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Cummings BM, Carballo V, Kalibatas O, Barysauskas CM, Rao S, Jacobson JO, Sequist TD. Impact of Clinical Process Improvement Training in an Integrated Delivery System. Am J Med Qual 2020; 36:156-162. [PMID: 32734765 DOI: 10.1177/1062860620943960] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Multiple integrated health systems use frontline staff training in quality and process improvement, although the optimal method to determine training success remains unknown. The authors assessed the Partners Clinical Process Improvement Leadership Program's short-term impact by evaluating data in project presentations during 14 courses between 2010 and 2016. Long-term impact was assessed via a graduate survey. Among 262 interprofessional teams, 180 (69%) achieved short-term improvement, including 78 (30%) achieving and 102 (39%) demonstrating improvement toward their project goal. Projects implementing ≥2 interventions were more likely to succeed. Of 231 graduates surveyed, 79% reported the ability to lead and 67% reported actual work on additional quality improvement projects. Ninety-seven percent of alumni reported a positive career impact. Hospital leadership support of clinical process improvement training meets short-term improvement needs and promotes long-term capacity for learning health systems.
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Affiliation(s)
- Brian M Cummings
- Massachusetts General Hospital, Boston, MA Harvard Medical School, Boston, MA Partners HealthCare, Boston, MA Dana-Farber Cancer Institute, Boston, MA Brigham and Women's Hospital, Boston, MA
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McCleary NJ, Greenberg TL, Barysauskas CM, Guerette EJ, Hassan M, Jacobson JO, Schrag D. Oncology Patient Portal Enrollment at a Comprehensive Cancer Center: A Quality Improvement Initiative. J Oncol Pract 2019; 14:e451-e461. [PMID: 30096276 DOI: 10.1200/jop.17.00008] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
PURPOSE Patient portals (PPs) provide patients access to their electronic health record and may facilitate active engagement in their care. Because PP use has not been well studied among patients with cancer, we sought to: understand the willingness of patients with cancer to use the PP, identify barriers to PP use, and improve PP accessibility. MATERIALS AND METHODS As part of an institutional quality improvement initiative, we used a stakeholder-driven approach to examine PP use at the Dana-Farber Cancer Institute (Boston, MA). We conducted a survey across all ambulatory oncology practices as well as staff and patient focus groups in one ambulatory practice. We deployed three interventions to address barriers: staff education, staff-assisted enrollment support, and independent enrollment support. RESULTS In October 2015, 1,019 (87%) of 1,178 eligible patients completed the survey (PP enrolled, 57%; non-PP enrolled, 43%). PP-enrolled patients reported reviewing test results and appointment schedules. Non-PP-enrolled patients cited difficult PP enrollment, lack of computer access, and concern about sharing data electronically as barriers to PP enrollment. Focus groups (staff, n = 20; patient representatives, n = 5) also identified lack of awareness of PP benefits as a barrier. The interventions, deployed from November to December 2015, increased PP enrollment from 47% to 53% by January 2016. CONCLUSION Patients with cancer want to communicate with their team through the PP, but barriers to enrollment impede use. Straightforward system-level interventions may increase enrollment. Further work is necessary to ascertain the degree to which increased PP enrollment leads to greater engagement and better outcomes.
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Affiliation(s)
- Nadine J McCleary
- Dana-Farber/Partners Cancer Care; and Dana-Farber Cancer Institute, Boston, MA
| | - Teresa L Greenberg
- Dana-Farber/Partners Cancer Care; and Dana-Farber Cancer Institute, Boston, MA
| | | | - Elissa J Guerette
- Dana-Farber/Partners Cancer Care; and Dana-Farber Cancer Institute, Boston, MA
| | - Malyun Hassan
- Dana-Farber/Partners Cancer Care; and Dana-Farber Cancer Institute, Boston, MA
| | - Joseph O Jacobson
- Dana-Farber/Partners Cancer Care; and Dana-Farber Cancer Institute, Boston, MA
| | - Deborah Schrag
- Dana-Farber/Partners Cancer Care; and Dana-Farber Cancer Institute, Boston, MA
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Serrano C, Leal A, Kuang Y, Morgan JA, Barysauskas CM, Phallen J, Triplett O, Mariño-Enríquez A, Wagner AJ, Demetri GD, Velculescu VE, Paweletz CP, Fletcher JA, George S. Phase I Study of Rapid Alternation of Sunitinib and Regorafenib for the Treatment of Tyrosine Kinase Inhibitor Refractory Gastrointestinal Stromal Tumors. Clin Cancer Res 2019; 25:7287-7293. [PMID: 31471313 DOI: 10.1158/1078-0432.ccr-19-2150] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2019] [Revised: 08/05/2019] [Accepted: 08/27/2019] [Indexed: 01/03/2023]
Abstract
PURPOSE Polyclonal emergence of KIT secondary mutations is a main mechanism of imatinib progression in gastrointestinal stromal tumor (GIST). Approved KIT inhibitors sunitinib and regorafenib have complementary activity against KIT resistance mutations. Preclinical evidence suggests that rapid alternation of sunitinib and regorafenib broadens the spectrum of imatinib-resistant subclones targeted. PATIENTS AND METHODS Phase Ib study investigating continuous treatment with cycles of sunitinib (3 days) followed by regorafenib (4 days) in patients with tyrosine kinase inhibitor (TKI)-refractory GIST. A 3+3 dosing schema was utilized to determine the recommended phase II dose (RP2D). Plasma samples were analyzed for pharmacokinetics and circulating tumor DNA (ctDNA) studies using targeted error correction sequencing (TEC-seq) and droplet digital PCR (ddPCR). RESULTS Of the 14 patients enrolled, 2 experienced dose-limiting toxicities at dose level 2 (asymptomatic grade 3 hypophosphatemia). Sunitinib 37.5 mg/day and regorafenib 120 mg/day was the RP2D. Treatment was well-tolerated and no unexpected toxicities resulted from the combination. Stable disease was the best response in 4 patients, and median progression-free survival was 1.9 months. Combined assessment of ctDNA with TEC-seq and ddPCR detected plasma mutations in 11 of 12 patients (92%). ctDNA studies showed that KIT secondary mutations remain the main mechanism of resistance in TKI-refractory GIST, revealing effective suppression of KIT-mutant subpopulations in patients benefiting from the combination. CONCLUSIONS Sunitinib and regorafenib combination is feasible and tolerable. Rapid alternation of TKIs with complementary activity might be effective when combining drugs with favorable pharmacokinetics, potentially allowing active doses while minimizing adverse events. Serial monitoring with ctDNA may guide treatment in patients with GIST.
