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Lim E, Waller D, Lau K, Steele J, Pope A, Ali C, Bilancia R, Keni M, Popat S, O'Brien M, Tokaca N, Maskell N, Stadon L, Fennell D, Nelson L, Edwards J, Tenconi S, Socci L, Rintoul RC, Wood K, Stone A, Muthukumar D, Ingle C, Taylor P, Cove-Smith L, Califano R, Summers Y, Tasigiannopoulos Z, Bille A, Shah R, Fuller E, Macnair A, Shamash J, Mansy T, Milton R, Koh P, Ionescu AA, Treece S, Roy A, Middleton G, Kirk A, Harris RA, Ashton K, Warnes B, Bridgeman E, Joyce K, Mills N, Elliott D, Farrar N, Stokes E, Hughes V, Nicholson AG, Rogers CA. Extended pleurectomy decortication and chemotherapy versus chemotherapy alone for pleural mesothelioma (MARS 2): a phase 3 randomised controlled trial. Lancet Respir Med 2024:S2213-2600(24)00119-X. [PMID: 38740044 DOI: 10.1016/s2213-2600(24)00119-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/17/2023] [Revised: 04/02/2024] [Accepted: 04/09/2024] [Indexed: 05/16/2024]
Abstract
BACKGROUND Extended pleurectomy decortication for complete macroscopic resection for pleural mesothelioma has never been evaluated in a randomised trial. The aim of this study was to compare outcomes after extended pleurectomy decortication plus chemotherapy versus chemotherapy alone. METHODS MARS 2 was a phase 3, national, multicentre, open-label, parallel two-group, pragmatic, superiority randomised controlled trial conducted in the UK. The trial took place across 26 hospitals (21 recruiting only, one surgical only, and four recruiting and surgical). Following two cycles of chemotherapy, eligible participants with pleural mesothelioma were randomly assigned (1:1) to surgery and chemotherapy or chemotherapy alone using a secure web-based system. Individuals aged 16 years or older with resectable pleural mesothelioma and adequate organ and lung function were eligible for inclusion. Participants in the chemotherapy only group received two to four further cycles of chemotherapy, and participants in the surgery and chemotherapy group received pleurectomy decortication or extended pleurectomy decortication, followed by two to four further cycles of chemotherapy. It was not possible to mask allocation because the intervention was a major surgical procedure. The primary outcome was overall survival, defined as time from randomisation to death from any cause. Analyses were done on the intention-to-treat population for all outcomes, unless specified. This study is registered with ClinicalTrials.gov, NCT02040272, and is closed to new participants. FINDINGS Between June 19, 2015, and Jan 21, 2021, of 1030 assessed for eligibility, 335 participants were randomly assigned (169 to surgery and chemotherapy, and 166 to chemotherapy alone). 291 (87%) participants were men and 44 (13%) women, and 288 (86%) were diagnosed with epithelioid mesothelioma. At a median follow-up of 22·4 months (IQR 11·3-30·8), median survival was shorter in the surgery and chemotherapy group (19·3 months [IQR 10·0-33·7]) than in the chemotherapy alone group (24·8 months [IQR 12·6-37·4]), and the difference in restricted mean survival time at 2 years was -1·9 months (95% CI -3·4 to -0·3, p=0·019). There were 318 serious adverse events (grade ≥3) in the surgery group and 169 in the chemotherapy group (incidence rate ratio 3·6 [95% CI 2·3 to 5·5], p<0·0001), with increased incidence of cardiac (30 vs 12; 3·01 [1·13 to 8·02]) and respiratory (84 vs 34; 2·62 [1·58 to 4·33]) disorders, infection (124 vs 53; 2·13 [1·36 to 3·33]), and additional surgical or medical procedures (15 vs eight; 2·41 [1·04 to 5·57]) in the surgery group. INTERPRETATION Extended pleurectomy decortication was associated with worse survival to 2 years, and more serious adverse events for individuals with resectable pleural mesothelioma, compared with chemotherapy alone. FUNDING National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (15/188/31), Cancer Research UK Feasibility Studies Project Grant (A15895).
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Affiliation(s)
- Eric Lim
- Royal Brompton and Harefield Hospitals, Guy's and St Thomas' NHS Foundation Trust, London, UK; Imperial College London, London, UK.
| | | | | | | | | | - Clinton Ali
- Beatson West of Scotland Cancer Centre, Glasgow, UK
| | | | | | - Sanjay Popat
- The Royal Marsden Hospital and the Institute of Cancer Research, London, UK
| | - Mary O'Brien
- The Royal Marsden Hospital and the Institute of Cancer Research, London, UK
| | - Nadza Tokaca
- The Royal Marsden Hospital and the Institute of Cancer Research, London, UK
| | | | | | | | | | - John Edwards
- Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Sara Tenconi
- Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Laura Socci
- Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Robert C Rintoul
- Papworth Trials Unit Collaboration, Royal Papworth Hospital, Cambridge, UK
| | - Kelly Wood
- Royal Papworth Hospital NHS Foundation Trust, Cambridge, UK
| | - Amanda Stone
- Royal Papworth Hospital NHS Foundation Trust, Cambridge, UK
| | | | - Charlotte Ingle
- East Sussex and North Essex NHS Foundation Trust, Colchester, UK
| | - Paul Taylor
- Manchester University NHS Foundation Trust, Manchester, UK
