The NUTRIENT Trial (NUTRitional Intervention among myEloproliferative Neoplasms): Results from a Randomized Phase I Pilot Study for Feasibility and Adherence

PURPOSE

Chronic inflammation is integral to myeloproliferative neoplasm (MPN) pathogenesis. JAK inhibitors reduce cytokine levels, but not without significant side effects. Nutrition is a low-risk approach to reduce inflammation and ameliorate symptoms in MPN. We performed a randomized, parallel-arm study to determine the feasibility of an education-focused Mediterranean diet intervention among patients with MPN.

EXPERIMENTAL DESIGN

We randomly assigned patients with MPN to either a Mediterranean diet or standard U.S. Dietary Guidelines for Americans (USDA). Groups received equal but separate education with registered dietician counseling and written dietary resources. Patients were prospectively followed for feasibility, adherence, and symptom burden assessments. Biological samples were collected at four timepoints during the 15-week study to explore changes in inflammatory biomarkers and gut microbiome.

RESULTS

The Mediterranean diet was as easy to follow for patients with MPN as the standard USDA diet. Approximately 80% of the patients in the Mediterranean diet group achieved a Mediterranean Diet Adherence Score of ≥8 throughout the entire active intervention period, whereas less than 50% of the USDA group achieved a score of ≥8 at any timepoint. Improvement in symptom burden was observed in both diet groups. No significant changes were observed in inflammatory cytokines. The diversity and composition of the gut microbiome remained stable throughout the duration of the intervention.

CONCLUSIONS

With dietician counseling and written education, patients with MPN can adhere to a Mediterranean eating pattern. Diet interventions may be further developed as a component of MPN care, and potentially incorporated into the management of other hematologic conditions.

SIGNIFICANCE

Diet is a central tenant of management of chronic conditions characterized by subclinical inflammation, such as cardiovascular disease, but has not entered the treatment algorithm for clonal hematologic disorders. Here, we establish that a Mediterranean diet intervention is feasible in the MPN patient population and can improve symptom burden. These findings warrant large dietary interventions in patients with hematologic disorders to test the impact of diet on clinical outcomes.

The NUTRIENT Trial (NUTRitional Intervention among myEloproliferative Neoplasms): Feasibility Phase

Purpose

Chronic inflammation is integral to Myeloproliferative Neoplasm (MPN) pathogenesis. JAK inhibitors reduce cytokine levels, but not without significant side effects. Nutrition is a low-risk approach to reduce inflammation and ameliorate symptoms in MPN. We performed a randomized, parallel-arm study to determine the feasibility of an education-focused Mediterranean diet intervention among MPN patients.

Experimental Design

We randomly assigned participants to either a Mediterranean diet or standard US Dietary Guidelines for Americans (USDA). Groups received equal but separate education with registered dietician counseling and written dietary resources. Patients were prospectively followed for feasibility, adherence, and symptom burden assessments. Biological samples were collected at four time points during the 15-week study to explore changes in inflammatory biomarkers and gut microbiome.

Results

The Mediterranean diet was as easy to follow for MPN patients as the standard USDA diet. Over 80% of the patients in the Mediterranean diet group achieved a Mediterranean Diet Adherence Score of ≥8 throughout the entire active intervention period, whereas less than 50% of the USDA group achieved a score of ≥8 at any time point. Improvement in symptom burden was observed in both diet groups. No significant changes were observed in inflammatory cytokines. The diversity and composition of the gut microbiome remained stable throughout the duration of the intervention.

Conclusions

With dietician counseling and written education MPN patients can adhere to a Mediterranean eating pattern. Diet interventions may be further developed as a component of MPN care, and potentially even be incorporated into the management of other chronic clonal hematologic conditions.