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Affiliation(s)
- César Serrano
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts. .,Department of Pathology, Brigham and Women's Hospital/Harvard Medical School, Boston, Massachusetts.,Sarcoma Translational Research Laboratory, Vall d'Hebron Institute of Oncology; Department of Oncology, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Alessandro Leal
- The Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Yanan Kuang
- Belfer Center for Applied Cancer Science, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Jeffrey A Morgan
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | | | - Jillian Phallen
- The Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Olivia Triplett
- Belfer Center for Applied Cancer Science, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Adrián Mariño-Enríquez
- Department of Pathology, Brigham and Women's Hospital/Harvard Medical School, Boston, Massachusetts
| | - Andrew J Wagner
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - George D Demetri
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts.,Ludwig Center for Cancer Research at Dana-Farber Cancer Institute and Harvard Medical School, Boston Massachusetts
| | - Victor E Velculescu
- The Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Cloud P Paweletz
- Belfer Center for Applied Cancer Science, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Jonathan A Fletcher
- Department of Pathology, Brigham and Women's Hospital/Harvard Medical School, Boston, Massachusetts
| | - Suzanne George
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts.
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Nathenson MJ, Barysauskas CM, Nathenson RA, Regine WF, Hanna N, Sausville E. Surgical resection for recurrent retroperitoneal leiomyosarcoma and liposarcoma. World J Surg Oncol 2018; 16:203. [PMID: 30309356 PMCID: PMC6182828 DOI: 10.1186/s12957-018-1505-4] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2018] [Accepted: 09/28/2018] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND Retroperitoneal soft tissue sarcomas (STS) include a number of histologies but are rare, with approximately 3000 cases in the USA per year. Retroperitoneal STS have a high incidence of local and distant recurrence. The purpose of this study was to review the University of Maryland Medical Center's (UMMC) treatment experience of retroperitoneal STS, where the patient population served represents a diverse socioeconomic and ethnic catchment. METHODS IRB approval was obtained. We constructed a de-identified database of patients diagnosed with retroperitoneal liposarcomas (LPS) or leiomyosarcomas (LMS) treated at UMMC between 2000 and 2013. A total of 49 patients (Pts) with retroperitoneal STS met our eligibility criteria. Kaplan-Meier plots were used to graphically portray progression-free survival (PFS) and overall survival (OS). The log-rank test was used to compare time-to-event distributions. RESULTS The median OS for all patients (Pts) was 6.3 years, and the 2-year OS rate was 81%. The median PFS for all Pts was 1.8 years, and the 2-year PFS rate was 45%. There was no difference in OS and PFS among LMS and LPS patients; the median OS for LMS was 3.8 years vs. LPS 6.4 years (p = 0.33), and the median PFS for LMS was 1.2 years vs. LPS 2.5 years (p = 0.28). There was a significant difference between histology and race (p = 0.001). LPS were primarily Caucasian 86% vs. 14% black, whereas LMS were primarily black 52% vs. 33% Caucasian. OS was influenced by functional status, gender, American Joint Committee on Cancer (AJCC) stage, grade, histology, tumor size, and extent of resection. PFS was influenced by AJCC stage, grade, and extent of resection. Neither adjuvant chemotherapy (1 Pt) nor neoadjuvant/adjuvant radiation therapy (18 Pts) influenced OS or PFS. There was a non-significant difference that Pts who could undergo resection of local recurrence had improved 2-year OS, with 100% LMS and LPS compared to 2-year OS of 71% (LMS) and 78% (LPS) not undergoing resection of local recurrence. CONCLUSIONS This study suggests a higher incidence of leiomyosarcoma in the African-American population. This study confirms the prognostic importance of grade, tumor size, AJCC stage, histology, and extent of resection in patient outcomes, at a large substantially diverse academic medical center. Future research into the biological features of liposarcoma and leiomyosarcoma Pts imparting these characteristics will be important to define.
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Affiliation(s)
- Michael J Nathenson
- Center for Sarcoma and Bone Oncology, Dana-Farber Cancer Institute, 450 Brookline Ave, Boston, MA 02215 USA
| | - Constance M Barysauskas
- Department of Biostatistics and Computational Biology, Dana-Farber Cancer Institute, 450 Brookline Ave, Boston, MA 02215 USA
| | - Robert A Nathenson
- University of Pennsylvania, 3440 Market Street Philadelphia, Philadelphia, PA 19146 USA
| | - William F Regine
- University of Maryland, Greenebaum Cancer Center, South Greene Street Suite 9d10 Baltimore, Baltimore, MD 21201 USA
| | - Nader Hanna
- University of Maryland, Greenebaum Cancer Center, South Greene Street Suite 9d10 Baltimore, Baltimore, MD 21201 USA
| | - Edward Sausville
- University of Maryland, Greenebaum Cancer Center, South Greene Street Suite 9d10 Baltimore, Baltimore, MD 21201 USA
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Cote GM, Barysauskas CM, DeLaney TF, Schwab J, Raskin K, Lozano-Calderon S, Bernstein K, Mullen JT, Haynes AB, Hornicek F, Chen YLE, Choy E. A Phase 1 Study of Nilotinib Plus Radiation in High-Risk Chordoma. Int J Radiat Oncol Biol Phys 2018; 102:1496-1504. [PMID: 30077789 DOI: 10.1016/j.ijrobp.2018.07.2013] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2018] [Revised: 06/25/2018] [Accepted: 07/26/2018] [Indexed: 10/28/2022]
Abstract
PURPOSE Chordomas are malignant tumors arising from remnant notochordal tissue. Despite improved local control with preoperative/postoperative radiation therapy (RT), progression-free survival and overall survival (OS) remain poor in patients with high-risk features. Chordoma has been identified to express and activate platelet-derived growth factor receptor signaling. We conducted a phase 1 trial to identify the maximum tolerated dose (MTD), safety, and feasibility of nilotinib with RT as either preoperative or definitive treatment for patients with high-risk chordoma. METHODS AND MATERIALS We recruited 23 patients with high-risk, nonmetastatic chordoma. High risk was defined as the presence of any of the following: local recurrence after surgery, previous intralesional resection, unplanned incomplete resection, unresectable or marginally resectable disease based on locally advanced stage, or declining surgery because of excessive morbidity. Patients were treated with nilotinib and concurrent RT to 50.4 Gy relative biological effectiveness (RBE) followed by surgery and postoperative RT to a cumulative dose up to 70.2 Gy RBE or definitively up to 77.4 Gy RBE without surgery. On completion of RT, patients were eligible to continue nilotinib until disease progression. RESULTS In patients receiving nilotinib 200 mg twice daily with RT, 3 dose-limiting toxicities (DLT) occurred in 5 patients. One DLT was seen among 6 patients receiving nilotinib 200 mg daily with RT. Therefore, 200 mg daily was declared the maximum tolerated dose. Eleven additional patients received nilotinib with RT at the maximum tolerated dose, and 1 additional DLT occurred. The objective best response rate was 6% (1 of 18 patients, 95% confidence interval [CI], 0.1%-27%). The median progression-free survival was 58.15 months (95% CI, 39.10-∞). The median OS was 61.5 months (43.1-∞), and the 2-year OS rate was 95%. CONCLUSIONS Nilotinib 200 mg/d with RT is safe and tolerated in patients with high-risk chordoma. Long-term follow-up is needed to understand whether nilotinib combined with RT, with or without surgery, adds greater improvement to progression-free survival or OS than with RT with or without surgery alone in patients with high-risk chordoma.