| | | | - Raffaele Califano
- The Christie NHS Foundation Trust and Division of Cancer Sciences, University of Manchester, Manchester, UK
| | - Yvonne Summers
- Manchester University NHS Foundation Trust, Manchester, UK
| | | | - Andrea Bille
- Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Riyaz Shah
- Maidstone and Tunbridge Wells NHS Trust, Maidstone, UK
| | - Elizabeth Fuller
- South Tyneside and Sunderland NHS Foundation Trust, South Shields, UK
| | - Andrew Macnair
- South Tyneside and Sunderland NHS Foundation Trust, South Shields, UK
| | - Jonathan Shamash
- Queen's Hospital, Barking Havering and Redbridge NHS Trust, Barking, UK
| | - Talal Mansy
- South Tees Hospital NHS Foundation Trust, Middlesbrough, UK
| | | | - Pek Koh
- Royal Wolverhampton NHS Trust, Wolverhampton, UK
| | | | - Sarah Treece
- North West Anglia NHS Foundation Trust, Peterborough, UK
| | - Amy Roy
- University Hospitals Plymouth NHS Trust, Plymouth, UK
| | | | - Alan Kirk
- Golden Jubilee National Hospital, Clydebank, UK
| | - Rosie A Harris
- Bristol Trials Centre, Bristol Medical School, University of Bristol, Bristol, UK
| | - Kate Ashton
- Bristol Trials Centre, Bristol Medical School, University of Bristol, Bristol, UK
| | - Barbara Warnes
- Bristol Trials Centre, Bristol Medical School, University of Bristol, Bristol, UK
| | - Emma Bridgeman
- Bristol Trials Centre, Bristol Medical School, University of Bristol, Bristol, UK
| | - Katherine Joyce
- Bristol Trials Centre, Bristol Medical School, University of Bristol, Bristol, UK
| | - Nicola Mills
- Population Health Sciences, University of Bristol, Bristol, UK
| | - Daisy Elliott
- Population Health Sciences, University of Bristol, Bristol, UK
| | - Nicola Farrar
- Population Health Sciences, University of Bristol, Bristol, UK
| | - Elizabeth Stokes
- University of Oxford Health Economics Research Centre, Oxford, UK
| | - Vikki Hughes
- Papworth Trials Unit Collaboration, Royal Papworth Hospital, Cambridge, UK
| | - Andrew G Nicholson
- Royal Brompton and Harefield Hospitals, Guy's and St Thomas' NHS Foundation Trust, London, UK; Imperial College London, London, UK
| | - Chris A Rogers
- Bristol Trials Centre, Bristol Medical School, University of Bristol, Bristol, UK
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Crockett C, Price J, Pham M, Abdulwahid D, Bayman N, Blackhall F, Bostock L, Califano R, Chan C, Coote J, Cove-Smith L, Eaton M, Fenemore J, Gomes F, Harris M, Halkyard E, Hughes S, Lindsay C, Neal H, McEntee D, Pemberton L, Sheikh H, Summers Y, Taylor P, Woolf D, Yorke J, Faivre-Finn C. Experience With the Routine Use of Electronic Patient-Reported Outcome Measures for Patients With Lung Cancer. JCO Clin Cancer Inform 2023; 7:e2200150. [PMID: 37071029 PMCID: PMC10281443 DOI: 10.1200/cci.22.00150] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2022] [Revised: 11/27/2022] [Accepted: 02/27/2023] [Indexed: 04/19/2023] Open
Abstract
PURPOSE The Christie NHS Foundation Trust launched their electronic patient-reported outcome measures (ePROMs) service in January 2019 in the routine clinical setting. The lung cancer questionnaires consist of 14 symptom items, adapted from the Common Terminology Criteria for Adverse Events (version 5.0) and the EuroQol EQ-5D-5L quality-of-life (QoL) tool. Patients with lung cancer are invited to complete questionnaires assessing their symptoms and QoL using an online platform. METHODS The ePROM responses and clinical, pathologic, and treatment data for patients who completed the questionnaires between January 2019 and December 2020 were extracted from electronic medical records. The symptom and QoL scores of patients who completed baseline pretreatment ePROMs and also those who completed ePROMs pre- and postpalliative lung systemic anticancer therapy (SACT) or radical thoracic radiotherapy were evaluated. Pretreatment questionnaires were analyzed according to age, Eastern Cooperative Oncology Group performance status (ECOG PS), and Adult Comorbidity Evaluation-27 (ACE-27) comorbidity score. RESULTS One thousand four hundred eighty patients with lung cancer were included. There were no statistically significant differences in symptoms and QoL scores between age groups. Cough (P = .006) and EQ-5D-5L mobility scores (P = .006) were significantly worse for patients with an ECOG PS of 0-1. Dyspnea (P = .035), hemoptysis (P = .023), nausea (P = .041), mobility (P = .004), and self-care (P = .0420) were significantly worse for those with higher ACE-27 scores (2-3 v 0-1). Palliative SACT was associated with a significant improvement in cough (P < .001) and hemoptysis (P = .025), but significantly negatively affected mobility (P = .013). Patients receiving radical thoracic radiotherapy reported a significant improvement in hemoptysis (P = .042) but worse pain (P = .002) and fatigue (P = .01). Other changes in symptom and QoL scores were not significant. CONCLUSION The symptoms and QoL reported at baseline and before and after both palliative SACT and radical thoracic radiotherapy are clinically relevant and meaningful. We have demonstrated that routine implementation of ePROMs into clinical practice is feasible and can inform clinical practice and future research.
