Advancing Digital Health Innovation in Oncology: Priorities for High-Value Digital Transformation in Cancer Care

Although health care delivery is becoming increasingly digitized, driven by the pursuit of improved access, equity, efficiency, and effectiveness, progress does not appear to be equally distributed across therapeutic areas. Oncology is renowned for leading innovation in research and in care; digital pathology, digital radiology, real-world data, next-generation sequencing, patient-reported outcomes, and precision approaches driven by complex data and biomarkers are hallmarks of the field. However, remote patient monitoring, decentralized approaches to care and research, "hospital at home," and machine learning techniques have yet to be broadly deployed to improve cancer care. In response, the Digital Medicine Society and Moffitt Cancer Center convened a multistakeholder roundtable discussion to bring together leading experts in cancer care and digital innovation. This viewpoint highlights the findings from these discussions, in which experts agreed that digital innovation is lagging in oncology relative to other therapeutic areas. It reports that this lag is most likely attributed to poor articulation of the challenges in cancer care and research best suited to digital solutions, lack of incentives and support, and missing standardized infrastructure to implement digital innovations. It concludes with suggestions for actions needed to bring the promise of digitization to cancer care to improve lives.

Oncology Medical Home: ASCO and COA Standards

PURPOSE

To provide Standards on the basis of evidence and expert consensus for a pilot of the Oncology Medical Home (OMH) certification program. The OMH model is a system of care delivery that features coordinated, efficient, accessible, and evidence-based care and includes a process for measurement of outcomes to facilitate continuous quality improvement. The OMH pilot is intended to inform further refinement of Standards for OMH model implementation.

METHODS

An Expert Panel was formed, and a systematic review of the literature on the topics of OMH, clinical pathways, and survivorship care plans was performed using PubMed and Google Scholar. Using this evidence base and an informal consensus process, the Expert Panel developed a set of OMH Standards. Public comments were solicited and considered in preparation of the final manuscript.

RESULTS

Three comparative peer-reviewed studies of OMH met the inclusion criteria. In addition, the results from 16 studies of clinical pathways and one systematic review of survivorship care plans informed the evidence review. Limitations of the evidence base included the small number of studies of OMH and lack of longer-term outcomes data. More data were available to inform the specific Standards for pathways and survivorship care; however, outcomes were mixed for the latter intervention. The Expert Panel concluded that in the future, practices should be encouraged to publish the results of OMH interventions in peer-reviewed journals to improve the evidence base.

STANDARDS

Standards are provided for OMH in the areas of patient engagement, availability and access to care, evidence-based medicine, equitable and comprehensive team-based care, quality improvement, goals of care, palliative and end-of-life care discussions, and chemotherapy safety. Additional information, including a Standards implementation manual, is available at www.asco.org/standards.

Integrating Somatic and Germline Next-Generation Sequencing Into Routine Clinical Oncology Practice

Next-generation sequencing (NGS) is rapidly expanding into routine oncology practice. Genetic variations in both the cancer and inherited genomes are informative for hereditary cancer risk, prognosis, and treatment strategies. Herein, we focus on the clinical perspective of integrating NGS results into patient care to assist with therapeutic decision making. Five key considerations are addressed for operationalization of NGS testing and application of results to patient care as follows: (1) NGS test ordering and workflow design; (2) result reporting, curation, and storage; (3) clinical consultation services that provide test interpretations and identify opportunities for molecularly guided therapy; (4) presentation of genetic information within the electronic health record; and (5) education of providers and patients. Several of these key considerations center on informatics tools that support NGS test ordering and referencing back to the results for therapeutic purposes. Clinical decision support tools embedded within the electronic health record can assist with NGS test utilization and identifying opportunities for targeted therapy including clinical trial eligibility. Challenges for project and change management in operationalizing NGS-supported, evidence-based patient care in the context of current information technology systems with appropriate clinical data standards are discussed, and solutions for overcoming barriers are provided.

The effect of clinical pathways utilization on total cost of care for the treatment of prostate cancer

20

Background: Moffitt Cancer Center (MCC) has developed evidence-based cancer care pathways which are integrated into the Electronic Health Record (EHR). We retrospectively compared the 1 year (yr) total cost of care in patients (pts) with newly diagnosed prostate cancer (PCA) treated at MCC based on EHR tool utilization and pathway alignment. Methods: Using existing Cancer Registry data, we retrospectively identified all pts presenting with newly diagnosed PCA between 7/1/2015-6/30/2017 who received all 1st course treatment (tx) at MCC. Pts direct costs were tracked for 1 yr from the Cancer Registry “date of 1st contact.” Tx was categorized as either radiation (RT) +/- hormone tx (HT), surgery (S) +/- HT, active surveillance only (ASO), HT only, palliative care, chemotherapy (CT), or mixed (a combination of S, RT, or CT). Pathway alignment was either electronically tracked through the EHR pathway tool or determined through manual chart review for pts tx’ed off the pathway tool. Results: 477 pts met inclusion criteria, including men with: low or favorable intermediate (n=259); unfavorable intermediate, high, or very high (n=186); and metastatic (n=32) risk group PCA. The majority (n=396, 83%) had tx in alignment with a pathway. The major tx modalities on pathway were S-HT (n=139), RT-HT (n=113), or ASO (n=110) and off pathway were RT-HT (n=52, 64%), S-HT (n=10), or ASO (n=9). Overall, treatment in alignment with a pathway was significantly associated with lower 1 yr total cost compared to off pathway tx (p <0.001) with a mean difference of $5,500 per pt yr. Conclusions: Clinical pathway alignment was significantly associated with less aggressive therapy and lower 1 yr cost of care for PCA pts treated at MCC. Cost of care was highly associated with tx modality selected. Further analyses are needed to understand the association between pathway alignment, patient risk factors and tx modality selection.

Understanding differences in total cancer care cost by service site

e18345

Background: Oncology providers are under mounting pressure to deliver high quality and increasingly complex cancer treatment while simultaneously managing the cost pressures coming from payers and patients alike. Developing an effective strategy to compare costs can be an important tool for assessing and improving performance and cost effectiveness from both a clinical and market competitive standpoint. This comparison can be difficult to achieve in practice, especially between different sites of care and across heterogeneous patient populations. Methods: A large commercial claims dataset with reimbursement data for claims incurred between 2014 and 2017 was used to identify lung cancer patients by site of care. We calculated average annual total cost of care (TCC) for a one year period for patients with a new cancer diagnosis following a one year period of no claims for lung cancer. For study purposes, Moffitt Cancer Center (MCC) was compared to two other peer groups: Large Hospital Systems (LHS) and small hospitals and community-based oncology practices (CBOP). Patients were assigned to each peer group when a majority of claims ( > 70%) were attributed to one of the peer groups. We analyzed overall average annual TCC for all patients and then created a sub-cohort of patients who received surgery within the study period to define early stage patients based on known standard patterns of care for newly diagnosed lung cancer. Results: There were 1249 new lung cancer patients in the study across all three peer groups with an average annual TCC of $134K per patient (range: $110K to $149K). When considering the sub-cohort of early stage patients (n = 396), MCC’s average annual TCC was $124K per patient which was significantly lower than LHS ($152K; p < 0.0499) and CBOP ($167K; p < 0.01). Conclusions: Although claims data generally contain only limited clinical information such as procedures, supplies and diagnosis, this limitation can be address by incorporating known standard of care patterns for cancer treatment to create comparable groups. Using this approach, national claims sets can be leveraged as the basis of a powerful analysis tool for understanding the Total Cost of Cancer care across institutional boundaries while still achieving meaningful comparability of the analyzed patient population.