Ruxolitinib Re-Treatment in Patients with Myelofibrosis: Real-World Evidence on Patient Characteristics and Outcomes

Ruxolitinib is an FDA-approved treatment of intermediate- and high-risk myelofibrosis. In the phase 3 COMFORT studies, ruxolitinib reduced spleen volume in patients with myelofibrosis, with a median time to response of 3 months. However, nearly 20% of patients discontinued by month 4 with few treatment options available following discontinuation of ruxolitinib treatment. In this study, 2 independent patient care data sources were queried (Cardinal Health Oncology Provider Extended Network [OPEN] and HealthCore Integrated Research Environment [HIRE®]), and a retrospective review of medical charts was conducted. Patients aged ≥18 years with a diagnosis of myelofibrosis (primary or secondary), use of ruxolitinib for myelofibrosis, and documented physician-directed ruxolitinib interruption were included. Among 26 included patients, pre-interruption median (interquartile range [IQR]) ruxolitinib treatment duration was 123 (57–391, OPEN) and 110 (37–148, HIRE) days. Half the patients interrupted treatment within 3 months, commonly for adverse events (42% and 71%, respectively). After restarting ruxolitinib, median (IQR) re-treatment duration was 196 (54–553) and 166 (108–262) days, respectively. Consistent with previous reports, symptoms and spleen size improved in (OPEN/HIRE) 45%/43% and 40%/33% of evaluable patients, respectively. Further studies investigating the management of dose modifications and interruptions are needed to optimize benefit from ruxolitinib therapy.

Changes in the incidence and overall survival of patients with myeloproliferative neoplasms between 2002 and 2016 in the United States

This analysis examined trends in incidence and survival among US adults with myeloproliferative neoplasms, including essential thrombocythemia (ET; n = 14,676), polycythemia vera (PV; n = 15,141), and primary myelofibrosis (PMF; n = 4214), using Surveillance, Epidemiology, and End User Results (SEER) data (SEER 18; 2002-2016). Incidence and survival rates over the study period and by diagnosis year (per 5-year time frames: 2002-2006; 2007-2011; 2012-2016) were assessed. The overall incidence rates (95% CI) were 1.55 (1.52-1.57) for ET, 1.57 (1.55-1.60) for PV, and 0.44 (0.43-0.45) per 100,000 person-years for PMF, with rising ET incidence. Five-year mortality over the study period was 19.2%, 19.0%, and 51.0% for ET, PV, and PMF, respectively. Improved survival over time was observed for PV and PMF, but not for ET. These findings highlight the need for effective ET therapies, as ET incidence has risen without concurrent improvements in survival over the past 2 decades.

Tobacco use in the Myeloproliferative neoplasms: symptom burden, patient opinions, and care

BACKGROUND

Patients with Philadelphia-negative Myeloproliferative Neoplasms (MPN) suffer from numerous symptoms and decreased quality of life. Smoking is associated with an increased symptom burden in several malignancies. The aim of this study was to analyze the association between smoking and MPN-related symptom burden and explore MPN patients' opinions on smoking.

METHODS

A total of 435 patients with MPN participated in a cross-sectional internet-based survey developed by the Mayo Clinic and the Myeloproliferative Neoplasm Quality of Life Group. Patients reported their demographics, disease characteristics, tobacco use, and opinions on tobacco use. In addition, MPN-related symptoms were reported via the validated 10-item version of the Myeloproliferative Neoplasms Symptom Assessment Form.

RESULTS

Current/former smokers reported worse fatigue (mean severity 5.6 vs. 5.0, p = 0.02) and inactivity (mean severity 4.0 vs. 3.4, p = 0.03) than never smokers. Moreover, current/former smokers more frequently experienced early satiety (68.5% vs. 58.3%, p = 0.03), inactivity (79.9% vs. 71.1%, p = 0.04), and concentration difficulties (82.1% vs. 73.1%, p = 0.04). Although not significant, a higher total symptom burden was observed for current/former smokers (mean 30.4 vs. 27.0, p = 0.07). Accordingly, overall quality of life was significantly better among never smokers than current/former smokers (mean 3.5 vs. 3.9, p = 0.03). Only 43.2% of the current/former smokers reported having discussed tobacco use with their physician, and 17.5% did not believe smoking increased the risk of thrombosis.

CONCLUSION

The current study suggests that smoking may be associated with increased prevalence and severity of MPN symptoms and underscores the need to enhance patient education and address tobacco use in the care of MPN patients.

