Pancreatic cancer is one of the most aggressive cancers with a high mortality rate even among patients with early-stage disease. Although recent studies with novel therapeutic approaches have led to modest improvement in survival outcomes, limited progress is achieved for the use of immunotherapeutics in this challenging cancer. Immune checkpoint inhibitors, thus far, single-agent or in combination, have not yielded significant improvement in survival outcomes except in mismatch repair-deficient pancreatic cancer. The tumor microenvironment of pancreatic cancer has been considered as an attractive target for over a decade based on preclinical studies that suggested it may adversely affect drug delivery and antitumor immunity. In this review article, we elaborate on the biology of pancreatic cancer microenvironment, its highly complicated interaction with cancer cells, and the immune system. We also discuss plausible explanations that led to the failure of immune checkpoint inhibitors as therapeutic agents and the potential impacts of pancreatic cancer stroma on these negative studies. Over the last decade, dramatic changes in immunotherapy and targeted therapy resulted in significant change in the horizons of cancer management in the field of cancer therapeutics. These novel drug development concepts have led to a dramatic shift in the paradigm of cancer treatment in solid tumors. For example, comprehensive molecular profiling with the next generation of sequencing has evolved significantly and is currently standard of care in advanced stage solid tumors including pancreatic adenocarcinoma,4. Upfront analysis of molecular alterations that are in actionable genes provides a framework to guide the therapy for personalized medicine. Notably, clinical trial concepts have also shifted to biomarker-based studies which make molecular profiling an essential tool for clinicians to practice precision medicine.Pancreatic adenocarcinoma is one of the most challenging cancers among solid tumors with limited progress in therapeutic options particularly in advanced-stage disease leading to dismal outcomes. Immunotherapy has also achieved some degree of progress, although limited, in pancreatic adenocarcinoma. Pembrolizumab, a humanized immunoglobulin G4 antibody directed against programmed cell death protein 1 (PD-1), has been approved by FDA in mismatch repair deficient (MMR-D) solid tumors, including pancreatic cancer. However, the frequency of MMR-D among pancreatic adenocarcinoma patients is approximately 1% and makes this promising therapy available to only a very small subset of pancreatic cancer patients. Although significant efforts have been placed for mismatch repair proficient (MMR-P) pancreatic adenocarcinoma patients, immunotherapy, unfortunately, has not achieved significant progress. Notably, both vaccine-based and single-agent immune checkpoint inhibitor therapies have led to disappointing results with no improvement in survival outcomes,10.This progress has also led to the development of novel therapeutic concepts in pancreatic adenocarcinoma as well. Recently, olaparib, a poly(ADP-ribose) polymerases inhibitor, has resulted in improvement in clinical outcomes in BRCA1/2 mutant metastatic pancreatic adenocarcinoma patients when given as maintenance therapy after initial induction cytotoxic treatment of pancreatic cancer as compared to highly immunogenic hypermutated tumors (> 50 mutations per Mb) was believed to be the underlying reason for the faint immune response against this aggressive cancer. The tumor microenvironment of pancreatic adenocarcinoma, which is also enriched with immunoregulatory cells and dense stroma with hypothetical physical barrier, was considered to play a role in the failure of immunotherapeutic agents.Intrinsic resistance mechanisms leading to ineffective response to immunotherapy in pancreatic adenocarcinoma have been investigated in several preclinical and translational studies; however, the exact mechanism of resistance remains unclear. Relatively low mutation burden (approximately 2-5 mutations per Mb)In this review article, we discuss characteristics of pancreatic cancer microenvironment, studies of immune checkpoint inhibitors in pancreatic adenocarcinoma with dismal outcomes, and elaborate on the impacts of the tumor microenvironment on these disappointing results. We also review possible therapeutic approaches to combat the adverse effects of tumor microenvironment on the anti-cancer immune response.. Pancreatic stellate cells are a highly heterogeneous population of mesenchymal cells that potentially carry myofibroblastic features and are highly responsive to signaling mediators such as platelet-derived growth factor and transforming growth factor-β (TGF-β). The reactive process in the pancreatic cancer stromal tissue which induces highly dense fibrotic tumor stroma and hypovascular microenvironment is called the stromal desmoplasia. Desmoplastic stroma is highly enriched with extracellular collagen and matrix creating poor microvascular circulation. These factors have been attributed to functional barrier formation in the tumor microenvironment.The pancreatic cancer microenvironment has been investigated in preclinical and clinical studies broadly. Stellate cells that are highly enriched in pancreatic cancer stroma create one of the unique characteristics of this aggressive disease with increased extracellular matrix and collagen leading to fibrotic tumor stroma. Increased sonic hedgehog signaling was shown to induce stellate cells and myofibroblasts, leading to their proliferation and subsequent desmoplastic reaction. This reaction results in dense stroma formation that further leads to tumor hypoxia and aggressive cancer features. Notably, tumor hypoxia itself appears to be one of the inducers of sonic hedgehog signaling. This chain reaction in the tumor microenvironment might have an impact on disease biology. For example, a preclinical study showed that upregulated sonic hedgehog signaling accelerates perineural invasion in pancreatic adenocarcinoma, which is associated with adverse outcomes,20. Moreover, the sonic hedgehog pathway was also shown to induce lymphangiogenesis, which endows pancreatic cancer cells with metastatic features. Notably, sonic hedgehog induced stellate cells reduce CD8+ T cell infiltration to juxtatumor compartment of tumor stroma and creating a potential mechanism to tumor escape,23. Sonic hedgehog-activated stromal cells in the tumor microenvironment also secrete several immune mediators including interleukin (IL)-6 and IL-1β which in turn recruit myeloid-derived suppressor cells (MDSCs) to the tumor microenvironment. Collectively, these data indicate that sonic hedgehog signaling may have a direct impact on the molecular biology of pancreatic adenocarcinoma along with immune regulation in the tumor microenvironment.The signaling cascades that mediate desmoplastic reaction have been investigated in pancreatic cancer extensively. Sonic hedgehog signaling, which is highly preserved embryonic signaling, is one of the driving forces of stromal reaction. They are known to induce cancer progression and are associated with adverse outcomes in pancreatic cancer. Notably, there is also evidence suggesting that depletion of T regs may accelerate the progression of pancreatic cancer. T regs directly impair CD8+ effector T cells activity, which results in tumor immune escape in solid tumors. For example, an in-vivo study reported increased TGF-β signaling orchestrated by T regs suppresses the cytotoxic effect of CD8 + T cells. Toll-like receptor-8 signaling has also been found to be a mediator suppressive function of T regs on cytotoxic T cells, which appears to induce immune tolerance. Notably, cytotoxic T-lymphocyte-associated protein 4 (CTLA4) expressing T regs impair the antigen-presenting function of dendritic cells, which in turn leads to inhibition of effector T cells. T regs also deplete IL-2 in the tumor microenvironment resulting in abrogated type 1 CD4+ T cell (Th1 cells) function and impaired antitumor response,31. There is also limited evidence indicating that T regs may convert ATP to AMP to induce adenosine-mediated effector T cell suppression by inhibiting infiltration of CD8+ T cells to the tumor stroma. MDSCs are also highly prevalent in pancreatic cancer stroma-34. MDSCs are recruited to the tumor microenvironment by cancer and tumor stromal cells by using tumor-associated inflammatory mediators,35,36. Similar to T regs, MDSCs also result in a diminished adaptive immune response against cancer cells. Notably, these immune regulatory cells compete with effector immune cells for cysteine and other essential nutritional elements that are essential for cytotoxic T cell function. MDSCs also secrete several interleukins such as IL-10, which upregulates T regs, and type 2 CD4+ T cells (Th2) function, which turns-off effector T cells. Tumor-associated macrophages are another group of negative regulators of effector T cell function in pancreatic cancer and the inhibition of these cells results in improved antitumor immune response in preclinical studies. Tumor-associated macrophages also recruit regulatory cells particularly T regs by stimulating 15-lipoxygenase-2 pathway. A study demonstrated increased expression of chemokine C-C motif ligand 20 (CCL20) by tumor-associated macrophages, which attracts T regs via CCR6 that serves as a receptor for CCL20. Collectively, these data suggest that tumor-associated macrophages mediate anticancer immunity by enhancing the T reg function in the pancreatic cancer microenvironment. Notably, there is also growing evidence that there is a cross-talk between tumor-associated macrophages and MDSC via secretion of IL-6, which leads to the increased negative regulatory activity of MDSCs and T regs in tumor stroma. These inflammatory cells in pancreatic cancer stroma play an important role in immune dysregulation promoting ineffective immune surveillance and antitumor response The stroma of pancreatic cancer is also highly enriched by immunosuppressor cells. FOXP3+ regulatory T cells (T regs) are found abundantly in the pancreatic cancer microenvironment and they have a direct role in the molecular behavior of cancer cells and their relationship with effector T cellsIn conclusion, the data above suggest a highly preserved and sophisticated interaction between cancer and tumor stromal cells and the immune system with multifaceted interaction leading to a unique tumor microenvironment with increased inhibitory signals on effector T cells and thus creating a safe haven for cancer growth in pancreatic cancer. Although these discoveries have enlightened important biological features of pancreatic cancer stroma, at this time, many aspects of this multifaceted communication remain unknown, which at least partially contributed to the failure of clinical trials discussed below.. This phase II trial enrolled 27 patients with advanced-stage disease and no objective response was reported by the authors. Another immune checkpoint inhibitor targeting programmed death-ligand (PD-L1) (BMS-936559) was investigated in patients with advanced-stage solid tumor and there was no signal in pancreatic cancer patients. Pembrolizumab, a humanized anti-PD-1 antibody, has been investigated in multiple solid tumors in phase Ib study, similar to previous experiences and no promising anti-cancer effect was observed. Most recently, durvalumab (a human immunoglobulin directed against PD-L1) was investigated with or without tremelimumab (a fully human antibody targeting CTLA4) in metastatic pancreatic adenocarcinoma patients,44. In this phase II study, 65 previously treated patients were enrolled. The objective response was noted in only one patient in combination arm (3.1%), and there was no objective response in single agent durvalumab arm, indicating that pancreatic adenocarcinoma has innate resistance to immune checkpoint inhibitors.Clinical trials have investigated the efficacy of immune checkpoint inhibitors in pancreatic cancers as a single agent and combination