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Petrovic B, Bender JL, Liddy C, Afkham A, McGee SF, Morgan SC, Segal R, O’Brien MA, Julian JA, Sussman J, Urquhart R, Fitch M, Schneider ND, Grunfeld E. Implementation of a Web-Based Communication System for Primary Care Providers and Cancer Specialists. Curr Oncol 2023; 30:3537-3548. [PMID: 36975482 PMCID: PMC10047665 DOI: 10.3390/curroncol30030269] [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: 02/06/2023] [Revised: 03/03/2023] [Accepted: 03/13/2023] [Indexed: 03/29/2023] Open
Abstract
Healthcare providers have reported challenges with coordinating care for patients with cancer. Digital technology tools have brought new possibilities for improving care coordination. A web- and text-based asynchronous system (eOncoNote) was implemented in Ottawa, Canada for cancer specialists and primary care providers (PCPs). This study aimed to examine PCPs' experiences of implementing eOncoNote and how access to the system influenced communication between PCPs and cancer specialists. As part of a larger study, we collected and analyzed system usage data and administered an end-of-discussion survey to understand the perceived value of using eOncoNote. eOncoNote data were analyzed for 76 shared patients (33 patients receiving treatment and 43 patients in the survivorship phase). Thirty-nine percent of the PCPs responded to the cancer specialist's initial eOncoNote message and nearly all of those sent only one message. Forty-five percent of the PCPs completed the survey. Most PCPs reported no additional benefits of using eOncoNote and emphasized the need for electronic medical record (EMR) integration. Over half of the PCPs indicated that eOncoNote could be a helpful service if they had questions about a patient. Future research should examine opportunities for EMR integration and whether additional interventions could support communication between PCPs and cancer specialists.
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Affiliation(s)
- Bojana Petrovic
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON M5T 3M7, Canada
- Department of Family and Community Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, ON M5G 1V7, Canada
| | - Jacqueline L. Bender
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON M5T 3M7, Canada
- Cancer Rehabilitation and Survivorship, Department of Supportive Care, Princess Margaret Cancer Centre, Toronto, ON M5G 2C4, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON M5T 3M7, Canada
| | - Clare Liddy
- Bruyère Research Institute, Ottawa, ON K1N 5C8, Canada
- Department of Family Medicine, Faculty of Medicine, University of Ottawa, Ottawa, ON K1G 5Z3, Canada
| | - Amir Afkham
- Ontario Health East, Ottawa, ON K1J 1J8, Canada
| | - Sharon F. McGee
- The Ottawa Hospital Cancer Centre, Ottawa, ON K1H 8L6, Canada
| | - Scott C. Morgan
- The Ottawa Hospital Cancer Centre, Ottawa, ON K1H 8L6, Canada
- Department of Radiology, Radiation Oncology and Medical Physics, Faculty of Medicine, University of Ottawa, Ottawa, ON K1N 6N5, Canada
| | - Roanne Segal
- The Ottawa Hospital Cancer Centre, Ottawa, ON K1H 8L6, Canada
| | - Mary Ann O’Brien
- Department of Family and Community Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, ON M5G 1V7, Canada
| | - Jim A. Julian
- Department of Oncology, Faculty of Health Sciences, McMaster University, Hamilton, ON L8V 5C2, Canada
| | - Jonathan Sussman
- Department of Oncology, Faculty of Health Sciences, McMaster University, Hamilton, ON L8V 5C2, Canada
| | - Robin Urquhart
- Department of Community Health and Epidemiology, Faculty of Medicine, Dalhousie University, Halifax, NS B3H 1V7, Canada
- Department of Surgery, Nova Scotia Health, Halifax, NS B3H 2Y9, Canada
| | - Margaret Fitch
- Bloomberg Faculty of Nursing, University of Toronto, Toronto, ON M5T 1P8, Canada
- CanIMPACT Patient Advisory Committee, Toronto, ON M5G 1V7, Canada
| | | | - Eva Grunfeld
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON M5T 3M7, Canada
- Department of Family and Community Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, ON M5G 1V7, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON M5T 3M7, Canada
- Ontario Institute for Cancer Research, Toronto, ON M5G 1N8, Canada
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Kukafka R, Julian JA, Liddy C, Afkham A, McGee SF, Morgan SC, Segal R, Sussman J, Pond GR, O'Brien MA, Bender JL, Grunfeld E. Web-Based Asynchronous Tool to Facilitate Communication Between Primary Care Providers and Cancer Specialists: Pragmatic Randomized Controlled Trial. J Med Internet Res 2023; 25:e40725. [PMID: 36652284 PMCID: PMC9892983 DOI: 10.2196/40725] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2022] [Revised: 10/28/2022] [Accepted: 11/13/2022] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Cancer poses a significant global health burden. With advances in screening and treatment, there are now a growing number of cancer survivors with complex needs, requiring the involvement of multiple health care providers. Previous studies have identified problems related to communication and care coordination between primary care providers (PCPs) and cancer specialists. OBJECTIVE This study aimed to examine whether a web- and text-based asynchronous system (eOncoNote) could facilitate communication between PCPs and cancer specialists (oncologists and oncology nurses) to improve patient-reported continuity of care among patients receiving treatment or posttreatment survivorship care. METHODS In this pragmatic randomized controlled trial, a total of 173 patients were randomly assigned to either the intervention group (eOncoNote plus usual methods of communication between PCPs and cancer specialists) or a control group (usual communication only), including 104 (60.1%) patients in the survivorship phase (breast and colorectal cancer) and 69 (39.9%) patients in the treatment phase (breast and prostate cancer). The primary outcome was patient-reported team and cross-boundary continuity (Nijmegen Continuity Questionnaire). Secondary outcome measures included the Generalized Anxiety Disorder Screener (GAD-7), Patient Health Questionnaire on Major Depression, and Picker Patient Experience Questionnaire. Patients completed the questionnaires at baseline and at 2 points following randomization. Patients in the treatment phase completed follow-up questionnaires at 1 month and at either 4 months (patients with prostate cancer) or 6 months following randomization (patients with breast cancer). Patients in the survivorship phase completed follow-up questionnaires at 6 months and at 12 months following randomization. RESULTS The results did not show an intervention effect on the primary outcome of team and cross-boundary continuity of care or on the secondary outcomes of depression and patient experience with their health care. However, there was an intervention effect on anxiety. In the treatment phase, there was a statistically significant difference in the change score from baseline to the 1-month follow-up for GAD-7 (mean difference -2.3; P=.03). In the survivorship phase, there was a statistically significant difference in the change score for GAD-7 between baseline and the 6-month follow-up (mean difference -1.7; P=.03) and between baseline and the 12-month follow-up (mean difference -2.4; P=.004). CONCLUSIONS PCPs' and cancer specialists' access to eOncoNote is not significantly associated with patient-reported continuity of care. However, PCPs' and cancer specialists' access to the eOncoNote intervention may be a factor in reducing patient anxiety. TRIAL REGISTRATION ClinicalTrials.gov NCT03333785; https://clinicaltrials.gov/ct2/show/NCT03333785.
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Affiliation(s)
| | - Jim A Julian
- Department of Oncology, McMaster University, Hamilton, ON, Canada
| | - Clare Liddy
- Bruyère Research Institute, Ottawa, ON, Canada.,Department of Family Medicine, University of Ottawa, Ottawa, ON, Canada
| | | | | | - Scott C Morgan
- The Ottawa Hospital Cancer Centre, Ottawa, ON, Canada.,Department of Radiology, Radiation Oncology and Medical Physics, Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Roanne Segal
- The Ottawa Hospital Cancer Centre, Ottawa, ON, Canada
| | - Jonathan Sussman
- Department of Oncology, McMaster University, Hamilton, ON, Canada
| | - Gregory R Pond
- Department of Oncology, McMaster University, Hamilton, ON, Canada
| | - Mary Ann O'Brien
- Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada
| | - Jacqueline L Bender
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada.,Cancer Rehabilitation and Survivorship, Department of Supportive Care, Princess Margaret Cancer Centre, Toronto, ON, Canada.,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Eva Grunfeld
- Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada.,Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada.,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada.,Ontario Institute for Cancer Research, Toronto, ON, Canada
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Krzyzanowska MK, Julian JA, Gu CS, Powis M, Li Q, Enright K, Howell D, Earle CC, Gandhi S, Rask S, Brezden-Masley C, Dent S, Hajra L, Freeman O, Spadafora S, Hamm C, Califaretti N, Trudeau M, Levine MN, Amir E, Bordeleau L, Chiarotto JA, Elser C, Husain J, Laferriere N, Rahim Y, Robinson AG, Vandenberg T, Grunfeld E. Remote, proactive, telephone based management of toxicity in outpatients during adjuvant or neoadjuvant chemotherapy for early stage breast cancer: pragmatic, cluster randomised trial. BMJ 2021; 375:e066588. [PMID: 34880055 PMCID: PMC8652580 DOI: 10.1136/bmj-2021-066588] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [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: 12/26/2022]
Abstract
OBJECTIVE To evaluate the effectiveness of remote proactive management of toxicities during chemotherapy for early stage breast cancer. DESIGN Pragmatic, cluster randomised trial. SETTING 20 cancer centres in Ontario, Canada, allocated by covariate constrained randomisation to remote management of toxicities or routine care. PARTICIPANTS All patients starting adjuvant or neoadjuvant chemotherapy for early stage breast cancer at each centre. 25 patients from each centre completed patient reported outcome questionnaires. INTERVENTIONS Proactive, standardised, nurse led telephone management of common toxicities at two time points after each chemotherapy cycle. MAIN OUTCOME MEASURES The primary outcome, cluster level mean number of visits to the emergency department or admissions to hospital per patient during the whole course of chemotherapy treatment, was evaluated with routinely available administrative healthcare data. Secondary patient reported outcomes included toxicity, self-efficacy, and quality of life. RESULTS Baseline characteristics of participants were similar in the intervention (n=944) and control arms (n=1214); 22% were older than 65 years. Penetration (that is, the percentage of patients who received the intervention at each centre) was 50-86%. Mean number of visits to the emergency department or admissions to hospital per patient was 0.91 (standard deviation 0.28) in the intervention arm and 0.94 (0.40) in the control arm (P=0.94); 47% (1014 of 2158 patients) had at least one visit to the emergency department or a hospital admission during chemotherapy. Among 580 participants who completed the patient reported outcome questionnaires, at least one grade 3 toxicity was reported by 48% (134 of 278 patients) in the intervention arm and by 58% (163 of 283) in the control arm. No differences in self-efficacy, anxiety, or depression were found. Compared with baseline, the functional assessment of cancer therapy trial outcome index decreased by 6.1 and 9.0 points in the intervention and control participants, respectively. CONCLUSIONS Proactive, telephone based management of toxicities during chemotherapy did not result in fewer visits to the emergency department or hospital admissions. With the rapid rise in remote care because of the covid-19 pandemic, identifying scalable strategies for remote management of patients during cancer treatment is particularly relevant. TRIAL REGISTRATION ClinicalTrials.gov NCT02485678.
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Affiliation(s)
- Monika K Krzyzanowska
- Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
- Institute for Clinical Evaluative Sciences, Toronto, ON, Canada
| | - Jim A Julian
- Ontario Clinical Oncology Group, McMaster University, Hamilton, ON, Canada
| | - Chu-Shu Gu
- Ontario Clinical Oncology Group, McMaster University, Hamilton, ON, Canada
| | - Melanie Powis
- Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
| | - Qing Li
- Institute for Clinical Evaluative Sciences, Toronto, ON, Canada
| | - Katherine Enright
- Trillium Health Partners, Credit Valley Hospital, Mississauga, ON, Canada
| | - Doris Howell
- Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
| | - Craig C Earle
- Institute for Clinical Evaluative Sciences, Toronto, ON, Canada
- Ontario Institute for Cancer Research, Toronto, ON, Canada
| | - Sonal Gandhi
- Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Sara Rask
- Simcoe Muskoka Regional Cancer Program, Royal Victoria Hospital, Barrier, ON, Canada
| | | | - Susan Dent
- Ottawa Hospital Cancer Centre, Ottawa, ON, Canada
| | - Leena Hajra
- Markham Stouffville Hospital, Markham, ON, Canada
| | - Orit Freeman
- Durham Regional Cancer Centre, Oshawa, ON, Canada
| | - Silvana Spadafora
- Algoma District Cancer Programme, Sault Area Hospital, Sault Ste Marie, ON, Canada
| | | | - Nadia Califaretti
- Grand River Hospital's Regional Cancer Centre, Kitchener, ON, Canada
| | - Maureen Trudeau
- Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Mark N Levine
- Ontario Clinical Oncology Group, McMaster University, Hamilton, ON, Canada
- Juravinski Cancer Centre, Hamilton, ON, Canada
| | - Eitan Amir
- Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
| | | | | | - Christine Elser
- Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
| | - Juhi Husain
- Brampton Civic Hospital, Brampton, ON, Canada
| | - Nicole Laferriere
- Regional Cancer Centre Northwest, Thunder Bay Regional Health Sciences Centre, Thunder Bay, ON, Canada
| | - Yasmin Rahim
- Stronach Regional Cancer Centre, Newmarket, ON, Canada
| | | | | | - Eva Grunfeld
- Ontario Institute for Cancer Research, Toronto, ON, Canada
- Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada
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Kearon C, Carrier M, Gu CS, Schulman S, Bates SM, Kahn SR, Chagnon I, Nguyen DT, Wu C, Rudd-Scott L, Julian JA. Rivaroxaban Compared to Placebo for the Treatment of Leg Superficial Vein Thrombosis: A Randomized Trial. Semin Thromb Hemost 2020; 46:977-985. [PMID: 33368114 DOI: 10.1055/s-0040-1718891] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
The role of rivaroxaban in the treatment of leg superficial venous thrombosis (SVT) is uncertain. This article aims to determine if rivaroxaban is an effective and safe treatment for leg SVT. Patients with symptomatic leg SVT of at least 5 cm length were randomized to 45 days of rivaroxaban 10 mg daily or to placebo, and followed for a total of 90 days. Treatment failure (required a nonstudy anticoagulant; had proximal deep vein thrombosis or pulmonary embolism; or had surgery for SVT) at 90 days was the primary efficacy outcome. Secondary efficacy outcomes included leg pain severity, and venous disease-specific and general health-related quality of life over 90 days. Major bleeding at 90 days was the primary safety outcome. Poor enrollment led to the trial being stopped after 85 of the planned 600 patients were randomized to rivaroxaban (n = 43) or placebo (n = 42). One rivaroxaban and five placebo patients had a treatment failure by 90 days (absolute risk reduction = 9.0%, 95% confidence interval: -22 to 5.9%). Leg pain improvement did not differ at 7 (p = 0.16) or 45 days (p = 0.89), but was greater with rivaroxaban at 90 days (p = 0.011). There was no difference in venous disease-specific (p = 0.99) or general health-related (p = 0.37) quality of life over 45 days. There were no major bleeds or deaths in either group. There were no identifiable differences in efficacy or safety between rivaroxaban and placebo in patients with symptomatic SVT but comparisons were undermined by a much smaller than planned sample size (NCT1499953).
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Affiliation(s)
- Clive Kearon
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Marc Carrier
- Department of Medicine, Ottawa Hospital Research Institute at the University of Ottawa, Ottawa, Ontario, Canada
| | - Chu-Shu Gu
- Department of Oncology, McMaster University, Hamilton, Ontario, Canada
| | - Sam Schulman
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada.,Department of Obstetrics and Gynecology, I.M. Sechenov First Moscow State Medical University, Moscow, Russia
| | - Shannon M Bates
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Susan R Kahn
- Department of Medicine, McGill University, Montreal, Quebec, Canada
| | - Isabelle Chagnon
- Department of Medicine, University of Montreal, Montreal, Quebec, Canada
| | - Doan Trang Nguyen
- Department of Medicine, University of Montreal, Montreal, Quebec, Canada
| | - Cynthia Wu
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Lisa Rudd-Scott
- Department of Oncology, McMaster University, Hamilton, Ontario, Canada
| | - Jim A Julian
- Department of Oncology, McMaster University, Hamilton, Ontario, Canada
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Kahn SR, Julian JA, Kearon C, Gu CS, Cohen DJ, Magnuson EA, Comerota AJ, Goldhaber SZ, Jaff MR, Razavi MK, Kindzelski AL, Schneider JR, Kim P, Chaer R, Sista AK, McLafferty RB, Kaufman JA, Wible BC, Blinder M, Vedantham S. Quality of life after pharmacomechanical catheter-directed thrombolysis for proximal deep venous thrombosis. J Vasc Surg Venous Lymphat Disord 2020; 8:8-23.e18. [PMID: 31843251 PMCID: PMC7681916 DOI: 10.1016/j.jvsv.2019.03.023] [Citation(s) in RCA: 45] [Impact Index Per Article: 11.3] [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: 12/16/2018] [Accepted: 03/07/2019] [Indexed: 12/19/2022]
Abstract
BACKGROUND After deep venous thrombosis (DVT), many patients have impaired quality of life (QOL). We aimed to assess whether pharmacomechanical catheter-directed thrombolysis (PCDT) improves short-term or long-term QOL in patients with proximal DVT and whether QOL is related to extent of DVT. METHODS The Acute Venous Thrombosis: Thrombus Removal with Adjunctive Catheter-Directed Thrombolysis (ATTRACT) trial was an assessor-blinded randomized trial that compared PCDT with no PCDT in patients with DVT of the femoral, common femoral, or iliac veins. QOL was assessed at baseline and 1 month, 6 months, 12 months, 18 months, and 24 months using the Venous Insufficiency Epidemiological and Economic Study on Quality of Life/Symptoms (VEINES-QOL/Sym) disease-specific QOL measure and the 36-Item Short Form Health Survey (SF-36) physical component summary (PCS) and mental component summary general QOL measures. Change in QOL scores from baseline to assessment time were compared in the PCDT and no PCDT treatment groups overall and in the iliofemoral DVT and femoral-popliteal DVT subgroups. RESULTS Of 692 ATTRACT patients, 691 were analyzed (mean age, 53 years; 62% male; 57% iliofemoral DVT). VEINES-QOL change scores were greater (ie, better) in PCDT vs no PCDT from baseline to 1 month (difference, 5.7; P = .0006) and from baseline to 6 months (5.1; P = .0029) but not for other intervals. SF-36 PCS change scores were greater in PCDT vs no PCDT from baseline to 1 month (difference, 2.4; P = .01) but not for other intervals. Among iliofemoral DVT patients, VEINES-QOL change scores from baseline to all assessments were greater in the PCDT vs no PCDT group; this was statistically significant in the intention-to-treat analysis at 1 month (difference, 10.0; P < .0001) and 6 months (8.8; P < .0001) and in the per-protocol analysis at 18 months (difference, 5.8; P = .0086) and 24 months (difference, 6.6; P = .0067). SF-36 PCS change scores were greater in PCDT vs no PCDT from baseline to 1 month (difference, 3.2; P = .0010) but not for other intervals. In contrast, in femoral-popliteal DVT patients, change scores from baseline to all assessments were similar in the PCDT and no PCDT groups. CONCLUSIONS Among patients with proximal DVT, PCDT leads to greater improvement in disease-specific QOL than no PCDT at 1 month and 6 months but not later. In patients with iliofemoral DVT, PCDT led to greater improvement in disease-specific QOL during 24 months.
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Affiliation(s)
- Susan R Kahn
- Center for Clinical Epidemiology, Lady Davis Institute, Jewish General Hospital, Montreal, Quebec, Canada.
| | - Jim A Julian
- Department of Oncology, McMaster University, Hamilton, Ontario, Canada; Juravinski Hospital and Cancer Centre, Hamilton, Ontario, Canada
| | - Clive Kearon
- Juravinski Hospital and Cancer Centre, Hamilton, Ontario, Canada; Thrombosis and Atherosclerosis Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Chu-Shu Gu
- Department of Oncology, McMaster University, Hamilton, Ontario, Canada; Juravinski Hospital and Cancer Centre, Hamilton, Ontario, Canada
| | - David J Cohen
- Department of Medicine, University of Missouri-Kansas City, Kansas City, Mo; St. Luke's Mid America Heart Institute, Kansas City, Mo
| | | | - Anthony J Comerota
- Inova Heart and Vascular Institute, Inova Alexandria Hospital, Alexandria, Va
| | - Samuel Z Goldhaber
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, Mass; Harvard Medical School, Boston, Mass
| | - Michael R Jaff
- Harvard Medical School, Boston, Mass; Newton-Wellesley Hospital, Newton, Mass
| | | | - Andrei L Kindzelski
- Division of Blood Diseases and Resources, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Md
| | - Joseph R Schneider
- Vascular Surgery and Interventional Radiology Partners/VSIR, Northwestern Medicine, Chicago, Ill
| | - Paul Kim
- Department of Radiology, Maine Medical Center, Portland, Me
| | - Rabih Chaer
- Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | | | | | - John A Kaufman
- Department of Interventional Radiology, Dotter Interventional Institute, Oregon Health & Science University, Portland
| | - Brandt C Wible
- Department of Radiology, St. Luke's Hospital, Kansas City, Mo
| | - Morey Blinder
- Department of Medicine, Washington University in St. Louis, St. Louis, Mo
| | - Suresh Vedantham
- Mallinckrodt Institute of Radiology, Washington University in St. Louis, St. Louis, Mo
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Whelan TJ, Julian JA, Berrang TS, Kim DH, Germain I, Nichol AM, Akra M, Lavertu S, Germain F, Fyles A, Trotter T, Perera FE, Balkwill S, Chafe S, McGowan T, Muanza T, Beckham WA, Chua BH, Gu CS, Levine MN, Olivotto IA. External beam accelerated partial breast irradiation versus whole breast irradiation after breast conserving surgery in women with ductal carcinoma in situ and node-negative breast cancer (RAPID): a randomised controlled trial. Lancet 2019; 394:2165-2172. [PMID: 31813635 DOI: 10.1016/s0140-6736(19)32515-2] [Citation(s) in RCA: 242] [Impact Index Per Article: 48.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2019] [Revised: 09/24/2019] [Accepted: 10/01/2019] [Indexed: 11/28/2022]
Abstract
BACKGROUND Whole breast irradiation delivered once per day over 3-5 weeks after breast conserving surgery reduces local recurrence with good cosmetic results. Accelerated partial breast irradiation (APBI) delivered over 1 week to the tumour bed was developed to provide a more convenient treatment. In this trial, we investigated if external beam APBI was non-inferior to whole breast irradiation. METHODS We did this multicentre, randomised, non-inferiority trial in 33 cancer centres in Canada, Australia and New Zealand. Women aged 40 years or older with ductal carcinoma in situ or node-negative breast cancer treated by breast conserving surgery were randomly assigned (1:1) to receive either external beam APBI (38·5 Gy in ten fractions delivered twice per day over 5-8 days) or whole breast irradiation (42·5 Gy in 16 fractions once per day over 21 days, or 50 Gy in 25 fractions once per day over 35 days). Patients and clinicans were not masked to treatment assignment. The primary outcome was ipsilateral breast tumour recurrence (IBTR), analysed by intention to treat. The trial was designed on the basis of an expected 5 year IBTR rate of 1·5% in the whole breast irradiation group with 85% power to exclude a 1·5% increase in the APBI group; non-inferiority was shown if the upper limit of the two-sided 90% CI for the IBTR hazard ratio (HR) was less than 2·02. This trial is registered with ClinicalTrials.gov, NCT00282035. FINDINGS Between Feb 7, 2006, and July 15, 2011, we enrolled 2135 women. 1070 were randomly assigned to receive APBI and 1065 were assigned to receive whole breast irradiation. Six patients in the APBI group withdrew before treatment, four more did not receive radiotherapy, and 16 patients received whole breast irradiation. In the whole breast irradiation group, 16 patients withdrew, and two more did not receive radiotherapy. In the APBI group, a further 14 patients were lost to follow-up and nine patients withdrew during the follow-up period. In the whole breast irradiation group, 20 patients were lost to follow-up and 35 withdrew during follow-up. Median follow-up was 8·6 years (IQR 7·3-9·9). The 8-year cumulative rates of IBTR were 3·0% (95% CI 1·9-4·0) in the APBI group and 2·8% (1·8-3·9) in the whole breast irradiation group. The HR for APBI versus whole breast radiation was 1·27 (90% CI 0·84-1·91). Acute radiation toxicity (grade ≥2, within 3 months of radiotherapy start) occurred less frequently in patients treated with APBI (300 [28%] of 1070 patients) than whole breast irradiation (484 [45%] of 1065 patients, p<0·0001). Late radiation toxicity (grade ≥2, later than 3 months) was more common in patients treated with APBI (346 [32%] of 1070 patients) than whole breast irradiation (142 [13%] of 1065 patients; p<0·0001). Adverse cosmesis (defined as fair or poor) was more common in patients treated with APBI than in those treated by whole breast irradiation at 3 years (absolute difference, 11·3%, 95% CI 7·5-15·0), 5 years (16·5%, 12·5-20·4), and 7 years (17·7%, 12·9-22·3). INTERPRETATION External beam APBI was non-inferior to whole breast irradiation in preventing IBTR. Although less acute toxicity was observed, the regimen used was associated with an increase in moderate late toxicity and adverse cosmesis, which might be related to the twice per day treatment. Other approaches, such as treatment once per day, might not adversely affect cosmesis and should be studied. FUNDING Canadian Institutes for Health Research and Canadian Breast Cancer Research Alliance.
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Affiliation(s)
- Timothy J Whelan
- Department of Oncology, McMaster University and Juravinski Cancer Centre, Hamilton, ON, Canada.
| | - Jim A Julian
- Department of Oncology, McMaster University and Juravinski Cancer Centre, Hamilton, ON, Canada
| | - Tanya S Berrang
- Radiation Therapy Program, BC Cancer - Victoria, University of British Columbia, Vancouver, BC, Canada
| | - Do-Hoon Kim
- Department of Oncology, McMaster University and Juravinski Cancer Centre, Hamilton, ON, Canada
| | - Isabelle Germain
- Department of Radiation Oncology, CHU de Québec - Université Laval, Québec, QC, Canada
| | - Alan M Nichol
- Division of Radiation Oncology, University of British Columbia and BC Cancer - Vancouver, BC, Canada
| | - Mohamed Akra
- Department of Radiation Oncology, University of Manitoba, Winnipeg, MB, Canada
| | - Sophie Lavertu
- Department of Radiation Oncology, Centre Hospitalier de l'Université de Montréal, Montreal, QC, Canada
| | - Francois Germain
- Department of Radiation Oncology, CHU de Québec - Université Laval, Québec, QC, Canada; Division of Radiation Oncology, University of British Columbia and BC Cancer - Kelowna, BC, Canada
| | - Anthony Fyles
- Department of Radiation Oncology, University of Toronto and Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, ON, Canada
| | | | - Francisco E Perera
- Department of Oncology, Western University and London Regional Cancer Program, London, ON, Canada
| | | | - Susan Chafe
- Department of Oncology, Division of Radiation Oncology, University of Alberta and Cross Cancer Institute, Edmonton, AB, Canada
| | - Thomas McGowan
- Trillium Health Partners Credit Valley Hospital, Mississauga, ON, Canada
| | - Thierry Muanza
- Department of Oncology, McGill University and Jewish General Hospital Segal Cancer Centre, Montreal, QC, Canada
| | - Wayne A Beckham
- Department of Physics and Astronomy, University of Victoria and BC Cancer - Victoria, BC, Canada
| | - Boon H Chua
- University of New South Wales and Prince of Wales Hospital, Sydney, NSW, Australia
| | - Chu Shu Gu
- Department of Oncology, McMaster University and Juravinski Cancer Centre, Hamilton, ON, Canada
| | - Mark N Levine
- Department of Oncology, McMaster University and Juravinski Cancer Centre, Hamilton, ON, Canada
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Comerota AJ, Kearon C, Gu CS, Julian JA, Goldhaber SZ, Kahn SR, Jaff MR, Razavi MK, Kindzelski AL, Bashir R, Patel P, Sharafuddin M, Sichlau MJ, Saad WE, Assi Z, Hofmann LV, Kennedy M, Vedantham S. Endovascular Thrombus Removal for Acute Iliofemoral Deep Vein Thrombosis. Circulation 2019; 139:1162-1173. [PMID: 30586751 DOI: 10.1161/circulationaha.118.037425] [Citation(s) in RCA: 149] [Impact Index Per Article: 29.8] [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] [Indexed: 02/02/2023]
Abstract
BACKGROUND The ATTRACT trial (Acute Venous Thrombosis: Thrombus Removal with Adjunctive Catheter-Directed Thrombolysis) previously reported that pharmacomechanical catheter-directed thrombolysis (PCDT) did not prevent postthrombotic syndrome (PTS) in patients with acute proximal deep vein thrombosis. In the current analysis, we examine the effect of PCDT in ATTRACT patients with iliofemoral deep vein thrombosis. METHODS Within a large multicenter randomized trial, 391 patients with acute deep vein thrombosis involving the iliac or common femoral veins were randomized to PCDT with anticoagulation versus anticoagulation alone (No-PCDT) and were followed for 24 months to compare short-term and long-term outcomes. RESULTS Between 6 and 24 months, there was no difference in the occurrence of PTS (Villalta scale ≥5 or ulcer: 49% PCDT versus 51% No-PCDT; risk ratio, 0.95; 95% CI, 0.78-1.15; P=0.59). PCDT led to reduced PTS severity as shown by lower mean Villalta and Venous Clinical Severity Scores ( P<0.01 for comparisons at 6, 12, 18, and 24 months), and fewer patients with moderate-or-severe PTS (Villalta scale ≥10 or ulcer: 18% versus 28%; risk ratio, 0.65; 95% CI, 0.45-0.94; P=0.021) or severe PTS (Villalta scale ≥15 or ulcer: 8.7% versus 15%; risk ratio, 0.57; 95% CI, 0.32-1.01; P=0.048; and Venous Clinical Severity Score ≥8: 6.6% versus 14%; risk ratio, 0.46; 95% CI, 0.24-0.87; P=0.013). From baseline, PCDT led to greater reduction in leg pain and swelling ( P<0.01 for comparisons at 10 and 30 days) and greater improvement in venous disease-specific quality of life (Venous Insufficiency Epidemiological and Economic Study Quality of Life unit difference 5.6 through 24 months, P=0.029), but no difference in generic quality of life ( P>0.2 for comparisons of SF-36 mental and physical component summary scores through 24 months). In patients having PCDT versus No-PCDT, major bleeding within 10 days occurred in 1.5% versus 0.5% ( P=0.32), and recurrent venous thromboembolism over 24 months was observed in 13% versus 9.2% ( P=0.21). CONCLUSIONS In patients with acute iliofemoral deep vein thrombosis, PCDT did not influence the occurrence of PTS or recurrent venous thromboembolism. However, PCDT significantly reduced early leg symptoms and, over 24 months, reduced PTS severity scores, reduced the proportion of patients who developed moderate-or-severe PTS, and resulted in greater improvement in venous disease-specific quality of life. CLINICAL TRIAL REGISTRATION URL: https://www.clinicaltrials.gov . Unique identifier: NCT00790335.
