From intuition to execution: Realizing the potential of wearables in oncology

As oncologists, we have noticed recently that many of our patients are coming to clinic wearing familiar-appearing wristbands. Although the particular brands are not always apparent, these wristbands are all activity trackers in one form or another. This phenomenon parallels the explosive growth of the consumer wearable industry and the ubiquitous presence of commercially available physical activity monitors throughout society. Oncologists have become enamored with the potential clinical and research usefulness of these devices. Intuitively, physical activity monitors could provide another perspective into how patients with cancer feel and function. The importance of patient-reported outcomes in providing this information has been amply demonstrated in recent years, and physical activity monitors promise to complement or, perhaps in some instances, replace this information with unbiased, objective data. If one patient averages 4,000 steps in a day and another averages 8,000 steps, or if a single patient averages 6,000 steps one week and 2,000 the next, should these differences not be telling us something important

Cathodic arc modulator systems for metallic plasma ion implantation

This paper describes the electrical design and operation of a cathodic arc modulator system for metallic plasma ion implantation. Depending on the ion implantation process recipe, various repetition rates, pulse widths, and currents are required. In addition, the cathodic arc system may be synchronized with a higher voltage target modulator system. The cathodic arc is water cooled and usually uses a self generated axial B-field, by use of a series connected solenoid around the arc anode. Typical arc currents of 800 amperes may be utilized with pulse widths ranging from 20 uS to 4 mS. Typical PRF`s may exceed 400 Hz, with overall system power limited by the presently available 10 kW transformer-rectifier. The cathodic arc modulator system consists of a command charged 10 kV trigger generator, a high voltage arc starter, and a low voltage, high current arc sustain circuit. The arc start and sustain circuits are independently adjustable and utilize a common IGBT device in a hot-deck configuration. This paper provides circuit design and performance information in addition to various process applications

Comparing Clinician-Assessed and Patient-Reported Performance Status for Predicting Morbidity and Mortality in Patients With Advanced Cancer Receiving Chemotherapy

PURPOSE: Performance status (PS) is assessed during cancer treatment to determine clinical trial eligibility, appropriateness for treatment, and need for supportive care. There is rising interest for patients to report this information directly. We determined whether clinician- and patient-reported PS were equally associated with mortality and service utilization in patients with cancer. METHODS: A secondary analysis was conducted using data from an radiotherapy plus chemotherapy in which 441 patients with advanced cancer and clinicians reported PS using the Eastern Cooperative Oncology Group scale. Simple kappa statistics measured agreement between clinician-reported performance status (cPS) and patient-reported performance status (pPS). Associations of cPS and pPS with emergency department (ED) and hospital visits and overall survival were evaluated via Cox regression, competing risk regression, and Fisher's exact tests. RESULTS: cPS and pPS correlated weakly (kappa = 0.27). Both pPS and cPS were associated with survival, ED visits, and hospitalizations, but only cPS remained associated after adjustment (survival: HR, 1.75; P < .0001). The first available cPS predicted mortality more strongly than the first available pPS (HR for death, comparing PS ≥ 1 v 0: 2.05 for cPS and 1.41 for pPS). When pPS questionnaires were repeated over time and averaged, associations with outcomes were stronger as measured by AIC model fit. Both pPS and cPS were associated with EQ-5D subcomponents (eg, 75%-77% with no usual activity deficits for PS 0, v 42%-51% for PS ≥ 1). CONCLUSION: Both clinician-reported PS and patient-reported PS provide useful information and can be considered for clinical trials and routine care

Disparities in mortality from noncancer causes among adolescents and young adults with cancer

