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Purpose To explore the interaction between practice setting (academic practice [AP], private practice [PP]) and gender in relation to physician burnout and satisfaction with work–life integration (WLI). Method In 2017, the authors administered a cross-sectional survey of U.S. physicians and characterized rates of burnout and satisfaction with WLI using previously validated and/or standardized tools. They conducted multivariable logistic regression to determine the interaction between the included variables. Results Of the 3,603 participants in the final analysis, female physicians reported a higher prevalence of burnout than male physicians in both AP (50.7% vs 38.2%, P < .0001) and PP (48.1% vs 40.7%, P = .001). However, the multivariable analysis found no statistically significant gender-based differences in burnout (odds ratio [OR] 0.94, 95% confidence interval [CI] 0.76–1.17, P = .60). Women and men in AP were less likely to report burnout than men in PP (OR 0.70, 95% CI 0.52–0.94, P = .01 and OR 0.69, 95% CI 0.53–0.90, P < .01, respectively); women in PP did not report different burnout rates from men in PP (OR 0.89, 95% CI 0.68–1.16, P = .38). Women in both AP and PP were less likely to be satisfied with WLI than men in PP (OR 0.62, 95% CI 0.47–0.83, P < .01 and OR 0.75, 95% CI 0.58–0.97, P = .03, respectively); men in AP did not report different satisfaction with WLI than men in PP (OR 1.05, 95% CI 0.82–1.33, P = .71). Conclusions Gender differences in rates of burnout are related to practice setting and other differences in physicians’ personal and professional lives. These results highlight the complex relationships among gender, practice setting, and other personal and professional factors in their influence on burnout and satisfaction with WLI.

8026 Background: CLL progression and CLL-related complications (infections and second malignancies) were the leading cause of death (COD) in a prospective cohort of CLL patients (Strati, BJH 2017). The CLL-IPI integrates major clinical and molecular prognostic factors and stratifies patients into 4 risk groups with distinct prognosis. It is unknown if COD differs according to CLL-IPI risk group in patients with newly diagnosed CLL. Methods: Patients diagnosed with CLL between 1/2000-12/2019 and seen within 1 year of diagnosis were identified from the Mayo Clinic CLL database. Cumulative incidences of cause-specific death were analyzed using Gray’s test, with deaths from different causes treated as competing events and deaths from unknown causes excluded. Results: 1276 patients were included in this study. The median age at diagnosis was 63 years (range 24-92), and 880 (69%) were male. Based on CLL-IPI score, 449 (35%) had low risk disease, 443 (35%) had intermediate risk disease, and 384 (30%) had high/very high risk disease. Median follow-up time for the study was 6 years; 286 deaths occurred. The COD was CLL progression in 99 (35%), infection in 16 (6%), second malignancy in 47 (16%), CLL-unrelated in 59 (21%), and unknown in 65 (23%) patients. The rates of death due to CLL progression were higher (17.3% at 5 years; 30.3% at 10 years) than the rates due to CLL-related complications (5.7% at 5 years; 12.9% at 10 years) or due to CLL-unrelated causes (8.6% at 5 years; 16.9% at 10 years) in the CLL-IPI high/very high risk group, but not the CLL-IPI low or intermediate risk group (Table). A higher CLL-IPI risk group was associated with a higher rate of death due to CLL progression ( P < 0.001), as well as a higher rate of death due to CLL-related complications ( P = 0.013), and CLL-unrelated causes ( P < 0.001). Conclusions: Causes of death in newly diagnosed CLL patients differ according to their CLL-IPI risk group. In patients with high/very high risk CLL, improving CLL disease control with novel agents seems justified. In patients with low/intermediate risk CLL, there should be increased efforts to reverse immune dysfunction to reduce infections and second malignancies. [Table: see text]