models. Ipilimumab, one of the first immune checkpoint inhibitors targeting CTLA4, has been investigated as a single agent in pancreatic adenocarcinoma patients. Tremelimumab was also combined with single-agent gemcitabine, and the results of this study were also similar to historical controls with a median OS of 7.4 months. The study of pembrolizumab in combination with gemcitabine and nab-paclitaxel investigated the efficacy of this triplet regimen in 17 pancreatic adenocarcinoma patients. Although the study showed a modest signal in median overall survival outcomes (a median OS of 15 months) compared to historical controls, the primary endpoint, which was a complete response rate of > 15%, was not met. These studies suggest that immune checkpoint inhibitors do not have an additive role in cytotoxic therapies for the treatment of pancreatic adenocarcinoma. The synergistic effect between immune checkpoint inhibitors and chemotherapy that have been noted in other solid tumors such as non-small cell carcinoma appears to be not applicable to pancreatic cancer, suggesting chemotherapy-mediated neoantigen release is not an appealing approach at this juncture.Immune checkpoint inhibitors were also investigated in combination with chemotherapeutics. In a phase Ib trial, ipilimumab was combined with gemcitabine and the study showed a median progression-free survival (PFS) of 2.78 months and median overall survival (OS) of 6.90 months, which are highly similar to historical control outcomes of gemcitabine alone. This novel vaccine concept is currently being investigated in clinical trials in combination with immune checkpoint inhibitor therapy. In a phase II trial, nivolumab is combined with GVAX and low dose cyclophosphamide (NCT02243371), and the results of this trial will be reported soon. Similarly, pembrolizumab is currently being investigated in combination with GVAX and low dose cyclophosphamide along with SBRT in locally advanced pancreatic adenocarcinoma (NCT02648282). In another clinical trial, the combination of nivolumab, ipilimumab, and CRS-207 as a triplet therapy is being investigated with or without GVAX (NCT03190265). The efficacy of immune checkpoint inhibitors and cancer vaccines is yet to be proven, and these ongoing studies may shed further light on our understanding of the immunogenicity of pancreatic adenocarcinoma.Immune checkpoint inhibitors were also investigated in combination with cancer vaccines. GVAX, a whole tumor vaccine designed to prime anticancer immunity, was investigated in previously treated metastatic pancreatic adenocarcinoma patients. GVAX in combination with live-attenuated listeria-encoding human mesothelin vaccine (CRS-207) and low dose cyclophosphamide  was investigated in a phase IIb trial, which failed to show any improvement in survival outcomes as compared to physician’s choice of single-agent chemotherapy. Pancreatic cancer patients with MMR-D have also been included in trials investigating immune checkpoint inhibitors therapy. These studies showed highly promising and durable treatment responses across all solid tumors,50. This led to the approval of pembrolizumab in a disease-agnostic manner across all solid tumors with MMR-D. Most recently, the Keynote 158 trial investigated the efficacy of pembrolizumab in different types of solid tumors  with MMR-D, which included 22 pancreatic adenocarcinoma patients. In this study, the authors reported the overall objective response of 34.8% in the overall cohort while the ORR for pancreatic adenocarcinoma was 18.2%. Notably, the PFS and OS were shorter in pancreatic adenocarcinoma patients as compared to other solid tumors . The duration of response was 13.4 months for pancreatic adenocarcinoma patients while this was unreached for the general population.Pancreatic adenocarcinoma patients with MMR-D carry classical characteristics of MMR-D with high tumor mutation burden and accelerated neoantigen generation, which are highly immunogenic self-proteins created by frameshift mutations. Unfortunately, this study did not result in any improvement in survival outcomes and, notably, also did not enhance the penetrance of gemcitabine to the tumor microenvironment. Saridegib, another sonic hedgehog inhibitor, also resulted in detrimental outcomes in another study with a higher rate of progression of disease when combined with gemcitabine, leading to termination of this phase II trial. Most recently, pegylated recombinant human hyaluronidase (PEGPH20) was investigated with chemotherapeutics. The combination of this agent with gemcitabine and nab-paclitaxel led to promising outcomes in a phase II trial , particularly in patients with high hyaluronan levels, and the authors reported improved PFS . The phase III trial of this agent (HALO-301), however, did not show any survival benefit with the addition of PEHPH20 to gemcitabine and nab-paclitaxel, leading to discontinuation of this agent from further development.The aggressive nature of pancreatic adenocarcinoma and its resistance to systemic treatments were attributed to unique characteristics of the pancreatic cancer stroma in preclinical studies, which led to drug development interest in this field. Vismodegib, a sonic hedgehog inhibitor, was investigated in pancreatic adenocarcinoma patients in combination with gemcitabine in a phase Ib/II study. Notably, stromal stellate cells, which promote desmoplastic reaction in the tumor environment, also appear to upregulate proinflammatory cytokines such as IL-6 and recruit MDSCs and tumor-associated macrophages. This myeloid inflammatory response has been shown to abrogate anticancer immunity. To reverse dysregulated immune balance against antitumor immune response, clinical trials have been designed with novel approaches to expand effector T cell infiltration. In an early-phase clinical trial that included pancreatic cancer patients, pegylated recombinant human IL-10 induced promising anti-cancer immunity by expanding CD8+ cytotoxic T cell infiltration in the tumor microenvironment and reversing the MDSC-derived negative regulatory effect on effector immune system,60. Based on this promising signal, this concept is further investigated in the phase III trial . This study combined pegylated IL-10 with FOLFOX in previously treated metastatic pancreatic cancer patients and, unfortunately, that did not result in improvement in survival outcomes, leading to further disappointment. Notably, the GVAX trial discussed above implemented low dose cyclophosphamide in the vaccination protocol to eliminate undesired inflammation, particularly T regs recruitment, and this did not translate into a clinical benefit as well,62. Taken together, thus far, targeting immune suppressor cells in the pancreatic cancer microenvironment has not led to substantial progress in pancreatic cancer field As detailed above, the pancreatic cancer microenvironment is also highly enriched with several types of suppressor immune cells, which are known to important factors for cancer progression,63. Notably, patients with MMR-D pancreatic cancer benefit from immune checkpoint inhibitors, although it appears somewhat less impressive compared to in colorectal and endometrial cancer. Collectively, these data suggest that the lack of immune checkpoint inhibitor response in MMR proficient pancreatic cancer is perhaps multifactorial, including both intrinsic and tumor stroma related factors. Therefore, novel strategies targeting the intrinsic factors (including the hypoimmunogenic nature of pancreatic cancer) and immunosuppressive microenvironment of pancreatic cancer might be more likely to overcome the resistance to immune checkpoint inhibitor monotherapy.The studies above investigating the targetability of pancreatic cancer stroma have not introduced practice-changing outcomes. Although the resistance to immune checkpoint inhibitors in pancreatic cancer could be at least partially due to tumor microenvironment, stroma depletion/modification in combination with cancer vaccines and cytotoxic agents have not translated into an improvement in survival outcomes of pancreatic cancer patients. Therefore, it is also important to recognize intrinsic factors directly related to pancreatic cancer characteristics, e.g., low tumor mutation burden and limited neoantigen generation may also have significant roles in resistance to immune checkpoint inhibitor therapy (NCT03168139). The preliminary results of this study suggest increased T helper 1-like signature in the tumor microenvironment. Currently, phase II trials are also investigating a similar concept with a C-X-C chemokine receptor type 4 (CXCR4) inhibitor and pembrolizumab in metastatic pancreatic cancer patients in different clinical settings with or without chemotherapy (NCT02907099). However, a recent phase II trial with a novel CXCR4 inhibitor in combination with pembrolizumab did not reveal promising outcomes, and only one patient (3.4%) achieved partial response without chemotherapy backbone. Colony-stimulating factor1-receptor (CSF-1R) signaling, which promotes macrophage recruitment to tumor microenvironment to fuel cancer growth, is also being targeted in a clinical trial in combination with pembrolizumab and GVAX to reverse the inhibitory signals in patients with borderline resectable pancreatic cancer (NCT03153410). Cabiralizumab , however, did not result in improvement in outcomes in a phase II clinical trial when combined with nivolumab and chemotherapy in metastatic pancreatic cancer patients. Currently, clinical trials are also investigating approaches targeting the myeloid checkpoint, CD47, and early results show promising results for the future. Stroma targeting concepts to prime the tumor microenvironment are also being investigated for nivolumab in pancreatic adenocarcinoma patients (NCT03519308). These studies will further enlighten the role of tumor stroma and stroma-driven immune regulatory cells in immune checkpoint inhibitor resistance Currently, new approaches are investigating the efficacy of the combination of immune checkpoint inhibitors and tumor microenvironment modification. Currently, the KEYNOTE 599 study is investigating the combination of a C-X-C motif chemokine 12 (CXCL12) inhibitor and pembrolizumab, intending to eliminate the negative immune regulatory effect of tumor microenvironment, which is highly enriched with CXCL12In summary, the studies above have led to significant disappointment in the field of pancreatic cancer research. An increasing number of negative studies investigating agents targeting tumor stroma as well as immune checkpoint inhibitors suggests that our knowledge about the tumor microenvironment of pancreatic cancer and its complex relationship with immune cells is highly limited. It is perhaps these gaps in knowledge that have led to a multitude of negative studies. The current fundamental hypothesis suggesting dense stroma-physical barrier is unable to explain this highly complex relationship and the failure of immune checkpoint inhibitor therapy. The hypoimmunogenic nature of pancreatic cancer with low tumor mutation burden at least partially contributes to the de novo resistance to these novel agents. Perhaps the promising responses with the use of immune checkpoint inhibitors seen in MMR-D pancreatic cancer patients indicate that low tumor mutation burden in MMR proficient pancreatic cancer is one of the underlying reasons for the insufficient response to immune checkpoint inhibitor therapy. Further translational studies to better characterize the expression of immune checkpoint protein expression levels, as well as other immune regulatory signals in the tumor microenvironment, are warranted to better understand this highly convoluted relationship. Therefore, while these disappointments have led to diminished enthusiasm for the approaches depleting dense stroma, they also bring with them an opportunity to better understand the relationship among cancer cells, stromal cells, and the immune system to create more precise therapeutic concepts to aggregate anticancer immunity for the future management of pancreatic cancer.


