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Landa K, Schmitz R, Farrow NE, Rushing C, Niedzwiecki D, Cerullo M, Herbert GS, Shah KN, Zani S, Blazer DG, Allen PJ, Lidsky ME. Surgical resection is associated with improved long-term survival of patients with resectable pancreatic head cancer compared to multiagent chemotherapy. HPB (Oxford) 2022; 24:1153-1161. [PMID: 34987008 DOI: 10.1016/j.hpb.2021.12.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2021] [Revised: 12/02/2021] [Accepted: 12/13/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND Standard of care for resectable pancreatic cancer is a combination of surgical resection (SR) and multiagent chemotherapy (MCT). We aim to determine whether SR or MCT is associated with superior survival for patients receiving only single-modality therapy. METHODS Patients with stage I-IIb pancreatic head adenocarcinoma who received either MCT or SR were identified in the NCDB (2013-2015). Following a piecewise approach to estimating hazards over the course of follow-up, conditional overall survival (OS) at 30, 60, and 90 days after treatment initiation was estimated using landmark analyses. RESULTS 3103 patients received MCT alone (60.3%) and 2043 underwent SR alone (39.7%). SR had an OS disadvantage at 30 (HR 3.99, 95% CI 3.12-5.11) and 60 days (HR 1.85, 95% CI 1.4-2.45), but an OS advantage after 90 days (HR 0.59, 95% CI 0.55-0.64). In a landmark analysis conditioned on 90 days survival post treatment initiation, median OS was improved for SR (17.0 vs. 12.2 months, p < 0.0001); SR improved 3-year OS by 21.3% (p < 0.05), despite patients being older (median 72 vs. 67 years, p < 0.0001) with higher Charlson-Deyo comorbidity scores (≥2: 11.2 vs. 8.6%, p = 0.006). CONCLUSION For patients with resectable pancreatic cancer, SR is associated with superior long-term survival compared to MCT.
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Affiliation(s)
- Karenia Landa
- Department of Surgery, Duke University Medical Center, Durham, NC 27710, USA
| | - Robin Schmitz
- Department of Surgery, Duke University Medical Center, Durham, NC 27710, USA.
| | - Norma E Farrow
- Department of Surgery, Duke University Medical Center, Durham, NC 27710, USA
| | - Christel Rushing
- Department of Biostatistics & Bioinformatics, Duke University, Durham, NC 27710, USA
| | - Donna Niedzwiecki
- Department of Biostatistics & Bioinformatics, Duke University, Durham, NC 27710, USA
| | - Marcelo Cerullo
- Department of Surgery, Duke University Medical Center, Durham, NC 27710, USA
| | - Garth S Herbert
- Department of Surgery, Duke University Medical Center, Durham, NC 27710, USA
| | - Kevin N Shah
- Department of Surgery, Duke University Medical Center, Durham, NC 27710, USA
| | - Sabino Zani
- Department of Surgery, Duke University Medical Center, Durham, NC 27710, USA
| | - Dan G Blazer
- Department of Surgery, Duke University Medical Center, Durham, NC 27710, USA
| | - Peter J Allen
- Department of Surgery, Duke University Medical Center, Durham, NC 27710, USA
| | - Michael E Lidsky
- Department of Surgery, Duke University Medical Center, Durham, NC 27710, USA
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2
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Moris D, Rushing C, McCracken E, Shah KN, Zani S, Perez A, Allen PJ, Niedzwiecki D, Fish LJ, Blazer DG. Quality of Life Associated with Open vs Minimally Invasive Pancreaticoduodenectomy: A Prospective Pilot Study. J Am Coll Surg 2022; 234:632-644. [PMID: 35290283 PMCID: PMC10166568 DOI: 10.1097/xcs.0000000000000102] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND This prospective study was designed to compare quality of life (QoL) among patients who underwent open (O-PD) vs minimally invasive pancreaticoduodenectomy (MI-PD), using a combination of validated qualitative and quantitative methodologies. STUDY DESIGN From 2017 to 2019, patients scheduled for pancreaticoduodenectomy (PD) were enrolled and presented with Functional Assessment of Cancer Therapy-Hepatobiliary surveys preoperatively, before discharge, at first postoperative visit and approximately 3 to 4 months after operation ("3 months"). Longitudinal plots of median QoL scores were used to illustrate change in each score over time. In a subset of patients, content analysis of semistructured interviews at postoperative time points (1.5 to 6 months after operation) was conducted. RESULTS Among 56 patients who underwent PD, 33 had an O-PD (58.9%). Physical and functional scores decreased in the postoperative period but returned to baseline by 3 months. No significant differences were found in any domains of QoL at baseline and in the postoperative period between patients who underwent O-PD and MI-PD. Qualitative findings were concordant with quantitative data (n = 14). Patients with O-PD and MI-PD reported similar experiences with complications, pain, and wound healing in the postoperative period. Approximately half the patients in both groups reported "returning to normal" in the 6-month postoperative period. A total of 4 patients reported significant long-term issues with physical and functional well-being. CONCLUSIONS Using a novel combination of qualitative and quantitative analyses in patients undergoing PD, we found no association between operative approach and QoL in patients who underwent O-PD vs MI-PD. Given the increasing use of minimally invasive techniques for PD and the steep learning curve associated with these techniques, continued assessment of patient benefit is critical.
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Affiliation(s)
- Dimitrios Moris
- Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - Christel Rushing
- Duke Cancer Institute-Biostatistics, Duke University Medical Center, Durham, NC, USA
| | - Emily McCracken
- Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - Kevin N. Shah
- Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - Sabino Zani
- Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - Alexander Perez
- Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - Peter J. Allen
- Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - Donna Niedzwiecki
- Duke Cancer Institute-Biostatistics, Duke University Medical Center, Durham, NC, USA
| | - Laura J. Fish
- Duke Family Medicine and Community Health, Duke University, Durham, NC, USA
- Duke Cancer Institute, Duke University Medical Center, Durham, NC, USA
| | - Dan G. Blazer
- Department of Surgery, Duke University Medical Center, Durham, NC, USA
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3
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Koontz BF, Levine E, McSherry F, Niedzwiecki D, Sutton L, Dale T, Streicher M, Rushing C, Owen L, Kraus WE, Bennett G, Pollak KI. Increasing physical activity in Cancer Survivors through a Text-messaging Exercise motivation Program (ICanSTEP). Support Care Cancer 2021; 29:7339-7349. [PMID: 34050402 DOI: 10.1007/s00520-021-06281-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Accepted: 05/05/2021] [Indexed: 10/21/2022]
Abstract
PURPOSE Cancer survivors are often sedentary. Self-monitoring may promote physical activity through self-activation. We conducted a pilot trial to evaluate whether wearable activity tracker with personalized text message feedback would increase physical activity. METHODS We enrolled 30 patients with solid tumor cancers into a non-randomized prospective intervention trial (NCT02627079): 15 had completed treatment in the past year and 15 under active treatment. Each participant received an activity tracker and daily text messages personalized to their activity level. We assessed patient-reported outcomes and 6-min walk (6 MW) at baseline and 3 months. RESULTS Twenty-six participants completed the study. There was substantial variation in baseline activity. Overall, 39% of participants increased their steps taken by at least 20%, and 23% increased their 6 MW distance by 20% or more. More participants who had completed treatment strongly agreed (73%) that the intervention increased their exercise levels than those receiving active treatment (47%). At 3 months, there was a significant improvement in median Beck Depression Inventory-II and Godin Leisure Index composite scores. At 6 months, 72% still wore their activity tracker at least 4 days per week. CONCLUSION We found that the intervention was well-accepted with a high completion rate at 3 months and continued self-use at 6 months. In this pilot study of combined activity tracker and motivational messaging, we found a signal for increased physical activity over a 3-month period. Future research is needed to study this technique for its impact on activity and other physical and psychological measures of well-being. IMPLICATION FOR CANCER SURVIVORS Activity tracker with personalized motivational messaging may be useful in promoting physical activity in cancer survivors.
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Affiliation(s)
- Bridget F Koontz
- Department of Radiation Oncology,, Duke Cancer Institute, DUMC Box 3085, NC, 27710, Durham, USA.
| | - Erica Levine
- Arnhold Institute for Global Health, Icahn School of Medicine at Mount Sinai, NY, New York, USA.,Duke Digital Health Science Center, Duke Global Health Institute, Duke University, Durham, NC, 27710, USA
| | - Frances McSherry
- Duke Department of Biostatistics and Bioinformatics, Duke Cancer Institute Biostatistics, Durham, NC, 27710, USA
| | - Donna Niedzwiecki
- Duke Department of Biostatistics and Bioinformatics, Duke Cancer Institute Biostatistics, Durham, NC, 27710, USA
| | - Linda Sutton
- Department of Medicine, Duke School of Medicine, Durham, NC, 27710, USA.,Duke Cancer Network, Durham, NC, 27710, USA
| | - Tykeytra Dale
- Department of Radiation Oncology,, Duke Cancer Institute, DUMC Box 3085, NC, 27710, Durham, USA
| | - Martin Streicher
- Department of Population Health Sciences, Duke School of Medicine, Durham, NC, 27710, USA
| | - Christel Rushing
- Duke Department of Biostatistics and Bioinformatics, Duke Cancer Institute Biostatistics, Durham, NC, 27710, USA
| | - Lynda Owen
- Duke Cancer Network, Durham, NC, 27710, USA
| | - William E Kraus
- Department of Medicine, Duke School of Medicine, Durham, NC, 27710, USA.,Department of Population Health Sciences, Duke School of Medicine, Durham, NC, 27710, USA
| | - Gary Bennett
- Duke Digital Health Science Center, Duke Global Health Institute, Duke University, Durham, NC, 27710, USA.,Cancer Control and Population Sciences Program, Duke Cancer Institute, Durham, NC, 27710, USA
| | - Kathryn I Pollak
- Department of Population Health Sciences, Duke School of Medicine, Durham, NC, 27710, USA.,Cancer Control and Population Sciences Program, Duke Cancer Institute, Durham, NC, 27710, USA
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4
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Oshima SM, Tait SD, Rushing C, Lane W, Hyslop T, Offodile AC, Wheeler SB, Zafar SY, Greenup R, Fish LJ. Patient Perspectives on the Financial Costs and Burdens of Breast Cancer Surgery. JCO Oncol Pract 2021; 17:e872-e881. [PMID: 33566677 DOI: 10.1200/op.20.00780] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [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
PURPOSE Although financial toxicity is a well-documented aspect of cancer care, little is known about how patients narratively characterize financial experiences related to breast cancer treatment. We sought to examine these patient experiences through mixed methods analysis. METHODS Women (≥ 18 years old) with a history of breast cancer were recruited from the Love Research Army and Sisters Network to complete an 88-item electronic survey including an open-ended response. Quantitative data were used to sort and stratify responses to the open-ended question, which comprised the qualitative data evaluated here. Descriptive statistics and qualitative content analysis were used to evaluate the financial costs and other burdens resulting from breast cancer surgery. RESULTS In total, 511 respondents completed the survey in its entirety and wrote an open-ended response. Participants reported significant financial burden in different categories including direct payments for medical care and indirect costs such as lost wages and travel expenses. Treatment-related costs burdened participants for years after diagnosis, forming a financial arc for many participants. Discrepancies existed between the degree of financial burden reported on multiple-choice questions and participants' corresponding open-ended descriptions of financial burden. Participants described a lack of communication surrounding costs with their providers and difficulty negotiating payments with insurance. CONCLUSION Breast cancer care can result in ongoing financial burden years after diagnosis among all patients, even those with adequate insurance patient populations.
