood of dysfunctional aerobic fitness. Multivariable least absolute shrinkage and selection operator (LASSO)-penalized regression analyses using variable importance measures (VIM) showed that 7.8-nm HDL particles (VIM = 1.000) and total HDL particle levels (VIM = 1.000) were more informative than clinical measures for the odds of dysfunctional aerobic fitness and 6-min walk functional fitness, respectively, while 10.3-nm HDL particles (VIM = 0.383) were more informative for grip strength. Time since diagnosis (VIM = 0.680) and having received treatment (VIM = 0.490) were more informative than lipoprotein measures for the odds of having dysfunctional SPPB. Taken together, we establish significant relationships between clinical and metabolic factors and physical characteristics that might prompt early use of ancillary support services.
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Affiliation(s)
- Andrea Sitlinger
- Hematologic Malignancies and Cellular Therapies, Duke University Medical Center, Durham, NC, United States
| | - Michael A. Deal
- Division of Medical Oncology, Duke University Medical Center, Durham, NC, United States
| | - Erwin Garcia
- Laboratory Corporation of America Holdings (Labcorp), Morrisville, NC, United States
| | - Margery Connelly
- Laboratory Corporation of America Holdings (Labcorp), Morrisville, NC, United States
| | - Dana Thompson
- Division of Hematology, Duke University Medical Center and VA Medical Center, Durham, NC, United States
| | - Tiffany Stewart
- Division of Hematology, Duke University Medical Center and VA Medical Center, Durham, NC, United States
| | - Grace Macdonald
- Division of Medical Oncology, Duke University Medical Center, Durham, NC, United States
| | - Erik D. Hanson
- Department of Exercise and Sport Science, University of North Carolina, Chapel Hill, NC, United States
| | - Megan Neely
- Department of Biostatistics and Bioinformatics, Duke University Medical Center, Durham, NC, United States
| | - Ben Neely
- Department of Biostatistics and Bioinformatics, Duke University Medical Center, Durham, NC, United States
| | - Ashley Artese
- Duke University Aging Center, Duke University Medical Center, Durham, NC, United States
| | - J. Brice Weinberg
- Division of Hematology, Duke University Medical Center and VA Medical Center, Durham, NC, United States
| | - Danielle Brander
- Hematologic Malignancies and Cellular Therapies, Duke University Medical Center, Durham, NC, United States
| | - David B. Bartlett
- Division of Medical Oncology, Duke University Medical Center, Durham, NC, United States
- Duke University Aging Center, Duke University Medical Center, Durham, NC, United States
- School of Bioscience and Medicine, University of Surrey, Guildford, United Kingdom
- *Correspondence: David B. Bartlett,
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Saber I, Adamski A, Kuchibhatla M, Abe K, Beckman M, Reyes N, Schulteis R, Pendurthi Singh B, Sitlinger A, Thames EH, Ortel TL. Racial differences in venous thromboembolism: A surveillance program in Durham County, North Carolina. Res Pract Thromb Haemost 2022; 6:e12769. [PMID: 35873215 PMCID: PMC9301530 DOI: 10.1002/rth2.12769] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Revised: 06/15/2022] [Accepted: 06/24/2022] [Indexed: 11/06/2022] Open
Abstract
Background Venous thromboembolism (VTE) affects approximately 1-2 individuals per 1000 annually and is associated with an increased risk for pulmonary hypertension, postthrombotic syndrome, and recurrent VTE. Objective To determine risk factors, incidence, treatments, and outcomes of VTE through a 2-year surveillance program initiated in Durham County, North Carolina (population approximately 280,000 at time of study). Patients/Methods We performed a retrospective analysis of data actively collected from three hospitals in Durham County during the surveillance period. Results A total of 987 patients were diagnosed with VTE, for an annual rate of 1.76 per 1000 individuals. Hospital-associated VTE occurred in 167 hospitalized patients (16.9%) and 271 outpatients who were hospitalized within 90 days of diagnosis (27.5%). Annual incidence was 1.98 per 1000 Black individuals compared to 1.25 per 1000 White individuals (p < 0.0001), and Black individuals with VTE were younger than White individuals (p < 0.0001). Common risk factors included active cancer, prolonged immobility, and obesity, and approximately half were still taking anticoagulant therapy 1 year later. A total of 224 patients died by 1 year (28.5% of patients for whom outcomes could be confirmed), and Black patients were more likely to have recurrent VTE than White patients during the first 6 months following initial presentation (9.4% vs. 4.1%, p = 0.01). Conclusions Ongoing surveillance provides an effective strategy to identify patients with VTE and monitor treatment and outcomes. We demonstrated that hospital-associated VTE continues to be a major contributor to the burden of VTE and confirmed the higher incidence of VTE in Black compared to White individuals.
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Affiliation(s)
- Ibrahim Saber
- Division of Hematology, Department of Medicine Duke University Medical Center Durham North Carolina USA
| | - Alys Adamski
- Centers for Disease Control and Prevention Atlanta Georgia USA
| | - Maragatha Kuchibhatla
- Department of Biostatistics and Bioinformatics Duke University Durham North Carolina USA
| | - Karon Abe
- Centers for Disease Control and Prevention Atlanta Georgia USA
| | - Michele Beckman
- Centers for Disease Control and Prevention Atlanta Georgia USA
| | - Nimia Reyes
- Centers for Disease Control and Prevention Atlanta Georgia USA
| | - Ryan Schulteis
- Durham Veterans' Administration Medical Center Durham North Carolina USA
| | | | - Andrea Sitlinger
- Division of Hematologic Malignancies and Cellular Therapy, Department of Medicine Duke University Medical Center Durham North Carolina USA
| | - Elizabeth H Thames
- Division of Hematology, Department of Medicine Duke University Medical Center Durham North Carolina USA
| | - Thomas L Ortel
- Division of Hematology, Department of Medicine Duke University Medical Center Durham North Carolina USA.,Department of Pathology Duke University Medical Center Durham North Carolina USA
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Zullig LL, Sung AD, Khouri MG, Jazowski S, Shah NP, Sitlinger A, Blalock DV, Whitney C, Kikuchi R, Bosworth HB, Crowley MJ, Goldstein KM, Klem I, Oeffinger KC, Dent S. Cardiometabolic Comorbidities in Cancer Survivors. JACC CardioOncol 2022; 4:149-165. [PMID: 35818559 PMCID: PMC9270612 DOI: 10.1016/j.jaccao.2022.03.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2021] [Revised: 03/16/2022] [Accepted: 03/18/2022] [Indexed: 12/28/2022] Open
Abstract
There are nearly 17 million cancer survivors in the United States, including those who are currently receiving cancer therapy with curative intent and expected to be long-term survivors, as well as those with chronic cancers such as metastatic disease or chronic lymphocytic leukemia, who will receive cancer therapy for many years. Current clinical practice guidelines focus on lifestyle interventions, such as exercise and healthy eating habits, but generally do not address management strategies for clinicians or strategies to increase adherence to medications. We discuss 3 cardiometabolic comorbidities among cancer survivors and present the prevalence of comorbidities prior to a cancer diagnosis, treatment of comorbidities during cancer therapy, and management considerations of comorbidities in long-term cancer survivors or those on chronic cancer therapy. Approaches to support medication adherence and potential methods to enhance a team approach to optimize care of the individual with cancer across the continuum of disease are discussed. Cancer survivors are at increased risk for several chronic conditions, including hypertension, dyslipidemia, and diabetes. Determining optimal management of comorbidities for patients with cancer is critical. A multidisciplinary care approach is recommended throughout the continuum of active cancer treatment and survivorship. Survivorship research should focus on medication adherence and coordination of care.
