Publications by authors named "Paulette Mehta"

68 Publications

The Impact of Donor Type on Outcomes and Cost of Allogeneic Hematopoietic Cell Transplantation for Pediatric Leukemia: A Merged Center for International Blood and Marrow Transplant Research and Pediatric Health Information System Analysis.

Biol Blood Marrow Transplant 2020 09 25;26(9):1747-1756. Epub 2020 May 25.

Cancer Care Manitoba, University of Manitoba, Winnipeg, Manitoba, Canada.

Allogeneic hematopoietic stem cell transplantation (alloHCT) may be associated with significant morbidity and mortality, resulting in increased healthcare utilization (HCU). To date, no multicenter comparative cost analyses have specifically evaluated alloHCT in children with acute leukemia. In this retrospective cohort study, we examined the relationship between survival and HCU while investigating the hypothesis that matched sibling donor (MSD) alloHCT has significantly lower inpatient HCU with unrelated donor (URD) alloHCT, and that among URDs, umbilical cord blood (UCB) alloHCT will have higher initial utilization but lower long-term utilization. Clinical and transplantation outcomes data from the Center for International Blood and Marrow Transplant Research (CIBMTR) were merged with inpatient cost data from the Pediatric Health Information System (PHIS) database using a probabilistic merge methodology. The merged dataset comprised US patients age 1 to 21 years who underwent alloHCT for acute leukemia between 2004 and 2011 with comprehensive CIBMTR data at a PHIS hospital. AlloHCT was analyzed by donor type, with specific analysis of utilization and costs using PHIS claims data. The primary outcomes of overall survival (OS), leukemia-free survival (LFS), and inpatient costs were evaluated using Kaplan-Meier curves and Cox and Poisson models. A total of 632 patients were identified in both the CIBMTR and PHIS data. The 5-year LFS was 60% for MSD alloHCT, 47% for well-matched matched unrelated donor bone marrow (MUD) alloHCT, 48% for mismatched unrelated donor alloHCT, and 45% for UCB alloHCT (P = .09). Total adjusted costs were significantly lower for MSD alloHCT versus MUD alloHCT by day 100 (adjusted cost ratio [ACR], .73; 95% confidence interval [CI], .62 to .86; P < .001), and higher for UCB alloHCT versus MUD alloHCT (ACR, 1.27; 95% CI, 1.11 to 1.45; P < .001). By 2 years, total adjusted costs remained significantly lower for MSD alloHCT compared with MUD alloHCT (ACR, .67; 95% CI, .56 to .81; P < .001) and higher for UCB alloHCT compared with MUD alloHCT (ACR, 1.25; 95% CI, 1.02 to 1.52; P = .0280). Our data show that UCB and MUD alloHCT provide similar survival outcomes; however, MUD alloHCT has a significant advantage in cost by day 100 and 2 years. More research is needed to determine whether the cost difference among URD alloHCT approaches remains significant with a larger sample size and/or beyond 2 years post-alloHCT.
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http://dx.doi.org/10.1016/j.bbmt.2020.05.016DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7518194PMC
September 2020

Reframing Clinician Distress: Moral Injury Not Burnout.

Fed Pract 2019 Nov;36(11):504-506

Central Arkansas Veterans Health Care System; University of Arkansas for Medical Sciences.

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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6913604PMC
November 2019

Systemic Anaplastic Lymphoma Kinase-positive Anaplastic Large Cell Lymphoma: A Population-based Analysis of Incidence and Survival.

Clin Lymphoma Myeloma Leuk 2017 04 16;17(4):201-206. Epub 2017 Feb 16.

Division of Hematology/Oncology, University of Arkansas for Medical Sciences, Little Rock, AR.

Introduction: Systemic ALK-positive anaplastic large cell lymphoma (ALK-positive ALCL) is a T-cell lymphoma. Owing to its rarity, variations in incidence and survival at the population level are not clearly known.

Materials And Methods: Using the Surveillance Epidemiology and End Results database (SEER 18), we selected patients aged ≥ 20 years with ALK-positive ALCL, diagnosed between 2001 and 2013. Incidence rate, overall survival (OS), and its determinants were analyzed with a significance level of P < .05.

Results: We identified 1604 patients with a median age of 54 years. The disease incidence increased significantly with advancing age, with higher incidence in Blacks and lower incidence in American Indians and Asian/Pacific Islanders as compared with Whites. The 5-year OS significantly declined as the age advanced (age 20-40 years, 68.7%; age 41-60 years, 53.8%; age 61-80 years, 28.9%; age > 80 years, 15.2%; P < .01) and varied with race (Whites, 49.7% vs. Blacks, 37.7% vs. Asian/Pacific Islander, 42.8% vs. American Indian, 35.8%; P = .03). On multivariate analysis, treatment with radiation (hazard ratio [HR], 0.72; 95% confidence interval [95% CI], 0.59-0.87; P < .01) and year of diagnosis from 2009 through 2013 (HR, 0.77; 95% CI, 0.65-0.93; P < .01) were associated with lower mortality. Advanced age, Black race (HR, 1.37; 95% CI, 1.14-1.65; P < .01), and advanced disease stage (HR, 1.74; 95% CI, 1.51-2.02; P < .01) were associated with higher mortality.

Conclusion: Incidence and survival of ALK-positive ALCL varies significantly with patients' demographic characteristics as identified in our study. Treatment strategies need to be tailored accordingly to address these variations and ensure uniform access to care.
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http://dx.doi.org/10.1016/j.clml.2017.02.003DOI Listing
April 2017

Addressing Opioid-Associated Constipation Using Quality Oncology Practice Initiative Scores and Plan-Do-Study-Act Cycles.

