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Knisely A, Hinchcliff E, Fellman B, Mosley A, Lito K, Hull S, Westin SN, Sood AK, Schmeler KM, Taylor JS, Huang SY, Sheth RA, Lu KH, Jazaeri AA. Phase 1b study of intraperitoneal ipilimumab and nivolumab in patients with recurrent gynecologic malignancies with peritoneal carcinomatosis. Med 2024; 5:311-320.e3. [PMID: 38471508 PMCID: PMC11015975 DOI: 10.1016/j.medj.2024.02.003] [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: 09/22/2023] [Revised: 12/04/2023] [Accepted: 02/02/2024] [Indexed: 03/14/2024]
Abstract
BACKGROUND Intravenous immune checkpoint blockade (ICB) has shown poor response rates in recurrent gynecologic malignancies. Intraperitoneal (i.p.) ICB may result in enhanced T cell activation and anti-tumor immunity. METHODS In this phase 1b study, registered at Clinical. TRIALS gov (NCT03508570), initial cohorts received i.p. nivolumab monotherapy, and subsequent cohorts received combination i.p. nivolumab every 2 weeks and i.p. ipilimumab every 6 weeks, guided by a Bayesian design. The primary objective was determination of the recommended phase 2 dose (RP2D) of the combination. Secondary outcomes included toxicity, objective response rate (ORR), progression-free survival (PFS), and overall survival (OS). FINDINGS The trial enrolled 23 patients: 18 with ovarian cancer, 2 with uterine cancer, and 3 with cervical cancer. Study evaluable patients (n = 16) received a median of 2 prior lines of therapy (range: 1-8). Partial response was observed in 2 patients (12.5%; 1 ovarian, 1 uterine), and complete response was observed in 1 patient (6.3%) with cervical cancer, for an ORR of 18.8% (95% confidence interval: 4.0%-45.6%). The median duration of response was 14.8 months (range: 4.1-20.8), with one complete response ongoing. Median PFS and OS were 2.7 months and not reached, respectively. Grade 3 or higher immune-related adverse events occurred in 2 (8.7%) patients. CONCLUSIONS i.p. administration of dual ICB is safe and demonstrated durable responses in a subset of patients with advanced gynecologic malignancy. The RP2D is 3 mg/kg i.p. nivolumab every 2 weeks plus 1 mg/kg ipilimumab every 6 weeks. FUNDING This work was funded by Bristol Myers Squibb (CA209-9C7), an MD Anderson Cancer Center Support Grant (CA016672), the Ovarian Cancer Moon Shots Program, the Emerson Collective Fund, and a T32 training grant (CA101642).
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Affiliation(s)
- Anne Knisely
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Emily Hinchcliff
- Division of Gynecologic Oncology, Robert H. Lurie Comprehensive Cancer Center, Northwestern Medicine, Chicago, IL, USA
| | - Bryan Fellman
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Ann Mosley
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Kathryn Lito
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Sara Hull
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Shannon N Westin
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Anil K Sood
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Kathleen M Schmeler
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jolyn S Taylor
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Steven Y Huang
- Department of Interventional Radiology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Rahul A Sheth
- Department of Interventional Radiology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Karen H Lu
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Amir A Jazaeri
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
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Knisely A, Iniesta MD, Marten CA, Chisholm G, Schmeler KM, Taylor JS. Metronidazole and cefazolin vs cefazolin alone for surgical site infection prophylaxis in gynecologic surgery at a comprehensive cancer center. Am J Obstet Gynecol 2024:S0002-9378(24)00507-6. [PMID: 38599478 DOI: 10.1016/j.ajog.2024.03.043] [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: 01/15/2024] [Revised: 03/21/2024] [Accepted: 03/24/2024] [Indexed: 04/12/2024]
Abstract
BACKGROUND Surgical site infection is one of the most common complications of gynecologic cancer surgery. Current guidelines recommend the administration of cefazolin preoperatively to reduce surgical site infection rates for patients undergoing clean-contaminated surgeries such as hysterectomy. OBJECTIVE To evaluate the impact of a quality improvement project adding metronidazole to cefazolin for antibiotic prophylaxis on surgical site infection rate for women undergoing gynecologic surgery at a comprehensive cancer center. STUDY DESIGN This retrospective, single-center cohort study included patients who underwent surgery in the gynecologic oncology department from May 2017 to June 2023. Patients with penicillin allergies and those undergoing concomitant bowel resections and/or joint cases were excluded. The preintervention group patients had surgery from May 2017 to April 2022, and the postintervention group patients had surgery from April 2022 to June 2023. The primary outcome was a 30-day surgical site infection rate. Sensitivity analyses were performed to compare surgical site infection rates on the basis of actual antibiotics received and for those who had a hysterectomy. Factors independently associated with surgical site infection were identified using a multivariable logistic regression model adjusting for confounding variables. RESULTS Of 3343 patients, 2572 (76.9%) and 771 (23.1%) were in the pre-post intervention groups, respectively. Most patients (74.7%) had a hysterectomy performed. Thirty-four percent of cases were for nononcologic (benign) indications. Preintervention patients were more likely to receive appropriate preoperative antibiotics (95.6% vs 90.7%; P<.001). The overall surgical site infection rate before the intervention was 4.7% compared with 2.6% after (P=.010). The surgical site infection rate for all patients who underwent hysterectomy was 4.9% (preintervention) vs 2.8% (postintervention) (P=.036); a similar trend was seen for benign cases (4.4% vs 2.4%; P=.159). On multivariable analysis, the odds ratio for surgical site infection was 0.49 (95% confidence interval, 0.38-0.63) for the postintervention compared with the preintervention group (P<.001). In a sensitivity analysis (n=3087), the surgical site infection rate was 4.5% for those who received cefazolin alone compared with 2.3% for those who received cefazolin plus metronidazole, with significantly decreased odds of surgical site infection for the cefazolin plus metronidazole group (adjusted odds ratio, 0.40 [95% confidence interval, 0.30-0.53]; P<.001). Among only those who had a hysterectomy performed, the odds of surgical site infection were significantly reduced for those in the postintervention group (adjusted odds ratio, 0.63 [95% confidence interval, 0.47-0.86]; P=.003). CONCLUSION The addition of metronidazole to cefazolin before gynecologic surgery decreased the surgical site infection rate by half, even after accounting for other known predictors of surgical site infection and differences in practice patterns over time. Providers should consider this combination regimen in women undergoing gynecologic surgery, especially for cases involving hysterectomy.
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Affiliation(s)
- Anne Knisely
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Maria D Iniesta
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Claire A Marten
- Division of Pharmacy, Department of Pharmacy Clinical Programs, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Gary Chisholm
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Kathleen M Schmeler
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Jolyn S Taylor
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX.
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Hinchcliff EM, Knisely A, Adjei N, Fellman B, Yuan Y, Patel A, Xu C, Westin SN, Sood AK, Soliman PT, Shafer A, Fleming ND, Gershenson DM, Vikram R, Bathala T, Vining D, Ganeshan DM, Lu KH, Sun CC, Meyer LA, Jazaeri AA. Randomized phase 2 trial of tremelimumab and durvalumab in combination versus sequentially in recurrent platinum-resistant ovarian cancer. Cancer 2024; 130:1061-1071. [PMID: 38009662 DOI: 10.1002/cncr.35126] [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: 08/03/2023] [Revised: 10/17/2023] [Accepted: 10/19/2023] [Indexed: 11/29/2023]
Abstract
BACKGROUND Single-agent immune checkpoint inhibitors (ICIs) have demonstrated limited responses in recurrent ovarian cancer; however, 30%-40% of patients achieve stable disease. The primary objective was to estimate progression-free survival (PFS) after sequential versus combination cytotoxic T-lymphocyte antigen 4 and programmed death ligand 1 ICIs in patients with platinum-resistant high-grade serous ovarian cancer (HGSOC). METHODS Patients were randomized to a sequential arm (tremelimumab followed by durvalumab on progression) or a combination arm (tremelimumab plus durvalumab, followed by durvalumab) via a Bayesian adaptive design that made it more likely for patients to be randomized to the more effective arm. The primary end point was immune-related PFS (irPFS). RESULTS Sixty-one subjects were randomized to sequential (n = 38) or combination therapy (n = 23). Thirteen patients (34.2%) in the sequential arm received durvalumab. There was no difference in PFS in the sequential arm (1.84 months; 95% CI, 1.77-2.17 months) compared with the combination arm (1.87 months; 95% CI, 1.77-2.43 months) (p = .402). In the sequential arm, no responses were observed, although 12 patients (31.6%) demonstrated stable disease. In the combination arm, two patients (8.7%) had partial response, whereas one patient (4.4%) had stable disease. Adverse events were consistent with those previously reported for ICIs. Patient-reported outcomes were similar in both arms. CONCLUSIONS There was no difference in irPFS for combination tremelimumab plus durvalumab compared to tremelimumab alone (administered as part of a sequential treatment strategy) in a heavily pretreated population of patients with platinum-resistant HGSOC. Response rates were comparable to prior reports, although the combination regimen did not add significant benefit, as has been previously described.
