Publications by authors named "Rebekah Rittberg"

13 Publications

  • Page 1 of 1

Radiation Induced Abscopal Effect in a Patient With Malignant Pleural Mesothelioma on Pembrolizumab.

Cureus 2022 Feb 12;14(2):e22159. Epub 2022 Feb 12.

Medicine, University of British Columbia, Vancouver, CAN.

Abscopal effect is a rare phenomenon in which treatment benefit from radiotherapy (RT) is seen outside the target field due to activation of the immune system inducing an anti-tumor effect. This phenomenon has been reported in cancer patients receiving immune checkpoint inhibitors (ICI). Here we report a case of presumed abscopal effect in malignant mesothelioma. The patient received second-line single-agent pembrolizumab however had disease progression after four cycles leading to palliative RT (20 Gray) to the right mainstem bronchus. Follow-up radiographic imaging confirmed benefit and pembrolizumab was continued. Follow-up computed tomography (CT) five months after RT, showed marked radiographic improvement of all measurable diseases with improvement in right-sided aerated lung volume. Because of the original disease progression on pembrolizumab, with marked improvements within and outside the RT field after RT, treatment response was presumed due to the abscopal effect.
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http://dx.doi.org/10.7759/cureus.22159DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8920754PMC
February 2022

Treatment Patterns, Toxicity, and Outcomes of Older Adults With Advanced Pancreatic Cancer Receiving First-line Palliative Chemotherapy.

Am J Clin Oncol 2022 02;45(2):55-60

Departments of Internal Medicine.

Objectives: Advanced pancreatic cancer (APC) disproportionately impacts older adults. Randomized trials demonstrate improved overall survival (OS) with combination chemotherapy including 5-fluorouracil, irinotecan, leucovorin, and oxaliplatin (FOLFIRINOX) or nab-paclitaxel and gemcitabine compared with gemcitabine alone, but with increased toxicity. Older adults are at increased risk of side effects from chemotherapy. The aim of this study was to assess the efficacy and toxicity of chemotherapy in older adults with APC.

Methods: Patients diagnosed with APC from 2011 to 2016 were identified using the Manitoba Cancer Registry. Patient and treatment characteristics, toxicity, and outcomes of patients 65 years of age and above treated with palliative chemotherapy were compared by treatment regimen. OS was assessed using the Kaplan-Meier method. A Cox regression was used to identify independent predictors of OS.

Results: A total of 87 patients aged 65 years and above received palliative chemotherapy: 52 (59.7%) FOLFIRINOX, 21 (24.1%) nab-paclitaxel and gemcitabine, and 14 (16.1%) gemcitabine, with a median age of 69 (65 to 84), 75 (65 to 88), and 73 (67 to 82), Eastern Cooperative Oncology Group (ECOG) performance status difference in hematologic toxicity between regimens (P=0.807). An increase in nonhematologic toxicity was seen with FOLFIRINOX (P<0.001), specifically neuropathy (P=0.008), fatigue (P<0.001), and nausea/vomiting (P=0.008). FOLFIRINOX was associated with improved radiologic response (P=0.05) and OS (P=0.035). PS, baseline carbohydrate antigen 19-9 level, and chemotherapy regimen were independent predictors of survival.

Conclusions: FOLFIRINOX is associated with improved response and OS in older adults with APC. FOLFIRINOX has a manageable safety profile in this population and should be considered in fit older adults with APC.
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http://dx.doi.org/10.1097/COC.0000000000000882DOI Listing
February 2022

Treatment and Prevention of Brain Metastases in Small Cell Lung Cancer.

Am J Clin Oncol 2021 12;44(12):629-638

Department of Internal Medicine, University of Manitoba.

