Seven decades of chemotherapy clinical trials: a pan-cancer social network analysis

Clinical trials establish the standard of cancer care, yet the evolution and characteristics of the social dynamics between the people conducting this work remain understudied. We performed a social network analysis of authors publishing chemotherapy-based prospective trials from 1946 to 2018 to understand how social influences, including the role of gender, have influenced the growth and development of this network, which has expanded exponentially from fewer than 50 authors in 1946 to 29,197 in 2018. While 99.4% of authors were directly or indirectly connected by 2018, our results indicate a tendency to predominantly connect with others in the same or similar fields, as well as an increasing disparity in author impact and number of connections. Scale-free effects were evident, with small numbers of individuals having disproportionate impact. Women were under-represented and likelier to have lower impact, shorter productive periods (P < 0.001 for both comparisons), less centrality, and a greater proportion of co-authors in their same subspecialty. The past 30 years were characterized by a trend towards increased authorship by women, with new author parity anticipated in 2032. The network of cancer clinical trialists is best characterized as strategic or mixed-motive, with cooperative and competitive elements influencing its appearance. Network effects such as low centrality, which may limit access to high-profile individuals, likely contribute to the observed disparities.

Quantifying interoperability: An analysis of oncology practice electronic health record data variability

e18080

Background: Implementation of electronic health records (EHRs) has engendered a large quantity of machine-readable data. However, different practices choose different EHR vendors and the same vendor product may be implemented differently at each practice. Motivated by the desire to facilitate appropriate integration of data, our goal was to describe and quantify the consistency and variation of structured data within EHRs. Methods: De-identified and aggregated CancerLinQ data from 47 practices regarding the standards and variability of structured data including race, diagnoses, encounters, cancer staging, selected cancer-relevant medications, lab values and biomarkers were analyzed. EHR represented included ARIA, MOSAIQ, Allscripts, Centricity, Epic, Intellidose, NextGen, and OncoEMR. Results: De-identified EHR implementations included 23 A, 12 B, C and 5 other vendors. Only 6 practices (13%) used non-standard race representation. All practices used ICD-9/10 for diagnoses. There was variability in coding of encounters. Sixteen practices always used CPT, 5 practices always used SNOMED CT and 26 practices used multiple standards. Multiple staging systems were used. An average of 48% (range 11%-; including patients staged more than once) of patient records included coded staging information. Only one practice used a standard (LOINC) for laboratory data. No standards were used for medications ordered/administered or biomarkers. The table shows the number of distinct names for selected lab tests, medications and biomarkers across systems. Conclusions: In this cross-sectional sample, standards are used consistently for diagnoses and encounter data, often for race and rarely for medications, laboratory tests or biomarkers.[Table: see text]

Identifying Health Information Technology Needs of Oncologists to Facilitate the Adoption of Genomic Medicine: Recommendations From the 2016 American Society of Clinical Oncology Omics and Precision Oncology Workshop

At the ASCO Data Standards and Interoperability Summit held in May 2016, it was unanimously decided that four areas of current oncology clinical practice have serious, unmet health information technology needs. The following areas of need were identified: 1) omics and precision oncology, 2) advancing interoperability, 3) patient engagement, and 4) value-based oncology. To begin to address these issues, ASCO convened two complementary workshops: the Omics and Precision Oncology Workshop in October 2016 and the Advancing Interoperability Workshop in December 2016. A common goal was to address the complexity, enormity, and rapidly changing nature of genomic information, which existing electronic health records are ill equipped to manage. The subject matter experts invited to the Omics and Precision Oncology Workgroup were tasked with the responsibility of determining a specific, limited need that could be addressed by a software application (app) in the short-term future, using currently available genomic knowledge bases. Hence, the scope of this workshop was to determine the basic functionality of one app that could serve as a test case for app development. The goal of the second workshop, described separately, was to identify the specifications for such an app. This approach was chosen both to facilitate the development of a useful app and to help ASCO and oncologists better understand the mechanics, difficulties, and gaps in genomic clinical decision support tool development. In this article, we discuss the key challenges and recommendations identified by the workshop participants. Our hope is to narrow the gap between the practicing oncologist and ongoing national efforts to provide precision oncology and value-based care to cancer patients.

