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Grivas P, Khaki AR, Wise-Draper TM, French B, Hennessy C, Hsu CY, Shyr Y, Li X, Choueiri TK, Painter CA, Peters S, Rini BI, Thompson MA, Mishra S, Rivera DR, Acoba JD, Abidi MZ, Bakouny Z, Bashir B, Bekaii-Saab T, Berg S, Bernicker EH, Bilen MA, Bindal P, Bishnoi R, Bouganim N, Bowles DW, Cabal A, Caimi PF, Chism DD, Crowell J, Curran C, Desai A, Dixon B, Doroshow DB, Durbin EB, Elkrief A, Farmakiotis D, Fazio A, Fecher LA, Flora DB, Friese CR, Fu J, Gadgeel SM, Galsky MD, Gill DM, Glover MJ, Goyal S, Grover P, Gulati S, Gupta S, Halabi S, Halfdanarson TR, Halmos B, Hausrath DJ, Hawley JE, Hsu E, Huynh-Le M, Hwang C, Jani C, Jayaraj A, Johnson DB, Kasi A, Khan H, Koshkin VS, Kuderer NM, Kwon DH, Lammers PE, Li A, Loaiza-Bonilla A, Low CA, Lustberg MB, Lyman GH, McKay RR, McNair C, Menon H, Mesa RA, Mico V, Mundt D, Nagaraj G, Nakasone ES, Nakayama J, Nizam A, Nock NL, Park C, Patel JM, Patel KG, Peddi P, Pennell NA, Piper-Vallillo AJ, Puc M, Ravindranathan D, Reeves ME, Reuben DY, Rosenstein L, Rosovsky RP, Rubinstein SM, Salazar M, Schmidt AL, Schwartz GK, Shah MR, Shah SA, Shah C, Shaya JA, Singh SRK, Smits M, Stockerl-Goldstein KE, Stover DG, Streckfuss M, Subbiah S, Tachiki L, Tadesse E, Thakkar A, Tucker MD, Verma AK, Vinh DC, Weiss M, Wu JT, Wulff-Burchfield E, Xie Z, Yu PP, Zhang T, Zhou AY, Zhu H, Zubiri L, Shah DP, Warner JL, Lopes G. Association of clinical factors and recent anticancer therapy with COVID-19 severity among patients with cancer: a report from the COVID-19 and Cancer Consortium. Ann Oncol 2021; 32:787-800. [PMID: 33746047 PMCID: PMC7972830 DOI: 10.1016/j.annonc.2021.02.024] [Citation(s) in RCA: 202] [Impact Index Per Article: 67.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Revised: 02/18/2021] [Accepted: 02/28/2021] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Patients with cancer may be at high risk of adverse outcomes from severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. We analyzed a cohort of patients with cancer and coronavirus 2019 (COVID-19) reported to the COVID-19 and Cancer Consortium (CCC19) to identify prognostic clinical factors, including laboratory measurements and anticancer therapies. PATIENTS AND METHODS Patients with active or historical cancer and a laboratory-confirmed SARS-CoV-2 diagnosis recorded between 17 March and 18 November 2020 were included. The primary outcome was COVID-19 severity measured on an ordinal scale (uncomplicated, hospitalized, admitted to intensive care unit, mechanically ventilated, died within 30 days). Multivariable regression models included demographics, cancer status, anticancer therapy and timing, COVID-19-directed therapies, and laboratory measurements (among hospitalized patients). RESULTS A total of 4966 patients were included (median age 66 years, 51% female, 50% non-Hispanic white); 2872 (58%) were hospitalized and 695 (14%) died; 61% had cancer that was present, diagnosed, or treated within the year prior to COVID-19 diagnosis. Older age, male sex, obesity, cardiovascular and pulmonary comorbidities, renal disease, diabetes mellitus, non-Hispanic black race, Hispanic ethnicity, worse Eastern Cooperative Oncology Group performance status, recent cytotoxic chemotherapy, and hematologic malignancy were associated with higher COVID-19 severity. Among hospitalized patients, low or high absolute lymphocyte count; high absolute neutrophil count; low platelet count; abnormal creatinine; troponin; lactate dehydrogenase; and C-reactive protein were associated with higher COVID-19 severity. Patients diagnosed early in the COVID-19 pandemic (January-April 2020) had worse outcomes than those diagnosed later. Specific anticancer therapies (e.g. R-CHOP, platinum combined with etoposide, and DNA methyltransferase inhibitors) were associated with high 30-day all-cause mortality. CONCLUSIONS Clinical factors (e.g. older age, hematological malignancy, recent chemotherapy) and laboratory measurements were associated with poor outcomes among patients with cancer and COVID-19. Although further studies are needed, caution may be required in utilizing particular anticancer therapies. CLINICAL TRIAL IDENTIFIER NCT04354701.
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Affiliation(s)
- P Grivas
- University of Washington/Fred Hutchinson Cancer Research Center/Seattle Cancer Care Alliance, Seattle, USA.
| | - A R Khaki
- University of Washington/Fred Hutchinson Cancer Research Center/Seattle Cancer Care Alliance, Seattle, USA; Stanford University, Stanford, USA
| | | | - B French
- Vanderbilt University Medical Center, Nashville, USA
| | - C Hennessy
- Vanderbilt University Medical Center, Nashville, USA
| | - C-Y Hsu
- Vanderbilt University Medical Center, Nashville, USA
| | - Y Shyr
- Vanderbilt University Medical Center, Nashville, USA
| | - X Li
- Vanderbilt University School of Medicine, Nashville, USA
| | | | - C A Painter
- Broad Institute, Cancer Program, Cambridge, USA
| | - S Peters
- Lausanne University, Lausanne, Switzerland
| | - B I Rini
- Vanderbilt University Medical Center, Nashville, USA
| | | | - S Mishra
- Vanderbilt University Medical Center, Nashville, USA
| | - D R Rivera
- Division of Cancer Control and Population Sciences, National Cancer Institute, Rockville, USA
| | - J D Acoba
- University of Hawaii Cancer Center, Honolulu, USA
| | - M Z Abidi
- University of Colorado School of Medicine, Aurora, USA
| | - Z Bakouny
- Dana-Farber Cancer Institute, Boston, USA
| | - B Bashir
- Sidney Kimmel Cancer Center at Thomas Jefferson University, Philadelphia, USA
| | | | - S Berg
- Cardinal Bernardin Cancer Center, Loyola University Medical Center, Maywood, USA
| | | | - M A Bilen
- Winship Cancer Institute of Emory University, Atlanta, USA
| | - P Bindal
- Beth Israel Deaconess Medical Center, Boston, USA
| | - R Bishnoi
- University of Florida, Gainesville, USA
| | - N Bouganim
- McGill University Health Centre, Montréal, Canada
| | - D W Bowles
- University of Colorado School of Medicine, Aurora, USA
| | - A Cabal
- University of California San Diego, Moores Cancer Center, La Jolla, USA
| | - P F Caimi
- University Hospitals Seidman Cancer Center, Cleveland, USA; Case Western Reserve University, Cleveland, USA
| | - D D Chism
- Thompson Cancer Survival Center, Knoxville, USA
| | - J Crowell
- St. Elizabeth Healthcare, Edgewood, USA
| | - C Curran
- Dana-Farber Cancer Institute, Boston, USA
| | - A Desai
- Mayo Clinic Cancer Center, Rochester, USA
| | - B Dixon
- St. Elizabeth Healthcare, Edgewood, USA
| | - D B Doroshow
- Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, USA
| | - E B Durbin
- Markey Cancer Center, University of Kentucky, Lexington, USA
| | - A Elkrief
- McGill University Health Centre, Montréal, Canada
| | - D Farmakiotis
- The Warren Alpert Medical School of Brown University, Providence, USA
| | - A Fazio
- Tufts Medical Center Cancer Center, Boston and Stoneham, USA
| | - L A Fecher
- University of Michigan Rogel Cancer Center, Ann Arbor, USA
| | - D B Flora
- St. Elizabeth Healthcare, Edgewood, USA
| | - C R Friese
- University of Michigan Rogel Cancer Center, Ann Arbor, USA
| | - J Fu
- Tufts Medical Center Cancer Center, Boston and Stoneham, USA
| | - S M Gadgeel
- Henry Ford Cancer Institute/Henry Ford Health System, Detroit, USA
| | - M D Galsky
- Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, USA
| | - D M Gill
- Intermountain Healthcare, Salt Lake City, USA
| | | | - S Goyal
- George Washington University, Washington DC, USA
| | - P Grover
- University of Cincinnati Cancer Center, Cincinnati, USA
| | - S Gulati
- University of Cincinnati Cancer Center, Cincinnati, USA
| | - S Gupta
- Cleveland Clinic Taussig Cancer Institute, Cleveland, USA
| | | | | | - B Halmos
- Albert Einstein Cancer Center/Montefiore Medical Center, Bronx, USA
| | - D J Hausrath
- Vanderbilt University School of Medicine, Nashville, USA
| | - J E Hawley
- Herbert Irving Comprehensive Cancer Center, Columbia University Irving Medical Center, New York, USA
| | - E Hsu
- Hartford HealthCare, Hartford, USA; University of Connecticut, Farmington, USA
| | - M Huynh-Le
- George Washington University, Washington DC, USA
| | - C Hwang
- Henry Ford Cancer Institute/Henry Ford Health System, Detroit, USA
| | - C Jani
- Mount Auburn Hospital, Cambridge, USA
| | | | - D B Johnson
- Vanderbilt University Medical Center, Nashville, USA
| | - A Kasi
- University of Kansas Medical Center, Kansas City, USA
| | - H Khan
- The Warren Alpert Medical School of Brown University, Providence, USA
| | - V S Koshkin
- University of California, San Francisco, San Francisco, USA
| | - N M Kuderer
- Advanced Cancer Research Group, LLC, Kirkland, USA
| | - D H Kwon
- University of California, San Francisco, San Francisco, USA
| | | | - A Li
- Baylor College of Medicine, Houston, USA
| | | | - C A Low
- Intermountain Healthcare, Salt Lake City, USA
| | | | - G H Lyman
- University of Washington/Fred Hutchinson Cancer Research Center/Seattle Cancer Care Alliance, Seattle, USA
| | - R R McKay
- University of California San Diego, Moores Cancer Center, La Jolla, USA
| | - C McNair
- Sidney Kimmel Cancer Center at Thomas Jefferson University, Philadelphia, USA
| | - H Menon
- Penn State Health/Penn State Cancer Institute/St. Joseph Cancer Center, Hershey, USA
| | - R A Mesa
- Mays Cancer Center at UT Health San Antonio MD Anderson, San Antonio, USA
| | - V Mico
- Sidney Kimmel Cancer Center at Thomas Jefferson University, Philadelphia, USA
| | - D Mundt