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Affiliation(s)
- Emily M Hinchcliff
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Anne Knisely
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Naomi Adjei
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Bryan Fellman
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Ying Yuan
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Ami Patel
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Cai Xu
- Department of Symptom Research, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Shannon N Westin
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Anil K Sood
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Pamela T Soliman
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Aaron Shafer
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Nicole D Fleming
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - David M Gershenson
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Raghunandan Vikram
- Department of Radiology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Tharakeswara Bathala
- Department of Radiology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - David Vining
- Department of Radiology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Dhakshina M Ganeshan
- Department of Radiology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Karen H Lu
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Charlotte C Sun
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Larissa A Meyer
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Amir A Jazaeri
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
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Knisely A, Iniesta MD, Batman S, Meyer LA, Soliman PT, Cain KE, Marten C, Chisholm G, Schmeler KM, Taylor JS, Fleming ND. Efficacy, safety, and feasibility of Apixaban for postoperative venous thromboembolism prophylaxis following open gynecologic cancer surgery at a comprehensive cancer center. Gynecol Oncol 2024:S0090-8258(24)00065-9. [PMID: 38368180 DOI: 10.1016/j.ygyno.2024.01.039] [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: 01/10/2024] [Revised: 01/22/2024] [Accepted: 01/25/2024] [Indexed: 02/19/2024]
Abstract
OBJECTIVES To evaluate safety, efficacy, and feasibility of apixaban for postoperative venous thromboembolism (VTE) prophylaxis following open gynecologic cancer surgery at a comprehensive cancer center. METHODS This retrospective, cohort study included patients with gynecologic cancer who underwent open surgery between 3/2021 and 3/2023 and received 28-day postoperative VTE prophylaxis. Patients on therapeutic anticoagulation preoperatively were excluded. Predictors of 90- and 30-day VTE and 30-day bleeding events were determined using multivariable logistic regression, adjusting for known confounders. RESULTS 452 patients were included in the cohort: 348 received apixaban and 104 received enoxaparin. Those who received enoxaparin were more likely to be American Society of Anesthesiologists class III/IV (compared to I/II) (p = 0.033), current or former smokers (p = 0.012) and have a higher BMI (p < 0.001), Charlson Comorbidity Index (p = 0.005), and age (p = 0.046). 30-day VTE rate was significantly lower in the apixaban group (0.6%) compared to the enoxaparin group (6.2%) (adjusted OR 0.13, 95% CI 0.03-0.56; p = 0.006). 90-day VTE rate was 2.7% and 6.2% in the apixaban and enoxaparin groups, respectively (adjusted OR 0.85, 95% CI 0.38-1.92; p = 0.704). Major bleeding complications (2.4% vs. 2.0%) and minor bleeding complications (0.9% vs. 3.0%) were similar in the apixaban and enoxaparin groups, respectively, on multivariate analyses. The median patient out of pocket cost was $10 (IQR 0.0-40.0) for apixaban and $20 (IQR 3.7-67.7) for enoxaparin (p = 0.001). CONCLUSIONS Our findings along with previously published data suggest that apixaban should be considered the standard of care for VTE prophylaxis in patients undergoing open surgery for gynecologic malignancies.
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Affiliation(s)
- Anne Knisely
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Maria D Iniesta
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Samantha Batman
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Larissa A Meyer
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Pamela T Soliman
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Katherine E Cain
- Division of Pharmacy, Department of Pharmacy Clinical Programs, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Claire Marten
- Division of Pharmacy, Department of Pharmacy Clinical Programs, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Gary Chisholm
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Kathleen M Schmeler
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jolyn S Taylor
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Nicole D Fleming
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
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Amaria R, Knisely A, Vining D, Kopetz S, Overman MJ, Javle M, Antonoff MB, Tzeng CWD, Wolff RA, Pant S, Lito K, Rangel K, Fellman B, Yuan Y, Lu KH, Sakellariou-Thompson D, Haymaker CL, Forget MA, Hwu P, Bernatchez C, Jazaeri AA. Efficacy and safety of autologous tumor-infiltrating lymphocytes in recurrent or refractory ovarian cancer, colorectal cancer, and pancreatic ductal adenocarcinoma. J Immunother Cancer 2024; 12:e006822. [PMID: 38309721 PMCID: PMC10840042 DOI: 10.1136/jitc-2023-006822] [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] [Accepted: 01/09/2024] [Indexed: 02/05/2024] Open
Abstract
BACKGROUND Tumor-infiltrating lymphocyte (TIL) therapy has shown efficacy in metastatic melanoma, non-small cell lung cancer, and other solid tumors. Our preclinical work demonstrated more robust CD8 predominant TIL production when agonistic anti-4-1BB and CD3 antibodies were used in early ex vivo TIL culture. METHODS Patients with treatment-refractory metastatic colorectal (CRC), pancreatic (PDAC) and ovarian (OVCA) cancers were eligible. Lymphodepleting chemotherapy was followed by infusion of ex vivo expanded TIL, manufactured at MD Anderson Cancer Center with IL-2 and agonistic stimulation of CD3 and 4-1BB (urelumab). Patients received up to six doses of high-dose IL-2 after TIL infusion. Primary endpoint was evaluation of objective response rate at 12 weeks using Response Evaluation Criteria in Solid Tumors version 1.1 with secondary endpoints including disease control rate (DCR), duration of response, progression-free survival (PFS), overall survival (OS), and safety. RESULTS 17 patients underwent TIL harvest and 16 were treated on protocol (NCT03610490), including 8 CRC, 5 PDAC, and 3 OVCA patients. Median age was 57.5 (range 33-70) and 50% were females. Median number of lines of prior therapy was 2 (range 1-8). No responses were observed at 12 weeks. Ten subjects achieved at least one stable disease (SD) assessment for a DCR of 62.5% (95% CI 35.4% to 84.8%). Best response included prolonged SD in a patient with PDAC lasting 17 months. Median PFS and OS across cohorts were 2.53 months (95% CI 1.54 to 4.11) and 18.86 months (95% CI 4.86 to NR), respectively. Grade 3 or higher toxicities attributable to therapy were seen in 14 subjects (87.5%; 95% CI 61.7% to 98.4%). Infusion product analysis showed the presence of effector memory cells with high expression of CD39 irrespective of tumor type and low expression of checkpoint markers. CONCLUSIONS TIL manufactured with assistance of 4-1BB and CD3 agonism is feasible and treatment is associated with no new safety signals. While no responses were observed, a significant portion of patients achieved SD suggesting early/partial immunological effect. Further research is required to identify factors associated with resistance and functionally enhance T cells for a more effective therapy.