Central nervous system (CNS) metastasis will develop in 50% of small cell lung cancer (SCLC) patients throughout disease course. Development of CNS metastasis poses a particular treatment dilemma due to the accompanied cognitive changes, poor permeability of the blood-brain barrier to systemic therapy and relatively advanced state of disease. Survival of patients with untreated SCLC brain metastases is generally <3 months with whole brain radiotherapy used as first-line management in most SCLC patients. To prevent development of CNS metastasis prophylactic cranial irradiation (PCI) is recommended in limited stage disease, after response to chemotherapy and radiation, while PCI may be considered in extensive stage disease after favorable response to upfront treatment. Neurocognitive toxicity with whole brain radiotherapy and PCI is a concern and remains difficult to predict. The mechanism of toxicity is likely multifactorial, but a potential mechanism of injury to the hippocampus has led to hippocampal sparing radiation techniques. Treatment of established non-small cell lung cancer CNS metastases has increasingly focused on using stereotactic radiotherapy (SRS) and it is tempting to extrapolate these results to SCLC. In this review, we explore the evidence surrounding the prediction, prevention, detection, and treatment of CNS metastases in SCLC. We further review whether existing evidence supports extrapolating less toxic treatments to SCLC patients with CNS metastases and discuss trials that may shed more light on this question.
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http://dx.doi.org/10.1097/COC.0000000000000867DOI Listing
December 2021

Feasibility of Randomized Controlled Trials for Cancer Drugs Approved by the Food and Drug Administration Based on Single-Arm Studies.

JNCI Cancer Spectr 2021 08 30;5(4). Epub 2021 Jun 30.

Section of Hematology/Oncology, Department of Internal Medicine, University of Manitoba, Winnipeg, MB, Canada.

Background: The US Food and Drug Administration (FDA) introduced an Accelerated Approval (AA) pathway to expedite patient access to new drugs. AA accepts less rigorous trial designs, including single-arm studies (SAS), owing to perceived lack of feasibility of timely randomized controlled trials (RCTs).

Methods: We designed hypothetical RCTs with endpoints of overall response rate (ORR), progression-free survival (PFS), and overall survival (OS) for FDA approvals based on SAS for solid tumors during 2010-2019. Existing standards of care served as controls. RCTs were designed to detect a difference with power of 0.80, α-error of 5% (2-sided), and 1:1 randomization. Accrual duration was estimated based on participation by less than 5% of eligible patients derived from cancer-specific incidence and mortality rates in the United States.

Results: Of 172 (18.0%) approvals during the study period, 31 (18.0%) were based on SAS. Median sample size was 104 (range = 23-411), and 77.4% were AA. All studies reported ORR, 55% reported duration of response, 19.4% reported PFS, and 22.5% reported OS. Median sample sizes needed to conduct RCTs with endpoints of ORR, PFS, and OS were 206, 130, and 396, respectively. It would have been theoretically possible to conduct RCTs within duration comparable with that required by SAS for 84.6%, 94.1%, and 80.0% of approvals with endpoints of ORR, PFS, and OS, respectively.

Conclusion: An overwhelming majority of FDA approvals based on SAS should be feasible as RCTs within a reasonable time frame. Given the collateral harms to patients and to scientific rigor, drug approval based on SAS should only be permitted under exceptional circumstances.
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http://dx.doi.org/10.1093/jncics/pkab061DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8364671PMC
August 2021

Canadian Cancer Centre Response to COVID-19 Pandemic: A National and Provincial Response.

Curr Oncol 2020 12 31;28(1):233-251. Epub 2020 Dec 31.

Section of Hematology/Oncology, Department of Internal Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB R3A 1R9, Canada.

Background: COVID-19 has spread rapidly, requiring health delivery systems to undertake dramatic transformations. To evaluate these system changes, we undertook one of the first Canadian health delivery system reviews and the first Canadian cancer centre evaluation of pandemic system modifications.

Methods: Questionnaires were distributed to the Canadian Association of Provincial Cancer Agencies (CAPCA) members in order to assess changes to cancer centre services and patient management. Documentation relating to COVID-19 from the CAPCA electronic space was accessed, and all publicly available cancer centre documentation related to COVID-19 was reviewed.