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Affiliation(s)
- Gregory M Cote
- Division of Hematology-Oncology, Massachusetts General Hospital, Boston, Massachusetts; Center for Sarcoma and Connective Tissue Oncology, Massachusetts General Hospital, Boston, Massachusetts.
| | | | - Thomas F DeLaney
- Center for Sarcoma and Connective Tissue Oncology, Massachusetts General Hospital, Boston, Massachusetts; Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | - Joseph Schwab
- Center for Sarcoma and Connective Tissue Oncology, Massachusetts General Hospital, Boston, Massachusetts; Orthopaedic Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | - Kevin Raskin
- Center for Sarcoma and Connective Tissue Oncology, Massachusetts General Hospital, Boston, Massachusetts; Orthopaedic Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | - Santiago Lozano-Calderon
- Center for Sarcoma and Connective Tissue Oncology, Massachusetts General Hospital, Boston, Massachusetts; Orthopaedic Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | - Karen Bernstein
- Center for Sarcoma and Connective Tissue Oncology, Massachusetts General Hospital, Boston, Massachusetts; Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | - John T Mullen
- Center for Sarcoma and Connective Tissue Oncology, Massachusetts General Hospital, Boston, Massachusetts; Division of Surgical Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | - Alex B Haynes
- Center for Sarcoma and Connective Tissue Oncology, Massachusetts General Hospital, Boston, Massachusetts; Division of Surgical Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | - Francis Hornicek
- Center for Sarcoma and Connective Tissue Oncology, Massachusetts General Hospital, Boston, Massachusetts; Orthopaedic Surgery, University of California, Los Angeles, Los Angeles, California
| | - Yen-Lin E Chen
- Center for Sarcoma and Connective Tissue Oncology, Massachusetts General Hospital, Boston, Massachusetts; Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | - Edwin Choy
- Division of Hematology-Oncology, Massachusetts General Hospital, Boston, Massachusetts; Center for Sarcoma and Connective Tissue Oncology, Massachusetts General Hospital, Boston, Massachusetts
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Pretz JL, Barysauskas CM, George S, Hornick JL, Raut CP, Chen YLE, Marcus KJ, Choy E, Hornicek F, Ready JE, DeLaney TF, Baldini EH. Localized Adult Ewing Sarcoma: Favorable Outcomes with Alternating Vincristine, Doxorubicin, Cyclophosphamide, and Ifosfamide, Etoposide (VDC/IE)-Based Multimodality Therapy. Oncologist 2017; 22:1265-1270. [PMID: 28550026 PMCID: PMC5634761 DOI: 10.1634/theoncologist.2016-0463] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [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: 11/23/2016] [Accepted: 03/10/2017] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND In children with localized Ewing sarcoma (ES), addition of ifosfamide and etoposide to cyclophosphamide, doxorubicin, and vincristine (VDC/IE) improved 5-year overall survival (OS) to 70%-80%. Prior to delivery of VDC/IE in adults, 5-year OS was <50%. We reviewed our institutional outcomes for adults with ES who received VDC/IE-based treatment. MATERIALS AND METHODS Between 1997-2013, 67 adults with localized ES were treated with curative intent. Local recurrence-free survival (LRFS), progression-free survival (PFS), and OS were determined using Kaplan-Meier method; comparisons were assessed with log-rank. Proportional hazard models were used to determine predictive factors. RESULTS All patients received VDC/IE (median 14 cycles.) Local therapy was surgery for 33, radiation therapy for 17, or both for 17. Median follow-up for living patients was 5.2 years. Six patients had disease progression on therapy. Site of first failure was local for three, local and distant for two, and distant for ten. Five-year LRFS was 91%; 5-year LRFS was 96% for nonpelvic disease and 64% for pelvic disease (p = .003). Five-year PFS was 66%, and 5-year OS was 79%. On multivariate analysis, pelvic site had a 3.3 times increased risk of progression (p = .01). CONCLUSION Survival for adults with localized ES treated with VDC/IE-based multimodality therapy appears to be better than historical data and similar to excellent outcomes in children. Pelvic site of disease remains a predictor of worse outcome. Given the paucity of literature for adult ES, these data help validate VDC/IE-based therapy as an appropriate treatment approach for this rare disease in adults. IMPLICATIONS FOR PRACTICE Ewing sarcoma (ES) is rare in adults. Treatment approaches for adults have been extrapolated from the pediatric experience, and there is a sense that adults fare less well than children. We reviewed treatment outcomes in adults with localized ES treated with cyclophosphamide, doxorubicin, and vincristine in alternation with ifosfamide and etoposide (VDC/IE) as part of multimodality therapy. Survival outcomes appear to be better than historical data for adults and similar to the excellent outcomes for children. These data help validate VDC/IE-based therapy as an appropriate treatment approach for this rare disease in adults.
