Effects of hospital facilities on patient outcomes after cancer surgery: an international, prospective, observational study

Background Early death after cancer surgery is higher in low-income and middle-income countries (LMICs) compared with in high-income countries, yet the impact of facility characteristics on early postoperative outcomes is unknown. The aim of this study was to examine the association between hospital infrastructure, resource availability, and processes on early outcomes after cancer surgery worldwide.Methods A multimethods analysis was performed as part of the GlobalSurg 3 study-a multicentre, international, prospective cohort study of patients who had surgery for breast, colorectal, or gastric cancer. The primary outcomes were 30-day mortality and 30-day major complication rates. Potentially beneficial hospital facilities were identified by variable selection to select those associated with 30-day mortality. Adjusted outcomes were determined using generalised estimating equations to account for patient characteristics and country-income group, with population stratification by hospital.Findings Between April 1, 2018, and April 23, 2019, facility-level data were collected for 9685 patients across 238 hospitals in 66 countries (91 hospitals in 20 high-income countries; 57 hospitals in 19 upper-middle-income countries; and 90 hospitals in 27 low-income to lower-middle-income countries). The availability of five hospital facilities was inversely associated with mortality: ultrasound, CT scanner, critical care unit, opioid analgesia, and oncologist. After adjustment for case-mix and country income group, hospitals with three or fewer of these facilities (62 hospitals, 1294 patients) had higher mortality compared with those with four or five (adjusted odds ratio [OR] 3.85 [95% CI 2.58-5.75]; p<0.0001), with excess mortality predominantly explained by a limited capacity to rescue following the development of major complications (63.0% vs 82.7%; OR 0.35 [0.23-0.53]; p<0.0001). Across LMICs, improvements in hospital facilities would prevent one to three deaths for every 100 patients undergoing surgery for cancer.Interpretation Hospitals with higher levels of infrastructure and resources have better outcomes after cancer surgery, independent of country income. Without urgent strengthening of hospital infrastructure and resources, the reductions in cancer-associated mortality associated with improved access will not be realised

Burnout among surgeons before and during the SARS-CoV-2 pandemic: an international survey

Background: SARS-CoV-2 pandemic has had many significant impacts within the surgical realm, and surgeons have been obligated to reconsider almost every aspect of daily clinical practice. Methods: This is a cross-sectional study reported in compliance with the CHERRIES guidelines and conducted through an online platform from June 14th to July 15th, 2020. The primary outcome was the burden of burnout during the pandemic indicated by the validated Shirom-Melamed Burnout Measure. Results: Nine hundred fifty-four surgeons completed the survey. The median length of practice was 10 years; 78.2% included were male with a median age of 37 years old, 39.5% were consultants, 68.9% were general surgeons, and 55.7% were affiliated with an academic institution. Overall, there was a significant increase in the mean burnout score during the pandemic; longer years of practice and older age were significantly associated with less burnout. There were significant reductions in the median number of outpatient visits, operated cases, on-call hours, emergency visits, and research work, so, 48.2% of respondents felt that the training resources were insufficient. The majority (81.3%) of respondents reported that their hospitals were included in the management of COVID-19, 66.5% felt their roles had been minimized; 41% were asked to assist in non-surgical medical practices, and 37.6% of respondents were included in COVID-19 management. Conclusions: There was a significant burnout among trainees. Almost all aspects of clinical and research activities were affected with a significant reduction in the volume of research, outpatient clinic visits, surgical procedures, on-call hours, and emergency cases hindering the training. Trial registration: The study was registered on clicaltrials.gov "NCT04433286" on 16/06/2020

Abstract P5-04-03: Aggressiveness of epithelial cancers is independent of epithelial-to-mesenchymal transition

