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Ventres WB, Stone LA, Gibson-Oliver LE, Meehan EK, Ricker MA, Loxterkamp D, Ogbeide SA, deGruy FV, Mahoney MR, Lin S, MacRae C, Mercer SW. Storylines of family medicine VIII: clinical approaches. Fam Med Community Health 2024; 12:e002795. [PMID: 38609085 PMCID: PMC11029325 DOI: 10.1136/fmch-2024-002795] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/14/2024] Open
Abstract
Storylines of Family Medicine is a 12-part series of thematically linked mini-essays with accompanying illustrations that explore the many dimensions of family medicine as interpreted by individual family physicians and medical educators in the USA and elsewhere around the world. In 'VIII: clinical approaches', authors address the following themes: 'Evaluation, diagnosis and management I-toward a working diagnosis', 'Evaluation, diagnosis and management II-process steps', 'Interweaving integrative medicine and family medicine', 'Halfway-the art of clinical judgment', 'Seamless integration in family medicine-team-based care', 'Technology-uncovering stories from noise' and 'Caring for patients with multiple long-term conditions'. May readers recognise in these essays the uniqueness of a family medicine approach to care.
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Affiliation(s)
- William B Ventres
- Family and Preventive Medicine, University of Arkansas for Medical Sciences College of Medicine, Little Rock, Arkansas, USA
| | - Leslie A Stone
- Family and Preventive Medicine, University of Arkansas for Medical Sciences College of Medicine, Little Rock, Arkansas, USA
| | - Lauren E Gibson-Oliver
- Family and Preventive Medicine, University of Arkansas for Medical Sciences College of Medicine, Little Rock, Arkansas, USA
| | - Elizabeth Kyle Meehan
- Family and Community Medicine, The University of Arizona College of Medicine - Tucson, Tucson, Arizona, USA
| | - Mari A Ricker
- Family and Community Medicine, The University of Arizona College of Medicine - Tucson, Tucson, Arizona, USA
| | | | - Stacy A Ogbeide
- Family and Community Medicine, UT Health San Antonio Long School of Medicine, San Antonio, Texas, USA
| | - Frank V deGruy
- Eugene S. Farley, Jr. Health Policy Center, University of Colorado Anschutz Medical Campus School of Medicine, Aurora, Colorado, USA
| | - Megan R Mahoney
- Family and Community Medicine, University of California San Francisco School of Medicine, San Francisco, California, USA
| | - Steven Lin
- Division of Primary Care and Population Health, Stanford Medicine, Palo Alto, California, USA
| | - Clare MacRae
- Usher Institute, Edinburgh Medical School, University of Edinburgh, Edinburgh, UK
| | - Stewart W Mercer
- Usher Institute, Edinburgh Medical School, University of Edinburgh, Edinburgh, UK
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Shaw JG, Winget M, Brown-Johnson C, Seay-Morrison T, Garvert DW, Levine M, Safaeinili N, Mahoney MR. Primary Care 2.0: A Prospective Evaluation of a Novel Model of Advanced Team Care With Expanded Medical Assistant Support. Ann Fam Med 2021; 19:411-418. [PMID: 34546947 PMCID: PMC8437557 DOI: 10.1370/afm.2714] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Revised: 12/08/2020] [Accepted: 02/08/2021] [Indexed: 11/09/2022] Open
Abstract
PURPOSE Assess effectiveness of Primary Care 2.0: a team-based model that incorporates increased medical assistant (MA) to primary care physician (PCP) ratio, integration of advanced practice clinicians, expanded MA roles, and extended the interprofessional team. METHODS Prospective, quasi-experimental evaluation of staff/clinician team development and wellness survey data, comparing Primary Care 2.0 to conventional clinics within our academic health care system. We surveyed before the model launch and every 6-9 months up to 24 months post implementation. Secondary outcomes (cost, quality metrics, patient satisfaction) were assessed via routinely collected operational data. RESULTS Team development significantly increased in the Primary Care 2.0 clinic, sustained across all 3 post implementation time points (+12.2, +8.5, + 10.1 respectively, vs baseline, on the 100-point Team Development Measure) relative to the comparison clinics. Among wellness domains, only "control of work" approached significant gains (+0.5 on a 5-point Likert scale, P = .05), but was not sustained. Burnout did not have statistically significant relative changes; the Primary Care 2.0 site showed a temporal trend of improvement at 9 and 15 months. Reversal of this trend at 2 years corresponded to contextual changes, specifically, reduced MA to PCP staffing ratio. Adjusted models confirmed an inverse relationship between team development and burnout (P <.0001). Secondary outcomes generally remained stable between intervention and comparison clinics with suggestion of labor cost savings. CONCLUSIONS The Primary Care 2.0 model of enhanced team-based primary care demonstrates team development is a plausible key to protect against burnout, but is not sufficient alone. The results reinforce that transformation to team-based care cannot be a 1-time effort and institutional commitment is integral.
