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Van Buren I, Madison C, Kohn A, Berry E, Kulkarni RP, Thompson RF. Survival Among Veterans Receiving Steroids for Immune-Related Adverse Events After Immune Checkpoint Inhibitor Therapy. JAMA Netw Open 2023; 6:e2340695. [PMID: 37906189 PMCID: PMC10618850 DOI: 10.1001/jamanetworkopen.2023.40695] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Accepted: 09/19/2023] [Indexed: 11/02/2023] Open
Abstract
Importance Systemic steroids are commonly used to manage immune-related adverse events (irAEs), but it remains unclear whether they may undermine immune checkpoint inhibitor (ICI) therapy outcomes. Few studies have assessed the impact of steroid timing and its association with continuation or cessation of ICI therapy. Objective To characterize how systemic steroids and steroid timing for irAEs are associated with survival in patients receiving ICI therapy. Design, Setting, and Participants This multicenter retrospective cohort study encompassed veterans receiving ICI for cancer between January 1, 2010, and December 31, 2021. Data analysis was conducted September 8, 2023. Exposures Identifiable primary diagnosis of cancer. Patients were categorized into 3 cohorts: those receiving no steroids, systemic steroids for irAEs, and steroids for non-irAE-associated reasons. All eligible patients received 1 or more doses of an ICI (atezolizumab, avelumab, cemiplimab, durvalumab, ipilimumab, nivolumab, or pembrolizumab). Eligible patients in the steroid group received at least 1 dose (intravenous, intramuscular, or oral) of dexamethasone, hydrocortisone, methylprednisolone, prednisone, or prednisolone. Steroid use at baseline for palliation or infusion prophylaxis or delivered as a single dose was deemed to be non-irAE associated. All other patterns of steroid use were assumed to be for irAEs. Main Outcomes and Measures The primary outcome was overall survival, with a 5-year follow-up after ICI initiation. Kaplan-Meier survival analyses were performed with pairwise log-rank tests to determine significance. Risk was modeled with Cox proportional hazard regression. Results The cohort consisted of 20 163 veterans receiving ICI therapy including 12 221 patients (mean [SD] age, 69.5 [8.0] years; 11 830 male patients [96.8%]; 9394 White patients [76.9%]) who received systemic steroids during ICI treatment and 7942 patients (mean [SD] age, 70.3 [8.5] years; 7747 male patients [97.5%]; 6085 White patients [76.6%]) who did not. Patients with an irAE diagnosis had significantly improved overall survival (OS) compared with those without (median [IQR] OS, 17.4 [6.6 to 48.5] months vs 10.5 [3.5 to 36.8] months; adjusted hazard ratio, 0.84; 95% CI, 0.81-0.84; P < .001). For patients with irAEs, systemic steroids for irAEs were associated with significantly improved survival compared with those who received steroids for non-irAE-related reasons or no steroid treatment (median [IQR] OS, 21.3 [9.3 to 58.2] months vs 13.6 [5.5 to 33.7] months vs 15.8 [4.9 to not reached] months; P <.001). However, among those who received steroids for irAEs, early steroid use (<2 months after ICI initiation) was associated with reduced relative survival benefit vs later steroid use, regardless of ICI continuation or cessation following steroid initiation (median [IQR] OS after ICI cessation 4.4 [1.9 to 19.5] months vs 16.0 [8.0 to 42.2] months; median [IQR] OS after ICI continuation, 16.0 [7.1 to not reached] months vs 29.2 [16.5 to 53.5] months; P <.001). Conclusions and Relevance This study suggests that steroids for irAE management may not abrogate irAE-associated survival benefits. However, early steroid administration within 2 months of ICI initiation is associated with shorter survival despite continuation of ICI therapy.
