Personal Payments from Pharmaceutical Companies to Authors of Oncology Clinical Practice Guidelines

BACKGROUND

Oncologists who author clinical practice guidelines frequently have financial relationships with the pharmaceutical industry. It is unknown whether participation on clinical practice guideline committees is associated with differences in the amounts of industry money received.

MATERIALS AND METHODS

We conducted a nested case-control study from August 2013 to December 2018. We manually abstracted membership records of National Comprehensive Cancer Network (NCCN) Guidelines committees for the 20 most common cancers and linked to Open Payments. The study sample included medical oncologists selected to join an NCCN Guidelines committee ("joiners") during the study period. Joiners were matched 1:2 to medical oncologists who had no participation on NCCN committees (controls) by gender, NCCN institution, and medical school graduation year. We performed difference-in-differences (DiD) estimation to assess whether selection to an NCCN committee was associated with the dollar value of payments received from industry, using generalized estimating equations to address correlation between matched pairs and between repeated observations of the same pair.

RESULTS

During the study period, 54 physicians joined an NCCN Guidelines committee. These physicians received more payments than matched controls in the year prior to joining ($11,259 vs. $3,427; p = .02); this difference did not increase in the year after joining (DiD = $731; p = .45).

CONCLUSION

Medical oncologists selected to NCCN Guidelines committees had greater financial ties to industry than their peers. The potential influence of industry in oncology clinical practice guidelines may be reduced through the selection of committee members with fewer ties to industry.

IMPLICATIONS FOR PRACTICE

Oncologists who author clinical practice guidelines frequently have financial conflicts of interest with the pharmaceutical industry. This creates concern about the potential for industry influence on guidelines. However, it is unknown whether oncologists who author guidelines have greater industry relationships than their peers. This study compared medical oncologists who were newly selected to join a National Comprehensive Cancer Network (NCCN) Guidelines panel with medical oncologists at the same institutions and at similar career stages. At the time they joined, oncologists joining NCCN Guidelines panels had received more than three times the dollar value of industry payments than their peers. The potential for industry influence may be reduced by the selection of less-conflicted panel members.

Long-term immunosuppression and multiple transplants predispose systemic lupus erythematosus patients with cytopenias to hematologic malignancies

Cytopenias in systemic lupus erythematosus (SLE) require clinical and laboratory workup and bone marrow (BM) examination to determine the cause and for appropriate patient management. Common causes include an increase in SLE activity, immune-mediated hemolysis, iron deficiency, antiphospholipid antibody syndrome, infection, or the effect of medications. We retrospectively evaluated the clinical and laboratory findings of patients with SLE and cytopenias who had undergone BM studies to determine the indicators of malignancy.We retrospectively reviewed medical records of patients with SLE who presented with cytopenias for their disease course, medications, laboratory parameters and documented the spectrum of morphological changes in BM including CD34 expression.Twenty patients with SLE had undergone BM biopsy for evaluation of cytopenias. 14/20 (70%) of the patients had reactive BM, and the rest had hematologic malignancies involving the BM. Of these 14 patients, 8 had hypocellular marrow with loss of precursor cells (low CD34), 4 had left shift in myeloid lineage, 3 had serous atrophy, and 1had multilineage dysplasia. The 6 patients with hematologic malignancies included 2 with diffuse large B cell lymphoma, and one each of natural killer/T cell lymphoma, post-transplant lymphoproliferative disorder, Hodgkin lymphoma, and myelodysplastic syndrome evolving to acute myelogenous leukemia. The presence of autoantibodies, SLE activity, and lupus nephritis were comparable in patients with and without neoplasia. However, the duration of the use of multiple immunosuppressants, years since renal transplant (22 vs 10), multiple transplants, and the presence of other autoimmune diseases were greater in those with neoplasia. Two of the 14 patients with non-neoplastic BM and 1 with the neoplastic BM had nonhematological malignancy.Clinical and laboratory findings, the number of transplants, and the use of immunosuppressive agents can guide physicians to identify patients with a higher risk of developing hematologic malignancy. BM findings of cytopenia in SLE are often due to increased disease activity causing global cell death and dysmaturation. SLE patients presenting with cytopenias, with a history of long-term exposure to immunosuppressive drugs, should be regularly screened for hematologic and nonhematologic malignancies.