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Affiliation(s)
- Jonathan G Shaw
- Evaluation Sciences Unit, Division of Primary Care & Population Health, Stanford University School of Medicine, Stanford, California
| | - Marcy Winget
- Evaluation Sciences Unit, Division of Primary Care & Population Health, Stanford University School of Medicine, Stanford, California
| | - Cati Brown-Johnson
- Evaluation Sciences Unit, Division of Primary Care & Population Health, Stanford University School of Medicine, Stanford, California
| | | | - Donn W Garvert
- Evaluation Sciences Unit, Division of Primary Care & Population Health, Stanford University School of Medicine, Stanford, California
| | - Marcie Levine
- Evaluation Sciences Unit, Division of Primary Care & Population Health, Stanford University School of Medicine, Stanford, California
| | - Nadia Safaeinili
- Evaluation Sciences Unit, Division of Primary Care & Population Health, Stanford University School of Medicine, Stanford, California
| | - Megan R Mahoney
- Evaluation Sciences Unit, Division of Primary Care & Population Health, Stanford University School of Medicine, Stanford, California
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Chen IQ, Chokron Garneau H, Seay-Morrison T, Mahoney MR, Filipowicz H, McGovern MP. What constitutes "behavioral health"? Perceptions of substance-related problems and their treatment in primary care. Addict Sci Clin Pract 2020; 15:29. [PMID: 32727589 PMCID: PMC7388518 DOI: 10.1186/s13722-020-00202-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2020] [Accepted: 07/18/2020] [Indexed: 11/15/2022] Open
Abstract
Background Integrating behavioral health in primary care is a widespread endeavor. Yet rampant variation exists in models and approaches. One significant question is whether frontline providers perceive that behavioral health includes substance use. The current study examined front line providers’: 1. definition of behavioral health, and 2. levels of comfort treating patients who use alcohol and other drugs. Frontline providers at two primary care clinics were surveyed using a 28-item instrument designed to assess their comfort and knowledge of behavioral health, including substance use. Two questions from the Integrated Behavioral Health Staff Perceptions Survey pertaining to confidence in clinics’ ability to care for patients’ behavioral health needs and comfort dealing with patients with behavioral health needs were used for the purposes of this report. Participants also self-reported their clinic role. Responses to these two items were assessed and then compared across roles. Chi square estimates and analysis of variance tests were used to examine relationships between clinic roles and comfort of substance use care delivery. Results Physicians, nurses/nurse practitioners, medical assistants, and other staff (N = 59) participated. Forty-nine participants included substance use in their definition of behavioral health. Participants reported the least comfort caring for patients who use substances (M = 3.5, SD = 1.0) compared to those with mental health concerns (M = 4.1, SD = 0.7), chronic medical conditions (M = 4.2, SD = 0.7), and general health concerns (M = 4.2, SD = 0.7) (p < 0.001). Physicians (M = 3.0, SD = 0.7) reported significantly lower levels of comfort than medical assistants (M = 4.2, SD = 0.9) (p < 0.001) caring for patients who use substances. Conclusions In a small sample of key stakeholders from two primary care clinics who participated in this survey, most considered substance use part of the broad umbrella of behavioral health. Compared to other conditions, primary care providers reported being less comfortable addressing patients’ substance use. Level of comfort varied by role, where physicians were least comfortable, and medical assistants most comfortable.
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Affiliation(s)
- Ida Q Chen
- Stanford University School of Medicine, Department of Psychiatry and Behavioral Sciences, 1520 Page Mill Road, Palo Alto, CA, 94304, USA
| | - Helene Chokron Garneau
- Stanford University School of Medicine, Department of Psychiatry and Behavioral Sciences, 1520 Page Mill Road, Palo Alto, CA, 94304, USA
| | - Timothy Seay-Morrison
- Department of Medicine, Stanford University School of Medicine, 1265 Welch Road, Stanford, CA, 94305, USA
| | - Megan R Mahoney
- Department of Medicine, Stanford University School of Medicine, 1265 Welch Road, Stanford, CA, 94305, USA
| | - Heather Filipowicz
- Department of Medicine, Stanford University School of Medicine, 1265 Welch Road, Stanford, CA, 94305, USA
| | - Mark P McGovern
- Stanford University School of Medicine, Department of Psychiatry and Behavioral Sciences, 1520 Page Mill Road, Palo Alto, CA, 94304, USA. .,Department of Medicine, Stanford University School of Medicine, 1265 Welch Road, Stanford, CA, 94305, USA.
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Lin SY, Mahoney MR, Sinsky CA. Ten Ways Artificial Intelligence Will Transform Primary Care. J Gen Intern Med 2019; 34:1626-1630. [PMID: 31090027 PMCID: PMC6667610 DOI: 10.1007/s11606-019-05035-1] [Citation(s) in RCA: 57] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Revised: 03/12/2019] [Accepted: 04/05/2019] [Indexed: 01/16/2023]
Abstract
Artificial intelligence (AI) is poised as a transformational force in healthcare. This paper presents a current environmental scan, through the eyes of primary care physicians, of the top ten ways AI will impact primary care and its key stakeholders. We discuss ten distinct problem spaces and the most promising AI innovations in each, estimating potential market sizes and the Quadruple Aims that are most likely to be affected. Primary care is where the power, opportunity, and future of AI are most likely to be realized in the broadest and most ambitious scale. We propose how these AI-powered innovations must augment, not subvert, the patient-physician relationship for physicians and patients to accept them. AI implemented poorly risks pushing humanity to the margins; done wisely, AI can free up physicians' cognitive and emotional space for patients, and shift the focus away from transactional tasks to personalized care. The challenge will be for humans to have the wisdom and willingness to discern AI's optimal role in twenty-first century healthcare, and to determine when it strengthens and when it undermines human healing. Ongoing research will determine the impact of AI technologies in achieving better care, better health, lower costs, and improved well-being of the workforce.
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Affiliation(s)
- Steven Y Lin
- Division of Primary Care and Population Health, Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA.
| | - Megan R Mahoney
- Division of Primary Care and Population Health, Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA
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Mahoney MR, Asch SM. Humanwide: A Comprehensive Data Base for Precision Health in Primary Care. Ann Fam Med 2019; 17:273. [PMID: 31085532 PMCID: PMC6827620 DOI: 10.1370/afm.2342] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2018] [Revised: 09/10/2018] [Accepted: 10/03/2018] [Indexed: 11/09/2022] Open
Affiliation(s)
- Megan R Mahoney
- Division of Primary Care and Population Health, Stanford University, Palo Alto, California
| | - Steven M Asch
- Division of Primary Care and Population Health, Stanford University, Palo Alto, California.,US Department of Veterans Affairs, Center for Innovation to Implementation, Palo Alto, California
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Sayed S, Ngugi AK, Mahoney MR, Kurji J, Talib ZM, Macfarlane SB, Wynn TA, Saleh M, Lakhani A, Nderitu E, Agoi F, Premji Z, Zujewski JA, Moloo Z. Breast Cancer knowledge, perceptions and practices in a rural Community in Coastal Kenya. BMC Public Health 2019; 19:180. [PMID: 30755192 PMCID: PMC6373063 DOI: 10.1186/s12889-019-6464-3] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2018] [Accepted: 01/21/2019] [Indexed: 11/13/2022] Open
Abstract
Background Data on breast healthcare knowledge, perceptions and practice among women in rural Kenya is limited. Furthermore, the role of the male head of household in influencing a woman’s breast health seeking behavior is also not known. The aim of this study was to assess the knowledge, perceptions and practice of breast cancer among women, male heads of households, opinion leaders and healthcare providers within a rural community in Kenya. Our secondary objective was to explore the role of male heads of households in influencing a woman’s breast health seeking behavior. Methods This was a mixed method cross-sectional study, conducted between Sept 1st 2015 Sept 30th 2016. We administered surveys to women and male heads of households. Outcomes of interest were analysed in Stata ver 13 and tabulated against gender. We conducted six focus group discussions (FGDs) and 22 key informant interviews (KIIs) with opinion leaders and health care providers, respectively. Elements of the Rapid Assessment Process (RAP) were used to guide analysis of the FGDs and the KIIs. Results A total of 442 women and 237 male heads of households participated in the survey. Although more than 80% of respondents had heard of breast cancer, fewer than 10% of women and male heads of households had knowledge of 2 or more of its risk factors. More than 85% of both men and women perceived breast cancer as a very serious illness. Over 90% of respondents would visit a health facility for a breast lump. Variable recognition of signs of breast cancer, limited decision- autonomy for women, a preference for traditional healers, lack of trust in the health care system, inadequate access to services, limited early-detection services were the six themes that emerged from the FGDs and the KIIs. There were discrepancies between the qualitative and quantitative data for the perceived role of the male head of household as a barrier to seeking breast health care. Conclusions Determining level of breast cancer knowledge, the characteristics of breast health seeking behavior and the perceived barriers to accessing breast health are the first steps in establishing locally relevant intervention programs. Electronic supplementary material The online version of this article (10.1186/s12889-019-6464-3) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Shahin Sayed
- Department of Pathology, Faculty of Health Sciences - East Africa, Aga, Khan University Nairobi, 3rd Parklands Avenue, P.O. Box 30270-00100, Nairobi, Kenya.
