Recommendations on Disease Management for Patients With Advanced Human Epidermal Growth Factor Receptor 2–Positive Breast Cancer and Brain Metastases: ASCO Clinical Practice Guideline Update

Purpose

To update the formal expert consensus-based guideline recommendations for practicing oncologists and others on the management of brain metastases for patients with human epidermal growth factor receptor 2–positive advanced breast cancer to 2018.

Methods

An Expert Panel conducted a targeted systematic literature review (for both systemic treatment and CNS metastases) and identified 622 articles. Outcomes of interest included overall survival, progression-free survival, and adverse events. In 2014, the American Society of Clinical Oncology (ASCO) convened a panel of medical oncology, radiation oncology, guideline implementation, and advocacy experts, and conducted a systematic review of the literature. When that failed to yield sufficiently strong quality evidence, the Expert Panel undertook a formal expert consensus–based process to produce these recommendations. ASCO used a modified Delphi process. The panel members drafted recommendations, and a group of other experts joined them for two rounds of formal ratings of the recommendations.

Results

Of the 622 publications identified and reviewed, no additional evidence was identified that would warrant a change to the 2014 recommendations.

Recommendations

Patients with brain metastases should receive appropriate local therapy and systemic therapy, if indicated. Local therapies include surgery, whole-brain radiotherapy, and stereotactic radiosurgery. Treatments depend on factors such as patient prognosis, presence of symptoms, resectability, number and size of metastases, prior therapy, and whether metastases are diffuse. Other options include systemic therapy, best supportive care, enrollment in a clinical trial, and/or palliative care. Clinicians should not perform routine magnetic resonance imaging to screen for brain metastases, but rather should have a low threshold for magnetic resonance imaging of the brain because of the high incidence of brain metastases among patients with HER2-positive advanced breast cancer. Additional information is available at www.asco.org/breast-cancer-guidelines .

Systemic Therapy for Patients With Advanced Human Epidermal Growth Factor Receptor 2–Positive Breast Cancer: ASCO Clinical Practice Guideline Update

Purpose

To update evidence-based guideline recommendations for practicing oncologists and others on systemic therapy for patients with human epidermal growth factor receptor 2 (HER2)–positive advanced breast cancer to 2018.

Methods

An Expert Panel conducted a targeted systematic literature review (for both systemic treatment and CNS metastases) and identified 622 articles. Outcomes of interest included overall survival, progression-free survival, and adverse events.

Results

Of the 622 publications identified and reviewed, no additional evidence was identified that would warrant a change to the 2014 recommendations.

Recommendations

HER2-targeted therapy is recommended for patients with HER2-positive advanced breast cancer, except for those with clinical congestive heart failure or significantly compromised left ventricular ejection fraction, who should be evaluated on a case-by-case basis. Trastuzumab, pertuzumab, and taxane for first-line treatment and trastuzumab emtansine for second-line treatment are recommended. In the third-line setting, clinicians should offer other HER2-targeted therapy combinations or trastuzumab emtansine (if not previously administered) and may offer pertuzumab if the patient has not previously received it. Optimal duration of chemotherapy is at least 4 to 6 months or until maximum response, depending on toxicity and in the absence of progression. HER2-targeted therapy can continue until time of progression or unacceptable toxicities. For patients with HER2-positive and estrogen receptor–positive/progesterone receptor–positive breast cancer, clinicians may recommend either standard first-line therapy or, for selected patients, endocrine therapy plus HER2-targeted therapy or endocrine therapy alone. Additional information is available at www.asco.org/breast-cancer-guidelines .

Cancer Informatics in 2017: A New Beginning and a Bright Future

Objective:  To summarize significant research contributions on cancer informatics published in 2017.

Methods:  An extensive search using PubMed/Medline, Google Scholar, and manual review was conducted to identify the scientific contributions published in 2017 that address topics in cancer informatics. The selection process comprised three steps: (i) 15 candidate best papers were first selected by the two section editors, (ii) external reviewers from internationally renowned research teams reviewed each candidate best paper, and (iii) the final selection of three best papers was conducted by the editorial board of the Yearbook.

Results:  Results: The three selected best papers present studies addressing many facets of cancer informatics, with immediate applicability in the research and clinical domains.

Conclusion: Cancer informatics is a broad and vigorous subfield of biomedical informatics. Strides in knowledge management, crowdsourcing, and visualization are especially notable in 2017.

Abstract CT041: Primary results from FAIRLANE (NCT02301988), a double-blind placebo (PBO)-controlled randomized phase II trial of neoadjuvant ipatasertib (IPAT) + paclitaxel (PAC) for early triple-negative breast cancer (eTNBC)

Purpose: This hypothesis-generating trial evaluated neoadjuvant IPAT + PAC for eTNBC.

