bluuebunny/crossref_metadata_2025 huggingface dataset:
Cost-effectiveness of denosumab (Dmab) versus zoledronic acid (ZA) for prevention of skeletal-related events (SREs) in patients (pts) with castrate-resistant prostate cancer (CRPC) and bone metastases (BM).
Authors: Rader Michael E. , Danese Mark , Cong Ze , Halperin Marc , Qian Yi , Goessl Carsten Dietrich , Chung Karen
Published: February 2017

59

Background: It has become more important to understand the incremental cost/benefit of new medicines as healthcare costs rise. Subcutaneous Dmab is superior to intravenous ZA for prevention of SREs in pts with CRPC and BM (Fizazi, 2011). In addition, a lower proportion of pts receiving Dmab progressed to moderate/severe pain than those receiving ZA (Brown, 2011). Dmab can be used in pts regardless of renal status or concomitant use of nephrotoxic drugs. These analyses assess the lifetime, real world cost-effectiveness of Dmab vs ZA in pts with CRPC and BM from a US managed care perspective.

Methods: A lifetime Markov model was developed to estimate SREs, quality adjusted life-years (QALYs), and costs. The relative rate reduction in SREs for Dmab vs ZA was based on a large head-to-head phase 3 trial (N=1,901). The real world SRE rate in ZA pts was derived from a large commercial claims database analysis (Hatoum, 2008). SRE QALY decrements were estimated using the time trade-off method (Matza, 2011). SRE costs were estimated from a nationally representative commercial claims database (Barlev, 2010). Wholesale acquisition drug cost (Analysource, 2011), drug administration, and renal monitoring costs (National Fee Analyzer, 2011) were included. Compliance and mortality were assumed to be the same in both groups. Costs and QALYs were discounted at 3% annually.

Results: With a median pt survival of 1.7 years, Dmab reduced the number of SREs and increased pts’ QALY vs ZA. The lifetime cost/pt on Dmab was $7,430 higher than ZA. Cost/QALY gained was $65,134, commonly considered good value based on oncologists’ implied threshold in the US (Nadler, 2006). Cost/SRE avoided was $9,212.

Conclusions: Dmab is cost-effective in preventing SREs in pts with CRPC and BM compared with ZA in the US. The overall value of Dmab is based on superior efficacy and more efficient administration.

[Table: see text]
Comparison of acute toxicity in patients treated with a 4-field box or IMRT to deliver elective pelvic nodal irradiation for localized high-risk prostate cancer.
Authors: Jain Suneil , Cheung Patrick , Loblaw D. Andrew , Morton Gerard , Danjoux Cyril , Szumacher Ewa , Chu William , Chung Hans T. , Vesprini Danny , Sahgal Arjun , Zhang Liying , Deabreu Andrea
Published: February 2017

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Background: To deliver elective pelvic nodal irradiation (EPNI), a 4-field box (4FB) has been a common technique. More recently, there are increasing reports of using IMRT to deliver EPNI. Even though studies show a clear dosimetric benefit to bowel and bladder, there is a lack of good data demonstrating decreased toxicity with the use of IMRT in this setting.

Methods: From 2004-2010, 230 patients with localized high risk prostate cancer were enrolled into 3 sequential prospective phase I/II trials of delivering EPNI (45 Gy) along with a concomitant hypofractionated IMRT boost to the prostate (67.5 Gy total) in 25 fractions over 5 weeks time. All patients were to receive 3 years of adjuvant androgen deprivation. During the accrual period, the method used to deliver the EPNI portion of the treatment changed as new literature emerged about target volumes for EPNI. The 3 methods used to deliver EPNI in this large cohort were 1) 4FB, 2) IMRT with 2cm CTV margins around the pelvic vessels as suggested by Shih et al (IMRT-Shih), and 3) IMRT with nodal volumes as suggested by RTOG (IMRT-RTOG). Common Terminology Criteria for Adverse Events v3.0 was used to assess acute toxicity prospectively during treatment and then at 3 months.

Results: For EPNI, 94 patients were treated with a 4FB, 53 were treated with IMRT-Shih, and 83 were treated with IMRT-RTOG. There were no acute grade 3 GI toxicities. Patients in the 4FB group had higher rates of acute grade ≥ 2 proctitis compared to the IMRT-Shih and IMRT-RTOG groups (16.0% vs 2.0% vs 2.4%, p=0.0009). The 4FB group also had higher rates of grade ≥ 2 flatulence compared to the 2 other IMRT groups (17.0% vs 7.6% vs 0%, p<0.0001). With regards to acute GU toxicities, patients in the 4FB group had higher rates of grade ≥ 3 urinary frequency compared to the 2 other IMRT groups (5.3% vs 0% vs 0%, p=0.027).

Conclusions: In this non-randomized comparison, IMRT resulted in statistically significant decreases in acute proctitis, flatulence, and urinary frequency when compared to a 4FB technique to deliver EPNI in localized high risk prostate cancer. Analysis for possible confounding factors will be performed.
Comprehension and preferences for graphical representations of quality of life after prostate cancer treatment.
Authors: Gore John L. , Izard Jason , Avery Daniel I. , Shih Cheryl , Hartzler Andrea
Published: February 2017

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Background: Integration of quality of life (QoL) measurement into clinical prostate cancer (PCa) practice may enhance patients’ communication with clinicians, improve satisfaction with care, and affect the delivery of secondary therapies. A necessary step to achieve these benefits is illustrating QoL in ways patients can understand and use. Through a patient-partnered project, we developed graphical representations of prostate cancer QoL (dashboards) and compared patients’ comprehension and preferences among four alternative formats: table, bar chart, line graph, and pictograph.