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Affiliation(s)
| | | | - Christel Rushing
- Biostatistics Shared Resource, Duke Cancer Institute, Duke University, Durham, NC
| | - Whitney Lane
- Department of Surgery, Duke University School of Medicine, Durham, NC
| | - Terry Hyslop
- Biostatistics Shared Resource, Duke Cancer Institute, Duke University, Durham, NC
| | - Anaeze C Offodile
- Department of Plastic Surgery, MD Anderson Cancer Center, Houston, TX
| | - Stephanie B Wheeler
- Department of Health Policy and Management, UNC Gillings School of Global and Public Health, Chapel Hill, NC
| | - S Yousuf Zafar
- Duke University School of Medicine, Durham, NC.,Department of Population Health Sciences, Duke University, Durham, NC.,Department of Medicine, Duke University, Durham, NC.,Duke Cancer Institute, Durham, NC
| | - Rachel Greenup
- Department of Surgery, Duke University School of Medicine, Durham, NC.,Duke Cancer Institute, Durham, NC
| | - Laura J Fish
- Department of Family Medicine and Community Health, Duke University School of Medicine, Durham, NC.,Behavioral Health and Survey Research Core, Duke Cancer Institute, Duke University, Durham, NC
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5
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Uronis HE, Rushing C, Blobe GC, Hsu SD, Mettu NB, Wells JL, Niedzwiecki D, Hartman L, Moyer A, Hurwitz HI, Strickler JH. KEYlargo: A phase II study of first-line pembrolizumab (P), capecitabine (C), and oxaliplatin (O) in HER2-negative gastroesophageal (GE) adenocarcinoma. J Clin Oncol 2021. [DOI: 10.1200/jco.2021.39.3_suppl.228] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
228 Background: Gastric and esophageal adenocarcinomas are a leading cause of cancer death worldwide. Many of these patients (pts) present with locally advanced unresectable or metastatic disease and are treated with combination cytotoxic chemotherapy. Single agent P is FDA approved for patients with recurrent locally advanced or metastatic gastric or gastroesophageal junction adenocarcinoma (GEJ) whose tumors have a combined positive score (CPS) ≥ 1 after disease progression on or after two lines of therapy including fluoropyrimidine and platinum and her2/neu-targeted therapy (if indicated). More effective therapy is needed earlier in the disease trajectory. We conducted a single-arm phase II trial to establish the safety and efficacy of first-line C and O + P. Methods: Pts with previously untreated metastatic GE adenocarcinoma regardless of PDL-1 status received intravenous (IV) P 200mg with IV O 130mg/m2 every three weeks and oral C 850mg/m2 twice daily for 14 days on/7 days off. After the 6 patient safety cohort, pts first completed a biomarker cycle that included fresh tumor biopsy before P and one week after P before chemotherapy started. Archived FFPE tumor samples were also obtained from all pts with available tissue. The primary endpoint was progression free survival (PFS); secondary endpoints included response rate (RR) and overall survival (OS). Results: 36 pts were enrolled and 34 pts were evaluable for efficacy (1 pt withdrew for personal reasons before end of cycle 1 and 1 pt had immune-related toxicity during cycle 1 and was taken off study before any efficacy assessment). 9 pts (26%) had an esophageal primary, 18 pts (53%) had a GEJ primary and 7 pts (21%) had a gastric primary. Median PFS was 7.6 months [95% CI: 5.8 to 12.2], RR was 72.7% [95% CI: 57% to 88%], and median OS was 15.8 months [95% CI: 11.6 to NE]. 27 patients (81.8%) had decrease in disease burden (ranging from -19% to -100%). After > 18 months of follow-up, 5 patients remained in durable complete response (CR). Immune-mediated treatment related adverse events (TRAEs) included thyroid disorders (n=5; 14%), colitis (n=4; 11%), adrenal insufficiency (n=2; 5%), and type 1 diabetes (n=1). Sixteen patients (44%) experienced grade 3 or 4 TRAEs. There were no grade 5 TRAEs. Conclusions: The combination of C and O + P had acceptable safety and significant clinical activity. These promising results indicate that C and O + P merits further study as a first line option for patients with unresectable locally advanced or metastatic GE adenocarcinoma. Updated survival and correlative data will be presented. Clinical trial information: NCT03342937.
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Affiliation(s)
| | - Christel Rushing
- Duke University Medical Center, Department of Biostatistics, Durham, NC
| | | | | | | | | | - Donna Niedzwiecki
- Department of Biostatistics and Bioinformatics, Duke University Medical Center, Durham, NC
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6
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Hussaini SMQ, Chino F, Rushing C, Samsa G, Altomare I, Nicolla J, Peppercorn J, Zafar SY. Does Cancer Treatment-Related Financial Distress Worsen Over Time? N C Med J 2021; 82:14-20. [PMID: 33397749 DOI: 10.18043/ncm.82.1.14] [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: 11/11/2022]
Abstract
BACKGROUND Patients with cancer are at risk for both objective and subjective financial distress. Financial distress during treatment is adversely associated with physical and mental well-being. Little is known about whether patients' subjective financial distress changes during the course of their treatment.method This is a cross-sectional study of insured adults with solid tumors on anti-cancer therapy for ≥1 month, surveyed at a referral center and three rural oncology clinics. The goal was to investigate how financial distress varies depending on where patients are in the course of cancer therapy. Financial distress (FD) was assessed via a validated measure; out-of-pocket (OOP) costs were estimated and medical records were reviewed for disease/treatment data. Logistic regression was used to evaluate the potential association between treatment length and financial distress.RESULTS Among 300 participants (86% response rate), median age was 60 years (range 27-91), 52.3% were male, 78.3% had stage IV cancer or metastatic recurrence, 36.7% were retired, and 56% had private insurance. Median income was $60,000/year and median OOP costs including insurance premiums were $592/month. Median FD score (7.4/10, SD 2.5) corresponded to low FD with 16.3% reporting high/overwhelming distress. Treatment duration was not associated with the odds of experiencing high/overwhelming FD in single-predictor (OR = 1.01, CI [.93, 1.09], P = .86) or multiple predictor regression models (OR = .98, CI [.86, 1.12], P = .79). Treatment duration was not correlated with FD as a continuous variable (P = .92).LIMITATIONS This study is limited by its cross-sectional design and generalizability to patients with early-stage cancer and those being treated outside of a major referral center.CONCLUSION Severity of cancer treatment-related financial distress did not correlate with time on treatment, indicating that patients are at risk for FD throughout the treatment continuum. Screening for and addressing financial distress should occur throughout the course of cancer therapy.
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Affiliation(s)
- S M Qasim Hussaini
- hematology-oncology fellow, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins Hospital, Baltimore, Maryland; former internal medicine resident, Department of Internal Medicine, Duke University Medical Center, Durham, North Carolina.
| | - Fumiko Chino
- radiation oncologist, Department of Radiation Oncology, Memorial Sloan-Kettering Cancer Center, New York City, New York
| | | | - Greg Samsa
- professor of biostatistics and bioinformatics, Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, North Carolina
| | - Ivy Altomare
- associate professor of medicine, Duke University School of Medicine; member, Duke Cancer Institute, Durham, North Carolina
| | | | - Jeffrey Peppercorn
- associate professor of medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - S Yousuf Zafar
- associate professor of medicine, Duke University School of Medicine; member, Duke Cancer Institute, Durham, North Carolina
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7
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Crosby EJ, Hobeika AC, Niedzwiecki D, Rushing C, Hsu D, Berglund P, Smith J, Osada T, Gwin Iii WR, Hartman ZC, Morse MA, Lyerly HK. Long-term survival of patients with stage III colon cancer treated with VRP-CEA(6D), an alphavirus vector that increases the CD8+ effector memory T cell to Treg ratio. J Immunother Cancer 2020; 8:jitc-2020-001662. [PMID: 33177177 PMCID: PMC7661359 DOI: 10.1136/jitc-2020-001662] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [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] [Accepted: 10/20/2020] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND There remains a significant need to eliminate the risk of recurrence of resected cancers. Cancer vaccines are well tolerated and activate tumor-specific immune effectors and lead to long-term survival in some patients. We hypothesized that vaccination with alphaviral replicon particles encoding tumor associated antigens would generate clinically significant antitumor immunity to enable prolonged overall survival (OS) in patients with both metastatic and resected cancer. METHODS OS was monitored for patients with stage IV cancer treated in a phase I study of virus-like replicon particle (VRP)-carcinoembryonic antigen (CEA), an alphaviral replicon particle encoding a modified CEA. An expansion cohort of patients (n=12) with resected stage III colorectal cancer who had completed their standard postoperative adjuvant chemotherapy was administered VRP-CEA every 3 weeks for a total of 4 immunizations. OS and relapse-free survival (RFS) were determined, as well as preimmunization and postimmunization cellular and humoral immunity. RESULTS Among the patients with stage IV cancer, median follow-up was 10.9 years and 5-year survival was 17%, (95% CI 6% to 33%). Among the patients with stage III cancer, the 5-year RFS was 75%, (95%CI 40% to 91%); no deaths were observed. At a median follow-up of 5.8 years (range: 3.9-7.0 years) all patients were still alive. All patients demonstrated CEA-specific humoral immunity. Patients with stage III cancer had an increase in CD8 +TEM (in 10/12) and decrease in FOXP3 +Tregs (in 10/12) following vaccination. Further, CEA-specific, IFNγ-producing CD8+granzyme B+TCM cells were increased. CONCLUSIONS VRP-CEA induces antigen-specific effector T cells while decreasing Tregs, suggesting favorable immune modulation. Long-term survivors were identified in both cohorts, suggesting the OS may be prolonged.