Abstract Background: Epithelial-to-Mesenchymal Transition (EMT)is postulated to be an important step in cancer progression and controlled by multiple mechanisms including EMT transcription factors (EMT-TFs) and splicing factors such as Epithelial Splicing Regulatory Proteins (ESRP1 and ESRP2). We previously have shown that the expression of ESRP1 and ESRP2 have significantly elevated in cases with high Oncotype DX scores and in ERα-positive cells with acquired endocrine resistance (SABCS 2013). This study seeks to identify the role of EMT-TFs and ESRP1s in the determination of outcomes of patients with ER+ breast cancer. Patients and Methods: The expression of EMT-TFs and ESRP1 was analyzed in the Affymetrix microarray and TCGA BRCA databases. Next, we generated genetically engineered knockdown models of ESRP1 to understand its functional role in endocrine resistance. We performed RNA-seq and MATS analysis to identify alternative splicing events (ASEs) between ESRP1 knockdown and control cell lines [(2C3 vs 2-control (LCC2 set) and 9C2 vs 9-control(LCC9 set)]. Validation of the ASEs was performed using a probe-based platform [Human Transcriptome Array 2.0 (HTA)] and TCGA SpliceSeq from breast tumors. Results: High levels of ESRP1 mRNA, but not EMT-TFs, are associated with poor prognosis in human ER+ breast tumors (Affymetrix; P=2.8e-07 and TCGA; P=0.00011). Knockdown of ESRP1 in ER+ endocrine resistant breast cancer induced glandular differentiation, rather than mesenchymal features. This was associated with significant reduction in cell and tumor growth in mammary fat pad orthotopic xenograft mice models of LCC2 and LCC9. No alterations in EMT-TFs were observed in these cells. Transcriptome profiling of ESRP1 knockdown cells further revealed altered ASEs in EMT splicing gene signature, but not at the gene level. These alterations (SE-skipped exon) were further validated for ARHGEF11, ENAH, FNIP1, SCRIB, and SLK using probe based HTA platform for ESRP1 knockdown cells and TCGA-SpliceSeq ER+ BRCA tumors in ER+ ESRP1low versus ESRP1high breast tumors. Conclusions: Our data demonstrates for the first time that high ESRP1 is associated with poor prognosis in ER+ breast cancer. Despite its involvement in regulation of EMT splicing signature, low levels (or knockdown) of ESRP1 were not associated with EMT phenotype in tumors or in endocrine-resistant ER+ cells. Taken together, our findings indicate that EMT is not important in determining prognosis in ER+ breast cancer and that ESRP1 exerts a different role in aggressive ER+ breast cancers. Citation Format: Badve SS, Neelamraju Y, Goswami CP, Gu X, Nallamothu G, Gu Y, Vieth E, Janga SC, Ryan M, Gokmen-Polar Y. Aggressiveness of epithelial cancers is independent of epithelial-to-mesenchymal transition [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P5-04-03.</jats:p

Hypermethylation of GADD45A Defines a Methylation Profile Distinct to Mutant IDH1/2, and Correlates with More Aggressive AML

