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Yoo JW, Laszkowska M, Mendelsohn RB. The Role of Screening and Early Detection in Upper Gastrointestinal Cancers. Hematol Oncol Clin North Am 2024; 38:693-710. [PMID: 38431494 DOI: 10.1016/j.hoc.2024.01.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/05/2024]
Abstract
Upper gastrointestinal cancers are among the leading causes of cancer deaths worldwide with exceptionally poor prognosis, which is largely attributable to frequently delayed diagnosis. Although effective screening is critical for early detection, the highly variable incidence of upper gastrointestinal cancers presents challenges, rendering universal screening programs suboptimal in most populations globally. Optimal strategies in regions of modest incidence, such as the United States, require a targeted approach, focused on high-risk individuals based on demographic, familial, and clinicopathologic risk factors. Assessment of underlying precancerous lesions has key implications for risk stratification and informing clinical decisions to improve patient outcomes.
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Affiliation(s)
- Jin Woo Yoo
- Gastroenterology, Hepatology and Nutrition Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA.
| | - Monika Laszkowska
- Gastroenterology, Hepatology and Nutrition Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA
| | - Robin B Mendelsohn
- Gastroenterology, Hepatology and Nutrition Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA
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2
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Li Y, Hahn AI, Laszkowska M, Jiang F, Zauber AG, Leung WK. Global burden of young-onset gastric cancer: a systematic trend analysis of the global burden of disease study 2019. Gastric Cancer 2024:10.1007/s10120-024-01494-6. [PMID: 38570392 DOI: 10.1007/s10120-024-01494-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2023] [Accepted: 03/13/2024] [Indexed: 04/05/2024]
Abstract
BACKGROUND While gastric cancer is generally declining globally, the temporal trend of young-onset (< 40 years) gastric cancer remains uncertain. We performed this analysis to determine the temporal trends of young-onset gastric cancer compared to late-onset cancer (≥ 40 years). METHODS We extracted cross-sectional data from the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2019. The burden of gastric cancer from 1990 to 2019 was assessed through indicators including incidence and mortality rates, which were classified at global, national, and regional levels, and according to socio-demographic indexes (SDI) and age or sex groups. Joinpoint regression analysis was used to identify specific years with significant changes. The correlation between AAPC with countries' average SDI was tested by Pearson's Test. RESULTS The global incidence rate of young-onset gastric cancer decreased from 2.20 (per 100,000) in 1990 to 1.65 in 2019 (AAPC: - 0.95; 95% confidence interval [CI] - 1.25 to - 0.65; P < 0.001). Late-onset cancer incidence also decreased from 59.53 (per 100,000) in 1990 to 41.26 in 2019 (AAPC: - 1.23; 95% CI - 1.39 to - 1.06, P < 0.001). Despite an overall decreasing trend, the incidence rate of young-onset cancer demonstrated a significant increase from 2015 to 2019 (annual percentage change [APC]: 1.39; 95% CI 0.06 to 2.74; P = 0.041), whereas no upward trend was observed in late-onset cancer. Mortality rates of young- and late-onset cancer both exhibited a significant decline during this period (AAPC: - 1.82; 95% CI - 2.15 to - 1.56; P < 0.001 and AAPC: - 1.69, 95% CI - 1.79 to - 1.59; P < 0.001). The male-to-female rate ratio for incidence and mortality in both age groups have been increasing since 1990. While countries with high SDI have had a greater decline in the incidence of late-onset gastric cancer (slope of AAPC change: - 0.20, P = 0.004), it was not observed in young-onset cancer (slope of AAPC change: - 0.11, P = 0.13). CONCLUSIONS The global incidence and mortality rates of both young- and late-onset gastric cancer have decreased since 1990. However, the incidence rate of young-onset cancer has demonstrated a small but significant upward trend since 2015. There was disparity in the decline in young-onset gastric cancer among male and high SDI countries. These findings could help to inform future strategies in preventing gastric cancer in younger individuals.
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Affiliation(s)
- Yunhao Li
- Department of Medicine, School of Clinical Medicine, Li Ka Shing Faculty of Medicine, Queen Mary Hospital, The University of Hong Kong, 102 Pokfulam Road, Hong Kong, China
| | - Anne I Hahn
- Department of Epidemiology & Biostatistics, Memorial Sloan Kettering Cancer Center, New York, USA
| | - Monika Laszkowska
- Gastroenterology, Hepatology, and Nutrition Service, Department of Subspecialty Medicine, Memorial Sloan Kettering Cancer Center, New York, USA
| | - Fang Jiang
- Department of Medicine, School of Clinical Medicine, Li Ka Shing Faculty of Medicine, Queen Mary Hospital, The University of Hong Kong, 102 Pokfulam Road, Hong Kong, China
| | - Ann G Zauber
- Department of Epidemiology & Biostatistics, Memorial Sloan Kettering Cancer Center, New York, USA
| | - Wai K Leung
- Department of Medicine, School of Clinical Medicine, Li Ka Shing Faculty of Medicine, Queen Mary Hospital, The University of Hong Kong, 102 Pokfulam Road, Hong Kong, China.
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Mülder DT, Hahn AI, Huang RJ, Zhou MJ, Blake B, Omofuma O, Murphy JD, Gutiérrez-Torres DS, Zauber AG, O'Mahony JF, Camargo MC, Ladabaum U, Yeh JM, Hur C, Lansdorp-Vogelaar I, Meester R, Laszkowska M. Prevalence of Gastric Precursor Lesions in Countries With Differential Gastric Cancer Burden: A Systematic Review and Meta-analysis. Clin Gastroenterol Hepatol 2024:S1542-3565(24)00227-1. [PMID: 38438000 DOI: 10.1016/j.cgh.2024.02.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2024] [Revised: 02/20/2024] [Accepted: 02/22/2024] [Indexed: 03/06/2024]
Abstract
BACKGROUND & AIMS The prevalence of precursor lesions for gastric cancer (GC) and the differential burden between countries of varying GC risk is not well-understood. We conducted a systematic review and meta-analysis to estimate the global prevalence of precursor lesions. METHODS We estimated the prevalence of atrophic gastritis (AG), gastric intestinal metaplasia (IM), and dysplasia in regions with low, medium, and high GC incidence. Because IM is an advanced manifestation of AG, we assessed the prevalence of less advanced precursors, regardless of the presence of more advanced lesions. Prevalence was sub-stratified by Helicobacter pylori infection, symptomatology, and period (<2000, 2000-2010, and >2010). RESULTS Among the 582 articles that underwent full-text review, 166 studies met inclusion criteria. The global prevalence estimates of AG, IM, and dysplasia were 25.4%, 16.2%, and 2.0%, respectively, on the basis of 126 studies that reported the prevalence of less advanced precursors, regardless of the presence of more advanced lesions. The prevalence of all precursor lesions was higher in high and medium compared with low GC incidence countries (P < .01). Prevalence of AG and IM was significantly higher among H pylori-infected individuals (P < .01) but not statistically different between symptomatic and asymptomatic individuals (P > .17). All precursors demonstrated a secular decrease in prevalence over time. CONCLUSIONS Gastric precursor lesions have differences in prevalence in regions with differential GC incidence and are associated with H pylori infection. Because of the substantial prevalence of precursor lesions in both symptomatic and asymptomatic individuals, symptomatic evaluation may not be sufficient to identify individuals at risk. These estimates provide important insights for tailoring GC prevention strategies.
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Affiliation(s)
- Duco T Mülder
- Department of Public Health, Erasmus Medical Center, Rotterdam, Netherlands
| | - Anne I Hahn
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Robert J Huang
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, California
| | - Margaret J Zhou
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, California
| | - Benjamin Blake
- Weill Cornell Medical College of Cornell University, New York, New York
| | - Omonefe Omofuma
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Rockville, Maryland
| | - John D Murphy
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Rockville, Maryland
| | | | - Ann G Zauber
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - James F O'Mahony
- Department of Public Health, Erasmus Medical Center, Rotterdam, Netherlands; School of Economics, University College Dublin, Dublin, Ireland
| | - M Constanza Camargo
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Rockville, Maryland
| | - Uri Ladabaum
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, California
| | - Jennifer M Yeh
- Department of Pediatrics, Harvard Medical School, Boston Children's Hospital, Boston, Massachusetts
| | - Chin Hur
- Division of General Medicine, Department of Medicine, Columbia University Irving Medical Center, New York, New York; Herbert Irving Comprehensive Cancer Center, Columbia University Irving Medical Center, New York, New York
| | | | - Reinier Meester
- Department of Public Health, Erasmus Medical Center, Rotterdam, Netherlands; Health Economics & Outcomes Research, Freenome Holdings Inc, San Francisco, California
| | - Monika Laszkowska
- Gastroenterology, Hepatology, and Nutrition Service, Department of Subspecialty Medicine, Memorial Sloan Kettering Cancer Center, New York, New York.
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Lumish MA, Walch H, Maron SB, Chatila W, Kemel Y, Maio A, Ku GY, Ilson DH, Won E, Li J, Joshi SS, Gu P, Schattner MA, Laszkowska M, Gerdes H, Jones DR, Sihag S, Coit DG, Tang LH, Strong VE, Molena D, Stadler ZK, Schultz N, Janjigian YY, Cercek A. Clinical and molecular characteristics of early-onset vs average-onset esophagogastric cancer. J Natl Cancer Inst 2024; 116:299-308. [PMID: 37699004 PMCID: PMC10852615 DOI: 10.1093/jnci/djad186] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Revised: 07/21/2023] [Accepted: 08/21/2023] [Indexed: 09/14/2023] Open
Abstract
BACKGROUND The rate of esophagogastric cancer is rising among individuals under 50 years of age. It remains unknown whether early-onset esophagogastric cancer represents a unique entity. This study investigated the clinical and molecular characteristics of early-onset and average-onset esophagogastric cancer . METHODS We reviewed the Memorial Sloan Kettering Cancer Center gastric, esophageal, and gastroesophageal junction cancer database. Associations between baseline characteristics and tumor and germline molecular alterations were compared between those with early-onset and average-onset esophagogastric cancer using Fisher exact tests and the Benjamini-Hochberg method for multiple-hypothesis correction. RESULTS We included 1123 patients with early-onset esophagogastric cancer (n = 219; median age = 43 years [range = 18-49 years]) and average-onset esophagogastric cancer (n = 904; median age = 67 years [range = 50-94 years]) treated between 2005 and 2018. The early-onset group had more women (39% vs 28%, P = .002). Patients with early-onset esophagogastric cancer were more likely to have a gastric primary site (64% vs 44%, P < .0001). The signet ring cell and/or diffuse type was 3 times more common in the early-onset esophagogastric cancer group (31% vs 9%, P < .0001). Early-onsite tumors were more frequently genomically stable (31% vs 18%, P = .0002) and unlikely to be microsatellite instability high (2% vs 7%, P = .003). After restricting to adenocarcinoma and signet ring cell and/or diffuse type carcinomas, we observed no difference in stage (P = .40) or overall survival from stage IV diagnosis (median = 22.7 vs 22.1 months, P = .78). CONCLUSIONS Our study supported a preponderance of gastric primary disease sites, signet ring histology, and genomically stable molecular subtypes in early-onset esophagogastric cancer. Our findings highlight the need for further research to define the underlying pathogenesis and strategies for early detection and prevention.