Methods: We conducted interviews with PCa patients and assessed health literacy, subjective numeracy, and graphic literacy with validated instruments (REALM, Subjective Numeracy Scale, Graphic Literacy Scale). We then presented patients the 4 candidate dashboards counterbalanced for format order, and assessed participants’ comprehension, helpfulness rating, and rank order preferences.

Results: Our study included 29 PCa patients, with mean age 71 years (range 53-90). Patients were mostly white (86%) and had at least a college degree (76%). Most had localized PCa (90%) and 55% were treated within the last 5 years; 9 patients had undergone more than one type of treatment. Patients’ health literacy (mean score 6.9±0.26 out of 7), numeracy (mean score 4.3±0.94 out of 6), and graphic literacy (mean score 11.4±1.4 out of 13) was high. Comprehension did not vary by dashboard format (p=0.39), ranging from 84% correct for line graph to 91% correct for bar chart. The pictograph exhibited lower helpfulness ratings (p=0.001). Preference elicitation strongly favored the bar chart (p=0.004), ranked 1st by 52% of patients, and disfavored pictograph, ranked 4th by 69% of patients.

Conclusions: Among a high literacy and numeracy sample of PCa patients, comprehension and preference ranking strongly favored bar charts for QoL dashboards. Pictographs, known to benefit low literacy patients, were not preferred despite good comprehension. Inclusion of lower literacy patients may yield different results. Future work will determine if clinical integration of QoL dashboards is associated with improved health outcomes.
Overall survival benefit and safety profile of radium-223 chloride, a first-in-class alpha-pharmaceutical: Results from a phase III randomized trial (ALSYMPCA) in patients with castration-resistant prostate cancer (CRPC) with bone metastases.
Authors: Parker Chris , Heinrich Daniel , O'Sullivan Joe M. , Fossa Sophie D. , Chodacki Ales , Demkow Tomasz , Logue John P. , Seke Mihalj , Widmark Anders , Johannessen Dag Clement , Nilsson Sten , Hoskin Peter , Solberg Arne , James Nicholas David , Syndikus Isabel , Cross Andrew , O'Bryan-Tear C. Gillies , Garcia-Vargas Jose E. , Sartor A. Oliver
Published: February 2017

8

Background: Radium-223 chloride (Ra-223) is a first-in-class alpha-pharmaceutical targeting bone metastases (mets) with high-energy alpha-particles of extremely short range (<100 μm). ALSYMPCA, a phase III, double-blind, randomized, multinational study, compared efficacy, in terms of overall survival (OS), and safety of Ra-223 plus best standard of care (BSC) vs placebo plus BSC in patients (pts) with bone mets in CRPC.

Methods: Eligible pts had progressive, symptomatic CRPC with ≥ 2 bone mets on scintigraphy and no known visceral mets; were receiving BSC; and either previously received docetaxel, were docetaxel ineligible, or refused docetaxel. Pts were randomized 2:1 to receive 6 injections of Ra‐223 (50 kBq/kg IV) q4 wks or matching placebo and stratified by prior docetaxel use, baseline alkaline phosphatase level, and current bisphosphonate use. A planned interim analysis (IA) was conducted to assess the effect of Ra-223 on the primary endpoint (OS) using a predefined threshold. Survival data were compared using a stratified log-rank test.

Results: 922 pts (Ra-223, n = 615; placebo, n = 307) were randomized from 6/2008-2/2011. 445 (58%) of 809 pts in the IA data set received prior treatment with docetaxel. Ra-223 significantly improved OS in pts with CRPC with bone mets vs placebo (two-sided P = 0.00185; HR = 0.695; 95% CI, 0.552-0.875; median OS 14.0 mo vs 11.2 mo, respectively). Safety and tolerability of Ra-223 were highly favorable and showed low incidence of myelosuppression (eg, grades 3/4 neutropenia in 1.8% and 0.8% and thrombocytopenia in 4% and 2% of the Ra-223 and placebo groups, respectively).

Conclusions: Ra-223 is an effective therapy that improved OS with a highly favorable safety profile, and may provide a new standard of care for the treatment of CRPC pts with bone mets.

[Table: see text]
Biologic activity of LSD1 inhibition by novel tranylcypromine structural analogues in prostate cancer cells.
Authors: Crabb Simon J. , Hayden Annette L , Strivens Rosemary A , Benelkebir Hanae , Ganesan A , Packham Graham
Published: February 2017

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Background: Hormonal strategies to inhibit androgen receptor (AR) signalling remain inadequate and so novel approaches are urgently required. Lysine (K)-specific demethylase 1A (LSD1), is an epigenetic AR co-activator which modifies chromatin structure through de-methylation of histone H3 lysine 9 at androgen response elements to activate transcriptional expression of AR target genes. LSD1 is over-expressed and a poor prognostic factor in prostate cancer. We have synthesised novel analogues of the monoamine oxidase (MAO) inhibitor tranylcypromine as LSD1 inhibitors to exploit MAO and LSD1 sequence homology.

Methods: We utilised prostate cancer cell line models to investigate the biological effect of LSD1 inhibition using tranylcypromine analogues.

Results: Chemical inhibition of LSD1 was effective in inhibiting cell proliferation in prostate cancer models with around 1000 fold greater potency for synthesised analogues over tranylcypromine in LNCaP prostate cancer cells. Chemical inhibition of LSD1 induced the predicted histone methylation changes consequent on LSD1 inhibition of mono- and di-methylation of histone H3 lysine 9. In addition LSD1 depletion, AR depletion and reduced expression of the AR target gene prostate-specific antigen was demonstrated. Fractional effect assays demonstrated synergistic interactions in cell proliferation assays for tranylcypromine analogues with the androgen receptor antagonists bicalutamide and MDV3100.