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Affiliation(s)
- Leah L. Zullig
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina, USA
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, North Carolina, USA
- Address for correspondence: Dr Leah Zullig, Duke University, 411 West Chapel Hill Street, Suite 600, Durham, North Carolina 27701, USA. @LeahZullig
| | - Anthony D. Sung
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Michel G. Khouri
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Shelley Jazowski
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina, USA
| | - Nishant P. Shah
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Andrea Sitlinger
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Dan V. Blalock
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, North Carolina, USA
- Department of Psychiatry and Behavioral Sciences, Duke University, Durham, North Carolina, USA
| | - Colette Whitney
- Department of Psychiatry and Behavioral Sciences, Duke University, Durham, North Carolina, USA
- Cascades East–Oregon Health and Science University, Klamath Falls, Oregon, USA
| | - Robin Kikuchi
- Keck School of Medicine, University of California-Los Angeles, Los Angeles, California, USA
| | - Hayden B. Bosworth
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina, USA
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, North Carolina, USA
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
- Department of Psychiatry and Behavioral Sciences, Duke University, Durham, North Carolina, USA
| | - Matthew J. Crowley
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, North Carolina, USA
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Karen M. Goldstein
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, North Carolina, USA
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Igor Klem
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Kevin C. Oeffinger
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Susan Dent
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
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7
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Bartlett D, MacDonald G, Deal M, Hanson E, Pieper C, Weinberg JB, Brander D, Sitlinger A. High-Intensity Interval Training in Older Adults With Treatment Naive Chronic Lymphocytic Leukemia. Innov Aging 2021. [PMCID: PMC8680096 DOI: 10.1093/geroni/igab046.1769] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Chronic lymphocytic leukemia (CLL) is the most common leukemia, affecting predominantly older adults. Treatment naïve patients (CLLtn) with low physical fitness have poor survival following commencement of treatment. CLLtn is characterized by inadequate immune functions, increased risk of secondary malignancies and infections. The aims of this study were to determine the feasibility and preliminary effects of 12-weeks of high-intensity interval training (HIIT) on CLLtn patients. We enrolled eighteen CLLtn patients (64.9±9.1yrs.). Eleven (5M/6F) were allocated to HIIT and seven (4M/3F) to the control group (CON). HIIT consisted of three 30-minute treadmill sessions/week plus two 30-minute strength training sessions/week. Feasibility was confirmed if >70% of HIIT participants completed >75% of prescribed sessions and prescribed minutes, and if >80% of high-intensity intervals were at a heart rate corresponding to 80% of aerobic capacity (139±19 bpm). Results are presented as mean±SD and effect sizes (d), with 0.2, 0.5 and 0.8 representing small, medium and large effect sizes, respectively. Feasibility was achieved, with HIIT completing 5.0±0.2 sessions/week and 99±3.6% of prescribed minutes/week at 142±19 bpm. No adverse safety events were observed. Compared to CON, HIIT increased leg (d=2.602), chest (d=1.285), and seated row (d=3.323) strength, while aerobic capacity difference between groups was d=0.431. Compared to CON, HIIT increased in vitro natural killer immune cell cytolytic activity against K562 (d=1.586) and OSU-CLL (d=0.917) cancer cell lines, and autologous CLL cells (d=1.362). HIIT is safe and feasible in older adults with CLLtn. Preliminary effects suggest that HIIT increases muscle strength and important components of immune function.
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Affiliation(s)
| | | | - Mike Deal
- Duke University, Durham, North Carolina, United States
| | - Erik Hanson
- University of North Carolina, Chapel Hill, North Carolina, United States
| | - Carl Pieper
- Duke University, Durham, North Carolina, United States
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MacDonald G, Sitlinger A, Deal MA, Hanson ED, Ferraro S, Pieper CF, Weinberg JB, Brander DM, Bartlett DB. A pilot study of high-intensity interval training in older adults with treatment naïve chronic lymphocytic leukemia. Sci Rep 2021; 11:23137. [PMID: 34848750 PMCID: PMC8633014 DOI: 10.1038/s41598-021-02352-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Accepted: 11/08/2021] [Indexed: 02/07/2023] Open
Abstract
Chronic lymphocytic leukemia (CLL) is the most common leukemia in the USA, affecting predominantly older adults. CLL is characterized by low physical fitness, reduced immunity, and increased risk of secondary malignancies and infections. One approach to improving CLL patients' physical fitness and immune functions may be participation in a structured exercise program. The aims of this pilot study were to examine physical and immunological changes, and feasibility of a 12-week high-intensity interval training (HIIT) combined with muscle endurance-based resistance training on older adults with treatment naïve CLL. We enrolled eighteen participants with CLL aged 64.9 ± 9.1 years and assigned them to groups depending on distance lived from our fitness center. Ten participants (4 M/6F) completed HIIT and six participants (4 M/2F) completed a non-exercising control group (Controls). HIIT consisted of three 30-min treadmill sessions/week plus two concurrent 30-min strength training sessions/week. Physical and immunological outcomes included aerobic capacity, muscle strength and endurance, and natural killer (NK) cell recognition and killing of tumor cells. We confirmed feasibility if > 70% of HIIT participants completed > 75% of prescribed sessions and prescribed minutes, and if > 80% of high-intensity intervals were at a heart rate corresponding to at least 80% of peak aerobic capacity (VO2peak). Results are presented as Hedge's G effect sizes (g), with 0.2, 0.5 and 0.8 representing small, medium and large effects, respectively. Following HIIT, leg strength (g = 2.52), chest strength (g = 1.15) and seated row strength (g = 3.07) were 35.4%, 56.1% and 39.5% higher than Controls, respectively, while aerobic capacity was 3.8% lower (g = 0.49) than Controls. Similarly, following HIIT, in vitro NK-cell cytolytic activity against the K562 cell line (g = 1.43), OSU-CLL cell line (g = 0.95), and autologous B-cells (g = 1.30) were 20.3%, 3.0% and 14.6% higher than Controls, respectively. Feasibility was achieved, with HIIT completing 5.0 ± 0.2 sessions/week and 99 ± 3.6% of the prescribed minutes/week at heart rates corresponding to 89 ± 2.8% of VO2peak. We demonstrate that 12-weeks of supervised HIIT combined with muscle endurance-based resistance training is feasible, and that high adherence and compliance are associated with large effects on muscle strength and immune function in older adults with treatment naïve CLL.Trial registration: NCT04950452.
