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Rodriguez NJ, Furniss CS, Yurgelun MB, Ukaegbu C, Constantinou PE, Fortes I, Caruso A, Schwartz AN, Stopfer JE, Underhill-Blazey M, Kenner B, Nelson SH, Okumura S, Zhou AY, Coffin TB, Uno H, Horiguchi M, Ocean AJ, McAllister F, Lowy AM, Klein AP, Madlensky L, Petersen GM, Garber JE, Lippman SM, Goggins MG, Maitra A, Syngal S. A Randomized Trial of Two Remote Health Care Delivery Models on the Uptake of Genetic Testing and Impact on Patient-Reported Psychological Outcomes in Families With Pancreatic Cancer: The Genetic Education, Risk Assessment, and Testing (GENERATE) Study. Gastroenterology 2024; 166:872-885.e2. [PMID: 38320723 PMCID: PMC11034726 DOI: 10.1053/j.gastro.2024.01.042] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Revised: 01/22/2024] [Accepted: 01/29/2024] [Indexed: 02/15/2024]
Abstract
BACKGROUND & AIMS Genetic testing uptake for cancer susceptibility in family members of patients with cancer is suboptimal. Among relatives of patients with pancreatic ductal adenocarcinoma (PDAC), The GENetic Education, Risk Assessment, and TEsting (GENERATE) study evaluated 2 online genetic education/testing delivery models and their impact on patient-reported psychological outcomes. METHODS Eligible participants had ≥1 first-degree relative with PDAC, or ≥1 first-/second-degree relative with PDAC with a known pathogenic germline variant in 1 of 13 PDAC predisposition genes. Participants were randomized by family, between May 8, 2019, and June 1, 2021. Arm 1 participants underwent a remote interactive telemedicine session and online genetic education. Arm 2 participants were offered online genetic education only. All participants were offered germline testing. The primary outcome was genetic testing uptake, compared by permutation tests and mixed-effects logistic regression models. We hypothesized that Arm 1 participants would have a higher genetic testing uptake than Arm 2. Validated surveys were administered to assess patient-reported anxiety, depression, and cancer worry at baseline and 3 months postintervention. RESULTS A total of 424 families were randomized, including 601 participants (n = 296 Arm 1; n = 305 Arm 2), 90% of whom completed genetic testing (Arm 1 [87%]; Arm 2 [93%], P = .014). Arm 1 participants were significantly less likely to complete genetic testing compared with Arm 2 participants (adjusted ratio [Arm1/Arm2] 0.90, 95% confidence interval 0.78-0.98). Among participants who completed patient-reported psychological outcomes questionnaires (Arm 1 [n = 194]; Arm 2 [n = 206]), the intervention did not affect mean anxiety, depression, or cancer worry scores. CONCLUSIONS Remote genetic education and testing can be a successful and complementary option for delivering genetics care. (Clinicaltrials.gov, number NCT03762590).
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Affiliation(s)
- Nicolette J Rodriguez
- Dana-Farber Cancer Institute, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts; Brigham and Women's Hospital, Boston, Massachusetts
| | - C Sloane Furniss
- Dana-Farber Cancer Institute, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts
| | - Matthew B Yurgelun
- Dana-Farber Cancer Institute, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts; Brigham and Women's Hospital, Boston, Massachusetts
| | - Chinedu Ukaegbu
- Dana-Farber Cancer Institute, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts
| | - Pamela E Constantinou
- Sheikh Ahmed Center for Pancreatic Cancer Research, University of Texas, MD Anderson Cancer Center, Houston, Texas
| | | | | | | | | | | | | | - Scott H Nelson
- Pancreatic Cancer Action Network Volunteer, Patient Advocate, and Pancreatic Cancer Survivor
| | | | | | - Tara B Coffin
- WIRB-Copernicus Group Institutional Review Board, Puyallup, Washington
| | - Hajime Uno
- Dana-Farber Cancer Institute, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts
| | - Miki Horiguchi
- Dana-Farber Cancer Institute, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts
| | | | - Florencia McAllister
- Sheikh Ahmed Center for Pancreatic Cancer Research, University of Texas, MD Anderson Cancer Center, Houston, Texas
| | - Andrew M Lowy
- Moores Cancer Center, UC San Diego, San Diego, California
| | - Alison P Klein
- Johns Hopkins University, Sol Goldman Pancreatic Cancer Research Center, Baltimore, Maryland
| | - Lisa Madlensky
- Moores Cancer Center, UC San Diego, San Diego, California
| | | | - Judy E Garber
- Dana-Farber Cancer Institute, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts; Brigham and Women's Hospital, Boston, Massachusetts
| | | | - Michael G Goggins
- Johns Hopkins University, Sol Goldman Pancreatic Cancer Research Center, Baltimore, Maryland
| | - Anirban Maitra
- Sheikh Ahmed Center for Pancreatic Cancer Research, University of Texas, MD Anderson Cancer Center, Houston, Texas
| | - Sapna Syngal
- Dana-Farber Cancer Institute, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts; Brigham and Women's Hospital, Boston, Massachusetts.
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Hantel A, Brunner AM, Plascak JJ, Uno H, Varela JC, Luskin MR, Rebbeck TR, Stone RM, Lathan CS, DeAngelo DJ, Abel GA. Race/ethnic associations with comprehensive cancer center access and clinical trial enrollment for acute leukemia. J Natl Cancer Inst 2024:djae067. [PMID: 38518098 DOI: 10.1093/jnci/djae067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Revised: 02/19/2024] [Accepted: 03/18/2024] [Indexed: 03/24/2024] Open
Abstract
BACKGROUND Clinical trial participation at Comprehensive Cancer Centers (CCC) is inequitable for minoritized race/ethnic groups with acute leukemia. CCCs care for a high proportion of adults with acute leukemia. It is unclear if participation inequities are due to CCC access, post-access enrollment, or both. METHODS We conducted a retrospective cohort study of adults with acute leukemia (2010-2019) residing within Massachusetts, the designated catchment area of the Dana-Farber/Harvard Cancer Center (DF/HCC). Individuals were categorized as non-Hispanic Asian (NHA), Black (NHB), White (NHW), Hispanic White (HW), or Other. Decomposition analyses assessed covariate contributions to disparities in (1) access to DF/HCC care and (2) post-access enrollment. RESULTS Of 3698 individuals with acute leukemia, 85.9% were NHW, 4.5% HW, 4.3% NHB, 3.7% NHA, and 1.3% Other. Access was lower for HW (age- and sex-adjusted OR 0.64 95%CI 0.45,0.90) and reduced post-access enrollment for HW (aOR 0.54 95%CI 0.34,0.86) and NHB (aOR 0.60 95%CI 0.39,0.92) compared to NHW. Payor and socioeconomic status (SES) accounted for 25.2% and 21.2% of the +1.1% absolute difference in HW access. Marital status and SES accounted for 8.0% and 7.0% of the -8.8% absolute disparity in HW enrollment; 76.4% of the disparity was unexplained. SES and marital status accounted for 8.2% and 7.1% of the -9.1% absolute disparity in NHB enrollment; 73.0% of the disparity was unexplained. CONCLUSIONS A substantial proportion of race/ethnic inequities in acute leukemia trial enrollment at CCCs are from post-access enrollment, the majority of which was not explained by sociodemographic factors.
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Affiliation(s)
- Andrew Hantel
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Andrew M Brunner
- Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Jesse J Plascak
- Division of Cancer Prevention and Control, The Ohio State University, Columbus, OH, USA
| | - Hajime Uno
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Juan C Varela
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Marlise R Luskin
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Timothy R Rebbeck
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
- Department of Epidemiology, Harvard TH Chan School of Public Health, Boston, MA, USA
| | - Richard M Stone
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | | | - Daniel J DeAngelo
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Gregory A Abel
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
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Paudel R, Enzinger AC, Uno H, Cronin C, Wong SL, Dizon DS, Hazard Jenkins H, Bian J, Osarogiagbon RU, Jensen RE, Mitchell SA, Schrag D, Hassett MJ. Effects of a change in recall period on reporting severe symptoms: an analysis of a pragmatic multisite trial. J Natl Cancer Inst 2024:djae049. [PMID: 38445744 DOI: 10.1093/jnci/djae049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Revised: 01/23/2024] [Accepted: 02/16/2024] [Indexed: 03/07/2024] Open
Abstract
BACKGROUND Optimal methods for deploying electronic patient-reported outcomes (ePROs) to manage symptoms in routine oncologic practice remain uncertain. The eSyM symptom management program asks chemotherapy and surgery patients to self-report 12 symptoms regularly. Feedback from nurses and patients led to changing the recall period from the past 7 days to the past 24 hours. METHODS Using questionnaires submitted during the 16-weeks surrounding the recall period change, we assessed the likelihood of reporting a severe, or a moderate-severe, symptom across all 12 symptoms and separately for the 5 most prevalent symptoms. Interrupted time series analyses modeled the effects of the change using generalized linear mixed-effects models. Surgery and chemotherapy cohorts were analyzed separately. Study-wide effects were estimated using a meta-analysis method. RESULTS In total, 1,692 patients from 6 institutions submitted 7,823 eSyM assessments during the 16-weeks surrounding the recall period change. Shortening the recall period was associated with lower odds of severe symptom reporting in the surgery cohort (OR 0.65; 95% CI 0.46 to 0.93; p = .02) and lower odds of moderate-severe symptom reporting in the chemotherapy cohort (OR 0.83, 95% CI 0.71 to 0.97; p = .02). Among the most prevalent symptoms, 24-hour recall was associated with lower rate of reporting post-operative constipation, but no differences in reporting rates for other symptoms. CONCLUSION A shorter recall period was associated with a reduction in the proportion of patients reporting moderate-severe symptoms. The optimal recall period may vary depending on whether ePROs are collected for active symptom management, as a clinical trial endpoint, or another purpose. (Clinicaltrails.gov (NCT03850912).
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Affiliation(s)
| | | | - Hajime Uno
- Dana-Farber Cancer Institute, Boston, MA, USA
| | | | - Sandra L Wong
- Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
| | - Don S Dizon
- Lifespan Cancer Institute and Brown University, Providence, RI, USA
| | | | | | | | | | | | - Deborah Schrag
- Memorial Sloan Kettering Cancer Center, New York, NY, USA
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Mack JW, Cernik C, Xu L, Laurent CA, Fisher L, Cannizzaro N, Munneke J, Cooper RM, Lakin JR, Schwartz CM, Casperson M, Altschuler A, Wiener L, Kushi LH, Chao CR, Uno H. Use of Cancer-Directed therapy at the end of life among adolescents and young adults. J Natl Cancer Inst 2024:djae038. [PMID: 38377408 DOI: 10.1093/jnci/djae038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Revised: 12/06/2023] [Accepted: 02/15/2024] [Indexed: 02/22/2024] Open
Abstract
BACKGROUND Adolescents and young adults (AYAs) frequently receive chemotherapy near death. We know less about use of targeted agents and immunotherapy or trends over time. METHODS We conducted a retrospective cohort study of 1,836 AYAs with cancer who died between 2009-2019 after receiving care at one of three sites (Dana-Farber Cancer Institute, Kaiser Permanente Northern California, and Kaiser Permanente Southern California). We reviewed electronic health data and medical records to examine use of cancer-directed therapy in the last 90 days of life, including chemotherapy, targeted therapy, immunotherapy, and investigational drugs. RESULTS Over the study period, 35% of AYAs received chemotherapy in the last 90 days of life; 24% received targeted therapy, 7% immunotherapy, and 5% investigational drugs. Fifty-six percent received at least one form of systemic cancer-directed therapy in the last 90 days of life. After adjustment for patient sex, race, ethnicity, age, site of care, diagnosis, and years from diagnosis to death, the proportion of AYAs receiving targeted therapy (odds ratio (OR) 1.05 per year of death, 95% confidence interval (CI) 1.02-1.10, P = .006), immunotherapy (OR 1.27, 95%CI 1.18-1.38, P<.0001), and any cancer-directed therapy (OR1.04, 95%CI 1.01-1.08, P=.01) in the last 90 days of life increased over time. CONCLUSIONS More than half of AYAs receive cancer therapy in the last 90 days of life, and use of novel agents such as targeted therapy and immunotherapy are increasing over time. While some AYAs may wish to continue cancer therapy while living with advanced disease, efforts are needed to ensure that use of cancer-directed therapy meets preferences of AYAs approaching death.
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Affiliation(s)
- Jennifer W Mack
- Division of Population Sciences, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
- Department of Pediatric Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Colin Cernik
- Division of Population Sciences, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Lanfang Xu
- MedHealth Statistical Consulting Inc. Solon, OH, USA
| | - Cecile A Laurent
- Division of Research, Kaiser Permanente Northern California, Oakland, California, USA
| | - Lauren Fisher
- Division of Population Sciences, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Nancy Cannizzaro
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California, USA
| | - Julie Munneke
- Division of Research, Kaiser Permanente Northern California, Oakland, California, USA
| | - Robert M Cooper
- Department of Pediatric Oncology, Kaiser Permanente Southern California, Pasadena, California, USA
| | - Joshua R Lakin
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Corey M Schwartz
- Division of Medical Oncology, Kaiser Permanente Northern California, Oakland, California, USA
| | | | - Andrea Altschuler
- Division of Research, Kaiser Permanente Northern California, Oakland, California, USA
| | - Lori Wiener
- Psychosocial Support and Research Program, National Cancer Institute, Bethesda, Maryland, USA
| | - Lawrence H Kushi
- Division of Research, Kaiser Permanente Northern California, Oakland, California, USA
| | - Chun R Chao
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California, USA
| | - Hajime Uno
- Division of Population Sciences, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
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5
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Mack JW, Cernik C, Uno H, Laurent CA, Fisher L, Xu L, Munneke J, Cannizzaro N, Casperson M, Schwartz CM, Lakin JR, Cooper RM, Altschuler A, Wiener L, Chao CR, Kushi L. Quality of End-of-Life Care Among Adolescents and Young Adults With Cancer. J Clin Oncol 2024; 42:621-629. [PMID: 37890132 DOI: 10.1200/jco.23.01272] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Revised: 07/21/2023] [Accepted: 08/24/2023] [Indexed: 10/29/2023] Open
Abstract
Adolescents, young adults with cancer receive limited psychosocial and spiritual support near death.
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Affiliation(s)
- Jennifer W Mack
- Division of Population Sciences, Dana-Farber Cancer Institute, Boston, MA
- Department of Pediatric Oncology, Dana-Farber Cancer Institute, Boston, MA
| | - Colin Cernik
- Division of Population Sciences, Dana-Farber Cancer Institute, Boston, MA
| | - Hajime Uno
- Division of Population Sciences, Dana-Farber Cancer Institute, Boston, MA
| | | | - Lauren Fisher
- Division of Population Sciences, Dana-Farber Cancer Institute, Boston, MA
| | | | | | - Nancy Cannizzaro
- Medical Oncology, Kaiser Permanente Northern California, Oakland, CA
| | - Mallory Casperson
- Pediatric Oncology, Kaiser Permanente Southern California, Pasadena, CA
| | - Corey M Schwartz
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA
| | - Joshua R Lakin
- Division of Research, Kaiser Permanente Northern California, Oakland, CA
| | - Robert M Cooper
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, MA
| | | | - Lori Wiener
- Psychosocial Support and Research Program, National Cancer Institute, Bethesda, MD
| | - Chun R Chao
- Medical Oncology, Kaiser Permanente Northern California, Oakland, CA
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Hantel A, Cernik C, Uno H, Walsh TP, Calip GS, DeAngelo DJ, Lathan CS, Abel GA. Sociodemographic associations with uptake of novel therapies for acute myeloid leukemia. Blood Cancer J 2023; 13:192. [PMID: 38123559 PMCID: PMC10733304 DOI: 10.1038/s41408-023-00964-x] [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: 11/02/2023] [Revised: 11/28/2023] [Accepted: 12/01/2023] [Indexed: 12/23/2023] Open
Abstract
Inequitable uptake of novel therapies (NT) in non-cancer settings are known for patients with lower socioeconomic status (SES), People of Color (POC), and older adults. NT uptake equity in acute myeloid leukemia (AML) is not well known. We performed a retrospective cohort study (1/2014-8/2022) of the United States nationwide Flatiron HealthTM electronic health record-derived, de-identified database. We estimated sociodemographic associations with AML NT receipt using incidence rate ratios (IRR). Odds ratios (OR) assessed differences in venetoclax (the most common NT) receipt at community sites and between site characteristics and NT adoption. Of 8081 patients (139 sites), 3102 (38%) received a NT. NT use increased annually (IRR 1.14, 95% confidence interval [1.07, 1.22]). NT receipt was similar between Non-Hispanic-Whites and POC (IRR 1.03, [0.91, 1.17]) and as age increased (IRR 1.02 [0.97, 1.07]). At community sites, Non-Hispanic-Whites were less likely to receive venetoclax (OR 0.77 [0.66, 0.91]); older age (OR 1.05 [1.04, 1.05]) and higher area-level SES were associated with venetoclax receipt (OR 1.23 [1.05, 1.43]). Early NT adopting sites had more prescribing physicians (OR 1.25 [1.13, 1.43]) and higher SES strata patients (OR 2.81 [1.08, 7.66]). Inequities in AML NT uptake were seen by SES; for venetoclax, differential uptake reflects its label indication for older adults and those with comorbidities.
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Affiliation(s)
- Andrew Hantel
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
- HMS Center for Bioethics, Boston, MA, USA
| | - Colin Cernik
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Hajime Uno
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Thomas P Walsh
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Gregory S Calip
- Flatiron Health, New York, NY, USA
- University of Southern California, Los Angeles, CA, USA
| | - Daniel J DeAngelo
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Christopher S Lathan
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Gregory A Abel
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA.
- Harvard Medical School, Boston, MA, USA.
- HMS Center for Bioethics, Boston, MA, USA.
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Shu D, Mukhopadhyay S, Uno H, Gerber JS, Schaubel DE. Multiply robust causal inference of the restricted mean survival time difference. Stat Methods Med Res 2023; 32:2386-2404. [PMID: 37965684 DOI: 10.1177/09622802231211009] [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] [Indexed: 11/16/2023]
Abstract
The hazard ratio (HR) remains the most frequently employed metric in assessing treatment effects on survival times. However, the difference in restricted mean survival time (RMST) has become a popular alternative to the HR when the proportional hazards assumption is considered untenable. Moreover, independent of the proportional hazards assumption, many comparative effectiveness studies aim to base contrasts on survival probability rather than on the hazard function. Causal effects based on RMST are often estimated via inverse probability of treatment weighting (IPTW). However, this approach generally results in biased results when the assumed propensity score model is misspecified. Motivated by the need for more robust techniques, we propose an empirical likelihood-based weighting approach that allows for specifying a set of propensity score models. The resulting estimator is consistent when the postulated model set contains a correct model; this property has been termed multiple robustness. In this report, we derive and evaluate a multiply robust estimator of the causal between-treatment difference in RMST. Simulation results confirm its robustness. Compared with the IPTW estimator from a correct model, the proposed estimator tends to be less biased and more efficient in finite samples. Additional simulations reveal biased results from a direct application of machine learning estimation of propensity scores. Finally, we apply the proposed method to evaluate the impact of intrapartum group B streptococcus antibiotic prophylaxis on the risk of childhood allergic disorders using data derived from electronic medical records from the Children's Hospital of Philadelphia and census data from the American Community Survey.