- Advocate Aurora Health, Milwaukee, USA
| | - G Nagaraj
- Loma Linda University Cancer Center, Loma Linda, USA
| | - E S Nakasone
- University of Washington/Fred Hutchinson Cancer Research Center/Seattle Cancer Care Alliance, Seattle, USA
| | - J Nakayama
- Case Western Reserve University, Cleveland, USA; University Hospitals Cleveland Medical Center, Cleveland, USA
| | - A Nizam
- Cleveland Clinic Taussig Cancer Institute, Cleveland, USA
| | - N L Nock
- University Hospitals Seidman Cancer Center, Cleveland, USA; Case Western Reserve University, Cleveland, USA
| | - C Park
- University of Cincinnati Cancer Center, Cincinnati, USA
| | - J M Patel
- Beth Israel Deaconess Medical Center, Boston, USA
| | - K G Patel
- University of California Davis Comprehensive Cancer Center, Sacramento, USA
| | - P Peddi
- Willis-Knighton Cancer Center, Shreveport, USA
| | - N A Pennell
- Cleveland Clinic Taussig Cancer Institute, Cleveland, USA
| | | | - M Puc
- Virtua Health, Marlton, USA
| | | | - M E Reeves
- Loma Linda University Cancer Center, Loma Linda, USA
| | - D Y Reuben
- Medical University of South Carolina, Charleston, USA
| | | | - R P Rosovsky
- Massachusetts General Hospital, Harvard Medical School, Boston, USA
| | | | - M Salazar
- Mays Cancer Center at UT Health San Antonio MD Anderson, San Antonio, USA
| | | | - G K Schwartz
- Herbert Irving Comprehensive Cancer Center, Columbia University Irving Medical Center, New York, USA
| | - M R Shah
- Rutgers Cancer Institute of New Jersey, New Brunswick, USA
| | - S A Shah
- Stanford University, Stanford, USA
| | - C Shah
- University of Florida, Gainesville, USA
| | - J A Shaya
- University of California San Diego, Moores Cancer Center, La Jolla, USA
| | - S R K Singh
- Henry Ford Cancer Institute/Henry Ford Health System, Detroit, USA
| | - M Smits
- ThedaCare Regional Cancer Center, Appleton, USA
| | | | - D G Stover
- The Ohio State University, Columbus, USA
| | | | - S Subbiah
- Stanley S. Scott Cancer Center, LSU Health Sciences Center, New Orleans, USA
| | - L Tachiki
- University of Washington/Fred Hutchinson Cancer Research Center/Seattle Cancer Care Alliance, Seattle, USA
| | - E Tadesse
- Advocate Aurora Health, Milwaukee, USA
| | - A Thakkar
- Albert Einstein Cancer Center/Montefiore Medical Center, Bronx, USA
| | - M D Tucker
- Vanderbilt University Medical Center, Nashville, USA
| | - A K Verma
- Albert Einstein Cancer Center/Montefiore Medical Center, Bronx, USA
| | - D C Vinh
- McGill University Health Centre, Montréal, Canada
| | - M Weiss
- ThedaCare Regional Cancer Center, Appleton, USA
| | - J T Wu
- Stanford University, Stanford, USA
| | | | - Z Xie
- Mayo Clinic Cancer Center, Rochester, USA
| | - P P Yu
- Hartford HealthCare, Hartford, USA
| | - T Zhang
- Duke University, Durham, USA
| | - A Y Zhou
- Siteman Cancer Center, Washington University School of Medicine, St. Louis, USA
| | - H Zhu
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, USA
| | - L Zubiri
- Massachusetts General Hospital, Harvard Medical School, Boston, USA
| | - D P Shah
- Mays Cancer Center at UT Health San Antonio MD Anderson, San Antonio, USA
| | - J L Warner
- Vanderbilt University Medical Center, Nashville, USA
| | - GdL Lopes
- University of Miami/Sylvester Comprehensive Cancer Center, Miami, USA
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Aapro M, Lyman GH, Bokemeyer C, Rapoport BL, Mathieson N, Koptelova N, Cornes P, Anderson R, Gascón P, Kuderer NM. Supportive care in patients with cancer during the COVID-19 pandemic. ESMO Open 2020; 6:100038. [PMID: 33421735 PMCID: PMC7808078 DOI: 10.1016/j.esmoop.2020.100038] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [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: 09/10/2020] [Revised: 11/25/2020] [Accepted: 12/10/2020] [Indexed: 12/11/2022] Open
Abstract
Cancer care has been profoundly impacted by the global pandemic of severe acute respiratory syndrome coronavirus 2 disease (coronavirus disease 2019, COVID-19), resulting in unprecedented challenges. Supportive care is an essential component of cancer treatment, seeking to prevent and manage chemotherapy complications such as febrile neutropenia, anaemia, thrombocytopenia/bleeding, thromboembolic events and nausea/vomiting, all of which are common causes of hospitalisation. These adverse events are an essential consideration under routine patient management, but particularly so during a pandemic, a setting in which clinicians aim to minimise patients' risk of infection and need for hospital visits. Professional medical oncology societies have been providing updated guidelines to support health care professionals with the management, treatment and supportive care needs of their patients with cancer under the threat of COVID-19. This paper aims to review the recommendations made by the most prominent medical oncology societies for devising and modifying supportive care strategies during the pandemic. Cancer care has been profoundly impacted by the global pandemic of COVID-19, resulting in unprecedented challenges. Oncology societies have updated guidelines for the supportive care needs of patients with cancer under the threat of COVID-19. This paper reviews recommendations from prominent oncology societies for providing supportive care during the pandemic.
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Affiliation(s)
- M Aapro
- Genolier Cancer Centre, Clinique de Genolier, Genolier, Switzerland
| | - G H Lyman
- Hutchinson Institute for Cancer Outcomes Research, Public Health Sciences and Clinical Research Divisions, Fred Hutchinson Cancer Research Center and the University of Washington Schools of Medicine, Public Health and Pharmacy, Seattle, USA.
| | - C Bokemeyer
- Department of Oncology, Hematology & BMT with Section of Pneumology, Universitaetsklinikum Hamburg Eppendorf, Hamburg, Germany
| | - B L Rapoport
- Department of Immunology, Faculty of Health Sciences, University of Pretoria, Pretoria, South Africa; The Medical Oncology Centre of Rosebank, Johannesburg, South Africa; Neutropenia, Infection and Myelosuppression Study Group (Chair), The Multinational Association for Supportive Care in Cancer, Aurora, Canada
| | | | | | - P Cornes
- Comparative Outcomes Group, Bristol, UK
| | - R Anderson
- Department of Immunology, Faculty of Health Sciences, University of Pretoria, Pretoria, South Africa
| | - P Gascón
- Department of Hematology-Oncology, Laboratory of Molecular & Translational Oncology-CELLEX University of Barcelona, Barcelona, Spain
| | - N M Kuderer
- Advanced Cancer Research Group, Seattle, USA
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Affiliation(s)
- G H Lyman
- Public Health Sciences and Clinical Research Divisions, Fred Hutchinson Cancer Research Center, Seattle, USA; University of Washington, Seattle, USA.
| | - N M Kuderer
- Advanced Cancer Research Group, Kirkland, USA
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Nguyen E, Caranfa JT, Lyman GH, Kuderer NM, Stirbis C, Wysocki M, Coleman CI, Weeda ER, Kohn CG. Clinical prediction rules for mortality in patients with pulmonary embolism and cancer to guide outpatient management: a meta-analysis. J Thromb Haemost 2018; 16:279-292. [PMID: 29215781 DOI: 10.1111/jth.13921] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [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: 09/17/2017] [Indexed: 01/27/2023]
Abstract
Essentials Clinical prediction rules (CPRs) can stratify patients with pulmonary embolism (PE) and cancer. A meta-analysis was done to assess prognostic accuracy in CPRs for mortality in these patients. Eight studies evaluating ten CPRs were included in this study. CPRs should continue to be used with other patient factors for mortality risk stratification. SUMMARY Background Cancer treatment is commonly complicated by pulmonary embolism (PE), which remains a leading cause of morbidity and mortality in these patients. Some guidelines recommend the use of clinical prediction rules (CPRs) to help clinicians identify patients at low risk of mortality and therefore guide care. Objective To determine and compare the accuracy of available CPRs for identifying cancer patients with PE at low risk of mortality. Methods A literature search of Medline and Scopus (January 2000 to August 2017) was performed. Studies deriving/validating ≥ 1 CPR for early post-PE all-cause mortality were included. A bivariate, random-effects model was used to pool sensitivity and specificity estimates for each CPR. Traditional random-effects meta-analysis was performed to estimate the weighted proportion of patients deemed at low risk of early mortality, mortality in low risk patients and odds ratios for death compared with higher-risk patients. Results Eight studies evaluating 10 CPRs were included. The highest sensitivities were observed with Hestia (98.1%, 95% confidence interval [CI] = 75.6-99.9%) and the EPIPHANY index (97.4%, 95% CI = 93.2-99.0%); sensitivities of remaining rules ranged from 59.9 to 96.6%. Of the six CPRs with sensitivities ≥ 95%, none had specificities > 33%. Random-effects meta-analysis suggested that 6.6-51.6% of cancer patients with PE were at low risk of mortality, 0-14.3% of low-risk patients died and low-risk patients had a 43-94% lower odds of death compared with those at higher risk. Conclusions Because of the limited total body of evidence regarding CPRs, their results, in conjunction with other pertinent patient-specific clinical factors, should continue to be used in identifying appropriate management for PE in patients with cancer.