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Affiliation(s)
- Anthony J Comerota
- Inova Heart and Vascular Institute, Inova Alexandria Hospital, VA (A.J.C.)
| | - Clive Kearon
- Thrombosis and Atherosclerosis Research Institute (C.K.), McMaster University, Hamilton, ON, Canada.,Juravinski Hospital and Cancer Centre, Hamilton, ON, Canada (C.K., C.-S.G., J.A.J.)
| | - Chu-Shu Gu
- Department of Oncology (C.-S.G., J.A.J.), McMaster University, Hamilton, ON, Canada.,Juravinski Hospital and Cancer Centre, Hamilton, ON, Canada (C.K., C.-S.G., J.A.J.)
| | - Jim A Julian
- Department of Oncology (C.-S.G., J.A.J.), McMaster University, Hamilton, ON, Canada.,Juravinski Hospital and Cancer Centre, Hamilton, ON, Canada (C.K., C.-S.G., J.A.J.)
| | - Samuel Z Goldhaber
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, and Harvard Medical School, Boston, MA (S.Z.G.)
| | - Susan R Kahn
- Jewish General Hospital, Lady Davis Institute, Center for Clinical Epidemiology, Montreal, QC, Canada (S.R.K.)
| | - Michael R Jaff
- Newton-Wellesley Hospital, and Harvard Medical School, Boston, MA (M.R.J.)
| | | | - Andrei L Kindzelski
- National Heart Lung and Blood Institute, National Institutes of Health, Bethesda, MD (A.L.K.)
| | - Riyaz Bashir
- Department of Medicine, Temple University Hospital, Philadelphia, PA (R.B.)
| | - Parag Patel
- Department of Radiology, Medical College of Wisconsin, Milwaukee (P.P.)
| | - Mel Sharafuddin
- Division of Vascular Surgery, University of Iowa, Iowa City (M.S.)
| | - Michael J Sichlau
- Vascular and Interventional Professionals LLC, Hinsdale, IL (M.J.S.)
| | - Wael E Saad
- Department of Radiology, University of Michigan, Ann Arbor (W.E.S.)
| | - Zakaria Assi
- Toledo Radiological Associates, Vascular & Interventional Radiology, OH (Z.A.)
| | | | | | - Suresh Vedantham
- Mallinckrodt Institute of Radiology, Washington University in St. Louis, MO (S.V.)
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8
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Kearon C, de Wit K, Parpia S, Schulman S, Afilalo M, Hirsch A, Spencer FA, Sharma S, D'Aragon F, Deshaies JF, Le Gal G, Lazo-Langner A, Wu C, Rudd-Scott L, Bates SM, Julian JA. Diagnosis of Pulmonary Embolism with d-Dimer Adjusted to Clinical Probability. N Engl J Med 2019; 381:2125-2134. [PMID: 31774957 DOI: 10.1056/nejmoa1909159] [Citation(s) in RCA: 168] [Impact Index Per Article: 33.6] [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] [Indexed: 11/19/2022]
Abstract
BACKGROUND Retrospective analyses suggest that pulmonary embolism is ruled out by a d-dimer level of less than 1000 ng per milliliter in patients with a low clinical pretest probability (C-PTP) and by a d-dimer level of less than 500 ng per milliliter in patients with a moderate C-PTP. METHODS We performed a prospective study in which pulmonary embolism was considered to be ruled out without further testing in outpatients with a low C-PTP and a d-dimer level of less than 1000 ng per milliliter or with a moderate C-PTP and a d-dimer level of less than 500 ng per milliliter. All other patients underwent chest imaging (usually computed tomographic pulmonary angiography). If pulmonary embolism was not diagnosed, patients did not receive anticoagulant therapy. All patients were followed for 3 months to detect venous thromboembolism. RESULTS A total of 2017 patients were enrolled and evaluated, of whom 7.4% had pulmonary embolism on initial diagnostic testing. Of the 1325 patients who had a low C-PTP (1285 patients) or moderate C-PTP (40 patients) and a negative d-dimer test (i.e., <1000 or <500 ng per milliliter, respectively), none had venous thromboembolism during follow-up (95% confidence interval [CI], 0.00 to 0.29%). These included 315 patients who had a low C-PTP and a d-dimer level of 500 to 999 ng per milliliter (95% CI, 0.00 to 1.20%). Of all 1863 patients who did not receive a diagnosis of pulmonary embolism initially and did not receive anticoagulant therapy, 1 patient (0.05%; 95% CI, 0.01 to 0.30) had venous thromboembolism. Our diagnostic strategy resulted in the use of chest imaging in 34.3% of patients, whereas a strategy in which pulmonary embolism is considered to be ruled out with a low C-PTP and a d-dimer level of less than 500 ng per milliliter would result in the use of chest imaging in 51.9% (difference, -17.6 percentage points; 95% CI, -19.2 to -15.9). CONCLUSIONS A combination of a low C-PTP and a d-dimer level of less than 1000 ng per milliliter identified a group of patients at low risk for pulmonary embolism during follow-up. (Funded by the Canadian Institutes of Health Research and others; PEGeD ClinicalTrials.gov number, NCT02483442.).
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Affiliation(s)
- Clive Kearon
- From the Departments of Medicine (C.K., K.W., S. Schulman, F.A.S., S. Sharma, S.M.B.), Health Research Methods, Evidence, and Impact (C.K., S.P., S. Schulman), and Oncology (S.P., L.R.-S., J.A.J.), McMaster University, Hamilton, ON, the Departments of Emergency Medicine (M.A.) and Medicine (A.H.), McGill University, Montreal, the Departments of Anesthesia (F.D.) and Family and Emergency Medicine (J.-F.D.), Sherbrooke University, Sherbrooke, QC, the Department of Medicine, University of Ottawa, Ottawa (G.L.G.), the Departments of Medicine and Epidemiology and Biostatistics, Western University, London, ON (A.L.-L.), and the Department of Medicine, University of Alberta, Edmonton (C.W.) - all in Canada
| | - Kerstin de Wit
- From the Departments of Medicine (C.K., K.W., S. Schulman, F.A.S., S. Sharma, S.M.B.), Health Research Methods, Evidence, and Impact (C.K., S.P., S. Schulman), and Oncology (S.P., L.R.-S., J.A.J.), McMaster University, Hamilton, ON, the Departments of Emergency Medicine (M.A.) and Medicine (A.H.), McGill University, Montreal, the Departments of Anesthesia (F.D.) and Family and Emergency Medicine (J.-F.D.), Sherbrooke University, Sherbrooke, QC, the Department of Medicine, University of Ottawa, Ottawa (G.L.G.), the Departments of Medicine and Epidemiology and Biostatistics, Western University, London, ON (A.L.-L.), and the Department of Medicine, University of Alberta, Edmonton (C.W.) - all in Canada
| | - Sameer Parpia
- From the Departments of Medicine (C.K., K.W., S. Schulman, F.A.S., S. Sharma, S.M.B.), Health Research Methods, Evidence, and Impact (C.K., S.P., S. Schulman), and Oncology (S.P., L.R.-S., J.A.J.), McMaster University, Hamilton, ON, the Departments of Emergency Medicine (M.A.) and Medicine (A.H.), McGill University, Montreal, the Departments of Anesthesia (F.D.) and Family and Emergency Medicine (J.-F.D.), Sherbrooke University, Sherbrooke, QC, the Department of Medicine, University of Ottawa, Ottawa (G.L.G.), the Departments of Medicine and Epidemiology and Biostatistics, Western University, London, ON (A.L.-L.), and the Department of Medicine, University of Alberta, Edmonton (C.W.) - all in Canada
| | - Sam Schulman
- From the Departments of Medicine (C.K., K.W., S. Schulman, F.A.S., S. Sharma, S.M.B.), Health Research Methods, Evidence, and Impact (C.K., S.P., S. Schulman), and Oncology (S.P., L.R.-S., J.A.J.), McMaster University, Hamilton, ON, the Departments of Emergency Medicine (M.A.) and Medicine (A.H.), McGill University, Montreal, the Departments of Anesthesia (F.D.) and Family and Emergency Medicine (J.-F.D.), Sherbrooke University, Sherbrooke, QC, the Department of Medicine, University of Ottawa, Ottawa (G.L.G.), the Departments of Medicine and Epidemiology and Biostatistics, Western University, London, ON (A.L.-L.), and the Department of Medicine, University of Alberta, Edmonton (C.W.) - all in Canada
| | - Marc Afilalo
- From the Departments of Medicine (C.K., K.W., S. Schulman, F.A.S., S. Sharma, S.M.B.), Health Research Methods, Evidence, and Impact (C.K., S.P., S. Schulman), and Oncology (S.P., L.R.-S., J.A.J.), McMaster University, Hamilton, ON, the Departments of Emergency Medicine (M.A.) and Medicine (A.H.), McGill University, Montreal, the Departments of Anesthesia (F.D.) and Family and Emergency Medicine (J.-F.D.), Sherbrooke University, Sherbrooke, QC, the Department of Medicine, University of Ottawa, Ottawa (G.L.G.), the Departments of Medicine and Epidemiology and Biostatistics, Western University, London, ON (A.L.-L.), and the Department of Medicine, University of Alberta, Edmonton (C.W.) - all in Canada
| | - Andrew Hirsch
- From the Departments of Medicine (C.K., K.W., S. Schulman, F.A.S., S. Sharma, S.M.B.), Health Research Methods, Evidence, and Impact (C.K., S.P., S. Schulman), and Oncology (S.P., L.R.-S., J.A.J.), McMaster University, Hamilton, ON, the Departments of Emergency Medicine (M.A.) and Medicine (A.H.), McGill University, Montreal, the Departments of Anesthesia (F.D.) and Family and Emergency Medicine (J.-F.D.), Sherbrooke University, Sherbrooke, QC, the Department of Medicine, University of Ottawa, Ottawa (G.L.G.), the Departments of Medicine and Epidemiology and Biostatistics, Western University, London, ON (A.L.-L.), and the Department of Medicine, University of Alberta, Edmonton (C.W.) - all in Canada
| | - Frederick A Spencer
- From the Departments of Medicine (C.K., K.W., S. Schulman, F.A.S., S. Sharma, S.M.B.), Health Research Methods, Evidence, and Impact (C.K., S.P., S. Schulman), and Oncology (S.P., L.R.-S., J.A.J.), McMaster University, Hamilton, ON, the Departments of Emergency Medicine (M.A.) and Medicine (A.H.), McGill University, Montreal, the Departments of Anesthesia (F.D.) and Family and Emergency Medicine (J.-F.D.), Sherbrooke University, Sherbrooke, QC, the Department of Medicine, University of Ottawa, Ottawa (G.L.G.), the Departments of Medicine and Epidemiology and Biostatistics, Western University, London, ON (A.L.-L.), and the Department of Medicine, University of Alberta, Edmonton (C.W.) - all in Canada
| | - Sangita Sharma
- From the Departments of Medicine (C.K., K.W., S. Schulman, F.A.S., S. Sharma, S.M.B.), Health Research Methods, Evidence, and Impact (C.K., S.P., S. Schulman), and Oncology (S.P., L.R.-S., J.A.J.), McMaster University, Hamilton, ON, the Departments of Emergency Medicine (M.A.) and Medicine (A.H.), McGill University, Montreal, the Departments of Anesthesia (F.D.) and Family and Emergency Medicine (J.-F.D.), Sherbrooke University, Sherbrooke, QC, the Department of Medicine, University of Ottawa, Ottawa (G.L.G.), the Departments of Medicine and Epidemiology and Biostatistics, Western University, London, ON (A.L.-L.), and the Department of Medicine, University of Alberta, Edmonton (C.W.) - all in Canada
| | - Frédérick D'Aragon
- From the Departments of Medicine (C.K., K.W., S. Schulman, F.A.S., S. Sharma, S.M.B.), Health Research Methods, Evidence, and Impact (C.K., S.P., S. Schulman), and Oncology (S.P., L.R.-S., J.A.J.), McMaster University, Hamilton, ON, the Departments of Emergency Medicine (M.A.) and Medicine (A.H.), McGill University, Montreal, the Departments of Anesthesia (F.D.) and Family and Emergency Medicine (J.-F.D.), Sherbrooke University, Sherbrooke, QC, the Department of Medicine, University of Ottawa, Ottawa (G.L.G.), the Departments of Medicine and Epidemiology and Biostatistics, Western University, London, ON (A.L.-L.), and the Department of Medicine, University of Alberta, Edmonton (C.W.) - all in Canada
| | - Jean-François Deshaies
- From the Departments of Medicine (C.K., K.W., S. Schulman, F.A.S., S. Sharma, S.M.B.), Health Research Methods, Evidence, and Impact (C.K., S.P., S. Schulman), and Oncology (S.P., L.R.-S., J.A.J.), McMaster University, Hamilton, ON, the Departments of Emergency Medicine (M.A.) and Medicine (A.H.), McGill University, Montreal, the Departments of Anesthesia (F.D.) and Family and Emergency Medicine (J.-F.D.), Sherbrooke University, Sherbrooke, QC, the Department of Medicine, University of Ottawa, Ottawa (G.L.G.), the Departments of Medicine and Epidemiology and Biostatistics, Western University, London, ON (A.L.-L.), and the Department of Medicine, University of Alberta, Edmonton (C.W.) - all in Canada
| | - Gregoire Le Gal
- From the Departments of Medicine (C.K., K.W., S. Schulman, F.A.S., S. Sharma, S.M.B.), Health Research Methods, Evidence, and Impact (C.K., S.P., S. Schulman), and Oncology (S.P., L.R.-S., J.A.J.), McMaster University, Hamilton, ON, the Departments of Emergency Medicine (M.A.) and Medicine (A.H.), McGill University, Montreal, the Departments of Anesthesia (F.D.) and Family and Emergency Medicine (J.-F.D.), Sherbrooke University, Sherbrooke, QC, the Department of Medicine, University of Ottawa, Ottawa (G.L.G.), the Departments of Medicine and Epidemiology and Biostatistics, Western University, London, ON (A.L.-L.), and the Department of Medicine, University of Alberta, Edmonton (C.W.) - all in Canada
| | - Alejandro Lazo-Langner
- From the Departments of Medicine (C.K., K.W., S. Schulman, F.A.S., S. Sharma, S.M.B.), Health Research Methods, Evidence, and Impact (C.K., S.P., S. Schulman), and Oncology (S.P., L.R.-S., J.A.J.), McMaster University, Hamilton, ON, the Departments of Emergency Medicine (M.A.) and Medicine (A.H.), McGill University, Montreal, the Departments of Anesthesia (F.D.) and Family and Emergency Medicine (J.-F.D.), Sherbrooke University, Sherbrooke, QC, the Department of Medicine, University of Ottawa, Ottawa (G.L.G.), the Departments of Medicine and Epidemiology and Biostatistics, Western University, London, ON (A.L.-L.), and the Department of Medicine, University of Alberta, Edmonton (C.W.) - all in Canada
| | - Cynthia Wu
- From the Departments of Medicine (C.K., K.W., S. Schulman, F.A.S., S. Sharma, S.M.B.), Health Research Methods, Evidence, and Impact (C.K., S.P., S. Schulman), and Oncology (S.P., L.R.-S., J.A.J.), McMaster University, Hamilton, ON, the Departments of Emergency Medicine (M.A.) and Medicine (A.H.), McGill University, Montreal, the Departments of Anesthesia (F.D.) and Family and Emergency Medicine (J.-F.D.), Sherbrooke University, Sherbrooke, QC, the Department of Medicine, University of Ottawa, Ottawa (G.L.G.), the Departments of Medicine and Epidemiology and Biostatistics, Western University, London, ON (A.L.-L.), and the Department of Medicine, University of Alberta, Edmonton (C.W.) - all in Canada
| | - Lisa Rudd-Scott
- From the Departments of Medicine (C.K., K.W., S. Schulman, F.A.S., S. Sharma, S.M.B.), Health Research Methods, Evidence, and Impact (C.K., S.P., S. Schulman), and Oncology (S.P., L.R.-S., J.A.J.), McMaster University, Hamilton, ON, the Departments of Emergency Medicine (M.A.) and Medicine (A.H.), McGill University, Montreal, the Departments of Anesthesia (F.D.) and Family and Emergency Medicine (J.-F.D.), Sherbrooke University, Sherbrooke, QC, the Department of Medicine, University of Ottawa, Ottawa (G.L.G.), the Departments of Medicine and Epidemiology and Biostatistics, Western University, London, ON (A.L.-L.), and the Department of Medicine, University of Alberta, Edmonton (C.W.) - all in Canada
| | - Shannon M Bates
- From the Departments of Medicine (C.K., K.W., S. Schulman, F.A.S., S. Sharma, S.M.B.), Health Research Methods, Evidence, and Impact (C.K., S.P., S. Schulman), and Oncology (S.P., L.R.-S., J.A.J.), McMaster University, Hamilton, ON, the Departments of Emergency Medicine (M.A.) and Medicine (A.H.), McGill University, Montreal, the Departments of Anesthesia (F.D.) and Family and Emergency Medicine (J.-F.D.), Sherbrooke University, Sherbrooke, QC, the Department of Medicine, University of Ottawa, Ottawa (G.L.G.), the Departments of Medicine and Epidemiology and Biostatistics, Western University, London, ON (A.L.-L.), and the Department of Medicine, University of Alberta, Edmonton (C.W.) - all in Canada
| | - Jim A Julian
- From the Departments of Medicine (C.K., K.W., S. Schulman, F.A.S., S. Sharma, S.M.B.), Health Research Methods, Evidence, and Impact (C.K., S.P., S. Schulman), and Oncology (S.P., L.R.-S., J.A.J.), McMaster University, Hamilton, ON, the Departments of Emergency Medicine (M.A.) and Medicine (A.H.), McGill University, Montreal, the Departments of Anesthesia (F.D.) and Family and Emergency Medicine (J.-F.D.), Sherbrooke University, Sherbrooke, QC, the Department of Medicine, University of Ottawa, Ottawa (G.L.G.), the Departments of Medicine and Epidemiology and Biostatistics, Western University, London, ON (A.L.-L.), and the Department of Medicine, University of Alberta, Edmonton (C.W.) - all in Canada
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9
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Magnuson EA, Chinnakondepalli K, Vilain K, Kearon C, Julian JA, Kahn SR, Goldhaber SZ, Jaff MR, Kindzelski AL, Herman K, Brady PS, Sharma K, Black CM, Vedantham S, Cohen DJ. Cost-Effectiveness of Pharmacomechanical Catheter-Directed Thrombolysis Versus Standard Anticoagulation in Patients With Proximal Deep Vein Thrombosis: Results From the ATTRACT Trial. Circ Cardiovasc Qual Outcomes 2019; 12:e005659. [PMID: 31592728 DOI: 10.1161/circoutcomes.119.005659] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [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] [Indexed: 11/16/2022]
Abstract
BACKGROUND In patients with acute deep vein thrombosis (DVT), pharmacomechanical catheter-directed thrombolysis (PCDT) in conjunction with anticoagulation therapy is increasingly used with the goal of preventing postthrombotic syndrome. Long-term costs and cost-effectiveness of these 2 treatment strategies from the perspective of the US healthcare system have not been compared. METHODS AND RESULTS Between 2009 and 2014, the ATTRACT trial (Acute Venous Thrombosis: Thrombus Removal With Adjunctive Catheter-Directed Thrombolysis) randomized 692 patients with acute proximal DVT to PCDT plus anticoagulation (n=337) or standard treatment with anticoagulation alone (n=355). Costs (2017 US dollars) were assessed over a 24-month follow-up period using a combination of resource-based costing, hospital bills, Medicare reimbursement rates, and the Drug Topics Red Book. Health state utilities were obtained from the Short Form-36. In-trial results and US life tables were used to develop a Markov cohort model to evaluate lifetime cost-effectiveness. For the PCDT group, mean costs of the initial procedure were $13 600; per-patient costs associated with the index hospitalization were $21 509 for PCDT and $3877 for standard care (difference=$17 632; 95% CI, $16 117-$19 243). The 24-month difference in costs was $20 045 (95% CI, $16 093-$24 120). Utility scores increased significantly between baseline and 6 months for both groups, with no significant differences between groups at any follow-up time point. Projected differences in lifetime costs of $16 740 and quality-adjusted life years (QALYs) of 0.08, yield an incremental cost-effectiveness ratio for PCDT of $222 041/QALY gained. In probabilistic sensitivity analysis, the probability that PCDT would achieve a lifetime incremental cost-effectiveness ratio <$50 000/QALY or <$150 000/QALY was 1% and 25%, respectively. For iliofemoral DVT, QALY gains with PCDT were greater, yielding an incremental cost-effectiveness ratio of $137 526/QALY; for femoral-popliteal DVT, standard therapy was an economically dominant strategy. CONCLUSIONS With an incremental cost-effectiveness ratio >$200 000/QALY gained, PCDT is not an economically attractive treatment for proximal DVT. PCDT may be of intermediate value in patients with iliofemoral DVT. Clinical Trial Registration URL: https://www.clinicaltrials.gov. Unique identifier: NCT00790335.
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Affiliation(s)
- Elizabeth A Magnuson
- Saint Luke's Mid America Heart Institute, Kansas City, MO (E.A.M., K.C., K.V., D.J.C.).,University of Missouri-Kansas City (E.A.M., D.J.C.)
| | | | - Katherine Vilain
- Saint Luke's Mid America Heart Institute, Kansas City, MO (E.A.M., K.C., K.V., D.J.C.)
| | - Clive Kearon
- Thrombosis and Atherosclerosis Research Institute (C.K.), McMaster University, Hamilton, ON, Canada.,Juravinski Hospital and Cancer Centre, Hamilton, ON, Canada (C.K., J.A.J.)
| | - Jim A Julian
- Department of Oncology (J.A.J.), McMaster University, Hamilton, ON, Canada.,Juravinski Hospital and Cancer Centre, Hamilton, ON, Canada (C.K., J.A.J.)
| | - Susan R Kahn
- Jewish General Hospital, Lady Davis Institute, Center for Clinical Epidemiology, Montreal, QC, Canada (S.R.K.)
| | - Samuel Z Goldhaber
- Division of Cardiovascular Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA (S.Z.G.)
| | - Michael R Jaff
- Newton-Wellesley Hospital, Newton, MA (M.R.J.).,Harvard Medical School, Boston, MA (M.R.J.)
| | - Andrei L Kindzelski
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD (A.L.K.)
| | - Kevin Herman
- Interventional Institute at Holy Name Medical Center, Teaneck, NJ (K.H.)
| | - Paul S Brady
- Thomas Jefferson University and Einstein Health Care Network, Philadelphia, PA (P.S.B.)
| | - Karun Sharma
- Children's National Medical Center and George Washington University School of Medicine and Health Sciences, Washington, DC (K.S.)
| | - Carl M Black
- Utah Valley Hospital/Intermountain Healthcare and IVC Vein and Interventional Center, Provo (C.M.B.)
| | - Suresh Vedantham
- Mallinckrodt Institute of Radiology, Washington University in St. Louis, MO (S.V.)
| | - David J Cohen
- Saint Luke's Mid America Heart Institute, Kansas City, MO (E.A.M., K.C., K.V., D.J.C.).,University of Missouri-Kansas City (E.A.M., D.J.C.)
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10
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Weinberg I, Vedantham S, Salter A, Hadley G, Al-Hammadi N, Kearon C, Julian JA, Razavi MK, Gornik HL, Goldhaber SZ, Comerota AJ, Kindzelski AL, Schainfeld RM, Angle JF, Misra S, Schor JA, Hurst D, Jaff MR. Relationships between the use of pharmacomechanical catheter-directed thrombolysis, sonographic findings, and clinical outcomes in patients with acute proximal DVT: Results from the ATTRACT Multicenter Randomized Trial. Vasc Med 2019; 24:442-451. [PMID: 31354089 PMCID: PMC6943930 DOI: 10.1177/1358863x19862043] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [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: 11/16/2022]
Abstract
Few studies have documented relationships between endovascular therapy, duplex ultrasonography (DUS), post-thrombotic syndrome (PTS), and quality of life (QOL). The Acute Venous Thrombosis: Thrombus Removal with Adjunctive Catheter-Directed Thrombolysis (ATTRACT) trial randomized 692 patients with acute proximal deep vein thrombosis (DVT) to receive anticoagulation or anticoagulation plus pharmacomechanical catheter-directed thrombolysis (PCDT). Compression DUS was obtained at baseline, 1 month and 12 months. Reflux DUS was obtained at 12 months in a subset of 126 patients. Clinical outcomes were collected over 24 months. At 1 month, patients who received PCDT had less residual thrombus compared to Control patients, evidenced by non-compressible common femoral vein (CFV) (21% vs 35%, p < 0.0001), femoral vein (51% vs 70%, p < 0.0001), and popliteal vein (61% vs 74%, p < 0.0001). At 12 months, in the ultrasound substudy, valvular reflux prevalence was similar between groups (85% vs 91%, p = 0.35). CFV non-compressibility at 1 month was associated with higher rates of any PTS (61% vs 46%, p < 0.001), a higher incidence of moderate-or-severe PTS (30% vs 19%, p = 0.003), and worse QOL (difference 8.2 VEINES-QOL (VEnous INsufficiency Epidemiological and Economic Study on Quality of Life) points; p = 0.004) at 24 months. Valvular reflux at 12 months was associated with moderate-or-severe PTS at 24 months (30% vs 0%, p = 0.01). In summary, PCDT results in less residual thrombus but does not reduce venous valvular reflux. CFV non-compressibility at 1 month is associated with more PTS, more severe PTS, and worse QOL at 24 months. Valvular reflux may predispose to moderate-or-severe PTS. ClinicalTrials.gov Identifier NCT00790335.
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Affiliation(s)
- Ido Weinberg
- Vascular Medicine Section, Cardiology Division, Massachusetts General Hospital, Boston, MA, USA
- Vascular Ultrasound Core-Laboratory (VasCore), Boston, MA, USA
| | - Suresh Vedantham
- Mallinckrodt Institute of Radiology, Washington University in St. Louis, St. Louis, MO, USA
| | - Amber Salter
- Division of Biostatistics, Washington University in St. Louis, St. Louis, MO, USA
| | - Gail Hadley
- Vascular Ultrasound Core-Laboratory (VasCore), Boston, MA, USA
| | - Noor Al-Hammadi
- Division of Biostatistics, Washington University in St. Louis, St. Louis, MO, USA
| | - Clive Kearon
- McMaster University, Department of Oncology, Hamilton, Ontario, Canada
| | - Jim A. Julian
- McMaster University, Department of Oncology, Hamilton, Ontario, Canada
- Juravinski Hospital and Cancer Centre, Hamilton, Ontario, Canada
| | | | - Heather L. Gornik
- Vascular Center, University Hospitals Harrington Heart & Vascular Institute, Cleveland, OH
| | - Samuel Z. Goldhaber
- Brigham and Women’s Hospital, Division of Cardiovascular Medicine, and Harvard Medical School, Boston, MA, USA
| | - Anthony J. Comerota
- Inova Heart and Vascular Institute, Inova Alexandria Hospital, Alexandria, VA, USA
| | - Andrei L. Kindzelski
- Division of Blood Diseases & Resources, National Heart, Lung, and Blood Institute, National Institutes of Health (NIH), Bethesda, MD, USA
| | - Robert M. Schainfeld
- Vascular Medicine Section, Cardiology Division, Massachusetts General Hospital, Boston, MA, USA
| | - John F. Angle
- Department of Radiology, University of Virginia, Charlottesville, VA, USA
| | - Sanjay Misra
- Department of Radiology, Mayo Clinic, Rochester, MN, USA
| | | | - Darren Hurst
- Department of Radiology, St. Elizabeth Healthcare, Edgewood, KY, USA
| | - Michael R. Jaff
- Newton-Wellesley Hospital, Newton, and Harvard Medical School, Boston, MA
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11
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Krzyzanowska MK, Julian JA, Powis M, Howell D, Earle CC, Enright KA, Mittmann N, Trudeau ME, Grunfeld E. Ambulatory Toxicity Management (AToM) in patients receiving adjuvant or neo-adjuvant chemotherapy for early stage breast cancer - a pragmatic cluster randomized trial protocol. BMC Cancer 2019; 19:884. [PMID: 31488084 PMCID: PMC6729066 DOI: 10.1186/s12885-019-6099-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2019] [Accepted: 08/27/2019] [Indexed: 01/16/2023] Open
Abstract
Background Population-based studies suggest that emergency department visits and hospitalizations are common among patients receiving chemotherapy and that rates in routine practice are higher than expected from clinical trials. Chemotherapy-related toxicities are often predictable and, consequently, acute care visits may be preventable with adequate treatment planning and support between visits to the cancer centre. We will evaluate the impact of proactive telephone-based toxicity management on emergency department visits and hospitalizations in women with early stage breast cancer receiving chemotherapy. Methods In this pragmatic covariate constraint-based cluster randomized trial, 20 centres in Ontario, Canada are randomly allocated to either proactive telephone toxicity management (intervention) or routine care (control). The primary outcome is the cluster-level mean number of ED + H visits per patient evaluated using Ontario administrative healthcare data. Participants are all patients with early stage (I-III) breast cancer commencing adjuvant or neo-adjuvant chemotherapy at participating institutions during the intervention period. At least 25 patients at each centre participate in a patient reported outcomes sub-study involving the collection of standardized questionnaires to measure: severity of treatment toxicities, self-care, self-efficacy, quality of life, and coordination of care. Patients participating in the patient reported outcomes (PRO) sub-study are asked to provide written consent to link their PRO data to administrative data. Unit costs will be applied to each per person resource utilized, and a total cost per population and patient will be generated. An incremental cost-effectiveness analysis will be undertaken to compare the incremental costs and outcomes between the intervention and control groups from the health system perspective. Discussion This study evaluates the effectiveness of a proactive toxicity management intervention in a routine care setting. The use of administrative healthcare data to evaluate the primary outcome enables an evaluation in a real world setting and at a much larger scale than previous studies. Trial registration Clinicaltrials.gov, NCT02485678. Registered 30 June 2015. Electronic supplementary material The online version of this article (10.1186/s12885-019-6099-x) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Monika K Krzyzanowska
- Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada. .,Department of Medicine, University of Toronto, Toronto, ON, Canada.
| | - Jim A Julian
- Ontario Clinical Oncology Group, McMaster University, Hamilton, ON, Canada
| | - Melanie Powis
- Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
| | - Doris Howell
- Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
| | - Craig C Earle
- Ontario Institute for Cancer Research, Toronto, ON, Canada
| | | | | | | | - Eva Grunfeld
- Ontario Institute for Cancer Research, Toronto, ON, Canada.,Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada
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12
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Kearon C, Parpia S, Spencer FA, Schulman S, Stevens SM, Shah V, Bauer KA, Douketis JD, Lentz SR, Kessler CM, Connors JM, Ginsberg JS, Spadafora L, Julian JA. Long-term risk of recurrence in patients with a first unprovoked venous thromboembolism managed according to d-dimer results; A cohort study. J Thromb Haemost 2019; 17:1144-1152. [PMID: 31033194 DOI: 10.1111/jth.14458] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [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: 01/18/2019] [Accepted: 04/17/2019] [Indexed: 11/26/2022]
Abstract
Essentials Long-term recurrence risk after a first unprovoked VTE with negative d-dimer levels is uncertain. Anticoagulation was stopped if d-dimer was negative, and was continued if d-dimer was positive. Five years after stopping anticoagulants, recurrent VTE was 30% in men and 17% in women. Negative d-dimers do not justify stopping anticoagulants in most men but appear to in most women. BACKGROUND The long-term risk of recurrence in patients with a first unprovoked venous thromboembolism (VTE) who have negative d-dimer results is uncertain. OBJECTIVES To determine this risk, including in subgroups based on sex. PATIENTS AND METHODS ln a prospective interventional cohort study of 410 patients with a first unprovoked VTE, anticoagulants were stopped if d-dimer was negative on therapy and 1 month after stopping therapy. Other patients remained on anticoagulant therapy. We previously reported findings after a mean of 2.2 years. The current report includes 3 years of additional follow-up in 293 of these patients. RESULTS During a median follow-up of 5.0 years, recurrent VTE after stopping therapy in response to negative d-dimer testing was 5.1% (95% confidence interval [CI], 3.6-6.5) per patient-year overall, 7.5% (95% CI, 5.5-10.0) in men, 3.8% (95% CI, 2.0-6.6) in women with VTE not associated with estrogens, and 0.4% (95% CI, 0.0-2.3) in women with VTE associated with estrogens (P < 0.001 for three-group comparison). Risk of recurrence at 5 years was 21.5% (95% CI, 16.4-26.5) overall, 29.7% (95% CI, 22.1-37.3) in men, 17.0% (95% CI, 8.1-25.9) in non-estrogen women, and 2.3% (95% CI, 0.0-6.8) in estrogen women. CONCLUSION The long-term risk of recurrence in patients with a first unprovoked VTE who have negative d-dimer results is not low enough to justify stopping anticoagulant therapy in men, but appears to be low enough in women for many to choose stopping therapy (ClinicalTrials.gov; NCT00720915).