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Affiliation(s)
- Rodabe Amaria
- Department of Melanoma Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Anne Knisely
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - David Vining
- Department of Diagnostic Radiology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Scott Kopetz
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Michael J Overman
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Milind Javle
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Mara B Antonoff
- Department of Thoracic and Cardiovascular Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Ching-Wei D Tzeng
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Robert A Wolff
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Shubham Pant
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Kathryn Lito
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Kelly Rangel
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Bryan Fellman
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Ying Yuan
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Karen H Lu
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | | | - Cara L Haymaker
- Department of Translational Molecular Pathology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Marie-Andrée Forget
- Department of Melanoma Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | | | - Chantale Bernatchez
- SVP Discovery & Platforms, Therapeutics Discovery, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Amir A Jazaeri
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
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Knisely A, Ahmed J, Stephen B, Piha-Paul SA, Karp D, Zarifa A, Fu S, Hong DS, Rodon Ahnert J, Yap TA, Tsimberidou AM, Alshawa A, Dumbrava EE, Yang Y, Song J, Meric-Bernstam F, Jazaeri AA, Naing A. Phase 1/2 trial of avelumab combined with utomilumab (4-1BB agonist), PF-04518600 (OX40 agonist), or radiotherapy in patients with advanced gynecologic malignancies. Cancer 2024; 130:400-409. [PMID: 37864520 PMCID: PMC10841432 DOI: 10.1002/cncr.35063] [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: 06/28/2023] [Revised: 08/10/2023] [Accepted: 08/16/2023] [Indexed: 10/23/2023]
Abstract
BACKGROUND Immune checkpoint blockade has shown mixed results in advanced/recurrent gynecologic malignancies. Efficacy may be improved through costimulation with OX40 and 4-1BB agonists. The authors sought to evaluate the safety and efficacy of avelumab combined with utomilumab (a 4-1BB agonist), PF-04518600 (an OX40 agonist), and radiotherapy in patients with recurrent gynecologic malignancies. METHODS The primary end point in this six-arm, phase 1/2 trial was safety of the combination regimens. Secondary end points included the objective response rate (ORR) according to Response Evaluation Criteria in Solid Tumors and immune-related Response Evaluation Criteria in Solid Tumors, the disease control rate (DCR), the duration of response, progression-free survival, and overall survival. RESULTS Forty patients were included (35% with cervical cancer, 30% with endometrial cancer, and 35% with ovarian cancer). Most patients (n = 33; 83%) were enrolled in arms A-C (no radiation). Among 35 patients who were evaluable for efficacy, the ORR was 2.9%, and the DCR was 37.1%, with a median duration of stable disease of 5.4 months (interquartile range, 4.1-7.3 months). Patients with cervical cancer in arm A (avelumab and utomilumab; n = 9 evaluable patients) achieved an ORR of 11% and a DCR of 78%. The median progression-free survival was 2.1 months (95% CI, 1.8-3.5 months), and overall survival was 9.4 months (95% CI, 5.6-11.9 months). No dose-limiting toxicities or grade 3-5 immune-related adverse events were observed. CONCLUSIONS The findings from this trial highlight that, in heavily pretreated patients with gynecologic cancer, even multidrug regimens targeting multiple immunologic pathways, although safe, did not produce significant responses. A DCR of 78% in patients with cervical cancer who received avelumab and utomilumab indicates that further research on this combination in select patients may be warranted.
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Affiliation(s)
- Anne Knisely
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Jibran Ahmed
- Department of Investigational Cancer Therapeutics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Bettzy Stephen
- Department of Investigational Cancer Therapeutics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Sarina A Piha-Paul
- Department of Investigational Cancer Therapeutics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Daniel Karp
- Department of Investigational Cancer Therapeutics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Abdulrazzak Zarifa
- Department of Investigational Cancer Therapeutics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Siqing Fu
- Department of Investigational Cancer Therapeutics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - David Sanghyun Hong
- Department of Investigational Cancer Therapeutics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Jordi Rodon Ahnert
- Department of Investigational Cancer Therapeutics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Timothy A Yap
- Department of Investigational Cancer Therapeutics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Apostolia M Tsimberidou
- Department of Investigational Cancer Therapeutics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Anas Alshawa
- Department of Investigational Cancer Therapeutics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Ecaterina E Dumbrava
- Department of Investigational Cancer Therapeutics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Yali Yang
- Department of Investigational Cancer Therapeutics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Juhee Song
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Funda Meric-Bernstam
- Department of Investigational Cancer Therapeutics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Amir A Jazaeri
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Aung Naing
- Department of Investigational Cancer Therapeutics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
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Jazaeri AA, Grisham R, Knisely A, Spranger S, Zamarin D, Hillman RT, Lawson BC, Burns KH, Lee S, Westin SN, Moiso E, Williams MJ, Bardhan NM, Pisanic T, Matulonis U, Weigelt B, Shih I, Konstantinopoulos PA, Gaillard S, Wang L, Aghajanian C, D'Andrea AD, Hammond P, Shah S, Wucherpfennig KW, Lu KH. Transforming ovarian cancer care by targeting minimal residual disease. Med 2023; 4:755-760. [PMID: 37951209 DOI: 10.1016/j.medj.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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Revised: 08/09/2023] [Accepted: 08/22/2023] [Indexed: 11/13/2023]
Abstract
Frontline treatment and resultant cure rates in patients with advanced ovarian cancer have changed little over the past several decades. Here, we outline a multidisciplinary approach aimed at gaining novel therapeutic insights by focusing on the poorly understood minimal residual disease phase of ovarian cancer that leads to eventual incurable recurrences.
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Affiliation(s)
- Amir A Jazaeri
- University of Texas MD Anderson Cancer Center, Houston, TX, USA.
| | - Rachel Grisham
- Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Anne Knisely
- University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Stefani Spranger
- David H. Koch Institute for Integrative Cancer Research, Massachusetts Institute of Technology, Cambridge, MA, USA
| | | | - R Tyler Hillman
- University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | | | | | - Sanghoon Lee
- University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | | | - Enrico Moiso
- David H. Koch Institute for Integrative Cancer Research, Massachusetts Institute of Technology, Cambridge, MA, USA
| | | | - Neelkanth M Bardhan
- David H. Koch Institute for Integrative Cancer Research, Massachusetts Institute of Technology, Cambridge, MA, USA; Break Through Cancer, Cambridge, MA, USA
| | | | | | - Britta Weigelt
- Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - IeMing Shih
- The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Baltimore, MD, USA
| | | | - Stephanie Gaillard
- The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Baltimore, MD, USA
| | - Linghua Wang
- University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | | | | | - Paula Hammond
- David H. Koch Institute for Integrative Cancer Research, Massachusetts Institute of Technology, Cambridge, MA, USA
| | - Sohrab Shah
- Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | | | - Karen H Lu
- University of Texas MD Anderson Cancer Center, Houston, TX, USA
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Knisely A, Seo YD, Wargo JA, Chelvanambi M. Monitoring and Modulating Diet and Gut Microbes to Enhance Response and Reduce Toxicity to Cancer Treatment. Cancers (Basel) 2023; 15:777. [PMID: 36765735 PMCID: PMC9913233 DOI: 10.3390/cancers15030777] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Revised: 01/20/2023] [Accepted: 01/26/2023] [Indexed: 01/28/2023] Open
Abstract
The gut microbiome comprises a diverse array of microbial species that have been shown to dynamically modulate host immunity both locally and systemically, as well as contribute to tumorigenesis. In this review, we discuss the scientific evidence on the role that gut microbes and diet play in response and toxicity to cancer treatment. We highlight studies across multiple cancer cohorts that have shown an association between particular gut microbiome signatures and an improved response to immune checkpoint blockade, chemotherapy, and adoptive cell therapies, as well as the role of particular microbes in driving treatment-related toxicity and how the microbiome can be modulated through strategies, such as fecal transplant. We also summarize the current literature that implicate high fiber and ketogenic diets in improved response rates to immunotherapy and chemotherapy, respectively. Finally, we discuss the relevance of these findings in the context of patient care, advocate for a holistic approach to cancer treatment, and comment on the next frontier of targeted gut and tumor microbiome modulation through novel therapeutics, dietary intervention, and precision-medicine approaches.
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Affiliation(s)
- Anne Knisely
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Yongwoo David Seo
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Jennifer A. Wargo
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Manoj Chelvanambi
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
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Knisely A, Huang Y, Li Y, Prabhu VS, Wright JD. Corrigendum to ‘Adjuvant and first line chemotherapy use for endometrial cancer’. Gynecol Oncol Rep 2022; 46:101112. [PMID: 37082519 PMCID: PMC10111931 DOI: 10.1016/j.gore.2022.101112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
[This corrects the article DOI: 10.1016/j.gore.2022.101002.].
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Knisely A, Huang Y, Li Y, Prabhu VS, Wright JD. Adjuvant and First Line Chemotherapy Use for Endometrial Cancer. Gynecol Oncol Rep 2022; 41:101002. [PMID: 35620299 PMCID: PMC9126968 DOI: 10.1016/j.gore.2022.101002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Revised: 05/07/2022] [Accepted: 05/09/2022] [Indexed: 11/30/2022] Open
Abstract
Among subjects who underwent hysterectomy for endometrial cancer, 19% received adjuvant chemotherapy. Platinum and taxane based chemotherapy is the most commonly used adjuvant chemotherapy. Platinum and taxane combination therapy was used in 48% of patients at first recurrence.