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Affiliation(s)
- E Nguyen
- Idaho State University College of Pharmacy, Meridian, ID, USA
| | - J T Caranfa
- University of Connecticut School of Medicine, Farmington, CT, USA
| | - G H Lyman
- Fred Hutchinson Cancer Research Center, Seattle, WA, USA
- University of Washington School of Medicine, Seattle, WA, USA
| | - N M Kuderer
- University of Washington School of Medicine, Seattle, WA, USA
| | - C Stirbis
- University of Saint Joseph School of Pharmacy, Hartford, CT, USA
| | - M Wysocki
- University of Connecticut School of Pharmacy, Storrs, CT, USA
| | - C I Coleman
- University of Connecticut School of Pharmacy, Storrs, CT, USA
- UConn/Hartford Hospital Evidence-based Practice Center, Hartford, CT, USA
| | - E R Weeda
- Medical University of South Carolina College of Pharmacy, Charleston, SC, USA
| | - C G Kohn
- University of Connecticut School of Medicine, Farmington, CT, USA
- UConn/Hartford Hospital Evidence-based Practice Center, Hartford, CT, USA
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Lyman GH, Dale DC, Culakova E, Poniewierski MS, Wolff DA, Kuderer NM, Huang M, Crawford J. The impact of the granulocyte colony-stimulating factor on chemotherapy dose intensity and cancer survival: a systematic review and meta-analysis of randomized controlled trials. Ann Oncol 2013; 24:2475-2484. [PMID: 23788754 DOI: 10.1093/annonc/mdt226] [Citation(s) in RCA: 141] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND The granulocyte colony-stimulating factor (G-CSF) is utilized to reduce neutropenic complications in patients receiving cancer chemotherapy. This study represents a systematic review and evidence summary of the impact of G-CSF support on chemotherapy dose intensity and overall mortality. MATERIALS AND METHODS All randomized controlled trials (RCTs) comparing chemotherapy with or without G-CSF support and reporting all-cause mortality with at least 2 years of follow-up were sought. Dual-blind data abstraction of disease, treatment, patient and outcome study results with conflict resolution by third party was carried out. RESULTS The search revealed 61 randomized comparisons of chemotherapy with or without initial G-CSF support. Death was reported in 4251 patients randomized to G-CSFs and in 5188 controls. Relative risk (RR) with G-CSF support for all-cause mortality was 0.93 (95% confidence interval: 0.90-0.96; P < 0.001). RR for mortality varied by intended chemotherapy dose and schedule: same dose and schedule (RR = 0.96; P = 0.060), dose dense (RR = 0.89; P < 0.001), dose escalation (RR = 0.92; P = 0.019) and drug substitution or addition (RR = 0.94; P = 0.003). Greater RR reduction was observed among studies with longer follow-up (P = 0.02), where treatment was for curative intent (RR = 0.91; P < 0.001), and where survival was the primary outcome (RR = 0.91; P < 0.001). CONCLUSIONS All-cause mortality is reduced in patients receiving chemotherapy with primary G-CSF support. The greatest impact was observed in RCTs in patients receiving dose-dense schedules.
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Affiliation(s)
- G H Lyman
- Department of Medicine, Duke University, Durham.
| | - D C Dale
- Department of Medicine, University of Washington, Seattle, USA
| | - E Culakova
- Department of Medicine, Duke University, Durham
| | | | - D A Wolff
- Department of Medicine, Duke University, Durham
| | - N M Kuderer
- Department of Medicine, Duke University, Durham
| | - M Huang
- Department of Medicine, Duke University, Durham
| | - J Crawford
- Department of Medicine, Duke University, Durham
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Lyman GH, Culakova E, Poniewierski MS, Wogu AF, Barry W, Ginsburg GS, Marcom PK, Ready N, Abernethy A, Geradts J, Hwang S, Kuderer NM. Abstract P3-06-07: Ki67 as a Predictive Marker of Response to Neoadjuvant Chemotherapy in Patients with Early-Stage Breast Cancer (ESBC): A Systematic Review and Evidence Summary. Cancer Res 2012. [DOI: 10.1158/0008-5472.sabcs12-p3-06-07] [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: Immunohistochemical (IHC) assessment of the proportion of cells staining for the KI67 nuclear antigen is being increasing utilized in the management of patients with early-stage breast cancer (ESBC). A comprehensive systematic review and evidence synthesis of biomarkers potentially predictive of response to systemic therapy was initiated as a part of an NCI-funded comparative effectiveness research program.
Methods: Studies of chemotherapy response prediction based on baseline IHC assessment of Ki67 in patients with ESBC receiving neoadjuvant systemic therapy were identified. Response was specified as pathologic complete response (pCR) or clinical response (ClinR). Assay predictive performance for response was assessed on the basis of sensitivity, specificity, predictive value and predictive odds ratio (POR±95%CLs) utilizing mixed effects models. Study results were fitted in an ROC analysis based on the method of DerSimonian and Laird. Publication bias was evaluated on the basis of funnel plot asymmetry assessed by Egger's regression intercept and Begg and Mazumdar's rank correlation.
Results: Of 469 potentially eligible studies, dual blind full text review identified 42 eligible studies reporting 44 independent cohorts with 6,716 patients (21–979). While Ki67 cutpoints varied considerably, they were most commonly between 10%–30% (median 20%, range 1–50%). The analysis prsented here is limited to the 30 studies of ESBC patients (N = 3,343) receiving neoadjuvant therapy of which 14 reported fewer than 100 patients. The proportion of patients with elevated Ki67 across studies ranged from 0.20–0.92 (median = 0.54). Sensitivity and specificity for treatment response in patients with high vs. low baseline Ki67 was 0.65 [0.61, 0.68] and 0.52 [0.50, 0.54], respectively. Estimated response rates across studies in patients with high vs. low Ki67 were 31% [29%, 34%] and 19% [17%, 21%], respectively. The estimated POR for response across studies was 2.82 [2.14, 3.72; P < .001].
POR was significantly greater in studies of anthracycline-based [3.0] than non-anthracycline regimens [0.92](Pinteraction = .043) and of cyclophosphamide-based [3.41] compared to non-cyclophosphamide regimens [2.00](P interaction=.039) but was not associated with treatment based on other drug classes. Although Ki67 predictive performance was not significantly associated with the cutpoint utilized or the proportion of patients with ER or PR+, Her2+, or high grade tumors across studies, analysis based on individual patient data is needed to assess performance in specific clinical subgroups. No significant publication bias was found.
Conclusions: A compelling need exists for larger studies with greater methodologic rigor and standardization to assess the clinical validity of Ki67 in ESBC as well its clinical utility in guiding neoadjuvant treatment decisions compared to the use of conventional predictive markers.
Funding: NCI: RC2CA14041-01
Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr P3-06-07.
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Culakova E, Poniewierski MS, Wogu AF, Kuderer NM, Crawford J, Dale DC, Lyman GH. Abstract P1-15-04: The relationship of relative dose intensity and supportive care to febrile neutropenia rates in patients with early stage breast cancer receiving chemotherapy: a prospective cohort study of chemotherapy-associated toxicity. Cancer Res 2012. [DOI: 10.1158/0008-5472.sabcs12-p1-15-04] [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: Febrile neutropenia (FN) represents a major dose-limiting toxicity of cancer chemotherapy resulting in considerable morbidity, mortality, and cost. Patients have the highest risk of the initial neutropenic event in cycle 1 when most patients receive full dose chemotherapy. This study evaluates time course of neutropenic events in patients receiving chemotherapy for early-stage breast cancer (ESBC) and supportive care interventions that modify FN risk in ESBC patients treated in actual oncology practice.
Methods: A prospective cohort study of adult cancer patients with solid tumors or lymphoma starting a chemotherapy regimen was conducted at 115 U.S. sites. Toxicities associated with chemotherapy were recorded in up to 4 cycles including severe neutropenia (SN), FN, and infection. Documented clinical interventions included reductions in chemotherapy relative dose intensity (RDI), the use of colony-stimulating factors (CSFs), and antibiotics.
Results: A total of 1202 ESBC patients starting chemotherapy were analyzed, of which 1154, 1099, and 896 reached the midcycle of cycles 2, 3, and 4, respectively. While the majority of neutropenic and infection events occurred in cycle 1, decreasing rates of FN and infection in later cycles correlated with increasing reductions in dose intensity and increased use of CSFs and antibiotics.
The overall risk of FN in all patients combined was 16.3 %. It reached 21.1% for patients who started with planned RDI≥85% and without primary CSF prophylaxis. There was no significant difference in FN rates by menopausal status or hormone receptors.
Conclusions: While the risk of neutropenic complications is highest during the first cycle of chemotherapy, reductions in neutropenic events during subsequent cycles are associated with reduced chemotherapy dose intensity or increased use of supportive care measures. Nevertheless, the cumulative risk of neutropenic events remains high in ESBC patients receiving full dose chemotherapy without prophylactic measures overall and across menopausal and hormone receptor subgroups.
Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr P1-15-04.
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Affiliation(s)
- E Culakova
- Duke University, Durham, NC; University of Washington, Seattle, WA
| | - MS Poniewierski
- Duke University, Durham, NC; University of Washington, Seattle, WA
| | - AF Wogu
- Duke University, Durham, NC; University of Washington, Seattle, WA
| | - NM Kuderer
- Duke University, Durham, NC; University of Washington, Seattle, WA
| | - J Crawford
- Duke University, Durham, NC; University of Washington, Seattle, WA
| | - DC Dale
- Duke University, Durham, NC; University of Washington, Seattle, WA
| | - GH Lyman
- Duke University, Durham, NC; University of Washington, Seattle, WA
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Kuderer NM, Lyman GH. Response: Re: Personalized Medicine and Cancer Supportive Care: Appropriate Use of Colony-Stimulating Factor Support of Chemotherapy. J Natl Cancer Inst 2011. [DOI: 10.1093/jnci/djr440] [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: 11/14/2022] Open
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Kuderer NM, Culakova E, Poniewierski MS, Crawford J, Dale D, Lyman GH. P5-20-03: Personalizing Supportive Care: A Clinical Prediction Model for Neutropenic Complications in Patients with Early-Stage Breast Cancer (ESBC) Receiving Intermediate Risk Chemotherapy. Cancer Res 2011. [DOI: 10.1158/0008-5472.sabcs11-p5-20-03] [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: Neutropenic complications including severe and febrile neutropenia (FN) represent major dose-limiting toxicities of cancer chemotherapy. A general risk model for neutropenic complications across major solid tumors has been developed and validated (Lyman et al. Cancer 2011). Current guidelines recommend consideration of primary prophylaxis with a colony-stimulating factor (CSF) in patients at >20% risk of FN. The decision for primary CSF prophylaxis in patients on intermediate risk chemotherapy (10-20%) is based on physician assessment of individual patient risk factors for FN. This study assesses the ability of this general FN risk model to identify ESBC patients on intermediate risk chemotherapy who are at a personal high risk for developing a neutropenic complication.
Methods: A prospective cohort study accrued 4458 consenting patients starting a new chemotherapy regimen at 115 randomly selected community oncology practices throughout the United States from 2002–2006. The risk of severe or febrile neutropenia (SNFN) in cycle 1 and across 4 cycles was estimated [±95% CI] utilizing logistic regression analysis and adjusting for key clinical factors including among others: age, prior chemotherapy, abnormal hepatic or renal function, low pretreatment white blood count, immunosuppressive medications, CSF prophylaxis, and planned relative dose intensity as well as major chemotherapeutic agents. The cumulative risk of FN across 4 cycles was also estimated by the product limit method of Kaplan and Meier.