Development, implementation, and initial evaluation of a foundational open interoperability standard for oncology treatment planning and summarization

OBJECTIVE

Develop and evaluate a foundational oncology-specific standard for the communication and coordination of care throughout the cancer journey, with early-stage breast cancer as the use case.

MATERIALS AND METHODS

Owing to broad uptake of the Health Level Seven (HL7) Consolidated Clinical Document Architecture (C-CDA) by health information exchanges and large provider organizations, we developed an implementation guide in congruence with C-CDA. The resultant product was balloted through the HL7 process and subsequently implemented by two groups: the Health Story Project (Health Story) and the Athena Breast Health Network (Athena).

RESULTS

The HL7 Implementation Guide for CDA, Release 2: Clinical Oncology Treatment Plan and Summary, DSTU Release 1 (eCOTPS) was successfully balloted and published as a Draft Standard for Trial Use (DSTU) in October 2013. Health Story successfully implemented the eCOTPS the 2014 meeting of the Healthcare Information and Management Systems Society (HIMSS) in a clinical vignette. During the evaluation and implementation of eCOPS, Athena identified two practical concerns: (1) the need for additional CDA templates specific to their use case; (2) the many-to-many mapping of Athena-defined data elements to eCOTPS.

DISCUSSION

Early implementation of eCOTPS has demonstrated successful vendor-agnostic transmission of oncology-specific data. The modularity enabled by the C-CDA framework ensures the relatively straightforward expansion of the eCOTPS to include other cancer subtypes. Lessons learned during the process will strengthen future versions of the standard.

CONCLUSION

eCOTPS is the first oncology-specific CDA standard to achieve HL7 DSTU status. Oncology standards will improve care throughout the cancer journey by allowing the efficient transmission of reliable, meaningful, and current clinical data between the many involved stakeholders.

An interoperable HL7 document standard to improve the quality of cancer care across multiple locations

12

Background: Cancer care is by nature interdisciplinary and increasingly depends on seamless electronic transmission of clinical data. Health information exchange and semantic understanding are critical for improved outcomes, personalized medicine, comparative effectiveness research, and cost control. While there is a growing focus on this, sharing patient information remains difficult due to a lack of standardization and general incompatibility between electronic health record products. There is a need for well-designed, oncology-specific interoperability standards. Thus ASCO is developing standards to improve the quality and insight of cancer care. Methods: ASCO volunteers formed a Standards Work Group (Standards WG) in 2012, and ASCO engaged an independent consulting firm to perform the technical work. The Standards WG first developed an interoperable standard with broad application that would also be a foundation for future standards work. They adapted ASCO’s Breast Cancer Adjuvant Treatment Plan and Summary (Breast TPS), which was originally developed as a paper-based form. This adaptation required extensive work involving input from medical and surgical oncologists, ASCO staff, and the consultants. This preparatory work was vital to define and disambiguate clinical concepts. Some value sets in the original Breast TPS were replaced with National Cancer Institute value sets. Multiple oncology and standards stakeholders reviewed the draft to ensure accurate representation of the data and harmonization with related standards. Results: The standard was developed using the Health Level Seven International (HL7) Clinical Document Architecture, a widely used XML-based markup standard with national and international recognition. The draft Breast Cancer Adjuvant Treatment Plan and Summary Standard was successfully balloted through HL7 in May 2013 and will subsequently be published for trial use in late 2013. Conclusions: The Breast Cancer Adjuvant Treatment Plan and Summary Standard will improve quality by allowing providers to efficiently transmit clinical data with semantic meaning to health professionals, patients, quality improvement initiatives, and registries.

Principles of Safe Practice Using an Oncology EHR System for Chemotherapy Ordering, Preparation, and Administration, Part 2 of 2

Integrating electronic health records into the oncology office, while taking into consideration the principles of electronic health record usage, is a great way to improve the chemotherapy ordering and administration process.

Principles of Safe Practice Using an Oncology EHR System for Chemotherapy Ordering, Preparation, and Administration, Part 1 of 2

An outline of broad principles that should be considered when integrating an electronic health record, and in particular, a chemotherapy ordering module, into practice.