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Affiliation(s)
- Melissa A Lumish
- Gastrointestinal Oncology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Department of Medicine, Weill Cornell Medical College, New York, NY, USA
| | - Henry Walch
- Computational Oncology, Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Marie-Josée and Henry R. Kravis Center for Molecular Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Steven B Maron
- Gastrointestinal Oncology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Department of Medicine, Weill Cornell Medical College, New York, NY, USA
| | - Walid Chatila
- Computational Oncology, Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Marie-Josée and Henry R. Kravis Center for Molecular Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Yelena Kemel
- Robert and Kate Niehaus Center for Inherited Cancer Genomics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Anna Maio
- Robert and Kate Niehaus Center for Inherited Cancer Genomics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Geoffrey Y Ku
- Gastrointestinal Oncology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Department of Medicine, Weill Cornell Medical College, New York, NY, USA
| | - David H Ilson
- Gastrointestinal Oncology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Department of Medicine, Weill Cornell Medical College, New York, NY, USA
| | - Elizabeth Won
- Gastrointestinal Oncology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Department of Medicine, Weill Cornell Medical College, New York, NY, USA
| | - Jia Li
- Gastrointestinal Oncology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Department of Medicine, Weill Cornell Medical College, New York, NY, USA
| | - Smita S Joshi
- Gastrointestinal Oncology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Department of Medicine, Weill Cornell Medical College, New York, NY, USA
| | - Ping Gu
- Gastrointestinal Oncology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Department of Medicine, Weill Cornell Medical College, New York, NY, USA
| | - Mark A Schattner
- Gastroenterology, Hepatology and Nutrition Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Monika Laszkowska
- Gastroenterology, Hepatology and Nutrition Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Hans Gerdes
- Gastroenterology, Hepatology and Nutrition Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - David R Jones
- Department of Surgery Memorial, Sloan Kettering Cancer Center, New York, NY, USA
| | - Smita Sihag
- Department of Surgery Memorial, Sloan Kettering Cancer Center, New York, NY, USA
| | - Daniel G Coit
- Department of Surgery Memorial, Sloan Kettering Cancer Center, New York, NY, USA
| | - Laura H Tang
- Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Vivian E Strong
- Department of Surgery Memorial, Sloan Kettering Cancer Center, New York, NY, USA
| | - Daniela Molena
- Department of Surgery Memorial, Sloan Kettering Cancer Center, New York, NY, USA
| | - Zsofia K Stadler
- Gastrointestinal Oncology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Department of Medicine, Weill Cornell Medical College, New York, NY, USA
- Robert and Kate Niehaus Center for Inherited Cancer Genomics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Nikolaus Schultz
- Computational Oncology, Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Marie-Josée and Henry R. Kravis Center for Molecular Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Yelena Y Janjigian
- Gastrointestinal Oncology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Department of Medicine, Weill Cornell Medical College, New York, NY, USA
| | - Andrea Cercek
- Gastrointestinal Oncology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Department of Medicine, Weill Cornell Medical College, New York, NY, USA
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Magahis PT, Maron SB, Faleck D, Laszkowska M. Response to Yu and Fuhler et al. J Immunother Cancer 2024; 12:e008784. [PMID: 38242719 PMCID: PMC10806506 DOI: 10.1136/jitc-2024-008784] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/09/2024] [Indexed: 01/21/2024] Open
Affiliation(s)
| | - Steven B Maron
- Gastrointestinal Oncology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - David Faleck
- Gastroenterology, Hepatology, and Nutrition Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Monika Laszkowska
- Gastroenterology, Hepatology, and Nutrition Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York, USA
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Magahis PT, Satish D, Esther Babady N, Kamboj M, Postow MA, Laszkowska M, Faleck DM. Prevalence of Enteric Infections in Patients on Immune Checkpoint Inhibitors and Impact on Management and Outcomes. Oncologist 2024; 29:36-46. [PMID: 37721546 PMCID: PMC10769809 DOI: 10.1093/oncolo/oyad226] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Accepted: 07/19/2023] [Indexed: 09/19/2023] Open
Abstract
BACKGROUND Stool pathogen testing is recommended as part of the initial evaluation for patients with new-onset diarrhea on immune checkpoint inhibitors (ICIs), yet its significance has not been well-studied. We aimed to determine the impact of multiplex gastrointestinal (GI) pathogen PCR testing on the clinical course and use of immunosuppressive therapy in patients who develop diarrhea on ICIs. METHODS This retrospective cohort included individuals who underwent GI pathogen panel PCR for diarrhea on ICIs at Memorial Sloan Kettering between 7/2015 and 7/2021. The primary outcome was use of immunosuppressive therapy for suspected immunotherapy-related enterocolitis (irEC). Secondary outcomes included diarrhea severity and endoscopic and histologic disease patterns. RESULTS Among 521 ICI-treated patients tested for GI pathogens, 61 (11.7%) had a positive PCR. Compared to patients without detectable infections, patients with infections had more frequent grades 3-4 diarrhea (37.7% vs. 19.6%, P < .01) and colitis (39.3% vs. 14.7%, P < .01). However, patients with infections did not have higher rates of persistent or recurrent diarrhea and were less likely to receive steroids (P < .01) and second-line immunosuppressive agents (P = .03). In 105 patients with lower endoscopy, similar trends were observed and no differences in endoscopic severity or histologic patterns were noted between groups. CONCLUSIONS GI infections in ICI-treated patients presenting with diarrhea are linked to more severe but self-limited clinical presentations and may be optimally treated with observation and supportive care alone. Routine and timely stool pathogen testing may help avert unnecessary empiric immunosuppression for suspected irEC, which has been linked to blunted antitumor responses and numerous adverse effects.
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Affiliation(s)
- Patrick T Magahis
- M.D. Program, Weill Cornell Medical College of Cornell University, New York, NY, USA
| | - Deepika Satish
- Gastroenterology, Hepatology, and Nutrition Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Ngolela Esther Babady
- Infectious Diseases, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Clinical Microbiology Service, Department of Laboratory Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Mini Kamboj
- Infectious Diseases, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Clinical Microbiology Service, Department of Laboratory Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Michael A Postow
- M.D. Program, Weill Cornell Medical College of Cornell University, New York, NY, USA
- Melanoma Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Monika Laszkowska
- M.D. Program, Weill Cornell Medical College of Cornell University, New York, NY, USA
- Gastroenterology, Hepatology, and Nutrition Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - David M Faleck
- M.D. Program, Weill Cornell Medical College of Cornell University, New York, NY, USA
- Gastroenterology, Hepatology, and Nutrition Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
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Magahis PT, Maron SB, Cowzer D, King S, Schattner M, Janjigian Y, Faleck D, Laszkowska M. Impact of Helicobacter pylori infection status on outcomes among patients with advanced gastric cancer treated with immune checkpoint inhibitors. J Immunother Cancer 2023; 11:e007699. [PMID: 37899129 PMCID: PMC10619027 DOI: 10.1136/jitc-2023-007699] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [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] [Accepted: 09/22/2023] [Indexed: 10/31/2023] Open
Abstract
BACKGROUND Gut microbiota composition can influence cancer immunotherapy response. Recent evidence suggests Helicobacter pylori infection may reduce immune checkpoint inhibitor (ICI) efficacy in lung cancer and melanoma, but thorough characterization of this association in patients with gastric cancer is lacking. We aimed to determine the impact of H. pylori on survival in this population. METHODS This single-center, retrospective study included all ICI-treated individuals with metastatic gastric cancer and documented H. pylori status at Memorial Sloan Kettering between July 2013 and October 2021. H. pylori-positive status was defined as history of infection obtained via breath test, stool antigen test, histopathology, and/or chart documentation. Negative status was defined as explicitly negative testing, histopathology, and/or chart documentation. Primary outcomes were progression-free survival (PFS) and overall survival (OS). RESULTS Of 215 included patients, 49 had documented history of H. pylori infection. Compared with H. pylori-negative patients, positive individuals tended to be younger, non-white, and Hispanic with non-cardia and intestinal-type gastric cancer. H. pylori-positive patients had significantly shorter median PFS (3.2 vs 6.8 months, HR 1.96, p<0.01) and OS (9.8 vs 17.9 months, HR 1.54, p=0.02). Multivariable analysis confirmed H. pylori infection as an independent predictor of PFS (HR 3.04, p<0.01) and OS (HR 2.24, p=0.01). CONCLUSIONS In this largest study of its kind, H. pylori infection was associated with inferior survival in ICI-treated patients with gastric cancer. This suggests H. pylori status may be a prognostic marker of immune responsiveness. Future studies are needed to elucidate immunoregulatory mechanisms and whether treatment of active infections would improve immunotherapy outcomes.
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Affiliation(s)
| | - Steven B Maron
- Gastrointestinal Oncology Service, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Darren Cowzer
- Gastrointestinal Oncology Service, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Stephanie King
- Gastroenterology, Hepatology, and Nutrition Service, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Mark Schattner
- Gastroenterology, Hepatology, and Nutrition Service, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Yelena Janjigian
- Gastrointestinal Oncology Service, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - David Faleck
- Gastroenterology, Hepatology, and Nutrition Service, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Monika Laszkowska
- Gastroenterology, Hepatology, and Nutrition Service, Memorial Sloan Kettering Cancer Center, New York, New York, USA
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Laszkowska M, Zhang X, Kuliszewski MG, Hur C. Heightened Risk for Gastric Cancer Among Immigrant Populations in New York State From High-Incidence Countries. Clin Gastroenterol Hepatol 2023; 21:2673-2675.e3. [PMID: 35988909 PMCID: PMC9938834 DOI: 10.1016/j.cgh.2022.08.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Revised: 07/22/2022] [Accepted: 08/06/2022] [Indexed: 02/07/2023]
Affiliation(s)
- Monika Laszkowska
- Department of Subspecialty Medicine, Gastroenterology, Hepatology, and Nutrition Service, Memorial Sloan Kettering Cancer Center, New York, New York.
| | - Xiuling Zhang
- Bureau of Cancer Epidemiology, New York State Department of Health, Albany, New York
| | - Margaret Gates Kuliszewski
- Bureau of Cancer Epidemiology, New York State Department of Health, Albany, New York, and, Department of Epidemiology and Biostatistics, University at Albany School of Public Health, Albany, New York
| | - Chin Hur
- Division of General Medicine, Department of Medicine, Herbert Irving Comprehensive Cancer Center, Columbia University Irving Medical Center, New York, New York
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9
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Laszkowska M, Tang L, Vos E, King S, Salo-Mullen E, Magahis PT, Abate M, Catchings A, Zauber AG, Hahn AI, Schattner M, Coit D, Stadler ZK, Strong VE, Markowitz AJ. Factors associated with detection of hereditary diffuse gastric cancer on endoscopy in individuals with germline CDH1 mutations. Gastrointest Endosc 2023; 98:326-336.e3. [PMID: 37094689 PMCID: PMC10524178 DOI: 10.1016/j.gie.2023.04.2071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Revised: 03/22/2023] [Accepted: 04/16/2023] [Indexed: 04/26/2023]
Abstract
BACKGROUND AND AIMS Individuals with germline pathogenic CDH1 variants have a high risk of hereditary diffuse gastric cancer. The sensitivity of EGD in detecting signet ring cell carcinoma (SRCC) in this population is low. We aimed to identify endoscopic findings and biopsy practices associated with detection of SRCC. METHODS This retrospective cohort included individuals with a germline pathogenic/likely pathogenic CDH1 variant undergoing at least 1 EGD at Memorial Sloan Kettering Cancer Center between January 1, 2006, and March 25, 2022. The primary outcome was detection of SRCC on EGD. Findings on gastrectomy were also assessed. The study included periods before and after implementation of the Cambridge protocol for endoscopic surveillance, allowing for assessment of a spectrum of biopsy practices. RESULTS Ninety-eight CDH1 patients underwent at least 1 EGD at our institution. SRCC was detected in 20 (20%) individuals on EGD overall and in 50 (86%) of the 58 patients undergoing gastrectomy. Most SRCC foci were detected in the gastric cardia/fundus (EGD, 50%; gastrectomy, 62%) and body/transition zone (EGD, 60%; gastrectomy, 62%). Biopsy results of gastric pale mucosal areas were associated with detection of SRCC (P < .01). The total number of biopsy samples taken on EGD was associated with increased detection of SRCC (P = .01), with 43% detected when ≥40 samples were taken. CONCLUSIONS Targeted biopsy sampling of gastric pale mucosal areas and increasing number of biopsy samples taken on EGD were associated with detection of SRCC. SRCC foci were mostly detected in the proximal stomach, supporting updated endoscopic surveillance guidelines. Further studies are needed to refine endoscopic protocols to improve SRCC detection in this high-risk population.
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Affiliation(s)
- Monika Laszkowska
- Gastroenterology, Hepatology, and Nutrition Service, Department of Medicine
| | - Laura Tang
- Department of Pathology and Laboratory Medicine
| | - Elvira Vos
- Gastric and Mixed Tumor Service, Department of Surgery
| | - Stephanie King
- Gastroenterology, Hepatology, and Nutrition Service, Department of Medicine
| | | | - Patrick T Magahis
- Joan and Sanford I. Weill Medical College of Cornell University, New York, New York, USA
| | - Miseker Abate
- Gastric and Mixed Tumor Service, Department of Surgery
| | | | - Ann G Zauber
- Department of Epidemiology & Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Anne I Hahn
- Department of Epidemiology & Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Mark Schattner
- Gastroenterology, Hepatology, and Nutrition Service, Department of Medicine
| | - Daniel Coit
- Gastric and Mixed Tumor Service, Department of Surgery
| | | | | | - Arnold J Markowitz
- Gastroenterology, Hepatology, and Nutrition Service, Department of Medicine.
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Huang RJ, Laszkowska M, In H, Hwang JH, Epplein M. Controlling Gastric Cancer in a World of Heterogeneous Risk. Gastroenterology 2023; 164:736-751. [PMID: 36706842 PMCID: PMC10270664 DOI: 10.1053/j.gastro.2023.01.018] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Revised: 01/12/2023] [Accepted: 01/17/2023] [Indexed: 01/29/2023]
Abstract
Gastric cancer (GC) is a leading cause of global mortality but also a cancer whose footprint is highly unequal. This review aims to define global disease epidemiology, critically appraise strategies of prevention and disease attenuation, and assess how these strategies could be applied to improve outcomes from GC in a world of variable risk and disease burden. Strategies of primary prevention focus on improving the detection and eradication of the main environmental risk factor, Helicobacter pylori. In certain countries of high incidence, endoscopic or radiographic screening of the asymptomatic general population has been adopted as a means of secondary prevention. By contrast, identification and targeted surveillance of individuals with precancerous lesions (such as intestinal metaplasia) is being increasingly embraced in nations of low incidence. This review also highlights existing knowledge gaps in GC prevention as well as the role of emerging technologies for early detection and risk stratification.