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Affiliation(s)
- Clive Kearon
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Sameer Parpia
- Department of Oncology, McMaster University, Hamilton, ON, Canada
| | | | - Sam Schulman
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Scott M Stevens
- Department of Medicine, Intermountain Medical Center, Murray, Utah
| | - Vinay Shah
- Department of Medicine, Henry Ford Hospital, Detroit, Michigan
| | - Kenneth A Bauer
- Department of Medicine, Harvard Medical School, Boston, Massachusetts
| | - James D Douketis
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Steven R Lentz
- Department of Medicine, University of Iowa, Iowa City, Iowa
| | - Craig M Kessler
- Department of Medicine, Georgetown University, Washington, District of Columbia
| | - Jean M Connors
- Department of Medicine, Harvard Medical School, Boston, Massachusetts
| | | | | | - Jim A Julian
- Department of Oncology, McMaster University, Hamilton, ON, Canada
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13
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Aslostovar L, Boyd AL, Almakadi M, Collins TJ, Leong DP, Tirona RG, Kim RB, Julian JA, Xenocostas A, Leber B, Levine MN, Foley R, Bhatia M. A phase 1 trial evaluating thioridazine in combination with cytarabine in patients with acute myeloid leukemia. Blood Adv 2018; 2:1935-1945. [PMID: 30093531 PMCID: PMC6093733 DOI: 10.1182/bloodadvances.2018015677] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [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: 01/02/2018] [Accepted: 07/04/2018] [Indexed: 12/19/2022] Open
Abstract
We completed a phase 1 dose-escalation trial to evaluate the safety of a dopamine receptor D2 (DRD2) antagonist thioridazine (TDZ), in combination with cytarabine. Thirteen patients 55 years and older with relapsed or refractory acute myeloid leukemia (AML) were enrolled. Oral TDZ was administered at 3 dose levels: 25 mg (n = 6), 50 mg (n = 4), or 100 mg (n = 3) every 6 hours for 21 days. Intermediate-dose cytarabine was administered on days 6 to 10. Dose-limiting toxicities (DLTs) included grade 3 QTc interval prolongation in 1 patient at 25 mg TDZ and neurological events in 2 patients at 100 mg TDZ (gait disturbance, depressed consciousness, and dizziness). At the 50-mg TDZ dose, the sum of circulating DRD2 antagonist levels approached a concentration of 10 μM, a level noted to be selectively active against human AML in vitro. Eleven of 13 patients completed a 5-day lead-in with TDZ, of which 6 received TDZ with hydroxyurea and 5 received TDZ alone. During this period, 8 patients demonstrated a 19% to 55% reduction in blast levels, whereas 3 patients displayed progressive disease. The extent of blast reduction during this 5-day interval was associated with the expression of the putative TDZ target receptor DRD2 on leukemic cells. These preliminary results suggest that DRD2 represents a potential therapeutic target for AML disease. Future studies are required to corroborate these observations, including the use of modified DRD2 antagonists with improved tolerability in AML patients. This trial was registered at www.clinicaltrials.gov as #NCT02096289.
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Affiliation(s)
- Lili Aslostovar
- Stem Cell and Cancer Research Institute and
- Department of Biochemistry and Biomedical Sciences, McMaster University, Hamilton, ON, Canada
| | | | - Mohammed Almakadi
- Stem Cell and Cancer Research Institute and
- Department of Biochemistry and Biomedical Sciences, McMaster University, Hamilton, ON, Canada
- Division of Malignant Hematology, Department of Oncology, Juravinski Hospital, Hamilton, ON, Canada
| | | | - Darryl P Leong
- Division of Cardiology, Department of Medicine, Population Health Research Institute, McMaster University, Hamilton, ON, Canada
| | - Rommel G Tirona
- Division of Clinical Pharmacology, Department of Medicine, University of Western Ontario, London Health Sciences Centre, London, ON, Canada
| | - Richard B Kim
- Division of Clinical Pharmacology, Department of Medicine, University of Western Ontario, London Health Sciences Centre, London, ON, Canada
| | - Jim A Julian
- Department of Oncology, McMaster University, Juravinski Hospital, Hamilton, ON, Canada
| | - Anargyros Xenocostas
- Division of Hematology, Department of Medicine, University of Western Ontario, London Health Sciences Centre, London, ON, Canada; and
| | - Brian Leber
- Department of Medicine, McMaster University, Juravinski Hospital, Hamilton, ON, Canada
| | - Mark N Levine
- Department of Oncology, McMaster University, Juravinski Hospital, Hamilton, ON, Canada
| | - Ronan Foley
- Department of Pathology and Molecular Medicine, McMaster University, Juravinski Hospital, Hamilton, ON, Canada
| | - Mickie Bhatia
- Stem Cell and Cancer Research Institute and
- Department of Biochemistry and Biomedical Sciences, McMaster University, Hamilton, ON, Canada
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14
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Takach Lapner S, Julian JA, Linkins LA, Bates SM, Kearon C. Questioning the use of an age-adjusted D-dimer threshold to exclude venous thromboembolism: reply. J Thromb Haemost 2018; 16:1448-1450. [PMID: 29771476 DOI: 10.1111/jth.14155] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Affiliation(s)
- S Takach Lapner
- Department of Medicine, McMaster University, Hamilton, ON, Canada
- Department of Medicine, University of Alberta, Edmonton, AB, Canada
| | - J A Julian
- Ontario Clinical Oncology Group, Juravinski Hospital, Hamilton, ON, Canada
| | - L-A Linkins
- Department of Medicine, McMaster University, Hamilton, ON, Canada
- Thrombosis and Atherosclerosis Research Institute, McMaster University, Hamilton, ON, Canada
| | - S M Bates
- Department of Medicine, McMaster University, Hamilton, ON, Canada
- Thrombosis and Atherosclerosis Research Institute, McMaster University, Hamilton, ON, Canada
| | - C Kearon
- Department of Medicine, McMaster University, Hamilton, ON, Canada
- Thrombosis and Atherosclerosis Research Institute, McMaster University, Hamilton, ON, Canada
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15
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Vedantham S, Goldhaber SZ, Julian JA, Kahn SR, Jaff MR, Cohen DJ, Magnuson E, Razavi MK, Comerota AJ, Gornik HL, Murphy TP, Lewis L, Duncan JR, Nieters P, Derfler MC, Filion M, Gu CS, Kee S, Schneider J, Saad N, Blinder M, Moll S, Sacks D, Lin J, Rundback J, Garcia M, Razdan R, VanderWoude E, Marques V, Kearon C. Pharmacomechanical Catheter-Directed Thrombolysis for Deep-Vein Thrombosis. N Engl J Med 2017; 377:2240-2252. [PMID: 29211671 PMCID: PMC5763501 DOI: 10.1056/nejmoa1615066] [Citation(s) in RCA: 439] [Impact Index Per Article: 62.7] [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] [Indexed: 12/18/2022]
Abstract
BACKGROUND The post-thrombotic syndrome frequently develops in patients with proximal deep-vein thrombosis despite treatment with anticoagulant therapy. Pharmacomechanical catheter-directed thrombolysis (hereafter "pharmacomechanical thrombolysis") rapidly removes thrombus and is hypothesized to reduce the risk of the post-thrombotic syndrome. METHODS We randomly assigned 692 patients with acute proximal deep-vein thrombosis to receive either anticoagulation alone (control group) or anticoagulation plus pharmacomechanical thrombolysis (catheter-mediated or device-mediated intrathrombus delivery of recombinant tissue plasminogen activator and thrombus aspiration or maceration, with or without stenting). The primary outcome was development of the post-thrombotic syndrome between 6 and 24 months of follow-up. RESULTS Between 6 and 24 months, there was no significant between-group difference in the percentage of patients with the post-thrombotic syndrome (47% in the pharmacomechanical-thrombolysis group and 48% in the control group; risk ratio, 0.96; 95% confidence interval [CI], 0.82 to 1.11; P=0.56). Pharmacomechanical thrombolysis led to more major bleeding events within 10 days (1.7% vs. 0.3% of patients, P=0.049), but no significant difference in recurrent venous thromboembolism was seen over the 24-month follow-up period (12% in the pharmacomechanical-thrombolysis group and 8% in the control group, P=0.09). Moderate-to-severe post-thrombotic syndrome occurred in 18% of patients in the pharmacomechanical-thrombolysis group versus 24% of those in the control group (risk ratio, 0.73; 95% CI, 0.54 to 0.98; P=0.04). Severity scores for the post-thrombotic syndrome were lower in the pharmacomechanical-thrombolysis group than in the control group at 6, 12, 18, and 24 months of follow-up (P<0.01 for the comparison of the Villalta scores at each time point), but the improvement in quality of life from baseline to 24 months did not differ significantly between the treatment groups. CONCLUSIONS Among patients with acute proximal deep-vein thrombosis, the addition of pharmacomechanical catheter-directed thrombolysis to anticoagulation did not result in a lower risk of the post-thrombotic syndrome but did result in a higher risk of major bleeding. (Funded by the National Heart, Lung, and Blood Institute and others; ATTRACT ClinicalTrials.gov number, NCT00790335 .).
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Affiliation(s)
- Suresh Vedantham
- From the Washington University School of Medicine, St. Louis (S.V., L.L., J.R.D., P.N., M.C.D., N.S., M.B.); Brigham and Women's Hospital, Harvard Medical School (S.Z.G.), and Massachusetts General Hospital, Harvard Medical School (M.R.J.) - all in Boston; McMaster University, Hamilton, ON (J.A.J., M.F., C.-S.G., C.K.), and McGill University, Jewish General Hospital, Montreal (S.R.K.) - all in Canada; the University of Missouri, St. Luke's Mid America Heart Institute, Kansas City (D.J.C., E.M.); St. Joseph's Vascular Institute, Orange (M.K.R.), and University of California, Los Angeles, Los Angeles (S.K.) - both in California; University of Michigan, Ann Arbor (A.J.C.); Cleveland Clinic Heart and Vascular Institute, Cleveland (H.L.G.); Rhode Island Hospital, Brown University, Providence (T.P.M.); Central DuPage Hospital, Winfield, IL (J.S.); University of North Carolina, Chapel Hill (S.M.); Reading Hospital, Reading, PA (D.S.); Henry Ford Hospital, Detroit (J.L.); Holy Name Hospital, Teaneck, NJ (J.R.); Christiana Care Hospital, Newark, DE (M.G.); St. Elizabeth's Regional Medical Center, Lincoln, NE (R.R., E.V.); and Pepin Heart Center, Tampa, FL (V.M.)
| | - Samuel Z Goldhaber
- From the Washington University School of Medicine, St. Louis (S.V., L.L., J.R.D., P.N., M.C.D., N.S., M.B.); Brigham and Women's Hospital, Harvard Medical School (S.Z.G.), and Massachusetts General Hospital, Harvard Medical School (M.R.J.) - all in Boston; McMaster University, Hamilton, ON (J.A.J., M.F., C.-S.G., C.K.), and McGill University, Jewish General Hospital, Montreal (S.R.K.) - all in Canada; the University of Missouri, St. Luke's Mid America Heart Institute, Kansas City (D.J.C., E.M.); St. Joseph's Vascular Institute, Orange (M.K.R.), and University of California, Los Angeles, Los Angeles (S.K.) - both in California; University of Michigan, Ann Arbor (A.J.C.); Cleveland Clinic Heart and Vascular Institute, Cleveland (H.L.G.); Rhode Island Hospital, Brown University, Providence (T.P.M.); Central DuPage Hospital, Winfield, IL (J.S.); University of North Carolina, Chapel Hill (S.M.); Reading Hospital, Reading, PA (D.S.); Henry Ford Hospital, Detroit (J.L.); Holy Name Hospital, Teaneck, NJ (J.R.); Christiana Care Hospital, Newark, DE (M.G.); St. Elizabeth's Regional Medical Center, Lincoln, NE (R.R., E.V.); and Pepin Heart Center, Tampa, FL (V.M.)
| | - Jim A Julian
- From the Washington University School of Medicine, St. Louis (S.V., L.L., J.R.D., P.N., M.C.D., N.S., M.B.); Brigham and Women's Hospital, Harvard Medical School (S.Z.G.), and Massachusetts General Hospital, Harvard Medical School (M.R.J.) - all in Boston; McMaster University, Hamilton, ON (J.A.J., M.F., C.-S.G., C.K.), and McGill University, Jewish General Hospital, Montreal (S.R.K.) - all in Canada; the University of Missouri, St. Luke's Mid America Heart Institute, Kansas City (D.J.C., E.M.); St. Joseph's Vascular Institute, Orange (M.K.R.), and University of California, Los Angeles, Los Angeles (S.K.) - both in California; University of Michigan, Ann Arbor (A.J.C.); Cleveland Clinic Heart and Vascular Institute, Cleveland (H.L.G.); Rhode Island Hospital, Brown University, Providence (T.P.M.); Central DuPage Hospital, Winfield, IL (J.S.); University of North Carolina, Chapel Hill (S.M.); Reading Hospital, Reading, PA (D.S.); Henry Ford Hospital, Detroit (J.L.); Holy Name Hospital, Teaneck, NJ (J.R.); Christiana Care Hospital, Newark, DE (M.G.); St. Elizabeth's Regional Medical Center, Lincoln, NE (R.R., E.V.); and Pepin Heart Center, Tampa, FL (V.M.)
| | - Susan R Kahn
- From the Washington University School of Medicine, St. Louis (S.V., L.L., J.R.D., P.N., M.C.D., N.S., M.B.); Brigham and Women's Hospital, Harvard Medical School (S.Z.G.), and Massachusetts General Hospital, Harvard Medical School (M.R.J.) - all in Boston; McMaster University, Hamilton, ON (J.A.J., M.F., C.-S.G., C.K.), and McGill University, Jewish General Hospital, Montreal (S.R.K.) - all in Canada; the University of Missouri, St. Luke's Mid America Heart Institute, Kansas City (D.J.C., E.M.); St. Joseph's Vascular Institute, Orange (M.K.R.), and University of California, Los Angeles, Los Angeles (S.K.) - both in California; University of Michigan, Ann Arbor (A.J.C.); Cleveland Clinic Heart and Vascular Institute, Cleveland (H.L.G.); Rhode Island Hospital, Brown University, Providence (T.P.M.); Central DuPage Hospital, Winfield, IL (J.S.); University of North Carolina, Chapel Hill (S.M.); Reading Hospital, Reading, PA (D.S.); Henry Ford Hospital, Detroit (J.L.); Holy Name Hospital, Teaneck, NJ (J.R.); Christiana Care Hospital, Newark, DE (M.G.); St. Elizabeth's Regional Medical Center, Lincoln, NE (R.R., E.V.); and Pepin Heart Center, Tampa, FL (V.M.)
| | - Michael R Jaff
- From the Washington University School of Medicine, St. Louis (S.V., L.L., J.R.D., P.N., M.C.D., N.S., M.B.); Brigham and Women's Hospital, Harvard Medical School (S.Z.G.), and Massachusetts General Hospital, Harvard Medical School (M.R.J.) - all in Boston; McMaster University, Hamilton, ON (J.A.J., M.F., C.-S.G., C.K.), and McGill University, Jewish General Hospital, Montreal (S.R.K.) - all in Canada; the University of Missouri, St. Luke's Mid America Heart Institute, Kansas City (D.J.C., E.M.); St. Joseph's Vascular Institute, Orange (M.K.R.), and University of California, Los Angeles, Los Angeles (S.K.) - both in California; University of Michigan, Ann Arbor (A.J.C.); Cleveland Clinic Heart and Vascular Institute, Cleveland (H.L.G.); Rhode Island Hospital, Brown University, Providence (T.P.M.); Central DuPage Hospital, Winfield, IL (J.S.); University of North Carolina, Chapel Hill (S.M.); Reading Hospital, Reading, PA (D.S.); Henry Ford Hospital, Detroit (J.L.); Holy Name Hospital, Teaneck, NJ (J.R.); Christiana Care Hospital, Newark, DE (M.G.); St. Elizabeth's Regional Medical Center, Lincoln, NE (R.R., E.V.); and Pepin Heart Center, Tampa, FL (V.M.)
| | - David J Cohen
- From the Washington University School of Medicine, St. Louis (S.V., L.L., J.R.D., P.N., M.C.D., N.S., M.B.); Brigham and Women's Hospital, Harvard Medical School (S.Z.G.), and Massachusetts General Hospital, Harvard Medical School (M.R.J.) - all in Boston; McMaster University, Hamilton, ON (J.A.J., M.F., C.-S.G., C.K.), and McGill University, Jewish General Hospital, Montreal (S.R.K.) - all in Canada; the University of Missouri, St. Luke's Mid America Heart Institute, Kansas City (D.J.C., E.M.); St. Joseph's Vascular Institute, Orange (M.K.R.), and University of California, Los Angeles, Los Angeles (S.K.) - both in California; University of Michigan, Ann Arbor (A.J.C.); Cleveland Clinic Heart and Vascular Institute, Cleveland (H.L.G.); Rhode Island Hospital, Brown University, Providence (T.P.M.); Central DuPage Hospital, Winfield, IL (J.S.); University of North Carolina, Chapel Hill (S.M.); Reading Hospital, Reading, PA (D.S.); Henry Ford Hospital, Detroit (J.L.); Holy Name Hospital, Teaneck, NJ (J.R.); Christiana Care Hospital, Newark, DE (M.G.); St. Elizabeth's Regional Medical Center, Lincoln, NE (R.R., E.V.); and Pepin Heart Center, Tampa, FL (V.M.)
| | - Elizabeth Magnuson
- From the Washington University School of Medicine, St. Louis (S.V., L.L., J.R.D., P.N., M.C.D., N.S., M.B.); Brigham and Women's Hospital, Harvard Medical School (S.Z.G.), and Massachusetts General Hospital, Harvard Medical School (M.R.J.) - all in Boston; McMaster University, Hamilton, ON (J.A.J., M.F., C.-S.G., C.K.), and McGill University, Jewish General Hospital, Montreal (S.R.K.) - all in Canada; the University of Missouri, St. Luke's Mid America Heart Institute, Kansas City (D.J.C., E.M.); St. Joseph's Vascular Institute, Orange (M.K.R.), and University of California, Los Angeles, Los Angeles (S.K.) - both in California; University of Michigan, Ann Arbor (A.J.C.); Cleveland Clinic Heart and Vascular Institute, Cleveland (H.L.G.); Rhode Island Hospital, Brown University, Providence (T.P.M.); Central DuPage Hospital, Winfield, IL (J.S.); University of North Carolina, Chapel Hill (S.M.); Reading Hospital, Reading, PA (D.S.); Henry Ford Hospital, Detroit (J.L.); Holy Name Hospital, Teaneck, NJ (J.R.); Christiana Care Hospital, Newark, DE (M.G.); St. Elizabeth's Regional Medical Center, Lincoln, NE (R.R., E.V.); and Pepin Heart Center, Tampa, FL (V.M.)
| | - Mahmood K Razavi
- From the Washington University School of Medicine, St. Louis (S.V., L.L., J.R.D., P.N., M.C.D., N.S., M.B.); Brigham and Women's Hospital, Harvard Medical School (S.Z.G.), and Massachusetts General Hospital, Harvard Medical School (M.R.J.) - all in Boston; McMaster University, Hamilton, ON (J.A.J., M.F., C.-S.G., C.K.), and McGill University, Jewish General Hospital, Montreal (S.R.K.) - all in Canada; the University of Missouri, St. Luke's Mid America Heart Institute, Kansas City (D.J.C., E.M.); St. Joseph's Vascular Institute, Orange (M.K.R.), and University of California, Los Angeles, Los Angeles (S.K.) - both in California; University of Michigan, Ann Arbor (A.J.C.); Cleveland Clinic Heart and Vascular Institute, Cleveland (H.L.G.); Rhode Island Hospital, Brown University, Providence (T.P.M.); Central DuPage Hospital, Winfield, IL (J.S.); University of North Carolina, Chapel Hill (S.M.); Reading Hospital, Reading, PA (D.S.); Henry Ford Hospital, Detroit (J.L.); Holy Name Hospital, Teaneck, NJ (J.R.); Christiana Care Hospital, Newark, DE (M.G.); St. Elizabeth's Regional Medical Center, Lincoln, NE (R.R., E.V.); and Pepin Heart Center, Tampa, FL (V.M.)
| | - Anthony J Comerota
- From the Washington University School of Medicine, St. Louis (S.V., L.L., J.R.D., P.N., M.C.D., N.S., M.B.); Brigham and Women's Hospital, Harvard Medical School (S.Z.G.), and Massachusetts General Hospital, Harvard Medical School (M.R.J.) - all in Boston; McMaster University, Hamilton, ON (J.A.J., M.F., C.-S.G., C.K.), and McGill University, Jewish General Hospital, Montreal (S.R.K.) - all in Canada; the University of Missouri, St. Luke's Mid America Heart Institute, Kansas City (D.J.C., E.M.); St. Joseph's Vascular Institute, Orange (M.K.R.), and University of California, Los Angeles, Los Angeles (S.K.) - both in California; University of Michigan, Ann Arbor (A.J.C.); Cleveland Clinic Heart and Vascular Institute, Cleveland (H.L.G.); Rhode Island Hospital, Brown University, Providence (T.P.M.); Central DuPage Hospital, Winfield, IL (J.S.); University of North Carolina, Chapel Hill (S.M.); Reading Hospital, Reading, PA (D.S.); Henry Ford Hospital, Detroit (J.L.); Holy Name Hospital, Teaneck, NJ (J.R.); Christiana Care Hospital, Newark, DE (M.G.); St. Elizabeth's Regional Medical Center, Lincoln, NE (R.R., E.V.); and Pepin Heart Center, Tampa, FL (V.M.)
| | - Heather L Gornik
- From the Washington University School of Medicine, St. Louis (S.V., L.L., J.R.D., P.N., M.C.D., N.S., M.B.); Brigham and Women's Hospital, Harvard Medical School (S.Z.G.), and Massachusetts General Hospital, Harvard Medical School (M.R.J.) - all in Boston; McMaster University, Hamilton, ON (J.A.J., M.F., C.-S.G., C.K.), and McGill University, Jewish General Hospital, Montreal (S.R.K.) - all in Canada; the University of Missouri, St. Luke's Mid America Heart Institute, Kansas City (D.J.C., E.M.); St. Joseph's Vascular Institute, Orange (M.K.R.), and University of California, Los Angeles, Los Angeles (S.K.) - both in California; University of Michigan, Ann Arbor (A.J.C.); Cleveland Clinic Heart and Vascular Institute, Cleveland (H.L.G.); Rhode Island Hospital, Brown University, Providence (T.P.M.); Central DuPage Hospital, Winfield, IL (J.S.); University of North Carolina, Chapel Hill (S.M.); Reading Hospital, Reading, PA (D.S.); Henry Ford Hospital, Detroit (J.L.); Holy Name Hospital, Teaneck, NJ (J.R.); Christiana Care Hospital, Newark, DE (M.G.); St. Elizabeth's Regional Medical Center, Lincoln, NE (R.R., E.V.); and Pepin Heart Center, Tampa, FL (V.M.)
| | - Timothy P Murphy
- From the Washington University School of Medicine, St. Louis (S.V., L.L., J.R.D., P.N., M.C.D., N.S., M.B.); Brigham and Women's Hospital, Harvard Medical School (S.Z.G.), and Massachusetts General Hospital, Harvard Medical School (M.R.J.) - all in Boston; McMaster University, Hamilton, ON (J.A.J., M.F., C.-S.G., C.K.), and McGill University, Jewish General Hospital, Montreal (S.R.K.) - all in Canada; the University of Missouri, St. Luke's Mid America Heart Institute, Kansas City (D.J.C., E.M.); St. Joseph's Vascular Institute, Orange (M.K.R.), and University of California, Los Angeles, Los Angeles (S.K.) - both in California; University of Michigan, Ann Arbor (A.J.C.); Cleveland Clinic Heart and Vascular Institute, Cleveland (H.L.G.); Rhode Island Hospital, Brown University, Providence (T.P.M.); Central DuPage Hospital, Winfield, IL (J.S.); University of North Carolina, Chapel Hill (S.M.); Reading Hospital, Reading, PA (D.S.); Henry Ford Hospital, Detroit (J.L.); Holy Name Hospital, Teaneck, NJ (J.R.); Christiana Care Hospital, Newark, DE (M.G.); St. Elizabeth's Regional Medical Center, Lincoln, NE (R.R., E.V.); and Pepin Heart Center, Tampa, FL (V.M.)
| | - Lawrence Lewis
- From the Washington University School of Medicine, St. Louis (S.V., L.L., J.R.D., P.N., M.C.D., N.S., M.B.); Brigham and Women's Hospital, Harvard Medical School (S.Z.G.), and Massachusetts General Hospital, Harvard Medical School (M.R.J.) - all in Boston; McMaster University, Hamilton, ON (J.A.J., M.F., C.-S.G., C.K.), and McGill University, Jewish General Hospital, Montreal (S.R.K.) - all in Canada; the University of Missouri, St. Luke's Mid America Heart Institute, Kansas City (D.J.C., E.M.); St. Joseph's Vascular Institute, Orange (M.K.R.), and University of California, Los Angeles, Los Angeles (S.K.) - both in California; University of Michigan, Ann Arbor (A.J.C.); Cleveland Clinic Heart and Vascular Institute, Cleveland (H.L.G.); Rhode Island Hospital, Brown University, Providence (T.P.M.); Central DuPage Hospital, Winfield, IL (J.S.); University of North Carolina, Chapel Hill (S.M.); Reading Hospital, Reading, PA (D.S.); Henry Ford Hospital, Detroit (J.L.); Holy Name Hospital, Teaneck, NJ (J.R.); Christiana Care Hospital, Newark, DE (M.G.); St. Elizabeth's Regional Medical Center, Lincoln, NE (R.R., E.V.); and Pepin Heart Center, Tampa, FL (V.M.)
| | - James R Duncan
- From the Washington University School of Medicine, St. Louis (S.V., L.L., J.R.D., P.N., M.C.D., N.S., M.B.); Brigham and Women's Hospital, Harvard Medical School (S.Z.G.), and Massachusetts General Hospital, Harvard Medical School (M.R.J.) - all in Boston; McMaster University, Hamilton, ON (J.A.J., M.F., C.-S.G., C.K.), and McGill University, Jewish General Hospital, Montreal (S.R.K.) - all in Canada; the University of Missouri, St. Luke's Mid America Heart Institute, Kansas City (D.J.C., E.M.); St. Joseph's Vascular Institute, Orange (M.K.R.), and University of California, Los Angeles, Los Angeles (S.K.) - both in California; University of Michigan, Ann Arbor (A.J.C.); Cleveland Clinic Heart and Vascular Institute, Cleveland (H.L.G.); Rhode Island Hospital, Brown University, Providence (T.P.M.); Central DuPage Hospital, Winfield, IL (J.S.); University of North Carolina, Chapel Hill (S.M.); Reading Hospital, Reading, PA (D.S.); Henry Ford Hospital, Detroit (J.L.); Holy Name Hospital, Teaneck, NJ (J.R.); Christiana Care Hospital, Newark, DE (M.G.); St. Elizabeth's Regional Medical Center, Lincoln, NE (R.R., E.V.); and Pepin Heart Center, Tampa, FL (V.M.)
| | - Patricia Nieters
- From the Washington University School of Medicine, St. Louis (S.V., L.L., J.R.D., P.N., M.C.D., N.S., M.B.); Brigham and Women's Hospital, Harvard Medical School (S.Z.G.), and Massachusetts General Hospital, Harvard Medical School (M.R.J.) - all in Boston; McMaster University, Hamilton, ON (J.A.J., M.F., C.-S.G., C.K.), and McGill University, Jewish General Hospital, Montreal (S.R.K.) - all in Canada; the University of Missouri, St. Luke's Mid America Heart Institute, Kansas City (D.J.C., E.M.); St. Joseph's Vascular Institute, Orange (M.K.R.), and University of California, Los Angeles, Los Angeles (S.K.) - both in California; University of Michigan, Ann Arbor (A.J.C.); Cleveland Clinic Heart and Vascular Institute, Cleveland (H.L.G.); Rhode Island Hospital, Brown University, Providence (T.P.M.); Central DuPage Hospital, Winfield, IL (J.S.); University of North Carolina, Chapel Hill (S.M.); Reading Hospital, Reading, PA (D.S.); Henry Ford Hospital, Detroit (J.L.); Holy Name Hospital, Teaneck, NJ (J.R.); Christiana Care Hospital, Newark, DE (M.G.); St. Elizabeth's Regional Medical Center, Lincoln, NE (R.R., E.V.); and Pepin Heart Center, Tampa, FL (V.M.)