| | - Anthony K Ngugi
- Centre for Population, Faculty of Health Sciences - East Africa, Aga Khan University, Nairobi, 3rd Parklands Avenue, P.O. Box 30270-00100, Nairobi, Kenya
| | - Megan R Mahoney
- Department of Medicine General Medicines Discipline Stanford, University, Palo Alto-C, 291 Campus Dr.Palo Alto, California, CA, 94305, USA
| | - Jaameeta Kurji
- University of Ottawa, School of Epidemiology, Public Health & Preventive Medicine, Alta Vista Campus 600 Peter Morand Crescent,Ottawa, Ontario, K1G 5Z3, Canada
| | - Zohray M Talib
- Department of Medicine and of Health Policy and Management, The George Washington University (GWU) Medical School, Ross Hall, 2300 Eye Street, Washington D.C., NW, 20037, USA
| | - Sarah B Macfarlane
- Department of Epidemiology and Biostatistics, School of Medicine, University of California San Francisco, San Francisco, Mission Hall: Global Health & Clinical Sciences Building 550 16th Street, 2nd Floor Box #0560, San Francisco, CA, 94158-2549, USA
| | - Theresa A Wynn
- University of Alabama at Birmingham, School of Medicine, Division of Preventive Medicine, University of Alabama, Medical Towers, MT-621. 1720 2nd Ave South, Birmingham, AL, 35294-4410, USA
| | - Mansoor Saleh
- Department of Medicine, University of Alabama Comprehensive Cancer Center, Birmingham, Alabama, USA Wallace Tumor Institute, WTI 202. 1720 2nd Ave South, Birmingham, AL, 35294-3300, USA
| | - Amyn Lakhani
- Mombasa Research Office, Faculty of Health Sciences - East Africa, Aga Khan University, 3rd Parklands Avenue, P.O. Box 30270-00100, Nairobi, Kenya
| | - Esther Nderitu
- School of Nursing and Midwifery, Aga Khan University Nairobi Kenya, 3rd Parklands Avenue, P.O. Box 30270-00100, Nairobi, Kenya
| | - Felix Agoi
- Mombasa Research Office, Faculty of Health Sciences - East Africa, Aga Khan University, 3rd Parklands Avenue, P.O. Box 30270-00100, Nairobi, Kenya
| | - Zul Premji
- Department of Pathology, Faculty of Health Sciences - East Africa, Aga, Khan University Nairobi, 3rd Parklands Avenue, P.O. Box 30270-00100, Nairobi, Kenya
| | - Jo Anne Zujewski
- JZ Oncology, JZ Oncology , 4525 North Chelsea Lane, Bethesda, MD, 20814, USA
| | - Zahir Moloo
- Department of Pathology, Faculty of Health Sciences - East Africa, Aga, Khan University Nairobi, 3rd Parklands Avenue, P.O. Box 30270-00100, Nairobi, Kenya
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Ngugi AK, Agoi F, Mahoney MR, Lakhani A, Mang’ong’o D, Nderitu E, Armstrong R, Macfarlane S. Utilization of health services in a resource-limited rural area in Kenya: Prevalence and associated household-level factors. PLoS One 2017; 12:e0172728. [PMID: 28241032 PMCID: PMC5328402 DOI: 10.1371/journal.pone.0172728] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2016] [Accepted: 02/08/2017] [Indexed: 11/25/2022] Open
Abstract
Background and methods Knowledge of utilization of health services and associated factors is important in planning and delivery of interventions to improve health services coverage. We determined the prevalence and factors associated with health services utilization in a rural area of Kenya. Our findings inform the local health management in development of appropriately targeted interventions. We used a cluster sample survey design and interviewed household key informants on history of illness for household members and health services utilization in the preceding month. We estimated prevalence and performed random effects logistic regression to determine the influence of individual and household level factors on decisions to utilize health services. Results and conclusions 1230/6,440 (19.1%, 95% CI: 18.3%-20.2%) household members reported an illness. Of these, 76.7% (95% CI: 74.2%-79.0%) sought healthcare in a health facility. The majority (94%) of the respondents visited dispensary-level facilities and only 60.1% attended facilities within the study sub-counties. Of those that did not seek health services, 43% self-medicated by buying non-prescription drugs, 20% thought health services were too costly, and 10% indicated that the sickness was not serious enough to necessitate visiting a health facility. In the multivariate analyses, relationship to head of household was associated with utilization of health services. Relatives other than the nuclear family of the head of household were five times less likely to seek medical help (Odds Ratio 0.21 (95% CI: 0.05–0.87)). Dispensary level health facilities are the most commonly used by members of this community, and relations at the level of the household influence utilization of health services during an illness. These data enrich the perspective of the local health management to better plan the allocation of healthcare resources according to need and demand. The findings will also contribute in the development of community-level health coverage interventions that target the disadvantaged household groups.
