Association of frailty with clinical outcomes in myelofibrosis: a retrospective cohort study

There is limited understanding of the impact of frailty on clinical outcomes in patients with myelofibrosis (MF). In this retrospective cohort study on 439 chronic phase MF patients [mean age: 68·7 ± 12 years; median follow-up: 3·4 years (IQR 0·4-8·6)] from 2004 till 2018, we used a 35-variable frailty index (FI) to categorise patient's frailty status as fit (FI < 0·2, reference), prefrail (FI 0·2-0·29) or frail (FI ≥ 0·3). The association of frailty with overall survival (OS) and cumulative JAK inhibitor (JAKi) therapy failure was measured using hazard ratio (HR, 95% CI). In multivariable analysis, prefrail (HR 1·7, 1·1-2·5) and frail patients (HR 2·9, 1·6-5·5), those with higher DIPSS score (HR 2·5, 1·6-3·9) and transfusion dependency (HR 1·9, 1·3-2·9) had shorter OS. In a subset analysis of patients on JAKi treatment (n = 222), frail patients (HR 2·5, 1·1-5·7), patients with higher DIPSS score (HR 1·7, 1·0-3·1) and transfusion dependence (HR 1·7, 1·1-2·7) had higher cumulative incidence of JAKi failure. Age, comorbidities, ECOG performance status, and MPN driver mutations did not impact outcomes. Thus, higher frailty scores are associated with worse OS and increased JAKi failure in MF, and is a superior indicator of fitness in comparison to age, comorbidities, and performance status.

Association of Factors Influencing Selection of Upfront Hematopoietic Cell Transplantation versus Nontransplantation Therapies in Myelofibrosis

Despite the curative potential of allogeneic hematopoietic cell transplantation (HCT) for myelofibrosis (MF), a significant number of patients with MF do not undergo HCT. Factors influencing treatment preferences in these patients have not been well studied. This study was conducted to identify patient-, disease-, and donor-related factors influencing the decision regarding HCT in patients with MF. A secondary objective was to compare survival between patients who elected upfront HCT and those who opted for nontransplantation therapy. We conducted a retrospective chart review amongst patients meeting criteria for transplant indication, evaluating clinical characteristics, treatment preferences, and outcomes. Of the 183 study eligible patients age <70 years, 129 (70%) developed an HCT indication. Age >60 years was significantly associated with higher rates of HLA-typing refusal (13 of 72 versus 1 of 44; P = .02). Caucasian ethnicity was significantly associated with an increased rate of identifying well-matched donors compared with non-Caucasian ethnicity (75% versus 48%; P = .02). Of the 69 patients with well-matched donors, 34 (49%) preferred to not pursue upfront HCT despite an indication for transplantation. Patient preference for nontransplantation therapies was the most common reason for declining HCT. We did not find any difference in survival between patients pursuing upfront HCT and those opting for nontransplantation therapies, although more patients in the HCT arm were in remission at the last follow-up. Patients of Caucasian ethnicity were significantly more likely than non-Caucasian patients to identify a well-matched donor. Despite availability of a well-matched donor, a significant proportion of MF patients with an indication for transplantation do not pursue HCT. Patient age, donor type, and patient preference play major roles in the selection of upfront HCT. Although a survival difference was not observed between upfront HCT versus non-transplant therapy, more patients in the HCT arm were in remission at the last follow-up.

Effect of selenium and vitamin E on risk of prostate cancer and other cancers: the Selenium and Vitamin E Cancer Prevention Trial (SELECT)

CONTEXT

Secondary analyses of 2 randomized controlled trials and supportive epidemiologic and preclinical data indicated the potential of selenium and vitamin E for preventing prostate cancer.

OBJECTIVE

To determine whether selenium, vitamin E, or both could prevent prostate cancer and other diseases with little or no toxicity in relatively healthy men.

DESIGN, SETTING, AND PARTICIPANTS

A randomized, placebo-controlled trial (Selenium and Vitamin E Cancer Prevention Trial [SELECT]) of 35,533 men from 427 participating sites in the United States, Canada, and Puerto Rico randomly assigned to 4 groups (selenium, vitamin E, selenium + vitamin E, and placebo) in a double-blind fashion between August 22, 2001, and June 24, 2004. Baseline eligibility included age 50 years or older (African American men) or 55 years or older (all other men), a serum prostate-specific antigen level of 4 ng/mL or less, and a digital rectal examination not suspicious for prostate cancer.

