Cancer Medicine by Alexandros G.Sfakianakis,Anapafseos 5 Agios Nikolaos,Crete 72100,Greece,tel :00302841026182 & 00306932607174
MET exon 14 alterations are a diverse group of mutations, many of which disrupt splice acceptor or donor sites leading to exon 14 skipping, impaired receptor degradation, and oncogenic transformation. These alterations are clinically targetable with MET-directed therapy.
The prognostic value of rectal invasion is still unclear in stage IVA cervical cancer. The objective of this study is to evaluate patient outcome and prognostic factors in stage IVA cervical cancer treated with radiation therapy.
A retrospective review of the medical records of patients treated with definitive photon radiation therapy for pathologically proven stage IVA cervical cancer between 1980 and 2010 was performed. Eligible patients for the present study were diagnosed with clinical stage IVA cervical cancer by cystoscopy or/and proctoscopy, and they received definitive radiation therapy consisting of a combination of external beam radiotherapy and high-dose-rate brachytherapy. All patients underwent CT scans of the abdomen and pelvis.
Among the 67 stage IVA patients studied, 53 patients were stage IVA on the basis of bladder invasion, 7 according to rectal mucosal invasion, and 7 because of both bladder and rectal mucosal invasion. Median follow-up of all patients and surviving patients was 19 months (range, 2–235 months) and 114 months (range, 14–223 months), respectively. The 5-year local control (LC), disease-free survival (DFS), and overall survival (OS) rate were 55, 17, and 24 %, respectively. Rectal invasion had significant impact on DFS, but bladder invasion had the opposite effect (p = 0.00006 and 0.005, respectively). There were significant differences of LC, DFS and OS rates between patients with and without rectal invasion (p = 0.006, 0.00006 and 0.05, respectively).
Patients with stage IVA cervical cancer had poor prognosis, with 5-year survival of only 24 %. Furthermore, in stage IVA, rectal invasion might be a worse prognostic factor than bladder invasion.
Organized cervical cancer screening services are presently lacking in Nigeria contributing to late presentation and diagnosis of invasive cervical cancer cases (ICCs) at advanced stages in most gynecologic units in Nigeria. We evaluated outcomes of ICCs diagnosed at Jos University Teaching Hospital (JUTH) to better understand factors associated with cervical cancer survival in similar resource limited settings.
We performed a retrospective cohort study with a prospective follow up data to estimate time from diagnosis to mortality among women diagnosed with ICCs at JUTH. Women who were diagnosed with ICCs between January 2011 and May 2013 were followed up after initial evaluation at JUTH and subsequent referral for specialized treatment in one of the national oncology treatment centers in Nigeria. The main outcome measured was all-cause mortality rate and overall survival (OS) after diagnosis of ICC. The follow up data were updated and observations were censored March 31, 2015. The overall death rate was estimated using the total number of death events and the cumulative follow-up time from diagnosis to death. We conducted Cox proportional hazard regression to assess factors associated with death.
A total of 65 histologically confirmed ICCs were followed up. The median age of the cohort was 50 years with a median parity of 7. The HIV prevalence in the cohort was 8.2 % and the majority (72.3 %) were diagnosed at advanced stages (AD) of ICC. Simple total abdominal hysterectomy (TAH) was performed in 38.9 % of patients who were diagnosed at early stage disease (ED). After a cumulative follow up of 526.17 months, 35 deaths occurred with an overall death rate of 79.8 per 100 women-years. We also found a significantly higher hazard of death in women with AD (HR = 3.3) and baseline anemia (HR = 3.0). In the subgroup of women with ED, the OS was significantly higher for those who had TAH compared to those who did not (26.5 versus 11.6 months respectively).
Advanced stage disease and baseline anemia were independently associated with higher death rate. Cervical cancer patients diagnosed at early stages by non-oncologic specialist in settings lacking the standard of care may benefit from improve survival with simple hysterectomy.
The Food and Drug Administration (FDA) has expanded the approved uses of the targeted therapy crizotinib (Xalkori®) for patients with non-small cell lung cancer (NSCLC).
The new approval is for the treatment of patients with advanced NSCLC whose tumors have alterations—known as rearrangements—in the ROS1 gene. Crizotinib was originally approved for patients with advanced NSCLC whose tumors have similar alterations in the ALK gene.
Future Oncology Ahead of Print.
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Future Oncology Ahead of Print.
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Future Oncology Ahead of Print.
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Future Oncology Ahead of Print.
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Future Oncology Ahead of Print.
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Future Oncology Ahead of Print.
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Cancer development is a complex process involving both genetic and epigenetic changes. Genetic changes in oncogenes and tumor-suppressor genes are generally considered as primary causes, since these genes may directly regulate cellular growth. In addition, it has been found that changes in epigenetic factors, through mutation or altered gene expression, may contribute to cancer development. In the nucleus of eukaryotic cells DNA and histone proteins form a structure called chromatin which consists of nucleosomes that, like beads on a string, are aligned along the DNA strand. Modifications in chromatin structure are essential for cell type-specific activation or repression of gene transcription, as well as other processes such as DNA repair, DNA replication and chromosome segregation. Alterations in epigenetic factors involved in chromatin dynamics may accelerate cell cycle progression and, ultimately, result in malignant transformation. Abnormal expression of remodeler and modifier enzymes, as well as histone variants, may confer to cancer cells the ability to reprogram their genomes and to yield, maintain or exacerbate malignant hallmarks. At the end, genetic and epigenetic alterations that are encountered in cancer cells may culminate in chromatin changes that may, by altering the quantity and quality of gene expression, promote cancer development.
During the last decade a vast number of studies has uncovered epigenetic abnormalities that are associated with the (anomalous) packaging and remodeling of chromatin in cancer genomes. In this review I will focus on recently published work dealing with alterations in the primary structure of chromatin resulting from imprecise arrangements of nucleosomes along DNA, and its functional implications for cancer development.
The primary chromatin structure is regulated by a variety of epigenetic mechanisms that may be deregulated through gene mutations and/or gene expression alterations. In recent years, it has become evident that changes in chromatin structure may coincide with the occurrence of cancer hallmarks. The functional interrelationships between such epigenetic alterations and cancer development are just becoming manifest and, therefore, the oncology community should continue to explore the molecular mechanisms governing the primary chromatin structure, both in normal and in cancer cells, in order to improve future approaches for cancer detection, prevention and therapy, as also for circumventing drug resistance.
The objective of this study was to investigate the relationship between diversity of 18F-fluorodeoxyglucose (18F-FDG) uptake of primary tumor in positron emission tomography (PET) and various clinicopathologic factors in breast cancer of same pathologic T1, T2 stage.
A total of 258 patients with invasive ductal breast cancer were enrolled in this study. All patients underwent 18F-FDG PET-CT before surgery. Patients were divided into two groups according to tumor size based on the pathologic T stage, and maximum standardized uptake value (SUVmax) of 2.5, respectively.
On the univariate analysis, estrogen receptor (ER), tumor size, lymphovascular invasion, p53, pathologic N status (pN) and Nottingham tumor grade (NG) were associated with high SUVmax in T1 and T2 breast cancer. On the multivariate logistic regression, tumor size and NG remained significant variables dividing high and low SUVmax. In the T1 group, ER, p53 and NG were significantly associated with high SUVmax on the univariate analysis. In this group, p53 and NG remained significant variables for dividing high and low SUVmax on the multivariate logistic regression. In the T2 group, only NG was associated with high SUVmax on the univariate analysis.