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Affiliation(s)
- Anthony K. Ngugi
- Centre for Population Health Sciences, Faculty of Health Sciences—East Africa, Aga Khan University, Nairobi, Kenya
- * E-mail:
| | - Felix Agoi
- Centre for Population Health Sciences, Faculty of Health Sciences—East Africa, Aga Khan University, Nairobi, Kenya
- Department of Community Health, Faculty of Health Sciences—East Africa, Aga Khan University, Mombasa, Kenya
| | - Megan R. Mahoney
- Department of Medicine, Stanford University, Stanford, California, United States of America
- Department of Family Medicine, Faculty of Health Sciences—East Africa, Aga Khan University, Nairobi, Kenya
| | - Amyn Lakhani
- Centre for Population Health Sciences, Faculty of Health Sciences—East Africa, Aga Khan University, Nairobi, Kenya
- Department of Community Health, Faculty of Health Sciences—East Africa, Aga Khan University, Mombasa, Kenya
| | - David Mang’ong’o
- Sub-County Health Management, Kaloleni Sub-County, Mariakani, Kilifi County, Kenya
| | - Esther Nderitu
- School of Nursing and Mid-wifery, Aga Khan University–East Africa, Nairobi, Kenya
| | - Robert Armstrong
- Medical College, Faculty of Health Sciences—East Africa, Aga Khan University, Nairobi, Kenya
| | - Sarah Macfarlane
- Centre for Population Health Sciences, Faculty of Health Sciences—East Africa, Aga Khan University, Nairobi, Kenya
- Global Health Sciences, University of California San Francisco, San Francisco, California, United States of America
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Dickson MA, Mahoney MR, Tap WD, D'Angelo SP, Keohan ML, Van Tine BA, Agulnik M, Horvath LE, Nair JS, Schwartz GK. Phase II study of MLN8237 (Alisertib) in advanced/metastatic sarcoma. Ann Oncol 2016; 27:1855-60. [PMID: 27502708 DOI: 10.1093/annonc/mdw281] [Citation(s) in RCA: 79] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2016] [Accepted: 07/08/2016] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Aurora kinase A (AURKA) is commonly overexpressed in sarcoma. The inhibition of AURKA by shRNA or by a specific AURKA inhibitor blocks in vitro proliferation of multiple sarcoma subtypes. MLN8237 (alisertib) is a novel oral adenosine triphosphate-competitive AURKA inhibitor. PATIENTS AND METHODS This Cancer Therapy Evaluation Program-sponsored phase II study of alisertib was conducted through the Alliance for Clinical Trials in Oncology (A091102). Patients were enrolled into histology-defined cohorts: (i) liposarcoma, (ii) leiomyosarcoma, (iii) undifferentiated sarcoma, (iv) malignant peripheral nerve sheath tumor, or (v) other. Treatment was alisertib 50 mg PO b.i.d. d1-d7 every 21 days. The primary end point was response rate; progression-free survival (PFS) was secondary. One response in the first 9 patients expanded enrollment in a cohort to 24 using a Simon two-stage design. RESULTS Seventy-two patients were enrolled at 24 sites [12 LPS, 10 LMS, 11 US, 10 malignant peripheral nerve sheath tumor (MPNST), 29 Other]. The median age was 55 years; 54% were male; 58%/38%/4% were ECOG PS 0/1/2. One PR expanded enrollment to the second stage in the other sarcoma cohort. The histology-specific cohorts ceased at the first stage. There were two confirmed PRs in the other cohort (both angiosarcoma) and one unconfirmed PR in dedifferentiated chondrosarcoma. Twelve-week PFS was 73% (LPS), 44% (LMS), 36% (US), 60% (MPNST), and 38% (Other). Grade 3-4 adverse events: oral mucositis (12%), anemia (14%), platelet count decreased (14%), leukopenia (22%), and neutropenia (42%). CONCLUSIONS Alisertib was well tolerated. Occasional responses, yet prolonged stable disease, were observed. Although failing to meet the primary RR end point, PFS was promising. TRIAL REGISTRATION ID NCT01653028.
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Affiliation(s)
- M A Dickson
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York Weill Cornell Medical College, New York
| | - M R Mahoney
- Biomedical Statistics & Informatics, Alliance Statistics and Data Center, Mayo Clinic, Rochester
| | - W D Tap
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York Weill Cornell Medical College, New York
| | - S P D'Angelo
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York Weill Cornell Medical College, New York
| | - M L Keohan
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York Weill Cornell Medical College, New York
| | - B A Van Tine
- Department of Internal Medicine, Washington University School of Medicine, Saint Louis
| | - M Agulnik
- Department of Hematology and Oncology, Northwestern University, Chicago
| | - L E Horvath
- Department of Medicine, Alliance for Clinical Trials in Oncology, Chicago
| | - J S Nair
- Department of Medicine, Columbia University Medical Center, New York, USA
| | - G K Schwartz
- Department of Medicine, Columbia University Medical Center, New York, USA
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Paul CD, Shea DJ, Mahoney MR, Chai A, Laney V, Hung WC, Konstantopoulos K. Interplay of the physical microenvironment, contact guidance, and intracellular signaling in cell decision making. FASEB J 2016; 30:2161-70. [PMID: 26902610 DOI: 10.1096/fj.201500199r] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2015] [Accepted: 02/05/2016] [Indexed: 12/23/2022]
Abstract
The peritumoral physical microenvironment consists of complex topographies that influence cell migration. Cell decision making, upon encountering anisotropic, physiologically relevant physical cues, has yet to be elucidated. By integrating microfabrication with cell and molecular biology techniques, we provide a quantitative and mechanistic analysis of cell decision making in a variety of well-defined physical microenvironments. We used MDA-MB-231 breast carcinoma and HT1080 fibrosarcoma as cell models. Cell decision making after lateral confinement in 2-dimensional microcontact printed lines is governed by branch width at bifurcations. Cells confined in narrow feeder microchannels prefer to enter wider branches at bifurcations. In contrast, in feeder channels that are wider than the cell body, cells elongate along one side wall of the channel and are guided by contact with the wall to the contiguous branch channel independent of its width. Knockdown of β1-integrins or inhibition of cellular contractility suppresses contact guidance. Concurrent, but not individual, knockdown of nonmuscle myosin isoforms IIA and IIB also decreases contact guidance, which suggests the existence of a compensatory mechanism between myosin IIA and myosin IIB. Conversely, knockdown or inhibition of cell division control protein 42 homolog promotes contact guidance-mediated decision making. Taken together, the dimensionality, length scales of the physical microenvironment, and intrinsic cell signaling regulate cell decision making at intersections.-Paul, C. D., Shea, D. J., Mahoney, M. R., Chai, A., Laney, V., Hung, W.-C., Konstantopoulos, K. Interplay of the physical microenvironment, contact guidance, and intracellular signaling in cell decision making.