Results: Among 1224 patients with ESBC, 822 received intermediate risk chemotherapy based on National Comprehensive Cancer Network guidelines. Among these patients, cycle 1 SNFN occurred in 37%, at least one episode of FN over 4 cycles of chemotherapy in 17%, with 15% receiving primary CSF prophylaxis. The predicted risk of cycle 1 SNFN ranged from 1%-79%, with mean (median) risk of 33.8% (39.0%). Model performance was good with a c-statistic of 0.73 [0.69−0.76]. Based on this general FN risk model, cycle 1 SNFN occurred in 47% of predicted high risk ESBC patients [42 — 52%] compared to 13% [8-17%] of low risk patients. One or more FN events over 4 cycles occurred in 20% [17-24%] of predicted high risk versus 10% [6-14%] in low risk patients. The cumulative risk of FN by Kaplan-Meier estimation was 23% in high risk and 10% in low risk patients. Model sensitivity and specificity for FN were 83% and 33%, respectively. The majority of SNFN (76%) and FN (58%) events among high risk patients occurred in cycle 1. 50% of high risk patients who did not receive primary CSF prophylaxis went on to receive CSF during subsequent cycles.
Conclusions: Based on good test performance characteristics, this clinical FN prediction model also identifies ESBC patients receiving intermediate risk chemotherapy at high personal risk for FN (FN >20%) over the first 4 cycles of chemotherapy. Half of predicted high risk patients without primary CSF prophylaxis will be given CSF in subsequent cycles after the occurrence of a neutropenic complication. This also confirms previous clinical trial findings that the majority of febrile neutropenic events occur in the first cycle.
Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P5-20-03.
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Affiliation(s)
- NM Kuderer
- 1Duke University, Durham, NC; University of Washington, Seattle, WA
| | - E Culakova
- 1Duke University, Durham, NC; University of Washington, Seattle, WA
| | - MS Poniewierski
- 1Duke University, Durham, NC; University of Washington, Seattle, WA
| | - J Crawford
- 1Duke University, Durham, NC; University of Washington, Seattle, WA
| | - D Dale
- 1Duke University, Durham, NC; University of Washington, Seattle, WA
| | - GH Lyman
- 1Duke University, Durham, NC; University of Washington, Seattle, WA
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Lyman GH, Culakova E, Poniewierski MS, Huang M, Barry W, Ginsburg G, Abernethy A, Marcom PK, Ready N, Kuderer NM. P5-13-17: Multigene Signature Assays in Patients with Early-Stage Breast Cancer (ESBC) Receiving Neoadjuvant Chemotherapy: An NCI-Funded Systematic Review and Evidence Summary of Predictive Performance. Cancer Res 2011. [DOI: 10.1158/0008-5472.sabcs11-p5-13-17] [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: A comprehensive literature search and evidence synthesis of multigene signatures predictive of response to systemic chemotherapy in patients with breast cancer was initiated as a part of an NCI-funded program on Comparative Effectiveness Research.
Methods: Validation studies were sought of multigene signatures for prediction of chemotherapy response (favorable vs unfavorable) in ESBC patient cohorts different from those used for signature development. Pooled estimates [±95% CI] of assay performance for predicting clinical outcome included sensitivity, specificity, likelihood ratio, predictive value (PV) and predictive odds ratio (POR) utilizing mixed effects models based on the method of Mantel-Haenszel. Exploratory metaregression analyses on log (POR) were also performed. Studies were classified by validation type including cell lines to patients, independent internal sample, random split sample, or external validation. Evidence for publication bias was assessed by Egger's regression intercept and Begg and Mazumdar's rank correction. Results: Dual-blind review of abstracts identified 33 studies of neoadjuvant chemotherapy response of which 29 stratified treatment response by signature classifier category. Classifier development was based on tumor response prediction in 20 studies, prognosis in 5, and molecular classification in 4. The Table shows assay performance measures overall and by study validation type. Assay performance based on the POR was positively associated with overall study quality (P=.015) and journal impact factor (P=.020). However, strong evidence for publication bias was observed based on both regression intercept (P<.001) and rank correlation (P=.005). No significant differences in assay performance were noted for assays originally developed for response prediction (POR=5.3), prognosis (POR=6.6) or molecular classification (P=6.9) (P=.770).
Conclusions: While assay performance in predicting response to neoadjuvant chemotherapy based on multigene classifiers is encouraging, a compelling need exists for greater methodologic rigor and standardization of reporting. The predictive performance of multigene assay signatures varies with the type of validation sample utilized with external validation providing the most conservative estimates. No differences were seen for assays developed for prediction, prognosis or molecular classification. Considerable evidence for publication bias exists reflecting a paucity of smaller negative studies. The clinical validity of genomic response prediction assays should be evaluated in patient cohorts independent of those utilized for signature development. The clinical utility of these assays must then be further assessed in comparative effectiveness studies compared to commonly utilized clinical and laboratory measures. Funding: NCI: UC2CA14041-01
Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P5-13-17.
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Affiliation(s)
- GH Lyman
- 1Duke University School of Medicine, Durham, NC; Duke University, Durham, NC
| | - E Culakova
- 1Duke University School of Medicine, Durham, NC; Duke University, Durham, NC
| | - MS Poniewierski
- 1Duke University School of Medicine, Durham, NC; Duke University, Durham, NC
| | - M Huang
- 1Duke University School of Medicine, Durham, NC; Duke University, Durham, NC
| | - W Barry
- 1Duke University School of Medicine, Durham, NC; Duke University, Durham, NC
| | - G Ginsburg
- 1Duke University School of Medicine, Durham, NC; Duke University, Durham, NC
| | - A Abernethy
- 1Duke University School of Medicine, Durham, NC; Duke University, Durham, NC
| | - PK Marcom
- 1Duke University School of Medicine, Durham, NC; Duke University, Durham, NC
| | - N Ready
- 1Duke University School of Medicine, Durham, NC; Duke University, Durham, NC
| | - NM Kuderer
- 1Duke University School of Medicine, Durham, NC; Duke University, Durham, NC
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Culakova E, Poniewierski MS, Huang M, Kuderer NM, Ginsburg GS, Barry W, Marcom PK, Ready N, Abernethy A, Lyman GH. P3-14-04: Assessment of Genomic Prognostic Signatures as Predictors of Response to Neoadjuvant Chemotherapy in Patients with Early Stage Breast Cancer. Cancer Res 2011. [DOI: 10.1158/0008-5472.sabcs11-p3-14-04] [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: Based on results from randomized clinical trials, adjuvant and neoadjuvant chemotherapy (NCT) strategies in early stage breast cancer patients (ESBC) achieve comparable long term results. Recently, a number of genomic signatures have been reported, distinguishing patients with low versus high risk of recurrence. While developed primarily as prognostic assays, these classifiers have also been proposed to be predictive of benefit from systemic chemotherapy. Neoadjuvant studies provide an opportunity to evaluate their predictive value for response to NCT.
Methods: A systematic review of gene expression profile studies in ESBC patients receiving chemotherapy was conducted. Medline search of original research articles of human studies published between January 2000 and February 2011 was based on key words and MeSH heading terms. Publications presenting outcomes for chemotherapy treated patients in groups stratified by multi-gene array signatures and utilizing a new independent cohort of patients compared to the original development cohort were selected. Information from eligible studies was extracted by dual abstraction. Reported results were synthesized into combined diagnostic odds ratio (DOR) using method of Mantel-Haenszel. This analysis is restricted to neoadjuvant studies investigating the association of genomic signature prognostic categories with objective tumor response to chemotherapy. Results: A total of 42 articles were eligible for data abstraction. Out of these, 6 publications evaluated response to NCT in good (low risk of recurrence) versus poor prognosis groups based on genomic prediction. Since two of the studies analyzed the same signature on a cohort with large overlap, only 5 studies were included in the final analysis, accounting for n=918 patients. Response consisted of pathologic complete response (pCR) in 3 studies, pCR or minimal residual disease (1 study), and clinical complete response (1 study). Prognostic genomic assays included Oncotype DX (1), MammaPrint (1), Genomic Grade Index (2) and PAM50 Risk of Relapse Score (1). Eight different chemotherapy regimens were utilized. The most common drugs were cyclophosphamide, anthracyclines, taxanes, and 5-fluorouracil. Across all genomic signatures, good prognosis patients, as defined by gene expression data, demonstrated consistently low rates of response to chemotherapy (median 3%, range 0–12%) compared to patients with less favorable prognosis (median 32%, range 19–43%). Odds ratio for response in poor versus good prognosis patients ranged from 3.9 to 21.7 with combined DOR= 6.6 (95% CI 3.9−11.3, P<0.0001). No heterogeneity was determined across studies (P=0.4). The C-statistic estimating assay discriminatory ability was reported in 3 studies ranged from 0.72 to 0.78.
Conclusions: Across all genomic prognostic signatures reported, only a very small proportion of patients with signature predicted good prognosis achieved complete response to NCT. This suggests low sensitivity to chemotherapy among good prognosis patients, as determined by the prognostic genomic signatures. This further confirms the association between poor prognosis tumors and higher responsiveness to chemotherapy.
Funding: NCI: UC2CA14041-01
Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P3-14-04.
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Affiliation(s)
| | | | - M Huang
- 1Duke University, Durham, NC
| | | | | | - W Barry
- 1Duke University, Durham, NC
| | | | - N Ready
- 1Duke University, Durham, NC
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Kuderer NM, Culakova E, Huang M, Poniewierski MS, Ginsburg GS, Barry WT, Marcom PK, Ready N, Abernethy AP, Lyman GH. Quality appraisal of clinical validation studies for multigene prediction assays of chemotherapy response in early-stage breast cancer. J Clin Oncol 2011. [DOI: 10.1200/jco.2011.29.15_suppl.3082] [Citation(s) in RCA: 2] [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: 11/20/2022] Open
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13
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Webb WB, Li Z, Mao J, Gautam S, Singh S, Kuderer NM. Role of personal history in the development of recurrent venous thromboembolism during cancer chemotherapy. J Clin Oncol 2011. [DOI: 10.1200/jco.2011.29.15_suppl.e19677] [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: 11/20/2022] Open
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14
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Lyman GH, Kuderer NM, Marcom PK, Olson, Jr JA. Abstract PD06-09: Sentinel Node Biopsy Versus Axillary Lymph Node Dissection in Early-Stage Breast Cancer: A Meta-Analysis of Randomized Controlled Trials. Cancer Res 2010. [DOI: 10.1158/0008-5472.sabcs10-pd06-09] [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: Lymphatic mapping with sentinel node biopsy (SNB) has become a widely used technology for reducing morbidity associated with breast cancer staging despite limited data from randomized controlled trials (RCTs). A previous review of cohort studies conducted for ASCO guidelines prior to results from RCTs found considerable variation in SNB staging accuracy. (Kim et al, Cancer 2005; Lyman GH et al J Clin Oncol 2005). Early results from several RCTs of SNB have now been reported. Methods: A systematic review of RCTs of SNB for breast cancer staging was conducted utilizing electronic databases. Study eligibility was limited to RCTs comparing SNB alone in SNB negative patients versus axillary lymph node dissection (ALND) with or without prior SNB. SNB staging accuracy was assessed in study arms where patients were randomized to immediate ALND. Data abstraction was conducted by two independent reviewers. Rates of axillary, locoregional and all recurrence were evaluated along with all-cause and breast cancer-specific mortality. Heterogeneity was assessed by Cochran's Q-statistic and the Inconsistency Index (I2). Weighted summary measures of relative risk (RR) and absolute risk difference (ARD) with 95% CIs were estimated using the method of Mantel-Haenszel.