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Affiliation(s)
- Robert J Huang
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, California.
| | - Monika Laszkowska
- Gastroenterology, Hepatology, and Nutrition Service, Department of Subspecialty Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Haejin In
- Rutgers Cancer Institute of New Jersey, New Brunswick, New Jersey
| | - Joo Ha Hwang
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, California
| | - Meira Epplein
- Duke University, Department of Population Health Sciences, and Cancer Risk, Detection, and Interception Program, Duke Cancer Institute, Durham, North Carolina
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11
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Drebin HM, Abate M, Fei T, Tang LH, Laszkowska M, Maron SB, Shimada S, Vardhana S, Vanderbilt C, Strong VE. Unique microbial profile identified in patients with gastric cancer with pathologic response to neoadjuvant chemotherapy. J Clin Oncol 2023. [DOI: 10.1200/jco.2023.41.4_suppl.458] [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: 01/25/2023] Open
Abstract
458 Background: Microbial dysbiosis has been shown to be associated with the pathogenesis of gastric cancer (GC). However, the relationship between the GC microbiome and response to systemic therapy, such as neoadjuvant chemotherapy (NAC), is largely unknown. This study aims to explore changes in the microbiome after neoadjuvant chemotherapy, by analyzing the microbial profile of patients who received NAC and comparing differences among those with varied pathologic response to therapy. Methods: A microbiome bioinformatics pipeline using multiple next generation sequencing platforms was developed and used for analysis. GC tissue from patients who received NAC (n=101) and those who did not (n=85) were acquired at the time of surgical resection. Shannon alpha diversity plot and enrichment analyses by odds ratio were used to compare the microbial differences of the treatment cohorts. The microbial profiles of patients with pathologic response to NAC (>20% response) were characterized. Results: Of patients who received NAC, 66 (65.3%) experienced a greater than 20% response to NAC, and 35 (34.6%) demonstrated a 20% or lower response. Patients with a pathologic response to NAC were enriched for Rhizobium, Streptomyces, Comamonas, Sphingomonas, Micrococcus, Mycobacterium, Thauera, Hyphomicrobium, and Sinorhizobium (OR>4). There were no statistically significant differences in alpha diversity (p>0.05). Conclusions: Our results demonstrate that patients with a greater than 20% pathologic response to NAC have a distinct microbial enrichment compared to those with a poor pathologic response. Given the variable NAC treatment responses in GC, understanding unique microbial signatures in tumors will provide the landscape to explore key microbial contributors to GC NAC treatment response that may improve our understanding of treatment response variability among patients. [Table: see text]
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Affiliation(s)
| | - Miseker Abate
- Memorial Sloan Kettering Cancer Center, New York, NY
| | - Teng Fei
- Memorial Sloan Kettering Cancer Center, New York, NY
| | - Laura H. Tang
- Memorial Sloan Kettering Cancer Center, New York, NY
| | | | | | - Shoji Shimada
- Memorial Sloan Kettering Cancer Center, New York, NY
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12
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Gudenkauf FJ, Mehta A, Ferri L, Aihara H, Draganov PV, Yang DJ, Jue TL, Munroe CA, Boparai ES, Mehta NA, Bhatt A, Kumta NA, Othman MO, Mercado M, Javaid H, Aadam AA, Siegel A, James TW, Grimm IS, DeWitt JM, Novikov A, Schlachterman A, Kowalski T, Samarasena J, Hashimoto R, Chehade NEH, Lee JG, Chang K, Su B, Ujiki MB, Sharaiha RZ, Carr-Locke DL, Chen A, Chen M, Chen YI, Tomizawa Y, von Renteln D, Kumbhari V, Khashab MA, Bechara R, Karasik M, Patel NJ, Fukami N, Nishimura M, Hanada Y, Song LMWK, Laszkowska M, Wang AY, Hwang JH, Friedland S, Sethi A, Ngamruengphong S. Factors Associated With Advanced Histological Diagnosis and Upstaging After Endoscopic Submucosal Dissection of Superficial Gastric Neoplasia. Techniques and Innovations in Gastrointestinal Endoscopy 2023; 25:2-10. [DOI: 10.1016/j.tige.2022.07.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/25/2023]
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13
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Abate M, Vos E, Gonen M, Janjigian YY, Schattner M, Laszkowska M, Tang L, Maron SB, Coit DG, Vardhana S, Vanderbilt C, Strong VE. A Novel Microbiome Signature in Gastric Cancer: A Two Independent Cohort Retrospective Analysis. Ann Surg 2022; 276:605-615. [PMID: 35822725 PMCID: PMC9463093 DOI: 10.1097/sla.0000000000005587] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
Abstract
OBJECTIVE The microbiome is hypothesized to have a significant impact on cancer development. In gastric cancer (GC), Helicobacter pylori is an established class I carcinogen. However, additional organisms in the intratumoral microbiome play an important role in GC pathogenesis and progression. In this study, we characterize the full spectrum of the microbes present within GC and identify distinctions among molecular subtypes. METHODS A microbiome bioinformatics pipeline that is generalizable across multiple next-generation sequencing platforms was developed. Microbial profiles for alpha diversity and enrichment were generated for 2 large, demographically distinct cohorts: (1) internal Memorial Sloan Kettering Cancer Center (MSKCC) and (2) The Cancer Genome Atlas (TCGA) cohorts. A total of 520 GC samples were compared with select tumor-adjacent nonmalignant samples. Microbiome differences among the GC molecular subtypes were identified. RESULTS Compared with nonmalignant samples, GC had significantly decreased microbial diversity in both MSKCC and TCGA cohorts ( P <0.05). Helicobacter , Lactobacillus , Streptococcus , Prevotella , and Bacteroides were significantly more enriched in GC samples when compared with nonmalignant tissue ( P <0.05). Microsatellite instability-high GC had distinct microbial enrichment compared with other GC molecular subtypes. CONCLUSION Distinct patterns of microbial diversity and species enrichment were identified in patients with GC. Given the varied spectrum of disease progression and treatment response of GC, understanding unique microbial signatures will provide the landscape to explore key microbial targets for therapy.
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Affiliation(s)
- Miseker Abate
- Gastric and Mixed Tumor Service, Department of Surgery, Memorial Sloan Kettering Cancer Center , New York, NY
- Human Oncology and Pathogenesis Program, Memorial Sloan Kettering Cancer Center, New York, NY
- New York Presbyterian Hospital, Weill Cornell Medicine, Department of Surgery
| | - Elvira Vos
- Gastric and Mixed Tumor Service, Department of Surgery, Memorial Sloan Kettering Cancer Center , New York, NY
| | - Mithat Gonen
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Yelena Y. Janjigian
- Gastrointestinal Oncology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, United States
| | - Mark Schattner
- Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Monika Laszkowska
- Gastroenterology, Hepatology, and Nutrition Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, United States
| | - Laura Tang
- Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Steven B. Maron
- Gastrointestinal Oncology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, United States
| | - Daniel G. Coit
- Gastric and Mixed Tumor Service, Department of Surgery, Memorial Sloan Kettering Cancer Center , New York, NY
| | - Santosh Vardhana
- Human Oncology and Pathogenesis Program, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Chad Vanderbilt
- Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Vivian E. Strong
- Gastric and Mixed Tumor Service, Department of Surgery, Memorial Sloan Kettering Cancer Center , New York, NY
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14
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Laszkowska M, Truong H, Faye AS, Kim J, Tan SX, Lim F, Abrams JA, Hur C. Prevalence of Extensive and Limited Gastric Intestinal Metaplasia and Progression to Dysplasia and Gastric Cancer. Dig Dis Sci 2022; 67:3693-3701. [PMID: 34657192 PMCID: PMC9013391 DOI: 10.1007/s10620-021-07276-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Accepted: 10/04/2021] [Indexed: 01/21/2023]
Abstract
BACKGROUND AND AIMS Guidelines cite extensive gastric intestinal metaplasia (GIM) as a bigger risk factor for gastric cancer (GC) than limited GIM and an indication for endoscopic surveillance. Data on progression of extensive GIM to GC in the USA are limited. This study aimed to estimate the prevalence and progression rates of extensive GIM in a US cohort. METHODS This retrospective study assessed the prevalence of extensive GIM between 1/1/1990 and 8/1/2019 at a large academic medical center. Multivariable regression was used to identify predictors of extensive GIM. Incidence of GC on follow-up was calculated as number of new diagnoses divided by person-years of follow-up. Presence of GIM on subsequent follow-up endoscopy was assessed. RESULTS Of 1256 individuals with GIM, 352 (28%) had extensive GIM and 904 (72%) had limited GIM. On multivariable analysis, older age (OR 1.01, 95% CI 1.00-1.02) and Hispanic ethnicity (OR 1.55, 95% CI 1.11-2.16) were predictive of extensive GIM. The annual incidence of GC for GIM overall was 0.09%. There was no difference in progression to GC between extensive or limited GIM (IRR 0, 95% CI 0-2.6), or to advanced lesions overall (IRR 0.37, 95% CI 0.04-1.62). 70% of individuals had persistent GIM on follow-up biopsy, and 22% with limited GIM had extensive GIM on follow-up biopsy. CONCLUSIONS 28% of individuals with GIM have the extensive subtype, and are more likely to be older and of Hispanic ethnicity. There was no difference in progression to GC between extensive and limited GIM. Further research is needed to better assess risk of GIM in the US context.
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Affiliation(s)
- Monika Laszkowska
- Division of Digestive and Liver Diseases, Department of Medicine, Columbia University Irving Medical Center, New York, NY, USA,Department of Subspecialty Medicine, Gastroenterology, Hepatology, and Nutrition Service, Memorial Sloan Kettering Cancer Center, 1275 York Ave, New York, NY 10065, USA
| | - Han Truong
- Division of General Medicine, Department of Medicine, Columbia University Irving Medical Center, New York, NY, USA
| | - Adam S. Faye
- Division of Digestive and Liver Diseases, Department of Medicine, Columbia University Irving Medical Center, New York, NY, USA,Division of Gastroenterology, New York University Langone Health, New York, NY, USA
| | - Judith Kim
- Division of Digestive and Liver Diseases, Department of Medicine, Columbia University Irving Medical Center, New York, NY, USA
| | - Sarah Xinhui Tan
- Division of General Medicine, Department of Medicine, Columbia University Irving Medical Center, New York, NY, USA
| | - Francesca Lim
- Division of General Medicine, Department of Medicine, Columbia University Irving Medical Center, New York, NY, USA
| | - Julian A. Abrams
- Division of Digestive and Liver Diseases, Department of Medicine, Columbia University Irving Medical Center, New York, NY, USA,Herbert Irving Comprehensive Cancer Center, Columbia University Irving Medical Center, New York, NY, USA
| | - Chin Hur
- Division of Digestive and Liver Diseases, Department of Medicine, Columbia University Irving Medical Center, New York, NY, USA,Division of General Medicine, Department of Medicine, Columbia University Irving Medical Center, New York, NY, USA,Herbert Irving Comprehensive Cancer Center, Columbia University Irving Medical Center, New York, NY, USA
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15
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Laszkowska M, Ludvigsson JF. Comment on: Prevalence of gastrointestinal, cardiovascular, autonomic and allergic manifestations in hospitalized patients with Ehlers-Danlos syndrome: a case-control study. Rheumatology (Oxford) 2021; 61:e105-e106. [PMID: 34918051 DOI: 10.1093/rheumatology/keab908] [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] [Received: 10/25/2021] [Accepted: 10/27/2021] [Indexed: 11/14/2022] Open
Affiliation(s)
- Monika Laszkowska
- Department of Medicine, Gastroenterology, Hepatology, and Nutrition Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Jonas F Ludvigsson
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, 171 77 Stockholm, Sweden.,Department of Pediatrics, Örebro University Hospital, 701 85 Örebro, Sweden.,Division of Epidemiology and Public Health, School of Medicine, University of Nottingham, Nottingham, UK
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16
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Laszkowska M, Kim J, Faye AS, Joelson AM, Ingram M, Truong H, Silver ER, May B, Greendyke WG, Zucker J, Lebwohl B, Hur C, Freedberg DE. Prevalence of Clostridioides difficile and Other Gastrointestinal Pathogens in Patients with COVID-19. Dig Dis Sci 2021; 66:4398-4405. [PMID: 33479861 PMCID: PMC7819769 DOI: 10.1007/s10620-020-06760-y] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2020] [Accepted: 12/04/2020] [Indexed: 01/08/2023]
Abstract
BACKGROUND Gastrointestinal symptoms are common in patients with COVID-19, but prevalence of co-infection with enteric pathogens is unknown. AIMS This study assessed the prevalence of enteric infections among hospitalized patients with COVID-19. METHODS We evaluated 4973 hospitalized patients ≥ 18 years of age tested for COVID-19 from March 11 through April 28, 2020, at two academic hospitals. The primary exposure was a positive COVID-19 test. The primary outcome was detection of a gastrointestinal pathogen by PCR stool testing. RESULTS Among 4973 hospitalized individuals, 311 were tested for gastrointestinal infections (204 COVID-19 positive, 107 COVID-19 negative). Patients with COVID-19 were less likely to test positive compared to patients without COVID-19 (10% vs 22%, p < 0.01). This trend was driven by lower rates of non-C.difficile infections (11% vs 22% in COVID-19 positive vs. negative, respectively, p = 0.04), but not C. difficile infection (5.1% vs. 8.2%, p = 0.33). On multivariable analysis, infection with COVID-19 remained significantly associated with lower odds of concurrent GI infection (aOR 0.49, 95% CI 0.24-0.97), again driven by reduced non-C.difficile infection. Testing for both C.difficile and non-C.difficile enteric infection decreased dramatically during the pandemic. CONCLUSIONS Pathogens aside from C.difficile do not appear to be a significant contributor to diarrhea in COVID-19 positive patients.
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Affiliation(s)
- Monika Laszkowska
- Department of Medicine, Division of Digestive and Liver Diseases, New York Presbyterian Columbia University Medical Center, New York, NY, USA.