Methods: Patients (pts) with eTNBC, T ≥1.5 cm and N0-2 were randomized 1:1 to receive 12 wks of weekly PAC 80 mg/m² + either IPAT 400 mg or PBO d1-21 q28d before surgery. Investigators chose adjuvant therapy. Stratification factors were PTEN status (Targos IHC), nodal status and tumor size. Co-primary endpoints were pathologic complete response (pCR) rate (ypT0/TisN0) in the intent-to-treat (ITT) and PTEN-low (Ventana IHC) populations. Secondary endpoints included pCR rate in pts with PIK3CA/AKT1/PTEN-altered tumors (NGS; Foundation Medicine), pre-surgery clinical response rates by MRI and safety.

Results: From Feb 2015 to Mar 2017, 151 pts were randomized. Most had T1/2 (87%) N0 (65%) tumors. At the final analysis (9 Nov 2017), 132 pts (87%) had completed surgery. In all 3 populations, rates of pCR, overall clinical response and complete response (CR) by MRI favored IPAT (Table). IPAT was associated with more grade ≥3 AEs (32% vs 16% with PBO), especially diarrhea (17% vs 1%). AEs leading to IPAT/PBO discontinuation (9% vs 3%) or dose reduction (16% vs 1%) or PAC interruption (20% vs 12%) were more common with IPAT but median PAC dose intensity was 100% (IQR 100-100%) in both arms. Incidences of neuropathy (57% vs 61%) and neutropenia (14% vs 13%) were similar with IPAT vs PBO.

Conclusions: Adding IPAT to PAC for eTNBC showed a small non-significant increase in pCR rate. The anti-tumor effect of IPAT was most pronounced in biomarker-selected pts: CR rates were 32% vs 6% in pts with PTEN-low tumors and 39% vs 9% in PIK3CA/AKT1/PTEN-altered tumors. Safety was consistent with prior IPAT + PAC experience. Similar to LOTUS in metastatic TNBC, FAIRLANE results support further evaluation of IPAT + PAC in pts with PIK3CA/AKT1/PTEN-altered tumors. A comprehensive translational research program is ongoing.

TableEndpointITTPTEN-low (by IHC)PIK3CA/AKT1/PTEN-altered (by NGS)IPAT + PACPBO + PACIPAT + PACPBO + PACIPAT + PACPBO + PACpCR rate (ypT0/TisN0)13/76 (17.1%)10/75 (13.3%)3/19 (15.8%)2/16 (12.5%)5/28 (17.9%)4/34 (11.8%)Difference (95% CI)3.8% (-9.0 to 16.5)3.3% (-25.5 to 32.1)6.1% (-15.0 to 27.2)Overall clinical response ratea by MRI51/76 (67.1%)42/75 (56.0%)14/19 (73.7%)8/16 (50.0%)19/28 (67.9%)18/34 (52.9%)Difference (95% CI)11.1% (-5.6 to 27.9)23.7% (-13.6 to 60.9)14.9% (-12.4% to 42.3%)CR rateb by MRI21/76 (27.6%)10/75 (13.3%)6/19 (31.6%)1/16 (6.3%)11/28 (39.3%)3/34 (8.8%)aUnconfirmed complete or partial response. bUnconfirmed complete response.

Citation Format: Mafalda Oliveira, Cristina Saura, Isabel Calvo, Jay Andersen, José Luis Passos Coelho, Miguel Gil Gil, Begoña Bermejo, Debra A. Patt, Eva Ciruelos, Stina M. Singel, Daniel J. Maslyar, Matthew Wongchenko, Wai Y. Chan, Amy V. Kapp, Lorena de la Peña, José Baselga, Steven J. Isakoff. Primary results from FAIRLANE (NCT02301988), a double-blind placebo (PBO)-controlled randomized phase II trial of neoadjuvant ipatasertib (IPAT) + paclitaxel (PAC) for early triple-negative breast cancer (eTNBC) [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2018; 2018 Apr 14-18; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2018;78(13 Suppl):Abstract nr CT041.

Abstract CT044: MONARCH 1: Final overall survival analysis of a phase 2 study of abemaciclib, a CDK4 and CDK6 inhibitor, as monotherapy, in patients with HR+/HER2- breast cancer, after chemotherapy for advanced disease

Background: Abemaciclib is an oral, selective inhibitor of CDK4 and CDK6 dosed on a continuous schedule. MONARCH 1 (NCT02102490) is a phase 2 single-arm study designed to evaluate safety and efficacy of abemaciclib monotherapy in women with HR+/HER2- MBC whose disease progressed on or after endocrine therapy and chemotherapy. Final analysis of the primary endpoint, objective response rate (ORR) at 12 months (mo), showed that abemaciclib monotherapy induced objective tumor responses in patients (pts) with refractory HR+/HER2- MBC following multiple prior therapies. Treatment was well tolerated, allowing prolonged exposure to therapy. We report the final 18 mo overall survival results.

