Amphiregulin as a biomarker for monitoring lifethreatening acute graft-versus-host disease: secondary analysis of two prospective clinical trials

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Impact of the Affordable Care Act on Pediatric Proton Radiation Therapy Access

PURPOSE/OBJECTIVE(S)

Previous work has demonstrated that socioeconomic factors affect the use of PT in children1. Medicaid expansion came into effect in 2014. In 2014, there were 15 proton centers in the US, which increased to 31 by 20202. The effects of increased PT center number and expansion of insurance coverage on PT access has yet to be investigated.

MATERIALS/METHODS

This was an observational cohort study using the National Cancer Database (NCDB) to assess for changes in utilization of PT for pediatric cancers before and after Medicaid expansion. Demographics and characteristics were summarized with one-way analysis of variance for continuous variables and χ2 for categorical variables. Data regarding geography of treated patients was suppressed. Logistic regression was performed to investigate the effect of SES and insurance on treatment type. All p values are two-sided, with a significance level of 0.05 used. Statistical analyses were performed in R (version 4.1.2).

RESULTS

There were 17,096 patients diagnosed at ages ≤21 years from 2004-2020 treated with either photon or PT with known insurance status. 14,491 patients were treated with photons; 2,605 patients received PT. The number of uninsured patients dropped after 2014 from 3.5% to 2.0%, p<0.001. The number of patients with Medicaid who received PT increased after 2014 (21.9% to 28.5%, p<0.001). From 2004-2020, PT increased from 0.4% to 12.4%, peaking in 2018 at 13.9%. Patients with private insurance had higher odds (OR1.5, CI 1.28-1.65) of PT compared to those with Medicaid when controlling for the increased likelihood of PT over time. Patients of higher SES had a higher likelihood of getting treated with PT both before and after Medicaid expansion, while those of the lowest quartile SES did not witness a significant change in the proportion of patients being treated with PT, (11.5% to 12.1% after 2014). Utilization based on race did not significantly change after 2014 among White, Black, and Asian/Pacific Islander populations, but did decrease for patients who identified as Spanish/Hispanic origin (16.9% to 15.0%, p<0.001), and American Indians from 0.7 to 1.3% (p<0.001).

CONCLUSION

Despite the benefits of Medicaid expansion from the ACA since 2014, pediatric patients of Black race and Hispanic ethnicity failed to experience improved access to PT. Pediatric patients with private insurance continued to be more likely to receive PT than patients on Medicaid. Investigation by geography, as well as tumor type, is necessary to provide essential data for creating effective policies to increase equitable access to PT.

Levels of Urinary Mercapturic Acids of Acrolein, Methacrolein, Crotonaldehyde, and Methyl Vinyl Ketone in Relationship to Chronic Obstructive Pulmonary Disease in Cigarette Smokers of the Subpopulations and Intermediate Outcome Measures in COPD Study (SPIROMICS)

Cigarette smoking is an established cause of chronic obstructive pulmonary disease (COPD). Numerous studies implicate acrolein, which occurs in relatively high concentrations in cigarette smoke and reacts readily with proteins, as one causative factor for COPD in smokers. Far less is known about the possible roles in COPD of the related α,β-unsaturated carbonyl compounds of cigarette smoke crotonaldehyde, methacrolein, and methyl vinyl ketone. In the study reported here, we analyzed mercapturic acids of these α,β-unsaturated compounds in the urine of 413 confirmed cigarette smokers in the Subpopulations and Intermediate Outcome Measures in COPD Study (SPIROMICS)─202 with COPD and 211 without COPD. The mercapturic acids analyzed were 3-hydroxypropyl mercapturic acid (3-HPMA) from acrolein, 3-hydroxy-1-methylpropyl mercapturic acid (HMPMA-1) from crotonaldehyde, 3-hydroxy-2-methylpropyl mercapturic acid (HMPMA-2) from methacrolein, and 3-hydroxy-3-methylpropyl mercapturic acid (HMPMA-3) from methyl vinyl ketone. In models adjusting for age, sex, race, pack years of tobacco use, and BMI, all four mercapturic acids were increased in individuals with COPD but not significantly. Stratified by the GOLD status, there were increased levels of the metabolites associated with GOLD 3-4 compared to that with GOLD 0, with the methacrolein metabolite HMPMA-2 reaching statistical significance (adjusted odds ratio 1.23 [95% CI: 1.00-1.53]). These results highlight the possible role of methacrolein, which has previously received little attention in this regard, as a causative factor in COPD in cigarette smokers.

Human Effectors of Acute and Chronic GVHD Overexpress CD83 and Predict Mortality

PURPOSE

Acute and chronic GVHD remain major causes of transplant-related morbidity and mortality (TRM) after allogeneic hematopoietic cell transplantation (alloHCT). We have shown CD83 chimeric antigen receptor (CAR) T cells prevent GVHD and kill myeloid leukemia cell lines. In this pilot study, we investigate CD83 expression on GVHD effector cells, correlate these discoveries with clinical outcomes, and evaluate critical therapeutic implications for transplant recipients.

EXPERIMENTAL DESIGN

CD83 expression was evaluated among circulating CD4+ T cells, B-cell subsets, T follicular helper (Tfh) cells, and monocytes from patients with/without acute or chronic GVHD (n = 48 for each group), respectively. CD83 expression was correlated with survival, TRM, and relapse after alloHCT. Differential effects of GVHD therapies on CD83 expression was determined.

RESULTS

CD83 overexpression on CD4+ T cells correlates with reduced survival and increased TRM. Increased CD83+ B cells and Tfh cells, but not monocytes, are associated with poor posttransplant survival. CD83 CAR T eliminate autoreactive CD83+ B cells isolated from patients with chronic GVHD, without B-cell aplasia as observed with CD19 CAR T. We demonstrate robust CD83 antigen density on human acute myeloid leukemia (AML), and confirm potent antileukemic activity of CD83 CAR T in vivo, without observed myeloablation.

CONCLUSIONS

CD83 is a promising diagnostic marker of GVHD and warrants further investigation as a therapeutic target of both GVHD and AML relapse after alloHCT.