Post-allogeneic hematopoietic stem cell transplantation viral reactivations and viremias: a focused review on human herpesvirus-6, BK virus and adenovirus

Human cytomegalovirus and Epstein-Barr virus have been recognized as potential drivers of morbidity and mortality of patients undergoing allogeneic stem cell transplantation for years. Specific protocols for monitoring, prophylaxis and pre-emptive therapy are in place in many transplant settings. In this review, we focus on the next three most frequent viruses, human herpesvirus-6, BK virus and adenovirus, causing reactivation and/or viremia after allogeneic transplant, which are increasingly detected in patients in the post-transplant period owing to emerging techniques of molecular biology, recipients' characteristics, treatment modalities used for conditioning and factors related donors or stem cell source. Given the less frequent detection of an illness related to these viruses, there are often no specific protocols in place for the management of affected patients. While some patients develop significant morbidity (generally older), others may not need therapy at all (generally younger or children). Furthermore, some of the antiviral therapies used are potentially toxic. With the addition of increased risk of secondary infections, risk of graft failure or increased risk of graft-versus-host disease as well as the relationship with other post-transplant complications, the outcomes of patients with these viremias remain unsatisfactory and even long-term survivors experience increased morbidity.

Germ cell tumors and associated hematologic malignancies evolve from a common shared precursor

Germ cell tumors (GCTs) are the most common cancer in men between the ages of 15 and 40. Although most patients are cured, those with disease arising in the mediastinum have distinctly poor outcomes. One in every 17 patients with primary mediastinal nonseminomatous GCTs develop an incurable hematologic malignancy and prior data intriguingly suggest a clonal relationship exists between hematologic malignancies and GCTs in these cases. To date, however, the precise clonal relationship between GCTs and the diverse additional somatic malignancies arising in such individuals have not been determined. Here, we traced the clonal evolution and characterized the genetic features of each neoplasm from a cohort of 15 patients with GCTs and associated hematologic malignancies. We discovered that GCTs and hematologic malignancies developing in such individuals evolved from a common shared precursor, nearly all of which harbored allelically imbalanced p53 and/or RAS pathway mutations. Hematologic malignancies arising in this setting genetically resembled mediastinal GCTs rather than de novo myeloid neoplasms. Our findings argue that this scenario represents a unique clinical syndrome, distinct from de novo GCTs or hematologic malignancies, initiated by an ancestral precursor that gives rise to the parallel evolution of GCTs and blood cancers in these patients.

Single-cell genomics reveals the genetic and molecular bases for escape from mutational epistasis in myeloid neoplasms

Large-scale sequencing studies of hematologic malignancies have revealed notable epistasis among high-frequency mutations. One of the most striking examples of epistasis occurs for mutations in RNA splicing factors. These lesions are among the most common alterations in myeloid neoplasms and generally occur in a mutually exclusive manner, a finding attributed to their synthetic lethal interactions and/or convergent effects. Curiously, however, patients with multiple-concomitant splicing factor mutations have been observed, challenging our understanding of one of the most common examples of epistasis in hematologic malignancies. In this study, we performed bulk and single-cell analyses of patients with myeloid malignancy who were harboring ≥2 splicing factor mutations, to understand the frequency and basis for the coexistence of these mutations. Although mutations in splicing factors were strongly mutually exclusive across 4231 patients (q < .001), 0.85% harbored 2 concomitant bona fide splicing factor mutations, ∼50% of which were present in the same individual cells. However, the distribution of mutations in patients with double mutations deviated from that in those with single mutations, with selection against the most common alleles, SF3B1K700E and SRSF2P95H/L/R, and selection for less common alleles, such as SF3B1 non-K700E mutations, rare amino acid substitutions at SRSF2P95, and combined U2AF1S34/Q157 mutations. SF3B1 and SRSF2 alleles enriched in those with double-mutations had reduced effects on RNA splicing and/or binding compared with the most common alleles. Moreover, dual U2AF1 mutations occurred in cis with preservation of the wild-type allele. These data highlight allele-specific differences as critical in regulating the molecular effects of splicing factor mutations as well as their cooccurrences/exclusivities with one another.

Trends in Female Representation on NCCN Guideline Panels

BACKGROUND

NCCN produces highly influential disease-specific oncology clinical practice guidelines. Because the number of women in academic oncology has increased, we assessed whether the composition of NCCN Guidelines Panels reflected this trend.

METHODS

Using historical guidelines requested from NCCN, we investigated time trends for female representation on 21 NCCN Guidelines Panels and analyzed the trends for female-predominant cancers (breast, ovarian, uterine, and cervical) compared with all cancers.

RESULTS

From 2013 to 2019, there was an increase from 123 women of 541 total panelists (22.7%) to 175 women of 542 panelists (32.3%). Within the 4 female-predominant cancers, the increase was more rapid: from 30 of 101 total panelists (29.7%) to 66 of 118 panelists (56.4%). Excluding female-predominant cancers, increases were minimal.

CONCLUSIONS

There could be multiple explanations for these differing trends, including the possibility of more rapid increases in the underlying pool of female physician-scientists in female-predominant specialties or more efforts to increase the representation of women in decisions about the standard of care in cancers predominantly affecting women.