Results: Seven provinces completed the questionnaire and had documentation available from the CAPCA electronic space. All screening programs across Canada were suspended. In most provinces surveyed, ≥50% of outpatient appointments were occurring virtually, with <25% using video platforms. Generally, the impact on diagnostic imaging and new patient referrals correlated with the impact of COVID-19. Most provinces had a reduction in operating room availability, with chemotherapy and radiation treatments continuing. Public health modification, including personal protective equipment and screening staff, varied across the country.

Conclusion: Canadian cancer centres underwent a rapid and aggressive transformation of services in response to COVID-19, with many similarities and differences across provinces. In part, this response was facilitated by communication under a national association, which in Canada remains unique to cancer. This response may serve to inform changes in other jurisdictions or disease states now and in future waves of the pandemic, as well as a record of changes for future health services and patient outcome research.
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http://dx.doi.org/10.3390/curroncol28010026DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7900889PMC
December 2020

Immune Checkpoint Inhibition as Primary Adjuvant Therapy for an -Mutant Anaplastic Astrocytoma in a Patient with CMMRD: A Case Report-Usage of Immune Checkpoint Inhibition in CMMRD.

Curr Oncol 2021 02 1;28(1):757-766. Epub 2021 Feb 1.

Section of Hematology/Oncology, Department of Internal Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB R3E 0V9, Canada.

Constitutional mismatch repair deficiency (CMMRD) is a rare autosomal recessive hereditary cancer syndrome due to biallelic germline mutation involving one of the four DNA mismatch repair genes. Here we present a case of a young female with CMMRD, homozygous for the c.2002A>G mutation in the gene. She developed an early stage adenocarcinoma of the colon at the age of 14. Surveillance MRI of the brain at age 18 resulted in the detection of an asymptomatic brain cancer. On resection, this was diagnosed as an anaplastic astrocytoma. Due to emerging literature suggesting benefit of immunotherapy in this patient population, she was treated with adjuvant dual immune checkpoint inhibition, avoiding radiation. The patient remains stable with no evidence of progression 20 months after resection. The patient's clinical course, as well as the rational for considering adjuvant immunotherapy in patients with CMMRD are discussed in this report.
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http://dx.doi.org/10.3390/curroncol28010074DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7985791PMC
February 2021

Immunotherapy Benefit in a Patient With Non-Small Cell Lung Cancer and a Rare BRAF Mutation.

Cureus 2020 Oct 28;12(10):e11224. Epub 2020 Oct 28.

Oncology and Hematology, CancerCare Manitoba, University of Manitoba, Winnipeg, CAN.

Immunotherapy is less effective in non-small cell lung cancer (NSCLC) with driver mutations in epidermal growth factor receptor or anaplastic lymphoma kinase and some may extrapolate this trend to other driver mutations. Up to 4% of NSCLC cases contain a mutation. Most mutations are V600E, and little is known about the impact of treatment in rare G469A mutations. We present a case of a patient found to have G469A mutated NSCLC. She was diagnosed with Stage IIIB NSCLC and treated with concurrent chemotherapy and radiation. Post-treatment imaging demonstrated disease progression and she was started on nivolumab, resulting in a dramatic and prolonged response which is ongoing after 76 cycles. Her substantial response and prolonged benefit suggest that -mutated NSCLC may respond better than - or -driven disease to immunotherapy. Due to the rarity of specific mutations, this case adds to the limited current published literature on NSCLC harbouring a G469A mutation and suggests that immunotherapy is a reasonable treatment option.
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http://dx.doi.org/10.7759/cureus.11224DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7704186PMC
October 2020

Utility of the modified frailty index in predicting toxicity and cancer outcomes for older adults with advanced pancreatic cancer receiving first-line palliative chemotherapy.

J Geriatr Oncol 2021 01 11;12(1):112-117. Epub 2020 Aug 11.

Department of Internal Medicine, University of Manitoba, 820 Sherbrook St, R3A 1R9 Winnipeg, MB, Canada; CancerCare Manitoba, Department of Hematology and Medical Oncology, 675 McDermot Ave, R3E 0V9 Winnipeg, MB, Canada; Research Institute in Oncology and Hematology, CancerCare Manitoba, 675 McDermot Ave, R3E 0V9 Winnipeg, MB, Canada. Electronic address:

Background: Pancreatic cancer primarily affects older adults and is associated with a high morbidity and mortality. Identifying frail patients with advanced pancreatic cancer (APC) helps to mitigate the risks of chemotherapy (CT). The modified Frailty Index (mFI) is an 11-point deficit measure used to identify frail patients. Although validated in surgical fields, it has not been assessed in an APC population.