Results: Seven eligible RCTs were identified of which six, involving 9,389 patients, reported either SNB performance and/or rates of recurrence and mortality. Eligibility in these studies was restricted to patients with clinically negative nodes with four limiting accrual to tumors <2-3 cm. Technical success of mapping was reported in five trials including 4,184 (97.1%) and 4,180 (96.8%) patients randomized to SNB versus SNB with immediate ALND, respectively. SNB was positive in 26.5% and 25.4% in those randomized to the SNB and SNB plus ALND arms, respectively. The false negative rate with SNB ranged from 5.5% to 22.9% with a summary estimate of 11.3% [7.5%-16.8%]. The median duration of follow-up across trials ranged from 12 to 95 months with an overall median of 65 months. The risk of axillary recurrence ranged from 0 - 0.8% in SNB patients and 0-0.9% in ALND patients, respectively with RR for axillary recurrence for SNB versus ALND patients of 1.59 [0.67-3.75; P=.292] and ARD of 0.2% [-0.01%-0.4%; P=.082]. The risk of locoregional recurrence ranged from 0.2%-4.6% in SNB patients and 0.8%-3.5% in ALND patients with RR of 1.13 [0.53-2.33; P=.776] and ARD of 0.3% [-1.0%-1.5%; P=.679]. Mortality from any cause has been reported in 222 and 196 patients in the SNB and ALND arms, respectively, with RR for mortality of 1.13 [0.94-1.36; P=.202] and ARD of 0.6% [-0.3%-1.6%; P=.201]. Breast cancer-specific mortality has been reported in 31 and 34 patients in the SNB and ALND arms, respectively, with a RR of 0.90 [0.56-1.45;P=.676] and ARD of 0.3% [-1.6%-1.0%; P=.676].
Conclusions: The overall false negative rate with SNB greater than 10% and limited follow-up continue to raise concerns. While no increase in risk of recurrence or mortality in low risk patients managed primarily with SNB is evident to date, continued observation in these studies will be important in addition to more specific data on the accuracy and safety of SNB in higher risk patients.
Citation Information: Cancer Res 2010;70(24 Suppl):Abstract nr PD06-09.
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Lyman GH, Dale DC, Culakova E, Poniewierski MS, Wolff DA, Kuderer NM, Crawford J. Overall survival in randomized controlled trials of chemotherapy (CT) with or without GCSF support: A systematic review. J Clin Oncol 2010. [DOI: 10.1200/jco.2010.28.15_suppl.9141] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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16
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Kuderer NM, Khorana AA, Francis CW, Lyman GH, Falanga A, Ortel TL. Low-molecular-weight heparin for venous thromboprophylaxis in ambulatory cancer patients: A meta-analysis. J Clin Oncol 2009. [DOI: 10.1200/jco.2009.27.15_suppl.9537] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
9537 Background: Patients with cancer have an increased risk of venous thromboembolism (VTE). However, routine VTE prophylaxis is generally not recommended in ambulatory cancer patients. Several randomized controlled trials (RCTs) of low-molecular-weight heparin (LMWH) in ambulatory cancer patients have been reported with inconclusive results. Methods: A systematic review of RCTs of LMWH in ambulatory cancer patients without a VTE diagnosis was conducted. Included trials had to report VTE as primary or secondary outcome. An extensive electronic database search was conducted, including Medline, EMBASE, Cochrane Library along with abstracts from major meetings. Dual-blinded data extraction was performed. Meta-analysis was conducted using Mantel and Haenszel method to estimate relative risk (RR) and absolute risk difference (ARD) ± 95% CI. Primary outcomes in this analysis were all reported VTE and major bleeds. Most trials did not require VTE screening by imaging, precluding a separate analysis of asymptomatic VTE events. Results: Six RCTs were identified with a total of 2,648 patients including 1,525 receiving LMWH and 1,123 controls. No significant heterogeneity was observed across trials. Among patients receiving LMWH, the crude incidence of VTE was 2.95% compared to 5.25% among control patients. LMWH reduced the RR of VTE by 36% compared to controls (RR=0.64 [0.44 - 0.94], P=0.021), and reduced the ARD by 1.8% [0.2% - 3.4%]. Major bleeding events were reported in 1.57% LMWH patients compared to 0.98% in controls. The non-significant RR increase by LMWH for major bleeding was 1.85 [0.923 - 3.68], P=0.081, with an ARD of 0.9% [0.0% - 1.8%]. Results were comparable in the analysis limited to studies with VTE as primary outcome. Conclusions: While patients experienced a 36% relative risk reduction in VTE with LMWH, the absolute risk reduction was small, and concerns remain about the potential increase in major bleeding. Therefore, routine VTE prophylaxis in ambulatory cancer patients cannot be recommended at this time. Additional research is needed to identify cancer outpatients at high risk for VTE, in whom prophylaxis may have a more favorable risk-benefit ratio. [Table: see text]
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Affiliation(s)
- N. M. Kuderer
- Duke University Medical Center, Durham, NC; University of Rochester Medical Center, Rochester, NY; Ospedali Riuniti di Bergamo, Bergamo, Italy
| | - A. A. Khorana
- Duke University Medical Center, Durham, NC; University of Rochester Medical Center, Rochester, NY; Ospedali Riuniti di Bergamo, Bergamo, Italy
| | - C. W. Francis
- Duke University Medical Center, Durham, NC; University of Rochester Medical Center, Rochester, NY; Ospedali Riuniti di Bergamo, Bergamo, Italy
| | - G. H. Lyman
- Duke University Medical Center, Durham, NC; University of Rochester Medical Center, Rochester, NY; Ospedali Riuniti di Bergamo, Bergamo, Italy
| | - A. Falanga
- Duke University Medical Center, Durham, NC; University of Rochester Medical Center, Rochester, NY; Ospedali Riuniti di Bergamo, Bergamo, Italy
| | - T. L. Ortel
- Duke University Medical Center, Durham, NC; University of Rochester Medical Center, Rochester, NY; Ospedali Riuniti di Bergamo, Bergamo, Italy
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Lyman GH, Dale DC, Culakova E, Poniewierski MS, Wolff D, Kuderer NM, Lambert K, Crawford J. Acute myeloid leukemia or myelodysplastic syndrome (AML/MDS) and overall mortality with chemotherapy (CT) and granulocyte colony-stimulating factor (G-CSF): A meta-analysis of randomized controlled trials (RCTs). J Clin Oncol 2009. [DOI: 10.1200/jco.2009.27.15_suppl.9524] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
9524 Background: To evaluate the risk of AML/MDS and overall mortality in patients receiving CT ± G-CSF, a meta-analysis of RCTs were conducted. Methods: Electronic databases searched through August 2008 identified 3,794 articles for initial screening. Eligibility included RCTs of solid tumor or lymphoma patients randomized to CT ± primary G-CSF support, ≥2 years follow-up and reporting AML/MDS or all second malignancies. Pre-specified study categories included: a)same dose/schedule, b)dose-dense or c)dose-escalated CT. Primary outcomes were AML/MDS and mortality. Dual blinded data extraction was performed. Relative risk (RR) and absolute risk difference (ARD) were estimated by Mantel-Haenszel. Results: Median follow-up was 54 months. 12,642 patients were randomized to CT ± primary G-CSF support. Second malignancies were reported in 3.3% and 3.2% with and without G-CSF, respectively (P=.942). RR for AML/MDS with CT+G-CSF compared to control was 1.92 [P=.006] with ARD increase of 0.4% [P=.008]. RR for AML/MDS in study categories to receive the same, dose-dense or dose-escalated CT+G-CSF were 1.95 [P=.346], 1.20 [P=.666] and 2.47 [P=.006], respectively. RR for mortality with CT+G-CSF was 0.898 [P<.0001] with ARD decrease of 3.3% [P<.0001]. RR for mortality in study categories to receive the same, dose-dense or dose-escalated CT+G-CSF were 0.95 [P=.140], 0.84 [P<.001] and 0.91 [P=.019], respectively. Delivered relative dose intensities (RDI) were 1.18, 1.46 and 1.23 in studies planned to receive the same, dose-dense or dose-escalated CT, respectively. A significant association was observed between delivered RDI and reduced mortality [P=.013]. No differences in estimates of AML/MDS or mortality were observed between industry and non-industry-funded studies. Conclusions: Risk of AML/MDS is increased with dose escalated CT+G-CSF. Nevertheless, CT+G-CSF is associated with greater reductions in overall mortality. Dose-dense regimens are associated with the greatest RR reduction in mortality and lowest risk of AML/MDS. Further research is needed to differentiate any impact of G-CSF on the risk of AML/MDS from that due to increased CT intensity. [Table: see text]
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Affiliation(s)
- G. H. Lyman
- Duke University, Durham, NC; University of Washington, Seattle, WA
| | - D. C. Dale
- Duke University, Durham, NC; University of Washington, Seattle, WA
| | - E. Culakova
- Duke University, Durham, NC; University of Washington, Seattle, WA
| | | | - D. Wolff
- Duke University, Durham, NC; University of Washington, Seattle, WA
| | - N. M. Kuderer
- Duke University, Durham, NC; University of Washington, Seattle, WA
