Returning to Work After Stroke

Factors such as intravenous thrombolysis and occupational therapy at 3 months independently and significantly predicted which patients would be employed 1 year after a first stroke, in a new registry study.

Overall, 34% of patients who were working at the time of their stroke were re-employed at 3 months. However, this proportion decreased to 27% at 1 year, to 25% at 5 years, and to 10% at 10 years.

“Another trend we saw is that patients who returned to work within 1 year were more likely to still be employed at 10 years,” said Arup Sen, MRCP, from the NIHR Biomedical Research Centre at Guy’s and St. Thomas’ NHS Foundation Trust of Ageing and Health at King’s College London, United Kingdom. “This suggests, in terms of planning post-stroke rehab, the time to get patients back to work would be as soon as possible — and ideally within the first year.”

In addition, a large proportion of the independent patients are not returning to work initially, Sen told Medscape Medical News. Only 39% of the functionally independent patients were back to work at 1 year, although this increased to 47% at 5 years and 69% at 10 years.

“We wanted to look at this in more detail because little is known about the long-term factors affecting return to work at different time points post-stroke,” he said during an ePoster presentation here at the 4th European Stroke Organisation Conference (ESOC) 2018. The researchers defined functional independence as a Barthel Index score greater than 90.

Sen and colleagues reviewed data for 5609 multiethnic urban patients from 2005 to 2014 from the South London Stroke Registry maintained by the Royal College of London. They further evaluated the 940 patients, or 17%, who were employed at the time the stroke occurred.

Emotional Toll of Returning to Work

The investigators also assessed anxiety and depression by using scores on the Hospital Anxiety and Depression Scale and 12-Item Short-Form survey at 1, 5, and 10 years. Potential long-term negative emotional consequences associated with a return to work emerged.

People who returned to work after stroke were statistically significantly more likely to experience anxiety and depression at 1 year (P < .01) and 5 years (P < .05) than those who did not.

“It’s paradoxical,” Sen said. “Previous studies have shown that return to work is seen as a recovery milestone.”

“Although patients are physically ready to go back to work, there may be other reasons for increased stress levels around going back to work,” he said, “such as lack of coping or adaption, social factors or workplace factors such as the work climate.”

Returning to work is a dynamic, multifaceted process that is difficult to explain by measures such as the Barthel Index alone, Sen said. “There may be other factors like fatigue, cognition, and personal factors.”

Quality-of-life concerns, including emotional issues, can persist even after successful treatment of acute ischemic stroke, suggested a study of 75 patients presented at the World Congress of Stroke in 2016.

In addition, other research in 279 people employed at the time of a stroke demonstrated that post-stroke depression predicted not returning to work almost to the same extent as physical disability.

Manual vs Nonmanual Labor

A meeting attendee asked Sen if he stratified patients by the type of employment before their stroke. Because it was a registry study, the data only indicated if a person was involved in manual labor or not, he replied.

“Interestingly, we did do a subanalysis,” he noted. “The nonmanual labor patients were less likely to return to work.” He speculated that more people in manual labor might have been physically able to go back to work, whereas people in office jobs may have been limited because of deficits in cognition.

However, session moderator Kenneth Butcher, MD, PhD, professor of neurology at the University of Alberta, Edmonton, Canada, speculated it may be more a matter of means. “In my experience, the white collar workers have the financial means to retire after they’ve had a stroke,” he said. “I think in the future you need to ask people if they want to return to work.”

“I think motivation is an important factor as well,” Sen said. “There also could be financial pressures and family pressures.”

“I think the biggest predictor of return to work is your age,” Butcher told Medscape Medical News when asked to comment. “The point estimate [for patient age] is very close to unity here, which means most stroke patients are close to the retirement age already.”

But the findings are still “quite significant,” he added. “He did show, in terms of occupation, that white collar workers were less likely to return to work. It’s plausible and requires more research, but it could also be possible that those people don’t need to return to work.”

Stroke is a life-changing event, “and if you’re in an occupation where you’re just working because you can — you might say, ‘That’s enough. I’m going to go retire now,'” he said.

The findings are interesting, but more prospective research looking at possible confounders is needed, Butcher added.

“Our database is limited, but I think we definitely will try to take the research forward,” Sen said.

Sen and Butcher have disclosed no relevant financial relationships.