Using cancer registry data to improve adherence with breast cancer pathways

127

Background: Evidence-based clinical pathways have been shown to improve quality and cost effectiveness. Moffitt Cancer Center (MCC) has developed clinical pathways for more than 50 cancer sites. Using data derived from multiple sources, we performed a series of measurements of adherence to breast cancer (ca) pathways, provided clinician feedback and evaluated changes over time. Methods: We developed an automated method to evaluate pathway adherence for 1st line systemic treatment (tx) recommendations using data from Stages I-IV analytic breast ca cases presenting to MCC for tx during calendar years (CY) 2013-2015. As a baseline, cases were manually audited for adherence in CY 2012. Data sources included Cancer Registry and electronic health record (EHR). A patient (pt) was considered “On” pathway if the correct tx, including relevant clinical trials, was administered based on various prognostic and clinical factors. Only pts who received all 1st line systemic tx at MCC were included. Pts who refused txor had contraindications, non-applicable histologies or multiple primary cancers were excluded. The EHR was reviewed to assure the accuracy of “Off” pathway determinations. Results: A total of 3727 analytic breast ca cases were seen at MCC between CY 2012-2015; 873 met all criteria and were eligible for analysis. 80% was set as an institutional target for adherence. The following table displays yearly trends for pts “On Pathway” for all applicable chemotherapy, immunotherapy and hormonal tx. Conclusions: Cancer Registry and EHR data can be used to automate surveillance of pathway adherence creating a feedback loop to clinicians who can, in turn, improve adherence over time. [Table: see text]

Building a provider network based on quality: The Moffitt Oncology Network initiative

49

Background: Before entering into risk bearing contracts with payors, ACOs are challenged to find a basis for forming partnerships. Specialty ACO networks, in particular, must find ways to provide a common, high standard of care among a typically varied set of partners. The Moffitt Oncology Network (MON) Initiative demonstrates a possible solution to forming a value based ACO network across a broad geographical area that is based upon using clinical pathways. Methods: Moffitt Cancer Center (MCC) has developed more than 24 different disease specific pathways. The MCC pathways translate evidence-based guidelines into personalized cancer care throughout the continuum of care from evaluation to treatment. MCC is using these pathways with other hospital systems and physician groups throughout the MON. To enhance the use of pathways in the MON, MCC uses Clinical Performance and Value (CPV) Vignettes. CPV’s, are virtual patient cases related to the specific clinical pathways. The report herein is on pathway implementation in several disease areas (breast, lung and gastrointestinal (GI) cancers) across multiple sites: Lehigh Valley Hospital (Pennsylvania), Norton Cancer Institute (Kentucky), and Space Coast Cancer Center (Florida). Results: Pathway based clinical care was measured at baseline using CPVs across disease and site (Table). A total of 67 breast cancer providers took 131 breast cancer vignettes; 35 lung cancer providers took 104 lung cancer vignettes; and to date 27 GI cancer providers have taken 54 GI vignettes. There is statistically significant variation in performance among providers and between sites. This is manifest in pathway-specified areas of work-up, diagnosis, and treatment. Conclusions: Fostering adoption of clinical pathways is a practical objective that can help guide the formation of an ACO oncology network. This may be useful for forming specialty ACOs that establish a standard of care and set the stage for adopting new payment models with payors. [Table: see text]

Measuring clinical pathway compliance using a simulated patient approach with clinical performance and value (CPV) vignettes

96

Background: Although clinical pathways have the promise to improve the quality of care, they have had limited success changing practice or standardizing care. Moffitt Cancer Center (MCC) has > 40 pathways incorporating interdisciplinary care strategies linked to evidence and decision support tools. Methods: To improve compliance with pathways we used an innovative measure to quantify quality of care, CPV vignettes. CPV vignettes are validated, simulated clinical scenarios constructed so that adherence to pathways is clear-cut. Providers care for identical cases so there is no need for case mix adjustment. After completing each case, providers are given personalized feedback. Twelve breast cancer (ca) vignettes were developed by MCC breast medical oncologists and surgeons and QURE, a healthcare measurement company. The cases were developed using MCC pathways, other evidence and core issues such as diagnostic work-up. The vignettes were randomized at the department level and given to all MCC providers who care for breast ca patients. A total of 18 providers took 34 CPVs: 7 medical oncologists, 6 advanced practitioners and 5 surgeons. QURE-trained physician abstractors blinded to the CPV-taker’s identity scored each vignette and provided confidential feedback. Results: Total scores for providers averaged 55.4%, s.d. 12.5%, a typical score for a CPV baseline study. Adherence to pathways varied by area with the highest concordance for radiation and hormonal therapy and the lowest for management of axillary lymph nodes (see Table). Conclusions: Adherence to pathways varied among providers and by clinical domain. Ongoing efforts will evaluate the impact of serial CPV measurement on pathway adherence. Simulations simplified the task of determining pathway adherence making pathway compliance at the physician level a reasonable expectation and standardization at the group level scientifically rigorous and feasible. [Table: see text]

A provider-payor approach for determining value in the health reform era: Early reports on the mQure initiative

255

Background: Determining value requires detailed measurement of clinical services and associated costs. In the health reform era value demonstration presents a challenge for both providers and payors: providers, unable to demonstrate value, will be unable to attract payors or patients and expand market share; payors, unable to choose the right providers, will lose opportunities to lower costs and raise quality. Methods: In July 2012, the Moffitt Cancer Center (MCC) launched the mQure (MCC – Quality Understanding Research and Evidence) Initiative to (1) measure and improve clinical performance, (2) increase compliance to evidence-based/cost conscious cancer-care pathways, and (3) demonstrate value. We introduced Clinical Performance and Value (CPV) vignettes, a value measurement tool, to measure pathway adherence, determine diagnostic accuracy and appropriate use of diagnostic tools starting with breast and lung cancer. For selected performance items identified by the CPVs, we audited medical records directly. Results: Measurement revealed high value practices, for example, diagnostic accuracy, appropriate rates of biopsy and more accurate staging compared to other groups. Value determination led to one signed plus two pending payor partnerships to implement a shared savings contract, find ways to reduce utilization and explore creating payor-led networks. The focus on individual responsibility for adherence to evidence-based practices has had an unanticipated and seemingly paradoxical benefit of shifting the group to narrow practice variation thereby shifting providers to a more self-aware culture. An external benefit is that the value signal has led to discussions to form accountable care organization (ACO) networks for cancer care. Since mQure’s inception, MCC has created partnerships with 3 hospitals. Based on the breast cancer initiative alone, financial models indicate an estimated savings of up to $2 million annually that arise from higher quality, fewer unnecessary tests and improved pathway compliance. Conclusions: In just one year, the large scale mQure project has led to expanded provider partnerships, new quality-based arrangements with payors and the formation a specialty-ACO.

Phase I Study of Topotecan, Ifosfamide, and Etoposide (TIME) with autologous stem cell transplant in refractory cancer: pharmacokinetic and pharmacodynamic correlates

PURPOSE

To determine the maximum tolerated dose (MTD) of topotecan in combination with ifosfamide, mesna, and etoposide (TIME), followed by autologous hematopoietic cell transplant (HCT), in patients with chemotherapy-refractory malignancies.

EXPERIMENTAL DESIGN

Patients were treated with (in mg/m(2)/d) ifosfamide 3,333, mesna 3,333, and topotecan 3.3 to 28.3 during days -8 through -6 and etoposide 500 (days -5 through -3) followed by HCT on day 0. Once MTD was defined, we expanded this dosing cohort to include patients with high-risk lymphoma due to activity seen during dose escalation. Topotecan pharmacokinetic analyses were carried out, and topoisomerase I levels and activity were measured.