Background: Few studies have examined noncancer outcomes among patients diagnosed with cancer as adolescents and young adults (AYA). We examined risk of mortality from noncancer causes after an AYA cancer diagnosis and investigated disparities according to race/ethnicity and other characteristics. Methods: Patients with a first primary cancer at ages 15 to 39 years diagnosed during 1987 to 2015 were identified in the Surveillance, Epidemiology, and End Results database (N = 242,940 women, 158,347 men). Survival months were accrued from diagnosis until death or December 2015. Multivariable-adjusted HRs were used to examine disparities in mortality from all noncancer causes, cardiovascular diseases (CVD), and infectious diseases (ID) according to race/ethnicity, geographic region, and county-level characteristics. Results: For all cancer types combined, the 10-year cumulative incidence of noncancer-related death after AYA cancer was 2% and 5% among women and men, respectively. With adjustment for cancer type, all noncancer mortality was increased among non-Hispanic Black AYAs [HR vs. nonHispanic White: HRWomen = 2.31; 95% confidence interval (CI): 2.16-2.47; HRMen = 2.17; 95% CI: 2.05-2.30] and those in the South (HR vs. Northeast: HRWomen = 1.18; 95% CI: 1.07-1.29; HRMen = 1.42; 95% CI: 1.31-1.55) or in rural counties (HR vs. metro: HRWomen = 1.74; 95% CI: 1.47-2.07; HRMen = 1.57; 95% CI: 1.33-1.86). Mortality from CVD and ID was also elevated among non-Hispanic Black AYAs. Conclusions: Results of this study suggest that noncancer mortality after AYA cancer is highest among survivors who are non-Hispanic Black or live in the South or in rural counties. Impact: Our analyses highlight disparities among AYAs with cancer and identify subgroups that may be targeted for increased medical surveillance or behavioral interventions

Acute and chronic increases in predation risk affect the territorial behaviour of juvenile Atlantic salmon in the wild

Optimality models predict that territory size will decrease as the costs of defence increase. One poorly understood cost is predation risk, especially the relative influence of short- versus long-term increases in predation risk. Under natural conditions, we quantified the territorial behaviour of juvenile Atlantic salmon, Salmo salar, exposed to either acute or chronic increases in perceived predation risk. The effects of an acute increase in predation risk were assessed by exposing 18 young-of-the-year (YOY) Atlantic salmon to a control of stream water and to an alarm cue (i.e. conspecific skin extract) while monitoring their territorial behaviour. We investigated the effects of a chronic increase in perceived predation risk by quantifying the territorial behaviour of YOY salmon in control versus risky sections of seven sites, where we manipulated the perceived predation risk over a 4-week period by releasing stream water in control sections and alarm cue in risky sections. We found that salmon exposed to the alarm cue decreased the number of switches between foraging stations, but they did not change their territory size or foraging rate. As predicted, YOY salmon in risky sections had smaller territories than in control sections. However, their foraging rates and number of switches between foraging stations did not differ between treatments. Our study suggests that juvenile Atlantic salmon are sensitive to both acute and chronic increases in perceived predation risk under natural conditions, and support the predictions of optimality models that territory size decreases with increasing predation risk

Comparative safety and health care expenditures among patients with chronic myeloid leukemia initiating first-line imatinib, dasatinib, or nilotinib

PURPOSE Tyrosine kinase inhibitors (TKIs) have dramatically improved survival for patients with chronic myeloid leukemia (CML). No overall survival differences were observed between patients initiating first- and second-generation TKIs in trials; however, real-world safety and cost outcomes are unclear. We evaluated comparative safety and health care expenditures between first-line imatinib, dasatinib, and nilotinib among patients with CML. PATIENTS AND METHODS Eligible patients had one or more fills for imatinib, dasatinib, or nilotinib in the MarketScan Commercial and Medicare Supplemental databases between January 1, 2011, and December 31, 2016 (earliest fill is the index date), 6 months pre-index continuous enrollment, CML diagnosis, and no TKI use in the pre-index period. Hospitalizations or emergency department visits (safety events) were compared across treatment groups using propensity-score-weighted 1-year relative risks (RRs) and subdistribution hazard ratios (HRs). Inflation-adjusted annual health care expenditures were compared using quantile regression. RESULTS Eligible patients included 1,417 receiving imatinib, 1,067 receiving dasatinib, and 647 receiving nilotinib. The 1-year risk of safety events was high: imatinib, 37%; dasatinib, 44%; and nilotinib, 40%, with higher risks among patients receiving dasatinib (RR, 1.17; 95% CI, 1.06 to 1.30) and nilotinib (RR, 1.07; 95% CI, 0.93 to 1.23) compared with those receiving imatinib. Over a median of 1.7 years, the cumulative incidence of safety events was higher among patients receiving dasatinib (HR, 1.23; 95% CI, 1.10 to 1.38) and nilotinib (HR, 1.08; 95% CI, 0.95 to 1.24) than among those receiving imatinib. One-year health care expenditures were high (median, $125,987) and were significantly higher among patients initiating second-generation TKIs compared with those receiving imatinib (difference in medians: dasatinib v imatinib,$22,393; 95% CI, $17,068 to$27,718; nilotinib v imatinib, $19,463; 95$14,689 to $24,236). CONCLUSION Patients receiving imatinib had the lowest risk of hospitalization or emergency department visits and 1-year health care expenditures. Given a lack of significant differences in overall survival, imatinib may represent the ideal first-line therapy for patients, on average