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Affiliation(s)
- Di Shu
- Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
- Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
- Clinical Futures, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Sagori Mukhopadhyay
- Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
- Clinical Futures, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Divisions of Neonatology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Hajime Uno
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
- Department of Data Sciences, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Jeffrey S Gerber
- Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
- Clinical Futures, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Divisions of Infectious Diseases, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Douglas E Schaubel
- Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
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Guha D, Misra V, Yin J, Horiguchi M, Uno H, Gabuzda D. Vascular injury markers associated with cognitive impairment in people with HIV on suppressive antiretroviral therapy. AIDS 2023; 37:2137-2147. [PMID: 37503603 PMCID: PMC10615701 DOI: 10.1097/qad.0000000000003675] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/29/2023]
Abstract
OBJECTIVE Human immunodeficiency virus (HIV)-associated neurocognitive disorders (HAND) remain prevalent despite viral suppression on antiretroviral therapy (ART). Vascular disease contributes to HAND, but peripheral markers that distinguish vascular cognitive impairment (VCI) from HIV-related etiologies remain unclear. DESIGN Cross-sectional study of vascular injury, inflammation, and central nervous system (CNS) injury markers in relation to HAND. METHODS Vascular injury (VCAM-1, ICAM-1, CRP), inflammation (IFN-γ, IL-1β, IL-6, IL-8, IL-15, IP-10, MCP-1, VEGF-A), and CNS injury (NFL, total Tau, GFAP, YKL-40) markers were measured in plasma and CSF from 248 individuals (143 HIV+ on suppressive ART and 105 HIV- controls). RESULTS Median age was 53 years, median CD4 + cell count, and duration of HIV infection were 505 cells/μl and 16 years, respectively. Vascular injury, inflammation, and CNS injury markers were increased in HIV+ compared with HIV- individuals ( P < 0.05). HAND was associated with increased plasma VCAM-1, ICAM-1, and YKL-40 ( P < 0.01) and vascular disease ( P = 0.004). In contrast, inflammation markers had no significant association with HAND. Vascular injury markers were associated with lower neurocognitive T scores in age-adjusted models ( P < 0.01). Furthermore, plasma VCAM-1 correlated with NFL ( r = 0.29, P = 0.003). Biomarker clustering separated HAND into three clusters: two clusters with high prevalence of vascular disease, elevated VCAM-1 and NFL, and distinctive inflammation profiles (CRP/ICAM-1/YKL-40 or IL-6/IL-8/IL-15/MCP-1), and one cluster with no distinctive biomarker elevations. CONCLUSIONS Vascular injury markers are more closely related to HAND and CNS injury in PWH on suppressive ART than inflammation markers and may help to distinguish relative contributions of VCI to HAND.
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Affiliation(s)
| | - Vikas Misra
- Department of Cancer Immunology and Virology
| | - Jun Yin
- Department of Cancer Immunology and Virology
| | - Miki Horiguchi
- Department of Data Science, Dana-Farber Cancer Institute
| | - Hajime Uno
- Department of Data Science, Dana-Farber Cancer Institute
| | - Dana Gabuzda
- Department of Cancer Immunology and Virology
- Department of Neurology, Harvard Medical School, Boston, Massachusetts, USA
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Avila J, DuMontier C, Cernik C, Uno H, Hshieh T, Ho K, Mozessohn L, Driver JA, Abel GA. Marital status, frailty, and survival in older adults with blood cancer. J Geriatr Oncol 2023; 14:101589. [PMID: 37453810 DOI: 10.1016/j.jgo.2023.101589] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Revised: 06/12/2023] [Accepted: 07/07/2023] [Indexed: 07/18/2023]
Affiliation(s)
- Jorge Avila
- Department of Medicine, St Elizabeth's Medical Center, Boston, MA, USA; Division of Population Sciences, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Clark DuMontier
- Division of Population Sciences, Dana-Farber Cancer Institute, Boston, MA, USA; New England Geriatrics Research, Education and Clinical Center, VA Boston Healthcare System, Boston, MA, USA; Division of Aging, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Colin Cernik
- Division of Population Sciences, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Hajime Uno
- Division of Population Sciences, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Tammy Hshieh
- Division of Aging, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Kristi Ho
- Division of Population Sciences, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Lee Mozessohn
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, USA
| | - Jane A Driver
- New England Geriatrics Research, Education and Clinical Center, VA Boston Healthcare System, Boston, MA, USA; Division of Aging, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Gregory A Abel
- Division of Population Sciences, Dana-Farber Cancer Institute, Boston, MA, USA; Division of Hematologic Oncology, Dana-Farber Cancer Institute, Boston, MA, USA.
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10
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Mack JW, Cernik C, Uno H, Xu L, Laurent CA, Fisher L, Cannizzaro N, Munneke J, Cooper RM, Lakin JR, Schwartz CM, Casperson M, Altschuler A, Wiener L, Kushi L, Chao CR. Discussions About Goals of Care and Advance Care Planning Among Adolescents and Young Adults With Cancer Approaching the End of Life. J Clin Oncol 2023; 41:4739-4746. [PMID: 37625111 PMCID: PMC10602508 DOI: 10.1200/jco.23.00641] [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: 03/23/2023] [Revised: 05/12/2023] [Accepted: 07/19/2023] [Indexed: 08/27/2023] Open
Abstract
PURPOSE Adolescents and young adults (AYAs) with cancer receive high rates of medically intensive measures at the end of life. This study aimed to characterize the prevalence and timing of conversations about goals of care and advance care planning among AYAs at the end of life as one potential influence on care received. METHODS This was a review of electronic health data and medical records for 1,929 AYAs age 12-39 years who died after receiving care at one of three sites between 2003 and 2019, including documented conversations about goals of care and advance care planning, and care received. RESULTS A majority of AYAs were female (54%) and White (61%); 12% were Asian, 8% Black, and 27% Hispanic. Most patients had documented discussions about prognosis (86%), goals of care (83%), palliative care (79%), hospice (79%), and preferred location of death (64%). When last documented goals of care were evaluated, 69% of patients wanted care focused on palliation; however, 29% of those with palliative goals spent time in the intensive care unit (ICU) in the last month of life, and 32% had multiple emergency room (ER) visits. When goals-of-care discussions happened earlier, >30 days before death, AYAs were less likely to receive chemotherapy in the last 14 days of life (P = .001), ICU care (P < .001), ER visits (P < .001), and hospitalizations in the last month (P < .001). CONCLUSION High rates of medically intensive measures among AYAs near the end of life do not appear to be the result of a lack of discussions about goals of care and advance care planning. Although some interventions may be used to support palliative goals, earlier discussions have potential to reduce late-life intensive measures.
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Affiliation(s)
- Jennifer W. Mack
- Division of Population Sciences, Dana-Farber Cancer Institute, Boston, MA
- Department of Pediatric Oncology, Dana-Farber Cancer Institute, Boston, MA
| | - Colin Cernik
- Division of Population Sciences, Dana-Farber Cancer Institute, Boston, MA
| | - Hajime Uno
- Division of Population Sciences, Dana-Farber Cancer Institute, Boston, MA
| | - Lanfang Xu
- MedHealth Statistical Consulting Inc, Solon, OH
| | - Cecile A. Laurent
- Division of Research, Kaiser Permanente Northern California, Oakland, CA
| | - Lauren Fisher
- Division of Population Sciences, Dana-Farber Cancer Institute, Boston, MA
| | - Nancy Cannizzaro
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA
| | - Julie Munneke
- Division of Research, Kaiser Permanente Northern California, Oakland, CA
| | - Robert M. Cooper
- Department of Pediatric Oncology, Kaiser Permanente Southern California, Pasadena, CA
| | - Joshua R. Lakin
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, MA
| | - Corey M. Schwartz
- Department of Medical Oncology, Kaiser Permanente Northern California, Oakland, CA
| | | | - Andrea Altschuler
- Division of Research, Kaiser Permanente Northern California, Oakland, CA
| | - Lori Wiener
- Psychosocial Support and Research Program, National Cancer Institute, Bethesda, MD
| | - Lawrence Kushi
- Division of Research, Kaiser Permanente Northern California, Oakland, CA
| | - Chun R. Chao
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA
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11
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Sandoval RL, Horiguchi M, Ukaegbu C, Furniss CS, Uno H, Syngal S, Yurgelun MB. PREMM5 distinguishes sporadic from Lynch syndrome-associated MMR-deficient/MSI-high colorectal cancer. Fam Cancer 2023; 22:459-465. [PMID: 37572151 DOI: 10.1007/s10689-023-00345-0] [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: 05/24/2023] [Accepted: 07/24/2023] [Indexed: 08/14/2023]
Abstract
Current algorithms for diagnosing Lynch syndrome (LS) include multistep molecular tumor tests to distinguish LS-associated from sporadic colorectal cancer (CRC), which add cost and complexity to the evaluation. We hypothesized that PREMM5, a clinical LS prediction tool, could be an alternative approach to screen for LS, thereby lessening the need for specialized molecular diagnostics. We reviewed a consecutively ascertained institutional cohort of 1058 CRC patients on whom pathologic and clinical data were available, including prior LS germline testing. Data from MMR-D/MSI-H CRC patients were reviewed and PREMM5 scores were calculated for each individual. Using a PREMM5 score cutoff ≥ 2.5% to characterize the need for germline testing, we determined the rate of pathogenic/likely pathogenic germline variants (PGVs) in LS genes in patients with PREMM5 scores ≥ 2.5% versus < 2.5%. Sensitivity and negative predictive values (NPV) of PREMM5 were calculated for all MMR-D/MSI-H CRC patients, and those with MLH1-deficient CRC. MMR IHC and/or MSI results were available on 572/1058 cases. We identified 74/572 (12.9%) cases as MMR-D/MSI-H, of which 28/74 (37.8%) harbored a LS PGV. 11/49 (22.4%) patients with MLH1-deficient CRC harbored a LS PGV. PREMM5 had 100% sensitivity (95% CI: 87.7-100 for any MMR-D/MSI-H; 95% CI: 71.5-100 for MLH1-deficient CRC) and 100% NPV (95% CI: 83.2-100 for any MMR-D/MSI-H; 95% CI: 82.4-100 for MLH1-deficient CRC) for identifying LS PGVs in these cohorts. PREMM5 accurately distinguishes LS- from non-LS-associated MMR-D/MSI-H CRC without additional somatic molecular testing. These findings are particularly relevant for limited-resource settings where advanced molecular diagnostics may be unavailable.
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Affiliation(s)
- Renata L Sandoval
- Hospital Sírio-Libanês, Brasília, Brazil
- Dana-Farber Cancer Institute, 450 Brookline Avenue Dana 1126, 02215, Boston, MA, USA
| | - Miki Horiguchi
- Dana-Farber Cancer Institute, 450 Brookline Avenue Dana 1126, 02215, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Chinedu Ukaegbu
- Dana-Farber Cancer Institute, 450 Brookline Avenue Dana 1126, 02215, Boston, MA, USA
| | - C Sloane Furniss
- Dana-Farber Cancer Institute, 450 Brookline Avenue Dana 1126, 02215, Boston, MA, USA
| | - Hajime Uno
- Dana-Farber Cancer Institute, 450 Brookline Avenue Dana 1126, 02215, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Sapna Syngal
- Dana-Farber Cancer Institute, 450 Brookline Avenue Dana 1126, 02215, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
- Brigham and Women's Hospital, Boston, MA, USA
| | - Matthew B Yurgelun
- Dana-Farber Cancer Institute, 450 Brookline Avenue Dana 1126, 02215, Boston, MA, USA.
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12
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Guha D, Misra V, Yin J, Horiguchi M, Uno H, Gabuzda D. Vascular injury markers associated with cognitive impairment in people with HIV on suppressive antiretroviral therapy. medRxiv 2023:2023.07.23.23293053. [PMID: 37546734 PMCID: PMC10402231 DOI: 10.1101/2023.07.23.23293053] [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] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/08/2023]
Abstract
Objective Human immunodeficiency virus (HIV)-associated neurocognitive disorders (HAND) remain prevalent despite viral suppression on antiretroviral therapy (ART). Vascular disease contributes to HAND, but peripheral markers that distinguish vascular cognitive impairment (VCI) from HIV-related etiologies remain unclear. Design Cross-sectional study of vascular injury, inflammation, and central nervous system (CNS) injury markers in relation to HAND. Methods Vascular injury (VCAM-1, ICAM-1, CRP), inflammation (IFN-γ, IL-1β, IL-6, IL-8, IL-15, IP-10, MCP-1, VEGF-A), and CNS injury (NFL, total Tau, GFAP, YKL-40) markers were measured in plasma and CSF from 248 individuals (143 HIV+ on suppressive ART and 105 HIV- controls). Results Median age was 53 years, median CD4 count, and duration of HIV infection were 505 cells/μl and 16 years, respectively. Vascular injury, inflammation, and CNS injury markers were increased in HIV+ compared with HIV- individuals (p<0.05). HAND was associated with increased plasma VCAM-1, ICAM-1, and YKL-40 (p<0.01) and vascular disease (p=0.004). In contrast, inflammation markers had no significant association with HAND. Vascular injury markers were associated with lower neurocognitive T scores in age-adjusted models (p<0.01). Furthermore, plasma VCAM-1 correlated with NFL (r=0.29, p=0.003). Biomarker clustering separated HAND into three clusters: two clusters with high prevalence of vascular disease, elevated VCAM-1 and NFL, and distinctive inflammation profiles (CRP/ICAM-1/YKL-40 or IL-6/IL-8/IL-15/MCP-1), and one cluster with no distinctive biomarker elevations. Conclusions Vascular injury markers are more closely related to HAND and CNS injury in PWH on suppressive ART than inflammation markers and may help to distinguish relative contributions of VCI to HAND.
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Affiliation(s)
- Debjani Guha
- Department of Cancer Immunology and Virology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
| | - Vikas Misra
- Department of Cancer Immunology and Virology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
| | - Jun Yin
- Department of Cancer Immunology and Virology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
| | - Miki Horiguchi
- Department of Data Science, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
| | - Hajime Uno
- Department of Data Science, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
| | - Dana Gabuzda
- Department of Cancer Immunology and Virology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
- Department of Neurology, Harvard Medical School, Boston, MA, USA
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13
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Schrag D, Uno H, Rosovsky R, Rutherford C, Sanfilippo K, Villano JL, Drescher M, Jayaram N, Holmes C, Feldman L, Zattra O, Farrar-Muir H, Cronin C, Basch E, Weiss A, Connors JM. Direct Oral Anticoagulants vs Low-Molecular-Weight Heparin and Recurrent VTE in Patients With Cancer: A Randomized Clinical Trial. JAMA 2023; 329:1924-1933. [PMID: 37266947 PMCID: PMC10265290 DOI: 10.1001/jama.2023.7843] [Citation(s) in RCA: 16] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2022] [Accepted: 04/22/2023] [Indexed: 06/03/2023]
Abstract
Importance In patients with cancer who have venous thromboembolism (VTE) events, long-term anticoagulation with low-molecular-weight heparin (LMWH) is recommended to prevent recurrent VTE. The effectiveness of a direct oral anticoagulant (DOAC) compared with LMWH for preventing recurrent VTE in patients with cancer is uncertain. Objective To evaluate DOACs, compared with LMWH, for preventing recurrent VTE and for rates of bleeding in patients with cancer following an initial VTE event. Design, Setting, and Participants Unblinded, comparative effectiveness, noninferiority randomized clinical trial conducted at 67 oncology practices in the US that enrolled 671 patients with cancer (any invasive solid tumor, lymphoma, multiple myeloma, or chronic lymphocytic leukemia) who had a new clinical or radiological diagnosis of VTE. Enrollment occurred from December 2016 to April 2020. Final follow-up was in November 2020. Intervention Participants were randomized in a 1:1 ratio to either a DOAC (n = 335) or LMWH (n = 336) and were followed up for 6 months or until death. Physicians and patients selected any DOAC or any LMWH (or fondaparinux) and physicians selected drug doses. Main Outcomes and Measures The primary outcome was the recurrent VTE rate at 6 months. Noninferiority of anticoagulation with a DOAC vs LMWH was defined by the upper limit of the 1-sided 95% CI for the difference of a DOAC relative to LMWH of less than 3% in the randomized cohort that received at least 1 dose of assigned treatment. The 6 prespecified secondary outcomes included major bleeding, which was assessed using a 2.5% noninferiority margin. Results Between December 2016 and April 2020, 671 participants were randomized and 638 (95%) completed the trial (median age, 64 years; 353 women [55%]). Among those randomized to a DOAC, 330 received at least 1 dose. Among those randomized to LMWH, 308 received at least 1 dose. Rates of recurrent VTE were 6.1% in the DOAC group and 8.8% in the LMWH group (difference, -2.7%; 1-sided 95% CI, -100% to 0.7%) consistent with the prespecified noninferiority criterion. Of 6 prespecified secondary outcomes, none were statistically significant. Major bleeding occurred in 5.2% of participants in the DOAC group and 5.6% in the LMWH group (difference, -0.4%; 1-sided 95% CI, -100% to 2.5%) and did not meet the noninferiority criterion. Severe adverse events occurred in 33.8% of participants in the DOAC group and 35.1% in the LMWH group. The most common serious adverse events were anemia and death. Conclusions and Relevance Among adults with cancer and VTE, DOACs were noninferior to LMWH for preventing recurrent VTE over 6-month follow-up. These findings support use of a DOAC to prevent recurrent VTE in patients with cancer. Trial Registration ClinicalTrials.gov Identifier: NCT02744092.
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Affiliation(s)
- Deborah Schrag
- Dana-Farber/Brigham and Women’s Cancer Center and Harvard Medical School, Boston, Massachusetts
- Memorial Sloan Kettering Cancer Center, New York, New York
| | - Hajime Uno
- Dana-Farber/Brigham and Women’s Cancer Center and Harvard Medical School, Boston, Massachusetts
| | - Rachel Rosovsky
- Massachusetts General Hospital and Harvard Medical School, Boston
| | | | | | | | - Monic Drescher
- Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire
| | - Nagesh Jayaram
- Southeastern Medical Oncology Center, Winston-Salem, North Carolina
| | | | | | - Ottavia Zattra
- Dana-Farber/Brigham and Women’s Cancer Center and Harvard Medical School, Boston, Massachusetts
| | | | - Christine Cronin
- Dana-Farber/Brigham and Women’s Cancer Center and Harvard Medical School, Boston, Massachusetts
| | - Ethan Basch
- UNC Lineberger Cancer Center Comprehensive Cancer Center, Chapel Hill, North Carolina
| | - Anna Weiss
- Brigham and Women’s Hospital, Boston, Massachusetts
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14
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Wilson RL, Soja J, Yunker AG, Uno H, Gordon E, Cooney T, Dieli-Conwright CM. Obesity Risk of Pediatric Central Nervous System Tumor Survivors: A Cross-Sectional Study. Nutrients 2023; 15:nu15102269. [PMID: 37242152 DOI: 10.3390/nu15102269] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Revised: 04/29/2023] [Accepted: 05/09/2023] [Indexed: 05/28/2023] Open
Abstract
Adult survivors of pediatric central nervous system (CNS) tumors are at the highest risk for morbidity and late mortality among all childhood cancers due to a high burden of chronic conditions, and environmental and lifestyle factors. This study aims to epidemiologically characterize young adult survivors of pediatric CNS tumors using body mass index (BMI) to assess risk factors for obesity. Using a cross-sectional design, young adults (18-39 years) previously treated for pediatric CNS tumors and followed in a survivorship clinic during 2016-2021 were examined. Demographic, BMI, and diagnosis information were extracted from medical records of the most recent clinic visit. Data were assessed using a two-sample t-test, Fisher's exact test, and multivariable logistical regression. 198 survivors (53% female, 84.3% White) with a BMI status of underweight (4.0%), healthy weight (40.9%), overweight (26.8%), obesity (20.2%), and severe obesity (8.1%) were examined. Male sex (OR, 2.414; 95% CI, 1.321 to 4.414), older age at follow-up (OR, 1.103; 95% CI, 1.037 to 1.173), and craniopharyngioma diagnosis (OR, 5.764; 95% CI, 1.197 to 27.751) were identified as significant (p < 0.05) obesity-related (≥25.0 kg/m2) risk factors. The majority of patients were overweight or obese. As such, universal screening efforts with more precise determinants of body composition than BMI, risk stratification, and targeted lifestyle interventions are warranted during survivorship care.