- Department of Medicine, Gastroenterology, Hepatology, and Nutrition Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
| | - Judith Kim
- Department of Medicine, Division of Digestive and Liver Diseases, New York Presbyterian Columbia University Medical Center, New York, NY, USA
| | - Adam S Faye
- Department of Medicine, Division of Digestive and Liver Diseases, New York Presbyterian Columbia University Medical Center, New York, NY, USA
- Department of Medicine, Henry D. Janowitz Division of Gastroenterology, Mount Sinai Hospital, New York, NY, USA
| | - Andrew M Joelson
- Department of Medicine, Division of Digestive and Liver Diseases, New York Presbyterian Columbia University Medical Center, New York, NY, USA
| | - Myles Ingram
- Department of Medicine, Division of General Medicine, Columbia University Irving Medical Center, New York, NY, USA
| | - Han Truong
- Department of Medicine, Division of General Medicine, Columbia University Irving Medical Center, New York, NY, USA
| | - Elisabeth R Silver
- Department of Medicine, Division of General Medicine, Columbia University Irving Medical Center, New York, NY, USA
| | - Benjamin May
- Herbert Irving Comprehensive Cancer Center, Columbia University Irving Medical Center, New York, NY, USA
| | - William G Greendyke
- Department of Medicine, Division of Infectious Diseases, Columbia University Irving Medical Center, New York, NY, USA
| | - Jason Zucker
- Department of Medicine, Division of Infectious Diseases, Columbia University Irving Medical Center, New York, NY, USA
| | - Benjamin Lebwohl
- Department of Medicine, Division of Digestive and Liver Diseases, New York Presbyterian Columbia University Medical Center, New York, NY, USA
- Department of Epidemiology, Mailman School of Public Health, Columbia University Irving Medical Center, New York, NY, USA
| | - Chin Hur
- Department of Medicine, Division of Digestive and Liver Diseases, New York Presbyterian Columbia University Medical Center, New York, NY, USA
- Department of Medicine, Division of General Medicine, Columbia University Irving Medical Center, New York, NY, USA
- Herbert Irving Comprehensive Cancer Center, Columbia University Irving Medical Center, New York, NY, USA
| | - Daniel E Freedberg
- Department of Medicine, Division of Digestive and Liver Diseases, New York Presbyterian Columbia University Medical Center, New York, NY, USA
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17
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Ngamruengphong S, Ferri L, Aihara H, Draganov PV, Yang DJ, Perbtani YB, Jue TL, Munroe CA, Boparai ES, Mehta NA, Bhatt A, Kumta NA, Othman MO, Mercado M, Javaid H, Aadam AA, Siegel A, James TW, Grimm IS, DeWitt JM, Novikov A, Schlachterman A, Kowalski T, Samarasena J, Hashimoto R, Chehade NEH, Lee J, Chang K, Su B, Ujiki MB, Mehta A, Sharaiha RZ, Carr-Locke DL, Chen A, Chen M, Chen YI, Pourmousavi Khoshknab M, Wang R, Kerdsirichairat T, Tomizawa Y, von Renteln D, Kumbhari V, Khashab MA, Bechara R, Karasik M, Patel NJ, Fukami N, Nishimura M, Hanada Y, Wong Kee Song LM, Laszkowska M, Wang AY, Hwang JH, Friedland S, Sethi A, Kalloo AN. Efficacy of Endoscopic Submucosal Dissection for Superficial Gastric Neoplasia in a Large Cohort in North America. Clin Gastroenterol Hepatol 2021; 19:1611-1619.e1. [PMID: 32565290 DOI: 10.1016/j.cgh.2020.06.023] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [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: 12/10/2019] [Revised: 06/07/2020] [Accepted: 06/11/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Endoscopic submucosal dissection (ESD) is a widely accepted treatment option for superficial gastric neoplasia in Asia, but there are few data on outcomes of gastric ESD from North America. We aimed to evaluate the safety and efficacy of gastric ESD in North America. METHODS We analyzed data from 347 patients who underwent gastric ESD at 25 centers, from 2010 through 2019. We collected data on patient demographics, lesion characteristics, procedure details and related adverse events, treatment outcomes, local recurrence, and vital status at the last follow up. For the 277 patients with available follow-up data, the median interval between initial ESD and last clinical or endoscopic evaluation was 364 days. The primary endpoint was the rate of en bloc and R0 resection. Secondary outcomes included curative resection, rates of adverse events and recurrence, and gastric cancer-related death. RESULTS Ninety patients (26%) had low-grade adenomas or dysplasia, 82 patients (24%) had high-grade dysplasia, 139 patients (40%) had early gastric cancer, and 36 patients (10%) had neuroendocrine tumors. Proportions of en bloc and R0 resection for all lesions were 92%/82%, for early gastric cancers were 94%/75%, for adenomas and low-grade dysplasia were 93%/ 92%, for high-grade dysplasia were 89%/ 87%, and for neuroendocrine tumors were 92%/75%. Intraprocedural perforation occurred in 6.6% of patients; 82% of these were treated successfully with endoscopic therapy. Delayed bleeding occurred in 2.6% of patients. No delayed perforation or procedure-related deaths were observed. There were local recurrences in 3.9% of cases; all occurred after non-curative ESD resection. Metachronous lesions were identified in 14 patients (6.9%). One of 277 patients with clinical follow up died of metachronous gastric cancer that occurred 2.5 years after the initial ESD. CONCLUSIONS ESD is a highly effective treatment for superficial gastric neoplasia and should be considered as a viable option for patients in North America. The risk of local recurrence is low and occurs exclusively after non-curative resection. Careful endoscopic surveillance is necessary to identify and treat metachronous lesions.
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Affiliation(s)
| | - Lorenzo Ferri
- Division of Thoracic Surgery, Montreal General Hospital, McGill University, Montreal, Quebec, Canada
| | - Hiroyuki Aihara
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Boston, Massachusetts
| | - Peter V Draganov
- Division of Gastroenterology and Hepatology, University of Florida, Gainesville, Florida
| | - Dennis J Yang
- Division of Gastroenterology and Hepatology, University of Florida, Gainesville, Florida
| | - Yaseen B Perbtani
- Division of Gastroenterology and Hepatology, University of Florida, Gainesville, Florida
| | - Terry L Jue
- Division of Gastroenterology, Kaiser Permanente San Francisco, San Francisco, California
| | - Craig A Munroe
- Division of Gastroenterology, Kaiser Permanente San Francisco, San Francisco, California
| | - Eshandeep S Boparai
- Division of Gastroenterology, Kaiser Permanente San Francisco, San Francisco, California
| | - Neal A Mehta
- Department of Gastroenterology and Hepatology, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, Ohio
| | - Amit Bhatt
- Department of Gastroenterology and Hepatology, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, Ohio
| | - Nikhil A Kumta
- Division of Gastroenterology, Mount Sinai Hospital, New York, New York
| | - Mohamed O Othman
- Division of Gastroenterology and Hepatology, Baylor University Medical Center, Houston, Texas
| | - Michael Mercado
- Division of Gastroenterology and Hepatology, Baylor University Medical Center, Houston, Texas
| | - Huma Javaid
- Division of Gastroenterology and Hepatology, Baylor University Medical Center, Houston, Texas
| | - Abdul Aziz Aadam
- Division of Gastroenterology and Hepatology, Northwestern University Medical Center, Chicago, Illinois
| | - Amanda Siegel
- Division of Gastroenterology and Hepatology, Northwestern University Medical Center, Chicago, Illinois
| | - Theodore W James
- Division of Gastroenterology and Hepatology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Ian S Grimm
- Division of Gastroenterology and Hepatology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - John M DeWitt
- Division of Gastroenterology and Hepatology, Indiana University, Indianapolis, Indiana
| | - Aleksey Novikov
- Division of Gastroenterology and Hepatology, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Alexander Schlachterman
- Division of Gastroenterology and Hepatology, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Thomas Kowalski
- Division of Gastroenterology and Hepatology, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Jason Samarasena
- Division of Gastroenterology and Hepatology, University of California, Irvine, Irvine, California
| | - Rintaro Hashimoto
- Division of Gastroenterology and Hepatology, University of California, Irvine, Irvine, California
| | - Nabil El Hage Chehade
- Division of Gastroenterology and Hepatology, University of California, Irvine, Irvine, California
| | - John Lee
- Division of Gastroenterology and Hepatology, University of California, Irvine, Irvine, California
| | - Kenneth Chang
- Division of Gastroenterology and Hepatology, University of California, Irvine, Irvine, California
| | - Bailey Su
- Department of Surgery, NorthShore University Health System, Evanston, Illinois
| | - Michael B Ujiki
- Department of Surgery, NorthShore University Health System, Evanston, Illinois
| | - Amit Mehta
- Division of Gastroenterology and Hepatology, Weill Cornell Medicine, New York, New York
| | - Reem Z Sharaiha
- Division of Gastroenterology and Hepatology, Weill Cornell Medicine, New York, New York
| | - David L Carr-Locke
- Division of Gastroenterology and Hepatology, Weill Cornell Medicine, New York, New York
| | - Alex Chen
- Division of Thoracic Surgery, Montreal General Hospital, McGill University, Montreal, Quebec, Canada
| | - Michael Chen
- Division of Thoracic Surgery, Montreal General Hospital, McGill University, Montreal, Quebec, Canada
| | - Yen-I Chen
- Division of Gastroenterology and Hepatology, Montreal General Hospital, McGill University, Montreal, Quebec, Canada
| | | | - Rui Wang
- Division of Gastroenterology, Johns Hopkins Hospital, Baltimore, Maryland
| | | | - Yutaka Tomizawa
- Division of Gastroenterology and Hepatology, University of Washington, Seattle, Washington
| | - Daniel von Renteln
- Division of Gastroenterology, University of Montreal Hospital Research Centre, University of Montreal Hospital Centre, Montreal, Quebec, Canada
| | - Vivek Kumbhari
- Division of Gastroenterology, Johns Hopkins Hospital, Baltimore, Maryland
| | - Mouen A Khashab
- Division of Gastroenterology, Johns Hopkins Hospital, Baltimore, Maryland
| | - Robert Bechara
- Division of Gastroenterology, Queen's University, Kingston, Ontario, Canada
| | - Michael Karasik
- Department of Gastroenterology, Hartford Hospital, Hartford, Connecticut
| | - Neej J Patel
- Division of Gastroenterology and Hepatology, Mayo Clinic Arizona, Phoenix, Arizona
| | - Norio Fukami
- Division of Gastroenterology and Hepatology, Mayo Clinic Arizona, Phoenix, Arizona
| | - Makoto Nishimura
- Gastroenterology and Nutrition Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Yuri Hanada
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | | | - Monika Laszkowska
- Division of Digestive and Liver Diseases, Columbia University Irving Medical Center, New York, New York
| | - Andrew Y Wang
- Division of Gastroenterology and Hepatology, University of Virginia, Charlottesville, Virginia
| | - Joo Ha Hwang
- Department of Gastroenterology, Stanford University School of Medicine, Stanford, California
| | - Shai Friedland
- Department of Gastroenterology, Hartford Hospital, Hartford, Connecticut
| | - Amrita Sethi
- Division of Digestive and Liver Diseases, Columbia University Irving Medical Center, New York, New York
| | - Antony N Kalloo
- Division of Gastroenterology, Johns Hopkins Hospital, Baltimore, Maryland
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Kastrinos F, Ingram MA, Silver ER, Oh A, Laszkowska M, Rustgi AK, Hur C. Gene-Specific Variation in Colorectal Cancer Surveillance Strategies for Lynch Syndrome. Gastroenterology 2021; 161:453-462.e15. [PMID: 33839100 PMCID: PMC9330543 DOI: 10.1053/j.gastro.2021.04.010] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Revised: 03/30/2021] [Accepted: 04/02/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND AIMS Lynch syndrome is associated with pathogenic variants in 4 mismatch repair (MMR) genes that increase lifetime risk of colorectal cancer. Guidelines recommend intensive colorectal cancer surveillance with colonoscopy every 1-2 years starting at age 25 years for all carriers of Lynch syndrome-associated variants, regardless of gene product. We constructed a simulation model to analyze the effects of different ages of colonoscopy initiation and surveillance intervals for each MMR gene (MLH1, MSH2, MSH6, and PMS2) on colorectal cancer incidence and mortality, quality-adjusted life-years, and cost. METHODS Using published literature, we developed a Markov simulation model of Lynch syndrome progression for patients with each MMR variant. The model simulated clinical trials of Lynch syndrome carriers, varying age of colonoscopy initiation (5-year increments from 25-40 years), and surveillance intervals (1-5 years). We assessed the optimal strategy for each gene, defined as the strategy with the highest quality-adjusted life-years and incremental cost-effectiveness ratio below a $100,000 willingness-to-pay threshold. RESULTS Optimal surveillance for patients with pathogenic variants in the MLH1 and MSH2 genes was colonoscopy starting at age 25 years, with 1- to 2-year surveillance intervals. Initiating colonoscopy at age 35 and 40 years, with 3-year intervals, was cost-effective for patients with pathogenic variants in MSH6 or PMS2, respectively. CONCLUSIONS We developed a simulation model to select optimal surveillance starting ages and intervals for patients with Lynch syndrome based on MMR variant. The model supports recommendations for intensive surveillance of patients with Lynch syndrome-associated variants in MLH1 or MSH2. However, for patients with Lynch syndrome-associated variants of MSH6 or PMS2, later initiation of surveillance at 35 and 40 years, respectively, and at 3-year intervals, can be considered.
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Affiliation(s)
- Fay Kastrinos
- Herbert Irving Comprehensive Cancer Center, Columbia University Irving Medical Center, New York, New York; Division of Digestive and Liver Diseases, Columbia University Irving Medical Cancer and Vagelos College of Physicians and Surgeons, New York, New York.
| | - Myles A. Ingram
- Division of General Medicine, Columbia University Irving Medical Cancer and the Vagelos College of Physicians and Surgeons, New York, New York
| | - Elisabeth R. Silver
- Division of General Medicine, Columbia University Irving Medical Cancer and the Vagelos College of Physicians and Surgeons, New York, New York
| | - Aaron Oh
- Division of General Medicine, Columbia University Irving Medical Cancer and the Vagelos College of Physicians and Surgeons, New York, New York
| | - Monika Laszkowska
- Herbert Irving Comprehensive Cancer Center, Columbia University Irving Medical Center, New York, New York,Division of Digestive and Liver Diseases, Columbia University Irving Medical Cancer and the Vagelos College of Physicians and Surgeons, New York, New York
| | - Anil K. Rustgi
- Herbert Irving Comprehensive Cancer Center, Columbia University Irving Medical Center, New York, New York,Division of Digestive and Liver Diseases, Columbia University Irving Medical Cancer and the Vagelos College of Physicians and Surgeons, New York, New York
| | - Chin Hur
- Herbert Irving Comprehensive Cancer Center, Columbia University Irving Medical Center, New York, New York,Division of Digestive and Liver Diseases, Columbia University Irving Medical Cancer and the Vagelos College of Physicians and Surgeons, New York, New York,Division of General Medicine, Columbia University Irving Medical Cancer and the Vagelos College of Physicians and Surgeons, New York, New York
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Laszkowska M, Faye AS, Kim J, Truong H, Silver ER, Ingram M, May B, Ascherman B, Bartram L, Zucker J, Sobieszczyk ME, Abrams JA, Lebwohl B, Freedberg DE, Hur C. Disease Course and Outcomes of COVID-19 Among Hospitalized Patients With Gastrointestinal Manifestations. Clin Gastroenterol Hepatol 2021; 19:1402-1409.e1. [PMID: 33007514 PMCID: PMC7525451 DOI: 10.1016/j.cgh.2020.09.037] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Revised: 09/12/2020] [Accepted: 09/24/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND & AIMS Our understanding of outcomes and disease time course of COVID-19 in patients with gastrointestinal (GI) symptoms remains limited. In this study we characterize the disease course and severity of COVID-19 among hospitalized patients with gastrointestinal manifestations in a large, diverse cohort from the Unites States. METHODS This retrospective study evaluated hospitalized individuals with COVID-19 between March 11 and April 28, 2020 at two affiliated hospitals in New York City. We evaluated the association between GI symptoms and death, and also explored disease duration, from symptom onset to death or discharge. RESULTS Of 2804 patients hospitalized with COVID-19, the 1,084 (38.7%) patients with GI symptoms were younger (aOR for age ≥75, 0.59; 95% CI, 0.45-0.77) and had more co-morbidities (aOR for modified Charlson comorbidity score ≥2, 1.22; 95% CI, 1.01-1.48) compared to those without GI symptoms. Individuals with GI symptoms had better outcomes, with a lower likelihood of intubation (aHR, 0.66; 95% CI, 0.55-0.79) and death (aHR, 0.71; 95% CI, 0.59-0.87), after adjusting for clinical factors. These patients had a longer median disease course from symptom onset to discharge (13.8 vs 10.8 days, log-rank p = .048; among 769 survivors with available symptom onset time), which was driven by longer time from symptom onset to hospitalization (7.4 vs 5.4 days, log-rank P < .01). CONCLUSION Hospitalized patients with GI manifestations of COVID-19 have a reduced risk of intubation and death, but may have a longer overall disease course driven by duration of symptoms prior to hospitalization.