e19132 Background: The Functional Assessment of Cancer Therapy–General has an item about patient tolerability of treatment: “I am bothered by side effects of treatment” (GP5). We examined the predictive value of this single item for early treatment discontinuation in clinical trials. Methods: GP5 level prior to protocol therapy (rated using a 5-point Likert scale) and treatment start/end dates and off treatment reason data at each treatment phase were drawn from five phase III clinical trials conducted by ECOG-ACRIN. In the present analysis, GP5 was dichotomized as 0 = “Not at all”/“A little bit” and 1 = “Somewhat”/“Quite a bit”/“Very Much”. Early treatment discontinuation was defined either as receiving less than protocol specified cycles of treatment when maximum cycles specified in the protocol (E1A06 induction, E1912 induction, E1609 induction, E1105 induction, E5103 adjuvant), analyzed using logistic regression via odds ratio [OR]), or treatment cessation for reasons other than progressive disease or death when treatment continued until progression or intolerability (E1A06 maintenance, E1912 maintenance, E1609 maintenance, E1105 maintenance), analyzed using Cox proportional hazard model via hazard ratio [HR]. Results: GP5 prior to treatment was significantly associated with early discontinuation of E1A06 maintenance, E1609 maintenance, E1912 maintenance, and E1912 induction. No significant association was found for other therapies examined in the study. Conclusions: High GP5 level prior to treatment is associated with higher likelihood of early treatment discontinuation in patients who have received previous treatment. The limited predictive value of GP5 for treatment naïve patients is more limited, serial on-treatment assessment should be considered in this setting. Clinical trial information: NCT00602641 . [Table: see text]

Abstract CLL/SLL and other CLPD are associated with an increased risk of autoimmune hemolytic anemia (AIHA), immune thrombocytopenic purpura (ITP), pure red blood cell aplasia (PRBCA), and autoimmune agranulocytosis (AIAG). CLL patients with AIHA and ITP have advanced stage disease according to the Rai and Binet clinical classifications, implying a poor prognosis. However, previous community based studies suggest that patients with CLL and immune cytopenias could have a similar prognosis to other patients with CLL. To further define the prognostic significance of autoimmune cytopenia, we studied a cohort of patients seen at the Mayo Clinic Rochester (MCR). Methods The MCR Division of Hematology Chronic Lymphoproliferative Disease Database was used to identify patients with CLPD and autoimmune complications (AID) over a 10 year period (1 January 1995 to 30 December 2004). The clinical records of all patients with AID were thoroughly reviewed and collated with additional biological data. Results Forty-one (6%) of 665 patients with CLPD had AID. Of the patients with CLPD and AID, 21 (51%) had AIHA, 19 (46%) had ITP, 8 (20%) had PRBCA and 2 (5%) had AIAG. 17% of patients had 2 or more AID diagnoses. In 4 patients (10%) the diagnosis of AID preceded the diagnosis of CLPD, and in 7 patients (17%) the diagnoses were made concurrently. In the 32 patients with CLL, the median lymphocyte count at diagnosis was 24.8 x 109/L (5.18 – 121.8). Of 27 CLL patients who had interphase FISH analysis performed, 12 (44%) had abnormalities associated with poor prognosis CLL (17p13–11% 11q22–22%, 12+ 11%), and 15 (56%) had results associated with a more favorable prognosis (no detectable abnormalities or 13q14 deletion as the sole abnormality). CD38 was positive (&gt; 30% of cells) in 38% of 21 tested patients. 39 patients required treatment for their AID. Treatment included corticosteroids (90%), splenectomy (31%), chemotherapy (31%), and rituximab (46%). Response rates following the first treatment for AID were: AIHA 53% complete response (CR) and 26% partial response (PR); ITP 56% CR and 22% PR; PRBCA 38% CR and 38% PR; AIAG no responses. Of the 41 patients seen over the 10 year period, there were 4 deaths (2 from CLPD). Conclusions This study of a large cohort of community and referred patients showed a prevalence of AID similar to that reported in community based studies. We found an equivalent prevalence of AIHA and ITP as well as a substantial number of patients with 2 or more AID complications. This could be due in part to detailed workup of all cytopenias. In addition, 27% of patients did not have a prior diagnosis of a B cell malignancy when presenting with AID. The measured biological risk factors (FISH anomalies and CD38) suggest that CLL patients with AID do not have a higher percentage of high risk CLL. The majority of patients responded well to AID treatment. Mortality appears to be lower than CLL patients with non-autoimmune cytopenia. These preliminary data suggest that AID is a common and often presenting complication of CLL/SLL and other CLPD. Early diagnosis and management of AID could lead to improved outcomes.