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Affiliation(s)
- Grace MacDonald
- Division of Medical Oncology, Duke University School of Medicine, Durham, NC, USA.,Duke Molecular Physiology Institute, Duke University School of Medicine, Durham, NC, USA
| | - Andrea Sitlinger
- Hematologic Malignancies and Cellular Therapies, Duke University School of Medicine, Durham, NC, USA
| | - Michael A Deal
- Division of Medical Oncology, Duke University School of Medicine, Durham, NC, USA.,Duke Molecular Physiology Institute, Duke University School of Medicine, Durham, NC, USA
| | - Erik D Hanson
- Department of Exercise and Sport Science, University of North Carolina, Chapel Hill, NC, USA
| | - Stephanie Ferraro
- Department of Exercise and Sport Science, University of North Carolina, Chapel Hill, NC, USA
| | - Carl F Pieper
- Duke University Aging Center, Duke University School of Medicine, Durham, NC, USA
| | - J Brice Weinberg
- Division of Hematology, Duke University School of Medicine and VA Medical Center, Durham, NC, USA
| | - Danielle M Brander
- Hematologic Malignancies and Cellular Therapies, Duke University School of Medicine, Durham, NC, USA
| | - David B Bartlett
- Division of Medical Oncology, Duke University School of Medicine, Durham, NC, USA. .,Duke Molecular Physiology Institute, Duke University School of Medicine, Durham, NC, USA. .,Faculty of Health and Medical Sciences, University of Surrey, Guildford, UK. .,Division of Medical Oncology, Department of Medicine, Duke Molecular Physiology Institute, Durham, NC, 27701, USA.
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9
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Gordon MJ, Kaempf A, Sitlinger A, Shouse G, Mei M, Brander DM, Salous T, Hill BT, Alqahtani H, Choi M, Churnetski MC, Cohen JB, Stephens DM, Siddiqi T, Rivera X, Persky D, Wisniewski P, Patel K, Shadman M, Park B, Danilov AV. The Chronic Lymphocytic Leukemia Comorbidity Index (CLL-CI): A Three-Factor Comorbidity Model. Clin Cancer Res 2021; 27:4814-4824. [PMID: 34168050 PMCID: PMC8416936 DOI: 10.1158/1078-0432.ccr-20-3993] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Revised: 03/03/2021] [Accepted: 06/16/2021] [Indexed: 11/16/2022]
Abstract
PURPOSE Comorbid medical conditions define a subset of patients with chronic lymphocytic leukemia (CLL) with poor outcomes. However, which comorbidities are most predictive remains understudied. EXPERIMENTAL DESIGN We conducted a retrospective analysis from 10 academic centers to ascertain the relative importance of comorbidities assessed by the cumulative illness rating scale (CIRS). The influence of specific comorbidities on event-free survival (EFS) was assessed in this derivation dataset using random survival forests to construct a CLL-specific comorbidity index (CLL-CI). Cox models were then fit to this dataset and to a single-center, independent validation dataset. RESULTS The derivation and validation sets comprised 570 patients (59% receiving Bruton tyrosine kinase inhibitor, BTKi) and 167 patients (50% receiving BTKi), respectively. Of the 14 CIRS organ systems, three had a strong and stable influence on EFS: any vascular, moderate/severe endocrine, moderate/severe upper gastrointestinal comorbidity. These were combined to create the CLL-CI score, which was categorized into 3 risk groups. In the derivation dataset, the median EFS values were 58, 33, and 20 months in the low, intermediate, and high-risk groups, correspondingly. Two-year overall survival (OS) rates were 96%, 91%, and 82%. In the validation dataset, median EFS values were 81, 40, and 23 months (two-year OS rates 97%/92%/88%), correspondingly. Adjusting for prognostic factors, CLL-CI was significantly associated with EFS in patients treated with either chemo-immunotherapy or with BTKi in each of our 2 datasets. CONCLUSIONS The CLL-CI is a simplified, CLL-specific comorbidity index that can be easily applied in clinical practice and correlates with survival in CLL.
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Affiliation(s)
- Max J Gordon
- Oregon Health and Science University, Portland, Oregon
| | | | | | - Geoffrey Shouse
- City of Hope Comprehensive Cancer Center, Duarte, California
| | - Matthew Mei
- City of Hope Comprehensive Cancer Center, Duarte, California
| | | | | | | | | | - Michael Choi
- Moores Cancer Center at UC San Diego, San Diego, California
| | | | | | | | - Tanya Siddiqi
- City of Hope Comprehensive Cancer Center, Duarte, California
| | | | | | | | | | - Mazyar Shadman
- Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Byung Park
- Knight Cancer Institute, Portland, Oregon.
| | - Alexey V Danilov
- Knight Cancer Institute, Portland, Oregon.