NG showed an association with 18F-FDG uptake in both T1 and T2 breast cancer independently; however, p53 in T1 breast cancer.
Socioeconomically disadvantaged cancer survivors are less likely to have adequate follow-up care. In this study, we examined whether socioeconomically disadvantaged survivors are at risk for not having follow-up care discussions with providers, a critical determinant of access to follow-up care and desirable health outcomes. Using the 2011 Medical Expenditure Panel Survey and Experiences with Cancer Survivorship Supplement, we used a binary logit model with sample weights to examine associations between 1320 cancer survivors' socioeconomic status (SES) and reports of follow-up care discussions with providers, controlling for clinical and demographic characteristics. The multivariable model indicated survivors with incomes ≤200 % Federal Poverty Level (FPL) had a lower probability of reporting a follow-up care discussion than survivors with incomes >400 % FPL (p < 0.05). Survivors with less than high school education had a lower probability of reporting a discussion than survivors who had a college education or greater (p < 0.05). However, even after controlling for income, survivors with financial hardship had a greater probability of reporting a discussion than survivors with no financial hardship (p < 0.05). Insurance status was not a significant predictor of reporting a discussion (p > 0.05). Socioeconomically disadvantaged cancer survivors are at risk for not having follow-up care discussions with providers, particularly those who report lower income and education. The development of educational interventions targeting provider communication with socioeconomically disadvantaged cancer survivors, and survivors' understanding of the benefits of follow-up care discussions, may promote access to these services. Future research assessing mechanisms underlying relationships between survivors' SES indicators and reports of follow-up care discussions with providers is also warranted.
Gemcitabine is an antimetabolite ranking among the most prescribed anticancer drugs worldwide. This nucleoside analog exerts its antiproliferative action after tumoral conversion into active triphosphorylated nucleotides interfering with DNA synthesis and targeting ribonucleotide reductase. Gemcitabine is a mainstay for treating pancreatic and lung cancers, alone or in combination with several cytotoxic drugs (nab-paclitaxel, cisplatin and oxaliplatin), and is an option in a variety of other solid or hematological cancers. Several determinants of response have been identified with gemcitabine, i.e., membrane transporters, activating and inactivating enzymes at the tumor level, or Hedgehog signaling pathway. More recent studies have investigated how germinal genetic polymorphisms affecting cytidine deaminase, the enzyme responsible for the liver disposition of gemcitabine, could act as well as a marker for clinical outcome (i.e., toxicity, efficacy) at the bedside. Besides, constant efforts have been made to develop alternative chemical derivatives or encapsulated forms of gemcitabine, as an attempt to improve its metabolism and pharmacokinetics profile. Overall, gemcitabine is a drug paradigmatic for constant searches of the scientific community to improve its administration through the development of personalized medicine in oncology.
Triple-negative breast cancer (TNBC) is characterized by a strong heterogeneity with regard to tumour biology as well as in the clinical course of the disease. This study aimed to analyse whether there are any prognostic factors enabling prediction of the clinical outcome in patients with TNBC. Particularly, the impact of Her2-neu score 0 versus Her2-neu score 1 and 2 on survival was investigated.
We retrospectively studied a cohort of 1013 patients with TNBC, diagnosed at seven hospitals between May 2002 and February 2015. We studied the impact of Her2-neu scores (0 vs. 1 or 2 with negative FISH) on disease-free survival (DFS) and overall survival (OS).
1013 patients were included in this study. 447 (44.13 %) of them had a T2–4 tumour. A total of 314 (31.00 %) were nodal-positive and 714 (70.48 %) had high-grade tumours. The Her2-neu score of all participating patients was determined. 588 (58.05 %) of them had a Her2-neu score 0, and 425 (41.95 %) had a score of 1 or 2. This study shows that TNBC patients with a Her2-neu score 0 had a significantly poorer outcome regarding DFS (p = 0.0001) and OS (p = 0.0051) compared to a score of 1 or 2. In contrast, grading did not seem to have any prognostic value for women with TNBC.
The Her2-neu score 0 might be considered as an innovative prognostic factor for patients with TNBC indicating poor clinical outcome.
The multifunctional trans-activator Tat is an essential regulatory protein for HIV-1 replication and is characterized by high sequence diversity. Numerous experimental studies have examined Tat in HIV-1 subtype B, but research on subtype C Tat is lacking, despite the high prevalence of infections caused by subtype C worldwide. We hypothesized that amino acid differences contribute to functional differences among Tat proteins. In the present study, we found that subtype B NL4-3 Tat and subtype C isolate HIV1084i Tat exhibited differences in stability by overexpressing the fusion protein Tat-Flag. In addition, 1084i Tat can activate LTR and NF-κB more efficiently than NL4-3 Tat. In analyses of the activities of the truncated forms of Tat, we found that the carboxyl-terminal region of Tat regulates its stability and transactivity. According to our results, we speculated that the differences in stability between B-Tat and C-Tat result in differences in transactivation ability.
Despite advances in the roles of long non-coding RNA (lncRNA) tumor suppressor candidate 7 (TUSC7) in cancer biology, which has been identified as a tumor suppressor by regulating cell proliferation, apoptosis, migration, invasion, cell cycle, and tumor growth, the function of TUSC7 in hepatocellular carcinoma (HCC) remains unknown. In this study, we observed that the expression of TUSC7 was immensely decreased in HCC. Clinically, the lower expression of TUSC7 predicted poorer survival and may be an independent risk factor for HCC patients. Moreover, TUSC7 inhibited cell metastasis, invasion, and epithelial-to-mesenchymal transformation (EMT) through competitively binding miR-10a. Furthermore, we found that TUSC7 could decrease the expression of Eph tyrosine kinase receptor A4 (EphA4), a downstream target of miR-10a as well as an EMT suppressor, through TUSC7-miR-10a-EphA4 axis. Taken together, we demonstrate that TUSC7 suppresses EMT through the TUSC7-miR-10a-EphA4 axis, which may be a potential target for therapeutic intervention in HCC.
The identification of new, effective drugs is a pressing need in colorectal cancer (CRC) rescue therapy. Data examining O 6-methylguanine-DNA-methyl transferase (MGMT) and its predictive role in temozolomide (TMZ) treatment in CRC are scarce. In this study, the effect of MGMT status on the cytotoxic sensitivity caused by TMZ was analyzed using cytology proliferation assays in colon cancer cell lines. MGMT protein expression was assessed with immunohistochemistry in 385 patients. Concordance between primary and metastatic sites and the role of MGMT status on survival were statistically analyzed. TMZ sensitivity was significantly affected by the level of MGMT protein expression. Of 385 cases, 13 (3.4 %) demonstrated loss of MGMT expression. However, low MGMT expression levels were significantly more common in signet ring cell carcinomas (p = 0.011). In 111 of 385 cases, the overall concordance of MGMT status between primary tumor and metastatic sites was 66.67 % (κ = 0.271, p < 0.001). The median progression-free survival was significantly different between groups with low or high MGMT expression for the irinotecan-based regimen (p = 0.025), but MGMT protein expression was not observed to be a prognostic factor. In conclusion, MGMT was an important in vitro predictor of TMZ activity in CRC. The rate of MGMT protein loss was low in metastatic CRC patients from China, and MGMT might be more commonly lost in signet ring cell carcinoma. The MGMT status at primary and metastatic sites was consistent, but the power of concordance was poor. Further study into these topics is warranted.