Conclusions: Our data demonstrate biological activity of LSD1 inhibition in prostate cancer cells with depletion of AR signalling using optimised structural analogues of established drugs for non-cancer indications. Therapeutic targeting of LSD1 for prostate cancer would represent a novel therapeutic paradigm for this disease.
Type 2 Diabetes Mellitus and Cancer: The Role of Pharmacotherapy
Authors: Shlomai Gadi , Neel Brian , LeRoith Derek , Gallagher Emily Jane
Published: February 2017

Purpose

Type 2 diabetes mellitus (T2DM) is becoming increasingly prevalent worldwide. Epidemiologic data suggest that T2DM is associated with an increased incidence and mortality from many cancers. The purpose of this review is to discuss the links between diabetes and cancer, the effects of various antidiabetic medications on cancer incidence and mortality, and the effects of anticancer therapies on diabetes.

Design

This study is a review of preclinical and clinical data regarding the effects of antidiabetic medications on cancer incidence and mortality and the effects of anticancer therapies on glucose homeostasis.

Results

T2DM is associated with an increased risk and greater mortality from many cancer types. Metformin use has been associated with a decrease in cancer incidence and mortality, and there are many ongoing randomized trials investigating the effects of metformin on cancer-related outcomes. However, data regarding the association of other antidiabetes medications with cancer incidence and mortality are conflicting. Glucocorticoids, hormone-based therapies, inhibitors that target the phosphatidylinositol 3-kinase-Akt-mammalian target of rapamycin pathway, and insulin-like growth factor 1 receptor–targeted therapy have been associated with high rates of hyperglycemia. These agents mediate their deleterious metabolic effects by reducing insulin secretion and increasing insulin resistance in peripheral tissues.

Conclusion

Studies must be performed to optimize cancer screening strategies in individuals with T2DM. A greater understanding of the mechanisms that link diabetes and cancer are needed to identify targets for therapy in individuals with diabetes who develop cancer. Data from clinical studies are needed to further elucidate the effects of antidiabetic medications on cancer incidence and progression. As several anticancer therapies alter glucose homeostasis, physicians need to be aware of these potential effects. Careful patient screening and monitoring during treatment with these agents is necessary.
Evaluation of a Web-Based Cognitive Rehabilitation Program in Cancer Survivors Reporting Cognitive Symptoms After Chemotherapy
Authors: Bray Victoria J. , Dhillon Haryana M. , Bell Melanie L. , Kabourakis Michael , Fiero Mallorie H. , Yip Desmond , Boyle Frances , Price Melanie A. , Vardy Janette L.
Published: February 2017

Purpose

Cognitive impairment is reported frequently by cancer survivors. There are no proven treatments. We evaluated a cognitive rehabilitation program (Insight) and compared it with standard care in cancer survivors self-reporting cognitive symptoms.

Patients and Methods

We recruited adult cancer survivors with a primary malignancy (excluding central nervous system malignancies) who had completed three or more cycles of adjuvant chemotherapy in the previous 6 to 60 months and reported persistent cognitive symptoms. All participants received a 30-minute telephone consultation and were then randomly assigned to the 15-week, home-based intervention or to standard care. Primary outcome was self-reported cognitive function (Functional Assessment of Cancer Therapy Cognitive Function [FACT-COG] perceived cognitive impairment [PCI] subscale): difference between groups after intervention (T2) and 6 months later (T3).

Results

A total of 242 participants were randomly assigned: median age, 53 years; 95% female. The primary outcome of difference in FACT-COG PCI was significant, with less PCI in the intervention group at T2 ( P < .001). This difference was sustained at T3 ( P < .001). At T2, there was a significant difference in all FACT-COG subscales, favoring the intervention. Neuropsychological results were not significantly different between the groups at T2 or T3. There were significantly lower levels of anxiety/depression and fatigue in the intervention group at T2. There were significant improvements in stress in the intervention group at both time points. There was no significant difference in quality of life between the groups at T2, but the intervention group had better quality of life at T3.

Conclusion

The intervention, Insight, led to improvements in cognitive symptoms compared with standard care. To our knowledge, this is the first large randomized controlled trial showing an improvement in self-reported cognitive function in cancer survivors, indicating that this intervention is a feasible treatment.
Outcome of Men With Relapse After Adjuvant Carboplatin for Clinical Stage I Seminoma
Authors: Fischer Stefanie , Tandstad Torgrim , Wheater Matthew , Porfiri Emilio , Fléchon Aude , Aparicio Jorge , Klingbiel Dirk , Skrbinc Breda , Basso Umberto , Shamash Jonathan , Lorch Anja , Dieckmann Klaus-Peter , Cohn-Cedermark Gabriella , Ståhl Olof , Chau Caroline , Arriola Edurne , Marti Kalena , Hutton Paul , Laguerre Brigitte , Maroto Pablo , Beyer Jörg , Gillessen Silke
Published: February 2017

Purpose

Adjuvant carboplatin is one of three management strategies that may follow inguinal orchiectomy in clinical stage I seminoma. However, little is known about the outcome of patients who experience a relapse after such treatment.

Patients and Methods

Data from 185 patients who relapsed after adjuvant carboplatin between January 1987 and August 2013 at 31 centers/groups from 20 countries were collected and retrospectively analyzed. Primary outcomes were disease-free survival and overall survival. Secondary outcomes were time to, stage at, and treatment of relapse as well as rate of subsequent relapses.

Results

With a median follow-up of 53 months (95% CI, 48 to 60 months) the 5-year disease-free survival was 82% (95% CI, 77% to 89%), and the 5-year overall survival was 98% (95% CI, 95% to 100%). The median time from orchiectomy to relapse was 19 months (95% CI, 17 to 23 months); 15% (95% CI, 10% to 21%) of relapses occurred > 3 years after treatment. The majority of relapses were detected by computed tomography scan during routine follow-up, 98% in the International Germ Cell Cancer Collaborative Group good prognosis group. Chemotherapy was administered to 92% of patients, mostly as standard first-line treatment corresponding to stage; 8% of patients had additional local treatments. Only 28 patients experienced a second relapse. At last follow-up, 174 (94%) of 185 patients were alive without disease, and four patients with disease. Seven patients died, three of whom due to progressive disease.