The COVID-19 pandemic has necessitated the trial of novel treatment regimens to improve clinical outcomes. However, the liberal use of antibiotic and steroid therapy during this period may have also contributed to unintended consequences including the development of multidrug-resistant (MDR) bacterial infections. In this report, we discuss the case of a 76-year-old woman treated with an extended course of steroids for COVID-19 infection. The patient then developed MDR bacterial sinusitis requiring multiple courses of antibiotics complicated by medication side effects. Thus, this case highlights the continued importance of discretion in long-term steroid use and antibiotic stewardship. Sinusitis is one of the most prevalent conditions prompting clinic visits in the United States, accounting for up to $2.4 billion yearly in medical costs . While vEscherichia coli and methicillin-resistant Staphylococcus aureus. Due to these culture results, the patient was initiated on vancomycin and meropenem with minimal improvement in edema. She underwent repeat surgical debridement two weeks later with cultures redemonstrating previously identified bacteria with rare Pseudomonas aeruginosa growth as well. The patient endorsed moderate improvement in frontal scalp tenderness following this debridement. She was thus discharged home on a six-week course of IV vancomycin through a peripherally inserted central catheter, PO levofloxacin, and PO posaconazole, with a plan to continue the latter until fungal cultures were finalized. Two weeks later, she presented to the outpatient clinic with new-onset generalized weakness. Initial workup revealed profound hypokalemia  and acute kidney injury  likely due to vancomycin-related renal derangements and potassium wasting due to posaconazole. The patient was admitted for fluid resuscitation and switched from vancomycin to daptomycin upon discharge to prevent further renal impairment. As all her fungal cultures were negative and no fungal forms were seen on pathology, posaconazole was discontinued. The patient was able to complete her course of treatment, though it was complicated by mild creatine kinase elevation due to daptomycin.A 76-year-old female with a past medical history of hypertension presented to the emergency department with persistent forehead swelling two months after recovering from COVID-19 infection. The patient was diagnosed with COVID-19 pneumonia in Egypt and completed a six-week course of dexamethasone. Per family, she also received multiple antibiotics during this time, the names and courses of which were unknown. She subsequently developed progressively tender frontal scalp swelling. Initial evaluation with otorhinolaryngology (ENT) in Egypt showed mucor-like organisms on pathology. She then came to the United States and was admitted for further evaluation. Her CT head showed evidence of multifocal sinusitis with breach of the inner and outer tables of the right frontal sinus with dural enhancement Figure . She wasRepeat MRI at the end of her antibiotic course demonstrated decreased soft tissue thickening along the anterior skull base and superior nasal cavity with improvement in mucosal thickening involving maxillary sinuses, sphenoid sinuses, and residual ethmoid air cells Figure . HoweverAs the COVID-19 pandemic has evolved, multimodal therapeutic interventions have been identified, with immunosuppressives such as steroids and interleukin 6 inhibitors being frequently used . In addiHere we describe a case of subacute pansinusitis caused by multiple MDR bacteria, leading to prolonged inpatient and outpatient treatment, significant antibiotic side effects, and the development of complications requiring extensive surgery to ensure cure. As such, this case highlights the importance of antibiotic stewardship and discretion in the use of broad-spectrum antibiotics, as well as steroids, in the treatment of COVID-19. Though mucor sinusitis has been more commonly described as a complication, clinicians should be aware of the possibility of a subacute bacterial process in patients presenting with sinusitis.


We present an update of the literature concerning long-term neuropsychological outcomes following surgery for refractory temporal lobe epilepsy (TLE). A thorough search was conducted through the PubMed and Medline electronic databases for studies investigating neuropsychological function in adult patients undergoing resective TLE surgery and followed for a mean/median > five years period. Two independent reviewers screened citations for eligibility and assessed relevant studies for the risk of bias. We found eleven studies fulfilling the above requirements. Cognitive function remained stable through long-term follow up despite immediate post-surgery decline; a negative relation between seizure control and memory impairment has emerged and a possible role of more selective surgery procedures is highlighted. Epilepsy surgery is nowadays an evidence-based treatment strategy for patients with drug-resistant epilepsy ,2. AccorWe conducted a review of the literature on long-term neuropsychological outcomes following TLE surgery. Our aim was to provide clinicians and researchers with a comprehensive summary reflecting a critical point of view of the current evidence.We performed a comprehensive literature search on PubMed with a restriction to full-length English articles published till November 2020, as well as reviews, original articles and book chapters, and consulted experts about other studies. We used the following search terms in various combinations: “refractory temporal seizures”, “neurosurgery”, “cognitive outcome”, “memory” and “long-term follow-up”.Reports of >20 patients with a medical history of drug-resistant temporal lobe epilepsy (TLE), undergoing resective surgery;Patients older than 16 years old;A mean/median >5 years post-surgery follow-up;Outcomes explored included long-term postoperative neuropsychological data and possible associated predictive factors .Two independent reviewers applied the following study inclusion criteria:Eleven studies explored long-term neuropsychological outcomes in adult patients undergoing TL surgery according to the above searching criteria. One study evaluating intelligence consistently reported no worsening of performance following long-term postoperative follow up , while two others reported slight IQ improvement especially in patients achieving seizure freedom . All studies looked at the long-term memory outcomes, with five showing a greater memory decline following left than right TL resection , and two older ones a progressive cognitive decline and lower memory scores in . These findings have been challenged by later data, where cognitive function remained stable at one year following surgery, showing no evidence of accelerated memory decline . Four other studies provided an account on which variables influenced postoperative memory improvement , while one study compared selective  with nonselective  surgery approaches with regard to neuropsychological outcomes, showing that risks of cognitive and/or verbal memory impairment were greater in patients with ATL than in those with SAH . It is well established that epilepsy surgery is an excellent treatment option for achieving seizure control in patients suffering refractory TLE. However, risk for memory impairment remains to be considered as a serious post-surgical result. So far, long-term neuropsychological outcomes following TLE surgery have been reported by various prospective studies ,20. GiveIn 2003, Helmstaedter and associates  reviewedIn the following years, various longitudinal investigations presented inconsistent findings as to the continuing and accelerated pattern of postoperative memory decline in TLE. Testing for the presence of continuing postoperative verbal memory deficits in TLE patients during a six-year follow-up interval, Alpherts and collaborators  firstly Since post-surgical cognitive course in general and memory impairment in particular remained an open issue, many authors were willing to identify important determinants, such as postoperative seizure control and age of surgery. By studying the relationship between postoperative memory decline and seizure outcome for over a five-year follow-up period, Baxendale and associates  put forwThe approach to surgery was another crucial factor studied extensively in the recent years. The rational underling elective surgery approaches is avoiding lesions following resective surgery to eloquent areas of the temporal neocortex, not directly involved in seizure generation. Mathon and collegues  comparedAs to the optimal extent of surgical resection in TLE, no specific neurosurgical approach seems to outweigh the others in terms of seizures control . A revieIn the realm of TLE surgery, the concept of cognitive reserve has been applied in two different models of hippocampal functioning , in relation to the risk for memory impairment following temporal lobectomy (TLY). The functional reserve model claims that the size of memory loss is related to the spare capacity of the contralateral temporal lobe to support memory functions following resection of the abnormal  one. IAT  injections contralateral to the side of epileptogenesis typically produce memory impairment, whereas in the non-epileptic hemisphere memory function remains intact following injections to its epileptic counterpart ,28,29,30Outcome studies in epilepsy surgery have identified several factors that have repeatedly been shown to be predictive of a poor prognosis, including the initial response to pharmacotherapy, the underlying etiology, and a patient’s history of seizure frequency . From a While neuropsychological outcome studies of long-term follow-up remain scarce, progress has been made through the recent years, thus enabling clinicians reach into some safe conclusions for neurocognition after epilepsy surgery. Through our review of the literature, cognitive stability appears to be a still valid assumption receiving empirical support. It is also acknowledged that whenever seizures are controlled and medication reduced, recovery is more frequently observed than continuing decline. Elegantly implemented selective surgical procedures seem to limit cognitive side effects following surgery. In conclusion, the decision to proceed to surgery remains a highly individualized procedure requiring patient-tailored clinical and theory-based neuropsychological approaches. A continuing growth of evidence will help both physicians and patients with this important decision-making process. Finally, further data in cognitive reserve studies is warranted to contribute both long-term neuropsychological prognosis and rehabilitation following TLE surgery.