| | - K. Lambert
- Duke University, Durham, NC; University of Washington, Seattle, WA
| | - J. Crawford
- Duke University, Durham, NC; University of Washington, Seattle, WA
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Coscio AM, Anguiano A, Kuderer NM, Kelley M. Improving quality at university based hematology/oncology fellowship continuity clinic with the quality oncology practice initiative (QOPI). J Clin Oncol 2008. [DOI: 10.1200/jco.2008.26.15_suppl.6578] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Kuderer NM, Francis CW, Culakova E, Khorana AA, Ortel T, Falanga A, Lyman GH. Venous thromboembolism and all-cause mortality in cancer patients receiving chemotherapy. J Clin Oncol 2008. [DOI: 10.1200/jco.2008.26.15_suppl.9521] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Lyman GH, Kuderer NM, Crawford J, Wolff DA, Culakova E, Poniewierski MS, Dale DC. Impact of pegfilgrastim on early all-cause mortality in patients receiving cancer chemotherapy. J Clin Oncol 2008. [DOI: 10.1200/jco.2008.26.15_suppl.6552] [Citation(s) in RCA: 3] [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: 11/20/2022] Open
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Poniewierski MS, Crawford J, Dale DC, Culakova E, Kuderer NM, Wolff DA, Lyman GH. Reduced chemotherapy dose intensity in patients with ovarian cancer: Results from a prospective nationwide study. J Clin Oncol 2008. [DOI: 10.1200/jco.2008.26.15_suppl.16508] [Citation(s) in RCA: 3] [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: 11/20/2022] Open
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Kuderer NM, Khorana AA, Lyman GH, Francis CW. A meta-analysis of anticoagulants as cancer treatment: Impact on survival and bleeding complications. J Clin Oncol 2007. [DOI: 10.1200/jco.2007.25.18_suppl.9071] [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: 11/20/2022] Open
Abstract
9071 Background: There is substantial laboratory evidence that anticoagulants, in particular the low-molecular-weight heparins (LMWH), exert an antitumor effect, while clinical trials have reported conflicting results. This study represents the first comprehensive systematic review and meta-analysis of the evidence from randomized controlled trials (RCTs) evaluating specifically the impact of anticoagulants on survival and safety in cancer patients without venous thromboembolism (VTE). Methods: An exhaustive systematic literature review of RCTs was performed without language restrictions, including a comprehensive search of electronic databases through May 2006 with subsequent weekly updates to the end of 2006 (Medline, EMBASE, Cochrane Database of Systematic Reviews, CENTRAL, DARE, and major conference proceedings) and relevant article references. Two reviewers extracted the data independently. Primary study outcomes were 1-year overall mortality and all bleeding complications. Major and fatal bleeding complications were secondary outcomes. The meta- analysis was performed utilizing the Mantel-Haenszel method. Results: All identified 11 RCTs were performed in solid tumor patients. Anticoagulation significantly decreased overall mortality across all studies with a relative risk (RR) of 0.905 (95%CI: 0.847–0.967; p=0.003). The survival improvement appears not to be due to the prevention of fatal VTE. All bleeding complications (RR=2.309; 95%CI: 1.928–2.764; p<0.0001) and major bleeding events (RR=2.598; 95%CI; 1.936–3.488; p<0.0001) occurred more frequently with anticoagulation. The relative risk for mortality was 0.877 (95%CI: 0.789–0.975; p=0.015) with LMWH, compared to warfarin (RR=0.942; 95%CI: 0.854–1.040; p=0.239). Warfarin resulted in higher rates for all and major bleeding complications compared to LMWH (p<0.0001, respectively). Conclusions: Anticoagulants significantly improved overall survival in cancer patients while increasing the risk of bleeding complications. Despite these encouraging findings, given limitations of available data and the potential for life-threatening complications, the use of anticoagulants as antineoplastic therapy cannot be recommended until additional RCTs confirm these results. No significant financial relationships to disclose.
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Abstract
9009 Background: Venous thromboembolism (VTE) contributes to morbidity and mortality in cancer patients and is a frequent complication of anti-cancer therapy. We examined the frequency, risk factors and trends associated with VTE among hospitalized US cancer patients. Methods: We conducted a retrospective cohort study using the discharge database of the University Health System Consortium. This included all 1,824,316 hospitalizations of cancer patients between 1995 and 2003 at 133 United States medical centers. To avoid overestimation, only a single randomly chosen hospitalization was included for patients with multiple admissions. Results: Among 1,015,598 individual cancer patients, 34,357 (3.4%) were diagnosed with deep venous thrombosis and 11,515 with pulmonary embolism (PE) (1.1%) for an overall VTE rate of 4.1%. Subgroups of cancer patients with highest rates included Black ethnicity (5.1% per hospitalization) and those on chemotherapy (4.9%). Sites of cancer with the highest rates of VTE included pancreas (8.2%), kidney (5.7%), ovary (5.6%), lung (5.1%) and stomach (4.9%). Amongst hematologic malignancies, myeloma (5%), non-Hodgkin’s lymphoma (4.8%) and Hodgkin’s disease (4.6%) had the highest rates of VTE. The rate of VTE rose from 3.6% per hospitalization in 1995–96 to 4.6% in 2002–03, an increase of 28%, including a near-doubling of PE rates from 0.8% to 1.5% (P<0.0001). Among patients receiving chemotherapy, rates of VTE rose from 3.9% per hospitalization to 5.7%, an increase of 47% (P<0.0001). In contrast, patients undergoing surgery for breast, head and neck, pancreatic or spinal cancers, experienced no significant change in the rate of VTE. Use of diagnostic procedures for VTE also did not increase over the study period. Conclusions: The rate of VTE, including PE, among hospitalized cancer patients has increased significantly in recent years. Black patients, those on chemotherapy and those with certain types of cancer are disproportionately at increased risk. The rise in VTE does not appear to be attributable to an increased utilization of diagnostic procedures. Further efforts to increase thromboprophylaxis compliance during hospitalization are needed. No significant financial relationships to disclose.
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Lyman GH, Kuderer NM, Poniewierski MS, Crawford J, Wolff DA, Culakova E, Dale DC. Factors associated with reductions in chemotherapy dose intensity: Impact of clinical, sociodemographic and practice setting. J Clin Oncol 2007. [DOI: 10.1200/jco.2007.25.18_suppl.6550] [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: 11/20/2022] Open
Abstract
6550 Background: A nationwide, prospective cohort study of patients receiving cancer chemotherapy was undertaken to better define treatment-associated toxicities and delivered dose intensity. Methods: Following informed consent, 3,670 patients initiating a new chemotherapy regimen with lymphoma (n=547) or carcinomas of the colon (n=521), breast (n=1,473), lung (n=907) or ovary (n=312) were prospectively registered at 117 randomly selected US oncology practices between March 2002 and December 2005. Pretreatment characteristics including clinical and sociodemographic factors and practice setting associated with reductions in chemotherapy dose intensity over 4 cycles were evaluated. Results: Chemotherapy regimen standards and intended dose and schedule were defined in 97% and 93% of patients, respectively. Average initial (planned) relative dose intensity (RDI) was 90% while the mean RDI actually delivered over 4 cycles was 83%. Reductions in RDI =15% of standard were planned in 23% of patients and actually occurred over 4 cycles in 38%. Body surface area (BSA) calculated by the method of Mosteller exceeded the BSA utilized by the oncology practices in two-thirds of patients most often due to capping at 2 m2. Obese patients with a body mass index (BMI) =30 were more likely to receive planned RDI reductions =15% (30%) than patients with BMI <30 (21%) (P<.0001). Other factors associated with planned reductions in RDI in multivariate analysis included: older age, male gender, lower education, absence of myeloid growth factor prophylaxis and cancers of the lung or ovary as well as the practice setting, size and geographic location. Factors associated with unplanned (subsequent) reductions in RDI included: older age, male gender, poorer Charlson comorbidity index, prior chemotherapy, lung cancer, low baseline hematocrit, white blood or platelet count, poor renal or hepatic function and low serum albumin as well as smaller practice and rural setting. Conclusions: A substantial proportion of patients receiving cancer chemotherapy experience both planned and unplanned reductions in RDI. Further understanding of factors associated with such reductions may provide opportunities for improving the quality of cancer care and clinical outcomes. No significant financial relationships to disclose.