| | - Mary C Derfler
- From the Washington University School of Medicine, St. Louis (S.V., L.L., J.R.D., P.N., M.C.D., N.S., M.B.); Brigham and Women's Hospital, Harvard Medical School (S.Z.G.), and Massachusetts General Hospital, Harvard Medical School (M.R.J.) - all in Boston; McMaster University, Hamilton, ON (J.A.J., M.F., C.-S.G., C.K.), and McGill University, Jewish General Hospital, Montreal (S.R.K.) - all in Canada; the University of Missouri, St. Luke's Mid America Heart Institute, Kansas City (D.J.C., E.M.); St. Joseph's Vascular Institute, Orange (M.K.R.), and University of California, Los Angeles, Los Angeles (S.K.) - both in California; University of Michigan, Ann Arbor (A.J.C.); Cleveland Clinic Heart and Vascular Institute, Cleveland (H.L.G.); Rhode Island Hospital, Brown University, Providence (T.P.M.); Central DuPage Hospital, Winfield, IL (J.S.); University of North Carolina, Chapel Hill (S.M.); Reading Hospital, Reading, PA (D.S.); Henry Ford Hospital, Detroit (J.L.); Holy Name Hospital, Teaneck, NJ (J.R.); Christiana Care Hospital, Newark, DE (M.G.); St. Elizabeth's Regional Medical Center, Lincoln, NE (R.R., E.V.); and Pepin Heart Center, Tampa, FL (V.M.)
| | - Marc Filion
- From the Washington University School of Medicine, St. Louis (S.V., L.L., J.R.D., P.N., M.C.D., N.S., M.B.); Brigham and Women's Hospital, Harvard Medical School (S.Z.G.), and Massachusetts General Hospital, Harvard Medical School (M.R.J.) - all in Boston; McMaster University, Hamilton, ON (J.A.J., M.F., C.-S.G., C.K.), and McGill University, Jewish General Hospital, Montreal (S.R.K.) - all in Canada; the University of Missouri, St. Luke's Mid America Heart Institute, Kansas City (D.J.C., E.M.); St. Joseph's Vascular Institute, Orange (M.K.R.), and University of California, Los Angeles, Los Angeles (S.K.) - both in California; University of Michigan, Ann Arbor (A.J.C.); Cleveland Clinic Heart and Vascular Institute, Cleveland (H.L.G.); Rhode Island Hospital, Brown University, Providence (T.P.M.); Central DuPage Hospital, Winfield, IL (J.S.); University of North Carolina, Chapel Hill (S.M.); Reading Hospital, Reading, PA (D.S.); Henry Ford Hospital, Detroit (J.L.); Holy Name Hospital, Teaneck, NJ (J.R.); Christiana Care Hospital, Newark, DE (M.G.); St. Elizabeth's Regional Medical Center, Lincoln, NE (R.R., E.V.); and Pepin Heart Center, Tampa, FL (V.M.)
| | - Chu-Shu Gu
- From the Washington University School of Medicine, St. Louis (S.V., L.L., J.R.D., P.N., M.C.D., N.S., M.B.); Brigham and Women's Hospital, Harvard Medical School (S.Z.G.), and Massachusetts General Hospital, Harvard Medical School (M.R.J.) - all in Boston; McMaster University, Hamilton, ON (J.A.J., M.F., C.-S.G., C.K.), and McGill University, Jewish General Hospital, Montreal (S.R.K.) - all in Canada; the University of Missouri, St. Luke's Mid America Heart Institute, Kansas City (D.J.C., E.M.); St. Joseph's Vascular Institute, Orange (M.K.R.), and University of California, Los Angeles, Los Angeles (S.K.) - both in California; University of Michigan, Ann Arbor (A.J.C.); Cleveland Clinic Heart and Vascular Institute, Cleveland (H.L.G.); Rhode Island Hospital, Brown University, Providence (T.P.M.); Central DuPage Hospital, Winfield, IL (J.S.); University of North Carolina, Chapel Hill (S.M.); Reading Hospital, Reading, PA (D.S.); Henry Ford Hospital, Detroit (J.L.); Holy Name Hospital, Teaneck, NJ (J.R.); Christiana Care Hospital, Newark, DE (M.G.); St. Elizabeth's Regional Medical Center, Lincoln, NE (R.R., E.V.); and Pepin Heart Center, Tampa, FL (V.M.)
| | - Stephen Kee
- From the Washington University School of Medicine, St. Louis (S.V., L.L., J.R.D., P.N., M.C.D., N.S., M.B.); Brigham and Women's Hospital, Harvard Medical School (S.Z.G.), and Massachusetts General Hospital, Harvard Medical School (M.R.J.) - all in Boston; McMaster University, Hamilton, ON (J.A.J., M.F., C.-S.G., C.K.), and McGill University, Jewish General Hospital, Montreal (S.R.K.) - all in Canada; the University of Missouri, St. Luke's Mid America Heart Institute, Kansas City (D.J.C., E.M.); St. Joseph's Vascular Institute, Orange (M.K.R.), and University of California, Los Angeles, Los Angeles (S.K.) - both in California; University of Michigan, Ann Arbor (A.J.C.); Cleveland Clinic Heart and Vascular Institute, Cleveland (H.L.G.); Rhode Island Hospital, Brown University, Providence (T.P.M.); Central DuPage Hospital, Winfield, IL (J.S.); University of North Carolina, Chapel Hill (S.M.); Reading Hospital, Reading, PA (D.S.); Henry Ford Hospital, Detroit (J.L.); Holy Name Hospital, Teaneck, NJ (J.R.); Christiana Care Hospital, Newark, DE (M.G.); St. Elizabeth's Regional Medical Center, Lincoln, NE (R.R., E.V.); and Pepin Heart Center, Tampa, FL (V.M.)
| | - Joseph Schneider
- From the Washington University School of Medicine, St. Louis (S.V., L.L., J.R.D., P.N., M.C.D., N.S., M.B.); Brigham and Women's Hospital, Harvard Medical School (S.Z.G.), and Massachusetts General Hospital, Harvard Medical School (M.R.J.) - all in Boston; McMaster University, Hamilton, ON (J.A.J., M.F., C.-S.G., C.K.), and McGill University, Jewish General Hospital, Montreal (S.R.K.) - all in Canada; the University of Missouri, St. Luke's Mid America Heart Institute, Kansas City (D.J.C., E.M.); St. Joseph's Vascular Institute, Orange (M.K.R.), and University of California, Los Angeles, Los Angeles (S.K.) - both in California; University of Michigan, Ann Arbor (A.J.C.); Cleveland Clinic Heart and Vascular Institute, Cleveland (H.L.G.); Rhode Island Hospital, Brown University, Providence (T.P.M.); Central DuPage Hospital, Winfield, IL (J.S.); University of North Carolina, Chapel Hill (S.M.); Reading Hospital, Reading, PA (D.S.); Henry Ford Hospital, Detroit (J.L.); Holy Name Hospital, Teaneck, NJ (J.R.); Christiana Care Hospital, Newark, DE (M.G.); St. Elizabeth's Regional Medical Center, Lincoln, NE (R.R., E.V.); and Pepin Heart Center, Tampa, FL (V.M.)
| | - Nael Saad
- From the Washington University School of Medicine, St. Louis (S.V., L.L., J.R.D., P.N., M.C.D., N.S., M.B.); Brigham and Women's Hospital, Harvard Medical School (S.Z.G.), and Massachusetts General Hospital, Harvard Medical School (M.R.J.) - all in Boston; McMaster University, Hamilton, ON (J.A.J., M.F., C.-S.G., C.K.), and McGill University, Jewish General Hospital, Montreal (S.R.K.) - all in Canada; the University of Missouri, St. Luke's Mid America Heart Institute, Kansas City (D.J.C., E.M.); St. Joseph's Vascular Institute, Orange (M.K.R.), and University of California, Los Angeles, Los Angeles (S.K.) - both in California; University of Michigan, Ann Arbor (A.J.C.); Cleveland Clinic Heart and Vascular Institute, Cleveland (H.L.G.); Rhode Island Hospital, Brown University, Providence (T.P.M.); Central DuPage Hospital, Winfield, IL (J.S.); University of North Carolina, Chapel Hill (S.M.); Reading Hospital, Reading, PA (D.S.); Henry Ford Hospital, Detroit (J.L.); Holy Name Hospital, Teaneck, NJ (J.R.); Christiana Care Hospital, Newark, DE (M.G.); St. Elizabeth's Regional Medical Center, Lincoln, NE (R.R., E.V.); and Pepin Heart Center, Tampa, FL (V.M.)
| | - Morey Blinder
- From the Washington University School of Medicine, St. Louis (S.V., L.L., J.R.D., P.N., M.C.D., N.S., M.B.); Brigham and Women's Hospital, Harvard Medical School (S.Z.G.), and Massachusetts General Hospital, Harvard Medical School (M.R.J.) - all in Boston; McMaster University, Hamilton, ON (J.A.J., M.F., C.-S.G., C.K.), and McGill University, Jewish General Hospital, Montreal (S.R.K.) - all in Canada; the University of Missouri, St. Luke's Mid America Heart Institute, Kansas City (D.J.C., E.M.); St. Joseph's Vascular Institute, Orange (M.K.R.), and University of California, Los Angeles, Los Angeles (S.K.) - both in California; University of Michigan, Ann Arbor (A.J.C.); Cleveland Clinic Heart and Vascular Institute, Cleveland (H.L.G.); Rhode Island Hospital, Brown University, Providence (T.P.M.); Central DuPage Hospital, Winfield, IL (J.S.); University of North Carolina, Chapel Hill (S.M.); Reading Hospital, Reading, PA (D.S.); Henry Ford Hospital, Detroit (J.L.); Holy Name Hospital, Teaneck, NJ (J.R.); Christiana Care Hospital, Newark, DE (M.G.); St. Elizabeth's Regional Medical Center, Lincoln, NE (R.R., E.V.); and Pepin Heart Center, Tampa, FL (V.M.)
| | - Stephan Moll
- From the Washington University School of Medicine, St. Louis (S.V., L.L., J.R.D., P.N., M.C.D., N.S., M.B.); Brigham and Women's Hospital, Harvard Medical School (S.Z.G.), and Massachusetts General Hospital, Harvard Medical School (M.R.J.) - all in Boston; McMaster University, Hamilton, ON (J.A.J., M.F., C.-S.G., C.K.), and McGill University, Jewish General Hospital, Montreal (S.R.K.) - all in Canada; the University of Missouri, St. Luke's Mid America Heart Institute, Kansas City (D.J.C., E.M.); St. Joseph's Vascular Institute, Orange (M.K.R.), and University of California, Los Angeles, Los Angeles (S.K.) - both in California; University of Michigan, Ann Arbor (A.J.C.); Cleveland Clinic Heart and Vascular Institute, Cleveland (H.L.G.); Rhode Island Hospital, Brown University, Providence (T.P.M.); Central DuPage Hospital, Winfield, IL (J.S.); University of North Carolina, Chapel Hill (S.M.); Reading Hospital, Reading, PA (D.S.); Henry Ford Hospital, Detroit (J.L.); Holy Name Hospital, Teaneck, NJ (J.R.); Christiana Care Hospital, Newark, DE (M.G.); St. Elizabeth's Regional Medical Center, Lincoln, NE (R.R., E.V.); and Pepin Heart Center, Tampa, FL (V.M.)
| | - David Sacks
- From the Washington University School of Medicine, St. Louis (S.V., L.L., J.R.D., P.N., M.C.D., N.S., M.B.); Brigham and Women's Hospital, Harvard Medical School (S.Z.G.), and Massachusetts General Hospital, Harvard Medical School (M.R.J.) - all in Boston; McMaster University, Hamilton, ON (J.A.J., M.F., C.-S.G., C.K.), and McGill University, Jewish General Hospital, Montreal (S.R.K.) - all in Canada; the University of Missouri, St. Luke's Mid America Heart Institute, Kansas City (D.J.C., E.M.); St. Joseph's Vascular Institute, Orange (M.K.R.), and University of California, Los Angeles, Los Angeles (S.K.) - both in California; University of Michigan, Ann Arbor (A.J.C.); Cleveland Clinic Heart and Vascular Institute, Cleveland (H.L.G.); Rhode Island Hospital, Brown University, Providence (T.P.M.); Central DuPage Hospital, Winfield, IL (J.S.); University of North Carolina, Chapel Hill (S.M.); Reading Hospital, Reading, PA (D.S.); Henry Ford Hospital, Detroit (J.L.); Holy Name Hospital, Teaneck, NJ (J.R.); Christiana Care Hospital, Newark, DE (M.G.); St. Elizabeth's Regional Medical Center, Lincoln, NE (R.R., E.V.); and Pepin Heart Center, Tampa, FL (V.M.)
| | - Judith Lin
- From the Washington University School of Medicine, St. Louis (S.V., L.L., J.R.D., P.N., M.C.D., N.S., M.B.); Brigham and Women's Hospital, Harvard Medical School (S.Z.G.), and Massachusetts General Hospital, Harvard Medical School (M.R.J.) - all in Boston; McMaster University, Hamilton, ON (J.A.J., M.F., C.-S.G., C.K.), and McGill University, Jewish General Hospital, Montreal (S.R.K.) - all in Canada; the University of Missouri, St. Luke's Mid America Heart Institute, Kansas City (D.J.C., E.M.); St. Joseph's Vascular Institute, Orange (M.K.R.), and University of California, Los Angeles, Los Angeles (S.K.) - both in California; University of Michigan, Ann Arbor (A.J.C.); Cleveland Clinic Heart and Vascular Institute, Cleveland (H.L.G.); Rhode Island Hospital, Brown University, Providence (T.P.M.); Central DuPage Hospital, Winfield, IL (J.S.); University of North Carolina, Chapel Hill (S.M.); Reading Hospital, Reading, PA (D.S.); Henry Ford Hospital, Detroit (J.L.); Holy Name Hospital, Teaneck, NJ (J.R.); Christiana Care Hospital, Newark, DE (M.G.); St. Elizabeth's Regional Medical Center, Lincoln, NE (R.R., E.V.); and Pepin Heart Center, Tampa, FL (V.M.)
| | - John Rundback
- From the Washington University School of Medicine, St. Louis (S.V., L.L., J.R.D., P.N., M.C.D., N.S., M.B.); Brigham and Women's Hospital, Harvard Medical School (S.Z.G.), and Massachusetts General Hospital, Harvard Medical School (M.R.J.) - all in Boston; McMaster University, Hamilton, ON (J.A.J., M.F., C.-S.G., C.K.), and McGill University, Jewish General Hospital, Montreal (S.R.K.) - all in Canada; the University of Missouri, St. Luke's Mid America Heart Institute, Kansas City (D.J.C., E.M.); St. Joseph's Vascular Institute, Orange (M.K.R.), and University of California, Los Angeles, Los Angeles (S.K.) - both in California; University of Michigan, Ann Arbor (A.J.C.); Cleveland Clinic Heart and Vascular Institute, Cleveland (H.L.G.); Rhode Island Hospital, Brown University, Providence (T.P.M.); Central DuPage Hospital, Winfield, IL (J.S.); University of North Carolina, Chapel Hill (S.M.); Reading Hospital, Reading, PA (D.S.); Henry Ford Hospital, Detroit (J.L.); Holy Name Hospital, Teaneck, NJ (J.R.); Christiana Care Hospital, Newark, DE (M.G.); St. Elizabeth's Regional Medical Center, Lincoln, NE (R.R., E.V.); and Pepin Heart Center, Tampa, FL (V.M.)
| | - Mark Garcia
- From the Washington University School of Medicine, St. Louis (S.V., L.L., J.R.D., P.N., M.C.D., N.S., M.B.); Brigham and Women's Hospital, Harvard Medical School (S.Z.G.), and Massachusetts General Hospital, Harvard Medical School (M.R.J.) - all in Boston; McMaster University, Hamilton, ON (J.A.J., M.F., C.-S.G., C.K.), and McGill University, Jewish General Hospital, Montreal (S.R.K.) - all in Canada; the University of Missouri, St. Luke's Mid America Heart Institute, Kansas City (D.J.C., E.M.); St. Joseph's Vascular Institute, Orange (M.K.R.), and University of California, Los Angeles, Los Angeles (S.K.) - both in California; University of Michigan, Ann Arbor (A.J.C.); Cleveland Clinic Heart and Vascular Institute, Cleveland (H.L.G.); Rhode Island Hospital, Brown University, Providence (T.P.M.); Central DuPage Hospital, Winfield, IL (J.S.); University of North Carolina, Chapel Hill (S.M.); Reading Hospital, Reading, PA (D.S.); Henry Ford Hospital, Detroit (J.L.); Holy Name Hospital, Teaneck, NJ (J.R.); Christiana Care Hospital, Newark, DE (M.G.); St. Elizabeth's Regional Medical Center, Lincoln, NE (R.R., E.V.); and Pepin Heart Center, Tampa, FL (V.M.)
| | - Rahul Razdan
- From the Washington University School of Medicine, St. Louis (S.V., L.L., J.R.D., P.N., M.C.D., N.S., M.B.); Brigham and Women's Hospital, Harvard Medical School (S.Z.G.), and Massachusetts General Hospital, Harvard Medical School (M.R.J.) - all in Boston; McMaster University, Hamilton, ON (J.A.J., M.F., C.-S.G., C.K.), and McGill University, Jewish General Hospital, Montreal (S.R.K.) - all in Canada; the University of Missouri, St. Luke's Mid America Heart Institute, Kansas City (D.J.C., E.M.); St. Joseph's Vascular Institute, Orange (M.K.R.), and University of California, Los Angeles, Los Angeles (S.K.) - both in California; University of Michigan, Ann Arbor (A.J.C.); Cleveland Clinic Heart and Vascular Institute, Cleveland (H.L.G.); Rhode Island Hospital, Brown University, Providence (T.P.M.); Central DuPage Hospital, Winfield, IL (J.S.); University of North Carolina, Chapel Hill (S.M.); Reading Hospital, Reading, PA (D.S.); Henry Ford Hospital, Detroit (J.L.); Holy Name Hospital, Teaneck, NJ (J.R.); Christiana Care Hospital, Newark, DE (M.G.); St. Elizabeth's Regional Medical Center, Lincoln, NE (R.R., E.V.); and Pepin Heart Center, Tampa, FL (V.M.)
| | - Eric VanderWoude
- From the Washington University School of Medicine, St. Louis (S.V., L.L., J.R.D., P.N., M.C.D., N.S., M.B.); Brigham and Women's Hospital, Harvard Medical School (S.Z.G.), and Massachusetts General Hospital, Harvard Medical School (M.R.J.) - all in Boston; McMaster University, Hamilton, ON (J.A.J., M.F., C.-S.G., C.K.), and McGill University, Jewish General Hospital, Montreal (S.R.K.) - all in Canada; the University of Missouri, St. Luke's Mid America Heart Institute, Kansas City (D.J.C., E.M.); St. Joseph's Vascular Institute, Orange (M.K.R.), and University of California, Los Angeles, Los Angeles (S.K.) - both in California; University of Michigan, Ann Arbor (A.J.C.); Cleveland Clinic Heart and Vascular Institute, Cleveland (H.L.G.); Rhode Island Hospital, Brown University, Providence (T.P.M.); Central DuPage Hospital, Winfield, IL (J.S.); University of North Carolina, Chapel Hill (S.M.); Reading Hospital, Reading, PA (D.S.); Henry Ford Hospital, Detroit (J.L.); Holy Name Hospital, Teaneck, NJ (J.R.); Christiana Care Hospital, Newark, DE (M.G.); St. Elizabeth's Regional Medical Center, Lincoln, NE (R.R., E.V.); and Pepin Heart Center, Tampa, FL (V.M.)
| | - Vasco Marques
- From the Washington University School of Medicine, St. Louis (S.V., L.L., J.R.D., P.N., M.C.D., N.S., M.B.); Brigham and Women's Hospital, Harvard Medical School (S.Z.G.), and Massachusetts General Hospital, Harvard Medical School (M.R.J.) - all in Boston; McMaster University, Hamilton, ON (J.A.J., M.F., C.-S.G., C.K.), and McGill University, Jewish General Hospital, Montreal (S.R.K.) - all in Canada; the University of Missouri, St. Luke's Mid America Heart Institute, Kansas City (D.J.C., E.M.); St. Joseph's Vascular Institute, Orange (M.K.R.), and University of California, Los Angeles, Los Angeles (S.K.) - both in California; University of Michigan, Ann Arbor (A.J.C.); Cleveland Clinic Heart and Vascular Institute, Cleveland (H.L.G.); Rhode Island Hospital, Brown University, Providence (T.P.M.); Central DuPage Hospital, Winfield, IL (J.S.); University of North Carolina, Chapel Hill (S.M.); Reading Hospital, Reading, PA (D.S.); Henry Ford Hospital, Detroit (J.L.); Holy Name Hospital, Teaneck, NJ (J.R.); Christiana Care Hospital, Newark, DE (M.G.); St. Elizabeth's Regional Medical Center, Lincoln, NE (R.R., E.V.); and Pepin Heart Center, Tampa, FL (V.M.)
| | - Clive Kearon
- From the Washington University School of Medicine, St. Louis (S.V., L.L., J.R.D., P.N., M.C.D., N.S., M.B.); Brigham and Women's Hospital, Harvard Medical School (S.Z.G.), and Massachusetts General Hospital, Harvard Medical School (M.R.J.) - all in Boston; McMaster University, Hamilton, ON (J.A.J., M.F., C.-S.G., C.K.), and McGill University, Jewish General Hospital, Montreal (S.R.K.) - all in Canada; the University of Missouri, St. Luke's Mid America Heart Institute, Kansas City (D.J.C., E.M.); St. Joseph's Vascular Institute, Orange (M.K.R.), and University of California, Los Angeles, Los Angeles (S.K.) - both in California; University of Michigan, Ann Arbor (A.J.C.); Cleveland Clinic Heart and Vascular Institute, Cleveland (H.L.G.); Rhode Island Hospital, Brown University, Providence (T.P.M.); Central DuPage Hospital, Winfield, IL (J.S.); University of North Carolina, Chapel Hill (S.M.); Reading Hospital, Reading, PA (D.S.); Henry Ford Hospital, Detroit (J.L.); Holy Name Hospital, Teaneck, NJ (J.R.); Christiana Care Hospital, Newark, DE (M.G.); St. Elizabeth's Regional Medical Center, Lincoln, NE (R.R., E.V.); and Pepin Heart Center, Tampa, FL (V.M.)
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Mittmann N, Earle CC, Cheng SY, Julian JA, Rahman F, Seung SJ, Levine MN. Population-Based Study to Determine the Health System Costs of Using the 21-Gene Assay. J Clin Oncol 2017; 36:238-243. [PMID: 29193984 DOI: 10.1200/jco.2017.74.2577] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023] Open
Abstract
Purpose The 21-gene assay Oncotype Dx (Genomic Health, Redwood City, CA) test is used to aid the decision about chemotherapy in patients with hormone receptor-positive breast cancer who received endocrine therapy. Economic studies to support test adoption used decision-analytic models with assumptions and data derived from disparate sources. The objective was to evaluate whether the 21-gene assay test resulted in an overall cost expense or saving to the health system. Patients and Methods One thousand participants enrolled in a field evaluation study, were linked to population-level health system administrative databases, and were observed for 20 months. The cost for the cohort, which included the cost of the test, subsequent treatments received, and health care encounters, was determined. The cost in the absence of the test was compared with the pretest recommendation about chemotherapy from the field study for a base case and under scenarios that reflected different adjuvant chemotherapy use. Overall health system costs and incremental costs were calculated. Results The 21-gene assay resulted in a net decrease in chemotherapy use of 23%. For the base case incremental analysis, the actual overall health system cost of this cohort, including the cost of 21-gene assay, was $29.2 million compared with $26.2 million in the absence of the test-an increase of $3.1 million. For three of the four scenario analyses, the actual overall cost to the health system exceeded the estimated cost in the absence of the test. Results showed that, when at least half of the population received adjuvant chemotherapy, the cost increased to $30.2 million. Conclusion The use of real-world administrative data showed that, despite lower rates of chemotherapy use, the 21-gene assay test results in an overall incremental cost to the health care system in the short-term under most assumptions.
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Affiliation(s)
- Nicole Mittmann
- Nicole Mittmann, Sunnybrook Research Institute, Cancer Care Ontario, and University of Toronto; Craig C. Earle, Ontario Institute for Cancer Research; Craig C. Earle, Stephanie Y. Cheng, and Farah Rahman, Institute for Clinical Evaluative Sciences; Soo Jin Seung, Health Outcomes and PharmacoEconomic (HOPE) Research Centre, Sunnybrook Research Institute, Toronto; and Jim A. Julian and Mark N. Levine, Juravinski Cancer Centre, McMaster University, and Ontario Clinical Oncology Group, Hamilton, Ontario, Canada
| | - Craig C Earle
- Nicole Mittmann, Sunnybrook Research Institute, Cancer Care Ontario, and University of Toronto; Craig C. Earle, Ontario Institute for Cancer Research; Craig C. Earle, Stephanie Y. Cheng, and Farah Rahman, Institute for Clinical Evaluative Sciences; Soo Jin Seung, Health Outcomes and PharmacoEconomic (HOPE) Research Centre, Sunnybrook Research Institute, Toronto; and Jim A. Julian and Mark N. Levine, Juravinski Cancer Centre, McMaster University, and Ontario Clinical Oncology Group, Hamilton, Ontario, Canada
| | - Stephanie Y Cheng
- Nicole Mittmann, Sunnybrook Research Institute, Cancer Care Ontario, and University of Toronto; Craig C. Earle, Ontario Institute for Cancer Research; Craig C. Earle, Stephanie Y. Cheng, and Farah Rahman, Institute for Clinical Evaluative Sciences; Soo Jin Seung, Health Outcomes and PharmacoEconomic (HOPE) Research Centre, Sunnybrook Research Institute, Toronto; and Jim A. Julian and Mark N. Levine, Juravinski Cancer Centre, McMaster University, and Ontario Clinical Oncology Group, Hamilton, Ontario, Canada
| | - Jim A Julian
- Nicole Mittmann, Sunnybrook Research Institute, Cancer Care Ontario, and University of Toronto; Craig C. Earle, Ontario Institute for Cancer Research; Craig C. Earle, Stephanie Y. Cheng, and Farah Rahman, Institute for Clinical Evaluative Sciences; Soo Jin Seung, Health Outcomes and PharmacoEconomic (HOPE) Research Centre, Sunnybrook Research Institute, Toronto; and Jim A. Julian and Mark N. Levine, Juravinski Cancer Centre, McMaster University, and Ontario Clinical Oncology Group, Hamilton, Ontario, Canada
| | - Farah Rahman
- Nicole Mittmann, Sunnybrook Research Institute, Cancer Care Ontario, and University of Toronto; Craig C. Earle, Ontario Institute for Cancer Research; Craig C. Earle, Stephanie Y. Cheng, and Farah Rahman, Institute for Clinical Evaluative Sciences; Soo Jin Seung, Health Outcomes and PharmacoEconomic (HOPE) Research Centre, Sunnybrook Research Institute, Toronto; and Jim A. Julian and Mark N. Levine, Juravinski Cancer Centre, McMaster University, and Ontario Clinical Oncology Group, Hamilton, Ontario, Canada
| | - Soo Jin Seung
- Nicole Mittmann, Sunnybrook Research Institute, Cancer Care Ontario, and University of Toronto; Craig C. Earle, Ontario Institute for Cancer Research; Craig C. Earle, Stephanie Y. Cheng, and Farah Rahman, Institute for Clinical Evaluative Sciences; Soo Jin Seung, Health Outcomes and PharmacoEconomic (HOPE) Research Centre, Sunnybrook Research Institute, Toronto; and Jim A. Julian and Mark N. Levine, Juravinski Cancer Centre, McMaster University, and Ontario Clinical Oncology Group, Hamilton, Ontario, Canada
| | - Mark N Levine
- Nicole Mittmann, Sunnybrook Research Institute, Cancer Care Ontario, and University of Toronto; Craig C. Earle, Ontario Institute for Cancer Research; Craig C. Earle, Stephanie Y. Cheng, and Farah Rahman, Institute for Clinical Evaluative Sciences; Soo Jin Seung, Health Outcomes and PharmacoEconomic (HOPE) Research Centre, Sunnybrook Research Institute, Toronto; and Jim A. Julian and Mark N. Levine, Juravinski Cancer Centre, McMaster University, and Ontario Clinical Oncology Group, Hamilton, Ontario, Canada
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Dayes IS, Parpia S, Gilbert J, Julian JA, Davis IR, Levine MN, Sathya J. Long-Term Results of a Randomized Trial Comparing Iridium Implant Plus External Beam Radiation Therapy With External Beam Radiation Therapy Alone in Node-Negative Locally Advanced Cancer of the Prostate. Int J Radiat Oncol Biol Phys 2017; 99:90-93. [PMID: 28816169 DOI: 10.1016/j.ijrobp.2017.05.013] [Citation(s) in RCA: 66] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2017] [Revised: 04/27/2017] [Accepted: 05/09/2017] [Indexed: 10/19/2022]
Abstract
PURPOSE To determine the impact on long-term survival from the addition of brachytherapy to external beam radiation therapy (EBRT) in patients with prostate cancer. METHODS AND MATERIALS Between 1992 and 1997, 104 men with cT2-3, surgically staged node-negative prostate cancer were randomized to receive either EBRT (40 Gy/20 fractions) with iridium implant (35 Gy/48 hours) or EBRT alone (66 Gy/33 fractions) to the prostate. According to T stage, Gleason score, and prostate-specific antigen level, 60% of patients had high-risk disease. Substantial improvements in biochemical control at 8 years have previously been reported. Additional follow-up was collected on deaths and metastases. RESULTS Median follow-up was 14 years. Five patients were lost to follow-up. All other patients have been followed a minimum of 13 years. There have been 75 deaths, including 21 from prostate cancer and 25 from second cancers. No patients developing a second cancer have died from prostate cancer. There was no difference in overall survival between the 2 treatment groups: 34 deaths (67%) in the implant arm and 41 (77%) in the EBRT arm (hazard ratio [HR] 1.00, 95% confidence interval [CI] 0.63-1.59). Similarly, there was no difference in prostate cancer-specific deaths: 9 (18%) patients in the implant arm compared with 12 (23%) in the EBRT arm (HR 0.79, 95% CI 0.34-1.87). There was no statistically significant difference in the number of patients developing metastatic disease: 10 (20%) in the implant arm and 15 (28%) in the EBRT arm (HR 0.70, 95% CI 0.32-1.57). Improvements in biochemical control were maintained (HR 0.53, 95% CI 0.31-0.88). CONCLUSIONS Despite a dramatic reduction of biochemical recurrence rates, the addition of iridium implant to EBRT did not translate into improved overall survival or prostate cancer-specific survival.