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Affiliation(s)
- Erika J Crosby
- Surgery, Duke University School of Medicine, Durham, North Carolina, USA
| | - Amy C Hobeika
- Surgery, Duke University School of Medicine, Durham, North Carolina, USA
| | - Donna Niedzwiecki
- Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, North Carolina, USA
- Biostatistics, Duke Cancer Institute, Durham, North Carolina, USA
| | - Christel Rushing
- Biostatistics, Duke Cancer Institute, Durham, North Carolina, USA
| | - David Hsu
- Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | | | | | - Takuya Osada
- Surgery, Duke University School of Medicine, Durham, North Carolina, USA
| | | | - Zachary C Hartman
- Surgery, Duke University School of Medicine, Durham, North Carolina, USA
- Pathology, Duke University School of Medicine, Durham, North Carolina, USA
| | - Michael A Morse
- Surgery, Duke University School of Medicine, Durham, North Carolina, USA
- Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Herbert Kim Lyerly
- Surgery, Duke University School of Medicine, Durham, North Carolina, USA
- Pathology, Duke University School of Medicine, Durham, North Carolina, USA
- Immunology, Duke University School of Medicine, Durham, North Carolina, USA
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8
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Shariff AI, Qamar A, Rivera JV, Mozingo LK, Thacker C, Rushing C, Jung S, Salama AK, D’Alessio DA. SAT-414 A Single Center Retrospective Analysis and Review of Endocrinopathies from Immune Checkpoint Inhibitors Between 2007 and 2017. J Endocr Soc 2020. [PMCID: PMC7209427 DOI: 10.1210/jendso/bvaa046.758] [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] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Immune checkpoint inhibitors (ICI) specifically target and dysregulate immune tolerance. As a result of this immune activation, immune related adverse events (irAEs) are common. These can include endocrinopathies like immune hypophysitis (IH), primary adrenal insufficiency (PAI), autoimmune thyroid disease, Graves disease and type 1 Diabetes Mellitus (T1DM)[1]. The aim of this retrospective review was to describe the prevalence, timing, and clinical characteristics of ICI-related endocrinopathies at our institution. Methods: A retrospective chart review was conducted for all patients between January 01, 2007 and February 01, 2017 who met predefined clinical, biochemical and imaging criteria for endocrinopathies including IH, T1DM, autoimmune thyroid disease, Graves disease and PAI. Results: Among 690 patients who received ICPI during the study period, 91 unique patients with complete data developed endocrinopathies, for an overall prevalence of 13%. The study included 50 (55%) men and 41 (45%) women with a median age of 64 years (range 20-96 years). Grade 2 endocrinopathies were reported more commonly (n=49, 54%); grade 3/4 events were rare (15%). Among the ICIs, Nivolumab was the most common ICI noted for study patients (n=51, 56%). Autoimmune thyroid disease was the most common irAE in our study (n= 63, 9.1% overall prevalence). We also report 25 cases of IH (3.6%), 2 cases of PAI (0.3%) and 1 case of Graves disease (0.1%). Most patients with autoimmune thyroid disease developed subclinical hypothyroidism (n=26, 3.8%) and overt hyperthyroidism (n=21, 3.0%). We note a high median TSH of 67.3 µIU/mL; range- 20.6-111.0 in overt hypothyroidism compared to subclinical hypothyroidism (14.0 µIU/mL; range- 5.6-100 µIU/mL). Overall, median time to developing any endocrinopathy after initiating ICI was 13.7 weeks; range- 0.7-351.5 weeks. Among the subjects who developed IH, the median TSH was 0.37 µIU/mL (0.01 - 62.39 µIU/mL) with a free T4 of 0.74 ng/dL (0.25-1.86 ng/dL) and the median cortisol was 0.80 µg/dL (0.25-24.5 µg/dL). Amongst the IH group, 17 patients developed isolated secondary adrenal insufficiency and 8 patients developed combination of other hormone deficiencies with secondary AI including 6 with secondary hypothyroidism, 1 patient with hypogonadotropic hypogonadism and 1 with hypothyroidism and hypogonadism in addition to secondary AI. Despite development of irAEs, ICI therapy was continued in 59 pts (65%) who developed an endocrine irAE. Conclusions: In summary, this is one of the largest single institution retrospective studies on ICI related endocrinopathies. The majority of endocrinopathies were low grade, and most patients continued ICI treatment. Reference: Barroso-Sousa, Romualdo. Incidence of Endocrine Dysfunction Following the Use of Different Immune Checkpoint Inhibitor Regimens: A Systematic Review and Meta-analysis. JAMA, Sept 2017
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9
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Greenup RA, Rushing C, Fish L, Campbell BM, Tolnitch L, Hyslop T, Peppercorn J, Wheeler SB, Zafar SY, Myers ER, Hwang ES. Financial Costs and Burden Related to Decisions for Breast Cancer Surgery. J Oncol Pract 2019; 15:e666-e676. [PMID: 31356147 DOI: 10.1200/jop.18.00796] [Citation(s) in RCA: 76] [Impact Index Per Article: 15.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
PURPOSE Financial toxicity is a well-recognized adverse effect of cancer care, yet little is known about how women consider treatment costs when facing preference-sensitive decisions for breast cancer surgery or how surgical treatment choice affects financial harm. We sought to determine how financial costs and burden relate to decisions for breast cancer surgery. METHODS Women (≥ 18 years old) with a history of breast cancer were recruited from the Army of Women and Sisters Network to complete an 88-item electronic survey. Descriptive statistics and regression analysis were used to evaluate the impact of costs on surgical decisions and financial harm after breast cancer surgery. RESULTS A total of 607 women with stage 0 to III breast cancer were included. Most were white (90%), were insured privately (70%) or by Medicare (25%), were college educated (78%), and reported household incomes of more than $74,000 (56%). Forty-three percent underwent breast-conserving surgery, 25% underwent mastectomy, 32% underwent bilateral mastectomy, and 36% underwent breast reconstruction. Twenty-eight percent reported that costs of treatment influenced their surgical decisions, and at incomes of $45,000 per year, costs were prioritized over breast preservation or appearance. Overall, 35% reported financial burden as a result of their cancer treatment, and 78% never discussed costs with their cancer team. When compared with breast-conserving surgery, bilateral mastectomy with or without reconstruction was significantly associated with higher incurred debt, significant to catastrophic financial burden, treatment-related financial hardship, and altered employment. Among the highest incomes, 65% of women were fiscally unprepared, reporting higher-than-expected (26%) treatment costs. CONCLUSION Cancer treatment costs influenced decisions for breast cancer surgery, and comparably effective surgical treatments differed significantly in their risk of patient-reported financial burden, debt, and impact on employment. Cost transparency may inform preference-sensitive surgical decisions and improve patient-centered care.
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Affiliation(s)
| | | | | | | | | | | | | | | | - S Yousuf Zafar
- 1Duke University, Durham, NC.,3University of North Carolina, Chapel Hill, NC
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10
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Corradetti MN, Torok JA, Hatch AJ, Xanthopoulos EP, Lafata K, Jacobs C, Rushing C, Calaway J, Jones G, Kelsey CR, Nixon AB. Dynamic Changes in Circulating Tumor DNA During Chemoradiation for Locally Advanced Lung Cancer. Adv Radiat Oncol 2019; 4:748-752. [PMID: 31673668 PMCID: PMC6817521 DOI: 10.1016/j.adro.2019.05.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2019] [Revised: 04/30/2019] [Accepted: 05/02/2019] [Indexed: 12/25/2022] Open
Abstract
Purpose Concurrent chemoradiation therapy (CRT) is the principal treatment modality for locally advanced lung cancer. Cell death due to CRT leads to the release of cell-free DNA (cfDNA) and circulating tumor DNA (ctDNA) into the bloodstream, but the kinetics and characteristics of this process are poorly understood. We hypothesized that there could be clinically meaningful changes in cfDNA and ctDNA during a course of CRT for lung cancer. Methods and materials Multiple samples of plasma were obtained from 24 patients treated with CRT for locally advanced lung cancer to a mean dose of 66 Gy (range, 58-74 Gy) at the following intervals: before CRT, at weeks 2 and 5 during CRT, and 6 weeks after treatment. cfDNA was quantified, and a novel next generation sequencing (NGS) technique using enhanced tagged/targeted-amplicon sequencing was performed to analyze ctDNA. Results Patients for whom specific mutations in ctDNA were undetectable at the baseline time point had improved survival, and potentially etiologic driver mutations could be tracked throughout the course of CRT via NGS in multiple patients. We quantified the levels of cfDNA from patients before CRT, at week 2, week 5, and at 6 weeks after treatment. No differences were observed at weeks 2 and 5 of therapy, but we noted a significant increase in cfDNA in the posttreatment follow-up samples compared with samples collected before CRT (P = .05). Conclusions Dynamic changes in both cfDNA and ctDNA were observed throughout the course of CRT in patients with locally advanced lung cancer. Specific mutations with therapeutic implications can be identified and tracked using NGS methodologies. Further work is required to characterize the changes in cfDNA and ctDNA over time in patients treated with CRT and to assess the predictive and prognostic potential of this powerful technology.
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Affiliation(s)
- Michael N Corradetti
- Department of Radiation Oncology, Duke University School of Medicine, Durham, North Carolina
| | - Jordan A Torok
- Department of Radiation Oncology, Duke University School of Medicine, Durham, North Carolina
| | - Ace J Hatch
- Department of Medicine, Division of Medical Oncology, Duke University Medical Center, Durham, North Carolina
| | - Eric P Xanthopoulos
- Department of Radiation Oncology, Columbia University School of Medicine, New York, New York
| | - Kyle Lafata
- Department of Radiation Oncology, Duke University School of Medicine, Durham, North Carolina
| | - Corbin Jacobs
- Department of Radiation Oncology, Duke University School of Medicine, Durham, North Carolina
| | - Christel Rushing
- Department of Radiation Oncology, Duke University School of Medicine, Durham, North Carolina
| | - John Calaway
- Inivata, Inc, Research Triangle Park, North Carolina
| | - Greg Jones
- Inivata, Inc, Research Triangle Park, North Carolina
| | - Chris R Kelsey
- Department of Radiation Oncology, Duke University School of Medicine, Durham, North Carolina
| | - Andrew B Nixon
- Department of Medicine, Division of Medical Oncology, Duke University Medical Center, Durham, North Carolina
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11
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Chino F, Peppercorn JM, Rushing C, Kamal AH, Altomare I, Samsa G, Zafar SY. Out-of-Pocket Costs, Financial Distress, and Underinsurance in Cancer Care. JAMA Oncol 2019; 3:1582-1584. [PMID: 28796862 DOI: 10.1001/jamaoncol.2017.2148] [Citation(s) in RCA: 106] [Impact Index Per Article: 21.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Fumiko Chino
- Department of Radiation Oncology, Duke University Medical Center, Durham, North Carolina
| | | | - Christel Rushing
- Department of Biostatistics and Bioinformatics, Duke University Medical Center, Durham, North Carolina
| | | | | | - Greg Samsa
- Department of Biostatistics and Bioinformatics, Duke University Medical Center, Durham, North Carolina
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12
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Mettu NB, Niedzwiecki D, Rushing C, Nixon AB, Jia J, Haley S, Honeycutt W, Hurwitz H, Bendell JC, Uronis H. A phase I study of gemcitabine + dasatinib (gd) or gemcitabine + dasatinib + cetuximab (GDC) in refractory solid tumors. Cancer Chemother Pharmacol 2019; 83:1025-1035. [PMID: 30895346 DOI: 10.1007/s00280-019-03805-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2019] [Accepted: 02/22/2019] [Indexed: 12/26/2022]
Abstract
PURPOSE This study was conducted to define the maximum tolerated dose (MTD), recommended phase two dose (RPTD), and toxicities of gemcitabine + dasatinib (GD) and gemcitabine + dasatinib + cetuximab (GDC) in advanced solid tumor patients. METHODS This study was a standard phase I 3 + 3 dose escalation study evaluating two combination regimens, GD and GDC. Patients with advanced solid tumors were enrolled in cohorts of 3-6 to either GD or GDC. Gemcitabine was dosed at 1000 mg/m2 weekly for 3 of 4 weeks, dasatinib was dosed in mg PO BID, and cetuximab was dosed at 250 mg/m2 weekly after a loading dose of cetuximab of 400 mg/m2. There were two dose levels for dasatinib: (1) gemcitabine + dasatinib 50 mg ± cetuximab, and (2) gemcitabine + dasatinib 70 mg ± cetuximab. Cycle length was 28 days. Standard cycle 1 dose-limiting toxicity (DLT) definitions were used. Eligible patients had advanced solid tumors, adequate organ and marrow function, and no co-morbidities that would increase the risk of toxicity. Serum, plasma, and skin biopsy biomarkers were obtained pre- and on-treatment. RESULTS Twenty-five patients were enrolled, including 21 with pancreatic adenocarcinoma. Three patients received prior gemcitabine. Twenty-one patients were evaluable for toxicity and 16 for response. Four DLTs were observed: Grade (Gr) 3 neutropenia (GDC1, n = 1), Gr 3 ALT (GD2, n = 2), and Gr 5 pneumonitis (GDC2, n = 1). Possible treatment-emergent adverse events (TEAEs) in later cycles included: Gr 3-4 neutropenia (n = 7), Gr 4 colitis (n = 1), Gr 3 bilirubin (n = 2), Gr 3 anemia (n = 2), Gr 3 thrombocytopenia (n = 2), Gr 3 edema/fluid retention (n = 1), and Gr 3 vomiting (n = 3). Six of 16 patients (3 of whom were gemcitabine-refractory) had stable disease (SD) as best response, median duration = 5 months (range 1-7). One gemcitabine-refractory patient had a partial response (PR). Median PFS was 2.9 months (95% CI 2.1, 5.8). Median OS was 5.8 months (95% CI 4.1, 11.8). Dermal wound biopsies demonstrated that dasatinib resulted in a decrease of total and phospho-Src levels, and cetuximab resulted in a decrease of EGFR and ERBB2 levels. CONCLUSIONS The MTD/RPTD of GD is gemcitabine 1000 mg/m2 weekly for 3 of 4 weeks and dasatinib 50 mg PO BID. The clinical activity of GD seen in this study was modest, and does not support its further investigation in pancreatic cancer.