RESULTS

The topotecan MTD in this regimen was 64 mg/m(2) (21.3 mg/m(2)/d). Mucositis was dose limiting and correlated with topotecan dose level and area under the curve (AUC). Dose level was also correlated with length of hospitalization, number of days of parenteral nutrition, and neutrophil and platelet engraftment. Topotecan AUC was significantly correlated with time to platelet recovery. The baseline peripheral blood mononuclear cell topoisomerase I level was found to be a significant positive predictor for overall and progression-free survival. Topotecan AUC was positively correlated with dose level, with a trend toward decreasing clearance with increasing dose.

CONCLUSION

Topotecan can be a useful drug in the high-dose setting given its activity in some malignancies when given in standard dose. Pharmacokinetic monitoring may be a valuable tool for optimizing the use of topotecan and to avoid toxicity seen with high-systemic exposures. Baseline topoisomerase I levels may have an important role in predicting topotecan efficacy.

Allogeneic hematopoietic cell transplantation for metastatic breast cancer

We reviewed 66 women with poor-risk metastatic breast cancer from 15 centers to describe the efficacy of allogeneic hematopoietic cell transplantation (HCT). Median follow-up for survivors was 40 months (range, 3-64). A total of 39 patients (59%) received myeloablative and 27 (41%) reduced-intensity conditioning (RIC) regimens. More patients in the RIC group had poor pretransplant performance status (63 vs 26%, P=0.002). RIC group developed less chronic GVHD (8 vs 36% at 1 year, P=0.003). Treatment-related mortality rates were lower with RIC (7 vs 29% at 100 days, P=0.03). A total of 9 of 33 patients (27%) who underwent immune manipulation for persistent or progressive disease had disease control, suggesting a graft-vs-tumor (GVT) effect. Progression-free survival (PFS) at 1 year was 23% with myeloablative conditioning and 8% with RIC (P=0.09). Women who developed acute GVHD after an RIC regimen had lower risks of relapse or progression than those who did not (relative risk, 3.05: P=0.03), consistent with a GVT effect, but this did not affect PFS. These findings support the need for preclinical and clinical studies that facilitate targeted adoptive immunotherapy for breast cancer to explore the benefit of a GVT effect in breast cancer.

Changes in cognitive functioning in the year after hematopoietic stem cell transplantation

BACKGROUND

The current study examined changes in multiple domains of cognitive functioning of hematopoietic stem cell transplantation (HSCT) candidates tested pretransplantation, 6 months posttransplantation, and 12 months posttransplantation.

METHODS

Using a sequential longitudinal design, 476 patients were randomized to be tested at all 3 time points, at 6 and 12 months posttransplantation, or at only 12 months posttransplantation. Participants completed a comprehensive battery of neuropsychologic tests that indexed memory, psychomotor speed, attention, and executive functioning, and provided a total neuropsychologic performance score (TNP).

RESULTS

The results indicate that performance on cognitive abilities, except for attention, significantly improved across the 1-year follow-up period after HSCT. Performance on the TNP and all cognitive domains was superior or equal to population normative values by the 12-month measurement point. The results also indicate that repeated exposure to tests led to better performance on motor speed and the TNP and that attrition influenced the TNP, such that those who remained in the longitudinal sample exhibited greater longitudinal improvement in scores as compared with patients who left the sample.

CONCLUSIONS

The findings of the current study suggest that although patients undergoing HSCT experience cognitive deficits during the period just before transplantation, cognitive functioning returns to normative values within a year after transplantation.

Valganciclovir is safe and effective as pre-emptive therapy for CMV infection in allogeneic hematopoietic stem cell transplantation

Despite significant advances in prevention and therapy, cytomegalovirus (CMV) infection continues to be an important cause of morbidity and mortality in the hematopoietic stem cell transplant (HSCT) recipient. The standard drug for pre-emptive therapy is intravenous ganciclovir (GCV). Valganciclovir (VGC), the oral pro-drug of GCV, has excellent bioavailability and is ideal for oral therapy. Since March 2002, VGC was adopted in our center for outpatient pre-emptive therapy in all patients undergoing allogeneic HSCT. Fifty-two allogeneic HSCT recipients were followed weekly via Digene hybrid capture assay. Patients with a positive assay were treated with VGC 900 mg p.o. b.i.d. x 14 days followed by 900 mg p.o. QD until at least 7 days after a negative test. Eighteen patients (14 sib, four MUD) had 30 episodes of CMV DNA detection treated with oral VGC. Median duration of therapy was 21 days (range 10-21 days). The rate of response was 93% (28/30) as confirmed by a negative assay within 14 days. No significant toxicity was encountered. Two patients failed oral VGC. One case of CMV enteritis was diagnosed in a patient with acute GVHD. Pre-emptive therapy of CMV infection with oral VGC is safe and effective in allogeneic HSCT recipients.

Predictors of posttraumatic growth following bone marrow transplantation for cancer

There is growing recognition that the experience of cancer can have a positive as well as a negative psychological impact. This longitudinal study sought to identify predictors of posttraumatic growth among cancer patients (N=72) undergoing bone marrow transplantation. Greater posttraumatic growth in the posttransplant period was related to younger age; less education; greater use of positive reinterpretation, problem solving, and seeking alternative rewards as coping strategies in the pretransplant period; more stressful appraisal of aspects of the transplant experience; and more negatively biased recall of pretransplant levels of psychological distress. Findings partially support J. A. Schaefer and R. H. Moos's (1992) model of life crises and personal growth and also suggest that temporal self-comparisons contribute to the experience of posttraumatic growth.

Pilot study of a home-based aerobic exercise program for sedentary cancer survivors treated with hematopoietic stem cell transplantation

We report a pilot study of a home-based aerobic exercise program in a group of 17 adult hematopoietic stem cell transplant (HSCT) recipients. Participants had received no cancer treatment for at least 6 months and reported leisure time physical activity less than 20 min per day and fewer than three times a week during the previous month. Following baseline assessments of aerobic fitness, fatigue symptoms, and quality of life, participants were placed on home-based aerobic exercise programs consisting of 20-40 min of activity in the target heart rate zone (40-60% predicted heart rate reserve) delivered in three to five sessions per week for 12 weeks. Subjects were supplied with electronic heart rate monitors and we encouraged program adherence using weekly telephone contacts and exercise diaries. In all, 32 of the 42 qualified candidates consented (acceptance=76%). Of these, 17 kept appointments for baseline assessments, four did not complete the study (attrition=46%), and no exercise-related adverse events were reported. Scores on measures of aerobic fitness, fatigue severity, and physical well-being improved (signed ranks test; P<0.05) during program participation. Our findings suggest that individually prescribed, home-based aerobic exercise is an acceptable, safe, and potentially effective intervention for improving physical functioning and fatigue in sedentary HSCT recipients.

Syngeneic hematopoietic stem cell transplantation for women with metastatic breast cancer

Metastatic breast cancer has been a common indication for autologous hematopoietic stem cell transplantation (HSCT). Previous reports indicate 3-year survival and progression-free survival (PFS) rates after autotransplant to be about 30 and 15%, respectively. Most deaths are from recurrent disease. One potential cause for high relapse rates is graft contamination with tumor. We describe 14 women with metastatic breast cancer transplanted between 1991 and 1998 with hematopoietic cells from identical twins. Median age was 41 y (range 34-50). Most women (12 of 14) were treated with mastectomy, and all received anthracycline-based regimens in their pretransplant course; nine women also received a taxane, seven radiotherapy and three hormonal therapy. Four women were in complete remission (one CR, three CRU) at transplant, five were in partial remission, two had stable disease and two had progressive disease. Eight women have died, one of treatment-related causes and seven of progressive breast cancer. Three-year survival was 48% (21-71%) and 3-year PFS was 21% (5-45%). Although the number of patients is small, outcomes for women transplanted with syngeneic grafts are similar to those of women receiving autologous grafts. This suggests that residual cancer in the patient is the major contributor to relapse after transplantation for breast cancer.