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Affiliation(s)
- Rebekah L Wilson
- Division of Population Sciences, Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA 02215, USA
- Department of Medicine, Harvard Medical School, Boston, MA 02215, USA
| | - Jacqueline Soja
- Boston Children's Cancer and Blood Disorders Center, Boston, MA 02215, USA
| | - Alexandra G Yunker
- Division of Population Sciences, Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA 02215, USA
- Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, MA 02215, USA
| | - Hajime Uno
- Division of Population Sciences, Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA 02215, USA
- Department of Medicine, Harvard Medical School, Boston, MA 02215, USA
| | - Erin Gordon
- Boston Children's Hospital, Boston, MA 02215, USA
| | - Tabitha Cooney
- Division of Population Sciences, Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA 02215, USA
- Department of Medicine, Harvard Medical School, Boston, MA 02215, USA
- Boston Children's Cancer and Blood Disorders Center, Boston, MA 02215, USA
| | - Christina M Dieli-Conwright
- Division of Population Sciences, Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA 02215, USA
- Department of Medicine, Harvard Medical School, Boston, MA 02215, USA
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15
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Horiguchi M, Tian L, Uno H. On assessing survival benefit of immunotherapy using long-term restricted mean survival time. Stat Med 2023; 42:1139-1155. [PMID: 36653933 DOI: 10.1002/sim.9662] [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: 01/10/2022] [Revised: 11/09/2022] [Accepted: 01/05/2023] [Indexed: 01/20/2023]
Abstract
The pattern of the difference between two survival curves we often observe in randomized clinical trials for evaluating immunotherapy is not proportional hazards; the treatment effect typically appears several months after the initiation of the treatment (ie, delayed difference pattern). The commonly used logrank test and hazard ratio estimation approach will be suboptimal concerning testing and estimation for those trials. The long-term restricted mean survival time (LT-RMST) approach is a promising alternative for detecting the treatment effect that potentially appears later in the study. A challenge in employing the LT-RMST approach is that it must specify a lower end of the time window in addition to a truncation time point that the RMST requires. There are several investigations and suggestions regarding the choice of the truncation time point for the RMST. However, little has been investigated to address the choice of the lower end of the time window. In this paper, we propose a flexible LT-RMST-based test/estimation approach that does not require users to specify a lower end of the time window. Numerical studies demonstrated that the potential power loss by adopting this flexibility was minimal, compared to the standard LT-RMST approach using a prespecified lower end of the time window. The proposed method is flexible and can offer higher power than the RMST-based approach when the delayed treatment effect is expected. Also, it provides a robust estimate of the magnitude of the treatment effect and its confidence interval that corresponds to the test result.
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Affiliation(s)
- Miki Horiguchi
- Department of Data Science, Dana-Farber Cancer Institute, Boston, Massachusetts, USA.,Department of Medical Oncology, Division of Population Sciences, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Lu Tian
- Department of Biomedical Data Science, Stanford University, School of Medicine, Palo Alto, California, USA
| | - Hajime Uno
- Department of Data Science, Dana-Farber Cancer Institute, Boston, Massachusetts, USA.,Department of Medical Oncology, Division of Population Sciences, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
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16
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Uno H, Horiguchi M. Ratio and difference of average hazard with survival weight: New measures to quantify survival benefit of new therapy. Stat Med 2023; 42:936-952. [PMID: 36604833 DOI: 10.1002/sim.9651] [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: 09/09/2021] [Revised: 09/02/2022] [Accepted: 12/22/2022] [Indexed: 01/07/2023]
Abstract
The hazard ratio (HR) has been the most popular measure to quantify the magnitude of treatment effect on time-to-event outcomes in clinical research. However, the traditional Cox's HR approach has several drawbacks. One major issue is that there is no clear interpretation when the proportional hazards (PH) assumption does not hold, because the estimated HR is affected by study-specific censoring time distribution in non-PH cases. Another major issue is that the lack of a group-specific absolute hazard value in each group obscures the clinical significance of the magnitude of the treatment effect. Given these, we propose average hazard with survival weight (AH-SW) as a summary metric of event time distribution and will use difference in AH-SW (DAH-SW) or ratio of AH-SW (RAH-SW) to quantify the treatment effect magnitude. The AH-SW is interpreted as a person-time incidence rate that does not depend on random censoring. It is defined as the ratio of cumulative incidence probability and restricted mean survival time (RMST), which can be estimated non-parametrically. Numerical studies demonstrate that DAH-SW and RAH-SW offer almost identical power to Cox's HR-based tests under PH scenarios and can be more powerful for delayed-difference patterns often seen in immunotherapy trials. Like median and RMST differences, the proposed approach is a good model-free alternative to the HR-based approach for evaluating the treatment effect magnitude. Such a model-free measure will increase the likelihood that results from clinical studies are correctly interpreted and generalized to future populations.
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Affiliation(s)
- Hajime Uno
- Department of Data Science, Dana-Farber Cancer Institute, Boston, Massachusetts, USA.,Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Miki Horiguchi
- Department of Data Science, Dana-Farber Cancer Institute, Boston, Massachusetts, USA.,Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
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17
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Kehl KL, Uno H, Gusev A, Groha S, Brown S, Lavery JA, Schrag D, Panageas KS. Elucidating Analytic Bias Due to Informative Cohort Entry in Cancer Clinico-genomic Datasets. Cancer Epidemiol Biomarkers Prev 2023; 32:344-352. [PMID: 36626408 PMCID: PMC9992002 DOI: 10.1158/1055-9965.epi-22-0875] [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: 08/13/2022] [Revised: 11/12/2022] [Accepted: 01/04/2023] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND Oncologists often order genomic testing to inform treatment for worsening cancer. The resulting correlation between genomic testing timing and prognosis, or "informative entry," can bias observational clinico-genomic research. The efficacy of existing approaches to this problem in clinico-genomic cohorts is poorly understood. METHODS We simulated clinico-genomic cohorts followed from an index date to death. Subgroups in each cohort who underwent genomic testing before death were "observed." We varied data generation parameters under four scenarios: (i) independent testing and survival times; (ii) correlated testing and survival times for all patients; (iii) correlated testing and survival times for a subset of patients; and (iv) testing and mortality exclusively following progression events. We examined the behavior of conditional Kendall tau (Tc) statistics, Cox entry time coefficients, and biases in overall survival (OS) estimation and biomarker inference across scenarios. RESULTS Scenario #1 yielded null Tc and Cox entry time coefficients and unbiased OS inference. Scenario #2 yielded positive Tc, negative Cox entry time coefficients, underestimated OS, and biomarker associations biased toward the null. Scenario #3 yielded negative Tc, positive Cox entry time coefficients, and underestimated OS, but biomarker estimates were less biased. Scenario #4 yielded null Tc and Cox entry time coefficients, underestimated OS, and biased biomarker estimates. Transformation and copula modeling did not provide unbiased results. CONCLUSIONS Approaches to informative clinico-genomic cohort entry, including Tc and Cox entry time statistics, are sensitive to heterogeneity in genotyping and survival time distributions. IMPACT Novel methods are needed for unbiased inference using observational clinico-genomic data.
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Affiliation(s)
- Kenneth L. Kehl
- Division of Population Sciences, Dana-Farber Cancer Institute; Harvard Medical School, Boston, MA
| | - Hajime Uno
- Division of Population Sciences, Dana-Farber Cancer Institute; Harvard Medical School, Boston, MA
| | - Alexander Gusev
- Division of Population Sciences, Dana-Farber Cancer Institute; Harvard Medical School, Boston, MA
| | - Stefan Groha
- Division of Population Sciences, Dana-Farber Cancer Institute; Harvard Medical School, Boston, MA
| | - Samantha Brown
- Departments of Epidemiology & Biostatistics, Memorial-Sloan Kettering Cancer Center, New York, NY
| | - Jessica A. Lavery
- Departments of Epidemiology & Biostatistics, Memorial-Sloan Kettering Cancer Center, New York, NY
| | - Deborah Schrag
- Departments of Medicine, Memorial-Sloan Kettering Cancer Center, New York, NY
| | - Katherine S. Panageas
- Departments of Epidemiology & Biostatistics, Memorial-Sloan Kettering Cancer Center, New York, NY
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18
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Zhong CS, Horiguchi M, Uno H, Ukaegbu C, Chittenden A, LeBoeuf NR, Syngal S, Nambudiri VE, Yurgelun MB. Clinical factors associated with skin neoplasms in individuals with Lynch syndrome in a longitudinal observational cohort. J Am Acad Dermatol 2023:S0190-9622(23)00173-1. [PMID: 36773823 DOI: 10.1016/j.jaad.2023.01.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Revised: 01/09/2023] [Accepted: 01/27/2023] [Indexed: 02/11/2023]
Abstract
BACKGROUND Little is known about patient-specific risk factors for skin neoplasia in individuals with Lynch syndrome (LS). OBJECTIVE Identify clinical factors associated with development of skin neoplasms in LS. METHODS Clinical data were systematically collected on a cohort of LS carriers (confirmed pathogenic germline variants in MLH1, MSH2, MSH6, PMS2, or EPCAM) age ≥18 undergoing clinical genetics care at Dana-Farber Cancer Institute from January 2000 to March 2020. Multivariable logistic regression was performed to evaluate clinical factors associated with skin neoplasia. RESULTS Of 607 LS carriers, 9.2% had LS-associated skin neoplasia and 15.0% had non-LS-associated skin neoplasia; 58.2% (353/607) had documentation of prior dermatologic evaluation; 29.7% (38/128) with skin neoplasms lacked a history of visceral LS-associated malignancy. LS-associated skin neoplasms were significantly associated with male sex, age, race, MLH1 pathogenic germline variants, MSH2/EPCAM pathogenic germline variants, and personal history of non-LS skin neoplasms. Non-LS-associated skin neoplasms was significantly associated with age, number of first- and second-degree relatives with non-LS-associated skin neoplasms, and personal history of LS-associated skin neoplasms. LIMITATIONS Single-institution observational study; demographic homogeneity. CONCLUSIONS Skin neoplasms are common in individuals with LS. We identified clinical factors associated with LS- and non-LS-associated skin neoplasms. Regular dermatologic surveillance should be considered for all LS carriers.
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Affiliation(s)
- Connie S Zhong
- Brigham & Women's Hospital, Department of Dermatology, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts
| | - Miki Horiguchi
- Harvard Medical School, Boston, Massachusetts; Dana-Farber Cancer Institute, Division of Population Sciences, Department of Medical Oncology, Boston, Massachusetts
| | - Hajime Uno
- Harvard Medical School, Boston, Massachusetts; Dana-Farber Cancer Institute, Division of Population Sciences, Department of Medical Oncology, Boston, Massachusetts
| | - Chinedu Ukaegbu
- Harvard Medical School, Boston, Massachusetts; Dana-Farber Cancer Institute, Division of Population Sciences, Department of Medical Oncology, Boston, Massachusetts; Dana-Farber Cancer Institute, Department of Medical Oncology, Center for Cancer Genetics and Prevention, Boston, Massachusetts
| | - Anu Chittenden
- Harvard Medical School, Boston, Massachusetts; Dana-Farber Cancer Institute, Department of Medical Oncology, Center for Cancer Genetics and Prevention, Boston, Massachusetts
| | - Nicole R LeBoeuf
- Brigham & Women's Hospital, Department of Dermatology, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts; Dana-Farber Cancer Institute, Department of Medical Oncology, Center for Cutaneous Oncology, Boston, Massachusetts
| | - Sapna Syngal
- Harvard Medical School, Boston, Massachusetts; Dana-Farber Cancer Institute, Division of Population Sciences, Department of Medical Oncology, Boston, Massachusetts; Dana-Farber Cancer Institute, Department of Medical Oncology, Center for Cancer Genetics and Prevention, Boston, Massachusetts; Brigham & Women's Hospital, Department of Medicine, Boston, Massachusetts
| | - Vinod E Nambudiri
- Brigham & Women's Hospital, Department of Dermatology, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts; Dana-Farber Cancer Institute, Department of Medical Oncology, Center for Cutaneous Oncology, Boston, Massachusetts
| | - Matthew B Yurgelun
- Harvard Medical School, Boston, Massachusetts; Dana-Farber Cancer Institute, Division of Population Sciences, Department of Medical Oncology, Boston, Massachusetts; Dana-Farber Cancer Institute, Department of Medical Oncology, Center for Cancer Genetics and Prevention, Boston, Massachusetts; Brigham & Women's Hospital, Department of Medicine, Boston, Massachusetts; Dana-Farber Cancer Institute, Department of Medical Oncology, Gastrointestinal Cancer Center, Boston, Massachusetts.
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19
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Guan Z, Huang T, McCarthy AM, Hughes K, Semine A, Uno H, Trippa L, Parmigiani G, Braun D. Combining Breast Cancer Risk Prediction Models. Cancers (Basel) 2023; 15:1090. [PMID: 36831433 PMCID: PMC9953824 DOI: 10.3390/cancers15041090] [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] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2023] [Revised: 01/31/2023] [Accepted: 02/02/2023] [Indexed: 02/11/2023] Open
Abstract
Accurate risk stratification is key to reducing cancer morbidity through targeted screening and preventative interventions. Multiple breast cancer risk prediction models are used in clinical practice, and often provide a range of different predictions for the same patient. Integrating information from different models may improve the accuracy of predictions, which would be valuable for both clinicians and patients. BRCAPRO is a widely used model that predicts breast cancer risk based on detailed family history information. A major limitation of this model is that it does not consider non-genetic risk factors. To address this limitation, we expand BRCAPRO by combining it with another popular existing model, BCRAT (i.e., Gail), which uses a largely complementary set of risk factors, most of them non-genetic. We consider two approaches for combining BRCAPRO and BCRAT: (1) modifying the penetrance (age-specific probability of developing cancer given genotype) functions in BRCAPRO using relative hazard estimates from BCRAT, and (2) training an ensemble model that takes BRCAPRO and BCRAT predictions as input. Using both simulated data and data from Newton-Wellesley Hospital and the Cancer Genetics Network, we show that the combination models are able to achieve performance gains over both BRCAPRO and BCRAT. In the Cancer Genetics Network cohort, we show that the proposed BRCAPRO + BCRAT penetrance modification model performs comparably to IBIS, an existing model that combines detailed family history with non-genetic risk factors.
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Affiliation(s)
- Zoe Guan
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY 10017, USA
| | | | - Anne Marie McCarthy
- Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Kevin Hughes
- Department of Surgery, Medical University of South Carolina, Charleston, SC 29425, USA
| | - Alan Semine
- Advanced Image Enhancement, Fall River, MA 02720, USA
| | - Hajime Uno
- Department of Data Science, Dana-Farber Cancer Institute, Boston, MA 02115, USA
- Department of Medicine, Harvard Medical School, Boston, MA 02115, USA
| | - Lorenzo Trippa
- Department of Data Science, Dana-Farber Cancer Institute, Boston, MA 02115, USA
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA 02115, USA
| | - Giovanni Parmigiani
- Department of Data Science, Dana-Farber Cancer Institute, Boston, MA 02115, USA
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA 02115, USA
| | - Danielle Braun
- Department of Data Science, Dana-Farber Cancer Institute, Boston, MA 02115, USA
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA 02115, USA
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20
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Chiu PF, Mok A, Leow J, Zhang K, Chiang C, Hsieh P, Lam W, Tsang W, Chan H, Fan Y, Lin T, Hayashi T, Kamoi K, Uno H, Letran J, Zhu Y, Wang H, Chan T, Huang C, Zhu G, Wu H, Chiong E, Ng C, Shoji S. The role of systematic biopsy in the era of MRI guided prostate biopsy in a multi-centre Asian cohort. Eur Urol 2023. [DOI: 10.1016/s0302-2838(23)00347-0] [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: 02/12/2023]
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21
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Yurgelun MB, Uno H, Furniss CS, Ukaegbu C, Horiguchi M, Yussuf A, LaDuca H, Chittenden A, Garber JE, Syngal S. Development and Validation of the PREMMplus Model for Multigene Hereditary Cancer Risk Assessment. J Clin Oncol 2022; 40:4083-4094. [PMID: 35960913 PMCID: PMC9746785 DOI: 10.1200/jco.22.00120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
PURPOSE With the availability of multigene panel testing (MGPT) for hereditary cancer risk assessment, clinicians need to assess the likelihood of pathogenic germline variants (PGVs) across numerous genes in parallel. This study's aim was to develop and validate a clinical prediction model (PREMMplus) for MGPT risk assessment. MATERIALS AND METHODS PREMMplus was developed in a single-institution cohort of 7,280 individuals who had undergone MGPT. Logistic regression models with Least Absolute Shrinkage and Selection Operator regularization were used to examine candidate predictors (age, sex, ethnicity, and personal/family history of 18 cancers/neoplasms) to estimate one's likelihood of carrying PGVs in 19 genes (broadly categorized by phenotypic overlap and/or relative penetrance: 11 category A [APC, BRCA1/2, CDH1, EPCAM, MLH1, MSH2, MSH6, biallelic MUTYH, PMS2, and TP53] and eight category B genes [ATM, BRIP1, CDKN2A, CHEK2, PALB2, PTEN, RAD51C, and RAD51D]). Model performance was validated in nonoverlapping data sets of 8,691 and 14,849 individuals with prior MGPT ascertained from clinic- and laboratory-based settings, respectively. RESULTS PREMMplus (score ≥ 2.5%) had 93.9%, 91.7%, and 89.3% sensitivity and 98.3%, 97.5%, and 97.8% negative-predictive value (NPV) for identifying category A gene PGV carriers in the development and validation cohorts, respectively. PREMMplus assessment (score ≥ 2.5%) had 89.9%, 85.6%, and 84.2% sensitivity and 95.0%, 93.5%, and 93.5% NPV, respectively, for identifying category A/B gene PGV carriers. Decision curve analyses support MGPT for individuals predicted to have ≥ 2.5% probability of a PGV. CONCLUSION PREMMplus accurately identifies individuals with PGVs in a diverse spectrum of cancer susceptibility genes with high sensitivity/NPV. Individuals with PREMMplus scores ≥ 2.5% should be considered for MGPT.