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Affiliation(s)
- Colin D Paul
- Department of Chemical and Biomolecular Engineering, The Johns Hopkins University, Baltimore, Maryland, USA; Institute for NanoBioTechnology, The Johns Hopkins University, Baltimore, Maryland, USA; and
| | - Daniel J Shea
- Department of Chemical and Biomolecular Engineering, The Johns Hopkins University, Baltimore, Maryland, USA
| | - Megan R Mahoney
- Department of Chemical and Biomolecular Engineering, The Johns Hopkins University, Baltimore, Maryland, USA
| | - Andreas Chai
- Department of Chemical and Biomolecular Engineering, The Johns Hopkins University, Baltimore, Maryland, USA
| | - Victoria Laney
- Department of Chemical and Biomolecular Engineering, The Johns Hopkins University, Baltimore, Maryland, USA
| | - Wei-Chien Hung
- Department of Chemical and Biomolecular Engineering, The Johns Hopkins University, Baltimore, Maryland, USA
| | - Konstantinos Konstantopoulos
- Department of Chemical and Biomolecular Engineering, The Johns Hopkins University, Baltimore, Maryland, USA; Institute for NanoBioTechnology, The Johns Hopkins University, Baltimore, Maryland, USA; and Department of Biomedical Engineering, The Johns Hopkins University, Baltimore, Maryland, USA
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Mahoney MR, Fogler J, Weber S, Goldschmidt RH. Applying HIV testing guidelines in clinical practice. Am Fam Physician 2009; 80:1441-1444. [PMID: 20000306] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
An estimated one fourth of persons with human immunodeficiency virus (HIV) are not aware they are infected. Early diagnosis of HIV has the potential to ensure optimal outcomes for infected persons and to limit the spread of the virus. Important barriers to testing among physicians include insufficient time, reimbursement issues, and lack of patient acceptance. Current HIV testing guidelines address many of these barriers by making the testing process more streamlined and less stigmatizing. The opt-out consent process has been shown to improve test acceptance. Formal pretest counseling and written consent are no longer recommended by the Centers for Disease Control and Prevention. Nevertheless, pretest discussions provide an opportunity to give information about HIV, address fears of discrimination, and identify ongoing high-risk activities. With increased HIV screening in the primary care setting, more persons with HIV could be identified earlier, receive timely and appropriate care, and get treatment to prevent clinical progression and transmission.
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Affiliation(s)
- Megan R Mahoney
- University of California-San Francisco, 995 Potrero Ave., San Francisco, CA 94110, USA.
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Fogler J, Weber S, Mahoney MR, Goldschmidt RH. Clinicians' knowledge of 2007 Food and Drug Administration recommendation to discontinue nelfinavir use during pregnancy. ACTA ACUST UNITED AC 2009; 8:249-52. [PMID: 19506052 DOI: 10.1177/1545109709337034] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
In 2007, the US Food and Drug Administration (FDA) and Pfizer Inc recommended immediate discontinuation of nelfinavir (NFV) during pregnancy due to contamination with a potential teratogen. A few weeks after the announcement, we surveyed antenatal HIV care providers to determine how widely the warning was disseminated. Overall, 69 of 121 (57.0%) providers knew to discontinue NFV. Callers with more than 50 HIV-infected patients were 2.54 times as likely to be aware as callers with 1-3 HIV-infected patients (P < .01). Only 12 (33.3%) obstetricians were aware, compared to 21 (80.8%) infectious diseases specialists (P < .001). The FDA/Pfizer Inc recommendation to avoid nelfinavir mesylate (NFV) in pregnancy appears to have successfully reached HIV experts. However, not all pregnant women have access to experts and may receive most of their care from providers without extensive HIV experience. More effective dissemination of critical HIV-related information to all antenatal care providers, including general obstetricians, family physicians, and midwives, may be needed.
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Affiliation(s)
- Jessica Fogler
- Department of Family and Community Medicine, San Francisco General Hospital, University of California, San Francisco, CA 94143, USA.
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Mahoney MR, Khamarko K, Goldschmidt RH. Care of HIV-infected Latinos in the United States: a description of calls to the National HIV/AIDS Clinicians' Consultation Center. J Assoc Nurses AIDS Care 2008; 19:302-10. [PMID: 18598905 DOI: 10.1016/j.jana.2008.05.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2008] [Revised: 05/02/2008] [Accepted: 05/02/2008] [Indexed: 10/21/2022]
Abstract
HIV disproportionately affects the Latino population in the United States. Little is known about clinicians who provide HIV care to the Latino community or the types of issues they face. This report presents descriptive analyses of calls made by clinicians who care for HIV-infected Latinos to two lines of the National HIV/AIDS Clinicians' Consultation Center, the National HIV Telephone Consultation Service (Warmline) and the National Perinatal HIV Consultation and Referral Service (Perinatal HIV Hotline). Separate analyses of data from Latino clinicians are also presented. The majority of Warmline calls about Latino patients (81.0%) concerned antiretroviral treatment strategies or HIV-related conditions. More than half (54.3%) of perinatal-specific calls concerned HIV management during pregnancy and the care of HIV-exposed infants. Latino clinicians most frequently called about minority patients. This descriptive study adds to the growing literature about the care of the Latino HIV-infected patient. The Warmline and Perinatal HIV Hotline are resources for HIV care providers in the nursing and medical care of Latinos.