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Affiliation(s)
- G. H. Lyman
- Univ of Rochester School of Medicine & Dentistry, Rochester, NY; Duke University Medical Center, Durham, NC; University of Washington School of Medicine, Seattle, WA
| | - N. M. Kuderer
- Univ of Rochester School of Medicine & Dentistry, Rochester, NY; Duke University Medical Center, Durham, NC; University of Washington School of Medicine, Seattle, WA
| | - M. S. Poniewierski
- Univ of Rochester School of Medicine & Dentistry, Rochester, NY; Duke University Medical Center, Durham, NC; University of Washington School of Medicine, Seattle, WA
| | - J. Crawford
- Univ of Rochester School of Medicine & Dentistry, Rochester, NY; Duke University Medical Center, Durham, NC; University of Washington School of Medicine, Seattle, WA
| | - D. A. Wolff
- Univ of Rochester School of Medicine & Dentistry, Rochester, NY; Duke University Medical Center, Durham, NC; University of Washington School of Medicine, Seattle, WA
| | - E. Culakova
- Univ of Rochester School of Medicine & Dentistry, Rochester, NY; Duke University Medical Center, Durham, NC; University of Washington School of Medicine, Seattle, WA
| | - D. C. Dale
- Univ of Rochester School of Medicine & Dentistry, Rochester, NY; Duke University Medical Center, Durham, NC; University of Washington School of Medicine, Seattle, WA
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Khorana AA, Francis CW, Culakova E, Kuderer NM, Lyman GH. Thromboembolism is a leading cause of death in cancer patients receiving outpatient chemotherapy. J Thromb Haemost 2007; 5:632-4. [PMID: 17319909 DOI: 10.1111/j.1538-7836.2007.02374.x] [Citation(s) in RCA: 1071] [Impact Index Per Article: 63.0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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Lyman GH, Kuderer NM, Crawford J, Wolff DA, Culakova E, Poniewierski MS. Prospective validation of a risk model for first cycle neutropenic complications in patients receiving cancer chemotherapy. J Clin Oncol 2006. [DOI: 10.1200/jco.2006.24.18_suppl.8561] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
8561 Background: A nationwide, prospective cohort study was undertaken to develop and validate a risk model for neutropenic complications (NC) in cancer patients receiving chemotherapy. Methods: 3,596 patients initiating a new chemotherapy regimen with solid tumors or lymphoma were registered at 115 randomly selected sites. Data on at least 1 cycle of chemotherapy were available on 3,468. A logistic regression model for cycle 1 NC was derived and then validated using a split sample random selection process. Results: The risk of cycle 1 NC ranged from 5.5%-30.2%, averaging 18.5% across tumor types. No significant differences in distribution of NC or predictive factors were observed between the derivation dataset (n=2,592) or the validation dataset (n=876). Major independent baseline clinical risk factors for cycle 1 NC in the derivation model include: prior chemotherapy (P=.044), number of myelosuppressive agents (P<.0001), anthracycline-based regimens (P<.0001), planned delivery >85% of standard (P<.0001), cancer type (P<.0001), concurrent antibiotics (P=.023) or phenothiazines (P=.006), abnormal alkaline phosphatase (P=.002), elevated bilirubin (P=.031), low platelets (P=.004), elevated glucose (P=.023) and reduced glomerular filtration rate (P=.013). Reduced risk of cycle 1 NC was associated with primary prophylaxis with a myeloid growth factor (P<.0001). Model R2 was 0.273 and c-statistic 0.80 [95% CI: 0.78–0.82; P<.0001]. At the median predicted risk of cycle 1 NC of 11%, model test performance consisted of: sensitivity 84%; specificity 57% and diagnostic odds ratio (DOR) 7.2 while cycle 1 NC risk was 31% and 6% among high risk and low risk half, respectively. The model performed well in the smaller validation dataset with a model R2 of 0.354 and c-statistic of 0.84 [95% CI: 0.81–0.87, P<.0001]. Test performance of the model in the validation sample included: sensitivity 90%; specificity 62%; DOR 14.1 and risks of 35% and 4% in high risk and low risk patients, respectively. Conclusions: Validation in a randomly selected patient sample suggests that this model has general applicability in identifying patients at increased risk for NC. Further validation in other independent cancer patient populations receiving chemotherapy is planned. [Table: see text]
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Affiliation(s)
- G. H. Lyman
- University of Rochester School of Medicine and Dentistry, Rochester, NY; Duke University Medical Center, Durham, NC; University of Washington School of Medicine, Seattle, WA
| | - N. M. Kuderer
- University of Rochester School of Medicine and Dentistry, Rochester, NY; Duke University Medical Center, Durham, NC; University of Washington School of Medicine, Seattle, WA
| | - J. Crawford
- University of Rochester School of Medicine and Dentistry, Rochester, NY; Duke University Medical Center, Durham, NC; University of Washington School of Medicine, Seattle, WA
| | - D. A. Wolff
- University of Rochester School of Medicine and Dentistry, Rochester, NY; Duke University Medical Center, Durham, NC; University of Washington School of Medicine, Seattle, WA
| | - E. Culakova
- University of Rochester School of Medicine and Dentistry, Rochester, NY; Duke University Medical Center, Durham, NC; University of Washington School of Medicine, Seattle, WA
| | - M. S. Poniewierski
- University of Rochester School of Medicine and Dentistry, Rochester, NY; Duke University Medical Center, Durham, NC; University of Washington School of Medicine, Seattle, WA
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Kuderer NM, Francis CW, Crawford J, Dale DC, Wolff DA, Culakova E, Poniewierski MS, Lyman GH. A prediction model for chemotherapy-associated thrombocytopenia in cancer patients. J Clin Oncol 2006. [DOI: 10.1200/jco.2006.24.18_suppl.8616] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
8616 Background: Thrombocytopenia (TP) can lead to serious complications, however, little is known about the incidence and risk factors for chemotherapy-associated TP. A prospective, nationwide cohort study was undertaken to better define the impact of TP in cancer treatment. Methods: 2,842 patients with cancer of the breast, lung, colon, ovary or lymphoma initiating a new chemotherapy regimen have been prospectively enrolled at 115 randomly selected US community oncology practices between 2002 and 2005. Risk factors for chemotherapy-associated TP were identified, a multivariate logistic regression model based on pretreatment characteristics was developed, and test performance characteristics were estimated. Results: Over a median of 3 cycles of chemotherapy, minimum recorded platelet counts were: ≥150K in 53% of patients; 100–150K in 26%; 75–100K in 8%; 50–75K in 6% and <50K in 7%. Significant independent predictive factors for platelets <75K include type of cancer (P<.0001), type of chemotherapy including gemcitabine-based (P<.0001), anthracycline-based (P<.0001) and platinum-based (P<.0001) regimens, prior chemotherapy (P<.0001) or surgery (P=.005), age (P=.015), Caucasian ethnicity (P=.022), body surface area (P=.0001), planned relative dose intensity ≥85% (P=.082), diabetes (P=.018), pulmonary disease (P=.011), abnormal baseline platelets (P<.0001), hematocrit (P=0.030), alkaline phosphatase (P=.072) or albumin (P=.017). Model fit was good (Chi-square, P<.0001), R2 = 0.735 and c-statistic = 0.816 [95% CI: 0.792–0.840, P<.0001]. Model test performance characteristics [95% CI] at a ≥20% risk of TP include: sensitivity 56% [51–61]; specificity 88% [87–89]; likelihood ratio positive 4.63 [4.02–5.33]; likelihood ratio negative 0.50 [0.45–0.57]; and diagnostic odds ratio 9.22 [7.23–11.75]. Validation of the model is underway. Conclusions: This prediction model based on pretreatment factors identifies with high specificity patients at risk for clinically important chemotherapy-associated thrombocytopenia early in the treatment course. It may provide a valuable tool for guiding chemotherapy and new supportive care measures. [Table: see text]
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Affiliation(s)
- N. M. Kuderer
- University of Rochester School of Medicine and Dentistry, Rochester, NY; Duke University Medical Center, Durham, NC; University of Washington School of Medicine, Seattle, WA
| | - C. W. Francis
- University of Rochester School of Medicine and Dentistry, Rochester, NY; Duke University Medical Center, Durham, NC; University of Washington School of Medicine, Seattle, WA
| | - J. Crawford
- University of Rochester School of Medicine and Dentistry, Rochester, NY; Duke University Medical Center, Durham, NC; University of Washington School of Medicine, Seattle, WA
| | - D. C. Dale
- University of Rochester School of Medicine and Dentistry, Rochester, NY; Duke University Medical Center, Durham, NC; University of Washington School of Medicine, Seattle, WA
| | - D. A. Wolff
- University of Rochester School of Medicine and Dentistry, Rochester, NY; Duke University Medical Center, Durham, NC; University of Washington School of Medicine, Seattle, WA
| | - E. Culakova
- University of Rochester School of Medicine and Dentistry, Rochester, NY; Duke University Medical Center, Durham, NC; University of Washington School of Medicine, Seattle, WA
| | - M. S. Poniewierski
- University of Rochester School of Medicine and Dentistry, Rochester, NY; Duke University Medical Center, Durham, NC; University of Washington School of Medicine, Seattle, WA
| | - G. H. Lyman
- University of Rochester School of Medicine and Dentistry, Rochester, NY; Duke University Medical Center, Durham, NC; University of Washington School of Medicine, Seattle, WA
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Cosler LE, Kuderer NM, Hornberger J, Lyman GH. 21-gene RT-PCR assay in lymph node negative (LN-), estrogen receptor positive (ER+) breast cancer: An economic analysis including prognostic and predictive information. J Clin Oncol 2006. [DOI: 10.1200/jco.2006.24.18_suppl.6024] [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: 11/20/2022] Open
Abstract
6024 Background: The prognostic accuracy of a 21-gene RT-PCR assay has undergone validation in 668 evaluable LN-, ER+ early stage breast cancer patients receiving tamoxifen on NSABP B-14 (Paik, NEJM 2004) and its economic evaluation (Hornberger, Am J Man Care 2005). Assay predictive accuracy for response to chemotherapy or tamoxifen has also undergone recent validation in 651 patients on NSABP B-20 and 645 patients on NSABP B-14 (Paik, SABCS 2004). Methods: Based on the model recurrence score (RS), women with LN−, ER+ breast cancer with and without adjuvant chemotherapy (C) or tamoxifen (T) were classified as high (RS ≥31), intermediate (RS 18–30) or low (RS <18) risk of distant recurrence at 10 years. Incremental costs ($), life-years (LYs), quality-adjusted LYs (QALYs) and cost-effectiveness (C/E; cost per LY gained) were estimated for: RS-guided treatment (RSGT) with T for low and intermediate risk patients and C+T for high-risk patients, compared to either T alone or C+T for all patients. Results: Under base case assumptions, no significant difference in life expectancy at 10 years is estimated between the RSGT and C+T strategies whereas RSGT is associated with a gain in individual life expectancy of 2.7 LYs compared to T alone. RSGT is estimated to yield a net cost savings of $4,502 compared to C+T with an incremental C/E of $1,059 per LY saved compared to T alone. At a utility of 90% associated with adjuvant chemotherapy, RSGT is associated with a gain in individual QALYs of 1.82 compared to T alone at a cost utility of $1,573/QALY and a gain in 3.21 QALYs compared to C+T. RSGT is associated with lower expected cost than C+T for total chemotherapy costs above $3,998. The gain in LYs with RSGT compared to T alone increases with healthy age-specific life expectancy (years) while the cost per LY gained decreases. Conclusions: Treatment based on the RSGT compared to T alone is associated with acceptable C/E ratios and substantially lower toxicity and cost compared to C+T. [Table: see text] [Table: see text]
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Affiliation(s)
- L. E. Cosler
- Albany College of Pharmacy, Albany, NY; University of Rochester School of Medicine and Dentistry, Rochester, NY; Stanford University School of Medicine, Burlingame, CA
| | - N. M. Kuderer
- Albany College of Pharmacy, Albany, NY; University of Rochester School of Medicine and Dentistry, Rochester, NY; Stanford University School of Medicine, Burlingame, CA
| | - J. Hornberger
- Albany College of Pharmacy, Albany, NY; University of Rochester School of Medicine and Dentistry, Rochester, NY; Stanford University School of Medicine, Burlingame, CA
| | - G. H. Lyman
- Albany College of Pharmacy, Albany, NY; University of Rochester School of Medicine and Dentistry, Rochester, NY; Stanford University School of Medicine, Burlingame, CA
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Kuderer NM, Crawford J, Dale DC, Lyman GH. Meta-analysis of prophylactic granulocyte colony-stimulating factor (G-CSF) in cancer patients receiving chemotherapy. J Clin Oncol 2005. [DOI: 10.1200/jco.2005.23.16_suppl.8117] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- N. M. Kuderer
- Univ of Rochester, Rochester, NY; Duke Univ, Durham, NC; Univ of Washington, Seattle, WA
| | - J. Crawford
- Univ of Rochester, Rochester, NY; Duke Univ, Durham, NC; Univ of Washington, Seattle, WA
| | - D. C. Dale
- Univ of Rochester, Rochester, NY; Duke Univ, Durham, NC; Univ of Washington, Seattle, WA
| | - G. H. Lyman
- Univ of Rochester, Rochester, NY; Duke Univ, Durham, NC; Univ of Washington, Seattle, WA