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Affiliation(s)
- Matthew B. Yurgelun
- Dana-Farber Cancer Institute, Boston, MA,Harvard Medical School, Boston, MA,Brigham & Women's Hospital, Boston, MA
| | - Hajime Uno
- Dana-Farber Cancer Institute, Boston, MA,Harvard Medical School, Boston, MA
| | | | | | - Miki Horiguchi
- Dana-Farber Cancer Institute, Boston, MA,Harvard Medical School, Boston, MA
| | | | | | | | - Judy E. Garber
- Dana-Farber Cancer Institute, Boston, MA,Harvard Medical School, Boston, MA,Brigham & Women's Hospital, Boston, MA
| | - Sapna Syngal
- Dana-Farber Cancer Institute, Boston, MA,Harvard Medical School, Boston, MA,Brigham & Women's Hospital, Boston, MA,Sapna Syngal, MD, MPH, Dana-Farber Cancer Institute, 450 Brookline Ave, Boston, MA 02215; Twitter: @SapnaSyngal; e-mail:
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22
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Rodriguez NJ, Furniss CS, Yurgelun MB, Ukaegbu C, Constantinou PE, Fortes I, Caruso A, Schwartz AN, Stopfer JE, Underhill-Blazey M, Kenner B, Nelson SH, Okumura S, Zhou AY, Coffin TB, Uno H, Horiguchi M, Ocean AJ, McAllister F, Lowy AM, Lippman SM, Klein AP, Madlensky L, Petersen GM, Garber JE, Goggins MG, Maitra A, Syngal S. Abstract A029: A randomized study of two Strategies of remote Genetic Education, Risk Assessment, and Testing (GENERATE) for family members of patients with pancreatic cancer. Cancer Res 2022. [DOI: 10.1158/1538-7445.panca22-a029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Abstract
Background: Uptake of genetic testing for cancer susceptibility in family members of cancer patients is suboptimal. The GENetic Education, Risk Assessment, and TEsting (GENERATE) study evaluated two strategies of remote genetic education and testing in relatives of pancreatic ductal adenocarcinoma (PDAC) patients. Methods: Eligible participants had: a first-degree relative with PDAC or had a known pathogenic germline variant (PGV) in one of thirteen PDAC predisposition genes (APC, ATM, BRCA1, BRCA2, CDKN2A, EPCAM, MLH1, MSH2, MSH6, PALB2, PMS2, STK11, or TP53) and a first- or second-degree relative with PDAC. Participants were cluster-randomized by family into one of two arms. Arm 1 included an interactive telemedicine session with a genetic counselor, followed by genetic testing at a commercial laboratory. Arm 2 involved remote online genetic education and testing at the commercial laboratory without the interactive session. The primary outcome was uptake of genetic testing across study arms, which was compared by permutation tests and mixed-effects logistic regression models. Results: Between 5/8/2019 and 6/1/2021, 424 families were randomized, including 601 participants (n=296 Arm 1; n=305 Arm 2). The uptake of genetic testing was 87% (257/296) in Arm 1 and 93% (284/305) in Arm 2 (p=0.014). Participants in Arm 1 were significantly less likely to obtain genetic testing compared to Arm 2 (Adjusted ratio [Arm1/Arm2] 0.90, 95% confidence interval 0.78-0.98). BRCA2, ATM, CDKN2A and PALB2 were the most common PDAC susceptibility genes in which PGVs were identified. Conclusions: Remote methods of genetic education and testing are successful alternatives to traditional germline susceptibility testing.
Citation Format: Nicolette J. Rodriguez, C. Sloane Furniss, Matthew B. Yurgelun, Chinedu Ukaegbu, Pamela E. Constantinou, Ileana Fortes, Alyson Caruso, Alison N. Schwartz, Jill E. Stopfer, Meghan Underhill-Blazey, Barbara Kenner, Scott H. Nelson, Sydney Okumura, Alicia Y. Zhou, Tara B. Coffin, Hajime Uno, Miki Horiguchi, Allyson J. Ocean, Florencia McAllister, Andrew M. Lowy, Scott M. Lippman, Alison P. Klein, Lisa Madlensky, Gloria M. Petersen, Judy E. Garber, Michael G. Goggins, Anirban Maitra, Sapna Syngal. A randomized study of two Strategies of remote Genetic Education, Risk Assessment, and Testing (GENERATE) for family members of patients with pancreatic cancer [abstract]. In: Proceedings of the AACR Special Conference on Pancreatic Cancer; 2022 Sep 13-16; Boston, MA. Philadelphia (PA): AACR; Cancer Res 2022;82(22 Suppl):Abstract nr A029.
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Affiliation(s)
- Nicolette J. Rodriguez
- 1Brigham and Women's Hospital, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA,
| | | | - Matthew B. Yurgelun
- 3Dana-Farber Cancer Institute, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA,
| | | | - Pamela E. Constantinou
- 5Sheikh Ahmed Center for Pancreatic Cancer Research, University of Texas MD Anderson Cancer Center, Houston, TX,
| | | | | | | | | | | | | | | | | | | | | | - Hajime Uno
- 2Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA,
| | - Miki Horiguchi
- 2Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA,
| | | | - Florencia McAllister
- 5Sheikh Ahmed Center for Pancreatic Cancer Research, University of Texas MD Anderson Cancer Center, Houston, TX,
| | | | | | - Alison P. Klein
- 13Johns Hopkins University Sol Goldman Pancreatic Cancer Research Center, Baltimore, MD,
| | | | | | - Judy E. Garber
- 3Dana-Farber Cancer Institute, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA,
| | - Michael G. Goggins
- 13Johns Hopkins University Sol Goldman Pancreatic Cancer Research Center, Baltimore, MD,
| | - Anirban Maitra
- 5Sheikh Ahmed Center for Pancreatic Cancer Research, University of Texas MD Anderson Cancer Center, Houston, TX,
| | - Sapna Syngal
- 3Dana-Farber Cancer Institute, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA,
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Shyr C, Blackford AL, Huang T, Ke J, Ouardaoui N, Trippa L, Syngal S, Ukaegbu C, Uno H, Nafa K, Stadler ZK, Offit K, Amos CI, Lynch PM, Chen S, Giardiello FM, Buchanan DD, Hopper JL, Jenkins MA, Southey MC, Win AK, Figueiredo JC, Braun D, Parmigiani G. A validation of models for prediction of pathogenic variants in mismatch repair genes. Genet Med 2022; 24:2155-2166. [PMID: 35997715 PMCID: PMC10312204 DOI: 10.1016/j.gim.2022.07.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Revised: 06/30/2022] [Accepted: 07/01/2022] [Indexed: 10/15/2022] Open
Abstract
PURPOSE Models used to predict the probability of an individual having a pathogenic homozygous or heterozygous variant in a mismatch repair gene, such as MMRpro, are widely used. Recently, MMRpro was updated with new colorectal cancer penetrance estimates. The purpose of this study was to evaluate the predictive performance of MMRpro and other models for individuals with a family history of colorectal cancer. METHODS We performed a validation study of 4 models, Leiden, MMRpredict, PREMM5, and MMRpro, using 784 members of clinic-based families from the United States. Predicted probabilities were compared with germline testing results and evaluated for discrimination, calibration, and predictive accuracy. We analyzed several strategies to combine models and improve predictive performance. RESULTS MMRpro with additional tumor information (MMRpro+) and PREMM5 outperformed the other models in discrimination and predictive accuracy. MMRpro+ was the best calibrated with an observed to expected ratio of 0.98 (95% CI = 0.89-1.08). The combination models showed improvement over PREMM5 and performed similar to MMRpro+. CONCLUSION MMRpro+ and PREMM5 performed well in predicting the probability of having a pathogenic homozygous or heterozygous variant in a mismatch repair gene. They serve as useful clinical decision tools for identifying individuals who would benefit greatly from screening and prevention strategies.
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Affiliation(s)
- Cathy Shyr
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA; Department of Data Science, Dana-Farber Cancer Institute, Boston, MA
| | - Amanda L Blackford
- Division of Biostatistics and Bioinformatics, Johns Hopkins School of Medicine, Baltimore, MD
| | - Theodore Huang
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA; Department of Data Science, Dana-Farber Cancer Institute, Boston, MA
| | - Jianfeng Ke
- Department of Data Science, Dana-Farber Cancer Institute, Boston, MA; Department of Mathematical Sciences, Tsinghua University, Beijing, China
| | - Nofal Ouardaoui
- Department of Computer Science, School of Engineering, Tufts University, Medford, MA
| | - Lorenzo Trippa
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA; Department of Data Science, Dana-Farber Cancer Institute, Boston, MA
| | - Sapna Syngal
- Cancer Genetics and Prevention Division, Dana-Farber Cancer Institute, Boston, MA; Division of Gastroenterology, Brigham and Women's Hospital, and Harvard Medical School, Boston, MA
| | - Chinedu Ukaegbu
- Cancer Genetics and Prevention Division, Dana-Farber Cancer Institute, Boston, MA
| | - Hajime Uno
- Department of Data Science, Dana-Farber Cancer Institute, Boston, MA; McGraw/Patterson Center for Population Sciences, Dana-Farber Cancer Institute, Boston, MA
| | - Khedoudja Nafa
- Department of Pathology and Laboratory Medicine, Molecular Diagnostic Service, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Zsofia K Stadler
- Clinical Genetics Service, Department of Medicine, Memorial Sloan Kettering Comprehensive Cancer Center, New York, NY; Niehaus Center for Inherited Cancer Genomics, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Kenneth Offit
- Clinical Genetics Service, Department of Medicine, Memorial Sloan Kettering Comprehensive Cancer Center, New York, NY; Niehaus Center for Inherited Cancer Genomics, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Christopher I Amos
- Institute for Clinical and Translational Research, Baylor College of Medicine, Houston, TX; Section of Epidemiology and Population Sciences, Department of Medicine, Baylor College of Medicine, Houston, TX; Dan L Duncan Comprehensive Cancer Center, Baylor College of Medicine, Houston, TX
| | - Patrick M Lynch
- Gastroenterology, Hepatology and Nutrition, University of Texas MD Anderson Cancer Center, Houston, TX
| | | | - Francis M Giardiello
- Department of Gastroenterology and Hepatology, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Daniel D Buchanan
- Colorectal Oncogenomics Group, Department of Clinical Pathology, The University of Melbourne, Parkville, Victoria, Australia; University of Melbourne Centre for Cancer Research, Victorian Comprehensive Cancer Centre, Parkville, Victoria, Australia; Genomic Medicine and Family Cancer Clinic, The Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - John L Hopper
- Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, Victoria, Australia
| | - Mark A Jenkins
- Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, Victoria, Australia; University of Melbourne Centre for Cancer Research, Victorian Comprehensive Cancer Centre, Parkville, Victoria, Australia
| | - Melissa C Southey
- Cancer Epidemiology Division, Cancer Council Victoria, Melbourne, Victoria, Australia; Department of Clinical Pathology, Melbourne Medical School, The University of Melbourne, Melbourne, Victoria, Australia; Precision Medicine, School of Clinical Sciences at Monash Health, Monash University, Clayton, Victoria, Australia
| | - Aung Ko Win
- Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, Victoria, Australia
| | - Jane C Figueiredo
- Department of Medicine, Samuel Oschin Comprehensive Cancer Institute, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Danielle Braun
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA; Department of Data Science, Dana-Farber Cancer Institute, Boston, MA.
| | - Giovanni Parmigiani
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA; Department of Data Science, Dana-Farber Cancer Institute, Boston, MA
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Claggett BL, McCaw ZR, Tian L, McMurray JJV, Jhund PS, Uno H, Pfeffer MA, Solomon SD, Wei LJ. Quantifying Treatment Effects in Trials with Multiple Event-Time Outcomes. NEJM Evid 2022; 1:10.1056/evidoa2200047. [PMID: 37645407 PMCID: PMC10465123 DOI: 10.1056/evidoa2200047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/31/2023]
Abstract
BACKGROUND Data on the occurrence times of multiple outcomes, reflecting the temporal profile of disease burden/progression, have been used to estimate treatment effects in various recent randomized trials. Most procedures for analyzing these data require specific model assumptions. When the assumptions are not met, the results may be misleading. Robust, model-free procedures for study design and analysis that enable clinically meaningful interpretations are warranted. METHODS For each treatment group, we constructed and summarized the estimated mean cumulative count of events over time by the area under the curve (AUC), which can be interpreted as the mean total event-free time lost from multiple undesirable outcomes. A higher curve, and resulting larger AUC, implies a worse treatment. The treatment effect is quantified by the ratio and/or difference of AUCs. The timing and occurrence of recurrent heart failure hospitalizations (HFHs) and cardiovascular (CV) death from Prospective Comparison of ARNI with ARB Global Outcomes in HF with Preserved Ejection Fraction (PARAGON-HF), comparing sacubitril/valsartan with valsartan, are presented for illustration. We also discuss the design of future studies on the basis of the proposed method. RESULTS With 48 months of follow-up, estimated AUCs, representing the total event-free time lost to HFHs and CV death, were 11.3 and 13.1 event-months for sacubitril/valsartan and valsartan, respectively. The ratio of these AUCs was 0.86 (95% confidence interval, 0.75 to 1.00; P=0.049), a 14% reduction of disease burden favoring combination therapy. A future study, similar to PARAGON-HF, designed using the new proposal would require fewer patients would than a conventional time-to-first-event analysis. CONCLUSIONS The proposed method is robust and model-free and provides a clinically interpretable, time-scale summary of the treatment effect. (Funded by National Institutes of Health.).
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Affiliation(s)
- Brian Lee Claggett
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston
| | | | - Lu Tian
- Department of Biomedical Data Science, Stanford University, Stanford, CA
| | - John J V McMurray
- British Heart Foundation Glasgow Cardiovascular Research Center, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, Scotland
| | - Pardeep S Jhund
- British Heart Foundation Glasgow Cardiovascular Research Center, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, Scotland
| | - Hajime Uno
- Department of Data Science, Dana-Farber Cancer Institute, Boston
| | - Marc A Pfeffer
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston
| | - Scott D Solomon
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston
| | - Lee-Jen Wei
- Harvard T.H. Chan School of Public Health, Boston
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Mack JW, Jaung T, Uno H, Brackett J. Change in the Parent-Clinician Relationship Throughout the First Year of Treatment in Pediatric Oncology. JAMA Netw Open 2022; 5:e2230503. [PMID: 36074466 PMCID: PMC9459655 DOI: 10.1001/jamanetworkopen.2022.30503] [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] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE Challenges in the therapeutic relationship between clinicians and parents of children with cancer have been shown to emerge immediately after diagnosis, but little is known about whether such relationships improve over time. OBJECTIVE To better understand the potential evolution of parent-clinician relationships over the first year after diagnosis of pediatric cancer. DESIGN, SETTING, AND PARTICIPANTS This survey study was conducted from November 2015 to September 2020 at Dana-Farber Cancer Institute/Boston Children's Hospital and Texas Children's Hospital. Participants were oncology clinicians (attending physicians and fellows or nurse practitioners) and parents of children (aged <18 years) with a cancer diagnosis. Surveys were completed at study enrollment (soon after diagnosis [baseline]) and at the 3-month and 12-month follow-up. EXPOSURES Children had to have had at least 3 previous clinical visits with a primary oncology clinician. MAIN OUTCOMES AND MEASURES Survey instruments included the parent and clinician versions of the Relationship Challenges Scale, and factors associated with changes in relationships, including parental, clinician, and health care system attributes, were measured. RESULTS Survey participants included 150 parents (118 women [78.7%]; 98 with White race and ethnicity [65.3%]) and 49 clinicians (39 [79.6%] women; 39 with White race and ethnicity [79.6%]). Parents reported on 175 relationships with clinicians, and clinicians reported on 98 relationships with parents at all 3 time points (baseline, 3-month follow-up, and 12-month follow-up). Of the 175 relationships, 33 (18.9%) were considered to be challenging by parents at baseline, 27 (15.4%) were considered to be challenging at the 3-month follow-up, and 32 (18.3%) were considered to be challenging at the 12-month follow-up. Of the 33 challenging relationships at baseline, 20 (60.6%) resolved at the 12-month follow-up, whereas 13 (39.4%) had persistent challenges. However, 19 relationships that were not challenging at baseline had new challenges at the 12-month follow-up, corresponding to 59.4% of all challenges at the 12-month follow-up. No clinician behaviors were associated with improvement. Strategies used frequently (≥50%) by clinicians in their relationships that were associated with improvement included holding family meetings, apologizing, adapting to the parent's communication style, and devoting extra time and attention. CONCLUSIONS AND RELEVANCE Results of this study showed that some parents experienced challenging relationships with their child's oncology clinicians beginning at diagnosis and throughout the first year after diagnosis. Although many such relationships improved, others worsened, reflecting the vulnerable and stressful nature of parent-clinician relationships.
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Affiliation(s)
- Jennifer W. Mack
- Department of Pediatric Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
- Division of Population Sciences’ Center for Outcomes and Policy Research, Dana-Farber Cancer Institute, Boston, Massachusetts
- Division of Pediatric Hematology/Oncology, Boston Children’s Hospital, Boston, Massachusetts
| | - Tim Jaung
- Division of Population Sciences’ Center for Outcomes and Policy Research, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Hajime Uno
- Division of Population Sciences’ Center for Outcomes and Policy Research, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Julienne Brackett
- Section of Pediatric Hematology/Oncology, Department of Pediatrics, Baylor College of Medicine, Houston, Texas
- Department of Pediatrics, Texas Children’s Hospital, Houston, Texas
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Manz CR, Tramontano AC, Uno H, Parikh RB, Bekelman JE, Schrag D. Association of Oncologist Participation in Medicare's Oncology Care Model With Patient Receipt of Novel Cancer Therapies. JAMA Netw Open 2022; 5:e2234161. [PMID: 36173630 PMCID: PMC9523492 DOI: 10.1001/jamanetworkopen.2022.34161] [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] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE Medicare's Oncology Care Model (OCM) was an alternative payment model that tied performance-based payments to cost and quality goals for participating oncology practices. A major concern about the OCM regarded inclusion of high-cost cancer therapies, which could potentially disincentivize oncologists from prescribing novel therapies. OBJECTIVE To examine whether oncologist participation in the OCM changed the likelihood that patients received novel therapies vs alternative treatments. DESIGN, SETTING, AND PARTICIPANTS This cohort study of Surveillance, Epidemiology, and End Results (SEER) Program data and Medicare claims compared patient receipt of novel therapies for patients treated by oncologists participating vs not participating in the OCM in the period before (January 2015-June 2016) and after (July 2016-December 2018) OCM initiation. Participants included Medicare fee-for-service beneficiaries in SEER registries who were eligible to receive 1 of 10 novel cancer therapies that received US Food and Drug Administration approval in the 18 months before implementation of the OCM. The study excluded the Hawaii registry because complete data were not available at the time of the data request. Patients in the OCM vs non-OCM groups were matched on novel therapy cohort, outcome time period, and oncologist specialist status. Analysis was conducted between July 2021 and April 2022. EXPOSURES Oncologist participation in the OCM. MAIN OUTCOMES AND MEASURES Preplanned analyses evaluated patient receipt of 1 of 10 novel therapies vs alternative therapies specific to the patient's cancer for the overall study sample and for racial subgroups. RESULTS The study included 2839 matched patients (760 in the OCM group and 2079 in the non-OCM group; median [IQR] age, 72.7 [68.3-77.6] years; 1591 women [56.0%]). Among patients in the non-OCM group, 33.2% received novel therapies before and 40.1% received novel therapies after the start of the OCM vs 39.9% and 50.3% of patients in the OCM group (adjusted difference-in-differences, 3.5 percentage points; 95% CI, -3.7 to 10.7 percentage points; P = .34). In subgroup analyses, second-line immunotherapy use in lung cancer was greater among patients in the OCM group vs non-OCM group (adjusted difference-in-differences, 17.4 percentage points; 95% CI, 4.8-30.0 percentage points; P = .007), but no differences were seen in other subgroups. Over the entire study period, patients with oncologists participating in the OCM were more likely to receive novel therapies than those with oncologists who were not participating (odds ratio, 1.47; 95% CI, 1.09-1.97; P = .01). CONCLUSIONS AND RELEVANCE This study found that participation in the OCM was not associated with oncologists' prescribing novel therapies to Medicare beneficiaries with cancer. These findings suggest that OCM financial incentives did not decrease patient access to novel therapies.