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Affiliation(s)
- Inga Van Buren
- Graduate Medical Education, St Joseph’s Medical Center, Stockton, California
| | - Cecelia Madison
- Research and Development, VA Portland Healthcare System, Portland, Oregon
| | - Aimee Kohn
- Division of Hematology and Medical Oncology, Oregon Health & Science University, Portland
| | - Elizabeth Berry
- Department of Dermatology, Oregon Health & Science University, Portland
| | - Rajan P. Kulkarni
- Department of Dermatology, Oregon Health & Science University, Portland
- Operative Care Division, VA Portland Healthcare System, Portland, Oregon
| | - Reid F. Thompson
- Department of Radiation Medicine, Oregon Health & Science University, Portland
- Division of Hospital and Specialty Medicine, VA Portland Healthcare System, Portland, Oregon
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Tereshchenko LG, Bishop A, Fisher-Campbell N, Levene J, Morris CC, Patel H, Beeson E, Blank JA, Bradner JN, Coblens M, Corpron JW, Davison JM, Denny K, Earp MS, Florea S, Freeman H, Fuson O, Guillot FH, Haq KT, Kim M, Kolseth C, Krol O, Lin L, Litwin L, Malik A, Mitchell E, Mohapatra A, Mullen C, Nix CD, Oyeyemi A, Rutlen C, Tam AE, Van Buren I, Wallace J, Khan A. Risk of Cardiovascular Events After COVID-19. Am J Cardiol 2022; 179:102-109. [PMID: 35843735 PMCID: PMC9282909 DOI: 10.1016/j.amjcard.2022.06.023] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2022] [Revised: 05/31/2022] [Accepted: 06/06/2022] [Indexed: 12/15/2022]
Abstract
We aimed to determine absolute and relative risks of either symptomatic or asymptomatic SARS-CoV-2 infection for late cardiovascular (CV) events and all-cause mortality. We conducted a retrospective double cohort study of patients with either symptomatic or asymptomatic SARS-CoV-2 infection (COVID-19+ cohort) and its documented absence (COVID-19- cohort). The study investigators drew a simple random sample of records from all patients under the Oregon Health & Science University Healthcare (n = 65,585), with available COVID-19 test results, performed March 1, 2020 to September 13, 2020. Exclusion criteria were age <18 years and no established Oregon Health & Science University care. The primary outcome was a composite of CV morbidity and mortality. All-cause mortality was the secondary outcome. The study population included 1,355 patients (mean age 48.7 ± 20.5 years; 770 women [57%], 977 White non-Hispanic [72%]; 1,072 ensured [79%]; 563 with CV disease history [42%]). During a median 6 months at risk, the primary composite outcome was observed in 38 of 319 patients who were COVID-19+ (12%) and 65 of 1,036 patients who were COVID-19- (6%). In the Cox regression, adjusted for demographics, health insurance, and reason for COVID-19 testing, SARS-CoV-2 infection was associated with the risk for primary composite outcome (hazard ratio 1.71, 95% confidence interval 1.06 to 2.78, p = 0.029). Inverse probability-weighted estimation, conditioned for 31 covariates, showed that for every patient who was COVID-19+, the average time to all-cause death was 65.5 days less than when all these patients were COVID-19-: average treatment effect on the treated -65.5 (95% confidence interval -125.4 to -5.61) days, p = 0.032. In conclusion, either symptomatic or asymptomatic SARS-CoV-2 infection is associated with an increased risk for late CV outcomes and has a causal effect on all-cause mortality in a late post-COVID-19 period.
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Affiliation(s)
- Larisa G Tereshchenko
- Knight Cardiovascular Institute and Division of Pulmonary and Critical Care Medicine, School of Medicine, Oregon Health & Science University, Portland, Oregon; Department of Quantitative Health Sciences, Cleveland Clinic Lerner Research Institute, Cleveland, Ohio.
| | - Adam Bishop
- Knight Cardiovascular Institute and Division of Pulmonary and Critical Care Medicine, School of Medicine, Oregon Health & Science University, Portland, Oregon
| | - Nora Fisher-Campbell
- Knight Cardiovascular Institute and Division of Pulmonary and Critical Care Medicine, School of Medicine, Oregon Health & Science University, Portland, Oregon
| | - Jacqueline Levene
- Knight Cardiovascular Institute and Division of Pulmonary and Critical Care Medicine, School of Medicine, Oregon Health & Science University, Portland, Oregon
| | - Craig C Morris
- Knight Cardiovascular Institute and Division of Pulmonary and Critical Care Medicine, School of Medicine, Oregon Health & Science University, Portland, Oregon
| | - Hetal Patel
- Knight Cardiovascular Institute and Division of Pulmonary and Critical Care Medicine, School of Medicine, Oregon Health & Science University, Portland, Oregon; Chicago Medical School at Rosalind Franklin University, Chicago, Illinois
| | - Erynn Beeson
- Knight Cardiovascular Institute and Division of Pulmonary and Critical Care Medicine, School of Medicine, Oregon Health & Science University, Portland, Oregon
| | - Jessica A Blank
