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Schostak M, Bradbury A, Briganti A, Gonzalez D, Gomella L, Mateo J, Penault-Llorca F, Stenzinger A, Wyatt AW, Bjartell A. Practical Guidance on Establishing a Molecular Testing Pathway for Alterations in Homologous Recombination Repair Genes in Clinical Practice for Patients with Metastatic Prostate Cancer. Eur Urol Oncol 2023:S2588-9311(23)00166-9. [PMID: 37714762 DOI: 10.1016/j.euo.2023.08.004] [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: 10/11/2022] [Revised: 08/01/2023] [Accepted: 08/14/2023] [Indexed: 09/17/2023]
Abstract
CONTEXT Prostate cancer is a molecularly heterogeneous disease that is amenable to diagnostic testing to identify patients potentially eligible for personalised treatments inform familial risk and provide relevant information about potential prognosis. Several guidelines support the integration of genomic testing in a shared decision-making framework so that both health care professionals (HCPs) and patients are involved in determining the best treatment approach. OBJECTIVE To review current guidelines on molecular diagnostic testing for homologous recombination repair (HRR) gene alterations in patients with metastatic prostate cancer, with the aim of providing practical considerations for effective guideline implementation and establishment of an appropriate pathway for molecular diagnostic testing. EVIDENCE ACQUISITION We undertook a nonsystematic narrative review of the literature using PubMed to identify current guidelines and recommendations on molecular diagnostic testing for BRCA and/or homologous recombination repair gene alterations (HRRm) in patients with prostate cancer. In addition, selected articles that included BRCA/HRRm testing in clinical trials in metastatic castration-resistant prostate cancer and real-world evidence were also evaluated. Websites for relevant societies were reviewed for molecular diagnostic guidelines not published on PubMed. EVIDENCE SYNTHESIS Our review of guidelines published by several international societies that include molecular testing in prostate cancer identified variations in molecular testing approaches. The review of testing approaches used in clinical trials and real-world settings also highlighted several aspects that require improvement. Therefore, we compiled practical guidance for establishing an appropriate BRCA/HRR mutation testing pathway. CONCLUSIONS While there are several challenges to molecular testing and interpretation of test results that require enhancement, a multidisciplinary team approach will empower HCPs and their institutions to improve on or initiate their own molecular testing pathways. This in turn will lead to improvements in management strategies for patients with metastatic prostate cancer, for whom better treatment outcomes is a significant unmet need. PATIENT SUMMARY Establishing a molecular testing pathway in clinical practice for patients with metastatic castration-resistant prostate cancer will lead to fairer and more equal access to personalised treatments. This should lead to better outcomes, particularly for patients whose disease has spread to other areas of the body.
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Affiliation(s)
- Martin Schostak
- Department of Urology, Urooncology, Robot-assisted and Focal Treatment, University Hospital Magdeburg, Magdeburg, Germany.
| | - Angela Bradbury
- Perelman Center for Advanced Medicine, Philadelphia, PA, USA
| | | | - David Gonzalez
- Patrick G. Johnston Centre for Cancer Research, Queen's University, Belfast, UK
| | - Leonard Gomella
- Department of Urology, Sidney Kimmel Cancer Center, Thomas Jefferson University, Philadelphia, PA, USA
| | - Joaquin Mateo
- Vall d'Hebron Institute of Oncology (VHIO), Vall d'Hebron University Hospital, Barcelona, Spain
| | | | | | - Alexander W Wyatt
- Vancouver Prostate Centre, University of British Columbia, Vancouver, Canada
| | - Anders Bjartell
- Department of Urology, Skåne University Hospital, Malmö, Sweden; Department of Translational Medicine, Lund University, Lund, Sweden
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Kaufmann T, Chang P, Rosenberg S, Frank E, Hobbs B, Bayne LJ, Nivar I, Goodspeed BL, Rohn KM, Kugler EM, Fox K, Domchek S, Bradbury A, Shah P, Knollman H, Jankowitz RC, Makhlin I, Clark AS, Chodosh LA, DeMichele A, Goodfellow K. Abstract P5-08-01: Pilot study of a patient-reported outcome (PRO) measurement strategy to determine impact of screening for minimal residual disease (MRD) in high-risk breast cancer survivors. Cancer Res 2023. [DOI: 10.1158/1538-7445.sabcs22-p5-08-01] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/06/2023]
Abstract
Abstract
Background: Patients treated for early stage breast cancer (BC) have a 30% lifetime risk of developing metastatic disease. Numerous studies have demonstrated that dormant bone marrow disseminated tumor cells (DTCs) are independently associated with risk of recurrence and death, yet interventions targeting these cells are lacking. The PENN-SURMOUNT (Surveillance Markers of Utility for Recurrence after (Neo)adjuvant Therapy) Screening Study was launched in 2016 to screen high risk BC survivors for DTCs using bone marrow aspirate (BMA) and identify eligible DTC positive patients for clinical trials. Given the novelty of this approach, we concurrently developed and pilot tested a PRO measurement strategy to study how the screening method of BMA and disclosure of DTC results impacts early-stage BC patients. Methods: PENN-SURMOUNT is a single center prospective, longitudinal cohort study examining BM and blood biomarkers of MRD among patients within 5 years of BC diagnosis who have high risk criteria (positive axillary nodes, triple negative biology, ER+ with Oncotype Dx ≥ 25 and/or high risk Mammaprint, or pathologic residual disease after neoadjuvant chemotherapy). From May 2019 – August 2021, we recruited patients on SURMOUNT to complete PRO surveys at baseline (T0), after BMA (T1), and after disclosure of DTC results (T2). Surveys were administered in paper form initially, then electronic form starting Feb 2021. PRO survey instruments were selected through literature review, followed by consensus among multidisciplinary clinical and research experts and patient advocates. PRO measures assess recurrence distress (Quality of Life in Adult Cancer Survivors, QLACS), illness intrusiveness (Illness Intrusiveness Ratings Scale, IIRS), and decision making (Decision Regret Scale). Additional survey items assess tolerability of the BMA and patients’ risk perception and cognitive understanding after DTC results disclosure. Descriptive statistics summarize PRO survey compliance and responses at T0, T1, and T2 in the total population and the population who reported longitudinal data for T2. Results: 61 of 66 eligible patients on the SURMOUNT trial enrolled in the PRO pilot study and completed a baseline survey, of which 47 (77%) tested negative for DTCs. Mean completion rates were 0.92 at T0, 0.85 at T1, and 0.56 at T2. After electronic survey implementation, completion rates increased to 0.94 (T0), 0.97 (T1) and 0.81 (T2). At T0, 36 (59%) patients reported a high risk perception of developing BC recurrence at 5 years and 42 (69%) during their lifetime. Mean T0 recurrence distress using the QLACS subscale was 14.6 (SD 6.3) out of possible score 4-28, compared to an expected mean of 11.42 (SD 5.48) in a general survivorship population. Mean T0 illness intrusiveness was 27.3 (SD 13.9) out of possible score 13-91. At T1, approximately 85% of patients agreed that they correctly understood the purpose of the bone marrow procedure and what the procedure would entail. 44 (72%) of patients reported a maximum pain score <= 4 in the week post-procedure and 42 (69%) reported the BMA was same or better than expected tolerability. Exploratory subset analysis of patients with complete longitudinal data at T2 (n = 34) showed average scores of 13.4 (SD 6.0), 30.1 (SD 14.0), and 2.8 (SD 6.2) for recurrence distress, illness intrusive, and decision regret scores (scale 0-100), respectively. At T2, 26 (76%) of patients reported no decision regret for undergoing testing for DTCs; 27 (79%) reported feeling less anxious after DTC results disclosure. Conclusions: Participants of PENN-SURMOUNT perceived risk of recurrence as high. The BMA procedure was well-tolerated and better than expected among the majority of this cohort, and most did not regret having undergone BMA after DTC status disclosure. Longitudinal completion rates were low, limiting assessment of PROs at later time points, a major focus of future work in this setting.
Citation Format: Tara Kaufmann, Patrick Chang, Shoshana Rosenberg, Elizabeth Frank, Brian Hobbs, Lauren J. Bayne, Isoris Nivar, Brooke L. Goodspeed, Killian M. Rohn, Emily M. Kugler, Kevin Fox, Susan Domchek, Angela Bradbury, Payal Shah, Hayley Knollman, Rachel C. Jankowitz, Igor Makhlin, Amy S. Clark, Lewis A. Chodosh, Angela DeMichele, Katherine Goodfellow. Pilot study of a patient-reported outcome (PRO) measurement strategy to determine impact of screening for minimal residual disease (MRD) in high-risk breast cancer survivors [abstract]. In: Proceedings of the 2022 San Antonio Breast Cancer Symposium; 2022 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2023;83(5 Suppl):Abstract nr P5-08-01.
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Affiliation(s)
| | | | | | | | - Brian Hobbs
- 5University of Texas at Austin, Dell Medical School
| | - Lauren J. Bayne
- 6University of Pennsylvania, Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Isoris Nivar
- 7University of Pennsylvania, Perelman School of Medicine
| | | | - Killian M. Rohn
- 9University of Pennsylvania, Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Emily M. Kugler
- 10University of Pennsylvania, Perelman School of Medicine, Pennsylvania
| | - Kevin Fox
- 11University of Pennsylvania Perleman School of Medicine
| | - Susan Domchek
- 12University of Pennsylvania School of Medicine, Philadelphia, PA
| | | | | | | | | | - Igor Makhlin
- 17University of Pennsylvania, Philadelphia, Pennsylvania
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Jennings C, Wynn J, Miguel C, Levinson E, Florido ME, White M, Sands CB, Schwartz LA, Daly M, O'Toole K, Buys SS, Glendon G, Hanna D, Andrulis IL, Terry MB, Chung WK, Bradbury A. Mother and Daughter Perspectives on Genetic Counseling and Testing of Adolescents for Hereditary Breast Cancer Risk. J Pediatr 2022; 251:113-119.e7. [PMID: 35777474 DOI: 10.1016/j.jpeds.2022.06.027] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Revised: 06/09/2022] [Accepted: 06/22/2022] [Indexed: 11/19/2022]
Abstract
OBJECTIVE To evaluate the risks, benefits, and utility of testing for adult-onset hereditary breast and ovarian cancer (HBOC) in adolescents and young adults. STUDY DESIGN We evaluated interest in genetic testing of adolescents for adult-onset HBOC genes through semistructured interviews with mothers and adolescents who had previously participated in breast cancer research or had pursued (mothers) clinical testing for HBOC. RESULTS The majority of mothers (73%) and daughters (75%) were interested in the daughter having genetic testing and were motivated by the future medical utility and current social utility of relieving anxiety and allowing them to prepare. Mothers and daughters both reported that approximately 3 years in the future was the best time to test the daughter regardless of the current age of the daughter. Overall, both mothers and daughters expressed the importance of the involvement of the mother to provide educational and emotional support but ultimately it was the daughter's decision to test. Balancing the independence and maturity of the daughter while reinforcing communication and support within the dyad was a prominent theme throughout the interviews. CONCLUSIONS There is interest among some high-risk adolescents and young adults to engage in genetic counseling and undergo testing. Providing pretest and posttest genetic counseling, assessing preferences for parent involvement, and offering psychosocial support may be important if genetic testing for HBOC is offered to adolescents and young adults before age 25 years.
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Affiliation(s)
- Catherine Jennings
- Vagelos College of Physicians & Surgeons, Columbia University Irving Medical Center, New York, NY
| | - Julia Wynn
- Department of Pediatrics, Columbia University Irving Medical Center, New York, NY; Genetic Counseling Graduate Program, Vagelos College of Physicians & Surgeons, Columbia University Irving Medical Center, New York, NY
| | - Cecilia Miguel
- Genetic Counseling Graduate Program, Vagelos College of Physicians & Surgeons, Columbia University Irving Medical Center, New York, NY
| | - Elana Levinson
- Genetic Counseling Graduate Program, Vagelos College of Physicians & Surgeons, Columbia University Irving Medical Center, New York, NY; Department of Medicine, Columbia University Irving Medical Center, New York, NY
| | - Michelle E Florido
- Genetic Counseling Graduate Program, Vagelos College of Physicians & Surgeons, Columbia University Irving Medical Center, New York, NY; Department of Genetics and Development, Vagelos College of Physicians and Surgeons, Columbia University Irving Medical Center, New York, NY
| | - Melissa White
- Department of Epidemiology, Columbia University Irving Medical Center, New York, NY
| | - Colleen Burke Sands
- Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Lisa A Schwartz
- Division of Oncology, Children's Hospital of Philadelphia, Philadelphia, PA; Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Mary Daly
- Department of Clinical Genetics, Fox Chase Cancer Center, Philadelphia, PA
| | - Karen O'Toole
- Department of Medicine, University of Utah School of Medicine, Salt Lake City, UT
| | - Saundra S Buys
- Department of Medicine, University of Utah School of Medicine, Salt Lake City, UT
| | - Gordon Glendon
- Lunenfeld-Tanenbaum Research Institute, Sinai Health System, Toronto, Ontario, Canada
| | - Danielle Hanna
- Lunenfeld-Tanenbaum Research Institute, Sinai Health System, Toronto, Ontario, Canada
| | - Irene L Andrulis
- Lunenfeld-Tanenbaum Research Institute, Sinai Health System, Toronto, Ontario, Canada; Department of Molecular Genetics, University of Toronto, Toronto, Ontario, Canada
| | - Mary Beth Terry
- Department of Epidemiology, Columbia University Irving Medical Center, New York, NY
| | - Wendy K Chung
- Vagelos College of Physicians & Surgeons, Columbia University Irving Medical Center, New York, NY; Department of Pediatrics, Columbia University Irving Medical Center, New York, NY; Department of Medicine, Columbia University Irving Medical Center, New York, NY.