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Affiliation(s)
- Monika Laszkowska
- Division of Digestive and Liver Diseases, Department of Medicine, Columbia University Irving Medical Center, New York, New York; Department of Subspecialty Medicine, Gastroenterology, Hepatology, and Nutrition Service, Memorial Sloan Kettering Cancer Center, New York, New York.
| | - Adam S Faye
- Division of Digestive and Liver Diseases, Department of Medicine, Columbia University Irving Medical Center, New York, New York; Department of Medicine, Henry D. Janowitz Division of Gastroenterology, Mount Sinai Hospital, New York, New York
| | - Judith Kim
- Division of Digestive and Liver Diseases, Department of Medicine, Columbia University Irving Medical Center, New York, New York
| | - Han Truong
- Division of General Medicine, Department of Medicine, Columbia University Irving Medical Center, New York, New York
| | - Elisabeth R Silver
- Division of General Medicine, Department of Medicine, Columbia University Irving Medical Center, New York, New York
| | - Myles Ingram
- Division of General Medicine, Department of Medicine, Columbia University Irving Medical Center, New York, New York
| | - Benjamin May
- Herbert Irving Comprehensive Cancer Center, Columbia University Irving Medical Center, New York, New York
| | - Benjamin Ascherman
- Vagelos College of Physicians and Surgeons, Columbia University, New York, New York
| | - Logan Bartram
- Division of Infectious Diseases, Department of Medicine, Columbia University Irving Medical Center, New York, New York
| | - Jason Zucker
- Division of Infectious Diseases, Department of Medicine, Columbia University Irving Medical Center, New York, New York
| | - Magdalena E Sobieszczyk
- Division of Infectious Diseases, Department of Medicine, Columbia University Irving Medical Center, New York, New York
| | - Julian A Abrams
- Division of Digestive and Liver Diseases, Department of Medicine, Columbia University Irving Medical Center, New York, New York
| | - Benjamin Lebwohl
- Division of Digestive and Liver Diseases, Department of Medicine, Columbia University Irving Medical Center, New York, New York
| | - Daniel E Freedberg
- Division of Digestive and Liver Diseases, Department of Medicine, Columbia University Irving Medical Center, New York, New York
| | - Chin Hur
- Division of Digestive and Liver Diseases, Department of Medicine, Columbia University Irving Medical Center, New York, New York; Division of General Medicine, Department of Medicine, Columbia University Irving Medical Center, New York, New York; Herbert Irving Comprehensive Cancer Center, Columbia University Irving Medical Center, New York, New York
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20
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Faye AS, Lee KE, Laszkowska M, Kim J, Blackett JW, McKenney AS, Krigel A, Giles JT, Wang R, Bernstein EJ, Green PHR, Krishnareddy S, Hur C, Lebwohl B. Risk of Adverse Outcomes in Hospitalized Patients With Autoimmune Disease and COVID-19: A Matched Cohort Study From New York City. J Rheumatol 2021; 48:454-462. [PMID: 33132221 PMCID: PMC8087816 DOI: 10.3899/jrheum.200989] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [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] [Accepted: 10/08/2020] [Indexed: 12/24/2022]
Abstract
OBJECTIVE To examine the effect of autoimmune (AI) disease on the composite outcome of intensive care unit (ICU) admission, intubation, or death from COVID-19 in hospitalized patients. METHODS Retrospective cohort study of 186 patients hospitalized with COVID-19 between March 1, 2020, and April 15, 2020 at NewYork-Presbyterian Hospital/Columbia University Irving Medical Center. The cohort included 62 patients with AI disease and 124 age- and sex-matched controls. The primary outcome was a composite of ICU admission, intubation, and death, with secondary outcome as time to in-hospital death. Baseline demographics, comorbidities, medications, vital signs, and laboratory values were collected. Conditional logistic regression and Cox proportional hazards regression were used to assess the association between AI disease and clinical outcomes. RESULTS Patients with AI disease were more likely to have at least one comorbidity (87.1% vs 74.2%, P = 0.04), take chronic immunosuppressive medications (66.1% vs 4.0%, P < 0.01), and have had a solid organ transplant (16.1% vs 1.6%, P < 0.01). There were no significant differences in ICU admission (13.7% vs 19.4%, P = 0.32), intubation (13.7% vs 17.7%, P = 0.47), or death (16.1% vs 14.5%, P = 0.78). On multivariable analysis, patients with AI disease were not at an increased risk for a composite outcome of ICU admission, intubation, or death (ORadj 0.79, 95% CI 0.37-1.67). On Cox regression, AI disease was not associated with in-hospital mortality (HRadj 0.73, 95% CI 0.33-1.63). CONCLUSION Among patients hospitalized with COVID-19, individuals with AI disease did not have an increased risk of a composite outcome of ICU admission, intubation, or death.
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Affiliation(s)
- Adam S Faye
- A.S. Faye, MD, MS, Department of Medicine, Division of Digestive and Liver Diseases, NewYork-Presbyterian/Columbia University Irving Medical Center, Department of Medicine, Henry D. Janowitz Division of Gastroenterology, Mount Sinai Hospital;
| | - Kate E Lee
- K.E. Lee, BA, Vagelos College of Physicians and Surgeons, Columbia University
| | - Monika Laszkowska
- M. Laszkowska, MD, MS, J. Kim, MD, J.W. Blackett, MD, A. Krigel, MD, MS, P.H. Green, MD, S. Krishnareddy, MD, MS, C. Hur, MD, MPH, B. Lebwohl, MD, MS, Department of Medicine, Division of Digestive and Liver Diseases, NewYork-Presbyterian/Columbia University Irving Medical Center
| | - Judith Kim
- M. Laszkowska, MD, MS, J. Kim, MD, J.W. Blackett, MD, A. Krigel, MD, MS, P.H. Green, MD, S. Krishnareddy, MD, MS, C. Hur, MD, MPH, B. Lebwohl, MD, MS, Department of Medicine, Division of Digestive and Liver Diseases, NewYork-Presbyterian/Columbia University Irving Medical Center
| | - John William Blackett
- M. Laszkowska, MD, MS, J. Kim, MD, J.W. Blackett, MD, A. Krigel, MD, MS, P.H. Green, MD, S. Krishnareddy, MD, MS, C. Hur, MD, MPH, B. Lebwohl, MD, MS, Department of Medicine, Division of Digestive and Liver Diseases, NewYork-Presbyterian/Columbia University Irving Medical Center
| | - Anna S McKenney
- A.S. McKenney, MD, PhD, MPH, Department of Radiology, NewYork-Presbyterian/Weill Cornell Medical College
| | - Anna Krigel
- M. Laszkowska, MD, MS, J. Kim, MD, J.W. Blackett, MD, A. Krigel, MD, MS, P.H. Green, MD, S. Krishnareddy, MD, MS, C. Hur, MD, MPH, B. Lebwohl, MD, MS, Department of Medicine, Division of Digestive and Liver Diseases, NewYork-Presbyterian/Columbia University Irving Medical Center
| | - Jon T Giles
- J.T. Giles, MD, MPH, R. Wang, MD, MHS, E.J. Bernstein, MD, MSc, Department of Medicine, Division of Rheumatology, NewYork-Presbyterian/Columbia University Irving Medical Center, New York, New York, USA
| | - Runsheng Wang
- J.T. Giles, MD, MPH, R. Wang, MD, MHS, E.J. Bernstein, MD, MSc, Department of Medicine, Division of Rheumatology, NewYork-Presbyterian/Columbia University Irving Medical Center, New York, New York, USA
| | - Elana J Bernstein
- J.T. Giles, MD, MPH, R. Wang, MD, MHS, E.J. Bernstein, MD, MSc, Department of Medicine, Division of Rheumatology, NewYork-Presbyterian/Columbia University Irving Medical Center, New York, New York, USA
| | - Peter H R Green
- M. Laszkowska, MD, MS, J. Kim, MD, J.W. Blackett, MD, A. Krigel, MD, MS, P.H. Green, MD, S. Krishnareddy, MD, MS, C. Hur, MD, MPH, B. Lebwohl, MD, MS, Department of Medicine, Division of Digestive and Liver Diseases, NewYork-Presbyterian/Columbia University Irving Medical Center
| | - Suneeta Krishnareddy
- M. Laszkowska, MD, MS, J. Kim, MD, J.W. Blackett, MD, A. Krigel, MD, MS, P.H. Green, MD, S. Krishnareddy, MD, MS, C. Hur, MD, MPH, B. Lebwohl, MD, MS, Department of Medicine, Division of Digestive and Liver Diseases, NewYork-Presbyterian/Columbia University Irving Medical Center
| | - Chin Hur
- M. Laszkowska, MD, MS, J. Kim, MD, J.W. Blackett, MD, A. Krigel, MD, MS, P.H. Green, MD, S. Krishnareddy, MD, MS, C. Hur, MD, MPH, B. Lebwohl, MD, MS, Department of Medicine, Division of Digestive and Liver Diseases, NewYork-Presbyterian/Columbia University Irving Medical Center
| | - Benjamin Lebwohl
- M. Laszkowska, MD, MS, J. Kim, MD, J.W. Blackett, MD, A. Krigel, MD, MS, P.H. Green, MD, S. Krishnareddy, MD, MS, C. Hur, MD, MPH, B. Lebwohl, MD, MS, Department of Medicine, Division of Digestive and Liver Diseases, NewYork-Presbyterian/Columbia University Irving Medical Center
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Lansdorp-Vogelaar I, Meester RGS, Laszkowska M, Escudero FA, Ward ZJ, Yeh JM. Cost-effectiveness of prevention and early detection of gastric cancer in Western countries. Best Pract Res Clin Gastroenterol 2021; 50-51:101735. [PMID: 33975689 DOI: 10.1016/j.bpg.2021.101735] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2021] [Revised: 02/15/2021] [Accepted: 02/19/2021] [Indexed: 02/08/2023]
Abstract
Gastric cancer (GC) is a significant global health problem, with Helicobacter pylori infection estimated to be responsible for 89% of non-cardiac GC cases, or 78% of all GC cases. The International Agency for Research on Cancer has called for Helicobacter pylori test-and-treat strategies in countries with high rates of GC. However, for countries with low rates of GC, such as most Western countries, the balance between benefits, harms and costs of screening is less clear-cut. GC is a disease with a well-characterized precancerous process, providing the basis for primary and secondary prevention efforts. However, rigorous data assessing the impact of such interventions in Western countries are lacking. In the absence of clinical trials, modelling offers a unique approach to evaluate the potential impact of various screening and surveillance interventions. In this paper, we provide an overview of modelling studies evaluating the cost-effectiveness of GC screening and surveillance in Western countries.
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Affiliation(s)
- Iris Lansdorp-Vogelaar
- Department of Public Health, Erasmus MC University Medical Center Rotterdam, the Netherlands.
| | - Reinier G S Meester
- Department of Public Health, Erasmus MC University Medical Center Rotterdam, the Netherlands.
| | - Monika Laszkowska
- Gastroenterology, Hepatology, and Nutrition Service, Memorial-Sloan Kettering Cancer Research Center New York, NY, USA.
| | | | - Zachary J Ward
- Center for Health Decision Science, Harvard T.H. Chan School of Public Health, Boston, MA, USA.
| | - Jennifer M Yeh
- Boston Children's Hospital, Harvard Medical School, Boston, MA, USA.