Jumping translocations in leukemia

Jumping translocations are an unusual phenomenon and have been rarely reported in leukemia. We report three patients whose leukemic cells had multiple related clones resulting from unbalanced jumping translocations of 1q and 7q to chromosomes 1, 8, 15, 21 and 22. The chromosome findings, together with limited published reports, suggest that jumping translocations are new non-random rearrangements and may represent poor prognostic biological markers. Although their origin is unknown, circumstantial evidence suggests that telomeric ends of receptor chromosomes may play a role in stabilizing jumping translocations in dividing malignant cells.

Myelodysplastic syndrome transforming to acute promyelocytic-like leukemia with trisomy and rearrangement of chromosome 11

Variants of the t(15;17)(q22;q12-q21) chromosomal rearrangement associated with acute promyelocytic leukemia (APL) have been previously described and they frequently involve either chromosome 15 and/or 17. Previously we reported a rare variant t(11;17). We now describe two patients with myelodysplastic syndrome (MDS) that transformed to APL-like leukemia. Both had trisomy 11 at the diagnosis of APL-like leukemia. Following treatment for APL, patient 1 reverted to MDS and showed a normal karyotype. When leukemia recurred, his bone marrow karyotype was 47,XY,t(4;11), +11,der(22)t(1;22). Both patients were treated with all-trans retinoic acid (ATRA) for APL for 5 weeks, but failed to respond. The karyotype of patient 1 after ATRA treatment was 46,XY,t(4;11); the trisomy 11 had been lost and the bone marrow was replaced with immature myeloblasts without promyelocytes. In patient 2, the karyotype remained the same as at diagnosis, i.e., 47,X,-Y,dir ins(4;7),del(5), +6,del(7), +8, + 11,-18. Molecular analysis by reverse transcriptase PCR analysis showed the presence of wild type retinoic acid receptor alpha (RARA) and the absence of the PML-RARA chimeric gene associated with t(15;17). Additional analysis of PLZF, a new zinc finger gene associated with t(11;17), also showed the absence of this hybrid gene. These data support the concept that APL is a heterogeneous disorder and that variants with chromosome 11 rearrangement exist that do not respond to ATRA.

Number of helper T cells and phytohemagglutinin stimulation correlate in cancer patients

Mononuclear cells from 12 normal controls (co), 10 advanced untreated (c1), and 6 advanced treated cancer patients (c2) have been isolated. The numbers of mononuclear cells bearing Leu1, Leu2, Leu3, Leu2/HLA-DR and LeuM3 were measured with a fluorescence-activated cell sorter. Only the quantity of helper T cells (Leu3) was decreased in cancer patients (co: 0.89, cl: 0.32, c2: 0.44 x 10(9)/l). Expression of all other markers, including activated suppressor T cells (Leu2/HLA-DR), did not differ significantly from the control. The proliferation of the lymphocytes was determined in a phytohemagglutinin-culture assay. The cancer groups showed a significantly decreased response (co: 95.8 x 10(9), cl: 28.7 x 10(9), c2: 25.7 x 10(9) cpm). These values correlated with the number of helper T cells but not with the suppressor T cells. Monocytes of cancer patients absorbed significantly more immunoglobulins than the monocytes of controls. The addition of indomethacin or isoprinosine to phytohemagglutinin-culture assay increased the proliferation of lymphocytes from both the cancer patients and normal controls.

Iatrogenic and idiopathic acute myelogenous leukemia: a comparison of clinical features and treatment complications

We have compared the clinical and laboratory features as well as treatment complications observed in 6 patients with iatrogenic acute myelogenous leukemia (I-AML) with those of 26 patients with idiopathic acute myelogenous leukemia (AML). I-AML patients were significantly younger and their disease appeared less virulent on admission than in the AML patients. Following identical chemotherapy, hemorrhagic complications and the need for platelet support were found to be similar for both groups. Major infections, including systemic candidiasis and Gram-negative septicemias, occurred 3 times more frequently among I-AML than AML patients. More marked suppression and delayed regeneration of the bone marrow also occurred in I-AML patients. These observations and other factors, such as post-splenectomy state and inherent immune deficiency among surgically staged lymphoma patients as well as radiation induced immunologic impairment, may have contributed to the increased propensity to develop infection observed in this group of patients. Five of the 6 I-AML and 17 of the 26 AML patients achieved remission. We attribute the satisfactory outcome in our I-AML patients to treatment in a protective environment and availability of facilities for hematologic supportive care.