4th European Stroke Organisation Conference (ESOC) 2018. Presented May 17, 2018.

https://wb.md/2xwOrdS

‘Cardiology culture’ a turnoff for women

It’s no wonder that fewer women opt to go into cardiology, given the work-life balance issues and gender discrimination problems that plague the field. The question is: will the community do something about it?

A survey of internal medicine resident physicians revealed that the top perceptions of cardiology were that, as a field, it is associated with adverse job conditions, interference with family life, and lack of diversity. Women and future non-cardiologists valued work-life balance more highly than did men or those committed to cardiology.

In turn, women and future non-cardiologists also had worse perceptions of cardiology as a whole, according to the survey results published online in JAMA Cardiology by Pamela Douglas, MD, of Duke University School of Medicine in Durham, North Carolina, and colleagues on the American College of Cardiology (ACC) Task Force on Diversity and Inclusion and the ACC Women in Cardiology Council.

“Little is known about factors influencing the selection of cardiology as a career. Our survey data suggest that internal medicine trainees’ most valued aspects of professional development related to work-life balance and mentorship, while their strongest perceptions of cardiology were of a negative culture and job description at odds with their perceived needs,” the authors concluded.

“Given the slight majority of female medical-school matriculants and internal medicine resident physicians, identifying and addressing cultural and societal barriers in women’s perceptions of cardiology is crucial for the field to access the full range of talent in internal medicine.”

The questionnaire had an overall response rate of 23.1%. Survey participants — totaling 1,123 individuals, or approximately 5% of all internal medicine trainees in the U.S. at the time — were contacted in 2009 and 2010 and came from 198 residency programs.

Poor Work-Life Balance

Coming in at the top of the list of professional development factors that were cited as being important to trainees were stable hours and positions that were family- and female-friendly.

And it is exactly these and other components of work-life balance — or perceived lack thereof in cardiology — that drives the underrepresentation of women in this field, suggested Anne Curtis, MD, of the University at Buffalo, State University of New York, and Fatima Rodriguez, MD, of Stanford University in California: “Why is our specialty losing so much talent?” they asked in an invited commentary, citing the fact that even though approximately half of those in medical school classes are female, women constitute only 21% of general cardiology trainees, 7.2% of interventional fellows, and 6% of electrophysiology fellows. In practice, women account for 13.2% of cardiologists and 4% of interventional cardiologists.

It seems that work-life balance is just not there in cardiology — making it a field especially undesirable among women.

“Having this factor be so important to career decisions today means that one needs to consider these issues in structuring positions in order to attract the best people,” Curtis and Rodriguez said. They explained that to reverse the “staggering problem” of the underrepresentation of women in cardiology, it will take, among other strategies, professional societies drawing attention to this problem and structured programs created to provide female role models and mentors to medical students and residents.

If cardiology has one thing going for it in the meantime, it’s the shift from a mainly private practice model to one of hospital or system employment,” the commentary states. “While there is some loss of autonomy with this model, it also creates opportunities for more structured and predictable work schedules.”

Sexual Harassment, Gender Discrimination

Last fall’s Transcatheter Cardiovascular Therapeutics (TCT) conference was dedicated to the theme of diversity and was supposed to be a call to attention and action for interventional cardiology. Instead, it was more of the same-old, said Roxana Mehran, MD, of Icahn School of Medicine at Mount Sinai in New York City, writing in a viewpoint article in the same issue of JAMA Cardiology.

“The intention was great; the reality, somewhat deflating. The sessions dedicated to diversity were bare. I watched many men in business suits waiting by the doors to get into the mitral and transcatheter aortic valve replacement sessions, while there were echoes in our empty rooms. Simply put, there was no interest.

“The attendees, men and women, had come to TCT to learn about improving their techniques, hear cutting-edge technology updates and results of late-breaking clinical trials, and enhance their practice and knowledge. Who wants to hear negative news about women and minorities? I guess I do not blame them.”

One session stood out however, and not in a good way, as Mehran shared the experience of a woman who described being asked about her “biological clock” several times during interviews for a fellowship in interventional cardiology: “I do not know of a single woman who has trained in cardiology and chosen interventional cardiology as her career who has not faced some level of sexual harassment or misconduct. This is not hyperbole,” Mehran wrote. “Nearly half of all female cardiologists report that they have been asked about their intention to have children during interviews, and more than 60% have experienced sex-based discrimination.”

It’s time for medicine to have its own #MeToo moment, she suggested, urging women to speak up about the injustices they have faced to force change — and leaders in the field to take solid action. “We all must act.”

