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The NCCN 2023 Annual Congress: Hematologic Malignancies

Crystal S. Denlinger

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Perioperative Management of Anticoagulation and Antithrombotic Therapy

Presented by: Michael B. Streiff

The latest updates to the NCCN Guidelines for perioperative management of anticoagulation and antithrombotic therapies reflect significant changes in the use of bridging anticoagulation. For patients with low- to intermediate-risk atrial fibrillation, the standard of care has shifted toward reduced reliance on bridging anticoagulation. The rationale for this shift is based on the BRIDGE trial, which revealed a 3-fold greater risk of major bleeding without significant reduction in thrombotic outcomes in patients receiving bridging therapy. In patients with mechanical heart valves, findings from the PERIOP2 study led to similar conclusions. Both of these studies have contributed to a paradigm shift in perioperative anticoagulation management, pivoting toward personalized therapy based on patient-specific bleeding and thrombotic risks. For emergent or elective surgeries, the NCCN Guidelines provide a framework for more individualized decision-making, emphasizing the need for ongoing cooperation among physicians, surgeons, and patients.

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Relapsed/Refractory CLL/SLL: Overcoming Resistance to Covalent BTKi and/or BCL2 Inhibitors

Presented by: Brian T. Hill

We are now in the era of targeted therapy for frontline chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL), with current treatments demonstrating favorable long-term outcomes. However, patients with double-refractory CLL whose disease has relapsed or been refractory to treatment with both a BTK and BCL-2 inhibitor present a unique challenge; although the number of patients experiencing relapse after first-line chemoimmunotherapy is likely to decrease, the number of those with double-refractory CLL is expected to increase. Various treatment strategies have been explored and noncovalent Bruton’s tyrosine kinase inhibitors, such as pirtobrutinib, show activity in the double-refractory CLL population. Further research and prospective trials are needed to refine these approaches and improve outcomes for patients with relapsed/refractory CLL/SLL.

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Revolutionizing Hematologic Cancer Treatment: The Promise of Bispecific T-Cell Engagers

Presented by: Lihua E. Budde, Stacy Pak, and Lauren R. Seipel

The advent of bispecific T-cell engager (TCE) therapies has marked a turning point in the management of hematologic malignancies. Several clinical trials of these agents have led to approvals from the FDA, resulting in their subsequent incorporation into standard patient care. Although ongoing efforts are being made to optimize bispecific TCE therapies, a focus on their equitable distribution is needed. At the NCCN 2023 Annual Congress: Hematologic Malignancies, panelists presented clinical trial data, 2 case studies, and updates from NCCN Guidelines to develop an evidence-based approach for the use of these immunotherapies in various clinical contexts.

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Updates in the Management of Myelofibrosis

Presented by: Andrew T. Kuykendall

The JAK inhibitors ruxolitinib, fedratinib, and pacritinib have demonstrated significant activity in improving symptoms and spleen size, as well as quality of life, in patients with myelofibrosis. Additionally, the recent approval of another JAK inhibitor, momelotinib, for patients with myelofibrosis and anemia has further expanded the available treatment options for this malignancy. As research continues to reveal the best treatment strategies, clinical trials will remain an essential avenue for improving outcomes in this patient population.

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Volume 21 (2023): Issue 11 (Nov 2023)

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Acute and Chronic Complications After Treatment of Locoregional Anal Cancer: Prevention and Management Strategies

Leah Katz, David P. Horowitz, and Lisa A. Kachnic

Definitive chemoradiotherapy (CRT) for anal cancer spares patients the morbidity of a colostomy surgery and optimizes cancer outcomes. CRT, however, has introduced a unique acute and chronic toxicity profile, which has greatly improved over the years with the introduction of advanced radiotherapy techniques. This article provides the multidisciplinary care team with practical tools to mitigate and manage acute and chronic complications from definitive treatment of anal cancer.

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Association Between Pretreatment Chest Imaging and Immune Checkpoint Inhibitor Pneumonitis Among Patients With Lung Cancer

Alexander Wong, Maria Riley, Songzhu Zhao, Jessica Zimmer, Matthew Viveiros, Jing Gennie Wang, Vincent Esguerra, Mingjia Li, Gabrielle Lopez, Kari Kendra, David P. Carbone, Kai He, Asrar Alahmadi, Jacob Kaufman, Regan M. Memmott, Peter G. Shields, Jeremy Brownstein, Karl Haglund, Meng Welliver, Gregory A. Otterson, Carolyn J. Presley, Lai Wei, Dwight H. Owen, and Kevin Ho