Conclusion

Within the limitations of a retrospective analysis, the results suggest that the majority of patients who experience a relapse after adjuvant carboplatin for clinical stage I seminoma can be successfully treated with a cisplatin-based chemotherapy regimen adequate for stage. Because 15% of the relapses occurred > 3 years after adjuvant treatment, a minimum of 5 years follow-up is recommended.
Comparative Efficacy and Safety of Adjuvant Letrozole Versus Anastrozole in Postmenopausal Patients With Hormone Receptor–Positive, Node-Positive Early Breast Cancer: Final Results of the Randomized Phase III Femara Versus Anastrozole Clinical Evaluation (FACE) Trial
Authors: Smith Ian , Yardley Denise , Burris Howard A. , De Boer Richard , Amadori Dino , McIntyre Kristi , Ejlertsen Bent , Gnant Michael , Jonat Walter , Pritchard Kathleen I. , Dowsett Mitch , Hart Lowell , Poggio Susan , Comarella Lisa , Salomon Herve , Wamil Barbara , O’Shaughnessy Joyce
Published: February 2017

Purpose

The Letrozole (Femara) Versus Anastrozole Clinical Evaluation (FACE) study compared the efficacy and safety of adjuvant letrozole versus anastrozole in postmenopausal patients with hormone receptor (HR) –positive and node-positive early breast cancer (eBC).

Methods

Postmenopausal women with HR-positive and node-positive eBC were randomly assigned to receive adjuvant therapy with either letrozole (2.5 mg) or anastrozole (1 mg) once per day for 5 years or until recurrence of disease. Patients were stratified on the basis of the number of lymph nodes and human epidermal growth factor receptor 2 status. The primary end point was 5-year disease-free survival (DFS), and the key secondary end points were overall survival and safety.

Results

A total of 4,136 patients were randomly assigned to receive either letrozole (n = 2,061) or anastrozole (n = 2,075). The final analysis was done at 709 DFS events (letrozole, 341 [16.5%]; anastrozole, 368 [17.7%]). The 5-year estimated DFS rate was 84.9% for letrozole versus 82.9% for anastrozole arm (hazard ratio, 0.93; 95% CI, 0.80 to 1.07; P = .3150). Exploratory analysis showed similar DFS with letrozole and anastrozole in all evaluated subgroups. The 5-year estimated overall survival rate was 89.9% for letrozole versus 89.2% for anastrozole arm (hazard ratio, 0.98; 95% CI, 0.82 to 1.17; P = .7916). Most common grade 3 to 4 adverse events (> 5% of patients) reported for letrozole versus anastrozole were arthralgia (3.9% v 3.3%, and 48.2% v 47.9% for all adverse events), hypertension (1.2% v 1.0%), hot flushes (0.8% v 0.4%), myalgia (0.8% v 0.7%), dyspnea (0.8% v 0.5%), and depression (0.8% v 0.6%).

Conclusion

Letrozole did not demonstrate significantly superior efficacy or safety compared with anastrozole in postmenopausal patients with HR-positive, node-positive eBC.
Ki67 Proliferation Index as a Tool for Chemotherapy Decisions During and After Neoadjuvant Aromatase Inhibitor Treatment of Breast Cancer: Results From the American College of Surgeons Oncology Group Z1031 Trial (Alliance)
Authors: Ellis Matthew J. , Suman Vera J. , Hoog Jeremy , Goncalves Rodrigo , Sanati Souzan , Creighton Chad J. , DeSchryver Katherine , Crouch Erika , Brink Amy , Watson Mark , Luo Jingqin , Tao Yu , Barnes Michael , Dowsett Mitchell , Budd G. Thomas , Winer Eric , Silverman Paula , Esserman Laura , Carey Lisa , Ma Cynthia X. , Unzeitig Gary , Pluard Timothy , Whitworth Pat , Babiera Gildy , Guenther J. Michael , Dayao Zoneddy , Ota David , Leitch Marilyn , Olson John A. , Allred D. Craig , Hunt Kelly
Published: February 2017

Purpose

To determine the pathologic complete response (pCR) rate in estrogen receptor (ER) –positive primary breast cancer triaged to chemotherapy when the protein encoded by the MKI67 gene (Ki67) level was > 10% after 2 to 4 weeks of neoadjuvant aromatase inhibitor (AI) therapy. A second objective was to examine risk of relapse using the Ki67-based Preoperative Endocrine Prognostic Index (PEPI).

Methods

The American College of Surgeons Oncology Group (ACOSOG) Z1031A trial enrolled postmenopausal women with stage II or III ER-positive (Allred score, 6 to 8) breast cancer whose treatment was randomly assigned to neoadjuvant AI therapy with anastrozole, exemestane, or letrozole. For the trial ACOSOG Z1031B, the protocol was amended to include a tumor Ki67 determination after 2 to 4 weeks of AI. If the Ki67 was > 10%, patients were switched to neoadjuvant chemotherapy. A pCR rate of > 20% was the predefined efficacy threshold. In patients who completed neoadjuvant AI, stratified Cox modeling was used to assess whether time to recurrence differed by PEPI = 0 score (T1 or T2, N0, Ki67 < 2.7%, ER Allred > 2) versus PEPI > 0 disease.

Results

Only two of the 35 patients in ACOSOG Z1031B who were switched to neoadjuvant chemotherapy experienced a pCR (5.7%; 95% CI, 0.7% to 19.1%). After 5.5 years of median follow-up, four (3.7%) of the 109 patients with a PEPI = 0 score relapsed versus 49 (14.4%) of 341 of patients with PEPI > 0 (recurrence hazard ratio [PEPI = 0 v PEPI > 0], 0.27; P = .014; 95% CI, 0.092 to 0.764).