Despite advances in the roles of long non-coding RNA (lncRNA) tumor suppressor candidate 7 (TUSC7) in cancer biology, which has been identified as a tumor suppressor by regulating cell proliferation, apoptosis, migration, invasion, cell cycle, and tumor growth, the function of TUSC7 in hepatocellular carcinoma (HCC) remains unknown. In this study, we observed that the expression of TUSC7 was immensely decreased in HCC. Clinically, the lower expression of TUSC7 predicted poorer survival and may be an independent risk factor for HCC patients. Moreover, TUSC7 inhibited cell metastasis, invasion, and epithelial-to-mesenchymal transformation (EMT) through competitively binding miR-10a. Furthermore, we found that TUSC7 could decrease the expression of Eph tyrosine kinase receptor A4 (EphA4), a downstream target of miR-10a as well as an EMT suppressor, through TUSC7-miR-10a-EphA4 axis. Taken together, we demonstrate that TUSC7 suppresses EMT through the TUSC7-miR-10a-EphA4 axis, which may be a potential target for therapeutic intervention in HCC.
The identification of new, effective drugs is a pressing need in colorectal cancer (CRC) rescue therapy. Data examining O 6-methylguanine-DNA-methyl transferase (MGMT) and its predictive role in temozolomide (TMZ) treatment in CRC are scarce. In this study, the effect of MGMT status on the cytotoxic sensitivity caused by TMZ was analyzed using cytology proliferation assays in colon cancer cell lines. MGMT protein expression was assessed with immunohistochemistry in 385 patients. Concordance between primary and metastatic sites and the role of MGMT status on survival were statistically analyzed. TMZ sensitivity was significantly affected by the level of MGMT protein expression. Of 385 cases, 13 (3.4 %) demonstrated loss of MGMT expression. However, low MGMT expression levels were significantly more common in signet ring cell carcinomas (p = 0.011). In 111 of 385 cases, the overall concordance of MGMT status between primary tumor and metastatic sites was 66.67 % (κ = 0.271, p < 0.001). The median progression-free survival was significantly different between groups with low or high MGMT expression for the irinotecan-based regimen (p = 0.025), but MGMT protein expression was not observed to be a prognostic factor. In conclusion, MGMT was an important in vitro predictor of TMZ activity in CRC. The rate of MGMT protein loss was low in metastatic CRC patients from China, and MGMT might be more commonly lost in signet ring cell carcinoma. The MGMT status at primary and metastatic sites was consistent, but the power of concordance was poor. Further study into these topics is warranted.
Single nucleotide polymorphisms (SNPs) in and near ABCA7, BIN1, CASS4, CD2AP, CD33, CELF1, CLU, complement receptor 1 (CR1), EPHA1, EXOC3L2, FERMT2, HLA cluster (DRB5-DQA), INPP5D, MEF2C, MS4A cluster (MS4A3-MS4A6E), NME8, PICALM, PTK2B, SLC24A4, SORL1, and ZCWPW1 have been associated with Alzheimer's disease (AD) in large meta-analyses. We aimed to determine whether established AD-associated genes are associated with longitudinal cognitive decline by examining aggregate variation across these gene regions. In two single-sex cohorts of older, community-dwelling adults, we examined the association between SNPs in previously implicated gene regions and cognitive decline (age-adjusted person-specific cognitive slopes) using a Sequence Kernel Association Test (SKAT). In regions which showed aggregate significance, we examined the univariate association between individual SNPs in the region and cognitive decline. Only two of the original AD-associated SNPs were significantly associated with cognitive decline in our cohorts. We identified significant aggregate-level associations between cognitive decline and the gene regions BIN1, CD33, CELF1, CR1, HLA cluster, and MEF2C in the all-female cohort and significant associations with ABCA7, HLA cluster, MS4A6E, PICALM, PTK2B, SLC24A4, and SORL1 in the all-male cohort. We also identified a block of eight correlated SNPs in CD33 and several blocks of correlated SNPs in CELF1 that were significantly associated with cognitive decline in univariate analysis in the all-female cohort.
Phosphatidylinositol-4,5-bisphosphate 3-kinase catalytic subunit alpha (PIK3CA) mutations and amplification are detected in 1% of primary lung adenocarcinomas (ADCs) and in 38% of primary lung squamous cell carcinomas. Alterations of PIK3CA in metastatic non–small cell lung carcinoma (NSCLC), however, are still not fully understood. This study investigated PIK3CA alterations in metastatic ADCs and correlated the findings with those for other commonly tested molecular abnormalities via fine-needle aspiration (FNA) and small-core biopsy materials.
This study identified 115 FNA cases of metastatic lung ADC with standard lung cancer panel analysis by targeted next-generation sequencing and fluorescence in situ hybridization at the Johns Hopkins Medical Institute over a 12-month period. The panel included mutational analysis of PIK3CA, AKT, BRAF, EGFR, ERBB2, KRAS, and NRAS genes and tests of rearrangements for ALK and ROS1 genes.
A PIK3CA mutation was detected in 7 of 115 cases of metastatic ADC (6.1%). The majority of the mutations were located in exon 9 or exon 20; however, a mutation in exon 1 was seen in 1 case. Furthermore, p.V344G in exon 4 was detected in 2 cases. Among cases with PIK3CA mutations, 4 had coexisting EGFR mutations, whereas 2 had a coexisting BRAF or KRAS mutation.
Several common mutations as well as a novel mutation in the PIK3CA gene were observed in metastatic NSCLC (particularly ADC). The unique role, however, of PIK3CA mutations in metastatic NSCLC and the clinical implications need to be further investigated. Cancer Cytopathol 2016. © 2016 American Cancer Society.
Preoperative chemoradiotherapy (CRT) has become a widely used treatment for improving local control of disease and increasing survival rates of rectal cancer patients. We aimed to identify a set of genes that can be used to predict responses to CRT in patients with rectal cancer.
Gene expression profiles of pre-therapeutic biopsy specimens obtained from 77 rectal cancer patients were analyzed using DNA microarrays. The response to CRT was determined using the Dworak tumor regression grade: grade 1 (minimal, MI), grade 2 (moderate, MO), grade 3 (near total, NT), or grade 4 (total, TO).
Top ranked genes for three different feature scores such as a p-value (pval), a rank product (rank), and a normalized product (norm) were selected to distinguish pre-defined groups such as complete responders (TO) from the MI, MO, and NT groups. Among five different classification algorithms, supporting vector machine (SVM) with the top 65 norm features performed at the highest accuracy for predicting MI using a 5-fold cross validation strategy. On the other hand, 98 pval features were selected for predicting TO by elastic net (EN). Finally we combined TO- and MI-finder models to build a three-class classification model and validated it using an independent dataset of rectal cancer mRNA expression.
We identified MI- and TO-finders for predicting preoperative CRT responses, and validated these data using an independent public dataset. This stepwise prediction model requires further evaluation in clinical studies in order to develop personalized preoperative CRT in patients with rectal cancer.
During a fraction of external beam radiotherapy for prostate cancer, a mismatch between target volume and dose coverage may accumulate over time due to intra-fraction motion. One way to remove the residual error is to perform a couch shift in opposite direction. In principle, such couch shifts could cause secondary displacements of the patient and prostate. Hence it is interesting to investigate if couch shifts might amplify intra-fraction motion.