- City of Hope Comprehensive Cancer Center, Duarte, California
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10
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Eyre TA, Lamanna N, Roeker LE, Ujjani CS, Hill BT, Barr PM, Lansigan E, Cheson BD, Yazdy M, Allan JN, Rhodes J, Schuster SJ, Nabhan C, Skarbnik A, Leslie L, Islam P, Whitaker K, Coombs CC, Tuncer HH, Pagel JM, Jacobs R, Winter AM, Bailey N, Sitlinger A, Schuh AH, Follows G, Fox CP, Brander DM, Shadman M, Mato AR. Comparative analysis of targeted novel therapies in relapsed, refractory chronic lymphocytic leukaemia. Haematologica 2021; 106:284-287. [PMID: 32079693 PMCID: PMC7776352 DOI: 10.3324/haematol.2019.241539] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Affiliation(s)
- Toby A Eyre
- Hematology, Churchill Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford
| | - Nicole Lamanna
- New York-Presbyterian Columbia University Medical Center, New York, NY
| | | | - Chaitra S Ujjani
- Seattle Cancer Care Alliance/Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Brian T Hill
- Dept. of Hematology and Medical Oncology, Taussig Cancer Institute, Cleveland Clinic Foundation
| | - Paul M Barr
- Division of Hematology/Oncology, Wilmot Cancer Institute, University of Rochester, Rochester, NY
| | | | - Bruce D Cheson
- Georgetown University Hospital, Lombardi Comprehensive Cancer Center, Washington, DC
| | - Maryam Yazdy
- Georgetown University Hospital, Lombardi Comprehensive Cancer Center, Washington, DC
| | - John N Allan
- Weill Cornell Medicine School of Medicine, Long Island City, NY
| | - Joanna Rhodes
- Div. of Hematology and Oncology, Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA
| | - Stephen J Schuster
- Div of Hematology and Oncology,Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA
| | | | | | - Lori Leslie
- John Theurer Cancer Center at Hackensack University Medical Center, Hackensack, NJ
| | - Prioty Islam
- Hematologic Malignancies and Cellular Therapy, Duke University Medical Center, Durham, NC
| | | | - Catherine C Coombs
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC
| | - Hande H Tuncer
- Department of Medicine, Cancer Center, Tufts Medical Center, Boston, MA
| | - John M Pagel
- Center for Blood Disorders and Stem Cell Transplantation, Swedish Cancer Institute, Seattle, WA
| | - Ryan Jacobs
- Department of Hematology, Lymphoma Division, Levine Cancer Institute, Charlotte, NC
| | - Allison M Winter
- Dept of Hematology and Medical Oncology, Taussig Cancer Institute, Cleveland Clinic Foundation
| | - Neil Bailey
- Center for Blood Disorders and Stem Cell Transplantation, Swedish Cancer Institute, Seattle, WA
| | - Andrea Sitlinger
- Hematologic Malignancies and Cellular Therapy, Duke University Medical Center, Durham, NC
| | - Anna H Schuh
- Haematology, Churchill Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford
| | | | | | - Danielle M Brander
- Hematologic Malignancies and Cellular Therapy, Duke University Medical Center, Durham, NC
| | - Mazyar Shadman
- Seattle Cancer Care Alliance/Fred Hutchinson Cancer Research Center, Seattle, WA
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11
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Mato AR, Roeker LE, Jacobs R, Hill BT, Lamanna N, Brander D, Shadman M, Ujjani CS, Yazdy MS, Perini GF, Pinilla-Ibarz JA, Barrientos J, Skarbnik AP, Torka P, Pu JJ, Pagel JM, Gohil S, Fakhri B, Choi M, Coombs CC, Rhodes J, Barr PM, Portell CA, Parry H, Garcia CA, Whitaker KJ, Winter AM, Sitlinger A, Khajavian S, Grajales-Cruz AF, Isaac KM, Shah P, Akhtar OS, Pocock R, Lam K, Voorhees TJ, Schuster SJ, Rodgers TD, Fox CP, Martinez-Calle N, Munir T, Bhavsar EB, Bailey N, Lee JC, Weissbrot HB, Nabhan C, Goodfriend JM, King AC, Zelenetz AD, Dorsey C, Bigelow K, Cheson BD, Allan JN, Eyre TA. Assessment of the Efficacy of Therapies Following Venetoclax Discontinuation in CLL Reveals BTK Inhibition as an Effective Strategy. Clin Cancer Res 2020; 26:3589-3596. [PMID: 32198151 PMCID: PMC8588795 DOI: 10.1158/1078-0432.ccr-19-3815] [Citation(s) in RCA: 54] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2019] [Revised: 02/05/2020] [Accepted: 03/17/2020] [Indexed: 11/16/2022]
Abstract
PURPOSE Venetoclax-based therapy is a standard-of-care option in first-line and relapsed/refractory chronic lymphocytic leukemia (CLL). Patient management following venetoclax discontinuation remains nonstandard and poorly understood. EXPERIMENTAL DESIGN To address this, we conducted a large international study to identify a cohort of 326 patients who discontinued venetoclax and have been subsequently treated. Coprimary endpoints were overall response rate (ORR) and progression-free survival for the post-venetoclax treatments stratified by treatment type [Bruton's tyrosine kinase inhibitor (BTKi), PI3K inhibitor (PI3Ki), and cellular therapies]. RESULTS We identified patients with CLL who discontinued venetoclax in the first-line (4%) and relapsed/refractory settings (96%). Patients received a median of three therapies prior to venetoclax; 40% were BTKi naïve (n = 130), and 81% were idelalisib naïve (n = 263). ORR to BTKi was 84% (n = 44) in BTKi-naïve patients versus 54% (n = 30) in BTKi-exposed patients. We demonstrate therapy selection following venetoclax requires prior novel agent exposure consideration and discontinuation reasons. CONCLUSIONS For BTKi-naïve patients, selection of covalently binding BTKis results in high ORR and durable remissions. For BTKi-exposed patients, covalent BTK inhibition is not effective in the setting of BTKi resistance. PI3Kis following venetoclax do not appear to result in durable remissions. We conclude that BTKi in naïve or previously responsive patients and cellular therapies following venetoclax may be the most effective strategies.See related commentary by Rogers, p. 3501.
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Affiliation(s)
- Anthony R Mato
- Memorial Sloan Kettering Cancer Center, New York, New York.