Background: Immune checkpoint inhibitors (ICIs) are a first-line and perioperative treatment for lung cancer. Pneumonitis is a potentially life-threatening complication of ICI treatment in 2% to 5% of patients; however, risk factors for developing ICI pneumonitis (ICI-p) remain undefined. Methods: We conducted a retrospective cohort study of consecutive patients with lung cancer who received at least one dose of ICI from 2015 through 2020 at The Ohio State University. Pneumonitis cases were documented by the treating oncologist and retrospectively evaluated for agreement between an oncologist and a pulmonologist. Patient demographic and clinical characteristics were recorded and summarized between those with and without pneumonitis for the overall cohort. Univariate and multivariable survival analyses using the Fine-Gray competing risk model were used to examine the associations. Results: A total of 471 patients with lung cancer were included, of which 402 had non–small cell lung cancer and 69 had small cell lung cancer; 39 (8%) patients in the overall cohort developed ICI-p. Preexisting interstitial abnormalities and prior chest radiation were both significantly associated with ICI-p on univariate analysis (hazard ratio [HR], 8.91; 95% CI, 4.69–16.92; P<.001; and HR, 2.81; 95% CI, 1.50–5.28; P=.001). On multivariable analyses, interstitial abnormalities remained a strong independent risk factor for ICI-p when controlling for chest radiation and type of immunotherapy (HR, 9.77; 95% CI, 5.17–18.46; P<.001). Among patients with ICI-p (n=39), those with severe (grade 3–5) pneumonitis had worse overall survival compared with those with mild (grade 1 or 2) pneumonitis (P=.001). Abnormal pulmonary function test results at both 12 and 18 months prior to ICI initiation were not significantly associated with ICI-p. Conclusions: Preexisting interstitial abnormalities on chest CT and prior chest radiation are independent risk factors that are strongly associated with ICI-p in patients with lung cancer. These findings highlight a potential need for closer observation for ICI-p among patients with these risk factors.

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Associations Between Surrogates’ Decisional Regret Trajectories and Bereavement Outcomes

Fur-Hsing Wen, Chia-Hsun Hsieh, Wen-Chi Shen, Ming-Mo Hou, Po-Jung Su, Wen-Chi Chou, Jen-Shi Chen, Wen-Cheng Chang, and Siew Tzuh Tang

Background: Family surrogates experience heterogeneous decisional regret and negative long-lasting postdecision impacts. Cross-sectional findings on the associations between decisional regret and surrogates’ bereavement outcomes are conflicting and cannot illustrate the directional and dynamic evolution of these associations. In this study, we sought to longitudinally examine the associations between 4 previously identified decisional-regret trajectories and bereavement outcomes among family surrogates of terminally ill patients with cancer. Patients and Methods: This prospective, longitudinal, observational study included 377 family surrogates. Decisional regret was measured using the 5-item Decision Regret Scale, and 4 decisional regret trajectories were identified: resilient, delayed-recovery, late-emerging, and increasing-prolonged. Associations between bereavement outcomes (depressive symptoms, prolonged grief symptoms, and physical and mental health-related quality of life [HRQoL]) and decisional-regret trajectories were examined simultaneously by multivariate hierarchical linear modeling using the resilient trajectory as a reference. Results: Surrogates in the delayed-recovery, late-emerging, and increasing-prolonged trajectories experienced significantly higher symptoms of prolonged grief (β [95% CI], 1.815 [0.782 to 2.848]; 2.312 [0.834 to 3.790]; and 7.806 [2.681 to 12.931], respectively) and poorer physical HRQoL (−1.615 [−2.844 to −0.386]; −1.634 [−3.226 to −0.042]; and −4.749 [−9.380 to −0.118], respectively) compared with those in the resilient trajectory. Membership in the late-emerging and increasing-prolonged trajectories was associated with higher symptoms of depression (β [95% CI], 2.942 [1.045 to 4.839] and 8.766 [2.864 to 14.668], respectively), whereas only surrogates in the increasing-prolonged decisional-regret trajectory reported significantly worse mental HRQoL (−4.823 [−8.216 to −1.430]) than those in the resilient trajectory. Conclusions: Surrogates who experienced delayed-recovery, unresolved, or late-emerging decisional regret may carry ceaseless doubt, guilt, or self-blame for patient suffering, leading to profound symptoms of prolonged grief, depressive symptoms, and worse HRQoL over their first 2 bereavement years.

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Authors’ Reply to the Letter to the Editor by Nguyen et al

Xudong Ni and Yao Zhu