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Affiliation(s)
- Ian S Dayes
- Department of Oncology, McMaster University, Hamilton, Ontario, Canada.
| | - Sameer Parpia
- Ontario Clinical Oncology Group, Juravinski Hospital, Hamilton, Ontario, Canada
| | - Jaclyn Gilbert
- Department of Anaesthesia, McMaster University, Hamilton, Ontario, Canada
| | - Jim A Julian
- Ontario Clinical Oncology Group, Juravinski Hospital, Hamilton, Ontario, Canada
| | - Ian R Davis
- Department of Urology, St. Joseph's Health Centre, Hamilton, Ontario, Canada
| | - Mark N Levine
- Department of Oncology, McMaster University, Hamilton, Ontario, Canada; Ontario Clinical Oncology Group, Juravinski Hospital, Hamilton, Ontario, Canada
| | - Jinka Sathya
- Department of Oncology, Memorial University, St. John's, Newfoundland, Canada
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Catton CN, Lukka H, Gu CS, Martin JM, Supiot S, Chung PWM, Bauman GS, Bahary JP, Ahmed S, Cheung P, Tai KH, Wu JS, Parliament MB, Tsakiridis T, Corbett TB, Tang C, Dayes IS, Warde P, Craig TK, Julian JA, Levine MN. Randomized Trial of a Hypofractionated Radiation Regimen for the Treatment of Localized Prostate Cancer. J Clin Oncol 2017; 35:1884-1890. [PMID: 28296582 DOI: 10.1200/jco.2016.71.7397] [Citation(s) in RCA: 455] [Impact Index Per Article: 65.0] [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
Purpose Men with localized prostate cancer often are treated with external radiotherapy (RT) over 8 to 9 weeks. Hypofractionated RT is given over a shorter time with larger doses per treatment than standard RT. We hypothesized that hypofractionation versus conventional fractionation is similar in efficacy without increased toxicity. Patients and Methods We conducted a multicenter randomized noninferiority trial in intermediate-risk prostate cancer (T1 to 2a, Gleason score ≤ 6, and prostate-specific antigen [PSA] 10.1 to 20 ng/mL; T2b to 2c, Gleason ≤ 6, and PSA ≤ 20 ng/mL; or T1 to 2, Gleason = 7, and PSA ≤ 20 ng/mL). Patients were allocated to conventional RT of 78 Gy in 39 fractions over 8 weeks or to hypofractionated RT of 60 Gy in 20 fractions over 4 weeks. Androgen deprivation was not permitted with therapy. The primary outcome was biochemical-clinical failure (BCF) defined by any of the following: PSA failure (nadir + 2), hormonal intervention, clinical local or distant failure, or death as a result of prostate cancer. The noninferiority margin was 7.5% (hazard ratio, < 1.32). Results Median follow-up was 6.0 years. One hundred nine of 608 patients in the hypofractionated arm versus 117 of 598 in the standard arm experienced BCF. Most of the events were PSA failures. The 5-year BCF disease-free survival was 85% in both arms (hazard ratio [short v standard], 0.96; 90% CI, 0.77 to 1.2). Ten deaths as a result of prostate cancer occurred in the short arm and 12 in the standard arm. No significant differences were detected between arms for grade ≥ 3 late genitourinary and GI toxicity. Conclusion The hypofractionated RT regimen used in this trial was not inferior to conventional RT and was not associated with increased late toxicity. Hypofractionated RT is more convenient for patients and should be considered for intermediate-risk prostate cancer.
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Affiliation(s)
- Charles N Catton
- Charles N. Catton, Peter W.M. Chung, Patrick Cheung, Padraig Warde, and Tim K. Craig, University of Toronto, Toronto; Himu Lukka, Chu-Shu Gu, Theodoros Tsakiridis, Tom B. Corbett, Ian S. Dayes, Jim A. Julian, and Mark N. Levine, McMaster University, Hamilton; Glenn S. Bauman, University of Western Ontario, London, Ontario; Jean-Paul Bahary, University of Montreal, Montreal, Quebec; Shahida Ahmed, University of Manitoba, Winnipeg, Manitoba; Jackson S. Wu, University of Calgary, Calgary; Matthew B. Parliament, University of Alberta, Edmonton, Alberta, Canada; Jarad M. Martin, University of Newcastle, Newcastle, New South Wales; Keen Hun Tai, University of Melbourne, Melbourne, Victoria; Colin Tang, Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia; and Stéphane Supiot, University of Nantes, Nantes, France
| | - Himu Lukka
- Charles N. Catton, Peter W.M. Chung, Patrick Cheung, Padraig Warde, and Tim K. Craig, University of Toronto, Toronto; Himu Lukka, Chu-Shu Gu, Theodoros Tsakiridis, Tom B. Corbett, Ian S. Dayes, Jim A. Julian, and Mark N. Levine, McMaster University, Hamilton; Glenn S. Bauman, University of Western Ontario, London, Ontario; Jean-Paul Bahary, University of Montreal, Montreal, Quebec; Shahida Ahmed, University of Manitoba, Winnipeg, Manitoba; Jackson S. Wu, University of Calgary, Calgary; Matthew B. Parliament, University of Alberta, Edmonton, Alberta, Canada; Jarad M. Martin, University of Newcastle, Newcastle, New South Wales; Keen Hun Tai, University of Melbourne, Melbourne, Victoria; Colin Tang, Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia; and Stéphane Supiot, University of Nantes, Nantes, France
| | - Chu-Shu Gu
- Charles N. Catton, Peter W.M. Chung, Patrick Cheung, Padraig Warde, and Tim K. Craig, University of Toronto, Toronto; Himu Lukka, Chu-Shu Gu, Theodoros Tsakiridis, Tom B. Corbett, Ian S. Dayes, Jim A. Julian, and Mark N. Levine, McMaster University, Hamilton; Glenn S. Bauman, University of Western Ontario, London, Ontario; Jean-Paul Bahary, University of Montreal, Montreal, Quebec; Shahida Ahmed, University of Manitoba, Winnipeg, Manitoba; Jackson S. Wu, University of Calgary, Calgary; Matthew B. Parliament, University of Alberta, Edmonton, Alberta, Canada; Jarad M. Martin, University of Newcastle, Newcastle, New South Wales; Keen Hun Tai, University of Melbourne, Melbourne, Victoria; Colin Tang, Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia; and Stéphane Supiot, University of Nantes, Nantes, France
| | - Jarad M Martin
- Charles N. Catton, Peter W.M. Chung, Patrick Cheung, Padraig Warde, and Tim K. Craig, University of Toronto, Toronto; Himu Lukka, Chu-Shu Gu, Theodoros Tsakiridis, Tom B. Corbett, Ian S. Dayes, Jim A. Julian, and Mark N. Levine, McMaster University, Hamilton; Glenn S. Bauman, University of Western Ontario, London, Ontario; Jean-Paul Bahary, University of Montreal, Montreal, Quebec; Shahida Ahmed, University of Manitoba, Winnipeg, Manitoba; Jackson S. Wu, University of Calgary, Calgary; Matthew B. Parliament, University of Alberta, Edmonton, Alberta, Canada; Jarad M. Martin, University of Newcastle, Newcastle, New South Wales; Keen Hun Tai, University of Melbourne, Melbourne, Victoria; Colin Tang, Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia; and Stéphane Supiot, University of Nantes, Nantes, France
| | - Stéphane Supiot
- Charles N. Catton, Peter W.M. Chung, Patrick Cheung, Padraig Warde, and Tim K. Craig, University of Toronto, Toronto; Himu Lukka, Chu-Shu Gu, Theodoros Tsakiridis, Tom B. Corbett, Ian S. Dayes, Jim A. Julian, and Mark N. Levine, McMaster University, Hamilton; Glenn S. Bauman, University of Western Ontario, London, Ontario; Jean-Paul Bahary, University of Montreal, Montreal, Quebec; Shahida Ahmed, University of Manitoba, Winnipeg, Manitoba; Jackson S. Wu, University of Calgary, Calgary; Matthew B. Parliament, University of Alberta, Edmonton, Alberta, Canada; Jarad M. Martin, University of Newcastle, Newcastle, New South Wales; Keen Hun Tai, University of Melbourne, Melbourne, Victoria; Colin Tang, Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia; and Stéphane Supiot, University of Nantes, Nantes, France
| | - Peter W M Chung
- Charles N. Catton, Peter W.M. Chung, Patrick Cheung, Padraig Warde, and Tim K. Craig, University of Toronto, Toronto; Himu Lukka, Chu-Shu Gu, Theodoros Tsakiridis, Tom B. Corbett, Ian S. Dayes, Jim A. Julian, and Mark N. Levine, McMaster University, Hamilton; Glenn S. Bauman, University of Western Ontario, London, Ontario; Jean-Paul Bahary, University of Montreal, Montreal, Quebec; Shahida Ahmed, University of Manitoba, Winnipeg, Manitoba; Jackson S. Wu, University of Calgary, Calgary; Matthew B. Parliament, University of Alberta, Edmonton, Alberta, Canada; Jarad M. Martin, University of Newcastle, Newcastle, New South Wales; Keen Hun Tai, University of Melbourne, Melbourne, Victoria; Colin Tang, Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia; and Stéphane Supiot, University of Nantes, Nantes, France
| | - Glenn S Bauman
- Charles N. Catton, Peter W.M. Chung, Patrick Cheung, Padraig Warde, and Tim K. Craig, University of Toronto, Toronto; Himu Lukka, Chu-Shu Gu, Theodoros Tsakiridis, Tom B. Corbett, Ian S. Dayes, Jim A. Julian, and Mark N. Levine, McMaster University, Hamilton; Glenn S. Bauman, University of Western Ontario, London, Ontario; Jean-Paul Bahary, University of Montreal, Montreal, Quebec; Shahida Ahmed, University of Manitoba, Winnipeg, Manitoba; Jackson S. Wu, University of Calgary, Calgary; Matthew B. Parliament, University of Alberta, Edmonton, Alberta, Canada; Jarad M. Martin, University of Newcastle, Newcastle, New South Wales; Keen Hun Tai, University of Melbourne, Melbourne, Victoria; Colin Tang, Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia; and Stéphane Supiot, University of Nantes, Nantes, France
| | - Jean-Paul Bahary
- Charles N. Catton, Peter W.M. Chung, Patrick Cheung, Padraig Warde, and Tim K. Craig, University of Toronto, Toronto; Himu Lukka, Chu-Shu Gu, Theodoros Tsakiridis, Tom B. Corbett, Ian S. Dayes, Jim A. Julian, and Mark N. Levine, McMaster University, Hamilton; Glenn S. Bauman, University of Western Ontario, London, Ontario; Jean-Paul Bahary, University of Montreal, Montreal, Quebec; Shahida Ahmed, University of Manitoba, Winnipeg, Manitoba; Jackson S. Wu, University of Calgary, Calgary; Matthew B. Parliament, University of Alberta, Edmonton, Alberta, Canada; Jarad M. Martin, University of Newcastle, Newcastle, New South Wales; Keen Hun Tai, University of Melbourne, Melbourne, Victoria; Colin Tang, Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia; and Stéphane Supiot, University of Nantes, Nantes, France
| | - Shahida Ahmed
- Charles N. Catton, Peter W.M. Chung, Patrick Cheung, Padraig Warde, and Tim K. Craig, University of Toronto, Toronto; Himu Lukka, Chu-Shu Gu, Theodoros Tsakiridis, Tom B. Corbett, Ian S. Dayes, Jim A. Julian, and Mark N. Levine, McMaster University, Hamilton; Glenn S. Bauman, University of Western Ontario, London, Ontario; Jean-Paul Bahary, University of Montreal, Montreal, Quebec; Shahida Ahmed, University of Manitoba, Winnipeg, Manitoba; Jackson S. Wu, University of Calgary, Calgary; Matthew B. Parliament, University of Alberta, Edmonton, Alberta, Canada; Jarad M. Martin, University of Newcastle, Newcastle, New South Wales; Keen Hun Tai, University of Melbourne, Melbourne, Victoria; Colin Tang, Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia; and Stéphane Supiot, University of Nantes, Nantes, France
| | - Patrick Cheung
- Charles N. Catton, Peter W.M. Chung, Patrick Cheung, Padraig Warde, and Tim K. Craig, University of Toronto, Toronto; Himu Lukka, Chu-Shu Gu, Theodoros Tsakiridis, Tom B. Corbett, Ian S. Dayes, Jim A. Julian, and Mark N. Levine, McMaster University, Hamilton; Glenn S. Bauman, University of Western Ontario, London, Ontario; Jean-Paul Bahary, University of Montreal, Montreal, Quebec; Shahida Ahmed, University of Manitoba, Winnipeg, Manitoba; Jackson S. Wu, University of Calgary, Calgary; Matthew B. Parliament, University of Alberta, Edmonton, Alberta, Canada; Jarad M. Martin, University of Newcastle, Newcastle, New South Wales; Keen Hun Tai, University of Melbourne, Melbourne, Victoria; Colin Tang, Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia; and Stéphane Supiot, University of Nantes, Nantes, France
| | - Keen Hun Tai
- Charles N. Catton, Peter W.M. Chung, Patrick Cheung, Padraig Warde, and Tim K. Craig, University of Toronto, Toronto; Himu Lukka, Chu-Shu Gu, Theodoros Tsakiridis, Tom B. Corbett, Ian S. Dayes, Jim A. Julian, and Mark N. Levine, McMaster University, Hamilton; Glenn S. Bauman, University of Western Ontario, London, Ontario; Jean-Paul Bahary, University of Montreal, Montreal, Quebec; Shahida Ahmed, University of Manitoba, Winnipeg, Manitoba; Jackson S. Wu, University of Calgary, Calgary; Matthew B. Parliament, University of Alberta, Edmonton, Alberta, Canada; Jarad M. Martin, University of Newcastle, Newcastle, New South Wales; Keen Hun Tai, University of Melbourne, Melbourne, Victoria; Colin Tang, Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia; and Stéphane Supiot, University of Nantes, Nantes, France
| | - Jackson S Wu
- Charles N. Catton, Peter W.M. Chung, Patrick Cheung, Padraig Warde, and Tim K. Craig, University of Toronto, Toronto; Himu Lukka, Chu-Shu Gu, Theodoros Tsakiridis, Tom B. Corbett, Ian S. Dayes, Jim A. Julian, and Mark N. Levine, McMaster University, Hamilton; Glenn S. Bauman, University of Western Ontario, London, Ontario; Jean-Paul Bahary, University of Montreal, Montreal, Quebec; Shahida Ahmed, University of Manitoba, Winnipeg, Manitoba; Jackson S. Wu, University of Calgary, Calgary; Matthew B. Parliament, University of Alberta, Edmonton, Alberta, Canada; Jarad M. Martin, University of Newcastle, Newcastle, New South Wales; Keen Hun Tai, University of Melbourne, Melbourne, Victoria; Colin Tang, Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia; and Stéphane Supiot, University of Nantes, Nantes, France
| | - Matthew B Parliament
- Charles N. Catton, Peter W.M. Chung, Patrick Cheung, Padraig Warde, and Tim K. Craig, University of Toronto, Toronto; Himu Lukka, Chu-Shu Gu, Theodoros Tsakiridis, Tom B. Corbett, Ian S. Dayes, Jim A. Julian, and Mark N. Levine, McMaster University, Hamilton; Glenn S. Bauman, University of Western Ontario, London, Ontario; Jean-Paul Bahary, University of Montreal, Montreal, Quebec; Shahida Ahmed, University of Manitoba, Winnipeg, Manitoba; Jackson S. Wu, University of Calgary, Calgary; Matthew B. Parliament, University of Alberta, Edmonton, Alberta, Canada; Jarad M. Martin, University of Newcastle, Newcastle, New South Wales; Keen Hun Tai, University of Melbourne, Melbourne, Victoria; Colin Tang, Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia; and Stéphane Supiot, University of Nantes, Nantes, France
| | - Theodoros Tsakiridis
- Charles N. Catton, Peter W.M. Chung, Patrick Cheung, Padraig Warde, and Tim K. Craig, University of Toronto, Toronto; Himu Lukka, Chu-Shu Gu, Theodoros Tsakiridis, Tom B. Corbett, Ian S. Dayes, Jim A. Julian, and Mark N. Levine, McMaster University, Hamilton; Glenn S. Bauman, University of Western Ontario, London, Ontario; Jean-Paul Bahary, University of Montreal, Montreal, Quebec; Shahida Ahmed, University of Manitoba, Winnipeg, Manitoba; Jackson S. Wu, University of Calgary, Calgary; Matthew B. Parliament, University of Alberta, Edmonton, Alberta, Canada; Jarad M. Martin, University of Newcastle, Newcastle, New South Wales; Keen Hun Tai, University of Melbourne, Melbourne, Victoria; Colin Tang, Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia; and Stéphane Supiot, University of Nantes, Nantes, France
| | - Tom B Corbett
- Charles N. Catton, Peter W.M. Chung, Patrick Cheung, Padraig Warde, and Tim K. Craig, University of Toronto, Toronto; Himu Lukka, Chu-Shu Gu, Theodoros Tsakiridis, Tom B. Corbett, Ian S. Dayes, Jim A. Julian, and Mark N. Levine, McMaster University, Hamilton; Glenn S. Bauman, University of Western Ontario, London, Ontario; Jean-Paul Bahary, University of Montreal, Montreal, Quebec; Shahida Ahmed, University of Manitoba, Winnipeg, Manitoba; Jackson S. Wu, University of Calgary, Calgary; Matthew B. Parliament, University of Alberta, Edmonton, Alberta, Canada; Jarad M. Martin, University of Newcastle, Newcastle, New South Wales; Keen Hun Tai, University of Melbourne, Melbourne, Victoria; Colin Tang, Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia; and Stéphane Supiot, University of Nantes, Nantes, France
| | - Colin Tang
- Charles N. Catton, Peter W.M. Chung, Patrick Cheung, Padraig Warde, and Tim K. Craig, University of Toronto, Toronto; Himu Lukka, Chu-Shu Gu, Theodoros Tsakiridis, Tom B. Corbett, Ian S. Dayes, Jim A. Julian, and Mark N. Levine, McMaster University, Hamilton; Glenn S. Bauman, University of Western Ontario, London, Ontario; Jean-Paul Bahary, University of Montreal, Montreal, Quebec; Shahida Ahmed, University of Manitoba, Winnipeg, Manitoba; Jackson S. Wu, University of Calgary, Calgary; Matthew B. Parliament, University of Alberta, Edmonton, Alberta, Canada; Jarad M. Martin, University of Newcastle, Newcastle, New South Wales; Keen Hun Tai, University of Melbourne, Melbourne, Victoria; Colin Tang, Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia; and Stéphane Supiot, University of Nantes, Nantes, France
| | - Ian S Dayes
- Charles N. Catton, Peter W.M. Chung, Patrick Cheung, Padraig Warde, and Tim K. Craig, University of Toronto, Toronto; Himu Lukka, Chu-Shu Gu, Theodoros Tsakiridis, Tom B. Corbett, Ian S. Dayes, Jim A. Julian, and Mark N. Levine, McMaster University, Hamilton; Glenn S. Bauman, University of Western Ontario, London, Ontario; Jean-Paul Bahary, University of Montreal, Montreal, Quebec; Shahida Ahmed, University of Manitoba, Winnipeg, Manitoba; Jackson S. Wu, University of Calgary, Calgary; Matthew B. Parliament, University of Alberta, Edmonton, Alberta, Canada; Jarad M. Martin, University of Newcastle, Newcastle, New South Wales; Keen Hun Tai, University of Melbourne, Melbourne, Victoria; Colin Tang, Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia; and Stéphane Supiot, University of Nantes, Nantes, France
| | - Padraig Warde
- Charles N. Catton, Peter W.M. Chung, Patrick Cheung, Padraig Warde, and Tim K. Craig, University of Toronto, Toronto; Himu Lukka, Chu-Shu Gu, Theodoros Tsakiridis, Tom B. Corbett, Ian S. Dayes, Jim A. Julian, and Mark N. Levine, McMaster University, Hamilton; Glenn S. Bauman, University of Western Ontario, London, Ontario; Jean-Paul Bahary, University of Montreal, Montreal, Quebec; Shahida Ahmed, University of Manitoba, Winnipeg, Manitoba; Jackson S. Wu, University of Calgary, Calgary; Matthew B. Parliament, University of Alberta, Edmonton, Alberta, Canada; Jarad M. Martin, University of Newcastle, Newcastle, New South Wales; Keen Hun Tai, University of Melbourne, Melbourne, Victoria; Colin Tang, Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia; and Stéphane Supiot, University of Nantes, Nantes, France
| | - Tim K Craig
- Charles N. Catton, Peter W.M. Chung, Patrick Cheung, Padraig Warde, and Tim K. Craig, University of Toronto, Toronto; Himu Lukka, Chu-Shu Gu, Theodoros Tsakiridis, Tom B. Corbett, Ian S. Dayes, Jim A. Julian, and Mark N. Levine, McMaster University, Hamilton; Glenn S. Bauman, University of Western Ontario, London, Ontario; Jean-Paul Bahary, University of Montreal, Montreal, Quebec; Shahida Ahmed, University of Manitoba, Winnipeg, Manitoba; Jackson S. Wu, University of Calgary, Calgary; Matthew B. Parliament, University of Alberta, Edmonton, Alberta, Canada; Jarad M. Martin, University of Newcastle, Newcastle, New South Wales; Keen Hun Tai, University of Melbourne, Melbourne, Victoria; Colin Tang, Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia; and Stéphane Supiot, University of Nantes, Nantes, France
| | - Jim A Julian
- Charles N. Catton, Peter W.M. Chung, Patrick Cheung, Padraig Warde, and Tim K. Craig, University of Toronto, Toronto; Himu Lukka, Chu-Shu Gu, Theodoros Tsakiridis, Tom B. Corbett, Ian S. Dayes, Jim A. Julian, and Mark N. Levine, McMaster University, Hamilton; Glenn S. Bauman, University of Western Ontario, London, Ontario; Jean-Paul Bahary, University of Montreal, Montreal, Quebec; Shahida Ahmed, University of Manitoba, Winnipeg, Manitoba; Jackson S. Wu, University of Calgary, Calgary; Matthew B. Parliament, University of Alberta, Edmonton, Alberta, Canada; Jarad M. Martin, University of Newcastle, Newcastle, New South Wales; Keen Hun Tai, University of Melbourne, Melbourne, Victoria; Colin Tang, Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia; and Stéphane Supiot, University of Nantes, Nantes, France
| | - Mark N Levine
- Charles N. Catton, Peter W.M. Chung, Patrick Cheung, Padraig Warde, and Tim K. Craig, University of Toronto, Toronto; Himu Lukka, Chu-Shu Gu, Theodoros Tsakiridis, Tom B. Corbett, Ian S. Dayes, Jim A. Julian, and Mark N. Levine, McMaster University, Hamilton; Glenn S. Bauman, University of Western Ontario, London, Ontario; Jean-Paul Bahary, University of Montreal, Montreal, Quebec; Shahida Ahmed, University of Manitoba, Winnipeg, Manitoba; Jackson S. Wu, University of Calgary, Calgary; Matthew B. Parliament, University of Alberta, Edmonton, Alberta, Canada; Jarad M. Martin, University of Newcastle, Newcastle, New South Wales; Keen Hun Tai, University of Melbourne, Melbourne, Victoria; Colin Tang, Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia; and Stéphane Supiot, University of Nantes, Nantes, France
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Takach Lapner S, Julian JA, Linkins LA, Bates S, Kearon C. Questioning the use of an age-adjusted D-dimer threshold to exclude venous thromboembolism: analysis of individual patient data from two diagnostic studies: reply. J Thromb Haemost 2016; 14:2555-2556. [PMID: 27661781 DOI: 10.1111/jth.13512] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Affiliation(s)
- S Takach Lapner
- Department of Medicine, McMaster University, Hamilton, ON, Canada
- Department of Medicine, University of Alberta, Edmonton, AB, Canada
| | - J A Julian
- Ontario Clinical Oncology Group, Juravinski Hospital, Hamilton, ON, Canada
| | - L-A Linkins
- Department of Medicine, McMaster University, Hamilton, ON, Canada
- Thrombosis and Atherosclerosis Research Institute, McMaster University, Hamilton, ON, Canada
| | - S Bates
- Department of Medicine, McMaster University, Hamilton, ON, Canada
- Thrombosis and Atherosclerosis Research Institute, McMaster University, Hamilton, ON, Canada
| | - C Kearon
- Department of Medicine, McMaster University, Hamilton, ON, Canada
- Thrombosis and Atherosclerosis Research Institute, McMaster University, Hamilton, ON, Canada
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Takach Lapner S, Julian JA, Linkins LA, Bates SM, Kearon C. Questioning the use of an age-adjusted D-dimer threshold to exclude venous thromboembolism: analysis of individual patient data from two diagnostic studies. J Thromb Haemost 2016; 14:1953-1959. [PMID: 27455175 DOI: 10.1111/jth.13424] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2016] [Accepted: 06/24/2016] [Indexed: 11/29/2022]
Abstract
Essentials It is unclear if raising the D-dimer level to exclude venous thrombosis in older patients is valid. We compared this 'age-adjusted' strategy with other ways of interpreting D-dimer results. A non-age adjusted increase, and using higher thresholds in younger patients, was just as accurate. Age-adjustment of D-dimer thresholds does not appear to be appropriate. Click to hear Prof. le Gal's presentation on controversies in venous thromboembolism diagnosis SUMMARY: Background Using a progressively higher D-dimer level to exclude venous thromboembolism (VTE) with increasing age has been proposed but is not well validated. Objective To determine whether it is appropriate to use a progressively higher D-dimer level to exclude VTE with increasing age. Patients/methods We analyzed clinical data and blood samples from 1649 patients with a first suspected deep vein thrombosis or pulmonary embolism. We compared the negative predictive values (NPVs) for VTE, and the proportions of patients with a negative D-dimer result, by using three D-dimer interpretation strategies: a progressively higher D-dimer threshold with increasing age (age-adjusted strategy); the same higher D-dimer threshold in all patients (mean D-dimer strategy); and a progressively higher D-dimer threshold with decreasing age (inverse age-adjusted strategy). Results The NPV with the age-adjusted strategy (99.6%; 95% confidence interval [CI] 99.0-99.9%) was not different from that with the mean D-dimer strategy (99.7%; 95% CI 99.0-99.9%) or that with the inverse age-adjusted strategy (99.8%; 95% CI 99.1-99.9%). The proportion of patients with a negative result with the age-adjusted strategy (50.9%; 95% CI 48.5-53.4%) was not different from the proportion of patients with a negative result with the mean D-dimer strategy (51.7%; 95% CI 49.3-54.1%) or with the inverse age-adjusted strategy (49.5%; 95% CI 47.1-51.9%). Conclusions Our analysis does not support the use of a progressively higher D-dimer level to exclude VTE with increasing age.
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Affiliation(s)
- S Takach Lapner
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada.
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada.
| | - J A Julian
- Ontario Clinical Oncology Group, Juravinski Hospital, Hamilton, Ontario, Canada
| | - L-A Linkins
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- Thrombosis and Atherosclerosis Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - S M Bates
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- Thrombosis and Atherosclerosis Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - C Kearon
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- Thrombosis and Atherosclerosis Research Institute, McMaster University, Hamilton, Ontario, Canada
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Serrano PE, Gafni A, Gu CS, Gulenchyn KY, Julian JA, Law C, Hendler AL, Moulton CA, Gallinger S, Levine MN. Positron Emission Tomography–Computed Tomography (PET-CT) Versus No PET-CT in the Management of Potentially Resectable Colorectal Cancer Liver Metastases: Cost Implications of a Randomized Controlled Trial. J Oncol Pract 2016; 12:e765-74. [DOI: 10.1200/jop.2016.011676] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Purpose: To evaluate whether positron emission tomography (PET) combined with computed tomography (PET-CT) is cost saving, or cost neutral, compared with conventional imaging in management of patients with resectable colorectal cancer liver metastases. Methods: Cost evaluation of a randomized trial that compared the effect of PET-CT on surgical management of patients with resectable colorectal cancer liver metastases. Health care use data ≤ 1 year after random assignment was obtained from administrative databases. Cost analysis was undertaken from the perspective of a third-party payer (ie, Ministry of Health). Mean costs with 95% credible intervals (CrI) were estimated by using a Bayesian approach. Results: The estimated mean cost per patient in the 263 patients who underwent PET-CT was $45,454 CAD (range, $1,340 to $181,420) and in the 134 control patients, $40,859 CAD (range, $279 to $293,558), with a net difference of $4,327 CAD (95% CrI, −$2,207 to $10,614). The primary cost driver was hospitalization for liver surgery (difference of $2,997 CAD for PET-CT; 95% CrI, −$2,144 to $8,010), which was mainly a result of a longer length of hospital stay for the PET-CT arm (median, 7 v 6 days; P = .03) and a higher postoperative complication rate (20% v 10%; P = .01). Baseline characteristics were similar between groups, including the number of liver segments involved with cancer, number of segments resected, and type of liver resection performed. No difference in survival was detected between arms. Conclusion: PET-CT was associated with limited clinical benefit and a nonsignificant increased cost. Universal funding of PET-CT in the management of patients with resectable colorectal cancer liver metastases does not seem justified.