| | | | - Ryan Jacobs
- Department of Hematology, Lymphoma Division, Levine Cancer Institute, Charlotte, North Carolina
| | - Brian T Hill
- Department of Hematology and Medical Oncology, Taussig Cancer Institute, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Nicole Lamanna
- Herbert Irving Comprehensive Cancer Center (New York-Presbyterian Columbia University Medical Center), New York, New York
| | | | - Mazyar Shadman
- Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Chaitra S Ujjani
- Seattle Cancer Care Alliance/Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Maryam Sarraf Yazdy
- Georgetown University Hospital Lombardi Comprehensive Cancer Center, Washington D.C
| | | | | | | | | | - Pallawi Torka
- Department of Medicine, Roswell Park Comprehensive Cancer Center, Buffalo, New York
| | - Jeffrey J Pu
- SUNY Upstate Medical University, Syracuse, New York
| | - John M Pagel
- Center for Blood Disorders and Stem Cell Transplantation, Swedish Cancer Institute, Seattle, Washington
| | - Satyen Gohil
- University College London, London, United Kingdom
| | - Bita Fakhri
- Department of Medicine, Division of Hematology/Oncology, University of California San Francisco, San Francisco, California
| | - Michael Choi
- Moores Cancer Center, University of California San Diego, La Jolla, California
| | - Catherine C Coombs
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, North Carolina
| | - Joanna Rhodes
- Division of Hematology and Oncology, Abramson Cancer Center, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Paul M Barr
- Division of Hematology/Oncology, Wilmot Cancer Institute, University of Rochester, Rochester, New York
| | - Craig A Portell
- Division of Hematology and Oncology, University of Virginia, Charlottesville, Virginia
| | - Helen Parry
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, United Kingdom
| | - Christine A Garcia
- Hillman Cancer Pavilion, Division of Hematology and Oncology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | | | - Allison M Winter
- Department of Hematology and Medical Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio
| | - Andrea Sitlinger
- Hematologic Malignancies and Cellular Therapy, Duke University Medical Center, Durham, North Carolina
| | | | | | - Krista M Isaac
- Division of Hematology and Oncology, University of Virginia, Charlottesville, Virginia
| | | | | | | | - Kentson Lam
- Moores Cancer Center, University of California San Diego, La Jolla, California
| | - Timothy J Voorhees
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, North Carolina
| | - Stephen J Schuster
- Division of Hematology and Oncology, Abramson Cancer Center, University of Pennsylvania, Philadelphia, Pennsylvania
| | | | - Christopher P Fox
- Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom
| | - Nicolas Martinez-Calle
- Clinical Haematology Department, Nottingham University Hospitals NHS Trust, Nottingham, England, United Kingdom
| | - Talha Munir
- Weill Cornell Medicine, Long Island City, New York
| | - Erica B Bhavsar
- Department of Haematology, St James's University Hospital, Leeds, United Kingdom
| | - Neil Bailey
- Center for Blood Disorders and Stem Cell Transplantation, Swedish Cancer Institute, Seattle, Washington
| | - Jason C Lee
- Herbert Irving Comprehensive Cancer Center (New York-Presbyterian Columbia University Medical Center), New York, New York
| | - Hanna B Weissbrot
- Herbert Irving Comprehensive Cancer Center (New York-Presbyterian Columbia University Medical Center), New York, New York
| | | | | | - Amber C King
- Clinical Pharmacy Specialist-Leukemia, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Andrew D Zelenetz
- Department of Medicine, Lymphoma Service, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Colleen Dorsey
- Memorial Sloan Kettering Cancer Center, New York, New York
| | - Kayla Bigelow
- Memorial Sloan Kettering Cancer Center, New York, New York
| | - Bruce D Cheson
- Georgetown University Hospital Lombardi Comprehensive Cancer Center, Washington D.C
| | - John N Allan
- Department of Haematology, St James's University Hospital, Leeds, United Kingdom
| | - Toby A Eyre
- Department of Haematology, Churchill Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
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12
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Bartlett DB, Sitlinger A, Deal M, Connelly MA, Stewart T, Guadalupe E, MacDonald G, Kraus WE, Weinberg JB, Brander DB. Physical Fitness As A Determinant Of Leukemia Cell Biology In Treatment-Naive Chronic Lymphocytic Leukemia (CLL). Med Sci Sports Exerc 2020. [DOI: 10.1249/01.mss.0000686300.11363.97] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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13
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Mato A, Schuster S, Lamanna N, Pagel J, Flinn I, Barrientos J, Reeves J, Cheson B, Barr P, Kambhampati S, Lansigan F, Pu J, Skarbnik A, Fonseca G, Dorsey C, LaRatta N, Weissbrot H, Svoboda J, Luning Prak E, Tsao P, Sitlinger A, Paskalis D, Sportelli P, Miskin H, Weiss M, Brander D. A PHASE 2 STUDY TO ASSESS THE SAFETY AND EFFICACY OF UMBRALISIB IN PATIENTS WITH CHRONIC LYMPHOCYTIC LEUKEMIA (CLL) WHO ARE INTOLERANT TO PRIOR BTK OR PI3K DELTA INHIBITOR THERAPY. Hematol Oncol 2019. [DOI: 10.1002/hon.56_2629] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Affiliation(s)
- A.R. Mato
- CLL Program; Leukemia Service, Memorial Sloan-Kettering Cancer Center; New York NY United States
| | - S.J. Schuster
- Lymphoma Department; University of Pennsylvania, Abramson Cancer Center; Philadelphia PA United States
| | - N. Lamanna
- Columbia University Medical Center; New York-Presbyterian; New York United States
| | - J.M. Pagel
- Department of Hematology; Swedish Cancer Institute; Seattle WA United States
| | - I.W. Flinn
- TN Oncology; Sarah Cannon Research Institute; Nashville TN United States
| | - J. Barrientos
- CLL Research and Treatment Program; Northwell Health; New Hyde Park NY United States
| | - J.A. Reeves
- Florida Cancer Specialists; Sarah Cannon Research Institute; Fort Myers FL United States
| | - B.D. Cheson
- Lombardi Comprehensive Cancer Center; Georgetown University Hospital; Washington DC United States
| | - P.M. Barr
- Wilmot Cancer Institute; University of Rochester; Rochester NY United States
| | - S. Kambhampati
- Research Medical Center; Sarah Cannon Research Institute; Kansas City MO United States
| | - F. Lansigan
- Department of Hematology; Dartmouth-Hitchcock Medical Center; Lebanon NH United States
| | - J.J. Pu
- Department of Hematology; Penn State Health; Hershey PA United States
| | - A. Skarbnik
- Department of Hematology; John Theurer Cancer Center; Hackensack NJ United States
| | - G. Fonseca
- Florida Cancer Specialists North; Sarah Cannon Research Institute; St. Petersburg FL United States
| | - C. Dorsey
- CLL Program; Leukemia Service, Memorial Sloan-Kettering Cancer Center; New York NY United States
| | - N.M. LaRatta
- Lymphoma Department; University of Pennsylvania, Abramson Cancer Center; Philadelphia PA United States
| | - H. Weissbrot
- Columbia University Medical Center; New York-Presbyterian; New York United States
| | - J. Svoboda
- Lymphoma Department; University of Pennsylvania, Abramson Cancer Center; Philadelphia PA United States
