Loss of the endocytic tumor suppressor HD-PTP phenocopies LKB1 and promotes RAS-driven oncogenesis

Oncogenic RAS mutations drive aggressive cancers that are difficult to treat in the clinic, and while direct inhibition of the most common KRAS variant in lung adenocarcinoma (G12C) is undergoing clinical evaluation, a wide spectrum of oncogenic RAS variants together make up a large percentage of untargetable lung and GI cancers. Here we report that loss-of-function alterations (mutations and deep deletions) in the gene that encodes HD-PTP (PTPN23) occur in up to 14% of lung cancers in the ORIEN Avatar lung cancer cohort, associate with adenosquamous histology, and occur alongside an altered spectrum of KRAS alleles. Furthermore, we show that in publicly available early-stage NSCLC studies loss of HD-PTP is mutually exclusive with loss of LKB1, which suggests they restrict a common oncogenic pathway in early lung tumorigenesis. In support of this, knockdown of HD-PTP in RAS-transformed lung cancer cells is sufficient to promote FAK-dependent invasion. Lastly, knockdown of the Drosophila homolog of HD-PTP (dHD-PTP/Myopic) synergizes to promote RAS-dependent neoplastic progression. Our findings highlight a novel tumor suppressor that can restrict RAS-driven lung cancer oncogenesis and identify a targetable pathway for personalized therapeutic approaches for adenosquamous lung cancer.

Treatment Outcomes and Roles of Transplantation and Maintenance Rituximab in Patients With Previously Untreated Mantle Cell Lymphoma: Results From Large Real-World Cohorts

PURPOSE

Commonly used first-line (1L) treatments for mantle cell lymphoma include high-dose cytarabine-based induction followed by autologous stem-cell transplant (ASCT) for younger patients and several chemoimmunotherapy regimens for older patients. Continuous debates exist on the role of ASCT in younger patients and maintenance rituximab (MR) after bendamustine plus rituximab (BR).

METHODS

Retrospective data from 4,216 patients with mantle cell lymphoma in the Flatiron Health electronic record-derived deidentified database diagnosed between 2011 and 2021, mostly in US community oncology settings, were evaluated for treatment patterns and outcomes. The efficacy findings with ASCT and MR were validated in an independent cohort of 1,168 patients from 12 academic centers.

RESULTS

Among 3,614 patients with documented 1L treatment, BR was the most used. Among 1,265 patients age < 65 years, 30.5% received cytarabine-based induction and 23.5% received ASCT. There was no significant association between ASCT and real-world time to next treatment (hazard ratio [HR], 0.84; 95% CI, 0.68 to 1.03; P = .10) or overall survival (HR, 0.86; 95% CI, 0.63 to 1.18; P = .4) among ASCT-eligible patients. Among MR-eligible patients, MR after BR versus BR alone was associated with a longer real-world time to next treatment (HR, 1.96; 95% CI, 1.61 to 2.38; P < .001) and overall survival (HR, 1.51; 95% CI, 1.19 to 1.92; P < .001). The efficacy findings were consistent in the validation cohort.

CONCLUSION

In this large cohort of patients treated primarily in the US community setting, only one in four young patients received cytarabine or ASCT consolidation, suggesting the need to develop treatments that can be delivered effectively in routine clinical practice. Together with the validation cohort, data support future clinical trials exploring regimens without ASCT consolidation in young patients, whereas MR should be considered for patients after 1L BR and rituximab plus cyclophosphamide, doxorubicin, vincristine, and prednisone.

Definitive intensity modulated proton re-irradiation for lung cancer in the immunotherapy era

Introduction

As immunotherapy has improved distant metastasis-free survival (DMFS) in Non-Small Cell Lung Cancer (NSCLC), isolated locoregional recurrences have increased. However, management of locoregional recurrences can be challenging. We report our institutional experience with definitive intent re-irradiation using Intensity Modulated Proton Therapy (IMPT).

Method

Retrospective cohort study of recurrent or second primary NSCLC or LS-SCLC treated with IMPT. Kaplan-Meier method and log-rank test were used for time-to-event analyses.

Results

22 patients were treated from 2019 to 2021. After first course of radiation (median 60 Gy, range 45-70 Gy), 45% received adjuvant immunotherapy. IMPT re-irradiation began a median of 28.2 months (8.8-172.9 months) after initial radiotherapy. The median IMPT dose was 60 GyE (44-60 GyE). 36% received concurrent chemotherapy with IMPT and 18% received immunotherapy after IMPT. The median patient's IMPT lung mean dose was 5.3 GyE (0.9-13.9 GyE) and 5 patients had cumulative esophagus max dose >100 GyE with 1-year overall survival (OS) 68%, 1-year local control 80%, 1-year progression free survival 45%, and 1-year DMFS 60%. Higher IMPT (HR 1.4; 95% CI 1.1-1.7, p=0.01) and initial radiotherapy mean lung doses (HR 1.3; 95% CI 1.0-1.6, p=0.04) were associated with worse OS. Two patients developed Grade 3 pneumonitis or dermatitis, one patient developed Grade 2 pneumonitis, and seven patients developed Grade 1 toxicity. There were no Grade 4 or 5 toxicities.