Birth outcomes among adolescent and young adult cancer survivors

IMPORTANCE: Cancer diagnosis and treatment may adversely affect reproductive outcomes among female cancer survivors. OBJECTIVE: To compare the birth outcomes of adolescent and young adult cancer survivors (AYA [diagnosed at ages 15-39 years]) with those of women without a cancer diagnosis. DESIGN, SETTING, AND PARTICIPANTS: The North Carolina Central Cancer Registry (CCR) was used to identify female AYA cancer survivors diagnosed from January 2000 to December 2013; CCR records were linked to statewide birth certificate files from January 2000 to December 2014 to identify postdiagnosis live births to AYA survivors (n = 2598). A comparison cohort of births to women without a recorded cancer diagnosis was randomly selected from birth certificate files (n = 12 990) with frequency matching on maternal age and year of delivery. MAIN OUTCOMES AND MEASURES: Prevalence of preterm birth, low birth weight, small-for-gestational-age births, cesarean delivery, and low Apgar score. RESULTS: Overall, 2598 births to AYA cancer survivors (mean [SD] maternal age, 31 [5] years) were included. Births to AYA cancer survivors had a significantly increased prevalence of preterm birth (prevalence ratio [PR], 1.52; 95% CI, 1.34-1.71), low birth weight (PR, 1.59; 95% CI, 1.38-1.83), and cesarean delivery (PR, 1.08; 95% CI, 1.01-1.14) relative to the comparison cohort of 1299. The higher prevalence of these outcomes was most concentrated among births to women diagnosed during pregnancy. Other factors associated with preterm birth and low birth weight included treatment with chemotherapy and a diagnosis of breast cancer, non-Hodgkin lymphoma, or gynecologic cancers. The prevalence of small-for-gestational-age births and low Apgar score (<7) did not differ significantly between groups. CONCLUSIONS AND RELEVANCE: Live births to AYA cancer survivors may have an increased risk of preterm birth and low birth weight, suggesting that additional surveillance of pregnancies in this population is warranted. Our findings may inform the reproductive counseling of female AYA cancer survivors

Statewide geographic variation in outcomes for adults with acute myeloid leukemia in North Carolina

BACKGROUND: Population-based studies have demonstrated survival disparities related to socioeconomic factors for patients with acute myeloid leukemia (AML). The objective of the current study was to determine whether the local health care infrastructure, represented by Area Health Education Centers (AHEC) region, or treating center experience, represented by National Cancer Institute Comprehensive Cancer Center (NCICCC) designation, were associated with outcomes among patients with AML in North Carolina. METHODS: Patients who were diagnosed with AML from 2003 to 2009 were identified using the University of North Carolina Lineberger Integrated Cancer Information and Surveillance System, a database linking insurance claims to the North Carolina Cancer Registry. A Cox proportional-hazards model was used to explore survival based on AHEC region. A subset of patients who received inpatient chemotherapy was examined to evaluate the impact of treatment at an NCICCC. RESULTS: Nine hundred patients were identified in the study period, 553 of whom received inpatient chemotherapy therapy within 30 days of diagnosis. Almost one-half of these patients (n5294) received chemotherapy at a non-NCICCC. Among the patients who received intensive inpatient therapy, residence in 3 of 9 AHEC regions was associated with a higher risk of mortality (hazard ratio: range, 1.97-4.03; P<.01) at 1 year in multivariate analysis. Treatment at a non-NCICCC was not associated with an increased risk of mortality at 1 year (hazard ratio, 1.25; 95% confidence interval, 0.95-1.65). CONCLUSIONS: Survival among patients with AML in North Carolina varies according to geographic region. Further examination of local practice and referral patterns may inform strategies to improve AML outcomes across the state