Simultaneous administration of G-CSF and GM-CSF for re-mobilization in patients with inadequate initial progenitor cell collections for autologous transplantation

BACKGROUND

A proportion of candidates for high-dose chemotherapy with autologous PBPC support (HDC-PBPCS) will not provide an adequate PBPC yield from their first mobilization. The value of re-mobilization and the best regimen for re-mobilization in these patients is unclear.

METHODS

In 23 patients who failed to provide > or = 3 x 10(6) CD34+ cells/kg after their first mobilization, PBPC were re-mobilized using a regimen of simultaneous administration of G-CSF and GM-CSF (10 microg/kg/day each) with leukaphereses (LP) starting Day 4 or 5 of CSF administration. Yields of WBC/kg, MNC/kg and CD34+ cells/kg/L of processed blood were compared between the first and second mobilization in each patient. The ability of the combined yield from the two mobilizations to achieve the desired threshold PBPC yield and the tolerability of the re-mobilization were determined.

RESULTS

The re-mobilization regimen was well-tolerated and no patient discontinued the regimen because of toxicity. Median collected WBC/kg/L (1.37 x 10(7) versus 2.62 x 10(7), p = 0.0065), MNC/kg/L (0.77 x 10(7) versus 1.97 x 10(7), p = 0.0003), CD34+ cells/kg/L (1.64 x 10(7) versus 4.18 x 10(7), p = 0.001) were significantly higher after the second mobilization (G-CSF/GM-CSF combination). Percentage of CD34+ cells in the leukapheresis was also significantly higher after the second mobilization (median 0.104% versus 0.195%, p = 0.036). Twelve of 22 patients achieved the target PBPC dose (> 3 x 10(6)/CD34+ cells/kg) after two mobilizations (six patients achieved the target from the second mobilization alone). A further eight underwent HDC-PBPCS without achieving the target PBPC dose. These patients experienced a significant delay in neutrophil and platelet engraftment when compared with those patients achieving the target dose.

DISCUSSION

This study demonstrates that the combination of G-CSF and GM-CSF is an effective and tolerable method for re-mobilization of PBPC in patients who fail to provide an adequate yield from their first mobilization.

Predictors of posttraumatic stress disorder symptomatology following bone marrow transplantation for cancer

This study examined the prevalence and predictors of posttraumatic stress disorder (PTSD) symptoms in 70 men and women treated with bone marrow transplantation for cancer. Findings indicated that the number of symptoms present ranged from 0 to a possible high of 17 (M = 3.0, SD = 3.9). As predicted. lower social support and higher avoidance coping I month pretransplant predicted greater PTSD symptom severity an average of 7 months posttransplant. These variables remained significant predictors of symptom severity even after accounting for pretransplant levels of psychological distress. Additional analyses indicated the presence of a significant interaction between social support and avoidance coping, with patients high in avoidance coping and low in social support reporting the most severe symptoms. These findings identify patients at risk for psychological disturbance posttransplant and can serve to guide future intervention efforts.

Preliminary evaluation of a clinical syndrome approach to assessing cancer-related fatigue

The objectives of this study were to evaluate the reliability, validity, and utility of a newly developed clinical syndrome approach to assessing cancer-related fatigue. Fifty-one patients who underwent blood or marrow transplantation an average of 6.9 months previously were administered a standardized interview designed to identify the presence of a clinical syndrome of cancer-related fatigue. Patients also completed self-report measures of fatigue, depression, and health-related quality of life. Comparisons among independent raters demonstrated high rates of reliability for the presence or absence of a cancer-related fatigue syndrome and its symptoms. Twenty-one percent of patients (n = 11) were found to meet criteria for diagnosis of a cancer-related fatigue syndrome. Compared to patients not meeting the diagnostic criteria, patients meeting the criteria reported fatigue that was greater (P < or = 0.05) in its severity, frequency, pervasiveness, and interference with quality of life. Patients who met criteria also demonstrated poorer role functioning, less vitality, and more depressive symptomatology (P < or = 0.05). These findings provide preliminary evidence of the reliability and validity of the methods used to assess the proposed clinical syndrome and suggest their utility in identifying patients experiencing clinically significant cancer-related fatigue.

Predictors of posttraumatic stress disorder symptomatology following bone marrow transplantation for cancer

This study examined the prevalence and predictors of posttraumatic stress disorder (PTSD) symptoms in 70 men and women treated with bone marrow transplantation for cancer. Findings indicated that the number of symptoms present ranged from 0 to a possible high of 17 (M = 3.0, SD = 3.9). As predicted. lower social support and higher avoidance coping I month pretransplant predicted greater PTSD symptom severity an average of 7 months posttransplant. These variables remained significant predictors of symptom severity even after accounting for pretransplant levels of psychological distress. Additional analyses indicated the presence of a significant interaction between social support and avoidance coping, with patients high in avoidance coping and low in social support reporting the most severe symptoms. These findings identify patients at risk for psychological disturbance posttransplant and can serve to guide future intervention efforts.

Relation of psychological vulnerability factors to posttraumatic stress disorder symptomatology in bone marrow transplant recipients

OBJECTIVE

Prior research suggests that the diagnosis and treatment of cancer can result in the development of symptoms of posttraumatic stress disorder (PTSD). Based on Lazarus and Folkman's model of stress, the current study examined whether trauma appraisals, coping, social support, and social constraint were associated with the severity of PTSD symptoms in cancer patients who had undergone bone marrow transplantation (BMT).

METHODS

Participants were 23 males and 79 females treated with BMT an average of 20 months previously (range = 3-62 months). Past and current psychiatric diagnoses were assessed through a structured clinical interview. PTSD symptomatology and other psychological variables were assessed using standardized self-report measures.

RESULTS

Results indicated that 5% of participants met diagnostic criteria for current PTSD. Participants reported an average of three to four symptoms of PTSD (range = 0-16). Univariate analyses confirmed predictions that increased PTSD symptomatology would be associated with more negative appraisals of the BMT experience, greater use of avoidance-based coping strategies, lower levels of social support, and greater social constraint (p < .05). Regression analyses indicated that each of these variables accounted for significant (p < .05) variability in PTSD symptomatology above and beyond relevant demographic and medical variables.

CONCLUSIONS

Results of the present study confirm and extend prior research regarding the prevalence of PTSD and PTSD symptoms among patients treated for cancer. In addition, the study identified a set of theoretically derived psychological characteristics that seem to place patients at risk for greater PTSD symptomatology after BMT.

Use of PEG-rHuMGDF in platelet engraftment after autologous stem cell transplantation

This paper summarizes a pilot, sequential dose-escalation study of PEG-rHuMGDF in patients with advanced malignancies who had delayed platelet recovery after autologous stem cell transplantation (ASCT). Patients were randomized to receive either placebo (n = 11) or PEG-rHuMGDF at 5 (n = 9), 10 (n = 6), or 25 (n = 7) microg/kg/day by subcutaneous injection for 14 days and were monitored for 5 weeks. Across all treatment groups, eight patients had platelet recovery to > or = 20 x 10(9)/l by day 21. The proportion of patients achieving platelet recovery, the median number of days and units of platelet transfusions were similar for the placebo and the PEG-rHuMGDF groups. PEG-rHuMGDF was well tolerated at all dosages. The incidence rates of adverse events in all groups were similar. No deaths on study, no drug-related serious adverse events, and no development of neutralizing antibodies to MGDF occurred.