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Affiliation(s)
- Jennifer L Pretz
- Department of Radiation Oncology, Dana-Farber Cancer Institute and Brigham & Women's Hospital, Boston, Massachusetts, USA
| | - Constance M Barysauskas
- Department of Biostatistics and Computational Biology, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Suzanne George
- Center for Sarcoma and Bone Oncology, Dana-Farber Cancer Institute and Brigham & Women's Hospital, Boston, Massachusetts, USA
| | - Jason L Hornick
- Department of Pathology, Dana-Farber Cancer Institute and Brigham & Women's Hospital, Boston, Massachusetts, USA
| | - Chandrajit P Raut
- Department of Surgical Oncology, Dana-Farber Cancer Institute and Brigham & Women's Hospital, Boston, Massachusetts, USA
- Center for Sarcoma and Bone Oncology, Dana-Farber Cancer Institute and Brigham & Women's Hospital, Boston, Massachusetts, USA
| | - Yen-Lin E Chen
- Center for Sarcoma and Connective Tissue Oncology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Karen J Marcus
- Department of Radiation Oncology, Dana-Farber Cancer Institute and Brigham & Women's Hospital, Boston, Massachusetts, USA
- Center for Sarcoma and Bone Oncology, Dana-Farber Cancer Institute and Brigham & Women's Hospital, Boston, Massachusetts, USA
| | - Edwin Choy
- Center for Sarcoma and Connective Tissue Oncology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Francis Hornicek
- Center for Sarcoma and Connective Tissue Oncology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - John E Ready
- Center for Sarcoma and Bone Oncology, Dana-Farber Cancer Institute and Brigham & Women's Hospital, Boston, Massachusetts, USA
| | - Thomas F DeLaney
- Department of Surgical Oncology, Dana-Farber Cancer Institute and Brigham & Women's Hospital, Boston, Massachusetts, USA
- Center for Sarcoma and Connective Tissue Oncology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Elizabeth H Baldini
- Department of Radiation Oncology, Dana-Farber Cancer Institute and Brigham & Women's Hospital, Boston, Massachusetts, USA
- Center for Sarcoma and Bone Oncology, Dana-Farber Cancer Institute and Brigham & Women's Hospital, Boston, Massachusetts, USA
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Ben-Ami E, Barysauskas CM, Solomon S, Tahlil K, Malley R, Hohos M, Polson K, Loucks M, Severgnini M, Patel T, Cunningham A, Rodig SJ, Hodi FS, Morgan JA, Merriam P, Wagner AJ, Shapiro GI, George S. Immunotherapy with single agent nivolumab for advanced leiomyosarcoma of the uterus: Results of a phase 2 study. Cancer 2017; 123:3285-3290. [PMID: 28440953 DOI: 10.1002/cncr.30738] [Citation(s) in RCA: 147] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2016] [Revised: 02/10/2017] [Accepted: 03/22/2017] [Indexed: 01/05/2023]
Abstract
BACKGROUND Immunotherapy has changed the therapeutic landscape in oncology. Advanced uterine leiomyosarcoma (ULMS) remains an incurable disease in most cases, and despite new drug approvals, improvements in overall survival have been modest at best. The goal of this study was to evaluate programmed-death 1 (PD-1) inhibition with nivolumab in this patient population. METHODS This single-center phase 2 trial completed enrollment between May and October 2015. Patients received 3 mg/kg of intravenous nivolumab on day 1 of each 2-week cycle until disease progression or unacceptable toxicity. The primary endpoint was objective response rate. We assessed PD-1, PD-ligand 1 (PD-L1), and PD-L2 expression in archival tumor samples and variations in immune-phenotyping of circulating immune cells during treatment. RESULTS Twelve patients were enrolled in the first stage of the 2-stage design. A median of 5 (range, 2-6) 2-week cycles of nivolumab were administered. Of the 12 patients, none responded to treatment. The overall median progression-free survival was 1.8 months (95% confidence interval, 0.8-unknown). The study did not open the second stage due to lack of benefit as defined by the statistical plan. Archival samples were available for 83% of patients. PD-1 (>3% of cells), PD-L1, and PD-L2 (>5% and >10% of tumor cells, respectively) expression were observed in 20%, 20%, and 90% of samples, respectively. No significant differences were observed between pre- and posttreatment cell phenotypes. CONCLUSION Single-agent nivolumab did not demonstrate a benefit in this cohort of previously treated advanced ULMS patients. Further biomarker-driven approaches and studies evaluating combined immune checkpoint-modulators should be considered. Cancer 2017;123:3285-90. © 2017 American Cancer Society.
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Affiliation(s)
- Eytan Ben-Ami
- Center for Sarcoma and Bone Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Constance M Barysauskas
- Department of Biostatistics and Computational Biology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Sarah Solomon
- Center for Sarcoma and Bone Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Kadija Tahlil
- Center for Sarcoma and Bone Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Rita Malley
- Center for Sarcoma and Bone Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Melissa Hohos
- Center for Sarcoma and Bone Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Kathleen Polson
- Center for Sarcoma and Bone Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Margaret Loucks
- Center for Sarcoma and Bone Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Mariano Severgnini
- Center for Immuno-oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Tara Patel
- Center for Immuno-oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Amy Cunningham
- Center for Immuno-oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Scott J Rodig
- Center for Immuno-oncology, Dana-Farber Cancer Institute, Boston, Massachusetts.,Department of Pathology, Brigham and Women's Hospital, Boston, Massachusetts
| | - F Stephen Hodi
- Center for Immuno-oncology, Dana-Farber Cancer Institute, Boston, Massachusetts.,Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Jeffrey A Morgan
- Center for Sarcoma and Bone Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Priscilla Merriam
- Center for Sarcoma and Bone Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Andrew J Wagner
- Center for Sarcoma and Bone Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Geoffrey I Shapiro
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA.,Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Suzanne George
- Center for Sarcoma and Bone Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
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8
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Schaefer IM, Hornick JL, Barysauskas CM, Raut CP, Patel SA, Royce TJ, Fletcher CDM, Baldini EH. Histologic Appearance After Preoperative Radiation Therapy for Soft Tissue Sarcoma: Assessment of the European Organization for Research and Treatment of Cancer-Soft Tissue and Bone Sarcoma Group Response Score. Int J Radiat Oncol Biol Phys 2017; 98:375-383. [PMID: 28463157 DOI: 10.1016/j.ijrobp.2017.02.087] [Citation(s) in RCA: 55] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2016] [Revised: 02/05/2017] [Accepted: 02/17/2017] [Indexed: 10/20/2022]
Abstract
PURPOSE To critically assess the prognostic value of the European Organization for Research and Treatment of Cancer-Soft Tissue and Bone Sarcoma Group (EORTC-STBSG) response score and define histologic appearance after preoperative radiation therapy (RT) for soft tissue sarcoma (STS). METHODS AND MATERIALS For a cohort of 100 patients with STS of the extremity/trunk treated at our institution with preoperative RT followed by resection, 2 expert sarcoma pathologists evaluated the resected specimens for percent residual viable cells, necrosis, hyalinization/fibrosis, and infarction. The EORTC response score and other predictors of recurrence-free survival (RFS) and overall survival (OS) were assessed by Kaplan-Meier and proportional hazard models. RESULTS Median tumor size was 7.5 cm; 92% were intermediate or high grade. Most common histologies were unclassified sarcoma (34%) and myxofibrosarcoma (25%). Median follow-up was 60 months. The 5-year local recurrence rate was 5%, 5-year RFS was 68%, and 5-year OS was 75%. Distribution of cases according to EORTC response score tiers was as follows: no residual viable tumor for 9 cases (9% pathologic complete response); <1% viable tumor for 0, ≥1% to <10% for 9, ≥10% to <50% for 44, and ≥50% for 38. There was no association between EORTC-STBSG response score and RFS or OS. Conversely, hyalinization/fibrosis was a significant independent favorable predictor for RFS (hazard ratio 0.49, P=.007) and OS (hazard ratio 0.36, P=.02). CONCLUSION Histologic evaluation after preoperative RT for STS showed a 9% pathologic complete response rate. The EORTC-STBSG response score and percent viable cells were not prognostic. Hyalinization/fibrosis was associated with favorable outcome, and if validated, may become a valid endpoint for neoadjuvant trials.