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Affiliation(s)
| | - James Price
- The Christie NHS Foundation Trust, Manchester, United Kingdom
| | - Mai Pham
- The Christie NHS Foundation Trust, Manchester, United Kingdom
| | | | - Neil Bayman
- The Christie NHS Foundation Trust, Manchester, United Kingdom
| | - Fiona Blackhall
- The Christie NHS Foundation Trust, Manchester, United Kingdom
- Division of Cancer Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, United Kingdom
| | - Layla Bostock
- The Christie NHS Foundation Trust, Manchester, United Kingdom
| | - Raffaele Califano
- The Christie NHS Foundation Trust, Manchester, United Kingdom
- Division of Cancer Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, United Kingdom
| | - Clara Chan
- The Christie NHS Foundation Trust, Manchester, United Kingdom
| | - Joanna Coote
- The Christie NHS Foundation Trust, Manchester, United Kingdom
| | | | - Marie Eaton
- The Christie NHS Foundation Trust, Manchester, United Kingdom
| | | | - Fabio Gomes
- The Christie NHS Foundation Trust, Manchester, United Kingdom
| | - Margaret Harris
- The Christie NHS Foundation Trust, Manchester, United Kingdom
| | - Emma Halkyard
- The Christie NHS Foundation Trust, Manchester, United Kingdom
| | - Sarah Hughes
- The Christie NHS Foundation Trust, Manchester, United Kingdom
| | - Colin Lindsay
- The Christie NHS Foundation Trust, Manchester, United Kingdom
| | - Hilary Neal
- The Christie NHS Foundation Trust, Manchester, United Kingdom
| | - Delyth McEntee
- The Christie NHS Foundation Trust, Manchester, United Kingdom
| | - Laura Pemberton
- The Christie NHS Foundation Trust, Manchester, United Kingdom
| | - Hamid Sheikh
- The Christie NHS Foundation Trust, Manchester, United Kingdom
| | - Yvonne Summers
- The Christie NHS Foundation Trust, Manchester, United Kingdom
| | - Paul Taylor
- The Christie NHS Foundation Trust, Manchester, United Kingdom
| | - David Woolf
- The Christie NHS Foundation Trust, Manchester, United Kingdom
| | - Janelle Yorke
- The Christie NHS Foundation Trust, Manchester, United Kingdom
- Christie Patient-Centred Research, Division of Nursing, Midwifery & Social Work, The University of Manchester, Manchester, United Kingdom
| | - Corinne Faivre-Finn
- The Christie NHS Foundation Trust, Manchester, United Kingdom
- Division of Cancer Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, United Kingdom
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3
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Garassino MC, Mazieres J, Reck M, Chouaid C, Bischoff H, Reinmuth N, Cove-Smith L, Mansy T, Cortinovis D, Migliorino MR, Delmonte A, Sánchez JG, Chara Velarde LE, Bernabe R, Paz-Ares L, Perez ID, Trunova N, Foroutanpour K, Faivre-Finn C. Durvalumab After Sequential Chemoradiotherapy in Stage III, Unresectable NSCLC: The Phase 2 PACIFIC-6 Trial. J Thorac Oncol 2022; 17:1415-1427. [PMID: 35961520 DOI: 10.1016/j.jtho.2022.07.1148] [Citation(s) in RCA: 26] [Impact Index Per Article: 13.0] [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: 05/26/2022] [Revised: 07/15/2022] [Accepted: 07/20/2022] [Indexed: 02/07/2023]
Abstract
INTRODUCTION On the basis of the findings of the phase 3 PACIFIC trial (NCT02125461), durvalumab is standard of care for patients with stage III, unresectable NSCLC and no disease progression after concurrent chemoradiotherapy (cCRT). Many patients are considered unsuitable for cCRT owing to concerns with tolerability. The phase 2 PACIFIC-6 trial (NCT03693300) evaluates the safety and tolerability of durvalumab after sequential CRT (sCRT). METHODS Patients with stage III, unresectable NSCLC and no progression after platinum-based sCRT were enrolled to receive durvalumab (1500 mg intravenously) every 4 weeks for up to 24 months. The primary end point was the incidence of grade 3 or 4 adverse events possibly related to treatment occurring within 6 months. Secondary end points included investigator-assessed progression-free survival (PFS; Response Evaluation Criteria in Solid Tumors version 1.1) and overall survival. RESULTS Overall, 117 patients were enrolled (59.8% with performance status >0, 65.8% aged ≥65 y, and 37.6% with stage IIIA disease). Median treatment duration was 32.0 weeks; 37.6% of patients remained on treatment at data cutoff (July 15, 2021). Grade 3 or 4 AEs occurred in 18.8% of patients. Five patients had grade 3 or 4 possibly related adverse events within 6 months (incidence: 4.3%; 95% confidence interval: 1.4-9.7), including two pneumonitis cases. Two patients (1.7%) had grade 5 AEs of any cause. Survival data maturity was limited. Median PFS was 10.9 months (95% confidence interval: 7.3-15.6), and 12-month PFS and overall survival rates were 49.6% and 84.1%, respectively. CONCLUSIONS Durvalumab after sCRT had a comparable safety profile with that observed with durvalumab after cCRT in PACIFIC and had encouraging preliminary efficacy in a frailer population.
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Affiliation(s)
- Marina C Garassino
- Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy; Department of Hematology/Oncology, The University of Chicago, Chicago, Illinois.
| | - Julien Mazieres
- Centre Hospitalier Universitaire, Université Paul Sabatier, Toulouse, France
| | - Martin Reck
- Lung Clinic Grosshansdorf, Airway Research Center North, German Center for Lung Research, Grosshansdorf, Germany
| | - Christos Chouaid
- Service de Pneumologie, Centre Hospitalier Intercommunal de Créteil, Créteil, France
| | | | - Niels Reinmuth
- Asklepios Fachkliniken München-Gauting, German Center for Lung Research, Gauting, Germany
| | - Laura Cove-Smith
- The Christie NHS Foundation Trust and Manchester University Hospitals Foundation Trust, Manchester, United Kingdom
| | - Talal Mansy
- South Tees Hospitals NHS Foundation Trust, Middlesbrough, United Kingdom
| | | | | | - Angelo Delmonte
- IRCCS Istituto Romagnolo per lo Studio dei Tumori (IRST) "Dino Amadori," Meldola, Italy
| | - José Garcia Sánchez
- Medical Oncology Department, Hospital Arnau de Vilanova, Fundación para el Fomento de la Investigación Sanitaria i Biomédica de la Comunidad Valenciana (FISABIO), Valencia, Spain
| | | | - Reyes Bernabe
- Hospital Universitario Virgen del Rocio, Seville, Spain
| | - Luis Paz-Ares
- Universidad Complutense, CiberOnc, CNIO and Hospital Universitario 12 de Octubre, Madrid, Spain
| | | | | | | | - Corinne Faivre-Finn
- The University of Manchester and The Christie NHS Foundation Trust, Manchester, United Kingdom
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4
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Ortega-Franco A, Hodgson C, Raja H, Carter M, Lindsay C, Hughes S, Cove-Smith L, Taylor P, Summers Y, Blackhall F, Califano R. Real-World Data on Pembrolizumab for Pretreated Non-Small-Cell Lung Cancer: Clinical Outcome and Relevance of the Lung Immune Prognostic Index. Target Oncol 2022; 17:453-465. [PMID: 35781861 DOI: 10.1007/s11523-022-00889-8] [Citation(s) in RCA: 3] [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] [Accepted: 05/05/2022] [Indexed: 12/12/2022]