RNA sequencing (RNAseq) can reveal gene fusions, splicing variants, mutations/indels in addition to differential gene expression, thus providing a more complete genetic picture than DNA sequencing. This most widely used technology in genomics tool box has evolved from classic bulk RNA sequencing (RNAseq), popular single cell RNA sequencing (scRNAseq) to newly emerged spatial RNA sequencing (spRNAseq). Bulk RNAseq studies average global gene expression, scRNAseq investigates single cell RNA biology up to 20,000 individual cells simultaneously, while spRNAseq has ability to dissect RNA activities spatially, representing next generation of RNA sequencing. This article highlights these technologies, characteristic features and suitable applications in precision oncology. Abnormal expression of RNA is frequently associated with human cancer initiation, development, progression and metastasis. In addition to the mutation of tumor suppressor genes and oncogenes, gene expression could be overactivated or epigenetically silenced which could lead to uncontrolled tumor cell growth and proliferation. Aberrant activation of cell growth signaling pathways and/or transcription factors could lead to high-level expression of genes associated with tumor development and progression. Different gene expression profiles may reflect different cancer subtypes, the stage of cancer development or tumor microenvironment4. Therefore, RNAseq is a powerful tool for understanding the molecular mechanisms of cancer development and developing novel strategies for cancer prevention and treatment.Ribonucleic acid (RNA) has multiple forms and plays a critical role in cell growth and differentiation. RNA transcription and stability are tightly regulated in response to physiological and pathological stimuli1, bulk RNAseq has become the most valuable and extensively used tool in understanding cancer biology. Its diverse translational research and potential clinical applications have been well reviewed in the past4. This section does not intend to discuss either technologies or its applications in details. Instead, we will highlight the bottlenecks of its clinical translation and the recent progresses toward their solutions.Since the first EST library was sequenced using Roche 454 sequencer in 2007By RNA species, bulk RNAseq involves sequencing two types of libraries: mRNA-only library and whole transcriptome library that includes all RNA species except for rRNA. By sequencing type, the most frequently used bulk RNAseq is a single end short sequencing focused on differentially expressed genes to understand molecular mechanisms implicated in various stage of tumorigenesis. This type of sequencing is simple and cost effective, largely focused on mRNA only. The less routinely used type is paired end longer sequencing aimed at additional knowledge on alternative splicing, point mutations, novel transcripts, long non-coding RNAs and gene fusions. This type of bulk RNAseq normally sequences rRNA-depleted libraries for more comprehensive information Fig. .Fig. 1Ou9. However, only a few such signature panels have been successfully translated into clinical practice due to low reproducibility. One of the main reasons for the poor performance across independent tumor patients is sampling bias inherent to intra-tumor heterogeneity10. A recent study provided a promising solution to tackle this issue through a novel strategy for biomarker selection11. By analyzing multiple RNAseq data from lung cancer patients, the team found that genes with homogeneous expression within individual tumors, despite high inter tumor variability, have significantly better prognostic potential. These genes “encode expression modules of cancer cell proliferation and are often driven by DNA copy-number gains”11. Such a transcriptomic signature minimizes sampling bias and offers robust prognostic performance in NSCLC survival. If this selection strategy is applicable in other tumor types, more biomarker signatures can be readily translated into clinical practice.Bulk RNAseq has broad utilities in cancer classification, biomarker and gene fusion discoveries, disease diagnosis, and optimizing therapeutic treatment. The translational research targeted for clinical oncology is primarily in two areas. The most informative area is the biomarker discoveries for cancer diagnosis, prognosis, and prediction. Numerous RNAseq-based signatures have been developed and validated across many major tumor types12, while others may be considered as prognostic biomarkers like TMPRSS2–ERG fusion in prostate cancer13. Using bulk RNAseq, numerous novel gene fusions have been discovered, many of which can be directly beneficial as FDA approved drugs or offer new therapeutic opportunities17. However, due to the high false positive rate and the low detection sensitivity, the diagnostic potential of these discoveries has not been fully realized in a clinical setting. Nevertheless, great advancements have recently been made towards addressing these two hurdles. A new computational modeling algorithm for fusion gene detection from bulk RNAseq data, named Data-Enriched Efficient PrEcise STatistical fusion detection (DEEPEST), was developed. DEEPEST is able to effectively minimize false positives and improve detection sensitivity18. In addition, Heyer EE et al19 reported a targeted RNAseq technique offering enhanced sensitivity and reduced background noise. Broad adoption of these new methodologies will facilitate accurate detection of gene fusion events for clinical applications.Another area subject to intensive clinical research is gene fusion discoveries. Fusion genes are well documented as major cancer drivers. Some recurrent fusion genes can be used as a diagnostic tool, such as the RUNX1–RUNX1T1 fusion for diagnosis of acute myeloid leukemia24, it holds great promise to develop more efficient and multi-tasked clinical applications. FoundationOne Heme is such an excellent example. This clinical test detects various gene fusions, substitutions, indels, and CNVs, and used for therapy selection, prognosis, and diagnosis in multiple tumor types. The wide adoption of this LDT test in clinical labs has demonstrated that the multi-faceted, targeted RNAseq panel has a broad clinical utility in clinical oncology.One valuable potential of bulk RNAseq is still underappreciated. Because bulk RNAseq includes diverse types of RNA species and detects multiple forms of genomic alterations at a single base resolution, many of which are not detected by the DNA approach or other traditional methodsBulk RNAseq uses a tissue or cell population as a starting material, and results in a mixture of different gene expression profiles from the studied material. The transcriptome programs of tumors are highly heterogeneous both between tumor cells, due to somatic genetic alterations, and within tumor microenvironments, resulting from significant infiltration of the stroma and other cell types in the tumor. The true signals driving the tumorigenesis or therapeutic resistance from a rare cell population or cell type can be obscured by an average gene expression profile from bulk RNASeq. This biological challenge catalyzed the birth of scRNAseq, an alternative RNAseq technology.26. However, none of those have been broadly applied in translational or clinical research until the recent development of the 10X genomics chromium system, which triggered a rapid adoption of this revolutionized technology.Every tumor cell is unique with distinct somatic alterations, transcriptional regulations and epigenetic modifications. Differences between cells are even greater for RNA since all of these changes will be most likely reflected at the RNA level. Furthermore, RNA is more vulnerable to the influence of micro- and macro-environmental stimuli. Given the extraordinary transcriptional diversity at the single cell scale, tumor cells deserve and require individualized treatment at the transcriptome level. This demand facilitated the development of several scRNAseq technologies10X genomics chromium system offers an integrated and complete solution for rapid analysis of gene expression profiles up to 20,000 individual cells in a single assay. The system consists of Chromium Controller or Chromium X for single cell partition, Chromium Connect for automated library construction, and several software package  for data analysis. The core technology of the 10X single cell platform is the ability to generate hundreds of thousands of single cell microdroplets, called GEMs, on the Chromium microfluidics chip. Each GEM contains a single cell, reverse transcription mixes and a gel bead conjugated with millions of 80-base pair oligo sequences. Each oligo sequence includes an i7 adapter sequence for Illumina sequencing, a cell-specific 10x barcode for decoding the origin of the RNA, a random molecular tag for identifying and quantifying unique mRNA transcript (UMI), and an oligo-dT primer for mRNA binding. Each gel bead has a unique cell-specific 10x barcode, but all oligo sequences on the same bead contain an identical 10x barcode. There are 3.6 million different gel beads to ensure each of the GEMs has a unique 10x barcode. Thus, the microfluidics chip holds the key to make single cell GEMs while the cell-specific 10x barcode on the gel bead is the code to recognize and separate mRNAs from individual cells. Cell lysis commence immediately after cell encapsulation. The detailed workflow is outlined in Fig. 27 and to promote tumorigenesis and treatment resistance28. This complex heterogeneity is partially due to the tumor cells themselves, derived from genetic variations among cells, as well as responses to other environmental factors. The tumor cell-derived heterogeneity is frequently morphologically indistinguishable. scRNAseq offers an unprecedented opportunity and has demonstrated its utility in dissecting intra-tumor heterogeneity at a single cell resolution in primary glioblastoma29, colorectal cancer30 and head and neck squamous cell carcinoma (HNSCC) or oral cancer31. Such a dissection is not only important for fundamental tumor biology, but is also effective for deciphering rare treatment-resistant cell populations and optimizing therapeutic strategy32. The partial epithelial-to-mesenchymal transition (p-EMT) has been identified to be associated with lymph node metastasis and adverse pathologic features. Tumor cells expressing the p-EMT program was found to be present at the invasive front of HNSCC31. Early scRNA-seq experiments found the presence of rare stem-like cells with treatment-resistance properties and a minor cell population expressing high levels of AXL that developed drug resistance after treatment with RAF or MEK inhibitors in melanoma33. Similarly, several drug-tolerant-specific RNA variants were also identified in a drug-tolerant breast cancer cell line that were absent in control cell lines34. These rare variants with