Role of plasmapheresis in primary biliary cirrhosis

Five patients with primary biliary cirrhosis and prolonged cholestasis underwent intensive plasmapheresis. The indications for plasmapheresis included intractable pruritus or hypercholesterolemia and xanthomatous neuropathy. Patients noted a rapid improvement of pruritus and fatigue which was sustained as long as plasmapheresis was continued. Cholesterol levels were lowered an average of 10.3 mmol/l and xanthomata were reduced in three of four patients. Two patients with painful neuropathy caused by xanthomata experienced relief of this symptom. The liver and spleen size were not affected by plasmapheresis, and activities of aminotransferases, alkaline phosphatase and titres of mitochondrial antibody remained unchanged. We conclude that plasmapheresis has a role in the therapeutic management of patients with advanced primary biliary cirrhosis who are disabled by the complications of pruritus, xanthomatous neuropathy, or hypercholesterolemia with xanthoma formation.

Combination chemotherapy with high-dose methotrexate, bleomycin, and cisplatin in management of head and neck squamous cell carcinoma

Fifty-nine patients with stage IV head and neck squamous cell cancer were treated with an intensive induction chemotherapy consisting of high-dose methotrexate-leucovorin, bleomycin, and cisplatin. Forty-five patients had recurrent disease following surgery and/or radiation therapy. The response rate in this group was 22%, with a median response duration of 10 weeks and a median survival of 19 weeks. The median survival in responders was 20 weeks and in nonresponders 18 weeks. Fourteen previously untreated patients (13 T4 and one T2) received identical chemotherapy followed by radiation and/or surgery. The response to chemotherapy in previously untreated patients was impressively higher (93%). These patients had a median survival of 48 weeks, and 30% survived 2 years. The initial chemotherapy did not compromise the succeeding radiation therapy or surgery. Toxicities were frequent, but generally well tolerated. It is concluded that prior surgery and/or radiation therapy compromises the efficacy of subsequent chemotherapy in head and neck cancer. Responses to intensive chemotherapy prior to surgery and/or radiation therapy are excellent in patients with T4 tumors and provides a basis for further intensive treatment in attempts to augment cure rates.

The clinical effectiveness and safety of chronic plasmapheresis in patients with primary biliary cirrhosis

Primary biliary cirrhosis (PBC) is a chronic nonsuppurative, destructive cholangitis, whose etiology is unknown. Morbidity arises early from pruritus and later from hypercholesterolemia with xanthoma formation. Therapy is supportive and directed at the complications of cholestasis. Plasmapheresis has been reported to benefit patients with hyperlipidemia and PBC; thus a pilot study of plasmapheresis utilizing the Haemonetics Model 30 with replacement by albumin and saline was conducted. Five patients (four female and one male) with a mean age of 43 (range 29-58) and a mean duration of illness of 9.5 years (range 6-21) with marked jaundice, xanthomas, xanthelasma, hepatomegaly, fatigability, anorexia, and pruritus, as well as mild nausea were studied. Peripheral neuropathy was present in two patients. Two patients had splenomegaly. Two patients had an associated Sjogren syndrome. All patients had high serum bilirubin, alkaline phosphatase, and cholesterol levels and mild elevations in aspartate amino transferase and alanine amino transferase activities. Immune complexes measured in four patients were present. Antimitochondrial antibody titers were significant in all patients. Patients underwent a mean of 63 plasmapheresis procedures over a mean of 112 weeks removing a mean of 94.7 liters of plasma. No serious toxicity was seen. All patients showed a reduction in pruritus, xanthomas, xanthelasmas, and serum cholesterol values. The two patients who had evidence of Sjogren syndrome noted subjective improvement. All patients who had fatigue, anorexia and nausea also noted moderate improvement. There was no change in hepatomegaly or splenomegaly in patients demonstrating such organomegaly. Liver function did not change significantly. Overall, four patients had improvement in their condition and one patient achieved stability.(ABSTRACT TRUNCATED AT 250 WORDS)

