Many oncologists remember the storied history of homoharringtonine (HHT) and wonder whatever happened to it. HHT showed initial promise for myeloid leukemias, particularly for chronic myelogenous leukemia (CML) where it seemed to induce more cytogenetic remissions than did interferon alpha.1 Unfortunately for HHT investigators, but fortunately for everybody else, these studies coincided with those being done with imatinib. The phenomenal introduction of imatinib contributed to the shelving of HHT in the mid to late 1990s.2 As is often the case, though, imatinib is not perfect. Some patients with CML develop resistance and approximately half of these do so through the acquisition of binding site mutations. One mutation in particular, T315I, rendered patients with CML resistant to all available tyrosine kinase inhibitors (TKI). In the meantime, a semisynthetic version of HHT, omacetaxine mepesuccinate, was developed. With the help of partners in industry, investigators at MD Anderson Cancer Center initiated new studies of omacetaxine in TKI resistant CML patients. Among 62 CML patients with a T315I mutation, complete hematologic response was achieved in 77% with median response duration of 9.1 months.3 Further, cytogenetic response was also achieved in a portion of patients, complete in 16%. These data prompted application for approval by the Food and Drug Administration, but were rejected for lack of a standardized test for T315I mutations. The additional data presented in the Community Translations article on page 194 formed the basis of a second application, this time for an indication in patients with CML resistant to 2 or more TKIs.

Many oncologists remember the storied history of homoharringtonine (HHT) and wonder whatever happened to it. HHT showed initial promise for myeloid leukemias, particularly for chronic myelogenous leukemia (CML) where it seemed to induce more cytogenetic remissions than did interferon alpha.1 Unfortunately for HHT investigators, but fortunately for everybody else, these studies coincided with those being done with imatinib. The phenomenal introduction of imatinib contributed to the shelving of HHT in the mid to late 1990s.2 As is often the case, though, imatinib is not perfect. Some patients with CML develop resistance and approximately half of these do so through the acquisition of binding site mutations. One mutation in particular, T315I, rendered patients with CML resistant to all available tyrosine kinase inhibitors (TKI). In the meantime, a semisynthetic version of HHT, omacetaxine mepesuccinate, was developed. With the help of partners in industry, investigators at MD Anderson Cancer Center initiated new studies of omacetaxine in TKI resistant CML patients. Among 62 CML patients with a T315I mutation, complete hematologic response was achieved in 77% with median response duration of 9.1 months.3 Further, cytogenetic response was also achieved in a portion of patients, complete in 16%. These data prompted application for approval by the Food and Drug Administration, but were rejected for lack of a standardized test for T315I mutations. The additional data presented in the Community Translations article on page 194 formed the basis of a second application, this time for an indication in patients with CML resistant to 2 or more TKIs.

Many oncologists remember the storied history of homoharringtonine (HHT) and wonder whatever happened to it. HHT showed initial promise for myeloid leukemias, particularly for chronic myelogenous leukemia (CML) where it seemed to induce more cytogenetic remissions than did interferon alpha.1 Unfortunately for HHT investigators, but fortunately for everybody else, these studies coincided with those being done with imatinib. The phenomenal introduction of imatinib contributed to the shelving of HHT in the mid to late 1990s.2 As is often the case, though, imatinib is not perfect. Some patients with CML develop resistance and approximately half of these do so through the acquisition of binding site mutations. One mutation in particular, T315I, rendered patients with CML resistant to all available tyrosine kinase inhibitors (TKI). In the meantime, a semisynthetic version of HHT, omacetaxine mepesuccinate, was developed. With the help of partners in industry, investigators at MD Anderson Cancer Center initiated new studies of omacetaxine in TKI resistant CML patients. Among 62 CML patients with a T315I mutation, complete hematologic response was achieved in 77% with median response duration of 9.1 months.3 Further, cytogenetic response was also achieved in a portion of patients, complete in 16%. These data prompted application for approval by the Food and Drug Administration, but were rejected for lack of a standardized test for T315I mutations. The additional data presented in the Community Translations article on page 194 formed the basis of a second application, this time for an indication in patients with CML resistant to 2 or more TKIs.