Abstract We have previously reported that hypermethylationof the GADD45A promoter (GADD45AmeHI) occurs frequently in AML at a specific CpG residue (CpG1) and associates with poor overall survival for patients on standard chemotherapy (Perugini et al, Leukemia 2013). Sequenom multiplex analysis of 195 AML patients revealed a co-occurrence of GADD45AmeHI with recurrent mutations at conserved residues in IDH1 and IDH2 (p&lt;0.0001, Fisher's exact test). These mutations in IDH1 and IDH2 result in enzyme isoforms that produce high levels of the onco-metabolite 2-hydroxyglutarate with a wide-range of effects including inhibition of α-KG-dependent dioxygenases and association with a profound DNA hypermethylation phenotype in AML (Figueroa et al, Cancer Cell 2010). Furthermore these mutations are found in pre-leukemic AML clones (Shlush et al, Nature 2014) and lead to pre-leukaemic phenotypes in mouse models (Sasaki et al, Nature 2012, Kats et al, Cell Stem Cell 2014, Ogawara et al, Cancer Research 2015). Here we investigated the relationship between hypermethylation at GADD45A CpG1, IDH1/2 mutation status, global methylation patterns and patient survival. We performed survival analysis to determine disease-free survival (DFS) and relapse-free survival (RFS) for AML patients with GADD45AmeHIor IDH1/2-mutations. This showed that GADD45AmeHI is a significant independent predictor of poor DFS and RFS, particularly in normal karyotype AML (Cox regression analysis, NK-AML DFS, P=0.009 HR=2.55, RFS, P=0.003 HR=2.75). Despite the co-association of GADD45AmeHI with mutations in IDH1 and IDH2, the mutation status of IDH1/2 did not predict DFS or RFS in these patients. To examine further the relationship between GADD45AmeHI and IDH1/2-mutation, and to investigate how this might influence tumour cell biology in AML, we determined global methylation patterns for a panel of AML diagnosis (Dx) samples (base-pair-resolution analysis using enhanced reduced representation bisulfite sequencing; ERRBS) in which both GADD45AmeHI and IDH mutation status has been determined. Unsupervised analyses of global methylation patterns grouped the AML Dx samples into three clusters including cluster 1 (n=12) which was associated with GADD45AmeHI samples with IDH- mutations, cluster 2 (n=13) which was enriched for GADD45AmeHIlacking IDH- mutations, and cluster 3 (n=9) which was associated with GADD45AmeLO(low CpG1 methylation) IDH-WT AML. We propose that this CpG in the GADD45A promoter may be subject to alternative events affecting DNA methylation in AML pathogenesis, including events distinct from IDH1/2 mutation. Finally, in GADD45AmeHI AML we detected hypermethylated regions compared to CD34+ normal bone marrow controls within 2016 gene promoters, 848 of which were unique to the GADD45AmeHI samples and not present in IDH1/2-mutant samples. We hypothesize that these differentially methylated genes may contribute mechanistically to the poor survival observed for this subtype. To determine how GADD45AmeHI status might associate with disease progression, DNA methylation assessment was performed on the patient panel-matched relapse samples (Rx). While GADD45AmeHI occurs frequently in both cluster 1 and 2 there is a significant difference in level of GADD45A CpG1 methylation at Dx and Rx for samples in cluster 1 vs cluster 2 and 3 (Figure 1), consistent with mutant IDH1/2 activity influencing methylation levels at this CpG site. Given that GADD45A has an established basal role in the maintenance of genomic stability (Liebermann &amp; Hoffman, Springer 2013), and is a determinant of HSC self-renewal and response to genotoxic insult (Wingert et al, Stem Cells 2016, Chen et al, Blood 2014) we are also investigating whether GADD45A methylation and silencing plays a direct role in determining aggressiveness and response to chemotherapy for GADD45AmeHIAML. In conclusion this data suggests that methylation at this specific CpGof the GADD45A promoter, in combination with IDH1/2 mutation status, associate with varying global methylation phenotypes. Importantly, we demonstrate that GADD45AmeHI better predicts poorer prognosis than IDH1/2 mutation status, despite the significant co-association of these characteristics in AML. SES and FEGB contributed equally to this work. Figure 1 GADD45A CpG1 methylation in patient cluster 1-3 at diagnosis and relapse. * P&lt;0.05, ** P&lt;0.01. Figure 1. GADD45A CpG1 methylation in patient cluster 1-3 at diagnosis and relapse. * P&lt;0.05, ** P&lt;0.01. Disclosures Guzman: Cellectis: Research Funding. Roboz:Agios, Amgen, Amphivena, Astex, AstraZeneca, Boehringer Ingelheim, Celator, Celgene, Genoptix, Janssen, Juno, MEI Pharma, MedImmune, Novartis, Onconova, Pfizer, Roche/Genentech, Sunesis, Teva: Consultancy; Cellectis: Research Funding. Levine:Qiagen: Membership on an entity's Board of Directors or advisory committees; Novartis: Consultancy. Melnick:Janssen: Research Funding. </jats:sec