J Oncol Pract 2017 01 31;13(1):e91-e97. Epub 2016 Oct 31.

Winthrop P. Rockefeller Cancer Institute, University of Arkansas for Medical Sciences; Central Arkansas Veterans Healthcare System, Little Rock, AR; and British Columbia Cancer Agency, Vancouver Island Cancer Center, Victoria, British Columbia, Canada.

Using the Quality Oncology Practice Initiative, an affiliate program of ASCO, we outlined opioid-associated constipation (OAC) as a subject in need of quality improvement (QI) in our fellowship program at the University of Arkansas for Medical Sciences and Central Arkansas Veterans Healthcare System. We initiated a fellow-led QI project to advance the quality of patient care and provide a valuable avenue for QI training of young physicians. Fellows organized meetings with all stakeholders, addressed the scope of the problem, and devised strategies for OAC management. Monthly meetings were organized using Plan-Do-Study-Act principles. Mandatory check boxes were inserted into our electronic medical record templates to remind all physicians to identify patients on opioid medications and assess and address OAC. Final chart audit and patient satisfaction surveys were performed 6 months after project initiation. Assessment of OAC improved from 52% at baseline to 92% ( P < .003). This improvement corresponded with high patient satisfaction scores, with 90% of surveyed patients reporting adequate management of their constipation. In this QI initiative, we showed that participation in ASCO's Quality Oncology Practice Initiative helps identify areas in need of QI, and such fellow-led QI projects can serve as models for QI training of young physicians.
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http://dx.doi.org/10.1200/JOP.2016.013797DOI Listing
January 2017

Acute Leukemia of Ambiguous Lineage in Elderly Patients - Analysis of Survival Using Surveillance Epidemiology and End Results-Medicare Database.

Clin Lymphoma Myeloma Leuk 2017 02 23;17(2):100-107. Epub 2016 Nov 23.

Division of Hematology/Oncology, University of Arkansas for Medical Sciences and Central Arkansas Veterans Healthcare System, Little Rock, AR.

Background: Acute leukemia of ambiguous lineage (ALAL) is a rare leukemia with sparse data availability about the survival and management strategies in elderly patients.

Methods: We used the Surveillance Epidemiology and End Results (SEER)-Medicare database to describe the overall survival (OS) and treatment pattern of elderly patients (age > 65 years) with ALAL. OS analysis was done using the Kaplan-Meier method, and its determinants were analyzed using the Cox proportional hazard regression method with a significant P < .05.

Results: We included 705 patients with ALAL and a median age of 80 years. The 2-year OS was 16.4% for patients aged 66 to 70 years, 8.1% for patients aged 71 to 75 years, 5.5% for patients aged 76 to 80 years, and 3.7% for patients aged > 80 years (P < .01). Two-year OS did not significantly vary by race or gender. Among the study cohort, 151 patients received chemotherapy. Two-year OS was 17% in the chemotherapy group and 3% in the no-chemotherapy group (P < .001). On multivariate analysis, age less than 80 years (Age 66-70 years: hazard ratio [HR]; 0.66, 95% confidence interval [CI], 0.52-0.85; age 71-75 years: HR, 0.80; 95% CI, 0.65-0.99; age 76-80 years: HR, 0.80; 95% CI, 0.66-0.98; P = .004) and chemotherapy (HR, 0.51; 95% CI, 0.42-0.62; P = .001) significantly reduced the hazard for mortality.

Conclusion: Our study suggests that the OS of elderly patients with ALAL remains poor. Although treatment improved the OS, only 21.5% of patients received therapy. The optimal choice of therapy needs to be determined by prospective studies.
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http://dx.doi.org/10.1016/j.clml.2016.11.007DOI Listing
February 2017

Incidence and survival outcomes of chronic myelomonocytic leukemia in the United States.

Leuk Lymphoma 2017 07 23;58(7):1648-1654. Epub 2016 Nov 23.

c Division of Hematology/Oncology , University of Arkansas for Medical Sciences and Central Arkansas Veterans Healthcare System , Little Rock , AR , USA.

Chronic myelomonocytic leukemia (CMML) is an aggressive neoplasm with sparse data on outcomes at a population level. Using Surveillance Epidemiology and End Results (SEER) database, we identified 2238 patients with CMML diagnosed in the period 2003-2013. We found that the disease incidence was significantly higher with advancing age and lower in females, Blacks, and Asian/pacific islanders. Median OS declined significantly with increasing age (age 20-39 - 25 months, age 40-59 - 20 months, age 60-79 - 18 months, and age ≥80 - 11 months, p < .01), but did not vary by gender or race. Median OS has improved in the period 2007-2013 as compared with 2003-2006 (17 months vs. 14 months, p < .01). In spite of advances in CMML biology and therapeutics, in general, the survival of CMML patients remains dismal. More effective therapies are needed to improve the outcomes of CMML.
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http://dx.doi.org/10.1080/10428194.2016.1258700DOI Listing
July 2017

Improving Communication on Intent of Chemotherapy Using QOPI Scores and PDSA Cycles.

J Cancer Educ 2016 12;31(4):736-741

Division of Hematology and Oncology, Winthrop P. Rockefeller Cancer Institute, University of Arkansas for Medical Sciences, Little Rock, AR, USA.