The association between drug industry payments and NCCN guideline panel membership

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Background: The high frequency of financial relationships between the pharmaceutical industry and influential oncologists who author clinical practice guidelines may influence guideline recommendations. Therefore, we assessed the financial relationships held by NCCN Guidelines panelists before and after joining the panel, compared to those held by a matched set of oncologists. Methods: Membership of NCCN Guidelines panels for the 20 most common cancers was obtained from archival guidelines and linked manually to Open Payments records of industry payments. We identified physicians who newly joined an NCCN panel during the August 2013-December 2018 study period, and we included medical oncologists who had at least 1 year of Open Payments data before and after joining. These medical oncologists who joined an NCCN panel (panelists) were matched 1:2 to medical oncologists with the same gender, institutional affiliation, and medical school graduation year, who did not join an NCCN panel (non-panelists). The dollar value of industry payments was then calculated over the 1 year before (pre-join) and after (post-join) the date that each panelist joined. We used generalized linear models to assess differences in industry payments between the panelists and matched non-panelists in the pre-join period. We used difference-in-difference estimation (DiD) to assess whether joining an NCCN panel was associated with increased payments in the post-join period. Results: There were 54 panelists and 108 non-panelists (matched from 1447 eligible oncologists at NCCN institutions). Mean per-oncologist payments among panelists were greater than non-panelists in the pre-join period ($11,259 vs $3,427, p = 0.02). From the pre-join to post-join period there was a similar increase in mean per-oncologist payments among panelists and non-panelists ($2,236 vs. $1,569, DiD estimate +$667, p = 0.77). Conclusions: Medical oncologists who were selected to an NCCN Guidelines panel had greater financial ties to industry compared to peer oncologists who were not selected. This difference was present prior to joining; oncologists did not experience a greater increase in financial payments from industry in the 1-year period after joining an NCCN panel. These results suggest an opportunity to reduce the potential influence of industry in oncology clinical practice guidelines through the selection of guideline panelists with fewer ties to industry.

Incidence and Associated Risk Factors of Chemotherapy-Induced Cardiomyopathy in the African American and Afro-Caribbean Populations

BACKGROUND

Chemotherapy-induced cardiomyopathy (CICM) and heart failure are major complications of cancer therapeutics and can result in significant morbidity and mortality. There is limited data on the incidence and risk factors of CICM in African American and Afro-Caribbean patients.

METHODS

We performed a retrospective chart review to evaluate the baseline characteristics that may predispose to CICM. Patients were African American and Afro-Caribbean ethnicity. Data was collected between 2014 to 2018. Patients had transthoracic echocardiogram (TTE) or multigated acquisition scan (MUGA) prior to cancer therapy and every 3 months thereafter, until the end of the regimen. CICM was defined as a ≥16% reduction in LVEF or ≥10% reduction in LVEF to a value <50%.

RESULTS

A total of 230 patients were studied, with a mean age of 54±12 years with 91% were females, BMI 30±4, 81% were taking anthracyclines, 87% were on Trastuzumab while 5% were receiving both medications. The prevalence of comorbidities was as follows: hypertension 8%, diabetes mellitus 8%, ESRD 8%, dyslipidemia 8%, CAD 7%. The incidence of CICM was 7% overall, while it was 6% and 8% for patients taking Anthracyclines and Trastuzumab, respectively. CICM was associated with dyslipidemia (r= .22, p= .001), hypertension (r= .12, p= .05), baseline ejection fraction (r= -.21, p= .001) and concomitant use of radiation therapy (r= .147, p= .02), but not with age, gender, beta blocker use, angiotensin converting enzyme inhibitor use, number of chemotherapy cycles or stage of the malignancy. On multivariate analysis CICM was independently associated with baseline ejection fraction (β= -.193, P= .003) and dyslipidemia (β= -.20, P= .003).

CONCLUSION

The incidence of CICM in African Americans and Afro-Caribbean is higher than reported in the general population. Dyslipidemia and baseline ejection fraction were seen as the major risk factors associated with the higher incidence of CICM.

Doxorubicin-associated takotsubo cardiomyopathy in a patient with adult T-cell leukemia/lymphoma

This case highlights the first reported association of doxorubicin with takotsubo cardiomyopathy (TC) presenting as cardiogenic shock during the first continuous infusion in a patient with adult T-cell leukemia/lymphoma. We aim to raise awareness to recognize and distinguish between irreversible doxorubicin-associated cardiomyopathy and reversible doxorubicin-associated TC in patients with cancer.

Abstract 105: Improving Compliance and Follow-Up for Chemotherapy-Induced Heart Failure in an Urban Underserved Tertiary Hospital

Background: Chemotherapy-induced cardiomyopathy and heart failure are major complications of cancer therapy and can result in significant morbidity and mortality. Unfortunately, there is a high risk of poor compliance and loss to follow-up in underserved areas.

Objective: Create a pathway to improve detection and management of chemotherapy-induced cardiotoxicity and heart failure in patients undergoing chemotherapy treatment in an urban underserved hospital.