| | - Angela Bradbury
- Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
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Torkington J, Harries R, O'Connell S, Knight L, Islam S, Bashir N, Watkins A, Fegan G, Cornish J, Rees B, Cole H, Jarvis H, Jones S, Russell I, Bosanquet D, Cleves A, Sewell B, Farr A, Zbrzyzna N, Fiera N, Ellis-Owen R, Hilton Z, Parry C, Bradbury A, Wall P, Hill J, Winter D, Cocks K, Harris D, Hilton J, Vakis S, Hanratty D, Rajagopal R, Akbar F, Ben-Sassi A, Francis N, Jones L, Williamson M, Lindsey I, West R, Smart C, Ziprin P, Agarwal T, Faulkner G, Pinkney T, Vimalachandran D, Lawes D, Faiz O, Nisar P, Smart N, Wilson T, Myers A, Lund J, Smolarek S, Acheson A, Horwood J, Ansell J, Phillips S, Davies M, Davies L, Bird S, Palmer N, Williams M, Galanopoulos G, Rao PD, Jones D, Barnett R, Tate S, Wheat J, Patel N, Rahmani S, Toynton E, Smith L, Reeves N, Kealaher E, Williams G, Sekaran C, Evans M, Beynon J, Egan R, Qasem E, Khot U, Ather S, Mummigati P, Taylor G, Williamson J, Lim J, Powell A, Nageswaran H, Williams A, Padmanabhan J, Phillips K, Ford T, Edwards J, Varney N, Hicks L, Greenway C, Chesters K, Jones H, Blake P, Brown C, Roche L, Jones D, Feeney M, Shah P, Rutter C, McGrath C, Curtis N, Pippard L, Perry J, Allison J, Ockrim J, Dalton R, Allison A, Rendell J, Howard L, Beesley K, Dennison G, Burton J, Bowen G, Duberley S, Richards L, Giles J, Katebe J, Dalton S, Wood J, Courtney E, Hompes R, Poole A, Ward S, Wilkinson L, Hardstaff L, Bogden M, Al-Rashedy M, Fensom C, Lunt N, McCurrie M, Peacock R, Malik K, Burns H, Townley B, Hill P, Sadat M, Khan U, Wignall C, Murati D, Dhanaratne M, Quaid S, Gurram S, Smith D, Harris P, Pollard J, DiBenedetto G, Chadwick J, Hull R, Bach S, Morton D, Hollier K, Hardy V, Ghods M, Tyrrell D, Ashraf S, Glasbey J, Ashraf M, Garner S, Whitehouse A, Yeung D, Mohamed SN, Wilkin R, Suggett N, Lee C, Bagul A, McNeill C, Eardley N, Mahapatra R, Gabriel C, Datt P, Mahmud S, Daniels I, McDermott F, Nodolsk M, Park L, Scott H, Trickett J, Bearn P, Trivedi P, Frost V, Gray C, Croft M, Beral D, Osborne J, Pugh R, Herdman G, George R, Howell AM, Al-Shahaby S, Narendrakumar B, Mohsen Y, Ijaz S, Nasseri M, Herrod P, Brear T, Reilly JJ, Sohal A, Otieno C, Lai W, Coleman M, Platt E, Patrick A, Pitman C, Balasubramanya S, Dickson E, Warman R, Newton C, Tani S, Simpson J, Banerjee A, Siddika A, Campion D, Humes D, Randhawa N, Saunders J, Bharathan B, Hay O. Incisional hernia following colorectal cancer surgery according to suture technique: Hughes Abdominal Repair Randomized Trial (HART). Br J Surg 2022; 109:943-950. [PMID: 35979802 PMCID: PMC10364691 DOI: 10.1093/bjs/znac198] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Revised: 05/09/2022] [Accepted: 05/13/2022] [Indexed: 11/14/2022]
Abstract
BACKGROUND Incisional hernias cause morbidity and may require further surgery. HART (Hughes Abdominal Repair Trial) assessed the effect of an alternative suture method on the incidence of incisional hernia following colorectal cancer surgery. METHODS A pragmatic multicentre single-blind RCT allocated patients undergoing midline incision for colorectal cancer to either Hughes closure (double far-near-near-far sutures of 1 nylon suture at 2-cm intervals along the fascia combined with conventional mass closure) or the surgeon's standard closure. The primary outcome was the incidence of incisional hernia at 1 year assessed by clinical examination. An intention-to-treat analysis was performed. RESULTS Between August 2014 and February 2018, 802 patients were randomized to either Hughes closure (401) or the standard mass closure group (401). At 1 year after surgery, 672 patients (83.7 per cent) were included in the primary outcome analysis; 50 of 339 patients (14.8 per cent) in the Hughes group and 57 of 333 (17.1 per cent) in the standard closure group had incisional hernia (OR 0.84, 95 per cent c.i. 0.55 to 1.27; P = 0.402). At 2 years, 78 patients (28.7 per cent) in the Hughes repair group and 84 (31.8 per cent) in the standard closure group had incisional hernia (OR 0.86, 0.59 to 1.25; P = 0.429). Adverse events were similar in the two groups, apart from the rate of surgical-site infection, which was higher in the Hughes group (13.2 versus 7.7 per cent; OR 1.82, 1.14 to 2.91; P = 0.011). CONCLUSION The incidence of incisional hernia after colorectal cancer surgery is high. There was no statistical difference in incidence between Hughes closure and mass closure at 1 or 2 years. REGISTRATION NUMBER ISRCTN25616490 (http://www.controlled-trials.com).
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Houghton LC, Wei Y, Wang T, Goldberg M, Paniagua-Avila A, Sweeden RL, Bradbury A, Daly M, Schwartz LA, Keegan T, John EM, Knight JA, Andrulis IL, Buys SS, Frost CJ, O’Toole K, White ML, Chung WK, Terry MB. Body mass index rebound and pubertal timing in girls with and without a family history of breast cancer: the LEGACY girls study. Int J Epidemiol 2022; 51:1546-1555. [PMID: 35157067 PMCID: PMC9799198 DOI: 10.1093/ije/dyac021] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Accepted: 02/02/2022] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND Heavier body mass index (BMI) is the most established predictor of earlier age at puberty. However, it is unknown whether the timing of the childhood switch to heavier BMI (age at BMI rebound) also matters for puberty. METHODS In the LEGACY Girls Study (n = 1040), a longitudinal cohort enriched with girls with a family history of breast cancer, we collected paediatric growth chart data from 852 girls and assessed pubertal development every 6 months. Using constrained splines, we interpolated individual growth curves and then predicted BMI at ages 2, 4, 6, 8 and 9 years for 591 girls. We defined age at BMI rebound as the age at the lowest BMI between ages 2 and 8 years and assessed its association with onset of thelarche, pubarche and menarche using Weibull survival models. RESULTS The median age at BMI rebound was 5.3 years (interquartile range: 3.6-6.7 years). A 1-year increase in age at BMI rebound was associated with delayed thelarche (HR = 0.90; 95% CI = 0.83-0.97) and menarche (HR = 0.86; 95% CI = 0.79-0.94). The magnitude of these associations remained after adjusting for weight between birth and 2 years, was stronger after adjusting for BMI at age 9, and was stronger in a subset of girls with clinically assessed breast development. CONCLUSIONS Earlier BMI rebound is associated with earlier pubertal timing. Our observation that BMI rebound may be a driver of pubertal timing in girls with and without a family history of breast cancer provides insight into how growth and pubertal timing are associated with breast cancer risk.
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Affiliation(s)
- Lauren C Houghton
- Corresponding author. Department of Epidemiology, Mailman School of Public Health, 722 West 168th Street, Room 706, New York, NY 10032, USA. E-mail:
| | - Ying Wei
- Department of Biostatistics, Columbia University Mailman School of Public Health, New York, NY, USA
| | - Tianying Wang
- Department of Biostatistics, Columbia University Mailman School of Public Health, New York, NY, USA
| | - Mandy Goldberg
- Department of Epidemiology, Columbia University Mailman School of Public Health, New York, NY, USA
| | - Alejandra Paniagua-Avila
- Department of Epidemiology, Columbia University Mailman School of Public Health, New York, NY, USA
| | - Rachel L Sweeden
- Department of Epidemiology, Columbia University Mailman School of Public Health, New York, NY, USA
| | - Angela Bradbury
- Departments of Medicine and Hematology/Oncology and of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Mary Daly
- Department of Clinical Genetics, Fox Chase Cancer Center, Philadelphia, PA, USA
| | - Lisa A Schwartz
- Division of Oncology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Theresa Keegan
- Department of Internal Medicine, Center for Oncology Hematology Outcomes Research and Training (COHORT), University of California, Davis, Sacramento, CA, USA
| | - Esther M John
- Departments of Epidemiology & Population Health and Medicine, Stanford University School of Medicine, Stanford, CA, USA
- Stanford Cancer Institute, Stanford University School of Medicine, Stanford, CA, USA
| | - Julia A Knight
- Stanford Cancer Institute, Stanford University School of Medicine, Stanford, CA, USA
- Lunenfeld-Tanenbaum Research Institute, Sinai Health System, Toronto, ON, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Irene L Andrulis
- Stanford Cancer Institute, Stanford University School of Medicine, Stanford, CA, USA
- Lunenfeld-Tanenbaum Research Institute, Sinai Health System, Toronto, ON, Canada
- Departments of Molecular Genetics and Laboratory Medicine and Pathobiology, University of Toronto, Toronto, ON, Canada
| | - Saundra S Buys
- Department of Medicine, Huntsman Cancer Institute, University of Utah Health, Salt Lake City, UT, USA
| | - Caren J Frost
- College of Social Work, University of Utah, Salt Lake City, UT, USA
| | - Karen O’Toole
- Department of Medicine, Huntsman Cancer Institute, University of Utah Health, Salt Lake City, UT, USA
| | - Melissa L White
- Department of Epidemiology, Columbia University Mailman School of Public Health, New York, NY, USA
| | - Wendy K Chung
- Departments of Pediatrics and Medicine, Columbia University Irving Medical Center, New York, NY, USA
| | - Mary Beth Terry
- Department of Epidemiology, Columbia University Mailman School of Public Health, New York, NY, USA
- Herbert Irving Comprehensive Cancer Center, Columbia University Irving Medical Center, New York, NY, USA
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Bayne L, Nivar I, Goodspeed B, Deluca S, Wileyto EP, Shih N, Nayak A, Feldman MD, Edwards J, Fox K, Matro JM, Domchek S, Knollman H, Jankowitz R, Bradbury A, Shah PD, Graves J, Woodfield G, Chislock E, Wang J, Belka G, Chodosh LA, Clark AS, DeMichele A. Abstract PD9-11: Identifying breast cancer survivors with dormant disseminated tumor cells: The PENN-SURMOUNT screening study. Cancer Res 2021. [DOI: 10.1158/1538-7445.sabcs20-pd9-11] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
Background: Patients (pts) treated for early stage breast cancer have a 30% lifetime risk of developing incurable, distant metastatic disease. Current models suggest that this occurs through escape of cells from the primary tumor into the circulation and subsequent sequestration of “disseminated tumor cells” (DTCs), in the bone marrow and other sequestration sites, where they enter dormancy. DTCs identified by immunohistochemistry (IHC) are associated with poor prognosis in longitudinal studies and meta-analyses, increasing odds of recurrence by approximately 2 to 5-fold. However, little is known about the test characteristics of the DTC-IHC assay, clinical DTC detection rates over time, and patient and disease risk factors that can identify pts harboring these cells.
Methods: The PENN-SURMOUNT Screening Study (NCT 02732171) is a prospective, longitudinal study examining bone marrow and blood biomarkers of recurrence among pts within 5 years of diagnosis who have completed therapy for primary breast cancer (with the exception of endocrine therapy). Pts with positive lymph nodes, triple negative receptors, ER-positivity with RS ≥ 25 and/or high-risk MammaPrint (MP), or residual disease after neoadjuvant chemotherapy were screened with bone marrow aspirate (BMA) for presence of DTCs. A positive DTC-IHC result is defined by the presence of at least one pancytokeratin-DAB positive cell utilizing the methods of Naume et al. Cytospin slides prepared from the BMA are independently reviewed by two pathologists with adjudication for the presence of DTCs; Pts who screen negative for DTCs are offered repeat screening annually. Pts who screen positive are referred to an interventional clinical trial (CLEVER, NCT 03032406).
Results: A total of 194 pts screened eligible for enrollment on PENN-SURMOUNT between 6/2016 and 3/2020. Of these, 158 consented and 151 underwent BMA with successful IHC analysis on 100%. Pts came from 22 U.S. states; ≥ 1/3 traveled over 50 miles to the study center. At baseline BMA, 36/151 (24%) had at least 1 measurable DTC by IHC. Patient characteristics and DTC distribution among subpopulations are shown in Table 1. Of the 78/115 who were initially DTC negative and continued to be eligible for repeat screening, as of 3/2020, 46 (59%) returned for at least one repeat BMA. 13/46 (28%) had at least 1 detectable DTC on 1 of up to 3 subsequent follow up assessments for a total DTC positivity rate of 32.5% (49/151). 48 (98%) DTC+ pts have subsequently enrolled on the CLEVER trial.
Conclusions: BMA assessment for DTCs is feasible in pts with high risk, early stage breast cancer. DTCs are detected in up to a third of breast cancer survivors with repeat assessment during the surveilance period. DTC positivity rates are relatively similar across all receptor subtypes, and after both neoadjuvant and adjuvant chemotherapy. Pts harboring DTCs are highly likely to enroll on interventional trials designed to reduce recurrence risk.
Table 1. Patient characteristics and distribution of % DTC positivity among subpopulationsDTC+ (N=49)DTC- (N=102)Total (N=151)DTC+ Rate (Overall: 32.5%)DEMOGRAPHICSMedian Age at BMA (yrs)51.9 (43.9-60.6*)50.5 (42.9-58.1)50.5 (43.8-58.8)N/ARaceCaucasian44 (89.8%)91 (89.2%)135 (89.4%)32.6%African American5 (10.2%)9 (8.8%)14 (9.3%)35.7%Other0 (0%)2 (2.0%)2 (1.3%)0%Menopausal StatusPre-15 (30.6%)34 (33.3%)49 (32.5%)30.6%Post-34 (69.4%)68 (66.7%)102 (67.5%)33.3%BMI at BMA (kg/m2)24.2 (21.9-28.9*)26.9 (23.4-31.4)26.1 (22.8-30.4)N/ARECEPTOR STATUSER/PR+ HER2neg (by ASCO/CAP)24 (49.0%)51 (50.0%)75 (49.7%)32.0%HER2+ (any ER/PR)9 (18.4%)12 (11.8%)21 (13.9%)42.9%ER/PRneg HER2neg23 (46.9%)48 (47.1%)71 (47.0%)32.4%RISK CRITERIALymph Node Positive24 (49.0%)65 (63.7%)89 (58.9%)27.0%Triple Negative (ER/PR<10%)27 (55.1%)50 (49.0%)77 (51.0%)35.0%Non-pCR11 (22.4%)25 (24.5%)36 (23.8%)30.6%RS ≥ 25 and/or High Risk MP6 (12.2%)8 (7.8%)14 (9.3%)42.9%Median T size (cm) -excluding NACT2.1 (1.5-2.9*)1.8 (1.3-2.8)1.8 (1.3-2.9)N/APRIOR THERAPYAdjuvant Chemo25 (51.0%)60 (58.8%)85 (56.3%)29.4%Neoadjuvant Chemo22 (44.9%)41 (40.2%)63 (41.7%)34.9%Endocrine Therapy19 (38.8%)47 (46.1%)66 (43.7%)28.8%XRT29 (59.2%)75 (73.5%)104 (69.3%^)27.9%*Ranges represent interquartile range^ XRT data not available on 1 patient; n=150 was used to figure percentage
Citation Format: Lauren Bayne, Isoris Nivar, Brooke Goodspeed, Shannon Deluca, E. Paul Wileyto, Natalie Shih, Anupma Nayak, Michael D Feldman, Joshua Edwards, Kevin Fox, Jennifer M. Matro, Susan Domchek, Hayley Knollman, Rachel Jankowitz, Angela Bradbury, Payal D. Shah, Jewell Graves, George Woodfield, Elizabeth Chislock, Jianping Wang, George Belka, Lewis A. Chodosh, Amy S. Clark, Angela DeMichele. Identifying breast cancer survivors with dormant disseminated tumor cells: The PENN-SURMOUNT screening study [abstract]. In: Proceedings of the 2020 San Antonio Breast Cancer Virtual Symposium; 2020 Dec 8-11; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2021;81(4 Suppl):Abstract nr PD9-11.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | - Kevin Fox
- University of Pennsylvania, Philadelphia, PA
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Le AN, Powers J, Zelley K, Bradbury A, Shah P, Freedman G, Nathanson K, Domchek SM, MacFarland SP, Maxwell KN. Abstract P4-12-33: Frequency of radiation-induced malignancies post-adjuvant radiotherapy for breast cancer in patients with Li-Fraumeni syndrome. Cancer Res 2020. [DOI: 10.1158/1538-7445.sabcs19-p4-12-33] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
Background. Women with Li-Fraumeni syndrome (LFS), a cancer predisposition syndrome caused by germline mutations in TP53, have an over 50% risk of developing breast cancer (BC) by age 70. Providers often avoid adjuvant radiotherapy to treat BC in LFS patients due to a reported high risk of radiation-induced malignancies of over 30%. We aimed to investigate the characteristics of LFS-associated BC and the risk of subsequent malignancy in BC patients with LFS following adjuvant radiotherapy.