The $2.5M Wage Gap

“We have arrived at moment when change is within arm’s reach; women and men must rally together to make the workplace fair, more productive, and better for everyone,” agreed Rashmee Shah, MD, MS, of the University of Utah School of Medicine in Salt Lake City, writing in another viewpoint in the issue.

Her focus, however, was on the wage gap between male and female cardiologists: Given that women cardiologists earn 7.3% less than male peers on average, one can estimate that they end up with $2.5 million less over a 35-year career, she estimated. And the problem actually manages to be even worse for those in academia, Shah said, where salary increases are often tied to promotion between ranks, and women are less likely than men to get those promotions, thereby being “stuck to the floor.”

“Rather than place the burden solely on women to change the status quo, the predominantly male leadership needs to assume responsibility by creating a system that measures the value provided to the organization in a uniform, transparent way,” Shah urged.

To understand why these patterns exist in the first place, it is imperative to look at the less obvious factors that prevent female advancement, she suggested: “Women, for example, receive less money for research start-up compared with men, a clear and measurable disadvantage that can propagate over time. Other factors that contribute to career success, such as a lack of sponsorship and opportunity, fewer networking options, and less effective negotiations, are more difficult to measure and not accounted for in studies of pay inequity.”

All these mechanisms not only put considerable female talent at a financial disadvantage, but also hurt employers and businesses.

“Prior research demonstrates that diverse groups, such as those that include women, have a higher collective intelligence and better performance rate,” Shah said. “The effect of collective intelligence is visible in the bottom line: organizations and companies with women in leadership positions have better financial performance rates and returns on investments. Investing in women’s salaries is not only socially and legally just, but also a financially smart investment.”

Douglas, Curtis, Rodriguez, and Shah reported having no relevant conflicts of interest.

Mehran reported various personal and institutional relationships with AstraZeneca, Bayer, Beth Israel Deaconess, Bristol-Myers Squibb, CSL Behring, Eli Lilly/DSI, Medtronic, Novartis Pharmaceuticals, OrbusNeich, Abbott Laboratories, CardioKinetix, Spectranetics, Medscape, Boston Scientific, The Medicines Company, Abiomed, Claret Medical, Elixir Medical, Janssen, Osprey Medical, and Watermark Research Partners.

• Primary Source

  JAMA Cardiology

  Source Reference: Douglas PS, et al “Career preferences and perceptions of cardiology among US internal medicine trainees: factors influencing cardiology career choice” JAMA Cardiol 2018; DOI: 10.1001/jamacardio.2018.1279.

• Secondary Source

  JAMA Cardiology

  Source Reference: Curtis AB, Rodriguez F “Choosing a career in cardiology: where are the women?” JAMA Cardiol 2018; DOI: 10.1001/jamacardio.2018.1286.

• Additional Source

  JAMA Cardiology

  Source Reference: Mehran R “Women’s voices in cardiology: an uncomfortable silence” JAMA Cardiol 2018; DOI: 10.1001/jamacardio.2018.1289.

https://bit.ly/2LdGzQd

Zymeworks has positive Phase 1 cancer data at ASCO

Zymeworks announced the presentation of ZW25 clinical data by Funda Meric-Bernstam, MD, Principal Investigator for the ZW25 study at the University of Texas MD Anderson Cancer Center. Data from the ongoing multi-center Phase 1 study showed single agent ZW25 induced anti-tumor activity and was well tolerated in heavily pretreated patients across a range of HER2-expressing cancers. “Since the first patient treated, ZW25’s compelling single agent activity has consistently exceeded our expectations,” said Ali Tehrani, Ph.D., President and CEO of Zymeworks. “The expanded body of data presented today supports our confidence that ZW25 is an active agent with the potential to become an approved cancer treatment.”

https://bit.ly/2syCazS

Amgen: KYPROLIS data shows extended progression-free myeloma survival

Amgen announced results from the Phase 3 A.R.R.O.W. trial of a once-weekly KYPROLIS dosing regimen in patients with relapsed and refractory multiple myeloma. In the trial, KYPROLIS administered once-weekly at 70 mg/m2 with dexamethasone achieved superior progression-free survival and overall response rates, with a comparable safety profile, versus twice-weekly KYPROLIS at 27 mg/m2 and dexamethasone. These data were presented during an oral session at the 54th Annual Meeting of the American Society of Clinical Oncology and simultaneously published in The Lancet Oncology. “Proteasome inhibitors, like KYPROLIS, are essential in treating patients with multiple myeloma and have helped improve patient outcomes,” said Maria-Victoria Mateos, M.D., Ph.D., director of the myeloma unit, University Hospital of Salamanca-IBSAL in Salamanca, Spain. “The A.R.R.O.W. trial showed that when given once per week at the higher dose of 70 mg/m2 with dexamethasone, KYPROLIS achieved superior progression-free survival and overall response rates, with a comparable safety profile, versus the twice-weekly regimen.”

