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Msaouel P, Oromendia C, Siefker-Radtke AO, Tannir NM, Subudhi SK, Gao J, Wang Y, Siddiqui BA, Shah AY, Aparicio AM, Campbell MT, Zurita AJ, Shaw LK, Lopez LP, McCord H, Chakraborty SN, Perales J, Lu C, Van Alstine ML, Elashoff M, Logothetis C. Evaluation of Technology-Enabled Monitoring of Patient-Reported Outcomes to Detect and Treat Toxic Effects Linked to Immune Checkpoint Inhibitors. JAMA Netw Open 2021; 4:e2122998. [PMID: 34459906 PMCID: PMC8406081 DOI: 10.1001/jamanetworkopen.2021.22998] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
IMPORTANCE Immune checkpoint inhibitors can produce distinct toxic effects that require prompt recognition and timely management. OBJECTIVE To develop a technology-enabled, dynamically adaptive protocol that can provide the accurate information needed to inform specific remedies for immune toxic effects in patients treated with immune checkpoint inhibitors. DESIGN, SETTING, AND PARTICIPANTS An open-label cohort study was conducted at a single tertiary referral center from September 6, 2019, to September 3, 2020. The median follow-up duration was 63 (interquartile range, 35.5-122) days. Fifty patients with genitourinary cancers treated with immune checkpoint inhibitors were enrolled. INTERVENTIONS A fit-for-purpose electronic platform was developed to enable active patient and care team participation. A smartphone application downloaded onto patients' personal mobile devices prompted them to report their symptoms at least 3 times per week. The set of symptoms and associated queries were paired with alert thresholds for symptoms requiring clinical action. MAIN OUTCOMES AND MEASURES The primary end point of this interim analysis was feasibility, as measured by patient and care team adherence, and lack of increase in care team staffing. Operating characteristics were estimated for each symptom alert and used to dynamically adapt the alert thresholds to ensure sensitivity while reducing unnecessary alerts. RESULTS Of the 50 patients enrolled, 47 had at least 1 follow-up visit and were included in the analysis. Median age was 65 years (range, 37-86), 39 patients (83%) were men, and 39 patients (83%) had metastatic cancer, with the most common being urothelial cell carcinoma and renal cell carcinoma (22 [47%] patients each). After initial onboarding, no further care team training or additional care team staffing was required. Patients had a median study adherence rate of 74% (interquartile range, 60%-86%) and 73% of automated alerts were reviewed within 3 days by the clinic team. Symptoms with the highest positive predictive value for adverse events requiring acute intervention included dizziness (21%), nausea/vomiting (26%), and shortness of breath (14%). The symptoms most likely to result in unnecessary alerts were arthralgia and myalgia, fatigue, and cough. CONCLUSIONS AND RELEVANCE The findings of this cohort study suggest an acceptable and fiscally sound method can be developed to create a dynamic learning system to detect and manage immune-related toxic effects.