Integrative Approaches to Managing Myeloproliferative Neoplasms: the Role of Nutrition, Exercise, and Psychological Interventions

PURPOSE OF REVIEW

Myeloproliferative neoplasms (MPNs) have a high symptom burden that affects functional status, emotional well-being, and quality of life for patients. Symptom control continues to be a challenging therapeutic goal despite available pharmacologic interventions. The goal of this review is to detail recent efforts that have focused on non-pharmacologic interventions, such as wholistic or integrative medicine, as an adjunctive method to alter symptom burden in this population.

RECENT FINDINGS

We discuss the ongoing physical, nutritional, and psychological interventional efforts which represent promising non-traditional interventions to date to help reduce symptom in MPN patients. In this article, we highlight the early promising data and importance of these various non-pharmacological interventions to dampen symptom burden and reduce disease-related inflammation. Nonpharmacologic interventions represent promising therapeutic strategies to alter traditional MPN treatment paradigms and improve MPN patient care.

Management of challenging myelofibrosis after JAK inhibitor failure and/or progression

The myeloproliferative neoplasms (MPNs) encompass a heterogenous set of diseases that have variable survival, but in the setting of treatment refractory and progressive disease, prognosis has been characteristically poor. JAK inhibition with ruxolitinib or fedratinib therapy has become the first line treatment for symptomatic or intermediate to high risk myelofibrosis. However, after three years of ruxolitinib therapy, approximately half of all patients with myelofibrosis will likely have stopped treatment. JAK inhibition failure represents a mixture of etiologies, including drug intolerance, suboptimal dosing, drug resistance, or progression of disease. JAK inhibition failure and accelerated/blast phase have now become the primary clinical challenges in the treatment of myelofibrosis and high risk polycythemia vera, and no phase III trials or clear treatment guidelines exist to guide management strategies in this setting. On the other hand, this represents an exciting time in treatment of JAK inhibitor failure and accelerated phase MPNs due to the advent of recently approved drugs as well as new targeted agents currently under investigation. In this article, we review the management options for these challenging clinical scenarios. We discuss the options for JAK inhibitor dose optimization and overcoming resistance by utilizing combinations of JAK inhibition, primarily ruxolitinib, with alternative commercially available therapies. For patients who have progressed, we discuss recent data regarding targeted therapy options approved for AML that represent potentially efficacious options in the progressive MPN setting. We also discuss the new clinical agents under development in MF and accelerated MPNs that may offer new therapeutic options in the years to come.

Assessing Symptom Burden in Myelodysplastic Syndrome/Myeloproliferative Neoplasm Overlap Patients

Myelodysplastic syndrome/myeloproliferative neoplasm overlap syndromes are rare types of chronic myeloid hematologic neoplasms. Patients with overlap syndrome have similar clinical features, mutations, and disease course, to other chronic myeloid malignancies. Limited data also suggests that overlap syndromes patients experience long standing and at times poorly controlled symptoms that may be underrecognized. In this article, we discuss the etiologies of symptoms in patients with overlap syndromes and currently available symptom burden assessment tools. Overall, symptom burden is an important consideration in patients with overlap syndrome, and efforts are ongoing to further investigate symptom burden and quality of life in this population.

Assessment of Quality of Life following Allogeneic Stem Cell Transplant for Myelofibrosis

Patient-reported outcomes (PROs) for patients with myelofibrosis (MF) have been well characterized, but little is known about quality of life (QoL) following allogeneic stem cell transplantation (allo-SCT). Medical data and PRO measures were collected before transplant and at day 30, day 100, and 1 year after allo-SCT. PRO measures include Myeloproliferative Neoplasm Symptom Assessment Form (MPN-SAF), Brief Fatigue Inventory, Global Assessment of Change, and Functional Assessment of Cancer Therapy-Bone Marrow Transplant. Forty-four patients who had baseline QoL and at least 1 post-transplant assessment were included. The median age of the patients was 62.5 years (range, 35 to 74 years). At baseline, the mean MPN Total Symptom Score was 28.0, and at day 30, day 100, and 1 year, it was 25.4, 32.3, and 24.3, respectively. However, in myeloproliferative neoplasm-specific symptoms, such as itching, night sweats, bone pain, and fever, a statistically significant improvement was observed for at least 1 time point following transplant. At day 30, 10 (26.3%) patients reported a little/moderately/very much better overall QoL since their transplant, and 26 (68.45%) had a little/moderately/very much worse QoL. At day 100, 10 (30.3%) reported better QoL and 19 (57.6%) reported worsening since transplant. By 1 year, 16 (61.5%) reported feeling better. Our study shows that there is very little change in symptom burden at 1 year following transplant in general, but MF-specific symptoms showed improvement. By 1 year, 61% felt that their QoL was better than it was before transplant.