Methods. A single institution retrospective chart review was conducted for female BC patients with a confirmed germline TP53 mutation. Statistical analyses were performed to compare the frequency of radiation-induced malignancies in LFS patients to non-LFS BC cases reported in the Penn Medicine Cancer Registry (PMCR) (n=6607 patients total, 3863 who received radiation).
Results. Among 95 patients with LFS, we identified 51 female BC patients with 74 primary BC diagnoses. Of 51 patients, 57% had a history of BC only, and 25% had BC as their presenting diagnosis of LFS. LFS-associated BCs were predominantly invasive ductal carcinoma (48%) and HER2+ (58%). We analyzed 20 LFS BC patients who underwent adjuvant radiotherapy with an average follow up of 11.1 (2-20) years. Of 18 patients who received radiation in a curative setting, one (6%) patient developed thyroid cancer and one (6%) patient developed sarcoma in the radiation field. The incidence of thyroid cancer did not significantly differ between LFS-associated and non-LFS BCs. The incidence of radiation-induced sarcoma in patients with LFS is significantly higher than in non-LFS BC patients (0.03%, p=0.01).
Conclusion. We found a 6% (one in 18 patients) risk of radiation-induced sarcoma in LFS BC patients, lower than the previously reported rate of 33%. Adjuvant radiotherapy should be considered in LFS BC patients when the potential risk for locoregional recurrence (LRR) or the mortality benefit to radiation is greater than 6%.
Citation Format: Anh N Le, Jacquelyn Powers, Kristin Zelley, Angela Bradbury, Payal Shah, Gary Freedman, Katherine Nathanson, Susan M Domchek, Suzanne P MacFarland, Kara N Maxwell. Frequency of radiation-induced malignancies post-adjuvant radiotherapy for breast cancer in patients with Li-Fraumeni syndrome [abstract]. In: Proceedings of the 2019 San Antonio Breast Cancer Symposium; 2019 Dec 10-14; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2020;80(4 Suppl):Abstract nr P4-12-33.
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Affiliation(s)
- Anh N Le
- 1University of Pennsylvania, Philadelphia, PA
| | | | | | | | - Payal Shah
- 1University of Pennsylvania, Philadelphia, PA
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Upshaw JN, Finkelman B, Hubbard RA, Smith AM, Narayan HK, Arndt L, Domchek S, DeMichele A, Fox K, Shah P, Clark A, Bradbury A, Matro J, Adusumalli S, Carver JR, Ky B. Comprehensive Assessment of Changes in Left Ventricular Diastolic Function With Contemporary Breast Cancer Therapy. JACC Cardiovasc Imaging 2020; 13:198-210. [PMID: 31542526 PMCID: PMC7236624 DOI: 10.1016/j.jcmg.2019.07.018] [Citation(s) in RCA: 67] [Impact Index Per Article: 16.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2018] [Revised: 06/20/2019] [Accepted: 07/08/2019] [Indexed: 01/21/2023]
Abstract
OBJECTIVES This study determined the effects of doxorubicin and/or trastuzumab on diastolic function and the relationship between diastolic function and systolic dysfunction. BACKGROUND Doxorubicin and trastuzumab can result in left ventricular ejection fraction (LVEF) declines. However, the effects of these therapies on diastolic function remain incompletely defined. METHODS In a rigorously phenotyped, longitudinal cohort study of 362 breast cancer participants treated with doxorubicin, doxorubicin followed by trastuzumab, or trastuzumab alone, changes in diastolic function were evaluated using linear models estimated via generalized estimating equations. Associations between baseline and changes in diastolic function with LVEF and longitudinal strain were also determined using generalized estimating equations. The Kaplan-Meier estimator derived the proportion of participants who experienced incident diastolic dysfunction. Cox proportional hazards models estimated the associations between participant characteristics and diastolic dysfunction risk, and between diastolic function and cancer therapy-related cardiac dysfunction risk, defined by an LVEF decline of ≥10% to <50%. RESULTS Over a median of 2.1 years (interquartile range [IQR]: 1.3 to 4.2 years), participants treated with doxorubicin or doxorubicin followed by trastuzumab demonstrated a persistent worsening in diastolic function, with reductions in the E/A ratio, lateral and septal e' velocities, and increases in E/e' (p < 0.01). These changes were not observed with trastuzumab alone. Incident abnormal diastolic function grade occurred in 60% at 1 year, 70% by 2 years, and 80% by 3 years. Abnormal diastolic function grade was associated with a subsequent decrease in LVEF (-2.1%; 95% confidence intervals [CI]: -3.1 to -1.2; p < 0.001) and worsening in longitudinal strain (0.6%; 95% CI: 0.1 to 1.1; p = 0.013) over time. Changes in E/e' ratio were modestly associated with worsening longitudinal strain (0.1%; 95% CI: 0.0 to 0.2; p = 0.022). CONCLUSIONS A modest, persistent worsening of diastolic function is observed with contemporary breast cancer therapy. Abnormal and worsening diastolic dysfunction is associated with a small risk of subsequent systolic dysfunction. (Cardiotoxicity of Cancer Therapy [CCT]; NCT01173341).
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Affiliation(s)
- Jenica N Upshaw
- Department of Medicine, Division of Cardiology, Tufts Medical Center, Medford, Massachusetts
| | - Brian Finkelman
- Department of Pathology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Rebecca A Hubbard
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Amanda M Smith
- Department of Medicine, Division of Cardiology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Hari K Narayan
- Department of Pediatrics, Division of Cardiology, Rady Children's Hospital San Diego, The University of California San Diego, San Diego, California
| | - Linzi Arndt
- Department of Medicine, Division of Cardiology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Susan Domchek
- Abramson Cancer Center, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Angela DeMichele
- Abramson Cancer Center, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Kevin Fox
- Abramson Cancer Center, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Payal Shah
- Abramson Cancer Center, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Amy Clark
- Abramson Cancer Center, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Angela Bradbury
- Abramson Cancer Center, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jennifer Matro
- Abramson Cancer Center, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Srinath Adusumalli
- Department of Medicine, Division of Cardiology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Joseph R Carver
- Department of Medicine, Division of Cardiology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; Abramson Cancer Center, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Bonnie Ky
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; Department of Medicine, Division of Cardiology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; Abramson Cancer Center, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania.
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9
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Langlois CM, Bradbury A, Wood EM, Roberts JS, Kim SYH, Riviere ME, Liu F, Reiman EM, Tariot PN, Karlawish J, Langbaum JB. Alzheimer's Prevention Initiative Generation Program: Development of an APOE genetic counseling and disclosure process in the context of clinical trials. Alzheimers Dement (N Y) 2019; 5:705-716. [PMID: 31921963 PMCID: PMC6944715 DOI: 10.1016/j.trci.2019.09.013] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Introduction As the number of Alzheimer's disease (AD) prevention studies grows, many individuals will need to learn their genetic and/or biomarker risk for the disease to determine trial eligibility. An alternative to traditional models of genetic counseling and disclosure is needed to provide comprehensive standardized counseling and disclosure of apolipoprotein E (APOE) results efficiently, safely, and effectively in the context of AD prevention trials. Methods A multidisciplinary Genetic Testing, Counseling, and Disclosure Committee was established and charged with operationalizing the Alzheimer's Prevention Initiative (API) Genetic Counseling and Disclosure Process for use in the API Generation Program trials. The objective was to provide consistent information to research participants before and during the APOE counseling and disclosure session using standardized educational and session materials. Results The Genetic Testing, Counseling, and Disclosure Committee created a process consisting of eight components: requirements of APOE testing and reports, psychological readiness assessment, determination of AD risk estimates, guidance for identifying providers of disclosure, predisclosure education, APOE counseling and disclosure session materials, APOE counseling and disclosure session flow, and assessing APOE disclosure impact. Discussion The API Genetic Counseling and Disclosure Process provides a framework for large-scale disclosure of APOE genotype results to study participants and serves as a model for disclosure of biomarker results. The process provides education to participants about the meaning and implication(s) of their APOE results while also incorporating a comprehensive assessment of disclosure impact. Data assessing participant safety and psychological well-being before and after APOE disclosure are still being collected and will be presented in a future publication. Participants may need to learn their risk for Alzheimer's disease to enroll in studies. Alternatives to traditional models of apolipoprotein E counseling and disclosure are needed. An alternative process was developed by the Alzheimer's Prevention Initiative. This process has been implemented by the Alzheimer's Prevention Initiative Generation Program.
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Affiliation(s)
| | - Angela Bradbury
- Department of Medical Ethics and Health Policy, University of Pennsylvania, Philadelphia, PA, USA
| | - Elisabeth M Wood
- Department of Medical Ethics and Health Policy, University of Pennsylvania, Philadelphia, PA, USA
| | - J Scott Roberts
- Department of Health Behavior and Health Education, University of Michigan School of Public Health, Ann Arbor, MI, USA
| | | | | | - Fonda Liu
- Novartis Pharmaceuticals Corporation, East Hanover, NJ, USA
| | - Eric M Reiman
- Banner Alzheimer's Institute, Phoenix, AZ, USA.,Neurodegenerative Disease Research Center, Arizona State University, Tempe, AZ, USA.,Department of Psychiatry, University of Arizona School of Medicine - Phoenix, Phoenix, AZ, USA.,Department of Psychiatry, University of Arizona, Tucson, AZ, USA.,Neurogenomics Division, Translational Genomics Research Institute, Phoenix, AZ, USA.,Arizona Alzheimer's Consortium, Phoenix, AZ, USA
| | | | - Jason Karlawish
- Departments of Medicine, Medical Ethics and Health Policy, and Neurology, University of Pennsylvania, Philadelphia, PA, USA
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Clark DF, Maxwell KN, Powers J, Lieberman DB, Ebrahimzadeh J, Long JM, McKenna D, Shah P, Bradbury A, Morrissette JJD, Nathanson KL, Domchek SM. Identification and Confirmation of Potentially Actionable Germline Mutations in Tumor-Only Genomic Sequencing. JCO Precis Oncol 2019; 3. [PMID: 31511844 DOI: 10.1200/po.19.00076] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
PURPOSE Tumor-only genomic profiling (TGP) is increasingly advocated for all patients with cancer given the possible therapeutic implications. It is critical to develop clinical algorithms to identify and address potentially actionable germline findings identified by TGP. METHODS A multidisciplinary team analyzed publicly available data for genes in which mutations are implicated in germline cancer susceptibility and established a pipeline to automate clinical referral for evaluation of TGP findings. RESULTS A total of 2,308 patients underwent TGP, with 81 patients (3.5%) identified by the automatic referral pipeline; 37 patients (1.6%) were referred outside the pipeline based on concerns by the molecular geneticist, pathologist, or oncologist regarding genotype-phenotype correlation. Thirty-one patients (38%) and 17 patients (46%) underwent germline testing from the automatic pipeline and other referrals, respectively, and of these patients, 23 (72%) and four (24%) had confirmed germline pathogenic variants (GPVs), respectively. The majority of confirmed GPVs were in automatic referral genes, with BRCA2 being most common (confirmed GPVs in 11 [85%] of 13 patients tested), followed by PALB2 (five [67%] of six patients), BRCA1 (two [40%] of five patients), MSH6 (two of three patients), and MLH1 (two of two patients). Forty-eight percent of confirmed GPVs were found in tumors known to be associated with germline mutations in the gene. Germline testing was not performed in 50 (62%) of 81 patients identified by automatic referral as a result of poor patient health or death (30%), lack of follow-up (30%), and patient refusal (30%). CONCLUSION Of patients undergoing TGP, 5% had somatic findings triggering referral, and implementation of an automatic referral pipeline based solely on gene versus other clinical or molecular features resulted in a 74% germline confirmation. However, only 41% of referred patients underwent germline testing. Systems-based approaches are needed to identify carriers of actionable germline cancer susceptibility mutations identified by TGP.
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Affiliation(s)
- Dana Farengo Clark
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA.,Basser Center for BRCA, Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA
| | - Kara N Maxwell
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA.,Basser Center for BRCA, Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA
| | - Jacquelyn Powers
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA.,Basser Center for BRCA, Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA
| | - David B Lieberman
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Jessica Ebrahimzadeh
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA.,Basser Center for BRCA, Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA
| | - Jessica M Long
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA.,Basser Center for BRCA, Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA
| | - Danielle McKenna
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA.,Basser Center for BRCA, Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA
| | - Payal Shah
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA.,Basser Center for BRCA, Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA
| | - Angela Bradbury
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA.,Basser Center for BRCA, Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA
| | | | - Katherine L Nathanson
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA.,Basser Center for BRCA, Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA
| | - Susan M Domchek
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA.,Basser Center for BRCA, Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA
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Langbaum JB, Karlawish J, Roberts JS, Wood EM, Bradbury A, High N, Walsh TL, Gordon D, Aggarwal R, Davis P, Stowell C, Trisko L, Langlois CM, Reiman EM, Tariot PN. GeneMatch: A novel recruitment registry using at-home APOE genotyping to enhance referrals to Alzheimer's prevention studies. Alzheimers Dement 2019; 15:515-524. [PMID: 30772251 PMCID: PMC6461487 DOI: 10.1016/j.jalz.2018.12.007] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [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: 09/06/2018] [Revised: 11/16/2018] [Accepted: 12/11/2018] [Indexed: 11/17/2022]
Abstract
INTRODUCTION Recruitment for Alzheimer's disease (AD) prevention research studies is challenging because of lack of awareness among cognitively healthy adults coupled with the high screen fail rate due to participants not having a genetic risk factor or biomarker evidence of the disease. Participant recruitment registries offer one solution for efficiently and effectively identifying, characterizing, and connecting potential eligible volunteers to studies. METHODS Individuals aged 55-75 years who live in the United States and self-report not having a diagnosis of cognitive impairment such as MCI or dementia are eligible to join GeneMatch. Participants enroll online and are provided a cheek swab kit for DNA extraction and apolipoprotein E (APOE) genotyping. Participants are not told their APOE results, although the results may be used in part to help match participants to AD prevention studies. RESULTS As of August 2018, 75,351 participants had joined GeneMatch. Nearly 30% of participants have one APOE4 allele, and approximately 3% have two APOE4 alleles. The percentages of APOE4 heterozygotes and homozygotes are inversely associated with age (P < .001). DISCUSSION GeneMatch, the first trial-independent research enrollment program designed to recruit and refer cognitively healthy adults to AD prevention studies based in part on APOE test results, provides a novel mechanism to accelerate prescreening and enrollment for AD prevention trials.