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Affiliation(s)
- Christopher R. Manz
- Division of Population Sciences, Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
- Department of Medical Oncology, Harvard Medical School, Boston, Massachusetts
| | - Angela C. Tramontano
- Division of Population Sciences, Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Hajime Uno
- Division of Population Sciences, Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Ravi B. Parikh
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Penn Center for Cancer Care Innovation, Abramson Cancer Center, University of Pennsylvania, Philadelphia
- Corporal Michael J. Crescenz Department of Veterans Affairs Medical Center, Philadelphia, Pennsylvania
| | - Justin E. Bekelman
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Penn Center for Cancer Care Innovation, Abramson Cancer Center, University of Pennsylvania, Philadelphia
| | - Deborah Schrag
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
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Lui G, Hassett MJ, Tramontano AC, Uno H, Punglia RS. Regional Disparities in the Use and Delivery of Adjuvant Radiation Therapy after Lumpectomy for Breast Cancer in the Medicare Population. Adv Radiat Oncol 2022; 7:101017. [DOI: 10.1016/j.adro.2022.101017] [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] [Received: 03/04/2022] [Accepted: 06/24/2022] [Indexed: 11/27/2022] Open
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Liang L, Hou J, Uno H, Cho K, Ma Y, Cai T. Semi-supervised approach to event time annotation using longitudinal electronic health records. Lifetime Data Anal 2022; 28:428-491. [PMID: 35753014 PMCID: PMC10044535 DOI: 10.1007/s10985-022-09557-5] [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] [Subscribe] [Scholar Register] [Received: 09/16/2021] [Accepted: 05/13/2022] [Indexed: 06/15/2023]
Abstract
Large clinical datasets derived from insurance claims and electronic health record (EHR) systems are valuable sources for precision medicine research. These datasets can be used to develop models for personalized prediction of risk or treatment response. Efficiently deriving prediction models using real world data, however, faces practical and methodological challenges. Precise information on important clinical outcomes such as time to cancer progression are not readily available in these databases. The true clinical event times typically cannot be approximated well based on simple extracts of billing or procedure codes. Whereas, annotating event times manually is time and resource prohibitive. In this paper, we propose a two-step semi-supervised multi-modal automated time annotation (MATA) method leveraging multi-dimensional longitudinal EHR encounter records. In step I, we employ a functional principal component analysis approach to estimate the underlying intensity functions based on observed point processes from the unlabeled patients. In step II, we fit a penalized proportional odds model to the event time outcomes with features derived in step I in the labeled data where the non-parametric baseline function is approximated using B-splines. Under regularity conditions, the resulting estimator of the feature effect vector is shown as root-n consistent. We demonstrate the superiority of our approach relative to existing approaches through simulations and a real data example on annotating lung cancer recurrence in an EHR cohort of lung cancer patients from Veteran Health Administration.
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Affiliation(s)
- Liang Liang
- Department of Biostatistics, Harvard T. H. Chan School of Public Health, Boston, MA, USA
| | - Jue Hou
- Department of Biostatistics, Harvard T. H. Chan School of Public Health, Boston, MA, USA
| | - Hajime Uno
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Kelly Cho
- Massachusetts Veterans Epidemiology Research and Information Center, US Department of Veteran Affairs, Boston, MA, USA
- Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Yanyuan Ma
- Department of Statistics, Penn State University, University Park, PA, Boston, USA
| | - Tianxi Cai
- Department of Biostatistics, Harvard T. H. Chan School of Public Health, Boston, MA, USA.
- Department of Biomedical Informatics, Harvard Medical School, Boston, MA, USA.
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Kang DW, Wilson RL, Gonzalo-Encabo P, Norris MK, Hans M, Tahbaz M, Dawson J, Nguyen D, Normann AJ, Yunker AG, Sami N, Uno H, Ligibel JA, Mittelman SD, Dieli-Conwright CM. Targeting Adiposity and Inflammation With Movement to Improve Prognosis in Breast Cancer Survivors (The AIM Trial): Rationale, Design, and Methods. Front Oncol 2022; 12:896995. [PMID: 35795051 PMCID: PMC9251632 DOI: 10.3389/fonc.2022.896995] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Accepted: 04/27/2022] [Indexed: 11/21/2022] Open
Abstract
Background Obesity is a significant contributor to breast cancer recurrence and mortality. A central mechanism by which obesity stimulates cancer progression is through chronic, low-grade inflammation in adipose tissue. Exercise interventions to target chronic inflammation has a potential to improve obesity- and breast cancer-related outcomes; however, no studies have investigated the roles of exercise in modulating adipose tissue inflammation in breast cancer survivors. Also, it is unclear which exercise prescription would be optimal to maximize the outcomes. Therefore, we designed a randomized controlled trial (Taking AIM at Breast Cancer: Targeting Adiposity and Inflammation with Movement to Improve Prognosis in Breast Cancer Survivors [AIM] Trial) to examine the mechanisms by which different modalities of exercise impact chronic inflammation as a biomarker of breast cancer prognosis. Methods The AIM trial is a prospective, three-armed, phase II randomized controlled trial investigating the effects of a 16-week supervised circuit aerobic and resistance exercise (CARE) program versus a traditional aerobic and resistance exercise (TARE) program and attention control (AC) on adipose tissue inflammation in breast cancer survivors. 276 patients who are diagnosed with stage 0-III breast cancer, post-treatment, sedentary, and centrally obese are randomized to one of the three groups. The CARE and TARE groups participate in thrice-weekly supervised exercise sessions for 16 weeks. The AC group are offered the CARE program after the intervention period. The primary endpoint is adipose tissue inflammation assessed by core biopsy and blood draw. The secondary and tertiary endpoints are sarcopenic obesity, physical fitness and function, and patient reported outcomes. The exploratory outcomes are long-term breast cancer outcomes. Discussion This is the first randomized controlled trial examining the effects of exercise on adipose tissue inflammation in obese, breast cancer survivors. Our findings are anticipated to contribute to a better understanding of exercise modalities and mechanisms on adipose tissue inflammation that can potentially improve breast cancer prognosis. Clinical Trial Registration https://clinicaltrials.gov/ct2/show/NCT03091842 identifier [NCT#03091842].
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Affiliation(s)
- Dong-Woo Kang
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, United States
- Department of Medicine, Harvard Medical School, Boston, MA, United States
| | - Rebekah L. Wilson
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, United States
- Department of Medicine, Harvard Medical School, Boston, MA, United States
| | - Paola Gonzalo-Encabo
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, United States
- Department of Medicine, Harvard Medical School, Boston, MA, United States
| | - Mary K. Norris
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, United States
| | - Marybeth Hans
- Division of Breast Surgery, Brigham and Women’s Hospital, Boston, MA, United States
| | - Meghan Tahbaz
- Department of Medicine, Morsani College of Medicine, University of South Florida, Tampa, FL, United States
| | - Jackie Dawson
- Department of Physical Therapy, California State University, Long Beach, Long Beach, CA, United States
| | - Danny Nguyen
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, United States
| | - Amber J. Normann
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, United States
- Department of Health Sciences, Boston University, Boston, MA, United States
| | - Alexandra G. Yunker
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, United States
- Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, MA, United States
| | - Nathalie Sami
- Department of Medicine, University of Southern California, Los Angeles, CA, United States
| | - Hajime Uno
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, United States
- Department of Medicine, Harvard Medical School, Boston, MA, United States
| | - Jennifer A. Ligibel
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, United States
- Department of Medicine, Harvard Medical School, Boston, MA, United States
| | - Steven D. Mittelman
- Children’s Discovery and Innovations Institute, University of California, Los Angeles, Los Angeles, CA, United States
| | - Christina M. Dieli-Conwright
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, United States
- Department of Medicine, Harvard Medical School, Boston, MA, United States
- *Correspondence: Christina M. Dieli-Conwright,
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Hassett MJ, Wong S, Osarogiagbon RU, Bian J, Dizon DS, Jenkins HH, Uno H, Cronin C, Schrag D. Implementation of patient-reported outcomes for symptom management in oncology practice through the SIMPRO research consortium: a protocol for a pragmatic type II hybrid effectiveness-implementation multi-center cluster-randomized stepped wedge trial. Trials 2022; 23:506. [PMID: 35710449 PMCID: PMC9202326 DOI: 10.1186/s13063-022-06435-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [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: 03/25/2022] [Accepted: 05/27/2022] [Indexed: 11/24/2022] Open
Abstract
Background Many cancer patients experience high symptom burden. Healthcare in the USA is reactive, not proactive, and doctor-patient communication is often suboptimal. As a result, symptomatic patients may suffer between clinic visits. In research settings, systematic assessment of electronic patient-reported outcomes (ePROs), coupled with clinical responses to severe symptoms, has eased this symptom burden, improved health-related quality of life, reduced acute care needs, and extended survival. Implementing ePRO-based symptom management programs in routine care is challenging. To study methods to overcome the implementation gap and improve symptom control for cancer patients, the National Cancer Institute created the Cancer-Moonshot funded Improving the Management of symPtoms during And following Cancer Treatment (IMPACT) Consortium. Methods Symptom Management IMplementation of Patient Reported Outcomes in Oncology (SIMPRO) is one of three research centers that make up the IMPACT Consortium. SIMPRO, a multi-disciplinary team of investigators from six US health systems, seeks to develop, test, and integrate an electronic symptom management program (eSyM) for medical oncology and surgery patients into the Epic electronic health record (EHR) system and associated patient portal. eSyM supports real-time symptom tracking for patients, automated clinician alerts for severe symptoms, and specialized reports to facilitate population management. To rigorously evaluate its impact, eSyM is deployed through a pragmatic stepped wedge cluster-randomized trial. The primary study outcome is the occurrence of an emergency department treat-and-release event within 30 days of starting chemotherapy or being discharged following surgery. Secondary outcomes include hospitalization rates, chemotherapy use (time to initiation and duration of therapy), and patient quality of life and satisfaction. As a type II hybrid effectiveness-implementation study, facilitators and barriers to implementation are assessed throughout the project. Discussion Creating and deploying eSyM requires collaboration between dozens of staff across diverse health systems, dedicated engagement of patient advocates, and robust support from Epic. This trial will evaluate eSyM in routine care settings across academic and community-based healthcare systems serving patients in rural and metropolitan locations. This trial’s pragmatic design will promote generalizable results about the uptake, acceptability, and impact of an EHR-integrated, ePRO-based symptom management program. Trial registration
ClinicalTrials.gov NCT03850912. Registered on February 22, 2019. Last updated on November 9, 2021.
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Affiliation(s)
- Michael J Hassett
- Dana-Farber Cancer Institute/Brigham and Women's Hospital, 450 Brookline Avenue, Boston, MA, 02215, USA.
| | - Sandra Wong
- Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
| | | | | | - Don S Dizon
- Lifespan Cancer Institute and Brown University, Providence, RI, USA
| | | | - Hajime Uno
- Dana-Farber Cancer Institute/Brigham and Women's Hospital, 450 Brookline Avenue, Boston, MA, 02215, USA
| | - Christine Cronin
- Dana-Farber Cancer Institute/Brigham and Women's Hospital, 450 Brookline Avenue, Boston, MA, 02215, USA
| | - Deborah Schrag
- Memorial Sloan Kettering Cancer Center, New York, NY, USA
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Dieli-Conwright CM, Kang DW, Wilson RM, Gonzalo-Encabo P, Norris M, Hans M, Tahbaz M, Dawson J, Nguyen D, Normann A, Yunker AG, Sami N, Uno H, Ligibel JA, Mittelman SD. Targeting adiposity and inflammation with movement to improve prognosis in breast cancer survivors (the AIM trial): Rationale, design, and methods. J Clin Oncol 2022. [DOI: 10.1200/jco.2022.40.16_suppl.tps12140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
TPS12140 Background: Obesity is considered a leading modifiable contributor to breast cancer mortality worldwide due to its association with increased recurrence and decreased overall survival rate. A central mechanism by which obesity stimulates cancer progression is through chronic, low-grade inflammation in adipose tissue. Exercise has shown potential in improving inflammation but has not been implemented with breast cancer survivors. Our hypothesis is that exercise designed to target chronic inflammation and associated sarcopenic obesity will improve prognosis in obese breast cancer survivors. Methods: The AIM trial is a prospective, three-armed, phase II randomized controlled trial investigating the effects of a 16-week supervised circuit aerobic and resistance exercise (CARE) program compared to a traditional aerobic and resistance exercise (TARE) program, and attention control (AC) group, on adipose tissue inflammation in 300 breast cancer survivors. Main inclusion criteria are histologically confirmed breast cancer stage 0-III, completion of chemotherapy and/or radiation, sedentary, centrally obese, and free from musculoskeletal disorders. The primary endpoint is adipose tissue inflammation as assessed by core biopsy and blood draw; secondary endpoint is sarcopenic obesity; and exploratory endpoints are physical fitness and function and patient reported outcomes. Participants randomized to the exercise groups participate in three weekly supervised exercise sessions for 16-weeks. Participants randomized to the attention control group are offered the CARE intervention after the 16-week period of observation. Discussion: This is the first randomized controlled trial examining the effects of exercise on adipose tissue inflammation in obese, breast cancer survivors. Results will contribute to a better understanding of exercise modality on adipose tissue inflammation that can potentially improve patient prognosis. Clinical trial information: NCT03091842.
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Affiliation(s)
| | | | | | | | | | | | | | - Jackie Dawson
- California State University Long Beach, Long Beach, CA
| | | | | | | | | | - Hajime Uno
- Dana-Farber Cancer Institute, Boston, MA
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32
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Gonzalo-Encabo P, Wilson RL, Kang DW, Norris MK, Uno H, Christopher CN, Chow C, Sami N, Fox FS, Ligibel JA, Dieli-Conwright CM. Reducing Metabolic Dysregulation in Obese Latina and/or Hispanic Breast Cancer Survivors Using Physical Activity (ROSA) Trial: A Study Protocol. Front Oncol 2022; 12:864844. [PMID: 35619910 PMCID: PMC9128380 DOI: 10.3389/fonc.2022.864844] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Accepted: 03/28/2022] [Indexed: 11/13/2022] Open
Abstract
Background Latina and Hispanic breast cancer survivors (LHBCS) are at increased risk for long-term complications and poorer metabolic health, including metabolic dysregulation (MetD) before and following breast cancer diagnosis. MetD can increase risk of cancer recurrence, death, and comorbid conditions by increasing inflammation and cancer cell proliferation. While exercise improves physical fitness and metabolic outcomes in breast cancer survivors, there is a lack of studies including underrepresented and disadvantaged minority groups such as LHBCS. Methods Our 12-month randomized (exercise or attention control) controlled trial (the ROSA trial) aims to utilize a progressive combined aerobic and resistance exercise program to improve MetD, insulin resistance, and visceral adiposity among obese LHBCS. We aim to recruit 160 women with Stage I-III breast cancer who are sedentary, centrally obese, and have completed treatment (e.g., surgery, radiation, chemotherapy) prior to enrollment. Participants randomized to the exercise group receive 16-weeks of virtually supervised aerobic and resistance training, followed by 16-weeks of unsupervised home-based aerobic and resistance exercise, and 16-weeks of follow-up. The attention control group receive a 12-month home-based stretching program. Primary and secondary outcomes are measured every 4-weeks during study visits. Discussion The ROSA trial is the first exercise oncology trial targeting high-risk sedentary, obese LHBCS to improve MetD-related outcomes. Results of this trial will help illuminate how exercise impacts health-related outcomes, survivorship, and recurrence, and inform future exercise oncology guidelines to reduce health disparities among minority cancer survivors.
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Affiliation(s)
- Paola Gonzalo-Encabo
- Division of Population Sciences, Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, United States.,Department of Medicine, Harvard Medical School, Boston, MA, United States
| | - Rebekah L Wilson
- Division of Population Sciences, Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, United States.,Department of Medicine, Harvard Medical School, Boston, MA, United States
| | - Dong-Woo Kang
- Division of Population Sciences, Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, United States.,Department of Medicine, Harvard Medical School, Boston, MA, United States
| | - Mary K Norris
- Division of Population Sciences, Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, United States
| | - Hajime Uno
- Division of Population Sciences, Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, United States.,Department of Medicine, Harvard Medical School, Boston, MA, United States
| | - Cami N Christopher
- Division of Population Sciences, Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, United States
| | - Christina Chow
- UCSF School of Dentistry, University of California, San Francisco, San Francisco, CA, United States
| | - Nathalie Sami
- Department of Internal Medicine, Los Angeles County-University of Southern California (LAC+USC) Medical Center, Keck School of Medicine, Los Angeles, CA, United States
| | - Frank S Fox
- Gerson Lehrman Group, New York, NY, United States
| | - Jennifer A Ligibel
- Department of Medicine, Harvard Medical School, Boston, MA, United States.,Division of Breast Oncology, Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, United States
| | - Christina M Dieli-Conwright
- Division of Population Sciences, Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, United States.,Department of Medicine, Harvard Medical School, Boston, MA, United States
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Wilson R, Kang DW, Tahbaz M, Norris M, Uno H, Ligibel J, Guenette J, Christopher C, Dieli-Conwright C. Improving cognitive function through high-intensity interval training in breast cancer patients undergoing chemotherapy – the CLARITY Trial: Protocol for a randomized study. (Preprint). JMIR Res Protoc 2022; 12:e39740. [PMID: 37027186 PMCID: PMC10132015 DOI: 10.2196/39740] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2022] [Revised: 12/23/2022] [Accepted: 12/25/2022] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND More than 75% of patients with breast cancer treated with chemotherapy experience cognitive impairments (eg, memory and attention problems), commonly known as chemo-brain. Exercise, especially aerobic high-intensity interval training (HIIT), is associated with better cognitive function in healthy populations. However, clinical trials testing the impact of exercise interventions on chemotherapy-induced cognitive decline in patients with cancer are lacking, and the mechanisms through which exercise could improve cognitive function are unclear. OBJECTIVE The objective of the Improving Cognitive Function Through High-Intensity Interval Training in Breast Cancer Patients Undergoing Chemotherapy trial is to examine the effects of HIIT on cognitive function in patients with breast cancer undergoing chemotherapy. METHODS This 2-arm, single-center, pilot randomized controlled trial will randomize 50 patients with breast cancer undergoing chemotherapy to HIIT or attention control. The HIIT group will perform a supervised 16-week, thrice-weekly intervention, with each session including a 5-minute warm-up at 10% maximal power output (POmax), 10 sets of alternating 1-minute high-intensity (90% POmax) and 1-minute recovery (10% POmax) intervals, and a 5-minute cooldown (10% POmax). The attention control group will receive a stretching program with no exercise components and be asked to maintain their exercise levels for 16 weeks. The primary outcomes of the study are executive function and memory measured using the National Institutes of Health toolbox and resting-state connectivity and diffusion tensor imaging microstructure evaluated using magnetic resonance imaging. The secondary and tertiary outcomes include cardiorespiratory fitness, body composition, physical fitness, and psychosocial health. The study has been approved by the institutional review board of the Dana-Farber Cancer Institute (20-222). RESULTS The trial was funded in January 2019, with recruitment started in June 2021. As of May 2022, a total of 4 patients have consented and been randomized (n=2, 50% to exercise; n=1, 25% to control; and n=1, 25% nonrandomized). Trial completion is expected in January 2024. CONCLUSIONS This first-of-its-kind study incorporates a novel exercise intervention (ie, HIIT) and comprehensive cognitive measures. If positive, our findings will establish the pilot efficacy of HIIT on chemotherapy-induced cognitive function in patients with breast cancer, providing the foundation for future larger phase-II and phase-III trials to confirm the findings and potentially establish HIIT as a standard of care for women undergoing chemotherapy for breast cancer. TRIAL REGISTRATION ClinicalTrials.gov NCT04724499; https://clinicaltrials.gov/ct2/show/NCT04724499. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) DERR1-10.2196/39740.