Using the standardized ASCO Quality Oncology Practice Initiative (QOPI) guidelines for assessing quality cancer care, we identified communication about intent of chemotherapy as an area needing improvement in our program at the University of Arkansas for Medical Sciences (UAMS) and the Central Arkansas Veterans Healthcare System (CAVHS). We organized training in communications on intent of treatment (palliative vs curative) and added optional checkboxes to our electronic templates for progress notes. Afterwards, we conducted a retrospective review of electronic medical records of initially often randomly selected patient charts. The first 10 patient charts after 1 month of implementation showed intent of treatment in 80 % of charts compared to 74 % at baseline. We then changed checkboxes from mandatory to optional and reviewed 30 randomly selected patient charts. Intent of treatment was documented in 96.7 % of cases compared to 74 % at baseline. We also assessed patient satisfaction through surveys distributed in clinic. Patient satisfaction scores were close to 100 % for receiving clear information, understanding the reason for which they were receiving chemotherapy, and willingness of oncologists to listen carefully, to take time to answer questions, to explain things clearly, and to spend adequate time with them. In this study, we showed that training in communication of intent of chemotherapy and use of checkboxes in progress note templates could improve competency in communication of intent of therapy in cancer patients.
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http://dx.doi.org/10.1007/s13187-015-0897-xDOI Listing
December 2016

Integrating Collaborative Learning and Competition in a Hematology/Oncology Training Program.

J Cancer Educ 2018 02;33(1):186-192

Department of Surgery, University of Arkansas for Medical Sciences, 4301 West Markham St, Little Rock, AR, 72205, USA.

New educational methods and structures to improve medical education are needed to face the challenge of an exponential increase and complexity of medical knowledge. Collaborative learning has been increasingly used in education, but its use in medical training programs is in its infancy, and its impact is still unknown; the role of competition in education is more controversial. We introduced these pedagogical methods to the hematology/oncology fellowship program at the University of Arkansas for Medical Sciences to improve attendance and performance at didactic activities and different educational outcomes. One year after the adoption of these methods, the fellowship program has reached many of the expected goals from this intervention without the negative consequences of competition observed in younger learners. The most important conclusion of this project is that collaboration and cross-generational team work provide a healthy and effective learning environment and competition may not add further benefit. Analysis, interpretation, and discussion of our experience are provided. This study was approved by the University of Arkansas for Medical Sciences IRB as a low risk educational intervention not requiring a consent form.
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http://dx.doi.org/10.1007/s13187-016-1095-1DOI Listing
February 2018

Updates on Cancer Survivorship Care Planning.

Fed Pract 2015 Aug;32(Suppl 7):64S-69S

, , and are staff hematology/oncologists, all at the John L. McClellan Memorial Veterans Hospital in Little Rock, Arkansas. is a resident, is a hematology/oncology fellow, Dr. Kunthur and Dr. Xiang are assistant professors of hematology/oncology, and Dr. Mehta is a professor of hematology/oncology, all at the University of Arkansas for Medical Sciences in Little Rock.

Cancer organizations have developed guides and tools to help build cancer survivorship programs and survivorship care plans.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6375428PMC
August 2015

Multiple Myeloma: Updates on Diagnosis and Management.

Fed Pract 2015 Aug;32(Suppl 7):49S-56S

is a hematology/oncology fellow, , , and are staff hematologist/oncologists, all in the Division of Hematology/ Oncology, Department of Internal Medicine, at the John L. McClellan Memorial Veterans Hospital in Little Rock, Arkansas. Dr. Xiang and Dr. Mehta are also faculty members at the University of Arkansas for Medical Sciences in Little Rock.

Two- and 3-drug treatment regimens and autologous stem cell transplants provide opportunities for longer term disease remission, though most patients will still develop relapsed multiple myeloma.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6375429PMC
August 2015

Castleman Disease.

Fed Pract 2015 Aug;32(Suppl 7):41S-46S

is a resident in the Department of Internal Medicine, and and are staff hematologist/oncologists, all at the Central Arkansas Veterans Healthcare System in Little Rock. Dr. Xiang and Dr. Kunthur are assistant professors and Dr. Mehta is a professor in the Division of Hematology/Oncology; all in the Department of Internal Medicine at the University of Arkansas for Medical Sciences in Little Rock.

An understanding of the disease pathogenesis has led to the discovery of therapuetic agents that target human herpesvirus-8 replication, CD20, and IL-6 and IL-6R antibodies.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6375432PMC
August 2015

MYC amplification in multiple marker chromosomes and EZH2 microdeletion in a man with acute myeloid leukemia.

Cancer Genet 2015 Mar 7;208(3):96-100. Epub 2015 Feb 7.

Department of Pathology, University of Arkansas for Medical Sciences, Little Rock, AR, USA; Pathology and Laboratory Medicine Service, Central Arkansas Veterans Healthcare System, Little Rock, AR, USA.