Abstract
BACKGROUND Pembrolizumab is licensed for the treatment of pre-treated and PD-L1 positive non-small cell lung cancer (NSCLC), but response is heterogeneous. In this context, the Lung Immune Prognostic Index (LIPI) has been proposed as tool to prognosticate outcome. OBJECTIVE To investigate the real-world efficacy and safety of pembrolizumab in pre-treated NSCLC patients and the clinical utility of LIPI for patients' selection. PATIENTS AND METHODS Patients with pre-treated NSCLC and PD-L1 ≥ 1% treated with pembrolizumab were included in this retrospective series. The LIPI was used to classify patients in 3 prognostics subgroups according to the pre-treatment dNLR (derived neutrophil to lymphocyte ratio) and LDH in blood. The prognostic impact of the LIPI on progression free survival (PFS) and overall survival (OS) was evaluated with Cox regression. The combined effect of LIPI and other relevant prognostic factors was explored with multivariate regression. RESULTS In total, 113 consecutive patients were included. Median (mPFS) and mOS was 4.3 (2.6-6.7) and 13.5 (10.3-17.7) months, respectively. Good-, intermediate-, and poor-LIPI was found in 54 (47.8%), 45 (39.8%), and 8 (7.1%) patients, respectively. Median PFS was 5.1 (2.8-9.1), 3.0 (2.5-6.8), and 1.4 (0.5-18.7) months, and mOS was 17.2 (12.0-26.4), 11.8 (8.4-17.1), and 3.7 (0.5-not calculable) months for good-, intermediate-, and poor-LIPI group, respectively. Patients with intermediate-LIPI and poor-LIPI had worse PFS versus good-LIPI, and statistically significant worse OS (p = 0.030 and p = 0.013, respectively). In the multivariate analysis, intermediate- versus good-LIPI (p = 0.190) was not independently associated to PFS or OS. Patients with both good-LIPI and high (≥ 50%) PD-L1 had better OS than all other subgroups defined by LIPI and PD-L1. Immune-related adverse events (irAEs) occurred in 47 (41.6%) patients (12.4% grade ≥ 3). In a time-varying analysis, irAEs were statistically associated with longer OS (HR 0.51, 0.31-0.84; p = 0.008). CONCLUSION In our series, the outcome of pembrolizumab in pre-treated NSCLC is consistent with the registration trial. Lung Immune Prognostic Index is a readily available tool able to prognosticate outcome, also in PD-L1-high patients. The positive association between irAEs and OS might aid decision making.
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Affiliation(s)
- Ana Ortega-Franco
- Experimental Cancer Medicine Team, The Christie NHS Foundation Trust, Manchester, UK
| | - Clare Hodgson
- Digital Services, The Christie NHS Foundation Trust, Manchester, UK
| | - Haseem Raja
- Department of ENT, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Mathew Carter
- Department of Medical Oncology, The Christie NHS Foundation Trust, Manchester, UK
| | - Colin Lindsay
- Department of Medical Oncology, The Christie NHS Foundation Trust, Manchester, UK.,Division of Cancer Sciences, University of Manchester, Manchester, UK
| | - Sarah Hughes
- Department of Medical Oncology, The Christie NHS Foundation Trust, Manchester, UK
| | - Laura Cove-Smith
- Department of Medical Oncology, The Christie NHS Foundation Trust, Manchester, UK.,Division of Cancer Sciences, University of Manchester, Manchester, UK
| | - Paul Taylor
- Department of Medical Oncology, The Christie NHS Foundation Trust, Manchester, UK
| | - Yvonne Summers
- Department of Medical Oncology, The Christie NHS Foundation Trust, Manchester, UK.,Division of Cancer Sciences, University of Manchester, Manchester, UK
| | - Fiona Blackhall
- Department of Medical Oncology, The Christie NHS Foundation Trust, Manchester, UK.,Division of Cancer Sciences, University of Manchester, Manchester, UK
| | - Raffaele Califano
- Department of Medical Oncology, The Christie NHS Foundation Trust, Manchester, UK. .,Division of Cancer Sciences, University of Manchester, Manchester, UK.
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King J, Shah D, Hewitt K, Punjabi A, Marshall K, Balata H, Brockelsby C, Sinnott N, Lyons J, Martin J, Crosbie P, Booton R, Ng C, Cove-Smith L, Evison M. The diagnostic pathway in lung cancer patients with best supportive care decisions: are there lessons to be learnt? Clin Med (Lond) 2022; 22:246-250. [PMID: 38589084 PMCID: PMC9135074 DOI: 10.7861/clinmed.2021-0160] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [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] [Indexed: 11/27/2022]
Abstract
INTRODUCTION A proportion of patients with lung cancer will not be suitable for anti-cancer treatment and are managed with best supportive care (BSC). The aim of this retrospective case series analysis was to critically review the use of diagnostic and staging investigations in patients who were ultimately managed with BSC. METHODS A retrospective review of all lung cancer patients with a multidisciplinary team outcome of BSC from 01 June 2018 to 01 June 2019 was performed. Patients were categorised into those with an early BSC decision and those that underwent further investigations prior to a BSC decision (investigations beyond initial computed tomography (CT)). Patient demographics, clinical characteristics and outcomes were collated and analysed. RESULTS Seventy-seven lung cancer patients managed with BSC were identified. Patients were elderly (average age 79 years), functionally limited (80% World Health Organization performance status ≥3), frail (70% clinical frailty score ≥6) and had advanced stage disease (90% stage III/IV). Thirty-one (40%) underwent further investigations beyond the initial CT prior to the BSC decision. The most common types of further investigations were endobronchial ultrasound-guided transbronchial needle aspiration (27/31; 74%), positron emission tomography - CT (18/31; 45%) and CT-guided lung biopsy (7/31; 23%). This is despite high levels of consultant chest physician review at first assessment (71%), cancer nurse specialist involvement (97%), specialist palliative care involvement (65%), a high pathological confirmation rate of sampling procedures (89%) and adequacy of molecular testing. The most common reason for a BSC recommendation was a lack of fitness for systemic therapy (17/31; 55%). Six out of thirty-one (19%) patients deteriorated rapidly and died on the cancer pathway and 5/31 (16%) patients had inadequate renal function for systemic anti-cancer treatment. There was low utilisation of serum epidermal growth factor receptor mutation testing across the study cohort (2/77; 3%). DISCUSSION In an older, functionally limited and frail patient with lung cancer, there is a risk of over-investigation. Impaired renal function is an important clinical factor to identify early to support discussions in this cohort. There will always be an unavoidable proportion of patients that undergo further investigations (often in search of rare targetable mutations) and are then ultimately recommended for best supportive care; such cases could form the basis of specific review and learning for lung cancer services.