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Affiliation(s)
| | - Jason Karlawish
- Department of Medical Ethics and Health Policy, University of Pennsylvania, Philadelphia, PA, USA
| | - J Scott Roberts
- Department of Health Behavior & Health Education, University of Michigan School of Public Health, Ann Arbor, MI, USA
| | - Elisabeth M Wood
- Department of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Angela Bradbury
- Department of Medical Ethics and Health Policy, University of Pennsylvania, Philadelphia, PA, USA; Department of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Nellie High
- Banner Alzheimer's Institute, Phoenix, AZ, USA
| | | | | | | | | | | | | | | | - Eric M Reiman
- Banner Alzheimer's Institute, Phoenix, AZ, USA; Neurodegenerative Disease Research Center, Arizona State University, Tempe, AZ, USA; Department of Psychiatry, University of Arizona, Tucson, AZ, USA; Neurogenomics Division, Translational Genomics Research Institute, Phoenix, AZ, USA; Arizona Alzheimer's Consortium, Phoenix, AZ, USA
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Upshaw J, Finkelman B, Hubbard R, Smith A, Narayan H, Arndt L, Domchek S, DeMichele A, Fox K, Shah P, Clark A, Bradbury A, Matro J, Adusumalli S, Carver J, Ky B. CHANGES IN LEFT VENTRICULAR DIASTOLIC FUNCTION WITH CONTEMPORARY BREAST CANCER THERAPY. J Am Coll Cardiol 2019. [DOI: 10.1016/s0735-1097(19)32282-x] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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13
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Epstein DM, Gohel MS, Heatley F, Liu X, Bradbury A, Bulbulia R, Cullum N, Nyamekye I, Poskitt KR, Renton S, Warwick J, Davies AH. Cost-effectiveness analysis of a randomized clinical trial of early versus deferred endovenous ablation of superficial venous reflux in patients with venous ulceration. Br J Surg 2019; 106:555-562. [PMID: 30741425 DOI: 10.1002/bjs.11082] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [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: 09/20/2018] [Revised: 11/05/2018] [Accepted: 11/16/2018] [Indexed: 11/07/2022]
Abstract
BACKGROUND Treatment of superficial venous reflux in addition to compression therapy accelerates venous leg ulcer healing and reduces ulcer recurrence. The aim of this study was to evaluate the costs and cost-effectiveness of early versus delayed endovenous treatment of patients with venous leg ulcers. METHODS This was a within-trial cost-utility analysis with a 1-year time horizon using data from the EVRA (Early Venous Reflux Ablation) trial. The study compared early versus deferred endovenous ablation for superficial venous truncal reflux in patients with a venous leg ulcer. The outcome measure was the cost per quality-adjusted life-year (QALY) over 1 year. Sensitivity analyses were conducted with alternative methods of handling missing data, alternative preference weights for health-related quality of life, and per protocol. RESULTS After early intervention, the mean(s.e.m.) cost was higher (difference in cost per patient £163(318) (€184(358))) and early intervention was associated with more QALYs at 1 year (mean(s.e.m.) difference 0·041(0·017)). The incremental cost-effectiveness ratio (ICER) was £3976 (€4482) per QALY. There was an 89 per cent probability that early venous intervention is cost-effective at a threshold of £20 000 (€22 546)/QALY. Sensitivity analyses produced similar results, confirming that early treatment of superficial reflux is highly likely to be cost-effective. CONCLUSION Early treatment of superficial reflux is highly likely to be cost-effective in patients with venous leg ulcers over 1 year. Registration number: ISRCTN02335796 (http://www.isrctn.com).
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Affiliation(s)
- D M Epstein
- Department of Applied Economics, University of Granada, Granada, Spain
| | - M S Gohel
- Department of Vascular Surgery, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - F Heatley
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - X Liu
- Imperial Clinical Trials Unit, Imperial College London, London, UK
| | - A Bradbury
- Department of Vascular Surgery, Institute of Cardiovascular Sciences, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - R Bulbulia
- Cheltenham Vascular Unit, Gloucestershire Hospitals NHS Foundation Trust, Cheltenham, UK
- Medical Research Council Population Health Research Unit, University of Oxford, Oxford, UK
- Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - N Cullum
- School of Health Sciences, University of Manchester, Manchester, UK
| | - I Nyamekye
- Department of Vascular Surgery, Worcestershire Acute Hospitals NHS Trust, Worcester, UK
| | - K R Poskitt
- Cheltenham Vascular Unit, Gloucestershire Hospitals NHS Foundation Trust, Cheltenham, UK
| | - S Renton
- Northwick Park Hospital, North West London Hospitals NHS Trust, London, UK
| | - J Warwick
- Department of Surgery and Cancer, Imperial College London, London, UK
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Warwick, UK
| | - A H Davies
- Department of Surgery and Cancer, Imperial College London, London, UK
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Cohen SA, Bradbury A, Henderson V, Hoskins K, Bednar E, Arun BK. Genetic Counseling and Testing in a Community Setting: Quality, Access, and Efficiency. Am Soc Clin Oncol Educ Book 2019; 39:e34-e44. [PMID: 31099680 DOI: 10.1200/edbk_238937] [Citation(s) in RCA: 50] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
There is an increasing need for genetic counseling and testing for individuals diagnosed with cancer, as treatment may be affected by the results. In addition, the identification of individuals before a diagnosis of cancer allows for optimal surveillance and early detection and prevention of cancer. With the recognition that as much as 10% of all cancers are hereditary, there is a growing need to improve access to genetic counseling and genetic testing, both before and at the time of diagnosis. This article focuses on models of identifying at-risk patients, including underserved communities; providing genetic counseling and testing in community practices; using telehealth; and collaborating with nongenetics health care providers and technological solutions to maximize efficiency and access.
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Affiliation(s)
- Stephanie A Cohen
- 1 Cancer Genetics Risk Assessment Program, Ascension St. Vincent, Indianapolis, IN
| | - Angela Bradbury
- 2 Department of Medicine, Division of Hematology-Oncology, Department of Medical Ethics and Health Policy, University of Pennsylvania, Philadelphia, PA
| | | | - Kent Hoskins
- 3 The University of Illinois at Chicago, Chicago, IL
| | - Erica Bednar
- 4 The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Banu K Arun
- 4 The University of Texas MD Anderson Cancer Center, Houston, TX
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Schwartz LA, Henry-Moss D, Egleston B, Patrick-Miller L, Markman E, Daly M, Tuchman L, Moore C, Rauch PK, Karpink K, Sands CB, Domchek SM, Bradbury A. Preventative Health and Risk Behaviors Among Adolescent Girls With and Without Family Histories of Breast Cancer. J Adolesc Health 2019; 64:116-123. [PMID: 30301677 PMCID: PMC7597848 DOI: 10.1016/j.jadohealth.2018.07.011] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2017] [Revised: 06/02/2018] [Accepted: 07/12/2018] [Indexed: 11/22/2022]
Abstract
PURPOSE To compare health behaviors (smoking, alcohol use, fruit and vegetable intake, and exercise frequency) and breast self-exam (BSE) between girls with breast cancer family history (BCFH+) and without (BCFH-) and assess associates of behaviors across all girls. METHODS A total of 208 BCFH+ girls (11-19 years old), with first- or second-degree relatives with breast cancer or a mother with a BRCA1/2 mutation, and 112 BCFH- peers reported their health behaviors, beliefs, and psychosocial function. RESULTS Despite higher BCFH+ girls' greater perceived breast cancer risk, there were no differences between BCFH+ and BCFH- girls on diet, exercise, alcohol initiation, or BSE. BCFH+ girls were slightly more likely to report trying cigarettes (11% vs. 5%, p = .04). In multivariable models with all girls, categorical associations with behaviors included the following: developmental and demographic factors with smoking, alcohol, diet, and exercise; family breast cancer history and experience with smoking, alcohol, and diet; psychosocial factors with smoking; girls perceptions of cancer controllability and mother support for health behaviors with alcohol, diet, exercise, and BSE; and mother behaviors with diet. CONCLUSIONS Adolescent girls from BCFH+ families reported similar health behaviors to BCFH- peers, signaling that they are not translating their higher perceived risk into cancer control behaviors. Both uncontrollable (i.e., breast cancer experiences) and modifiable factors relate to health behaviors and warrant further investigation. Results indicate that interventions with teens and parents that target modifiable variables such as controllability perceptions, maternal modeling, and communication may relate to better health behaviors and reduced future breast cancer risk.
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Affiliation(s)
- Lisa A. Schwartz
- The Children’s Hospital of Philadelphia and the Perelman School of Medicine of the University of Pennsylvania, 3501 Civic Center Blvd, CTRB 10311, Philadelphia, PA19104;
| | - Dare Henry-Moss
- The Perelman School of Medicine of the University of Pennsylvania, 3400 Civic Center Blvd, PCAM 10, Philadelphia, PA 19104;
| | - Brian Egleston
- Fox Chase Cancer Center of Temple University Health, 333 Cottman Avenue, Philadelphia, PA 19111;
| | | | - Elisabeth Markman
- The Children’s Hospital of Philadelphia, 3501 Civic Center Blvd, CTRB 10311, Philadelphia, PA19104;
| | - Mary Daly
- Fox Chase Cancer Center of Temple University Health, 333 Cottman Avenue, Philadelphia, PA 19111;
| | - Lisa Tuchman
- Children’s National Medical Center, 111 Michigan Ave, NW, Washington, DC 20010;
| | - Cynthia Moore
- Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114;
| | - Paula K. Rauch
- Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114;
| | - Kelsey Karpink
- The Perelman School of Medicine of the University of Pennsylvania, 3400 Civic Center Blvd, PCAM 10, Philadelphia, PA;
| | - Colleen Burke Sands
- The Perelman School of Medicine of the University of Pennsylvania, 3400 Civic Center Blvd, PCAM 10, Philadelphia, PA;
| | - Susan M. Domchek
- The Basser Research Center for BRCA in the Abramson Cancer Center at the University of Pennsylvania, 3400 Civic Center Blvd, PCAM 3 SPE, Philadelphia, PA;
| | - Angela Bradbury
- The Perelman School of Medicine of the University of Pennsylvania, 3400 Civic Center Blvd, PCAM 10, Philadelphia, PA;
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Abstract
A 50 year old woman experienced an episode of vertigo and nystagmus about 10 minutes after receiving her first treatment with acupuncture for shoulder pain. The nystagmus was confirmed by several health professionals. She had no previous history of nystagmus, and the symptom was not associated with feelings of faintness. Her blood pressure was 90/50 at the onset of symptoms but returned to normal while the symptoms continued. She recovered spontaneously after about five hours. Nystagmus after acupuncture has not been unequivocally reported before, though dizziness associated with hypotension is common. In this case the association may be coincidental, or a focal neurological response to needling; if the latter, then it should be regarded as an unavoidable idiosyncratic reaction.
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Murray MF, Evans JP, Angrist M, Uhlmann WR, Lochner Doyle D, Fullerton SM, Ganiats TG, Hagenkord J, Imhof S, Rim SH, Ortmann L, Aziz N, Dotson WD, Matloff E, Young K, Kaphingst K, Bradbury A, Scott J, Wang C, Zauber A, Levine M, Korf B, Leonard DG, Wicklund C, Isham G, Khoury MJ. A Proposed Approach for Implementing Genomics-Based Screening Programs for Healthy Adults. NAM Perspect 2018. [DOI: 10.31478/201812a] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Joan Scott
- Health Resources and Services Administration
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DeMichele A, Soucier-Ernst DJ, Clark C, Shih N, Stavropoulos W, Maxwell KN, Feldman M, Lierbamen D, Morrissette JJD, Paul MR, Pan TC, Wang J, Belka GK, Chen Y, Yee S, Carpenter E, Fox K, Matro J, Clark A, Shah P, Domchek S, Bradbury A, Chodosh L. Abstract OT2-06-03: METAMORPH: METAstatic markers of recurrent tumor PHenotype for breast cancer. Cancer Res 2018. [DOI: 10.1158/1538-7445.sabcs17-ot2-06-03] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
Up to 30% of patients diagnosed with breast cancer will develop recurrent disease within their lifetime, and currently this form of the disease is incurable. There are unmet needs to better understand underlying metastatic biology, identify new therapeutic targets and develop better methods for monitoring changes in disease, both to monitor response and elucidate resistance mechanisms. To address these needs, the METAMORPH Study encompasses a comprehensive approach that combines serial molecular tissue profiling at the RNA and DNA level with circulating markers (DTCs, CTCs, plasma tumor DNA), and ongoing assessment of therapeutic response.
METAMORPH is a prospective cohort study of women with suspected or confirmed recurrent breast cancer and accessible tumor by standard clinical biopsy, who are enrolled at the University of Pennsylvania prior to starting a new therapy for recurrent metastatic disease. The aims of this trial are to (1) evaluate the mechanisms through which recurrent breast cancer are genetically distinct from the primary tumor, (2) evaluate the circulating tumor biomarker trajectory of recurrent disease, (3) elucidate “escape pathways” of progressing tumors that emerge during the selective pressure of therapy, and (4) explore clinical utility of tumor and blood testing. The study protocol integrates research aims into clinical care, including a standardized approach to disease assessment and biopsy, pathologic confirmation of histology and receptor subtype, panel-based CLIA-approved genomic profiling, collection of research specimens, and standardized reporting of results, which are returned to patients and physicians. Patients are followed for treatment and outcome, and serial samples are collected at progression. A companion protocol, COMET, provides education about genomic testing and assesses patient understanding and impact of results. To date, 155 patients have enrolled, 142 (92%) have been biopsied, 120 (77%) have had sufficient DNA for molecular profiling and 109 (70%) have had genomic panel testing. Accrual is ongoing, with an initial target of 300 patients. Multiple sites within the UPHS Health System are enrolling. Contact information: angela.demichele@uphs.upenn.edu.
Key words: Metastatic disease, tumor profiling.
Citation Format: DeMichele A, Soucier-Ernst DJ, Clark C, Shih N, Stavropoulos W, Maxwell KN, Feldman M, Lierbamen D, Morrissette JJD, Paul MR, Pan T-C, Wang J, Belka GK, Chen Y, Yee S, Carpenter E, Fox K, Matro J, Clark A, Shah P, Domchek S, Bradbury A, Chodosh L. METAMORPH: METAstatic markers of recurrent tumor PHenotype for breast cancer [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr OT2-06-03.
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Affiliation(s)
- A DeMichele
- University of Pennsylvania, Philadelphia, PA
| | | | - C Clark
- University of Pennsylvania, Philadelphia, PA
| | - N Shih
- University of Pennsylvania, Philadelphia, PA
| | | | - KN Maxwell
- University of Pennsylvania, Philadelphia, PA
| | - M Feldman
- University of Pennsylvania, Philadelphia, PA
| | - D Lierbamen
- University of Pennsylvania, Philadelphia, PA
| | | | - MR Paul
- University of Pennsylvania, Philadelphia, PA
| | - T-C Pan
- University of Pennsylvania, Philadelphia, PA
| | - J Wang
- University of Pennsylvania, Philadelphia, PA
| | - GK Belka
- University of Pennsylvania, Philadelphia, PA
| | - Y Chen
- University of Pennsylvania, Philadelphia, PA
| | - S Yee
- University of Pennsylvania, Philadelphia, PA
| | - E Carpenter
- University of Pennsylvania, Philadelphia, PA
| | - K Fox
- University of Pennsylvania, Philadelphia, PA
| | - J Matro
- University of Pennsylvania, Philadelphia, PA
| | - A Clark
- University of Pennsylvania, Philadelphia, PA
| | - P Shah
- University of Pennsylvania, Philadelphia, PA
| | - S Domchek
- University of Pennsylvania, Philadelphia, PA
| | - A Bradbury
- University of Pennsylvania, Philadelphia, PA
| | - L Chodosh
- University of Pennsylvania, Philadelphia, PA
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Finkelman BS, Putt M, Wang T, Wang L, Narayan H, Domchek S, DeMichele A, Fox K, Matro J, Shah P, Clark A, Bradbury A, Narayan V, Carver JR, Tang WHW, Ky B. Arginine-Nitric Oxide Metabolites and Cardiac Dysfunction in Patients With Breast Cancer. J Am Coll Cardiol 2017; 70:152-162. [PMID: 28683962 DOI: 10.1016/j.jacc.2017.05.019] [Citation(s) in RCA: 74] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2017] [Accepted: 05/11/2017] [Indexed: 12/24/2022]
Abstract
BACKGROUND Oxidative/nitrosative stress and endothelial dysfunction are hypothesized to be central to cancer therapeutics-related cardiac dysfunction (CTRCD). However, the relationship between circulating arginine-nitric oxide (NO) metabolites and CTRCD remains unstudied. OBJECTIVES This study sought to examine the relationship between arginine-NO metabolites and CTRCD in a prospective cohort of 170 breast cancer patients treated with doxorubicin with or without trastuzumab. METHODS Plasma levels of arginine, citrulline, ornithine, asymmetric dimethylarginine (ADMA), symmetric dimethylarginine (SDMA), and N-monomethylarginine (MMA) were quantified at baseline, 1 month, and 2 months after doxorubicin initiation. Determinants of baseline biomarker levels were identified using multivariable linear regression, and Cox regression defined the association between baseline levels and 1- or 2-month biomarker changes and CTRCD rate in 139 participants with quantitated echocardiograms at all time points. RESULTS Age, hypertension, body mass index, and African-American race were independently associated with ≥1 of baseline citrulline, ADMA, SDMA, and MMA levels. Decreases in arginine and citrulline and increases in ADMA were observed at 1 and 2 months (all p < 0.05). Overall, 32 participants experienced CTRCD over a maximum follow-up of 5.4 years. Hazard ratios for ADMA and MMA at 2 months were 3.33 (95% confidence interval [CI]: 1.12 to 9.96) and 2.70 (95% CI: 1.35 to 5.41), respectively, and 0.78 (95% CI: 0.64 to 0.97) for arginine at 1 month. CONCLUSIONS In breast cancer patients undergoing doxorubicin therapy, early alterations in arginine-NO metabolite levels occurred, and early biomarker changes were associated with a greater CTRCD rate. Our findings highlight the potential mechanistic and translational relevance of this pathway to CTRCD.