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Affiliation(s)
- Megan R Mahoney
- National HIV/AIDS Clinicians' Consultation Center and Department of Family and Community Medicine at the University of California, San Francisco, USA
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Mahoney MR, Sterkenburg C, Thom DH, Goldschmidt RH. African-American clinicians providing HIV care: the experience of the National HIV/AIDS Clinicians' Consultation Center. J Natl Med Assoc 2008; 100:779-82. [PMID: 18672554 DOI: 10.1016/s0027-9684(15)31371-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [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] [Indexed: 11/18/2022]
Abstract
This analysis compares patient and provider characteristics of African-American clinicians and non-African-American clinicians who called the National HIV Telephone Consultation Service (Warmline). In 2004, a total of 2,077 consultations were provided for 1,020 clinicians, 70 (6.9%) of whom were African American. Compared to the non-African-American group, a higher percentage of African-American clinicians were nurses (20.0% vs. 8.8%, p=0.002). A significantly lower percentage of African-American physicians were infectious disease specialists (3.5% vs. 25.6%, p=0.007). African-American clinicians were more likely to work in a community clinic (48.5% vs. 34.1%, p=0.015). Both African-American and non-African American clinicians reported caring for a similar number of HIV-infected patients. Patient-provider racial concordance was common among African-American clinicians (76.4%), whereas non-African-American clinicians called about patients of more diverse racial and ethnic backgrounds. African-American clinicians who called Warmline exhibited differences in patient and provider characteristics when compared to all other clinicians. These findings contribute to the growing body of research on HIV providers in the United States.
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Affiliation(s)
- Megan R Mahoney
- Department of Family and Community Medicine, University of California, San Francisco, San Francisco General Hospital, San Francisco, CA, USA.
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Abstract
PURPOSE To examine the perceptions and experiences of ethnic minority faculty at University of California-San Francisco regarding racial and ethnic diversity in academic medicine, in light of a constitutional measure outlawing race- and gender-based affirmative action programs by public universities in California. METHOD In 2005, underrepresented minority faculty in the School of Medicine at University of California-San Francisco were individually interviewed to explore three topics: participants' experiences as minorities, perspectives on diversity and discrimination in academic medicine, and recommendations for improvement. Interviews were tape-recorded, transcribed verbatim, and subsequently coded using principles of qualitative, text-based analysis in a four-stage review process. RESULTS Thirty-six minority faculty (15 assistant professors, 11 associate professors, and 10 full professors) participated, representing diversity across specialties, faculty rank, gender, and race/ethnicity. Seventeen were African American, 16 were Latino, and 3 were Asian. Twenty participants were women. Investigators identified four major themes: (1) choosing to participate in diversity-related activities, driven by personal commitment and institutional pressure, (2) the gap between intention and implementation of institutional efforts to increase diversity, (3) detecting and reacting to discrimination, and (4) a need for a multifaceted approach to mentorship, given few available minority mentors. CONCLUSIONS Minority faculty are an excellent resource for identifying strategies to improve diversity in academic medicine. Participants emphasized the strong association between effective mentorship and career satisfaction, and many delineated unique mentoring needs of minority faculty that persist throughout academic ranks. Findings have direct application to future institutional policies in recruitment and retention of underrepresented minority faculty.
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Affiliation(s)
- Megan R Mahoney
- Department of Family and Community Medicine, University of California-San Francisco, San Francisco, California, USA
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15
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Fogler JA, Weber S, Goldschmidt RH, Mahoney MR, Cohan D. Consultation needs in perinatal HIV care: experience of the National Perinatal HIV Consultation Service. Am J Obstet Gynecol 2007; 197:S137-41. [PMID: 17825645 DOI: 10.1016/j.ajog.2007.02.033] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [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: 12/15/2006] [Revised: 01/29/2007] [Accepted: 02/26/2007] [Indexed: 11/19/2022]
Abstract
This study evaluates the consultation needs of clinicians who provide perinatal human immunodeficiency virus (HIV) care in the United States. The Perinatal Hotline (1-888-448-8765) is a telephone consultation service for providers who treat HIV-infected pregnant women and their infants. Hotline calls were analyzed for demographics about callers and their patients and information about consultation topics. There were 430 calls to the hotline from January 1, 2005, through June 30, 2006. Most calls (59.5%) were related to pregnant patients; 5.1% of the calls pertained to women currently in labor. The most common topic was HIV care in pregnancy (49.1%), particularly antiretroviral drug use (42.1%). HIV testing was discussed in 21.9%, and intrapartum treatment was discussed in 24.0%. Callers most often requested help choosing antiretroviral drug regimens; many of the discussions were about drug toxicities and viral resistance. Although the hotline received few calls about women in labor, the need for these consultations is expected to increase with the expanding use of rapid HIV testing. Access to 24-hour consultation can help ensure that state-of-the-art care is provided.
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Affiliation(s)
- Jessica A Fogler
- National Clinicians' Consultation Center, Department of Family and Community Medicine, San Francisco General Hospital, University of California, San Francisco, San Francisco, CA, USA.
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16
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Mahoney MR, Goldschmidt RH. The changing role of family physicians in HIV care. Am Fam Physician 2006; 74:1683-4. [PMID: 17136997] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/12/2023]
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Abstract
BACKGROUND New agents with antitumor activity in patients with neuroendocrine tumors are sorely needed. A Phase II study of high-dose paclitaxel in patients with metastatic carcinoid and islet cell tumors was performed at the Mayo Clinic. Granulocyte-colony-stimulating factor (GCSF) also was administered to ameliorate neutropenia. METHODS Twenty-four patients (14 with carcinoid tumors, 9 with islet cell tumors, and 1 with an anaplastic tumor) were enrolled on this Phase II study of paclitaxel given as a 24-hour continuous infusion at a dose of 250 mg/m(2) every 3 weeks plus GCSF at a dose of 5 microg/kg/day subcutaneously, beginning 24 hours after the completion of the paclitaxel dose and continuing until the absolute neutrophil count was > 10,000/microL. RESULTS All 24 patients were evaluable for analysis. The overall response rate was 8% (95% confidence interval [95% CI], 0-0.11). At last follow-up all patients except 1 had developed disease progression, with an estimated median time to disease progression of 3.2 months (95% CI, 1.6-6.0 months). The estimated median survival was 1.5 years (95% CI, 1.0-1.8 years). Hematologic toxicity was significant with 12 of 24 patients developing Grade 4 (according to the National Cancer Institute Common Toxicity Criteria scale) neutropenia; however, there were no septic deaths reported. There were 17 episodes of Grade 4 neutropenia in these 12 patients and the duration of these events ranged from 2-5 days. More common nonhematologic toxicities included arthralgia (21 patients), anorexia (15 patients), nausea (15 patients), diarrhea (12 patients), and allergic reactions (2 patients). CONCLUSIONS Given the lack of antitumor activity of paclitaxel and the significant hematologic toxicity observed despite the use of GCSF support in the current study cohort of patients with neuroendocrine tumors, further studies of this combination in this particular patient population are not recommended.