Abstract 4911: Collaboration on quality of life in myeloproliferative neoplasms: Analysis of body mass index and symptom burden

Introduction

BMI increases the risk of Philadelphia-chromosome negative myeloproliferative neoplasms (MPN) development. Patients with MPN often suffer from a severe symptom burden reduced quality of life. The aim of this study was to examine the association between BMI and symptom burden.

Methods

A comprehensive analysis of data from two large cross-sectional surveys of health-related quality of life in MPN patients was done by merging data from the Danish Population-based Study with data from the international Fatigue Study. Both surveys included the validated MPN-SAF questionnaire and questions addressing lifestyle.

Results

Comparing Danish patients with US patients, Danish patients were significantly older (69.2y vs 60.9y, P < 0.001), a smaller proportion were female (56.5%, vs 67.3% P < 0.001) and less patients worked (24.8%, vs 43.3% P < 0.001).

In both the US and the Danish (DK) dataset Normal Weight was most frequent (DK/US=52.4/46.3%), followed by Overweight (DK/US=31.7/30.5%), Obese (DK/US=13.2/21.7%) and least frequent Underweight (DK/US=2.7%/1.5%). Interestingly, we observed a U-shaped association between BMI and Symptom Burden in both datasets with significant higher values of total symptom score for underweight and obese patients relative to normal weight. Furthermore, significant higher scores for Underweight or Obese patients were observed for most individual symptoms (Table 1).

Conclusion

Despite significant differences in demographics, the U-shaped relation between BMI and symptom burden reflects a general pattern of many variables consistent across countries. Weight alteration might be considered as a therapeutic strategy to alter symptom burden in MPN patients, bearing in mind that unintentional weight loss has been demonstrated in some MPN subtypes to be predictive of worsened survival. Further analysis for possible confounders are planned.