With this issue of COMMUNITY ONCOLOGY, memories of this year’s annual meeting of the American Society of Clinical Oncology in Chicago are starting to fade, but we are still trying to make sense of the wealth of data that was presented there. I found a number of the presentations particularly noteworthy and some of the findings likely to have an impact on how we practice. The aTTom trial1 by a group of British researchers was presented at the plenary session and dovetailed nicely with the ATLAS trial² findings that were presented at last year’s San Antonio Breast Cancer Symposium. Both trials examined 5 and 10 years of adjuvant tamoxifen in women with early stage, hormone-positive breast cancer, and findings from both trials showed reductions in recurrence, breast cancer mortality, and overall mortality in women who remained on tamoxifen to year 10. Two presentations examined frequency of scanning in Hodgkin and non-Hodgkin lymphoma and both groups of researchers concluded what many of us have often suspected – that we overscan, and that clinical surveillance is an adequate strategy for detecting recurrence. One study showed that most diffuse large B-cell lymphoma relapses were found by detection of symptoms during a physical exam, lab abnormalities, or even the patients themselves, and that routine surveillance scans did not add much to the detection of relapse.³ Findings from a second study showed that routine surveillance did not result in any survival advantage in patients with classical Hodgkin lymphoma who had achieved complete remission.⁴

With this issue of COMMUNITY ONCOLOGY, memories of this year’s annual meeting of the American Society of Clinical Oncology in Chicago are starting to fade, but we are still trying to make sense of the wealth of data that was presented there. I found a number of the presentations particularly noteworthy and some of the findings likely to have an impact on how we practice. The aTTom trial1 by a group of British researchers was presented at the plenary session and dovetailed nicely with the ATLAS trial² findings that were presented at last year’s San Antonio Breast Cancer Symposium. Both trials examined 5 and 10 years of adjuvant tamoxifen in women with early stage, hormone-positive breast cancer, and findings from both trials showed reductions in recurrence, breast cancer mortality, and overall mortality in women who remained on tamoxifen to year 10. Two presentations examined frequency of scanning in Hodgkin and non-Hodgkin lymphoma and both groups of researchers concluded what many of us have often suspected – that we overscan, and that clinical surveillance is an adequate strategy for detecting recurrence. One study showed that most diffuse large B-cell lymphoma relapses were found by detection of symptoms during a physical exam, lab abnormalities, or even the patients themselves, and that routine surveillance scans did not add much to the detection of relapse.³ Findings from a second study showed that routine surveillance did not result in any survival advantage in patients with classical Hodgkin lymphoma who had achieved complete remission.⁴

With this issue of COMMUNITY ONCOLOGY, memories of this year’s annual meeting of the American Society of Clinical Oncology in Chicago are starting to fade, but we are still trying to make sense of the wealth of data that was presented there. I found a number of the presentations particularly noteworthy and some of the findings likely to have an impact on how we practice. The aTTom trial1 by a group of British researchers was presented at the plenary session and dovetailed nicely with the ATLAS trial² findings that were presented at last year’s San Antonio Breast Cancer Symposium. Both trials examined 5 and 10 years of adjuvant tamoxifen in women with early stage, hormone-positive breast cancer, and findings from both trials showed reductions in recurrence, breast cancer mortality, and overall mortality in women who remained on tamoxifen to year 10. Two presentations examined frequency of scanning in Hodgkin and non-Hodgkin lymphoma and both groups of researchers concluded what many of us have often suspected – that we overscan, and that clinical surveillance is an adequate strategy for detecting recurrence. One study showed that most diffuse large B-cell lymphoma relapses were found by detection of symptoms during a physical exam, lab abnormalities, or even the patients themselves, and that routine surveillance scans did not add much to the detection of relapse.³ Findings from a second study showed that routine surveillance did not result in any survival advantage in patients with classical Hodgkin lymphoma who had achieved complete remission.⁴

A new study shows that in patients with acute ischemic stroke, every 15 minutes counts when talking about the time it takes to begin intravenous tissue-type plasminogen activator (tPA) therapy.

According to a report in JAMA, patients who received tPA treatment within 4.5 hours of symptom onset and had faster onset to treatment (OTT) had reduced in-hospital mortality and symptomatic intracranial hemorrhage rates (odds ratio for each, 0.96). Each 15-minute reduction in OTT also increased rates of independent ambulation at discharge and discharge to the home.

"This study emphasizes and characterizes better than before the fundamental importance of rapid start of thrombolytic therapy for acute ischemic stroke," says lead author Jeffrey Saver, MD, professor of neurology at the Geffen School of Medicine at the University of California at Los Angeles (UCLA) and director of the UCLA Stroke Center. "[For] every 15-minute delay of start of therapy, two fewer of out of 100 patients benefit. And this means that hospital systems need to be optimized to ensure that the target of door-to-needle time for start of tPA being under 60 minutes is achieved more often."