Discussion

Definitive IMPT re-irradiation for lung cancer can prolong disease control with limited toxicity, particularly in the immunotherapy era.

Impact of multi-agent systemic therapy on all-cause and disease-specific survival for people living with HIV who are diagnosed with non-Hodgkin lymphoma: population-based analyses from the state of Georgia

For people living with HIV (PLWH) who are subsequently diagnosed with non-Hodgkin lymphoma (NHL), we investigate the impact of standard-of-care (SoC) cancer treatment on all-cause, NHL-specific, and HIV-specific survival outcomes. The focus is on a registry-derived, population-based sample of HIV + adults diagnosed with NHL within 2004-2012 in the state of Georgia. SoC treatment is defined as receipt of multi-agent systemic therapy (MAST). In multivariable survival analyses, SoC cancer treatment is significantly associated with better all-cause and NHL-specific survival, but not better HIV-specific survival across 2004-2017. Having a CD4 count <200 near the time of cancer diagnosis and Ann Arbor stage III/IV disease are associated with worse all-cause and HIV-specific survival; the effects on NHL survival trend negative but are not significant. Future work should expand the geographic base and cancers examined, deepen the level of clinical detail brought to bear, and incorporate the perspectives and recommendations of patients and providers.

Racial Disparities in Clinical Outcomes on Investigator-Initiated Breast Cancer Clinical Trials at an Urban Medical Center

BACKGROUND

Black women are 40% more likely to die of breast cancer compared to White women. Inadequate representation of Black patients in clinical trials may contribute to health care inequity. We aimed to assess breast cancer clinical outcomes in Non-Hispanic Black (Black) versus Non-Hispanic White (White) women with metastatic breast cancer (MBC) enrolled on investigator-initiated clinical trials at Winship Cancer Institute at Emory University, given the significant number of patients from underrepresented minority groups seen at Winship.

MATERIALS AND METHODS

Black and White women with MBC on investigator-initiated trials at Emory between 2009 and 2019 were retrospectively evaluated. Univariate analyses and multiple logistic regression models were used to assess clinical response and treatment toxicities. Differences in overall survival between groups was assessed using quantile analysis.

RESULTS

Sixty-two women with MBC were included (66% White vs. 34% Black). Black patients had less clinical benefit from the trial therapy as only 57% had partial response or stable disease as best response compared to 78% of White women (P = .09). Quantile analysis showed significant difference in mean survival between Whites and Blacks by the end of follow up (64 vs. 38 months). There were no significant differences in toxicities between groups.

CONCLUSION

Participation rates of Black women with MBC on investigator-initiated clinical trials at an urban cancer center were higher compared to key national trials. Black women had worse treatment response and survival. These results reinforce the need for assessment of tumor differences by ancestry and continued improvement in minority representation on clinical trials.

Oncologic Outcomes After Clinically Node-Negative Salvage Laryngectomy

Importance

Controversy exists regarding management of the clinically node-negative neck in patients with recurrent larynx or hypopharynx cancers who received total laryngectomy after definitive radiation with or without chemotherapy.

Objective

To explore clinical and oncologic outcomes after elective neck dissection vs observation in patients who received clinically node-negative salvage total laryngectomy.

Design, Setting, and Participants

This cohort study was performed from January 2009 to June 2021 at a single, high-volume tertiary care center. Follow-up was conducted through June 2021 for all patients. Survival outcomes were based on at least 2 years of follow-up. Patients aged 18 years or older with recurrent, clinically node-negative larynx or hypopharynx tumors after definitive nonsurgical treatment who were treated with a salvage total laryngectomy were included. Data were analyzed from October 2021 through September 2022.

Exposures

Elective neck dissection.

Main Outcomes and Measures

Presence and location of occult nodal metastasis in electively dissected necks, along with differences in fistula rates and overall and disease-free survival between patients receiving elective neck dissection vs observation.