- Knight Cardiovascular Institute and Division of Pulmonary and Critical Care Medicine, School of Medicine, Oregon Health & Science University, Portland, Oregon
| | - Jg N Bradner
- Knight Cardiovascular Institute and Division of Pulmonary and Critical Care Medicine, School of Medicine, Oregon Health & Science University, Portland, Oregon
| | - Michelle Coblens
- Knight Cardiovascular Institute and Division of Pulmonary and Critical Care Medicine, School of Medicine, Oregon Health & Science University, Portland, Oregon
| | - Jacob W Corpron
- Knight Cardiovascular Institute and Division of Pulmonary and Critical Care Medicine, School of Medicine, Oregon Health & Science University, Portland, Oregon
| | - Jenna M Davison
- Knight Cardiovascular Institute and Division of Pulmonary and Critical Care Medicine, School of Medicine, Oregon Health & Science University, Portland, Oregon
| | - Kathleen Denny
- Knight Cardiovascular Institute and Division of Pulmonary and Critical Care Medicine, School of Medicine, Oregon Health & Science University, Portland, Oregon
| | - Mary S Earp
- Knight Cardiovascular Institute and Division of Pulmonary and Critical Care Medicine, School of Medicine, Oregon Health & Science University, Portland, Oregon
| | - Simeon Florea
- Knight Cardiovascular Institute and Division of Pulmonary and Critical Care Medicine, School of Medicine, Oregon Health & Science University, Portland, Oregon
| | - Howard Freeman
- Knight Cardiovascular Institute and Division of Pulmonary and Critical Care Medicine, School of Medicine, Oregon Health & Science University, Portland, Oregon
| | - Olivia Fuson
- Knight Cardiovascular Institute and Division of Pulmonary and Critical Care Medicine, School of Medicine, Oregon Health & Science University, Portland, Oregon
| | - Florian H Guillot
- Knight Cardiovascular Institute and Division of Pulmonary and Critical Care Medicine, School of Medicine, Oregon Health & Science University, Portland, Oregon
| | - Kazi T Haq
- Knight Cardiovascular Institute and Division of Pulmonary and Critical Care Medicine, School of Medicine, Oregon Health & Science University, Portland, Oregon
| | - Morris Kim
- Knight Cardiovascular Institute and Division of Pulmonary and Critical Care Medicine, School of Medicine, Oregon Health & Science University, Portland, Oregon
| | - Clinton Kolseth
- Knight Cardiovascular Institute and Division of Pulmonary and Critical Care Medicine, School of Medicine, Oregon Health & Science University, Portland, Oregon
| | - Olivia Krol
- Chicago Medical School at Rosalind Franklin University, Chicago, Illinois
| | - Lisa Lin
- Knight Cardiovascular Institute and Division of Pulmonary and Critical Care Medicine, School of Medicine, Oregon Health & Science University, Portland, Oregon
| | - Liat Litwin
- Knight Cardiovascular Institute and Division of Pulmonary and Critical Care Medicine, School of Medicine, Oregon Health & Science University, Portland, Oregon
| | - Aneeq Malik
- Knight Cardiovascular Institute and Division of Pulmonary and Critical Care Medicine, School of Medicine, Oregon Health & Science University, Portland, Oregon
| | - Evan Mitchell
- Knight Cardiovascular Institute and Division of Pulmonary and Critical Care Medicine, School of Medicine, Oregon Health & Science University, Portland, Oregon
| | - Aman Mohapatra
- Knight Cardiovascular Institute and Division of Pulmonary and Critical Care Medicine, School of Medicine, Oregon Health & Science University, Portland, Oregon; Chicago Medical School at Rosalind Franklin University, Chicago, Illinois
| | - Cassandra Mullen
- Knight Cardiovascular Institute and Division of Pulmonary and Critical Care Medicine, School of Medicine, Oregon Health & Science University, Portland, Oregon
| | - Chad D Nix
- Knight Cardiovascular Institute and Division of Pulmonary and Critical Care Medicine, School of Medicine, Oregon Health & Science University, Portland, Oregon
| | - Ayodele Oyeyemi
- Knight Cardiovascular Institute and Division of Pulmonary and Critical Care Medicine, School of Medicine, Oregon Health & Science University, Portland, Oregon
| | - Christine Rutlen
- Knight Cardiovascular Institute and Division of Pulmonary and Critical Care Medicine, School of Medicine, Oregon Health & Science University, Portland, Oregon
| | - Ashley E Tam
- Knight Cardiovascular Institute and Division of Pulmonary and Critical Care Medicine, School of Medicine, Oregon Health & Science University, Portland, Oregon
| | - Inga Van Buren
- Knight Cardiovascular Institute and Division of Pulmonary and Critical Care Medicine, School of Medicine, Oregon Health & Science University, Portland, Oregon
| | - Jessica Wallace
- Knight Cardiovascular Institute and Division of Pulmonary and Critical Care Medicine, School of Medicine, Oregon Health & Science University, Portland, Oregon
| | - Akram Khan
- Division of Pulmonary and Critical Care Medicine, School of Medicine, Oregon Health & Science University, Portland, Oregon
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