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Affiliation(s)
- Pablo E. Serrano
- McMaster University, Hamilton, Ontario; and University of Toronto, Toronto, Ontario, Canada
| | - Amiram Gafni
- McMaster University, Hamilton, Ontario; and University of Toronto, Toronto, Ontario, Canada
| | - Chu-Shu Gu
- McMaster University, Hamilton, Ontario; and University of Toronto, Toronto, Ontario, Canada
| | - Karen Y. Gulenchyn
- McMaster University, Hamilton, Ontario; and University of Toronto, Toronto, Ontario, Canada
| | - Jim A. Julian
- McMaster University, Hamilton, Ontario; and University of Toronto, Toronto, Ontario, Canada
| | - Calvin Law
- McMaster University, Hamilton, Ontario; and University of Toronto, Toronto, Ontario, Canada
| | - Aaron L. Hendler
- McMaster University, Hamilton, Ontario; and University of Toronto, Toronto, Ontario, Canada
| | - Carol-Anne Moulton
- McMaster University, Hamilton, Ontario; and University of Toronto, Toronto, Ontario, Canada
| | - Steven Gallinger
- McMaster University, Hamilton, Ontario; and University of Toronto, Toronto, Ontario, Canada
| | - Mark N. Levine
- McMaster University, Hamilton, Ontario; and University of Toronto, Toronto, Ontario, Canada
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Catton CN, Lukka H, Julian JA, Gu CS, Martin J, Supiot S, Chung PWM, Bauman G, Bahary JP, Ahmed S, Cheung P, Tai KH, Wu J, Parliament M, Levine MN. A randomized trial of a shorter radiation fractionation schedule for the treatment of localized prostate cancer. J Clin Oncol 2016. [DOI: 10.1200/jco.2016.34.15_suppl.5003] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- Charles N Catton
- Department of Radiation Oncology, Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - Himu Lukka
- Juravinski Cancer Centre, Hamilton, ON, Canada
| | - Jim A. Julian
- Ontario Clinical Oncology Group, McMaster University, Hamilton, ON, Canada
| | - Chu-Shu Gu
- Ontario Clinical Oncology Group, McMaster University, Hamilton, ON, Canada
| | - Jarad Martin
- Oncology Research Australia, Toowoomba, Australia
| | - Stéphane Supiot
- Institut de Cancérologie de l'Ouest René Gauducheau, Nantes Saint Herblain, France
| | - Peter W. M. Chung
- Department of Radiation Oncology, Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - Glenn Bauman
- London Regional Cancer Program, London, ON, Canada
| | | | | | | | - Keen Hun Tai
- Peter MacCallum Cancer Centre, East Melbourne, Australia
| | - Jackson Wu
- Tom Baker Cancer Centre, Calgary, AB, Canada
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Serrano Aybar PE, Gafni A, Gu CS, Julian JA, Moulton CA, Gallinger S, Levine MN. PET-CT compared to no PET-CT in the management of potentially resectable colorectal cancer liver metastases: The costs implications of a randomized controlled trial. J Clin Oncol 2016. [DOI: 10.1200/jco.2016.34.4_suppl.296] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
296 Background: PETCAM was a randomized trial evaluating the effect of PET-CT compared to conventional imaging (control) on the surgical management of patients with resectable colorectal cancer liver metastases (CRLM). It concluded that PET-CT did not result in frequent change in surgical management (8·0%, 21/263) with only 2·7% (7/263) avoidance of liver resections. In this study we conducted a cost analysis of these two arms up to one year following randomization. Methods: Health care utilization was collected for all study participants. Unit costs for hospitalization, physician services, chemotherapy and outpatient radiological and endoscopic procedures were obtained from administrative databases. Cost analysis was undertaken from the perspective of a third-party payer (i.e., Ministry of Health). Mean cost with its 95% credible interval was estimated using a Bayesian approach. Results: The estimated mean cost per patient in the PET-CT arm was CAN $45,454 (min-max: 1,340-181,420) and in the control arm, CAN $40,859 (min-max: 279-293,558), with a net difference of CAN $4,327, 95% credible interval -2,207 to 10,614. The primary cost driver was cost of hospitalization for liver surgery (+ $2,997 CAN for the PET-CT arm), mainly due to a longer length of hospital stay for the PET-CT arm compared to control (median 7 days vs. 6 days, P= 0·034) and a higher rate of postoperative complications (52/255, 20% vs. 13/128, 10%, P = 0·014). Baseline characteristics were similar between groups, including a similar number of liver segments involved with cancer, number of segments resected and type of liver resection performed. Conclusions: PET-CT does not appear to provide a significant clinical benefit in the surgical management of patients with resectable CRLM and it is not cost saving compared to control.
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Affiliation(s)
| | | | - Chu-Shu Gu
- Ontario Clinical Oncology Group, McMaster University, Hamilton, ON, Canada
| | - Jim A. Julian
- Ontario Clinical Oncology Group, McMaster University, Hamilton, ON, Canada
| | | | - Steven Gallinger
- Department of Surgery, Toronto General Hospital, University of Toronto, Toronto, ON, Canada
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Levine MN, Julian JA, Bedard PL, Eisen A, Trudeau ME, Higgins B, Bordeleau L, Pritchard KI. Prospective Evaluation of the 21-Gene Recurrence Score Assay for Breast Cancer Decision-Making in Ontario. J Clin Oncol 2015; 34:1065-71. [PMID: 26598746 DOI: 10.1200/jco.2015.62.8503] [Citation(s) in RCA: 58] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
PURPOSE To evaluate the 21-gene recurrence score (RS) on decision-making in a population-based cohort. PATIENTS AND METHODS Patients with axillary node-negative or nodal micrometastases, estrogen receptor-positive, and human epidermal growth factor receptor 2-negative breast cancer being considered for chemotherapy were eligible. All cancer treatment centers in Ontario, Canada, participated. Oncologists made a preliminary recommendation for endocrine therapy with or without chemotherapy on the basis of Adjuvant! Online (AOL) risk estimation. Patients were asked for their preference regarding chemotherapy. After RSs were available, patients returned for final decision-making. Patient satisfaction was measured by using the decisional conflict scale. RESULTS Between January 2012 and July 2013, 1,000 patients were recruited. RSs were available for 979 patients. In 58% of patients, risk was categorized as low (RS, 0 to 18); in 33%, intermediate (RS, 19 to 30); and in 9%, high (RS, ≥ 31). Oncologists' recommendations pretest and post-test remained the same in 464 patients (48%), changed from unsure or chemotherapy to no chemotherapy in 365 (38%), and changed from unsure or no chemotherapy to chemotherapy in 143 (15%). After the test, oncologists recommended chemotherapy for 236 patients, 81% of whom received chemotherapy. Of 151 patients in whom risk was classified as intermediate by means of AOL, 41% were a low risk and 44% intermediate risk with RS. Of 298 patients at high risk with AOL, 16% had a high risk RS. None of 236 patients with grade I tumors had a high-risk RS. Mean total decisional conflict scale score significantly improved from pretest to post-test from 34 to 19 (P < .001). CONCLUSION The RS substantially influenced both oncologists' recommendations and patients' preferences for chemotherapy. The major effect was avoidance of chemotherapy when AOL indicated high or intermediate risk.
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Affiliation(s)
- Mark N Levine
- Mark N. Levine, Jim A. Julian, and Louise Bordeleau, McMaster University, Hamilton; Mark N. Levine and Louise Bordeleau, Hamilton Health Sciences Juravinski Cancer Centre, Hamilton; Mark N. Levine and Jim A. Julian, Ontario Clinical Oncology Group and Escarpment Cancer Research Institute, Hamilton; Philippe L. Bedard, Andrea Eisen, Maureen E. Trudeau, and Kathleen I. Pritchard, University of Toronto, Toronto; Phillipe L. Bedard, Princess Margaret Hospital, Toronto; Andrea Eisen, Maureen E. Trudeau, and Kathleen I. Pritchard, Odette Sunnybrook Regional Cancer Centre; Toronto; and Brian Higgins, Peel Regional Cancer Centre, Mississauga, Ontario, Canada.
| | - Jim A Julian
- Mark N. Levine, Jim A. Julian, and Louise Bordeleau, McMaster University, Hamilton; Mark N. Levine and Louise Bordeleau, Hamilton Health Sciences Juravinski Cancer Centre, Hamilton; Mark N. Levine and Jim A. Julian, Ontario Clinical Oncology Group and Escarpment Cancer Research Institute, Hamilton; Philippe L. Bedard, Andrea Eisen, Maureen E. Trudeau, and Kathleen I. Pritchard, University of Toronto, Toronto; Phillipe L. Bedard, Princess Margaret Hospital, Toronto; Andrea Eisen, Maureen E. Trudeau, and Kathleen I. Pritchard, Odette Sunnybrook Regional Cancer Centre; Toronto; and Brian Higgins, Peel Regional Cancer Centre, Mississauga, Ontario, Canada
| | - Philippe L Bedard
- Mark N. Levine, Jim A. Julian, and Louise Bordeleau, McMaster University, Hamilton; Mark N. Levine and Louise Bordeleau, Hamilton Health Sciences Juravinski Cancer Centre, Hamilton; Mark N. Levine and Jim A. Julian, Ontario Clinical Oncology Group and Escarpment Cancer Research Institute, Hamilton; Philippe L. Bedard, Andrea Eisen, Maureen E. Trudeau, and Kathleen I. Pritchard, University of Toronto, Toronto; Phillipe L. Bedard, Princess Margaret Hospital, Toronto; Andrea Eisen, Maureen E. Trudeau, and Kathleen I. Pritchard, Odette Sunnybrook Regional Cancer Centre; Toronto; and Brian Higgins, Peel Regional Cancer Centre, Mississauga, Ontario, Canada
| | - Andrea Eisen
- Mark N. Levine, Jim A. Julian, and Louise Bordeleau, McMaster University, Hamilton; Mark N. Levine and Louise Bordeleau, Hamilton Health Sciences Juravinski Cancer Centre, Hamilton; Mark N. Levine and Jim A. Julian, Ontario Clinical Oncology Group and Escarpment Cancer Research Institute, Hamilton; Philippe L. Bedard, Andrea Eisen, Maureen E. Trudeau, and Kathleen I. Pritchard, University of Toronto, Toronto; Phillipe L. Bedard, Princess Margaret Hospital, Toronto; Andrea Eisen, Maureen E. Trudeau, and Kathleen I. Pritchard, Odette Sunnybrook Regional Cancer Centre; Toronto; and Brian Higgins, Peel Regional Cancer Centre, Mississauga, Ontario, Canada
| | - Maureen E Trudeau
- Mark N. Levine, Jim A. Julian, and Louise Bordeleau, McMaster University, Hamilton; Mark N. Levine and Louise Bordeleau, Hamilton Health Sciences Juravinski Cancer Centre, Hamilton; Mark N. Levine and Jim A. Julian, Ontario Clinical Oncology Group and Escarpment Cancer Research Institute, Hamilton; Philippe L. Bedard, Andrea Eisen, Maureen E. Trudeau, and Kathleen I. Pritchard, University of Toronto, Toronto; Phillipe L. Bedard, Princess Margaret Hospital, Toronto; Andrea Eisen, Maureen E. Trudeau, and Kathleen I. Pritchard, Odette Sunnybrook Regional Cancer Centre; Toronto; and Brian Higgins, Peel Regional Cancer Centre, Mississauga, Ontario, Canada
| | - Brian Higgins
- Mark N. Levine, Jim A. Julian, and Louise Bordeleau, McMaster University, Hamilton; Mark N. Levine and Louise Bordeleau, Hamilton Health Sciences Juravinski Cancer Centre, Hamilton; Mark N. Levine and Jim A. Julian, Ontario Clinical Oncology Group and Escarpment Cancer Research Institute, Hamilton; Philippe L. Bedard, Andrea Eisen, Maureen E. Trudeau, and Kathleen I. Pritchard, University of Toronto, Toronto; Phillipe L. Bedard, Princess Margaret Hospital, Toronto; Andrea Eisen, Maureen E. Trudeau, and Kathleen I. Pritchard, Odette Sunnybrook Regional Cancer Centre; Toronto; and Brian Higgins, Peel Regional Cancer Centre, Mississauga, Ontario, Canada
| | - Louise Bordeleau
- Mark N. Levine, Jim A. Julian, and Louise Bordeleau, McMaster University, Hamilton; Mark N. Levine and Louise Bordeleau, Hamilton Health Sciences Juravinski Cancer Centre, Hamilton; Mark N. Levine and Jim A. Julian, Ontario Clinical Oncology Group and Escarpment Cancer Research Institute, Hamilton; Philippe L. Bedard, Andrea Eisen, Maureen E. Trudeau, and Kathleen I. Pritchard, University of Toronto, Toronto; Phillipe L. Bedard, Princess Margaret Hospital, Toronto; Andrea Eisen, Maureen E. Trudeau, and Kathleen I. Pritchard, Odette Sunnybrook Regional Cancer Centre; Toronto; and Brian Higgins, Peel Regional Cancer Centre, Mississauga, Ontario, Canada
| | - Kathleen I Pritchard
- Mark N. Levine, Jim A. Julian, and Louise Bordeleau, McMaster University, Hamilton; Mark N. Levine and Louise Bordeleau, Hamilton Health Sciences Juravinski Cancer Centre, Hamilton; Mark N. Levine and Jim A. Julian, Ontario Clinical Oncology Group and Escarpment Cancer Research Institute, Hamilton; Philippe L. Bedard, Andrea Eisen, Maureen E. Trudeau, and Kathleen I. Pritchard, University of Toronto, Toronto; Phillipe L. Bedard, Princess Margaret Hospital, Toronto; Andrea Eisen, Maureen E. Trudeau, and Kathleen I. Pritchard, Odette Sunnybrook Regional Cancer Centre; Toronto; and Brian Higgins, Peel Regional Cancer Centre, Mississauga, Ontario, Canada
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You JJ, Cline KJ, Gu CS, Pritchard KI, Dayes IS, Gulenchyn KY, Inculet RI, Dhesy-Thind SK, Freeman MA, Chan AM, Julian JA, Levine MN. (18)F-fluorodeoxyglucose positron-emission tomography-computed tomography to diagnose recurrent cancer. Br J Cancer 2015; 112:1737-43. [PMID: 25942398 PMCID: PMC4647251 DOI: 10.1038/bjc.2015.151] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2015] [Revised: 03/03/2015] [Accepted: 04/13/2015] [Indexed: 11/19/2022] Open
Abstract
Background: Sometimes the diagnosis of recurrent cancer in patients with a previous malignancy can be challenging. This prospective cohort study assessed the clinical utility of 18F-fluorodeoxyglucose positron-emission tomography-computed tomography (18F-FDG PET-CT) in the diagnosis of clinically suspected recurrence of cancer. Methods: Patients were eligible if cancer recurrence (non-small-cell lung (NSCL), breast, head and neck, ovarian, oesophageal, Hodgkin's or non-Hodgkin's lymphoma) was suspected clinically, and if conventional imaging was non-diagnostic. Clinicians were asked to indicate their management plan before and after 18F-FDG PET-CT scanning. The primary outcome was change in planned management after 18F-FDG PET-CT. Results: Between April 2009 and June 2011, 101 patients (age, median 65 years; 55% female) were enroled from four cancer centres in Ontario, Canada. Distribution by primary tumour type was: NSCL (55%), breast (19%), ovarian (10%), oesophageal (6%), lymphoma (6%), and head and neck (4%). Of the 99 subjects who underwent 18F-FDG PET-CT, planned management changed after 18F-FDG PET-CT in 52 subjects (53%, 95% confidence interval (CI), 42–63%); a major change in plan from no treatment to treatment was observed in 38 subjects (38%, 95% CI, 29–49%), and was typically associated with 18F-FDG PET-CT findings that were positive for recurrent cancer (37 subjects). After 3 months, the stated post-18F-FDG PET-CT management plan was actually completed in 88 subjects (89%, 95% CI, 81–94%). Conclusion: In patients with suspected cancer recurrence and conventional imaging that is non-diagnostic, 18F-FDG PET-CT often provides new information that leads to important changes in patient management.
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Affiliation(s)
- J J You
- 1] Department of Medicine, McMaster University, 1280 Main Street West, Room HSC-2C8, Hamilton, Ontario L8S 4K1, Canada [2] Department of Clinical Epidemiology & Biostatistics, McMaster University, 1280 Main Street West, Room HSC-2C8, Hamilton, Ontario L8S 4K1, Canada
| | - K J Cline
- Ontario Clinical Oncology Group, Department of Oncology, McMaster University, 711 Concession Street, G Wing, Hamilton, Ontario L8V 1C3, Canada
| | - C-S Gu
- Ontario Clinical Oncology Group, Department of Oncology, McMaster University, 711 Concession Street, G Wing, Hamilton, Ontario L8V 1C3, Canada
| | - K I Pritchard
- Sunnybrook Odette Cancer Centre, Department of Medicine, University of Toronto, T2-107, 2075 Bayview Avenue, Toronto, Ontario M4N 3M5, Canada
| | - I S Dayes
- Department of Oncology, Juravinski Cancer Centre, Hamilton Health Sciences, 699 Concession Street, Hamilton, Ontario L8V 5C3, Canada
| | - K Y Gulenchyn
- Department of Nuclear Medicine & Molecular Imaging, Hamilton Health Sciences & St Joseph's Healthcare Hamilton, McMaster University, 1200 Main Street West, Room HSC-1P15, Hamilton, Ontario L8N 3Z5, Canada
| | - R I Inculet
- Department of Surgery, Division of Thoracic Surgery, London Health Sciences Centre, University of Western Ontario, 800 Commissioners Road East, Suite E2-122, London, Ontario N6A 5W9, Canada
| | - S K Dhesy-Thind
- Department of Oncology, Juravinski Cancer Centre, Hamilton Health Sciences, 699 Concession Street, Hamilton, Ontario L8V 5C3, Canada
| | - M A Freeman
- Department of Medical Imaging, University of Toronto, University Health Network, Eaton Wing, 1-ES-416, 200 Elizabeth Street, Toronto, Ontario M5G 2C4, Canada
| | - A M Chan
- Department of Oncology, Thunder Bay Regional Health Sciences Centre, 980 Oliver Road, Thunder Bay, Ontario P7B 6V4, Canada
| | - J A Julian
- Ontario Clinical Oncology Group, Department of Oncology, McMaster University, 711 Concession Street, G Wing, Hamilton, Ontario L8V 1C3, Canada
| | - M N Levine
- 1] Ontario Clinical Oncology Group, Department of Oncology, McMaster University, 711 Concession Street, G Wing, Hamilton, Ontario L8V 1C3, Canada [2] Department of Oncology, Juravinski Cancer Centre, Hamilton Health Sciences, 699 Concession Street, Hamilton, Ontario L8V 5C3, Canada
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Affiliation(s)
- Clive Kearon
- From Hamilton Health Sciences, Hamilton, Ontario, Canada; Intermountain Medical Center, Murray, Utah; and Ontario Clinical Oncology Group, Hamilton, Ontario, Canada
| | - Scott M. Stevens
- From Hamilton Health Sciences, Hamilton, Ontario, Canada; Intermountain Medical Center, Murray, Utah; and Ontario Clinical Oncology Group, Hamilton, Ontario, Canada
| | - Jim A. Julian
- From Hamilton Health Sciences, Hamilton, Ontario, Canada; Intermountain Medical Center, Murray, Utah; and Ontario Clinical Oncology Group, Hamilton, Ontario, Canada
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Forbes M, Wong R, Sagar SM, Julian JA, Levine MN, Hayward J. Abstract P3-12-02: Lifestyle interventions combined with acupuncture-like transcutaneous electrical nerve stimulation in managing vasomotor symptoms induced by breast cancer treatment: Results of a phase 2 randomized controlled trial. Cancer Res 2015. [DOI: 10.1158/1538-7445.sabcs14-p3-12-02] [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: Women with breast cancer can experience significant treatment induced vasomotor symptoms (TIVS). Non-hormonal strategies for TIVS (e.g. acupuncture, Venlafaxine) provide some relief but may be intolerable because of the invasive nature of the treatment and possible side effects. As such, women often prefer lifestyle strategies (LS) that can be self-administered. Acupuncture-like transcutaneous electrical nerve stimulation (ALTENS) is a non-invasive needleless technique that uses specific electrical parameters to stimulate selected acupoints to achieve clinical response with minimal toxicity. ALTENS can be administered with minimal training. It is amenable to quality assurance and can allow for self treatment by women. This study aimed to evaluate the efficacy of ALTENS in addition to LS in relieving TIVS in women with breast cancer.
Methods: Eligible subjects were postmenopausal women with Stages 0-3 breast cancer who had completed cancer treatment and were experiencing hot flashes for ≥ one month with a Hot Flash Score (HFS) ≥15 in one week prior to consent. Anti-estrogen therapy was permitted. Non-hormonal drug therapies were prohibited. Subjects were randomized to either LS (control) or LS with concurrent ALTENS (combined). LS consisted of standardized lifestyle strategies (e.g. environmental control, managing hot flash triggers) counseling delivered by a specially trained nurse practitioner at week 0 with reinforcing counseling at weeks 12 and 24. ALTENS was given twice weekly for 12 treatments over an 8-week period. The HFS, Hot Flash Related Daily Interference Scale and the Short Form version 2 health survey were administered at weeks 0, 12 and 24. Heart rate variability was measured at weeks 0 and 12. The primary study endpoint was the number of responders, defined as women who had > 50% reduction in their HFS between weeks 0 and 12.
Results: 71 eligible subjects with a median age of 52 (range: 40-87) were randomized to combined arm (n=36) and control (n=35). At 12 weeks there were 11 (30.6%) responders in the combined arm versus 2 (5.7%) in the control (p=0.012).The results at 24 weeks were 14 versus 4, respectively (p=0.013). Arms were balanced for anti-estrogen use. Two subjects chose to discontinue ALTENS after experiencing symptoms improvement. There were no serious adverse events.
Conclusion: ALTENS in combination with lifestyle strategies is a promising non-pharmacologic approach that showed improvement in managing treatment induced vasomotor symptoms in women with breast cancer. Our trial results support its evaluation in phase 3 studies.
Citation Format: Margaret Forbes, Raimond Wong, Stephen M Sagar, Jim A Julian, Mark N Levine, Joseph Hayward. Lifestyle interventions combined with acupuncture-like transcutaneous electrical nerve stimulation in managing vasomotor symptoms induced by breast cancer treatment: Results of a phase 2 randomized controlled trial [abstract]. In: Proceedings of the Thirty-Seventh Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2014 Dec 9-13; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2015;75(9 Suppl):Abstract nr P3-12-02.
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Affiliation(s)
- Margaret Forbes
- 1McMaster University
- 2Juravinski Cancer Centre/Hamilton Health Sciences
| | - Raimond Wong
- 1McMaster University
- 2Juravinski Cancer Centre/Hamilton Health Sciences
| | - Stephen M Sagar
- 1McMaster University
- 2Juravinski Cancer Centre/Hamilton Health Sciences
| | - Jim A Julian
- 1McMaster University
- 2Juravinski Cancer Centre/Hamilton Health Sciences
- 3Ontario Clinical Oncology Group
| | - Mark N Levine
- 1McMaster University
- 2Juravinski Cancer Centre/Hamilton Health Sciences
- 3Ontario Clinical Oncology Group
| | - Joseph Hayward
- 1McMaster University
- 2Juravinski Cancer Centre/Hamilton Health Sciences
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Boekhout AH, Maunsell E, Pond GR, Julian JA, Coyle D, Levine MN, Grunfeld E. A survivorship care plan for breast cancer survivors: extended results of a randomized clinical trial. J Cancer Surviv 2015; 9:683-91. [PMID: 25896265 DOI: 10.1007/s11764-015-0443-1] [Citation(s) in RCA: 73] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2014] [Accepted: 02/18/2015] [Indexed: 11/24/2022]
Abstract
PURPOSE Prevailing wisdom suggests that implementation of a survivorship care plan (SCP) will address deficits in survivorship care planning and delivery for cancer patients. Here, we present 24-month results of a randomized clinical trial on health service and patient-reported outcomes among breast cancer patients transferred to their primary care physician for follow-up care. The 24-month assessments represent the long-term benefit and sustainability of the implantation of a SCP. METHODS In all, 408 patients with early-stage breast cancer were randomized to the SCP or control group. Patient self-completed questionnaires, supplemented with telephone interviews, during the 24-month study period assessed health service and patient-reported outcomes. The primary outcome was cancer-specific distress. Secondary outcomes included health-related quality of life, patient satisfaction, continuity and coordination of care, and health service outcomes such as adherence to guidelines. RESULTS Over the course of 24 months, there were no differences between both groups in health service and patient-reported outcomes. Women from Quebec compared to those from Western Canada (p < 0.001), women within 2 years of completion of primary treatment compared to a longer period (p = 0.013), and those with a higher SF-36 mental component score compared to a lower score (p = 0.044) were positively associated with adherence to guidelines. CONCLUSION The implementation of a SCP in the transition of survivorship care from cancer center to primary care did not contribute to improved health service or patient-reported outcomes in this study population. Therefore, additional research is needed before widespread implementation of a SCP in clinical practice. IMPLICATIONS OF CANCER SURVIVORS The transition of survivorship care from cancer center to the primary care setting showed no negative effect on health service and patient-reported outcomes.
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Affiliation(s)
- Annelies H Boekhout
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada. .,Netherlands Cancer Institute, Antoni van Leeuwenhoek Hospital, Plesmanlaan 121, 1066 CX, Amsterdam, The Netherlands.
| | - Elizabeth Maunsell
- Center de Recherché du CHU de Québec, Québec, Québec, Canada.,Département de Médecine Sociale et Préventive, Université Laval, Québec, Québec, Canada
| | - Gregory R Pond
- Ontario Clinical Oncology Group, Hamilton, Ontario, Canada.,Department of Oncology, McMaster University, Hamilton, Ontario, Canada
| | - Jim A Julian
- Ontario Clinical Oncology Group, Hamilton, Ontario, Canada.,Department of Oncology, McMaster University, Hamilton, Ontario, Canada
| | - Doug Coyle
- Department of Epidemiology and Community Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Mark N Levine
- Ontario Clinical Oncology Group, Hamilton, Ontario, Canada.,Department of Oncology, McMaster University, Hamilton, Ontario, Canada
| | - Eva Grunfeld
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada.,Ontario Institute for Cancer Research, Toronto, Ontario, Canada
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Peterson D, Truong PT, Parpia S, Olivotto IA, Berrang T, Kim DH, Kong I, Germain I, Nichol A, Akra M, Roy I, Reed M, Fyles A, Trotter T, Perera F, Balkwill S, Lavertu S, Elliott E, Julian JA, Levine MN, Whelan TJ. Predictors of Adverse Cosmetic Outcome in the RAPID Trial: An Exploratory Analysis. Int J Radiat Oncol Biol Phys 2015; 91:968-76. [DOI: 10.1016/j.ijrobp.2014.12.040] [Citation(s) in RCA: 66] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2014] [Revised: 11/12/2014] [Accepted: 12/17/2014] [Indexed: 01/17/2023]
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Kearon C, Spencer FA, O'Keeffe D, Parpia S, Schulman S, Baglin T, Stevens SM, Kaatz S, Bauer KA, Douketis JD, Lentz SR, Kessler CM, Moll S, Connors JM, Ginsberg JS, Spadafora L, Julian JA. D-dimer testing to select patients with a first unprovoked venous thromboembolism who can stop anticoagulant therapy: a cohort study. Ann Intern Med 2015; 162:27-34. [PMID: 25560712 DOI: 10.7326/m14-1275] [Citation(s) in RCA: 98] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Normal D-dimer levels after withdrawal of anticoagulant therapy are associated with a reduced risk for recurrence in patients with unprovoked venous thromboembolism (VTE) and may justify stopping treatment. OBJECTIVE To determine whether patients with a first unprovoked VTE and negative D-dimer test result who stop anticoagulant therapy have a low risk for recurrence. DESIGN Prospective management study with blinded outcome assessment. (ClinicalTrials.gov: NCT00720915). SETTING 13 university-affiliated clinical centers. PATIENTS 410 adults aged 75 years or younger with a first unprovoked proximal deep venous thrombosis or pulmonary embolism who had completed 3 to 7 months of anticoagulant therapy. INTERVENTION Anticoagulant therapy was stopped if D-dimer test results were negative and was not restarted if results were still negative after 1 month. MEASUREMENTS Recurrent VTE during an average follow-up of 2.2 years. RESULTS In 319 patients (78%) who had 2 negative D-dimer results and did not restart anticoagulant therapy, rates of recurrent VTE were 6.7% (95% CI, 4.8% to 9.0%) per patient-year overall (42 of 319), 9.7% (CI, 6.7% to 13.7%) per patient-year in men (33 of 180), 5.4% (CI, 2.5% to 10.2%) per patient-year in women with VTE not associated with estrogen therapy (9 of 81), and 0.0% (CI, 0.0% to 3.0%) per patient-year in women with VTE associated with estrogen therapy (0 of 58) (P = 0.001 for the 3-group comparison). LIMITATIONS Imprecision in female subgroups. Results may not be generalizable to different D-dimer assays from the one used in the study. CONCLUSION The risk for recurrence in patients with a first unprovoked VTE who have negative D-dimer results is not low enough to justify stopping anticoagulant therapy in men but may be low enough to justify stopping therapy in women. PRIMARY FUNDING SOURCE Canadian Institutes of Health Research.