significant implications are inaccessible by classic bulk RNAseq.Since 2017, scRNAseq has become one of the most popular genomic tools to dissect transcriptome heterogeneity, discovering rare cell types and cell states in tumors. Tumors are transcriptionally heterogeneous. These diversified transcriptional programs provide tumors with a plasticity to adapt to various environments35. A small subset of CD8 + T cells is associated with favorable response to adaptive cell transfer immunotherapy in melanoma patients36, while a large number of regulatory T lymphocytes have a poor prognosis in liver cancer37. Very recently, we showed that the immune checkpoint inhibitor targeting CD276 remodels the heterogeneity of HNSCC by reducing EMT and promote CD8 + T cell infiltration to kill cancer stem cells using scRNAseq38.Tumor heterogeneity is also the result of the tumor microenvironment. Tumors are infiltrated by various immune and stromal cell populations that are constantly evolving and have been recruited from surrounding tissues. The diversity of different cell populations creates a unique tumor microenvironment. These non-tumor cells within the tumor also have distinct transcriptional programs and play important roles in tumor progression, metastasis, and cancer therapy resistance through constant communication with tumor cells. The characterization of transcriptional diversity of these non-tumor cells in the tumor is essential to the successful treatment of cancer patients. A recent scRNAseq study discovered that a high proportion of active CD8 + T lymphocytes are associated with a better outcome in non-small cell lung cancer39. Using Hydro-seq technique, drug targets for hormone therapies were identified from CTCs of breast cancer patients. Although there are several CTC enrichment technologies available on the market, their clinical utility is limited by high background cells and lack of genetic knowledge of captured CTCs. Hydro-Seq provides a new approach for direct genetic characterization of CTCs at a single-cell resolution and opens a feasible path for making non-invasive tumor diagnosis, targeted therapy and treatment monitoring.Another exciting application of scRNAseq is the identification of circulating tumor cells (CTCs) for non-invasive tumor diagnostics and treatment from a simple liquid biopsy. A recent report shows that a modified scRNAseq technique, Hydro-seq, has enhanced CTC capturing capacity while effectively minimizing background cells40 since it selected single cell sequencing as the method of the Year in 201341. Several recent publications have thoroughly reviewed the utility of integrating scRNAseq data with other types of omic data43. It is highly expected that single-cell multimodal omics analysis will become a major focus in the upcoming years and reveals a more in-depth understanding of intratumoral heterogeneity of tumor cells and tumor microenvironment than scRNAseq alone.Until now, single cell sequencing has been centered around scRNAseq. However, scRNAseq data alone does not provide insight into upstream regulatory networks or downstream functional consequences. Integrated scRNAseq analysis with other single cell omic data will link these networks together and provides additional values in decoding complex causal relationships among different omic data. Recently, integrated single-cell multimodal omics is emerging as a major step toward interactively dissecting tumor heterogeneity at multiple layers of genetics. Nature Methods named single-cell multimodal omics as the method of the Year in 201944. Driven by these limitations, spRNAseq is emerging as a game changing technology.scRNAseq, jointly with other genetic, epigenetic and proteomic data, will have a profound impact on cancer research. However, scRNAseq has several limitations, including: 1) the requirement for cell dissociation, removal of cell debris and dead cells to obtain viable, individual fresh cells, which can potentially stress the cells and alter the transcriptional profile; 2) the data only recover a few thousand unique transcripts from a single cell, far less than a whole transcriptome profile, that limits its broad applications; and 3) scRNAseq data (as well as bulk RNAseq data) loses critical spatial information, which negatively impacts the understanding of cell functionality and pathological changes45.spRNAseq is a recently developed transformative technology. It combines the strengths of the global transcriptional analysis of bulk RNAseq and in situ hybridization, providing whole transcriptome data with spatial information. Tumors comprise of diverse cell types that often communicate in highly structured manners both spatially and temporally. Unlocking such complex spatial structures enables us to understand how tumor cells communicate with each other, escape immune surveillance, develop drug-resistance, and eventually metastasize. Thus, to fully understand tumorigenesis and design effective treatment strategies, it is essential to study gene expression spatially43. The workflow starts with imaging the fresh-frozen tissue section placed on the visium spatial gene expression slide. The visium slide is functionalized with printed oligo capture probes. The composition of the probes is similar to that of the oligo sequences coated on the gel beads as described in the scRNAseq section. After the tissue section is fixed, stained, and imaged, it is permeabilized to release RNA to bind to adjacent capture probes for on-slide cDNA synthesis. The double stranded cDNA, carrying the spatial barcode, is denatured, and the second strand cDNA is collected for off-slide library preparation , GeoMx DSP, was launched in 2019. The GeoMx DSP is built on Nanostring’s digital molecular barcoding core technology and is further extended by linking the target complementary sequence probe to a unique DSP barcode through a UV cleavable linker. A pool of such barcode-labeled probes is hybridized to mRNA targets that are released from fresh or FFPE tissue sections mounted on a glass slide. The slide is also stained using fluorescent markers  and imaged to establish tissue “geography” using the GeoMx DSP instrument. After the regions-of-interest (ROIs) are selected, the DSP barcodes are released via UV exposure and collected from the ROIs on the tissue. These barcodes are sequenced through standard NGS procedures Fig. . The ideThe DSP technology has several advantages over the 10X spatial transcriptomics technology, including profiling both RNA and protein, applying multiple samples on the same slide for cost savings, and flexibility to apply different protein or RNA panels for integrative analysis. The DSP whole transcriptome panel offers a targeted approach to quantify transcripts instead of the polyA approach like 10X transcriptome panel, thus excludes biologically uninformative high-expressors like ribosomal RNAs. It also allows user to add up to 60 custom targets of interest to quantify unique transcript variants such as isoforms, lncRNA and exogenous transcripts.There are several common challenges in 10X visium and Nanostring GeoMx technologies that limit their applications, including non-single cell resolution, relatively low sensitivity, high cost, labor intensive process, and inability or limited capacity to do protein profiling. Both platforms cannot provide much needed single cell resolution today. The 10x Visium platform is limited by a spot size of 55 µm, which is larger than the size of many mammalian cells. Nanostring GeoMx can technically draw a region of interest at a single cell size, but high signal to noise ration limits this capacity. Before the resolution issue can be addressed, integration of scRNA-seq with spRNAseq is a viable option.49, and in elucidating tumor heterogeneity and its dynamic microenvironments. Early spRNAseq studies, resulting from early product access programs, showed the coexistence of several distinct expression profiles from the same biopsy in melanoma that can be linked to specific histologic entities, but have more complex and detailed information than a histopathologic analysis can possibly reveal50. The lymphoid area adjacent to the tumor region displayed a specific expression pattern, which was later validated as a unique cancer expression profile that progresses gradually beyond tumor boundaries in prostate cancer51. Recent spRNAseq studies on tumor microenvironments revealed more insightful data. Using multimodal intersection analysis, Moncada R et al52 found that subpopulations of ductal cells, macrophages, dendritic cells and cancer cells have spatially restricted enrichments and coenrichments of inflammatory fibroblasts with cancer cells in primary pancreatic tumors. The distinct architecture among intercellular subpopulations and cross-talking networks within tumor microenvironments likely vary among patients and could have prognostic and therapeutic value. Similarly, Ji et al.53, identified four tumor subpopulations in cutaneous squamous cell carcinoma (cSCC). Of those, a tumor-specific keratinocyte (TSK) population unique to cancer is localized to a fibrovascular niche that is used as a hub for intercellular communication. In murine carcinomas, the co-existence of distinct subsets of cancer-associated fibroblasts (CAFs) has unique phenotypic features and functions that can be remodeled by TGFβ-blockade leading to enhanced efficacy of PD1 immunotherapy54. These findings demonstrate that the cell-cell interactions in a spatial context in the tumor microenvironment are critical components in understanding tumor progression, drug resistance and therapeutic efficacy.The spRNAseq is still in its early stages and has already shown promising applications that yielded inaccessible knowledge in biomarker discoveries, optimizing therapeutic strategyThree main RNAseq technologies described above have their unique features and suitable applications. It is likely that bulk RNAseq will remain the primary choice for clinical oncology in the near future. scRNAseq will further expand in the clinical research arena, and eventually get into the clinical practice when the cost significantly decreases. As for spRNASeq, it is still in its infancy. Given its capacity to dissect intercellular subpopulations of tumor microenvironment sensitively and spatially, spatial oncology will inevitably become a fundamental area of research in both discovery and therapeutics.56 has recently demonstrated the possibility of spatial genome wide epigenome profiling with three histone modification markers  at tissue scale and cellular level. By combining epigenome, transcriptome and proteome datasets at a single cell resolution will have profound implications for understanding causative relationships of the multi-omics data, how genome organizes and functions, and how cancer develops.The ultimate goal in spatial biology is to develop a spatial multi-omics technology at a single cell resolution. Deng et al.