Methods: A retrospective cohort study evaluated consecutive patients, aged ≥65 years, diagnosed with APC from 2011 to 2016 and treated with first line palliative-intent CT. mFI was categorized as: 0, 1, 2 and ≥ 3. Descriptive analysis was completed comparing patient characteristics, CT toxicity, response to treatment, and overall survival (OS) by mFI score.

Results: 87 patients with APC received palliative CT. Median age was 71 (65-88), 54% male. A mFI score of 0, 1, 2, and ≥ 3 occurred for 20 (23%), 28 (32.2%), 25 (28.7%) and 14 (16.1%) patients respectively. Patients with mFI scores of 0-1 were more likely to receive: 5-fluorouracil, irinotecan and oxaliplatin. CT toxicity, emergency room (ED) and urgent cancer clinic (UCC) presentation, and hospitalization length did not differ by mFI. Longer OS was associated with better ECOG and receipt of combination CT.

Conclusion: This is the first assessment of the mFI in an APC population receiving CT. The mFI score did not correlate with toxicity, ED/UCC visits, hospitalization length or OS. Ongoing assessment of tools that accurately identify frailty in patients with APC is critical to help better select candidates for aggressive CT.
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http://dx.doi.org/10.1016/j.jgo.2020.07.004DOI Listing
January 2021

Effect of Hospitalization During First Chemotherapy and Performance Status on Small-cell Lung Cancer Outcomes.

Clin Lung Cancer 2020 09 26;21(5):e388-e404. Epub 2020 Feb 26.

Department of Internal Medicine, University of Manitoba, Winnipeg, MB, Canada; Department of Hematology and Medical Oncology, CancerCare Manitoba, Winnipeg, MB, Canada; Research Institute in Oncology and Hematology, CancerCare Manitoba, Winnipeg, MB, Canada. Electronic address:

Introduction: Small-cell lung cancer (SCLC) is highly responsive to chemotherapy (CT) and one of the few malignancies treated in hospitalized patients with poor Eastern Cooperative Oncology Group (ECOG) performance status (PS). Because of the little current information available on the outcomes experienced by hospitalized patients with SCLC receiving CT, we explored the outcomes for these patients to improve the evidence base for practice.

Materials And Methods: We conducted a retrospective cohort study to evaluate patients with a diagnosis of SCLC and treated with CT during a 10-year period. Progression-free survival (PFS) and overall survival (OS) were evaluated according to site of first CT (inpatient vs. outpatient) and PS. Multivariable analysis was completed to assess for independent survival predictors.

Results: A total of 530 patients with SCLC were treated, with 82 (15%) receiving their first CT in hospital. Inpatients had a greater burden of disease and poorer PS. Neutropenia, thrombocytopenia, nephrotoxicity, and fatigue were all experienced less often by the inpatient cohort (P < .001, P < .001, P < .001, and P = .007, respectively). For inpatients and outpatients, the OS rate at 12, 24, and 60 months was 22%, 9%, and 7% and 43%, 20%, and 9%, respectively (P < .001 for all). The median PFS and OS were longer for outpatients and highly functional patients. On multivariable analysis, ECOG PS was an independent predictor of the outcome and the site of first CT was not (P = .04 and P = .49, respectively).

Conclusion: Patients with SCLC initially treated as inpatients and those with poor functional status had shorter PFS and OS; however, some experienced long-term survival, including 5-year survival of 7% for the inpatient cohort and 5% for the ECOG PS 3-4 cohort. CT toxicities were less common in the inpatient cohort, validating that administration of CT in hospital should be considered for these patients because they could experience a meaningful long-term response to therapy.
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http://dx.doi.org/10.1016/j.cllc.2020.02.013DOI Listing
September 2020

Assessing the learning needs of the multidisciplinary team on geriatric oncology and frailty.

