Myocardial necrosis is now recognized as a common feature of thrombotic thrombocytopenic purpura (TTP), usually due to platelet plugging in the microvasculature. Despite reports that TTP patients with myocardial damage have higher morbidity and mortality, there are no established guidelines for managing these high‐risk patients. The universal occurrence of thrombocytopenia and variable findings including renal dysfunction present unique challenges in this setting. Established therapies including plasma exchange and immunosuppression are the mainstay of therapy for all TTP patients. For the subset of patients with myocardial damage, therapy with more potent antiplatelet drugs, agents that enhance NO availability and alleviate vasospasm and drugs that suppress von Willebrand factor levels may have additional benefit. However, clinical trials are needed to optimize therapy for this subset of TTP patients.
This phase II study investigated dose-intense erlotinib maintenance after dose-dense chemotherapy for patients with metastatic non-small cell lung cancer and examined two cell cycle biomarkers. Patients with newly diagnosed metastatic non-small cell lung cancer received docetaxel 75 mg/m2 and cisplatin 75 mg/m2 on day 1 and pegfilgrastim on day 2 every 14 days for four cycles. Patients then received erlotinib with initial doses based on smoking status. Doses were increased in 75 mg increments every two weeks depending on toxicities until each patient's maximal tolerable dose (MTD) was achieved. Cyclin D1 and D3 biomarkers were measured by immunohistochemistry. The objectives of the study were to evaluate time to progression (TTP) and overall survival (OS) for the entire population and biomarker subgroups. Forty-five patients were enrolled. Intra-patient erlotinib MTD ranged from 0 to 525 mg. Median MTD achieved in smokers was higher than in non-smokers (300 vs. 150 mg; P=0.019). TTP for the entire cohort was not significantly improved compared to historical controls. Patients with high cyclin D1 expressing tumors demonstrated improved TTP on erlotinib (8.2 vs. 4.7 months; hazard ratio, 4.1; 95% CI, 1.6–0.6; P=0.003) and improved OS (20.5 vs. 8.0 months; hazard ratio 2.8; 95% CI, 1.2–6.3; P=0.016). Intratumoral cyclin D3 expression did not impact clinical outcomes. Current smokers but not former smokers exhibit a higher erlotinib MTD. High cyclin D1 expression was associated with favorable TTP and OS.
46 Background: Patients with advanced cancer are at risk for repeated hospitalizations and aggressive therapy near the end of life. For these patients, an unscheduled hospitalization predicts survival of < 6 months and represents an opportunity to discuss goals of care which may decrease subsequent health care utilization. Our objective was to describe healthcare utilization for inpatients with advanced malignancies and investigate the association between goals-of-care discussion and subsequent healthcare utilization. Methods: We conducted a chart review of 100 patients with end-stage malignancies consecutively admitted to an academic medical center’s Oncology services beginning January 2013. Eligible patients had advanced incurable malignancy and an unscheduled admission. Exclusion criteria included hematologic malignancies, and hormone therapy responsive breast and prostate cancer. Descriptive statistics were used to characterize the population; variables were compared by code status using chi-square for categorical variables and t-tests for continuous variables. Results: Among 100 patients, the mean age was 62 (range 19-86), and 61% were male. Common cancer types were GI (32%) and lung (31%). Average # of lines of prior chemotherapy was 1.3 (SD 1.5), and 48% had received chemotherapy within 4 weeks of admission. Common reasons for admission were infection (25%), neurologic (13%), and pulmonary complaints (10%). During the hospitalization, 21% required an ICU setting; in-hospital mortality was 1%. Following discharge, 54% were readmitted to the hospital, and, of those patients, 56% spent time in an ICU. On the index admission, only 51% of patients had resuscitation preference documented which increased to 65% by discharge. The patients who had a discussion of code status while inpatient were more likely to be enrolled in hospice at discharge (40% vs. 0%, p < 0.0001) and had fewer readmissions following discharge (1.1 vs. 2.0 readmissions, p = 0.05). Conclusions: Patients with end-stage malignancies have high rates of healthcare utilization. Enhancing goals of care discussions during hospitalization may have a positive impact on readmissions and hospice enrollment.
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