Methods: Eligible pts had measurable disease, ECOG PS of 0/1, no CNS metastases, and received at least 1 but no more than 2 lines of chemotherapy in the metastatic setting. Abemaciclib (200 mg) was administered orally on a continuous schedule every 12 hours until disease progression. The primary objective was to evaluate ORR per RECIST v1.1. at 12 mo after the last pt enrolled. Secondary objectives included duration of response (DoR), progression-free survival (PFS), overall survival (OS), disease control rate (DCR = CR + PR + SD), clinical benefit rate (CBR= CR + PR + SD ≥ 6 mo) and safety. Final OS analysis occurred 18 mo after the last pt was enrolled.

Results: A total of 132 pts received abemaciclib monotherapy. The primary endpoint of ORR by investigator assessment at 12 mo was 19.7% (95% CI: 13.3, 27.5) and did not change at 18 mo. Of the 26 responding pts, 19 (73.1%) had responses ≥ 6 mo, and 6 pts still on treatment have response durations ranging from 9.5+ to 20.5+ mo. There was no change at 18 mo vs 12 mo for DCR (67.4%) or CBR (42.4%). Median PFS (6.0 mo, 95% CI: 4.2, 7.5) and median DoR (8.9 mo, 95% CI: 6.1, 14.0) were also consistent with 12 mo follow up. At the 18 mo update, 7 pts (5.3%) remained on treatment (6 PR and 1 SD). At 18 mo, the median OS was 22.3 mo (95% CI: 17.7, NR), and the survival rate was 58.7%. TEAEs ≥ Grade 3 were experienced by 93 pts (70.5%) at 18 mo, compared to 90 pts (68.2%) at 12 mo. The most common Grade 3/4 TEAEs were neutropenia (25.0%), diarrhea (19.7%), fatigue (13.6%), leukopenia (6.8%), anemia (4.5%) and nausea (4.5%). Treatment discontinuations due to AEs were infrequent (7.6 %).

Conclusions: The results of the 18 month analysis are consistent with the 12 month results of MONARCH 1. Median OS was 22.3 months. The efficacy results from the MONARCH 1 study indicate that continuous administration of single-agent abemaciclib induces durable confirmed tumor responses. There were no clinically significant changes in safety. The results of the 18 month analysis support the earlier results and indicate that single-agent abemaciclib may offer a more favorable benefit-risk profile than expected from available cytotoxic chemotherapies.

Citation Format: Hope S. Rugo, Sara M. Tolaney, Javier Cortés, Véronique Diéras, Debra A. Patt, Hans Wildiers, Shivani Nanda, Andrew G. Koustenis, Maura N. Dickler, José Baselga. MONARCH 1: Final overall survival analysis of a phase 2 study of abemaciclib, a CDK4 and CDK6 inhibitor, as monotherapy, in patients with HR+/HER2- breast cancer, after chemotherapy for advanced disease [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2017; 2017 Apr 1-5; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2017;77(13 Suppl):Abstract nr CT044. doi:10.1158/1538-7445.AM2017-CT044

An observational study of patients with advanced melanoma receiving pembrolizumab in a real-world U.S. community oncology practice

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Background: PD-1 monoclonal antibodies are promising immunotherapies approved for treatment of patients (pts) with advanced melanoma. As the first US FDA approved PD-1 antibody, pembrolizumab (pembro) has demonstrated efficacy and safety in clinical trial settings. However, patterns of real world utilization and pt outcomes associated with pembro are limited. Methods: Adult pts with advanced melanoma who initiated pembro between 9/1/ 2014-3/31/2016 were identified retrospectively fromelectronic health records (EHR) of McKesson Specialty Health and followed through 9/ 30/2016. Pts in clinical trials were excluded. Demographic, disease, treatment characteristics and reasons for treatment discontinuation of pembro were abstracted from structured data elements of the EHR with further supplementation of unstructured data within the patient chart (progress notes, radiology scan reports). Overall survival (OS) and physician-reported progression free survival (PFS) from pembro initiation were analyzed using Kaplan Meier analysis. Results: 182 pts, with a median follow-up of 9.9 mos (range = 0.0-25.0), were included. Median age at pembro initiation was 66.0 yrs; 30.8% had an elevated lactate dehydrogenase (LDH); 23.6% had brain metastases and 65.4% had an ECOG performance status of 0 or 1. The most common reason for pembro discontinuation was progression (45.5%) followed by treatment-related toxicity (24.4%). In the overall population, median PFS from pembro initiation was 4.2 mos (95% CI = 3.2-5.3). Median OS was 19.4 mos (14.0-NR) with 12 and 24-month survival probabilities of 61.4% (95% CI = 53.4-68.5) and 43.9% (95% CI = 31.1-55.9). In multivariable analyses, characteristics predictive of worse survival included receipt of pembro at a later line of therapy (HR = 3.36, p = 0.0013 for 3L+), presence of brain metastases (HR = 2.67, p = 0.0007) and elevated LDH (HR = 4.10, p < 0.0001). Conclusions: The study results are consistent with those from pembro clinical trials (KeyNote001) and are in support of the effectiveness of pembro in real world treatment of advanced melanoma. Presence of brain metastases, elevated LDH, and use of pembro 3L+ were associated with worse survival outcome.