J Geriatr Oncol 2019 09 26;10(5):829-831. Epub 2018 Dec 26.

Department of Internal Medicine, University of Manitoba, Winnipeg, MB, Canada; Cancer Care Manitoba, Department of Hematology and Medical Oncology, Winnipeg, MB, Canada; Research Institute in Oncology and Hematology, Winnipeg, MB, Canada. Electronic address:

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http://dx.doi.org/10.1016/j.jgo.2018.12.002DOI Listing
September 2019

Salvage HIFU for biopsy confirmed local prostate cancer recurrence after radical prostatectomy and radiation therapy: Case report and literature review.

Can Urol Assoc J 2015 Sep-Oct;9(9-10):E671-2. Epub 2015 Sep 9.

Section of Urology, Department of Surgery, University of Manitoba, Winnipeg, MB;

High-intensity focused ultrasound (HIFU) is a treatment option for low- and intermediate-risk prostate cancer and more recently has been used as salvage therapy after failed radiation therapy. We present a case of local recurrence with biochemical failure after radical prostatectomy and salvage external beam radiation therapy with salvage HIFU without biochemical recurrence at 20 months.
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http://dx.doi.org/10.5489/cuaj.2888DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4581943PMC
October 2015

A qualitative analysis of methotrexate self-injection education videos on YouTube.

Clin Rheumatol 2016 May 6;35(5):1329-33. Epub 2015 Mar 6.

Department of Medicine, 562 Heritage Medical Research Centre, University of Alberta, Edmonton, Alberta, T6G 2S2, Canada.

The aim of this study is to identify and evaluate the quality of videos for patients available on YouTube for learning to self-administer subcutaneous methotrexate. Using the search term "Methotrexate injection," two clinical reviewers analyzed the first 60 videos on YouTube. Source and search rank of video, audience interaction, video duration, and time since video was uploaded on YouTube were recorded. Videos were classified as useful, misleading, or a personal patient view. Videos were rated for reliability, comprehensiveness, and global quality scale (GQS). Reasons for misleading videos were documented, and patient videos were documented as being either positive or negative towards methotrexate (MTX) injection. Fifty-one English videos overlapped between the two geographic locations; 10 videos were classified as useful (19.6 %), 14 misleading (27.5 %), and 27 personal patient view (52.9 %). Total views of videos were 161,028: 19.2 % useful, 72.8 % patient, and 8.0 % misleading. Mean GQS: 4.2 (±1.0) useful, 1.6 (±1.1) misleading, and 2.0 (±0.9) for patient videos (p < 0.0001). Mean reliability: 3.3 (±0.6) useful, 0.9 (±1.2) misleading, and 1.0 (±0.7) for patient videos (p < 0.0001). Comprehensiveness: 2.2 (±1.9) useful, 0.1 (±0.3) misleading, and 1.5 (±1.5) for patient view videos (p = 0.0027). This study demonstrates a minority of videos are useful for teaching MTX injection. Further, video quality does not correlate with video views. While web video may be an additional educational tool available, clinicians need to be familiar with specific resources to help guide and educate their patients to ensure best outcomes.
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http://dx.doi.org/10.1007/s10067-015-2910-5DOI Listing
May 2016

Angiomyolipoma with caval extension and regional nodal involvement: Aggressive behaviour or just rare natural history? Case report and review of literature.

Can Urol Assoc J 2014 Mar;8(3-4):E276-8

Department of Surgery, Section of Urology, University of Manitoba, Winnipeg, MB;

Renal angiomyolipoma (AML) is predominantly a non-aggressive benign tumour. Cases of more aggressive AMLs are present in the literature. We present 2 cases of aggressive AML behaviour. The first case is an AML with vascular extension in a young female and the second case is of AML found in regional lymph nodes in a female with a left renal AML and renal cell carcinoma.
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http://dx.doi.org/10.5489/cuaj.1781DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4001661PMC
March 2014
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