tbuckley/cabot-search huggingface dataset:
AUA and NCCN surveillance guidelines for RCC: Do they effectively capture recurrences following nephrectomy?
Authors: Suzanne B. Stewart, Christine M. Lohse, Sarah P. Psutka, John C. Cheville, Stephen A. Boorjian, Robert Houston Thompson, Bradley C. Leibovich
Journal: Journal of Clinical Oncology (2014)

402 Background: The American Urological Association (AUA) and the National Comprehensive Cancer Network (NCCN) are highly utilized sources for surveillance strategies following surgical treatment for renal cell carcinoma (RCC). However, the duration of follow-up may be inadequate to capture the majority of recurrences. Herein, we assess the ability of these guidelines to effectively capture recurrences of RCC following primary surgical resection. Methods: We reviewed our institutional database of 3,725 patients treated with radical or partial nephrectomy for M0 sporadic RCC between 1970-2008. For comparison to the AUA guidelines, patients were stratified into low risk following partial nephrectomy (LRp) or radical nephrectomy (LRr) = pT1N0, and moderate/high risk (M/HR) = pT2-4 N0-1. Guideline effectiveness was assessed by calculating the percentage of recurrences detected within the prescribed follow-up periods given for site-specific recurrence: AUA—LRp: 3yrs for all sites; LRr: 1yr for abdominal and 3yrs for chest/bone/other sites; M/HR: 5yrs for all sites; NCCN—6 months for abdominal/chest sites and 5yrs for bone/other sites. Results: Of the 3,725 patients, 2721 (73.1%) underwent radical nephrectomy, 2,210 (59.3%) were classified as pT1 NX-0 and 2,910 (78.1%) as clear cell RCC. Median postoperative follow-up was 8.9yrs (IQR 5.5-14.2) during which 1,114 (29.9%) patients developed recurrence. Of these recurrences, 760 (68.2%) would have been detected using the AUA guidelines and 432 (38.8%) by NCCN recommendations. Within AUA risk groups, 37.2% recurrences were captured in LRp, 31.4% in LRr and 80.2% in M/HR. Capture of 90% of recurrences in the abdomen and chest would require surveillance for 9yrs and 8 yrs, respectively in LRp, 15yrs and 12yrs in LRr and 11yrs and 10yrs in M/HR. Conclusions: Duration of follow-up recommended by current surveillance algorithms by the AUA and NCCN do not adequately capture many recurrences in RCC following radical or partial nephrectomy. Guidelines using risk stratification and site-specific recurrence parameters to assign length of surveillance may allow providers to better individualize surveillance regimens.
Prognostic factors for recurrence in elderly patients with cervical carcinoma
Authors: O. O. Castillo Fernandez, R. Arauz, R. Zarak, E. Diaz, J. C. Alcedo, R. I. Lopez, F. Cebamanos
Journal: Journal of Clinical Oncology (2008)

16564 Background: Uterine cervix carcinoma is the most commonly diagnosed, fatal cancer in women in developing countries. World wide the age distribution of new cases is bimodal with peaks at ages 30–39 and at ages 60–69 years. Age has been reported as an adverse prognostic factor however other issues related to co-morbidity conditions and treatment might influence the impact of age as an independent prognostic factor. The aim of this study was to describe the characteristics and outcomes of elderly patients with invasive cervical cancer treated in our institution Methods: Records of patients age 60 and older with invasive cervical cancer treated with radiation with or without concomitant chemotherapy between 2004 to 2006 were reviewed. Recurrence free survival and predictors of outcomes were analyzed using Kaplan-Meier method and Cox regression analysis Results: 85 patients with invasive cervical carcinoma were identified (median age = 68, median age at first intercourse = 18, median number of sexual partners = 2, median number of pregnancy = 7). 55% had co-morbidity, 17% smokers, 83% had inadequate cytologic screening, 88% squamous cell carcinoma 12% adenocarcinoma. Stage distribution: IA2-IB2- 35%, IIA, B- 34.%, IIIA, B-28% IVA 3%. Treatment modality: Radiotherapy alone 27 pts (32%), chemoradiation 48 pts (57%), surgery and adjuvant radiation therapy 8pts (9%), neoadjuvant chemoradiation followed by surgery 2 pts (2%). Median dose of irradiation was 75 Gy. 65 pts (76%) underwent low dose rate brachytherapy. Cisplatin was used as radiosensitizer in 45 pts (82%) and Gemcitabine in 6 pts (12%). After a median follow up of 17 months (range 3–44 months), 20 pts (23%) relapsed. Factor associated with recurrence free survival in the univariate analysis were smoking (p=0.015), radiation therapy dose (p=0.010), stage I-II vs III-IV (p=0.024) and not receiving brachytherapy (p=0.021). In multivariable analysis only smoking was an independent prognostic factor (HR 4.1 CI 95% 1.4–11.6 p=0.007). Conclusions: This study suggest a role of smoking as an adverse prognostic factor for early recurrence in cervical carcinoma, further studies evaluating this factor in prospective setting are recommended. Agressive policies should be implemented to improve the screening of cervix cancer in our country. No significant financial relationships to disclose.
Quality of febrile neutropenia management in a regional cancer center emergency department.
Authors: Priyanka Kapil, Katherine Enright
Journal: Journal of Clinical Oncology (2014)