| | - E.T. Luning Prak
- Clinical Immunology Laboratory; University of Pennsylvania; Philadelphia PA United States
| | - P. Tsao
- Clinical Immunology Laboratory; University of Pennsylvania; Philadelphia PA United States
| | - A. Sitlinger
- Department of Hematology; Duke University Medical Center; Durham NC United States
| | - D. Paskalis
- Clinical Development; TG Therapeutics, Inc.; New York NY United States
| | - P. Sportelli
- Clinical Development; TG Therapeutics, Inc.; New York NY United States
| | - H.P. Miskin
- Clinical Development; TG Therapeutics, Inc.; New York NY United States
| | - M.S. Weiss
- Clinical Development; TG Therapeutics, Inc.; New York NY United States
| | - D.M. Brander
- Department of Hematology; Duke University Medical Center; Durham NC United States
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14
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Ortel TL, Arnold K, Beckman M, Brown A, Reyes N, Saber I, Schulteis R, Singh BP, Sitlinger A, Thames EH. Design and Implementation of a Comprehensive Surveillance System for Venous Thromboembolism in a Defined Region Using Electronic and Manual Approaches. Appl Clin Inform 2019; 10:552-562. [PMID: 31365941 PMCID: PMC6669040 DOI: 10.1055/s-0039-1693711] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2019] [Accepted: 06/16/2019] [Indexed: 10/26/2022] Open
Abstract
BACKGROUND Systematic surveillance for venous thromboembolism (VTE) in the United States has been recommended by several organizations. Despite adoption of electronic medical records (EMRs) by most health care providers and facilities, however, systematic surveillance for VTE is not available. OBJECTIVES This article develops a comprehensive, population-based surveillance strategy for VTE in a defined geographical region. METHODS The primary surveillance strategy combined computerized searches of the EMR with a manual review of imaging data at the Duke University Health System in Durham County, North Carolina, United States. Different strategies of searching the EMR were explored. Consolidation of results with autopsy reports (nonsearchable in the EMR) and with results from the Durham Veterans' Administration Medical Center was performed to provide a comprehensive report of new VTE from the defined region over a 2-year timeframe. RESULTS Monthly searches of the primary EMR missed a significant number of patients with new VTE who were identified by a separate manual search of radiology records, apparently related to delays in data entry and coding into the EMR. Comprehensive searches incorporating a location-restricted strategy were incomplete due to the assigned residence reflecting the current address and not the address at the time of event. The most comprehensive strategy omitted the geographic restriction step and identified all patients with VTE followed by manual review of individual records to remove incorrect entries (e.g., outside the surveillance time period or geographic location; no evidence for VTE). Consolidation of results from the EMR searches with results from autopsy reports and the separate facility identified additional patients not diagnosed within the Duke system. CONCLUSION We identified several challenges with implementing a comprehensive VTE surveillance program that could limit accuracy of the results. Improved electronic strategies are needed to cross-reference patients across multiple health systems and to minimize the need for manual review and confirmation of results.
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Affiliation(s)
- Thomas L. Ortel
- Division of Hematology, Department of Medicine, Duke University Medical Center, Durham, North Carolina, United States
- Department of Pathology, Duke University Medical Center, Durham, North Carolina, United States
| | - Katie Arnold
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina, United States
| | - Michele Beckman
- Centers for Disease Control and Prevention, Atlanta, Georgia, United States
| | - Audrey Brown
- Social & Scientific Systems, Inc., Durham, North Carolina, United States
| | - Nimia Reyes
- Centers for Disease Control and Prevention, Atlanta, Georgia, United States
| | - Ibrahim Saber
- Division of Hematology, Department of Medicine, Duke University Medical Center, Durham, North Carolina, United States
| | - Ryan Schulteis
- Durham Veterans' Administration Medical Center, Durham, North Carolina, United States
| | | | - Andrea Sitlinger
- Hematologic Malignancies and Cellular Therapy, Department of Medicine, Duke University Medical Center, Durham, North Carolina, United States
| | - Elizabeth H. Thames
- Division of Hematology, Department of Medicine, Duke University Medical Center, Durham, North Carolina, United States
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15
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Roeker LE, Fox CP, Eyre TA, Brander DM, Allan JN, Schuster SJ, Nabhan C, Hill BT, Shah NN, Lansigan F, Yazdy M, Cheson BD, Lamanna N, Singavi AK, Coombs CC, Barr PM, Skarbnik AP, Shadman M, Ujjani CS, Tuncer HH, Winter AM, Rhodes J, Dorsey C, Morse H, Kabel C, Pagel JM, Williams AM, Jacobs R, Goy A, Muralikrishnan S, Pearson L, Sitlinger A, Bailey N, Schuh A, Kirkwood AA, Mato AR. Tumor Lysis, Adverse Events, and Dose Adjustments in 297 Venetoclax-Treated CLL Patients in Routine Clinical Practice. Clin Cancer Res 2019; 25:4264-4270. [PMID: 31004001 DOI: 10.1158/1078-0432.ccr-19-0361] [Citation(s) in RCA: 53] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Revised: 03/08/2019] [Accepted: 04/15/2019] [Indexed: 11/16/2022]
Abstract
PURPOSE Clinical trials of venetoclax reported negligible rates of clinical tumor lysis syndrome (TLS) in patients with chronic lymphocytic leukemia (CLL) when using an extended dose escalation schedule. We aimed to understand TLS prophylaxis, rates of select adverse events (AE), and impact of dosing modifications in routine clinical practice. EXPERIMENTAL DESIGN This retrospective cohort study included 297 CLL venetoclax-treated patients outside of clinical trials in academic and community centers. Demographics, baseline disease characteristics, venetoclax dosing, TLS risk and prophylaxis, and AEs were collected. RESULTS The group was 69% male, 96% had relapsed/refractory CLL, 45% had deletion chromosome 17p, 84% had unmutated IGHV, 80% received venetoclax monotherapy, and median age was 67. TLS risk was categorized as low (40%), intermediate (32%), or high (28%), and 62% had imaging prior to venetoclax initiation. Clinical TLS occurred in 2.7% of patients and laboratory TLS occurred in 5.7%. Pre-venetoclax TLS risk group and creatinine clearance independently predict TLS development in multivariable analysis. Grade 3/4 AEs included neutropenia (39.6%), thrombocytopenia (29.2%), infection (25%), neutropenic fever (7.9%), and diarrhea (6.9%). Twenty-two patients (7.4%) discontinued venetoclax due to an AE. Progression-free survival was similar regardless of number of dose interruptions, length of dose interruption, and stable venetoclax dose. CONCLUSIONS These data provide insights into current use of venetoclax in clinical practice, including TLS rates observed in clinical practice. We identified opportunities for improved adherence to TLS risk stratification and prophylaxis, which may improve safety.