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Affiliation(s)
- Niharika B Mettu
- Duke University Medical Center, Seeley G. Mudd Bldg 10 Bryan Searle Drive, Box 3505, Durham, NC, 27710, USA.
| | - Donna Niedzwiecki
- Duke University Medical Center, Seeley G. Mudd Bldg 10 Bryan Searle Drive, Box 3505, Durham, NC, 27710, USA
| | - Christel Rushing
- Duke University Medical Center, Seeley G. Mudd Bldg 10 Bryan Searle Drive, Box 3505, Durham, NC, 27710, USA
| | - Andrew B Nixon
- Duke University Medical Center, Seeley G. Mudd Bldg 10 Bryan Searle Drive, Box 3505, Durham, NC, 27710, USA
| | - Jingquan Jia
- Duke University Medical Center, Seeley G. Mudd Bldg 10 Bryan Searle Drive, Box 3505, Durham, NC, 27710, USA
| | - Sherri Haley
- Duke University Medical Center, Seeley G. Mudd Bldg 10 Bryan Searle Drive, Box 3505, Durham, NC, 27710, USA
| | - Wanda Honeycutt
- Duke University Medical Center, Seeley G. Mudd Bldg 10 Bryan Searle Drive, Box 3505, Durham, NC, 27710, USA
| | | | | | - Hope Uronis
- Duke University Medical Center, Seeley G. Mudd Bldg 10 Bryan Searle Drive, Box 3505, Durham, NC, 27710, USA
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13
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Lane W, Rushing C, Nussbaum D, Blazer DG, Greenup RA. The quality of breast cancer quality measures. J Clin Oncol 2018. [DOI: 10.1200/jco.2018.36.30_suppl.108] [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
108 Background: To assess quality in breast cancer care, standardized metrics are needed. Many accepted breast performance metrics are based on evidence-based practice; however, most fail to reflect patient choice in treatment decisions. Given the focus on patient-centered breast care, we sought to determine how compliance with established quality metrics correlates with receipt of breast cancer care impacted by patient preference. Methods: American College of Surgeons (ACS) National Cancer Data Base facilities were designated compliant or non-compliant based on Commission of Cancer (CoC) breast metrics MASTRT, BCSRT and HT*, which all improve survival. Compliant facilities met the expected performance rate (EPR) for all three metrics, while non-compliant facilities failed to meet the EPR for any. Rates of breast conserving surgery (BCS) for early stage cancer, immediate breast reconstruction (IBR), and contralateral prophylactic mastectomy (CPM) are proposed metrics that are impacted by patient preference. For these, quality is defined as high rates of BCS, high rates of IBR, and low rates of CPM. Multivariable logistic regression models were used to estimate the association between facility level rates on these measures and the probability of treatment at a CoC compliant facility. Results: 729 facilities were included in the analysis. Based on the CoC measures, 79 (10.8%) were considered compliant and 650 (89.2%) non-compliant. Rates of BCS and IBR did not differ between compliant and non-compliant facilities; however, women treated at compliant facilities were more likely to undergo CPM (26.3% vs 21.4%; p = 0.02). In a multivariate model treatment at compliant facilities was associated with higher rates of BCS, IBR, and CPM; however, the predictive value of these metrics was minimal (Estimated OR range: 1.01-1.03). Conclusions: Rates of preference driven therapies do not differentiate CoC compliant and non-compliant hospitals. The quality of a hospital’s breast care is likely poorly measured by metrics that are influenced by, but cannot account for patient values. *MASTRT (RT≤1yr of diagnosis in women with ≥4 +lymph nodes); BCSRT (RT ≤1yr of diagnosis for women ≤70 receiving BCS); HT (hormone therapy recommended ≤1yr of diagnosis for HR-positive breast cancer)
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Affiliation(s)
- Whitney Lane
- Duke University Medical Center, Department of Surgery, Durham, NC
| | - Christel Rushing
- Duke University Medical Center, Department of Biostatistics, Durham, NC
| | - Daniel Nussbaum
- Duke University Medical Center, Department of Surgery, Durham, NC
| | - Dan G. Blazer
- Duke University Medical Center, Department of Surgery and Duke Cancer Institute, Durham, NC
| | - Rachel Adams Greenup
- Duke University Medical Center, Department of Surgery and Duke Cancer Institute, Durham, NC
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Greenup RA, Rushing C, Fish L, Hyslop T, Peppercorn JM, Wheeler SB, Zafar Y, Myers E, Hwang ESS. The costs of breast cancer care: Patient-reported experiences and preferences for transparency. J Clin Oncol 2018. [DOI: 10.1200/jco.2018.36.30_suppl.207] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [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
207 Background: Despite the recognized side effect of financial toxicity after cancer, treatment decisions for breast cancer rarely include the costs of care. We sought to determine women’s experiences with breast cancer treatment costs, and their preferences for cost transparency at diagnosis. Methods: Women ≥18 years old with a history of breast cancer completed an 88-question electronic survey based on validated or published items. Descriptive statistics and regression analysis were used. Results: In total, 607 women with stage 0-III breast cancer participated. Median age at diagnosis was 49.6 years. Median time from diagnosis was 6.7 years (range 0.1-37.1). The majority had private (70%) insurance or Medicare (25%), and reported an annual household income ≥$74,000. 43% reported considering costs in treatment decisions. Median reported out-of-pocket (OOP) costs were $3,500; 25% reported OOP costs ≥$8,000, 10% reported OOP costs ≥$18,000 and 5% reported OOP costs ≥$30,000. 15.5% reported significant to catastrophic financial burden. Bilateral mastectomy +/- reconstruction vs lumpectomy (OR 1.9, p 0.03), greater stage at diagnosis (stage 3 vs 0, OR 3.9, p < 0.01), and discussion of costs during the clinical encounter (OR 2.3, p < 0.01) were associated with a higher risk of financial harm. Women who reported discussing costs were more likely to be stage 2 or 3 (56% vs 40%, p = 0.02), less likely to be depressed (24% vs 30%, p = 0.03), and had less insurance coverage (trend p = 0.02) compared to those who did not. Older age (OR 0.95, p < 0.01), increasing household income (overall p < 0.001), better insurance coverage (OR 0.5, p < 0.001), and longer time since diagnosis (OR 0.65, p < 0.001) was associated with a decreased risk of financial harm. 78% of participants never discussed costs with their cancer team. 79% preferred cost transparency prior to embarking on care, and 40% preferred that doctors consider costs when making recommendations. Conclusions: Many women with breast cancer reported significant financial burden related to their care, and the vast majority preferred knowing costs at diagnosis. Cost transparency may improve the quality of preference-sensitive treatment decisions and reduce the risk of financial harm.
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Affiliation(s)
| | - Christel Rushing
- Duke University Medical Center, Department of Biostatistics, Durham, NC
| | | | - Terry Hyslop
- Department of Biostatistics and Bioinformatics, Duke Cancer Institute, Durham, NC
| | | | | | | | - Evan Myers
- Duke University Medical Center, Durham, NC
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15
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Chino F, Peppercorn JM, Rushing C, Nicolla J, Kamal AH, Altomare I, Samsa G, Zafar SY. Going for Broke: A Longitudinal Study of Patient-Reported Financial Sacrifice in Cancer Care. J Oncol Pract 2018; 14:e533-e546. [PMID: 30138052 DOI: 10.1200/jop.18.00112] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [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
PURPOSE Patients with cancer are at risk for substantial treatment-related costs; however, little is known about patients' willingness to sacrifice to receive cancer care and how their attitudes and burden may change with time. PATIENTS AND METHODS We conducted a longitudinal survey of insured patients with solid tumor cancers receiving chemotherapy or hormonal therapy. Patients were surveyed at two time points about their willingness to make financial sacrifices and their actual sacrifices, including out-of-pocket costs. Patient attitudes and sacrifices were compared over time. RESULTS Of 349 patients approached, 300 completed the baseline survey (86% response) and 245 completed the follow-up survey 3 months later (82% retention). Median patient-reported cancer-related out-of-pocket costs for patients who completed both surveys were $393 per month (range, $0 to $26,586 per month) at baseline and $328 per month (range, $0 to $8,210 per month) at follow-up. At baseline, 49% were willing to declare personal bankruptcy, 38% were willing to sell their homes, and ≥ 65% were willing to make other sacrifices, including borrowing money to afford their cancer care. Upon follow-up, there were minor decreases in willingness; the maximum net change was a 7% decline in patients willing to declare bankruptcy. Actual sacrifice increased over time; the greatest increase was in patients who used their savings (increased from 41% to 54%). CONCLUSION A large proportion of insured patients with cancer were willing to make considerable personal and financial sacrifices to receive care; these attitudes did not change greatly over time. Shared decision making is important to ensure patients fully understand the goals, risks, and benefits of therapy before they make such personal sacrifices.
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Affiliation(s)
- Fumiko Chino
- Duke University Medical Center; Duke Cancer Institute, Durham, NC; and Massachusetts General Hospital Cancer Center, Boston, MA
| | - Jeffrey M Peppercorn
- Duke University Medical Center; Duke Cancer Institute, Durham, NC; and Massachusetts General Hospital Cancer Center, Boston, MA
| | - Christel Rushing
- Duke University Medical Center; Duke Cancer Institute, Durham, NC; and Massachusetts General Hospital Cancer Center, Boston, MA
| | - Jonathan Nicolla
- Duke University Medical Center; Duke Cancer Institute, Durham, NC; and Massachusetts General Hospital Cancer Center, Boston, MA
| | - Arif H Kamal
- Duke University Medical Center; Duke Cancer Institute, Durham, NC; and Massachusetts General Hospital Cancer Center, Boston, MA
| | - Ivy Altomare
- Duke University Medical Center; Duke Cancer Institute, Durham, NC; and Massachusetts General Hospital Cancer Center, Boston, MA
| | - Greg Samsa
- Duke University Medical Center; Duke Cancer Institute, Durham, NC; and Massachusetts General Hospital Cancer Center, Boston, MA
| | - S Yousuf Zafar
- Duke University Medical Center; Duke Cancer Institute, Durham, NC; and Massachusetts General Hospital Cancer Center, Boston, MA
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16
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Liu Y, Starr MD, Brady JC, Rushing C, Pang H, Adams B, Alvarez D, Theuer CP, Hurwitz HI, Nixon AB. Modulation of Circulating Protein Biomarkers in Cancer Patients Receiving Bevacizumab and the Anti-Endoglin Antibody, TRC105. Mol Cancer Ther 2018; 17:2248-2256. [DOI: 10.1158/1535-7163.mct-17-0916] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2017] [Revised: 02/23/2018] [Accepted: 07/06/2018] [Indexed: 11/16/2022]
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17
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Vlahovic G, Meadows KL, Hatch AJ, Jia J, Nixon AB, Uronis HE, Morse MA, Selim MA, Crawford J, Riedel RF, Zafar SY, Howard LA, O'Neill M, Meadows JJ, Haley ST, Arrowood CC, Rushing C, Pang H, Hurwitz HI. A Phase I Trial of the IGF-1R Antibody Ganitumab (AMG 479) in Combination with Everolimus (RAD001) and Panitumumab in Patients with Advanced Cancer. Oncologist 2018; 23:782-790. [PMID: 29572245 DOI: 10.1634/theoncologist.2016-0377] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2016] [Accepted: 08/17/2017] [Indexed: 11/17/2022] Open
Abstract
PURPOSE This study evaluated the maximum tolerated dose or recommended phase II dose (RPTD) and safety and tolerability of the ganitumab and everolimus doublet regimen followed by the ganitumab, everolimus, and panitumumab triplet regimen. MATERIALS AND METHODS This was a standard 3 + 3 dose escalation trial. Doublet therapy consisted of ganitumab at 12 mg/kg every 2 weeks; doses of everolimus were adjusted according to dose-limiting toxicities (DLTs). Panitumumab at 4.8 mg/kg every 2 weeks was added to the RPTD of ganitumab and everolimus. DLTs were assessed in cycle 1; toxicity evaluation was closely monitored throughout treatment. Treatment continued until disease progression or undesirable toxicity. Pretreatment and on-treatment skin biopsies were collected to assess insulin-like growth factor 1 receptor and mammalian target of rapamycin (mTOR) target modulation. RESULTS Forty-three subjects were enrolled. In the doublet regimen, two DLTs were observed in cohort 1, no DLTs in cohort -1, and one in cohort -1B. The triplet combination was discontinued because of unacceptable toxicity. Common adverse events were thrombocytopenia/neutropenia, skin rash, mucositis, fatigue, and hyperglycemia. In the doublet regimen, two patients with refractory non-small cell lung cancer (NSCLC) achieved prolonged complete responses ranging from 18 to >60 months; one treatment-naïve patient with chondrosarcoma achieved prolonged stable disease >24 months. In dermal granulation tissue, the insulin-like growth factor receptor and mTOR pathways were potently and specifically inhibited by ganitumab and everolimus, respectively. CONCLUSION The triplet regimen of ganitumab, everolimus, and panitumumab was associated with unacceptable toxicity. However, the doublet of ganitumab at 12 mg/kg every 2 weeks and everolimus five times weekly had an acceptable safety profile and demonstrated notable clinical activity in patients with refractory NSCLC and sarcoma. IMPLICATIONS FOR PRACTICE This trial evaluated the maximum tolerated dose or recommended phase II dose and safety and tolerability of the ganitumab and everolimus doublet regimen followed by the ganitumab, everolimus, and panitumumab triplet regimen. Although the triplet regimen of ganitumab, everolimus, and panitumumab was associated with unacceptable toxicity, the doublet of ganitumab at 12 mg/kg every 2 weeks and everolimus at five times weekly had an acceptable safety profile and demonstrated notable clinical activity in patients with refractory non-small cell lung cancer and sarcoma.