104 Background: ASCO's current guidelines for febrile neutropenia (FN) management support antibiotic administration within one hour of presentation to the emergency department (ED). Prompt initiation of antibiotic therapy is vital to decrease the likelihood of adverse outcomes. Many studies, however, have reported significant delays in antibiotic initiation with mean wait times far exceeding ASCO's guidelines. We aimed to assess the quality of FN management at a regional cancer centre ED. Methods: Patients undergoing chemotherapy who visited the ED at the Peel Regional Cancer Center in Ontario, Canada between 04/12 - 03/13 were identified using electronic medical records. Patients were excluded if there was no record of chemotherapy delivery within 30 days prior to ED visit. ICD-10 codes and chart data were used to identify patients who had presented for either fever or infection. The primary outcome measures were three major quality of health indicators; time to assessment by a physician, Canadian Triage and Acuity Scale (CTAS) score, and time to initiation of intravenous antibiotics. Results: In total 239 records were included in the analysis. CTAS score was concordant with recommendation for FN (level 1-2) in 85% of patients and did not vary based on primary cancer site (p = 0.17). The mean time to physician assessment was 97.2 min and the mean time to initiation of IV antibiotics was 194.7 min. Overall, 14.6% of patients received their first dose of antibiotic therapy within the recommended 1 hour window. Conclusions: Our audit identified a large margin for improvement in the time to initiation of antibiotic therapy for chemotherapy patients with suspected FN. Prompt recognition and initiation of standardized treatment pathways for FN in the ED may improve the time to initiation of antibiotic therapy. In an attempt to address this gap in quality we have developed and distributed a standardized wallet-sized fever card to all patients receiving cytotoxic chemotherapy within our regional cancer program. This card contains information pertaining to the current chemotherapy treatment and recommended ED treatment protocols for FN. An evaluation of the impact of these cards is ongoing.
Prechemotherapy hemoglobin (Hgb) and cognitive impairment among breast cancer patients
Authors: L. I. Wagner, J. J. Sweet, J. Desai, J. Beaumont, K. A. Havlin, Z. A. Butt, D. Cella
Journal: Journal of Clinical Oncology (2005)

8124 Background: Prospective findings suggest 15–30% of breast cancer patients demonstrate cognitive impairment prior to beginning chemotherapy. Factors contributing to prechemotherapy cognitive dysfunction are not well understood. Methods: Fifty-five breast cancer patients completed a study assessment 3–21 days before Cycle 1 Day 1 of chemotherapy, including a neuropsychological battery to evaluate cognitive function and self-report questionnaires to assess symptom burden, health status and quality of life. Participants scoring > 1 SD below the age-adjusted mean on ≥ 3 domains of neuropsychological functioning were classified as cognitively impaired. Age, education, stage of disease, recent surgery, Hgb, and HADS scores were entered into a logistic regression model to predict cognitive impairment. The ability of Hgb to differentiate impaired from non-impaired patients was evaluated using receiver operating characteristic (ROC) analysis. Results: Most participants were female (95%), college educated (mean = 16.0 ± 2 years education) and diagnosed with Stage II (73%) or Stage III (18%) breast cancer. Mean age was 51.1 ± 9.4 years. Based on chart abstraction, mean Hgb was 12.8 ± 1.1 g/dL (range 10.5 - 14.8 g/dL). Hospital Anxiety and Depression Scale (HADS) scores were in the normal range for anxiety and depression (mean = 6.1, 3.1 respectively). Thirteen participants (23.6%) met criteria for cognitive impairment. Hgb was the only statistically significant predictor of cognitive impairment. Participants with higher Hgb were less likely to be cognitively impaired (p < .01; OR = .40; 95% CI = 0.19–0.78). Based on ROC analysis, a cut-off of 12.85 g/dL Hgb had a sensitivity of 83.3% and a specificity of 75.0% to predict impairment (area under the curve = 0.78). Conclusions: Nearly one-fourth of breast cancer patients met criteria for cognitive impairment before beginning chemotherapy. Low Hgb prior to chemotherapy may be a risk factor for cognitive impairment. Author Disclosure Employment or Leadership Consultant or Advisory Role Stock Ownership Honoraria Research Funding Expert Testimony Other Remuneration Ortho-Biotech
Use of a 3-dimensional lumpectomy marker for targeting interstitial accelerated partial breast irradiation (APBI).
Authors: Linda Ann Smith, Erika N. Nelums, Margaret B. Snyder, Robert R. Kuske
Journal: Journal of Clinical Oncology (2015)