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Affiliation(s)
- Brian S Finkelman
- Department of Biostatistics and Epidemiology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Mary Putt
- Department of Biostatistics and Epidemiology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Teresa Wang
- Department of Medicine, Division of Cardiology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Le Wang
- Department of Biostatistics and Epidemiology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Hari Narayan
- Department of Pediatrics, Division of Cardiology, Rady Children's Hospital, University of California San Diego, San Diego, California
| | - Susan Domchek
- Department of Medicine, Division of Oncology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; Abramson Cancer Center, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Angela DeMichele
- Department of Biostatistics and Epidemiology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; Department of Medicine, Division of Oncology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; Abramson Cancer Center, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Kevin Fox
- Department of Medicine, Division of Oncology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; Abramson Cancer Center, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jennifer Matro
- Department of Medicine, Division of Oncology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; Abramson Cancer Center, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Payal Shah
- Department of Medicine, Division of Oncology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; Abramson Cancer Center, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Amy Clark
- Department of Medicine, Division of Oncology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; Abramson Cancer Center, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Angela Bradbury
- Department of Medicine, Division of Oncology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; Abramson Cancer Center, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Vivek Narayan
- Department of Medicine, Division of Oncology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; Abramson Cancer Center, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Joseph R Carver
- Department of Biostatistics and Epidemiology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; Abramson Cancer Center, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - W H Wilson Tang
- Division of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio
| | - Bonnie Ky
- Department of Biostatistics and Epidemiology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; Department of Medicine, Division of Cardiology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; Abramson Cancer Center, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania.
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20
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DeMichele AM, Clark AS, Holmes R, Volpe M, Medrano C, Troxel A, Fox K, Domchek S, Matro J, Bradbury A, Shih N, Feldman M, Hexner E, Bromberg J. Abstract P2-08-03: Targeting inflammatory pathways: A phase 2 trial of the JAK-inhibitor ruxolitinib in combination with exemestane for aromatase inhibitor-resistant, estrogen receptor-positive breast cancer. Cancer Res 2017. [DOI: 10.1158/1538-7445.sabcs16-p2-08-03] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
Background: In vitro mechanisms link IL-6 to poor outcome in breast cancer via inflammatory pathways, activated JAK/STAT tumor signaling and upregulation of aromatase, leading to an aggressive tumor phenotype. Epidemiological data from our group and others support these mechanisms in women with ER-positive (+) disease. We therefore hypothesized that the JAK inhibitor, ruxolitinib (RUX, INCB018424; Incyte), would enhance activity of exemestane (EXE) in women with ER+ breast cancer who relapsed after non-steroidal aromatase inhibitor therapy, particularly among carriers of a germ-line polymorphism in IL-6, conferring elevated levels of IL-6 in the tumor microenvironment.
Methods: The “JAKEE trial” is a phase II trial to determine the safety and efficacy of RUX + EXE in postmenopausal women with relapsed, ER+ advanced breast cancer. Eligible patients were required to have progressed on a non-steroidal AI and either measureable or bone-only disease. CRP, a putative biomarker of tumor microenvironment inflammation, was measured at baseline and serially during treatment. Using a Simon 2-stage design, we treated 15 patients with RUX at 25 mg BID and EXE at 25mg daily on a continuous 28-day schedule. First stage results were previously presented (AACR, 2014). Accrual proceeded to second stage after no patient met the pre-defined stopping rule of grade (G) 3/4 toxicity requiring discontinuation from the study within the first treatment cycle. Due to the substantial rate of anemia requiring dose reductions, however, RUX dose was reduced to 15 mg BID in second stage.
Results: A total of 25 patients were enrolled; 24/25 had progressed on AI in metastatic setting; 1 relapsed on adjuvant AI. RUX+EXE was well-tolerated overall, with only 2 G4 events (creatinine elevation, hepatic failure); both were due to disease progression. 16% had G3 fatigue, anemia or hypertension; 12% had G3 neutropenia or depression. Other lower grade toxicities in >20% included musculoskeletal pain, increased ALT, and headache. Overall, patients stayed on therapy for a median of 3 cycles (range 2 – 21). There were no CR or PR, but 6/25 (24%) had prolonged disease control (SD> 6 months). Median CRP at study entry was 6.4 (range 0.3-38.9), with 8/25 (32%) having CRP>10. Achieving SD>6 months was not associated with baseline CRP (CRP>10 in 32% with vs. 33% without SD>6 months, p(exact)=1.0). A novel pharmacodynamic assay to assess STAT3 phosphorylation in peripheral blood mononuclear cells after RUX exposure demonstrated differential effects in patients with response.
Conclusions: Targeting JAK/STAT signaling in AI-resistant breast cancer with RUX+EXE was safe and well-tolerated. 24% of patients had prolonged SD, but baseline CRP level did not predict response. Correlative studies to determine whether host and/or tumor biomarkers predict response to therapy, including germline IL-6 genotype, immune profiles, p-STAT3 and estradiol levels, are currently underway.
Citation Format: DeMichele AM, Clark AS, Holmes R, Volpe M, Medrano C, Troxel A, Fox K, Domchek S, Matro J, Bradbury A, Shih N, Feldman M, Hexner E, Bromberg J. Targeting inflammatory pathways: A phase 2 trial of the JAK-inhibitor ruxolitinib in combination with exemestane for aromatase inhibitor-resistant, estrogen receptor-positive breast cancer [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P2-08-03.
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Affiliation(s)
- AM DeMichele
- University of Pennsylvania, Philadelphia, PA; Memorial Sloan Kettering Cancer Center, New York, NY
| | - AS Clark
- University of Pennsylvania, Philadelphia, PA; Memorial Sloan Kettering Cancer Center, New York, NY
| | - R Holmes
- University of Pennsylvania, Philadelphia, PA; Memorial Sloan Kettering Cancer Center, New York, NY
| | - M Volpe
- University of Pennsylvania, Philadelphia, PA; Memorial Sloan Kettering Cancer Center, New York, NY
| | - C Medrano
- University of Pennsylvania, Philadelphia, PA; Memorial Sloan Kettering Cancer Center, New York, NY
| | - A Troxel
- University of Pennsylvania, Philadelphia, PA; Memorial Sloan Kettering Cancer Center, New York, NY
| | - K Fox
- University of Pennsylvania, Philadelphia, PA; Memorial Sloan Kettering Cancer Center, New York, NY
| | - S Domchek
- University of Pennsylvania, Philadelphia, PA; Memorial Sloan Kettering Cancer Center, New York, NY
| | - J Matro
- University of Pennsylvania, Philadelphia, PA; Memorial Sloan Kettering Cancer Center, New York, NY
| | - A Bradbury
- University of Pennsylvania, Philadelphia, PA; Memorial Sloan Kettering Cancer Center, New York, NY
| | - N Shih
- University of Pennsylvania, Philadelphia, PA; Memorial Sloan Kettering Cancer Center, New York, NY
| | - M Feldman
- University of Pennsylvania, Philadelphia, PA; Memorial Sloan Kettering Cancer Center, New York, NY
| | - E Hexner
- University of Pennsylvania, Philadelphia, PA; Memorial Sloan Kettering Cancer Center, New York, NY
| | - J Bromberg
- University of Pennsylvania, Philadelphia, PA; Memorial Sloan Kettering Cancer Center, New York, NY
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21
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Lilge L, Terry MB, Walter J, Pinnaduwage D, Glendon G, Hanna D, Tammemagi ML, Bradbury A, Buys S, Daly M, John EM, Knight JA, Andrulis IL. Non-invasive optical spectroscopic monitoring of breast development during puberty. Breast Cancer Res 2017; 19:12. [PMID: 28166807 PMCID: PMC5294901 DOI: 10.1186/s13058-017-0805-x] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [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: 11/16/2016] [Accepted: 01/12/2017] [Indexed: 11/18/2022] Open
Abstract
Background Tanner staging (TS), a five-stage classification indicating no breast tissue (TS1) to full breast development (TS5), is used both in health research and clinical care to assess the onset of breast development (TS2) and duration in each stage. Currently, TS is measured both visually and through palpation but non-invasive methods will improve comparisons across settings. Methods We used optical spectroscopy (OS) measures from 102 girls at the Ontario site of the LEGACY girls study (average age 12 years, range 10.0–15.4 years) to determine whether breast tissue optical properties map to each TS. We further examined whether these properties differed by age, body mass index (BMI), and breast cancer risk score (BCRS) by examining the major principal components (PC). Results Age and BMI increased linearly with increasing TS. Eight PCs explained 99.9% of the variation in OS data. Unlike the linear increase with age and BMI, OS components had distinct patterns by TS: the onset of breast development (TS1 to TS2) was marked by elevation of PC3 scores indicating an increase in adipose tissue and decrease in signal from the pectoral muscle; transition to TS3 was marked by elevation of PC6 and PC7 and decline of PC2 scores indicating an increase in glandular or dense tissue; and transition to TS4+ by decline of PC2 scores representing a further increase in glandular tissue relative to adipose tissue. Of the eight PCs, three component scores (PC4, PC5, and PC8) remained in the best-fitting model of BCRS, suggesting different levels of collagen in the breast tissue by BCRS. Conclusions Our results suggest that serial measures of OS, a non-invasive assessment of breast tissue characteristics, can be used as an objective outcome that does not rely on visual inspection or palpation, for studying drivers of breast development. Electronic supplementary material The online version of this article (doi:10.1186/s13058-017-0805-x) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Lothar Lilge
- Princess Margaret Cancer Centre, University Health Network, 101 College Street, Toronto, ON, M5G1L7, Canada.,Medical Biophysics, University of Toronto, 101 College Street, Toronto, ON, M5G1L7, Canada
| | - Mary Beth Terry
- Department of Epidemiology, Columbia University Mailman School of Public Health, New York, NY, USA.,Herbert Irving Comprehensive Cancer Center, Columbia University Medical Center, New York, NY, USA
| | - Jane Walter
- Medical Biophysics, University of Toronto, 101 College Street, Toronto, ON, M5G1L7, Canada
| | - Dushanthi Pinnaduwage
- Lunenfeld-Tanenbaum Research Institute, Sinai Health System, 600 University Avenue, Toronto, ON, M5G 1X5, Canada
| | - Gord Glendon
- Lunenfeld-Tanenbaum Research Institute, Sinai Health System, 600 University Avenue, Toronto, ON, M5G 1X5, Canada
| | - Danielle Hanna
- Lunenfeld-Tanenbaum Research Institute, Sinai Health System, 600 University Avenue, Toronto, ON, M5G 1X5, Canada
| | - Mai-Liis Tammemagi
- Lunenfeld-Tanenbaum Research Institute, Sinai Health System, 600 University Avenue, Toronto, ON, M5G 1X5, Canada
| | - Angela Bradbury
- Departments of Medicine and Medical Ethics & Health Policy, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, PA, USA
| | - Saundra Buys
- Department of Medicine, Huntsman Cancer Institute, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Mary Daly
- Department of Clinical Genetics, Fox Chase Cancer Center, Philadelphia, PA, USA
| | - Esther M John
- Cancer Prevention Institute of California, Fremont, CA, USA.,Department of Health Research & Policy (Epidemiology), and Stanford Cancer Institute, Stanford School of Medicine, Stanford, CA, USA
| | - Julia A Knight
- Lunenfeld-Tanenbaum Research Institute, Sinai Health System, 600 University Avenue, Toronto, ON, M5G 1X5, Canada.,Division of Epidemiology, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Irene L Andrulis
- Lunenfeld-Tanenbaum Research Institute, Sinai Health System, 600 University Avenue, Toronto, ON, M5G 1X5, Canada. .,Department of Molecular Genetics, University of Toronto, Toronto, ON, Canada.
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22
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Affiliation(s)
- Mary Beth Terry
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York; and
| | - Angela Bradbury
- Departments of Medicine and Hematology/Oncology and Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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23
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Bauml JM, Troxel A, Epperson CN, Cohen RB, Schmitz K, Stricker C, Shulman LN, Bradbury A, Mao JJ, Langer CJ. Scan-associated distress in lung cancer: Quantifying the impact of "scanxiety". Lung Cancer 2016; 100:110-113. [PMID: 27597289 DOI: 10.1016/j.lungcan.2016.08.002] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [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: 02/16/2016] [Revised: 07/27/2016] [Accepted: 08/07/2016] [Indexed: 01/12/2023]
Abstract
OBJECTIVES Diagnostic imaging may be a major source of cancer-related distress, a condition known as "scanxiety". Scant scholarly work has been performed to evaluate scan-associated distress in cancer. We sought to characterize risk factors for scan-associated distress among patients with Non-Small Cell Lung Cancer (NSCLC), and to evaluate the impact of scan-associated distress on quality of life. MATERIALS AND METHODS We conducted a cross-sectional survey study of patients with recurrent/metastatic NSCLC treated at an academic medical center. Clinical and demographic variables were obtained through chart abstraction and patient self-report. We used a modified version of the Impact of Event Scale 6 (IES-6) to specifically assess distress associated with scans, and quality of life was measured using the Functional Assessment of Cancer Therapy - Lung (FACT-L). RESULTS Among 103 participants (survey response rate 76.3%), median age was 67, 61.2% were women, and 82.5% were white. At the study visit, 72.8% of subjects discussed a recent scan, and 83% reported some scan-associated distress. Scan-associated distress was not associated with whether the patient had a recent scan, progressive disease or time from diagnosis. Scan-associated distress was associated with impaired quality of life (p=0.004); each unit increase in IES-6 corresponded to an approximately one-unit decrease in FACT-L score. CONCLUSION Scan-associated distress is a common problem among patients with NSCLC, and is associated with impaired quality of life. Scan-associated distress severity was not associated with time since diagnosis or whether a recent scan was discussed at the study visit, which implies scan-associated distress may be a persistent problem.