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Affiliation(s)
| | | | - Ace J Hatch
- Duke Cancer Institute, Durham, North Carolina, USA
| | - Jingquan Jia
- Duke Cancer Institute, Durham, North Carolina, USA
| | | | | | | | - M Angelica Selim
- Department of Pathology, Duke University Medical Center, Durham, North Carolina, USA
| | | | | | | | | | | | | | | | | | | | - Herbert Pang
- Department of Biostatistics and Bioinformatics, Duke University Medical Center, Durham, North Carolina, USA
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18
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Erhunmwunsee L, Gulack BC, Rushing C, Niedzwiecki D, Berry MF, Hartwig MG. Socioeconomic Status, Not Race, Is Associated With Reduced Survival in Esophagectomy Patients. Ann Thorac Surg 2017; 104:234-244. [PMID: 28410639 DOI: 10.1016/j.athoracsur.2017.01.049] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2016] [Revised: 12/23/2016] [Accepted: 01/09/2017] [Indexed: 12/24/2022]
Abstract
BACKGROUND Black patients with esophageal cancer have worse survival than white patients. This study examines this racial disparity in conjunction with socioeconomic status (SES) and explores whether race-based outcome differences exist using a national database. METHODS The associations between race and SES with overall survival of patients treated with esophagectomy for stages I to III esophageal cancer between 2003 and 2011 in the National Cancer Data Base were investigated using the Kaplan-Meier method and proportional hazards analyses. Median income by zip code and proportion of the zip code residents without a high school diploma were grouped into income and education quartiles, respectively and used as surrogates for SES. The association between race and overall survival stratified by SES is explored. RESULTS Of 11,599 esophagectomy patients who met study criteria, 3,503 (30.2%) were in the highest income quartile, 2,847 (24.5%) were in the highest education quartile, and 610 patients (5%) were black. Before adjustment for SES, black patients had worse overall survival than white patients (median survival 23.0 versus 34.7 months, log rank p < 0.001), and overall, survival times improved with increasing income and education (p < 0.001 for both). After adjustment for putative prognostic factors, SES was associated with overall survival, whereas race was not. CONCLUSIONS Prior studies have suggested that survival of esophageal cancer patients after esophagectomy is associated with race. Our study suggests that race is not significantly related to overall survival when adjusted for other prognostic variables. Socioeconomic status, however, remains significantly related to overall survival in our model.
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Affiliation(s)
- Loretta Erhunmwunsee
- Division of Thoracic Surgery, Department of Surgery, City of Hope Cancer Center, Duarte, California.
| | - Brian C Gulack
- Division of General Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Christel Rushing
- Duke Cancer Institute, Biostatistics, Duke University Medical Center, Durham, North Carolina
| | - Donna Niedzwiecki
- Duke Cancer Institute, Biostatistics, Duke University Medical Center, Durham, North Carolina
| | - Mark F Berry
- Department of Cardiothoracic Surgery, Stanford Medical Center, Stanford, California
| | - Matthew G Hartwig
- Division of Cardiothoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina
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19
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Bendersky V, Sun Z, Adam MA, Rushing C, Kim J, Youngwirth L, Turner M, Migaly J, Mantyh CR. Determining the Optimal Quantitative Threshold for Preoperative Albumin Level Before Elective Colorectal Surgery. J Gastrointest Surg 2017; 21:692-699. [PMID: 28138809 DOI: 10.1007/s11605-017-3370-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2016] [Accepted: 01/12/2017] [Indexed: 01/31/2023]
Abstract
BACKGROUND Hypoalbuminemia is associated with adverse surgical outcomes. A minimum threshold and the impact of incrementally decreasing albumin remain undefined for colorectal surgery patients. STUDY DESIGN The 2011-2013 National Surgical Quality Improvement Program (NSQIP) dataset was queried for patients undergoing elective colorectal surgery. Multivariable regression analyses with restricted cubic splines (RCS) were used to examine the adjusted association between preoperative serum albumin level and the incidence of complications and to establish an optimal threshold. RCS allows for flexible evaluation in multivariable models without having to assume a specific relationship a priori. RESULTS Sixteen thousand one hundred forty-five patients met study criteria. RCS analysis demonstrated an inflection point at serum albumin level of 3.9 mg/dL. Patients with preoperative albumin <3.9 mg/dL vs. albumin ≥3.9 mg/dL had a higher likelihood of experiencing a major complication (odds ratio (OR) = 1.18, confidence interval (CI) 1.07-1.30, p = 0.0007) or any complications (OR 1.18, CI 1.08-1.29, p = 0.0002,) and had a lengthened hospital stay (p < 0.001). CONCLUSIONS This study objectively determines that a threshold preoperative serum albumin of ≥3.9 mg/dL is associated with improved outcomes in elective colorectal surgery patients. Each 0.5 mg/dL decrease in albumin was progressively associated with increased risk for complications. Identifying a minimum albumin threshold has implications in perioperative optimization of patients undergoing colorectal surgery.
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Affiliation(s)
| | - Zhifei Sun
- Department of Surgery, Duke University, Durham, NC, USA
| | | | - Christel Rushing
- Duke Department of Biostatics and Bioinformatics, Durham, NC, USA
| | - Jina Kim
- Department of Surgery, Duke University, Durham, NC, USA
| | | | - Megan Turner
- Department of Surgery, Duke University, Durham, NC, USA
| | - John Migaly
- Department of Surgery, Duke University, Durham, NC, USA
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20
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Boyer M, Rushing C, Peterson B, Papagikos M, Kiteley R, Lee W. Toxicity and Quality of Life Report of a Phase 2 Study of Stereotactic Body Radiation Therapy (SBRT) for Low- and Intermediate-Risk Prostate Cancer. Int J Radiat Oncol Biol Phys 2016. [DOI: 10.1016/j.ijrobp.2016.06.1266] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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21
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Chino F, Peppercorn J, Rushing C, Samsa G, Nicolla J, Altomare I, Zafar S. “Going for Broke”: Out-of-Pocket Costs, Financial Distress, and Patient-Reported Willingness to Pay and Sacrifice in Cancer Care. Int J Radiat Oncol Biol Phys 2016. [DOI: 10.1016/j.ijrobp.2016.06.330] [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: 10/20/2022]
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22
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Strickler JH, Rangwala FA, Rushing C, Niedzwiecki D, Altomare I, Uronis HE, Hsu SD, Zafar Y, Morse M, Chang DZ, Wells JL, Blackwell KL, Marcom PK, Webb AR, Dropkin E, Arrowood C, Hurwitz H. X-TRAP: Phase I/II study of capecitabine (X) plus ziv-aflibercept (TRAP) in metastatic colorectal cancer (mCRC). J Clin Oncol 2016. [DOI: 10.1200/jco.2016.34.4_suppl.687] [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
687 Background: Patients (pts) with chemotherapy refractory mCRC have a poor prognosis, with a median survival of approximately 6 months (mos). Ziv-aflibercept is FDA-approved in combination with FOLFIRI for the 2nd line treatment of mCRC, but its tolerability and activity in pts with chemotherapy refractory disease is unknown. We designed a phase I/II study of X+TRAP to define the recommended phase II dose (RPTD), and assess the safety, tolerability, and clinical activity for the combination. Methods: Eligible pts with refractory, advanced solid tumors were enrolled in a 3+3 dose escalation cohort (ESC) to identify the RPTD. Cycle length was 21 days. Radiographic assessment occurred every 3 cycles. X was administered po bid on days 1-14. The dose of X was 850 mg/m2 bid in ESC cohort 1 and 1,000 mg/m2 bid in ESC cohort 2. TRAP was administered on day 1 of each cycle (6 mg/kg IV). Pts with mCRC that had progressed on all standard therapies were then enrolled in a single-arm, phase II expansion cohort (EXP) and treated at the RPTD. The primary endpoint was progression free survival (PFS). Secondary endpoints included response rate (RR) and overall survival (OS). Results: As of 6/19/2015, 55 pts were evaluable for toxicity (13 ESC; 42 EXP) and 47 pts were evaluable efficacy (12 ESC; 35 EXP). In the phase I ESC cohorts, 3 DLTs occurred (1/6 cohort 1; 2/6 cohort 2): GI perforation (1), oral mucositis (1), and fatigue (1). The RPTD was X (850 mg/m2 po bid, days 1-14) and TRAP (6 mg/kg IV, day 1). In the ESC and EXP cohorts, there were no treatment related grade 4/5 adverse events (AEs). The most frequently reported treatment related AEs (grades 2+3; grade 3) were palmar-plantar erythrodysesthesia (36%; 5%), hypertension (29%; 20%), and oral mucositis (18%; 4%). Median follow up in the phase II EXP cohort was 9.3 mos (95% C.I., 6.5–11.1). Median PFS was 4.1 mos (95% C.I., 2.3-4.8). Response assessment in 35 pts (n; %): partial response (PR) (2; 6%); stable disease (SD) (12; 34%); SD > 6 mos (2; 6%). Median OS was 9.3 mos (95% C.I., 6.2–n/a). Conclusions: The combination of X+TRAP demonstrated an acceptable safety profile, with encouraging clinical activity at the RPTD. Recruitment for the phase II EXP cohort is now complete. Clinical trial information: NCT01661972.