The role of MYC and EZH2 in acute myeloid leukemia (AML) pathogenesis is poorly understood. Herein we present a case of AML with MYC amplification in marker chromosomes and a microdeletion of chromosome 7 below cytogenetic resolution. The karyotype of the patient's bone marrow aspirate showed three to five marker chromosomes in all dividing cells without other structural or numerical chromosomal abnormalities. Analysis by fluorescence in situ hybridization (FISH) with a probe specific for the human MYC gene revealed amplification of the oncogene localized to the marker chromosomes. Using whole genome single nucleotide polymorphism (SNP) microarray analysis, an approximately 4.4 Mb amplicon containing the MYC gene was identified with an estimated amplification of about 30 copies per leukemic cell and, thus, an average of about 8 copies per marker chromosome. A 6.4 Mb hemizygous microdeletion of chromosome 7 within band q36.1 was also found by SNP microarray analysis in a cellular-equivalent dosage of 50%. The microdeletion spans multiple genes, including EZH2, a gene with well-known cancer association. No mutation was found in the remaining EZH2 allele by next generation gene sequencing. The combination of MYC amplification and EZH2 deletion, which has not been described previously in AML, may suggest a synergistic role of the two oncogenes in the pathogenesis of the patient's acute leukemia.
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http://dx.doi.org/10.1016/j.cancergen.2015.01.010DOI Listing
March 2015

A Phase II trial of weekly bortezomib and dexamethasone in veterans with newly diagnosed multiple myeloma not eligible for or who deferred autologous stem cell transplantation.

Br J Haematol 2015 Apr 8;169(1):36-43. Epub 2015 Jan 8.

VA Boston Healthcare System, Boston, MA, USA; University of Cincinnati College of Medicine, Cincinnati, OH, USA.

Once-weekly administration of bortezomib has reduced bortezomib-induced peripheral neuropathy without affecting response rates, but this has only been demonstrated prospectively in three- and four- drug combinations. We report a phase II trial of alternate dosing and schedule of bortezomib and dexamethasone in newly diagnosed multiple myeloma patients who are not eligible for or refused autologous stem cell transplantation. Bortezomib 1·6 mg/m(2) intravenously was given once-weekly for six cycles, together with dexamethasone 40 mg on the day of and day after bortezomib. Fifty patients were enrolled; 58% did not require any dose modification. The majority of patients had multiple co-morbidities, including cardiovascular (76%) and renal insufficiency (54%), and the median number of medications prior to enrollment was 13. Of all evaluable patients, the overall response rate was 79% and at least 45% had at least a very good partial response. The median time to first response was 1·3 months (range, 0·25-2·4 months). The progression-free and overall survivals were 8 months and 46·5 months, respectively. Twenty-four percent developed worsening neuropathy. We conclude that alternate dosing and scheduling of bortezomib and dexamethasone is both safe and effective for management of newly diagnosed multiple myeloma in frail patients. (ClinicalTrials.gov number, NCT01090921).
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http://dx.doi.org/10.1111/bjh.13243DOI Listing
April 2015

New cancers after autotransplantations for multiple myeloma.

Biol Blood Marrow Transplant 2015 Apr 31;21(4):738-45. Epub 2014 Dec 31.

Celgene Corporation, Summit, New Jersey.

We describe baseline incidence and risk factors for new cancers in 4161 persons receiving autotransplants for multiple myeloma in the United States from 1990 to 2010. Observed incidence of invasive new cancers was compared with expected incidence relative to the US population. The cohort represented 13,387 person-years at-risk. In total, 163 new cancers were observed, for a crude incidence rate of 1.2 new cancers per 100 person-years and cumulative incidences of 2.6% (95% confidence interval [CI], 2.09 to 3.17), 4.2% (95% CI, 3.49 to 5.00), and 6.1% (95% CI, 5.08 to 7.24) at 3, 5, and 7 years, respectively. The incidence of new cancers in the autotransplantation cohort was similar to age-, race-, and gender-adjusted comparison subjects with an observed/expected (O/E) ratio of 1.00 (99% CI, .81 to 1.22). However, acute myeloid leukemia and melanoma were observed at higher than expected rates with O/E ratios of 5.19 (99% CI, 1.67 to 12.04; P = .0004), and 3.58 (99% CI, 1.82 to 6.29; P < .0001), respectively. Obesity, older age, and male gender were associated with increased risks of new cancers in multivariate analyses. This large data set provides a baseline for comparison and defines the histologic type specific risk for new cancers in patients with MM receiving postautotransplantation therapies, such as maintenance.
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http://dx.doi.org/10.1016/j.bbmt.2014.12.028DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4359647PMC
April 2015

Natural history of chronic myelomonocytic leukemia: gene sequencing identifies multiple clonal molecular abnormalities associated with rapid progression to acute myeloid leukemia.

Clin Case Rep 2014 Dec 13;2(6):265-70. Epub 2014 Nov 13.

Department of Pathology, University of Arkansas for Medical Sciences Little Rock, Arkansas ; Pathology and Laboratory Medicine Service, Central Arkansas Veterans Healthcare System Little Rock, Arkansas.

Key Clinical Message: Gene panel sequencing in a CMML patient without any detectable genetic abnormality by conventional genetic studies identified four concurrent somatic mutations in three genes. Gene panel mutation analysis is a rapidly emerging clinical tool to demonstrate the clonality in hematologic malignancies, and to identify the potential targets for therapy.
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http://dx.doi.org/10.1002/ccr3.110DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4270708PMC
December 2014

Trends in survival outcomes of B-lineage acute lymphoblastic leukemia in elderly patients: analysis of Surveillance, Epidemiology, and End Results database.

Leuk Lymphoma 2015 21;56(8):2296-300. Epub 2015 Jan 21.

c Division of Hematology/Oncology, University of Arkansas for Medical Sciences and Central Arkansas Veterans Health System , Little Rock , AR , USA.