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Affiliation(s)
| | | | | | | | | | | | - Chris Brockelsby
- Wythenshawe Hospital, Manchester, UK and Mid Cheshire Hospitals NHS Foundation Trust, Crewe, UK
| | | | | | | | - Philip Crosbie
- University of Manchester, Manchester, UK and lung cancer physician, Wythenshawe Hospital, Manchester, UK
| | - Richard Booton
- Wythenshawe Hospital, Manchester, UK and honourary chair in respiratory medicine, University of Manchester, Manchester, UK
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Garassino M, Mazieres J, Reck M, Chouaid C, Bischoff H, Reinmuth N, Cove-Smith L, Mansy T, Cortinovis D, Migliorino M, Delmonte A, Garcia Sánchez J, Chara Velarde L, Bernabe R, Paz-Ares L, Diaz Perez I, Trunova N, Foroutanpour K, Faivre-Finn C. 108MO Safety and efficacy outcomes with durvalumab after sequential chemoradiotherapy (sCRT) in stage III, unresectable NSCLC (PACIFIC-6). Ann Oncol 2022. [DOI: 10.1016/j.annonc.2022.02.135] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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7
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Beardsworth S, Bayman N, Coote J, Cove-Smith L, Faivre-Finn C, Harris M, Salem A, Sheikh H, Taylor P, Woolf D, Fenemore J, Chan C. An evaluation of concurrent chemoradiotherapy practice for locally advanced non-small cell lung cancer (NSCLC) in a single centre institution. Lung Cancer 2022. [DOI: 10.1016/s0169-5002(22)00157-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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8
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Iyer A, Blackhall F, Bayman N, Cove-Smith L, Faivre-Finn C, Woolf D, Brown L, Bailey S, Grundy S, Fullerton D, Craig C, Granato F, Rammohan K, Fenemore J, Taylor P, Evison M. Early evaluation of a new regional pathway for tri-modality treatment in stage III-N2 NSCLC in Greater Manchester. Lung Cancer 2022. [DOI: 10.1016/s0169-5002(22)00054-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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9
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Osborne L, Ortega-Franco A, Hodgson C, Pearce M, Moss A, Lindsay C, Hughes S, Taylor P, Califano R, Rafee S, Gomes F, Summers Y, Blackhall F, Cove-Smith L, Halkyard E, Fenemore J. Real-world use of different pembrolizumab regimens (3 weekly versus 6 weekly) in non-small cell lung cancer (NSCLC) patients. Lung Cancer 2022. [DOI: 10.1016/s0169-5002(22)00144-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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10
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King J, Shah D, Hewitt K, Punjabi A, Marshall K, Balata H, Brocklesby C, Sinnott N, Lyons J, Martin J, Crosbie P, Booton R, Ng C, Cove-Smith L, Evison M. Reviewing the diagnostic pathway in lung cancer patients with best supportive care decisions – are there lessons to be learnt? Lung Cancer 2021. [DOI: 10.1016/s0169-5002(21)00358-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Ortega Franco A, Tay R, Raja H, Ackermann C, Carter M, Lindsay C, Hughes S, Cove-Smith L, Taylor P, Summers Y, Blackhall F, Califano R. 108P Pembrolizumab in pre-treated advanced non-small cell lung cancer (NSCLC) patients (pts): Impact of blood-based biomarkers on survival outcomes. Ann Oncol 2020. [DOI: 10.1016/j.annonc.2020.08.229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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Tivey A, Ullah M, Beech A, Ng C, Cove-Smith L. Can frailty screening tools predict completion of chemotherapy and chemotherapy toxicity in patients with thoracic malignancy? J Geriatr Oncol 2020; 11:1154-1156. [DOI: 10.1016/j.jgo.2020.03.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2019] [Revised: 01/21/2020] [Accepted: 03/04/2020] [Indexed: 12/20/2022]
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Beech A, Faivre-Finn C, Bayman N, Blackhall F, Califano R, Chan C, Cobben D, Coote J, Cove-Smith L, Harris M, Hughes S, Martimarti F, Pemberton L, Salem A, Summers Y, Taylor P, Wang X, Woolf D, Sheikh H. Pneumocystis jirovecii pneumonia (PJP) prophylaxis in lung cancer patients receiving radical radiotherapy (RT) ± chemotherapy (CTRT): audit of the first UK departmental guideline. Lung Cancer 2020. [DOI: 10.1016/s0169-5002(20)30113-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Kahai R, Ullah M, Beech A, Cove-Smith L, Lyons J, Ng C. Are there any benefits to consumption of an oral nutritional supplement (ONS) ice lolly in lung cancer patients? Lung Cancer 2020. [DOI: 10.1016/s0169-5002(20)30218-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Birley J, Summers Y, Taylor P, Beanland L, Lam C, Califano R, Cove-Smith L. Incidence of cardiovascular adverse events (AEs) in resected non-small cell lung cancer (NSCLC) patients receiving adjuvant platinum-based chemotherapy: a single institution experience from Wythenshawe Hospital, Manchester, UK. Lung Cancer 2020. [DOI: 10.1016/s0169-5002(20)30129-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Gomes F, Baker K, Woods J, Bruce J, Eaton M, Higham P, Cove-Smith L, Garbett A, Cree A, Ng C, Blackhall F, Bayman N. MA19.09 Assessing Clinical Frailty in Advanced Lung Cancer Patients - An Opportunity to Improve Patient Outcomes? J Thorac Oncol 2019. [DOI: 10.1016/j.jtho.2019.08.661] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Li F, Morgan A, McCullagh A, Johnson A, Giles C, Greenfield D, Crawford G, Gath J, Lyons J, Andreyev J, Tobutt J, Tugwell J, Robb K, Cove-Smith L, Bennister L, Doyle N, Lee N, Nash R, Simcock R, Stephens R, Best S, Moug S, Staley K, Regan S, Ellis P, Griffiths S, Lewis I. Abstract 3348: Top 10 living with and beyond cancer research priorities. Cancer Res 2019. [DOI: 10.1158/1538-7445.am2019-3348] [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
