JCO oncology practice最新文献

Purpose: To examine real-world treatment patterns and effectiveness among patients with metastatic triple-negative breast cancer (mTNBC) in the United States.

Design: Retrospective, observational study using Flatiron Enhanced Datamart electronic health records from patients diagnosed with mTNBC between January 1, 2018, and June 30, 2023, who received ≥1 line of therapy (LoT) for metastatic disease. Patients were followed until date of death, last recorded activity, or data cutoff (December 30, 2023). Patient characteristics, treatments received from LoT1-5, and clinical outcomes (overall and by LoT) were described.

Results: The cohort comprised 1,044 patients. Most were female (99.2%); the median age was 61 years (IQR, 52-71); 52.1% were White and 21.7% were Black. The most common drug class in all LoTs was chemotherapy, as monotherapy or in combination with other agents: LoT1 85.5%, LoT2 73.2%, LoT3 65.8%, LoT4 64.7%, and LoT5 71.7%. Among patients with known PD-L1 status (n = 367), 109 (29.7%) were PD-L1-positive and 258 (70.3%) were PD-L1-negative. For the overall cohort, the median real-world overall survival (rwOS) from diagnosis was 14.0 (95% CI, 12.9 to 16.0) months. Real-world progression-free survival was 4.5 (95% CI, 4.0 to 5.0) months in LoT1 and 4.1 (95% CI, 3.5 to 4.9) months in LoT2. The median rwOS was 18.6 (95% CI, 15.2 to 24.4) months in the PD-L1-positive cohort versus 12.7 (95% CI, 11.0 to 16.0) months in the PD-L1-negative cohort. From December 1, 2021, onward, immunotherapy was received in LoT1 by 63.6% (21/33) of patients who had PD-L1-positive tumors and by 84.6% (33/39) of patients with PD-L1-positive tumors across all LoTs.

Conclusion: Real-world clinical outcomes in patients with mTNBC in the United States remain poor, particularly for patients with PD-L1-negative disease. There is an unmet need for more effective treatments for mTNBC.

Purpose: With new evidence emerging about breast cancer risk following anthracycline chemotherapy, the International Late Effects of Childhood Cancer Guideline Harmonization Group updated the evidence and breast cancer surveillance recommendations for female childhood, adolescent, and young adult (CAYA) cancer survivors.

Methods: The Grading of Recommendations Assessment, Development, and Evaluation methodology was used to incorporate new knowledge and refine breast cancer surveillance recommendations. The guideline panel updated the systematic literature review and revised recommendations based on new evidence, clinical judgment, and assessments of benefits and harms of surveillance, ensuring adaptability across various health care systems.

Results: The literature update revealed new findings on the effects of anthracyclines on breast cancer risk in female CAYA cancer survivors. Moderate-quality evidence shows no significant association between doxorubicin doses <100 mg/m² and breast cancer risk. High-quality evidence indicates a statistically significant but weak association between breast cancer risk and 100-199 mg/m² doxorubicin (relative risk, <2) and a moderate breast cancer risk (relative risk, 2-4) for those treated with ≥200 mg/m² in the absence of radiotherapy exposing breast tissue (chest radiation). Routine breast cancer surveillance after ≥200 mg/m² doxorubicin in the absence of chest radiation is reasonable from age 30 years onward or ≥8 years from exposure (whichever occurs last). Due to inconclusive evidence, no recommendation could be formulated for routine breast cancer surveillance after daunorubicin, epirubicin, or idarubicin, in the absence of chest radiation.

Conclusion: The newly identified evidence on breast cancer risk after anthracyclines supports changes in the 2019 recommendations regarding breast cancer surveillance for survivors treated with ≥200 mg/m² doxorubicin without chest radiation.

Familial adenomatous polyposis (FAP) is an autosomal dominant hereditary colorectal cancer (CRC) syndrome caused by germline pathogenic variants in the adenomatous polyposis coli (APC) gene. FAP is typically characterized by the development of hundreds to thousands of adenomatous polyps throughout the colon and rectum, with a nearly 100% chance of developing CRC if left untreated. Duodenal cancer is the second leading cause of cancer for patients with FAP; however, gastric cancer has become more prevalent in recent years with improved surveillance of the colon, rectum, and duodenum. Patients frequently develop other extracolonic manifestations including desmoid disease, which holds the highest extracolonic mortality risk, and thyroid nodules, which are more frequently associated with the cribriform morular variant of papillary thyroid cancer. Management of FAP is complex, and patients require frequent and lifelong surveillance. This review will discuss the current understanding and clinical management of FAP as well as innovations and challenges in clinical practice.