B-lineage acute lymphoblastic leukemia (B-ALL) in the elderly population is generally considered to have a poor prognosis. It is unclear whether their survival has improved in the current era. Using the Surveillance, Epidemiology, and End Results database, we selected 717 elderly patients (age≥60) with B-ALL diagnosed between 1992 and 2011. Overall survival (OS) was compared based on their period of diagnosis and age. Patients in the age group 60-69 had an improvement in OS over time, both 1-year OS (49.4% in 2002-2011 vs. 33.1% in 1992-2001) and 5-year OS (20.4% in 2002-2011 vs. 8.1% in 1992-2001, p=0.002). Patients≥70 years had no significant improvement in 1-year OS or 5-year OS (5-year OS 5.5% in 1992-2001 vs. 9.7% in 2002-2011, p=0.326). Hence, there are discrepancies in the improvement of OS among elderly patients with B-ALL. Further focus of research in elderly patients with B-ALL is needed to improve their outcome.
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http://dx.doi.org/10.3109/10428194.2014.991921DOI Listing
April 2016

Effect of radiotherapy on the survival of patients with stage I and stage II mantle cell lymphoma: analysis of the Surveillance, Epidemiology and End Results database.

Clin Lymphoma Myeloma Leuk 2014 Sep;14 Suppl:S90-5

Division of Hematology/Oncology, University of Arkansas for Medical Sciences and Central Arkansas Veterans Health System, Little Rock, AR.

Background: Radiotherapy is a treatment option for stage I and stage II MCL. However, data demonstrating the role of RT in a larger patient population and its real world effects are unknown.

Materials And Methods: To demonstrate the role of RT in the OS of patients with stage I and stage II MCL, we performed a retrospective analysis of the SEER database. Included patients were adults with age > 40 years who had MCL stages I and II, and diagnosis between 1992 and 2010. We excluded patients lacking information on demographic characteristics, survival, and RT. Patients were analyzed in 2 groups, those treated with initial RT (RT group) and those not treated with initial RT (no-RT group).

Results: A total of 657 patients were eligible for analysis with 178 patients in the RT group and 479 patients in the no-RT group. The median age of the study group was 68 years. The RT group had a significantly greater proportion of patients with age < 60, male sex, and extranodal disease. Median OS was 103 months in the RT group versus 66 months in the no-RT group (P = .002). On Multivariate analysis, treatment with initial RT was associated with a lower hazard for mortality (hazard ratio, 0.767; 95% confidence interval, 0.602-0.979; P = .033). Age < 60, stage I disease, and extranodal disease were independently associated with a significantly decreased hazard for mortality on Multivariate analysis.

Conclusion: Although stage I and stage II MCL constitute only a small proportion of this disease, our study demonstrates that upfront RT improves the OS of these patients.
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http://dx.doi.org/10.1016/j.clml.2014.04.013DOI Listing
September 2014

Ibrutinib-associated tumor lysis syndrome in a patient with chronic lymphocytic leukemia.

Blood 2014 Nov;124(23):3503-5

Division of Hematology/Oncology, Department of Internal Medicine, University of Arkansas for Medical Sciences, Little Rock, AR.

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http://dx.doi.org/10.1182/blood-2014-08-591875DOI Listing
November 2014

Long-term survival and late effects among one-year survivors of second allogeneic hematopoietic cell transplantation for relapsed acute leukemia and myelodysplastic syndromes.

Biol Blood Marrow Transplant 2015 Jan 12;21(1):151-8. Epub 2014 Oct 12.

Division of Blood and Marrow Transplantation, Center for Cancer and Blood Disorders, Children's National Health Systems, Washington, District of Columbia.

We analyzed the outcomes of patients who survived disease-free for 1 year or more after a second allogeneic hematopoietic cell transplantation (HCT) for relapsed acute leukemia or myelodysplastic syndromes between 1980 and 2009. A total of 1285 patients received a second allogeneic transplant after disease relapse; among these, 325 were relapse free at 1 year after the second HCT. The median time from first to second HCT was 17 and 24 months for children and adults, respectively. A myeloablative preparative regimen was used in the second transplantation in 62% of children and 45% of adult patients. The overall 10-year conditional survival rates after second transplantation in this cohort of patients who had survived disease-free for at least 1 year was 55% in children and 39% in adults. Relapse was the leading cause of mortality (77% and 54% of deaths in children and adults, respectively). In multivariate analyses, only disease status before second HCT was significantly associated with higher risk for overall mortality (hazard ratio, 1.71 for patients with disease not in complete remission before second HCT, P < .01). Chronic graft-versus-host disease (GVHD) developed in 43% and 75% of children and adults after second transplantation. Chronic GVHD was the leading cause of nonrelapse mortality, followed by organ failure and infection. The cumulative incidence of developing at least 1 of the studied late effects within 10 years after second HCT was 63% in children and 55% in adults. The most frequent late effects in children were growth disturbance (10-year cumulative incidence, 22%) and cataracts (20%); in adults they were cataracts (20%) and avascular necrosis (13%). Among patients with acute leukemia and myelodysplastic syndromes who receive a second allogeneic HCT for relapse and survive disease free for at least 1 year, many can be expected to survive long term. However, they continue to be at risk for relapse and nonrelapse morbidity and mortality. Novel approaches are needed to minimize relapse risk and long-term transplantation morbidity in this population.
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http://dx.doi.org/10.1016/j.bbmt.2014.10.006DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4272862PMC
January 2015

Do we know why deaths from heart disease have declined?

Am J Cardiol 2014 Nov 23;114(10):1627. Epub 2014 Aug 23.

Little Rock, Arkansas.