Table 1.MPN patients’ assessment of symptom severity by BMI category and CountryDenmark (n=2064)Median [IQR]USA (n=894)Median [IQR]BMIUnder-weight(<18.5)Normal Weight(18.5-24.9)Over-weight(25.0-29.9)Obese(≥ 30)P-valueUnder-weight(<18.5)Normal Weight(18.5-24.9)Over-weight(25.0-29.9)Obese(≥ 30)P-valueFatigue (BFI)3 [0-6]3 [0-5]3 [0-5]3 [1-7]0.0278 [5-9]6 [4-8]7 [5-8]7 [6-9]<0.001Early satiety4 [1-5]2 [0-5]2 [0-5]2 [0-5]0.0013 [0-5]2 [0-5]2 [0-5]3 [0-5]0.494Abdominal pain0 [0-2]0 [0-2]0 [0-2]0 [0-2]0.1681 [0-3]0 [0-2]0 [0-3]1 [0-4]<0.001Abdominal discomfort1 [0-4]0 [0-3]1 [0-3]1 [0-3]0.2963 [1-4]1[0-3]1 [0-4]2 [0-5]0.001Inactivity3 [0-5]1 [0-4]1 [0-4]2 [0-5]0.0034 [1-6]2 [0-5]3 [1-6]5 [3-7]<0.001Headache0 [0-2]0 [0-2]0 [0-3]0 [0-3]0.4012 [0-5]1 [0-4]1 [0-4]2 [0-6]<0.001Concentration problem2 [0-5]1 [0-4]1 [0-4]1 [0-5]0.3110 [0-7]3 [0-6]4 [1-6]5 [2-7]<0.001Dizziness3 [1-5]1 [0-4]1 [0-4]1 [0-4]0.0680 [0-3]1 [0-4]1 [0-5]3 [0-6]0.001Numbness3 [0-5]1 [0-4]1 [0-4]2 [0-5]0.0014 [0-7]1 [0-5]2 [0-5]3 [0-6]0.003Insomnia2 [0-5]2 [0-5]1 [0-5]3 [0-6]0.0035 [3-8]3 [1-6]4 [1-7]5 [2-7]0.004Sad mood2 [0-4]1 [0-3]1 [0-3]1 [0-4]0.5551 [0-5]2 [0-5]3 [0-6]4 [2-6]<0.001Sexuality problems1 [0-5]2 [0-6]3 [0-7]3 [0-8]0.0574 [0-7]3 [0-7]4 [0-7]6 [1-8]0.001Cough2 [0-6]0 [0-3]1 [0-3]1 [0-4]<0.0010 [0-4]0 [0-2]0 [0-3]1[0-5]0.001Night sweats1 [0-4]1 [0-4]2 [0-5]2 [0-5]0.0210 [0-2]1 [0-4]1 [0-5]3 [0-6]<0.001Itching1 [0-3]1 [0-3]1 [0-4]1 [0-4]0.0100 [0-5]1 [0-4]2 [0-5]2 [0-7]<0.001Bone pain1 [0-5]0 [0-3]0 [0-3]1 [0-5]0.0081 [0-4]0 [0-4]0 [0-5]3 [0-6]<0.001Fever0 [0-0]0 [0-0]0 [0-0]0 [0-0]0.2940 [0-0]0 [0-0]0 [0-0]0 [0-0]0.013Weight loss4 [0-7]0 [0-1]0 [0-0]0 [0-0]<0.0012 [0-5]0 [0-1]0 [0-0]0 [0-0]<0.001QoL3 [1-5]2 [1-5]2 [1-5]2 [1-5]0.1154 [3-5]3 [1-5]4 [2-5]4 [3-6]<0.001TSS22 [12-37]16[7-30]16[7-29]21[10-33]0.00126[23-41]22[12-34]26[13-40]32[23-44]<0.001

Citation Format: Sarah F. Christensen, Robyn M. Scherber, Martin Goros, Jonathan Gelfond, Nana Brochmann, Christen L. Andersen, Esben M. Flachs, Hans C. Hasselbalch, Ruben A. Mesa. Collaboration on quality of life in myeloproliferative neoplasms: Analysis of body mass index and symptom burden [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2019; 2019 Mar 29-Apr 3; Atlanta, GA. Philadelphia (PA): AACR; Cancer Res 2019;79(13 Suppl):Abstract nr 4911.

Abstract 4912: A snapshot of myeloproliferative neoplasms in the United States: Analysis of the “myMPN” patient registry

Introduction: The myeloproliferative neoplasms (MPNs) are an uncommon type of hematologic malignancy which can be accompanied by a medically complex sequalae and severe symptom burden. Patient registries allow for the evaluation and monitoring of clinically meaningful outcomes in rare diseases over time. Although patient registries exist for MPNs, the utility of these registries has been limited by inclusion of only particular institutions and/or regions or the lack of patient reported outcomes, specifically symptoms and quality of life. In September 2017, the “myMPN” patient registry began enrollment as the first MPN patient-centered registry. The purpose of this analysis is to report patient-reported disease features, outcomes, and events uploaded to the registry to date.

Methods: The “myMPN” patient registry was created by the MPN Research Foundation’s steering committee and hosted on the Genetic Alliance registry platform. Utilizing previous questions created for MPN populations and validated assessment tools, the myMPN patient registry allows patients to input data disclosures, disease features, treatments, blood counts and symptoms. The registry has been granted independent IRB approval.