Intra-fraction motion of the prostate and patient couch position were simultaneously recorded during 359 fractions in 15 patients. During this time, a total of 22 couch shifts of up to 31.5 mm along different axes were recorded. Prostate position and couch position were plotted before, during and after each couch shift. There was no visible impact of couch shifts on prostate motion. The standard deviation of prostate position was calculated before, during and after each couch shift. The standard deviation did not significantly increase during couch shifts (by 3 % on average, p = 0.88) and even slightly decreased after a couch shift (by 37 % on average; p = 0.02).
Shifts of the patient couch did not adversely affect the motion of the prostate relative to the patient couch. Hence, shifts of the patient couch may be a viable way to correct the position of the prostate relative to the dose distribution.
To evaluate the current status of prospective interventional clinical trials that includes brachytherapy (BT) procedures.
The records of 175,538 (100 %) clinical trials registered at ClinicalTrials.gov were downloaded on September 2014 and a database was established. Trials using BT as an intervention were identified for further analyses. The selected trials were manually categorized according to indication(s), BT source, applied dose rate, primary sponsor type, location, protocol initiator and funding source. We analyzed trials across 8 available trial protocol elements registered within the database.
In total 245 clinical trials were identified, 147 with BT as primary investigated treatment modality and 98 that included BT as an optional treatment component or as part of the standard treatment. Academic centers were the most frequent protocol initiators in trials where BT was the primary investigational treatment modality (p < 0.01). High dose rate (HDR) BT was the most frequently investigated type of BT dose rate (46.3 %) followed by low dose rate (LDR) (42.0 %). Prostate was the most frequently investigated tumor entity in trials with BT as the primary treatment modality (40.1 %) followed by breast cancer (17.0 %). BT was rarely the primary investigated treatment modality for cervical cancer (6.8 %).
Most clinical trials using BT are predominantly in early phases, investigator-initiated and with low accrual numbers. Current investigational activities that include BT mainly focus on prostate and breast cancers. Important questions concerning the optimal usage of BT will not be answered in the near future.
Publication date: May 2016
Source:European Journal of Cancer, Volume 59
Author(s): Jeanny Kwon, Byoung Hyuck Kim, Hee-Won Jung, Nikola Besic, Iwao Sugitani, Hong-Gyun Wu
BackgroundOptimal postoperative managements for anaplastic thyroid carcinoma (ATC) have not yet been sufficiently clarified. We conducted a systematic review and meta-analysis focussing on the impact of postoperative radiotherapy (PORT) in the patients with resected ATC.Materials and methodsFollowing the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines, a comprehensive search was performed in the several databases. We included the studies that reported survival outcome in the patients with or without PORT following any type of surgical resection except biopsy only. Hazard ratio (HR) was extracted, and the random-effects model was used for the pooled analysis.ResultsSeventeen retrospective studies including 1147 analysable patients met all inclusion criteria. The overall research quality was relatively low with considerable methodological limitations. The pooled results showed that PORT significantly reduced the risk of death in all the patients with resected ATC compared with those with surgery alone (HR, 0.556; 95% confidence interval, 0.419–0.737; p < 0.001). Exploratory analyses demonstrated that patients with stage IVA (HR, 0.364; p = 0.012) and IVB (HR, 0.460; p = 0.059) may also have survival benefit from PORT, whereas stage IVC may not. No evidence of publication bias was found (p = 0.352).ConclusionsThis study is the first meta-analysis assessing PORT in patients with ATC and provides convincing evidence that adequate resection followed by PORT may offer the prolonged survival. However, without evidence based on prospective randomised trials, it is still not known which subset of patients can really benefit from PORT.
Publication date: May 2016
Source:European Journal of Cancer, Volume 59
Author(s): Nina Munk Lyhne, Jørgen Johansen, Claus Andrup Kristensen, Elo Andersen, Hanne Primdahl, Lisbeth Juhler Andersen, Susanne Oksbjerg, Jens Overgaard
AimTo describe the incidence, disease-specific mortality (DSM), and overall survival (OS) of patients with glottic squamous cell carcinomas (SCC) in Denmark from 1971–2011 in a national population-based cohort of consecutive patients.Materials and methodsAll patients diagnosed with glottic SCC stage I–IV between 1971 and 2011 in Denmark were included. Patients were identified from the Danish Head and Neck Cancer database, which has a coverage of approximately 100% of registered glottic cancer in Denmark. Information on vital status and cause of death were updated using patient charts and national registries.ResultsIn total 5132 patients with glottic SCC were included. The yearly number of new cases increased from 107 in the 1970s to 139 in the 2000s. Overall, the incidence increased from 1.9 to 2.6 per 100,000, with a more prominent increase in men (3.5 to 4.7) compared with women (0.4 to 0.6). The 5-year DSM was 16% (15–17%) and the 5-year OS was 63% (61–64). The hazard rate of DSM adjusted for patient characteristics, tumour characteristics and waiting-time was significantly lower in the 2000s (p < 0.01), and the hazard rate of OS was significantly higher (p < 0.01) compared to the earlier decades. Longer waiting-time for treatment (>25 d) significantly increased DSM and reduced OS.ConclusionDespite being highly avoidable with smoking cessation, the incidence of glottic SCC increased in Denmark from 1971–2011. The adjusted hazard rate of DSM and overall death after glottic SCC was significantly lower in the 2000s compared to previous decades. Waiting-time for treatment significantly influenced DSM and OS.
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10.1080/15384047.2016.1139229<br/>Chun Chen
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Studies have demonstrated a relationship between clinical outcomes after curative resection for colorectal cancer (CRC) and gene mutations of the EGFR pathway, however no studies have examined metastatic CRC (mCRC) patients with metastasectomy. The aim of this study was to evaluate the relationship between gene mutations of EGFR pathway and clinical outcomes after metastasectomy in mCRC patients. A total of 1053 patients histopathologically confirmed CRC received a genotyping test for the EGFR pathway from February 2012 to October 2013. Detailed information was obtained through review of medical records. Gene mutations of EGFR pathway were analyzed by Luminex assay. Overall survival (OS) and recurrence free survival (RFS) were estimated by the Kaplan-Meier method and the log-rank test was used to compare the survival outcomes by gene mutation status. A total of 132 patients received metastasectomy. The frequencies of KRAS exon 2, KRAS exon 3.4, NRAS, BRAF, and PIK3CA mutations were 38.6% (51/132), 3.6% (5/132), 5.1% (7/132), 5.1% (7/132), and 8.7% (12/132), respectively. With a median follow up of 84.1 months (57.2–NA) for a survivor, the 4-year OS rate was 65.6% for mCRC with RAS mutation, and 81.3% for mCRC with wild-type RAS (p < 0.05). We observed a statistically significant correlation for only the RAS mutation and OS. In multivariate analysis, RAS mutation and liver metastasis were independent factors for shorter OS. There were no significant differences between gene mutations of EGFR pathway and RFS.
RAS mutation in mCRC metastasectomy patients was associated with shorter overall survival. This article is protected by copyright. All rights reserved.
The general aim of this systematic review is to mitigate breast cancer (BC) overdiagnosis and overtreatment. The specific aim is to summarize available data on the occurrence and features of indolent invasive or in situ (DCIS) BC, and precisely survival of untreated cases, prevalence of occult cancers found in autopsies, frequency of regressive BC.