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Affiliation(s)
- Rebekah Wilson
- Division of Population Sciences, Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, United States
- Harvard Medical School, Boston, MA, United States
| | - Dong-Woo Kang
- Division of Population Sciences, Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, United States
- Harvard Medical School, Boston, MA, United States
| | - Meghan Tahbaz
- Department of Medicine, Morsani College of Medicine, University of South Florida, Tampa, FL, United States
| | - Mary Norris
- Division of Population Sciences, Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, United States
| | - Hajime Uno
- Division of Population Sciences, Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, United States
- Harvard Medical School, Boston, MA, United States
| | - Jennifer Ligibel
- Harvard Medical School, Boston, MA, United States
- Division of Breast Oncology, Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, United States
| | - Jeffrey Guenette
- Division of Neuroradiology, Brigham and Women's Hospital, Dana-Farber Cancer Institute, Boston, MA, United States
| | - Cameron Christopher
- Division of Population Sciences, Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, United States
| | - Christina Dieli-Conwright
- Division of Population Sciences, Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, United States
- Harvard Medical School, Boston, MA, United States
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DuMontier C, Uno H, Hshieh T, Zhou G, Chen R, Magnavita ES, Mozessohn L, Javedan H, Stone RM, Soiffer RJ, Driver JA, Abel GA. Randomized controlled trial of geriatric consultation versus standard care in older adults with hematologic malignancies. Haematologica 2022; 107:1172-1180. [PMID: 34551505 PMCID: PMC9052912 DOI: 10.3324/haematol.2021.278802] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Accepted: 09/03/2021] [Indexed: 02/02/2023] Open
Abstract
We conducted a randomized controlled trial in older adults with hematologic malignancies to determine the impact of geriatrician consultation embedded in our oncology clinic alongside standard care. From February 2015 to May 2018, transplant-ineligible patients aged ≥75 years who presented for initial consultation for lymphoma, leukemia, or multiple myeloma at Dana-Farber Cancer Institute (Boston, MA, USA) were eligible. Pre-frail and frail patients, classified based on phenotypic and deficit-accumulation approaches, were randomized to receive either standard oncologic care with or without consultation with a geriatrician. The primary outcome was 1-year overall survival. Secondary outcomes included unplanned care utilization within 6 months of follow-up and documented end-of-life (EOL) goals-of-care discussions. Clinicians were surveyed as to their impressions of geriatric consultation. One hundred sixty patients were randomized to either geriatric consultation plus standard care (n=60) or standard care alone (n=100). The median age of the patients was 80.4 years (standard deviation = 4.2). Of those randomized to geriatric consultation, 48 (80%) completed at least one visit with a geriatrician. Consultation did not improve survival at 1 year compared to standard care (difference: 2.9%, 95% confidence interval: -9.5% to 15.2%, P=0.65), and did not significantly reduce the incidence of emergency department visits, hospital admissions, or days in hospital. Consultation did improve the odds of having EOL goals-of-care discussions (odds ratio = 3.12, 95% confidence interval: 1.03 to 9.41) and was valued by surveyed hematologic-oncology clinicians, with 62.9%-88.2% of them rating consultation as useful in the management of several geriatric domains.
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Affiliation(s)
- Clark DuMontier
- Division of Aging, Brigham and Women's Hospital, Boston, MA; New England Geriatric Research Education and Clinical Center, VA Boston Healthcare System, Boston
| | - Hajime Uno
- Department of Data Sciences, Dana-Farber Cancer Institute, Boston
| | - Tammy Hshieh
- Division of Aging, Brigham and Women's Hospital, Boston, MA; Department of Medical Oncology, Dana-Farber Cancer Institute, Boston
| | - Guohai Zhou
- Division of Aging, Brigham and Women's Hospital, Boston
| | - Richard Chen
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston
| | - Emily S Magnavita
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston
| | | | | | - Richard M Stone
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston
| | - Robert J Soiffer
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston
| | - Jane A Driver
- Division of Aging, Brigham and Women's Hospital, Boston, MA; New England Geriatric Research Education and Clinical Center, VA Boston Healthcare System, Boston
| | - Gregory A Abel
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston.
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Abstract
IMPORTANCE Patient factors help explain disparities in breast cancer treatments and outcomes. OBJECTIVE To determine the extent to which geospatial variation in initial breast cancer care can be attributed to region vs patient factors with the aim of guiding quality improvement efforts. DESIGN, SETTING, AND PARTICIPANTS This was a retrospective population-based cohort study from January 1, 2007, through December 31, 2016, using the Surveillance, Epidemiology, and End Results (SEER)-Medicare database that included 31 571 patients diagnosed with stage I to III breast cancer from 2007 through 2013. Five metrics of care delivery were defined: stage I at diagnosis, chemotherapy receipt, radiation therapy receipt, endocrine therapy (ET) initiation (year 1), and ET continuation (years 3-5). Data analysis was performed from January to June 2021. EXPOSURES Stage I diagnosis and treatment with chemotherapy, radiation therapy, or ET. MAIN OUTCOMES AND MEASURES For each metric, total variance was attributed proportionally to 4 domains-random, patient factors (eg, age, race and ethnicity, socioeconomic status), region (health service area [HSA]), and unexplained-using hierarchical multivariable modeling. RESULTS Of 31 571 total patients (median [IQR] age, 71 [68-75] years), 19 391 (61.4%) had stage I disease at diagnosis. Among eligible patients, 17 297 of 21 190 (81.6%) received radiation therapy, 7204 of 9903 (72.8%) received chemotherapy, 13 115 of 26 855 (48.8%) initiated ET, and 13 944 of 26 855 (52.1%) continued ET. Geospatial density (ie, heat) maps highlight regional performance patterns. For all 5 metrics, region/HSA explained more observed variation (24%-48%) than patient factors (1%-4%); the largest share of variation was unexplained (35%-54%). The metrics with the largest proportion of total variance attributed to region/HSA were ET initiation and continuation (28% and 39%, respectively). CONCLUSIONS AND RELEVANCE In this cohort study, there was substantial unexplained geospatial variation in initial breast cancer care. The variance attributed to region/HSA was multifold larger than that explained by patient factors. The importance of patient factors such as race and ethnicity notwithstanding, future quality improvement efforts should focus on reducing unwarranted geospatial variation, especially including optimizing the delivery of ET in low-performing regions.
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Affiliation(s)
- Michael J. Hassett
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts,Harvard Medical School, Boston, Massachusetts
| | - Angela C. Tramontano
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Hajime Uno
- Harvard Medical School, Boston, Massachusetts,Department of Data Sciences, Dana-Farber Cancer Institute, Boston, Massachusetts
| | | | - Rinaa S. Punglia
- Harvard Medical School, Boston, Massachusetts,Department of Radiation Oncology, Brigham & Women’s Hospital, Boston, Massachusetts
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Banegas MP, Hassett MJ, Keast EM, Carroll NM, O'Keeffe-Rosetti M, Fishman PA, Uno H, Hornbrook MC, Ritzwoller DP. Patterns of Medical Care Cost by Service Type for Patients With Recurrent and De Novo Advanced Cancer. Value Health 2022; 25:69-76. [PMID: 35031101 DOI: 10.1016/j.jval.2021.06.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Revised: 06/11/2021] [Accepted: 06/29/2021] [Indexed: 06/14/2023]
Abstract
OBJECTIVES There is limited knowledge about the cost patterns of patients who receive a diagnosis of de novo and recurrent advanced cancers in the United States. METHODS Data on patients who received a diagnosis of de novo stage IV or recurrent breast, colorectal, or lung cancer between 2000 and 2012 from 3 integrated health systems were used to estimate average annual costs for total, ambulatory, inpatient, medication, and other services during (1) 12 months preceding de novo or recurrent diagnosis (preindex) and (2) diagnosis month through 11 months after (postindex), from the payer perspective. Generalized linear regression models estimated costs adjusting for patient and clinical factors. RESULTS Patients who developed a recurrence <1 year after their initial cancer diagnosis had significantly higher total costs in the preindex period than those with recurrence ≥1 year after initial diagnosis and those with de novo stage IV disease across all cancers (all P < .05). Patients with de novo stage IV breast and colorectal cancer had significantly higher total costs in the postindex period than patients with cancer recurrent in <1 year and ≥1 year (all P < .05), respectively. Patients in de novo stage IV and those with recurrence in ≥1 year experienced significantly higher postindex costs than the preindex period (all P < .001). CONCLUSIONS Our findings reveal distinct cost patterns between patients with de novo stage IV, recurrent <1-year, and recurrent ≥1-year cancer, suggesting unique care trajectories that may influence resource use and planning. Future cost studies among patients with advanced cancer should account for de novo versus recurrent diagnoses and timing of recurrence to obtain estimates that accurately reflect these care pattern complexities.
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Affiliation(s)
- Matthew P Banegas
- Center for Health Research, Kaiser Permanente Northwest, Portland, OR, USA; University of California San Diego, La Jolla, CA, USA.
| | | | - Erin M Keast
- Center for Health Research, Kaiser Permanente Northwest, Portland, OR, USA
| | - Nikki M Carroll
- Institute for Health Research, Kaiser Permanente Colorado, Denver, CO, USA
| | | | - Paul A Fishman
- Department of Health Services, University of Washington School of Public Health, Seattle, WA, USA
| | - Hajime Uno
- Dana Farber Cancer Institute, Boston, MA, USA
| | - Mark C Hornbrook
- Center for Health Research, Kaiser Permanente Northwest, Portland, OR, USA
| | - Debra P Ritzwoller
- Institute for Health Research, Kaiser Permanente Colorado, Denver, CO, USA
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Rodriguez NJ, Furniss CS, Yurgelun MB, Ukaegbu C, Constantinou PE, Schwartz AN, Stopfer J, Underhill-Blazey M, Kenner B, Nelson S, Okumura S, Law S, Zhou AY, Coffin TB, Uno H, Ocean A, McAllister F, Lowy AM, Lippman SM, Klein AP, Madlensky L, Petersen GM, Garber JE, Goggins MG, Maitra A, Syngal S. Abstract PO-013: Comparison of novel healthcare delivery models on the uptake of genetic education and testing in families with a history of pancreatic cancer: The GENetic Education, Risk Assessment and TEsting (GENERATE) study. Cancer Res 2021. [DOI: 10.1158/1538-7445.panca21-po-013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
Background: Roughly 7–10% of patients with pancreatic ductal adenocarcinoma (PDAC) have a deleterious germline variant. Although identification of germline variants in family members has implications for cancer surveillance and can lead to early cancer detection and interception for PDAC, as well as other cancers, cascade genetic testing rates are low. The GENetic Education, Risk Assessment and TEsting (GENERATE) study evaluates novel methods of providing genetic education and testing for individuals at risk for hereditary PDAC. Methods: Eligible participants had: (1) a first- or second-degree relative with a diagnosis of PDAC and a known familial germline variant in APC, ATM, BRCA1, BRCA2, CDKN2A, EPCAM, MLH1, MSH2, MSH6, PALB2, PMS2, STK11, or TP53 (Known Familial Mutation (KFM)), (2) or were first-degree relatives of PDAC patients (no KFM). Participants were recruited through six academic centers, patient advocacy organizations and online outreach. Enrollment occurred through the study website (www.GENERATEstudy.org). All study participation, including genetic testing via a at home saliva sample kit, was done remotely. Participants were cluster randomized at the family level into one of two arms. Arm 1 (Doxy.me plus Color Genomics) included remote genetic education and testing through a video-based telemedicine platform (Doxy.me) and physician-mediated testing through Color Genomics. Arm 2 included remote genetic education and testing through Color Genomics only. Results: Between 5/8/2019–6/01/2021, 423 families were randomized, comprising 595 participants. Recruitment occurred through patient invitation via healthcare providers (n=128, 21.5%), family members (n=271, 45.5%), friends, advocacy groups, and online outreach (n=223, 37.5%). Participants were referred from the six GENERATE academic centers (n=270, 45.4%) and other institutions (n=325, 54.6%). Study participants were 52.5 years on average, primarily identified as White (n=577, 97%) and from the Northeast (n=184, 30.9%), Midwest (n=154, 25.9%), South (n=158, 26.6%) and West (n=99, 16.6%). Participants were randomized into each arm (n=296 Doxy.me plus Color Genomics; n=299 Color Genomics only). To date, 527 (88.6%) participants have ordered genetic testing. The uptake of genetic testing was 253/296 (85.5%) in the Doxy.me plus Color Genomics arm and 274/299 (91.6%) in the Color Genomics only arm (p=0.049, generalized mixed-effects model). A total of 82 PDAC associated pathogenic variants were identified. The most frequently detected variants were BRCA2 (n=32), ATM (n=25) and PALB2 (n=6). Additionally, 13 non-PDAC associated pathogenic variants and 20 low penetrance variants were detected. Conclusions: Remote methods of genetic education and testing are successful alternatives to traditional cascade testing, with genetic testing rates nearly 90%. Participant follow up will assess if satisfaction with decision making, cancer-risk distress, knowledge gained, family communication, and uptake of surveillance were impacted by the mode of delivery of pre-test genetic education.
Citation Format: Nicolette J. Rodriguez, Constance S. Furniss, Matthew B. Yurgelun, Chinedu Ukaegbu, Pamela E. Constantinou, Alison N. Schwartz, Jill Stopfer, Meghan Underhill-Blazey, Barbara Kenner, Scott Nelson, Sydney Okumura, Sherman Law, Alicia Y. Zhou, Tara B. Coffin, Hajime Uno, Allyson Ocean, Florencia McAllister, Andrew M. Lowy, Scott M. Lippman, Alison P. Klein, Lisa Madlensky, Gloria M. Petersen, Judy E. Garber, Michael G. Goggins, Anirban Maitra, Sapna Syngal. Comparison of novel healthcare delivery models on the uptake of genetic education and testing in families with a history of pancreatic cancer: The GENetic Education, Risk Assessment and TEsting (GENERATE) study [abstract]. In: Proceedings of the AACR Virtual Special Conference on Pancreatic Cancer; 2021 Sep 29-30. Philadelphia (PA): AACR; Cancer Res 2021;81(22 Suppl):Abstract nr PO-013.
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Affiliation(s)
- Nicolette J. Rodriguez
- 1Dana-Farber Cancer Institute/Brigham and Women's Hospital/Harvard Medical School, Boston, MA,
| | | | - Matthew B. Yurgelun
- 3Dana-Farber Cancer Institute/Brigham and Women’s Hospital/Harvard Medical School, Boston, MA,
| | | | - Pamela E. Constantinou
- 5Sheikh Ahmed Center for Pancreatic Cancer Research/University of Texas MD Anderson Cancer Center, Houston, TX,
| | | | | | | | | | - Scott Nelson
- 8Pancreatic Cancer Action Network Volunteer, Manhattan Beach, CA,
| | | | | | | | | | - Hajime Uno
- 2Dana-Farber Cancer Institute/Harvard Medical School, Boston, MA,
| | | | - Florencia McAllister
- 5Sheikh Ahmed Center for Pancreatic Cancer Research/University of Texas MD Anderson Cancer Center, Houston, TX,
| | | | | | - Alison P. Klein
- 13Johns Hopkins University/Sol Goldman Pancreatic Cancer Research Center, Baltimore, MD,
| | | | | | - Judy E. Garber
- 1Dana-Farber Cancer Institute/Brigham and Women's Hospital/Harvard Medical School, Boston, MA,
| | - Michael G. Goggins
- 13Johns Hopkins University/Sol Goldman Pancreatic Cancer Research Center, Baltimore, MD,
| | - Anirban Maitra
- 5Sheikh Ahmed Center for Pancreatic Cancer Research/University of Texas MD Anderson Cancer Center, Houston, TX,
| | - Sapna Syngal
- 3Dana-Farber Cancer Institute/Brigham and Women’s Hospital/Harvard Medical School, Boston, MA,
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Abstract
IMPORTANCE Parents of children with cancer value strong therapeutic relationships with oncology clinicians, but not every relationship is positive. OBJECTIVE To identify the prevalence of challenging parent-clinician relationships in pediatric oncology and factors associated with these challenges from parent and clinician perspectives. DESIGN, SETTING, AND PARTICIPANTS This survey was conducted among parents and oncology clinicians of children with cancer within 3 months of diagnosis from November 2015 to July 2019 at Dana-Farber Cancer Institute/Boston Children's Hospital and Texas Children's Hospital. Participants were 400 parents of children with cancer and 80 clinicians (ie, oncology physicians and nurse practitioners). Parents completed surveys about relationships with 1 to 2 primary oncology clinicians; clinicians completed surveys about relationships with parents. Data were analyzed from July 2020 to August 2021. EXPOSURES At least 3 previous clinical visits between parent and clinician. MAIN OUTCOMES AND MEASURES The Relationship Challenges Scale Parent Version and Clinician Version were developed and used to measure threats to the therapeutic alliance. For the Relationship Challenges Scale-Parent version, relationships were considered challenging if a parent responded to any single question in the 2 lowest of 4 possible categories. For the Relationship Challenges Scale-Clinician version, challenges were considered to be present if a clinician reported responses in the 3 lowest of 6 possible response categories to any question. RESULTS Among 400 parents, there were 298 [74.5%] women, 25 Asian individuals (6.3%), 28 Black individuals (7.0%), 97 Hispanic individuals (24.3%), 223 White individuals (55.8%), and 10 individuals (2.4%) with other race or ethnicity; race and ethnicity data were missing for 17 (4.3%) individuals. Among 80 clinicians, there were 57 (71.3%) women, 38 attending physicians (47.5%), 32 fellows (40.0%), and 10 nurse practitioners (12.5%). Parents identified 676 unique relationships with clinicians, and clinician reports were available for 338 relationships. Among 338 relationships with paired parent and clinician surveys, 81 relationships (24.0%) were considered challenging by parents, 127 relationships (37.6%) were considered challenging by clinicians, and 33 relationships (9.8%) were considered challenging by parent and clinician. Parents with Asian or other race or ethnicity (odds ratio [OR] vs White parents, 3.62; 95% CI, 1.59-8.26) or who had lower educational attainment (OR for ≤high school vs >high school, 3.03; 95% CI, 1.56-5.90) were more likely to experience relationships as challenging. Clinicians used a variety of strategies more frequently in 127 relationships in which they perceived challenges vs 211 relationships in which they did not perceive challenges, such as holding regular family meetings (22 relationships [17.3%] vs 13 relationships [6.2%]; P = .009) and offering extra time and attention (66 relationships [52%] vs 60 relationships [28.4%]; P < .001). However, these strategies were not used with increased frequency when parents experienced relationships as challenging vs when parents did not experience this. CONCLUSIONS AND RELEVANCE This survey study found that nearly one-quarter of parents of children with cancer reported challenges in the therapeutic relationship with their oncologist and that clinicians used strategies to improve relationships more frequently when they experienced the relationship as challenging. These findings suggest that new strategies are needed to improve experiences for parents and to help clinicians recognize and attend to parents whose experiences are suboptimal.