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Affiliation(s)
- S M Ansell
- Division of Medical Oncology, Mayo Clinic, Rochester, Minnesota 55905, USA
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18
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Pitot HC, Knost JA, Mahoney MR, Kugler J, Krook JE, Hatfield AK, Sargent DJ, Goldberg RM. A North Central Cancer Treatment Group Phase II trial of 9-aminocamptothecin in previously untreated patients with measurable metastatic colorectal carcinoma. Cancer 2000; 89:1699-705. [PMID: 11042563] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/18/2023]
Abstract
BACKGROUND Topoisomerase I inhibitors have demonstrated clinical activity in patients with metastatic colorectal carcinoma. The authors performed a Phase II study to evaluate the objective tumor response rate of 2 different doses and schedules of 9-aminocamptothecin (9-AC) in previously untreated patients with measurable recurrent metastatic colorectal carcinoma. METHODS Fifty-one patients were registered. One schedule evaluated 9-AC given at 1100 microgram/m(2)/24 hours by continuous infusion for 72 hours along with granulocyte-colony stimulating factor at 5 microgram/kg/day on Days 5 through 12. Another schedule involved 9-AC at 480 microgram/m(2)/24 hours by continuous infusion for 120 hours on Days 1, 8, and 15 given every 4 weeks. RESULTS Forty-eight of 51 patients (94%) were evaluable (28 patients who received 72-hour infusion and 20 patients who received 120-hour infusion) for response and toxicity. Significant hematologic toxicities were encountered, especially with the 72-hour infusion schedule, in which 43% (12 of 28) and 28% (8 of 28) experienced Grade 4 (National Cancer Institute Common Toxicity Criteria) leukopenia and thrombocytopenia, respectively. Grade 4 neutropenia was encountered in 61% (17 of 28) and 11% (2 of 19) of patients on the 72-hour and 120-hour infusion schedules, respectively. Diarrhea, nausea, vomiting, and hepatotoxicity were troublesome nonhematologic toxicities. Seventy-nine percent (11 of 14) and 57% (4 of 7) of the patients experiencing Grade 3 or 4 nonhematologic toxicity were on the 72-hour infusion schedule. Three patients died of chemotherapy-related toxicity. One response was observed in 48 evaluable patients (2%). CONCLUSIONS 9-AC did not demonstrate sufficient antitumor activity and had unacceptable toxicity in previously untreated patients with metastatic colorectal carcinoma.
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Affiliation(s)
- H C Pitot
- Mayo Clinic and Mayo Foundation, Rochester, Minnesota, USA.
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Sargent DJ, Goldberg RM, Mahoney MR, Hillman DW, McKeough T, Hamilton SF, Darcy JM, Anderson VL, Krook JE, O'Connell MJ. Rapid reporting and review of an increased incidence of a known adverse event. J Natl Cancer Inst 2000; 92:1011-3. [PMID: 10861314 DOI: 10.1093/jnci/92.12.1011] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- D J Sargent
- Mayo Clinic and Mayo Foundation, Rochester, MN 55905, USA.
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20
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Perry A, Jenkins RB, O'Fallon JR, Schaefer PL, Kimmel DW, Mahoney MR, Scheithauer BW, Smith SM, Hill EM, Sebo TJ, Levitt R, Krook J, Tschetter LK, Morton RF, Buckner JC. Clinicopathologic study of 85 similarly treated patients with anaplastic astrocytic tumors. An analysis of DNA content (ploidy), cellular proliferation, and p53 expression. Cancer 1999. [PMID: 10440696 DOI: 10.1002/(sici)1097-0142(19990815)86:4<672::aid-cncr17>3.0.co;2-g] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
BACKGROUND The biologic behavior of anaplastic (World Health Organization Grade III) astrocytomas and oligoastrocytomas is highly variable, ranging from rapid progression to prolonged survival. It is difficult to predict the outcome of an individual patient based on morphology alone. METHODS To determine the prognostic value of commonly used clinicopathologic markers, we reviewed our experience with 85 similarly treated patients enrolled in 3 North Central Cancer Treatment Group high grade glioma protocols. The pathology was comprised exclusively of primary anaplastic astrocytic tumors (66 astrocytomas and 19 oligoastrocytomas). Variables examined included patient age, morphologic type, preoperative performance score, extent of surgery, solitary versus multiple mitoses, DNA flow cytometric and image morphometric parameters, and expression of proliferating cell nuclear antigen, MIB-1, and p53 expression. RESULTS The study was comprised of 48 men and 37 women ranging in age from 14-79 years (median age, 47 years). Overall survival ranged from <1 month to >12 years (median, 21.6 months). Statistical analyses revealed that age accounted for the majority of this extensive variability in survival. The median survival times were 65. 5 months, 22.1 months, and 4.4 months, respectively, for the groups <40 years, 40-59 years, and >/=60 years, respectively (P < 0.0001). On univariate analyses, aneuploidy by flow cytometry and a low performance score also predicted a better survival (P values of 0.04 and 0.009, respectively). Statistical trends predicting a better survival were observed for patients with a solitary mitosis and p53 immunopositivity. However, only patient age remained significant in multivariate models. CONCLUSIONS In a small but relatively uniformly treated cohort of patients with anaplastic astrocytomas and oligoastrocytomas, patient age was associated strongly and inversely with overall survival. Once patient age was taken into account, the clinical and pathologic markers tested appeared to be of limited prognostic value.