Neutropenia related hospitalization risk in lung cancer patients with chemotherapy

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Background: We sought to describe outcomes following granulocyte-colony stimulating factor (G-CSF) prophylaxis in patients with lung cancer receiving chemotherapy regimens with low to intermediate risk for inducing neutropenia related hospitalization. Methods: We identified 11,233 lung cancer (all histologies) patients ≥ 18 years from 14 commercial US health plans. All patients received first cycle chemotherapy during 2008–2013. 5,423 patients received one of the 3 regimens: carboplatin and paclitaxel, cisplatin and etoposide, carboplatin and etoposide. Primary prophylaxis (PP) was defined as G-CSF administration within 5 days of chemotherapy. Outcome was neutropenia, fever, or infection-related hospitalization within 21 days. Regression and number-needed-to-treat (NNT) analyses were used. Results: A total of 11,233 patients received any chemotherapy (21.2% PP), were older (median years 64 PP; 64 no PP) and had at least 1 non-cancer comorbidity (79.8% PP; 77.9% no PP). About 2,776 patients received Carbo/Paclitaxel (13.9% PP), 1,356 patients received Cisp/Etop (23% PP) and 1,291 patients received Carbo/Etop (45.8% PP) regimens. PP was associated with lower risk of neutropenia related hospitalization for any chemotherapy (4.7% PP; 7.5% no PP; odds ratio [OR] 0.61; 95% CI 0.49 – 0.74), for Cisp/Etop (5.1% PP; 8.8% no PP; OR 0.56; 95% CI 0.32 – 0.97) and Carbo/Etop (5.6% PP; 11% no PP; OR 0.48; 95% CI 0.31 – 0.73), but not Carbo/Paclitaxel (5.7% PP; 6.7% no PP; OR 0.84; 95% CI 0.53 – 1.32) regimens. Based on NNT, the total cost of PP for 36 patients with any chemotherapy regimen to avoid one hospitalization would be $128,952 (mean hospitalization cost = $11,900, Standard Deviation [SD] = $9,541). For 28 patients with Cisp/Etop, it would be $101,920 (mean hospitalization cost = $16,957, SD = $16,135). For 19 patients with Carbo/Etop, it would be $63,270 (mean hospitalization cost = $11,356, SD = $6,949). Conclusions: Primary G-CSF prophylaxis was associated with some benefit in lowering neutropenia-related hospitalization in patients with lung cancer receiving Cisp/Etop and Carbo/Etop regimens, although the cost to treat patients remains high. Future studies need to examine the value of continued G-CSF use in subsequent cycles.

Measuring quality in cancer care: Utilizing a clinical decision support system to assess pathway adherence

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Background: Quality-based programs depend on clinical data documentation for reporting, treatment planning, and measuring pathways (PW) compliance. Adherence to treatment PW reduces variability and costs of care. Clinical decision support systems (CDSS) are tools embedded in the EHR to capture assessable data: stage, biomarkers, line of therapy, etc. With such data, CDSS can measure and report on clinical quality improvement programs like PW adherence, assessable data and exception reporting. Methods: A retrospective cohort study from Jan 1, 2014 - May 30, 2016 measured the impact of an integrated CDSS assessing compliance to PW and exception reporting across 9 independent oncology practices over a 9 month period. Assessable data, PW adherence, and exception reporting were tracked in 4 month intervals pre and post CDSS intervention by practice and physician. A one month wash out period was included post CDSS implementation. Overall rates of positivity, assessable data, and exception reporting were compared pre and post intervention using the Chi-square test. To account for the effect of time on the intervention, a segmented regression analysis was performed to analyze weekly rates of positivity pre and post intervention. Results: 9 practices, 633 physicians, and 30,666 treatment regimens were included. The weekly adherence rate increased by 7.2% after intervention (p = 0.005) across the group. Assessable data capture significantly improved across the cohort OR 6.79 (5.64-8.16) and individually for most practices. Physicians adherent to PW 75% of the time increased post intervention collectively, OR 1.83 (1.44-2.31), and individually. Exception reporting improved from 29% to 99% (p<0.0001). Conclusions: Across a cohort of community oncology practices rates of assessable data, PW adherence, and exception reporting improved after implementation of an integrated CDSS. Effective CDSSs are a critical component of quality improvement programs and may be used to improve data capture, increase adherence to PW and overall contribute to quality cancer care delivery. [Table: see text]

More Medicine, Fewer Clicks: How Informatics Can Actually Help Your Practice

In the information age, we expect data systems to make us more effective and efficient-not to make our lives more difficult! In this article, we discuss how we are using data systems, such as electronic health records (EHRs), to improve care delivery. We illustrate how US Oncology is beginning to use real-world evidence to facilitate trial accrual by automatic identification of eligible patients and how big data and predictive analytics will transform the field of oncology. Some information systems are already being used at the point of care and are already empowering clinicians to improve the care of their patients in real time. Telehealth platforms are being used to bridge gaps that currently exist in expertise, geography, and technical capability. Optimizing virtual collaboration, such as through virtual tumor boards, is empowering communities that are geographically disparate to coordinate care. Informatics methods can provide solutions to the challenging problems of how to manage the vast amounts of data confronting the practicing oncologist, including information about treatment regimens, side effects, and the influence of genomics on the practice of oncology. We also discuss some of the challenges of clinical documentation in the modern era, and review emerging efforts to engage patients as digital donors of their EHR data.