Objective The objective of this study was to describe patterns of utilization of cytotoxic, hormonal, and immunotherapy in patients with endometrial cancer in the adjuvant setting and at the time of first recurrence. Methods We identified patients in the IBM MarketScan database with endometrial cancer who underwent hysterectomy from 2011 to 2019. The use of clinically relevant therapeutic agents and combination regimens was determined in the adjuvant setting and at the time of first recurrence. Results A total of 22,632 patients were identified. Of these, 7,147 patients (31.6%) received adjuvant radiation and 4,381 (19.4%) received adjuvant chemotherapy following surgery. Of those who received adjuvant chemotherapy, the most commonly utilized agents were carboplatin (90.3%), paclitaxel (85.8%), cisplatin (9.4%), docetaxel (9.3%), gemcitabine (3.8%), and doxorubicin (2.0%), while bevacizumab was utilized in 1.5% of patients. A combination of platinum and a taxane were utilized as adjuvant therapy in 88.8% of women. Of the cohort, 1,825 patients (8.1%) recurred, of whom 1,017 patients had already received adjuvant chemotherapy. The median time from hysterectomy to initiation of chemotherapy for recurrence was 13.3 months (IQR: 7.6–23.1 months). Overall, platinum and taxane combination therapy was used in 788 (46.8%) of patients with recurrent disease, platinum alone or with other drugs in 194 (11.5%), taxanes alone or with other drugs in 145 (8.6%), and non-platinum and non-taxane based therapy in 31.3%. Conclusions Among patients with endometrial cancer who underwent hysterectomy, platinum-taxane combination chemotherapy was used in almost 90% of patients who received adjuvant chemotherapy while nearly 70% of patients who recurred were treated with platinum or taxane based therapy at first recurrence.
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Lara OD, Smith M, Wang Y, O'Cearbhaill RE, Blank SV, Kolev V, Carr C, Knisely A, McEachron J, Gabor L, Chapman-Davis E, Cohen S, Fehniger J, Lee YC, Isani S, Liu M, Wright JD, Pothuri B. COVID-19 outcomes of patients with gynecologic cancer in New York City: An updated analysis from the initial surge of the pandemic. Gynecol Oncol 2021; 164:304-310. [PMID: 34922769 PMCID: PMC8648583 DOI: 10.1016/j.ygyno.2021.12.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [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: 09/01/2021] [Revised: 11/16/2021] [Accepted: 12/01/2021] [Indexed: 12/12/2022]
Abstract
Background Despite significant increase in COVID-19 publications, characterization of COVID-19 infection in patients with gynecologic cancer remains limited. Here we present an update of COVID-19 outcomes among people with gynecologic cancer in New York City (NYC) during the initial surge of severe acute respiratory syndrome coronavirus 2 (coronavirus disease 2019 [COVID-19]). Methods Data were abstracted from gynecologic oncology patients with COVID-19 infection among 8 NYC area hospital systems between March and June 2020. Multivariable logistic regression was utilized to estimate associations between factors and COVID-19 related hospitalization and mortality. Results Of 193 patients with gynecologic cancer and COVID-19, the median age at diagnosis was 65.0 years (interquartile range (IQR), 53.0–73.0 years). One hundred six of the 193 patients (54.9%) required hospitalization; among the hospitalized patients, 13 (12.3%) required invasive mechanical ventilation, 39 (36.8%) required ICU admission. Half of the cohort (49.2%) had not received anti-cancer treatment prior to COVID-19 diagnosis. No patients requiring mechanical ventilation survived. Thirty-four of 193 (17.6%) patients died of COVID-19 complications. In multivariable analysis, hospitalization was associated with an age ≥ 65 years (odds ratio [OR] 2.12, 95% confidence interval [CI] 1.11, 4.07), Black race (OR 2.53, CI 1.24, 5.32), performance status ≥2 (OR 3.67, CI 1.25, 13.55) and ≥ 3 comorbidities (OR 2.00, CI 1.05, 3.84). Only former or current history of smoking (OR 2.75, CI 1.21, 6.22) was associated with death due to COVID-19 in multivariable analysis. Administration of cytotoxic chemotherapy within 90 days of COVID-19 diagnosis was not predictive of COVID-19 hospitalization (OR 0.83, CI 0.41, 1.68) or mortality (OR 1.56, CI 0.67, 3.53). Conclusions The case fatality rate among patients with gynecologic malignancy with COVID-19 infection was 17.6%. Cancer-directed therapy was not associated with an increased risk of mortality related to COVID-19 infection.
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Affiliation(s)
- Olivia D Lara
- Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, Laura and Isaac Perlmutter Cancer Center, NYU Langone Health, New York, NY, United States of America
| | - Maria Smith
- Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, Laura and Isaac Perlmutter Cancer Center, NYU Langone Health, New York, NY, United States of America
| | - Yuyan Wang
- Department of Population Health, NYU Langone Health, New York, NY, United States of America
| | - Roisin E O'Cearbhaill
- Department of Medical Oncology, Memorial Sloan Kettering Cancer Center, Weill Cornell Medical College, New York, NY, United States of America
| | - Stephanie V Blank
- Department of Obstetrics, Gynecologic and Reproductive Science, Division of Gynecologic Oncology, Icahn School of Medicine at Mount Sinai, New York, NY, United States of America
| | - Valentin Kolev
- Department of Obstetrics, Gynecologic and Reproductive Science, Division of Gynecologic Oncology, Icahn School of Medicine at Mount Sinai, New York, NY, United States of America
| | - Caitlin Carr
- Department of Obstetrics, Gynecologic and Reproductive Science, Division of Gynecologic Oncology, Icahn School of Medicine at Mount Sinai, New York, NY, United States of America
| | - Anne Knisely
- Department of Obstetrics and Gynecology, College of Physicians and Surgeons, Columbia University, New York, NY, United States of America
| | - Jennifer McEachron
- Department of Obstetrics and Gynecology, State University of New York Downstate Medical Center, Brooklyn, NY, United States of America
| | - Lisa Gabor
- Department of Obstetrics & Gynecology and Women's Health, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, NY, United States of America
| | - Eloise Chapman-Davis
- Department of Obstetrics & Gynecology, Cornell University, New York, NY, United States of America
| | - Seth Cohen
- Department of Medical Oncology, Memorial Sloan Kettering Cancer Center, Weill Cornell Medical College, New York, NY, United States of America
| | - Julia Fehniger
- Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, Laura and Isaac Perlmutter Cancer Center, NYU Langone Health, New York, NY, United States of America
| | - Yi-Chun Lee
- Department of Obstetrics and Gynecology, State University of New York Downstate Medical Center, Brooklyn, NY, United States of America
| | - Sara Isani
- Department of Obstetrics & Gynecology and Women's Health, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, NY, United States of America
| | - Mengling Liu
- Department of Population Health, NYU Langone Health, New York, NY, United States of America; Department of Environmental Medicine, NYU Langone Health, New York, NY, United States of America
| | - Jason D Wright
- Department of Obstetrics and Gynecology, College of Physicians and Surgeons, Columbia University, New York, NY, United States of America
| | - Bhavana Pothuri
- Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, Laura and Isaac Perlmutter Cancer Center, NYU Langone Health, New York, NY, United States of America.