Results

Among 107 patients receiving clinically node-negative salvage total laryngectomy (median [IQR] age, 65.0 [57.8-71.3] years; 91 [85.0%] men), 81 patients underwent elective neck dissection (75.7%) and 26 patients underwent observation (24.3%). Among patients with elective neck dissection, 13 patients had occult nodal positivity (16.0%). Recurrent supraglottic (4 of 20 patients [20.0%]) or advanced T classification (ie, T3-T4; 12 of 61 patients [19.7%]) had an occult nodal positivity rate of 20% or more, and positive nodes were most likely to occur in levels II and III (II: 6 of 67 patients [9.0%]; III: 6 of 65 patients [9.2%]; VI: 3 of 44 patients [6.8%]; IV: 3 of 62 patients [4.8%]; V: 0 of 4 patients; I: 0 of 18 patients). There was a large difference in fistula rate between elective neck dissection (12 patients [14.8%]) and observed (8 patients [30.8%]) groups (difference, 16.0 percentage points; 95% CI, -3.4 to 35.3 percentage points), while the difference in fistula rate was negligible between 50 patients undergoing regional or free flap reconstruction (10 patients [20.0%]) vs 57 patients undergoing primary closure (10 patients [17.5%]) (difference, 2.5 percentage points; 95% CI, -12.4 to 17.3 percentage points). Undergoing elective neck dissection was not associated with a clinically meaningful improvement in overall or disease-free survival compared with observation. Recurrent hypopharynx subsite was associated with an increased risk of death (hazard ratio, 4.28; 95% CI, 1.81 to 10.09) and distant recurrence (hazard ratio, 7.94; 95% CI, 2.07 to 30.48) compared with glottic subsite.

Conclusions and Relevance

In this cohort study, patients with recurrent supraglottic or advanced T classification tumors had an increased occult nodal positivity rate, elective neck dissection was not associated with survival, and patients with recurrent hypopharynx subsite were more likely to have a distant recurrence and die of their disease. These findings suggest that underlying disease pathology rather than surgical management may be associated with survival outcomes in this population.

Antibody binding and neutralization of live SARS-CoV-2 variants including BA.4/5 following booster vaccination of patients with B-cell malignancies

Non-Hodgkin lymphoma and chronic lymphocytic leukemia (NHL/CLL) patients elicit inadequate antibody responses after initial SARS-CoV-2 vaccination and remain at high risk of severe COVID-19 disease. We investigated IgG, IgA, and IgM responses after booster vaccination against recent SARS-CoV-2 variants including Omicron BA.5 in 67 patients. Patients had lower fold increase and total anti-spike binding titers after booster than healthy individuals. Antibody responses negatively correlated with recent anti-CD20 therapy and low B cell numbers. Antibodies generated after booster demonstrated similar binding properties against SARS-CoV-2 variants compared to those generated by healthy controls with lower binding against Omicron variants. Importantly, 43% of patients showed anti-Omicron BA.1 neutralizing antibodies after booster and all these patients also had anti-Omicron BA.5 neutralizing antibodies. NHL/CLL patients demonstrated inferior antibody responses after booster vaccination, particularly against Omicron variants. Prioritization of prophylactic and treatment agents and vaccination of patients and close contacts with updated vaccine formulations are essential.

Surgery in combination with systemic chemotherapy is associated with improved survival in stage IV gallbladder cancer

BACKGROUND

Gallbladder cancer (GBC) is the most common biliary malignancy frequently metastatic at diagnosis with poor prognosis. While surgery remains the standard for early-stage GBC, the role of surgery in patients with metastatic gastrointestinal cancers is expanding due to improvements in systemic therapies. We sought to evaluate the survival of patients with stage IV GBC undergoing surgery in an era of improved multi-agent systemic therapy.

METHODS

A retrospective review of the National Cancer Database was performed. Patients with stage IV GBC who underwent systemic therapy were included. Patients who received radiation therapy, palliative therapy or had missing survival data were excluded. Univariable and multivariable analysis was performed.

RESULTS

4,145 patients were identified between 2004 and 2016. Mean age was 69. Surgery combined with systemic therapy predicted improved median survival compared with chemotherapy alone (11.1mo versus 6.8mo, HR 0.65, p < 0.001). Additionally, receipt of treatment after 2011 predicted improved survival (HR 0.86, p < 0.001). Patients treated with multi-agent chemotherapy in combination with surgery were associated with the greatest hazard ratio benefit (0.40, p < 0.001) versus single agent therapy alone.

CONCLUSION

Patients with stage IV gallbladder cancer treated with a combination of surgery and chemotherapy are associated with an improved overall survival compared to chemotherapy alone. Patients receiving care during the more recent era demonstrated improved survival. These results support a role for surgery in selected patients with stage IV gallbladder cancer receiving chemotherapy.

Accuracy and Safety of Scout Dose Resin Yttrium-90 Microspheres for Radioembolization Therapy Treatment Planning: A Prospective Single-Arm Clinical Trial

PURPOSE

To compare the accuracy and safety of 0.56 GBq resin yttrium-90 (⁹⁰Y) (scout⁹⁰Y) microspheres with those of technetium-99m macroaggregated albumin (MAA) in predicting the therapeutic ⁹⁰Y (Rx⁹⁰Y) dose for patients with hepatocellular carcinoma (HCC).