PubMed, Embase and Cochrane Library were systematically searched up to 3/31/2014. Eligibility criteria were: cohort studies, case-control studies, uncontrolled case series assessing survival in women with a diagnosis of BC who did not receive treatment compared to treated women; case series of autopsies estimating the prevalence of undiagnosed BC; cohort studies, case-control studies, uncontrolled case series, case reports assessing the occurrence of spontaneous regression of BC in women with a confirmed histology diagnosis.
Untreated BC: 8 cohort studies and 12 case series (3593 BC) were included. In 3 controlled cohort studies (diagnoses 1978-2006), the 5-years overall survival was 19%-43%.
Occult BC: 8 case series (2279 autopsies) were included. The prevalence of invasive BC undiagnosed during lifetime range was 0-1.5%, while for DCIS the range was 0.2%-14.7%.
Spontaneous regression: 2 cohort studies, 3 case reports, 1 case series included. In the cohort studies the relative risk of regression for screen detected compared to non-screened BC was estimated as 1.2 and 1.1.
It seems plausible that around 10% of invasive BC are not symptomatic during life, and that one fith of BC patients if untreated would be alive after 5 years. Around 1 of 10 screen-detected BC may regress according two studies. This article is protected by copyright. All rights reserved.
In this prospective cohort study, we compared the performance of human papillomavirus (HPV) mRNA and DNA testing of women with atypical squamous cells of undetermined significance (ASC-US) during cervical cancer screening. Using a nationwide Danish pathology register, we identified women aged 30–65 years with ASC-US during 2005–2011 who were tested for HPV16/18/31/33/45 mRNA using PreTect HPV-Proofer (n=3,226) or for high-risk HPV (hrHPV) DNA using Hybrid Capture 2 (HC2) (n=9,405) or Linear Array HPV-Genotyping test (LA) (n=1,533). Women with ≥1 subsequent examination in the register (n=13,729) were followed for up to 9.5 years for high-grade cervical intraepithelial neoplasia (CIN) or cancer. After 3 years' follow-up, mRNA testing had higher specificity for CIN3 or worse (CIN3+) than HC2 testing (88.1% [95% confidence interval (CI): 86.8%–89.6%] versus 59.3% [95% CI: 58.1%–60.4%]) and higher positive predictive value (PPV) (38.2% [95% confidence interval [CI]: 33.8%–43.1%] versus 19.5% [95% CI: 17.8%–20.9%]). However, the sensitivity of mRNA testing was lower than that of HC2 testing (66.7% [95% CI: 59.3%–74.5%] versus 97.0% [95% CI: 95.5%–98.4%]), and women testing mRNA negative had higher 3-year risk for CIN3+ than those testing HC2 negative (3.2% [95% CI: 2.2%–4.2%] versus 0.5% [95% CI: 0.3%–0.7%]). Patterns were similar after 18 months and 5 years' follow-up; for CIN2+ and cancer as outcomes; across all age groups; and when comparing mRNA testing to hrHPV DNA testing using LA. In conclusion, the HPV16/18/31/33/45 mRNA test is not optimal for ASC-US triage due to its low sensitivity and the substantial risk for precancer following a negative test. This article is protected by copyright. All rights reserved.
The incidence of cervical cancer in Malawi is the highest in the world and projected to increase in the absence of interventions. Although Government policy supports screening using visual inspection with acetic acid (VIA), screening provision is limited due to lack of infrastructure, trained personnel, cost and availability of gas for cryotherapy. Recently, thermo-coagulation has been acknowledged as a safe and acceptable procedure suitable for low–resource settings. We introduced thermo-coagulation for treatment of VIA positive lesions as an alternative to cryotherapy within a cervical screening service based on VIA, coupled with appropriate, sustainable pathways of care for women with high grade lesions and cancers. Detailed planning was undertaken for VIA clinics, approvals were obtained from the Ministry of Health, and Regional and Village Chiefs. Educational resources were developed. Thermo-coagulators were introduced into hospital and health centre settings, with theoretical and practical training in safe use and maintenance of equipment. 7088 previously unscreened women attended VIA clinics between October 2013 and March 2015. Screening clinics were held daily in the hospital and weekly in the health centres. Overall VIA positivity was 6.1%. Almost 90% received same day treatment in the hospital setting, and 3-6 month cure rates of over 90% are observed. Thermo-coagulation proved feasible and acceptable in this setting. Effective implementation requires comprehensive training and provider support, ongoing competency assessment, quality assurance and improvement audit. Thermo-coagulation offers an effective alternative to cryotherapy and encouraged VIA screening of many more women. This article is protected by copyright. All rights reserved.
Indocyanine green (ICG) is a fluorescent agent approved for clinical applications by the Food and Drug Administration and European Medicines Agency. This study examined the mechanism of tumor imaging using intravenously administered ICG. The in vivo kinetics of intravenously administered ICG were determined in tumor xenografts using microscopic approaches that enabled both spatio-temporal and high-magnification analyses. The mechanism of ICG-based tumor imaging was examined at the cellular level in six phenotypically different human colon cancer cell lines exhibiting different grades of epithelioid organization. ICG fluorescence imaging detected xenograft tumors, even those < 1 mm in size, based on their preferential cellular uptake and retention of the dye following its rapid tissue-non-specific delivery, in contrast to its rapid clearance by normal tissue. Live-cell imaging revealed that cellular ICG uptake is temperature-dependent and occurs after ICG binding to the cellular membrane, a pattern suggesting endocytic uptake as the mechanism. Cellular ICG uptake correlated inversely with the formation of tight junctions. Intracellular ICG was entrapped in the membrane traffic system, resulting in its slow turnover and prolonged retention by tumor cells. Our results suggest that tumor-specific imaging by ICG involves non-specific delivery of the dye to tissues followed by preferential tumor cellular uptake and retention. The tumor cell-preference of ICG is driven by passive tumor-cell-targeting, the inherent ability of ICG to bind to cell membranes, and the high endocytic activity of tumor cells in association with the disruption of their tight junctions. This article is protected by copyright. All rights reserved.
Socioeconomically disadvantaged cancer survivors are less likely to have adequate follow-up care. In this study, we examined whether socioeconomically disadvantaged survivors are at risk for not having follow-up care discussions with providers, a critical determinant of access to follow-up care and desirable health outcomes. Using the 2011 Medical Expenditure Panel Survey and Experiences with Cancer Survivorship Supplement, we used a binary logit model with sample weights to examine associations between 1320 cancer survivors' socioeconomic status (SES) and reports of follow-up care discussions with providers, controlling for clinical and demographic characteristics. The multivariable model indicated survivors with incomes ≤200 % Federal Poverty Level (FPL) had a lower probability of reporting a follow-up care discussion than survivors with incomes >400 % FPL (p < 0.05). Survivors with less than high school education had a lower probability of reporting a discussion than survivors who had a college education or greater (p < 0.05). However, even after controlling for income, survivors with financial hardship had a greater probability of reporting a discussion than survivors with no financial hardship (p < 0.05). Insurance status was not a significant predictor of reporting a discussion (p > 0.05). Socioeconomically disadvantaged cancer survivors are at risk for not having follow-up care discussions with providers, particularly those who report lower income and education. The development of educational interventions targeting provider communication with socioeconomically disadvantaged cancer survivors, and survivors' understanding of the benefits of follow-up care discussions, may promote access to these services. Future research assessing mechanisms underlying relationships between survivors' SES indicators and reports of follow-up care discussions with providers is also warranted.