42 Background: APBI via high-dose-rate (HDR) interstitial catheter implants is an effective, highly customizable method of delivering radiotherapy in breast cancer patients. The technique is amenable to challenging anatomy such as pendulous and/or very small breasts, augmented breasts or superficial lumpectomy sites. The challenge for any APBI technique is identification of the lumpectomy cavity, which can be difficult to visualize after surgery due to post-surgical changes or tissue mobilization for oncoplastic closure. In the past we have used x-ray contrast injected into the cavity to facilitate the radiographic visualization of the cavity or individual clips. A new 3-D tissue marker (BioZorb, Focal Therapeutics, Inc.) has recently been used by surgeons to mark the area of the lumpectomy cavity at greatest risk for recurrence. In effect this acts as a communication tool to help guide the radiation oncologist for treatment planning and delivery. We examined this device for target volume localization in 15 patients receiving interstitial HDR APBI. Methods: The marker mimicking the tumor size was surgically sutured at the base of the lumpectomy cavity in 15 patients with T1T2N0N1 breast cancer with a variety of closure techniques. The clinical target volume (CTV) was taken as the 3-D outline made by the six embedded titanium markers and a 2 cm margin expanded around that structure (the planning target volume, PTV). Multiple interstitial catheters were spaced 1.5 cm apart within the PTV and 34 Gy was delivered in 10 fractions delivered over 5 treatment days. Results: The marker/CTV was easily visualized on CT images, without clips or injected contrast, making catheter insertion and planning more efficient, easier, and reproducible. The CTV volume was small (12.5 +/- 8.7cc; mean +/- SD, range 4.4–33.4cc) as was the PTV (137 +/- 60cc; mean +/- SD, range 75–327cc), relative to typical HDR APBI implants. Conclusions: The technique facilitated identification of the lumpectomy cavity in all patients treated regardless of surgical closure technique. The unambiguous margin demarcation facilitated target contouring and reproducibility for APBI.
Timeliness of adjuvant chemotherapy (AT) for stage III adenocarcinoma of colon (CC): A measure of quality of care.
Authors: Steven Yu, Maryam Shabihkhani, Sarmad Sadeghi, Heinz-Josef Lenz, Anthony Senagore, Afsaneh Barzi
Journal: Journal of Clinical Oncology (2012)

282 Background: In the past three decades multiple clinical trials have proven the benefit of AT for CC, establishing combination chemotherapy after recovery from surgery as a quality measure in stage III CC. The majority of clinical trials require enrollment for AT within eight weeks from surgery nonetheless there is no established standard time for delivery of AT. Timeliness of service is defined as one of the domains of quality care by Institute of Medicine. We explore the timing of AT as a quality measure in patients (pts) with CC. Methods: We conducted a retrospective analysis of pts with CC who underwent surgery in Los Angeles County Hospital between January 2005 through December of 2009, with at least six months of follow up after surgery. Pt, disease and treatment characteristics were recorded. Disease free survival (DFS) was measured as the time from surgery to the last follow up or recurrence. Results: 52 pts, median age 58 years (28 – 86), 62% female, 65% Hispanics, 21% Asian, 6% black and 6% white, with CC were included all of whom received adjuvant FOLFOX. 24 pts had right and 26 left-sided cancers. Median start day for AT was 60 days after surgery (12-145 days), with 60% waiting more than 8 and 19% more than 12 weeks. 4 pts received 6, 1 pt 10, 2 pts 11 and 45 pts 12 cycles of therapy. 17 pts had recurrence, 3 local and 14 systemic. Median DFS was 25.3 month (range 8-70). In univariable analysis only age was a predictor of recurrence (HR 0.96 95% CI 0.92-0.99). Time from surgery to adjuvant chemotherapy was not a predictor of recurrence (systemic, local and combined), or DFS. Conclusions: In several meta-analyses time form surgery to AT is identified as an independent risk factor for death from colon cancer. In this study there was no association between time from surgery to AT and DFS. Delivery of AT depends on several factors including recovery from surgery, medical oncology visit, placement of a central line, and initiation of the treatment. Quality measures to assess each of these processes can improve the adherence to available data and improve enrollment on clinical trials. The major limitation of our study is the limited sample size and lack of power to detect a small effect.
Clinical outcomes for patients with liver-limited metastatic colorectal cancer: Arguing the case for specialist hepatobiliary multidisciplinary assessment.
Authors: Kiruthikah Thillai, Dimitra Repana, Ippokratis Korantzis, Andreas Prachalias, Pauline Kane, Paul J. Ross
Journal: Journal of Clinical Oncology (2014)