Abstract The prognostic power of immunoglobulin (Ig) somatic mutation status in B cell chronic lymphocytic leukemia (B-CLL) is widely appreciated and has served as the rationale to systematically determine this molecular feature in B-CLL patients. Consistent with other reports, our study of Ig mutation status in a large cohort of B-CLL patients (n=599) found the most commonly used Ig heavy chain variable (VH) region gene was VH 1–69. The VH1–69 gene is of particular interest as there are numerous reports demonstrating that VH1–69 expressing B-CLL cells predominantly express the 51p1-like allele in an unmutated (UM) form and it is frequently associated with use of the D gene segment, D3-3; the J gene segment, JH6; and a relatively long third, complementarity-determining region (CDR3). Despite molecular definition of a commonly used form of VH1–69 in B-CLL, the clinical significance of CLL B cell usage of this prototypic form of VH1–69 remains to be determined. The goal of this study, therefore, was to perform a molecular and clinical analysis on our cohort of B-CLL patients expressing the VH1–69 gene. Our cohort consisted of 19 females and 55 males, with 89.5% expressing UM Ig VH. The 51p1-like allele was present in 75.7% of patients and the predominant D region used was D3 (64.7%). Patients in our cohort were classified by Rai risk as follows: 20 low (28.2%), 40 intermediate (56.3%), and 11 high (15.5%). For those patients with Rai stage available, analysis of specific D and J regions resulted in 16 D3-3/JH6 (26.7%); 14 D3-3/non-JH6 (23.3%); 16 non-D3-3/JH6 (26.7%); and 14 non-D3-3/non-JH6 (23.3%). Despite observing an overwhelming majority of leukemic cells with UM Ig VH, and the known relationship between mutation status and disease progression, it is interesting that our cohort included almost 30% with a low Rai risk. Of note, Ig VH mutation status did not segregate with Rai risk group or VH1–69 allele use (although few patients overall were mutated). However, an UM Ig VH status was associated with a CDR3 length &gt;20 (p = 0.001) and with use of the JH6 segment (p = 0.003). When mutation status was analyzed in concert with specific use of the D3-3 allele, no relationship emerged; however, when this D region allele was analyzed for JH6 vs non-JH6 usage, combination of the D3-3 allele with JH6 was significantly associated with an UM Ig VH status (p = 0.004). Moreover, when J and D segment usage was analyzed in concert with Rai stage group, a significant (p = 0.019) relationship emerged between paired use of D3-3 and a JH6 segment and advanced (intermediate/high) Rai stage. Strikingly, only 1 of 18 VH1–69 patients with low Rai risk for whom D and J data were available expressed the specific combination of D3-3 and JH6. Although analysis of a larger cohort is clearly required to more formally and fully evaluate these relationships, to our knowledge, this is the first suggestion that D and J usage in VH1-69 expressing B-CLL patients correlates with advanced stages of disease. Because Ig VH usage is not believed to change over the course of disease, it is tempting to speculate that VH1–69 B-CLL patients that do not express the prototypic VH1–69 receptor may have a more favorable disease course. In summary, these data add further support to the notion that there is selection for specific Ig receptors in B-CLL and that the antigenic specificity of certain receptors may be associated with risk of progression.