More and more people are living with the consequences of cancer and its treatment (living with and beyond cancer), yet the level of relevant research is low compared to other types of cancer research in the UK. NCRI aims to increase the level of research in this area and to ultimately improve the lives of those affected by cancer. Undefined research priorities in this broad area has been a barrier to research. The 2015 NHS Independent Cancer Taskforce report also recommends defining research priorities and to enable this research to happen. To address this barrier the NCRI has undertaken a James Lind Alliance Priority Setting Partnership (PSP) to identify priorities that matter most to people affected by cancer and the health and social care professionals.A PSP consists of patients and carers, health and social care professionals. PSPs have several stages and begin with a UK-wide survey to gather questions about uncertainties in living with and beyond cancer. Once the results were analysed, an interim exercise takes place to further prioritise the uncertainties. The last stage is a final workshop where partners debate and finally arrive at a top 10 list of shared uncertainties.The living with and beyond cancer PSP received 3500 questions submitted by people affected by cancer and healthcare professionals. Through a 18-month established rigorous process, the questions are prioritised down to the Top 10 living with and beyond cancer priorities for research in June 2018. This is the first time that clear research priorities have been identified in this area. They are the most impactful research questions that will help improve the lives of people affected by cancer. The Top 10 uncertainties will be publicised widely to ensure that researchers and those who fund research really understand what matters to people affected by cancer. The top uncertainties will be promoted to many research organizations and relevant funders in the UK. We anticipate they will directly influence future research.
Citation Format: Feng Li, Adrienne Morgan, Angela McCullagh, Anne Johnson, Ceinwen Giles, Diana Greenfield, Graeme Crawford, Jacqui Gath, Jane Lyons, Jervoise Andreyev, Jonathan Tobutt, Julia Tugwell, Karen Robb, Laura Cove-Smith, Lindsey Bennister, Natalie Doyle, Nicolas Lee, Rebecca Nash, Richard Simcock, Richard Stephens, Sabine Best, Susan Moug, Kristina Staley, Sandra Regan, Patricia Ellis, Stuart Griffiths, Ian Lewis. Top 10 living with and beyond cancer research priorities [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2019; 2019 Mar 29-Apr 3; Atlanta, GA. Philadelphia (PA): AACR; Cancer Res 2019;79(13 Suppl):Abstract nr 3348.
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Affiliation(s)
- Feng Li
- 1National Cancer Research Institute, London, United Kingdom
| | | | - Angela McCullagh
- 3National Cancer Research Institute Consumer Forum, London, United Kingdom
| | | | | | - Diana Greenfield
- 6Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, United Kingdom
| | - Graeme Crawford
- 7Bangor Health Centre, Northern Ireland, Bangor, United Kingdom
| | - Jacqui Gath
- 2Independent Cancer Patients' Voice, London, United Kingdom
| | | | - Jervoise Andreyev
- 9United Lincolnshire Hospitals NHS Trust, Lincolnshire, United Kingdom
| | | | - Julia Tugwell
- 3National Cancer Research Institute Consumer Forum, London, United Kingdom
| | - Karen Robb
- 11Transforming Cancer Services Team in London, London, United Kingdom
| | | | | | - Natalie Doyle
- 14The Royal Marsden NHS Foundation Trust, London, United Kingdom
| | - Nicolas Lee
- 15Macmillan Cancer Support, London, United Kingdom
| | - Rebecca Nash
- 15Macmillan Cancer Support, London, United Kingdom
| | - Richard Simcock
- 16Brighton and Sussex University Hospital Trust, Brighton, United Kingdom
| | - Richard Stephens
- 3National Cancer Research Institute Consumer Forum, London, United Kingdom
| | | | - Susan Moug
- 18Royal Alexandra Hospital Paisley, Glasgow, United Kingdom
| | | | - Sandra Regan
- 20NIHR Oxford Health Biomedical Research Centre, Oxford, United Kingdom
| | | | | | - Ian Lewis
- 1National Cancer Research Institute, London, United Kingdom
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Gomes F, Yip K, Tokaca N, Greystoke A, Escriu C, Conibear J, Ghosh S, Doherty G, Funingana I, Ahmad T, Ahmed S, Cox R, Newsom-Davis T, Mills H, Shah R, Dorey N, Harle A, Dancey G, Baijal S, Geldart T, Ghafoor Q, Tarver K, Talbot T, Forster M, Cove-Smith L, Califano R, Blackhall F, Popat S, Summers Y. The ALK project: a real-world national network and database. Lung Cancer 2019. [DOI: 10.1016/s0169-5002(19)30121-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Tivey A, Wu K, Tay R, Gomes F, Taylor P, Blackhall F, Summers Y, Califano R, Cove-Smith L. Pembrolizumab monotherapy for advanced/recurrent non-small cell lung cancer: a Greater Manchester experience. Lung Cancer 2019. [DOI: 10.1016/s0169-5002(19)30150-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Cheng A, Craig C, Summers Y, Taylor P, Califano R, Cove-Smith L, Woolf D, Duerden R, Sharman A, Lyons J, Crosbie P, Booton R, Evison M. Metachronous oligometastatic non-small cell lung cancer: are we selecting the appropriate patients for radical treatment? Lung Cancer 2019. [DOI: 10.1016/s0169-5002(19)30128-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Griffin LL, Cove-Smith L, Alachkar H, Radford JA, Brooke R, Linton KM. Toxic epidermal necrolysis (TEN) associated with the use of nivolumab (PD-1 inhibitor) for lymphoma. JAAD Case Rep 2018; 4:229-231. [PMID: 29687056 PMCID: PMC5909477 DOI: 10.1016/j.jdcr.2017.09.028] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Affiliation(s)