Human TNF-related apoptotic-inducing ligand (TRAIL) has been used successfully for targeted therapy of almost all cancers. Leukemia is the most common type of cancer in children, and despite the advances in therapeutic strategies, the survival rate in leukemia cases is very low. Overexpression of interleukin 2 receptor (IL2R) in hematological malignancies has been utilized to target leukemia. Here, we report an immunotoxin fusion construct of human IL2α and TRAIL for targeting leukemia.
Our aim was to develop an immunotoxin to target CD25+ leukemic cells.
Recombinant fusion construct comprising human IL2α and TRAIL114–281 was cloned, expressed and purified. Surface expression levels of IL2α and TRAIL receptors (CD25 and DR5 respectively) were compared in four leukemic cell lines and patient-derived peripheral blood mononuclear cells (PBMCs). Efficacy of immunotoxins was tested in cell lines and PBMCs by cell viability assay and compared with receptor expression.
The efficacy of IL2-TRAIL was higher than TRAIL alone and showed an IC50 ranging from 0.2-0.8 μM in cell lines. IL2-TRAIL induced cell death in PBMCs from leukemic patients in vitro, which was proportional to CD25 expression. Out of 34 leukemic samples, 24 samples were susceptible to immunotoxin-mediated cytotoxicity. The efficacy of IL2-TRAIL (87.5 %) was significantly high compared to TRAIL protein (29 %) in both myeloid and lymphoid leukemic patient samples. IL2-TRAIL fusion protein was highly specific for CD25+ leukemia and showed 100 % efficacy in lymphocytic leukemia [acute lymphoblastic leukemia and chronic lymphocytic leukemia] that overexpressed CD25.
The skin is the largest organ of the body and is composed of epidermis (the outermost layer of cells consisting mainly of keratinized, stratified, squamous epithelium) and dermis (a layer of connective tissue composed of cells and fibrils such as collagen bundles). The aim of this study was to assess the effect of excess methionine on the histomorphology and histomorphometry of collagen bundles in these layers. Eighty, 9–10-week old, male rats were randomly allocated into eight equal groups. Each group received one of the following treatments: L-methionine (50, 100 or 200 mg/kg B.W.), vitamin C (50 mg/kg B.W), combination of L-methionine (all 3 concentrations) and vitamin C (Met + Vit C), or normal saline as control (CT) for 20 consecutive days. After terminating the animals on day 21, skin samples were taken, and the epidermis, papillary, and reticular layers were evaluated histologically. The data obtained revealed that methionine does not increase collagen bundle thickness unless combined with vitamin C. We suggest that lack of crosslinking occurs when using methionine alone. The greatest increase in both epidermis and dermis occurred in the Met 100 + Vit C group. There was no significant difference between Vit C and control groups. Histopathology did not show any congestion or inflammatory cell infiltration in any treatment groups compared to the controls.
Mouse Double Minute 2 Homolog (MDM2) is a key negative regulator of the master tumor suppressor p53. MDM2 regulates p53 on multiple levels, including acting as an ubiquitin ligase for the protein, thereby promoting its degradation by the proteasome. MDM2 is oncogenic and is frequently found to be over-expressed in human tumors, suggesting its dysregulation plays an important role in human cancers. We have recently found that the Ras effector and RASSF (Ras Association Domain Family) family member RASSF5/NORE1A enhances the levels of nuclear p53. We have also found that NORE1A (Novel Ras Effector 1A) binds the substrate recognition component of the SCF-ubiquitin ligase complex β-TrCP. Here, we now show that NORE1A regulates MDM2 protein levels by targeting it for ubiquitination by SCF-β-TrCP. We also show the suppression of NORE1A protein levels enhances MDM2 protein expression. Finally, we show that MDM2 can suppress the potent senescence phenotype induced by NORE1A over-expression. Thus, we identify a mechanism by which Ras/NORE1A can modulate p53 protein levels. As MDM2 has several important targets in addition to p53, this finding has broad implications for cancer biology in tumor cells that have lost expression of NORE1A due to promoter methylation.
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The modified Glasgow Prognostic Score (mGPS), which combines indices of decreased plasma albumin and elevated CRP, has reported independent prognostic significance in colorectal cancer, but its value in upper gastrointestinal cancer is unclear. The aim of this study was to assess the prognostic significance of mGPS in patients with operable esophageal malignancy.
Patients undergoing resection with curative intent between January 2008 and June 2013 were included. The mGPS was scored as 0, 1, or 2 based on CRP(>10 mg/L) and albumin(<35g/L). The mGPS score (0 vs. 1/2 combined) was correlated with patient and tumor characteristics, and operative and oncologic outcomes.
Two hundred and twenty-three patients were included. Median (range) follow-up was 21(12–70) months. The mGPS was 0 in 174 patients(78%). mGPS was significantly associated with positive nodal status(P = 0.008) and stage ≥III (P = 0.017). There was a significant improvement in overall survival in patients with mGPS = 0 (47.8 vs. 37.5 months, P = 0.014) but in multivariate analysis, only TNM-stage and nodal status were found to be independent prognostic indicators.
mGPS is associated with advanced stage but has no independent prognostic significance and does not impact on operative outcomes. Consequently, this data does not support its routine application in patient selection or prognostication. J. Surg. Oncol. © 2016 Wiley Periodicals, Inc.
QUESTION ASKED:
This study aimed to address the question of which modality for adjuvant breast radiotherapy costs more: whole breast radiotherapy (WBRT) or accelerated partial breast irradiation (APBI) with balloon-based brachytherapy. Using time-driven activity-based costing (TDABC), we were able to evaluate the fundamental cost based on resources consumed rather than charges billed to the payer.
SUMMARY ANSWER:Our study found APBI to cost 30% more than WBRT. This difference is primarily driven by discrepancies in the cost of both materials and personnel, and in particular, the degree of involvement by the attending physician.
METHODS:For WBRT (25 fractions with 5-fraction boost) and APBI (10 fractions twice daily), process maps were created outlining each activity from consultation to post-treatment follow up (Figure 1). Through staff interviews, time estimates were obtained for each activity. The capacity cost rate (CCR), defined as cost per minute, was calculated for personnel, equipment, and physical space. Total cost was calculated by multiplying the time required of each resource by its CCR. This was then summed and combined with the cost of consumable materials.
MAIN RESULTS:The total cost for WBRT was $5,333 and comprised 56% personnel costs and 44% space/equipment costs. For APBI, the total cost was $6,941 (30% higher than WBRT) and comprised 51% personnel costs, 6% space/equipment costs, and 43% consumable materials costs. The attending physician had the highest CCR of all personnel ($4.28/min), and APBI required 24% more attending time than WBRT. The most expensive activity for APBI was balloon placement and for WBRT it was CT simulation.
BIAS, CONFOUNDING FACTOR(S), DRAWBACKS:This study used data based on our local costs and institutional procedures. Generalizability outside of our department is therefore limited. In addition, our analysis accounted for departmental overhead, but did not measure hospital-wide overhead, such as information technology, marketing, lobby space, and hospital administration. Lastly, our time estimates came from interviews as opposed to direct measurements from patient encounters. This was done to prevent potential outliers from impacting our findings.