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Affiliation(s)
- Inga-Marie Schaefer
- Department of Pathology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Jason L Hornick
- Department of Pathology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Constance M Barysauskas
- Department of Biostatistics and Computational Biology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts
| | - Chandrajit P Raut
- Division of Surgical Oncology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts; Center for Sarcoma and Bone Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts
| | - Sagar A Patel
- Department of Radiation Oncology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Trevor J Royce
- Department of Radiation Oncology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Christopher D M Fletcher
- Department of Pathology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Elizabeth H Baldini
- Center for Sarcoma and Bone Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts; Department of Radiation Oncology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.
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Patel SA, Royce TJ, Barysauskas CM, Thornton KA, Raut CP, Baldini EH. Surveillance Imaging Patterns and Outcomes Following Radiation Therapy and Radical Resection for Localized Extremity and Trunk Soft Tissue Sarcoma. Ann Surg Oncol 2017; 24:1588-1595. [PMID: 28058559 DOI: 10.1245/s10434-016-5755-5] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2016] [Indexed: 11/18/2022]
Abstract
BACKGROUND Optimal surveillance imaging (SI) regimens following radiation therapy (RT) and radical resection for localized soft tissue sarcoma (STS) are unknown and practice patterns vary. METHODS Between 2006 and 2014, 94 patients with localized STS of the extremity/trunk treated with preoperative RT and radical resection were identified. Timing of local recurrence (LR), distant recurrence (DR), and SI were evaluated. The Kaplan-Meier method was used to determine recurrence-free and overall survival (OS), and the method of recurrence detection (SI or due to signs/symptoms) was determined. RESULTS Median tumor size was 7.5 cm, and 92% were intermediate/high grade. After a median follow-up of 60 months for surviving patients, 30 patients (32%) recurred, including 5 LRs and 26 DRs. The median time to LR and DR was 36.2 months (range 14.4-65.7) and 10.4 months (range 5.2-76.9), respectively, and the 5-year local recurrence-free survival (RFS), distant RFS, and OS was 95, 71, and 76%, respectively. Local SI was performed for 90% of patients, mostly by magnetic resonance imaging (MRI; 91%). Of the five LRs, two were detected by SI and three had signs/symptoms preceding imaging. All patients underwent distant SI. Of the 26 DRs, 23 (88%) were in the lung. SI detected 22 (85%) DRs, and only 4 of 26 had signs/symptoms prompting imaging. CONCLUSION Given excellent local control with RT and radical resection for intermediate/high-grade STS of the extremity/trunk, SI of the primary site should be reserved for select patients at high risk of LR. Conversely, due to frequent occurrence of asymptomatic DR in the lungs, periodic lung SI is appropriate. Routine abdominopelvic SI may not be indicated for most histologies.
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Affiliation(s)
- Sagar A Patel
- Harvard Radiation Oncology Program, Harvard Medical School, Boston, MA, USA
| | - Trevor J Royce
- Harvard Radiation Oncology Program, Harvard Medical School, Boston, MA, USA
| | - Constance M Barysauskas
- Department of Biostatistics and Computational Biology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Katherine A Thornton
- Center for Bone and Soft Tissue Sarcoma, Brigham and Women's Hospital/Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
| | - Chandrajit P Raut
- Center for Bone and Soft Tissue Sarcoma, Brigham and Women's Hospital/Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, USA.,Division of Surgical Oncology, Brigham and Women's Hospital/Dana-Farber Cancer-Institute, Boston, MA, USA
| | - Elizabeth H Baldini
- Center for Bone and Soft Tissue Sarcoma, Brigham and Women's Hospital/Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, USA. .,Department of Radiation Oncology, Brigham and Women's Hospital/Dana-Farber Cancer Institute, Boston, MA, USA.