Results: Accrual: To date, the registry has 744 participants. Of these, 62% were female and mean age was 61 years (range 18-94). Disease-related information: The registry includes 38% essential thrombocythemia (ET) patients, 36% polycythemia vera (PV) patients, 23% myelofibrosis (MF) patients, and 3% patients who reported an alternative MPN diagnosis. 11.5% of patients were not aware of their mutation status. Disease events: Over the year since study initiation, there have been 2,100 reported disease-related events, which have included 825 blood draws, 298 phlebotomies, 207 MPN medication changes, 144 bone marrow biopsies, 77 transfusions, 39 thrombotic or bleeding events, and 30 genetic testing events. Since registry initiation, 6 patients reported a new ET to MF transformation, and 4 patients reported a PV to MF transformation. Disease Symptom Burden: To date, 400 patients have completed 675 independent symptom assessments. Many have completed two or more symptom assessments. In general, MPN-10 symptom scores are similar to previously published cohorts, but provide data on longitudinal symptom change.

Conclusions: The myMPN patient registry facilitates the research and care of MPN patients by clinicians, researchers, patients, patient-advocates, and caregivers a common platform to interface prospectively. Future goals of the registry are to 1) explore variables related to disease progression/transformation, 2) expand outside of the United states to other English-speaking countries, 3) allow patients to connect with their physicians regarding their registry information, and 4) to develop a compendium medical record and specimen registry.

Citation Format: Robyn M. Scherber, Lindsey Whyte, Michelle Woehrle, Claire Harrison, John Mascarenhas, Srdan Verstovsek, Alison Moliterno, Ruben A. Mesa. A snapshot of myeloproliferative neoplasms in the United States: Analysis of the “myMPN” patient registry [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2019; 2019 Mar 29-Apr 3; Atlanta, GA. Philadelphia (PA): AACR; Cancer Res 2019;79(13 Suppl):Abstract nr 4912.

Item nonresponse on the Myeloproliferative Neoplasms Symptom Assessment Form (MPN-SAF): a comparison of missing data strategies

Administering questionnaires to patients is an efficient and effective method for assessing patients' symptoms. However, item nonresponse (skipped questions) potentially compromises the utility of these questionnaires. Using an international sample of 2,067 patients with myeloproliferative neoplasms, we evaluated the impact of item nonresponse on scoring of the Myeloproliferative Neoplasms Symptom Assessment Form Total Symptom Score (MPN-SAF TSS or MPN-10). We characterized item nonresponse on the MPN-10 and compared strategies for addressing item nonresponse (available-case analysis, proration, and multiple imputation) on the MPN-10 (multi-symptom assessment) and Brief Fatigue Inventory (BFI; single-symptom assessment). Characteristics of multi-symptom assessments would be expected to adversely affect proration, yet proration and multiple imputation provided very similar results for both the MPN-10 and BFI. This is likely because the MPN-10 item missing data rates were low, consistent with prior clinic- and internet-based studies. These results support the published scoring method for the MPN-10 (proration).

Managing myelofibrosis (MF) that "blasts" through: advancements in the treatment of relapsed/refractory and blast-phase MF

Myelofibrosis (MF) is the most aggressive form of Philadelphia chromosome-negative myeloproliferative neoplasm, and it is complicated by severe symptom burden, thrombotic events, infections, cytopenias, and transformation to acute myeloid leukemia (AML). Ruxolitinib, the first-line therapy for symptomatic or intermediate- and high-prognostic risk MF, has improved overall survival for this population. However, approximately one-half of MF patients will discontinue ruxolitinib by the first few years of therapy due to a spectrum of resistance, intolerance, relapse, or progression to blast phase disease. Danazol, erythropoietin-stimulating agents, and spleen-directed therapies can be useful in the ruxolitinib-resistant setting. In the ruxolitinib-refractory or -intolerant setting, commercial and novel therapies, either alone or in combination with ruxolitinib, have shown clinical utility. For blast-phase MF, the recent advancements in available AML therapies have increased the options with targeted and more tolerable therapies. In this article, we will discuss our paradigm for the management of relapsed/refractory and blast-phase MF in the context of therapeutic advancements in both AML and MF.