REAL-LIFE IMPLICATIONS:The United States spends far more on health care than any other nation, and one of the key driving factors in this is a reimbursement system that rewards volume. As a departure from this, Michael Porter has advocated for a system based on value, defined as health outcomes achieved per dollar spent. To incentivize value, reimbursement must transition to bundled payments for the comprehensive management of a medical condition. In addition, transparent outcome reporting would hold physicians accountable for the quality of care. To formulate bundled payments, it is essential to have a thorough understanding of cost. TDABC is a bottom-up costing method with granular calculations based on personnel, space, equipment, and material resources consumed. This is in contrast to other costing methods which are primarily founded on charges billed to the payer. Ours is the first study to apply TDABC to breast radiotherapy, and has provided insight regarding what drives the higher cost for APBI compared with WBRT. More importantly, we hope it will lead to further research aimed at lowering health care costs and defining bundled payments.
FIG 1.
Process map for breast brachytherapy initial consultation. Each box denotes one activity, with personnel coded by color and the time (minutes) required for each activity denoted in the bottom-right corner.
QUESTION ASKED:
How will the increasing use of hypofractionation (use of a fewer number of fractions) affect reimbursement and staffing in a hospital-based radiation oncology department?
SUMMARY ANSWER:From a 40% use rate of hypofractionation, a department could anticipate an annual reduction in technical revenue of $540,661 and a reduction in workflow of approximately five patients or 1 to 1.5 operating hours per day.
METHODS:We modeled the effects on reimbursement on a typical average-sized hospital-based radiation oncology department of moving to hypofractionation for the most common cancers that make up the bulk of a typical hospital-based practice using 2015 Centers for Medicare and Medicaid Services reimbursement rates and relative value unit values.
RESULTS:A radiotherapy department treating 40% with hypofractionation would experience an approximate $540,663 decrease in global revenue with a per-case marginal reduction of $9,498, $4,297, $9,040, and $1,777 for lung, breast, and prostate cancers and palliative care, respectively. The reduction in relative value units would be 2,121 with a per-case marginal reduction of 20.88 for lung and prostate cancers, 10.44 for breast cancer, and 5.22 for palliative care treatment.
BIAS, COUNFOUNDING FACTOR(S), DRAWBACKS:We modeled basing our assumptions on a Medicare fee schedule and hospital-based practice, so the marginal reduction in revenue could be greater for commercial insurances and in the setting of free-standing practices. We assumed hypofractionation for breast, prostate, and lung cancer and palliative cases only, because clinical effectiveness data in other cancers are inconclusive. We also assumed no use of intensity-modulated radiation therapy or brachytherapy for breast cancer, and no use of stereotactic radiation for prostate or lung cancer or palliative treatment, because these technologies do not have conclusive data and/or widespread use in clinical practice.
REAL-LIFE IMPLICATIONS:The move to hypofractionation in the United States is justified where evidence exists and offers great benefits to patients and the field of radiation oncology in general. At the same time it will lead to increased pressures on departments to address budget shortfalls resulting from the decrease in per-patient revenue. This will affect departments' ability to update or replace equipment and may encourage consolidation or centralization of departments. There may be reduced radiation technologist needs because of reduction in workflow hours per day and challenges in funding nonreimbursed but important clinical support staff. For the physician, these hypofractionated treatment programs require greater skill, time, and effort for each fraction delivered, which also requires changes in residency training (Table 1).
Table 1.
Reduction in Hospital-Based Technical Billing Through Adoption of Evidence-Based Hypofractionation in Radiation Oncology Clinic
Hypofractionation (%)Change in Technical Revenue ($)Lung Cancer (n = 21)Breast Cancer (n = 100)Prostate Cancer (n = 75)Palliation (n = 25)1019,945.5542,969.9967,807443.272039,891.0985,939.99135,6148,886.543059,836.64128,909.99203,42113,329.804079,782.18171,879.99271,22817,773.075099,727.73214,849.99339,03522,216.3360119,673.27257,819.99406,84226,659.6070139,618.82300,789.98474,64931,102.8680159,564.36343,759.98542,45635,546.1390179,509.91386,729.98610,26339,989.40100199,455.95429,699.98678,07044,432.86Per-case marginal reduction9,4984,2979,0411,777QUESTION ASKED:
In light of the projected shortage of oncologists, is there evidence that pharmacists could help fill the gap and, if so, what particular clinical services could they provide during those visits?
SUMMARY ANSWER:We estimated that by year 2020, over 3,000 pharmacists who are board-certified in oncology could contribute 2.6 to 3.3 million 30-minute patient visits. Specific clinical services were identified by board-certified oncology pharmacists (BCOPs) using multiple surveys (Table 1).
METHODS:We used available data to estimate how many BCOPs could be available by year 2020. We also used a Delphi expert panel process to identify clinical services BCOPs could provide along with how many 30-minute patient visits they could potentially contribute.
BIASES, CONFOUNDING FACTOR(S), DRAWBACKS:The Delphi panel consisted solely of oncology pharmacists; other health care team members might have responded differently to survey questions. Estimates could be subject to changes in data trends. It is likely that the estimate of available BCOPs by 2020 is high because available data include international BCOPs. A confounding factor is that current regulations from the Center for Medicare and Medicaid Services (CMS) do not recognize pharmacists as health care providers, thereby limiting reimbursement for clinical services. Until the CMS modifies these regulations, the employment of pharmacists to provide patient care will likely be restricted.
REAL-LIFE IMPLICATIONS:These results suggest that practicing oncologists may benefit by utilizing BCOPs to see some of their patients that need particular clinical services. The clinical services that BCOPs could provide that received the strongest consensus (> 80%) are shown in Table 1. These services overlap and also complement those provided by nurse practitioners and physician assistants. Oncology practices wishing to improve capacity, breadth, and/or efficiency are encouraged to consider using BCOPs, particularly for those services identified in this study.
Table 1.
Characteristics of Delphi Panelists
CharacteristicDescriptionPractice setting10 academic, 3 office basedGeographic locationStates represented by US Census region:Northeast: Maine, New York (2)Midwest: NoneSouth: Alabama, Maryland, North Carolina (2), Oklahoma, TexasWest: Arizona, Colorado, Idaho, OregonHold or have held BCOP status13 (100%)Experience, yearsMedian, 16; mean, 16.8 (SD, 9.0)PGY2 oncology pharmacy residency9 of 13 (69%)PGY1 pharmacy residency8 of 13 (62%)Abbreviations: BCOP, Board-certified oncology pharmacist; PGY1, postgraduate year 1; PGY2, postgraduate year 2; SD, standard deviation.
QUESTION ASKED:
Are there benchmark data that I can use to assess my practice?
CONTEXT AND ANSWER:The National Practice Benchmark (NPB) provides a unique tool by which oncology practices can measure and analyze their current business practices. The data presented are drawn from practices from across the country and of various sizes and settings. With these metrics, a practice should be able to identify significant variances, analyze current business practices, and make appropriate changes, if necessary.
The data presented do not impute judgment. However, they provide context by which questions can be framed. There are no right or wrong inferences to be made. The data simply encourage practices to measure and to become self-aware. It is anticipated that the process of measurement will drive performance improvement.
METHODS:More than 1,700 medical oncologists, radiation oncologists, and practice administrators representing over 200 community practices and cancer centers across the United States were invited to participate in the NPB. The complete report and data collection includes 42 practices representing 587.8 full-time equivalent (FTE) hematology/oncology (HemOnc) physicians and 755.5 FTE physicians in all specialties.