Dr. Saver says door-to-needle times under one hour have improved in recent years to nearly 50% from 25%, but hospitals can do better.

Recommended steps to improve that figure include having ambulances provide pre-arrival notification of stroke patients, having everyone on a stroke/hospitalist team paged at once to prepare all physicians who would potentially interact with the patients, premixing thrombolytic drugs to allow for quicker use, and having a data feedback system so institutions can figure out where the obstacles are to achieving improved performance.

"This is the type of system change that occurs by evolution, not revolution," Dr. Saver adds. "You need to bring your team together, you need physician champions to take the lead, and then you need to slowly drive system change based on the data in your institution. This is not an easy task, but it’s the type of task that hospitalists are perfect for."

Visit our website for more information on stroke treatments.

A new study shows that in patients with acute ischemic stroke, every 15 minutes counts when talking about the time it takes to begin intravenous tissue-type plasminogen activator (tPA) therapy.

According to a report in JAMA, patients who received tPA treatment within 4.5 hours of symptom onset and had faster onset to treatment (OTT) had reduced in-hospital mortality and symptomatic intracranial hemorrhage rates (odds ratio for each, 0.96). Each 15-minute reduction in OTT also increased rates of independent ambulation at discharge and discharge to the home.

"This study emphasizes and characterizes better than before the fundamental importance of rapid start of thrombolytic therapy for acute ischemic stroke," says lead author Jeffrey Saver, MD, professor of neurology at the Geffen School of Medicine at the University of California at Los Angeles (UCLA) and director of the UCLA Stroke Center. "[For] every 15-minute delay of start of therapy, two fewer of out of 100 patients benefit. And this means that hospital systems need to be optimized to ensure that the target of door-to-needle time for start of tPA being under 60 minutes is achieved more often."

Dr. Saver says door-to-needle times under one hour have improved in recent years to nearly 50% from 25%, but hospitals can do better.

Recommended steps to improve that figure include having ambulances provide pre-arrival notification of stroke patients, having everyone on a stroke/hospitalist team paged at once to prepare all physicians who would potentially interact with the patients, premixing thrombolytic drugs to allow for quicker use, and having a data feedback system so institutions can figure out where the obstacles are to achieving improved performance.

"This is the type of system change that occurs by evolution, not revolution," Dr. Saver adds. "You need to bring your team together, you need physician champions to take the lead, and then you need to slowly drive system change based on the data in your institution. This is not an easy task, but it’s the type of task that hospitalists are perfect for."

Visit our website for more information on stroke treatments.

A new study shows that in patients with acute ischemic stroke, every 15 minutes counts when talking about the time it takes to begin intravenous tissue-type plasminogen activator (tPA) therapy.

According to a report in JAMA, patients who received tPA treatment within 4.5 hours of symptom onset and had faster onset to treatment (OTT) had reduced in-hospital mortality and symptomatic intracranial hemorrhage rates (odds ratio for each, 0.96). Each 15-minute reduction in OTT also increased rates of independent ambulation at discharge and discharge to the home.

"This study emphasizes and characterizes better than before the fundamental importance of rapid start of thrombolytic therapy for acute ischemic stroke," says lead author Jeffrey Saver, MD, professor of neurology at the Geffen School of Medicine at the University of California at Los Angeles (UCLA) and director of the UCLA Stroke Center. "[For] every 15-minute delay of start of therapy, two fewer of out of 100 patients benefit. And this means that hospital systems need to be optimized to ensure that the target of door-to-needle time for start of tPA being under 60 minutes is achieved more often."

Dr. Saver says door-to-needle times under one hour have improved in recent years to nearly 50% from 25%, but hospitals can do better.

Recommended steps to improve that figure include having ambulances provide pre-arrival notification of stroke patients, having everyone on a stroke/hospitalist team paged at once to prepare all physicians who would potentially interact with the patients, premixing thrombolytic drugs to allow for quicker use, and having a data feedback system so institutions can figure out where the obstacles are to achieving improved performance.

"This is the type of system change that occurs by evolution, not revolution," Dr. Saver adds. "You need to bring your team together, you need physician champions to take the lead, and then you need to slowly drive system change based on the data in your institution. This is not an easy task, but it’s the type of task that hospitalists are perfect for."

Visit our website for more information on stroke treatments.