637 Background: In patients (pts) with liver-limited metastatic colorectal cancer (mCRC), surgical resection or radiofrequency ablation (RFA) can lead to a significant overall survival benefit. Specialist hepato-biliary (HPB) multidisciplinary meetings (MDMs) are currently believed to provide the best forum to discuss this cohort of pts and assess their suitability for surgery or RFA. Methods: A retrospective analysis was undertaken of pts diagnosed with liver-limited mCRC over a period of 6 months within a specified cancer network in the United Kingdom. In addition to discussed cases, pts who were diagnosed but not referred to the HPB MDM were also discussed within the MDM setting. For these pts, contributors were blinded and decisions were made regarding resectability and appropriateness for RFA based on patient imaging and clinical history. Results: In a six month period, 159 pts were diagnosed with liver-limited mCRC within our cancer network. Of these, 68 (43%) were referred at the time of initial diagnosis, with a further 38 (24%) referred after commencing systemic treatment. 35 (56%) who were discussed at the time of their original diagnosis went on to have either a hepatectomy or RFA, as did 18 (51%) patients referred after initiating systemic treatment. 81 pts (78%) referred to the HPB MDM had synchronous liver metastases. Of the remaining 53 (33%) patients who were not referred to the HPB MDM, the average age was 70.2 years and 38 (86%) had synchronous liver metastases. Imaging was available for 31 (58%) of these pts. Decisions regarding resectability or RFA were made within the MDM based solely on history and radiology findings. Of these cases, 13 (41.9%) were identified as resectable or potentially resectable and 11 (35.5%) may have been suitable for a clinical trial. None of these 31 pts (100%) had hepatic surgery or RFA. Conclusions: Whilst the majority of pts with liver-limited mCRC were referred appropriately, this study highlights that a number of pts with potentially resectable disease are not being discussed at a specialist HPB MDM. A review of all diagnosed cases would ensure that an increased number of pts are offered hepatic resection or RFA.
Genomic testing to enhance treatment choices and clinical trial accrual in metastatic colorectal cancer: Results of a prospective cohort study.
Authors: Davendra Sohal, Brian I. Rini, Robert James Pelley, Bassam N. Estfan, Dale Randall Shepard, Robert Dreicer, Brian James Bolwell, Alok A. Khorana
Journal: Journal of Clinical Oncology (2015)

593 Background: Tumor genome sequencing is being used widely in clinical settings but its value to individual patients has not been well-studied. A prospective cohort study of outpatient genomic testing to identify prevalence of actionable alterations and their impact on management decisions was conducted. Methods: Eligibility requirements included pathologic diagnosis of select solid tumor malignancies without a known curative option, age ≥18 years, and an ECOG PS of 0-2. Data for the colorectal cancer (CRC) subgroup are presented here. Tumor samples were sequenced for up to 315 candidate genes using FoundationOne (Cambridge, MA). Results were discussed at the Cleveland Clinic Genomics Tumor Board that made therapeutic recommendations to treating physicians. Results: From Aug 2013 to Aug 2014, samples from 45 patients with CRC were analyzed. Median age was 60 years; 23 (51%) were female; 38 (84%) were white. Median time from consent to result was 25 (range, 7-75) days. One (2%) sample had inadequate tissue. A median of 5 (range, 2-19) mutations were detected per sample; APC (89%), TP53 (73%) and KRAS (66%) were most common. A therapy targeting an actionable alteration was recommended in 22 (51%) patients; 88% of these recommendations were for clinical trials. To date, 6 (33%) of 18 patients who switched management after test results received genomics-driven therapies (Table). Previously unknown RAS (KRAS Q61H, NRAS) mutations were detected in an additional 3 patients, influencing EGFR antibody use decisions. The commonest reason for non-receipt of therapy based on the test result was non-availability of clinical trials. Conclusions: Routine tumor genome profiling in CRC patients is feasible and influenced treatment decisions in a third of patients. A genomics tumor board for the interpretation of rapidly evolving information, and improved access to clinical trials of targeted agents are critical to the success of precision oncology. [Table: see text]
The inclusion of palliative care in initial treatment planning for women with gynecologic cancer and the use of advanced directives.
Authors: Rachel Regn, William Robinson, William R. Robinson
Journal: Journal of Clinical Oncology (2016)