Purpose: For patients with bladder cancer (BCa) undergoing radical cystectomy (RC), National Cancer Institute-designated (NCI-D) cancer centers are considered the gold standard treatment hospital. Underserved populations face disparities in access to NCI-D and receive care at safety net hospitals (SNHs). Variation in quality of care for the underserved at safety-nets remains understudied. We hypothesized that safety-nets with NCI-D partnerships (affiliated safety-nets) would have superior RC outcomes compared with unaffiliated safety-nets.

Methods: We compared outcomes for BCa undergoing RC between affiliated and unaffiliated safety-nets using the Texas Cancer Registry. Federal payments to hospitals for uncompensated care were used to identify safety-nets. Multivariate accelerated failure time modeled the primary outcome of overall (OS); secondary outcomes of pelvic lymph node dissection (PLND) and neoadjuvant chemotherapy (NAC) were modeled with logistic regression.

Results: From 2004 to 2019, there were 1,927 cases of RC. Overall survival was no different at affiliated safety-nets and NCI-D (hazard ratio [HR], 0.99; P = .96), and was worse at unaffiliated safety-nets compared with NCI-D (HR, 1.28; P = .03). Unaffiliated safety-nets had lower odds of NAC (odds ratio [OR], 0.61; P = .02) and PLND (OR, 0.48; P < .001) compared with NCI-D or affiliated safety-nets.

Conclusion: NCI-D affiliated safety-nets may represent a subset of high preforming safety net hospitals for BCa patients undergoing RC. Survival differences are partly explained by greater odds of NAC and PLND at affiliated safety-nets. More work is needed to understand the drivers of higher-quality care at NCI-D affiliated safety net hospitals to improve BCa care across all safety net hospitals.

Purpose: Adolescent and young adult (AYA) patients with cancer frequently receive intensive measures at the end of life; many also express care goals that align with a palliative approach. We sought to understand the extent to which AYAs are referred to palliative care before death, the timing of referrals, and associations between referral timing and end-of-life care outcomes.

Methods: Review of electronic health data and medical records for 1,918 AYAs age 12-39 years who died after receiving care at one of the three sites between 2003 and 2019. Patients who received palliative care but lacked documentation of referral timing were excluded.

Results: Most included AYAs were White (61%); 12% were Asian, 8% Black, and 27% Hispanic. Nearly three quarters (73%) were referred to palliative care before death. Thirty-six percent of palliative care referrals took place before the last 90 days of life; 30% were in the last month of life. Palliative care referrals and their timing were associated with care received at the end of life, with earlier referrals associated with fewer intensive measures near death, including chemotherapy in the last 14 days of life (P = .001) as well as intensive care unit admissions, emergency room visits, and hospitalizations in the last month of life (P < .001 for all). Patients who were referred to palliative care were more likely to have symptoms assessed in the last 90 days of life, including pain, dyspnea, nausea, diarrhea, constipation, depression, and anxiety (P < .001 for all).

Conclusion: Although many AYAs receive intensive measures at the end of life, most are also referred to palliative care. Earlier referrals have potential to reduce care intensity and enhance attention to symptoms and quality of life near death.

Purpose: Immediate side effects after chimeric antigen receptor (CAR) T-cell therapy are well documented and include cytokine release syndrome (CRS) and immune effector-cell-associated neurotoxicity (ICANS). However, long-term patient-reported outcomes are understudied. Using a social determinants of health (SDoH) framework, we described the long-term health-related quality of life (HRQoL), cognitive function, and symptom burden of patients in sustained remission after CAR T-cell therapy and examined the relationship between acute CRS and ICANS and long-term cognitive function and symptom burden.

Methods: This cross-sectional study included adults in remission after CAR T-cell therapy for multiple myeloma or B-cell lymphoma who were within 1-5 years post-treatment. We used bivariate analyses to measure associations between clinical and SDoH variables and long-term outcomes and linear regression to examine the relationship between ICANS and CRS toxicity and longer-term outcomes.