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Affiliation(s)
- Clive Kearon
- From McMaster University, Hamilton, Ontario, Canada; University of Limerick, Limerick, Ireland; Addenbrooke's Hospital, Cambridge, United Kingdom; Intermountain Medical Center, Murray, Utah; Hurley Medical Center, Flint, Michigan; Harvard Medical School, Boston, Massachusetts; University of Iowa, Iowa City, Iowa; Georgetown University, Washington, DC; and University of North Carolina, Chapel Hill, North Carolina
| | - Frederick A. Spencer
- From McMaster University, Hamilton, Ontario, Canada; University of Limerick, Limerick, Ireland; Addenbrooke's Hospital, Cambridge, United Kingdom; Intermountain Medical Center, Murray, Utah; Hurley Medical Center, Flint, Michigan; Harvard Medical School, Boston, Massachusetts; University of Iowa, Iowa City, Iowa; Georgetown University, Washington, DC; and University of North Carolina, Chapel Hill, North Carolina
| | - Denis O'Keeffe
- From McMaster University, Hamilton, Ontario, Canada; University of Limerick, Limerick, Ireland; Addenbrooke's Hospital, Cambridge, United Kingdom; Intermountain Medical Center, Murray, Utah; Hurley Medical Center, Flint, Michigan; Harvard Medical School, Boston, Massachusetts; University of Iowa, Iowa City, Iowa; Georgetown University, Washington, DC; and University of North Carolina, Chapel Hill, North Carolina
| | - Sameer Parpia
- From McMaster University, Hamilton, Ontario, Canada; University of Limerick, Limerick, Ireland; Addenbrooke's Hospital, Cambridge, United Kingdom; Intermountain Medical Center, Murray, Utah; Hurley Medical Center, Flint, Michigan; Harvard Medical School, Boston, Massachusetts; University of Iowa, Iowa City, Iowa; Georgetown University, Washington, DC; and University of North Carolina, Chapel Hill, North Carolina
| | - Sam Schulman
- From McMaster University, Hamilton, Ontario, Canada; University of Limerick, Limerick, Ireland; Addenbrooke's Hospital, Cambridge, United Kingdom; Intermountain Medical Center, Murray, Utah; Hurley Medical Center, Flint, Michigan; Harvard Medical School, Boston, Massachusetts; University of Iowa, Iowa City, Iowa; Georgetown University, Washington, DC; and University of North Carolina, Chapel Hill, North Carolina
| | - Trevor Baglin
- From McMaster University, Hamilton, Ontario, Canada; University of Limerick, Limerick, Ireland; Addenbrooke's Hospital, Cambridge, United Kingdom; Intermountain Medical Center, Murray, Utah; Hurley Medical Center, Flint, Michigan; Harvard Medical School, Boston, Massachusetts; University of Iowa, Iowa City, Iowa; Georgetown University, Washington, DC; and University of North Carolina, Chapel Hill, North Carolina
| | - Scott M. Stevens
- From McMaster University, Hamilton, Ontario, Canada; University of Limerick, Limerick, Ireland; Addenbrooke's Hospital, Cambridge, United Kingdom; Intermountain Medical Center, Murray, Utah; Hurley Medical Center, Flint, Michigan; Harvard Medical School, Boston, Massachusetts; University of Iowa, Iowa City, Iowa; Georgetown University, Washington, DC; and University of North Carolina, Chapel Hill, North Carolina
| | - Scott Kaatz
- From McMaster University, Hamilton, Ontario, Canada; University of Limerick, Limerick, Ireland; Addenbrooke's Hospital, Cambridge, United Kingdom; Intermountain Medical Center, Murray, Utah; Hurley Medical Center, Flint, Michigan; Harvard Medical School, Boston, Massachusetts; University of Iowa, Iowa City, Iowa; Georgetown University, Washington, DC; and University of North Carolina, Chapel Hill, North Carolina
| | - Kenneth A. Bauer
- From McMaster University, Hamilton, Ontario, Canada; University of Limerick, Limerick, Ireland; Addenbrooke's Hospital, Cambridge, United Kingdom; Intermountain Medical Center, Murray, Utah; Hurley Medical Center, Flint, Michigan; Harvard Medical School, Boston, Massachusetts; University of Iowa, Iowa City, Iowa; Georgetown University, Washington, DC; and University of North Carolina, Chapel Hill, North Carolina
| | - James D. Douketis
- From McMaster University, Hamilton, Ontario, Canada; University of Limerick, Limerick, Ireland; Addenbrooke's Hospital, Cambridge, United Kingdom; Intermountain Medical Center, Murray, Utah; Hurley Medical Center, Flint, Michigan; Harvard Medical School, Boston, Massachusetts; University of Iowa, Iowa City, Iowa; Georgetown University, Washington, DC; and University of North Carolina, Chapel Hill, North Carolina
| | - Steven R. Lentz
- From McMaster University, Hamilton, Ontario, Canada; University of Limerick, Limerick, Ireland; Addenbrooke's Hospital, Cambridge, United Kingdom; Intermountain Medical Center, Murray, Utah; Hurley Medical Center, Flint, Michigan; Harvard Medical School, Boston, Massachusetts; University of Iowa, Iowa City, Iowa; Georgetown University, Washington, DC; and University of North Carolina, Chapel Hill, North Carolina
| | - Craig M. Kessler
- From McMaster University, Hamilton, Ontario, Canada; University of Limerick, Limerick, Ireland; Addenbrooke's Hospital, Cambridge, United Kingdom; Intermountain Medical Center, Murray, Utah; Hurley Medical Center, Flint, Michigan; Harvard Medical School, Boston, Massachusetts; University of Iowa, Iowa City, Iowa; Georgetown University, Washington, DC; and University of North Carolina, Chapel Hill, North Carolina
| | - Stephan Moll
- From McMaster University, Hamilton, Ontario, Canada; University of Limerick, Limerick, Ireland; Addenbrooke's Hospital, Cambridge, United Kingdom; Intermountain Medical Center, Murray, Utah; Hurley Medical Center, Flint, Michigan; Harvard Medical School, Boston, Massachusetts; University of Iowa, Iowa City, Iowa; Georgetown University, Washington, DC; and University of North Carolina, Chapel Hill, North Carolina
| | - Jean M. Connors
- From McMaster University, Hamilton, Ontario, Canada; University of Limerick, Limerick, Ireland; Addenbrooke's Hospital, Cambridge, United Kingdom; Intermountain Medical Center, Murray, Utah; Hurley Medical Center, Flint, Michigan; Harvard Medical School, Boston, Massachusetts; University of Iowa, Iowa City, Iowa; Georgetown University, Washington, DC; and University of North Carolina, Chapel Hill, North Carolina
| | - Jeffrey S. Ginsberg
- From McMaster University, Hamilton, Ontario, Canada; University of Limerick, Limerick, Ireland; Addenbrooke's Hospital, Cambridge, United Kingdom; Intermountain Medical Center, Murray, Utah; Hurley Medical Center, Flint, Michigan; Harvard Medical School, Boston, Massachusetts; University of Iowa, Iowa City, Iowa; Georgetown University, Washington, DC; and University of North Carolina, Chapel Hill, North Carolina
| | - Luciana Spadafora
- From McMaster University, Hamilton, Ontario, Canada; University of Limerick, Limerick, Ireland; Addenbrooke's Hospital, Cambridge, United Kingdom; Intermountain Medical Center, Murray, Utah; Hurley Medical Center, Flint, Michigan; Harvard Medical School, Boston, Massachusetts; University of Iowa, Iowa City, Iowa; Georgetown University, Washington, DC; and University of North Carolina, Chapel Hill, North Carolina
| | - Jim A. Julian
- From McMaster University, Hamilton, Ontario, Canada; University of Limerick, Limerick, Ireland; Addenbrooke's Hospital, Cambridge, United Kingdom; Intermountain Medical Center, Murray, Utah; Hurley Medical Center, Flint, Michigan; Harvard Medical School, Boston, Massachusetts; University of Iowa, Iowa City, Iowa; Georgetown University, Washington, DC; and University of North Carolina, Chapel Hill, North Carolina
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Abstract
BACKGROUND In non-inferiority trials of radiotherapy in patients with early stage breast cancer, it is inevitable that some patients will cross over from the experimental arm to the standard arm prior to initiation of any treatment due to complexities in treatment planning or subject preference. Although the intention-to-treat (ITT) analysis is the preferred approach for superiority trials, its role in non-inferiority trials is still under debate. This has led to the use of alternative approaches such as the per-protocol (PP) analysis or the as-treated (AT) analysis, despite the inherent biases of such approaches. METHODS Using simulations, we investigate the effect of 2%, 5% and 10% random and non-random crossovers prior to radiotherapy initiation on the ITT, PP, AT and the combination of ITT and PP analyses with respect to type I error in trials with time-to-event outcomes. We also evaluate bias and SE of the estimates from the ITT, PP and AT approaches. RESULTS The AT approach had the best performance in terms of type I error, but was anticonservative as non-random crossover increased. The ITT and PP approaches were anticonservative under all percentages of random and non-random crossover. Similarly, lowest bias was seen with the AT approach; however, bias increased as the percentage of non-random crossover increased. The ITT and PP had poor performance in terms of bias as crossovers increased. CONCLUSIONS If minimal crossovers were to occur, we have shown that the AT approach has the lowest type I error rates and smallest opportunity for bias. Results of trials with a high number of crossovers should be interpreted with caution, especially when crossover is non-random. Attempts to prevent crossovers should be maximised.
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Affiliation(s)
- Sameer Parpia
- Ontario Clinical Oncology Group, Department of Oncology, McMaster University, Hamilton, Ontario, Canada
| | - Jim A Julian
- Ontario Clinical Oncology Group, Department of Oncology, McMaster University, Hamilton, Ontario, Canada
| | - Lehana Thabane
- Centre of Evaluation of Medicines, St Joseph's Hospital, Hamilton, Ontario, Canada
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada
| | - Chushu Gu
- Ontario Clinical Oncology Group, Department of Oncology, McMaster University, Hamilton, Ontario, Canada
| | - Timothy J Whelan
- Ontario Clinical Oncology Group, Department of Oncology, McMaster University, Hamilton, Ontario, Canada
- Juravinski Cancer Centre, Hamilton, Ontario, Canada
| | - Mark N Levine
- Ontario Clinical Oncology Group, Department of Oncology, McMaster University, Hamilton, Ontario, Canada
- Juravinski Cancer Centre, Hamilton, Ontario, Canada
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Parpia S, Julian JA, Gu C, Thabane L, Levine MN. Interim analysis for binary outcome trials with a long fixed follow-up time and repeated outcome assessments at pre-specified times. Springerplus 2014; 3:323. [PMID: 25019050 PMCID: PMC4087327 DOI: 10.1186/2193-1801-3-323] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/02/2014] [Accepted: 06/20/2014] [Indexed: 01/27/2023]
Abstract
In trials with binary outcomes, assessed repeatedly at pre-specified times and where the subject is considered to have experienced a failure at the first occurrence of the outcome, interim analyses are performed, generally, after half or more of the subjects have completed follow-up. Depending on the duration of accrual relative to the length of follow-up, this may be inefficient, since there is a possibility that the trial will have completed accrual prior to the interim analysis. An alternative is to plan the interim analysis after subjects have completed follow-up to a time that is less than the fixed full follow-up duration. Using simulations, we evaluated three methods to estimate the event proportion for the interim analysis in terms of type I and II errors and the probability of early stopping. We considered: 1) estimation of the event proportion based on subjects who have been followed for a pre-specified time (less than the full follow-up duration) or who experienced the outcome; 2) estimation of the event proportion based on data from all subjects that have been randomized by the time of the interim analysis; and 3) the Kaplan-Meier approach to estimate the event proportion at the time of the interim analysis. Our results show that all methods preserve and have comparable type I and II errors in certain scenarios. In these cases, we recommend using the Kaplan-Meier method because it incorporates all the available data and has greater probability of early stopping when the treatment effect exists.
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Affiliation(s)
- Sameer Parpia
- Ontario Clinical Oncology Group, Department of Oncology, McMaster University, 711 Concession Street - G (60) Wing 1st Floor, Hamilton, ON L8V 1C3 Canada
| | - Jim A Julian
- Ontario Clinical Oncology Group, Department of Oncology, McMaster University, 711 Concession Street - G (60) Wing 1st Floor, Hamilton, ON L8V 1C3 Canada
| | - Chushu Gu
- Ontario Clinical Oncology Group, Department of Oncology, McMaster University, 711 Concession Street - G (60) Wing 1st Floor, Hamilton, ON L8V 1C3 Canada
| | - Lehana Thabane
- Biostatistics Unit - FSORC, St Joseph's Healthcare - Hamilton, 50 Charlton Avenue East, Hamilton, ON L8N 4A6 Canada
| | - Mark N Levine
- Ontario Clinical Oncology Group, Department of Oncology, McMaster University, 711 Concession Street - G (60) Wing 1st Floor, Hamilton, ON L8V 1C3 Canada
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Levine MN, Cochrane BL, Julian JA, Trudeau ME, Eisen A, Bedard PL, Pritchard KI. Population-based evaluation of 21-gene assay in treatment decision making for early breast cancer in Ontario. J Clin Oncol 2014. [DOI: 10.1200/jco.2014.32.15_suppl.583] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- Mark Norman Levine
- Ontario Clinical Oncology Group, McMaster University, Hamilton, ON, Canada
| | | | - Jim A. Julian
- Ontario Clinical Oncology Group, McMaster University, Hamilton, ON, Canada
| | - Maureen E. Trudeau
- Sunnybrook Odette Cancer Centre, University of Toronto, Toronto, ON, Canada
| | - Andrea Eisen
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
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Moulton CA, Gu CS, Law CH, Tandan VR, Hart R, Quan D, Fairfull Smith RJ, Jalink DW, Husien M, Serrano PE, Hendler AL, Haider MA, Ruo L, Gulenchyn KY, Finch T, Julian JA, Levine MN, Gallinger S. Effect of PET before liver resection on surgical management for colorectal adenocarcinoma metastases: a randomized clinical trial. JAMA 2014; 311:1863-9. [PMID: 24825641 DOI: 10.1001/jama.2014.3740] [Citation(s) in RCA: 125] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
IMPORTANCE Patients with colorectal cancer with liver metastases undergo hepatic resection with curative intent. Positron emission tomography combined with computed tomography (PET-CT) could help avoid noncurative surgery by identifying patients with occult metastases. OBJECTIVES To determine the effect of preoperative PET-CT vs no PET-CT (control) on the surgical management of patients with resectable metastases and to investigate the effect of PET-CT on survival and the association between the standardized uptake value (ratio of tissue radioactivity to injected radioactivity adjusted by weight) and survival. DESIGN, SETTING, AND PARTICIPANTS A randomized trial of patients older than 18 years with colorectal cancer treated by surgery, with resectable metastases based on CT scans of the chest, abdomen, and pelvis within the previous 30 days, and with a clear colonoscopy within the previous 18 months was conducted between 2005 and 2013, involving 21 surgeons at 9 hospitals in Ontario, Canada, with PET-CT scanners at 5 academic institutions. INTERVENTIONS Patients were randomized using a 2 to 1 ratio to PET-CT or control. MAIN OUTCOMES AND MEASURES The primary outcome was a change in surgical management defined as canceled hepatic surgery, more extensive hepatic surgery, or additional organ surgery based on the PET-CT. Survival was a secondary outcome. RESULTS Of the 263 patients who underwent PET-CT, 21 had a change in surgical management (8.0%; 95% CI, 5.0%-11.9%). Specifically, 7 patients (2.7%) did not undergo laparotomy, 4 (1.5%) had more extensive hepatic surgery, 9 (3.4%) had additional organ surgery (8 of whom had hepatic resection), and the abdominal cavity was opened in 1 patient but hepatic surgery was not performed and the cavity was closed. Liver resection was performed in 91% of patients in the PET-CT group and 92% of the control group. After a median follow-up of 36 months, the estimated mortality rate was 11.13 (95% CI, 8.95-13.68) events/1000 person-months for the PET-CT group and 12.71 (95% CI, 9.40-16.80) events/1000 person-months for the control group. Survival did not differ between the 2 groups (hazard ratio, 0.86 [95% CI, 0.60-1.21]; P = .38). The standardized uptake value was associated with survival (hazard ratio, 1.11 [90% CI, 1.07-1.15] per unit increase; P < .001). The C statistic for the model including the standardized uptake value was 0.62 (95% CI, 0.56-0.68) and without it was 0.50 (95% CI, 0.44-0.56). The difference in C statistics is 0.12 (95% CI, 0.04-0.21). The low C statistic suggests that the standard uptake value is not a strong predictor of overall survival. CONCLUSIONS AND RELEVANCE Among patients with potentially resectable hepatic metastases of colorectal adenocarcinoma, the use of PET-CT compared with CT alone did not result in frequent change in surgical management. These findings raise questions about the value of PET-CT scans in this setting. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00265356.
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Affiliation(s)
| | - Chu-Shu Gu
- McMaster University, Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Calvin H Law
- Sunnybrook Health Sciences Centre and Odette Cancer Centre, Toronto, Ontario, Canada
| | - Ved R Tandan
- McMaster University, Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Richard Hart
- St Joseph's Health Centre, Toronto, Ontario, Canada
| | - Douglas Quan
- London Health Sciences Centre, London, Ontario, Canada
| | | | - Diederick W Jalink
- Cancer Centre of Southeastern Ontario at Kingston General Hospital, Kingston, Canada
| | - Mohamed Husien
- Grand River Regional Cancer Centre, Kitchener, Ontario, Canada
| | | | | | - Masoom A Haider
- Sunnybrook Health Sciences Centre and Odette Cancer Centre, Toronto, Ontario, Canada
| | - Leyo Ruo
- McMaster University, Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Karen Y Gulenchyn
- McMaster University, Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Terri Finch
- McMaster University, Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Jim A Julian
- McMaster University, Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Mark N Levine
- McMaster University, Hamilton Health Sciences, Hamilton, Ontario, Canada
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Coyle D, Grunfeld E, Coyle K, Pond G, Julian JA, Levine MN. Cost Effectiveness of a Survivorship Care Plan for Breast Cancer Survivors. J Oncol Pract 2014; 10:e86-92. [DOI: 10.1200/jop.2013.001142] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [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
The authors conclude that this survivorship care plan would be costly to introduce and would not be a cost-effective use of scarce health care resources.
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Affiliation(s)
- Doug Coyle
- University of Ottawa; Ottawa Hospital Research Institute; Applied Health Economics Research Unit, Ottawa; Ontario Institute for Cancer Research; University of Toronto, Toronto; Ontario Clinical Oncology Group; McMaster University; and Juravinski Regional Cancer Centre, Hamilton, Ontario, Canada
| | - Eva Grunfeld
- University of Ottawa; Ottawa Hospital Research Institute; Applied Health Economics Research Unit, Ottawa; Ontario Institute for Cancer Research; University of Toronto, Toronto; Ontario Clinical Oncology Group; McMaster University; and Juravinski Regional Cancer Centre, Hamilton, Ontario, Canada
| | - Kathryn Coyle
- University of Ottawa; Ottawa Hospital Research Institute; Applied Health Economics Research Unit, Ottawa; Ontario Institute for Cancer Research; University of Toronto, Toronto; Ontario Clinical Oncology Group; McMaster University; and Juravinski Regional Cancer Centre, Hamilton, Ontario, Canada
| | - Gregory Pond
- University of Ottawa; Ottawa Hospital Research Institute; Applied Health Economics Research Unit, Ottawa; Ontario Institute for Cancer Research; University of Toronto, Toronto; Ontario Clinical Oncology Group; McMaster University; and Juravinski Regional Cancer Centre, Hamilton, Ontario, Canada
| | - Jim A. Julian
- University of Ottawa; Ottawa Hospital Research Institute; Applied Health Economics Research Unit, Ottawa; Ontario Institute for Cancer Research; University of Toronto, Toronto; Ontario Clinical Oncology Group; McMaster University; and Juravinski Regional Cancer Centre, Hamilton, Ontario, Canada
| | - Mark N. Levine
- University of Ottawa; Ottawa Hospital Research Institute; Applied Health Economics Research Unit, Ottawa; Ontario Institute for Cancer Research; University of Toronto, Toronto; Ontario Clinical Oncology Group; McMaster University; and Juravinski Regional Cancer Centre, Hamilton, Ontario, Canada
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Dayes IS, Whelan TJ, Julian JA, Parpia S, Pritchard KI, D'Souza DP, Kligman L, Reise D, LeBlanc L, McNeely ML, Manchul L, Wiernikowski J, Levine MN. Randomized trial of decongestive lymphatic therapy for the treatment of lymphedema in women with breast cancer. J Clin Oncol 2013; 31:3758-63. [PMID: 24043733 DOI: 10.1200/jco.2012.45.7192] [Citation(s) in RCA: 104] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Because of its morbidity and chronicity, arm lymphedema remains a concerning complication of breast cancer treatment. Although massage-based decongestive therapy is often recommended, randomized trials have not consistently demonstrated benefit over more conservative measures. PATIENTS AND METHODS Women previously treated for breast cancer with lymphedema were enrolled from six institutions. Volumes were calculated from circumference measurements. Patients with a minimum of 10% volume difference between their arms were randomly assigned to either compression garments (control) or daily manual lymphatic drainage and bandaging followed by compression garments (experimental). The primary outcome was percent reduction in excess arm volume from baseline to 6 weeks. RESULTS A total of 103 women were randomly assigned, and 95 were evaluable. Mean reduction of excess arm volume was 29.0% in the experimental group and 22.6% in the control group (difference, 6.4%; 95% CI, -6.8% to 20.5%; P = .34). Absolute volume loss was 250 mL and 143 mL in the experimental and control groups, respectively (difference, 107 mL; 95% CI, 13 to 203 mL; P = .03). There was no difference between groups in the proportion of patients losing 50% or greater excess arm volume. Quality of life (Short Form-36 Health Survey) and arm function were not different between groups. CONCLUSION This trial was unable to demonstrate a significant improvement in lymphedema with decongestive therapy compared with a more conservative approach. The failure to detect a difference may have been a result of the relatively small size of our trial.
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Affiliation(s)
- Ian S Dayes
- Ian S. Dayes, Tim J. Whelan, Jim A. Julian, Sameer Parpia, and Mark N. Levine, McMaster University; Tim J. Whelan, Jim A. Julian, Sameer Parpia, Kathleen I. Pritchard, and Mark N. Levine, Ontario Clinical Oncology Group; Ian S. Dayes, Tim J. Whelan, and Mark N. Levine, Juravinski Cancer Centre; Donna Reise, Talspar Nursing Services; Jennifer Wiernikowski, Hamilton Health Sciences, Hamilton; Kathleen I. Pritchard and Lee Manchul, University of Toronto; Kathleen I. Pritchard, Odette Sunnybrook Cancer Centre; Lee Manchul, University Health Network, Toronto; David Paul D'Souza and Lyn Kligman, London Regional Cancer Program, London; David Paul D'Souza, University of Western Ontario, London, Ontario; Linda LeBlanc, Dr Leon Richard Oncology Centre, Moncton, New Brunswick; Margaret L. McNeely, University of Alberta; and Margaret L. McNeely, Cross Cancer Institute, Edmonton, Alberta, Canada
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Olivotto IA, Whelan TJ, Parpia S, Kim DH, Berrang T, Truong PT, Kong I, Cochrane B, Nichol A, Roy I, Germain I, Akra M, Reed M, Fyles A, Trotter T, Perera F, Beckham W, Levine MN, Julian JA. Interim cosmetic and toxicity results from RAPID: a randomized trial of accelerated partial breast irradiation using three-dimensional conformal external beam radiation therapy. J Clin Oncol 2013; 31:4038-45. [PMID: 23835717 DOI: 10.1200/jco.2013.50.5511] [Citation(s) in RCA: 309] [Impact Index Per Article: 28.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
PURPOSE To report interim cosmetic and toxicity results of a multicenter randomized trial comparing accelerated partial-breast irradiation (APBI) using three-dimensional conformal external beam radiation therapy (3D-CRT) with whole-breast irradiation (WBI). PATIENTS AND METHODS Women age > 40 years with invasive or in situ breast cancer ≤ 3 cm were randomly assigned after breast-conserving surgery to 3D-CRT APBI (38.5 Gy in 10 fractions twice daily) or WBI (42.5 Gy in 16 or 50 Gy in 25 daily fractions ± boost irradiation). The primary outcome was ipsilateral breast tumor recurrence (IBTR). Secondary outcomes were cosmesis and toxicity. Adverse cosmesis was defined as a fair or poor global cosmetic score. After a planned interim cosmetic analysis, the data, safety, and monitoring committee recommended release of results. There have been too few IBTR events to trigger an efficacy analysis. RESULTS Between 2006 and 2011, 2,135 women were randomly assigned to 3D-CRT APBI or WBI. Median follow-up was 36 months. Adverse cosmesis at 3 years was increased among those treated with APBI compared with WBI as assessed by trained nurses (29% v 17%; P < .001), by patients (26% v 18%; P = .0022), and by physicians reviewing digital photographs (35% v 17%; P < .001). Grade 3 toxicities were rare in both treatment arms (1.4% v 0%), but grade 1 and 2 toxicities were increased among those who received APBI compared with WBI (P < .001). CONCLUSION 3D-CRT APBI increased rates of adverse cosmesis and late radiation toxicity compared with standard WBI. Clinicians and patients are cautioned against the use of 3D-CRT APBI outside the context of a controlled trial.
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Affiliation(s)
- Ivo A Olivotto
- Ivo A. Olivotto, Tanya Berrang, Pauline T. Truong, Alan Nichol, Melanie Reed, and Wayne Beckham, British Columbia Cancer Agency; Ivo A. Olivotto, Tanya Berrang, and Pauline T. Truong, University of British Columbia; Wayne Beckham, University of Victoria, Victoria; Alan Nichol, University of British Columbia, Vancouver; Melanie Reed, University of British Columbia, Kelowna, British Columbia; Timothy J. Whelan, Do-Hoon Kim, Iwa Kong, and Mark N. Levine, Juravinski Cancer Centre; Timothy J. Whelan, Sameer Parpia, Do-Hoon Kim, Iwa Kong, Brandy Cochrane, Mark N. Levine, and Jim A. Julian, McMaster University; Timothy J. Whelan, Sameer Parpia, Brandy Cochrane, Mark N. Levine, and Jim A. Julian, Ontario Clinical Oncology Group, Hamilton; Anthony Fyles, Princess Margaret Hospital, University of Toronto, Toronto; Francisco Perera, London Regional Cancer Centre, University of Western Ontario, London, Ontario; Isabelle Roy, Hôpital Notre-Dame, University of Montreal, Montreal; Isabelle Germain, Hôtel-Dieu de Quebec, Laval University, Quebec City, Quebec; Mohamed Akra, Cancer Care Manitoba, University of Manitoba, Winnipeg, Manitoba; and Theresa Trotter, Tom Baker Cancer Centre, University of Calgary, Calgary, Alberta, Canada
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Parpia S, Thabane L, Julian JA, Whelan TJ, Levine MN. Empirical comparison of methods for analyzing multiple time-to-event outcomes in a non-inferiority trial: a breast cancer study. BMC Med Res Methodol 2013; 13:44. [PMID: 23517401 PMCID: PMC3610213 DOI: 10.1186/1471-2288-13-44] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2012] [Accepted: 03/12/2013] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Subjects with breast cancer enrolled in trials may experience multiple events such as local recurrence, distant recurrence or death. These events are not independent; the occurrence of one may increase the risk of another, or prevent another from occurring. The most commonly used Cox proportional hazards (Cox-PH) model ignores the relationships between events, resulting in a potential impact on the treatment effect and conclusions. The use of statistical methods to analyze multiple time-to-event events has mainly been focused on superiority trials. However, their application to non-inferiority trials is limited. We evaluate four statistical methods for multiple time-to-event endpoints in the context of a non-inferiority trial. METHODS Three methods for analyzing multiple events data, namely, i) the competing risks (CR) model, ii) the marginal model, and iii) the frailty model were compared with the Cox-PH model using data from a previously-reported non-inferiority trial comparing hypofractionated radiotherapy with conventional radiotherapy for the prevention of local recurrence in patients with early stage breast cancer who had undergone breast conserving surgery. These methods were also compared using two simulated examples, scenario A where the hazards for distant recurrence and death were higher in the control group, and scenario B. where the hazards of distant recurrence and death were higher in the experimental group. Both scenarios were designed to have a non-inferiority margin of 1.50. RESULTS In the breast cancer trial, the methods produced primary outcome results similar to those using the Cox-PH model: namely, a local recurrence hazard ratio (HR) of 0.95 and a 95% confidence interval (CI) of 0.62 to 1.46. In Scenario A, non-inferiority was observed with the Cox-PH model (HR = 1.04; CI of 0.80 to 1.35), but not with the CR model (HR = 1.37; CI of 1.06 to 1.79), and the average marginal and frailty model showed a positive effect of the experimental treatment. The results in Scenario A contrasted with Scenario B with non-inferiority being observed with the CR model (HR = 1.10; CI of 0.87 to 1.39), but not with the Cox-PH model (HR = 1.46; CI of 1.15 to 1.85), and the marginal and frailty model showed a negative effect of the experimental treatment. CONCLUSION When subjects are at risk for multiple events in non-inferiority trials, researchers need to consider using the CR, marginal and frailty models in addition to the Cox-PH model in order to provide additional information in describing the disease process and to assess the robustness of the results. In the presence of competing risks, the Cox-PH model is appropriate for investigating the biologic effect of treatment, whereas the CR models yields the actual effect of treatment in the study.
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Affiliation(s)
- Sameer Parpia
- Ontario Clinical Oncology Group, Department of Oncology, McMaster University, 711 Concession Street - G (60) Wing 1st Floor, Hamilton, ON L8V 1C3, Canada.
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Elit LM, Lee AY, Parpia S, Swystun LL, Liaw PC, Hoskins P, Julian DH, Julian JA, Levine MN. Dalteparin Low Molecular Weight Heparin (LMWH) in ovarian cancer: A phase II randomized study. Thromb Res 2012; 130:894-900. [DOI: 10.1016/j.thromres.2012.09.010] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2012] [Revised: 09/13/2012] [Accepted: 09/14/2012] [Indexed: 01/28/2023]
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You JJ, Inculet RI, Dhesy-Thind SK, Chan AM, Freeman M, Cline KJ, Pritchard KI, Dayes IS, Gu CS, Julian JA, Gulenchyn KY, Evans WK, Levine MN. Positron emission tomography/computed tomography (PET/CT) for the diagnosis of recurrent cancer (PETREC): A multicenter, prospective cohort study. J Clin Oncol 2012. [DOI: 10.1200/jco.2012.30.15_suppl.6049] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [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
6049 Background: The clinical utility of PET/CT in patients with suspected cancer recurrence remains unclear. The aim of this multi-center, prospective, comparative effectiveness study is to assess the impact of PET/CT on clinical management of patients with suspected cancer recurrence. Methods: Patients were eligible if cancer recurrence (non-small cell lung, breast, head and neck, ovarian, esophageal, Hodgkin’s or non-Hodgkin’s lymphoma) was clinically suspected, and if conventional imaging (e.g. X-ray, ultrasound, CT, or MRI) was non-diagnostic. As a pre-requisite to PET/CT booking, clinicians were asked at enrolment to indicate their planned management if PET/CT were not available. Patients then underwent 18FDG-PET/CT. Clinicians were then asked to indicate their management plan based on PET/CT findings. Patients were followed up once at 3 months. The primary outcome was change in planned management after PET/CT and was assessed independently and in duplicate by external outcome adjudicators using all available source documents. Results: 101 patients (mean age 64 y, 45% male, median 1.3 y since last treatment) were enrolled from 4 centers in Ontario, Canada between April 2009 and June 2011. Distribution of tumor types was: non-small cell lung (55%), breast (19%), ovarian (10%), esophageal (6%), lymphoma (6%), head and neck (4%). 8 patients did not complete the study (non-adherence to protocol, 2; death, 5; disease progression prior to PET/CT, 1), of whom 2 did not receive PET/CT. PET/CT changed planned management in 52 (53%) patients (Table). At 3 months, planned management was carried out in 46/52 (88%) patients. Conclusions: In patients with suspected cancer recurrence, PET/CT changes planned management from non-treatment to treatment for approximately 1 in every 3 patients (“number needed to scan” = 3) and contributes importantly to clinical management. [Table: see text]
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Affiliation(s)
| | | | | | - Adrien M. Chan
- Thunder Bay Regional Health Sciences Centre, Thunder Bay, ON, Canada
| | | | - Kathryn J. Cline
- Ontario Clinical Oncology Group, McMaster University, Hamilton, ON, Canada
| | | | | | - Chu-Shu Gu
- Ontario Clinical Oncology Group, McMaster University, Hamilton, ON, Canada
| | - Jim A Julian
- Ontario Clinical Oncology Group, McMaster University, Hamilton, ON, Canada
| | | | | | - Mark Norman Levine
- Ontario Clinical Oncology Group, McMaster University, Hamilton, ON, Canada
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Affiliation(s)
- Eva Grunfeld
- Ontario Institute for Cancer Research; University of Toronto, Toronto,Ontario, Canada
| | - Jim A. Julian
- Ontario Clinical Oncology Group; McMaster University, Hamilton,Ontario, Canada
| | - Elizabeth Maunsell
- Unité de Recherche en Santé des Populations, Université Laval, Québec,Québec, Canada
| | - Gregory Pond
- Ontario Clinical Oncology Group; McMaster University, Hamilton,Ontario, Canada
| | - Douglas Coyle
- Ottawa Health Research Institute, Ottawa, Ontario, Canada
| | - Mark N. Levine
- Ontario Clinical Oncology Group; McMaster University, Hamilton,Ontario, Canada
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Pritchard KI, Julian JA, Holloway CMB, McCready D, Gulenchyn KY, George R, Hodgson N, Lovrics P, Perera F, Elavathil L, O'Malley FP, Down N, Bodurtha A, Shelley W, Levine MN. Prospective study of 2-[¹⁸F]fluorodeoxyglucose positron emission tomography in the assessment of regional nodal spread of disease in patients with breast cancer: an Ontario clinical oncology group study. J Clin Oncol 2012; 30:1274-9. [PMID: 22393089 DOI: 10.1200/jco.2011.38.1103] [Citation(s) in RCA: 68] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
PURPOSE 2-[(18)F]fluorodeoxyglucose (FDG) positron emission tomography (PET) is potentially useful in assessing lymph nodes and detecting distant metastases in women with primary breast cancer. PATIENTS AND METHODS Women diagnosed with operable breast cancer within 3 months underwent FDG-PET at one of five Ontario study centers followed by axillary lymph node assessment (ALNA) consisting of sentinel lymph node biopsy (SLNB) alone if sentinel lymph nodes (SLNs) were negative, SLNB with axillary lymph node dissection (ALND) if SLNB or PET was positive, or ALND alone if SLNs were not identified. RESULTS Between January 2005 and March 2007, 325 analyzable women entered this study. Sentinel nodes were found for 312 (96%) of 325 women and were positive for tumor in 90 (29%) of 312. ALND was positive in seven additional women. Using ALNA as the gold standard, sensitivity for PET was 23.7% (95% CI, 15.9% to 33.6%), specificity was 99.6% (95% CI, 97.2% to 99.9%), positive predictive value was 95.8% (95% CI, 76.9% to 99.8%), negative predictive value was 75.4% (95% CI, 70.1% to 80.1%), and prevalence was 29.8% (95% CI, 25.0% to 35.2%). Using logistic regression, tumor size was predictive for prevalence of tumor in the axilla and for PET sensitivity. PET scan was suspicious for distant metastases in 13 patients; three (0.9%) were confirmed as metastatic disease and 10 (3.0%) were false positive. CONCLUSION FDG-PET is not sufficiently sensitive to detect positive axillary lymph nodes, nor is it sufficiently specific to appropriately identify distant metastases. However, the very high positive predictive value (96%) suggests that PET when positive is indicative of disease in axillary nodes, which may influence surgical care.