MATERIALS AND METHODS

This prospective single-arm clinical trial (Clinicaltrials.gov: NCT04172714) recruited patients with HCC. Patients underwent same-day mapping with MAA and scout⁹⁰Y. Rx⁹⁰Y activity was administered 3 days after mapping. Using paired t test and Pearson correlation, the tumor-to-normal ratio (TNR), lung shunt fraction (LSF), predicted mean tumor dose (TD), and nontumoral liver dose (NTLD) by MAA and scout⁹⁰Y were compared with those by Rx⁹⁰Y. Bland-Altman plots compared the level of agreement between the TNR and LSF of scout⁹⁰Y and MAA with that of Rx⁹⁰Y. The safety of scout⁹⁰Y was evaluated by examining the discrepancy in extrahepatic activity between MAA and scout⁹⁰Y.

RESULTS

Thirty patients were treated using 19 segmental and 14 nonsegmental (ie, 2 contiguous segments or nonsegmental) therapies. MAA had weak LSF, moderate TNR, and moderate TD linear correlation with Rx⁹⁰Y. Scout⁹⁰Y had a moderate LSF, strong TNR, strong TD, and very strong NTLD in correlation with those of Rx⁹⁰Y. Furthermore, the TNR and LSF of scout⁹⁰Y had a stronger agreement with those of Rx⁹⁰Y than with those of MAA. In the nonsegmental subgroup, MAA had no significant correlation with the TD and NTLD of Rx⁹⁰Y, whereas scout⁹⁰Y had a very strong correlation with both of these factors. In the segmental subgroup, both MAA and scout⁹⁰Y had a strong linear correlation with the TD and NTLD of Rx⁹⁰Y.

CONCLUSIONS

Compared with MAA, scout⁹⁰Y is a more accurate surrogate for Rx⁹⁰Y biodistribution for nonsegmental therapies.

The Impact of Carbohydrate Antigen 19-9 on Survival in Patients with Clinical Stage I and II Pancreatic Cancer

BACKGROUND

Carbohydrate antigen (CA) 19-9 is a biomarker to monitor treatment effect. A threshold to predict prognostic significance remains undefined. We evaluated the impact of CA19-9 on overall survival (OS) in patients with early-stage pancreatic cancer (PC) utilizing the National Cancer Database (NCDB).

METHODS

The NCDB was queried from 2010 to 2014 to identify patients with clinical stage I-II PC. Patients who had undocumented pretreatment CA19-9 were excluded. Patients were stratified into two cohorts: CA19-9 < 98 U/mL and CA19-9 ≥ 98 U/mL, and further categorized into surgery versus no surgery. Twelve- and 24-month OS rates are reported.

RESULTS

Overall, 32,382 patients (stage I: 12,173; stage II: 20,209) were included. The majority of stage I (52.1%) and II (60%) patients had CA19-9 ≥ 98 U/mL. Stage I-II patients with CA19-9 < 98 U/mL had improved OS rates (stage I: 67.5%, 42.6%; stage II: 59.8%, 32.8%) compared with stage I and II patients with CA19-9 ≥ 98 U/mL (stage I: 50.7%, 26.9%; stage II: 48.1%, 22%). Among resected stage I patients, CA19-9 <98 U/mL was associated with improved OS (< 98: 80.5%, 56%; ≥ 98: 70.2%, 42.8%), and a similar trend was seen in resected stage II patients (< 98: 77.6%, 49.9%; ≥ 98: 71%, 39.2%). Unresected stage I patients with lower CA19-9 had improved OS (< 98: 42.1%, 17.5; ≥ 98: 29.9%, 10%), with similar findings in unresected stage II patients (< 98: 41.1%, 15.3%; ≥ 98: 33.4%, 10.6%).

CONCLUSIONS

Our study demonstrated the prognostic value of CA19-9 in patients with clinical stage I-II PC, with a value < 98 U/mL demonstrating improved survival. Surgery significantly improved survival at 12 and 24 months irrespective of CA19-9.

A review of hepatic epithelioid hemangioendothelioma-Analyzing patient characteristics and treatment strategies

BACKGROUND

Hepatic epithelioid hemangioendothelioma (HEH) is a rare vascular tumor of unknown etiology and unpredictable natural history. To date, no large-scale studies have been published evaluating this disease due to its rare occurrence.

METHODS

The National Cancer Database was reviewed between 2004 and 2016 to identify patients with HEH. Univariate analysis with overall survival (OS) was performed by Cox proportional hazards model. Kaplan-Meier method was used to create OS curves and compared using the log-rank test.

RESULTS

We identified 229 patients with HEH. The majority of patients were female (61.1%), white (84.3%), and had a Charlson-Deyo score of 0 (75%). Chemotherapeutic intervention was seen in 26% of the patients while 33% received surgical intervention in the form of wedge/segmental liver resection (n = 27), hepatectomy lobectomy/extended lobectomy (n = 18), and liver transplant (n = 22). Five-year survival in surgical patients was 90.5%, 66.5% and 81%, respectively (p = 0.485). Age greater than 55 years (hazard ratio [HR], 2.78; p < 0.001), Asian ethnicity compared to white (HR, 2.84; p = 0.012), and a higher Charlson-Deyo score (score 1: HR, 2.28; p < 0.001 and score ≥2: HR, 2.76; p = 0.011) were associated with worse OS.