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http://dx.doi.org/10.1016/j.amjcard.2014.08.004DOI Listing
November 2014

Hospital length of stay in the first 100 days after allogeneic hematopoietic cell transplantation for acute leukemia in remission: comparison among alternative graft sources.

Biol Blood Marrow Transplant 2014 Nov 23;20(11):1819-27. Epub 2014 Jul 23.

Blood and Marrow Transplant Program, Cleveland Clinic, Cleveland, Ohio. Electronic address:

Several studies have shown comparable survival outcomes with different graft sources, but the relative resource needs of hematopoietic cell transplantation (HCT) by graft source have not been well studied. We compared total hospital length of stay in the first 100 days after HCT in 1577 patients with acute leukemia in remission who underwent HCT with an umbilical cord blood (UCB), matched unrelated donor (MUD), or mismatched unrelated donor (MMUD) graft between 2008 and 2011. To ensure a relatively homogenous study population, the analysis was limited to patients with acute myelogenous leukemia and acute lymphoblastic leukemia in first or second complete remission who underwent HCT in the United States. To account for early deaths, we compared the number of days alive and out of the hospital in the first 100 days post-transplantation. For children who received myeloablative conditioning, the median time alive and out of the hospital in the first 100 days was 50 days for single UCB recipients, 54 days for double UCB recipients, and 60 days for MUD bone marrow (BM) recipients. In multivariate analysis, use of UCB was significantly associated with fewer days alive and out of the hospital compared with MUD BM. For adults who received myeloablative conditioning, the median time alive and out of the hospital in first 100 days was 52 days for single UCB recipients, 55 days for double UCB recipients, 69 days for MUD BM recipients, 75 days for MUD peripheral blood stem cell (PBSC) recipients, 63 days for MMUD BM recipients, and 67 days for MMUD PBSC recipients. In multivariate analysis, UCB and MMUD BM recipients had fewer days alive and out of the hospital compared with recipients of other graft sources. For adults who received a reduced-intensity preparative regimen, the median time alive and out of the hospital during the first 100 days was 65 days for single UCB recipients, 63 days for double UCB recipients, 79 days for MUD PBSC recipients, and 79 days for MMUD PBSC recipients. Similar to the other 2 groups, receipt of UCB was associated with a fewer days alive and out of the hospital. In conclusion, length of stay in the first 100 days post-transplantation varies by graft source and is longer for UCB HCT recipients. These data provide insight into the resource needs of patients who undergo HCT with these various graft sources.
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http://dx.doi.org/10.1016/j.bbmt.2014.07.021DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4194253PMC
November 2014

Older patients with myeloma derive similar benefit from autologous transplantation.

Biol Blood Marrow Transplant 2014 Nov 18;20(11):1796-803. Epub 2014 Jul 18.

Academische Ziekenhuis Maastricht, Maastricht, Netherlands.

Autologous hematopoietic cell transplantation (AHCT) for plasma cell myeloma is performed less often in people >70 years old than in people ≤70 years old. We analyzed 11,430 AHCT recipients for plasma cell myeloma prospectively reported to the Center for International Blood and Marrow Transplant Research between 2008 and 2011, representing the majority of US AHCT activity during this period. Survival (OS) was compared in 3 cohorts: ages 18 to 59 years (n = 5818), 60 to 69 years (n = 4666), and >70 years (n = 946). Median OS was not reached for any cohort. In multivariate analysis, increasing age was associated with mortality (P = .0006). Myeloma-specific mortality was similar among cohorts at 12%, indicating an age-related effect on nonmyeloma mortality. Analyses were performed in a representative subgroup comparing relapse rate, progression-free survival (PFS), and nonrelapse mortality (NRM). One-year NRM was 0% for age >70 years and 2% for other ages (P = not significant). The three-year relapse rate was 56% in age 18 to 59 years, 61% in age 60 to 69 years, and 63% age >70 (P = not significant). Three-year PFS was similar at 42% in age 18 to 59 years, 38% in age 60 to 69 years, and 33% in age >70 years (P = not significant). Postrelapse survival was significantly worse for the older cohort (P = .03). Older subjects selected for AHCT derived similar antimyeloma benefit without worse NRM, relapse rate, or PFS.
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http://dx.doi.org/10.1016/j.bbmt.2014.07.013DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4194262PMC
November 2014

Survival improvements in adolescents and young adults after myeloablative allogeneic transplantation for acute lymphoblastic leukemia.

Biol Blood Marrow Transplant 2014 Jun 7;20(6):829-36. Epub 2014 Mar 7.

Center for International Blood and Marrow Transplant Research, Minneapolis, Minnesota; Blood and Marrow Transplant Program, Cleveland Clinic, Cleveland, Ohio. Electronic address:

Adolescents and young adults (AYAs, ages 15 to 40 years) with cancer have not experienced survival improvements to the same extent as younger and older patients. We compared changes in survival after myeloablative allogeneic hematopoietic cell transplantation (HCT) for acute lymphoblastic leukemia (ALL) among children (n = 981), AYAs (n = 1218), and older adults (n = 469) who underwent transplantation over 3 time periods: 1990 to 1995, 1996 to 2001, and 2002 to 2007. Five-year survival varied inversely with age group. Survival improved over time in AYAs and paralleled that seen in children; however, overall survival did not change over time for older adults. Survival improvements were primarily related to lower rates of early treatment-related mortality in the most recent era. For all cohorts, relapse rates did not change over time. A subset of 222 AYAs between the ages of 15 and 25 at 46 pediatric or 49 adult centers were also analyzed to describe differences by center type. In this subgroup, there were differences in transplantation practices among pediatric and adult centers, although HCT outcomes did not differ by center type. Survival for AYAs undergoing myeloablative allogeneic HCT for ALL improved at a similar rate as survival for children.
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http://dx.doi.org/10.1016/j.bbmt.2014.02.021DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4019683PMC
June 2014

Using population data to reduce disparities in colorectal cancer screening, Arkansas, 2006.