Description: The project is performed at Kings County Hospital, a major cancer treatment center in Brooklyn, NY. Our findings indicate that over the past five years, patients with chemotherapy-induced cardiomyopathy were lost to follow-up with outpatient cardiology services. Therefore, we developed and applied a new collaborative protocol for patients who were diagnosed with any cancer undergoing treatment complicated by cardiomyopathy. The protocol is as follows; Firstly, patients are sent for a multigated acquisition (MUGA) scan prior to beginning chemotherapy, and every three months thereafter over the course of their chemotherapy treatment. The reading physician then identifies all patients with a 10% or more reduction in ejection fraction between MUGA scans, and notifies the Heart Health Center at Kings County Hospital to contact the patient with an appointment with cardiology services. At the Heart Health Center, the patient is then counseled on guideline-recommended treatment for heart failure. Further follow up with the nurse practitioner is done for medication reconciliation, education regarding activity, weight monitoring, dietary intake, and warning symptoms for heart failure exacerbations. The patient will receive follow-up with a nutritionist for guideline directed dietary recommendations for heart failure and social work services to ensure appropriate social conditions and support. The oncology service will monitor if the patient has followed up with outpatient cardiology before continuing chemotherapy. If the patient was lost to follow up, oncology will notify the Heart Health Center and assist with providing the patient with an appointment.

Conclusions: We aim to improve compliance for follow up and guideline directed management for chemotherapy-induced heart failure in an urban underserved tertiary hospital.

Molecular cytogenetic characterization of pancreas cancer cell lines reveals high complexity chromosomal alterations

Karyotype analysis can provide clues to significant genes involved in the genesis and growth of pancreas cancer. The genome of pancreas cancer is complex, and G-band analysis cannot resolve many of the karyotypic abnormalities seen. We studied the karyotypes of 15 recently established cell lines using molecular cytogenetic tools. Comparative genomic hybridization (CGH) analysis of all 15 lines identified genomic gains of 3q, 8q, 11q, 17q, and chromosome 20 in nine or more cell lines. CGH confirmed frequent loss of chromosome 18, 17p, 6q, and 8p. 14/15 cell lines demonstrated loss of chromosome 18q, either by loss of a copy of chromosome 18 (n = 5), all of 18q (n = 7) or portions of 18q (n = 2). Multicolor FISH (Spectral Karyotyping, or SKY) of 11 lines identified many complex structural chromosomal aberrations. 93 structurally abnormal chromosomes were evaluated, for which SKY added new information to 67. Several potentially site-specific recurrent rearrangements were observed. Chromosome region 18q11.2 was recurrently involved in nine cell lines, including formation of derivative chromosomes 18 from a t(18;22) (three cell lines), t(17;18) (two cell lines), and t(12;18), t(15;18), t(18;20), and ins(6;18) (one cell line each). To further define the breakpoints involved on chromosome 18, YACs from the 18q11.2 region, spanning approximately 8 Mb, were used to perform targeted FISH analyses of these lines. We found significant heterogeneity in the breakpoints despite their G-band similarity, including multiple independent regions of loss proximal to the already identified loss of DPC4 at 18q21.

Quantitative analysis of quinidine analogs using ion-pairing HPLC

Quinidine, a useful antiarrhythmic compound, is usually contaminated with dihydroquinidine, a compound that itself shows potent antiarrhythmic activity. Complete hydrogenation of quinidine followed by conversion to dihydroquinidine derivatives was explored as a basis for eliminating the analytical problems inherent in the quality control of quinidine products and for determining their pharmacological potency and pharmacokinetic parameters without interfering impurities. Attempts to resolve the quinidine analogs, dihydrocupreidine, and its benzoyloxy ester failed with normal and reversed-phase chromatography. Ion-pairing chromatography using n-octanesulfonate in methanol:water proved successful. Using 9-hydroxy-4-methoxy acridine as internal standard, separation and quantitation of the dihydroquinidine analogs from spiked plasma samples was achieved with 92 to 95% efficiency.

First-pass metabolism of ethinyl estradiol in dogs and rats

The contraceptive steroid ethinyl estradiol was extensively metabolized when given orally in solution to dogs. It was thought at first that metabolism occurred exclusively in the liver. However, use of standard equations to predict the oral bioavailability of drugs known to be metabolized by hepatic first pass resulted in significantly higher values than those obtained experimentally. To rationalize the data and to determine whether ethinyl estradiol also is metabolized in the gut wall during absorption, metabolism in rats was studied. The drug was administered in solution intraduodenally, intraportally, and intravenously as a bolus by first-order infusion. The results indicate that, in rats, 40% of the drug is metabolized by the gut wall and 79% of the drug in the portal blood is metabolized by the liver intraduodenal administration.