Abstract Background: Results of conventional cytogenetic studies on specimens processed without B-cell mitogens are usually normal in B-CLL: this observation is often attributed to lack of mitotic B-CLL cells. Using metaphase FISH with D13S319, we now have evidence that these apparently normal mitotic B-CLL cells often exhibit submicroscopic interstitial deletions in 13q14. This observation indicates B-CLL cells do divide in unstimulated cultures, but the abnormal metaphases are not detected because the abnormalities are submicroscopic and represent a low percentage of proliferating cells. Methods: We studied 12 patients with B-CLL who had normal metaphases by conventional cytogenetics, but abnormal interphase nuclei by FISH with D13S319. This cohort consisted of 7 females and 5 males who ranged in age from 50 to 87 years. Clinical information was available for 11 patients: Rai stages were 0, I, II, III, or IV for 6, 1, 1, 2, and 1 patients, respectively; 8 patients received treatment and 3 have died. Conventional cytogenetic studies and metaphase FISH were done on bone marrow specimens that were processed by standard 24 and 48-hour unstimulated cultures with Chang Medium BMC. Interphase FISH studies were done on blood or bone marrow (collected within 3 days of specimens for conventional cytogenetic studies) using probes to detect anomalies of chromosomes 6, 11, 12, 13, 14 and 17. For each patient, metaphase FISH was done with commercial probes from Vysis Inc., Downers Grove, IL for D13S319/13q34 using leftover fixed cells from conventional cytogenetics studies. Results: Metaphase FISH results were normal for 3 bone marrow specimens: the remaining 9 specimens had 1.9 to 13.8% metaphases with interstitial deletions of 13q14. One patient had a cytogenetically visible chromosome 13 deletion in 2.2% of metaphases. In the remaining 8 specimens, the size of the abnormal 13 was similar to the normal 13 homolog and other acrocentric chromosomes. By comparison, interphase FISH revealed 13 to 93% nuclei with 13q-x1 or 13q-x2. Seven patients had additonal anomalies in their interphase nuclei; 3 had 11q-, 2 had 17p-, 1 had +12 and 1 had +IGH. Conclusions: This investigation indicates that metaphase FISH detects submicroscopic deletions in chromosome 13 as well as infrequent mitotic B-CLL cells in patients who have normal conventional cytogenetic results. Therefore, metaphase FISH is a novel and useful technique to detect abnormal mitotic cells in B-CLL in cultures without special B-cell mitogens. The prognostic significance of abnormal metaphase FISH results is still under investigation. We speculate that this method will allow for identification of more aggressive proliferating disease even in so-called “favorable” prognostic groups based on interphase FISH results.

Abstract The IgVH mutation status is an independent predictor of time to treatment and survival in CLL. However, the biological basis of this difference is unknown. Clinical use of the IgVH mutation status as a prognostic marker is limited due to the technical difficulties of assessing this feature. As such, we probed for differences in protein expression by CLL cells with unmutated (UM) vs mutated (M) IgVH using phage peptide display libraries (PDPL). Methods: PDPL consists of phages engineered to express random peptides (7-mer) on the coat protein. From approximately 2x1011 phages displaying all possible permutations of 7-mer peptide, we selected phages binding to UM cells by incubation with 106 UM cells and elution of bound phages. Then, from numerous phages initially binding to UM cells, we subtracted phages binding to M cells by multiple incubations with M cells (106). Thus, the phages that bound only to UM cells were selected. The procedure was repeated multiple times to increase selection specificity. The peptide sequences displayed by selected phages were evaluated. We identified phage targets on UM cells by immunoprecipitation (IP) of CLL protein with specific phage and by sequencing of precipitated protein. The expression of target protein in CLL cells was confirmed by immunobloting and flow cytometry. Results: Sequencing of phages from the 3rd round of selection (UM v. M) revealed several peptides, with the most predominant being FPSAHFL. IP identified the cellular target for FPSAHFL as vimentin, an intermediate filament protein involved in cell motility and activation. The level of vimentin expressed by CLL cells varied between patient samples (n=15). UM CLL cases were found to express higher levels of vimentin (the mean MFI was 1002; SD 381), than cases of M CLL (mean MFI 547; SD 109), p=0.0128. To evaluate the prognostic significance of vimentin, we assessed vimentin expression by flow cytometry in a separate subgroup of 40 CLL patients. Archived cell samples collected between 6/2000 – 6/2001 were used. The median follow up was 81 months (40–233). Vimentin expression (MFI) as a continuous variable was a risk factor for a shortened time to treatment (TTT) with a proportional hazard ratio of 4.152 (95% CI 1.33–15.220, p=0.0317). Using MFI closest to the median (and rounded to 2 decimal places) as a cutoff, we stratified patients in high (n=21) and low (n=19) vimentin expression groups. The median times to treatment (TTT) in patients with high vs low level expression of vimentin were 2.8 and 12.9 years respectively, p=0.0025 (Fig.). Conclusion: Using novel proteomic technology, we found that CLL cells with unmutated IgVH expressed higher levels of vimentin than CLL cells with mutated IgVH. A high-level of vimentin expression defined by flow cytometry appears to be associated with high-risk disease. Validation of these findings could allow for the vimentin level to be used as a surrogate marker for expression of unmutated IgVH in CLL. Figure Figure