Prev Chronic Dis 2012 ;9:E138

Fay W. Boozman College of Public Health, University of Arkansas for Medical Sciences, 4301 W Markham no. 820, Little Rock, AR 72205, USA.

Introduction: Colorectal cancer is a common disease, and incidence and death rates are higher in medically underserved populations. The colorectal cancer death rate in Arkansas exceeds the national rate. The objective of this study was to examine population characteristics relevant to the design and implementation of a state-sponsored colorectal cancer screening program that is responsive to medically underserved populations.

Methods: Trained interviewers in 2006 conducted a random-digit-dialed telephone survey comprising items selected from the Health Information National Trends Survey to characterize demographic factors, health care variables, and colorectal screening history in a sample (n = 2,021) representative of the Arkansas population. Univariate and multivariate analyses identified associations among population characteristics and screening status.

Results: Participants who were aged 50 to 64, who did not have health insurance, or who had an annual household income of $15,000 or less were significantly less likely than their counterparts to be in compliance with screening guidelines. Those who reported having a health care provider, having 5 or more health care visits during the past year, and receiving physician advice for colorectal screening were more likely to be in compliance with screening guidelines. Although a larger percentage of white participants were in compliance with screening guidelines, blacks had higher screening rates than whites when we controlled for screening advice.

Conclusion: Survey results informed efforts to decrease disparities in colorectal cancer screening in Arkansas. Efforts should focus on reimbursing providers and patients for screening costs, encouraging the use of physicians as a point of entry to screening programs, and promoting a balanced approach (ie, multiple options) to screening recommendations. Our methods established a model for developing screening programs for medically underserved populations.
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http://dx.doi.org/10.5888/pcd9.110256DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3475514PMC
November 2012

Late effects in hematopoietic cell transplant recipients with acquired severe aplastic anemia: a report from the late effects working committee of the center for international blood and marrow transplant research.

Biol Blood Marrow Transplant 2012 Dec 1;18(12):1776-84. Epub 2012 Aug 1.

Department of Hematology, Children's Hospital of Orange County, Orange, California, USA.

With improvements in hematopoietic cell transplant (HCT) outcomes for severe aplastic anemia (SAA), there is a growing population of SAA survivors after HCT. However, there is a paucity of information regarding late effects that occur after HCT in SAA survivors. This study describes the malignant and nonmalignant late effects in survivors with SAA after HCT. A descriptive analysis was conducted of 1718 patients post-HCT for acquired SAA between 1995 and 2006 reported to the Center for International Blood and Marrow Transplant Research (CIBMTR). The prevalence and cumulative incidence estimates of late effects are reported for 1-year HCT survivors with SAA. Of the HCT recipients, 1176 (68.5%) and 542 (31.5%) patients underwent a matched sibling donor (MSD) or unrelated donor (URD) HCT, respectively. The median age at the time of HCT was 20 years. The median interval from diagnosis to transplantation was 3 months for MSD HCT and 14 months for URD HCT. The median follow-up was 70 months and 67 months for MSD and URD HCT survivors, respectively. Overall survival at 1 year, 2 years, and 5 years for the entire cohort was 76% (95% confidence interval [CI]: 74-78), 73% (95% CI: 71-75), and 70% (95% CI: 68-72). Among 1-year survivors of MSD HCT, 6% had 1 late effect and 1% had multiple late effects. For 1-year survivors of URD HCT, 13% had 1 late effect and 2% had multiple late effects. Among survivors of MSD HCT, the cumulative incidence estimates of developing late effects were all <3% and did not increase over time. In contrast, for recipients of URD HCT, the cumulative incidence of developing several late effects exceeded 3% by 5 years: gonadal dysfunction 10.5% (95% CI: 7.3-14.3), growth disturbance 7.2% (95% CI: 4.4-10.7), avascular necrosis 6.3% (95% CI: 3.6-9.7), hypothyroidism 5.5% (95% CI: 2.8-9.0), and cataracts 5.1% (95% CI: 2.9-8.0). Our results indicated that all patients undergoing HCT for SAA remain at risk for late effects, must be counseled about, and should be monitored for late effects for the remainder of their lives.
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http://dx.doi.org/10.1016/j.bbmt.2012.06.018DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3496823PMC
December 2012

Relationship of race/ethnicity and survival after single umbilical cord blood transplantation for adults and children with leukemia and myelodysplastic syndromes.

Biol Blood Marrow Transplant 2012 Jun 4;18(6):903-12. Epub 2011 Nov 4.

Division of Hematology/Oncology, Massachusetts General Hospital, Boston, MA 02114, USA.