The Road of Mentorship

Mentorship can be the cornerstone of professional development and career satisfaction. There is literature to support that mentorship not only improves job satisfaction, but also improves productivity, facilitates personal growth, and can rekindle our passion while lessening the risk of compassion fatigue. Mentorship is a developmental relationship that changes as the relationship evolves. There are two broad categories of mentorship: traditional and transformational. There are four subtypes within each of those areas: formal, informal, spot, or peer. Mentorship is critical to the professional development of junior colleagues. Good mentorship is guiding and steering younger partners and other colleagues toward paths of success. As a mentor, one should be looking for opportunities for formal professional development and engagement of mentees. Self-motivation is the hallmark of the successful mentee. The mentee should be able to set his or her own goals, strive to actively seek feedback, ask questions, and keep an accurate record of progress. Although the onus is on the mentee to reach out, mentorship has bidirectional value directly related to the efforts of both parties. There are many benefits to mentorship, such as the promotion of learning, personal development, improved job satisfaction, and improved job performance. Barriers exist, including the rapidly changing landscape of oncology, time constraints, lack of self-awareness, and generational differences. Through a career, mentoring needs will change, as will mentors.

Risk of Neutropenia-Related Hospitalization in Patients Who Received Colony-Stimulating Factors With Chemotherapy for Breast Cancer

Purpose

To describe outcomes after granulocyte colony-stimulating factor (G-CSF) prophylaxis in patients with breast cancer who received chemotherapy regimens with low-to-intermediate risk of induction of neutropenia-related hospitalization.

Patients and Methods

We identified 8,745 patients age ≥ 18 years from a medical and pharmacy claims database for 14 commercial US health plans. This retrospective analysis included patients with breast cancer who began first-cycle chemotherapy from 2008 to 2013 using docetaxel and cyclophosphamide (TC); docetaxel, carboplatin, and trastuzumab (TCH); or doxorubicin and cyclophosphamide (conventional-dose AC) regimens. Primary prophylaxis (PP) was defined as G-CSF administration within 5 days of beginning chemotherapy. Outcome was neutropenia, fever, or infection-related hospitalization within 21 days of initiating chemotherapy. Multivariable regressions and number-needed-to-treat analyses were used.

Results

A total of 4,815 patients received TC (2,849 PP; 1,966 no PP); 2,292 patients received TCH (1,444 PP; 848 no PP); and 1,638 patients received AC (857 PP; 781 no PP) regimen. PP was associated with reduced risk of neutropenia-related hospitalization for TC (2.0% PP; 7.1% no PP; adjusted odds ratio [AOR], 0.29; 95% CI, 0.22 to 0.39) and TCH (1.3% PP; 7.1% no PP; AOR, 0.19; 95% CI, 0.12 to 0.30), but not AC (4.7% PP; 3.8% no PP; AOR, 1.21; 95% CI, 0.75 to 1.93) regimens. For the TC regimen, 20 patients (95% CI, 16 to 26) would have to be treated for 21 days to avoid one neutropenia-related hospitalization; with the TCH regimen, 18 patients (95% CI, 13 to 25) would have to be treated.

Conclusion

Primary G-CSF prophylaxis was associated with low-to-modest benefit in lowering neutropenia-related hospitalization in patients with breast cancer who received TC and TCH regimens. Further evaluation is needed to better understand which patients benefit most from G-CSF prophylaxis in this setting.

Real-world treatment patterns and outcomes in HER2 positive MBC patients with brain metastasis in the U.S. community oncology setting