Abstract Background: Loss of p53 is detected by fluorescence in situ hybridization (FISH) in interphase nuclei in 8–10% of patients with B-CLL and has been associated with aggressive disease and poor response to therapy. Results of chromosome studies suggest loss of p53 is often due to structural anomalies of chromosome 17 rather than monosomy 17. To characterize chromosome 17 anomalies in B-CLL, we used interphase and metaphase FISH to study a series of patients with this disorder. Methods: We studied 16 patients with B-CLL who had chromosome 17 anomalies detected by conventional chromosome studies or interphase FISH. The study cohort consisted of 8 females and 8 males (age 54 – 73 years). Clinical data was available for 15 patients: Rai stages were I, II, III and IV for 1, 2, 6 and 6 patients, respectively; 14 patients received treatment and 10 have died. Metaphase and interphase FISH studies were performed using left-over fixed bone marrow or peripheral blood cell pellets from conventional cytogenetic studies. To identify recurrent chromosome 17 breakpoint cluster regions, patients were first studied with p53(17p13.1) and D17Z1(centromere17), and then with FISH probes for SMS(17p11.2) and RARA(17q21). For patients retaining the SMS probe site, we did FISH for HNPP(17p11.2–12) and D17Z1(centromere17). A total of 200 interphase nuclei and up to 20 metaphases were analyzed by each probe set. Results: The karyotype was normal for 3 patients and complex involving various abnormalities of chromosome 17 for the remaining 13. All patients showed loss of one p53 probe site with retention of both chromosome 17 centromeres. The SMS locus was absent in 13 patients indicating a breakpoint cluster region between the centromere and SMS probe site. In the remaining 3 patients, HNPP was absent, but the SMS probe site was retained indicating chromosome breakage between the SMS and HNPP probe sites. Metaphase FISH results indicate loss of p53 was due to an isochromosome 17p11.2 in 4 patients and an unbalanced translocation involving 17p11.2 in 12 patients. Conclusions: This study shows that loss of p53 in B-CLL cells is due to isochromosome formation or unbalanced translocations that involve a ~6,400 kb breakpoint cluster region adjacent to the centromere on the short arm of chromosome 17. Importantly, our findings indicate that loss of p53 is not due to loss of chromosome 17, simple deletions of p53, or chromosome breakage near the p53 locus. The region between the centromere and HNPP on chromosome 17 is known to be rich in low copy repeats and homologous DNA sequences are dispersed throughout the genome. In somatic cells, these repeats can result in pairing of the same or different chromosomes; crossing over within these homologous regions can result in translocations or isochromosomes. Undoubtedly, this genetic mechanism plays an important role in the origin of structural anomalies of chromosome 17 in B-CLL.

Abstract Background: Angiogenesis has been found to be an important regulator in the disease progression of both solid tumors and hematologic malignancies. In solid tumors, the balance of pro and anti-angiogenic factors appears to be a critical factor in tumorigenesis, with disturbance in favor of angiogenesis promoting tumor growth and metastasis. This observation led to the concept of an “angiogenic switch” where pro-angiogenic influences outweigh anti-angiogenic factors. Patients with CLL have detectable levels of plasma and cellular pro and anti-angiogenic cytokines as well as abnormal neovascularization in the marrow and lymph nodes. Limited studies of pro-angiogenic cytokines have suggested that inter-patient variation in serum/plasma and cellular levels of these markers may have prognostic implications. We evaluated pro- and anti-angiogenic cytokines in a large sample of patients with CLL to evaluate the presence of angiogenic switching and its implications for disease progression. Methods: In a prospective, longitudinal study, we analyzed the serum/plasma, intracellular(determined by flow cytometry), and CLL B cell secreted (24 hour medium values) levels of pro-angiogenic cytokines (VEGF, bFGF) and an anti-angiogenic cytokine (Thrombospondin [TSP]) in 311 patients with previously untreated CLL. VEGF:TSP and bFGF:TSP ratios were calculated to evaluate for evidence of angiogenic switching (higher ratio suggests a pro-angiogenic phenotype). The relationship of angiogenic cytokines to Rai stage, IgVH