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Affiliation(s)
- Joshua M Bauml
- Abramson Cancer Center at the University of Pennsylvania, Philadelphia, PA, United States; Division of Hematology/Oncology, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, United States.
| | - Andrea Troxel
- Abramson Cancer Center at the University of Pennsylvania, Philadelphia, PA, United States; Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, United States
| | - C Neill Epperson
- Department of Psychiatry, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, United States
| | - Roger B Cohen
- Abramson Cancer Center at the University of Pennsylvania, Philadelphia, PA, United States; Division of Hematology/Oncology, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, United States
| | | | - Carrie Stricker
- Abramson Cancer Center at the University of Pennsylvania, Philadelphia, PA, United States; Division of Hematology/Oncology, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, United States; Carevive Systems, United States
| | - Lawrence N Shulman
- Abramson Cancer Center at the University of Pennsylvania, Philadelphia, PA, United States; Division of Hematology/Oncology, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, United States
| | - Angela Bradbury
- Abramson Cancer Center at the University of Pennsylvania, Philadelphia, PA, United States; Division of Hematology/Oncology, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, United States
| | - Jun J Mao
- Memorial Sloan Kettering Cancer Center, New York, NY, United States
| | - Corey J Langer
- Abramson Cancer Center at the University of Pennsylvania, Philadelphia, PA, United States; Division of Hematology/Oncology, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, United States
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Nicolaides AN, Shifrin EG, Bradbury A, Dhanjil S, Griffin M, Belcaro G, Williams M. Angiographic and Duplex Grading of Internal Carotid Stenosis: Can We Overcome the Confusion? J Endovasc Ther 2016; 3:158-65. [PMID: 8798134 DOI: 10.1177/152660289600300207] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The stroke risk reduction benefit of surgical intervention in carotid occlusive disease has been validated in multicenter trials for various angiographically defined lesion severity categories. The two divergent angiographic grading methods used for internal carotid artery stenosis in these trials have caused confusion in the clinical application of their recommendations. Moreover, while today's highly accurate carotid duplex scanning can obviate the need for preoperative angiography in many cases, the duplex criteria must be tailored to achieve sufficiently reliable results on which therapeutic decisions can be made. This review offers a clarification of the discrepancies between the angiographic grading techniques and how their measurements of percent stenosis correlate to the duplex criteria needed to support the treatment decision-making process for carotid obliterative disease.
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Affiliation(s)
- A N Nicolaides
- Irvine Laboratory for Cardiovascular Investigation and Research, Imperial College of Science, Technology & Medicine, London, United Kingdom
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Narayan HK, French B, Khan AM, Plappert T, Hyman D, Bajulaiye A, Domchek S, DeMichele A, Clark A, Matro J, Bradbury A, Fox K, Carver JR, Ky B. Noninvasive Measures of Ventricular-Arterial Coupling and Circumferential Strain Predict Cancer Therapeutics-Related Cardiac Dysfunction. JACC Cardiovasc Imaging 2016; 9:1131-1141. [PMID: 27085442 DOI: 10.1016/j.jcmg.2015.11.024] [Citation(s) in RCA: 60] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2015] [Revised: 11/04/2015] [Accepted: 11/05/2015] [Indexed: 10/21/2022]
Abstract
OBJECTIVES This study sought to determine the relationships between echocardiography-derived measures of myocardial mechanics and cancer therapeutics-related cardiac dysfunction (CTRCD). BACKGROUND Doxorubicin and trastuzumab are highly effective breast cancer therapies, but have a substantial risk of CTRCD. There is a critical need for the early detection of patients at increased risk of toxicity. METHODS We performed a prospective, longitudinal cohort study of breast cancer participants undergoing doxorubicin and/or trastuzumab therapy. Echocardiography was performed prior to therapy initiation (baseline) and at standardized follow-up intervals during and after completion of therapy. Ejection fraction (EF), strain, strain rate, and ventricular-arterial coupling (effective arterial elastance [Ea]/end-systolic elastance [Eessb]) were quantitated. CTRCD was defined as a ≥10% reduction in EF from baseline to <50%. Multivariable logistic regression models were used to determine the associations between baseline levels and changes from baseline in echocardiographic measures and CTRCD. Receiver-operating characteristic curves were used to evaluate the predictive ability of these measures. RESULTS In total, 135 participants contributed 517 echocardiograms to the analysis. Over a median follow-up time of 1.9 years (interquartile range: 0.9 to 2.4 years), 21 participants (15%) developed CTRCD. In adjusted models, baseline levels and changes in Ea/Eessb, circumferential strain, and circumferential strain rate were associated with 21% to 38% increased odds of CTRCD (p < 0.001). Changes in longitudinal strain (p = 0.037), radial strain (p = 0.015), and radial strain rate (p = 0.006) were also associated with CTRCD. Ea/Eessb (area under the curve: 0.703; 95% confidence interval: 0.583 to 0.807) and circumferential strain (area under the curve: 0.655; 95% confidence interval: 0.517 to 0.767) demonstrated the greatest predictive utility. Sensitivity analyses using an alternative CTRCD definition did not impact our results. CONCLUSIONS Over an extended follow-up time, ventricular-arterial coupling and circumferential strain were strongly predictive of CTRCD. Our findings suggest a noninvasive strategy to identify high-risk patients prior to, during, and after cardiotoxic cancer therapy.
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Affiliation(s)
- Hari K Narayan
- Department of Pediatrics, Division of Cardiology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Benjamin French
- Department of Biostatistics and Epidemiology, The University of Pennsylvania, Philadelphia, Pennsylvania
| | - Abigail M Khan
- Department of Medicine, Division of Cardiology, The University of Pennsylvania, Philadelphia, Pennsylvania
| | - Theodore Plappert
- Department of Medicine, Division of Cardiology, The University of Pennsylvania, Philadelphia, Pennsylvania
| | - David Hyman
- Department of Medicine, Division of Cardiology, The University of Pennsylvania, Philadelphia, Pennsylvania
| | - Akinyemi Bajulaiye
- Department of Medicine, Division of Cardiology, The University of Pennsylvania, Philadelphia, Pennsylvania
| | - Susan Domchek
- Department of Medicine, Division of Oncology, The University of Pennsylvania, Philadelphia, Pennsylvania; Abramson Cancer Center, The University of Pennsylvania, Philadelphia, Pennsylvania
| | - Angela DeMichele
- Department of Biostatistics and Epidemiology, The University of Pennsylvania, Philadelphia, Pennsylvania; Department of Medicine, Division of Oncology, The University of Pennsylvania, Philadelphia, Pennsylvania; Abramson Cancer Center, The University of Pennsylvania, Philadelphia, Pennsylvania
| | - Amy Clark
- Department of Medicine, Division of Oncology, The University of Pennsylvania, Philadelphia, Pennsylvania; Abramson Cancer Center, The University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jennifer Matro
- Department of Medicine, Division of Oncology, The University of Pennsylvania, Philadelphia, Pennsylvania; Abramson Cancer Center, The University of Pennsylvania, Philadelphia, Pennsylvania
| | - Angela Bradbury
- Department of Medicine, Division of Oncology, The University of Pennsylvania, Philadelphia, Pennsylvania; Abramson Cancer Center, The University of Pennsylvania, Philadelphia, Pennsylvania
| | - Kevin Fox
- Department of Medicine, Division of Oncology, The University of Pennsylvania, Philadelphia, Pennsylvania; Abramson Cancer Center, The University of Pennsylvania, Philadelphia, Pennsylvania
| | - Joseph R Carver
- Department of Medicine, Division of Cardiology, The University of Pennsylvania, Philadelphia, Pennsylvania; Abramson Cancer Center, The University of Pennsylvania, Philadelphia, Pennsylvania
| | - Bonnie Ky
- Department of Biostatistics and Epidemiology, The University of Pennsylvania, Philadelphia, Pennsylvania; Department of Medicine, Division of Cardiology, The University of Pennsylvania, Philadelphia, Pennsylvania; Abramson Cancer Center, The University of Pennsylvania, Philadelphia, Pennsylvania.
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Clark AS, O'Dwyer P, Troxel A, Lal P, Feldman M, Gallagher M, Driscoll A, Colameco C, Lewis D, Rosen M, Matro J, Bradbury A, Domchek S, Fox K, DeMichele A. Abstract P6-13-08: Palbociclib and paclitaxel on an alternating schedule for advanced breast cancer: Results of a phase Ib trial. Cancer Res 2016. [DOI: 10.1158/1538-7445.sabcs15-p6-13-08] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
Background: Palbociclib (P) is an oral CDK 4/6 inhibitor (CDKi) that was recently FDA approved in combination with endocrine therapy for metastatic breast cancer. We have performed a Phase I trial of P in combination with paclitaxel (T) based on preclinical studies suggesting that P synergizes with T when given on an alternating schedule, enabling cell cycle synchronization in tumor cells. We now present the dose expansion cohort.
Methods: Patients (Pts) enrolled on the trial had Rb-expressing tumors of any estrogen/progesterone/HER2 receptor type, adequate organ function, and ≤3 prior chemotherapy regimens for metastatic breast cancer (mBC). Prior adjuvant or metastatic taxane was allowed. Dose escalation led to expansion at P100mg or 75mg, starting with 3 days of P (run-in) and reduction of P dosing from 5-day to 3-day intervals (days 2-4, 9-11, 16-18 of each 28 day cycle). T at 80mg/m2 was given weekly for 3 cycles; thereafter, T was administered days 1, 8 and 15 of 28 day cycle. Weekly toxicity assessments were performed; RECIST 1.0 response was assessed every 2 cycles as partial response (PR), stable disease (SD) or progressive disease (PD). Pts had the option to discontinue T and continue on P alone (3 on/1 off schedule) if they attained SD after cycle 6.
Results: 27 pts enrolled on study (15- dose escalation, 12- dose expansion). Results are shown in the Table. 21 pts had received prior taxane; pts had received a median of 2 chemotherapy regimens for mBC. DLTs were grade 3 AST/ALT (n=1, at 125 mg) and febrile neutropenia (FN) (n=1, at 100 mg). Uncomplicated grade 3/4 NTP was common and frequently led to dose reduction or dose interruption during the first cycle of therapy. Frequency of NTP did not change with reducing the days of P. Among 24 evaluable patients, 14 (58%), had PR or SD ≥ 6 months across all dose levels. Of 14 pts who responded, 10 (71%) had received prior taxane. 20 pts are off study; 19 for PD, and 2 for toxicity (NTP in cycle 17 and FN in cycle 1); 7 pts remain on study. Prolonged tumor responses were seen.
Conclusions: P and T can be safely combined on an alternating dosing schedule; the optimal combination dose is 75 mg of P and 80mg/m2 of weekly T. The high response rate warrants a randomized trial to determine the incremental benefit over T alone. Additional mechanistic studies are in progress to understand the in vivo effects of the alternating dosing schedule on cell cycle activity and tumor proliferation.
Starting Dose Level P (mg)Number (Total 27)DLTGrade 3/4 NTP (n)Final Dose P mg (n)Dose Interruption (n)Best Response (n)5030050 (1) 50 (1) 50 (1)No (2) Yes (1)PR (1) SD (1) PD (1)7530275 (1) 50 (1) 25 (1)No (1) Yes (2)PR (2) SD (1)100605100 (2) 75 (3) 25 (1)No (1) Yes (5)PR (2) SD (1) PD (3)12531- LFT375 (1) 50 (2)No (0) Yes (3)PR (1) SD (2)75 (Run-In)60175 (5) 50 (1)No (4) Yes (2)PR (1) SD (2) PD (1) N/A (2)*100 (Run-In)61- FN5100 (1) 75 (4) 25(1)No (1) Yes (5)PR (4) SD (1) N/A (1)^*2 pts not yet evaluable. ^1 pt went off study due to FN after cycle 1.
Citation Format: Clark AS, O'Dwyer P, Troxel A, Lal P, Feldman M, Gallagher M, Driscoll A, Colameco C, Lewis D, Rosen M, Matro J, Bradbury A, Domchek S, Fox K, DeMichele A. Palbociclib and paclitaxel on an alternating schedule for advanced breast cancer: Results of a phase Ib trial. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P6-13-08.
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Affiliation(s)
- AS Clark
- Perelman School of Medicine, University of Pennsylvania; Division of Hematology/Oncology, Philadelphia, PA; Abramson Cancer Center, Philadelphia, PA; Center for Clinical Epidemiology and Biostatistics, Philadelphia, PA; Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - P O'Dwyer
- Perelman School of Medicine, University of Pennsylvania; Division of Hematology/Oncology, Philadelphia, PA; Abramson Cancer Center, Philadelphia, PA; Center for Clinical Epidemiology and Biostatistics, Philadelphia, PA; Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - A Troxel
- Perelman School of Medicine, University of Pennsylvania; Division of Hematology/Oncology, Philadelphia, PA; Abramson Cancer Center, Philadelphia, PA; Center for Clinical Epidemiology and Biostatistics, Philadelphia, PA; Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - P Lal
- Perelman School of Medicine, University of Pennsylvania; Division of Hematology/Oncology, Philadelphia, PA; Abramson Cancer Center, Philadelphia, PA; Center for Clinical Epidemiology and Biostatistics, Philadelphia, PA; Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - M Feldman
- Perelman School of Medicine, University of Pennsylvania; Division of Hematology/Oncology, Philadelphia, PA; Abramson Cancer Center, Philadelphia, PA; Center for Clinical Epidemiology and Biostatistics, Philadelphia, PA; Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - M Gallagher
- Perelman School of Medicine, University of Pennsylvania; Division of Hematology/Oncology, Philadelphia, PA; Abramson Cancer Center, Philadelphia, PA; Center for Clinical Epidemiology and Biostatistics, Philadelphia, PA; Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - A Driscoll
- Perelman School of Medicine, University of Pennsylvania; Division of Hematology/Oncology, Philadelphia, PA; Abramson Cancer Center, Philadelphia, PA; Center for Clinical Epidemiology and Biostatistics, Philadelphia, PA; Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - C Colameco
- Perelman School of Medicine, University of Pennsylvania; Division of Hematology/Oncology, Philadelphia, PA; Abramson Cancer Center, Philadelphia, PA; Center for Clinical Epidemiology and Biostatistics, Philadelphia, PA; Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - D Lewis
- Perelman School of Medicine, University of Pennsylvania; Division of Hematology/Oncology, Philadelphia, PA; Abramson Cancer Center, Philadelphia, PA; Center for Clinical Epidemiology and Biostatistics, Philadelphia, PA; Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - M Rosen
- Perelman School of Medicine, University of Pennsylvania; Division of Hematology/Oncology, Philadelphia, PA; Abramson Cancer Center, Philadelphia, PA; Center for Clinical Epidemiology and Biostatistics, Philadelphia, PA; Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - J Matro
- Perelman School of Medicine, University of Pennsylvania; Division of Hematology/Oncology, Philadelphia, PA; Abramson Cancer Center, Philadelphia, PA; Center for Clinical Epidemiology and Biostatistics, Philadelphia, PA; Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - A Bradbury
- Perelman School of Medicine, University of Pennsylvania; Division of Hematology/Oncology, Philadelphia, PA; Abramson Cancer Center, Philadelphia, PA; Center for Clinical Epidemiology and Biostatistics, Philadelphia, PA; Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - S Domchek
- Perelman School of Medicine, University of Pennsylvania; Division of Hematology/Oncology, Philadelphia, PA; Abramson Cancer Center, Philadelphia, PA; Center for Clinical Epidemiology and Biostatistics, Philadelphia, PA; Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - K Fox
- Perelman School of Medicine, University of Pennsylvania; Division of Hematology/Oncology, Philadelphia, PA; Abramson Cancer Center, Philadelphia, PA; Center for Clinical Epidemiology and Biostatistics, Philadelphia, PA; Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - A DeMichele
- Perelman School of Medicine, University of Pennsylvania; Division of Hematology/Oncology, Philadelphia, PA; Abramson Cancer Center, Philadelphia, PA; Center for Clinical Epidemiology and Biostatistics, Philadelphia, PA; Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
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Soucier-Ernst D, Colameco C, Troxel AB, Clark C, Shih N, Maxwell KN, Morrissette J, Lieberman D, Feldman M, Goodman N, Bradbury A, Clark A, Domchek S, Fox K, Glick J, Matro J, Nathanson K, Chodosh L, DeMichele A. Abstract P6-07-05: Mutational spectrum and tumor response in metastatic breast cancer. Cancer Res 2016. [DOI: 10.1158/1538-7445.sabcs15-p6-07-05] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
Background: While several comprehensive genomic sequencing tests are clinically available for breast cancer(BC), little is known about the spectrum of findings reported in the general population and clinical utility of findings for patients(pts). Here we report tumor sequencing from the METAMORPH study, a comprehensive genomic testing approach in pts with metastatic(met) BC.