Results: Participants (n = 58) were a median of 67 years of age (22-88), 72% had lymphoma, 28% had multiple myeloma, and they were a median of 2 years (1-4.7) post-CAR T-cell infusion. Most of the participants reported good HRQoL. Over one third of participants reported mild-to-moderate impairment in physical function, social roles and activities, or pain domains. Higher income and employment were significantly associated with better physical HRQoL (P < .05). Participants reported low symptom burden, with fatigue most commonly reported. Neither CRS nor ICANS toxicity predicted long-term cognitive function or symptom burden.

Conclusion: Patients in long-term remission after CAR T-cell therapy have good HRQoL and cognitive function with minimal symptom burden. Importantly, there was no relationship between CRS and ICANS and long-term symptom burden or cognitive function. Results support the long-term clinical benefit of CAR T-cell therapy.

Purpose: Many cancer survivors consume alcohol above recommended limits, increasing their risk of recurrence, second cancers, and cancer-related mortality. Alcohol screening, brief intervention, and referral to treatment (SBIRT) is a guideline-recommended strategy for reducing unhealthy alcohol consumption among adult primary care patients. To our knowledge, no prior studies have evaluated SBIRT's reach among cancer survivors.

Methods: We conducted a cross-sectional study of adults who completed the National Survey on Drug Use and Health from 2015 to 2022. We examined past-year receipt of alcohol screening and-among respondents who endorsed unhealthy alcohol use-brief intervention and treatment. All outcomes were examined among cancer survivors and those with no cancer history. We used modified Poisson regression to assess the associations of cancer history with each outcome, adjusting for sociodemographic characteristics.

Results: The cohort included 86,410 respondents with no history of cancer and 9,963 cancer survivors. The percentages of respondents endorsing past-year receipt of alcohol screening (approximately 40%), brief intervention (approximately 8%), and treatment (approximately 2%) were similarly low in both groups. After adjustment, there was a small but statistically significant difference in alcohol screening, with cancer survivors more likely than people without a history of cancer to receive alcohol screening (adjusted risk ratio [aRR], 1.07; 95% CI, 1.02 to 1.13). Among those with unhealthy alcohol use, cancer survivors were no more or less likely than people without a history of cancer to receive brief alcohol intervention (aRR, 1.00; 95% CI, 0.93 to 1.07) or alcohol treatment (aRR, 0.92; 95% CI, 0.47 to 1.69).

Conclusion: Results reveal an important opportunity to improve SBIRT uptake across the board and especially for cancer survivors, who are at increased risk of alcohol-related adverse health effects and, potentially, more motivated to change cancer-related health behaviors.

Purpose: Given the impact of cancer treatment on fertility among adolescents and young adults (AYAs: 15-39 years), it is important to ensure AYAs access to fertility preservation (FP). However, the availability of FP services for AYAs treated in community settings is unknown. We examined FP access at National Cancer Institute Community Oncology Research Program (NCORP) practice groups.

Methods: The 2022 NCORP Landscape Assessment survey captured available resources and cancer care services including FP services at practice groups. We described FP services as accessible (on-site or off-site) versus not accessible by AYA-treating status (as previously defined). Univariable and multivariable analyses were used to evaluate associations between FP services and practice characteristics (NCORP classification [minority/underserved or community] and proportion of Medicaid or uninsured above/below the national average).

Results: Among 271 practice groups responding to the survey, 100 were categorized as AYA-treating, of which 32% had neither male nor female FP services available. Sperm banking was available at 59 AYA-treating practices, among which 43 (73%) referred for sperm banking off-site. Although approximately half of AYA-treating practices reported accessible female FP services (embryo = 54%, oocyte = 55%, ovarian tissue = 40%), most of them referred patients off-site (embryo = 72%, oocyte = 80%, ovarian tissue = 83%). The odds of access to male FP were lower at minority/underserved practices (odds ratio, 0.34 [95% CI, 0.13 to 0.88]; P = .026; ref = community); however, this same relationship was not seen for females.

Conclusion: Despite guidelines surrounding FP discussions before cancer therapy, and strong consensus regarding the importance of FP access, many AYA-treating practices in community settings lack access to FP services. Understanding how to leverage available services and broadly expand access is urgently needed to facilitate guideline-concordant, high-quality cancer care for AYAs.