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22
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Kim J, Oh A, Truong H, Laszkowska M, Camargo MC, Abrams J, Hur C. Low sodium diet for gastric cancer prevention in the United States: Results of a Markov model. Cancer Med 2020; 10:684-692. [PMID: 33259151 PMCID: PMC7877368 DOI: 10.1002/cam4.3615] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Revised: 10/20/2020] [Accepted: 10/30/2020] [Indexed: 11/23/2022] Open
Abstract
Background and Aims High sodium consumption has been associated with an increased risk of gastric cancer. The mean daily sodium intake in the United States substantially exceeds the national recommended amount. The low sodium‐DASH diet has been shown to decrease the risk of cardiovascular disease in the United States, but its impact on gastric cancer has not been well studied. We therefore aimed to model the impact and cost‐effectiveness of the low sodium‐DASH diet for gastric cancer prevention in the U.S. population. Methods A Markov cohort state‐transition model was developed to simulate the impact of the low sodium‐DASH diet on gastric cancer outcomes for the average 40‐year‐old in the United States compared to no intervention. Primary outcomes of interest were gastric cancer incidence and incremental cost‐effectiveness ratios (ICER). Results Our model found that compared to the no intervention cohort, the risk of gastric cancer decreased by 24.8% for males and 21.2% for females on the low sodium‐DASH diet. 27 cases and 14 cases per 10,000 individuals were prevented for males and females, respectively, in the intervention group. The ICER for the low sodium‐DASH diet strategy was $287,726 for males and $423,878 for females compared to the no intervention strategy. Conclusions Using a Markov model of gastric cancer risk, we found that adherence to a low sodium‐DASH diet could decrease the risk of gastric cancer. This intervention was not cost‐effective due to the high cost of a low sodium‐DASH accordant diet, but significantly improved for high‐risk populations and when the cost of the diet became slightly more affordable.
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Affiliation(s)
- Judith Kim
- Division of Digestive and Liver Diseases, Department of Medicine, Columbia University Irving Medical Center, New York, NY, USA
| | - Aaron Oh
- Division of General Medicine, Department of Medicine, Columbia University Irving Medical Center, New York, NY, USA
| | - Han Truong
- Division of General Medicine, Department of Medicine, Columbia University Irving Medical Center, New York, NY, USA
| | - Monika Laszkowska
- Department of Medicine, Gastroenterology, Hepatology, and Nutrition Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - M Constanza Camargo
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Rockville, MD, USA
| | - Julian Abrams
- Division of Digestive and Liver Diseases, Department of Medicine, Columbia University Irving Medical Center, New York, NY, USA
| | - Chin Hur
- Division of Digestive and Liver Diseases, Department of Medicine, Columbia University Irving Medical Center, New York, NY, USA.,Division of General Medicine, Department of Medicine, Columbia University Irving Medical Center, New York, NY, USA
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Laszkowska M, Tramontano AC, Kim J, Camargo MC, Neugut AI, Abrams JA, Hur C. Racial and ethnic disparities in mortality from gastric and esophageal adenocarcinoma. Cancer Med 2020; 9:5678-5686. [PMID: 32573964 PMCID: PMC7402817 DOI: 10.1002/cam4.3063] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Revised: 03/20/2020] [Accepted: 03/30/2020] [Indexed: 12/11/2022] Open
Abstract
Background Racial/ethnic differences in mortality have not been well studied for either non‐cardia gastric cancer (NCGC) or cardia gastric cancer (CGC). The aim of this study was to examine the US mortality rates for these cancer subtypes, as well as esophageal adenocarcinoma (EAC) as a comparator. Methods We identified 14 164 individuals who died from NCGC, 5235 from CGC, and 13 982 from EAC in the Surveillance, Epidemiology, and End Results database between 2004 and 2016. Age‐adjusted incidence‐based mortality rates and corresponding annual percent changes (APCs) were calculated. Analyses were stratified by race/ethnicity, age, and stage of disease at diagnosis. Results The mortality rate in NCGC was two‐ to threefold higher in blacks, Hispanics, and Asians/Pacific Islanders (PI) than non‐Hispanic whites, and was significant across all age groups and stages of disease (P < .01). Mortality in CGC was higher in non‐Hispanic whites than blacks and Asians/PI, particularly in individuals in the 50‐64 year age group and those with stage IV disease. Mortality in EAC was two‐ to sixfold higher in non‐Hispanic whites than all other groups across all age groups and stages of disease. From 2004 to 2016, mortality rates were stable across all racial/ethnic groups in NCGC and CGC, and in minority groups with EAC, but have been rising in non‐Hispanic whites with EAC (APC 3.03, 95% CI 0.17‐5.96). Conclusions This is the largest study of incidence‐based mortality in CGC and NCGC and demonstrates racial/ethnic differences in mortality between these subtypes. Mortality rates for NCGC are highest in minority groups, and have been stable in recent years despite declining incidence. Mortality rates for CGC are marginally higher in middle‐aged non‐Hispanic whites with advanced disease, though have remained stable. In contrast, mortality in EAC has been rising for non‐Hispanic whites, in parallel to incidence. Further studies are needed to refine prevention strategies for high‐risk individuals dying from these specific cancer subtypes.
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Affiliation(s)
- Monika Laszkowska
- Division of Digestive and Liver Diseases, Department of Medicine, Vagelos College of Physicians & Surgeons, Columbia University, New York, NY, USA
| | - Angela C Tramontano
- Institute for Technology Assessment, Massachusetts General Hospital, Boston, MA, USA
| | - Judith Kim
- Division of Digestive and Liver Diseases, Department of Medicine, Vagelos College of Physicians & Surgeons, Columbia University, New York, NY, USA
| | - M Constanza Camargo
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Rockville, MD, USA
| | - Alfred I Neugut
- Department of Medicine, Division of Hematology/Oncology, Vagelos College of Physicians & Surgeons, Columbia University, New York, NY, USA.,Herbert Irving Comprehensive Cancer Center, Vagelos College of Physicians & Surgeons, Columbia University, New York, NY, USA
| | - Julian A Abrams
- Division of Digestive and Liver Diseases, Department of Medicine, Vagelos College of Physicians & Surgeons, Columbia University, New York, NY, USA.,Herbert Irving Comprehensive Cancer Center, Vagelos College of Physicians & Surgeons, Columbia University, New York, NY, USA
| | - Chin Hur
- Division of Digestive and Liver Diseases, Department of Medicine, Vagelos College of Physicians & Surgeons, Columbia University, New York, NY, USA.,Herbert Irving Comprehensive Cancer Center, Vagelos College of Physicians & Surgeons, Columbia University, New York, NY, USA
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Laszkowska M, Silver ER, Schrope B, Kastrinos F, Wang TC, Hur C. Optimal Timing of Total Gastrectomy to Prevent Diffuse Gastric Cancer in Individuals With Pathogenic Variants in CDH1. Clin Gastroenterol Hepatol 2020; 18:822-829.e4. [PMID: 31220641 DOI: 10.1016/j.cgh.2019.06.009] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [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: 03/27/2019] [Revised: 05/07/2019] [Accepted: 06/07/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Carriers of pathogenic variants in CDH1 have a high risk of hereditary diffuse gastric cancer (HDGC). Guidelines recommend prophylactic total gastrectomy (PTG) at age 20-30 years, although there is controversy over the optimal age. We developed a simulation model to analyze the effects of PTG at different ages on quality-adjusted life-years (QALYs), cancer mortality, and life expectancy. METHODS We used a Markov model of HDGC progression associated with pathogenic variants in CDH1 to simulate outcomes of hypothetical cohorts with different ages at time of PTG (ages 20-79 years). Model inputs including health state transition probabilities, mortality and complication rates, quality of life utility values, and endoscopic surveillance sensitivity were derived from publications. The primary outcome, used to determine the optimal strategy, was age at which PTG yielded the highest QALYs. Secondary outcomes were cancer mortality and unadjusted life-years. RESULTS Our model found that for men, the optimal age for PTG is 39 years, resulting in 32.01 incremental QALYs, 58.81 life-years (biologic age, 72.81 years), and lifetime cancer mortality of 8.5%. Incorporating endoscopic surveillance prior to PTG decreased cancer mortality to 6.7%, but had lower QALYs (31.59). PTG at age 30 reduced cancer mortality to 3.2%, with 31.45 incremental QALYs. For women, the optimal age for PTG was calculated to be 30 years, with 33.09 incremental QALYs, 66.17 life-years (biologic age, 80.17 years), and lifetime cancer mortality of 1.6%. Addition of endoscopic surveillance did not decrease the risk of HDGC mortality in women. CONCLUSIONS Using a Markov model of HDGC progression associated with pathogenic variants in CDH1 to simulate outcomes, we found the optimal ages for PTG to be 39 years for men and 30 years for women, when QALYs are the primary endpoint. These ages for PTG are older than those of current recommendations.
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Affiliation(s)
- Monika Laszkowska
- Department of Medicine, Division of Digestive and Liver Diseases, New York Presbyterian Columbia University Medical Center, New York, New York
| | - Elisabeth R Silver
- Department of Medicine, Division of General Medicine, New York Presbyterian Columbia University Medical Center, New York, New York
| | - Beth Schrope
- Columbia University Irving Cancer Center, New York, New York; Department of Surgery, New York Presbyterian Columbia University Medical Center, New York, New York
| | - Fay Kastrinos
- Department of Medicine, Division of Digestive and Liver Diseases, New York Presbyterian Columbia University Medical Center, New York, New York; Columbia University Irving Cancer Center, New York, New York
| | - Timothy C Wang
- Department of Medicine, Division of Digestive and Liver Diseases, New York Presbyterian Columbia University Medical Center, New York, New York; Columbia University Irving Cancer Center, New York, New York
| | - Chin Hur
- Department of Medicine, Division of Digestive and Liver Diseases, New York Presbyterian Columbia University Medical Center, New York, New York; Department of Medicine, Division of General Medicine, New York Presbyterian Columbia University Medical Center, New York, New York; Columbia University Irving Cancer Center, New York, New York.
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25
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Jang SR, Truong H, Oh A, Choi J, Tramontano AC, Laszkowska M, Hur C. Cost-effectiveness Evaluation of Targeted Surgical and Endoscopic Therapies for Early Colorectal Adenocarcinoma Based on Biomarker Profiles. JAMA Netw Open 2020; 3:e1919963. [PMID: 32150269 PMCID: PMC7063501 DOI: 10.1001/jamanetworkopen.2019.19963] [Citation(s) in RCA: 2] [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] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
IMPORTANCE Colorectal cancer (CRC) is the second leading cause of cancer-related mortality in the United States. The prognosis for patients with CRC varies widely, but new prognostic biomarkers provide the opportunity to implement a more individualized approach to treatment selection. OBJECTIVE To assess the cost-effectiveness of 3 therapeutic strategies, namely, endoscopic therapy (ET), laparoscopic colectomy (LC), and open colectomy (OC), for patients with T1 CRC with biomarker profiles that prognosticate varying levels of tumor progression in the US payer perspective. DESIGN, SETTING, AND PARTICIPANTS In this economic evaluation study, a Markov model was developed for the cost-effectiveness analysis. Risks of all-cause mortality and recurrent cancer after ET, LC, or OC were estimated with a 35-year time horizon. Quality of life was based on EuroQoL 5 Dimensions scores reported in the published literature. Hospital and treatment costs reflected Medicare reimbursement rates. Deterministic and probabilistic sensitivity analyses were performed. Data from patients with T1 CRC and 6 biomarker profiles that included adenomatous polyposis coli (APC), TP53 and/or KRAS, or BRAFV600E were used as inputs for the model. Data analyses were conducted from February 27, 2019, to May 13, 2019. EXPOSURES Endoscopic therapy, LC, and OC. MAIN OUTCOMES AND MEASURES The primary outcomes were unadjusted life-years, quality-adjusted life-years (QALYs), and the incremental cost-effectiveness ratio (ICER) between competing treatment strategies. RESULTS Endoscopic therapy had the highest QALYs and the lowest cost and was the dominant treatment strategy for T1 CRC with the following biomarker profiles: BRAFV600E, APC(1)/KRAS/TP53, APC(2) or APC(2)/KRAS or APC(2)/TP53, or APC(1) or APC(1)/KRAS or APC(1)/TP53. The QALYs gained ranged from 16.97 to 17.22, with costs between $68 902.75 and $77 784.53 in these subgroups. For the 2 more aggressive biomarker profiles with worse prognoses (APC(2)/KRAS/TP53 and APCwt [wild type]), LC was the most effective strategy (with 16.45 and 16.61 QALYs gained, respectively) but was not cost-effective. Laparoscopic colectomy cost $65 234.87 for APC(2)/KRAS/TP53 and $71 250.56 for APCwt, resulting in ICERs of $113 290 per QALY and $178 765 per QALY, respectively. CONCLUSIONS AND RELEVANCE This modeling analysis found that ET was the most effective strategy for patients with T1 CRC with less aggressive biomarker profiles. For patients with more aggressive profiles, LC was more effective but was costly, rendering ET the cost-effective option. This study highlights the potential utility of prognostic biomarkers in T1 CRC treatment selection.
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Affiliation(s)
- Se Ryeong Jang
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York
- now with College of Population Health, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Han Truong
- Herbert Irving Comprehensive Cancer Center, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York
| | - Aaron Oh
- Herbert Irving Comprehensive Cancer Center, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York
| | - Jin Choi
- Herbert Irving Comprehensive Cancer Center, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York
| | - Angela C. Tramontano
- Institute for Technology Assessment, Massachusetts General Hospital, Harvard Medical School, Boston
| | - Monika Laszkowska
- Department of Medicine, New York Presbyterian/Columbia University Medical Center, New York, New York
| | - Chin Hur
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York
- Herbert Irving Comprehensive Cancer Center, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York
- Department of Medicine, New York Presbyterian/Columbia University Medical Center, New York, New York
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Lauren B, Ostvar S, Silver E, Ingram M, Oh A, Kumble L, Laszkowska M, Chu JN, Hershman DL, Manji G, Neugut AI, Hur C. Cost-Effectiveness Analysis of Biomarker-Guided Treatment for Metastatic Gastric Cancer in the Second-Line Setting. J Oncol 2020; 2020:2198960. [PMID: 32148492 PMCID: PMC7048937 DOI: 10.1155/2020/2198960] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/04/2019] [Accepted: 12/26/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND The 5-year survival rate of patients with metastatic gastric cancer (GC) is only 5%. However, trials have demonstrated promising antitumor activity for targeted therapies/immunotherapies among chemorefractory metastatic GC patients. Pembrolizumab has shown particular efficacy among patients with programmed death ligand-1 (PD-L1) expression and high microsatellite instability (MSI-H). The aim of this study was to assess the effectiveness and cost-effectiveness of biomarker-guided second-line GC treatment. METHODS We constructed a Markov decision-analytic model using clinical trial data. Our model compared pembrolizumab monotherapy and ramucirumab/paclitaxel combination therapy for all patients and pembrolizumab for patients based on MSI status or PD-L1 expression. Paclitaxel monotherapy and best supportive care for all patients were additional comparators. Costs of drugs, treatment administration, follow-up, and management of adverse events were estimated from a US payer perspective. The primary outcomes were quality-adjusted life years (QALYs) and incremental cost-effectiveness ratios (ICERs) with a willingness-to-pay threshold of $100,000/QALY over 60 months. Secondary outcomes were unadjusted life years (survival) and costs. Deterministic and probabilistic sensitivity analyses were performed to evaluate model uncertainty. RESULTS The most effective strategy was pembrolizumab for MSI-H patients and ramucirumab/paclitaxel for all other patients, adding 3.8 months or 2.0 quality-adjusted months compared to paclitaxel. However, this strategy resulted in a prohibitively high ICER of $1,074,620/QALY. The only cost-effective strategy was paclitaxel monotherapy for all patients, with an ICER of $53,705/QALY. CONCLUSION Biomarker-based treatments with targeted therapies/immunotherapies for second-line metastatic GC patients substantially improve unadjusted and quality-adjusted survival but are not cost-effective at current drug prices.