Methods: Pts with either known or suspected BC mets consented to and clinically underwent concurrent diagnostic and research tumor biopsies(bx). FFPE specimens were profiled via Illumina TruSeq Cancer Panel next generation sequencing platform covering 212 amplicons in 47 cancer genes. Pathology, treatment and outcome data were prospectively collected and tracked. Aside from Her2-directed treatment, therapy was not mutation (mut)-matched.
Results: 64 pts enrolled between 11/2013 – 05/2015. Of these, 48 had bx successfully sequenced (75%). Of those without sequencing, 5 had negative/insufficient tissue, 2 had insufficient DNA, remainder no bx/pending. Median age of those sequenced was 56 (range 31-78); 81% Caucasian, 17% African American. 25% (12 pts) presented with de novo stage IV disease. Of those with recurrence (n=36), 83% had prior adjuvant chemotherapy; 81% hormone receptor positive(HR+) had prior endocrine therapy. Median # prior lines of therapy for met disease was 2 (IQR 0 – 8). Tumor characteristics, including mut analyses, are shown in Table 1. # muts did not differ significantly by subtype(p=0.22). Frequency of TP53 and PIK3CA hotspot muts was nearly identical to TCGA. Median # muts was 1 for pts with both de novo mets and recurrence(p=0.79). # of muts was not associated with time to recurrence(p=0.80). Excluding pts found to have TP53 mut only or ERBB2 alterations in known Her2+ disease, 42% of pts were identified as having at least one potentially actionable alteration (PIK3CA mut, AKT1 mut or EGFR amplification). Median time to treatment failure(TTF) on subsequent therapy was 4.1 months for overall group, and 4.1, 6.2, and 1.6 months for HR+/Her2-, any Her2+ and TN, respectively, adjusted for line of therapy(p=0.03). After adjustment for # lines of prior met therapy, TTF was 4.7 vs. 4.1 months for pts with any mut vs. none(p=0.89); 5.7 vs 4.1 months for PIK3CA+ vs. not (p=0.94); 3.3 vs. 6.5 months for TP53+ vs. not (p=0.03).
Conclusion: Pts with met BC have frequent and potentially actionable muts.While overall # of muts did not affect response, tumors with TP53 muts had shorter response to subsequent therapy in this cohort. Additional data are needed to determine the clinical utility of mut testing in met BC, for both standard and mut-matched therapy.
Total (n=48)HR+/Her2- (n=28)Any HER2+ (n=7)TN (n=13)Receptor concordant with primary 100%78%77%# Mutations Median (Range)1 (0-4)1 (0-3)1 (1-2)1 (0-4)014 (29%)10 (36 %)04 (31%)118 (38%)11 (39%)4 (57%)3 (23%)213 (27%)5 (18%)3 (43%)5 (38%)3+3 (6%)2 (7%)01 (8%)Prevalent Mutations (>20%)TP53 (38%), PIK3CA (35%)PIK3CA (50%), TP53 (25%)TP53 (60%), ERBB2amp (86%)TP53 (62%),PIK3CA (23%)Other Alterations (#)ATM (1), KIT (1), PDGFRA (1), PTEN(1), RB1 (1), SMAD4 (1), SMO (1), STK11 (1)AKT1 (1), ATM VUS (1), ERBB2 (1), PTEN (1), SMAD4 VUS (1), SMO VUS (1)ERBB2 (1), STK11(1)EGFR amp (2), KIT amp (1),PDGFRA amp (1), RB1 VUS (1)
Citation Format: Soucier-Ernst D, Colameco C, Troxel AB, Clark C, Shih N, Maxwell KN, Morrissette J, Lieberman D, Feldman M, Goodman N, Bradbury A, Clark A, Domchek S, Fox K, Glick J, Matro J, Nathanson K, Chodosh L, DeMichele A. Mutational spectrum and tumor response in metastatic breast cancer. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P6-07-05.
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Affiliation(s)
| | - C Colameco
- University of Pennsylvania, Philadelphia, PA
| | - AB Troxel
- University of Pennsylvania, Philadelphia, PA
| | - C Clark
- University of Pennsylvania, Philadelphia, PA
| | - N Shih
- University of Pennsylvania, Philadelphia, PA
| | - KN Maxwell
- University of Pennsylvania, Philadelphia, PA
| | | | - D Lieberman
- University of Pennsylvania, Philadelphia, PA
| | - M Feldman
- University of Pennsylvania, Philadelphia, PA
| | - N Goodman
- University of Pennsylvania, Philadelphia, PA
| | - A Bradbury
- University of Pennsylvania, Philadelphia, PA
| | - A Clark
- University of Pennsylvania, Philadelphia, PA
| | - S Domchek
- University of Pennsylvania, Philadelphia, PA
| | - K Fox
- University of Pennsylvania, Philadelphia, PA
| | - J Glick
- University of Pennsylvania, Philadelphia, PA
| | - J Matro
- University of Pennsylvania, Philadelphia, PA
| | - K Nathanson
- University of Pennsylvania, Philadelphia, PA
| | - L Chodosh
- University of Pennsylvania, Philadelphia, PA
| | - A DeMichele
- University of Pennsylvania, Philadelphia, PA
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Bradbury A, Patrick-Miller L, Harris D, Stevens E, Egleston B, Smith K, Mueller R, Brandt A, Stopfer J, Rauch S, Forman A, Kim R, Fetzer D, Fleisher L, Daly M, Domchek S. Utilizing Remote Real-Time Videoconferencing to Expand Access to Cancer Genetic Services in Community Practices: A Multicenter Feasibility Study. J Med Internet Res 2016; 18:e23. [PMID: 26831751 PMCID: PMC4754531 DOI: 10.2196/jmir.4564] [Citation(s) in RCA: 56] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2015] [Revised: 09/28/2015] [Accepted: 10/07/2015] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Videoconferencing has been used to expand medical services to low-access populations and could increase access to genetic services at community sites where in-person visits with genetic providers are not available. OBJECTIVE To evaluate the feasibility of, patient feedback of, and cognitive and affective responses to remote two-way videoconferencing (RVC) telegenetic services at multiple sociodemographically diverse community practices without access to genetic providers. METHODS Patients at 3 community sites in 2 US states outside the host center completed RVC pretest (visit 1, V1) and post-test (visit 2, V2) genetic counseling for cancer susceptibility. Surveys evaluated patient experiences, knowledge, satisfaction with telegenetic and cancer genetics services, anxiety, depression, and cancer worry. RESULTS A total of 82 out of 100 (82.0%) approached patients consented to RVC services. A total of 61 out of 82 patients (74%) completed pretest counseling and 41 out of 61 (67%) proceeded with testing and post-test counseling. A total of 4 out of 41 (10%) mutation carriers were identified: BRCA2, MSH2, and PMS2. Patients reported many advantages (eg, lower travel burden and convenience) and few disadvantages to RVC telegenetic services. Most patients reported feeling comfortable with the video camera--post-V1: 52/57 (91%); post-V2: 39/41 (95%)--and that their privacy was respected--post-V1: 56/57 (98%); post-V2: 40/41 (98%); however, some reported concerns that RVC might increase the risk of a confidentiality breach of their health information--post-V1: 14/57 (25%); post-V2: 12/41 (29%). While the majority of patients reported having no trouble seeing or hearing the genetic counselor--post-V1: 47/57 (82%); post-V2: 39/41 (95%)--51 out of 98 (52%) patients reported technical difficulties. Nonetheless, all patients reported being satisfied with genetic services. Compared to baseline, knowledge increased significantly after pretest counseling (+1.11 mean score, P=.005); satisfaction with telegenetic (+1.74 mean score, P=.02) and genetic services (+2.22 mean score, P=.001) increased after post-test counseling. General anxiety and depression decreased after pretest (-0.97 mean anxiety score, P=.003; -0.37 mean depression score, P=.046) and post-test counseling (-1.13 mean anxiety score, P=.003; -0.75 mean depression score, P=.01); state anxiety and cancer-specific worry did not significantly increase. CONCLUSIONS Remote videoconferencing telegenetic services are feasible, identify genetic carriers in community practices, and are associated with high patient satisfaction and favorable cognitive and affective outcomes, suggesting an innovative delivery model for further study to improve access to genetic providers and services. Potential barriers to dissemination include technology costs, unclear billing and reimbursement, and state requirements for provider licensure.
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Affiliation(s)
- Angela Bradbury
- Division of Hematology-Oncology, Department of Medicine, The University of Pennsylvania, Philadelphia, PA, United States.
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Davies A, Popplewell M, Kelly L, Bate G, Darvall K, Bradbury A. Impact of UK National Institute of Health and Care Excellent (NICE) Clinical Guidelines (CG 168) on the Referral and Management of Leg Ulcers. J Vasc Surg Venous Lymphat Disord 2016. [DOI: 10.1016/j.jvsv.2015.10.028] [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: 10/22/2022]
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Marsden G, Perry M, Bradbury A, Hickey N, Kelley K, Trender H, Wonderling D, Davies A. A Cost-effectiveness Analysis of Surgery, Endothermal Ablation, Ultrasound-guided Foam Sclerotherapy and Compression Stockings for Symptomatic Varicose Veins. J Vasc Surg 2015. [DOI: 10.1016/j.jvs.2015.10.084] [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: 10/22/2022]
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Marsden G, Perry M, Bradbury A, Hickey N, Kelley K, Trender H, Wonderling D, Davies A. A Cost-effectiveness Analysis of Surgery, Endothermal Ablation, Ultrasound-guided Foam Sclerotherapy and Compression Stockings for Symptomatic Varicose Veins. Eur J Vasc Endovasc Surg 2015; 50:794-801. [DOI: 10.1016/j.ejvs.2015.07.034] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2015] [Accepted: 07/08/2015] [Indexed: 10/23/2022]
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Patrick-Miller L, Harris D, Stevens E, Egleston B, Fleisher L, Mueller R, Brandt A, Stopfer J, Domchek S, Bradbury A. Abstract P1-11-02: Telemedicine: Expanding access to cancer genetic services to underserved populations. Cancer Res 2015. [DOI: 10.1158/1538-7445.sabcs14-p1-11-02] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
Background: Given the increasing demand for genetic services and limited genetic workforce, many patients do not receive recommended pre- and post-test genetic counseling. Telemedicine has been used to expand specialized medical services to low access populations. The feasibility and outcomes of telemedicine in clinical genetics are not well described.
Methods: Patients at 3 community sites without genetic counseling services received real-time pre-test (V1) and post-test (V2) counseling for cancer susceptibility with a genetic counselor (GC) at a center of expertise via community sites’ and host institution’s computers equipped with web cameras and videoconferencing software. Mixed-methods surveys assessed patient knowledge, satisfaction, psychosocial responses and experiences at baseline (BL), post-V1 and post-V2. We used paired T-tests to assess change between time points and linear regressions.
Results: Of 100 patients approached, 83% consented to telegenetic services. To date, 57 have completed BL and V1, and 70% proceeded with genetic testing, 31 patients have received results, including 3 carriers (BRCA2, MSH2, PMS2). Patient characteristics did not differ between those who agreed to and declined telegenetics. 4% of sessions were aborted due to technology failures. 30% experienced disconnections but were completed. Nearly all (94%) were satisfied with their telegenetic experience. Knowledge and satisfaction with telegenetic services significantly increased and general anxiety and depression significantly decreased. Event related (state) anxiety did not change significantly.
Table 1.OutcomeBL Mean (sd)Post-V1 Mean(sd)Post-V2 Mean(sd)pKnowledge (6-28)20.9(2.8)22.0 (3.0) 0.007 20.8 (3.3)21.8(3.2)21.5(3.1)NSSGeneral Anxiety (0-21)7.4(4.1)6.6(4.1) 0,02 6.6 ((4.0)5.7 (3.8)5.7 (3.5)0.06Genarla Depression(0-21)3.9 (3.9)3.5 (3.4) 0,05 3.6 (3.7)3.4(3.5)2.9 (3.5)0.07State Anxiety(20-80)36.0(15.2)35.7(13.7) NSS 34.6(15.0)34.5(13.1)32.1(12.5)NSSSatisfaction with Genetic Services 39.5(3.( 39.8(4.0)42.2(3.6)0.002Satisfaction with Telemedicine 51.3(5.6) 51.5(5.7)53.0(5.3)0.008
Patients reported several advantages to telegenetics (e.g. decreased travel burden) and few disadvantages (e.g. audio challenges and technical glitches).Conclusions: Telemedicine delivery of cancer genetic services is feasible, identifies genetic mutation carriers, increases knowledge, decreases anxiety and depression and is associated with high satisfaction, suggesting an innovative model for delivery of genetic services for patients and community practices without access to local genetic providers.
Citation Format: Linda Patrick-Miller, Diana Harris, Evelyn Stevens, Brian Egleston, Linda Fleisher, Rebbeca Mueller, Amanda Brandt, Jill Stopfer, Susan Domchek, Angela Bradbury. Telemedicine: Expanding access to cancer genetic services to underserved populations [abstract]. In: Proceedings of the Thirty-Seventh Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2014 Dec 9-13; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2015;75(9 Suppl):Abstract nr P1-11-02.
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Darvall K, Davies H, Bate G, Bradbury A. The Effect of Obesity on Long-Term Outcomes After Ultrasound-Guided Foam Sclerotherapy. J Vasc Surg Venous Lymphat Disord 2015; 3:124-5. [PMID: 26993711 DOI: 10.1016/j.jvsv.2014.10.024] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- K Darvall
- Birmingham University Department of Vascular Surgery, Solihull, United Kingdom
| | - H Davies
- Birmingham University Department of Vascular Surgery, Solihull, United Kingdom
| | - G Bate
- Birmingham University Department of Vascular Surgery, Solihull, United Kingdom
| | - A Bradbury
- Birmingham University Department of Vascular Surgery, Solihull, United Kingdom
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Marsden G, Perry M, Bradbury A, Hickey N, Kelley K, Trender H, Wonderling D, Davies AH. A Cost-Effectiveness Analysis Of Interventions For Symptomatic Varicose Veins. Value Health 2014; 17:A488-A489. [PMID: 27201447 DOI: 10.1016/j.jval.2014.08.1438] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Affiliation(s)
- G Marsden
- Office of Health Economics, London, UK
| | - M Perry
- National Clinical Guideline Centre, London, UK
| | | | - N Hickey
- Worcestershire Royal Hospital, Worcester, UK
| | - K Kelley
- National Clinical Guideline Centre, London, UK
| | - H Trender
- Sheffield Teaching Hospital Foundation Trust, Sheffield, UK
| | | | - A H Davies
- Imperial College & Imperial College NHS Trust, London, UK
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Jagsi R, Spence R, Rathmell WK, Bradbury A, Peppercorn J, Grubbs S, Moy B. Ethical considerations for the clinical oncologist in an era of oncology drug shortages. Oncologist 2014; 19:186-92. [PMID: 24449096 DOI: 10.1634/theoncologist.2013-0301] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Shortages of injectable drugs affect many cancer patients and providers in the U.S. today. Scholars and policymakers have recently begun to devote increased attention to these issues, but only a few tangible resources exist to guide clinical oncologists in developing strategies for dealing with drug shortages on a recurring basis. This article discusses existing information from the scholarly literature, policy analyses, and other relevant sources and seeks to provide practical ethical guidance to the broad audience of oncology professionals who are increasingly confronted with such cases in their practice. We begin by providing a brief overview of the history, causes, and regulatory context of oncology drug shortages in the U.S., followed by a discussion of ethical frameworks that have been proposed in this setting. We conclude with practical recommendations for ethical professional behavior in these increasingly common and challenging situations.