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10
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Mak KS, Phillips JG, Barysauskas CM, Lee LK, Mannarino EG, Van Benthuysen L, Raut CP, Mullen JT, Fairweather M, DeLaney TF, Baldini EH. Acute gastrointestinal toxicity and bowel bag dose-volume parameters for preoperative radiation therapy for retroperitoneal sarcoma. Pract Radiat Oncol 2016; 6:360-366. [DOI: 10.1016/j.prro.2015.12.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2015] [Revised: 12/13/2015] [Accepted: 12/15/2015] [Indexed: 10/22/2022]
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11
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Ben-Ami E, Barysauskas CM, von Mehren M, Heinrich MC, Corless CL, Butrynski JE, Morgan JA, Wagner AJ, Choy E, Yap JT, Van den Abbeele AD, Solomon SM, Fletcher JA, Demetri GD, George S. Long-term follow-up results of the multicenter phase II trial of regorafenib in patients with metastatic and/or unresectable GI stromal tumor after failure of standard tyrosine kinase inhibitor therapy. Ann Oncol 2016; 27:1794-9. [PMID: 27371698 DOI: 10.1093/annonc/mdw228] [Citation(s) in RCA: 71] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2016] [Accepted: 05/30/2016] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND This investigator-initiated trial provided the justification for the phase III GRID study resulting in worldwide regulatory approval of regorafenib as a third-line therapy for patients with metastatic gastrointestinal stromal tumors (GIST). We report the genotype analyses, long-term safety, and activity results from this initial trial of regorafenib in GIST. PATIENTS AND METHODS The trial was conducted between February 2010 and January 2014, among adult patients with metastatic GIST, after failure of at least imatinib and sunitinib. Patients received regorafenib orally, 160 mg once daily, days 1-21 of a 28-day cycle. Clinical benefit rate (CBR), defined as complete or partial response (PR), or stable disease lasting ≥16 weeks per RECIST 1.1, progression-free survival (PFS), overall survival (OS), long-term safety data, and metabolic response by functional imaging were assessed. RESULTS Thirty-three patients received at least one dose of regorafenib. The median follow-up was 41 months. CBR was documented in 25 of 33 patients [76%; 95% confidence interval (CI) 58% to 89%], including six PRs. The median PFS was 13.2 months (95% CI 9.2-18.3 months) including four patients who remained progression-free at study closure, each achieving clinical benefit for more than 3 years (range 36.8-43.5 months). The median OS was 25 months (95% CI 13.2-39.1 months). Patients whose tumors harbored a KIT exon 11 mutation demonstrated the longest median PFS (13.4 months), whereas patients with KIT/PDGFRA wild-type, non-SDH-deficient tumors experienced a median 1.6 months PFS (P < 0.0001). Long-term safety profile is consistent with previous reports; hand-foot skin reaction and hypertension were the most common reasons for dose reduction. Notably, regorafenib induced objective responses and durable benefit in SDH-deficient GIST. CONCLUSIONS Long-term follow-up of patients with metastatic GIST treated with regorafenib suggests particular benefit among patients with primary KIT exon 11 mutations and those with SDH-deficient GIST. Dose modifications are frequently required to manage treatment-related toxicities. CLINICAL TRIAL NUMBER NCT01068769.
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Affiliation(s)
- E Ben-Ami
- Center for Sarcoma and Bone Oncology, Dana Farber Cancer Institute, Boston
| | - C M Barysauskas
- Department of Biostatistics and Computational Biology, Dana Farber Cancer Institute, Boston
| | - M von Mehren
- Department of Medical Oncology, Fox Chase Cancer Center, Philadelphia
| | - M C Heinrich
- VA Portland Health Care System and Oregon Health and Science University, Portland
| | - C L Corless
- Oregon Health and Science University, Portland
| | - J E Butrynski
- Center for Sarcoma and Bone Oncology, Dana Farber Cancer Institute, Boston
| | - J A Morgan
- Center for Sarcoma and Bone Oncology, Dana Farber Cancer Institute, Boston
| | - A J Wagner
- Center for Sarcoma and Bone Oncology, Dana Farber Cancer Institute, Boston
| | - E Choy
- Division of Hematology Oncology, Massachusetts General Hospital, Boston
| | - J T Yap
- Huntsman Cancer Institute, University of Utah, Salt Lake City Department of Radiology, University of Utah, Salt Lake City
| | - A D Van den Abbeele
- Department of Imaging, Dana Farber Cancer Institute, Boston Department of Radiology
| | - S M Solomon
- Center for Sarcoma and Bone Oncology, Dana Farber Cancer Institute, Boston
| | - J A Fletcher
- Department of Pathology, Brigham and Women's Hospital and Harvard Medical School, Boston
| | - G D Demetri
- Center for Sarcoma and Bone Oncology, Dana Farber Cancer Institute, Boston Department of Ludwig Center at Dana Farber/Harvard Cancer Center and Harvard Medical School, Boston, USA
| | - S George
- Center for Sarcoma and Bone Oncology, Dana Farber Cancer Institute, Boston
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12
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George S, Barysauskas CM, Solomon S, Tahlil K, Malley R, Hohos M, Polson K, Loucks M, Wagner AJ, Merriam P, Morgan JA, Rodig SJ, Hodi FS, Shapiro G, Demetri GD. Phase 2 study of nivolumab in metastatic leiomyosarcoma of the uterus. J Clin Oncol 2016. [DOI: 10.1200/jco.2016.34.15_suppl.11007] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- Suzanne George
- Dana-Farber Cancer Center/Brigham and Women's Hospital, Boston, MA
| | | | | | | | | | | | | | | | | | | | | | - Scott J. Rodig
- Department of Pathology, Division of Hematopathology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | | | | | - George D. Demetri
- Dana-Farber Cancer Institute and Ludwig Center at Harvard Medical School, Boston, MA
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13
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Zerillo JA, Barysauskas CM, Santacroce E, Zimmerman MA, Freeman M, Lau Greenberg T, Nguyen P, Wallace DJ, Hill EA, Chi SN, Bandopadhayay P, Lane S, Szabatura A, Houlahan K, Catalano PJ, Billett A. Engaging pediatric patients and caregivers in an oral chemotherapy safety assessment. J Clin Oncol 2016. [DOI: 10.1200/jco.2016.34.15_suppl.e18156] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Amy Billett
- Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Boston, MA
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14
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Shinagare AB, Barysauskas CM, Braschi-Amirfarzan M, O'Neill AC, Catalano PJ, George S, Ramaiya NH. Comparison of performance of various tumor response criteria in assessment of sunitinib activity in advanced gastrointestinal stromal tumors. Clin Imaging 2016; 40:880-4. [PMID: 27179958 DOI: 10.1016/j.clinimag.2016.04.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [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: 01/26/2016] [Revised: 03/30/2016] [Accepted: 04/21/2016] [Indexed: 11/30/2022]
Abstract
PURPOSE To compare the performance of various tumor response criteria (TRC) in the assessment of patients with advanced gastrointestinal stromal tumor (GIST) treated with sunitinib after failure of imatinib. METHODS Sixty-two participants with advanced GIST in two clinical trials received oral sunitinib after prior failure of imatinib (median duration 24 weeks; interquartile range 14-56) and were followed with contrast-enhanced computed tomography at baseline and thereafter at median intervals of 6 weeks (IRQ 6-9). Tumor response was prospectively determined using Response Evaluation Criteria in Solid Tumors (RECIST) 1.0, and retrospectively reassessed for comparison using RECIST 1.1, Choi criteria, and modified Choi (mChoi) criteria using the original target lesions. For mChoi criteria, progressive disease was defined as 20% increase in sum of the longest dimension, similar to RECIST 1.1. Clinical benefit rate (CBR; complete response, partial response, or stable disease ≥12 weeks) and progression-free survival were compared between various TRCs using kappa statistics. RESULTS While partial response as the best response was more frequent by Choi and mChoi criteria (50% each) than RECIST 1.1 (15%) and RECIST 1.0 (13%), CBR was similar between various TRCs (overall CBR 60%-77%, 77%-94% agreement between all TRC pairs). Time to best response was shorter for Choi and mChoi criteria (median 11 weeks each) compared to RECIST 1.1 and RECIST 1.0 (median 25 and 24 weeks, respectively). PFS was similar for RECIST 1.1, RECIST 1.0, and mChoi (median 35 weeks each), and shortest for Choi criteria (median 23 weeks). CONCLUSIONS CBR was similar among the various TRCs, although Choi criteria led to earlier determination of disease progression. Therefore, RECIST 1.1 and mChoi criteria may be preferred for response assessment in patients with advanced GIST.