Licensed systemic treatment options for platinum-sensitive recurrent ovarian cancer are platinum-based chemotherapy and maintenance treatment with bevacizumab and poly (ADP-ribose) polymerase inhibitors. For platinum-resistant disease, several non-platinum options are available. We aimed to assess the clinical benefit of these treatments according to the European Society of Medical Oncology (ESMO)-Magnitude of Clinical Benefit Scale (MCBS).A PubMed search was carried out including all studies evaluating systemic treatment of recurrent epithelial ovarian cancer, from 1990 onwards. Randomised trials with an adequate comparator and design showing a statistically significant benefit of the study arm were independently scored by two blinded observers using the ESMO-MCBS.A total of 1127 papers were identified, out of which 61 reported results of randomised trials of sufficient quality. Nineteen trials showed statistically significant results and the studied treatments were graded according to ESMO-MCBS. Only three treatments showed substantial benefit  according to the ESMO-MCBS: platinum-based chemotherapy with paclitaxel in the platinum-sensitive setting and the addition of bevacizumab to chemotherapy in the platinum-resistant setting. The WEE1 inhibitor adavosertib (not licensed) also scores a 4, based on a recent small phase II study. Assessment of quality-of-life data and toxicity using the ESMO-MCBS showed to be complex, which should be taken into account in using this score for clinical decision making.Only a few licensed systemic therapies for recurrent ovarian cancer show substantial clinical benefit based on ESMO-MCBS scores. Trials demonstrating overall survival benefit are sparse. •Benefit of systemic treatments for recurrent ovarian cancer was scored on the ESMO-MCBS.•From 1127 identified papers, only 3 trials out of 19 that were suitable for grading showed substantial clinical benefit.•Trials demonstrating overall survival benefit are sparse. BRCA mutation status and physician and patients' preferences.,First-line therapy for advanced epithelial ovarian cancer (EOC) consists of debulking surgery and platinum-based chemotherapy. EOC is usually diagnosed at an advanced stage, which has a poor prognosis with the majority of women eventually developing recurrent disease. Ovarian cancer-specific survival at 5 years is 40% for stage III disease and only 20% for stage IV disease.A PubMed search was carried out in 2019 and updated in March 2021 using the following Medical Subject Headings (MeSH) terms: ‘recurrent’ OR ‘refractory’ AND ‘ovarian’ OR ‘ovary’ AND ‘neoplasm’ OR ‘cancer’ OR ‘carcinoma’; the search was limited to trials in humans. Studies evaluating systemic treatment in recurrent EOC patients were screened, from the introduction of taxanes in 1990 onwards.Titles and abstracts were screened independently by two observers (KEB and MvK) and categorised into three categories: category I contained large phase III randomised controlled trials (RCTs) in the target population with an adequate comparator and a primary endpoint of overall survival (OS) or progression-free survival (PFS); category II for other studies that could potentially be scored on the ESMO-MCBS; and category III for studies that did not meet the inclusion criteria for scoring . After all articles had been assigned to a category, the assessments of the two independent observers were compared and conflicting results were resolved at a consensus meeting. Studies in category I and II were analysed in more detail by reading the full paper, assessing study methodology, patient numbers, study design, endpoints and outcome. From category II, only randomised studies comparing a new agent or combination to a clinically relevant comparator were included, and thus single-arm studies and studies evaluating different dose regimens of the same drug were excluded from the analysis. Non-platinum-based chemotherapy was inferior to platinum-based chemotherapy in the MITO-8 study,Finally, references of included studies and relevant guidelines were checked to identify relevant publications not retrieved by the search strategy. All included studies showing a statistically significant benefit of the study arm were graded according to the ESMO-MCBS.,The ESMO-MCBS can be used to rank the value of systemic therapies based on reported relative and absolute benefits in terms of improved survival  and better survival . For palliative treatments, as is the case in recurrent ovarian cancer, there are several MCBS evaluation forms available and the correct form is chosen based on the primary endpoint used in the study  and the duration of survival in the control group.https://doi.org/10.1016/j.esmoop.2021.100229). Finally, nine additional studies were included after checking relevant guidelines and references.Our search retrieved 1127 studies in ovarian cancer published since 1990. There was an excellent overall agreement between the two observers (98%) when categorising the studies into the three specified groups. A flow chart indicating the selection procedure is shown in In total, 61 publications reporting the results of 46 original clinical trials were assessed. Fourteen phase III studies and five randomised phase II studies with statistically significant results were graded for clinical benefit using the ESMO-MCBS  and 2. TNine randomised phase III studies evaluating chemotherapy in platinum-sensitive disease in a total of 5470 patients were assessed for clinical benefit. Of these nine trials, five (55%) showed significant improvement of either PFS (3/9), OS (1/9) or QoL (1/9) .With regard to the platinum-based options, the highest clinical benefit (ESMO-MCBS grade 4) was obtained for the combination of paclitaxel plus platinum-based chemotherapy.The remaining three trials with significant results investigated carboplatin doublet chemotherapy plus bevacizumab (versus carboplatin doublet chemotherapy), carboplatin plus gemcitabine (versus carboplatin monotherapy) and carboplatin plus PLD plus bevacizumab (versus carboplatin/gemcitabine/bevacizumab), which all showed an improved PFS over the comparator, but did not result in OS benefit and showed no improved QoL.Studies with negative results included the addition of the folate receptor antibody farletuzumab to carboplatin plus taxane,In conclusion, for platinum-sensitive recurrence, the first-choice treatment is a carboplatin-based combination regimen. Direct comparison in the CALYPSO trial demonstrated that carboplatin plus PLD has a slightly better toxicity profile than carboplatin/paclitaxel. Carboplatin/paclitaxel renders comparable OS,,,,Nine randomised studies in 3394 patients evaluated maintenance therapy after response to platinum-based chemotherapy for recurrent disease. Seven of nine trials (78%) reported significant results: three phase III RCTs evaluating maintenance therapy with PARP inhibitors,BRCA-mutated subgroup (germline or somatic). This resulted in the preliminary score of 3 for the observed PFS benefit which was downgraded to a grade 2 in both populations.BRCA (gBRCA) mutation.n = 295) did not reach statistical significance with an HR of 0.74 , which results in a downgrade to grade 2 for the ITT gBRCA-mutated population. Remarkably, a pre-planned sensitivity analysis in patients with Myriad-confirmed gBRCA mutation  did show a statistically significant OS benefit of 15 months  compared to placebo (OS 37.4 months). However, because there was no correction for multiple testing, this analysis was considered exploratory and the results were not scored on the ESMO-MCBS.The phase II STUDY19 compared olaparib capsules with placebo: there was no significant improvement in OS or QoL for the intention-to-treat (ITT) population or for the prespecified BRCA status, although the included study populations differed somewhat between studies. The absolute benefit was largest for patients with a BRCA mutation with a gain in PFS of 11 and 15 months for rucaparib and niraparib, respectively. For niraparib, analysis of PFS in the subgroups of patients with and without a gBRCA mutation was predefined. The non-gBRCA subgroup included patients with homologous recombination deficiency (HRD) , of which a minority had a somatic BRCA (sBRCA) mutation .sBRCA-mutated tumours were exploratory and therefore not scored on the MCBS. For rucaparib, both the analyses in the subgroup of patients with HRD-associated disease  and the BRCA-mutated subgroup (germline and somatic) were predefined and therefore scored.Treatment with the PARP inhibitors niraparib and rucaparib resulted in moderate benefit according to ESMO-MCBS (grade 3) when compared to placebo, all based on PFS as primary endpoint. This score was the same for the benefit in the unselected ITT population as well as the prespecified subgroup analyses based on ,Maintenance treatment with cediranib improved PFS by 2 months compared to placebo in the ICON6 trial, but not OS,,The benefit of bevacizumab maintenance therapy after platinum-based chemotherapy combined with bevacizumab was assessed in the OCEANS trial and GOG-0213 trial. In the OCEANS trial, addition of bevacizumab to carboplatin/gemcitabine resulted in a PFS gain only, without improvement of OS or QoL, qualifying as only limited clinical benefit with an ESMO-MCBS grade 2.gBRCA mutation, with a score of 2 according to the ESMO-MCBS. The benefit was moderate for other PARP inhibitors based on a PFS benefit. As of yet, OS results for other PARP inhibitors than olaparib are awaited which may result in either a downgrade or an upgrade of the preliminary score. Maintenance therapy with bevacizumab does not provide moderate or substantial benefit according to ESMO-MCBS in patients with platinum-sensitive recurrence.In conclusion, despite the promise and biological rationale of targeted treatment with PARP inhibitors after response to platinum-based chemotherapy, in the recurrent setting a substantial clinical benefit based on OS gain cannot be confirmed for olaparib (tablets) in patients with a A total of 8137 patients with platinum-resistant ovarian cancer were treated in 28 randomised studies included in our analysis, out of which only 6 trials (21%) resulted in significant improvement of either PFS (5/6) or OS (1/6).Two trials showed substantial benefit (ESMO-MCBS grade 4) in this setting. In the AURELIA study, the addition of bevacizumab to standard chemotherapy with either PLD, paclitaxel or topotecan was compared to PLD, paclitaxel or topotecan monotherapy.,One trial showed moderate benefit (grade 3) of sorafenib plus topotecan compared to topotecan alone, with a statistically significant 2.3-month PFS gain, evaluated in a phase II study.Therapies studied in the platinum-resistant setting that were unable to improve PFS or OS are listed in In conclusion, topotecan, PLD and paclitaxel are used for treatment of platinum-refractory ovarian cancer but there are no studies comparing these therapies to best supportive care. Addition of bevacizumab to these agents improved PFS and some symptoms; however, no OS benefit was observed. The WEE1 inhibitor adavosertib combined with gemcitabine has a preliminary score of 4 based on an OS benefit observed in a phase II study; this drug has not yet been licensed. Other treatments or combinations have shown only limited benefit compared to monotherapy with topotecan, PLD or paclitaxel.Analysis of the clinical benefit of systemic therapies for recurrent ovarian cancer using the ESMO-MCBS shows substantial benefit of only a few licensed treatments: carboplatin with either paclitaxel or PLD in the platinum-sensitive setting and the addition of bevacizumab to topotecan, paclitaxel or PLD in the platinum-resistant setting. Considering that over 18 000 patients were enrolled in randomised clinical trials in ovarian cancer over the last three decades, this result is disappointing. This is in line with the moderate improvement of 5-year survival rate in advanced ovarian cancer of only 2% from 1983 to 2012.BRCA-mutated ovarian cancer.gBRCA mutation. Surprisingly, a sensitivity analysis in the population with a Myriad-confirmed gBRCA mutation, which included only nine additional patients, did result in a statistically significant OS benefit. However, because correction for multiple testing was not applied, this sensitivity analysis is considered exploratory and its results were not scored on the ESMO-MCBS. Grading of the other licensed PARP inhibitor therapies (niraparib and rucaparib) on the ESMO-MCBS labels their benefit as only ‘moderate’ with a score of 3. This score was not higher in the prespecified subgroup of patients with a BRCA mutation compared to the unselected ITT population. The PFS gain in the ITT population for rucaparib, and in the non-gBRCA-mutated patients for niraparib was, however, numerically lower than in the other subgroups. It is, therefore, essential to understand the benefit of PARP inhibitors in patients with BRCA wild-type disease and absence of HRD, since the gain observed for the ITT population is likely to be largely driven by the inclusion of patients with either HRD tumours or BRCA-mutated tumours. This supports restricting use of olaparib tablets to this group of patients.BRCA mutation status. The registration trial for olaparib capsules (STUDY19) also included BRCA-negative patients, but it received a restricted licensed indication only in patients with a BRCA mutation. Later, an updated OS analysis indeed only showed a numerical OS gain in patients with a BRCA mutation supporting this.BRCA mutation. Remarkably, registration was partly based on data from the ITT analysis of STUDY19, leading to a broader licensed label for olaparib tablets, including treatment of patients without a BRCA mutation.Based on their mechanism of action, PARP inhibitors are expected to especially benefit patients with homologous recombination-deficient tumours, such as Despite the use of debulking surgery for selected patients with recurrent disease, given the low chance of cure for these patients, we considered chemotherapy after debulking surgery for recurrent ovarian cancer a palliative treatment and therefore used ESMO-MCBS forms 2 or 3. For treatments that only show a PFS benefit, without an OS benefit, the ESMO-MCBS score is downgraded if toxicity is increased or QoL analysis does not show an improvement. Obviously, if mature OS data or QoL results are not published, as is yet still the case for most PARP inhibitor trials, this downgrade will not be applied. ESMO-MCBS forms do not currently allow downgrading when OS and QoL data are not published, but this could be relevant in cases in which sufficient time has passed for data to become mature and publication of OS data is no longer expected to follow. In ovarian cancer trials, a PFS benefit often does not predict a benefit in OS.Downgrading for toxicity can be a matter of debate. For example, in the AURELIA trial, global QoL was comparable but there was an improvement in a subscale of QoL measuring GI symptoms.There are some other points to consider in interpreting the current analysis. First of all, studies from 1990 onwards were included. Surgical treatment and supportive care have changed during this time period, complicating the comparison of study results within these three decades. Furthermore, the ESMO-MCBS was developed to grade the results of well-designed registration studies, and the standards for performing and reporting of clinical trials have become more stringent during the years. However, even in recent times, only a minority of studies testing anticancer drugs were adequately designed to be able to meet ESMO-MCBS thresholds of substantial clinical benefit.Only a few licensed systemic therapies for recurrent ovarian cancer show substantial clinical benefit based on ESMO-MCBS scores. Carboplatin + paclitaxel scores a grade 4 indicating substantial clinical benefit in the platinum-sensitive setting. Addition of bevacizumab to either PLD, paclitaxel or topotecan in platinum-resistant disease also has substantial benefit (grade 4), but the QoL data supporting this score are subject to interpretation. The unlicensed WEE1 inhibitor adavosertib combined with gemcitabine has a preliminary score of 4 based on an OS benefit observed in a phase II study. For PARP inhibitors, only moderate clinical benefit can be confirmed, based on OS results for olaparib tablets and PFS results for the other drugs.