Extraskeletal Ewing sarcoma with computed tomography correlation

Extraosseous Ewing sarcoma--a rare clinical entity--is described and the radiographic and histologic features discussed. Histologically this type of tumor may be differentiated from other soft tissue malignancies, but the ultrastructural glycogen content of the cytoplasm makes it frequently inseparable from the conventional osseous form of Ewing sarcoma. In spite of the presence of a huge paraosseal mass with bone erosion or periosteal new bone, computed tomography was the only preoperative modality able to provide evidence of non-involvement of the marrow cavity. However, histologic documentation is necessary to prove that one is dealing with a totally extraosseous Ewing sarcoma.

Role of opsonins in clinical response to granulocyte transfusion in granulocytopenic patients

Fifty febrile severely granulocytopenic patients were given four daily transfusions of 2.2 X 10(10) normal donor granulocytes. Twenty-three (46 percent) responded clinically, although both responders and nonresponders were similar in clinical characteristics at the outset. This study examines the relation between serum opsonic activity before initiation of granulocyte administration and clinical response. Opsonic activity to three test organisms (Escherichia coli 286 and ON 2, and Staphylococcus aureus) and to 15 blood stream isolates from 14 patients was measured as serum-dependent uptake of heat-killed 14C-labeled bacteria by normal donor leukopheresis granulocytes in an in vitro assay and compared with results obtained with a standard normal serum in each assay. At a concentration of 8 percent serum, all patient groups were equivalent to standard (90 to 102 percent) for the three test organisms. When rate-limiting concentrations of serum (1 to 2 percent) were employed, opsonic activity remained similar to standard for S. aureus in all patient groups and for the two E. coli strains in responders (82 to 98 percent). In contrast, opsonins for E. coli decreased to 41 to 50 percent of standard in nonresponders (p less than 0.01). When patients with proved infection were separately analyzed, opsonin activity for E. coli 286 and ON 2 was significantly greater in responders than nonresponders (73.6 versus 34.9 percent and 124.8 versus 58.1 percent, respectively for the two strains) (p less than 0.01). Patients with opsonin activity of 50 percent or greater of standard had a greater response rate (73 versus 19 percent and 45 versus 0 percent for the two E. coli strains) (p less than 0.005 and p = 0.08, respectively). Eight of 10 patients with 75 percent or greater of standard for opsonic activity against their own blood stream isolates also responded, whereas zero of four with opsonins less than 75 percent of standard had a favorable outcome. These results indicate that serum opsonic activity may be a determinant of clinical response to granulocyte transfusion in infected granulocytopenic patients and may be predictive of outcome. We conclude that opsonic activity should be assessed in such patients before granulocyte administration and suggest a trial of plasma infusion in opsonin-deficient patients.

Therapeutic leukapheresis in a patient with hairy cell leukemia presenting with a white cell count greater than 500,000 /microliter

A 49-year-old man presented with anemia, thrombocytopenia, and white cell count over 500,000 /microliters. Studies were diagnostic of hairy cell leukemia. Splenectomy was considered hazardous because of his general poor condition and the danger of leukostasis from the high white cell count. He was managed with leukapheresis with reduction in the white cell count from 556,000 /microliters to 20,000 /microliters followed by an uneventful splenectomy. Leukapheresis should be considered for patients with hairy cell leukemia and extremely elevated white cell counts.

Acetylcholine receptor antibodies in myasthenia gravis

A multivariate statistical analysis of levels of serum acetylcholine receptor antibody (AChR Ab) obtained from 197 patients with various clinical forms of myasthenia gravis (MG) was performed. Elevated AChR Ab levels are specific for MG, but normal AChR Ab levels do not rule out MG. Patients in remission or with purely ocular MG had the lowest incidence of elevation of serum AChR Ab levels, while patients with generalized, severe MG, particularly in the presence of thymoma, tended to have the greatest antibody elevations. Corticosteroids depressed AChR Ab levels, but thymectomy did not exert a consistent effect on antibody levels within a 24- to 30-month postoperative period. The relatively low 55% positivity of antibody elevations in all 197 patients probably reflects the use of heterologous (rat) AChR.