Conclusion

Chemotherapy efficacy was lower than expected in ER-positive tumors exhibiting AI-resistant proliferation. The optimal therapy for these patients should be further investigated. For patients with PEPI = 0 disease, the relapse risk over 5 years was only 3.6% without chemotherapy, supporting the study of adjuvant endocrine monotherapy in this group. These Ki67 and PEPI triage approaches are being definitively studied in the ALTERNATE trial (Alternate Approaches for Clinical Stage II or III Estrogen Receptor Positive Breast Cancer Neoadjuvant Treatment in Postmenopausal Women: A Phase III Study; clinical trial information: NCT01953588).
Management of Brain Metastases in Tyrosine Kinase Inhibitor–Naïve Epidermal Growth Factor Receptor–Mutant Non–Small-Cell Lung Cancer: A Retrospective Multi-Institutional Analysis
Authors: Magnuson William J. , Lester-Coll Nataniel H. , Wu Abraham J. , Yang T. Jonathan , Lockney Natalie A. , Gerber Naamit K. , Beal Kathryn , Amini Arya , Patil Tejas , Kavanagh Brian D. , Camidge D. Ross , Braunstein Steven E. , Boreta Lauren C. , Balasubramanian Suresh K. , Ahluwalia Manmeet S. , Rana Niteshkumar G. , Attia Albert , Gettinger Scott N. , Contessa Joseph N. , Yu James B. , Chiang Veronica L.
Published: February 2017

Purpose

Stereotactic radiosurgery (SRS), whole-brain radiotherapy (WBRT), and epidermal growth factor receptor (EGFR)-tyrosine kinase inhibitors (TKIs) are treatment options for brain metastases in patients with EGFR-mutant non–small-cell lung cancer (NSCLC). This multi-institutional analysis sought to determine the optimal management of patients with EGFR-mutant NSCLC who develop brain metastases and have not received EGFR-TKI.

Materials and Methods

A total of 351 patients from six institutions with EGFR-mutant NSCLC developed brain metastases and met inclusion criteria for the study. Exclusion criteria included prior EGFR-TKI use, EGFR-TKI resistance mutation, failure to receive EGFR-TKI after WBRT/SRS, or insufficient follow-up. Patients were treated with SRS followed by EGFR-TKI, WBRT followed by EGFR-TKI, or EGFR-TKI followed by SRS or WBRT at intracranial progression. Overall survival (OS) and intracranial progression-free survival were measured from the date of brain metastases.

Results

The median OS for the SRS (n = 100), WBRT (n = 120), and EGFR-TKI (n = 131) cohorts was 46, 30, and 25 months, respectively ( P < .001). On multivariable analysis, SRS versus EGFR-TKI, WBRT versus EGFR-TKI, age, performance status, EGFR exon 19 mutation, and absence of extracranial metastases were associated with improved OS. Although the SRS and EGFR-TKI cohorts shared similar prognostic features, the WBRT cohort was more likely to have a less favorable prognosis ( P = .001).

Conclusion

This multi-institutional analysis demonstrated that the use of upfront EGFR-TKI, and deferral of radiotherapy, is associated with inferior OS in patients with EGFR-mutant NSCLC who develop brain metastases. SRS followed by EGFR-TKI resulted in the longest OS and allowed patients to avoid the potential neurocognitive sequelae of WBRT. A prospective, multi-institutional randomized trial of SRS followed by EGFR-TKI versus EGFR-TKI followed by SRS at intracranial progression is urgently needed.
Concurrent Chemotherapy and Radiation Therapy for Inoperable Locally Advanced Non–Small-Cell Lung Cancer
Authors: Rosenzweig Kenneth E. , Gomez Jorge E.
Published: February 2017

The Oncology Grand Rounds series is designed to place original reports published in the Journal into clinical context. A case presentation is followed by a description of diagnostic and management challenges, a review of the relevant literature, and a summary of the authors’ suggested management approaches. The goal of this series is to help readers better understand how to apply the results of key studies, including those published in Journal of Clinical Oncology, to patients seen in their own clinical practice.

A 72-year-old man with a 40-pack-year tobacco history developed a cough and decreased exercise tolerance. A chest x-ray demonstrated a right-upper-lobe opacity. Chest computed tomography (CT) scan revealed a 2.5-cm mass in the right upper lobe with multiple mediastinal lymph node disease ( Fig 1 ). A positron emission tomography (PET) scan confirmed the lung lesion and the mediastinal lymphadenopathy without distant metastases. Brain magnetic resonance imaging results were negative. The biopsy specimen revealed adenocarcinoma with no actionable mutations present. Cervical mediastinoscopy was positive for carcinoma in level 2, 3, 4R, and 7 lymph nodes; level 4L was negative. The patient’s stage was T1bN2M0, stage IIIA. His medical history was significant for hyperlipidemia and hypothyroidism. He had smoked one pack a day for 40 years and had quit 15 years earlier. Physical examination was unrevealing, and the patient had an Eastern Cooperative Oncology Group performance status of 0. Because of the extent of lung cancer in the mediastinum, the patient’s cancer was deemed inoperable, and he was referred for consideration of concurrent chemotherapy and radiation.
BTKC481S-Mediated Resistance to Ibrutinib in Chronic Lymphocytic Leukemia
Authors: Woyach Jennifer A. , Ruppert Amy S. , Guinn Daphne , Lehman Amy , Blachly James S. , Lozanski Arletta , Heerema Nyla A. , Zhao Weiqiang , Coleman Joshua , Jones Daniel , Abruzzo Lynne , Gordon Amber , Mantel Rose , Smith Lisa L. , McWhorter Samantha , Davis Melanie , Doong Tzyy-Jye , Ny Fan , Lucas Margaret , Chase Weihong , Jones Jeffrey A. , Flynn Joseph M. , Maddocks Kami , Rogers Kerry , Jaglowski Samantha , Andritsos Leslie A. , Awan Farrukh T. , Blum Kristie A. , Grever Michael R. , Lozanski Gerard , Johnson Amy J. , Byrd John C.
Published: February 2017

Purpose

Therapeutic targeting of Bruton tyrosine kinase (BTK) with ibrutinib in chronic lymphocytic leukemia has led to a paradigm shift in therapy, and relapse has been uncommon with current follow-up. Acquired mutations in BTK and PLCG2 can cause relapse, but data regarding the prevalence and natural history of these mutations are limited.