The uncertainty principle and industry-sponsored research

BACKGROUND

Reporting of pharmaceutical-industry-sponsored randomised clinical trials often result in biased findings, either due to selective reporting of studies with non-equivalent arms or publication of low-quality papers, wherein unfavourable results are incompletely described. A randomised trial should be conducted only if there is substantial uncertainty about the relative value of one treatment versus another. Studies in which intervention and control are thought to be non-equivalent violates the uncertainty principle.

METHODS

We examined the quality of 136 published randomised trials that focused on one disease category (multiple myeloma) and adherence to the uncertainty principle. To evaluate whether the uncertainty principle was upheld, we compared the number of studies favouring experimental treatments over standard ones. We analysed data according to the source of funding.

FINDINGS

Trials funded solely or in part by 35 profit-making organisations had a trend toward higher quality scores (mean 2.94 [SD 1.3]; median 3) than randomised trials supported by 95 governmental or other non-profit organisations (2.4 [0.8]; 2; p=0.06). Overall, the uncertainty principle was upheld, with 44% of randomised trials favouring standard treatments and 56% innovative treatments (p=0.17); mean and median preference evaluation scores were 3.7 (1.0) and 4. However, when the analysis was done according to the source of funding, studies funded by non-profit organisations maintained equipoise favouring new therapies over standard ones (47% vs 53%; p=0.608) to a greater extent than randomised trials supported solely or in part by profit-making organisations (74% vs 26%; p=0.004).

INTERPRETATION

The reported bias in research sponsored by the pharmaceutical industry may be a consequence of violations of the uncertainty principle. Sponsors of clinical trials should be encouraged to report all results and to choose appropriate comparative controls.

Patients' psychosocial concerns following stem cell transplantation

Information regarding the nature, frequency, correlates and temporal trajectory of concerns of stem cell transplantation (SCT) recipients is critical to the development of interventions to enhance quality of life (QOL) in these individuals. This study examined psychosocial concerns in 110 SCT (87% autologous) recipients drawn from two SCT centers. Participants were a mean of 46 years of age and 17 months post-SCT (range 3-62 months). Information regarding current and past SCT-related concerns, performance status, and demographic characteristics was collected by telephone interview or questionnaire. Recipients reported a wide variety of psychosocial concerns following SCT. Recipients who were younger, female and evidenced a poorer performance status reported a larger number of post-SCT concerns. Examination of the temporal trajectory of concerns suggests that some concerns are salient throughout the course of post-SCT recovery (eg disease recurrence, energy level, 'returning to normal'), some are salient early in the course of recovery (eg quality of medical care, overprotectiveness by others), and others emerge later in the course of recovery (eg feeling tense or anxious, sexual life, sleep, relationship with spouse/partner, ability to be affectionate). Implications for the development of interventions to enhance post-SCT QOL are identified.

Factors correlated with progression-free survival after high-dose chemotherapy and hematopoietic stem cell transplantation for metastatic breast cancer

CONTEXT

Women with breast cancer are the most frequent recipients of high-dose chemotherapy followed by autologous hematopoietic stem cell transplantation (autotransplants) in North America. Despite widespread use, controversy exists about the benefits of and appropriate patients for this therapy.

OBJECTIVE

To determine factors associated with disease progression or death after autotransplantation in women with metastatic breast cancer.

DESIGN

Analysis of data collected retrospectively (January 1989 to 1992) and prospectively (1992 through January 1995) for the Autologous Blood and Marrow Transplant Registry.

SETTING

Sixty-three hospitals in North America, Brazil, and Russia.

PARTICIPANTS

A total of 1188 consecutive women aged 18 to 70 years receiving autotransplants for metastatic or locally recurrent breast cancer, with a median follow-up of 291/2 months.

MAIN OUTCOME MEASURE

Time to treatment failure (disease progression, disease recurrence, or death) after autotransplantation.

RESULTS

Factors associated with significantly (P<.05) increased risk of treatment failure in a Cox multivariate analysis included age older than 45 years (relative hazard, 1.17; 95% confidence interval [CI], 1.02-1.33), Karnofsky performance score less than 90% (1.27; 95% CI, 1.07-1.51), absence of hormone receptors (1.31; 95% CI, 1.15-1.51), prior use of adjuvant chemotherapy (1.31; 95% CI, 1.10-1.56), initial disease-free survival interval after adjuvant treatment of no more than 18 months (1.99; 95% CI, 1.62-2.43), metastases in the liver (1.47; 95% CI, 1.20-1.80) or central nervous system (1.56; 95% CI, 0.99-2.46 [approaches significance]) vs soft tissue, bone, or lung, 3 or more sites of metastatic disease (1.32; 95% CI, 1.13-1.54), and incomplete response vs complete response to standard-dose chemotherapy (1.65; 95% CI, 1.36-1.99). Receiving tamoxifen posttransplantation was associated with a reduced risk of treatment failure in women with hormone receptor-positive tumors (relative hazard, 0.60; 95% CI, 0.47-0.87). Women with no risk factors (n = 38) had a 3-year probability of progression-free survival of 43% (95% CI, 27%-61 %) vs 4% (95% CI, 2%-8%) for women with more than 3 risk factors (n = 343).

CONCLUSION

These data indicate that some women are unlikely to benefit from autotransplantation and should receive this treatment only after being provided with prognostic information and in the context of clinical trials attempting to improve outcome.

Fatigue and quality of life in breast cancer patients undergoing autologous stem cell transplantation: a longitudinal comparative study

As more individuals are being treated for cancer with high-dose therapy and autologous stem cell rescue (ASCR), there is growing interest in treatment side effects and their impact on quality of life. The primary aim of this study was to determine if the severity of fatigue and its impact on quality of life is significantly greater in women undergoing ASCR for breast cancer than in women of similar age with no history of cancer. A group of women being treated with ASCR for breast cancer (n = 31) and a group of women of similar age with no history of cancer (n = 49) participated in this study. Patients completed measures of fatigue and psychosocial functioning prior to treatment, midway through treatment, and toward the end of treatment. Healthy comparison subjects completed the same measures three separate times. Breast cancer patients undergoing ASCR reported significantly more frequent fatigue and more severe fatigue than women with no cancer history. In addition, fatigue had a significantly greater impact on daily functioning and quality of life in patients than in women with no cancer history. Fatigue during ASCR for breast cancer was related to both medical factors (i.e., time since transplant) and psychosocial factors. During ASCR for breast cancer, women experience fatigue which is worse than what is "normally" experienced and which interferes with daily functioning and quality of life. Future research should focus on identifying the biological correlates of fatigue, psychological and physiological mechanisms by which fatigue is produced, and interventions to alleviate fatigue.

Borderline personality disorder and bone marrow transplantation: ethical considerations and review

Bone marrow transplantation (BMT) is rapidly becoming a part of conventional cancer treatment. However, it remains a 'last-ditch' treatment option for patients who have exhausted other treatment modalities. Patients experience a significant amount of emotional distress during all stages of the BMT process. Patients with personality disorders experience even more emotional distress than average and their behavior is often detrimental to effective patient-staff interactions. A case of a borderline patient is presented with a discussion of the ethical issues involved in the evaluation of these patients and the determination of their appropriateness for transplant.