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Moulton CA, Levine MN, Law C, Hart R, Ruo L, Gu CS, Hendler A, Gulenchyn KY, Haider MA, Marcaccio M, Tandan V, Quan D, Jalink D, Fairfull Smith R, Luu S, Greig PD, Husien M, Finch T, Julian JA, Gallinger S. Survival analysis of PETCAM: A multicenter randomized controlled trial of PET/CT versus no PET/CT for patients with resectable liver colorectal adenocarcinoma metastases. J Clin Oncol 2012. [DOI: 10.1200/jco.2012.30.4_suppl.390] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [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
390 Background: An increasing proportion of patients with liver CAM are undergoing hepatic resection with curative intent. Detection of occult metastastic disease is important in this setting, and PET/CT is used to identify patients with either inoperable, or limited resectable extrahepatic disease not identified with conventional imaging. We recently reported the results related to the primary objective of PETCAM, a randomized trial for patients with resectable liver CAM, where 7.6% had a change in management based on PET/CT (ASCO 2011). As a secondary objective, we examined whether patients undergoing PET/CT derived a survival benefit, as they may be considered to be better selected. Methods: PETCAM was a multicenter trial with 404 subjects randomized 2:1 to receive PET/CT or no PET/CT once they were assessed by a hepatobiliary surgeon to have resectable CAM. Subjects were followed over 4 years for overall survival (OS). As well as the intervention, we considered the SUV, Fong Score and other baseline factors as predictors for OS. Results: After a median 2.8 years of follow-up, 107 of the 404 (26%) study subjects had died. The 270 PET/CT subjects [and the 245 of these who underwent surgery] showed no statistically significant survival advantage over the 134 No PET/CT subjects [123 who underwent surgery] with a hazard ratio (HR) of 0.85, 95% confidence interval (CI): 0.57 to 1.3; p=0.41 [HR=0.81, 95% CI: 0.52 to 1.3; p=0.34]. Fong score was a strong predictor of OS for all patients (HR=1.4, 95% CI: 1.1 to 1.6), and for those who had surgery (HR=1.4, 95% CI, 1.1 to 1.7). In the PET/CT arm, SUV is strongly predictive of OS [HR per unit SUV increase =1.11, 95% CI: 1.05 to 1.18; p=0.0007. Conclusions: The addition of PET/CT had no effect on improving overall survival for patients who did or did not have hepatic resection for CAM. SUV is strongly predictive of survival for patients who had PET/CT, and Fong score is predictive of survival for all patients. The overall role of PET/CT in patients with resectable CAM appears limited and should be reevaluated in the current era of comparative effectiveness research and health care cost containment.
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Affiliation(s)
- Carol-anne Moulton
- Toronto General Hospital, Toronto, ON, Canada; McMaster University, Hamilton, ON, Canada; Sunnybrook Odette Cancer Centre, Toronto, ON, Canada; St. Joseph's Health Centre, Toronto, ON, Canada; McMaster University Medical Centre, Hamilton, ON, Canada; Ontario Clinical Oncology Group, Hamilton, ON, Canada; Mount Sinai Hospital, Toronto, ON, Canada; Hamilton Health Sciences, Hamilton, ON, Canada; Department of Medical Imaging, Princess Margaret Hospital and University of Toronto, Toronto, ON, Canada; St
| | - Mark Norman Levine
- Toronto General Hospital, Toronto, ON, Canada; McMaster University, Hamilton, ON, Canada; Sunnybrook Odette Cancer Centre, Toronto, ON, Canada; St. Joseph's Health Centre, Toronto, ON, Canada; McMaster University Medical Centre, Hamilton, ON, Canada; Ontario Clinical Oncology Group, Hamilton, ON, Canada; Mount Sinai Hospital, Toronto, ON, Canada; Hamilton Health Sciences, Hamilton, ON, Canada; Department of Medical Imaging, Princess Margaret Hospital and University of Toronto, Toronto, ON, Canada; St
| | - Calvin Law
- Toronto General Hospital, Toronto, ON, Canada; McMaster University, Hamilton, ON, Canada; Sunnybrook Odette Cancer Centre, Toronto, ON, Canada; St. Joseph's Health Centre, Toronto, ON, Canada; McMaster University Medical Centre, Hamilton, ON, Canada; Ontario Clinical Oncology Group, Hamilton, ON, Canada; Mount Sinai Hospital, Toronto, ON, Canada; Hamilton Health Sciences, Hamilton, ON, Canada; Department of Medical Imaging, Princess Margaret Hospital and University of Toronto, Toronto, ON, Canada; St
| | - Richard Hart
- Toronto General Hospital, Toronto, ON, Canada; McMaster University, Hamilton, ON, Canada; Sunnybrook Odette Cancer Centre, Toronto, ON, Canada; St. Joseph's Health Centre, Toronto, ON, Canada; McMaster University Medical Centre, Hamilton, ON, Canada; Ontario Clinical Oncology Group, Hamilton, ON, Canada; Mount Sinai Hospital, Toronto, ON, Canada; Hamilton Health Sciences, Hamilton, ON, Canada; Department of Medical Imaging, Princess Margaret Hospital and University of Toronto, Toronto, ON, Canada; St
| | - Leyo Ruo
- Toronto General Hospital, Toronto, ON, Canada; McMaster University, Hamilton, ON, Canada; Sunnybrook Odette Cancer Centre, Toronto, ON, Canada; St. Joseph's Health Centre, Toronto, ON, Canada; McMaster University Medical Centre, Hamilton, ON, Canada; Ontario Clinical Oncology Group, Hamilton, ON, Canada; Mount Sinai Hospital, Toronto, ON, Canada; Hamilton Health Sciences, Hamilton, ON, Canada; Department of Medical Imaging, Princess Margaret Hospital and University of Toronto, Toronto, ON, Canada; St
| | - Chu-Shu Gu
- Toronto General Hospital, Toronto, ON, Canada; McMaster University, Hamilton, ON, Canada; Sunnybrook Odette Cancer Centre, Toronto, ON, Canada; St. Joseph's Health Centre, Toronto, ON, Canada; McMaster University Medical Centre, Hamilton, ON, Canada; Ontario Clinical Oncology Group, Hamilton, ON, Canada; Mount Sinai Hospital, Toronto, ON, Canada; Hamilton Health Sciences, Hamilton, ON, Canada; Department of Medical Imaging, Princess Margaret Hospital and University of Toronto, Toronto, ON, Canada; St
| | - Aaron Hendler
- Toronto General Hospital, Toronto, ON, Canada; McMaster University, Hamilton, ON, Canada; Sunnybrook Odette Cancer Centre, Toronto, ON, Canada; St. Joseph's Health Centre, Toronto, ON, Canada; McMaster University Medical Centre, Hamilton, ON, Canada; Ontario Clinical Oncology Group, Hamilton, ON, Canada; Mount Sinai Hospital, Toronto, ON, Canada; Hamilton Health Sciences, Hamilton, ON, Canada; Department of Medical Imaging, Princess Margaret Hospital and University of Toronto, Toronto, ON, Canada; St
| | - Karen Y. Gulenchyn
- Toronto General Hospital, Toronto, ON, Canada; McMaster University, Hamilton, ON, Canada; Sunnybrook Odette Cancer Centre, Toronto, ON, Canada; St. Joseph's Health Centre, Toronto, ON, Canada; McMaster University Medical Centre, Hamilton, ON, Canada; Ontario Clinical Oncology Group, Hamilton, ON, Canada; Mount Sinai Hospital, Toronto, ON, Canada; Hamilton Health Sciences, Hamilton, ON, Canada; Department of Medical Imaging, Princess Margaret Hospital and University of Toronto, Toronto, ON, Canada; St
| | - Masoom A. Haider
- Toronto General Hospital, Toronto, ON, Canada; McMaster University, Hamilton, ON, Canada; Sunnybrook Odette Cancer Centre, Toronto, ON, Canada; St. Joseph's Health Centre, Toronto, ON, Canada; McMaster University Medical Centre, Hamilton, ON, Canada; Ontario Clinical Oncology Group, Hamilton, ON, Canada; Mount Sinai Hospital, Toronto, ON, Canada; Hamilton Health Sciences, Hamilton, ON, Canada; Department of Medical Imaging, Princess Margaret Hospital and University of Toronto, Toronto, ON, Canada; St
| | - Michael Marcaccio
- Toronto General Hospital, Toronto, ON, Canada; McMaster University, Hamilton, ON, Canada; Sunnybrook Odette Cancer Centre, Toronto, ON, Canada; St. Joseph's Health Centre, Toronto, ON, Canada; McMaster University Medical Centre, Hamilton, ON, Canada; Ontario Clinical Oncology Group, Hamilton, ON, Canada; Mount Sinai Hospital, Toronto, ON, Canada; Hamilton Health Sciences, Hamilton, ON, Canada; Department of Medical Imaging, Princess Margaret Hospital and University of Toronto, Toronto, ON, Canada; St
| | - Ved Tandan
- Toronto General Hospital, Toronto, ON, Canada; McMaster University, Hamilton, ON, Canada; Sunnybrook Odette Cancer Centre, Toronto, ON, Canada; St. Joseph's Health Centre, Toronto, ON, Canada; McMaster University Medical Centre, Hamilton, ON, Canada; Ontario Clinical Oncology Group, Hamilton, ON, Canada; Mount Sinai Hospital, Toronto, ON, Canada; Hamilton Health Sciences, Hamilton, ON, Canada; Department of Medical Imaging, Princess Margaret Hospital and University of Toronto, Toronto, ON, Canada; St
| | - Douglas Quan
- Toronto General Hospital, Toronto, ON, Canada; McMaster University, Hamilton, ON, Canada; Sunnybrook Odette Cancer Centre, Toronto, ON, Canada; St. Joseph's Health Centre, Toronto, ON, Canada; McMaster University Medical Centre, Hamilton, ON, Canada; Ontario Clinical Oncology Group, Hamilton, ON, Canada; Mount Sinai Hospital, Toronto, ON, Canada; Hamilton Health Sciences, Hamilton, ON, Canada; Department of Medical Imaging, Princess Margaret Hospital and University of Toronto, Toronto, ON, Canada; St
| | - Diederick Jalink
- Toronto General Hospital, Toronto, ON, Canada; McMaster University, Hamilton, ON, Canada; Sunnybrook Odette Cancer Centre, Toronto, ON, Canada; St. Joseph's Health Centre, Toronto, ON, Canada; McMaster University Medical Centre, Hamilton, ON, Canada; Ontario Clinical Oncology Group, Hamilton, ON, Canada; Mount Sinai Hospital, Toronto, ON, Canada; Hamilton Health Sciences, Hamilton, ON, Canada; Department of Medical Imaging, Princess Margaret Hospital and University of Toronto, Toronto, ON, Canada; St
| | - Robin Fairfull Smith
- Toronto General Hospital, Toronto, ON, Canada; McMaster University, Hamilton, ON, Canada; Sunnybrook Odette Cancer Centre, Toronto, ON, Canada; St. Joseph's Health Centre, Toronto, ON, Canada; McMaster University Medical Centre, Hamilton, ON, Canada; Ontario Clinical Oncology Group, Hamilton, ON, Canada; Mount Sinai Hospital, Toronto, ON, Canada; Hamilton Health Sciences, Hamilton, ON, Canada; Department of Medical Imaging, Princess Margaret Hospital and University of Toronto, Toronto, ON, Canada; St
| | - Shelly Luu
- Toronto General Hospital, Toronto, ON, Canada; McMaster University, Hamilton, ON, Canada; Sunnybrook Odette Cancer Centre, Toronto, ON, Canada; St. Joseph's Health Centre, Toronto, ON, Canada; McMaster University Medical Centre, Hamilton, ON, Canada; Ontario Clinical Oncology Group, Hamilton, ON, Canada; Mount Sinai Hospital, Toronto, ON, Canada; Hamilton Health Sciences, Hamilton, ON, Canada; Department of Medical Imaging, Princess Margaret Hospital and University of Toronto, Toronto, ON, Canada; St
| | - Paul David Greig
- Toronto General Hospital, Toronto, ON, Canada; McMaster University, Hamilton, ON, Canada; Sunnybrook Odette Cancer Centre, Toronto, ON, Canada; St. Joseph's Health Centre, Toronto, ON, Canada; McMaster University Medical Centre, Hamilton, ON, Canada; Ontario Clinical Oncology Group, Hamilton, ON, Canada; Mount Sinai Hospital, Toronto, ON, Canada; Hamilton Health Sciences, Hamilton, ON, Canada; Department of Medical Imaging, Princess Margaret Hospital and University of Toronto, Toronto, ON, Canada; St
| | - Mohamed Husien
- Toronto General Hospital, Toronto, ON, Canada; McMaster University, Hamilton, ON, Canada; Sunnybrook Odette Cancer Centre, Toronto, ON, Canada; St. Joseph's Health Centre, Toronto, ON, Canada; McMaster University Medical Centre, Hamilton, ON, Canada; Ontario Clinical Oncology Group, Hamilton, ON, Canada; Mount Sinai Hospital, Toronto, ON, Canada; Hamilton Health Sciences, Hamilton, ON, Canada; Department of Medical Imaging, Princess Margaret Hospital and University of Toronto, Toronto, ON, Canada; St
| | - Terri Finch
- Toronto General Hospital, Toronto, ON, Canada; McMaster University, Hamilton, ON, Canada; Sunnybrook Odette Cancer Centre, Toronto, ON, Canada; St. Joseph's Health Centre, Toronto, ON, Canada; McMaster University Medical Centre, Hamilton, ON, Canada; Ontario Clinical Oncology Group, Hamilton, ON, Canada; Mount Sinai Hospital, Toronto, ON, Canada; Hamilton Health Sciences, Hamilton, ON, Canada; Department of Medical Imaging, Princess Margaret Hospital and University of Toronto, Toronto, ON, Canada; St
| | - Jim A Julian
- Toronto General Hospital, Toronto, ON, Canada; McMaster University, Hamilton, ON, Canada; Sunnybrook Odette Cancer Centre, Toronto, ON, Canada; St. Joseph's Health Centre, Toronto, ON, Canada; McMaster University Medical Centre, Hamilton, ON, Canada; Ontario Clinical Oncology Group, Hamilton, ON, Canada; Mount Sinai Hospital, Toronto, ON, Canada; Hamilton Health Sciences, Hamilton, ON, Canada; Department of Medical Imaging, Princess Margaret Hospital and University of Toronto, Toronto, ON, Canada; St
| | - Steven Gallinger
- Toronto General Hospital, Toronto, ON, Canada; McMaster University, Hamilton, ON, Canada; Sunnybrook Odette Cancer Centre, Toronto, ON, Canada; St. Joseph's Health Centre, Toronto, ON, Canada; McMaster University Medical Centre, Hamilton, ON, Canada; Ontario Clinical Oncology Group, Hamilton, ON, Canada; Mount Sinai Hospital, Toronto, ON, Canada; Hamilton Health Sciences, Hamilton, ON, Canada; Department of Medical Imaging, Princess Margaret Hospital and University of Toronto, Toronto, ON, Canada; St
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Schulman S, Parpia S, Stewart C, Rudd-Scott L, Julian JA, Levine M. Warfarin dose assessment every 4 weeks versus every 12 weeks in patients with stable international normalized ratios: a randomized trial. Ann Intern Med 2011; 155:653-9, W201-3. [PMID: 22084331 DOI: 10.7326/0003-4819-155-10-201111150-00003] [Citation(s) in RCA: 73] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Guidelines recommend that patients receiving warfarin undergo international normalized ratio (INR) monitoring every 4 weeks. OBJECTIVE To investigate whether assessment of warfarin dosing every 12 weeks is as safe as assessment every 4 weeks. DESIGN Noninferiority randomized trial. The randomization schedule (in a 1:1 ratio) was computer-generated, and allocation was concealed until the database was locked by using a centralized schedule. Patients, study and clinical personnel, adjudicators of clinical events, and the study statistician were blinded to treatment assignment. (ClinicalTrials.gov registration number: NCT00356759) SETTING: Single center in Hamilton, Ontario, Canada. PATIENTS 250 patients receiving long-term warfarin therapy, whose dose was unchanged for at least 6 months; 226 completed the study. INTERVENTION Dosing assessment every 12 weeks (n = 124) compared with every 4 weeks (n = 126) for 12 months. Patients in the 12-week group were tested every 4 weeks; sham INRs within the target range were reported for two of the three 4-week periods. MEASUREMENTS Percentage of time in the therapeutic range (primary outcome) and number of extreme INRs, changes in maintenance dose, major bleeding events, objectively verified thromboembolism, and death (secondary outcomes). RESULTS The percentage of time in the therapeutic range was 74.1% (SD, 18.8%) in the 4-week group compared with 71.6% (SD, 20.0%) in the 12-week group (absolute difference, 2.5 percentage points [1-sided 97.5% upper confidence bound, 7.3 percentage points]; noninferiority P = 0.020 for a 7.5-percentage point margin). Fewer patients in the 12-week group than in the 4-week group had any dose changes (37.1% vs. 55.6%; absolute difference, 18.5 percentage points [95% CI, 6.1 to 30.0 percentage points]; P = 0.004). Secondary outcomes did not differ between groups. LIMITATIONS Patients in the 12-week group had testing and contact with clinic staff every 4 weeks. The study was conducted at a single center and used surrogate outcomes. CONCLUSION Assessment of warfarin dosing every 12 weeks seems to be safe and noninferior to assessment every 4 weeks. A comparison of INR testing, patient contact, and warfarin dose assessment every 12 weeks versus every 4 weeks is necessary before INR testing every 12 weeks can be routinely recommended for practice. PRIMARY FUNDING SOURCE Physicians' Services Incorporated Foundation.
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Affiliation(s)
- Sam Schulman
- McMaster University, Thrombosis and Atherosclerosis Research Institute, and Ontario Clinical Oncology Group, Hamilton, Ontario, Canada.
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Grunfeld E, Julian JA, Pond G, Maunsell E, Coyle D, Folkes A, Joy AA, Provencher L, Rayson D, Rheaume DE, Porter GA, Paszat LF, Pritchard KI, Robidoux A, Smith S, Sussman J, Dent S, Sisler J, Wiernikowski J, Levine MN. Evaluating survivorship care plans: results of a randomized, clinical trial of patients with breast cancer. J Clin Oncol 2011; 29:4755-62. [PMID: 22042959 DOI: 10.1200/jco.2011.36.8373] [Citation(s) in RCA: 244] [Impact Index Per Article: 18.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
PURPOSE An Institute of Medicine report recommends that patients with cancer receive a survivorship care plan (SCP). The trial objective was to determine if an SCP for breast cancer survivors improves patient-reported outcomes. PATIENTS AND METHODS Women with early-stage breast cancer who completed primary treatment at least 3 months previously were eligible. Consenting patients were allocated within two strata: less than 24 months and ≥ 24 months since diagnosis. All patients were transferred to their own primary care physician (PCP) for follow-up. In addition to a discharge visit, the intervention group received an SCP, which was reviewed during a 30-minute educational session with a nurse, and their PCP received the SCP and guideline on follow-up. The primary outcome was cancer-related distress at 12 months, assessed by the Impact of Event Scale (IES). Secondary outcomes included quality of life, patient satisfaction, continuity/coordination of care, and health service measures. RESULTS Overall, 408 survivors were enrolled through nine tertiary cancer centers. There were no differences between groups on cancer-related distress or on any of the patient-reported secondary outcomes, and there were no differences when the two strata were analyzed separately. More patients in the intervention than control group correctly identify their PCP as primarily responsible for follow-up (98.7% v 89.1%; difference, 9.6%; 95% CI, 3.9 to 15.9; P = .005). CONCLUSION The results do not support the hypothesis that SCPs are beneficial for improving patient-reported outcomes. Transferring follow-up to PCPs is considered an important strategy to meet the demand for scarce oncology resources. SCPs were no better than a standard discharge visit with the oncologist to facilitate transfer.
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Affiliation(s)
- Eva Grunfeld
- Ontario Institute for Cancer Research, Ontario, Canada.
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Parpia S, Julian JA, Thabane L, Lee AYY, Rickles FR, Levine MN. Competing events in patients with malignant disease who are at risk for recurrent venous thromboembolism. Contemp Clin Trials 2011; 32:829-33. [PMID: 21777700 DOI: 10.1016/j.cct.2011.07.005] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2011] [Revised: 06/29/2011] [Accepted: 07/04/2011] [Indexed: 12/19/2022]
Abstract
Patients with malignant disease enrolled in trials of thrombotic disorders may experience competing events such as death. The occurrence of a competing event may prevent the thrombotic event from being observed. Standard survival analysis techniques ignore competing risks, resulting in possible bias and distorted inferences. To assess the impact of competing events on the results of a previously reported trial comparing low molecular weight heparin (LMWH) with oral anticoagulant (OAC) therapy for the prevention of recurrent venous thromboembolism (VTE) in patients with advanced cancer, we compare the results from standard survival analysis with those from competing risk techniques which are based on the cumulative incidence function (CIF) and Gray's test. The Kaplan-Meier method overestimates the risk of recurrent VTE (17.2% in the OAC group and 8.7% in the LMWH group). Risk of recurrence using the CIF is 12.0% and 6.0% in the OAC and LMWH groups, respectively. Both the log-rank test (p=0.002) and Gray's test (p=0.006) suggest evidence in favor of LMWH. The overestimation of risk is 30% in each treatment group, resulting in a similar relative treatment effect; using the Cox model the hazard ratio (HR) is 0.48 (95% confidence interval [CI], 0.30 to 0.78) and HR=0.47 (95% CI, 0.29 to 0.74) using the CIF model. Failing to account for competing risks may lead to incorrect interpretations of the probability of recurrent VTE. However, when the distribution of competing risks is similar within each treatment group, standard and competing risk methods yield comparable relative treatment effects.
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Affiliation(s)
- S Parpia
- Ontario Clinical Oncology Group, Dept of Oncology, McMaster University, 711 Concession Street, 60 (G) Wing, Hamilton, ON, L8V 1C3, Canada
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Douketis JD, Julian JA, Crowther MA, Kearon C, Bates SM, Barone M, Piovella F, Middeldorp S, Prandoni P, Johnston M, Costantini L, Ginsberg JS. The effect of prothrombotic blood abnormalities on risk of deep vein thrombosis in users of hormone replacement therapy: a prospective case-control study. Clin Appl Thromb Hemost 2010; 17:E106-13. [PMID: 21159708 DOI: 10.1177/1076029610387587] [Citation(s) in RCA: 18] [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: 11/16/2022] Open
Abstract
BACKGROUND Few studies have assessed the effect of prothrombotic blood abnormalities on the risk of deep vein thrombosis (DVT) with hormone replacement therapy (HRT). METHODS We studied postmenopausal women with suspected DVT in whom HRT use and prothrombotic blood abnormalities were sought. Cases had unprovoked DVT and controls had no DVT and without DVT risk factors. The risk of DVT was determined in women with and without prothrombotic abnormalities. RESULTS A total of 510 postmenopausal women with suspected DVT were assessed; 57 cases and 283 controls were identified. Compared to HRT, nonusers without the factor V Leiden mutation, the risk of DVT was increased in estrogen-progestin HRT users (odds ratio [OR], 3.2; 95% confidence interval [CI]: 1.2-8.6) and in nonusers with the factor V Leiden mutation (OR, 5.3; 1.9-15.4) and appears multiplied in users of estrogen-progestin HRT with the factor V Leiden mutation (OR, 17.1; 3.7-78). Compared to HRT, nonusers with normal factor VIII, the risk of DVT was increased in estrogen-progestin HRT users with normal factor VIII (OR, 2.8; 1.0-7.9) and in HRT nonusers with the highest factor VIII quartile (OR, 6.0; 2.1-17), and appears to be multiplied in women who are users of estrogen-progestin HRT with the highest factor VIII quartile (OR, 17.0; 3.6-80). CONCLUSIONS In postmenopausal women who are estrogen-progestin HRT users, the presence of the factor V Leiden mutation or an elevated factor VIII level appears to have a multiplicative effect on their overall risk of DVT, increasing it 17-fold compared to women without these blood abnormalities who are HRT nonusers.
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Affiliation(s)
- Jim D Douketis
- Department of Medicine, McMaster University, Hamilton, Canada.
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Elit L, Levine MN, Julian JA, Sellors JW, Lytwyn A, Chong S, Mahony JB, Gu C, Finch T, Zeferino LC. Expectant management versus immediate treatment for low-grade cervical intraepithelial neoplasia. Cancer 2010; 117:1438-45. [DOI: 10.1002/cncr.25635] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2010] [Revised: 08/03/2010] [Accepted: 08/04/2010] [Indexed: 11/10/2022]
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Abstract
BACKGROUND Rate of major bleeding is generally accepted as a good measure of the risks associated with anticoagulant therapy, but this may not be true if the proportion of major bleeds with the most serious consequences differs according to the indication for anticoagulant therapy. OBJECTIVE To determine whether the indication for long-term oral anticoagulant therapy influences the proportion of major bleeds that are intracranial and fatal. PATIENTS/METHODS Two authors abstracted intracranial and fatal bleeds from randomized trials of patients who received anticoagulant therapy for a minimum of 6months for atrial fibrillation, ischemic heart disease, venous thromboembolism, prosthetic heart valves and ischemic stroke. RESULTS There were 877 major bleeds among 23,518 patients in 39 studies. The proportion of bleeds that were intracranial was significantly higher in patients with ischemic stroke (36%; 95% CI, 22-52%; P=0.02) compared with patients with venous thromboembolism (10%; 95% CI, 5-20%). The difference in the proportion of bleeds that were intracranial among atrial fibrillation, ischemic heart disease, venous thromboembolism and prosthetic heart valves was not statistically significant; however, the estimates varied from 10% to 27%. The proportion of bleeds that were fatal did not differ significantly according to indication, but varied from 8% to 20%. For all indications for anticoagulation, intracranial bleeds were much more likely to be fatal than extracranial major bleeds (44% vs. 4% overall). CONCLUSIONS In current practise, the indication for oral anticoagulant therapy has limited influence on the proportion of major bleeds that are intracranial or fatal.
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Affiliation(s)
- L Linkins
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada.
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Perry JR, Julian JA, Laperriere NJ, Geerts W, Agnelli G, Rogers LR, Malkin MG, Sawaya R, Baker R, Falanga A, Parpia S, Finch T, Levine MN. PRODIGE: a randomized placebo-controlled trial of dalteparin low-molecular-weight heparin thromboprophylaxis in patients with newly diagnosed malignant glioma. J Thromb Haemost 2010; 8:1959-65. [PMID: 20598077 DOI: 10.1111/j.1538-7836.2010.03973.x] [Citation(s) in RCA: 175] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
BACKGROUND AND OBJECTIVES Venous thromboembolism (VTE) occurs in 20-30% of patients with malignant glioma per year of survival. We tested the efficacy of long-term dalteparin low-molecular-weight heparin (LMWH) for prevention of VTE in these patients. PATIENTS/METHODS Adults with newly diagnosed malignant glioma were randomized to receive dalteparin 5000 anti-Xa units or placebo, both subcutaneously once daily for 6 months starting within 4 weeks of surgery. Treatment continued for up to 12 months. The primary outcome was the cumulative risk of VTE over 6 months. The target sample size was 512 patients. Events were adjudicated by a committee unaware of treatment. RESULTS The trial began in 2002 and closed in May 2006 because of expiration of study medication. Ninety-nine patients were randomized to LMWH and 87 to placebo. Twenty-two patients developed VTE in the first 6 months: nine in the LMWH group and 13 in the placebo group [hazard ratio (HR) = 0.51, 95% confidence interval (CI): 0.19-1.4, P = 0.29]. At 6 months, there were three major bleeds on LMWH and none on placebo; at 12 months, 5 (5.1%) major bleeds on LMWH and 1 (1.2%) on placebo occurred (HR = 4.2, 95% CI: 0.48-36, P = 0.22). All major bleeds were intracranial and occurred while on study medication. The 12-month mortality rates were 47.8% for LMWH and 45.4% for placebo (HR = 1.2, 95% CI: 0.73-2.0, P = 0.48). CONCLUSIONS Trends suggesting reduced VTE and increased intracranial bleeding were seen in the LMWH thromboprophylaxis group. The role of long-term anticoagulant thromboprophylaxis in patients with brain tumors remains uncertain.
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Affiliation(s)
- J R Perry
- Division of Neurology, Sunnybrook Health Science Centre, Toronto Ontario, Canada.
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