Patients and Methods

Patients accrued to four sequential studies of ibrutinib were included in these analyses. Deep sequencing for BTK and PLCG2 was performed retrospectively on patients who experienced relapse and prospectively on a screening population.

Results

With a median follow-up time of 3.4 years, the estimated cumulative incidence of progression at 4 years is 19% (95% CI, 14% to 24%). Baseline karyotypic complexity, presence of del(17)(p13.1), and age less than 65 years were risk factors for progression. Among patients who experienced relapse, acquired mutations of BTK or PLCG2 were found in 85% (95% CI, 71% to 94%), and these mutations were detected an estimated median of 9.3 months (95% CI, 7.6 to 11.7 months) before relapse. Of a group of 112 patients examined prospectively, eight patients have experienced relapse, and all of these patients had acquired resistance mutations before relapse. A resistance mutation was detected in an additional eight patients who have not yet met criteria for clinical relapse.

Conclusion

Relapse of chronic lymphocytic leukemia after ibrutinib is an issue of increasing clinical significance. We show that mutations in BTK and PLCG2 appear early and have the potential to be used as a biomarker for future relapse, suggesting an opportunity for intervention.
Clinical Implications of Novel Genomic Discoveries in Chronic Lymphocytic Leukemia
Authors: Lazarian Gregory , Guièze Romain , Wu Catherine J.
Published: February 2017

Chronic lymphocytic leukemia (CLL) is a common B-cell malignancy with a remarkably heterogeneous course, ranging from indolent disease with no need for immediate therapy to rapidly progressive disease associated with therapeutic resistance. The recent US Food and Drug Administration approvals of novel targeted therapies such as inhibitors of B-cell receptor signaling and B-cell lymphoma 2 have opened up new opportunities in the clinical management of patients with CLL and heralded a new era in the clinical treatment of this disease. In parallel, the implementation of novel sequencing technologies has provided new insights into CLL complexity, identifying a growing list of putative drivers that underlie inter- and intratumor heterogeneities in CLL affecting disease progression and resistance. The identification of these novel genomic features that can indicate future drug resistance or guide therapeutic management is now becoming a major goal in CLL so that patients can best benefit from the increasingly diverse available therapies, as discussed herein.
Survey of Implementation of Antiemetic Prescription Standards in Indian Oncology Practices and Its Adherence to the American Society of Clinical Oncology Antiemetic Clinical Guideline
Authors: Patil Vijay , Noronha Vanita , Joshi Amit , Parikh Purvish , Bhattacharjee Atanu , Chakraborty Santam , Jandyal Sunny , Muddu Vamshi , Ramaswamy Anant , Babu K. Govinda , Lokeshwar Nilesh , Hingmire Sachin , Ghadyalpatil Nikhil , Banavali Shripad , Prabhash Kumar
Published: February 2017

Purpose

Adherence to international antiemetic prophylaxis guidelines like those of ASCO can result in better control of chemotherapy-induced nausea and vomiting; however, the extent of implementation of such guidelines in India is unknown. Therefore, this survey was planned.

Methods

This study was an anonymized cross-sectional survey approved by the ethics committee. Survey items were generated from the clinical questions given in the ASCO guidelines. The survey was disseminated through personal contacts at an oncology conference and via e-mail to various community oncology centers across India. The B1, B2, and B3 domains included questions regarding the optimal antiemetic prophylaxis for high, moderate, and low-minimal emetogenic regimens.

Results

Sixty-six (62.9%) of 105 responded and 65 centers (98.5%) were aware of the published guidelines. The partial, full, and no implementation scores were 92.5%, 4.5%, and 3.0%, respectively. Full implementation was better for the low-minimal emetogenic regimens (34.8%) than the highly emetogenic regimens (6.1%). The three most frequent reasons for hampered implementation of ASCO guidelines in routine chemotherapy practice cited by centers were a lack of sensitization (26 centers; 39.4%), lack of national guidelines (12 centers; 18.2%), and lack of administrative support (10 centers; 15.2%).

Conclusion

Awareness regarding ASCO antiemetic guidelines is satisfactory in Indian oncology practices; however, there is a need for sensitization of oncologists toward complete implementation of these guidelines in their clinical practice.
Evolving Treatment Paradigms for Oropharyngeal Squamous Cell Carcinoma
Authors: Cleary Ryan K. , Cmelak Anthony J.
Published: February 2017

Oropharyngeal squamous cell carcinoma (OPSCC) is increasing in incidence in the United States and in many countries worldwide primarily as a result of increasing rates of human papillomavirus (HPV) infection. HPV-positive OPSCC represents a distinct disease entity from head and neck squamous cell carcinoma caused by traditional risk factors such as tobacco and alcohol, with different epidemiology, patterns of failure, and expected outcomes. Because patients with HPV-positive OPSCC have a younger median age and superior prognosis compared with their HPV-negative counterparts, they live longer with the morbidity of treatment, which can be severe. Therefore, efforts are under way to de-escalate therapy in favorable-risk patients while maintaining treatment efficacy. Additional work is being undertaken to discover new therapies that may benefit both HPV-positive and HPV-negative patient subsets. Herein, we will review the available data for the evolving treatment paradigms in OPSCC as well as discuss ongoing clinical trials.
Health-Seeking Behavior and Barriers to Care in Patients With Rectal Bleeding in Nigeria
Authors: Alatise Olusegun I. , Fischer Sara E. , Ayandipo Omobolaji O. , Omisore Akinlolu G. , Olatoke Samuel A. , Kingham T. Peter
Published: February 2017