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Knisely A, Huang Y, Gockley A, Melamed A, Tergas A, Clair CS, Hou J, Collado FK, Wright J. Disparities in access to high volume surgeons within high volume hospitals for hysterectomy. Gynecol Oncol 2021. [DOI: 10.1016/s0090-8258(21)00897-0] [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: 10/20/2022]
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13
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Lara OD, Smith MJ, Wang Y, O'Cearbhaill R, Blank SV, Kolev V, Carr C, Knisely A, McEachron J, Gabor L, Chapman-Davis E, Jee J, Fehniger J, Lee YC, Isani S, Liu M, Wright JD, Pothuri B. Racial disparities in patients with coronavirus disease 2019 infection and gynecologic malignancy. Cancer 2020; 127:1057-1067. [PMID: 33294978 DOI: 10.1002/cncr.33335] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [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: 09/17/2020] [Revised: 10/18/2020] [Accepted: 10/22/2020] [Indexed: 12/24/2022]
Abstract
BACKGROUND Mounting evidence suggests disproportionate coronavirus disease 2019 (COVID-19) hospitalizations and deaths because of racial disparities. The association of race in a cohort of gynecologic oncology patients with severe acute respiratory syndrome-coronavirus 2 infection is unknown. METHODS Data were abstracted from gynecologic oncology patients with COVID-19 infection among 8 New York City area hospital systems. A multivariable mixed-effects logistic regression model accounting for county clustering was used to analyze COVID-19-related hospitalization and mortality. RESULTS Of 193 patients who had gynecologic cancer and COVID-19, 67 (34.7%) were Black, and 126 (65.3%) were non-Black. Black patients were more likely to require hospitalization compared with non-Black patients (71.6% [48 of 67] vs 46.0% [58 of 126]; P = .001). Of 34 (17.6%) patients who died from COVID-19, 14 (41.2%) were Black. Among those who were hospitalized, compared with non-Black patients, Black patients were more likely to: have ≥3 comorbidities (81.1% [30 of 37] vs 59.2% [29 of 49]; P = .05), to reside in Brooklyn (81.0% [17 of 21] vs 44.4% [12 of 27]; P = .02), to live with family (69.4% [25 of 36] vs 41.6% [37 of 89]; P = .009), and to have public insurance (79.6% [39 of 49] vs 53.4% [39 of 73]; P = .006). In multivariable analysis, among patients aged <65 years, Black patients were more likely to require hospitalization compared with non-Black patients (odds ratio, 4.87; 95% CI, 1.82-12.99; P = .002). CONCLUSIONS Although Black patients represented only one-third of patients with gynecologic cancer, they accounted for disproportionate rates of hospitalization (>45%) and death (>40%) because of COVID-19 infection; younger Black patients had a nearly 5-fold greater risk of hospitalization. Efforts to understand and improve these disparities in COVID-19 outcomes among Black patients are critical.
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Affiliation(s)
- Olivia D Lara
- Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, Perlmutter Cancer Center, New York University (NYU) Langone Health, New York, New York
| | - Maria J Smith
- Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, Perlmutter Cancer Center, New York University (NYU) Langone Health, New York, New York
| | - Yuyan Wang
- Department of Population Health, NYU Langone Health, New York, New York
| | - Roisin O'Cearbhaill
- Department of Medical Oncology, Memorial Sloan Kettering Cancer Center, Weill Cornell Medical College, New York, New York
| | - Stephanie V Blank
- Department of Obstetrics, Gynecologic and Reproductive Science, Division of Gynecologic Oncology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Valentin Kolev
- Department of Obstetrics, Gynecologic and Reproductive Science, Division of Gynecologic Oncology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Caitlin Carr
- Department of Obstetrics, Gynecologic and Reproductive Science, Division of Gynecologic Oncology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Anne Knisely
- Department of Obstetrics and Gynecology, College of Physicians and Surgeons, Columbia University, New York, New York
| | - Jennifer McEachron
- Department of Obstetrics and Gynecology, State University of New York Downstate Medical Center, Brooklyn, New York
| | - Lisa Gabor
- Department of Obstetrics and Gynecology and Women's Health, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, New York
| | | | - Justin Jee
- Department of Population Health, NYU Langone Health, New York, New York
| | - Julia Fehniger
- Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, Perlmutter Cancer Center, New York University (NYU) Langone Health, New York, New York
| | - Yi-Chun Lee
- Department of Obstetrics and Gynecology, State University of New York Downstate Medical Center, Brooklyn, New York
| | - Sara Isani
- Department of Obstetrics and Gynecology and Women's Health, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, New York
| | - Mengling Liu
- Department of Population Health, NYU Langone Health, New York, New York.,Department of Environmental Medicine, NYU Langone Health, New York, New York
| | - Jason D Wright
- Department of Obstetrics and Gynecology, College of Physicians and Surgeons, Columbia University, New York, New York
| | - Bhavana Pothuri
- Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, Perlmutter Cancer Center, New York University (NYU) Langone Health, New York, New York
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Knisely A, Gamble CR, St Clair CM, Hou JY, Khoury-Collado F, Gockley AA, Wright JD, Melamed A. The Role of Minimally Invasive Surgery in the Care of Women with Ovarian Cancer: A Systematic Review and Meta-analysis. J Minim Invasive Gynecol 2020; 28:537-543. [PMID: 33202311 DOI: 10.1016/j.jmig.2020.11.007] [Citation(s) in RCA: 8] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Revised: 11/10/2020] [Accepted: 11/11/2020] [Indexed: 01/14/2023]
Abstract
OBJECTIVE To synthesize evidence from studies investigating survival outcomes for patients with ovarian cancer undergoing minimally invasive surgery (traditional or robotic laparoscopy) compared with those for patients with ovarian cancer undergoing laparotomy. DATA SOURCES We searched Ovid MEDLINE and Embase (from inception to December 2019). METHODS OF STUDY SELECTION Observational cohort studies and randomized controlled trials that compared risk of recurrence or death between women undergoing minimally invasive and open procedures for staging (10), interval cytoreduction (4), secondary cytoreduction (2), and evaluation of resectability (1) were included. TABULATION, INTEGRATION, AND RESULTS Data on the number of participants, number of deaths and recurrences, and results of analyses of overall or progression-free survival were abstracted for all studies. A random-effects meta-analysis was used to pool the results of studies comparing minimally invasive staging and open staging. The surgical approach (minimally invasive versus open) was not significantly associated with hazard of death or recurrence (pooled hazard ratio 0.92; 95% confidence interval, 0.61-1.38) or all-cause mortality (pooled hazard ratio 0.96; 95% confidence interval, 0.49-1.89). One randomized trial demonstrated that diagnostic laparoscopy could triage patients to neoadjuvant chemotherapy and avoid suboptimal primary surgery, without affecting recurrence-free or overall survival. Most studies included in this review were observational and at high risk for bias, and few studies accounted for potential confounding. CONCLUSION Although existing studies do not demonstrate deleterious survival effects associated with minimally invasive surgery for ovarian cancer, these data must be viewed with caution given the significant methodologic shortcomings in the existing literature.
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Affiliation(s)
- Anne Knisely
- Department of Obstetrics and Gynecology, Columbia University Vagelos College of Physicians and Surgeons, NewYork-Presbyterian/Columbia University Irving Medical Center, New York, New York (all authors)
| | - Charlotte R Gamble
- Department of Obstetrics and Gynecology, Columbia University Vagelos College of Physicians and Surgeons, NewYork-Presbyterian/Columbia University Irving Medical Center, New York, New York (all authors)
| | - Caryn M St Clair
- Department of Obstetrics and Gynecology, Columbia University Vagelos College of Physicians and Surgeons, NewYork-Presbyterian/Columbia University Irving Medical Center, New York, New York (all authors)
| | - June Y Hou
- Department of Obstetrics and Gynecology, Columbia University Vagelos College of Physicians and Surgeons, NewYork-Presbyterian/Columbia University Irving Medical Center, New York, New York (all authors)
| | - Fady Khoury-Collado
- Department of Obstetrics and Gynecology, Columbia University Vagelos College of Physicians and Surgeons, NewYork-Presbyterian/Columbia University Irving Medical Center, New York, New York (all authors)
| | - Allison A Gockley
- Department of Obstetrics and Gynecology, Columbia University Vagelos College of Physicians and Surgeons, NewYork-Presbyterian/Columbia University Irving Medical Center, New York, New York (all authors)
| | - Jason D Wright
- Department of Obstetrics and Gynecology, Columbia University Vagelos College of Physicians and Surgeons, NewYork-Presbyterian/Columbia University Irving Medical Center, New York, New York (all authors)
| | - Alexander Melamed
- Department of Obstetrics and Gynecology, Columbia University Vagelos College of Physicians and Surgeons, NewYork-Presbyterian/Columbia University Irving Medical Center, New York, New York (all authors)..