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Background: Patients (pts) with HER2 positive (HER2+) metastatic breast cancer (MBC) have different patterns of disease and treatment (tx) from HER2 negative MBC. Brain metastasis (BM) frequently occurs and txs vary. Methods: This retrospective study included adult HER2+ MBC pts from a community oncology network electronic health record (EHR) database and diagnosed between 2009-2011, with follow-up until 11/2014. Pts with other primary tumors were excluded. Two cohorts were defined: pts diagnosed with BM and pts with no evidence of BM (NBM), and were initially matched on age and performance status at MBC diagnosis (dx) and stage. Eligibility and txs were examined in electronic chart review. Overall survival (OS) from MBC dx was estimated using a weighted Kaplan-Meier method. Results: The final sample consisted of 86 BM and 101 NBM pts. All baseline MBC demographics were similar across cohorts. Median age was 54 and 52 years for BM and NBM, respectively. The cohorts (BM:NBM) included 57%:75% Caucasians, 12%:6% Blacks, and 31%:19% other/unknown. There were fewer estrogen receptor positive pts in the BM cohort (58%:74%; p = 0.02). Except for bone (p = 0.01), both cohorts had similar prevalence of metastatic sites: liver 35%:35%; lung 31%:30%; bone 41%:62. Of all the BM pts, 54% had first CNS imaging after symptoms, 37% were first imaged for other known reasons. After BM dx, 20% had surgical resection, 67% whole brain radiation (XRT), 37% stereotactic XRT, and 22% palliative XRT (not mutually exclusive). 25% of pts had both XRT and surgery while 72% had only XRT. Among pts receiving systemic therapy after BM dx, the first regimen contained trastuzumab in 55% of pts and lapatinib in 41% of pts. Among pts changing txs after BM dx, 1/3 switched to a trastuzumab but not lapatinib-based regimen; 1/3 to a lapatinib but not trastuzumab-based regimen; 17% to a lapatinib + trastuzumab-based regimen; and 17% to non-HER2-based therapy. Weighted median OS from MBC dx for BM vs. NBM pts was 30.2 and 46.1 months (p = 0.01). Conclusions: For HER2+ MBC pts, survival was shorter for pts with BM vs. NBM and a high degree of tx variability for BM existed. Understanding how detection and tx impacts outcomes will improve care of BM pts.

Outcomes by schedule and line of therapy in patients (pts) with metastatic breast cancer (MBC) treated with nab-paclitaxel (nab-P): A U.S. retrospective, community-based, real-world cohort analysis

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Background: In a phase III study in MBC, nab-P showed activity across lines of therapy. nab-P is approved for MBC at 260 mg/m2 every 3 weeks (q3w). This analysis evaluated outcomes with use of nab-P in MBC by schedule and line of therapy in a U.S. community setting. Methods: A multicenter, retrospective cohort analysis was conducted using iKnowMed electronic health record data and electronic medical chart review of women with ≥ 5 visits to a site in the US Oncology Network. Vital status was supplemented by the Social Security Death Index. Pts with MBC treated with nab-P between April 1, 2011, and February 1, 2013, were followed through August 1, 2013. Pts diagnosed with another primary cancer or with prior nab-P use were excluded. Data were analyzed by line (first [1L] vs ≥ second [≥2L]) or schedule (weekly [qw] vs q3w) based on the first therapy (index therapy) received in the study period. The usage pattern of index therapy was described by pt demographics and baseline characteristics. Effectiveness of index therapy was assessed by adjusted duration of treatment (DOT; time from first to last date of treatment + 6 days for qw and 20 days for q3w [to reflect true treatment duration]), time to new treatment (TTNT; time from start of index therapy), and overall survival (OS; time from start of index therapy). Analyses of other efficacy/safety endpoints, healthcare utilization, and corresponding costs will be performed. Results: 766 pts were included; 333 and 433 initiated index therapy as 1L and ≥ 2L, and 650 and 116 received index therapy qw and q3w. 76% received nab-P monotherapy. Most pts were < 65 years (64%), HER2− (76%), ER+ (76%), ER+/HER2− (60%), and postmenopausal (79%). 16% had triple-negative MBC. No notable differences in pt characteristics between the 1L/≥ 2L or qw/q3w groups were seen. Sensory neuropathy rates were 35% vs 39% for the 1L and ≥ 2L and 36% vs 45% for qw vs q3w. Conclusions: This analysis of a community-based cohort indicated that nab-P was primarily used as monotherapy on a qw schedule and in the ≥ 2L setting. [Table: see text]

Advanced practice providers and survivorship care plans

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Background: The American College of Surgeons mandate in 2012 challenged organizations to create and develop quality survivorship care programs. The NCCN and Commission on Cancer set the standard for quality psychosocial care recognizing distress as part of the cancer continuum. In order to meet this challenge, community cancer care organizations are incorporating delivery of survivorship and psychosocial care into the Advanced Practice Provider (APP) role. APPs include Physician Assistants (PAs) and Advanced Practice Nurses (APNs). We describe the development and feasibility testing of an APP-led survivorship program in a large network of community oncology practices. Methods: A descriptive study design was used with ten practices participating in the implementation of a structured APP-led survivorship program. The goals of each survivorship visit were to: review recommendations for care and healthy lifestyle behaviors, review surveillance recommendations, and to reconnect patients with their primary care providers. Nineteen APPs in the study site practices offered survivorship management between October 2012 and May 2015 to female breast and colon cancers at all stages. Results: Study sites used structured process maps to identify and refer patients to survivorship visits. Evaluations of additional referral strategies are ongoing. Participating APPs reported high self-efficacy in delivering survivorship care plans and high patient satisfaction following visits. All female breast or colon cancer patients, regardless of stage at diagnosis, attended the appointment and received a complete care plan based upon the ASCO Survivorship Care Plan. Surveillance education was provided specific to diagnosis utilizing the NCCN guidelines delivering person-centered care. Visits lasted an average of 60 minutes and were billable as counseling and coordination. Conclusions: Patients diagnosed with breast or colon cancer make up the largest majority of cancer survivors. This project reveals that an APP-led survivorship program is feasible and can help to meet the ASCO and NCCN challenge of providing survivorship care to this large population.