CONCLUSION

Treatment for HEH remains variable with only a third of the patients undergoing surgery. International collaboration is necessary to determine the optimal treatment for this rare disease.

AB, McCook-Veal AA, Switchenko JM, Cole TE, Khanna N, Han CH, Gordon AN, Starbuck KD, Remick JS. Incidence and predictors of toxicity in the management of vulvar squamous cell carcinoma treated with radiation therapy

Purpose/Objective

Given the rarity of vulvar cancer, data on the incidence of acute and late severe toxicity and patients' symptom burden from radiotherapy (RT) are lacking.

Materials/Methods

This multi-center, single-institution study included patients with vulvar squamous cell carcinoma treated with curative intent RT between 2009 and 2020. Treatment-related acute and late grade ≥ 3 toxicities and late patient subjective symptoms (PSS) were recorded.

Results

Forty-two patients with predominantly stage III/IV disease (n = 25, 59.5 %) were treated with either definitive (n = 25, 59.5 %) or adjuvant (n = 17, 40.5 %) external beam RT to a median dose of 64 Gy and 59.4 Gy, respectively. Five patients received a brachytherapy boost with a median total dose of 84.3 Gy in 2 Gy-equivalent dose (EQD2). Intensity-modulated RT was used in 37 (88.1 %) of patients, and 25 patients (59.5 %) received concurrent chemotherapy. Median follow-up was 27 months. Acute grade ≥ 3 toxicity occurred in 17 patients (40.5 %), including 13 (31.0 %) acute grade 3 skin events. No factors, including total RT dose (p = 0.951), were associated with acute skin toxicity. Eleven (27.5 %) patients developed late grade ≥ 3 toxicity events, including 10 (23.8 %) late grade ≥ 3 skin toxicity events. Patients with late grade ≥ 3 skin toxicity had a higher mean body-mass index (33.0 vs 28.2 kg/m²; p = 0.009). Common late PSS included vaginal pain (n = 15, 35.7 %), skin fibrosis (n = 10, 23.8 %), and requirement of long-term opiates (n = 12, 28.6 %).

Conclusion

RT for vulvar cancer is associated with considerable rates of severe acute and late toxicity and PSS burden. Larger studies are needed to identify risk factors, explore toxicity mitigation strategies, and assess patient-reported outcomes.

Treatment out-of-pocket cost communication and remote financial navigation in patients with cancer: a feasibility study

OBJECTIVE

We conducted a pilot study assessing the feasibility of a personalized out-of-pocket cost communication, remote financial navigation, and counseling (CostCOM) intervention in cancer patients.

METHODS

Twenty-three adult, newly diagnosed cancer patients at a single community oncology practice were asked to complete a survey and participate in a CostCOM intervention, including patient-specific out-of-pocket cost communication, remote financial navigation, and counseling. Feasibility was defined as patient participation in CostCOM, and its impact on financial worry measured using the Comprehensive Score for Financial Toxicity (COST) (higher score = less worry) was assessed. Eight patients' and two providers' experience with CostCOM was evaluated using qualitative interviews.

RESULTS

Mean patient age was 61 (78.3% female; 100% white). Of 23 CostCOM patients, 86.9% completed CostCOM, 60% of them completed a financial assistance application, and 25% of those who applied were enrolled in a co-pay assistance program. Patients' financial worry significantly improved following CostCOM (COST score of 10.0 ± 9.6 at enrollment vs. 16.9 ± 8.1 at follow-up; p < 0.001). Mean general satisfaction (out of 5) with CostCOM was 4.1 ± 0.7. In qualitative interviews following OOPC communication, 75% felt a positive impact on their mental health, and all patients reported no change in their treatment plan; 83.3% found financial navigation beneficial. In providers' interviews, buy-in from relevant stakeholders, integration of the CostCOM with existing workflow, and larger studies to assess the effectiveness of CostCOM were identified as factors needed for CostCOM implementation in practice.

CONCLUSION

CostCOM interventions are feasible and acceptable and decrease financial worry in patients with cancer.

Drivers of racial, regional, and socioeconomic disparities in late-stage breast cancer mortality

BACKGROUND

The authors identified tumor, treatment, and patient characteristics that may contribute to differences in breast cancer (BC) mortality by race, rurality, and area-level socioeconomic status (SES) among women diagnosed with stage IIIB-IV BC in Georgia.