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Affiliation(s)
- Pavlos Msaouel
- Division of Cancer Medicine, Department of Genitourinary Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston
- Division of Pathology and Laboratory Medicine, Department of Translational Molecular Pathology, The University of Texas MD Anderson Cancer Center, Houston
| | | | - Arlene O. Siefker-Radtke
- Division of Cancer Medicine, Department of Genitourinary Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston
| | - Nizar M. Tannir
- Division of Cancer Medicine, Department of Genitourinary Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston
| | - Sumit K. Subudhi
- Division of Cancer Medicine, Department of Genitourinary Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston
| | - Jianjun Gao
- Division of Cancer Medicine, Department of Genitourinary Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston
| | - Yinghong Wang
- Division of Internal Medicine, Department of Gastroenterology, Hepatology, and Nutrition, The University of Texas MD Anderson Cancer Center, Houston
| | - Bilal A. Siddiqui
- Division of Cancer Medicine, The University of Texas MD Anderson Cancer Center, Houston
| | - Amishi Y. Shah
- Division of Cancer Medicine, Department of Genitourinary Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston
| | - Ana M. Aparicio
- Division of Cancer Medicine, Department of Genitourinary Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston
| | - Matthew T. Campbell
- Division of Cancer Medicine, Department of Genitourinary Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston
| | - Amado J. Zurita
- Division of Cancer Medicine, Department of Genitourinary Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston
| | - Leah K. Shaw
- Division of Cancer Medicine, Department of Genitourinary Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston
| | - Lidia P. Lopez
- Division of Cancer Medicine, Department of Genitourinary Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston
| | - Heather McCord
- Division of Cancer Medicine, Department of Genitourinary Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston
| | - Sandip N. Chakraborty
- Division of Cancer Medicine, Department of Genitourinary Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston
| | - Jacqueline Perales
- Division of Cancer Medicine, Department of Genitourinary Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston
| | - Cong Lu
- The Ronin Project, San Mateo, California
| | | | | | - Christopher Logothetis
- Division of Cancer Medicine, Department of Genitourinary Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston
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Galsky MD, Balar AV, Black PC, Campbell MT, Dykstra GS, Grivas P, Gupta S, Hoimes CJ, Lopez LP, Meeks JJ, Plimack ER, Rosenberg JE, Shore N, Steinberg GD, Kamat AM. Society for Immunotherapy of Cancer (SITC) clinical practice guideline on immunotherapy for the treatment of urothelial cancer. J Immunother Cancer 2021; 9:e002552. [PMID: 34266883 PMCID: PMC8286774 DOI: 10.1136/jitc-2021-002552] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/24/2021] [Indexed: 12/12/2022] Open
Abstract
A number of immunotherapies have been developed and adopted for the treatment of urothelial cancer (encompassing cancers arising from the bladder, urethra, or renal pelvis). For these immunotherapies to positively impact patient outcomes, optimal selection of agents and treatment scheduling, especially in conjunction with existing treatment paradigms, is paramount. Immunotherapies also warrant specific and unique considerations regarding patient management, emphasizing both the prompt identification and treatment of potential toxicities. In order to address these issues, the Society for Immunotherapy of Cancer (SITC) convened a panel of experts in the field of immunotherapy for urothelial cancer. The expert panel developed this clinical practice guideline (CPG) to inform healthcare professionals on important aspects of immunotherapeutic treatment for urothelial cancer, including diagnostic testing, treatment planning, immune-related adverse events (irAEs), and patient quality of life (QOL) considerations. The evidence- and consensus-based recommendations in this CPG are intended to give guidance to cancer care providers treating patients with urothelial cancer.
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Affiliation(s)
- Matthew D Galsky
- Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Arjun V Balar
- Perlmutter Cancer Center, New York University Langone Medical Center, New York, New York, USA
| | - Peter C Black
- Department of Urologic Sciences, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Matthew T Campbell
- Department of Genitourinary Medical Oncology, Division of Cancer Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Gail S Dykstra
- Bladder Cancer Advocacy Network (BCAN), Bethesda, Maryland, USA
- Dykstra Research, Seattle, Washington, USA
| | - Petros Grivas
- Department of Medicine, Division of Oncology, University of Washington, Seattle, Washington, USA
- Seattle Cancer Care Alliance, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA
| | - Shilpa Gupta
- Department of Hematology and Oncology, Cleveland Clinic Taussig Cancer Institute, Cleveland, Ohio, USA
| | - Christoper J Hoimes
- Department of Medicine, Duke Cancer Institute, Duke University, Durham, North Carolina, USA
| | - Lidia P Lopez
- Division of Hematology-Oncology, Department of Medicine, University of California Los Angeles, Los Angeles, California, USA
| | - Joshua J Meeks
- Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
- The Jesse Brown VA Medical Center, Chicago, Illinois, USA
| | - Elizabeth R Plimack
- Department of Hematology/Oncology, Fox Chase Cancer Center, Philadelphia, Pennsylvania, USA
| | - Jonathan E Rosenberg
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York, USA
- Deparment of Medicine, Weill Cornell Medical College, New York, New York, USA
| | - Neal Shore
- Carolina Urologic Research Center, Myrtle Beach, South Carolina, USA
| | - Gary D Steinberg
- Department of Urology and Perlmutter Cancer Center, NYU Langone Medical Center, New York, New York, USA
| | - Ashish M Kamat
- Department of Urology under Division of Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
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Chen J, Alhalabi O, Han G, Wang WL, Zhang XQ, Song JH, Lopez LP, Ramachandran S, Hoang AG, Garnett T, Campbell M, Shah AY, Wang J, Siefker-Radtke AO, Tu SM, Titus M, Guo CC, Gallick GE, Efstathiou E, Benedict WF, Logothetis CJ, Ho TH, Wang L, Gao J. Abstract 385: MTAP gene deficiency creates vulnerability to anti-folate therapy in urothelial bladder carcinoma. Cancer Res 2019. [DOI: 10.1158/1538-7445.am2019-385] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
Background: The methylthioadenosine phosphorylase (MTAP) gene encodes an essential enzyme for the salvage pathway of adenosine synthesis and is frequently lost in different types of cancer including urothelial bladder carcinoma. Therefore, MTAP-deficient tumors are theoretically very sensitive to anti-folate agents such as pemetrexed that can effectively block the de novo pathway of adenosine synthesis and as a result, create a state of synthetic lethality. We thus hypothesize that tumor MTAP gene deficiency is associated with response to pemetrexed therapy in bladder cancer.