https://bit.ly/2Ldzsat

Celgene has results from Phase 3 myeloma study: ASCO

Celgene announced results from the OPTIMISMM study, a phase III, randomized, open-label, international clinical study of the investigational combination regimen of Pomalyst, bortezomib and dexamethasone in patients with relapsed or refractory multiple myeloma, or RRMM, who had received at least one prior treatment including lenalidomide. The results were presented at the 54th Annual American Society of Clinical Oncology Scientific Sessions, or ASCO. OPTIMISMM evaluated the efficacy and safety of Pomalyst/Imnovid plus bortezomib and low-dose dexamethasone, or PVd, versus bortezomib and low-dose dexamethasone, or Vd, in patients with early RRMM. It is the only phase III trial to report results with a triplet combination in patients who have all received prior lenalidomide therapy. With lenalidomide becoming a standard of care, this represents a patient population for which there is a growing unmet medical need. An analysis of the results found that the treatment with PVd resulted in significantly improved progression-free survival, or PFS, and an earlier, deeper, more durable response in these patients compared to Vd treatment. The study, which included a high percentage of patients refractory to lenalidomide, met its primary endpoint of PFS. Those receiving PVd achieved a statistically significant longer PFS than those in the Vd treatment arm, reducing the risk of disease progression or death by 39% in the PVd arm. The PFS benefit was observed in the following subgroups of patients: LEN-refractory, LEN-nonrefractory, prior PI exposure or high-risk cytogenetics. Overall response rate, or ORR, one of the study’s secondary endpoints, was also significantly higher in the PVd treatment arm, compared to those receiving Vd. Additionally, time to treatment response was longer in the PVd arm, complete response was higher in the PVd arm and those receiving PVd experienced a longer duration of response than those in the Vd arm. In an exploratory sub-group analysis, patients who had received one prior line of therapy reported longer PFS and ORR with a 46% reduction in the risk of disease progression or death in the PVd treatment arm compared with Vd. Other secondary endpoints included overall survival and safety. Pomalyst plus dexamethasone in combination with bortezomib is not approved in any country for any use.

https://bit.ly/2sz9o1Q

Lilly: To price new rheumatoid arthritis med at 60% less than rival

Eli Lilly (LLY) and Incyte (INCY) confirmed earlier that the U.S. FDA has approved the 2-mg dose of Olumiant, a once-daily oral medication for the treatment of adults with moderately-to-severely active rheumatoid arthritis who have had an inadequate response to one or more tumor necrosis factor inhibitor therapies. Lilly said it will launch Olumiant in the U.S. by the end of the second quarter of 2018. The price of Olumiant will be 60% less than the leading TNF inhibitor, noted Lilly, which will also be offering a patient support program, “Olumiant Together.” Incyte is now eligible to receive a $100M milestone payment from Lilly as a result of the Olumiant approval, which Incyte expects to recognize in the second quarter of 2018

https://bit.ly/2szKvTE

ASCO 2018: Extending the Reach of Precision Medicine

The 54th annual meeting of the American Society of Clinical Oncology (ASCO) will once again feature the latest news, information, and data about advances in clinical cancer, but the program content also reflects a desire to broaden the reach of those advances and ensure that the maximum number of patients derive maximum benefit.

With a working theme of “Delivering Discoveries: Expanding the Reach of Precision Medicine,” ASCO will provide the venue for more than 2,500 research abstracts that will be reported during the meeting. An additional 3,350 abstracts were accepted for publication online. Beyond conventional basic and clinical research, a substantial portion of the program will be devoted to issues such as access to care; social, economic, and clinical disparities; use of technology to broaden the reach of cancer care and make it more efficient; greater emphasis on patient-reported outcomes and shared decision-making; and caring for the growing population of cancer survivors.

“The promise of precision medicine is only as good as our ability to make these treatments available to all patients,” said ASCO President Bruce E. Johnson, MD.