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Affiliation(s)
- Atul B Shinagare
- Department of Imaging, Dana-Farber Cancer Institute, 450 Brookline Ave, Boston, MA 02215, USA; Department of Radiology, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, USA.
| | - Constance M Barysauskas
- Department of Biostatistics and Computational Biology, Dana-Farber Cancer Institute, 450 Brookline Ave, Boston, MA 02215, USA
| | - Marta Braschi-Amirfarzan
- Department of Imaging, Dana-Farber Cancer Institute, 450 Brookline Ave, Boston, MA 02215, USA; Department of Radiology, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, USA
| | - Ailbhe C O'Neill
- Department of Imaging, Dana-Farber Cancer Institute, 450 Brookline Ave, Boston, MA 02215, USA; Department of Radiology, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, USA
| | - Paul J Catalano
- Department of Biostatistics and Computational Biology, Dana-Farber Cancer Institute, 450 Brookline Ave, Boston, MA 02215, USA; Department of Biostatistics, Harvard School of Public Health, 655 Huntington Ave, Boston, MA 02115, USA
| | - Suzanne George
- Department of Medical Oncology, Dana-Farber Cancer Institute, 450 Brookline Ave, Boston, MA 02215, USA
| | - Nikhil H Ramaiya
- Department of Imaging, Dana-Farber Cancer Institute, 450 Brookline Ave, Boston, MA 02215, USA; Department of Radiology, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, USA
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15
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Ellison RT, Barysauskas CM, Rundensteiner EA, Wang D, Barton B. A Prospective Controlled Trial of an Electronic Hand Hygiene Reminder System. Open Forum Infect Dis 2015; 2:ofv121. [PMID: 26430698 PMCID: PMC4589647 DOI: 10.1093/ofid/ofv121] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2015] [Accepted: 08/17/2015] [Indexed: 11/13/2022] Open
Abstract
Background. The use of electronic hand hygiene reminder systems has been proposed as an approach to improve hand hygiene compliance among healthcare workers, although information on efficacy is limited. We prospectively assessed whether hand hygiene activities among healthcare workers could be increased using an electronic hand hygiene monitoring and reminder system. Methods. A prospective controlled clinical trial was conducted in 2 medical intensive care units (ICUs) at an academic medical center with comparable patient populations, healthcare staff, and physical layout. Hand hygiene activity was monitored concurrently in both ICUs, and the reminder system was installed in the test ICU. The reminder system was tested during 3 administered phases including: room entry/exit chimes, display of real-time hand hygiene activity, and a combination of the 2. Results. In the test ICU, the mean number of hand hygiene events increased from 1538 per day at baseline to 1911 per day (24% increase) with the use of a combination of room entry/exit chimes, real-time displays of hand hygiene activity, and manager reports (P < .001); in addition, the ratio of hand hygiene to room entry/exit events also increased from 26.1% to 36.6% (40% increase, P < .001). The performance returned to baseline (1473 hand hygiene events per day) during the follow-up phase. There was no significant change in hand hygiene activity in the control ICU during the course of the trial. Conclusions. In an ICU setting, an electronic hand hygiene reminder system that provided real-time feedback on overall unit-wide hand hygiene performance significantly increased hand hygiene activity.
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Affiliation(s)
- Richard T Ellison
- Division of Infectious Diseases and Immunology, Department of Medicine
| | - Constance M Barysauskas
- Department of Quantitative Health Sciences , University of Massachusetts Medical School , Worcester ; Department of Biostatistics and Computational Biology , Dana-Farber Cancer Institute , Boston
| | - Elke A Rundensteiner
- Department of Computer Sciences , Worcester Polytechnic Institute , Massachusetts
| | - Di Wang
- Department of Computer Sciences , Worcester Polytechnic Institute , Massachusetts ; Microsoft Corporation , Redmond, Washington
| | - Bruce Barton
- Department of Quantitative Health Sciences , University of Massachusetts Medical School , Worcester
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16
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Gibson L, Barysauskas CM, McManus M, Dooley S, Lilleri D, Fisher D, Srivastava T, Diamond DJ, Luzuriaga K. Reduced frequencies of polyfunctional CMV-specific T cell responses in infants with congenital CMV infection. J Clin Immunol 2015; 35:289-301. [PMID: 25712611 PMCID: PMC4366322 DOI: 10.1007/s10875-015-0139-3] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2014] [Accepted: 02/04/2015] [Indexed: 10/23/2022]
Abstract
PURPOSE CMV infection remains a priority for vaccine development. Vaccination of infants could modify congenital infection and provide lifetime immunity. Properties of CMV-specific T cells associated with control of viral replication in early life have not been fully defined. METHODS CMV-specific CD4 and CD8 T cell responses were investigated in infants with congenital CMV infection and compared to adults with primary or chronic infection. PBMC were stimulated with UL83 (pp65) or UL122 (IE-2) peptide pools then stained with antibodies to markers of T cell subset (CD4 or CD8), phenotype (CD45RA, CCR7), or function (MIP1β, CD107, IFNγ, IL2) for flow cytometry analysis. RESULTS Detection of CMV pp65-specific CD4 T cells was less common in infants than adults. Responder cells were primarily effector memory (EM, CD45RA-CCR7-) in adults, but mixed memory subsets in infants. Detection of CMV pp65-specific CD8 T cells did not differ between the groups, but infants had lower frequencies of total responding cells and of MIP1β- or CD107-expressing cells. Responder cells were EM or effector memory RA (CD45RA + CCR7-) in all groups. Polyfunctional T cells were less commonly detected in infants than adults. Responses to IE-2 were detected in adults but not infants. All infants had detectable circulating CMV DNA at initial study (versus 60 % of adults with primary infection) despite longer duration of CMV infection. CONCLUSIONS Reduced frequencies and altered functional profile of CMV-specific CD4 and CD8 T cell responses were detected in infants compared to adults, and were associated with persistent CMV DNA in peripheral blood.