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15
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Knisely A, Wu J, Kaplan SJ, Zhou ZN, Melamed A, Tergas AI, St Clair CM, Hou JY, Khoury-Collado F, Huang YYC, Hershman DL, Wright JD. Coronavirus Spectrum Infections (COVID-19, MERS, SARS) in Cancer Patients: A Systematic Review of the Literature. Cancer Invest 2020; 38:436-444. [PMID: 32787597 DOI: 10.1080/07357907.2020.1809668] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND Coronavirus 2019 (COVID-19) has spread rapidly around the world to become a global pandemic. There is limited data on the impact of COVID-19 among patients with cancer. METHODS A systematic review was performed to determine outcomes of adult patients with cancer affected by coronavirus infections, specifically SARS, MERS, and COVID-19. Studies were independently screened by two reviewers and assessed for quality and bias. Outcomes measured included study characteristics, cancer type, phase of care at the time of diagnosis, and clinical presentation. Morbidity and mortality outcomes were analyzed to assess the severity of infection as compared to the general population. RESULTS A total of 19 studies with 110 patients were included. Of these, 66.4% had COVID-19 infections, 32.7% MERS and only one patient with SARS. The majority of COVID-19 studies were based on studies in China. There was a 56.6% rate of a severe event, including ICU admission or requiring mechanical ventilation, with an overall 44.5% fatality rate. CONCLUSIONS Patients with cancer with coronavirus infections may be more susceptible to higher morbidity and mortality.
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Affiliation(s)
- Anne Knisely
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York, USA.,New York Presbyterian Hospital, New York, New York, USA
| | - Jenny Wu
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York, USA.,New York Presbyterian Hospital, New York, New York, USA.,Duke University School of Medicine, Durham, North Carolina, USA
| | | | - Zhen Ni Zhou
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York, USA.,New York Presbyterian Hospital, New York, New York, USA
| | - Alexander Melamed
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York, USA.,New York Presbyterian Hospital, New York, New York, USA.,Herbert Irving Comprehensive Cancer Center, New York, New York, USA
| | - Ana I Tergas
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York, USA.,New York Presbyterian Hospital, New York, New York, USA.,Herbert Irving Comprehensive Cancer Center, New York, New York, USA
| | - Caryn M St Clair
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York, USA.,New York Presbyterian Hospital, New York, New York, USA.,Herbert Irving Comprehensive Cancer Center, New York, New York, USA
| | - June Y Hou
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York, USA.,New York Presbyterian Hospital, New York, New York, USA.,Herbert Irving Comprehensive Cancer Center, New York, New York, USA
| | - Fady Khoury-Collado
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York, USA.,New York Presbyterian Hospital, New York, New York, USA.,Herbert Irving Comprehensive Cancer Center, New York, New York, USA
| | - Yolanda Ya-Chin Huang
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York, USA.,New York Presbyterian Hospital, New York, New York, USA
| | - Dawn L Hershman
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York, USA.,New York Presbyterian Hospital, New York, New York, USA.,Herbert Irving Comprehensive Cancer Center, New York, New York, USA
| | - Jason D Wright
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York, USA.,New York Presbyterian Hospital, New York, New York, USA.,Herbert Irving Comprehensive Cancer Center, New York, New York, USA
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Smith M, Lara OD, O'Cearbhaill R, Knisely A, McEachron J, Gabor L, Carr C, Blank S, Prasad-Hayes M, Frey M, Jee J, Fehniger J, Wang Y, Lee YC, Isani S, Wright JD, Pothuri B. Inflammatory markers in gynecologic oncology patients hospitalized with COVID-19 infection. Gynecol Oncol 2020; 159:618-622. [PMID: 33019984 PMCID: PMC7518173 DOI: 10.1016/j.ygyno.2020.09.036] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2020] [Accepted: 09/21/2020] [Indexed: 12/15/2022]
Abstract
Objective Elevated inflammatory markers are predictive of COVID-19 infection severity and mortality. It is unclear if these markers are associated with severe infection in patients with cancer due to underlying tumor related inflammation. We sought to further understand the inflammatory response related to COVID-19 infection in patients with gynecologic cancer. Methods Patients with a history of gynecologic cancer hospitalized for COVID-19 infection with available laboratory data were identified. Admission laboratory values and clinical outcomes were abstracted from electronic medical records. Severe infection was defined as infection requiring ICU admission, mechanical ventilation, or resulting in death. Results 86 patients with gynecologic cancer were hospitalized with COVID-19 infection with a median age of 68.5 years (interquartile range (IQR), 59.0–74.8). Of the 86 patients, 29 (33.7%) patients required ICU admission and 25 (29.1%) patients died of COVID-19 complications. Fifty (58.1%) patients had active cancer and 36 (41.9%) were in remission. Patients with severe infection had significantly higher ferritin (median 1163.0 vs 624.0 ng/mL, p < 0.01), procalcitonin (median 0.8 vs 0.2 ng/mL, p < 0.01), and C-reactive protein (median 142.0 vs 62.3 mg/L, p = 0.02) levels compared to those with moderate infection. White blood cell count, lactate, and creatinine were also associated with severe infection. D-dimer levels were not significantly associated with severe infection (p = 0.20). Conclusions The inflammatory markers ferritin, procalcitonin, and CRP were associated with COVID-19 severity in gynecologic cancer patients and may be used as prognostic markers at the time of admission.
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Affiliation(s)
- Maria Smith
- Department of Obstetrics and Gynecology, NYU Langone Health, New York, NY, United States of America
| | - Olivia D Lara
- Department of Obstetrics and Gynecology, NYU Langone Health, New York, NY, United States of America
| | - Roisin O'Cearbhaill
- Department of Medical Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, United States of America; Weill Cornell Medical College, New York, NY, United States of America
| | - Anne Knisely
- Department of Obstetrics and Gynecology, College of Physicians and Surgeons, Columbia University, New York, NY, United States of America
| | - Jennifer McEachron
- Department of Obstetrics and Gynecology, State University of New York Downstate Medical Center, Brooklyn, NY, United States of America
| | - Lisa Gabor
- Department of Obstetrics & Gynecology and Women's Health, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, NY, United States of America
| | - Caitlin Carr
- Department of Obstetrics, Gynecologic and Reproductive Science, Division of Gynecologic Oncology, Icahn School of Medicine at Mount Sinai, New York, NY, United States of America
| | - Stephanie Blank
- Department of Obstetrics, Gynecologic and Reproductive Science, Division of Gynecologic Oncology, Icahn School of Medicine at Mount Sinai, New York, NY, United States of America
| | - Monica Prasad-Hayes
- Department of Obstetrics, Gynecologic and Reproductive Science, Division of Gynecologic Oncology, Icahn School of Medicine at Mount Sinai, New York, NY, United States of America
| | - Melissa Frey
- Department of Obstetrics and Gynecology, Weill Cornell Medicine, New York, NY, United States of America
| | - Justin Jee
- Department of Medical Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, United States of America
| | - Julia Fehniger
- Department of Obstetrics and Gynecology, NYU Langone Health, New York, NY, United States of America
| | - Yuyan Wang
- Department of Population Health, NYU Langone Health, New York, NY, United States of America
| | - Yi-Chun Lee
- Department of Obstetrics and Gynecology, State University of New York Downstate Medical Center, Brooklyn, NY, United States of America
| | - Sara Isani
- Department of Obstetrics & Gynecology and Women's Health, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, NY, United States of America
| | - Jason D Wright
- Department of Obstetrics and Gynecology, College of Physicians and Surgeons, Columbia University, New York, NY, United States of America
| | - Bhavana Pothuri
- Department of Obstetrics and Gynecology, NYU Langone Health, New York, NY, United States of America.