High-Dose Chemotherapy in the Adjuvant Treatment of Breast Cancer: Benefit/Risk Analysis

BACKGROUND: High-dose chemotherapy (HDRx) may improve the prognosis of patients with high-risk breast cancer but at the expense of increased toxicity. However, no randomized, controlled trials have been published that clearly demonstrate the superiority of HDRx over conventional adjuvant chemotherapy. METHODS: We developed a simple model to compare benefits and risks of HDRx with conventional adjuvant chemotherapy (SDRx). The model integrates data on efficacy and risks of two competing treatment strategies into a single decision rule. RESULTS AND CONCLUSIONS: Using data from phase II studies, we show that if a disease-free survival is considered to be the most important outcome, HDRx should be administered when the probability of breast cancer relapse at five years exceeds 54% to 71% for patients with 4 to 9 positive nodes and exceeds 29% to 40% for patients with >9 positive nodes. If the endpoint of interest is five-year overall survival, then the treatment should be administered when the probability of relapse exceeds 77% to 83% for patients with 4 to 9 nodes involved and 22% to 31% for those with >9 lymph nodes involved. While awaiting results of randomized, controlled trials to definitively establish the efficacy rate of HDRx, we also found that HDRx could be considered in the management of high-risk breast cancer if its efficacy rate is at least 54% to 60% superior to SDRx in reducing relapse risk in breast cancer patients with 4 to 9 nodes and at least 31% to 38% for >9 positive nodes. If survival data are used instead of disease-free survival outcomes, HDRx efficacy should be at least 47% to 48% superior to SDRx in reducing death risk in breast cancer patients with 4 to 9 nodes and at least 27% to 30% superior for >9 positive nodes to consider its use in the adjuvant setting.

Posttraumatic stress disorder symptoms after bone marrow transplantation for breast cancer

OBJECTIVE

On the basis of revisions of DSM criteria, questions have been raised concerning the occurrence of posttraumatic stress disorder (PTSD) symptoms among adults who have been diagnosed and treated for life-threatening illnesses. The present study examined the prevalence and correlates of PTSD symptoms among women who had undergone autologous bone marrow transplantation (ABMT) for breast cancer.

METHODS

Participants were 43 women who had undergone ABMT for breast cancer an average of 19 months previously (range = 2 to 62 months) and had no clinical evidence of disease at their most recent follow-up visit. PTSD symptoms and quality of life were assessed using standardized self-report instruments.

RESULTS

Between 12% and 19% of participants were likely to meet DSM-IV criteria for the current diagnosis of PTSD. Women who were less well educated, had more advanced disease at the time of the transplantation and had longer hospital stays for the transplantation reported more symptoms of PTSD. Greater PTSD symptomatology was associated with reports of poorer physical health, mental health, and sleep quality.

CONCLUSION

Comparisons with previous research suggest that rates of PTSD are higher among women who undergo ABMT as opposed to less intensive forms of breast cancer treatment. These findings are consistent with the view that development of PTSD symptoms is associated with the degree of life threat. The clinical significance of PTSD in this patient population is underscored by findings indicating that greater PTSD symptoms are associated with poorer health-related quality of life.

Measurement of fatigue in cancer patients: development and validation of the Fatigue Symptom Inventory

Although fatigue is one of the most common and debilitating symptoms experienced by cancer patients, it has received little systematic attention. This situation is due in large part to the lack of adequate instruments to measure fatigue. The primary aim of this study was to validate a newly developed measure of fatigue for use with cancer patients: the Fatigue Symptom Inventory (FSI). This 13 item self-report measure was designed to measure the intensity and duration of fatigue and its impact on quality of life. The psychometric properties of the FSI were assessed in women undergoing treatment for breast cancer, women who had completed treatment for breast cancer and women with no history of cancer. A seven-item interference subscale was found to have good internal consistency, with alpha coefficients above 0.90 in all three groups. The complete FSI was found to have rather weak to moderate test-retest reliability among patients in active treatment and healthy comparison subjects assessed on three separate occasions. Convergent validity was demonstrated using comparisons with existing measures of fatigue. Construct validity was demonstrated using comparisons between and within groups as well as comparisons with measures of anxiety and depression. Overall, the FSI was established as a valid and reliable measure of fatigue in cancer patients and healthy individuals. Suggestions are made for the potential application of the measure in clinical research.

Defining the role of novel high-dose chemotherapy regimens for the treatment of high-risk breast cancer

We have explored several novel high-dose combinations in an attempt to increase antitumor activity while decreasing treatment-related toxicity. From October 1989 through June 1997, we performed phase I/II dose-escalation trials exploring novel high-dose regimens including ifosfamide/carboplatin/etoposide, mitoxantrone/thiotepa, and paclitaxel (Taxol; Bristol-Myers Squibb Company, Princeton, NJ)/mitoxantrone/thiotepa. We have also evaluated busulfan/cyclophosphamide and cyclophosphamide/thiotepa/carboplatin in phase II trials. Three hundred ninety-three patients have been treated in these trials and followed for a minimum of 3 months. Event-free survival (including relapses and treatment-related mortality; +/-SE) at 3 years by stage and chemosensitivity is as follows: stage II, four to nine positive nodes (n=16), 52%+/-17%; stage II, greater than nine nodes (n=30), 46%+/-11%; stage III (n=59), 50%+/-8%; inflammatory stage III (n=15), 27%+/-17%; stage IV, anthracycline responsive (n=69), 19%+/-5%; stage IV, anthracycline refractory but responsive to salvage therapy with ifosfamide, carboplatin, and etoposide or paclitaxel (n=53), 12%+/-6%; stage IV, refractory (n=128), 5%+/-2%; and stage IV, not evaluable for response (n=23), 10%+/-8%. Treatment-related mortality was 4% for both phase I and II studies involving stage II breast cancer patients, 5% for stage III breast cancer, 15% for inflammatory breast cancer, and 18% for all stage IV breast cancers, responsive and refractory. We conclude that high-dose therapy for the treatment of high-risk early stage breast cancer or metastatic breast cancer results in durable remissions. Chemosensitivity to induction regimens remains the most important prognostic indicator, although long-term survival has been seen even in patients with highly refractory disease. Further studies are necessary to define optimal high-dose strategies based on stage and chemosensitivity of disease.

Nephrotoxicity of high-dose ifosfamide/carboplatin/etoposide in adults undergoing autologous stem cell transplantation

The objective of this study was to evaluate nephrotoxicity in adult patients treated with high-dose ifosfamide, carboplatin, and etoposide followed by autologous stem cell transplantation. We conducted a retrospective analysis of clinical and laboratory data from 131 patients with various malignancies who received treatment with escalating doses of ifosfamide, carboplatin, and etoposide followed by autologous stem cell transplantation as part of a phase I/II therapeutic trial. Abnormalities in glomerular filtration were evaluated by measuring peak creatinine levels and tubular dysfunction by the lowest recorded serum levels of potassium, magnesium, and bicarbonate, at different time periods after administration of ifosfamide, carboplatin, and etoposide, and after autologous stem cell transplantation. For the entire group of 131 patients, peak creatinine levels were > 1.5 mg/dL but < 3.0 mg/dL in 37% and levels were > 3.0 mg/dL in 11% at some time during their hospital stay. At the time of discharge, creatinine levels were 1.6 mg/dL to 3.0 mg/dL in 25% of patients and were > 3 mg/dL in 5%. Immediately after high-dose therapy, peak creatinine levels were significantly higher in patients receiving higher doses of ifosfamide compared to those receiving lower doses (P < 0.00001) and those receiving intermediate doses (P < 0.005). There was a dramatic decrease in serum bicarbonate, potassium, and magnesium levels immediately after chemotherapy, and they remained significantly decreased throughout the patient's hospital stay, despite massive replacement efforts (P ranging between < 0.008 and < 0.001). This is the largest adult population study documenting the incidence and severity of ifosfamide/carboplatin/etoposide-associated acute nephrotoxicity. Renal dysfunction was dose related and reversible in the majority of patients.