RESULTS (OR WHAT WE FOUND):Multiple metrics are presented within the report. Widely accepted as a predictor of financial health of a practice is the number of new patients served by the practice (Fig A4). The definition of new patient is a patient who has not been seen by a clinician in the exact same specialty at the practice in the last 3 years. This year, the number of new patient visits in a 12-month period (calendar year or fiscal year) per standard HemOnc physician was 358 as compared with 325 last year. The metrics surrounding the finances of providing anticancer drugs are always of interest. The adjusted average drug spend (cost of goods paid for) per FTE HemOnc this year is $3,600,000 and continues to rise compared with last year's adjusted average of $3,100,000.
BIAS, CONFOUNDING FACTOR(S), DRAWBACKS:In the event that data were missing, nonsensical, or illogical, the practice data were excluded from the data used to generate the NPB results. All successful submissions are included in the demographic data. Data were submitted by HemOnc single-specialty practices, as well as by multispecialty practices, hospital-based practices, and other institutions.
REAL-LIFE IMPLICATIONS:Do you feel like you are working harder while your expenses are increasing and reimbursement is decreasing? As you read the results of this year's NPB report, we hope you consider using these metrics and data to answer that question for your practice: to measure what matters.
FIG A4.
Number of new hematology/oncology (HemOnc) patients in the 12-month period per full-time equivalent (FTE) HemOnc physician (new office patients: practices, n = 36; FTE HemOnc physicians, n = 573.4; new hospital patients: practices, n = 34; FTE HemOnc physicians, n = 569.6).
QUESTION ASKED:
Recognizing that it is a challenge for clinical research managers to determine appropriate workload for research staff, we asked if the ASCO Clinical Trial Workload Assessment Tool is helpful at gauging protocol-specific complexity and workload effort for clinical trials across multiple practice settings.
SUMMARY ANSWER:The majority of 51 participating research programs (96%) were able to provide at least 5 months of data. This response rate, along with feedback received from the participants, demonstrates that the Tool is simple and easy to use and supports its long-term feasibility and utility for community-based research programs.
METHODS:Two interrelated tools were used to conduct the project. First, the "ASCO Protocol Acuity Scoring Worksheet" which incorporated a 4-point protocol complexity rating scale where a score of 1.0 reflected a lower complexity and workload and a score of 4.0 reflected a complex trial and greater workload. Second, a web-based platform entitled the "ASCO Clinical Trial Workload Assessment Tool" was created to facilitate the collection of clinical trial–associated workload data. Data were collected monthly over 6 months beginning May 2013.
RESULTS:In total, 51 research programs entered clinical trial associated workload data for 323 staff members representing 963 unique protocols and 165 unique sponsors. The results from this project support the idea that work associated with some trials exceeds that associated with others. Treatment trial acuity scores were consistently higher compared with cancer control trials, and industry trials had higher acuity scores than NIH/NCI funded trials. Evidence of trial acuity (complexity) being a better measure of workload was also evident when comparing groups.
BIAS, CONFOUNDING FACTOR(S), DRAWBACKS:An initial objective of the project was to establish an average, single benchmark acuity score for various types of trials and trial sponsors that could be used as a reference for community-based research programs to anticipate workload and staffing needs. Due to high variability in the participating programs, this objective proved to be unrealistic. In an effort to counter this dilemma, programs were grouped into similar categories based on type and size. This approach would consequently allow similar research programs to be compared. Participation in this project was limited to community-based research programs. However, notwithstanding infrastructure and organizational differences, the data obtained as a result of this project could also be referred to and used by non-community-based programs, such as academic-based centers.
REAL-LIFE IMPLICATIONS:No matter the tool(s) used or type of program, every research program should be regularly assessing its staff workload and staffing metrics, and preferably should consider the level of complexity of the work being conducted. Such information captured and assessed at regular intervals over time may provide a means for research programs to establish their own benchmarks, to monitor trends and shifts, inform management and institutional administration to justify current staffing and the need to hire additional staff, assist with budget planning; provide metrics for staff performance, ensure workload balance, and ultimately improve staff satisfaction, potentially reducing staff burnout and turnover. The final version of the ASCO Clinical Trial Workload Assessment Tool was released in October 2014 and has close to 200 research programs registered to use the tool. It is accessible for free at http://ift.tt/1PqItHi.
QUESTION ASKED:
Can an interface be constructed to automatically populate an Internet-based survivorship care plan tool from the electronic medical record (EMR) in order to facilitate accurate and timely distribution of customized care plans?
SUMMARY ANSWER:After a significant upfront investment of time and resources, clinical testing demonstrated that the integrated tool could be used for the population for whom it was designed.
METHODS:An information technology application was developed to extract data from the EMR in use at our center (Epic). Data were transferred to auto-populate an Internet-based tool for creation of survivorship care plans (LIVESTRONG Care Plan) that had been previously used for creation of more than 35,000 plans.
MAIN RESULTS (OR WHAT WE FOUND):The intended data (demographics, surgeries, chemotherapy drugs, radiation sites) were extracted from the EMR and transferred to the care plan platform without transfer of protected health information; customized survivorship care plans were created and transferred back to the EMR where they were housed as separate patient encounters.
This approach was tested clinically: survivorship care plans were created by nurse practitioners during scheduled clinic visits for 146 sequential, eligible patients (67% breast, 33% colorectal) with automatically populated data points reviewed by practitioners. Data entered into generated care plans were accurate in 97% of audited cases, and the process of care plan generation could be completed in < 1 minute.
BIAS, CONFOUNDING FACTOR(S), DRAWBACKS:This process required upfront resource investment and was customized to our institution. As the patient population expands outside of that tested in the setting of a feasibility study, several options may exist to address this limitation, including manual data entry, more complex information technology builds, and the use of a comprehensive tumor registry for expanded data access.
REAL-LIFE IMPLICATIONS:The established feasibility of survivorship care plans fully integrated with an EMR at a major cancer center represents a tremendous milestone in the ultimate goal of care plan provision for all cancer survivors. This integrated technology has the potential to overcome the majority of barriers that have limited care plan use since it was first called for by the Institute of Medicine (IOM) 10 years ago, and allows clear vision of a method through which the ultimate goals of the IOM and Commission on Cancer may be reached in the very near future.
Table 1.
Data Elements Extracted From Electronic Medical Record With Brief Description of Location Within EMR Databases and/or Technique for Extraction
Element ExtractedMethod for Location Within EMRGenderExtracted from patient demographicsAgeCalculated from date of birth (extracted from patient demographics)RaceExtracted from patient demographicsCancer typeExtracted from the patient's active problem list and/or historical visit diagnoses; coded as ICD-9-CM diagnosis codesSurgeriesExtracted from procedure charges billed; coded as ICD-9-CM procedure codes (inpatient) and CPT codes (outpatient)Chemotherapy drugsExtracted from the medication administration record; coded as RxNorm concept unique identifiersRadiation typeNot present in EMR; extracted separately from radiation treatment planning systemRadiation indicationNot present in EMR; extracted separately from radiation treatment planning systemGenetic abnormality or syndromeExtracted from the patient's active problem list and/or historical visit diagnoses; coded as ICD-9-CM diagnosis codesAbbreviations: CPT, current procedural terminology; EMR, electronic medical record; ICD-9-CM, International Classification of Diseases (9th revision, clinical modification).