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Morse MA, Hobeika A, Gwin W, Osada T, Gelles J, Rushing C, Niedzwiecki D, Lyerly HK. Phase I study of alphaviral vector (AVX701) in colorectal cancer patients: comparison of immune responses in stage III and stage IV patients. J Immunother Cancer 2015. [PMCID: PMC4652494 DOI: 10.1186/2051-1426-3-s2-p444] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
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Zafar SY, Chino F, Ubel PA, Rushing C, Samsa G, Altomare I, Nicolla J, Schrag D, Tulsky JA, Abernethy AP, Peppercorn JM. The utility of cost discussions between patients with cancer and oncologists. Am J Manag Care 2015; 21:607-615. [PMID: 26618364] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
OBJECTIVES Patients with cancer can experience substantial financial burden. Little is known about patients' preferences for incorporating cost discussions into treatment decision making or about the ramifications of those discussions. The objective of this study was to determine patient preferences for and benefits of discussing costs with doctors. STUDY DESIGN Cross-sectional, survey study. METHODS We enrolled insured adults with solid tumors on anticancer therapy who were treated at a referral cancer center or an affiliated rural cancer clinic. Patients were surveyed at enrollment and again 3 months later about cost discussions with doctors, decision making, and financial burden. Medical records were abstracted for disease and treatment data. Logistic regression investigated characteristics associated with greater desire to discuss costs. RESULTS Of 300 patients (86% response rate), 52% expressed some desire to discuss treatment-related out-of-pocket costs with doctors and 51% wanted their doctor to take costs into account to some degree when making treatment decisions. However, only 19% had talked to their doctor about costs. Of those, 57% reported lower out-of-pocket costs as a result of cost discussions. In multivariable logistic regression, higher subjective financial distress was associated with greater likelihood to desire cost discussions (odds ratio [OR], 1.22; 95% CI, 1.10-1.36). Nonwhite race was associated with lower likelihood to desire cost discussions (OR, 0.53; 95% CI, 0.30-0.95). CONCLUSIONS Patients with cancer varied in their desire to discuss costs with doctors, but most who discussed costs believed the conversations helped reduce their expenses. Patient-physician cost communication might reduce out-of-pocket costs even in oncology where treatment options are limited.
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Affiliation(s)
- S Yousuf Zafar
- Duke Cancer Institute, DUMC 3505, Durham, NC 27705. E-mail:
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Hwang ESS, Rushing C, Locklear TD, Samsa G, Abernethy AP, Atisha DM. Patient-reported outcomes following choice for contralateral prophylactic mastectomy. J Clin Oncol 2015. [DOI: 10.1200/jco.2015.33.15_suppl.9554] [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)
| | | | | | - Greg Samsa
- Department of Biostatistics and Bioinformatics, Duke University Medical Center, Durham, NC
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Jia J, Dellinger AE, Weiss ES, Bulusu A, Rushing C, Li H, Howard LA, Kaplan N, Pang H, Hurwitz HI, Nixon AB. Direct Evidence of Target Inhibition with Anti-VEGF, EGFR, and mTOR Therapies in a Clinical Model of Wound Healing. Clin Cancer Res 2015; 21:3442-52. [PMID: 25878330 DOI: 10.1158/1078-0432.ccr-14-2819] [Citation(s) in RCA: 5] [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] [Received: 11/03/2014] [Accepted: 04/01/2015] [Indexed: 12/19/2022]
Abstract
PURPOSE In early clinical testing, most novel targeted anticancer therapies have limited toxicities and limited efficacy, which complicates dose and schedule selection for these agents. Confirmation of target inhibition is critical for rational drug development; however, repeated tumor biopsies are often impractical and peripheral blood mononuclear cells and normal skin are often inadequate surrogates for tumor tissue. Based upon the similarities of tumor and wound stroma, we have developed a clinical dermal granulation tissue model to evaluate novel targeted therapies. EXPERIMENTAL DESIGN A 4-mm skin punch biopsy was used to stimulate wound healing and a repeat 5-mm punch biopsy was used to harvest the resulting granulation tissue. This assay was performed at pretreatment and on-treatment evaluating four targeted therapies, bevacizumab, everolimus, erlotinib, and panitumumab, in the context of three different clinical trials. Total and phosphorylated levels VEGFR2, S6RP, and EGFR were evaluated using ELISA-based methodologies. RESULTS Significant and consistent inhibition of the VEGF pathway (using VEGFR2 as the readout) was observed in granulation tissue biopsies from patients treated with bevacizumab and everolimus. In addition, significant and consistent inhibition of the mTOR pathway (using S6RP as the readout) was observed in patients treated with everolimus. Finally, significant inhibition of the EGFR pathway (using EGFR as the readout) was observed in patients treated with panitumumab, but this was not observed in patients treated with erlotinib. CONCLUSIONS Molecular analyses of dermal granulation tissue can be used as a convenient and quantitative pharmacodynamic biomarker platform for multiple classes of targeted therapies.
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Affiliation(s)
- Jingquan Jia
- Department of Medicine, Division of Medical Oncology, Duke University Medical Center, Durham, North Carolina
| | - Andrew E Dellinger
- Department of Biostatistics and Bioinformatics, Duke University Medical Center, Durham, North Carolina
| | - Eric S Weiss
- Temple University School of Medicine, Philadelphia, Pennsylvania
| | - Anuradha Bulusu
- Department of Biostatistics and Bioinformatics, Duke University Medical Center, Durham, North Carolina
| | - Christel Rushing
- Department of Biostatistics and Bioinformatics, Duke University Medical Center, Durham, North Carolina
| | - Haiyan Li
- Department of Medicine, Center for Musculoskeletal Research, University of Rochester Medical Center, Rochester, New York
| | - Leigh A Howard
- Department of Medicine, Division of Medical Oncology, Duke University Medical Center, Durham, North Carolina
| | - Neal Kaplan
- Department of Medicine, Division of Medical Oncology, Duke University Medical Center, Durham, North Carolina
| | - Herbert Pang
- Department of Biostatistics and Bioinformatics, Duke University Medical Center, Durham, North Carolina. School of Public Health, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Pok Fu Lam, Hong Kong SAR, China
| | - Herbert I Hurwitz
- Department of Medicine, Division of Medical Oncology, Duke University Medical Center, Durham, North Carolina
| | - Andrew B Nixon
- Department of Medicine, Division of Medical Oncology, Duke University Medical Center, Durham, North Carolina.
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Liu Y, Starr MD, Brady JC, Rushing C, Bulusu A, Pang H, Honeycutt W, Amara A, Altomare I, Uronis HE, Hurwitz HI, Nixon AB. Biomarker signatures correlate with clinical outcome in refractory metastatic colorectal cancer patients receiving bevacizumab and everolimus. Mol Cancer Ther 2015; 14:1048-56. [PMID: 25695956 DOI: 10.1158/1535-7163.mct-14-0923-t] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2014] [Accepted: 02/04/2015] [Indexed: 11/16/2022]
Abstract
A novel combination of bevacizumab and everolimus was evaluated in refractory colorectal cancer patients in a phase II trial. In this retrospective analysis, plasma samples from 49 patients were tested for over 40 biomarkers at baseline and after one or two cycles of drug administration. Analyte levels at baseline and change on-treatment were correlated with progression-free survival (PFS) and overall survival (OS) using univariate Cox proportional hazard modeling. Multivariable analyses were conducted using Cox modeling. Significant changes in multiple markers were observed following bevacizumab and everolimus treatment. Baseline levels of six markers significantly correlated with PFS and OS, including CRP, Gro-α, IGFBP-1, TF, ICAM-1, and TSP-2 (P < 0.05). At C2D1, changes of IGFBP-3, TGFβ-R3, and IGFBP-2 correlated with PFS and OS. Prognostic models were developed for OS and PFS (P = 0.0002 and 0.004, respectively). The baseline model for OS consisted of CRP, Gro-α, and TF, while the on-treatment model at C2D1 included IGFBP-2, IGFBP-3, and TGFβ-R3. These data demonstrated that multiple biomarkers were significantly modulated in response to bevacizumab and everolimus. Several markers correlated with both PFS and OS. Interestingly, these markers are known to be associated with inflammation and IGF signaling, key modulators of mTOR biology.
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Affiliation(s)
- Yingmiao Liu
- Department of Medicine, Division of Medical Oncology, Duke University Medical Center, Durham, North Carolina
| | - Mark D Starr
- Department of Medicine, Division of Medical Oncology, Duke University Medical Center, Durham, North Carolina
| | - John C Brady
- Department of Medicine, Division of Medical Oncology, Duke University Medical Center, Durham, North Carolina
| | - Christel Rushing
- Department of Biostatistics and Bioinformatics, Duke University Medical Center, Durham, North Carolina
| | - Anuradha Bulusu
- Department of Biostatistics and Bioinformatics, Duke University Medical Center, Durham, North Carolina
| | - Herbert Pang
- Department of Biostatistics and Bioinformatics, Duke University Medical Center, Durham, North Carolina. School of Health, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, China
| | - Wanda Honeycutt
- Department of Medicine, Division of Medical Oncology, Duke University Medical Center, Durham, North Carolina
| | - Anthony Amara
- Department of Medicine, Division of Medical Oncology, Duke University Medical Center, Durham, North Carolina
| | - Ivy Altomare
- Department of Medicine, Division of Medical Oncology, Duke University Medical Center, Durham, North Carolina
| | - Hope E Uronis
- Department of Medicine, Division of Medical Oncology, Duke University Medical Center, Durham, North Carolina
| | - Herbert I Hurwitz
- Department of Medicine, Division of Medical Oncology, Duke University Medical Center, Durham, North Carolina
| | - Andrew B Nixon
- Department of Medicine, Division of Medical Oncology, Duke University Medical Center, Durham, North Carolina.
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Rushing C, Bulusu A, Hurwitz HI, Nixon AB, Pang H. A leave-one-out cross-validation SAS macro for the identification of markers associated with survival. Comput Biol Med 2015; 57:123-9. [PMID: 25553357 PMCID: PMC4306627 DOI: 10.1016/j.compbiomed.2014.11.015] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2014] [Revised: 11/20/2014] [Accepted: 11/28/2014] [Indexed: 11/30/2022]
Abstract
A proper internal validation is necessary for the development of a reliable and reproducible prognostic model for external validation. Variable selection is an important step for building prognostic models. However, not many existing approaches couple the ability to specify the number of covariates in the model with a cross-validation algorithm. We describe a user-friendly SAS macro that implements a score selection method and a leave-one-out cross-validation approach. We discuss the method and applications behind this algorithm, as well as details of the SAS macro.
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Affiliation(s)
- Christel Rushing
- Department of Biostatistics and Bioinformatics & Duke Cancer Biostatistics, Duke University School of Medicine, Durham, NC, United States
| | - Anuradha Bulusu
- Department of Biostatistics and Bioinformatics & Duke Cancer Biostatistics, Duke University School of Medicine, Durham, NC, United States
| | - Herbert I Hurwitz
- Department of Medicine, Duke University School of Medicine, Durham, NC, United States
| | - Andrew B Nixon
- Department of Medicine, Duke University School of Medicine, Durham, NC, United States
| | - Herbert Pang
- Department of Biostatistics and Bioinformatics & Duke Cancer Biostatistics, Duke University School of Medicine, Durham, NC, United States; School of Public Health, Li Ka Shing Faculty of Medicine, Pok Fu Lam, Hong Kong SAR, China.
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Meadows KL, Rushing C, Honeycutt W, Latta K, Howard L, Arrowood CA, Niedzwiecki D, Hurwitz HI. Treatment of palmar-plantar erythrodysesthesia (PPE) with topical sildenafil: a pilot study. Support Care Cancer 2014; 23:1311-9. [PMID: 25341548 DOI: 10.1007/s00520-014-2465-z] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2014] [Accepted: 10/01/2014] [Indexed: 11/27/2022]
Abstract
PURPOSE Palmar-plantar erythrodysesthesia (PPE) is a common chemotherapy and anti-VEGF multi-kinase inhibitor class-related toxicity that often results in debilitating skin changes and often limits the use of active anti-cancer regimens. Mechanistic and anecdotal clinical evidence suggested that topical application of sildenafil cream may help reduce the severity of PPE. Therefore, we conducted a randomized, double-blind, placebo-controlled pilot study to evaluate the feasibility, safety and efficacy of topical sildenafil cream for the treatment of PPE. METHODS Eligible subjects were required to have grade 1-3 PPE associated with either capecitabine or sunitinib. Subjects were randomized to receive 1 % topical sildenafil cream to the left extremities or right extremities and placebo cream on the opposite extremity. Two times per day, 0.5 mL of cream was applied to each affected hand/foot. The primary endpoint was improvement in PPE grading at any point on study. Clinical assessments were evaluated by NCI-CTC 4.0 grading and patient self-reported pain. RESULTS Ten subjects were enrolled, nine were evaluable for safety and efficacy. Five of nine subjects reported some improvement in foot pain and three of eight subjects for hand pain improvement. One of these subjects noted specific improvement in tactile function. No treatment-related toxicities were observed. CONCLUSIONS In this limited, single-center study, topical cream containing 1 % sildenafil is feasible to administer, is well-tolerated, and may mitigate PPE-related symptoms due to anti-cancer therapeutic agents. Further validation is necessary.
