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  • 1
    Publication Date: 2019-11-13
    Description: Introduction: Two surveys were conducted to understand the rationale for hematologists/oncologists (hem/oncs) to seek continuing medical education (CME) as well as how the information is applied to clinical practice. Additionally, we studied the clinical decision making of hem/oncs who treat patients with multiple myeloma (MM) in order to understand the areas to focus for future CME activities. Methods: We conducted two incentivized surveys where only hem/oncs in the US who treat patients were eligible: 1) MM decision-making survey (MM survey) in November 2018 where they were asked case-based questions to assess practice patterns and they were asked to rate their level of confidence in their decisions for the cases; and 2) Information seeking behaviors and preferences survey (behavior survey) in May and June 2019 where they responded to questions about what information informs practice and how often they need new information. Physicians were paid for their participation in the surveys. Results: 93 hem/oncs participated in the behavior survey with 56% from the community setting and 44% practicing exclusively in an academic setting. Community hem/oncs visit online CME more frequently than academic hem/oncs (daily or at least once a week: 67 vs 51%, respectively). The primary factors driving hem/oncs to access online CME include the need to learn about the latest developments (45%) and looking for an answer to a specific question (25%). Community hem/oncs are 2x more likely than academic hem/oncs to access online CME in order to earn credits. All of the hem/oncs surveyed have modified or implemented a new clinical practice in the last year, with the majority of the modified or new practices related to treatment (69%). Community hem/oncs are 174% more likely than academic hem/oncs to use CME as the source of the information leading to modified/new practice (27% vs 10%). The influence of CME on clinical practices is especially striking among hem/oncs practicing in a community vs academic setting on both gaining more confidence in their current practices (71% vs 59%) and modifying treatment practices (64% vs 54%). There were 101 hem/oncs who participated in the MM survey with 51% practicing in the community setting and 55% seeing between 1 to 10 patients with MM per month, whereas 22% saw more than 20 patients with MM per month. Case 1 highlights the lack of confidence among hem/oncs in making treatment decisions for patients with relapsed/refractory MM, with the majority, between 55% to 72%, only somewhat or not confident in their clinical decision. Although various options would be acceptable and not harmful, ideally treatment decisions would be made with a sense of confidence. In case 2, a striking 48% of hem/oncs would use a bortezomib-based regimen in a patient who has severe peripheral neuropathy, despite bortezomib's known side effect of peripheral neuropathy. For those who would use carfilzomib (52%) or a non-bortezomib regimen (13%), less than half (42% and 46%, respectively) were confident in their decision. Case 3 highlights the complexity of tailoring therapy for patients with MM as any of the answers could be appropriate, but between 37% and 67% of hem/oncs were only somewhat or not confident in their choices, indicating a need for additional education. Conclusions: Large Impact of CME on Community Hem/Oncs: A majority of hem/oncs access online CME at least once a week in order to learn about the latest developments and to find answers to specific questions, with the need for CME credits being a minor driver of CME consumption. The data show that CME has a high impact on clinical practices as the majority of hem/oncs surveyed modified or implemented new clinical practices in the last year as a result of what was learned in CME activities. The impact of CME on clinical practices is particularly striking among hem/oncs who practice in community-based settings. Additional Multiple Myeloma-Focused CME is Needed:The treatment paradigm for MM is rapidly evolving and this analysis shows that in order to improve the skills of hem/oncs as well as their confidence in their clinical decision making, additional CME is needed in the areas of (1) individualizing treatment for R/R MM, (2) managing adverse events, and (3) selecting maintenance therapy for high-risk MM. Table Disclosures No relevant conflicts of interest to declare.