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Affiliation(s)
- Lindsey E Roeker
- Leukemia Service, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - Christopher P Fox
- Department of Clinical Haematology, Nottingham University Hospitals NHS Foundation Trust, Nottingham, United Kingdom
| | - Toby A Eyre
- Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
| | - Danielle M Brander
- Duke Cancer Institute, Duke University Health System, Durham, North Carolina
| | - John N Allan
- Division of Hematology and Oncology, Weill Cornell Medicine, New York, New York
| | - Stephen J Schuster
- Lymphoma Program, Abramson Cancer Center, University of Pennsylvania, Philadelphia, Pennsylvania
| | | | - Brian T Hill
- Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio
| | - Nirav N Shah
- Division of Hematology & Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | | | - Maryam Yazdy
- Georgetown University Hospital Lombardi Comprehensive Cancer Center, Washington, D
| | - Bruce D Cheson
- Georgetown University Hospital Lombardi Comprehensive Cancer Center, Washington, D
| | - Nicole Lamanna
- Hematology/Oncology Division, Columbia University Medical Center, New York, New York
| | - Arun K Singavi
- Division of Hematology & Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Catherine C Coombs
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, North Carolina
| | - Paul M Barr
- Wilmot Cancer Institute, University of Rochester, Rochester, New York
| | - Alan P Skarbnik
- John Theurer Cancer Center, Hackensack University Medical Center, Closter, New Jersey
| | - Mazyar Shadman
- Fred Hutchinson Cancer Research Center, Seattle, Washington
| | | | | | | | - Joanna Rhodes
- Lymphoma Program, Abramson Cancer Center, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Colleen Dorsey
- Leukemia Service, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - Hannah Morse
- Leukemia Service, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - Charlene Kabel
- Leukemia Service, Memorial Sloan-Kettering Cancer Center, New York, New York
| | | | | | - Ryan Jacobs
- Levine Cancer Institute, Carolinas Healthcare System, Charlotte, North Carolina
| | - Andre Goy
- John Theurer Cancer Center, Hackensack University Medical Center, Closter, New Jersey
| | | | | | - Andrea Sitlinger
- Duke Cancer Institute, Duke University Health System, Durham, North Carolina
| | - Neil Bailey
- Swedish Cancer Institute, Seattle, Washington
| | - Anna Schuh
- Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
| | - Amy A Kirkwood
- Cancer Research UK and University College London Cancer Trials Centre, London, United Kingdom
| | - Anthony R Mato
- Leukemia Service, Memorial Sloan-Kettering Cancer Center, New York, New York.
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16
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Sitlinger A, Shelby RA, Van Denburg AN, White H, Edmond SN, Marcom PK, Bosworth HB, Keefe FJ, Kimmick GG. Higher symptom burden is associated with lower function in women taking adjuvant endocrine therapy for breast cancer. J Geriatr Oncol 2018; 10:317-321. [PMID: 30553719 DOI: 10.1016/j.jgo.2018.11.008] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2018] [Revised: 09/06/2018] [Accepted: 11/28/2018] [Indexed: 10/27/2022]
Abstract
OBJECTIVE To explore the impact of symptoms on physical function in women on adjuvant endocrine therapy for breast cancer. METHODS Eligible women were postmenopausal, had hormone receptor positive, stage I-IIIA breast cancer, completed surgery, chemotherapy, radiation, and on adjuvant endocrine therapy. At a routine follow-up visit, women (N = 107) completed standardized symptom measures: Brief Fatigue Inventory, Brief Pain Inventory, Menopause Specific Quality of Life Questionnaire, Functional Assessment of Cancer Therapy Neurotoxicity scales. Two performance measures assessed function: grip strength (Jamar dynamometer; n = 71) and timed get-up-and-go (TUG; n = 103). Analyses were performed with an overall symptom composite score. Correlations and multiple linear regression analyses were performed to test adverse effects on physical function. RESULTS The mean age was 64 years (range 45-84), 81% white, 84% on an aromatase inhibitor, and on endocrine therapy for mean 35 months (range 1-130 months). Dominant hand grip strength was inversely correlated with symptom composite scores (r = -0.29, p = .02). Slower TUG was positively correlated with higher Charlson comorbidity level (r = 0.36, p < .001) and higher symptom composite scores (r = 0.24, p = .01). In multivariate analyses, weaker dominant and non-dominant hand grip strength were significantly associated with greater symptom composite scores (β = -0.27, t = 2.43, p = .02 and β = -0.36, t = 3.15, p = .003, respectively) and slower TUG was associated with higher symptom composite scores (β = 0.18, t = 1.97, p = .05). CONCLUSIONS Higher symptom burden is associated with worse physical function, as measured by hand grip strength and TUG. Further study to determine the impact of endocrine therapy and its side effects on function is warranted.
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Affiliation(s)
- Andrea Sitlinger
- Medical Oncology, Duke University Medical Center, Durham, NC 27710, United States
| | - Rebecca A Shelby
- Psychiatry and Behavioral Sciences, Duke University Medical Center, 2200 W. Main St, Ste 340, Durham, NC 27705, United States
| | - Alyssa N Van Denburg
- Psychiatry and Behavioral Sciences, Duke University Medical Center, 2200 W. Main St, Ste 340, Durham, NC 27705, United States
| | - Heidi White
- Center for Aging, Duke University Medical Center, Durham, NC 27710, United States
| | - Sarah N Edmond
- Psychiatry and Behavioral Sciences, Duke University Medical Center, 2200 W. Main St, Ste 340, Durham, NC 27705, United States
| | - Paul K Marcom
- Medical Oncology, Duke University Medical Center, Durham, NC 27710, United States
| | - Hayden B Bosworth
- Center for Health Services Research, Durham VAMC, Durham, NC 27710, United States
| | - Francis J Keefe
- Psychiatry and Behavioral Sciences, Department of Population Health Science, Duke University Medical Center, 2200 W. Main St, Ste 340, Durham, NC 27705, United States
| | - Gretchen G Kimmick
- Medical Oncology, Duke University Medical Center, Durham, NC 27710, United States.
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17
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Abstract
In the age of ever-expanding treatments and precision medicine, the hope for cure remains the ultimate goal for patients and providers. Equally important to many patients is the quality of life achieved during and after treatment. Evidence suggests that overall quality of life is important to patients and plays a role in determining outcomes in patients with cancer. This article examines components of health-related quality of life and cancer treatment, including physical, psychosocial, and financial burden, as well as how these components affect patients' overall wellbeing and survival.
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Affiliation(s)
- Andrea Sitlinger
- Hematology and Oncology, Duke University Medical Center, 2424 Erwin Road, Suite 602, Room 6046, Durham, NC 27705, USA
| | - Syed Yousuf Zafar
- Duke Cancer Institute, Sanford School of Public Policy, 2424 Erwin Road, Suite 602, Room 6046, Durham, NC 27705, USA.