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Lara OD, O'Cearbhaill RE, Smith MJ, Sutter ME, Knisely A, McEachron J, Gabor LR, Jee J, Fehniger JE, Lee YC, Isani SS, Wright JD, Pothuri B. COVID-19 outcomes of patients with gynecologic cancer in New York City. Cancer 2020; 126:4294-4303. [PMID: 32729142 DOI: 10.1002/cncr.33084] [Citation(s) in RCA: 43] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Revised: 06/18/2020] [Accepted: 06/19/2020] [Indexed: 12/23/2022]
Abstract
BACKGROUND New York City (NYC) is the epicenter of severe acute respiratory syndrome coronavirus 2 (coronavirus disease 2019 [COVID-19]) in the United States. Clinical characteristics and outcomes of vulnerable populations, such as those with gynecologic cancer who develop COVID-19 infections, is limited. METHODS Patients from 6 NYC-area hospital systems with known gynecologic cancer and a COVID-19 diagnosis were identified. Demographic and clinical outcome data were abstracted through a review of electronic medical records. RESULTS Records for 121 patients with gynecologic cancer and COVID-19 were abstracted; the median age at the COVID-19 diagnosis was 64.0 years (interquartile range, 51.0-73.0 years). Sixty-six of the 121 patients (54.5%) required hospitalization; among the hospitalized patients, 45 (68.2%) required respiratory intervention, 20 (30.3%) were admitted to the intensive care unit, and 9 (13.6%) underwent invasive mechanical ventilation. Seventeen patients (14.0%) died of COVID-19 complications. No patient requiring mechanical ventilation survived. On multivariable analysis, hospitalization was associated with an age ≥64 years (risk ratio [RR], 1.73; 95% confidence interval [CI], 1.18-2.51), African American race (RR, 1.56; 95% CI, 1.13-2.15), and 3 or more comorbidities (RR, 1.43; 95% CI, 1.03-1.98). Only recent immunotherapy use (RR, 3.49; 95% CI, 1.08-11.27) was associated with death due to COVID-19 on multivariable analysis; chemotherapy treatment and recent major surgery were not predictive of COVID-19 severity or mortality. CONCLUSIONS The case fatality rate among gynecologic oncology patients with a COVID-19 infection is 14.0%. Recent immunotherapy use is associated with an increased risk of mortality related to COVID-19 infection. LAY SUMMARY The case fatality rate among gynecologic oncology patients with a coronavirus disease 2019 (COVID-19) infection is 14.0%; there is no association between cytotoxic chemotherapy and cancer-directed surgery and COVID-19 severity or death. As such, patients can be counseled regarding the safety of continued anticancer treatments during the pandemic. This is important because the ability to continue cancer therapies for cancer control and cure is critical.
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Affiliation(s)
- Olivia D Lara
- Department of Obstetrics and Gynecology, Perlmutter Cancer Center, NYU Langone Health, New York, New York
| | - Roisin E O'Cearbhaill
- Department of Medical Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Maria J Smith
- Department of Obstetrics and Gynecology, Perlmutter Cancer Center, NYU Langone Health, New York, New York
| | - Megan E Sutter
- Department of Obstetrics and Gynecology, Perlmutter Cancer Center, NYU Langone Health, New York, New York.,Department of Population Health, NYU Langone Health, New York, New York
| | - Anne Knisely
- Department of Obstetrics and Gynecology, College of Physicians and Surgeons, Columbia University, New York, New York
| | - Jennifer McEachron
- Department of Obstetrics and Gynecology, State University of New York Downstate Medical Center, Brooklyn, New York
| | - Lisa R Gabor
- Department of Obstetrics & Gynecology and Women's Health, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, New York
| | - Justin Jee
- Department of Medical Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Julia E Fehniger
- Department of Obstetrics and Gynecology, Perlmutter Cancer Center, NYU Langone Health, New York, New York
| | - Yi-Chun Lee
- Department of Obstetrics and Gynecology, State University of New York Downstate Medical Center, Brooklyn, New York
| | - Sara S Isani
- Department of Obstetrics & Gynecology and Women's Health, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, New York
| | - Jason D Wright
- Department of Obstetrics and Gynecology, College of Physicians and Surgeons, Columbia University, New York, New York
| | - Bhavana Pothuri
- Department of Obstetrics and Gynecology, Perlmutter Cancer Center, NYU Langone Health, New York, New York
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Knisely A, Huang Y, Melamed A, Tergas AI, St Clair CM, Hou JY, Khoury-Collado F, Ananth CV, Neugut AI, Hershman DL, Wright JD. Travel distance, hospital volume and their association with ovarian cancer short- and long-term outcomes. Gynecol Oncol 2020; 158:415-423. [PMID: 32456990 DOI: 10.1016/j.ygyno.2020.05.017] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [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] [Received: 03/27/2020] [Accepted: 05/12/2020] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To examine patterns of patient travel among women with ovarian cancer and to explore the association between travel distance and short and long-term outcomes. METHODS Women with stage II-IV epithelial ovarian cancer diagnosed from 2004 to 2016 who underwent primary surgery were identified in the National Cancer Database. Mixed-effect log-linear models and proportional hazards models were developed to evaluate the association between travel distance and short and long-term outcomes after propensity score weighting. A further analysis was performed to compare patients who traveled a short distance to a low volume center (Local) to patients who traveled farther to a high volume hospital (Travel). RESULTS We identified 56,834 patients treated in 1201 hospitals. Hispanic women were 58% and black women 64% less likely than white women to travel to a center in the greatest distance quartile for care. Similarly, Medicaid recipients (vs. commercially insured) were less likely to travel to a quartile four hospital (compared to Q1 of distance traveled). Of all patients, 90-day mortality was significantly lower in patients who traveled farther (Q4 vs. Q1; P < 0.0001). Compared to women in the Local group, patients in the Travel group had a decreased 30-day readmission rate. There was no difference in 30-day, 90-day, or 5-year mortality when comparing the Local to the Travel group. CONCLUSIONS Travel distance for ovarian cancer surgery has increased over time. While there may be some short-term benefits in traveling to a regional center for care, there was little difference in long term outcomes based on travel distance.
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Affiliation(s)
- Anne Knisely
- Columbia University College of Physicians and Surgeons, United States of America; New York Presbyterian Hospital, United States of America
| | - Yongmei Huang
- Columbia University College of Physicians and Surgeons, United States of America
| | - Alexander Melamed
- Columbia University College of Physicians and Surgeons, United States of America; New York Presbyterian Hospital, United States of America
| | - Ana I Tergas
- Columbia University College of Physicians and Surgeons, United States of America; Joseph L. Mailman School of Public Health, Columbia University, United States of America; Herbert Irving Comprehensive Cancer Center, United States of America; New York Presbyterian Hospital, United States of America
| | - Caryn M St Clair
- Columbia University College of Physicians and Surgeons, United States of America; Herbert Irving Comprehensive Cancer Center, United States of America; New York Presbyterian Hospital, United States of America
| | - June Y Hou
- Columbia University College of Physicians and Surgeons, United States of America; Herbert Irving Comprehensive Cancer Center, United States of America; New York Presbyterian Hospital, United States of America
| | - Fady Khoury-Collado
- Columbia University College of Physicians and Surgeons, United States of America; Herbert Irving Comprehensive Cancer Center, United States of America; New York Presbyterian Hospital, United States of America
| | - Cande V Ananth
- Joseph L. Mailman School of Public Health, Columbia University, United States of America; Rutgers Robert Wood Johnson Medical School, United States of America; Environmental and Occupational Health Sciences Institute (EOHSI), United States of America
| | - Alfred I Neugut
- Columbia University College of Physicians and Surgeons, United States of America; Joseph L. Mailman School of Public Health, Columbia University, United States of America; Herbert Irving Comprehensive Cancer Center, United States of America; New York Presbyterian Hospital, United States of America
| | - Dawn L Hershman
- Columbia University College of Physicians and Surgeons, United States of America; Joseph L. Mailman School of Public Health, Columbia University, United States of America; Herbert Irving Comprehensive Cancer Center, United States of America; New York Presbyterian Hospital, United States of America
| | - Jason D Wright
- Columbia University College of Physicians and Surgeons, United States of America; Herbert Irving Comprehensive Cancer Center, United States of America; New York Presbyterian Hospital, United States of America.