INTERVENTIONS

Oral selenium (200 microg/d from L-selenomethionine) and matched vitamin E placebo, vitamin E (400 IU/d of all rac-alpha-tocopheryl acetate) and matched selenium placebo, selenium + vitamin E, or placebo + placebo for a planned follow-up of minimum of 7 years and a maximum of 12 years.

MAIN OUTCOME MEASURES

Prostate cancer and prespecified secondary outcomes, including lung, colorectal, and overall primary cancer.

RESULTS

As of October 23, 2008, median overall follow-up was 5.46 years (range, 4.17-7.33 years). Hazard ratios (99% confidence intervals [CIs]) for prostate cancer were 1.13 (99% CI, 0.95-1.35; n = 473) for vitamin E, 1.04 (99% CI, 0.87-1.24; n = 432) for selenium, and 1.05 (99% CI, 0.88-1.25; n = 437) for selenium + vitamin E vs 1.00 (n = 416) for placebo. There were no significant differences (all P>.15) in any other prespecified cancer end points. There were statistically nonsignificant increased risks of prostate cancer in the vitamin E group (P = .06) and type 2 diabetes mellitus in the selenium group (relative risk, 1.07; 99% CI, 0.94-1.22; P = .16) but not in the selenium + vitamin E group.

CONCLUSION

Selenium or vitamin E, alone or in combination at the doses and formulations used, did not prevent prostate cancer in this population of relatively healthy men.

TRIAL REGISTRATION

clinicaltrials.gov identifier: NCT00006392.

Analysis of PTEN deletions and mutations in multiple myeloma

Clonal plasma cells from patients with multiple myeloma (MM), plasma cell leukemia (PCL) and human myeloma cell lines (HMCLs) were analyzed for deletions/mutations of the tumor suppressor gene PTEN. By interphase-FISH, hemizygous PTEN deletions were detected in 4 (5.6%) of 71 MM patients, 2 (20%) of 10 PCLs, and 2 (20%) of 10 HMCLs. PTEN deletions were detected in 4 MM patients at diagnosis with stage III disease (Durie-Salmon). Of the six cases with PTEN deletions, 1 MM had a 13q deletion, 1 PCL had a t(11;14), and the other PCL had a t(14;16), a 13q deletion and a p53 deletion. Sequencing analysis did not detect PTEN mutations in 11 primary MM and 5 PCL cases. Our results indicate that alterations of PTEN are uncommon in MM patients, and PTEN deletions tend to occur in advanced disease suggesting that they are secondary, rather than primary, events in the pathogenesis of MM.

Accuracy of precordial percussion in detecting cardiomegaly

STUDY OBJECTIVE

To assess the value of precordial percussion in detecting cardiomegaly, and to compare it with palpation of the apical impulse.

DESIGN

Descriptive study.

SETTING

Hospitals and clinics of a university medical center.

PATIENTS

Light indirect percussion of the precordium was performed on 72 inpatients and 28 outpatients. All patients had a posteroanterior radiograph of the chest. Percussors were unaware of the clinical history and of chest roentgenogram results.

MEASUREMENTS AND MAIN RESULTS

Thirty-six patients (36%) had cardiomegaly, defined as a cardiothoracic ratio of greater than 0.5 on chest roentgenogram. The cardiothoracic ratio was significantly correlated with percussion distance from the midsternal line in the left fourth (r = 0.35, p less than 0.0006), fifth (r = 0.65, p less than 0.00001), and sixth (r = 0.40, p less than 0.0001) intercostal spaces. After adjustment for clinical symptoms and systolic and diastolic blood pressures, percussion distance in the left fifth intercostal space remained a significant independent predictor of the cardiothoracic ratio. Percussion distance in the left fifth interspace discriminated cardiomegaly with a receiver-operating characteristic (ROC) area of 0.95. Percussion dullness more than 10.5 cm from the midsternal line in the left fifth interspace had a sensitivity of 94.4% (95% confidence interval [CI], 79.9% to 99.0%) and a specificity of 67.2% (CI, 54.2% to 78.1%). Distance of the apical impulse from the midsternal line discriminated with an ROC area of 0.95, but an impulse was palpated in only 40% of cases.

CONCLUSIONS

Percussion in the left fifth intercostal space accurately discriminates patients with and without cardiomegaly, and adds information beyond that obtainable from the history and other parts of the physical examination.