The relationship of race/ethnicity with outcomes of umbilical cord blood transplantation (UCBT) is not well known. We analyzed the association between race/ethnicity and outcomes of unrelated single UCBT for leukemia and myelodysplastic syndromes. Our retrospective cohort study consisted of 885 adults and children (612 whites, 145 blacks, and 128 Hispanics) who received unrelated single UCBT for leukemia and myelodysplastic syndromes between 1995 and 2006 and were reported to the Center for International Blood and Marrow Transplant Research. A 5-6/6 HLA-matched unit with a total nucleated cell count infused of ≥2.5 × 10(7)/kg was given to 40% white and 42% Hispanic, but only 21% black patients. Overall survival at 2 years was 44% for whites, 34% for blacks, and 46% for Hispanics (P = .008). In multivariate analysis adjusting for patient, disease, and treatment factors (including HLA match and cell dose), blacks had inferior overall survival (relative risk of death, 1.31; P = .02), whereas overall survival of Hispanics was similar (relative risk, 1.03; P = .81) to that of whites. For all patients, younger age, early-stage disease, use of units with higher cell dose, and performance status ≥80 were independent predictors of improved survival. Black patients and white patients infused with well-matched cords had comparable survival; similarly, black and white patients receiving units with adequate cell dose had similar survival. These results suggest that blacks have inferior survival to whites after single UCBT, but outcomes are improved when units with a higher cell dose are used.
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http://dx.doi.org/10.1016/j.bbmt.2011.10.040DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3874400PMC
June 2012

Cancer Survivorship Care: Summarizing the 6 Tools for Success.

Fed Pract 2011 Sep;28(Suppl 6):43S-49S

the Department of Psychiatry at Harvard Medical School and director of the Geriatric Mental Health Clinic, Brockton Division, at the VA Boston Healthcare System, both in Boston, Massachusetts.

With nearly 12 million cancer survivors living in the United States today-including those receiving care within the VHA-attention is quickly shifting toward care of the cancer survivor. Although challenging, these authors offer essential tools for long-term management of this fast-growing population.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4429039PMC
September 2011

Evaluating coalition capacity to strengthen community-academic partnerships addressing cancer disparities.

J Cancer Educ 2011 Dec;26(4):658-63

School of Education, University of Arkansas at Pine Bluff, Little Rock, AR, USA.

The Arkansas Cancer Connection Program is a community-academic partnership between the University of Arkansas for Medical Sciences and nine community-based coalitions designed to address cancer health disparities through community-based participatory research. In 2005, a survey measuring coalition capacity was administered to 51 Cancer Council members to assess training needs and increase coalition capacity. The highest scoring components were leadership and member engagement while the lowest were development and capacity effectiveness. Effectiveness correlated with aspects of coalition capacity. The evaluation identified training needs, which were met by projects leveraging the coalition's strengths to advance community-based participatory research addressing cancer disparities.
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http://dx.doi.org/10.1007/s13187-011-0240-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7057538PMC
December 2011

Development of a community-based participatory colorectal cancer screening intervention to address disparities, Arkansas, 2008-2009.

Prev Chronic Dis 2011 Mar 15;8(2):A47. Epub 2011 Feb 15.

University of Arkansas for Medical Sciences, Department of Health Behavior and Health Education, Little Rock, AR 72205-7199, USA.

Background: The death rate from colorectal cancer is high and affects poor and medically underserved populations disproportionately. In the United States, health disparities are particularly acute in the Lower Mississippi River Delta region. Because many in the region have limited access to basic health care resources, they are not screened for cancer, even though screening is one of the most effective strategies to prevent colorectal cancer. Community-based participatory research is a promising approach to prevent colorectal cancer in this population.

Community Context: The Empowering Communities for Life program was implemented in 2 underserved counties in the Arkansas Lower Mississippi River Delta. The program arose from a 9-year partnership between the University of Arkansas for Medical Sciences and 9 cancer councils across Arkansas.

Methods: Empowering Communities for Life is a community-based participatory intervention designed to increase colorectal cancer screening in rural, underserved communities through fecal occult blood testing. Community and academic partners collaborated to develop research infrastructure, intervention materials and methods, and the assessment instrument.

Outcome: Project outcomes were strengthened community-academic partnerships, certification of community partners in conducting human subjects research, development of a randomized controlled design to test the intervention's efficacy, an interactive PowerPoint presentation, an informational pamphlet, the certification of 6 lay health advisors and 22 role models to provide the intervention, and an assessment tool using an audience response system.

Interpretation: Lessons learned in working collaboratively with diverse groups include the importance of meeting face to face and listening.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3073440PMC
March 2011

Change in mortality from coronary heart disease and stroke in Arkansas (1979 to 2007).

Am J Cardiol 2011 Jan;107(2):156-60

Department of Medicine, University of Arkansas for Medical Sciences, Little Rock, USA.

Coronary heart disease (CHD)- and stroke-related mortality rates have been greater in the Southern states than in the rest of the United States. Although a sustained decrease in mortality from CHD and stroke has occurred in the United States during the past 3 decades, it is not known whether a similar decrease occurred in the Southern states. We examined CHD- and stroke-related deaths from 1979 to 2007 in Arkansas and observed a marked and steady decrease in both death rates. A concurrent increase occurred in the prevalence of obesity, hypertension, and diabetes mellitus, with a decrease in physical inactivity and poverty during this period. However, we noted a significant decrease in the per capita cigarette sales in Arkansas that closely paralleled the decrease in CHD- and stroke-related deaths. In conclusion, although the extensive use of cardioprotective drugs, as well as coronary revascularization, might have contributed to the decrease, we have provided evidence to suggest that the decrease in cigarette smoking was a very important factor in the decrease in CHD- and stroke-related mortality.
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http://dx.doi.org/10.1016/j.amjcard.2010.09.009DOI Listing
January 2011