Bridging the Medical Education and Quality Cancer Care Divide: A Call to Action

ASCO Leadership Development Program members were tasked by the ASCO Board of Directors to explore how to optimize integration of key aspects of oncology care in order to facilitate continuous quality improvement for the practicing oncologist. This Perspective summarizes their findings.

Economic impact of disease progression following front-line therapy in classical Hodgkin lymphoma

The current study aimed to assess the economic burden of progressive disease among patients with Hodgkin lymphoma (HL) receiving second- or third-line therapy in a large US network of community-based practices. This retrospective, observational cohort analysis used electronic health records to examine adult patients with classical HL who received chemotherapy between 2007 and 2011. Of 291 observations, 112 had non-progressive disease (received only one line of therapy; LOT1), 114 received second-line therapy (LOT2), and 65 received third-line therapy (LOT3). In LOT2, 49 patients (43%) underwent transplant. In LOT3, 13 patients (20%) underwent transplant. The mean total cost per line of therapy was $21 956 in LOT1, $77 219 in LOT2, and $59 442 in LOT3. When transplant was required, the mean total cost per line of therapy increased 7- to 8-fold when compared with the cost of LOT1 (approximately $154 000 for LOT2 and $193 000 for LOT3). Future therapies that intervene as early as possible in the treatment algorithm to prevent or significantly delay relapse will likely result in significant cost savings.

Abstract P3-10-06: Real-world efficacy and safety outcomes of nab-paclitaxel (nab-P) in patients (pts) with metastatic breast cancer (MBC): Results from a US health insurance database

Background: nab-P, an albumin-bound formulation of paclitaxel, was approved in 2005 for the treatment of breast cancer after failure of combination chemotherapy for metastatic disease or relapse within 6 mo of adjuvant chemotherapy based on clinical trials. nab-P demonstrated efficacy and safety when administered weekly in phase II trials and every 3 weeks (q3w) in an international phase III trial. Little is known about the treatment patterns and outcomes of nab-P in the real-world setting. Using health insurance claims data, this study was conducted to characterize efficacy and safety of nab-P in pts with MBC treated in US clinical practices.

Methods: This retrospective claims analysis used data in the Optum Research Database (United Health affiliate). Data were supplemented by Social Security Death Index sources. The analysis included women aged ≥ 18 y with MBC diagnosis (≥ 2 claims of BC diagnosis separated by ≥ 30 d and ≥ 2 claims of metastatic spread) prior to nab-P initiation. Pts had ≥ 6 mo of continuous enrollment in the health plan from January 2005-September 2012, complete medical coverage and pharmacy benefits, no other primary malignancy, and no prior chemotherapy. Cohorts were determined by line of therapy, nab-P regimen, and schedule. Endpoints included treatment patterns, time to next therapy or death (TNTD), overall survival (OS), and safety.

Results: Of the 664 eligible pts, most were between 40-69 y of age (88%) and had received nab-P as ≥ second-line therapy (74%), monotherapy (61%), and weekly dosing (71%). In combination, nab-P was most often given with bevacizumab (58%) or human epidermal growth factor receptor 2 (HER2)–targeted therapy (24%) vs another cytotoxic agent (19%). Median TNTD and OS were 6.1 and 17.4 mo, respectively. By line of therapy (first, second, and ≥ third), TNTD was 7.1, 6.6, and 5.3 mo, and OS was 22.7, 17.4, and 15.1 mo. The OS data are comparable with published clinical trial results (Table). In a subgroup of pts (n = 400) with aggressive disease features (≤ 50 y of age or having ≥ 3 metastases), median OS was 15.6 mo. These data are comparable with a retrospective analysis of pts with visceral dominant metastasis (VDM) or a short disease-free interval (SDFI; Table). Toxicities reported in healthcare claims were consistent with those previously published.

Conclusions: Consistent with clinical trial data, outcomes of this analysis demonstrated the efficacy and safety of nab-P across lines of therapy in a real-world population of patients with MBC.

Clinical Trial Experience in MBC for Pts Treated With nab-PTrialnab-P dose (mg/m2) and schedulenMedian OS, moCA0121 (Ph III)ITT (all lines)260 q3w22915.0≥ second line260 q3w13113.0CA0242 (Ph II, first line)300 q3w7627.7100 qw 3/47622.2150 qw 3/47433.8Median OS, moSubgroups With Aggressive Disease FeaturesnVDMnSDFICA0123 (first line)260 q3w7415.14214.6CA0243 (first line)300 q3w6127.72016.6100 qw 3/46019.62119.1150 qw 3/45932.11418.6qw 3/4, weekly for the first 3 of 4 weeks.