- Liezel L Griffin
- Dermatology Centre, Salford Royal NHS Foundation Trust, Salford, United Kingdom
| | - Laura Cove-Smith
- Manchester Academic Health Sciences Centre, University of Manchester, Manchester, United Kingdom.,Department of Medical Oncology, Christie NHS Foundation Trust, Manchester, United Kingdom
| | - Hana Alachkar
- Department of Immunology, Salford Royal NHS Foundation Trust, Salford, United Kingdom
| | - John A Radford
- Manchester Academic Health Sciences Centre, University of Manchester, Manchester, United Kingdom.,Department of Medical Oncology, Christie NHS Foundation Trust, Manchester, United Kingdom
| | - Rebecca Brooke
- Dermatology Centre, Salford Royal NHS Foundation Trust, Salford, United Kingdom
| | - Kim M Linton
- Manchester Academic Health Sciences Centre, University of Manchester, Manchester, United Kingdom.,Department of Medical Oncology, Christie NHS Foundation Trust, Manchester, United Kingdom
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Cove-Smith L, Schmitt M, Dive C, Backen A, Mescallado N, Roberts R, Mellor H, Morris D, Naish J, Jackson A, Kirk J, Hargreaves A, Galvin M, Smith S, Brocklehurst S, Price S, Betts C, Hockings P, Woodhouse N, Radford J, Linton K. 019 Chemotherapy-induced cardiotoxicity: could a translational cardiac MRI model help identify patients at risk? Heart 2017. [DOI: 10.1136/heartjnl-2017-311399.19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Cross MJ, Berridge BR, Clements PJM, Cove-Smith L, Force TL, Hoffmann P, Holbrook M, Lyon AR, Mellor HR, Norris AA, Pirmohamed M, Tugwood JD, Sidaway JE, Park BK. Physiological, pharmacological and toxicological considerations of drug-induced structural cardiac injury. Br J Pharmacol 2015; 172:957-74. [PMID: 25302413 PMCID: PMC4314188 DOI: 10.1111/bph.12979] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2014] [Revised: 09/30/2014] [Accepted: 10/06/2014] [Indexed: 01/01/2023] Open
Abstract
The incidence of drug-induced structural cardiotoxicity, which may lead to heart failure, has been recognized in association with the use of anthracycline anti-cancer drugs for many years, but has also been shown to occur following treatment with the new generation of targeted anti-cancer agents that inhibit one or more receptor or non-receptor tyrosine kinases, serine/threonine kinases as well as several classes of non-oncology agents. A workshop organized by the Medical Research Council Centre for Drug Safety Science (University of Liverpool) on 5 September 2013 and attended by industry, academia and regulatory representatives, was designed to gain a better understanding of the gaps in the field of structural cardiotoxicity that can be addressed through collaborative efforts. Specific recommendations from the workshop for future collaborative activities included: greater efforts to identify predictive (i) preclinical; and (ii) clinical biomarkers of early cardiovascular injury; (iii) improved understanding of comparative physiology/pathophysiology and the clinical predictivity of current preclinical in vivo models; (iv) the identification and use of a set of cardiotoxic reference compounds for comparative profiling in improved animal and human cellular models; (v) more sharing of data (through publication/consortia arrangements) on target-related toxicities; (vi) strategies to develop cardio-protective agents; and (vii) closer interactions between preclinical scientists and clinicians to help ensure best translational efforts.
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Affiliation(s)
- M J Cross
- MRC Centre for Drug Safety Science, Department of Molecular and Clinical Pharmacology, University of LiverpoolLiverpool, UK
| | - B R Berridge
- Safety Assessment, GlaxoSmithKlineResearch Triangle Park, NC, USA
| | - P J M Clements
- David Jack Centre for Research & Development, GlaxoSmithKlineWare, Herts, UK
| | - L Cove-Smith
- Clinical & Experimental Pharmacology, Cancer Research UK Manchester Institute, University of ManchesterManchester, UK
| | - T L Force
- Center for Translational Medicine and Cardiology Division, Temple University School of MedicinePhiladelphia, PA, USA
| | - P Hoffmann
- Preclinical Safety, Novartis Pharm CorpEast Hanover, NJ, USA
| | - M Holbrook
- Safety Pharmacology, Covance Laboratories, Ltd.Harrogate, North Yorkshire, UK
| | - A R Lyon
- NIHR Cardiovascular Biomedical Research Unit, Royal Brompton Hospital and Imperial CollegeLondon, UK
| | - H R Mellor
- Drug Safety Evaluation, Vertex Pharmaceuticals (Europe), Ltd.Abingdon, Oxfordshire, UK
| | - A A Norris
- MRC Centre for Drug Safety Science, Department of Molecular and Clinical Pharmacology, University of LiverpoolLiverpool, UK
| | - M Pirmohamed
- The Wolfson Centre for Personalised Medicine, Institute of Translational Medicine, University of LiverpoolLiverpool, UK
| | - J D Tugwood
- Clinical & Experimental Pharmacology, Cancer Research UK Manchester Institute, University of ManchesterManchester, UK
| | - J E Sidaway
- Innovative Medicines, AstraZeneca R&DMacclesfield, UK
| | - B K Park
- MRC Centre for Drug Safety Science, Department of Molecular and Clinical Pharmacology, University of LiverpoolLiverpool, UK