Precision immunotherapy, mutational landscape, and emerging tools to optimize clinical outcomes in patients with classical myeloproliferative neoplasms

Following the 47th American Society of Hematology Meeting in 2005, the late John Goldman and Tariq Mughal commenced a conference, the 1st Post-ASH Workshop, which brought together clinicians and scientists, to accelerate the adoption of new therapies for patients with myeloproliferative neoplasms (MPNs). The concept began with recognition of the CML success story following imatinib therapy, the discovery of JAK2^V617F , and the demonstration that BCR-ABL1-negative MPNs are driven by abnormal JAK2 activation. This review is based on the presentations and deliberations at the XIIth Post-ASH Workshop on BCR-ABL1 positive and negative MPNs that took place on December 12 to 13, 2017, in Atlanta, Georgia, immediately following the 59th American Society of Hematology Meeting. We have selected some of the translational research and clinical topics, rather than an account of the proceedings. We discuss the role of immunotherapy in MPNs and the impact of the mutational landscape on TKI treatment in CML. We also consider how we might reduce TKI cardiovascular side effects, the potential role of nutrition as adjunctive nonpharmacologic intervention to reduce chronic inflammation in MPNs, and novel investigational therapies for MPNs.

The Critical Role of Inflammation in the Pathogenesis and Progression of Myeloid Malignancies

Hematopoietic stem cells (HSCs) maintain an organism's immune system for a lifetime, and derangements in HSC proliferation and differentiation result in hematologic malignancies. Chronic inflammation plays a contributory if not causal role in HSC dysfunction. Inflammation induces HSC exhaustion, which promotes the emergence of mutant clones that may be resistant to an inflammatory microenvironment; this likely promotes the onset of a myeloid hematologic malignancy. Inflammatory cytokines are characteristically high in patients with myeloid malignancies and are linked to disease initiation, symptom burden, disease progression, and worsened prognostic survival. This review will cover our current understanding of the role of inflammation in the initiation, progression, and complications of myeloid hematologic malignancies, drawing from clinical studies as well as murine models. We will also highlight inflammation as a therapeutic target in hematologic malignancies.

The role of sexuality symptoms in myeloproliferative neoplasm symptom burden and quality of life: An analysis by the MPN QOL International Study Group

BACKGROUND

Patients with myeloproliferative neoplasms (MPNs) including polycythemia vera, essential thrombocythemia, and myelofibrosis, are faced with oppressive symptom profiles that compromise daily functioning and quality of life. Among these symptoms, sexuality-related symptoms have emerged as particularly prominent and largely unaddressed. In the current study, the authors evaluated how sexuality symptoms from MPN relate to other patient characteristics, disease features, treatments, and symptoms.

METHODS

A total of 1971 patients with MPN (827 with essential thrombocythemia, 682 with polycythemia vera, 456 with myelofibrosis, and 6 classified as other) were prospectively evaluated and patient responses to the Myeloproliferative Neoplasm Symptom Assessment Form (MPN-SAF) and the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Core 30 (EORTC-QLQ C30) were collected, along with information regarding individual disease characteristics and laboratory data. Sexuality scores were compared with an age-matched, healthy control population.

RESULTS

Overall, patients with MPN were found to have greater sexual dysfunction compared with the healthy population (MPN-SAF score of 3.6 vs 2.0; P<.001), with 64% of patients with MPN describing some degree of sexual dysfunction and 43% experiencing severe symptoms. The presence of sexual symptoms correlated closely with all domains of patient functionality (physical, social, cognitive, emotional, and role functioning) and were associated with a reduced quality of life. Sexual problems also were found to be associated with other MPN symptoms, particularly depression and nocturnal and microvascular-related symptoms. Sexual dysfunction was more severe in patients aged >65 years and in those with cytopenias and transfusion requirements, and those receiving certain therapies such as immunomodulators or steroids.

CONCLUSIONS

The results of the current study identify the topic of sexuality as a prominent issue for the MPN population, and this area would appear to benefit from additional investigation and management. Cancer 2016;122:1888-96. © 2016 American Cancer Society.

Angiosarcoma Causing Cardiac Constriction Late after Radiation Therapy for Breast Carcinoma

Therapeutic radiotherapy rarely causes sarcoma, and this occurs years after completion of the intended treatment. In treating breast carcinoma, careful planning in the application of modern radiotherapeutic techniques usually can shield the heart and pericardium. We report a rare case of angiosarcoma of the pericardium, which presented in a 41-year-old woman as constrictive pericarditis 8 years after irradiation for cancer of the left breast. To our knowledge, this is only the 2nd report of angiosarcoma of the pericardium after radiotherapy.