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Affiliation(s)
- A Perry
- Washington University School of Medicine, St. Louis, Missouri, USA
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21
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Perry A, Jenkins RB, O'Fallon JR, Schaefer PL, Kimmel DW, Mahoney MR, Scheithauer BW, Smith SM, Hill EM, Sebo TJ, Levitt R, Krook J, Tschetter LK, Morton RF, Buckner JC. Clinicopathologic study of 85 similarly treated patients with anaplastic astrocytic tumors. An analysis of DNA content (ploidy), cellular proliferation, and p53 expression. Cancer 1999; 86:672-83. [PMID: 10440696 DOI: 10.1002/(sici)1097-0142(19990815)86:4<672::aid-cncr17>3.0.co;2-g] [Citation(s) in RCA: 54] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND The biologic behavior of anaplastic (World Health Organization Grade III) astrocytomas and oligoastrocytomas is highly variable, ranging from rapid progression to prolonged survival. It is difficult to predict the outcome of an individual patient based on morphology alone. METHODS To determine the prognostic value of commonly used clinicopathologic markers, we reviewed our experience with 85 similarly treated patients enrolled in 3 North Central Cancer Treatment Group high grade glioma protocols. The pathology was comprised exclusively of primary anaplastic astrocytic tumors (66 astrocytomas and 19 oligoastrocytomas). Variables examined included patient age, morphologic type, preoperative performance score, extent of surgery, solitary versus multiple mitoses, DNA flow cytometric and image morphometric parameters, and expression of proliferating cell nuclear antigen, MIB-1, and p53 expression. RESULTS The study was comprised of 48 men and 37 women ranging in age from 14-79 years (median age, 47 years). Overall survival ranged from <1 month to >12 years (median, 21.6 months). Statistical analyses revealed that age accounted for the majority of this extensive variability in survival. The median survival times were 65. 5 months, 22.1 months, and 4.4 months, respectively, for the groups <40 years, 40-59 years, and >/=60 years, respectively (P < 0.0001). On univariate analyses, aneuploidy by flow cytometry and a low performance score also predicted a better survival (P values of 0.04 and 0.009, respectively). Statistical trends predicting a better survival were observed for patients with a solitary mitosis and p53 immunopositivity. However, only patient age remained significant in multivariate models. CONCLUSIONS In a small but relatively uniformly treated cohort of patients with anaplastic astrocytomas and oligoastrocytomas, patient age was associated strongly and inversely with overall survival. Once patient age was taken into account, the clinical and pathologic markers tested appeared to be of limited prognostic value.
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Affiliation(s)
- A Perry
- Washington University School of Medicine, St. Louis, Missouri, USA
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Halling KC, French AJ, McDonnell SK, Burgart LJ, Schaid DJ, Peterson BJ, Moon-Tasson L, Mahoney MR, Sargent DJ, O'Connell MJ, Witzig TE, Farr GH, Goldberg RM, Thibodeau SN. Microsatellite instability and 8p allelic imbalance in stage B2 and C colorectal cancers. J Natl Cancer Inst 1999; 91:1295-303. [PMID: 10433618 DOI: 10.1093/jnci/91.15.1295] [Citation(s) in RCA: 310] [Impact Index Per Article: 12.4] [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] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Microsatellite instability (MSI) and allelic imbalance involving chromosome arms 5q, 8p, 17p, and 18q are genetic alterations commonly found in colorectal cancer. We investigated whether the presence or absence of these genetic alterations would allow stratification of patients with Astler-Coller stage B2 or C colorectal cancer into favorable and unfavorable prognostic groups. METHODS Tumors from 508 patients were evaluated for MSI and allelic imbalance by use of 11 microsatellite markers located on chromosome arms 5q, 8p, 15q, 17p, and 18q. Genetic alterations involving each of these markers were examined for associations with survival and disease recurrence. All P values are two-sided. RESULTS In univariate analyses, high MSI (MSI-H), i.e., MSI at 30% or more of the loci examined, was associated with improved survival (P =.02) and time to recurrence (P =.01). The group of patients whose tumors exhibited allelic imbalance at chromosome 8p had decreased survival (P =.02) and time to recurrence (P =.004). No statistically significant associations with survival or time to recurrence were observed for markers on chromosome arms 5q, 15q, 17p, or 18q. In multivariate analyses, MSI-H was an independent predictor of improved survival (hazard ratio [HR] = 0.51; 95% confidence interval [CI] = 0.31-0.82; P =.006) and time to recurrence (HR = 0.42; 95% CI = 0.24-0.74; P =.003), and 8p allelic imbalance was an independent predictor of decreased survival (HR = 1.89; 95% CI = 1.25-2.83; P =. 002) and time to recurrence (HR = 2.07; 95% CI = 1.32-3.25; P =.002). CONCLUSIONS Patients whose tumors exhibited MSI-H had a favorable prognosis, whereas those with 8p allelic imbalance had a poor prognosis; both alterations served as independent prognostic factors. To our knowledge, this is the first report of an association between 8p allelic imbalance and survival in patients with colorectal cancer.
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Affiliation(s)
- K C Halling
- Departments of Laboratory Medicine and Pathology, Mayo Foundation, Rochester, MN 55905, USA
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Sloan JA, Loprinzi CL, Kuross SA, Miser AW, O'Fallon JR, Mahoney MR, Heid IM, Bretscher ME, Vaught NL. Randomized comparison of four tools measuring overall quality of life in patients with advanced cancer. J Clin Oncol 1998; 16:3662-73. [PMID: 9817289 DOI: 10.1200/jco.1998.16.11.3662] [Citation(s) in RCA: 189] [Impact Index Per Article: 7.3] [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] [Indexed: 11/20/2022] Open
Abstract
PURPOSE We report on a clinical trial developed to compare four different instruments that provide overall quality-of-life (QOL) scores, ranging from a simple, one-item instrument to more detailed instruments. Two issues addressed were (1) Will QOL tools suffer from missing data when used in a community-based cooperative group setting?, and (2) Are there additional data generated by a more detailed multiitem instrument over that provided by a single-item global QOL question? MATERIALS AND METHODS A four-arm randomized trial was designed to compare four instruments that provide overall QOL scores in patients with advanced colorectal cancer. Patients and physicians completed the single-item Spitzer Uniscale (UNISCALE) at baseline and monthly. Patients were randomly assigned to complete, in addition, either the 22-item Functional Living Index-Cancer (FLIC), the five-item Spitzer QOL index (QLI), a picture-face scale (PICT), or nothing else. RESULTS A total of 128 patients were randomized. Greater than 90% complete QOL data were obtained. There was strong correlation, concordance, and criterion-related validity among all four patient-completed tools. The UNISCALE had a greater decrease over time than did the FLIC (P=.005), which suggests a greater sensitivity; the UNISCALE was similar to the QLI and the PICT in this regard. Physicians provided lower UNISCALE scores than patients. Results supported the hypothesis that QOL is prognostic for survival. CONCLUSION Patients can effectively complete QOL tools in a cooperative group setting with proper education of health care providers and patients. A simple single-item tool (UNISCALE) appears to be appropriate to obtain a measure of overall QOL.
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Affiliation(s)
- J A Sloan
- Mayo Clinic and Mayo Foundation, Rochester, MN 55905, USA
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