    Print ISSN: 0006-4971
    Electronic ISSN: 1528-0020
    Topics: Biology , Medicine
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  • 2
    Publication Date: 2015-12-03
    Description: Graft-versus-host disease (GVHD) remains a major cause of morbidity and mortality after allogeneic hematopoietic stem cell transplantation (allo-HSCT). GVHD involves complex interactions of immune cells, induction of host-reactive donor effector T cells, and donor T cell-mediated injury to normal tissues. Epigenetic changes have been implicated in T cell-mediated GVHD. We previously described that genetic deletion of Ezh2, which catalyzes trimethylation of histone H3 at lysine 27 (H3K27me3), reduced GVHD in mice but preserved graft-versus-leukemia (GVL) responses. Several selective inhibitors of Ezh2 have been recently discovered (e.g. GSK126, UNC1999 and EPZ6438), which specifically reduce the levels of H3K27me3 but not EZH2 protein. Unexpectedly, our preliminary studies showed that administration of GSK126 failed to prevent GVHD in mice. This stands in contrast to our findings that genetic deletion of T cell Ezh2 leads to GVHD inhibition, and suggest that Ezh2 may regulate GVHD through a mechanism independent of H3K27me3. Identifying an optimal method to target T cell Ezh2 for controlling GVHD remains an unmet need. Using experimental mouse models, we demonstrate that functional heat shock protein (Hsp)90 is critical for maintaining Ezh2 protein stability and function in activated T cells. Pharmacological inhibition of Hsp90 destablizes Ezh2 protein in alloreactive T cells, reduces GVHD but preserves GVL effects in mice. To determinethe molecule(s) that is critical for maintaining Ezh2 protein stablility in T cells, we performed mass spectrum (MS) analysis and identified 25 Ezh2-interacting proteins that showed higher intensities than others in T cell receptor (TCR)-activated CD8+ T cells. Among them, we found a group of proteins associated with protein folding and degradation, including Hsp90. Hsp90 is a molecular chaperone required for the stability and function of several key signaling intermediates (e.g., AKT, Raf1 and ERK1/2). Using reciprocal co-immunoprecipitation assay, we confirmed that Ezh2 and Hsp90 directly interacted with each other in TCR-activated CD8+ T cells. Pharmacological inhibition of Hsp90 using its specific inhibitor AUY922, which is currently in phase II clinical trials for cancer therapy, effectively reduced Ezh2 protein without decreasing H3K27me3 24 hours after treatment. This effect was accompanied by decreased proliferation and survival of TCR-activated T cells in vitro. Retroviral overexpression of Ezh2 in T cells markedly improved their proliferation in the presence of AUY922, suggesting that reducing Ezh2 by Hsp90 inhibition is an important mechanism that reduces proliferation and survival of activated CD8+ T cells. Building on these observations, we examined the impact of inhibiting Hsp90 on GVHD by administering AUY922 to B6 mice receiving MHC-identical minor histocompatibility antigen-mismatched C3H.SW mouse CD8+ T cells and T cell-depleted bone marrow (BM). While about 80% of control B6 recipients died from severe GVHD, 80% of AUY922-treated B6 recipients survived without clinical signs of severe GVHD by 84 days after transplantation. In vivo AUY922 administration reduced the survival and expansion of alloreactive T cells, and decreased the fequency of alloreactive T effector cells producing IFN-g and TNF-a. To rule out the model-specific effect of AUY922, we used a haplo-identical B6 into BDF1 mouse model of GVHD. Using CFSE-labeled donor T cells, we first validated that in vivo administration of AUY922 to unirradiated BDF1 mice receiving parent B6 T cells selectively reduced the expansion of alloantigen-reactive donor T cells, but did not impair the expansion and survival of donor T cells that did not respond to alloantigens. In lethally irradiated BDF1 mice receiving B6 T cells and BM, AUY922 administration reduces lethal GVHD, with approximately 50% of them surviving long-time. Importantly, AUY922 treatment preserved GVL activity of donor T cells, leading to significantly improved survival of BDF1 recipients challenged with A20 leukemic cells (Fig.1). Taken together, our findings identified a previously unrecognized molecular mechanism by which Ezh2 and Hsp90 are integrated to regulate alloreactive T cell responses and GVHD. Targeting the Ezh2-Hsp90 complex using AUY922 represents a novel and clinically relevant approach to reduce GVHD while preserving GVL effects, thereby improving the efficacy of allo-HSCT. Disclosures No relevant conflicts of interest to declare.
    Print ISSN: 0006-4971
    Electronic ISSN: 1528-0020
    Topics: Biology , Medicine
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  • 3
    Publication Date: 2017-05-18
    Description: Key Points Ezh2 requires Hsp90 to maintain Ezh2 protein stability and function in alloreactive T cells. Pharmacological inhibition of Hsp90 destabilizes Ezh2 protein in alloreactive T cells and reduces GVHD but preserves graft-versus-leukemia effects.