Purpose

Colorectal cancer (CRC) incidence rates are steadily increasing in Nigeria. Organized screening is still largely unused because of financial and logistical barriers; most CRCs are detected by symptoms. One symptom of CRC is rectal bleeding. This study sought to determine health-seeking behavior and barriers to care in patients with rectal bleeding in Nigeria. This study also surveyed physicians to determine major breakdowns in access to care.

Methods

The recruitment process for this study involved patients referred for colonoscopy because of rectal bleeding as well as response to a media advertisement for a free colonoscopy. Physicians were recruited at the African Research Group for Oncology meeting. Patient responses were scored on the basis of knowledge of rectal bleeding. The physician questionnaire was supporting information and mainly descriptive in nature.

Results

A total of 82 patients and 45 physicians participated in this study. Less than 40% of patients knew that rectal bleeding could be caused by cancer. Major barriers to care were resolution of the symptom (42%), no consideration of the bleeding as problematic (40%), and financial constraint (22%). Education was strongly correlated with knowledge of rectal bleeding and health-seeking behavior. Although physicians regularly saw patients with rectal bleeding, most of them provided a differential diagnosis of hemorrhoids and few referred patients for colonoscopy.

Conclusion

General awareness about the signs of colorectal cancer is lacking. This demonstrates the strong need for patient education programs about this issue. Physicians should also receive additional training on differentiation of a potential cancer diagnosis from something more benign, such as hemorrhoids.
Outcomes in Lung Cancer: 9-Year Experience From a Tertiary Cancer Center in India
Authors: Murali Aditya Navile , Radhakrishnan Venkatraman , Ganesan Trivadi S. , Rajendranath Rejiv , Ganesan Prasanth , Selvaluxmy Ganesarajah , Swaminathan Rajaraman , Sundersingh Shirley , Krishnamurthy Arvind , Sagar Tenali Gnana
Published: February 2017

Purpose

Lung cancer is the most common cause of cancer mortality in the world. There are limited studies on survival outcomes of lung cancer in developing countries such as India. This study analyzed the outcomes of patients with lung cancer who underwent treatment at Cancer Institute (WIA), Chennai, India, between 2006 and 2015 to determine survival outcomes and identify prognostic factors.

Patients and Methods

In all, 678 patients with lung cancer underwent treatment. Median age was 58 years, and 91% of patients had non–small-cell lung cancer (NSCLC). Testing for epidermal growth factor receptor mutation was performed in 132 of 347 patients and 61 (46%) were positive.

Results

Median progression-free survival was 6.9 months and overall survival (OS) was 7.6 months for patients with NSCLC. Median progression-free survival was 6 months and OS was 7.2 months for patients with small-cell lung cancer. On multivariable analysis, the factors found to be significantly associated with inferior OS in NSCLC included nonadenocarcinoma histology, performance status more than 2, and stage. In small-cell lung cancer, younger age and earlier stage at presentation showed significantly better survival.

Conclusion

Our study highlights the challenges faced in treating lung cancer in India. Although median survival in advanced-stage lung cancer is still poor, strategies such as personalized medicine and use of second-line and maintenance chemotherapy may significantly improve the survival in patients with advanced-stage lung cancer in developing countries.
Differences in Health Care Use and Costs Among Patients With Cancer Receiving Intravenous Chemotherapy in Physician Offices Versus in Hospital Outpatient Settings
Authors: Fisher Maxine D. , Punekar Rajeshwari , Yim Yeun Mi , Small Arthur , Singer Joseph R. , Schukman Jay , McAneny Barbara L. , Luthra Rakesh , Malin Jennifer
Published: February 2017

Purpose:

The current shift in site of care from community oncology practices to the hospital outpatient department to deliver oncology services may have significant implications for the economic and clinical outcomes of cancer care. Therefore, this study compares health care use and costs among patients with cancer receiving intravenous (IV) chemotherapy in physician offices (PO) versus in hospital outpatient settings (HOP).

Methods:

This retrospective study, which was based on medical and pharmacy claims data, included patients (age, 18 to 64 years) initiating IV chemotherapy/biologic treatment between January 1, 2006, and August 31, 2012, who were diagnosed with early or metastatic breast cancer, metastatic lung cancer, metastatic colorectal cancer, or non-Hodgkin lymphoma or chronic lymphocytic leukemia. Patients were assigned to PO or HOP groups on the basis of where they received > 95% of their IV cancer therapy.

Results:

The study sample included 18,740 patients (12,899 PO; 5,841 HOP) who had a mean age of 51.6 years and a Deyo-Charlson Comorbidity Index score of 5.37. Overall office visits (21.8 ± 13.8 PO v 21.2 ± 12.9, P < .005) and outpatient services (50.8 ± 35.5 PO v 48.5 ± 33.6, P < .001) were higher in the PO group than in the HOP group. Cancer-related inpatient hospitalizations (0.6 ± 1.2 PO v 0.7 ± 1.4 HOP, P = .002) were lower in the PO group than in the HOP group. Although quality-of-care metrics were similar between the HOP and PO groups, follow-up all-cause costs ($82,773 PO v $122,473 HOP) and cancer-related health care costs ($69,037 PO v $108,177 HOP) were higher in the HOP group than in the PO group.