The Center for Medicare & Medicaid Innovation's Rick Gilfillan, MD, will be leaving at the end of June, just as the organization prepares to start accepting round-two grant applications for up to $1 billion in Health Care Innovation Awards. Replacing him as acting director will be Patrick Conway, MD, MSc, FAAP, SFHM, a practicing pediatric hospitalist, former director of hospital medicine at Cincinnati Children's Hospital, and HM13 keynote speaker.

Dr. Conway will continue in his current role as CMS' chief medical officer.

"We applaud Patrick Conway's appointment to the Center for Medicare & Medicaid Innovation," says SHM President Eric Howell, MD, SFHM. "His work, compassion, and vision are tremendous validations of the hospitalist model as both a change agent and as a career path. Patients across the country will be the true beneficiaries of his new work.

"Hospitalists should continue to look toward the CMS Innovation Center as a leader in transforming healthcare."

The center was created by the 2010 Affordable Care Act to offer solutions to healthcare cost and delivery problems. Its first round of 107 innovations awards, averaging $8.4 million each over three years, was announced in 2012 and included several that focused on preventing hospitalizations, avoidable rehospitalizations, and ED visits. One award went to David Meltzer, MD, PhD, FHM, of the University of Chicago to test a model in which the same doctor would see selected high-risk patients both in and out of the hospital.

Round two "provides hospitalists—who have an exceptionally broad perspective—with a unique opportunity to share new approaches to delivering the best patient care at an affordable cost," Dr. Conway told The Hospitalist.

Visit our website for more information on CMS Innovation Center initiatives.

The Center for Medicare & Medicaid Innovation's Rick Gilfillan, MD, will be leaving at the end of June, just as the organization prepares to start accepting round-two grant applications for up to $1 billion in Health Care Innovation Awards. Replacing him as acting director will be Patrick Conway, MD, MSc, FAAP, SFHM, a practicing pediatric hospitalist, former director of hospital medicine at Cincinnati Children's Hospital, and HM13 keynote speaker.

Dr. Conway will continue in his current role as CMS' chief medical officer.

"We applaud Patrick Conway's appointment to the Center for Medicare & Medicaid Innovation," says SHM President Eric Howell, MD, SFHM. "His work, compassion, and vision are tremendous validations of the hospitalist model as both a change agent and as a career path. Patients across the country will be the true beneficiaries of his new work.

"Hospitalists should continue to look toward the CMS Innovation Center as a leader in transforming healthcare."

The center was created by the 2010 Affordable Care Act to offer solutions to healthcare cost and delivery problems. Its first round of 107 innovations awards, averaging $8.4 million each over three years, was announced in 2012 and included several that focused on preventing hospitalizations, avoidable rehospitalizations, and ED visits. One award went to David Meltzer, MD, PhD, FHM, of the University of Chicago to test a model in which the same doctor would see selected high-risk patients both in and out of the hospital.

Round two "provides hospitalists—who have an exceptionally broad perspective—with a unique opportunity to share new approaches to delivering the best patient care at an affordable cost," Dr. Conway told The Hospitalist.

Visit our website for more information on CMS Innovation Center initiatives.

The Center for Medicare & Medicaid Innovation's Rick Gilfillan, MD, will be leaving at the end of June, just as the organization prepares to start accepting round-two grant applications for up to $1 billion in Health Care Innovation Awards. Replacing him as acting director will be Patrick Conway, MD, MSc, FAAP, SFHM, a practicing pediatric hospitalist, former director of hospital medicine at Cincinnati Children's Hospital, and HM13 keynote speaker.

Dr. Conway will continue in his current role as CMS' chief medical officer.

"We applaud Patrick Conway's appointment to the Center for Medicare & Medicaid Innovation," says SHM President Eric Howell, MD, SFHM. "His work, compassion, and vision are tremendous validations of the hospitalist model as both a change agent and as a career path. Patients across the country will be the true beneficiaries of his new work.

"Hospitalists should continue to look toward the CMS Innovation Center as a leader in transforming healthcare."

The center was created by the 2010 Affordable Care Act to offer solutions to healthcare cost and delivery problems. Its first round of 107 innovations awards, averaging $8.4 million each over three years, was announced in 2012 and included several that focused on preventing hospitalizations, avoidable rehospitalizations, and ED visits. One award went to David Meltzer, MD, PhD, FHM, of the University of Chicago to test a model in which the same doctor would see selected high-risk patients both in and out of the hospital.

Round two "provides hospitalists—who have an exceptionally broad perspective—with a unique opportunity to share new approaches to delivering the best patient care at an affordable cost," Dr. Conway told The Hospitalist.

Visit our website for more information on CMS Innovation Center initiatives.