Methods: In this study, we investigated MTAP gene deficiency rates in the TCGA database and confirmed MTAP protein loss by immunohistochemistry using a tumor tissue microarray containing bladder tumor tissues from 151 patients. We then performed in vitro and in vivo studies using MTAP-proficient and MTAP-deficient human bladder cancer cell lines. Functional loss of MTAP was verified with mass spectrometry, which detects its substrate methylthioadenosine (MTA) levels. We also correlated these pre-clinical studies with clinical response data on patients with metastatic bladder cancer treated with pemetrexed.
Results: We identified that 27.8% bladder cancer patients have MTAP protein deficiency, which is consistent with exome sequencing data from the TCGA database. In vitro data showed MTAP-deficient human bladder cancer cell lines were significantly more sensitive to pemetrexed, with IC50 at least 40 times lower than MTAP-proficient cell lines. Subsequent knockdown of the MTAP gene in MTAP-proficient cell lines increased sensitivities to pemetrexed treatment. Consistent with the in vitro data, pemetrexed significantly inhibited the growth of MTAP-deficient or knockdown xenograft tumors but not MTAP-proficient tumors. Furthermore, 4 of 4 (100%) patients with MTAP-deficient metastatic bladder cancer responded to pemetrexed treatment, whereas only 1 of 11 (9%) patients with MTAP-proficient metastatic bladder cancer responded to pemetrexed.
Conclusion: Our data demonstrate that MTAP gene loss in urothelial bladder cancer leads to a metabolic state of synthetic lethality with pemetrexed therapy. Therefore, bladder tumor MTAP loss should be further investigated as a potential biomarker for selection of patients for anti-folate therapy.
Citation Format: Jianfeng Chen, Omar Alhalabi, Guangchun Han, Wei-Lien Wang, Xin-Qiao Zhang, Jian H. Song, Lidia P. Lopez, Sumankalai Ramachandran, Anh G. Hoang, Tyrone Garnett, Matthew Campbell, Amishi Y. Shah, Jennifer Wang, Arlene O. Siefker-Radtke, Shi-Ming Tu, Mark Titus, Charles C. Guo, Gary E. Gallick, Eleni Efstathiou, William F. Benedict, Christopher J. Logothetis, Thai H. Ho, Linghua Wang, Jianjun Gao. MTAP gene deficiency creates vulnerability to anti-folate therapy in urothelial bladder carcinoma [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 385.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | | | - Shi-Ming Tu
- 1The UT MD Anderson Cancer Center, Houston, TX
| | - Mark Titus
- 1The UT MD Anderson Cancer Center, Houston, TX
| | | | | | | | | | | | | | | | - Jianjun Gao
- 1The UT MD Anderson Cancer Center, Houston, TX
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Azul AC, Lopez LP, Azul AM. [Intraosseous cylindrical implants]. Rev Port Estomatol Cir Maxilofac 1990; 31:61-4. [PMID: 2396061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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