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Affiliation(s)
- Jennifer W. Mack
- Department of Pediatric Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
- Division of Population Sciences Center for Outcomes and Policy Research, Dana-Farber Cancer Institute, Boston, Massachusetts
- Division of Pediatric Hematology/Oncology, Boston Children’s Hospital, Boston, Massachusetts
| | - Tim Jaung
- Division of Population Sciences Center for Outcomes and Policy Research, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Hajime Uno
- Division of Population Sciences Center for Outcomes and Policy Research, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Julienne Brackett
- Department of Pediatrics, Section of Pediatric Hematology/Oncology, Texas Children’s Hospital, Houston
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Sun R, McCaw Z, Tian L, Uno H, Hong F, Kim DH, Wei LJ. Moving beyond conventional stratified analysis to assess the treatment effect in a comparative oncology study. J Immunother Cancer 2021; 9:e003323. [PMID: 34799398 PMCID: PMC8606770 DOI: 10.1136/jitc-2021-003323] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/22/2021] [Indexed: 11/03/2022] Open
Abstract
In a comparative oncology study with progression-free or overall survival as the endpoint, the primary or key secondary analysis is routinely stratified by patients' baseline characteristics when evaluating the treatment difference. The validity of a conventional strategy such as a stratified HR analysis depends on stringent model assumptions that are unlikely to be met in practice, especially in immunotherapy studies. Thus, the resulting summary is generally neither valid nor interpretable. This article discusses issues with conventional stratified analyses and presents alternatives using data from KEYNOTE-189, a recent immunotherapy trial for treating patients with metastatic, non-squamous, non-small-cell lung cancer.
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Affiliation(s)
- Ryan Sun
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | | | - Lu Tian
- Department of Biomedical Data Science, Stanford University, Stanford, California, USA
| | - Hajime Uno
- Department of Data Sciences, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Fangxin Hong
- Department of Data Sciences, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Dae Hyun Kim
- Hinda and Arthur Marcus Institute for Aging Research, Harvard Medical School, Boston, Massachusetts, USA
| | - Lee-Jen Wei
- Department of Biostatistics, Harvard University T H Chan School of Public Health, Boston, Massachusetts, USA
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40
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Furniss CS, Yurgelun MB, Ukaegbu C, Constantinou PE, Lafferty CC, Talcove-Berko ER, Schwartz AN, Stopfer JE, Underhill-Blazey M, Kenner B, Nelson SH, Okumura S, Law S, Zhou AY, Coffin TB, Rodriguez NJ, Uno H, Ocean AJ, McAllister F, Lowy AM, Lippman SM, Klein AP, Madlensky L, Petersen GM, Garber JE, Goggins MG, Maitra A, Syngal S. Novel Models of Genetic Education and Testing for Pancreatic Cancer Interception: Preliminary Results from the GENERATE Study. Cancer Prev Res (Phila) 2021; 14:1021-1032. [PMID: 34625409 PMCID: PMC8563400 DOI: 10.1158/1940-6207.capr-20-0642] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Revised: 04/20/2021] [Accepted: 07/09/2021] [Indexed: 12/13/2022]
Abstract
Up to 10% of patients with pancreatic ductal adenocarcinoma (PDAC) carry underlying germline pathogenic variants in cancer susceptibility genes. The GENetic Education Risk Assessment and TEsting (GENERATE) study aimed to evaluate novel methods of genetic education and testing in relatives of patients with PDAC. Eligible individuals had a family history of PDAC and a relative with a germline pathogenic variant in APC, ATM, BRCA1, BRCA2, CDKN2A, EPCAM, MLH1, MSH2, MSH6, PALB2, PMS2, STK11, or TP53 genes. Participants were recruited at six academic cancer centers and through social media campaigns and patient advocacy efforts. Enrollment occurred via the study website (https://GENERATEstudy.org) and all participation, including collecting a saliva sample for genetic testing, could be done from home. Participants were randomized to one of two remote methods that delivered genetic education about the risks of inherited PDAC and strategies for surveillance. The primary outcome of the study was uptake of genetic testing. From 5/8/2019 to 5/6/2020, 49 participants were randomized to each of the intervention arms. Overall, 90 of 98 (92%) of randomized participants completed genetic testing. The most frequently detected pathogenic variants included those in BRCA2 (N = 15, 17%), ATM (N = 11, 12%), and CDKN2A (N = 4, 4%). Participation in the study remained steady throughout the onset of the Coronavirus disease (COVID-19) pandemic. Preliminary data from the GENERATE study indicate success of remote alternatives to traditional cascade testing, with genetic testing rates over 90% and a high rate of identification of germline pathogenic variant carriers who would be ideal candidates for PDAC interception approaches. PREVENTION RELEVANCE: Preliminary data from the GENERATE study indicate success of remote alternatives for pancreatic cancer genetic testing and education, with genetic testing uptake rates over 90% and a high rate of identification of germline pathogenic variant carriers who would be ideal candidates for pancreatic cancer interception.
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Affiliation(s)
- C Sloane Furniss
- Dana-Farber Cancer Institute, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Matthew B Yurgelun
- Dana-Farber Cancer Institute, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
- Brigham and Women's Hospital, Boston, Massachusetts
| | | | - Pamela E Constantinou
- Sheikh Ahmed Center for Pancreatic Cancer Research, University of Texas, MD Anderson Cancer Center, Houston, Texas
| | | | | | | | | | | | | | - Scott H Nelson
- Pancreatic Cancer Action Network Volunteer, Patient Advocate, and Pancreatic Cancer Survivor, St. Anthony, Minnesota
| | | | | | | | | | - Nicolette J Rodriguez
- Dana-Farber Cancer Institute, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
- Brigham and Women's Hospital, Boston, Massachusetts
| | - Hajime Uno
- Dana-Farber Cancer Institute, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | | | - Florencia McAllister
- Sheikh Ahmed Center for Pancreatic Cancer Research, University of Texas, MD Anderson Cancer Center, Houston, Texas
| | - Andrew M Lowy
- Moores Cancer Center, UC San Diego, San Diego, California
| | | | - Alison P Klein
- Johns Hopkins University, Sol Goldman Pancreatic Cancer Research Center, Baltimore, Maryland
| | - Lisa Madlensky
- Moores Cancer Center, UC San Diego, San Diego, California
| | | | - Judy E Garber
- Dana-Farber Cancer Institute, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
- Brigham and Women's Hospital, Boston, Massachusetts
| | - Michael G Goggins
- Johns Hopkins University, Sol Goldman Pancreatic Cancer Research Center, Baltimore, Maryland
| | - Anirban Maitra
- Sheikh Ahmed Center for Pancreatic Cancer Research, University of Texas, MD Anderson Cancer Center, Houston, Texas
| | - Sapna Syngal
- Dana-Farber Cancer Institute, Boston, Massachusetts.
- Harvard Medical School, Boston, Massachusetts
- Brigham and Women's Hospital, Boston, Massachusetts
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Ritzwoller DP, Hassett MJ, Uno H. Regarding the Utility of Unstructured Data and Natural Language Processing for Identification of Breast Cancer Recurrence. JCO Clin Cancer Inform 2021; 5:1024-1025. [PMID: 34637320 PMCID: PMC9848577 DOI: 10.1200/cci.21.00091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Accepted: 08/20/2021] [Indexed: 01/23/2023] Open
Affiliation(s)
- Debra P. Ritzwoller
- Debra P. Ritzwoller, PhD, Institute for Health Research, Kaiser
Permanente Colorado, Aurora, CO; Michael J. Hassett, MD, MPH, Department of
Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, Harvard Medical
School, Boston, MA; and Hajime Uno, PhD, Harvard Medical School, Boston,
MA
| | - Michael J. Hassett
- Debra P. Ritzwoller, PhD, Institute for Health Research, Kaiser
Permanente Colorado, Aurora, CO; Michael J. Hassett, MD, MPH, Department of
Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, Harvard Medical
School, Boston, MA; and Hajime Uno, PhD, Harvard Medical School, Boston,
MA
| | - Hajime Uno
- Debra P. Ritzwoller, PhD, Institute for Health Research, Kaiser
Permanente Colorado, Aurora, CO; Michael J. Hassett, MD, MPH, Department of
Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, Harvard Medical
School, Boston, MA; and Hajime Uno, PhD, Harvard Medical School, Boston,
MA
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Chen T, Tracy S, Uno H. OptBand: optimization-based confidence bands for functions to characterize time-to-event distributions. Lifetime Data Anal 2021; 27:481-498. [PMID: 33847858 PMCID: PMC8238757 DOI: 10.1007/s10985-021-09522-8] [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] [Figures] [Subscribe] [Scholar Register] [Received: 08/15/2019] [Accepted: 03/19/2021] [Indexed: 06/12/2023]
Abstract
Classical simultaneous confidence bands for survival functions (i.e., Hall-Wellner, equal precision, and empirical likelihood bands) are derived from transformations of the asymptotic Brownian nature of the Nelson-Aalen or Kaplan-Meier estimators. Due to the properties of Brownian motion, a theoretical derivation of the highest confidence density region cannot be obtained in closed form. Instead, we provide confidence bands derived from a related optimization problem with local time processes. These bands can be applied to the one-sample problem regarding both cumulative hazard and survival functions. In addition, we present a solution to the two-sample problem for testing differences in cumulative hazard functions. The finite sample performance of the proposed method is assessed by Monte Carlo simulation studies. The proposed bands are applied to clinical trial data to assess survival times for primary biliary cirrhosis patients treated with D-penicillamine.
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Affiliation(s)
- T. Chen
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care, Boston, USA
| | - S. Tracy
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, USA
- Department of Data Science, Dana-Faber Cancer Institute, Boston, USA
| | - H. Uno
- Department of Data Science, Dana-Faber Cancer Institute, Boston, USA
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Biller LH, Horiguchi M, Uno H, Ukaegbu C, Syngal S, Yurgelun MB. Familial Burden and Other Clinical Factors Associated With Various Types of Cancer in Individuals With Lynch Syndrome. Gastroenterology 2021; 161:143-150.e4. [PMID: 33794268 PMCID: PMC9115644 DOI: 10.1053/j.gastro.2021.03.039] [Citation(s) in RCA: 5] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2019] [Revised: 02/25/2021] [Accepted: 03/18/2021] [Indexed: 12/20/2022]
Abstract
BACKGROUND & AIMS Lynch syndrome (LS) is associated with increased risks of various gastrointestinal, gynecologic, genitourinary, and other cancers. Many clinical practice guidelines recommend that LS carriers' screening strategies be devised based on their family history of various cancers, in addition to age-, sex-, and gene-specific considerations. The aim of this study was to examine the association between family history and other clinical factors with LS carriers' histories of various cancers. METHODS Two cohorts of LS carriers were analyzed: a laboratory-based cohort of consecutively ascertained individuals undergoing germline LS testing and a clinic-based cohort of LS carriers undergoing clinical care at an academic medical center. Multivariable logistic regression was performed to assess clinical factors associated with LS carriers' histories of various cancers/neoplasms. Familial burden was defined as LS carriers' aggregate number of first-/second-degree relatives with a history of a given malignancy. RESULTS Multivariable analysis of the laboratory-based cohort (3828 LS carriers) identified familial burden as being incrementally associated with LS carriers' personal history of endometrial (odds ratio [OR], 1.37 per affected first-/second-degree relative; 95% confidence interval [CI], 1.21-1.56), urinary tract (OR, 2.72; 95% CI, 2.02-3.67), small bowel (OR, 3.17; 95% CI, 1.65-6.12), gastric (OR, 1.93; 95% CI, 1.24-3.02), and pancreaticobiliary cancers (OR, 2.10; 95% CI, 1.21-3.65) and sebaceous neoplasms (OR, 7.39; 95% CI, 2.71-20.15). Multivariable analysis of the clinic-based cohort (607 LS carriers) confirmed a significant association of familial burden of endometrial and urinary tract cancers. CONCLUSIONS Familial burden - in addition to age, sex, and specific LS gene - should be used to assess LS carriers' risks of specific cancers and guide decision-making about organ-specific surveillance.
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Affiliation(s)
- Leah H. Biller
- Dana-Farber Cancer Institute, Boston, Massachusetts;,Harvard Medical School, Boston, Massachusetts;,Brigham & Women’s Hospital, Boston, Massachusetts
| | - Miki Horiguchi
- Dana-Farber Cancer Institute, Boston, Massachusetts;,Harvard Medical School, Boston, Massachusetts
| | - Hajime Uno
- Dana-Farber Cancer Institute, Boston, Massachusetts;,Harvard Medical School, Boston, Massachusetts
| | | | - Sapna Syngal
- Dana-Farber Cancer Institute, Boston, Massachusetts;,Harvard Medical School, Boston, Massachusetts;,Brigham & Women’s Hospital, Boston, Massachusetts
| | - Matthew B. Yurgelun
- Dana-Farber Cancer Institute, Boston, Massachusetts;,Harvard Medical School, Boston, Massachusetts;,Brigham & Women’s Hospital, Boston, Massachusetts
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Schrag D, Uno H, Rosovsky RPG, Rutherford C, Sanfilippo KM, Villano JL, Drescher MR, Jayaram NH, Holmes CE, Feldman LE, Zattra O, Cronin C, Basch EM, Weiss A, Connors JM. The comparative effectiveness of direct oral anti-coagulants and low molecular weight heparins for prevention of recurrent venous thromboembolism in cancer: The CANVAS pragmatic randomized trial. J Clin Oncol 2021. [DOI: 10.1200/jco.2021.39.15_suppl.12020] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
12020 Background: Previous randomized trials in cancer patients suggest that DOACs are non-inferior to LMWH for preventing recurrent VTE but have higher risk of bleeding. However, the balance of benefits and burdens remains uncertain. Objective: The CANVAS pragmatic trial compared recurrent VTE, bleeding and death in cancer patients following an initial VTE treated with either DOAC or LMWH therapy. Methods: CANVAS was an unblinded hybrid comparative effectiveness non-inferiority trial, with randomized and preference cohorts. Between 12/16 and 4/20, 671 participants were randomized and followed for 6-months. Between 12/16 and 12/17, 140 participants declined randomization, chose their preferred anticoagulant and were followed for 6-months. The preference cohort was closed when predetermined stopping criteria were met. Final follow-up was 11/30/20. Randomized patients were assigned 1:1 to receive either a DOAC or a LMWH. If assigned to LMWH, transitions to warfarin were allowed. Physicians and patients could choose among any DOAC or LMWH. Doses were suggested based on FDA-approved labeling but not mandated. Patients from 67 practices in the US with any invasive solid tumor, lymphoma, multiple myeloma or CLL and a diagnosis of symptomatic or radiographically detected VTE within 30 days of enrollment were eligible. The 1° analysis was conducted in the randomized modified-into to treat popululation, (all subjects who received study drug). The 1° outcome was recurrent VTE. The aim was to establish noninferiority of anticoagulation with a DOAC as defined by the upper limit of the 2-sided 90% CI for the difference in the event rate at 6 months of < 3%. Secondary outcomes included death and bleeding. Hypothesis testing included only the randomized cohort but propensity score adjusted results for the preference and combined cohorts are also shown. Results: The non-inferiority criteria for recurrent VTE was met. Conclusions: Among adult cancer patients with VTE, the use of a DOAC compared with a LMWH resulted in a noninferior risk of recurrent VTE with no differences in rates of bleeding or death in randomized patients. Clinical trial information: NCT02744092. [Table: see text]
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Affiliation(s)
| | - Hajime Uno
- Dana-Farber Cancer Institute, Boston, MA
| | | | | | | | | | | | | | | | | | | | | | - Ethan M. Basch
- UNC Lineberger Comprehensive Cancer Center, Chapel Hill, NC
| | - Anna Weiss
- Dana-Farber Cancer Institute, Boston, MA
| | - Jean M. Connors
- Hematology Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
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Schrag D, Uno H, Zattra O, Tramontano A, Rosovsky RPG, Rutherford C, Sanfilippo KM, Villano JL, Drescher MR, Jayaram NH, Holmes CE, Feldman LE, Cronin C, Basch EM, Weiss A, Connors J. Patient-reported benefits and burdens of direct oral-anticoagulants (DOACs) and low molecular weight heparins (LMWHs): The CANVAS pragmatic randomized trial (AFT-28). J Clin Oncol 2021. [DOI: 10.1200/jco.2021.39.15_suppl.12112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
12112 Background: Previous randomized trials in cancer patients suggest that DOACs are non-inferior to LMWHs for preventing recurrent venous thromboembolism (VTE). However, patients’ perspectives have not been reported. Objective: CANVAS compared LMWHs to DOACs for preventing recurrent VTE in cancer patients. Key 2° endpoints were: 1) health-related quality of life (QOL); and, 2) treatment satisfaction. Methods: CANVAS was an unblinded hybrid comparative effectiveness non-inferiority trial. Between 12/2016 and 4/2020, 671 participants were randomized and followed for 6-months. Patients were assigned 1:1 to receive either a DOAC or a LMWH. Physicians could select any DOAC or LMWH at standard dosing, and patients assigned to LMWH were allowed to transition to Warfarin. Patients from 67 US practices with any invasive solid tumor, lymphoma, multiple myeloma or CLL and a diagnosis of VTE within 30 days of enrollment were eligible. The 1° analysis was conducted in the randomized modified intent-to-treat population, (all subjects who received assigned treatment). Key 2° endpoints were to establish: 1) non-inferior change in HR-QOL; 2) greater perception of benefit; and 3) lower perception of burden for participants receiving DOACs versus LMWHs. Participants reported QOL at 0, 3 and 6 months on the SF-12 survey. At 3 and 6 months, they also reported satisfaction via the Anti-Clot Treatment Scale (ACTS), which includes a burden and a benefit scale. A 2-point change was pre-specified as significant. Results: Neither QOL nor patients’ perceptions of treatment benefits differed between groups. However, patients on DOACs reported lower treatment burden compared to those assigned LMWHs. Conclusions: Among adult cancer patients with VTE, the use of a DOAC compared with a LMWH resulted in no difference in QOL but higher patient-reported satisfaction stemming from decreased perception of the burden of treatment. Clinical trial information: NCT02744092. [Table: see text]
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Affiliation(s)
| | - Hajime Uno
- Dana-Farber Cancer Institute, Boston, MA
| | | | | | | | | | | | | | | | | | | | | | | | - Ethan M. Basch
- UNC Lineberger Comprehensive Cancer Center, Chapel Hill, NC
| | - Anna Weiss
- Dana-Farber Cancer Institute, Boston, MA
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Ukaegbu C, Levi Z, Fehlmann TD, Uno H, Chittenden A, Inra JA, Grover S, Kastrinos F, Syngal S, Yurgelun MB. Characterizing germline APC and MUTYH variants in Ashkenazi Jews compared to other individuals. Fam Cancer 2021; 20:111-116. [PMID: 32743790 PMCID: PMC7854904 DOI: 10.1007/s10689-020-00198-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [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: 03/04/2020] [Accepted: 07/25/2020] [Indexed: 12/20/2022]
Abstract
Germline variants in the APC and MUTYH genes contribute to colorectal cancer (CRC) and adenoma risk, though may occur with varying frequencies in individuals of different ancestries. The aim of this study was to evaluate the prevalence of APC, monoallelic MUTYH and biallelic MUTYH germline variants in Ashkenazi Jewish (AJ) and Other Ancestry (OA) individuals with colorectal adenomas. We studied 7225 individuals with colorectal adenomas who had germline APC and MUTYH testing at a commercial laboratory. Cross-sectional medical history data were extracted from provider-completed test requisition forms. We performed bivariate analysis to compare the frequency of APC and MUTYH variants between AJ and OA, and examined APC p.I1307K and monoallelic MUTYH carrier phenotypes using logistic regression. Pathogenic APC variants occurred in 38/285 AJ (13%) and 1342/6940 OA (19%; P = 0.09); biallelic MUTYH variants in 2/285 (1%) AJ and 399/6940 (6%) OA (P < 0.0001); APC p.I1307K in 35/285 (12%) AJ and 29/6940 (1%) OA (P < 0.0001); and monoallelic MUTYH in 2/285 (1%) AJ and 133/6940 (2%) OA (P = 0.06). Monoallelic MUTYH variants were significantly associated with having a personal history of CRC, regardless of ancestry (OR 1.78; 95% CI 1.21-2.49; P < 0.01), but no significant association was found between APC p.I1307K variants and personal history of CRC (OR 1.38; 95% CI 0.79-2.44; P = 0.26). Ashkenazim with colorectal adenomas rarely have monoallelic or biallelic MUTYH variants, suggesting different genetic etiologies for polyposis in AJ compared to OA individuals. AJ ancestry assessment may be important in clinical evaluation for polyposis.