Conclusion:

Despite similar resource use, all-cause and cancer-related health care costs in HOP were significantly higher compared with those in PO settings.
Anxiety, Culture, and Expectations: Oncologist-Perceived Factors Associated With Use of Nonrecommended Serum Tumor Marker Tests for Surveillance of Early-Stage Breast Cancer
Authors: Hahn Erin E. , Munoz-Plaza Corrine , Wang Jianjin , Garcia Delgadillo Jazmine , Schottinger Joanne E. , Mittman Brian S. , Gould Michael K.
Published: February 2017

Purpose:

Breast cancer offers several opportunities for reducing use of ineffective practices based on American Society of Clinical Oncology guidelines. We assessed oncologist-perceived factors associated with use of one such practice—serum tumor markers for post-treatment breast cancer surveillance—focusing on medical oncologists with high, medium, or low test use.

Methods:

Using a mixed-methods design, we identified patients who had been treated for early-stage breast cancer diagnosed between January 1, 2009, and December 31, 2012, within Kaiser Permanente Southern California and calculated the number of tests ordered from January 1, 2010, to December 31, 2014. We identified oncologists with high, medium, or low use and subsequently performed semistructured interviews. We used patient satisfaction data to assess association between pattern of use and satisfaction score.

Results:

We identified 7,363 patients, with 40,114 tests ordered. High-use oncologists were defined as those ordering at least one test annually for 35% of patients or more, low-use oncologists as those ordering at least one test for 5% of patients or less; 42% of oncologists were high, 27% low, and 31% medium users. We interviewed 17 oncologists: six high, eight low, and three medium users. Factors associated with high use included: perceived patient anxiety, oncologist anxiety, belief that there was nothing else to offer, concern about satisfaction, patient competition, peer use, and system barriers. Factors associated with low use included: beliefs about consequences (eg, causes harms) and medical center culture (eg, collective decision to follow guidelines). We found no association between satisfaction score and pattern of use.

Conclusion:

Barriers to deimplementation are numerous and complex. Traditional strategies of practice change alone are unlikely to be effective. Multifaceted, multilevel strategies deployed to address patient-, clinician-, and system-related barriers may be required.
Treatment Burden of Medicare Beneficiaries With Stage I Non–Small-Cell Lung Cancer
Authors: Presley Carolyn J. , Soulos Pamela R. , Tinetti Mary , Montori Victor M. , Yu James B. , Gross Cary P.
Published: February 2017

Purpose:

To quantify the burden and complexity associated with treatment of Medicare beneficiaries with stage I non–small-cell lung cancer (NSCLC).

Methods:

Using the SEER-Medicare database, we conducted a retrospective cohort study of Medicare beneficiaries who were diagnosed with stage I NSCLC from 2007 to 2011 and who were treated with surgery, stereotactic body radiation therapy, or external beam radiation therapy. Main outcome measures were the number of days a patient was in contact with the health care system (encounter days), the number of physicians involved in a patient’s care, and the number of medications prescribed. Logistic regression modeled the association between patient characteristics, treatment type, and high treatment burden (defined as ≥ 66 encounter days).

Results:

On average, 7,955 patients spent 1 in 3 days interacting with the health care system during the initial 60 days of treatment. Patients experienced a median of 44 encounter days with high variability (interquartile range [IQR], 29 to 66) in the 12 months after treatment initiation. The median number of physicians involved was 20 (IQR, 14 to 28), and the median number of medications prescribed was 12 (IQR, 8 to 17). Patients who were treated with surgery had high treatment burden (predicted probability, 21.6%; 95% CI, 20.2 to 23.1) compared with patients who were treated with stereotactic body radiation therapy (predicted probability, 16.1%; 95% CI, 12.9 to 19.3), whereas patients who were treated with external beam radiation therapy had the highest burden (predicted probability, 46.8%; 95% CI, 43.3 to 50.2).

Conclusion:

The treatment burden imposed on patients with early-stage NSCLC was substantial in terms of the number of encounters, physicians involved, and medications prescribed. Because treatment burden varied markedly across patients and treatment types, future work should identify opportunities to understand and ameliorate this burden.
Integrating Oncology Massage Into Chemoinfusion Suites: A Program Evaluation
Authors: Mao Jun J. , Wagner Karen E. , Seluzicki Christina M. , Hugo Audra , Galindez Laura K. , Sheaffer Heather , Fox Kevin R.
Published: February 2017

Objective:

This article reports on the development, implementation, and evaluation of an integrative clinical oncology massage program for patients undergoing chemotherapy for breast cancer in a large academic medical center.

Materials and Methods:

We describe the development and implementation of an oncology massage program embedded into chemoinfusion suites. We used deidentified program evaluation data to identify specific reasons individuals refuse massage and to evaluate the immediate impact of massage treatments on patient-reported outcomes using a modified version of the Distress Thermometer delivered via iPad. We analyzed premassage and postmassage data from the Distress Thermometer using paired t test and derived qualitative data from participants who provided written feedback on their massage experiences.

Results:

Of the 1,090 massages offered, 692 (63%) were accepted. We observed a significant decrease in self-reported anxiety (from 3.9 to 1.7), nausea (from 2.5 to 1.2), pain (from 3.3 to 1.9), and fatigue (from 4.8 to 3.0) premassage and postmassage, respectively (all P < .001). We found that 642 survey participants (93%) were satisfied with their massage, and 649 (94%) would recommend it to another patient undergoing treatment. Spontaneous patient responses overwhelmingly endorsed the massage as relaxing. No adverse events were reported. Among the 398 patients (36%) who declined a massage, top reasons were time concerns and lack of interest.

Conclusion:

A clinical oncology massage program can be safely and effectively integrated into chemoinfusion units to provide symptom control for patients with breast cancer. This integrative approach overcomes patient-level barriers of cost, time, and travel, and addresses the institutional-level barrier of space.