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Barnes C, Kelsall J, Smith S, Cove-Smith L, Mellor H, Hargreaves A, Price S. Localisation of novel miRNA biomarkers of doxorubicin-induced cardiotoxicity in rats. Toxicol Lett 2014. [DOI: 10.1016/j.toxlet.2014.06.816] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Cove-Smith L, Woodhouse N, Hargreaves A, Price S, Marsden M, Betts C, Brocklehurst S, Backen A, Radford J, Roberts R, Schmitt M, Dive C, Tugwood J, Hockings P, Mellor H. An integrated characterisation of serological, pathological and functional events in doxorubicin-induced cardiotoxicity. Toxicol Lett 2014. [DOI: 10.1016/j.toxlet.2014.06.800] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Cove-Smith L, Woodhouse N, Hargreaves A, Kirk J, Smith S, Price SA, Galvin M, Betts CJ, Brocklehurst S, Backen A, Radford J, Linton K, Roberts RA, Schmitt M, Dive C, Tugwood JD, Hockings PD, Mellor HR. An integrated characterization of serological, pathological, and functional events in doxorubicin-induced cardiotoxicity. Toxicol Sci 2014; 140:3-15. [PMID: 24675088 DOI: 10.1093/toxsci/kfu057] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [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: 02/11/2024] Open
Abstract
Many efficacious cancer treatments cause significant cardiac morbidity, yet biomarkers or functional indices of early damage, which would allow monitoring and intervention, are lacking. In this study, we have utilized a rat model of progressive doxorubicin (DOX)-induced cardiomyopathy, applying multiple approaches, including cardiac magnetic resonance imaging (MRI), to provide the most comprehensive characterization to date of the timecourse of serological, pathological, and functional events underlying this toxicity. Hannover Wistar rats were dosed with 1.25 mg/kg DOX weekly for 8 weeks followed by a 4 week off-dosing "recovery" period. Electron microscopy of the myocardium revealed subcellular degeneration and marked mitochondrial changes after a single dose. Histopathological analysis revealed progressive cardiomyocyte degeneration, hypertrophy/cytomegaly, and extensive vacuolation after two doses. Extensive replacement fibrosis (quantified by Sirius red staining) developed during the off-dosing period. Functional indices assessed by cardiac MRI (including left ventricular ejection fraction (LVEF), cardiac output, and E/A ratio) declined progressively, reaching statistical significance after two doses and culminating in "clinical" LV dysfunction by 12 weeks. Significant increases in peak myocardial contrast enhancement and serological cardiac troponin I (cTnI) emerged after eight doses, importantly preceding the LVEF decline to <50%. Troponin I levels positively correlated with delayed and peak gadolinium contrast enhancement, histopathological grading, and diastolic dysfunction. In summary, subcellular cardiomyocyte degeneration was the earliest marker, followed by progressive functional decline and histopathological manifestations. Myocardial contrast enhancement and elevations in cTnI occurred later. However, all indices predated "clinical" LV dysfunction and thus warrant further evaluation as predictive biomarkers.
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Affiliation(s)
- Laura Cove-Smith
- Clinical & Experimental Pharmacology, Cancer Research UK Manchester Institute, University of Manchester, Wilmslow Road, Manchester M20 4BX, UK Department of Medical Oncology, Christie Hospital NHS Trust, Wilmslow Road, Manchester M20 4BX, UK
| | - Neil Woodhouse
- Personalised Healthcare & Biomarkers, AstraZeneca R&D, Alderley Park Macclesfield, Cheshire, SK10 4TF, UK
| | - Adam Hargreaves
- Drug Safety & Metabolism, Innovative Medicines, AstraZeneca R&D, Alderley Park Macclesfield, Cheshire, SK10 4TF, UK
| | - Jason Kirk
- Drug Safety & Metabolism, Innovative Medicines, AstraZeneca R&D, Alderley Park Macclesfield, Cheshire, SK10 4TF, UK
| | - Susan Smith
- Drug Safety & Metabolism, Innovative Medicines, AstraZeneca R&D, Alderley Park Macclesfield, Cheshire, SK10 4TF, UK
| | - Sally A Price
- Drug Safety & Metabolism, Innovative Medicines, AstraZeneca R&D, Alderley Park Macclesfield, Cheshire, SK10 4TF, UK
| | - Melanie Galvin
- Drug Safety & Metabolism, Innovative Medicines, AstraZeneca R&D, Alderley Park Macclesfield, Cheshire, SK10 4TF, UK
| | - Catherine J Betts
- Drug Safety & Metabolism, Innovative Medicines, AstraZeneca R&D, Alderley Park Macclesfield, Cheshire, SK10 4TF, UK
| | - Simon Brocklehurst
- Drug Safety & Metabolism, Innovative Medicines, AstraZeneca R&D, Alderley Park Macclesfield, Cheshire, SK10 4TF, UK
| | - Alison Backen
- Clinical & Experimental Pharmacology, Cancer Research UK Manchester Institute, University of Manchester, Wilmslow Road, Manchester M20 4BX, UK
| | - John Radford
- University of Manchester, Institute of Cancer Sciences, Oxford Road, Manchester M13 9PT, UK Department of Medical Oncology, Christie Hospital NHS Trust, Wilmslow Road, Manchester M20 4BX, UK
| | - Kim Linton
- University of Manchester, Institute of Cancer Sciences, Oxford Road, Manchester M13 9PT, UK Department of Medical Oncology, Christie Hospital NHS Trust, Wilmslow Road, Manchester M20 4BX, UK
| | - Ruth A Roberts
- Drug Safety & Metabolism, Innovative Medicines, AstraZeneca R&D, Alderley Park Macclesfield, Cheshire, SK10 4TF, UK
| | - Matthias Schmitt
- North West Regional Heart Centre, University Hospital of South Manchester, Wythenshawe, Manchester M23 9LT, UK
| | - Caroline Dive
- Clinical & Experimental Pharmacology, Cancer Research UK Manchester Institute, University of Manchester, Wilmslow Road, Manchester M20 4BX, UK
| | - Jonathan D Tugwood
- Clinical & Experimental Pharmacology, Cancer Research UK Manchester Institute, University of Manchester, Wilmslow Road, Manchester M20 4BX, UK
| | - Paul D Hockings
- Drug Safety & Metabolism, Innovative Medicines, AstraZeneca R&D, Alderley Park Macclesfield, Cheshire, SK10 4TF, UK MedTech West, Chalmers University of Technology, 41296 Gothenburg, Sweden
| | - Howard R Mellor
- Drug Safety & Metabolism, Innovative Medicines, AstraZeneca R&D, Alderley Park Macclesfield, Cheshire, SK10 4TF, UK
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