High-dose chemotherapy and autologous peripheral blood stem cell transplantation in patients with multiple myeloma and renal insufficiency

Six patients with multiple myeloma and chronic renal insufficiency (serum creatinine >3.0 mg/dl), including four on dialysis, received high-dose busulfan and cyclophosphamide (BUCY) followed by autologous peripheral stem cell transplantation. Peripheral blood stem cells were collected after priming with cyclophosphamide, etoposide and G-CSF. Patterns of engraftment and toxicities were not apparently different from those seen in myeloma patients with normal renal function. There was one toxicity-related death, resulting from a massive spontaneous subdural hematoma. One patient died of disease progression 6 months after transplant, while the remaining four patients are alive and free of myeloma progression 6 to 39 months after high-dose therapy. Two of these patients have remained in complete remission for 28 and 39 months. Our experience suggests that high-dose therapy with BUCY and autologous peripheral blood stem cell rescue is feasible in patients with multiple myeloma and renal failure.

High-dose chemotherapy with autologous hematopoietic stem-cell support for breast cancer in North America

PURPOSE

To identify trends in high-dose therapy with autologous hematopoietic stem-cell support (autotransplants) for breast cancer (1989 to 1995).

PATIENTS AND METHODS

Analysis of patients who received autotransplants and were reported to the Autologous Blood and Marrow Transplant Registry. Between January 1, 1989 and June 30, 1995, 19,291 autotransplants were reviewed; 5,886 were for breast cancer. Main outcomes were progression-free survival (PFS) and survival.

RESULTS

Between 1989 and 1995, autotransplants for breast cancer increased sixfold. After 1992, breast cancer was the most common indication for autotransplant. Significant trends included increasing use for locally advanced rather than metastatic disease (P < .00001) and use of blood-derived rather than marrow-derived stem cells (P < .00001). One-hundred-day mortality decreased from 22% to 5% (P < .0001). Three-year PFS probabilities were 65% (95% confidence intervals [Cls], 59 to 71) for stage 2 disease, and 60% (95% Cl, 53 to 67) for stage 3 disease. In metastatic breast cancer, 3-year probabilities of PFS were 7% (95% Cl, 4 to 10) for women with no response to conventional dose chemotherapy; 13% (95% Cl, 9 to 17) for those with partial response; and 32% (95% Cl, 27 to 37) for those with complete response. Eleven percent of women with stage 2/3 disease and less than 1% of those with stage 4 disease participated in national cooperative group randomized trials.

CONCLUSION

Autotransplants increasingly are used to treat breast cancer. One-hundred-day mortality has decreased substantially. Three-year survival is better in women with earlier stage disease and in those who respond to pretransplant chemotherapy.

Dexamethasone, cyclophosphamide, idarubicin and etoposide (DC-IE): a novel, intensive induction chemotherapy regimen for patients with high-risk multiple myeloma

We evaluated toxicities and responses to a novel, dose intensive and time sequenced, chemotherapy programme (DC-IE) in 45 patients with high-risk myeloma. DC-IE consisted of: dexamethasone (days 1-4); cyclophosphamide (day 5); idarubicin and etoposide (days 8-10). Complete response (CR) was achieved in four patients, six patients achieved near complete responses (nCR) and 21 patients achieved a partial remission (PR). Overall response rate was 76% (CI 56-94%) for newly diagnosed patients (n = 21) and 62% (CI 36-81%) for relapsed/refractory patients (n = 24). Toxicities were limited to myelosuppression; two patients died of sepsis during neutropenia (4%). DC-IE is active and tolerable for high-risk multiple myeloma, including patients with relapsed or refractory disease to anthracycline containing regimens.

Quality of life following bone marrow transplantation for breast cancer: a comparative study

As more women are treated with bone marrow transplantation (BMT) for breast cancer, there is growing interest in quality of life (QOL) following treatment. Although there have been some clinical studies of QOL following BMT, this area has received little systematic attention. In particular, it is unclear how QOL for women treated with BMT for breast cancer differs from that which might be expected for 'healthy' women of about the same age. To address this issue, we compared QOL reported by women treated with autologous BMT for breast cancer with that of a group of women of similar age with no history of cancer. In addition, we examined the relationship of demographic factors, medical factors, and self-reported symptom prevalence, severity, and distress to QOL in post-BMT patients. All participants completed the SF-36 Health Survey developed from the Medical Outcomes Study (SF-36). Post-BMT patients also completed the ECOG Performance Status Rating Scale (PSR) and the Memorial Symptom Assessment Scale (MSAS). Results indicated that, compared to the women with no cancer history, post-BMT patients reported significantly impaired physical functioning, physical role functioning, general health, vitality, social functioning, and emotional role functioning. Impaired QOL following BMT was significantly associated with lower income, a longer time to engraftment, longer hospital stay, poor performance status, and greater symptom prevalence, severity, and distress. The problems identified in this study may be important targets for intervention when trying to improve QOL following BMT.

Fatigue in women treated with bone marrow transplantation for breast cancer: a comparison with women with no history of cancer

As more individuals undergo autologous bone marrow transplantation (BMT), there is growing interest in the impact of treatment side effects on quality of life. Fatigue is a potentially disruptive treatment side effect that has not been systematically assessed following BMT. The primary aim of this study was to determine whether the severity of fatigue and its impact on quality of life is significantly greater in women who had undergone BMT for breast cancer than in women of similar age with no history of cancer. Another aim was to identify the medical and psychosocial correlates of fatigue in women who had completed BMT. A group of women treated with autologous BMT for breast cancer (n = 43; mean age = 44; mean time since BMT = 20 months) and a group of women of similar age with no history of cancer (n = 43; mean age = 46) participated in this study. Subjects completed measures of fatigue, anxiety, depression, and sleep habits. Medical data were obtained from computerized patient records. Women who had completed BMT for breast cancer reported significantly more frequent and severe fatigue than women with no cancer history. In addition, fatigue had a significantly greater impact on daily functioning and quality of life in BMT recipients than in women with no cancer history. Fatigue following BMT for breast cancer was related to both medical factors (i.e., time since BMT) and psychosocial factors (i.e., anxiety, depressive symptoms and sleep difficulties). Following BMT for breast cancer, women may experience fatigue that is worse than might "normally" be expected and can interfere with daily functioning and quality of life. Future research should focus on identifying the biological correlates of fatigue, psychological and physiological mechanisms by which fatigue is produced, and interventions to alleviate fatigue.

High-sensitivity detection of minimal residual breast carcinoma using the polymerase chain reaction and primers for cytokeratin 19

We have developed a reverse transcriptase-polymerase chain reaction (RT-PCR) assay to identify breast carcinoma cells in bone marrow aspirates with high sensitivity and specificity. This assay relies on the detection of cytokeratin 19 (K19) RNA by nested primer PCR followed by annealing to a (32P)-labeled internal sequence probe and autoradiography. In reconstitution experiments, this assay is capable of detecting 10 fg of admixed mammary tumor RNA in 1 microgram of normal marrow RNA (a dilution of 1:10(7)). Thirty of 30 primary breast tumor specimens, 19 of 19 cytologically positive bone marrow aspirate specimens, and three of 11 aspirate negative/biopsy positive specimens showed detectable K19 transcript. This assay shows high specificity, with 50 of 52 negative control aspirates showing no detectable amplification product. False-positive amplification was noted in two of 18 aspirates obtained from patients with active chronic myelogenous leukemia. Of stage II and III postsurgical breast carcinoma patients with histologically negative bone marrows and no radiographic bone disease, 14 of 30 were K19 positive by PCR. RT-PCR analysis of K19 transcript is a highly sensitive and specific method of detecting and monitoring low-level metastatic disease in patients with primary carcinoma of the breast. The presence of K19 RNA in histologically negative bone marrows suggests that this assay may prove a powerful monitor for patients undergoing curative therapy as well as a novel prognostic indicator.