Changes of the Mutational Landscape in Relapsed Acute Myeloid Leukemia

Abstract Acute myeloid leukemia (AML) is the most common type of acute leukemia in adults. Unfortunately, a significant proportion of patients relapse after responding to initial treatment reflecting our poor understanding of the mechanisms mediating therapy resistance and relapse. We hypothesized that understanding the evolution of the mutational landscape between diagnosis and relapse is essential in order to identify mutational markers associated with sensitivity or resistance to treatment. To address this hypothesis we assembled a cohort of 53 clinically annotated, paired AML patient samples (diagnosis, relapse and patient-matched germline samples; mean age = 52 years). All patients achieved clinical remission after treatment with combination chemotherapy (cytarabine arabinoside and an anthracycline) during induction phase followed by consolidation chemotherapy treatment with or without a stem cell transplantation in first remission. Serial samples were collected at the time of initial diagnosis and within three months of relapse (mean time to relapse 455 days). We performed whole-exome and targeted capture followed by high-throughput sequencing. We aligned samples with BWA, recalibrated them with The Genome Analysis Toolkit (GATK) and then compiled integrated calls from substitution and indel callers (Mutect, Scalpel, Strelka, Varscan and Somatic Sniper). We performed several layers of post-processing filtering on these calls, including removing non-oncogenic mutations and previously documented non-somatic variants, and correcting for the variant allele fraction of indel calls. We filtered out the variants that were found to occur in non-copy number neutral re-arrangements using the clinically determined cytogenetic data. Furthermore, we assessed for copy number events, including loss of heterozygosity events, and for the presence and the variant allele frequency of the FLT3-ITD in our samples. We observed a median of 4.5 and 5 mutations per patient at diagnosis and relapse, respectively, with 3.5 mutations being shared by paired diagnosis and relapse samples. When limiting our analysis to genes previously shown to contribute to leukemogenesis, we found a median of 1.5 and 2 mutations per patient at diagnosis and relapse, with 1 mutation being shared. FLT3, DNMT3A, IDH2, NRAS, RUNX1 and TET2 were among the most commonly mutated genes, with a detected presence rate of 28%, 25%, 19%, 19%, 11% and 11%, respectively, in the diagnosis samples and 39%, 23%, 19%, 4%, 13% and 11% in the relapse samples. We identified significant variation in the variant allele frequency (VAF) for several of the mutations related to these genes and others, denoting variations in the cellular prevalence of the related clones after adjustment for tumor content using the mutations with the highest VAF to delineate clonal architecture. Specifically, we observed that DNMT3A, IDH2, TET2 variants are most commonly present in the bulk AML clone, and persist after treatment. WT1, GATA2 and FLT3mutations are predicted to confer relative resistance to standard combination chemotherapy treatment based on their increased VAF at relapse, whereas KRAS and NRAS subclone(s) are more sensitive to chemotherapy since their VAFs decrease following multiagent chemotherapy. Fifteen patients presented new events in leukemogenesis-related genes at relapse. Overall, our results support a model of AML as a disease with a complex mutational hierarchy and clonal architecture and provide further insight into how these change in response to standard induction therapy. Our data suggests that future efforts to develop targeted therapies with maximal clinical benefit in combination with standard induction treatments should be placed on mutated genes identified to be more strongly associated with disease relapse. Authors contributed equally: F. Rapaport and M.R. De Massy Authors contributed equally: A. al Hinai and M.A. Sanders Disclosures Guzman: Cellectis: Research Funding. Roboz:Cellectis: Research Funding; Agios, Amgen, Amphivena, Astex, AstraZeneca, Boehringer Ingelheim, Celator, Celgene, Genoptix, Janssen, Juno, MEI Pharma, MedImmune, Novartis, Onconova, Pfizer, Roche/Genentech, Sunesis, Teva: Consultancy. Melnick:Janssen: Research Funding. Levine:Qiagen: Membership on an entity's Board of Directors or advisory committees; Novartis: Consultancy. </jats:sec