1 Gradishar WJ, et al. J Clin Oncol. 2005;23:7794-7803.

2 Gradishar WJ, et al. Clin Breast Cancer. 2012;12:313-321.

3 O’Shaughnessy J, et al. Breast Cancer Res Treat. 2013;138:829-837.

Citation Format: Debra A Patt, Caihua Liang, Ling Li, Amy Ko, Cindy Duval Fraser, Deyanira Corzo, Cheryl Enger. Real-world efficacy and safety outcomes of nab-paclitaxel (nab-P) in patients (pts) with metastatic breast cancer (MBC): Results from a US health insurance database [abstract]. In: Proceedings of the Thirty-Seventh Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2014 Dec 9-13; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2015;75(9 Suppl):Abstract nr P3-10-06.

Patient characteristics and survival outcomes associated with early versus delayed molecular testing in metastatic NSCLC

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Background: Evidence-based guidelines recommend molecular testing for appropriate patients with advanced NSCLC at the time of diagnosis of adenocarcinoma. This study evaluated patient demographics, clinical characteristics and survival outcomes associated with early molecular testing (EMT) as compared to delayed molecular testing (DMT) in patients with metastatic NSCLC. Methods: Retrospective analysis of patients’ electronic medical records from The US Oncology Network Practices that utilize iKnowMed (iKM). Patients with a diagnosis of metastatic NSCLC between March 2011 and June 2012, >2 visits and >6 months of follow-up were eligible. EMT and DMT was defined as occurring <45 days and >45 days of diagnosis, respectively. Patient characteristics were compared using t-test and chi-square tests as appropriate. Logistic regression was used to predict the likelihood of higher performance status in the cohorts. Progression-free survival (PFS) and overall survival (OS) were compared using Cox proportional hazards models controlling for age, gender, stage at diagnosis, performance status and comorbidities. Results: A total of 350 patients were eligible and had a median follow-up of 17.3 months. Average age was 64, majority were female (55%) and diagnosed with adenocarcinoma (93%). There were no significant differences in demographic characteristics between EMT and DMT cohorts, however DMT patients were more likely to have ECOG 0 or 1 (OR=2.95, 95%CI=1.33-6.54, p=0.008). No difference in OS or PFS was observed between EMT and DMT patients, p>0.05 (log-rank test). However, poor performance status was found to increase risk of progression/death in multivariate OS and PFS analysis, p<0.02 and p<0.01, respectively. Conclusions: While patients undergoing EMT were nearly three times more likely to exhibit poorer performance status as compared to DMT cohort, their survival outcomes were no different, reinforcing the importance of molecular testing in these patients who may otherwise be less likely to receive treatment. Although limited to small sample size, results of this analysis call for further investigation of potential benefits of EMT in metastatic NSCLC in real-world setting.

Secondary nonbreast malignancies (SNBM) after primary breast cancer (BC)

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Background: BC survivors are at higher risk of developing SNBM due to treatment effects and shared behavioral and genetic factors. Associations between histologic subtypes of primary BC and secondary endometrial or ovarian cancer have been reported. Less is known about subtype-specific associations with other secondary solid tumors. We aimed to determine the prevalence of SNBM across US Oncology practices and what subtype-specific associations, if any, exist between primary BC and SNBM. Methods: We conducted a retrospective database analysis identifying BC patients (pts) diagnosed between 01/2007 and 05/2013. SNBM were ascertained from codified fields in pts electronic records. Age at BC diagnosis, BC stage, estrogen receptor (ER), progesterone receptor (PR), HER2 status, BMI and smoking history were collected. Chi-square tests were used to compare categorical variables. Logistic regression was used to predict likelihood of secondary malignancies in separate multivariate models. Results: 105,795 pts with stage 0-IV BC were identified. 2,237 (2.1%) were diagnosed with ≥ 1 SNBM. Mean age at diagnosis and follow-up were 59.5 and 2.6 years respectively. Pts with SNBM were more likely to have: older age, ≥ stage I, HER-2 negative disease, BMI ≥25 and past/current smoking history. SNBM were most commonly: Non-small cell lung cancer (NSCLC) (n=346), colorectal (CRC) (n=250), uterine (n=192), ovarian (n=130), thyroid (n=106) and kidney cancer (n=73). No associations were found between BC subtypes and ovarian, uterine, thyroid or NSCLC. Significant positive and negative associations between triple-negative breast cancer (TNBC) and secondary CRC and kidney cancer, respectively, were noted. In multivariate analysis, TNBC was predictive of secondary kidney cancer (OR 2.00, p=0.019). TNBC (OR 0.47, p=0.009), age ≤55 (OR 0.27, p<0.0001) and BMI ≤30 (OR 0.64 for BMI 25-30, p=0.019) were negative predictors of secondary CRC. Conclusions: Our study is the first to report direct and inverse associations between primary TNBC and secondary kidney and CRC, respectively. The short follow-up precludes treatment-related effects. Results may potentially be attributed to genetic, environmental or lifestyle factors and warrant further research.