Phase I-II study of high-dose busulfan and cyclophosphamide followed by autologous peripheral blood stem cell transplantation for hematological malignancies: toxicities and hematopoietic recovery

In a phase I-II study, we evaluated toxicities, tolerability, pace of engraftment, and tumor responses to high-dose bulsulfan and cyclophosphamide followed by autologous peripheral blood stem cell transplantation in patients with hematological malignancies. We treated 51 patients with various hematological malignancies involving the bone marrow with busulfan (16 mg/kg) and cyclophosphamide (120 mg/kg) followed by reinfusion of autologous peripheral blood stem cells. Stem cells were previously collected during hematopoietic recovery after cyclophosphamide (100 mg/kg) and etoposide (600 mg/m2) followed by G-CSF (5 micrograms/kg/day). Neutrophil recovery (>0.5 x 10(9)/I) was rapid in the majority of patients (median 10 days after transplant, range 7-91 days), resulting in a low number of days with severe neutropenia (median 7 days, range 5-85 days) and with fever (median 5 days, range 1-13 days). Platelet recovery, however, was delayed in 60% of patients. There was one acute transplant-related death (2%). Four patients died of late, presumed infections, pulmonary complications (interstitial pneumonia). Tumor responses were documented in a significant proportion of these patients with high-risk hematological malignancies. We conclude that peripheral blood stem cell transplantation results in rapid recovery of neutrophils but variable recovery of platelets after high-dose busulfan and cyclophosphamide, when stem cells are harvested following priming with cyclophosphamide/etoposide and G-CSF. The regimen is well-tolerated with limited non-hematological toxicities and transplant-related mortality. While significant tumor responses were documented in this trial, the ultimate efficacy of the regimen needs to be further defined.

Clinical significance of bone marrow metastases as detected using the polymerase chain reaction in patients with breast cancer undergoing high-dose chemotherapy and autologous bone marrow transplantation

PURPOSE

The present study evaluates the clinical significance of detection of cytokeratin 19 (K19) in the bone marrow of patients with breast cancer undergoing high-dose chemotherapy (HDCT) and autologous bone marrow transplantation (ABMT).

PATIENTS AND METHODS

We studied retrospectively cryopreserved bone marrow aspirates from 83 patients with high-risk stage II, III, and IV breast cancer obtained before bone marrow harvest but after induction chemotherapy. All samples were histologically negative for metastases. Polymerase chain reaction (PCR) for K19 was performed according to methods described previously and results were correlated with the probability of relapse following HDCT and ABMT.

RESULTS

The incidence of occult metastases as defined by PCR for K19 message was 52% for 19 stage II, 57% for 14 stage III, and 82% for 50 stage IV patients (two-tailed P = .0075, chi 2 test). The probability of relapse at 3 years after ABMT was 32% and 94% for K19-positive stage II/III and stage IV patients, respectively, versus 10% and 14% for K19-negative stage II/III and stage IV patients, respectively. The difference was significant for stage IV patients (two-tailed P = .0002).

CONCLUSION

It has been shown that PCR is a highly sensitive method to detect K19 message in the bone marrow. The incidence of K19 positivity in bone marrow increases significantly with advancing stage. In patients with breast cancer, especially metastatic breast cancer, undergoing HDCT and ABMT, the presence of K19 is associated with a poor prognosis.

Analysis of dose-response relationships in the setting of high-dose ifosfamide, carboplatin, and etoposide and autologous hematopoietic stem cell transplantation: implications for the treatment of patients with advanced breast cancer

Dose intensity appears to play a role in the treatment of breast cancer. Although many reports have been published regarding dose intensity using nonmyeloablative doses, little data have been presented in the setting of high-dose chemotherapy and autologous hematopoietic stem cell transplantation. The results of a retrospective review of a phase I/II trial evaluating the effect of escalating doses of ifosfamide/carboplatin/etoposide on survival of patients with locally advanced and metastatic breast cancer are discussed here. Patients were divided by ifosfamide dose: low dose (6,000 to 14,400 mg/m2) and high dose (17,100 to 24,000 mg/m2). Three-year event-free survival was no different between the two dose groups in patients with locally advanced disease (71% [low] v 56% [high]). In patients with metastatic disease, however, although the difference did not meet statistical significance, there did appear to be a trend toward improved survival with increased dose intensity (8% [low] v 25% [high]). Our results show that dose intensity may be important in inflammatory and metastatic breast cancer. This trend was seen in both anthracycline-responsive and -refractory patients. While further study of dose intensity in this setting is warranted, dose-intensive high-dose therapy with autologous hematopoietic stem cell transplantation can be considered for patients with advanced breast cancer.

Optimization of high-dose therapy for the treatment of patients with metastatic breast cancer

Objective. To determine the effect of chemorespon siveness and dose intensity on event-free survival (EFS) for metastatic breast cancer patients following high-dose chemotherapy and autologous stem cell rescue.

Design. This is a retrospective review of data from three allocated, parallel, dose escalation, high dose phase I/II trials.

Setting. These trials were carried out at H. Lee Moffitt Cancer, Tampa, Florida.

Patients. Since October 1989, 215 patients with metastatic (stage IV) breast cancer receiving the following high-dose treatment regimens with stem cell rescue: (1) ifosfamide, carboplatin, and etoposide (ICE); (2) mitoxantrone and thiotepa (MITT); and (3) Taxol, Novantrone, thiotepa (TNT).

Intervention. Patients received either escalating doses of ICE (ifosfamide 6000 to 24,000 mg/m 2, carboplatin 1200 to 2100 mg/m2, etoposide 1800 to 3000 mg/m2), or MITT (mitoxantrone 45 to 105 mg/m2, thiotepa 900 to 1350 mg/m2) or TNT (thiote pa 900 mg/m2, Novantrone 45 to 75 mg/m2, Taxol 120 to 360 mg/m2) followed by stem cell rescue. Patients were then grouped by degree of dose inten sity and chemoresponsiveness.

Main Outcome Measures. EFS curves were generated by the Kaplan-Meier product limit method and compared by log rank or Kruskal-Wallis analysis. Events were defined as disease progression or death (from whatever cause) which ever came first. P values reported are two-tailed.

Results. Probability of EFS (±SE) for all 215 metastatic breast cancer patients treated with ICE divided by degree of dose intensity (Phase I—lower dose intensity vs Phase II— higher dose intensity) at 3 years is 2.4 ± 2.3% for Phase I patients as compared with 18.4 ± 3.8% for phase II patients (P = .0951). The EFS for Phase II anthracycline responsive patients (n = 42) at 2 years is 36 ± 10%, 33 ± 19%, 29 ± 17% for MITT, ICE dose 11 through 15, and ICE dose level 16, respectively. The EFS for TNT at 5 months is 43 ± 19%. Overall percentages of toxic deaths were higher for patients receiving MITT (32%) and TNT (29%) as compared with the patients receiving ICE (8%) (P = .24). These differences are mainly attributed to an increased risk of cardiac toxicity in patients treated with MITT or TNT. All phase II patients (n = 139) treated with ICE, MITT and TNT were categorized by chemotherapy sensitivity status, the EFS at 3 years for the anthracycline responsive group is 31 ± 8%, as compared with for the anthracycline refractory/mini- ICE (lower doses of ICE) responsive group 19 ± 9% and 0% for the refractory group (P = .004). Conclusions. These results suggest that ICE, MITT, and TNT in the high-dose setting suggests that there may be a therapeutic advantage for delivering "highest" dose intensive therapy in patients with metastatic breast cancer. When all phase II patients treated with ICE, MITT, and TNT were categorized by chemotherapy sensitivity status, a significant differ ence in EFS among the three categories of sensitivity to anthracyclines and mini-ICE was observed. Further study of dose intensity in the setting of high-dose therapy for the treatment of metastatic breast cancer is warranted.