METHODS

Using the Georgia Cancer Registry, 3084 patients with stage IIIB-IV primary BC (2013-2017) were identified. Cox proportional hazards regression was used to calculate the hazard ratios (HRs) and 95% confidence intervals (CIs) comparing mortality among non-Hispanic Black (NHB) versus non-Hispanic White (NHW), residents of rural versus urban neighborhoods, and residents of low- versus high-SES neighborhoods by tumor, treatment, and patient characteristics. The mediating effects of specific characteristics on the association between race and BC mortality were estimated.

RESULTS

Among the study population, 41% were NHB, 21% resided in rural counties, and 72% resided in low SES neighborhoods. The authors observed mortality disparities by race (HR, 1.27; 95% CI, 1.13, 1.41) and rurality (HR, 1.14; 95% CI, 1.00, 1.30), but not by SES (HR, 1.04; 95% CI, 0.91, 1.19). In the stratified analyses, racial disparities were the most pronounced among women with HER2 overexpressing tumors (HR, 2.30; 95% CI, 1.53, 3.45). Residing in a rural county was associated with increased mortality among uninsured women (HR, 2.25; 95% CI, 1.31, 3.86), and the most pronounced SES disparities were among younger women (<40 years: HR, 1.46; 95% CI, 0.88, 2.42).

CONCLUSIONS

There is considerable variation in racial, regional, and socioeconomic disparities in late-stage BC mortality by tumor, treatment, and patient characteristics.

Humoral Responses Against SARS-CoV-2 and Variants of Concern After mRNA Vaccines in Patients With Non-Hodgkin Lymphoma and Chronic Lymphocytic Leukemia

PURPOSE

Patients with non-Hodgkin lymphoma including chronic lymphocytic leukemia (NHL/CLL) are at higher risk of severe SARS-CoV-2 infection. We investigated vaccine-induced antibody responses in patients with NHL/CLL against the original SARS-CoV-2 strain and variants of concern including B.1.167.2 (Delta) and B.1.1.529 (Omicron).

MATERIALS AND METHODS

Blood from 121 patients with NHL/CLL receiving two doses of vaccine were collected longitudinally. Antibody binding against the full-length spike protein, the receptor-binding, and N-terminal domains of the original strain and of variants was measured using a multiplex assay. Live-virus neutralization against Delta, Omicron, and the early WA1/2020 strains was measured using a focus reduction neutralization test. B cells were measured by flow cytometry. Correlation between vaccine response and clinical factors was determined.

RESULTS

Mean anti-SARS-CoV-2 spike immunoglobulin G-binding titers were 85-fold lower in patients with NHL/CLL compared with healthy controls, with seroconversion occurring in only 67% of patients. Neutralization titers were also lower and correlated with binding titers (P < .0001). Treatment with anti-CD20-directed therapies within 1 year resulted in 136-fold lower binding titers. Peripheral blood B-cell count also correlated with vaccine response. At 3 months from last anti-CD20-directed therapy, B-cell count ≥ 4.31/μL blood around the time of vaccination predicted response (OR 7.46, P = .04). Antibody responses also correlated with age. Importantly, neutralization titers against Delta and Omicron were reduced six- and 42-fold, respectively, with 67% of patients seropositive for WA1/2020 exhibiting seronegativity for Omicron.

CONCLUSION

Antibody binding and live-virus neutralization against SARS-CoV-2 and its variants of concern including Delta and Omicron were substantially lower in patients with NHL/CLL compared with healthy vaccinees. Anti-CD20-directed therapy < 1 year before vaccination and number of circulating B cells strongly predict vaccine response.

African American and Caucasian patients with Sézary syndrome have no differences in outcomes at an ethnically diverse urban medical center

Sézary syndrome (SS) is an aggressive cutaneous T-cell lymphoma with poor survival. We performed a retrospective review of SS patients at Emory University from 1990 to 2020. We collected data on race, clinical characteristics, therapy, and social determinants of health. Clinical endpoints were overall survival (OS) and time to next treatment (TTNT). Univariate association and multivariable analyses were assessed by Cox proportional hazards models. Among 62 patients, 45.2% were AA. The median OS and TTNT were 3.1 years and 6.3 months, respectively, with no difference by race. AA patients had a higher median baseline LDH (360 vs. 232, p = 0.002) and a longer delay in initiation of systemic therapy compared to CC patients (3.17 vs. 2.14 months, p = 0.039), but a shorter commute (<10 miles) and no difference in insurance coverage (p = 0.260). AA patients at an academic center had unique clinical features and treatment patterns, but similar survival to CC SS patients.

Abstract 3482: Correlative analysis of metformin and nivolumab combination in treatment-refractory microsatellite stable (MSS) metastatic colorectal cancer (mCRC)

Background: Preclinical results indicate that metformin can modulate immune cell populations in the tumor microenvironment of solid tumors by diminishing exhaustion of CD8+ tumor infiltrating cells and improving T cell responses. Studies also suggest that metformin could complement PD-1 blockade and potentiate its antitumor activity. Previously we reported the results of a phase II trial with metformin and nivolumab and here we report the findings of correlative analysis of the prospectively collected research samples of 18 patients.