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Affiliation(s)
- Laura Gibson
- Department of Medicine, University of Massachusetts Medical School, Worcester, MA, 01605, USA,
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17
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Anatchkova MD, Barysauskas CM, Kinney RL, Kiefe CI, Ash AS, Lombardini L, Allison JJ. Psychometric evaluation of the Care Transition Measure in TRACE-CORE: do we need a better measure? J Am Heart Assoc 2014; 3:e001053. [PMID: 24901109 PMCID: PMC4309102 DOI: 10.1161/jaha.114.001053] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background The quality of transitional care is associated with important health outcomes such as rehospitalization and costs. The widely used Care Transitions Measure (CTM‐15) was developed with a classic test theory approach; its short version (CTM‐3) was included in the CAHPS Hospital Survey. We conducted a psychometric evaluation of both measures and explored whether item response theory (IRT) could produce a more precise measure. Methods and Results As part of the Transitions, Risks, and Actions in Coronary Events Center for Outcomes Research and Education, 1545 participants were interviewed during an acute coronary syndrome hospitalization, providing information on general health status (Short Form‐36), CTM‐15, health utilization, and care process questions at 1 month postdischarge. We used classic and IRT analyses and compared the measurement precision of CTM‐15–, CTM‐3–, and CTM‐IRT–based score using relative validity. Participants were 79% non‐Hispanic white and 67% male, with an average age of 62 years. The CTM‐15 had good internal consistency (Cronbach's α=0.95) but demonstrated acquiescence bias (8.7% participants responded “Strongly agree” and 19% responded “Agree” to all items) and limited score variability. These problems were more pronounced for the CTM‐3. The CTM‐15 differentiated between patient groups defined by self‐reported health status, health care utilization, and care transition process indicators. Differences between groups were small (2 to 3 points). There was no gain in measurement precision from IRT scoring. The CTM‐3 was not significantly lower for patients reporting rehospitalization or emergency department visits. Conclusion We identified psychometric challenges of the CTM, which may limit its value in research and practice. These results are in line with emerging evidence of gaps in the validity of the measure.
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Affiliation(s)
- Milena D Anatchkova
- Department of Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA (M.D.A., R.L.K., C.I.K., A.S.A., L.L., J.J.A.)
| | - Constance M Barysauskas
- Department of Biostatistics and Computational Biology, Dana Farber Cancer Institute, Harvard Medical School, Boston, MA (C.M.B.)
| | - Rebecca L Kinney
- Department of Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA (M.D.A., R.L.K., C.I.K., A.S.A., L.L., J.J.A.)
| | - Catarina I Kiefe
- Department of Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA (M.D.A., R.L.K., C.I.K., A.S.A., L.L., J.J.A.)
| | - Arlene S Ash
- Department of Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA (M.D.A., R.L.K., C.I.K., A.S.A., L.L., J.J.A.)
| | - Lisa Lombardini
- Department of Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA (M.D.A., R.L.K., C.I.K., A.S.A., L.L., J.J.A.)
| | - Jeroan J Allison
- Department of Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA (M.D.A., R.L.K., C.I.K., A.S.A., L.L., J.J.A.)
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18
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Pirie CG, Alario AF, Barysauskas CM, Gradil C, Uricchio CK. Manual corneal thickness measurements of healthy equine eyes using a portable spectral-domain optical coherence tomography device. Equine Vet J 2013; 46:631-4. [PMID: 24131285 DOI: 10.1111/evj.12198] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2013] [Accepted: 10/05/2013] [Indexed: 11/30/2022]
Abstract
REASONS FOR PERFORMING STUDY Corneal thickness measurements of the equine globe using spectral-domain optical coherence tomography (SD-OCT) have not been reported. OBJECTIVES To determine corneal thickness measurements and the intra- and interoperator reliability of a portable SD-OCT device in equine eyes. STUDY DESIGN Prospective observational study. METHODS Horses free of ocular disease were used for this study. Gentle manual restraint, in combination with detomidine hydrochloride and a head stand, were employed to ensure proper animal positioning. Corneal pachymetry measurements were obtained from both eyes of each animal 3 times by 2 operators in succession. A 6 mm corneal pachymetry protocol was performed using a portable SD-OCT device. All measurements were obtained manually by one operator (C.G.P.) using the integrated calliper function. Measurements included epithelial thickness, stromal thickness, Descemet's membrane thickness and total corneal thickness. All recorded measurements were analysed to determine both intra- and interoperator reliability. RESULTS Thirty horses with a mean age of 10.6 ± 6.4 years were examined. Mean epithelial, stromal, Descemet's membrane and total corneal thickness values obtained were, respectively, 174.7 ± 13.6, 599.2 ± 45.4, 38.4 ± 15.3 and 812.0 ± 44.1 μm for operator A and 175.9 ± 12.9, 599.2 ± 44.9, 38.4 ± 15.0 and 812.9 ± 42.9 μm for operator B. A positive correlation was found between Descemet's membrane thickness and age, whereby Descemet's membrane thickness increased by 2 μm/year (P<0.0001). The coefficients of variation for both operators were <4% for all measurements. Intraclass correlations ranged from 0.92 to 0.98. CONCLUSIONS Manual corneal thickness measurement using a portable SD-OCT device provides epithelial, stromal, Descemet's membrane and total corneal thickness measurements with clinically acceptable intra- and interoperator reliability in healthy equine eyes.
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Affiliation(s)
- C G Pirie
- Department of Clinical Sciences, Tufts Cummings School of Veterinary Medicine (TCSVM), North Grafton, Massachusetts, USA
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