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Affiliation(s)
- Kellen L Meadows
- Duke Cancer Institute, Seeley G. Mudd Bldg., 10 Bryan Searle Drive, Box 3052, Durham, NC, 27710, USA
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Zullig LL, Rushing C, Chino FL, Samsa G, Altomare I, Tulsky JA, Ubel PA, Nicolla J, Abernethy AP, Peppercorn JM, Zafar Y. Can we identify patients at risk for discordance in preferred and actual role in cancer treatment decision making? J Clin Oncol 2014. [DOI: 10.1200/jco.2014.32.15_suppl.6615] [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)
- Leah L. Zullig
- Health Services Research and Development, Durham VA Medical Center, Durham, NC
| | | | | | - Greg Samsa
- Duke University Medical Center, Durham, NC
| | | | - James A Tulsky
- Center for Palliative Care, Duke University Medical Center, Durham, NC
| | - Peter A Ubel
- Fuqua School of Business, Duke University, Durham, NC
| | - Jonathan Nicolla
- Center for Learning Health Care, Duke Clinical Research Institute, Durham, NC
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Van Nimwegen L, Rushing C, Chino FL, Samsa G, Altomare I, Tulsky JA, Ubel PA, Nicolla J, Abernethy AP, Peppercorn JM, Zafar Y. Does cancer treatment-related financial distress worsen over time? J Clin Oncol 2014. [DOI: 10.1200/jco.2014.32.15_suppl.6559] [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)
| | | | | | - Greg Samsa
- Duke University Medical Center, Durham, NC
| | | | - James A Tulsky
- Center for Palliative Care, Duke University Medical Center, Durham, NC
| | - Peter A Ubel
- Fuqua School of Business, Duke University, Durham, NC
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Liu Y, Clarke JM, Starr MD, Brady JC, Pang H, Rushing C, Alvarez D, Adams BJ, Theuer CP, Hurwitz H, Nixon AB. Biomarker modulation in patients (pts) receiving TRC105 (T) and bevacizumab (B) in a phase Ib clinical trial. J Clin Oncol 2014. [DOI: 10.1200/jco.2014.32.15_suppl.11020] [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
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Nipp RD, Rushing C, Samsa G, Locke SC, Kamal A, Abernethy AP, LeBlanc TW. Correlation between the international consensus definition of the cancer anorexia cachexia syndrome (CACS) and patient outcomes in advanced non-small cell lung cancer (NSCLC). J Clin Oncol 2014. [DOI: 10.1200/jco.2014.32.15_suppl.e19042] [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)
- Ryan David Nipp
- Department of Medicine, Duke University Medical Center, Durham, NC
| | | | - Greg Samsa
- Duke University Medical Center, Durham, NC
| | | | - Arif Kamal
- Duke University Medical Center, Durham, NC
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Bestvina CM, Zullig LL, Rushing C, Chino F, Samsa GP, Altomare I, Tulsky J, Ubel P, Schrag D, Nicolla J, Abernethy AP, Peppercorn J, Zafar SY. Patient-oncologist cost communication, financial distress, and medication adherence. J Oncol Pract 2014; 10:162-7. [PMID: 24839274 PMCID: PMC10445786 DOI: 10.1200/jop.2014.001406] [Citation(s) in RCA: 178] [Impact Index Per Article: 17.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Little is known about the association between patient-oncologist discussion of cancer treatment out-of-pocket (OOP) cost and medication adherence, a critical component of quality cancer care. METHODS We surveyed insured adults receiving anticancer therapy. Patients were asked if they had discussed OOP cost with their oncologist. Medication nonadherence was defined as skipping doses or taking less medication than prescribed to make prescriptions last longer, or not filling prescriptions because of cost. Multivariable analysis assessed the association between nonadherence and cost discussions. RESULTS Among 300 respondents (86% response), 16% (n = 49) reported high or overwhelming financial distress. Nineteen percent (n = 56) reported talking to their oncologist about cost. Twenty-seven percent (n = 77) reported medication nonadherence. To make a prescription last longer, 14% (n = 42) skipped medication doses, and 11% (n = 33) took less medication than prescribed; 22% (n = 66) did not fill a prescription because of cost. Five percent (n = 14) reported chemotherapy nonadherence. To make a prescription last longer, 1% (n = 3) skipped chemotherapy doses, and 2% (n = 5) took less chemotherapy; 3% (n = 10) did not fill a chemotherapy prescription because of cost. In adjusted analyses, cost discussion (odds ratio [OR] = 2.58; 95% CI, 1.14 to 5.85; P = .02), financial distress (OR = 1.64, 95% CI, 1.38 to 1.96; P < .001) and higher financial burden than expected (OR = 2.89; 95% CI, 1.41 to 5.89; P < .01) were associated with increased odds of nonadherence. CONCLUSION Patient-oncologist cost communication and financial distress were associated with medication nonadherence, suggesting that cost discussions are important for patients forced to make cost-related behavior alterations. Future research should examine the timing, content, and quality of cost-discussions.
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Affiliation(s)
- Christine M Bestvina
- Duke Cancer Institute; Duke Clinical Research Institute; Durham Veterans Affairs Medical Center, Durham; University of North Carolina, Chapel Hill, NC; and Dana Farber Cancer Institute, Boston, MA
| | - Leah L Zullig
- Duke Cancer Institute; Duke Clinical Research Institute; Durham Veterans Affairs Medical Center, Durham; University of North Carolina, Chapel Hill, NC; and Dana Farber Cancer Institute, Boston, MA
| | - Christel Rushing
- Duke Cancer Institute; Duke Clinical Research Institute; Durham Veterans Affairs Medical Center, Durham; University of North Carolina, Chapel Hill, NC; and Dana Farber Cancer Institute, Boston, MA
| | - Fumiko Chino
- Duke Cancer Institute; Duke Clinical Research Institute; Durham Veterans Affairs Medical Center, Durham; University of North Carolina, Chapel Hill, NC; and Dana Farber Cancer Institute, Boston, MA
| | - Gregory P Samsa
- Duke Cancer Institute; Duke Clinical Research Institute; Durham Veterans Affairs Medical Center, Durham; University of North Carolina, Chapel Hill, NC; and Dana Farber Cancer Institute, Boston, MA
| | - Ivy Altomare
- Duke Cancer Institute; Duke Clinical Research Institute; Durham Veterans Affairs Medical Center, Durham; University of North Carolina, Chapel Hill, NC; and Dana Farber Cancer Institute, Boston, MA
| | - James Tulsky
- Duke Cancer Institute; Duke Clinical Research Institute; Durham Veterans Affairs Medical Center, Durham; University of North Carolina, Chapel Hill, NC; and Dana Farber Cancer Institute, Boston, MA
| | - Peter Ubel
- Duke Cancer Institute; Duke Clinical Research Institute; Durham Veterans Affairs Medical Center, Durham; University of North Carolina, Chapel Hill, NC; and Dana Farber Cancer Institute, Boston, MA
| | - Deborah Schrag
- Duke Cancer Institute; Duke Clinical Research Institute; Durham Veterans Affairs Medical Center, Durham; University of North Carolina, Chapel Hill, NC; and Dana Farber Cancer Institute, Boston, MA
| | - Jon Nicolla
- Duke Cancer Institute; Duke Clinical Research Institute; Durham Veterans Affairs Medical Center, Durham; University of North Carolina, Chapel Hill, NC; and Dana Farber Cancer Institute, Boston, MA
| | - Amy P Abernethy
- Duke Cancer Institute; Duke Clinical Research Institute; Durham Veterans Affairs Medical Center, Durham; University of North Carolina, Chapel Hill, NC; and Dana Farber Cancer Institute, Boston, MA
| | - Jeffrey Peppercorn
- Duke Cancer Institute; Duke Clinical Research Institute; Durham Veterans Affairs Medical Center, Durham; University of North Carolina, Chapel Hill, NC; and Dana Farber Cancer Institute, Boston, MA
| | - S Yousuf Zafar
- Duke Cancer Institute; Duke Clinical Research Institute; Durham Veterans Affairs Medical Center, Durham; University of North Carolina, Chapel Hill, NC; and Dana Farber Cancer Institute, Boston, MA
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Strickler JH, McCall S, Nixon AB, Brady JC, Pang H, Rushing C, Cohn A, Starodub A, Arrowood C, Haley S, Meadows KL, Morse MA, Uronis HE, Blobe GC, Hsu SD, Zafar SY, Hurwitz HI. Phase I study of dasatinib in combination with capecitabine, oxaliplatin and bevacizumab followed by an expanded cohort in previously untreated metastatic colorectal cancer. Invest New Drugs 2014; 32:330-9. [PMID: 24173967 PMCID: PMC4108590 DOI: 10.1007/s10637-013-0042-9] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2013] [Accepted: 10/16/2013] [Indexed: 01/07/2023]
Abstract
PURPOSE Dasatinib inhibits src family kinases and has anti-angiogenic properties. We conducted a phase I study of dasatinib, capecitabine, oxaliplatin, and bevacizumab (CapeOx/bevacizumab), with an expansion cohort in metastatic colorectal cancer (CRC). METHODS Patients were enrolled in a dose escalation cohort to establish the maximum tolerated dose (MTD) and the recommended phase II dose (RP2D). Using a "3 + 3" design, twelve patients with advanced solid tumors received dasatinib (50 mg twice daily or 70 mg daily), capecitabine (850 mg/m(2) twice daily, days 1-14), oxaliplatin (130 mg/m(2) on day 1) and bevacizumab (7.5 mg/kg on day1), every 3 weeks. Ten patients with previously untreated metastatic CRC were then enrolled in an expansion cohort. Activated src (src(act)) expression was measured by immunohistochemistry, using an antibody that selectively recognizes the active conformation of src (clone 28). RESULTS Twenty-two patients were enrolled between June 2009 and May 2011. Two DLTs were observed in the 50 mg bid dasatinib cohort, and one DLT was observed in the 70 mg daily dasatinib cohort. The MTD and RP2D for dasatinib was 70 mg daily. The most common treatment-related adverse events were fatigue (20; 91 %) and diarrhea (18; 82 %). Biomarker analysis of src(act) expression demonstrated that the overall response rate (ORR) was 75 % (6/8) for patients with high src(act) expression (IHC ≥ 2), compared to 0 % (0/8) for patients with low srcact expression (IHC 0 or 1); (p = 0.007). CONCLUSIONS The RP2D of dasatinib is 70 mg daily in combination with CapeOx/bevacizumab. High levels of srcact expression may predict those patients most likely to benefit from dasatinib.