Methods: We conducted a phase II trial with nivolumab and metformin in treatment-refractory microsatellite stable (MSS) metastatic colorectal cancer (mCRC). Nivolumab 480 mg IV every 4 weeks and metformin 1000 mg orally twice daily was administered in 28-day cycles following a 14-day metformin only lead-in phase. The primary endpoint was overall response rate (ORR). Secondary endpoints were overall survival (OS) and progression free survival (PFS). Pre-treatment and on-treatment research biopsies and correlative peripheral blood specimens were collected. Paired biopsies obtained at baseline and following treatment with metformin only (n=9) or metformin and nivolumab (n=9) and were stained with a panel of 13 markers using ChipCytometry technology by Canopy Biosciences. Sample was assessed prior to establishing the multiplex assay. 30 out of 36 samples were imaged and analyzed up to 30 Fields of View. Single cell recognition and quantitative biomarker analysis were performed to compare immune cell numbers and population distribution in pre- versus post-treatment samples.

Results: As previously reported, no patients had objective response based on RECIST version 1.1 and the study was stopped after the first stage for futility. Median OS and PFS was 5.1 months [95% CI (2-11.7)] and 2.3 months [95% CI (1.7-2.4)], respectively. Multiplex analysis of tissues from patients receiving lead in with metformin alone revealed fewer effector CD4 T cells and effector and effector memory CD8 T cells after treatment vs. baseline biopsy. Biopsy tissue from patients treated with metformin and nivolumab had lower pAMPK and decreased PDL-1 expression vs. baseline. The combination also increased percentages of leukocytes, effector CD4 T cells, effector and effector memory CD8 T cells as well as levels of PDL1-Tim3+ cells.

Conclusion: In the setting of MSS mCRC, metformin as a single agent did not enhance effector CD4 and CD8 T cell percentages in clinical samples in our patient cohort. Metformin in combination with nivolumab was associated with increased percentages of effector CD4 and CD8 T cells in biopsy specimens, although these improvements did not translate into enhanced clinical endpoints. Analysis of peripheral blood samples are currently underway to corroborate the findings in the tissue samples.

Citation Format: Batoul Farran, Jeffrey M. Switchenko, Lana Khalil, Walid L. Shaib, Brian Olson, Amanda Ruggieri, Christina Wu, Olatunji B. Alese, Maria Diab, Gregory B. Lesinski, Bassel El-Rayes, Mehmet Akce. Correlative analysis of metformin and nivolumab combination in treatment-refractory microsatellite stable (MSS) metastatic colorectal cancer (mCRC) [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2022; 2022 Apr 8-13. Philadelphia (PA): AACR; Cancer Res 2022;82(12_Suppl):Abstract nr 3482.

NEO-GAP: A phase II single-arm prospective feasibility study of neoadjuvant gemcitabine/cisplatin/nab-paclitaxel for resectable high-risk intrahepatic cholangiocarcinoma

4097

Background: Given a high recurrence rate, surgical resection for localized intrahepatic cholangiocarcinoma (IHCC) is curative in only 30-35% of patients. BILCAP has established a standard of care for adjuvant therapy with monotherapy capecitabine. Gemcitabine, cisplatin and nab-paclitaxel combination chemotherapy (GAP) was associated with a response rate of 45% in biliary cancer and 20% of patients who were previously inoperable underwent margin negative resection. Based on these data, we conducted a neoadjuvant study of GAP for resectable but high-risk IHCC. Methods: A multi-institutional prospective single-arm phase II trial was conducted for patients with resectable high-risk disease, as defined by tumor size > 5cm, multiple tumors, presence of radiographic major vascular invasion, and lymph node involvement. Patients were administered 4 cycles (3 months) of preoperative GAP (gemcitabine 800 mg/m2, cisplatin 25 mg/m2 and nab-paclitaxel 100 mg/m2 on days 1 and 8 of a 21-day cycle) prior to an attempt at curative-intent surgical resection. The primary endpoint was completion of all therapy, including both preoperative chemotherapy and resection. Secondary endpoints were toxicity, radiologic response according to Response Evaluation Criteria in Solid Tumor (RECIST) criteria, RFS, and OS. Thirty evaluable patients provided 73% power to reject a null therapy completion rate of 50%, with a target completion rate of 70% using a one-sided exact test with a Type I error of 0.05. Results: Thirty-seven patients were screened and 30 evaluable patients were enrolled. The trial was sequentially activated at each of the 4 sites from 09/18-02/21 and the final patient was enrolled in 09/21. Median age was 60.5 years and 40% were female. Twenty-three patients (77%, 90% CI: 60.6-88.5%; p = 0.0026) completed all preoperative chemotherapy and underwent surgical resection. Ten patients (33%) experienced grade 3-4 treatment-related adverse events, the most common being neutropenia and diarrhea; 47% required at least one dose reduction. Partial response rate was 23% and disease control rate was 90% (PD: 10%, PR: 23%, SD: 67%). Of the 23 patients who successfully underwent surgical resection, 2 (9%) had minor postoperative complications. Median size of largest tumor was 5.5cm, median number of tumors was 3, and 39% were lymph node positive. Median length of hospital stay was 4 days. There was zero treatment related mortality. Conclusions: This study met its primary endpoint and demonstrated that neoadjuvant gemcitabine/cisplatin/nab-paclitaxel is feasible and safe prior to resection of intrahepatic cholangiocarcinoma and does not adversely impact perioperative outcomes. Continued follow-up for RFS and OS with this treatment strategy is underway and larger validation studies are planned. Clinical trial information: NCT03579771.