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Affiliation(s)
| | - Sassan Ostvar
- Columbia University Medical Center, New York, NY, USA
| | | | - Myles Ingram
- Columbia University Medical Center, New York, NY, USA
| | - Aaron Oh
- Columbia University Medical Center, New York, NY, USA
| | | | | | | | - Dawn L. Hershman
- Columbia University Medical Center, New York, NY, USA
- Columbia University Irving Cancer Research Center, New York, NY, USA
| | - Gulam Manji
- Columbia University Medical Center, New York, NY, USA
- Columbia University Irving Cancer Research Center, New York, NY, USA
| | - Alfred I. Neugut
- Columbia University Irving Cancer Research Center, New York, NY, USA
| | - Chin Hur
- Columbia University Medical Center, New York, NY, USA
- Columbia University Irving Cancer Research Center, New York, NY, USA
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Laszkowska M, Oh A, Hur C. Screening for Upper Gastrointestinal Malignancies in the United States-Which Immigrant Groups Should Be Considered High-Risk? Gastroenterology 2020; 158:4-8. [PMID: 31614125 DOI: 10.1053/j.gastro.2019.09.047] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2019] [Revised: 09/14/2019] [Accepted: 09/23/2019] [Indexed: 02/07/2023]
Affiliation(s)
| | - Aaron Oh
- Columbia University, New York, New York
| | - Chin Hur
- Columbia University, New York, New York
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Axelrad JE, Sharma R, Laszkowska M, Packey C, Rosenberg R, Lebwohl B. Increased Healthcare Utilization by Patients With Inflammatory Bowel Disease Covered by Medicaid at a Tertiary Care Center. Inflamm Bowel Dis 2019; 25:1711-1717. [PMID: 30989212 PMCID: PMC7327156 DOI: 10.1093/ibd/izz060] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [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: 11/12/2018] [Indexed: 12/13/2022]
Abstract
BACKGROUND Low socioeconomic status has been linked with numerous poor health outcomes, but data are limited regarding the impact of insurance status on inflammatory bowel disease (IBD) outcomes. We aimed to characterize utilization of healthcare resources by IBD patients based on health insurance status, using Medicaid enrollment as a proxy for low socioeconomic status. METHODS We retrospectively identified adult patients with IBD engaged in a colorectal cancer surveillance colonoscopy program from July 2007 to June 2017. Our primary outcomes included emergency department (ED) visits, inpatient hospitalizations, biologic infusions, and steroid exposure, stratified by insurance status. We compared patients who had ever been enrolled in Medicaid with all other patients. RESULTS Of 947 patients with IBD, 221 (23%) had been enrolled in Medicaid. Compared with patients with other insurance types, patients with Medicaid had higher rates of ever being admitted to the hospital (77.6% vs 42.6%, P < 0.0001) or visiting the ED (90.5% vs 38.4%, P < 0.0001). When adjusted for sex, age at first colonoscopy, and ethnicity, patients with Medicaid had a higher rate of inpatient hospitalizations (Rate ratio [RR] 2.95; 95% CI 2.59-3.36) and ED visits (RR 4.24; 95% CI 3.82-4.70) compared to patients with other insurance. Patients with Medicaid had significantly higher prevalence of requiring steroids (62.4% vs 37.7%, P < 0.0001), and after adjusting for the same factors, the odds of requiring steroids in the patients with Medicaid was increased (OR 3.77; 95% CI 2.53-5.62). CONCLUSIONS Medicaid insurance was a significant predictor of IBD care and outcomes. Patients with Medicaid may have less engagement in IBD care and seek emergency care more often.
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Affiliation(s)
- Jordan E Axelrad
- Inflammatory Bowel Disease Center, Division of Gastroenterology, NYU Langone Health, New York, USA
| | - Rajani Sharma
- Division of Digestive and Liver Diseases, Columbia University Medical Center, New York, USA,Address correspondence to: Rajani Sharma, MD, 630 West 168 Street, Box 83, P&S 3 Floor, Room 3–401, New York, NY 10032 ()
| | - Monika Laszkowska
- Division of Digestive and Liver Diseases, Columbia University Medical Center, New York, USA
| | - Christopher Packey
- Division of Digestive and Liver Diseases, Columbia University Medical Center, New York, USA
| | - Richard Rosenberg
- Division of Digestive and Liver Diseases, Columbia University Medical Center, New York, USA
| | - Benjamin Lebwohl
- Division of Digestive and Liver Diseases, Columbia University Medical Center, New York, USA
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Lauren B, Silver E, Ingram M, Oh A, Kumble L, Ostvar S, Laszkowska M, Chu JN, Manji GA, Neugut AI, Hur C. Second-line treatment of metastatic gastric cancer in the era of predictive biomarkers: A cost-effectiveness analysis. J Clin Oncol 2019. [DOI: 10.1200/jco.2019.37.15_suppl.e15517] [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
e15517 Background: Gastric cancer is the third leading cause of cancer-related mortality, with only a 30% five-year survival rate. Patients who progress after one round of systemic therapy face an especially poor prognosis. The National Comprehensive Cancer Network guidelines include both pembrolizumab (PEM) and ramucirumab plus paclitaxel (RAM/PAC) as second-line (2L) therapy for gastric cancer based on data from the Phase II KEYNOTE-059 and Phase III RAINBOW trials, respectively. Recently, the Phase III KEYNOTE-061 trial reported on the effectiveness of PEM for patients with programmed death-ligand 1 (PD-L1) expression and high microsatellite instability (MSI-H). Given the high prices of targeted therapies, it is important to determine if cost-effectiveness is possible using personalized treatment strategies. The aim of this study was to assess the cost-effectiveness of these regimens in both the general patient population and specific biomarker populations. Methods: A decision-analytic (Markov) model was constructed using data from the KEYNOTE-059, KEYNOTE-061, RAINBOW, and REGARD trials. The analysis compared PEM and RAM/PAC for all patients, as well as PEM for patients based on MSI status or PD-L1 expression (combined positive score of 1% or 10%) in the 2L setting. Comparators were paclitaxel monotherapy (PAC) for all patients and best supportive care (BSC) for all patients. Costs (USD) and utility values were estimated from Medicare and the literature. The primary outcome was the incremental cost-effectiveness ratio (ICER) with a willingness-to-pay (WTP) threshold of $100,000. Results: The only cost-effective strategy was PAC monotherapy for all patients, with an ICER of $53,705/QALY. PEM for MSI-H patients and RAM/PAC for microsatellite stable patients was the most effective strategy (greatest QALYs), but was not cost-effective with an ICER of $1,074,620/QALY. Conclusions: Despite their effectiveness, PEM and RAM/PAC are not cost-effective as 2L treatments for metastatic gastric cancer. Although personalizing treatment based on biomarkers improved cost-effectiveness, the ICERs surpassed the WTP threshold at current drug prices.
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Affiliation(s)
| | | | - Myles Ingram
- Columbia University Medical Center, New York, NY
| | - Aaron Oh
- Columbia University Medical Center, New York, NY
| | | | | | - Monika Laszkowska
- New York Presbyterian - Columbia University Medical Center, New York, NY
| | | | - Gulam Abbas Manji
- Columbia University Medical Center and New York-Presbyterian Hospital, New York, NY
| | | | - Chin Hur
- Columbia University Medical Center, Bronx, NY
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Laszkowska M, Mahadev S, Sundström J, Lebwohl B, Green PHR, Michaelsson K, Ludvigsson JF. Systematic review with meta-analysis: the prevalence of coeliac disease in patients with osteoporosis. Aliment Pharmacol Ther 2018; 48:590-597. [PMID: 29984519 DOI: 10.1111/apt.14911] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [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: 02/27/2018] [Revised: 03/25/2018] [Accepted: 06/24/2018] [Indexed: 12/12/2022]
Abstract
BACKGROUND Earlier studies have produced highly varying risk estimates for the prevalence of coeliac disease (CD) in osteoporosis. AIMS To investigate the prevalence of CD among individuals with osteoporosis. METHODS We conducted a systematic review of articles published in PubMed, Medline or EMBASE through May 2017 to identify studies looking at prevalence of CD in patients with osteoporosis. Search terms included "coeliac disease" combined with "fractures", "bone disease", "bone density", "densitometry", "osteoporos*", "osteomal*", "osteodys" or "dexa" or "dxa" or "skelet". Non-English papers with English-language abstracts were included. We used fixed-effects inverse variance-weighted models, and tested heterogeneity through subgroup analysis as well as through meta-regression. RESULTS We identified eight relevant studies, comprising data from 3188 individuals with osteoporosis. Of these, 59 individuals (1.9%) had CD. A weighted pooled analysis demonstrated biopsy-confirmed CD in 1.6% (95% CI = 1.1%-2.0%) of individuals with osteoporosis. The heterogeneity was moderate (I2 = 40.1%), and influenced by the underlying CD prevalence in the general population. After adding four studies (n = 814) with CD defined as positive tissue transglutaminase or endomysial antibodies, the pooled prevalence was comparable (1.6%; 95% CI = 1.2%-2.0%). CONCLUSIONS About 1 in 62 individuals with osteoporosis, or 1.6%, have biopsy-verified CD. This prevalence is comparable to that in the general population. These findings argue against routinely screening patients with osteoporosis for CD, which is contrary to current guideline recommendations. Additional studies are needed to determine the true utility of such screening programs.
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Affiliation(s)
- M Laszkowska
- Department of Medicine, Celiac Disease Center, Columbia University College of Physicians and Surgeons, New York, NY, USA
| | - S Mahadev
- Department of Medicine, Celiac Disease Center, Columbia University College of Physicians and Surgeons, New York, NY, USA
| | - J Sundström
- Department of Medical Sciences, Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - B Lebwohl
- Department of Medicine, Celiac Disease Center, Columbia University College of Physicians and Surgeons, New York, NY, USA
| | - P H R Green
- Department of Medicine, Celiac Disease Center, Columbia University College of Physicians and Surgeons, New York, NY, USA
| | - K Michaelsson
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - J F Ludvigsson
- Department of Medicine, Celiac Disease Center, Columbia University College of Physicians and Surgeons, New York, NY, USA.,Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden.,Department of Paediatrics, Örebro University Hospital, Örebro, Sweden.,Division of Epidemiology and Public Health, School of Medicine, University of Nottingham, Nottingham, UK
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Mahadev S, Laszkowska M, Sundström J, Björkholm M, Lebwohl B, Green PHR, Ludvigsson JF. Prevalence of Celiac Disease in Patients With Iron Deficiency Anemia-A Systematic Review With Meta-analysis. Gastroenterology 2018; 155:374-382.e1. [PMID: 29689265 PMCID: PMC7057414 DOI: 10.1053/j.gastro.2018.04.016] [Citation(s) in RCA: 63] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2018] [Revised: 04/10/2018] [Accepted: 04/17/2018] [Indexed: 02/06/2023]
Abstract
BACKGROUND & AIMS Anemia is common in patients with celiac disease (CD) and a frequent mode of presentation. Guidelines recommend screening patients with iron-deficiency anemia (IDA) for CD. However, the reported prevalence of CD in patients with IDA varies. We performed a systematic review to determine the prevalence of biopsy-verified CD in patients with IDA. METHODS We performed a systematic review of articles published in PubMed Medline or EMBASE through July 2017 for the term "celiac disease" combined with "anemia" or "iron deficiency." We used fixed-effects inverse variance-weighted models to measure the pooled prevalence of CD. Meta-regression was used to assess subgroup heterogeneity. RESULTS We identified 18 studies composed of 2998 patients with IDA for inclusion in our analysis. Studies originated from the United Kingdom, United States, Italy, Turkey, Iran, and Israel. The crude unweighted prevalence of CD was 4.8% (n = 143). Using a weighted pooled analysis, we found a prevalence of biopsy-confirmed CD of 3.2% (95% confidence interval = 2.6-3.9) in patients with IDA. However, heterogeneity was high (I2 = 67.7%). The prevalence of CD was not significantly higher in studies with a mean participant age older or younger than 18 years or in studies with a mixed-sex vs female-predominant (≥60%) population. On meta-regression, year of publication, female proportion, age at CD testing, and prevalence in the general population were not associated with the prevalence of CD in patients with IDA. In the 8 studies fulfilling all our quality criteria, the pooled prevalence of CD was 5.5% (95% confidence interval = 4.1-6.9). CONCLUSIONS In a systematic review and meta-analysis, we found that approximately 1 in 31 patients with IDA have histologic evidence of CD. This prevalence value justifies the practice of testing patients with IDA for CD.