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18
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Mato AR, Thompson M, Allan JN, Brander DM, Pagel JM, Ujjani CS, Hill BT, Lamanna N, Lansigan F, Jacobs R, Shadman M, Skarbnik AP, Pu JJ, Barr PM, Sehgal AR, Cheson BD, Zent CS, Tuncer HH, Schuster SJ, Pickens PV, Shah NN, Goy A, Winter AM, Garcia C, Kennard K, Isaac K, Dorsey C, Gashonia LM, Singavi AK, Roeker LE, Zelenetz A, Williams A, Howlett C, Weissbrot H, Ali N, Khajavian S, Sitlinger A, Tranchito E, Rhodes J, Felsenfeld J, Bailey N, Patel B, Burns TF, Yacur M, Malhotra M, Svoboda J, Furman RR, Nabhan C. Real-world outcomes and management strategies for venetoclax-treated chronic lymphocytic leukemia patients in the United States. Haematologica 2018; 103:1511-1517. [PMID: 29880613 PMCID: PMC6119152 DOI: 10.3324/haematol.2018.193615] [Citation(s) in RCA: 122] [Impact Index Per Article: 20.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2018] [Accepted: 06/05/2018] [Indexed: 11/09/2022] Open
Abstract
Venetoclax is a BCL2 inhibitor approved for 17p-deleted relapsed/refractory chronic lymphocytic leukemia with activity following kinase inhibitors. We conducted a multicenter retrospective cohort analysis of patients with chronic lymphocytic leukemia treated with venetoclax to describe outcomes, toxicities, and treatment selection following venetoclax discontinuation. A total of 141 chronic lymphocytic leukemia patients were included (98% relapsed/refractory). Median age at venetoclax initiation was 67 years (range 37-91), median prior therapies was 3 (0-11), 81% unmutated IGHV, 45% del(17p), and 26.8% complex karyotype (≥ 3 abnormalities). Prior to venetoclax initiation, 89% received a B-cell receptor antagonist. For tumor lysis syndrome prophylaxis, 93% received allopurinol, 92% normal saline, and 45% rasburicase. Dose escalation to the maximum recommended dose of 400 mg daily was achieved in 85% of patients. Adverse events of interest included neutropenia in 47.4%, thrombocytopenia in 36%, tumor lysis syndrome in 13.4%, neutropenic fever in 11.6%, and diarrhea in 7.3%. The overall response rate to venetoclax was 72% (19.4% complete remission). With a median follow up of 7 months, median progression free survival and overall survival for the entire cohort have not been reached. To date, 41 venetoclax treated patients have discontinued therapy and 24 have received a subsequent therapy, most commonly ibrutinib. In the largest clinical experience of venetoclax-treated chronic lymphocytic leukemia patients, the majority successfully completed and maintained a maximum recommended dose. Response rates and duration of response appear comparable to clinical trial data. Venetoclax was active in patients with mutations known to confer ibrutinib resistance. Optimal sequencing of newer chronic lymphocytic leukemia therapies requires further study.
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Affiliation(s)
- Anthony R Mato
- CLL Program, Leukemia Service, Division of Hematologic Oncology, Department of Internal Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Meghan Thompson
- Center for CLL, Division of Hematology and Oncology, University of Pennsylvania, Philadelphia, PA, USA
| | | | - Danielle M Brander
- Division of Hematologic Malignancies and Cellular Therapy, Duke University, Durham, NC, USA
| | - John M Pagel
- Center for Blood Disorders and Stem Cell Transplantation, Swedish Cancer Institute, Seattle, WA, USA
| | - Chaitra S Ujjani
- Georgetown University Hospital Lombardi Comprehensive Cancer Center, Washington, DC, USA
| | - Brian T Hill
- Taussig Cancer Institute, Cleveland Clinic Foundation, OH, USA
| | | | | | - Ryan Jacobs
- Department of Hematologic Oncology and Blood Disorders, Levine Cancer Institute, Carolinas Healthcare System, Charlotte, NC, USA
| | - Mazyar Shadman
- University of Washington/Fred Hutchinson Cancer Research Center, Seattle Cancer Care Alliance, WA, USA
| | - Alan P Skarbnik
- John Theurer Cancer Center, Hackensack Meridian Health, NJ, USA
| | | | - Paul M Barr
- Wilmot Cancer Institute Division of Hematology/Oncology, University of Rochester Medical Center, NY, USA
| | | | - Bruce D Cheson
- Georgetown University Hospital Lombardi Comprehensive Cancer Center, Washington, DC, USA
| | - Clive S Zent
- Wilmot Cancer Institute Division of Hematology/Oncology, University of Rochester Medical Center, NY, USA
| | | | - Stephen J Schuster
- Center for CLL, Division of Hematology and Oncology, University of Pennsylvania, Philadelphia, PA, USA
| | | | - Nirav N Shah
- Division of Hematology & Oncology, Medical College of Wisconsin, Brookfield, WI, USA
| | - Andre Goy
- John Theurer Cancer Center, Hackensack Meridian Health, NJ, USA
| | | | | | - Kaitlin Kennard
- Center for CLL, Division of Hematology and Oncology, University of Pennsylvania, Philadelphia, PA, USA
| | - Krista Isaac
- Internal Medicine, Lankenau Medical Center, Wynnewood, PA, USA
| | - Colleen Dorsey
- Center for CLL, Division of Hematology and Oncology, University of Pennsylvania, Philadelphia, PA, USA
| | - Lisa M Gashonia
- Center for CLL, Division of Hematology and Oncology, University of Pennsylvania, Philadelphia, PA, USA
| | - Arun K Singavi
- Division of Hematology & Oncology, Medical College of Wisconsin, Brookfield, WI, USA
| | - Lindsey E Roeker
- CLL Program, Leukemia Service, Division of Hematologic Oncology, Department of Internal Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Andrew Zelenetz
- CLL Program, Leukemia Service, Division of Hematologic Oncology, Department of Internal Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Annalynn Williams
- Wilmot Cancer Institute Division of Hematology/Oncology, University of Rochester Medical Center, NY, USA
| | | | | | - Naveed Ali
- Abington Hem. Onc. Assoc., Inc., Willow Grove, PA, USA
| | - Sirin Khajavian
- University of Washington/Fred Hutchinson Cancer Research Center, Seattle Cancer Care Alliance, WA, USA
| | - Andrea Sitlinger
- Division of Hematologic Malignancies and Cellular Therapy, Duke University, Durham, NC, USA
| | - Eve Tranchito
- Taussig Cancer Institute, Cleveland Clinic Foundation, OH, USA
| | - Joanna Rhodes
- Center for CLL, Division of Hematology and Oncology, University of Pennsylvania, Philadelphia, PA, USA
| | | | - Neil Bailey
- Center for Blood Disorders and Stem Cell Transplantation, Swedish Cancer Institute, Seattle, WA, USA
| | | | | | | | | | - Jakub Svoboda
- Center for CLL, Division of Hematology and Oncology, University of Pennsylvania, Philadelphia, PA, USA
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