Is stratified care an efficacious and cost-effective approach to psychological treatment selection compared with stepped care?In this cluster randomized clinical trial of 951 adults with common mental disorders, stratified care was efficacious and cost-effective for the treatment of depression symptoms relative to stepped care.These findings suggest that stratified care has the potential to improve depression treatment outcomes at a modest incremental cost. This cluster randomized clinical trial assesses whether stratified care is effective and cost-effective compared with usual stepped care among patients seeking psychological treatment for common mental disorders, including depression. Depression is a major cause of disability worldwide. Although empirically supported treatments are available, there is scarce evidence on how to effectively personalize psychological treatment selection.To compare the clinical effectiveness and cost-effectiveness of 2 treatment selection strategies: stepped care and stratified care.This multisite, cluster randomized clinical trial recruited participants from the English National Health Service from July 5, 2018, to February 1, 2019. Thirty clinicians working across 4 psychological therapy services were randomly assigned to provide stratified (n = 15) or stepped (n = 15) care. In stepped care, patients sequentially access low-intensity guided self-help followed by high-intensity psychotherapy. In stratified care, patients are matched with either low- or high-intensity treatments at initial assessment. Data were analyzed from May 18, 2020, to October 13, 2021, using intention-to-treat principles.All clinicians used the same interview schedule to conduct initial assessments with patients seeking psychological treatment for common mental disorders, but those in the stratified care group received a personalized treatment recommendation for each patient generated by a machine learning algorithm. Eligible patients received either stratified or stepped care .The preregistered outcome was posttreatment reliable and clinically significant improvement (RCSI) of depression symptoms . The RCSI outcome was compared between groups using logistic regression adjusted for baseline severity. Cost-effectiveness analyses compared incremental costs and health outcomes of the 2 treatment pathways.P = .03). Stratified care was associated with a higher mean additional cost per patient ]; P < .001) because more patients accessed high-intensity treatments , but this additional cost resulted in an approximately 7% increase in the probability of RCSI.A total of 951 patients were included . The proportion of cases of RCSI was significantly higher in the stratified care arm compared with the stepped care arm (264 of 505 [52.3%] vs 134 of 297 [45.1%]; odds ratio, 1.40 ; In this cluster randomized clinical trial of adults with common mental disorders, stratified care was efficacious and cost-effective for the treatment of depression symptoms compared with stepped care. Stratified care can improve depression treatment outcomes at a modest additional cost.ISRCTN11106183isrctn.org Identifier:  In theory, stepped care is a self-correcting model4 in which patients eventually receive an appropriately intensive treatment for their needs. This model widens access to care by offering the least restrictive and least costly interventions to most people.5Clinical guidelines for the management of depression recommend psychological interventions organized in a stepped care model, in which most patients access only low-intensity treatments such as guided self-help, and patients who remain symptomatic after this step can access more intensive and costly psychotherapies such as cognitive behavioral therapy.6 A systematic review of studies arising from the IAPT program7 indicated that stepped care is generally associated with large pre- to posttreatment effect sizes for depression (Cohen d = 0.87). However, these effects were attenuated in subgroups of patients with more complex presentations,7 such as those with comorbid physical illnesses,8 personality disorder traits,9 disabilities,10 and low treatment expectancies10 and those living in socioeconomically deprived circumstances.11 These complicating factors have a cumulative effect, such that patients with several of these features tend to have poorer treatment outcomes.12 On this basis, some have argued that IAPT services should move toward a stratified approach to psychological treatment selection, which would involve matching the intensity of treatment to the level of complexity in each individual case.12Stepped care has been implemented at a national level in England, through the Improving Access to Psychological Therapies (IAPT) program, which currently receives more than 1 million referrals per year.13 Recent studies15 have indicated that stratified care has potential to improve the effectiveness of psychological care for depression. However, most of these studies draw their conclusions from post hoc analyses of retrospective data, and the only prospective study16 was underpowered to test its primary hypothesis. Rigorous and adequately powered experimental studies are necessary to determine whether stratified care may be an effective and affordable way to organize psychological interventions. To fill this evidence gap, we conducted a cluster randomized clinical trial of stratified care vs stepped care in IAPT services. We hypothesized that stratified care would improve depression treatment outcomes compared with stepped care and that this would be explained by higher improvement rates in complex cases matched with high-intensity treatment.Stratified medicine aims to identify individuals who will have the most clinical benefit or least harm from specific treatments.1 The trial protocol (CONSORT) reporting guideline.This pragmatic, multisite, single-blind, cluster randomized clinical trial involved 4 IAPT services in northern England that were managed by Lancashire and South Cumbria NHS  Foundation Trust and Rotherham Doncaster and South Humber NHS Foundation Trust. These services implemented stepped care in line with national guidelines.protocol  was prerThe research team recruited clinicians after presenting the study rationale at clinical team meetings. Interested clinicians provided written informed consent via email. Patients seeking psychological treatment were recruited by participating clinicians using a standardized recruitment script at the start of routine assessments that aimed to determine suitability for treatment in the IAPT program. Patients provided verbal consent because assessments were conducted via telephone.17 Patients were excluded from these services and the study if they were already accessing psychological treatment elsewhere . No other exclusion criteria were applied, and patients were eligible for participation regardless of their current use of medications or other medical interventions.Clinicians were included if they were psychological well-being practitioners who conducted initial assessments in the participating services and were qualified with a nationally recognized postgraduate certificate in low-intensity psychological interventions  control group by an independent research assistant using a computer-generated 1:1 randomization schedule in blocks of 4, stratified by team. Randomization was clustered by clinicians to minimize contamination bias that may occur if clinicians applied stratified care with some patients and stepped care with others. Clinicians were therefore aware of their random allocation, which was communicated to them after randomization. Patients provided informed consent for clinicians to gather assessment information, enter it into a computer system, and use it to inform their treatment recommendation, but they were blinded to the decision-making process that guided each of the treatment groups.17 The assessments covered the patient’s presenting problems and their impact, history, current life circumstances, and treatment goals. As part of this assessment, clinicians in both groups gathered clinical and demographic data that were entered in a computerized application as part of the study procedures. Race and ethnicity were self-reported by participants. Although they provided a self-reported category to clinicians who undertook the assessments, this information was aggregated in a binary variable  by clinical services before data were shared with the research team. No other details about race and ethnicity were available to the research team.All consenting patients were assessed by participating clinicians using the same semistructured interview schedule. These were routine telephone-based assessments that lasted an average of 40 minutes and followed practice guidelines for IAPT services.18 and came to a final treatment allocation decision that was recorded in the application. Clinicians in the stepped care control group used the application only to enter data, but they did not receive a personalized recommendation, and they allocated patients to treatment following guidelines for stepped care.17 Consistent with these guidelines, stepped care initially allocates most patients to low-intensity treatments, but patients with specific disorders  and those who have severe impairment can be referred directly for high-intensity treatments.17 Treatment allocation decisions in routine care are often made after initial assessment interviews with patients and in consultation with supervisors or senior clinicians.Clinicians in the stratified care group used a version of the application that provided a personalized treatment recommendation in real time, recommending either a low- or high-intensity treatment based on each patient’s features. These clinicians were trained to discuss this recommendation with patients following good practice principles of shared decision-making19 anxiety,20 functional impairment,21 personality traits,22 employment status, and race and ethnicity. The algorithm calculates an expected prognosis  based on which cases are classified as standard (better expected prognosis) or complex (poorer expected prognosis). Standard cases are matched with low-intensity treatments, and patients later have the option to move to high-intensity treatment if necessary, whereas complex cases are matched directly with high-intensity treatments. The rationale is to offer more intensive treatments to patients with higher risk of poor treatment outcomes, consistent with principles of stratified medicine.13 Further technical details about the data sources, machine learning approach , model development, and external cross-validation are available elsewhere.12 In addition, the stratified care application was programmed to implement decision rules that would ensure compliance with national clinical guidelines1 for the treatment allocation of patients with the aforementioned disorders that are treated only with high-intensity psychotherapies in the IAPT program.17 As such, this treatment selection approach was designed to fast-track 2 groups of patients to high-intensity treatments: patients with specific conditions for which only psychotherapy is indicated and patients whose cases are classified as complex.The stratified care application used in this trial is a technology that (1) collects data, (2) processes inputs using a machine learning algorithm, and (3) outputs a personalized treatment recommendation using automated decision rules. The inputs for the algorithm were patient-reported measures of depression,23 for up to 8 sessions (each lasting 30 minutes). Low-intensity interventions can be delivered as