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Affiliation(s)
- Srihari Mahadev
- Celiac Disease Center, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, New York, USA
| | - Monika Laszkowska
- Celiac Disease Center, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, New York, USA
| | - Johan Sundström
- Department of Medical Sciences, Uppsala University, and Uppsala Clinical Research Center, SE-751 85 Uppsala, Sweden
| | - Magnus Björkholm
- Department of Medicine, Division of Hematology, Karolinska University Hospital and Karolinska Institutet, SE-171 76 Stockholm, Sweden
| | - Benjamin Lebwohl
- Celiac Disease Center, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, New York, USA
| | - Peter HR Green
- Celiac Disease Center, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, New York, USA
| | - Jonas F Ludvigsson
- Celiac Disease Center, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, New York; Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden; Department of Pediatrics, Örebro University Hospital, Örebro, Sweden; Division of Epidemiology and Public Health, School of Medicine, University of Nottingham, Nottingham, United Kingdom.
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Laszkowska M, Shiwani H, Belluz J, Ludvigsson JF, Green PHR, Sheehan D, Rundle A, Lebwohl B. Socioeconomic vs Health-related Factors Associated With Google Searches for Gluten-Free Diet. Clin Gastroenterol Hepatol 2018; 16:295-297. [PMID: 28826915 DOI: 10.1016/j.cgh.2017.07.042] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2017] [Revised: 07/28/2017] [Accepted: 07/31/2017] [Indexed: 02/07/2023]
Affiliation(s)
- Monika Laszkowska
- Celiac Disease Center, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, New York
| | - Henna Shiwani
- Celiac Disease Center, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, New York
| | | | - Jonas F Ludvigsson
- Celiac Disease Center, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, New York; Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden; Department of Pediatrics, Örebro University Hospital, Örebro, Sweden; Division of Epidemiology and Public Health, School of Medicine, University of Nottingham, Nottingham, United Kingdom
| | - Peter H R Green
- Celiac Disease Center, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, New York
| | | | - Andrew Rundle
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York
| | - Benjamin Lebwohl
- Celiac Disease Center, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, New York; Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York.
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Laszkowska M, Roy A, Lebwohl B, Green PHR, Sundelin HEK, Ludvigsson JF. Nationwide population-based cohort study of celiac disease and risk of Ehlers-Danlos syndrome and joint hypermobility syndrome. Dig Liver Dis 2016; 48:1030-4. [PMID: 27321543 DOI: 10.1016/j.dld.2016.05.019] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [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: 04/08/2016] [Revised: 05/18/2016] [Accepted: 05/21/2016] [Indexed: 12/11/2022]
Abstract
BACKGROUND Patients with celiac disease (CD) often have articular complaints, and small prior studies suggest an association with Ehlers-Danlos syndrome (EDS)/joint hypermobility syndrome (JHS). AIMS This study examines the risks of EDS/JHS in patients with CD. METHODS This cohort study compared all individuals in Sweden diagnosed with CD based on small intestinal biopsy between 1969-2008 (n=28,631) to 139,832 matched reference individuals, and to a second reference group undergoing biopsy without having CD (n=16,104). Rates of EDS/JHS were determined based on diagnostic codes in the Swedish Patient Register. Hazard ratios (HRs) for EDS/JHS were estimated through Cox regression. RESULTS There are 45 and 148 cases of EDS/JHS in patients with CD and reference individuals, respectively. This corresponds to a 49% increased risk of EDS/JHS in CD (95%CI=1.07-2.07). The HR for EDS was 2.43 (95%CI=1.20-4.91) and for JHS 1.34 (95%CI=0.93-1.95). Compared to reference individuals undergoing intestinal biopsy, CD was not a risk factor for EDS/JHS. A stronger association was seen in patients initially diagnosed with EDS/JHS and subsequently diagnosed with CD (odds ratio=2.29; 95%CI=1.21-4.34). CONCLUSIONS Individuals with CD have higher risk of EDS/JHS than the general population, which may be due to surveillance bias or factors intrinsic to celiac development.
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Affiliation(s)
- Monika Laszkowska
- Celiac Disease Center, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, NY, USA
| | - Abhik Roy
- Celiac Disease Center, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, NY, USA
| | - Benjamin Lebwohl
- Celiac Disease Center, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, NY, USA; Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Peter H R Green
- Celiac Disease Center, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, NY, USA
| | | | - Jonas F Ludvigsson
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden; Department of Pediatrics, Örebro University Hospital, Örebro, Sweden; Division of Epidemiology and Public Health, School of Medicine, University of Nottingham, Nottingham, UK.
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Roy A, Laszkowska M, Sundström J, Lebwohl B, Green PHR, Kämpe O, Ludvigsson JF. Prevalence of Celiac Disease in Patients with Autoimmune Thyroid Disease: A Meta-Analysis. Thyroid 2016; 26:880-90. [PMID: 27256300 DOI: 10.1089/thy.2016.0108] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [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] [Indexed: 12/16/2022]
Abstract
BACKGROUND Several screening studies have indicated an increased prevalence of celiac disease (CD) among individuals with autoimmune thyroid disease (ATD), but estimates have varied substantially. OBJECTIVE The aim of this study was to examine the prevalence of CD in patients with ATD. METHOD A systematic review was conducted of articles published in PubMed Medline or EMBASE until September 2015. Non-English papers with English-language abstracts were also included, as were research abstracts without full text available when relevant data were included in the abstract. Search terms included "celiac disease" combined with "hypothyroidism" or "hyperthyroidism" or "thyroid disease." Fixed-effects inverse variance-weighted models were used. Meta-regression was used to examine heterogeneity in subgroups. RESULTS A pooled analysis, based on 6024 ATD patients, found a prevalence of biopsy-confirmed CD of 1.6% [confidence interval (CI) 1.3-1.9%]. Heterogeneity was large (I(2) = 70.7%). The prevalence was higher in children with ATD (6.2% [CI 4.0-8.4%]) than it was in adults (2.7%) or in studies examining both adults and children (1.0%). CD was also more prevalent in hyperthyroidism (2.6% [CI 0.7-4.4%]) than it was in hypothyroidism (1.4% [CI 1.0-1.9%]). CONCLUSIONS About 1/62 patients with ATD have biopsy-verified CD. It is argued that patients with ATD should be screened for CD, given this increased prevalence.
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Affiliation(s)
- Abhik Roy
- 1 Celiac Disease Center, Department of Medicine, Columbia University College of Physicians and Surgeons , New York, New York
| | - Monika Laszkowska
- 1 Celiac Disease Center, Department of Medicine, Columbia University College of Physicians and Surgeons , New York, New York
| | - Johan Sundström
- 2 Department of Medical Sciences, Uppsala University , Uppsala, Sweden
| | - Benjamin Lebwohl
- 1 Celiac Disease Center, Department of Medicine, Columbia University College of Physicians and Surgeons , New York, New York
| | - Peter H R Green
- 1 Celiac Disease Center, Department of Medicine, Columbia University College of Physicians and Surgeons , New York, New York
| | - Olle Kämpe
- 3 Department of Medicine (Solna), Karolinska University Hospital , Karolinska Institutet, Stockholm, Sweden
| | - Jonas F Ludvigsson
- 1 Celiac Disease Center, Department of Medicine, Columbia University College of Physicians and Surgeons , New York, New York
- 4 Department of Medical Epidemiology and Biostatistics, Karolinska University Hospital , Karolinska Institutet, Stockholm, Sweden
- 5 Department of Paediatrics, Örebro University Hospital , Örebro, Sweden
- 6 Division of Epidemiology and Public Health, School of Medicine, University of Nottingham , Nottingham, United Kingdom
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Putnam AL, Safinia N, Medvec A, Laszkowska M, Wray M, Mintz MA, Trotta E, Szot GL, Liu W, Lares A, Lee K, Laing A, Lechler RI, Riley JL, Bluestone JA, Lombardi G, Tang Q. Clinical grade manufacturing of human alloantigen-reactive regulatory T cells for use in transplantation. Am J Transplant 2013; 13:3010-20. [PMID: 24102808 PMCID: PMC4161737 DOI: 10.1111/ajt.12433] [Citation(s) in RCA: 208] [Impact Index Per Article: 18.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2013] [Revised: 07/15/2013] [Accepted: 07/15/2013] [Indexed: 01/25/2023]
Abstract
Regulatory T cell (Treg) therapy has the potential to induce transplantation tolerance so that immunosuppression and associated morbidity can be minimized. Alloantigen-reactive Tregs (arTregs) are more effective at preventing graft rejection than polyclonally expanded Tregs (PolyTregs) in murine models. We have developed a manufacturing process to expand human arTregs in short-term cultures using good manufacturing practice-compliant reagents. This process uses CD40L-activated allogeneic B cells to selectively expand arTregs followed by polyclonal restimulation to increase yield. Tregs expanded 100- to 1600-fold were highly alloantigen reactive and expressed the phenotype of stable Tregs. The alloantigen-expanded Tregs had a diverse TCR repertoire. They were more potent than PolyTregs in vitro and more effective at controlling allograft injuries in vivo in a humanized mouse model.
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Affiliation(s)
- A. L. Putnam
- UCSF Diabetes Center, University of California, San Francisco, San Francisco CA
| | - N. Safinia
- MRC Centre for Transplantation, King’s College London, London, UK
| | - A. Medvec
- Department of Microbiology, University of Pennsylvania, Philadelphia, PA
| | - M. Laszkowska
- Department of Surgery, University of California, San Francisco, San Francisco CA
| | - M. Wray
- Department of Surgery, University of California, San Francisco, San Francisco CA
| | - M. A. Mintz
- Department of Surgery, University of California, San Francisco, San Francisco CA
| | - E. Trotta
- UCSF Diabetes Center, University of California, San Francisco, San Francisco CA,Department of Surgery, University of California, San Francisco, San Francisco CA
| | - G. L. Szot
- UCSF Diabetes Center, University of California, San Francisco, San Francisco CA,Department of Surgery, University of California, San Francisco, San Francisco CA
| | - W. Liu
- UCSF Diabetes Center, University of California, San Francisco, San Francisco CA
| | - A. Lares
- UCSF Diabetes Center, University of California, San Francisco, San Francisco CA
| | - K. Lee
- Department of Surgery, University of California, San Francisco, San Francisco CA
| | - A. Laing
- MRC Centre for Transplantation, King’s College London, London, UK
| | - R. I. Lechler
- MRC Centre for Transplantation, King’s College London, London, UK
| | - J. L. Riley
- Department of Microbiology, University of Pennsylvania, Philadelphia, PA
| | - J. A. Bluestone
- UCSF Diabetes Center, University of California, San Francisco, San Francisco CA
| | - G. Lombardi
- MRC Centre for Transplantation, King’s College London, London, UK
| | - Q. Tang
- Department of Surgery, University of California, San Francisco, San Francisco CA,Corresponding author: Qizhi Tang,
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Taylor KN, Laszkowska M, Cohick E, Colson YL. Induction of FoxP3+CD4+CD25+ regulatory T cells by a bone marrow population distinct from plasmacytoid-DC. Cell Immunol 2008; 251:43-9. [PMID: 18457820 DOI: 10.1016/j.cellimm.2008.03.003] [Citation(s) in RCA: 9] [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: 01/15/2008] [Revised: 03/13/2008] [Accepted: 03/13/2008] [Indexed: 12/13/2022]
Abstract
Facilitating cells (FC) are bone marrow-derived cells that facilitate allogeneic hematopoietic stem cell (SC) engraftment and induce transplantation tolerance without causing graft vs. host disease. Although there is evidence for FC directing the development of FoxP3+CD4+CD25+ regulatory T cells, the specific FC subsets that control regulatory T cell development have not been defined. The current study investigates the role of FC-CD3epsilon+ and FC-CD3epsilon- subpopulations in the development of FoxP3+CD4+CD25+ regulatory T cells. Here, we demonstrate that the induction of FoxP3+CD4+CD25+ regulatory T cells in coculture is mediated by not only the FC-CD3epsilon- subset but also the FC-CD3epsilon+ subset, which is distinct from plasmacytoid precursor dendritic cells (p-preDC). The identification of cell populations distinct from p-preDC that efficiently induce the generation of FoxP3+CD4+CD25+ regulatory T cells may prove useful for future therapeutic applications for the induction of tolerance following allogeneic SC transplantation.
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Affiliation(s)
- Kendra N Taylor
- Division of Thoracic Surgery, Department of Surgery, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, USA
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Abstract
p53 promotes tumor suppression through its ability to function as a transcriptional factor and is activated by posttranslational modifications that include acetylation. Our earlier study demonstrated that p53 acetylation can enhance its sequence-specific DNA binding in vitro, and this notion was later confirmed in several other studies. However, a recent study has reported that in vitro acetylation of p53 fails to stimulate its DNA binding to large DNA fragments, raising an important issue that requires further investigation. Here, we show that unacetylated p53 is able to bind weakly to its consensus site within the context of large DNA fragments, although it completely fails to bind the same site within short oligonucleotide probes. Strikingly, by using highly purified and fully acetylated p53 proteins obtained from cells, we show that acetylation of the C-terminal domain can dramatically enhance site-specific DNA binding on both short oligonucleotide probes and long DNA fragments. Moreover, endogenous p53 apparently can be fully acetylated in response to DNA damage when both histone deacetylase complex 1 (HDAC1)- and Sir2-mediated deacetylation are inhibited, indicating dynamic p53 acetylation and deacetylation events during the DNA damage response. Finally, we also show that acetylation of endogenous p53 indeed significantly augments its ability to bind an endogenous target gene and that p53 acetylation levels correlate well with p53-mediated transcriptional activation in vivo. Thus, our results clarify some of the confusion surrounding acetylation-mediated effects on p53 binding to DNA and suggest that acetylation of p53 in vivo may contribute, at least in part, to its transcriptional activation functions.
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Affiliation(s)
- Jianyuan Luo
- Institute for Cancer Genetics and Department of Pathology, College of Physicians and Surgeons, Columbia University, New York, NY 10032, USA
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