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Affiliation(s)
| | | | | | - John C. Brady
- Duke University Medical Center, Durham, NC, 27710, USA
| | - Herbert Pang
- Duke University Medical Center, Durham, NC, 27710, USA
| | | | - Allen Cohn
- Rocky Mountain Cancer Centers Denver, CO, 80218, USA
| | - Alexander Starodub
- Duke University Medical Center, Durham, NC, 27710, USA
- Indiana University Health Goshen Cancer Center, Goshen, IN, 46526, USA
| | | | - Sherri Haley
- Duke University Medical Center, Durham, NC, 27710, USA
| | | | | | | | | | - S. David Hsu
- Duke University Medical Center, Durham, NC, 27710, USA
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Bestvina CM, Zullig LL, Rushing C, Chino FL, Samsa G, Altomare I, Tulsky JA, Ubel PA, Schrag D, Nicolla J, Abernethy AP, Peppercorn JM, Zafar Y. Patient-oncologist cost communication, financial distress, and medication adherence. J Clin Oncol 2013. [DOI: 10.1200/jco.2013.31.31_suppl.2] [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
2 Background: Little is known about the association between patient-oncologist discussion of cancer treatment out-of-pocket (OOP) cost and medication adherence, a critical component of quality cancer care. Methods: We conducted a cross-sectional survey of insured adults receiving anti-cancer therapy. Patients were asked if they had discussed OOP cost with their oncologist. Medication non-adherence was defined as skipping doses to make prescriptions last longer, taking less medication than prescribed to make prescriptions last longer, or not filling prescriptions due to cost. Multivariable analysis assessed the association between cost discussions with an oncologist and non-adherence. Results: Among 300 respondents (84% response), 77% (n=230) were white and 53% (n=158) were men. 17% (n=52) reported “high” or “overwhelming” financial distress. 19% (n=56) had talked to their oncologist about cost. 27% (n=81) reported medication non-adherence. 14% (n=43) skipped medication doses to make the prescription last longer; 7% (n=3) of these had skipped chemotherapy. 11% (n=34) took less medication than prescribed to make the prescription last longer; 15% (n=5) of these took less chemotherapy. 22% (n=67) did not fill a prescription because of cost; 15% (n=10) of these did not fill a chemotherapy prescription. In adjusted analyses, cost discussion (OR 2.56, 95% CI 1.15-5.68; p=0.02), financial distress (OR 1.57, 95% CI 1.33-1.85, P<0.001) and female gender (OR 2.02, 95% CI 1.005-4.07, p=0.048) were associated with increased odds of non-adherence. Private insurance was associated with lower odds of non-adherence (OR 0.30, 95% CI 0.14-0.60, p<0.001). Conclusions: Patients reported non-adherence to medications and chemotherapy in order to make prescriptions last longer or due to cost. While these data cannot determine temporality or the affect of cost discussion on medication non-adherence, patient-oncologist cost communication and financial distress were associated with non-adherence. Future research should examine the timing, content, and quality of cost-related discussions.
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Affiliation(s)
| | - Leah L. Zullig
- Health Services Research and Development, Durham VA Medical Center, Durham, NC
| | | | | | - Greg Samsa
- Department of Biostatistics and Bioinformatics, Duke University Medical Center, Durham, NC
| | | | - James A Tulsky
- Center for Palliative Care, Duke University Medical Center, Durham, NC
| | - Peter A Ubel
- Fuqua School of Business, Duke University, Durham, NC
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Chino F, Peppercorn JM, Tulsky JA, Ubel PA, Schrag D, Rushing C, Nicolla J, Altomare I, Samsa G, Abernethy AP, Zafar Y. The financial burden of cancer care: Do patients know what to expect? J Clin Oncol 2013. [DOI: 10.1200/jco.2013.31.15_suppl.6516] [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
6516 Background: Patients receiving cancer treatment can experience significant financial distress (FD), but little is known about whether patients are adequately informed about costs of care. Methods: This is a planned interim analysis of an ongoing cross-sectional study of insured adults with solid tumors on anticancer therapy for ≥1 month. Consecutive patients were surveyed, in person, at a referral center and 3 rural oncology clinics. Participants were asked about subjective FD (via validated measure), out-of-pocket costs, expected burden, and willingness to accept high out-of-pocket costs. Medical records were reviewed for disease and treatment data. Logistic regression assessed the relationship between FD, expected burden, quality of life (QOL), and willingness to accept high out-of-pocket costs. Results: Among 119 participants (85% response), median age was 60 years (range 27-86), 54% were men, 29% were non-white, 96% had completed high school, and 40% were retired. 81% had incurable cancer. Median income was $50,000/yr. Median out-of-pocket costs were $480/mo. 19% reported high/overwhelming FD. Median time on treatment was 200 days. Compared to anticipated levels of personal financial burden at the start of treatment, 40% were experiencing a higher degree of burden, 24% were experiencing a lower degree of burden, and 32% were experiencing the same degree of burden. In adjusted analyses, both high/overwhelming FD score (OR 4.79; 95% CI 1.64-13.95; p=0.004) and a lower QOL score (OR 0.81; 95% CI 0.67-0.99; p=0.035) were associated with a higher than expected financial burden. The following were not associated with higher than expected financial burden: age, gender, education, cancer stage, cost as a proportion of income, time on treatment, or willingness to accept high out-of-pocket costs. Conclusions: A large portion of insured patients faced out-of-pocket costs that were greater than expected. Those who were least prepared for financial burden reported higher FD and lower QOL. Since patient characteristics could not identify those at highest risk for unexpected cost burden, future research should focus on how to identify patients at risk and better prepare them for potential treatment-related financial burden.
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Affiliation(s)
| | | | - James A Tulsky
- Center for Palliative Care, Duke University Medical Center, Durham, NC
| | - Peter A Ubel
- Fuqua School of Business, Duke University, Durham, NC
| | | | | | | | | | - Greg Samsa
- Department of Biostatistics and Bioinformatics, Duke University Medical Center, Durham, NC
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Zafar Y, Abernethy AP, Tulsky JA, Ubel PA, Schrag D, Rushing C, Chino F, Nicolla J, Altomare I, Samsa G, Peppercorn JM. Financial distress, communication, and cancer treatment decision making: Does cost matter? J Clin Oncol 2013. [DOI: 10.1200/jco.2013.31.15_suppl.6506] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [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
6506 Background: Financial distress (FD) increases the burden of living with cancer. Even insured patients may experience considerable FD, but little is known about whether patients want to include cost discussions in treatment decision-making. Methods: This is an ongoing cross-sectional study of insured adults with solid tumors on anticancer therapy for ≥1 month. Consecutive patients were surveyed, in person, at a referral center and 3 rural oncology clinics. Participants were asked about FD (via a validated measure), out-of-pocket (OOP) costs, discussion of costs with their doctor, and decision-making. Medical records were reviewed for disease and treatment data. Logistic regression assessed the relationship between FD and cost communication. Results: 119 participants (85% response) had a median age of 60 years (range 27-86). 54% were men, 29% non-white, and 96% completed high school. 81% had incurable cancer. 58% had private insurance. Median income was $50,000/yr. Median OOP costs were $480/mo. The mean FD score (6.7, SD 2.5) corresponded to moderate FD. 19% reported high/overwhelming FD. Overall, 48% (n=57) expressed any desire to discuss costs with their doctor, but only 21% (n=25) had actually done so. Of the 19% with highest FD, 36% (n=8) had discussed costs with a doctor, and 68% (n=15) expressed any desire to discuss costs. The most common reasons for not discussing costs with doctors were: “no problems with costs” (n=47); “want best care regardless of cost” (n=36); and “doctors shouldn’t have to worry about costs” (n=19). Of those who discussed costs with their doctor, 48% (n=12) felt the discussion helped decrease costs. 54% (n=64) wanted their doctors to account for costs in cancer treatment decision-making; 20% (n=24) always wanted costs considered in decision-making. High FD was the only variable associated with greater willingness to discuss costs (adjusted OR 2.81; 95%CI 1.05-7.50; p=0.04). Conclusions: FD was prevalent among insured cancer patients. A large proportion wanted costs discussed with doctors and included in treatment decision-making. Discussing finances may lower costs, but the discussion rarely occurs. Communication and decision-making present a potential focus for intervening on FD.
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Affiliation(s)
| | | | - James A Tulsky
- Center for Palliative Care, Duke University Medical Center, Durham, NC
| | - Peter A Ubel
- Fuqua School of Business, Duke University, Durham, NC
| | | | | | | | | | | | - Greg Samsa
- Department of Biostatistics and Bioinformatics, Duke University Medical Center, Durham, NC
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Strickler JH, McCall S, Nixon AB, Pang H, Rushing C, Arrowood C, Haley S, Meadows K, Hurwitz H. Correlation of Src activation with response to dasatinib, capecitabine, oxaliplatin, and bevacizumab in advanced solid tumors. J Clin Oncol 2013. [DOI: 10.1200/jco.2013.31.15_suppl.11036] [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
11036 Background: Src inhibition may augment sensitivity to chemotherapy, but in unselected patients (pts) with advanced solid tumors, src inhibitors have shown limited clinical activity. Biomarkers to predict benefit from src inhibitors in advanced solid tumors are not yet known. Methods: 22 pts (dose escalation cohort= 12 pts; colorectal cancer [CRC] expansion cohort= 10 pts) were enrolled in a phase I study to determine the safety and tolerability of the src inhibitor dasatinib with capecitabine, oxaliplatin, and bevacizumab (J Clin Oncol 29: 2011 [suppl; abstr 3586]). Src activation (src-a) was assessed in tumors from 16 evaluable pts. Src-a was measured by immunohistochemistry (IHC) in formalin-fixed, paraffin-embedded tumor samples using an antibody that selectively recognizes the active conformation of src (clone 28). A GI pathologist who was blinded to pt outcomes graded membranous src-a using a standard semi-quantitative method. The endpoint of this exploratory analysis was objective response rate ([ORR]= PR+CR). 2-sided Fisher’s Exact test was used to evaluate the association between ORR and src-a. Results: Across all tumor types, 8 tumors had no/faint src-a (IHC=0/1); 8 tumors had moderate/strong src-a (IHC≥2). Benign colonic epithelium had no src-a (IHC=0). The ORR was 75% (6/8) for pts with moderate/strong src-a versus (vs) 0% (0/8) for pts with no/faint src-a (p =0.007). In the CRC expansion cohort, the ORR was 83% (5/6) for patients with moderate/strong src-a vs 0% (0/2) for pts with no/faint src-a (p=0.107); progression free survival range was 7.9-24.4 months for pts with moderate/strong src-a. Conclusions: In this small phase I study, src-a is associated with benefit from the combination of dasatinib and oxaliplatin-based chemotherapy. Further evaluation of dasatinib in patients whose tumors demonstrate high levels of src-a may be warranted. Clinical trial information: NCT00920868.
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Affiliation(s)
| | | | | | - Herbert Pang
- Cancer and Leukemia Group B Statistical Center, Durham, NC
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Reese V, Ondracek C, Rushing C, Li L, Oropeza CE, McLachlan A. Multiple nuclear receptors may regulate hepatitis B virus biosynthesis during development. Int J Biochem Cell Biol 2009; 43:230-7. [PMID: 19941970 DOI: 10.1016/j.biocel.2009.11.016] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2009] [Revised: 09/22/2009] [Accepted: 11/18/2009] [Indexed: 01/01/2023]
Abstract
Hepatitis B virus (HBV) replicates by the reverse transcription of the viral 3.5 kb pregenomic RNA. Therefore the level of expression of this transcript in the liver is a primary determinant of HBV biosynthesis. In vivo neonatal transcription of the HBV 3.5 kb pregenomic RNA is developmental regulated by hepatocyte nuclear factor 4α (HNF4α). In addition, viral biosynthesis in non-hepatoma cells can be supported directly by this nuclear receptor. However HBV transcription and replication can be supported by additional nuclear receptors including the retinoid X receptor α/peroxisome proliferator-activated receptor α (RXRα/PPARα), retinoid X receptor α/farnesoid X receptor α (RXRα/FXRα), liver receptor homolog 1 (LRH1) and estrogen-related receptors (ERR) in non-hepatoma cells. Therefore during neonatal liver development, HNF4α may progressively activate viral transcription and replication by binding directly to the proximal HNF4α recognition sequence within the nucleocapsid promoter. Alternatively, HNF4α may support viral biosynthesis in vivo indirectly by activating a network of liver-enriched nuclear receptors that, in combination, direct HBV 3.5 kb pregenomic RNA transcription and replication.
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Affiliation(s)
- Vanessa Reese
- Department of Microbiology and Immunology, College of Medicine, University of Illinois at Chicago, Chicago, IL 60612-7344, USA.
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