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Daniel DB, Crawford J, Kuderer NM, Dale DC, Lyman GH. Risk and mortality associated with febrile neutropenia in lung cancer patients. J Clin Oncol 2004. [DOI: 10.1200/jco.2004.22.90140.7223] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- D. B. Daniel
- Duke University Medical Center, Durham, NC; University of Rochester Medical Center, Rochester, NY; University of Washington Medical Center, Seattle, WA
| | - J. Crawford
- Duke University Medical Center, Durham, NC; University of Rochester Medical Center, Rochester, NY; University of Washington Medical Center, Seattle, WA
| | - N. M. Kuderer
- Duke University Medical Center, Durham, NC; University of Rochester Medical Center, Rochester, NY; University of Washington Medical Center, Seattle, WA
| | - D. C. Dale
- Duke University Medical Center, Durham, NC; University of Rochester Medical Center, Rochester, NY; University of Washington Medical Center, Seattle, WA
| | - G. H. Lyman
- Duke University Medical Center, Durham, NC; University of Rochester Medical Center, Rochester, NY; University of Washington Medical Center, Seattle, WA
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Affiliation(s)
- N. M. Kuderer
- University of Rochester Medical Center, Rochester, NY; Duke University Medical Center, Durham, NC; University of Washington Medical Center, Seattle, WA
| | - J. Crawford
- University of Rochester Medical Center, Rochester, NY; Duke University Medical Center, Durham, NC; University of Washington Medical Center, Seattle, WA
| | - D. C. Dale
- University of Rochester Medical Center, Rochester, NY; Duke University Medical Center, Durham, NC; University of Washington Medical Center, Seattle, WA
| | - G. H. Lyman
- University of Rochester Medical Center, Rochester, NY; Duke University Medical Center, Durham, NC; University of Washington Medical Center, Seattle, WA
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Affiliation(s)
- E. Culakova
- University of Rochester Medical Center, Rochester, NY; Duke University Medical Center, Durham, NC; University of Washington Medical Center, Seattle, WA
| | - A. Khorana
- University of Rochester Medical Center, Rochester, NY; Duke University Medical Center, Durham, NC; University of Washington Medical Center, Seattle, WA
| | - N. M. Kuderer
- University of Rochester Medical Center, Rochester, NY; Duke University Medical Center, Durham, NC; University of Washington Medical Center, Seattle, WA
| | - J. Crawford
- University of Rochester Medical Center, Rochester, NY; Duke University Medical Center, Durham, NC; University of Washington Medical Center, Seattle, WA
| | - D. C. Dale
- University of Rochester Medical Center, Rochester, NY; Duke University Medical Center, Durham, NC; University of Washington Medical Center, Seattle, WA
| | - G. H. Lyman
- University of Rochester Medical Center, Rochester, NY; Duke University Medical Center, Durham, NC; University of Washington Medical Center, Seattle, WA
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Lyman GH, Kuderer NM. The economics of the colony-stimulating factors in the prevention and treatment of febrile neutropenia. Crit Rev Oncol Hematol 2004; 50:129-46. [PMID: 15157662 DOI: 10.1016/j.critrevonc.2004.01.001] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/13/2004] [Indexed: 11/16/2022] Open
Abstract
Healthcare costs continue to rise with hospitalization representing the single largest component of direct medical costs associated with cancer care. Neutropenia and its complications including febrile neutropenia remain the major dose-limiting toxicity associated with systemic cancer chemotherapy. Febrile neutropenia often occurs early in the course of chemotherapy and is associated with substantial morbidity, mortality and cost. The colony-stimulating factors (CSFs) have been used effectively in a variety of clinical settings to prevent or treat febrile neutropenia and to assist patients receiving dose-intensive chemotherapy. A meta-analysis of the available randomized controlled trials (RCTs) has confirmed the efficacy of prophylactic CSFs. Economic models based on measures of resource utilization derived from RCTs have provided estimates of expected treatment costs along with febrile neutropenia risk threshold estimates for the cost saving use of the CSFs. Recent studies have demonstrated the potential value of targeting the CSFs toward patients at greatest risk based on accurate and valid predictive models.
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Affiliation(s)
- G H Lyman
- Department of Medicine, James P Wilmot Cancer Center, University of Rochester Medical Center, University of Rochester, Rochester, NY 14642, USA.
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Abstract
BACKGROUND Reporting of pharmaceutical-industry-sponsored randomised clinical trials often result in biased findings, either due to selective reporting of studies with non-equivalent arms or publication of low-quality papers, wherein unfavourable results are incompletely described. A randomised trial should be conducted only if there is substantial uncertainty about the relative value of one treatment versus another. Studies in which intervention and control are thought to be non-equivalent violates the uncertainty principle. METHODS We examined the quality of 136 published randomised trials that focused on one disease category (multiple myeloma) and adherence to the uncertainty principle. To evaluate whether the uncertainty principle was upheld, we compared the number of studies favouring experimental treatments over standard ones. We analysed data according to the source of funding. FINDINGS Trials funded solely or in part by 35 profit-making organisations had a trend toward higher quality scores (mean 2.94 [SD 1.3]; median 3) than randomised trials supported by 95 governmental or other non-profit organisations (2.4 [0.8]; 2; p=0.06). Overall, the uncertainty principle was upheld, with 44% of randomised trials favouring standard treatments and 56% innovative treatments (p=0.17); mean and median preference evaluation scores were 3.7 (1.0) and 4. However, when the analysis was done according to the source of funding, studies funded by non-profit organisations maintained equipoise favouring new therapies over standard ones (47% vs 53%; p=0.608) to a greater extent than randomised trials supported solely or in part by profit-making organisations (74% vs 26%; p=0.004). INTERPRETATION The reported bias in research sponsored by the pharmaceutical industry may be a consequence of violations of the uncertainty principle. Sponsors of clinical trials should be encouraged to report all results and to choose appropriate comparative controls.
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Affiliation(s)
- B Djulbegovic
- Division of Blood and Bone Marrow Transplantation, H Lee Moffitt Cancer Center and Research Institute at the University of South Florida, Tampa 33612, USA.
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Abstract
The granulopoiesis-stimulating agents (GSAs) have been effectively utilized in a variety of fashions to treat or prevent febrile neutropenia or to assist patients receiving dose-intensive chemotherapy with or without stem cell support. The high cost of these agents, along with their wide-scale clinical application, has fostered a number of economic analyses. Cost minimization models based on randomized trials and driven by hospitalization costs have provided febrile neutropenia risk thresholds for the use of the GSAs which have been incorporated into clinical practice guidelines. A number of important studies concerning the clinical and economic impact of these agents have been reported over the past year. The clinical role and economic impact of the GSAs in the management of either established febrile neutropenia or afebrile neutropenia remains uncertain. While several studies have confirmed the clinical value of the prophylactic use of these agents in both solid tumors and hematological malignancies, few have addressed their effect on cost or quality of life. The GSAs have demonstrated clinical as well as potential economic benefit in patients receiving high-dose chemotherapy with either bone marrow or peripheral blood stem cell support. Recent studies suggest a clinical and economic advantage for growth factor mobilization and peripheral blood stem cell support compared with bone marrow transplantation in patients receiving high-dose chemotherapy. The rapid evolution of technological and supportive care methods in this area will necessitate further clinical and economic evaluation.
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Affiliation(s)
- G H Lyman
- H. Lee Moffitt Cancer Center, University of South Florida, Tampa 33612, USA
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Affiliation(s)
- GH Lyman
- H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida 33612, USA
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Affiliation(s)
- G H Lyman
- H. Lee Moffitt Cancer Center and Research Institute, University of South Florida, Tampa 33612, USA
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Abstract
BACKGROUND: Evidence-based medicine demands the use of information from clinical trials to direct medical care. Knowledge of the principles of trial design and conduct is important to assess the validity of results. METHODS: The authors review the key principles behind clinical study design and conduct, and they summarize important biases and confounding issues. RESULTS: Clear hypotheses, a well-described study population, precise measurements, freedom from bias, and consideration of any interactions are attributes of good clinical trials. CONCLUSIONS: The greatest level of evidence in support of a difference in outcome is associated with randomized, controlled clinical trials, particularly when combined with other randomized trials in a systematic fashion (meta-analysis).
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Affiliation(s)
- GH Lyman
- Department of Internal Medicine, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida 33612, USA
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Lyman GH, Kuderer NM, Lyman SL, Debus M, Minton S, Balducci L, Horton J, Reintgen D, Cox C. Menopausal Status and the Impact of Early Recurrence on Breast Cancer Survival. Cancer Control 1997; 4:335-341. [PMID: 10763039 DOI: 10.1177/107327489700400405] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND: Breast cancer represents the leading form of invasive cancer among American women, killing nearly 50,000 annually. Several prognostic factors that are associated with survival include age, race, menopausal status, and the stage of disease at presentation. METHODS: Patient characteristics were collected based on a systematic chart audit of demographic features and medical, family, and social histories. We studied the survival of 220 patients with recurrent disease out of 1,429 consecutive patients with breast cancer seen over a 15-year period. RESULTS: Patients with a disease-free interval following diagnosis of less than 24 months were more frequently premenopausal and hormone receptor-negative than those with a disease-free interval of 24 months or greater. Patients with early recurrence had a shorter survival than patients with late recurrence. Menopausal status, nodal involvement, receptor status, and the site of recurrent disease were independent predictors of survival following recurrence. CONCLUSIONS: Premenopausal women with early recurrence of breast cancer experience a significantly shorter survival than those with late recurrence, even after adjustment for hormone receptor status and site of recurrence. This effect was not seen in postmenopausal women.
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Affiliation(s)
- GH Lyman
- Department of Internal Medicine, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida 33612, USA
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Abstract
BACKGROUND Breast cancer survival has been shown to be significantly less among black women than white women. The reason for this difference in survival is unclear. METHODS Data were obtained retrospectively on 439 women seen between 1985 and 1993 based on a detailed chart audit. The impact of race and several known prognostic factors on overall survival, time to relapse, and survival after relapse were studied. RESULTS Black women with breast cancer were found to have a greater risk of recurrence, shorter overall survival, and shorter survival after relapse than did white women. Black patients were found to be younger and have higher stage of disease and lower hormone receptor levels than were white patients. After adjustment for menopausal status and disease stage, a significant independent effect of race was observed on overall survival but not risk of recurrence. In multivariate analysis, a significant interaction was observed between race and age in some models. Survival after recurrence of disease was lower among black than white women after adjustment for menopausal status and estrogen receptor level. CONCLUSION Black women experience shorter survival times than do white women, including a shorter survival time after disease recurrence. Breast cancer in black women is associated with younger age, higher stage at presentation, and low hormone receptor levels. After adjustment for known prognostic factors, race remains a significant independent predictor of breast cancer survival.
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Affiliation(s)
- G H Lyman
- Department of Internal Medicine, University of South Florida, Tampa 33612, USA
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