Reducing symptom burden in patients with myeloproliferative neoplasms in the era of Janus kinase inhibitors

Philadelphia chromosome-negative myeloproliferative neoplasms (MPNs) are clonal stem cell-derived malignancies that include primary myelofibrosis, polycythemia vera and essential thrombocythemia and are characterized by dysregulated Janus kinase-signal transducers and activators of transcription (JAK-STAT) signaling. Clinical manifestations include splenomegaly, cytopenias and/or systemic inflammation. Patients have a heterogeneous symptom profile that includes fatigue, loss of appetite, pruritus and night sweats, which significantly impact quality of life (QoL) and lead to poor survival outcomes. With the introduction of JAK inhibitors, improvement in disease-related symptoms has emerged as a realistic expectation of therapy and an integral measure of clinical efficacy. The JAK1/JAK2 inhibitor ruxolitinib is approved for the treatment of myelofibrosis and is currently under clinical development for polycythemia vera. Ruxolitinib has demonstrated significant reductions in symptom burden, with consequent improvements in QoL measures. With the potential to improve QoL, recognition of the impact and burden of symptoms on patients with MPNs is critical.

Targeting African American nonsmokers to motivate smokers to quit: a qualitative inquiry

African Americans bear a disproportionate health burden from smoking but are less likely than other populations to engage in cessation treatment. Intervening on adult nonsmokers residing with a smoker might represent an innovative approach to motivate smokers to engage in smoking behavior change. Twelve focus groups were conducted with African American smokers (four groups, n = 27), nonsmokers (four groups, n = 26) and pairs of cohabitating smokers and nonsmokers (four groups, n = 22) to assess attitudes and/or beliefs regarding engaging a nonsmoker in the home in smoking behavior change efforts. Participants ( N = 75) were middle-aged (45.1 ±3.7 years) females (68.0%) with 11.8 ±1.5 years of education. Smokers smoked 14.9 ±11.3 cigarettes per day, made 3.0 ±4.4 quit attempts in the past year, and are interested in receiving cessation assistance from a nonsmoker in their home. African American nonsmokers living with a smoker may be an appropriate target group to motivate smoking behavior change in the smoker. Suggestions for future research considerations are provided.

Abstinence and relapse rates following a college campus-based quit & win contest

OBJECTIVE

To conduct and evaluate Quit & Win contests at 2 2-year college and 2 4-year university campuses.

PARTICIPANTS

During Spring semester, 2006, undergraduates (N = 588) interested in quitting smoking signed up for a Quit & Win 30-day cessation contest for a chance to win a lottery prize.

METHODS

Participants (N = 588) completed a baseline survey, provided a urine sample to verify smoking status before joining the contest, and completed a follow-up survey at contest end to assess abstinence. Participants reporting continuous 30-day abstinence were surveyed again 2 weeks post contest to assess relapse.

RESULTS

Participants smoked an average of 9.8 +/- 6.7 cigarettes/day on 26.7 +/- 5.7 days/month. Among participants completing a follow-up survey (74%), 72.1% reported abstinence during the entire contest period (Intent-to-Treat Analysis = 53.2%). 55.3% of those abstinent at the end of contest had resumed smoking 2 weeks post contest.

CONCLUSIONS

Campus Quit & Win contests appear feasible, acceptable, and effective at facilitating short-term abstinence. Further research is needed to identify strategies to prevent postcontest relapse.

Support needs of overweight African American women for weight loss

OBJECTIVES

To examine social support needs of obese and overweight African American women for weight loss.

METHODS

Focus groups were conducted with overweight and obese African American women. Data were analyzed using standard grounded theory text analysis.

RESULTS

Our middle-aged (45.7 years; SD = 12.6) women (N = 66) were interested in receiving support from others focused on the health benefits of weight loss. Behaviors perceived as supportive include co-participating in exercise, providing nutrition education, using positive reinforcements, and avoiding criticism.

CONCLUSIONS

African American women are interested in a program designed to increase social support for their weight loss.