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Affiliation(s)
- Chinedu Ukaegbu
- Division of Population Sciences, Dana-Farber Cancer Institute, 450 Brookline Avenue, Boston, MA, 02215, USA
- Harvard Medical School, Boston, MA, USA
| | - Zohar Levi
- The Gastroenterology Department, Rabin Medical Center, Petach Tikva, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv-Yafo, Israel
| | - Tara D Fehlmann
- Division of Population Sciences, Dana-Farber Cancer Institute, 450 Brookline Avenue, Boston, MA, 02215, USA
| | - Hajime Uno
- Division of Population Sciences, Dana-Farber Cancer Institute, 450 Brookline Avenue, Boston, MA, 02215, USA
| | - Anu Chittenden
- Division of Population Sciences, Dana-Farber Cancer Institute, 450 Brookline Avenue, Boston, MA, 02215, USA
| | | | - Shilpa Grover
- Harvard Medical School, Boston, MA, USA
- Division of Gastroenterology, Brigham and Women's Hospital, Boston, MA, USA
| | - Fay Kastrinos
- Division of Digestive and Liver Diseases, Columbia University Medical Center, New York, NY, USA
- Herbert Irving Comprehensive Cancer Center, New York, NY, USA
| | - Sapna Syngal
- Division of Population Sciences, Dana-Farber Cancer Institute, 450 Brookline Avenue, Boston, MA, 02215, USA
- Harvard Medical School, Boston, MA, USA
- Division of Gastroenterology, Brigham and Women's Hospital, Boston, MA, USA
| | - Matthew B Yurgelun
- Division of Population Sciences, Dana-Farber Cancer Institute, 450 Brookline Avenue, Boston, MA, 02215, USA.
- Harvard Medical School, Boston, MA, USA.
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Chittenden A, Haraldsdottir S, Ukaegbu C, Underhill-Blazey M, Gaonkar S, Uno H, Brais LK, Perez K, Wolpin BM, Syngal S, Yurgelun MB. Implementing Systematic Genetic Counseling and Multigene Germline Testing for Individuals With Pancreatic Cancer. JCO Oncol Pract 2021; 17:e236-e247. [PMID: 33439686 PMCID: PMC8257923 DOI: 10.1200/op.20.00678] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [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: 07/29/2020] [Revised: 09/28/2020] [Accepted: 11/06/2020] [Indexed: 12/13/2022] Open
Abstract
PURPOSE National guidelines recommend genetic counseling and multigene germline testing (GC/MGT) for all patients with pancreatic ductal adenocarcinoma (PDAC). This study's aim was to assess real-world effectiveness of implementing systematic GC/MGT for all patients with PDAC at a high-volume academic institution. METHODS An iterative process for systematizing GC/MGT was developed in which gastrointestinal oncology providers at the Dana-Farber Cancer Institute were recommended to refer all patients with PDAC for GC/MGT (clinician-directed referral). Workflows were subsequently changed such that patients with PDAC were automatically offered GC/MGT when scheduling their initial oncology consultation (automated referral). Clinical and germline data were collected on a consecutive cohort of patients with PDAC undergoing GC/MGT during a 25-month enrollment period (19-month clinician-directed referrals; 6-month automated referrals). RESULTS One thousand two hundred fourteen patients with PDAC were seen for initial oncologic evaluation, 266 (21.9%) of whom underwent GC/MGT. Compared with baseline clinician-directed referrals, implementation of automated referrals led to a significant increase in patients with PDAC undergoing GC/MGT (16.5% v 38.0%, P < .001), including those undergoing multigene germline testing (MGT) ≤ 7 days of initial oncology evaluation (14.7% v 60.3%, P < .001), with preserved pathogenic variant detection rates (10.0% v 11.2%, P = 0.84). 16 of 28 (57.1%) pathogenic variant carriers had relatives who pursued cascade germline testing, and 13 of 26 (50.0%) carriers with incurable disease received targeted therapy based on MGT results. CONCLUSION Implementation of systematic GC/MGT in patients with PDAC is feasible and leads to management changes for patients with PDAC and their families. GC/MGT workflows that bypass the need for clinician referral result in superior uptake and time to testing. Further investigation is needed to identify other barriers and facilitators of universal GC/MGT.
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Affiliation(s)
| | - Sigurdis Haraldsdottir
- Dana-Farber Cancer Institute, Boston, MA
- Harvard Medical School, Boston, MA
- Brigham and Women's Hospital, Boston, MA
| | | | - Meghan Underhill-Blazey
- Dana-Farber Cancer Institute, Boston, MA
- Harvard Medical School, Boston, MA
- University of Rochester, Rochester, NY
| | | | - Hajime Uno
- Dana-Farber Cancer Institute, Boston, MA
| | | | - Kimberly Perez
- Dana-Farber Cancer Institute, Boston, MA
- Harvard Medical School, Boston, MA
- Brigham and Women's Hospital, Boston, MA
| | - Brian M. Wolpin
- Dana-Farber Cancer Institute, Boston, MA
- Harvard Medical School, Boston, MA
- Brigham and Women's Hospital, Boston, MA
| | - Sapna Syngal
- Dana-Farber Cancer Institute, Boston, MA
- Harvard Medical School, Boston, MA
- Brigham and Women's Hospital, Boston, MA
| | - Matthew B. Yurgelun
- Dana-Farber Cancer Institute, Boston, MA
- Harvard Medical School, Boston, MA
- Brigham and Women's Hospital, Boston, MA
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Enzinger AC, Uno H, McCleary N, Frank E, Sanoff H, Van Loon K, Matin K, Bullock A, Cronin C, Cibotti H, Bagley J, Schrag D. Effectiveness of a Multimedia Educational Intervention to Improve Understanding of the Risks and Benefits of Palliative Chemotherapy in Patients With Advanced Cancer: A Randomized Clinical Trial. JAMA Oncol 2021; 6:1265-1270. [PMID: 32672806 DOI: 10.1001/jamaoncol.2020.1921] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance Despite requirements of informed consent, patients with advanced cancer often receive palliative chemotherapy (PC) without understanding that the likelihood of cure is remote. Objective To determine whether a PC educational video and booklet at treatment initiation could improve patients' understanding of its benefits and risks. Interventions Regimen-specific PC videos and booklets presenting information about logistics, potential benefits, life expectancy (optional), adverse effects, and alternatives. Videos featured authentic patients sharing diverse experiences. After receiving treatment recommendations, research assistants distributed materials to patients for independent review. Design, Setting, and Participants Multicenter randomized clinical trial of patients with advanced colorectal or pancreatic cancer starting first-line or second-line PC in 5 US cancer centers with enrollment from June 2015 to September 2017 and follow-up to December 2019. Main Outcomes and Measures The primary outcome was accurate expectations of chemotherapy benefits at 3 months, defined as responding "not at all likely" to "What is your understanding of how likely the chemotherapy is to cure your cancer?" (from the Cancer Care Outcomes Research and Surveillance study). Secondary outcomes included understanding of adverse effects, decisional conflict (SURE test), regret (Decisional Regret Scale), and distress (Functional Assessment of Cancer Therapy-General emotional well-being subscale). Results Among 186 patients with advanced colorectal or pancreatic cancer who were starting first-line or second-line PC (94 randomized to usual care, 92 to intervention; mean [SD] age, 59.3 [12.6] [range, 28-86] years; 107 [58%] male; 118 [63.4%] colorectal and 68 [36.6%] pancreatic cancer), most patients wanted "a lot" of information or "as much information as possible" about adverse effects (149, 80.1%), likelihood of cure (148, 79.6%), and prognosis (148, 79.6%). Among the intervention arm, 59 (78%) reviewed the booklet and 30 (40%) reviewed the video within 2 weeks. The primary outcome did not differ between intervention and control arms (52.6%; 95% CI, 40.3%-65.0%; vs 55.5%; 95% CI, 45.1%-66.0%). Accurate adverse effect understanding was more common among intervention than control patients (56.0%; 95% CI, 44.3%-67.7%; vs 40.2%; 95% CI, 29.5%-50.9%; P = .05), although this did not meet the threshold for statistical significance. The intervention did not increase distress, despite frank prognostic information. Other secondary outcomes were similar. Conclusions and Relevance Provision of an educational video and booklet did not alter patients' expectation of cure from PC. Alternative delivery strategies, such as integration with nurse teaching, could be explored in future studies. Trial Registration ClinicalTrials.gov Identifier: NCT02282722.
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Affiliation(s)
- Andrea C Enzinger
- Division of Population Sciences, Dana-Farber/Partners CancerCare, Boston, Massachusetts.,Division of Gastrointestinal Oncology, Dana-Farber/Partners CancerCare, Boston, Massachusetts
| | - Hajime Uno
- Division of Population Sciences, Dana-Farber/Partners CancerCare, Boston, Massachusetts
| | - Nadine McCleary
- Division of Gastrointestinal Oncology, Dana-Farber/Partners CancerCare, Boston, Massachusetts
| | - Elizabeth Frank
- Susan F. Smith Center for Women's Cancers, Dana-Farber/Partners CancerCare, Boston, Massachusetts
| | - Hanna Sanoff
- Division of Medical Oncology, University of North Carolina Lineberger Cancer Center, Chapel Hill
| | - Katherine Van Loon
- Division of Hematology and Oncology, Department of Medicine, University of California, San Francisco
| | - Khalid Matin
- Division of Medical Oncology, Virginia Commonwealth University, Richmond
| | - Andrea Bullock
- Division of Medical Oncology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Christine Cronin
- Division of Population Sciences, Dana-Farber/Partners CancerCare, Boston, Massachusetts
| | - Heather Cibotti
- Department of Nursing, Dana-Farber/Partners CancerCare, Boston, Massachusetts
| | - Janet Bagley
- Department of Nursing, Dana-Farber/Partners CancerCare, Boston, Massachusetts
| | - Deborah Schrag
- Division of Population Sciences, Dana-Farber/Partners CancerCare, Boston, Massachusetts.,Division of Gastrointestinal Oncology, Dana-Farber/Partners CancerCare, Boston, Massachusetts
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Lorenz DR, Misra V, Chettimada S, Uno H, Wang L, Blount BC, De Jesús VR, Gelman BB, Morgello S, Wolinsky SM, Gabuzda D. Acrolein and other toxicant exposures in relation to cardiovascular disease among marijuana and tobacco smokers in a longitudinal cohort of HIV-positive and negative adults. EClinicalMedicine 2021; 31:100697. [PMID: 33554087 PMCID: PMC7846668 DOI: 10.1016/j.eclinm.2020.100697] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Marijuana smoke contains some of the same toxicants present in tobacco smoke. Marijuana smoking is prevalent among HIV+ individuals, but few studies have characterized smoke-related toxicants or associated health outcomes in exclusive marijuana users. METHODS This longitudinal study included 245 participants over age 40 (76% HIV+). 33 plasma and 28 urine metabolites of nicotine, ∆-9-trans-tetrahydrocannabinol, polycyclic aromatic hydrocarbons, and volatile organic compounds were assayed by liquid or gas chromatography/mass spectrometry. Exposures and health outcomes were assessed from surveys and medical records. FINDINGS At baseline, 18% of participants were marijuana-only smokers, 20% tobacco-only smokers, and 24% dual marijuana-tobacco smokers (median (IQR) age 53 (47-60) years, 78% male, 54% white race). Marijuana smoking was independently associated with elevated plasma naphthalenes, 2-hydroxyfluorene sulfate, 4-vinylphenol sulfate, and o-cresol sulfate (p<0·05) and urine acrylonitrile and acrylamide metabolites (p<0·05), but levels were lower than those associated with tobacco smoking. Acrolein metabolite N-Acetyl-S-(3-hydroxypropyl)-l-cysteine (3HPMA) was significantly elevated in plasma and urine in tobacco-only and dual but not marijuana-only smokers, and correlated with nicotine metabolites (p<0·05). The highest tertile of 3HPMA was associated with increased cardiovascular disease diagnoses independent of tobacco smoking, traditional risk factors, and HIV status (odds ratio [95% CI] 3·34 [1·31-8·57]; p = 0·012). INTERPRETATION Smoke-related toxicants, including acrylonitrile and acrylamide metabolites, are detectable in exclusive marijuana smokers, but exposures are lower compared with tobacco or dual smokers. Acrolein exposure is increased by tobacco smoking but not exclusive marijuana smoking in HIV+ and HIV- adults, and contributes to cardiovascular disease in tobacco smokers. FUNDING U.S. NIH.
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Affiliation(s)
- David R. Lorenz
- Department of Cancer Immunology and Virology, Dana-Farber Cancer Institute, Center for Life Science 1010, 450 Brookline Avenue, Boston, MA 02215, USA
| | - Vikas Misra
- Department of Cancer Immunology and Virology, Dana-Farber Cancer Institute, Center for Life Science 1010, 450 Brookline Avenue, Boston, MA 02215, USA
| | - Sukrutha Chettimada
- Department of Cancer Immunology and Virology, Dana-Farber Cancer Institute, Center for Life Science 1010, 450 Brookline Avenue, Boston, MA 02215, USA
| | - Hajime Uno
- Department of Data Sciences, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Lanqing Wang
- Division of Laboratory Sciences, National Center for Environmental Health, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Benjamin C. Blount
- Division of Laboratory Sciences, National Center for Environmental Health, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Víctor R. De Jesús
- Division of Laboratory Sciences, National Center for Environmental Health, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Benjamin B. Gelman
- Department of Pathology, University of Texas Medical Branch, Galveston, TX, USA
| | - Susan Morgello
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Steven M. Wolinsky
- Division of Infectious Diseases, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Dana Gabuzda
- Department of Cancer Immunology and Virology, Dana-Farber Cancer Institute, Center for Life Science 1010, 450 Brookline Avenue, Boston, MA 02215, USA
- Corresponding author.
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50
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Enzinger AC, Uno H, McCleary N, Frank E, Sanoff H, Van Loon K, Matin K, Bullock A, Cronin C, Bagley J, Schrag D. The Effect of Disclosing Life Expectancy Information on Patients' Prognostic Understanding: Secondary Outcomes From a Multicenter Randomized Trial of a Palliative Chemotherapy Educational Intervention. J Pain Symptom Manage 2021; 61:1-11.e3. [PMID: 32777456 PMCID: PMC7769864 DOI: 10.1016/j.jpainsymman.2020.07.025] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Revised: 07/21/2020] [Accepted: 07/25/2020] [Indexed: 01/09/2023]
Abstract
CONTEXT Many advanced patients with cancer have unrealistic prognostic expectations. OBJECTIVES We tested whether offering life expectancy (LE) statistics within palliative chemotherapy (PC) education promotes realistic expectations. METHODS In this multicenter trial, patients with advanced colorectal and pancreatic cancers initiating first or second line PC were randomized to usual care versus a PC educational tool with optional LE information. Surveys at two weeks and three months assessed patients' review of the LE module and their reactions; at three months, patients estimated their LE and reported occurrence of prognosis and end-of-life (EOL) discussions. Wilcoxon tests and proportional odds models evaluated between-arm differences in LE self-estimates, and how realistic those estimates were (based on cancer type and line of treatment). RESULTS From 2015 to 2017, 92 patients were randomized to the intervention and 94 to usual care. At baseline most patients (80.9%) wanted "a lot" or "as much information as possible" about the impact of chemotherapy on LE. Among patients randomized to the intervention, 52.0% reviewed the LE module by two weeks and 66.7% by three months-of whom 88.2% reported the information was important, 31.4% reported it was upsetting, and 3.9% regretted reviewing it. Overall, patients' LE self-estimates were very optimistic; 71.4% of patients with colorectal cancer estimated greater than five years; 50% pancreatic patients estimated greater than two years. The intervention had no effect on the length or realism of patients' LE self-estimates, or on the occurrence of prognostic or EOL discussions. CONCLUSIONS Offering LE information within a PC educational intervention had no effect on patients' prognostic expectations.
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Affiliation(s)
- Andrea C Enzinger
- Division of Population Sciences, Dana-Farber/Partners CancerCare, Boston, Massachusetts, USA; Division of Gastrointestinal Oncology, Dana-Farber/Partners CancerCare, Boston, Massachusetts, USA.
| | - Hajime Uno
- Division of Population Sciences, Dana-Farber/Partners CancerCare, Boston, Massachusetts, USA
| | - Nadine McCleary
- Division of Gastrointestinal Oncology, Dana-Farber/Partners CancerCare, Boston, Massachusetts, USA
| | - Elizabeth Frank
- Susan F. Smith Center for Women's Cancers, Dana-Farber/Partners CancerCare, Boston, Massachusetts, USA
| | - Hanna Sanoff
- Division of Medical Oncology, University of North Carolina Lineberger Cancer Center, Chapel Hill, North Carolina, USA
| | - Katherine Van Loon
- Division of Hematology and Oncology, Department of Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Khalid Matin
- Division of Medical Oncology, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Andrea Bullock
- Division of Medical Oncology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Christine Cronin
- Division of Population Sciences, Dana-Farber/Partners CancerCare, Boston, Massachusetts, USA
| | - Janet Bagley
- Department of Nursing, Dana-Farber/Partners CancerCare, Boston, Massachusetts, USA
| | - Deborah Schrag
- Division of Population Sciences, Dana-Farber/Partners CancerCare, Boston, Massachusetts, USA; Division of Gastrointestinal Oncology, Dana-Farber/Partners CancerCare, Boston, Massachusetts, USA
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