23 Background: To determine differences in Advanced Directive (AD) utilization among women with gynecologic cancer at a facility with a functioning Palliative Care (PC) program, vs those in a facility without access to a PC program. Also, to identify possible ethnic differences or relationships to other PC needs to AD utilization. Methods: 95 subjects with gynecologic cancer were prospectively identified, 30 from an inner-city academic facility (Site A), and 65 from a suburban community facility in the same metropolitan area. (Site B) All patients received treatment from board-certified oncologists. All subjects were approached by Master’s trained Social Workers at presentation with a diagnosis of cancer and asked to complete a standardized, validated questionnaire (modified Distress Thermometer (DT)) to determine their palliative care needs and whether they had an AD prior to treatment (baseline), and 6 months later. Completed questionnaires were collected and data was depersonalized and analyzed by the authors. Statistical differences were assessed using standard methods. Results: Site A patients were younger (56.3 vs 61.5 years) less likely to be Caucasian (12/30, 40% vs 40/65, 61.5%) and less likely to have private insurance (10/30, 33.3% vs 41/65, 63%). The presence of AD was similar in both sites at baseline. (8/65, 12.3% vs. 4/30, 13.3%) At 6 months, Site B patients were more likely to have an active AD. (50/65, 77.0% vs 5/30, 16.7%) No differences were seen based on ethnicity (Caucasian vs. Black) at either baseline or 6 months. No differences were seen based on the stage or type of gynecologic cancer. No relationship between AD utilization and any other PC needs (as recorded by DT) were identified. All differences were significant at a p &lt; 0.05. Conclusions: Advanced Directive utilization is uncommon in women diagnosed with gynecologic cancer in the facilities analyzed. Subsequent creation of an AD is strongly associated with the presence of a PC program. PC programs have multiple benefits for gynecologic cancer patients, and should be offered routinely as part of the initial treatment plan.
Gene expression profiles to predict outcome following liver resection in patients with metastasis of colorectal cancer.
Authors: H. Ito, Q. Mo, A. V. Maker, Q. Li-Xuan, P. Allen, R. P. DeMatteo, Y. Fong, L. H. Blumgart, W. R. Jarnagin, M. I. D'Angelica
Journal: Journal of Clinical Oncology (2010)

3576 Background: A validated clinical risk scoring (CRS) system developed at our institution has proven to be a powerful predictor of long-term outcome after hepatic resection for metastatic colorectal cancer (MCRC). The CRS, however, does not preclude long-term survival and is imperfect. The aim of this study was to build a model predictive of survival based on gene signatures. Methods: Using the Illumina Human HT-12 expression gene chip containing 25,000 annotated genes, RNA samples from the liver metastases from 96 patients were analyzed. The patients were randomly assigned to a training set or a test set. All patients underwent R0 liver resection and no extrahepatic disease. At a median follow-up of 30 months, 39 patients (41%) died of recurrent cancer. The genes associated with cancer-related death were identified by Cox-regression and selected to construct a molecular risk score (MRS) using the supervised principle component method in a training set of patients (n = 60). The MRS was then evaluated in an independent test set of patients (n = 36) using the Log-rank test and Cox-regression. The prognostic strength of MRS and CRS was assessed with a concordance index. Results: Nineteen genes were selected to construct the MRS. The MRS was validated to predict disease-specific survival (DSS); 5-year predicted DSS rates were 77% and 36% for patients with low MRS and those with high MRS, respectively (p = 0.0046). In multivariate analysis, MRS emerged as an independent predictor for DSS, while CRS did not (p = 0.034 and p = 0.11, respectively). The concordance index of MRS and CRS predicting DSS were 0.71 and 0.65, respectively. Conclusions: An MRS based on gene expression profiling is highly predictive of outcome and is independent of CRS. This finding provides a potential strategy for better risk-stratification of patients with resected liver MCRC. No significant financial relationships to disclose.