individual-guided self-help, in group settings, or as telephone-guided computerized cognitive behavioral therapy. High-intensity interventions are lengthier (≤20 one-hour sessions) evidence-based psychotherapies including cognitive behavioral therapy, person-centered experiential counseling for depression, and eye movement desensitization and reprocessing for posttraumatic stress disorder. These interventions were delivered by clinicians qualified to a postgraduate level, following structured treatment protocols endorsed by national guidelines,24 and under regular supervision . Consistent with the pragmatic trial design, we did not record, monitor, or modify these interventions in any way to preserve the integrity of routinely delivered psychological care.After initial assessment interviews, patients accessed their assigned interventions with the first available clinician in each service (the treating clinician was not the same person as the assessing clinician). Low-intensity interventions are based on principles of cognitive behavioral therapy and involve learning coping skills with the support of a qualified psychological well-being practitioner18 .All participating clinicians attended a 2-hour training course that covered the study design, informed consent and recruitment tasks, and data collection tasks. Clinicians randomized to the stratified care group attended 1 additional hour of training , which covered the stratified care algorithm, its decision-making process, and principles of good practice in shared decision-making19 The cutoff of at least 10 is recommended to screen for clinically significant depression symptoms,19 and a change of at least 6 points is indicative of statistically reliable change.25 Patients in the IAPT program complete this measure on a session-by-session basis to monitor treatment response.6 Given that treatment duration is variable in routine care, the primary end point was defined at the time of each patient’s last attended treatment session.The 9-item Patient Health Questionnaire (PHQ-9) is a measure of depression symptoms, where each item is rated on a Likert scale ranging from 0 to 3 representing symptom frequency in the past 2 weeks, yielding an overall severity score ranging from 0 to 27.26 which is important in the context of stepped care, because patients who do not attain symptomatic remission have the opportunity to access further interventions to attain the best possible outcome. This outcome is consistent with the stratified care algorithm, which was specifically trained to calculate a prognosis (probability of RCSI) using this definition, and which was expected to result in better depression (PHQ-9) but not anxiety  treatment outcomes based on prior evidence.12The primary (preregistered) outcome of the study was the proportion of patients meeting criteria for reliable and clinically significant improvement (RCSI) in the PHQ-9 measure (posttreatment scores <10 and improved by ≥6 points). Reliable and clinically significant improvement is a clinically stringent and statistically conservative outcome that prioritizes full remission of symptoms,20 was examined. Furthermore, IAPT services use an outcome definition termed reliable recovery, which is a stringent outcome definition that requires patients to have achieved RCSI in both the PHQ-9 and GAD-7 measures.17 Additional comparisons examined the proportions of patients who accessed low- vs high-intensity treatments, treatment duration (number of sessions), and treatment dropout . Adherence to the experimental intervention was measured by comparing the percentage of agreement and interrater reliability (κ statistic) in the stratified care model–recommended vs actual treatment selection decisions.We compared between-group differences in a range of secondary outcomes of interest. Reliable and clinically significant improvement status in the GAD-7P = .11), so subsequent models applied a parsimonious logistic regression that improved goodness of fit . A full output of the model-building process and goodness-of-fit indices can be found in eMethods 3 in 2 and Mann-Whitney U tests. Fifth, an economic analysis evaluated the relative cost-effectiveness of stratified vs stepped care from a health services perspective using a cost-effectiveness acceptability curve to aid interpretation. Further details about sample size calculation and economic analyses are provided in eMethods 2 and 4, respectively, in P < .05 indicated statistical significance.Data were analyzed from May 18, 2020, to October 13, 2021. All analyses followed intention-to-treat principles, and missing (n = 38) posttreatment PHQ-9 and/or GAD-7 scores were imputed with an expectation maximization method using baseline features as predictors. Data analysis was conducted in 5 steps. First, the proportion of patients with posttreatment remission (RCSI) of depression symptoms (PHQ-9) was compared between groups using logistic regression adjusted for baseline PHQ-9 scores. A mixed model (clustering by assessing clinician) was estimated first, showing no significant cluster effects (The CONSORT diagram is presented in P = .03). Patients in the stratified care group were also significantly more likely to meet criteria for IAPT reliable recovery (276 of 573 [48.2%]) after treatment compared with patients in the stepped care group . Subgroup analyses indicated that between-group differences in depression outcomes were not significant in the subsample of complex cases , but they were significant in the subsample of standard cases . Between-group comparisons in the anxiety outcome measure were not statistically significant .U test, 121106.00 ; P < .001). This is explained by the higher proportion of patients who accessed high-intensity interventions in stratified care , because dropout rates were not significantly different , but resulted in an approximately 7% increase in the probability of RCSI. Adherence to the stratified care model was high in the experimental group (κ = 0.81) and significantly different from the treatment selection decisions observed in the stepped care group, which had low concordance with the stratified care algorithm (κ = 0.22). As illustrated in Stratified care was associated with a higher median number of treatment sessions  compared with stepped care  (Mann-Whitney P < .001). The cost-effectiveness acceptability curve in The estimated incremental cost of stratified care was £104.5  per patient   were consistent with data from IAPT services.7 Furthermore, the stratified care model was feasible to implement and had a high adherence rate (κ= 0.81). Treatment selection decisions made in the stepped care group had nearly chance-level convergence with those in the stratified care algorithm (κ= 0.22), indicating that decision-making across these models is highly distinctive. Stratified care also increased the efficiency of initial assessments, because clinicians in the experimental group were able to assess a larger sample of patients in the same allotted weekly time, whereas decisions in the stepped care group were sometimes protracted by the need to consult with colleagues or supervisors about suitability for available treatments, which is commonplace in stepped care.23A growing literature in the field of depression suggests that treatment outcomes could be improved through personalized treatment selection.12 A plausible explanation is that there was little difference in the treatment allocation of patients with anxiety disorders between stratified and stepped care, because both models refer patients with some conditions  directly to high-intensity treatments in line with clinical guidelines.17 These results are consistent with prior evidence that IAPT services that have a higher proportion of patients accessing high-intensity treatments tend to have better treatment outcomes.25 Related to this point, a possible explanation for the observed effect may be owing to an absolute increase in the proportion of patients allocated to high-intensity treatment, rather than a strategic matching effect. Future implementation trials could examine whether the effect of stratified treatment selection varies across IAPT services, with variable proportions of patients allocated to high-intensity treatment.As expected, the proportions of patients with full remission (RCSI) of depression and anxiety symptoms were higher in stratified care compared with stepped care, but differences were statistically significant only in the PHQ-9 measure. This is consistent with prior evidence suggesting that stratified care could improve remission rates in the PHQ-9 but not in the GAD-7 measure.28 suggests that the presence of patients with chronic conditions in a clinical sample may obscure the differential treatment response in those with more treatable conditions. It is, of course, possible that stratified care does not work for complex cases as defined in this study, and future research should consider how to improve outcomes for those at the highest risk of poor treatment response.Contrary to our expectations, only standard  cases had significantly better outcomes in stratified care. In the present study, relatively few patients with the poorest expected prognosis were classified as complex cases (225 of 951 [23.7%]), and it may be that the observed trend toward better outcomes in stratified care for the complex cases could be diluted by the inclusion of some patients with chronic conditions that simply do not respond to interventions available in IAPT services. Previous researchThe pragmatic trial design maximized feasibility, sample size, and external validity to the routine care context, but inevitably had some weaknesses in terms of internal validity. Outcomes were patient reported, and no formal diagnostic interviews or observer-rated outcomes were available. The sole reliance on patient-reported measures means that we cannot rule out or examine the potential influence of biases such as motivated responding and social desirability bias. Although the PHQ-9 and GAD-7 measures are relevant to the broad range of affective and anxiety symptoms reported by participants, a significant limitation is that disorder-specific measures were unavailable for conditions such as posttraumatic stress disorder and obsessive-compulsive disorder. In addition, most of the participants were White individuals, which limits the generalizability of these findings to other racial and ethnic minority groups. Furthermore, outcomes were defined at the last attended treatment session, and therefore the maintenance of these effects over a longer time frame could not be established. A further implication is that, on average, the final outcomes in the stratified care group were measured at a later time compared with those in stepped care, because more patients had lengthier high-intensity treatments in the experimental group. Thus, there are uncertainties related to the pragmatic design, and future studies could establish a fixed follow-up measurement schedule to understand short- and longer-term effects with greater precision. The economic analysis was limited to a comparative examination of acute-phase treatment costs, but wider outcomes such as quality-adjusted life-years and use of health services after the end of treatment remain unknown.Overall, the present findings indicate that stratified care is feasible to implement in routine IAPT services, improving the efficiency and precision of psychological assessments in a way that preserves shared decision-making. Implementation of stratified care resulted in better depression treatment outcomes albeit with an additional cost per treatment.