Plasmapheresis in refractory generalized myasthenia gravis

A group of 16 patients with severe generalized myasthenia gravis (MG) (five with thymoma) that was resistant to anticholinesterases, thymectomy, and corticosteroids were treated by plasmapheresis. Twelve patients showed an excellent clinical response. Plasmapheresis is an effective treatment modality for many patients with severe generalized MG resistant to other forms of therapy. Unfortunately, the beneficial results are only transient and periodic plasmapheresis treatments are necessary.

Filtration versus gravity leukapheresis in febrile granulocytopenic patients: a randomized prospective trial

Forty-eight patients with fever greater than 38.3 degrees C for at least 24 hr despite broad spectrum antibiotics and an absolute granulocyte count less than 1000/microliter were randomly allocated to 4 days of granulocyte transfusions obtained by leukapheresis using filtration (n = 27) or gravity (n = 21) techniques, the latter permitting simultaneous nonmechanical collection of granulocytes and platelets utilizing hydroxyethyl starch as a sedimenting agent. Patient characteristics and dose of granulocytes obtained from both techniques were similar. Complete response to granulocyte transfusions was established by a reduction in temperature to less than 37.2 degrees C sustained for at least 48 hr after the fourth transfusion with sterilization of cultures where previously positive and diminution of measurable infection when present. This occurred in 6/21 (29%) for gravity leukapheresis and 9/27 (33%) for filtration leukapheresis. An additional group had diminution in temperature and clinical improvement during transfusions (6/21 gravity leukapheresis versus 10/27 filtration leukapheresis). Eighty-six percent of patients transfused with gravity leukapheresis cells were alive at day 20 compared with 81% for filtration leukapheresis cells. Transfusion reactions were comparable. Thus, gravity leukapheresis appears to be as efficacious as filtration leukapheresis for treating granulocytopenic febrile patients, with the added advantages of availability to any blood bank without new equipment, of having platelets as by-products, and of not requiring donor heparinization.

High dose methotrexate followed by citrovorum factor reversal in patients with advanced cancer

High dose methotrexate followed by citrovorum factor reversal has been utilized in twenty-six patients with advanced cancer. Four of 10 patients with head and neck cancer had an objective response. One of 7 patients with metastatic osteosarcoma to the lungs had stabilization with twenty treatments over 23 months. One patient with acute lymphocytic leukemia developed marrow aplasia but did not attain remission. The regimen was well tolerated when meticulous attention was paid to hydration, urine alkalinization, renal function and third space fluid accumulation. Life-threatening or lethal toxicity was encountered when these phenomena were not scrupulously observed.

Therapeutic leukopheresis of acute myelo-monocytic leukemia in pregnancy

Cytopheresis techniques have proven useful in the provision of platelets and granulocytes for transfusion to the pancytopenic patient. Mechanical cell removal has been applied to the treatment of chronic myelocytic and lymphocytic leukemias and the Sezary syndrome. We have treated a 16-year-old pregnant acute myelomonocytic leukemia (AMML) patient for 12 weeks solely with the use of intensive leukopheresis utilizing batch processing centrifugation and packed red cell transfusions. The patient presented with a white blood cell count of 54,000/mm3 with 64% myelomonoblasts, a platelet count of 45,000/mm3, marked gingival hyperplasia, and splenomegaly. Patient had a normal spontaneous delivery of a 2.5-kg male infant without complications. At the time of delivery, 12 weeks later, the white blood count had fallen to 4,9000/mm3 with 8% blasts and the platelet count had risen to over 100,000/mm3. Gingival hyperplasia decreased and the patient felt well. We have treated an additional small group of patients with acute myelogenous leukemia (AML) with high white counts with short term intensive leukopheresis followed by chemotherapy with promising results.