gene mutation status, % CD38 protein expression, and time to treatment (TTT) from the date of sample were evaluated (median follow-up=11 months). Sequential samples were available on &gt;90% of patients and were evaluated to assess if changes in levels of angiogenic cytokines occurred in patients requiring treatment. Results: Serum, cellular, and secreted levels of VEGF, bFGF, and TSP showed no correlation with Rai stage, IgVH gene mutation (continuous variable), or % expression of CD38 (continuous variable). However, among patients with Rai stage 0-II disease, individuals with lower TSP levels (&lt;75 percentile, p=0.007) or higher bFGF:TSP ratios (continuous variable; p=0.003) had shorter TTT (Figure 1). Similar relationships for a shorter TTT were also observed for secreted TSP levels (p=0.007) and the cellular bFGF:TSP ratio (p=0.009). On analysis of sequential samples, no clear difference in serum, cellular, or secreted levels of VEGF, bFGF, TSP, VEGF:TSP, or bFGF:TSP occurred among those who required treatment. Conclusions: Angiogenic cytokines appear to have prognostic significance in patients with previously untreated early stage CLL. Importantly, we report the original observation that the ratio of bFGF (pro-angiogenic) to TSP (anti-angiogenic) correlates with time to treatment as a continuous variable. This result provides further evidence that angiogenic switching relates to clinical progression in CLL. Longer follow-up of this cohort is needed to fully define the prognostic implications of angiogenic cytokines in CLL and determine if integration of these markers with other prognostic parameters improves risk stratification for early stage patients. Survival According to Serum Thrombospondin Level Survival According to Serum Thrombospondin Level

Abstract Background: Chronic lymphocytic leukemia (CLL) can have a profound effect on the quality of life (QOL) of patients living with the illness. To our knowledge, no studies to date have evaluated the influence of the doctor-patient relationship on patient’s emotional distress or QOL. Methods: We conducted an international, web-based survey of patients with CLL using standardized instruments to evaluate QOL. Additional questions on the survey explored how often patients thought about their disease and evaluated their satisfaction with specific aspects of their relationship with the physician caring for them. Patients were also asked to indicate what phrases their physicians had used to describe/characterize CLL. Results: Between June and October 2006, 1482 patients responded to the survey. The diagnosis of CLL was validated in a randomly selected subset of patients. Over half (55.9%; n=822) of patients reported they thought about their CLL diagnosis daily. Although the proportion of patients who thought about CLL daily decreased with time, two or more years after diagnosis over 50% of patients still thought about their disease every day. When asked to indicate their satisfaction with various aspects of the physician caring for their CLL, more than 90% (n=1340) of patients felt their doctor had a good understanding of how their disease was progressing (i.e., the stage, blood counts, lymph nodes) but only 69% (n=1024) felt their physician had a good understanding of how CLL affected their QOL (anxiety, worry, fatigue, etc.). Similarly, while 90% (n=1324) of patients felt comfortable talking to their doctor about treatment and management of CLL, only 77% (n=1134) felt comfortable talking to their doctor about how CLL affected QOL. Reported satisfaction with their physician in these areas strongly related to patients’ measured emotional and overall QOL on standardized instruments (all p&lt;0.001). This effect on QOL remained (p&lt;0.002) after adjustment for age, extent of co-morbid health conditions, measured fatigue, and treatment status in a regression analysis. Finally, patients were asked to indicate whether the physician caring for them had used specific phrases to describe CLL. Thirty-three percent of patients had been told “CLL is the ‘good’ leukemia,” 24% had been told “don’t worry about your CLL,” and 35% had been told “if you could pick what cancer to have, this is what you would choose.” Overall, 52% of patients had received one or more of these characterizations of CLL by their physician. The emotional and overall QOL were worse among patients who reported their physician had used these phrases to describe CLL (all p≤0.001). This effect on QOL remained after regression analysis (p&lt;0.002). Patients whose physician had used one of these phrases to describe CLL were also less likely to feel their physician understood how CLL was effecting their QOL and to feel comfortable discussing the effects of CLL on their QOL with their physician (all p&lt;0.001). Conclusions: Physicians play an important role helping patients adjust to the physical, intellectual, and emotional challenges of CLL. The effectiveness with which physicians accomplish these tasks appears to impact the QOL of patients with CLL. Additional studies exploring how physicians can best support patients with CLL are needed.