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Knisely A, Huang Y, Melamed A, Tergas AI, St. Clair CM, Hou JY, Khoury-Collado F, Ananth CV, Neugut AI, Hershman DL, Wright JD. Effect of regionalization of endometrial cancer care on site of care and patient travel. Am J Obstet Gynecol 2020; 222:58.e1-58.e10. [PMID: 31344350 DOI: 10.1016/j.ajog.2019.07.026] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2019] [Revised: 07/10/2019] [Accepted: 07/16/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND Complex oncologic surgeries, including those for endometrial cancer, increasingly have been concentrated to greater-volume centers, owing to previous research that has demonstrated associations between greater surgical volume and improved outcomes. There is a potential for concentration of care to have unwanted consequences, including cost burden, delayed treatment, patient dissatisfaction, and possibly worse clinical outcomes, especially for more vulnerable populations. OBJECTIVE To describe changes in site of care for patients with endometrial cancer in New York State and to determine whether the distance women traveled for hysterectomy has changed over time. STUDY DESIGN We used the New York Statewide Planning and Research Cooperative System to identify women with endometrial cancer who underwent hysterectomy from 2000 to 2014. Demographic and clinical data as well as hospital data were collected. Trends in travel distance (straight-line distance) were analyzed within all hospital referral regions and differences in travel distance over times and across sociodemographic characteristics analyzed. RESULTS We identified 41,179 subjects. The number of hospitals and surgeons performing hysterectomy decreased across all hospital referral regions over time. The decline in the number of hospitals caring for women with endometrial cancer ranged from -16.7% in Syracuse (12 to 10 hospitals) to -76.5% in Rochester (17 to 4 hospitals). Similarly, the percentage of surgeons within a given hospital referral region operating on women declined from -45.2% in Buffalo (84-46 surgeons) to -77.8% in Albany (72 to 16 surgeons). The median distance to the index hospital for patients increased in all Hospital Referral Regions. For residents in Binghamton, median travel distance increased by 46.9 miles (95% confidence interval, 33.8-60.0) whereas distance increased in Elmira by 19.7 miles (95% confidence interval, 7.3-32.1) and by 12.4 miles (95% confidence interval, 6.4-18.4) in Albany. For residents of Binghamton and Albany, there was a greater than 100% increase in distance traveled over the 15-year time period, with increases of 551.8% (46.9 miles; 95% confidence interval, 33.8-60.0 miles) and 102.5% (12.4 miles; 95% confidence interval, 6.4-18.4 miles), respectively. Travel distance increased for all races and regardless of insurance status but was greatest for white patients and those with private insurance (P<.0001 for both). CONCLUSION The number of surgeons and hospitals caring for women with endometrial cancer in New York State has decreased, whereas the distance that patients travel to receive care has increased over time.
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Naik BI, Tsang S, Knisely A, Yerra S, Durieux ME. Retrospective case-control non-inferiority analysis of intravenous lidocaine in a colorectal surgery enhanced recovery program. BMC Anesthesiol 2017; 17:16. [PMID: 28143397 PMCID: PMC5282801 DOI: 10.1186/s12871-017-0306-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [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: 10/20/2016] [Accepted: 01/19/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Enhanced recovery after surgery (ERAS) programs typically utilizes multi-modal analgesia to reduce perioperative opioid consumption. Systemic lidocaine is used in several of these ERAS algorithms and has been shown to reduce opioid use after colorectal surgery. However it is unclear how much the other components of an ERAS protocol contribute to the final outcome. Using a noninferiority analysis we sought to assess the role of perioperative lidocaine in an ERAS program for colorectal surgery, using pain and opioid consumption as outcomes. METHODS We conducted a retrospective review of patients who had received intravenous lidocaine perioperatively during colorectal surgery. We matched them with patients who were managed using a multi-component ERAS protocol, which included perioperative lidocaine. We tested a joint hypothesis of noninferiority of lidocaine infusion to ERAS protocol in postoperative pain scores and opioid consumption. We assigned a noninferiority margin of 1 point (on an 11-point numerical rating scale) difference in pain and a ratio [mean (lidocaine) / mean (ERAS)] of 1.2 in opioid consumption, respectively. RESULTS Fifty-two patients in the lidocaine group were matched with patients in the ERAS group. With regards to opioid consumption, in the overall [1.68 (1.43-1.98)] [odds ratio (95% confidence interval)] analysis and on postoperative day (POD) 1 [2.38 (1.74-3.31)] lidocaine alone was inferior to multi-modal analgesia. On POD 2 and beyond, although the mean odds ratio for opioid consumption was 1.43 [1.43 (1.17-1.73)], the lower limit extended beyond the pre-defined cut-off of 1.2, rendering the outcome inconclusive. For pain scores lidocaine is non-inferior to ERAS [-0.17 (-1.08-0.74)] on POD 2 and beyond. Pain scores on POD 1 and in the overall cohort were inconclusive based on the noninferiority analysis. CONCLUSIONS The addition of a multi-component ERAS protocol to intravenous lidocaine incrementally reduces opioid consumption, most evident on POD 1. For pain scores the data is inconclusive on POD 1, however on POD 2 and beyond lidocaine alone is non-inferior to an ERAS program with lidocaine. Opioid-related complications, including return of bowel function, were not different between the groups despite reduced opioid use in the ERAS group.
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Affiliation(s)
- Bhiken I Naik
- Department of Anesthesiology, University of Virginia, Charlottesville, VA, USA. .,Department of Neurosurgery, University of Virginia, Charlottesville, VA, USA.
| | - Siny Tsang
- Department of Epidemiology, Columbia University, New York, NY, USA
| | - Anne Knisely
- Department of Anesthesiology, University of Virginia, Charlottesville, VA, USA
| | - Sandeep Yerra
- Department of Anesthesiology, University of Virginia, Charlottesville, VA, USA
| | - Marcel E Durieux
- Department of Anesthesiology, University of Virginia, Charlottesville, VA, USA.,Department of Neurosurgery, University of Virginia, Charlottesville, VA, USA
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Naik BI, Durieux ME, Knisely A, Sharma J, Bui-Huynh VC, Yalamuru B, Terkawi AS, Nemergut EC. SEER Sonorheometry Versus Rotational Thromboelastometry in Large Volume Blood Loss Spine Surgery. Anesth Analg 2016; 123:1380-1389. [DOI: 10.1213/ane.0000000000001509] [Citation(s) in RCA: 21] [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] [Indexed: 11/05/2022]
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Harvey R, Malek J, Winder M, Davidson A, Steel T, Mrad M, Barham H, Knisely A, Teo C. Download Sinonasal morbidity following tumour resection with and without nasoseptal flap reconstruction. Rhinology 2015. [DOI: 10.4193/rhin14.247] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Nadler EP, Dickinson E, Knisely A, Zhang XR, Boyle P, Beer-Stolz D, Watkins SC, Ford HR. Expression of inducible nitric oxide synthase and interleukin-12 in experimental necrotizing enterocolitis. J Surg Res 2000; 92:71-7. [PMID: 10864485 DOI: 10.1006/jsre.2000.5877] [Citation(s) in RCA: 176] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Previous investigators have relied on administration of pro-inflammatory cytokines or invasive surgical procedures to reproduce the morphologic changes of necrotizing enterocolitis (NEC) in rats. However, these artificial insults do not mimic the human disease. We developed a reproducible model of NEC in rats that more closely resembles human NEC and determined the pattern of inflammatory cytokine expression in this model. MATERIALS AND METHODS Newborn rats were randomized into four groups. Groups 1 and 2 were breast-fed, while Groups 3 and 4 were gavaged with formula thrice daily. In addition, Groups 2 and 4 were subjected to 3 min of hypoxia thrice daily, prior to each feeding. The rats were killed on day 4 and the distal 2 cm of terminal ileum was harvested for morphological studies and analysis of inflammatory cytokine mRNA expression. RESULTS Nearly 70% of formula-fed neonatal rats displayed moderate or severe morphological abnormalities resembling human NEC. Breast-fed pups had normal histology. The terminal ileum from rats with abnormal histology demonstrated increased inducible nitric oxide synthase (iNOS) expression, decreased interleukin-12 (IL-12) mRNA expression, and enterocyte apoptosis. There was a trend toward upregulation of IFN-gamma mRNA, but no difference in expression of TNF-alpha mRNA. Hypoxia did not significantly alter intestinal morphology or mRNA expression. CONCLUSIONS Formula-fed neonatal rats, with or without hypoxia, exhibit morphological changes in the intestinal epithelium similar to those seen in patients with acute NEC. The mechanism likely involves upregulation of iNOS mRNA, enterocyte apoptosis, and decreased IL-12 production in the intestinal epithelium. This model may offer a simple reproducible method for inducing experimental NEC.
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Affiliation(s)
- E P Nadler
- Department of Surgery, Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania 15213, USA
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Affiliation(s)
- R Jakacki
- Cancer Research Center, Children's Hospital of Philadelphia, Pennsylvania
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