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  • 4
    Publication Date: 1999-02-15
    Description: We have recently demonstrated that CD11b−/dullCD11c+ and CD11b+hiCD11c+ dendritic cell (DC) precursor subsets represent two distinct DC differentiation pathways from murine bone marrow lineage-phenotype negative (Lin−)c-kit+ hematopoietic progenitor cells (HPCs) stimulated with granulocyte-macrophage colony-stimulating factor (GM-CSF) + stem cell factor (SCF) + tumor necrosis factor  (TNF). We show here that transforming growth factor-β1 (TGF-β1) significantly inhibits the generation of these CD11b−/dullCD11c+ and CD11b+hiCD11c+ DC precursors. Phenotypically, this inhibitory effect was accompanied by markedly suppressed expression of Ia and CD86 antigens as well as major histocompatibility complex (MHC) class II transactivator (CIITA) and CC-chemokine receptor 7 (CCR7) mRNAs in Lin−c-kit+ HPC cultures stimulated with GM-CSF + SCF + TNF at day 6. TGF-β1 could also suppress mature DC differentiation from CD11b+hiCD11c+ DC precursors, but not the differentiation from CD11b−/dullCD11c+ DC precursors. In the absence of TNF, TGF-β1 markedly suppressed the expression of CIITA and CCR7 mRNAs in GM-CSF + SCF-stimulated Lin−c-kit+ HPCs at either day 6 or day 12 and induced the differentiation solely into monocytes/macrophages as evident in morphology, active phagocytic, and endocytic activities. These cells expressed high levels of F4/80 and E-cadherin antigens, but low or undetectable levels of Ia, CD86, and CD40 molecules. However, upon the stimulation with TNF + GM-CSF, these cells could further differentiate into mature DCs expressing high levels of Ia and E-cadherin, characteristics for Langerhans cells (LCs), and gained the capacity of enhancing allogenic MLR. Taken together, all of these findings suggest that TGF-β1 polarizes murine HPCs to generate LC-like DCs through a monocyte/macrophage differentiation pathway.
    Print ISSN: 0006-4971
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  • 5
    Publication Date: 1999-02-15
    Description: We have recently demonstrated that CD11b−/dullCD11c+ and CD11b+hiCD11c+ dendritic cell (DC) precursor subsets represent two distinct DC differentiation pathways from murine bone marrow lineage-phenotype negative (Lin−)c-kit+ hematopoietic progenitor cells (HPCs) stimulated with granulocyte-macrophage colony-stimulating factor (GM-CSF) + stem cell factor (SCF) + tumor necrosis factor  (TNF). We show here that transforming growth factor-β1 (TGF-β1) significantly inhibits the generation of these CD11b−/dullCD11c+ and CD11b+hiCD11c+ DC precursors. Phenotypically, this inhibitory effect was accompanied by markedly suppressed expression of Ia and CD86 antigens as well as major histocompatibility complex (MHC) class II transactivator (CIITA) and CC-chemokine receptor 7 (CCR7) mRNAs in Lin−c-kit+ HPC cultures stimulated with GM-CSF + SCF + TNF at day 6. TGF-β1 could also suppress mature DC differentiation from CD11b+hiCD11c+ DC precursors, but not the differentiation from CD11b−/dullCD11c+ DC precursors. In the absence of TNF, TGF-β1 markedly suppressed the expression of CIITA and CCR7 mRNAs in GM-CSF + SCF-stimulated Lin−c-kit+ HPCs at either day 6 or day 12 and induced the differentiation solely into monocytes/macrophages as evident in morphology, active phagocytic, and endocytic activities. These cells expressed high levels of F4/80 and E-cadherin antigens, but low or undetectable levels of Ia, CD86, and CD40 molecules. However, upon the stimulation with TNF + GM-CSF, these cells could further differentiate into mature DCs expressing high levels of Ia and E-cadherin, characteristics for Langerhans cells (LCs), and gained the capacity of enhancing allogenic MLR. Taken together, all of these findings suggest that TGF-β1 polarizes murine HPCs to generate LC-like DCs through a monocyte/macrophage differentiation pathway.
    Print ISSN: 0006-4971
    Electronic ISSN: 1528-0020
    Topics: Biology , Medicine
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  • 6
    Publication Date: 2020-11-05
    Description: Background: Chimeric antigen receptor (CAR) T-cell therapies have revolutionized the treatment of relapsed/refractory diffuse large B-cell lymphoma (R/R DLBCL) and these novel therapies have unique administration considerations and toxicity profiles. Underlying clinical practice gaps and educational needs were identified and a study was conducted to determine if an online educational intervention specifically designed to address the identified practice gaps could improve knowledge and competence of hematologists/oncologists (hem/oncs) with respect to evidence-based use of CAR T-cell therapies in patients with R/R DLBCL and management of CAR T-cell toxicities. Methods: A cohort of hem/oncs participated in an innovative educational intervention that used a problem-based learning model and short-branching technology. Clinical decision questions were included at 3 critical points in each of the 2 case vignettes, with tailored feedback and clinical consequences provided based on the specific decision made. Learners who did not make the correct decision on the first attempt were given a second opportunity to change the decision that was made. Each case also included knowledge assessment questions pre- and post-intervention and self-efficacy assessment (Figure 1). The educational activity was launched on December 16, 2019 and data collected through April 8, 2020 were analyzed and reported. McNemar's tests were used to assess changes in percent correct responses to individual questions between the 1st and 2nd attempt to determine the effectiveness of the clinical feedback provided following an incorrect answer on the 1st attempt. P value
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    Topics: Biology , Medicine
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