Recent advances in cancer research, and their subsequent translation into clinical practice, have had a transformative effect on the way cancer is treated. In a video developed for the 2018 annual meeting, Johnson talked about how advances that began in laboratories often have evolved into life-changing experiences for patients. He said that as a lung cancer specialist, his personal favorite is the discovery that mutations in the EGFR gene drive the progression of cancer in some patients, a development that for the first time allowed many patients to be treated with a pill instead of chemotherapy.

One example of potential practice-changing clinical research at this year’s meeting has already emerged: A study showing that 6 months of adjuvant trastuzumab (Herceptin) is at least as effective as the standard-of-care 12 months for women with HER2-positive breast cancer, causes less cardiac toxicity, and costs less.

Something for Everyone

Oncology practitioners look forward to ASCO for a variety of reasons. Heading the list for many attendees are the opportunities to learn about new research, attend discussions and lectures by leaders in the field of oncology, and participate in interactive sessions to exchange information and ideas.

“I like to attend ASCO each year because it allows me to think about the new data presented and have vibrant discussions with colleagues in terms of how we can use this data to establish great practice patterns that may best benefit our cancer patients,” said Daneng Li, MD, of City of Hope in Duarte, Calif.

One study in particular caught Li’s attention: A randomized trial showing improved progression-free survival in patients with pancreatic neuroendocrine tumors treated with temozolomide and capecitabine instead of temozolomide alone.

Gynecologic oncologist Rebecca Arend, MD, of the University of Alabama at Birmingham, said she is attracted to several studies in ovarian cancer: the value of secondary debulking in platinum-resistant disease, retreating patients with bevacizumab (Avastin), and long-term survival data from a study of upfront treatment with bevacizumab. A session on developmental therapeutics in immunotherapy and another on emerging therapeutics in gynecologic cancers also hold special interest for her.

“ASCO, for me as a physician-scientist, is a meeting where the basic science is all extremely relevant to patient care and the data presented helps shape how we should treat our patients in the future,” she said. “More importantly, it provides platforms for discussions about understanding where the field is going and what we should be exploring further in order to better focus our research effectors in the lab and in clinical trials.

“In addition, clinicians have always been extremely collaborative and traditionally keep the focus on helping the patients and improving survival of the cancer survivors that we see in clinic and in our practice, which makes ASCO a very productive and important meeting for me.”

Connecting, Reconnecting, Affirming

Hossein Borghaei, DO, a lung cancer specialist at Fox Chase Cancer Center in Philadelphia, said he is looking forward to hearing the results of a late-breaking study comparing the PD-1 inhibitor pembrolizumab (Keytruda) with standard platinum-based chemotherapy as first-line treatment for patients with advanced non-small cell lung cancer and different levels of PD-L1 expression.

“This study potentially could affect what we do in the clinic, if it shows a benefit for single-agent immunotherapy,” he said. “This study will be included in the plenary session, and to be included in an ASCO plenary session is a big deal, indicating that a study is important.”

Several studies of immunotherapy-containing combinations for lung cancer will likely attract a lot of interest among lung cancer specialists, he added. Updated information on some previously reported clinical trials also will provide anticipated information that might readily apply to clinical practice, particularly mature data from studies involving targeted therapies.

“Some of these studies have the potential to change clinical practice, and others may affirm what we are already doing,” said Borghaei, who will also moderate an education session about strategies for treating patients with lung cancers that are not molecularly driven (without EGFR, ALK, or ROS1 mutations, for example).

Borghaei said that as a frequent attendee of ASCO, he has found that the meeting also affords opportunities for interactions that go beyond scientific research and clinical practice: “It’s a good way to reconnect with colleagues and friends, establish collaborations, and affirm existing connections with people you know.”

Two studies in advanced/metastatic renal cell carcinoma (RCC) head the list of new research on the radar of genitourinary cancer specialist Elizabeth Plimack, MD, also of Fox Chase Cancer Center. One study showed an “impressive response rate” with the immune checkpoint inhibitor pembrolizumab as first-line therapy for patients with advanced clear-cell RCC.

The second study provided insight into patient-reported outcomes (PROs) for treatment with the combination of a VEGF inhibitor and another immune checkpoint inhibitor for metastatic RCC.

“This trial shows better overall PROs with the combination of bevacizumab and atezolizumab [Tecentriq] versus sunitinib [Sutent],” said Plimack. “This refutes the dogma that combination therapy typically leads to higher side effects compared with monotherapy.”

The meeting continues here through Tuesday, and MedPage Today will have comprehensive coverage of the news and developments.

https://bit.ly/2LfDQFQ