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Affiliation(s)
- Reshma Jagsi
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan, USA; American Society of Clinical Oncology, Alexandria, Virginia, USA; University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA; University of Pennsylvania, Philadelphia, Pennsylvania USA; Duke University, Durham, North Carolina, USA; Medical Oncology Hematology Consultants, Newark, Delaware, USA; Massachusetts General Hospital, Boston, Massachusetts, USA
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Bermingham S, Sparrow K, Mullis R, Fox M, Shearman C, Bradbury A, Michaels J. The Cost-effectiveness of Supervised Exercise for the Treatment of Intermittent Claudication. Eur J Vasc Endovasc Surg 2013; 46:707-14. [DOI: 10.1016/j.ejvs.2013.09.005] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2013] [Accepted: 09/04/2013] [Indexed: 11/27/2022]
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Bermingham S, Sparrow K, Mullis R, Fox M, Shearman C, Bradbury A, Michaels J. The Cost-effectiveness of Supervised Exercise for the Treatment of Intermittent Claudication. J Vasc Surg 2013. [DOI: 10.1016/j.jvs.2013.10.066] [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: 11/27/2022]
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Offit K, Bradbury A, Storm C, Merz JF, Noonan KE, Spence R. Gene patents and personalized cancer care: impact of the Myriad case on clinical oncology. J Clin Oncol 2013; 31:2743-8. [PMID: 23766521 PMCID: PMC5795665 DOI: 10.1200/jco.2013.49.7388] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.8] [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] [Indexed: 12/13/2022] Open
Abstract
Genomic discoveries have transformed the practice of oncology and cancer prevention. Diagnostic and therapeutic advances based on cancer genomics developed during a time when it was possible to patent genes. A case before the Supreme Court, Association for Molecular Pathology v Myriad Genetics, Inc seeks to overturn patents on isolated genes. Although the outcomes are uncertain, it is suggested here that the Supreme Court decision will have few immediate effects on oncology practice or research but may have more significant long-term impact. The Federal Circuit court has already rejected Myriad's broad diagnostic methods claims, and this is not affected by the Supreme Court decision. Isolated DNA patents were already becoming obsolete on scientific grounds, in an era when human DNA sequence is public knowledge and because modern methods of next-generation sequencing need not involve isolated DNA. The Association for Molecular Pathology v Myriad Supreme Court decision will have limited impact on new drug development, as new drug patents usually involve cellular methods. A nuanced Supreme Court decision acknowledging the scientific distinction between synthetic cDNA and genomic DNA will further mitigate any adverse impact. A Supreme Court decision to include or exclude all types of DNA from patent eligibility could impact future incentives for genomic discovery as well as the future delivery of medical care. Whatever the outcome of this important case, it is important that judicial and legislative actions in this area maximize genomic discovery while also ensuring patients' access to personalized cancer care.
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Affiliation(s)
- Kenneth Offit
- Clinical Genetics Service, Memorial Sloan-Kettering Cancer Center, 1275 York Ave, New York, NY 10065, USA.
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Domchek SM, Bradbury A, Garber JE, Offit K, Robson ME. Multiplex genetic testing for cancer susceptibility: out on the high wire without a net? J Clin Oncol 2013; 31:1267-70. [PMID: 23460708 DOI: 10.1200/jco.2012.46.9403] [Citation(s) in RCA: 194] [Impact Index Per Article: 17.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
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Bradbury A, Stansby G, Nyamekye I. VEnous INtervention (VEIN) 3 project: introduction. Phlebology 2012; 27 Suppl 2:1. [PMID: 22457299 DOI: 10.1258/phleb.2012.012s30] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
- A Bradbury
- Northern Vascular Centre, Freeman Hospital, Newcastle University, Newcastle upon Tyne, UK
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Abstract
Despite the fact that venous thromboembolism (VTE) is one of the most widely studied areas in medicine, and despite the availability of data from numerous RCTs, there are many areas where the evidence is insufficient to allow grade A recommendations to be made. In these areas published guidelines often differ in their advice. In this chapter we primarily discuss the National Institute of Clinical and Health Excellence (NICE) VTE prophylaxis pathways in the context of other guidance published by the Scottish Intercollegiate Guideline Network and the American Colleges of Physicians and Chest Physicians. Evidence for the use of both mechanical and pharmacological thromboprophylaxis is discussed for both medical and surgical patients.
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Affiliation(s)
- K Darvall
- University Department of Vascular Surgery, Heart of England NHS Foundation Trust, Solihull Hospital, Lode Lane, Solihull, West Midlands, UK
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Bowden L, Bradbury A. Stephen Arthur Roberts. West J Med 2011. [DOI: 10.1136/bmj.d7360] [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: 11/04/2022]
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Burgos-Dago-Oc J, Corbman M, Bradbury A. P153 HER2 positive breast cancer among BRCA1/2 mutation carriers. Breast 2011. [DOI: 10.1016/s0960-9776(11)70096-0] [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: 10/18/2022] Open
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Muster T, Bradbury A, Trinchi A, Cole I, Markley T, Lau D, Dligatch S, Bendavid A, Martin P. The atmospheric corrosion of zinc: The effects of salt concentration, droplet size and droplet shape. Electrochim Acta 2011. [DOI: 10.1016/j.electacta.2010.09.099] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Bradbury A, Patrick-Miller L, Li T, Egleston B, Sands C, Schmidheiser H, Hlubocky F, Olopade O, Daly M, Daugherty C. Should Minors Be Offered BRCA1/2 Testing for Hereditary Breast Cancer? Opinions of Parents Who Have Undergone BRCA1/2 Testing. Cancer Res 2009. [DOI: 10.1158/0008-5472.sabcs-09-4071] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
Background: Professional societies recommend against the genetic testing of minors for hereditary cancer syndromes that present in adulthood. Yet, many adolescent specialists indicate that they would consider BRCA1/2 testing of minor children. We conducted interviews with parents who have had BRCA1/2 testing, to evaluate their opinions regarding the genetic testing of minors for BRCA1/2. Methods: 244 parents, including 67 BRCA1/2 mutation carriers (MCs), 140 parents with uninformative negative results (UN), 14 with true negative results (TN) & 23 with a variant of uncertain significance (VUS), from two cancer risk assessment programs completed semi-structured interviews. We used multiple logistic regressions to evaluate the associations among biomedical factors, demographic factors and support of testing minors. Wald tests and likelihood ratio tests were used to assess statistical significance for binary covariates and nominal covariates. Results: 38% of parents supported testing minors for BRCA1/2 in response to a dichotomous (Y/N) question. Support was greatest among parents with TN (64%) and UN (40%) results and lower among MCs (31%) and parents with a VUS (26%). In a multivariable analysis, support was greatest among parents who tested negative (p=0.02), were of minority race (p=0.06) and among fathers (<0.01). Responses to open-ended questions suggest that 27% of parents unconditionally support testing of minors, and 25% support testing only in certain situations. Psychological risks, a lack of medical necessity and the insufficient maturity of minors, were frequent concerns of those opposed. The potential to positively impact minors' health behaviors was the most reported reason for supporting testing. Conclusions: Up to 52% of parents who have undergone BRCA1/2 testing support pediatric testing for BRCA1/2. Given willingness among general and pediatric practitioners and interest among parents, further research is necessary to formally evaluate the risks and benefits of providing genetic testing to minors for adult-onset hereditary cancer syndromes in order to inform clinical practice and public policy that will ensure optimal psychosocial and medical outcomes for all members of families at risk for hereditary cancer.
Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 4071.
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Affiliation(s)
| | | | - T. Li
- 1Fox Chase Cancer Center, PA,
| | | | | | | | | | | | - M. Daly
- 1Fox Chase Cancer Center, PA,
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Malaka DO, Lee R, Lewin R, Cummings S, Curlin F, Bradbury A, Olopade O. Lifestyle modifications including complementary and alternative medicine and quality of life among women at high risk for breast cancer. J Clin Oncol 2009. [DOI: 10.1200/jco.2009.27.15_suppl.e20583] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
e20583 Background: Breast cancer (BC) patients commonly employ lifestyle modifications (LM) such as complementary and alternative medicine (CAM), but limited information exists among women who are high risk for BC (HRBC). This study's aims were to estimate the prevalence of LM use among HRBC patients, describe communication patterns, and determine correlations with quality of life (QoL) measures. Methods: Women enrolled in a multi-modality screening study for HRBC patients (≥20% lifetime risk) were distributed a questionnaire asking about the use of CAM therapies and other LM, timing of use, reasons, costs, and communication patterns. QoL measures included the Short-Form 36 (SF-36) and Beck Depression Inventory (BDI). Demographic variables and those instruments with significant correlations (p<0.05) were included in a multivariate model. Results: A total of 173 HRBC patients are enrolled on this study and 123 have completed the survey. General characteristics of these women include a median age of 45 years, 91% Caucasian, 30% have a gene mutation (e.g. BRCA1/2), and 33% have had breast and/or ovarian cancer. Ninety-nine percent reported a lifetime prevalence of LM and CAM, and nearly half of subjects (48%) did so for cancer-related reasons. The most popular LM were exercise (83%), massage (68%), yoga (44%), vitamin E (38%), and chiropractic medicine (36%). The most common cancer-related changes were low fat diet (15%), exercise (11%), and meditation (10%). Half of subjects (48%) did not discuss any of these LM with their physicians, and the most common reason was their physician did not ask. In the multivariate model for cancer-related LM, subjects having a history of BC or ovarian cancer were 6.2 times (p<0.001) more likely to use LM and CAM. Subjects with a below average SF-36 general health subscale score were 3.4 times (p<0.05) more likely to pursue non-biologically based CAM, and those with an elevated BDI (score>9) were 6.2 times (p<0.05) less likely to pursue dietary changes. Conclusions: LM including CAM are highly prevalent among women at HRBC. Oncologists should inquire about LM and CAM use and explore reasons for this including QoL. No significant financial relationships to disclose.
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Affiliation(s)
| | - R. Lee
- University of Chicago, Chicago, IL
| | - R. Lewin
- University of Chicago, Chicago, IL
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Patrick-Miller LJ, Fetzer D, Schmidheiser H, Daly M, Toppmeyer D, Olopade O, Bradbury A. Telephone disclosure of BRCA1/2 test results? Experience and opinions of genetic counselors and consumers. J Clin Oncol 2009. [DOI: 10.1200/jco.2009.27.15_suppl.1510] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
1510 Background: BRCA1/2 test results have historically been disclosed in person (IPD) by a certified genetic counselor (GC). Greater consumer demand and access to BRCA1/2 testing, and greater prevalence and acceptance of telemedicine, have interested providers in conducting BRCA1/2 testing and disclosing results by telephone (TD) and internet. GC and consumer experiences and opinions about TD have not been well described. Methods: To determine experience, opinions and interest in TD of BRCA1/2 test results we conducted semi-structured interviews with 194 GC recruited via NSGC Cancer Special Interest Group and with 30 consumers (to date) less than 9 months post IPD of BRCA1/2 test results at two cancer centers. Descriptive statistics characterize GC and consumer experiences and opinions. Results: 98% GC had provided TD; 46% rarely. Most frequent reasons for TD: perceived consumer hardship of IPD (n = 190); consumer preference (n = 49) and medical benefit (n = 30). GC comfort with TD varied by test result (true negative [TN] 77%, indeterminate [IND] 49%; mutation carriers [MC] 37%; variant of unknown significance [VUS] 33%). GC cited consumer convenience (n = 132), medical (n = 71) and psychological benefit (n = 42), and greater GC counseling capacity (n = 33) as TD advantages. No nonverbal communication (n = 161), poorer communication/understanding (n = 67), and difficulty explaining complex results (n = 41) were disadvantages GC most frequently reported. 46% post-IPD consumers reported interest in TD; interest varied by test result (VUS 67%; IND, 63%; TN 57%; MC 25%). Consumers’ perceived advantages: convenience (n = 22) and medical benefit (n = 9); and disadvantage to TD; lack of visual and personal connection with GC (n = 18). Conclusions: Results of the ongoing study suggest many consumers of BRCA1/2 testing are interested in, and nearly all GC have conducted, TD. GC and consumers share perceptions of TD convenience, and of challenges of lack of visual cues, however, GC comfort with, and consumer preference for, TD vary differently by test result. Given consumer and provider interest, longitudinal study of TD impact on knowledge, risk perception, communication, and health behaviors, and their mediators will be critical to develop policy and procedures optimizing adaptive responses to TD. No significant financial relationships to disclose.
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Affiliation(s)
- L. J. Patrick-Miller
- The Cancer Institute of New Jersey, New Brunswick, NJ; Fox Chase Cancer Center, Philadelphia, PA; The University of Chicago, Chicago, IL
| | - D. Fetzer
- The Cancer Institute of New Jersey, New Brunswick, NJ; Fox Chase Cancer Center, Philadelphia, PA; The University of Chicago, Chicago, IL
| | - H. Schmidheiser
- The Cancer Institute of New Jersey, New Brunswick, NJ; Fox Chase Cancer Center, Philadelphia, PA; The University of Chicago, Chicago, IL
| | - M. Daly
- The Cancer Institute of New Jersey, New Brunswick, NJ; Fox Chase Cancer Center, Philadelphia, PA; The University of Chicago, Chicago, IL
| | - D. Toppmeyer
- The Cancer Institute of New Jersey, New Brunswick, NJ; Fox Chase Cancer Center, Philadelphia, PA; The University of Chicago, Chicago, IL
| | - O. Olopade
- The Cancer Institute of New Jersey, New Brunswick, NJ; Fox Chase Cancer Center, Philadelphia, PA; The University of Chicago, Chicago, IL
| | - A. Bradbury
- The Cancer Institute of New Jersey, New Brunswick, NJ; Fox Chase Cancer Center, Philadelphia, PA; The University of Chicago, Chicago, IL
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Bradbury A. Message from the Editors. Protein Eng Des Sel 2008; 22:111. [DOI: 10.1093/protein/gzn082] [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: 11/13/2022] Open
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Bradbury A. The use of phage display in neurobiology. ACTA ACUST UNITED AC 2008; Chapter 5:Unit 5.12. [PMID: 18428495 DOI: 10.1002/0471142301.ns0100s07] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
Phage display is a technique that involves the coupling of phenotype to genotype in a selectable format. It has been extensively used in molecular biology to study protein-protein interactions, receptor and antibody binding sites, and immune responses; to modify protein properties; and to select antibodies against a wide range of different antigens. In the format most often used, a polypeptide is displayed on the surface of a filamentous phage by genetic fusion to one of the coat proteins, creating a chimeric coat protein. As the gene encoding the chimeric coat protein is packaged within the phage, selection of the phage on the basis of the binding properties of the polypeptide displayed on the surface simultaneously results in the isolation of the gene encoding the polypeptide. This unit describes the background of the technique and illustrates how it has been applied to a number of different problems, each of which has its neurobiological counterparts.
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Affiliation(s)
- A Bradbury
- Los Alamos National Laboratories, Los Alamos, New Mexico, USA
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