Molecular testing and patterns of treatment in patients with NSCLC: An IASLC analysis of ASCO CancerLinQ Discovery Data

9128

Background: Precision medicine has resulted in improved outcomes for non-small cell lung cancer (NSCLC); while molecular testing is considered critical for guiding treatment decisions for advanced stage NSCLC, adoption of testing in routine practice is variable. We analyzed the factors contributing to molecular testing and treatment patterns in patients with lung cancer. Methods: The ASCO CancerLinQ Discovery dataset was queried to identify patients diagnosed with lung cancer between the years 2010-2018. Data on demographics, tumor stage, histology and treatments were extracted, and receipt of molecular testing was investigated as the primary outcome. Univariate association of each clinicopathological variable with molecular testing outcome was performed using chi-square test for categorical variables and ANOVA test for numerical variables. A multivariable logistic regression analysis with backward selection at an alpha of 0.05 was reported. All analyses were conducted using SAS 9.4. Results: A total of 37,925 NSCLC patients with stage IV disease were analyzed. Patient characteristics: median age 65 years, 51% male, 68% white, 33.5% adenocarcinoma. Approximately 22% of all NSCLC patients had molecular testing results. In adenocarcinoma patients, 49% had molecular testing results available. In the stage IV group, 47% were treated with chemotherapy, 16% with immunotherapy and 3% with targeted therapy. On multivariable analysis, females were more likely to have molecular testing compared to males [(OR: 1.29 (1.22-1.37); p < 0.001]. Compared to White patients, Black patients were less likely to have molecular testing [OR: 0.89 (0.81-0.97); p = 0.009] and Asians were more likely to undergo testing [OR: 2.22 (1.79-2.75); p < 0.001]. Hispanic patients were more likely to undergo molecular testing compared to non-Hispanics [OR:1.24 (1.02-1.52); p = 0.03]. Additionally, treatment with immunotherapy [OR: 1.86 (1.72-2.01); p < 0.001] and targeted therapy [OR: 2.29 (2.00-2.64); p < 0.001] were associated with significantly higher likelihood of having molecular testing. These results were also confirmed on a subgroup analysis of adenocarcinoma patients. Conclusions: In this analysis of a US-based real-world dataset of stage IV NSCLC patients, White race and female sex are associated with higher likelihood of having molecular test performed. The percentage of patients undergoing testing remains sub-optimal.

Comparison of sociodemographic characteristics of a phase 1 clinical trial population at an NCI-designated comprehensive cancer center in the Southeast to catchment area

e18591

Background: Racial and ethnic minority populations are consistently under-represented in oncology clinical trials despite comprising a disproportionate share of cancer burden. Due in part to difficulties associated with participation, phase 1 trials pose a unique challenge and opportunity for minority inclusion. Here we examine the sociodemographics of phase 1 clinical trial patients at an NCI-designated Comprehensive Cancer Center compared to all patients treated at the center, patients with new cancer diagnoses in metropolitan Atlanta, and the state of Georgia (GA). Methods: Patients enrolled on phase 1 trials at the Winship Cancer Institute (WCI) from 2015-2020, identified from a data warehouse, were compared to new patient registrations at WCI from 2015-2019. Patients with cancer in metro Atlanta and GA were identified from the Surveillance, Epidemiology, and End Results (SEER) Program: Nov 2018 Submission. Covariates for the phase 1 and institutional cohort included sex, race, ECOG PS, insurance, and age at consent. Covariates for SEER patients included sex, race, and age at diagnosis. Summary statistics are reported for categorical variables using frequencies and percentages, and for continuous variables using mean, median, standard deviation, and range. One-sample proportion tests were utilized to compare observed demographic proportions on phase 1 trials with proportions calculated from new patient registrations at WCI and from SEER case data. Results: From 2015-2020, 2325 patients (43.4% F, 56.6% M) signed consent for phase 1 trials. Grouped race distribution was 70.3% White, 26.2% Black, 3.5% Other. Insurance distribution was 42.9% private, 48% government, 9.1% uninsured/other. Mean age at consent was 61.7 years (MD 63, ran 19-92). Of new patient registrations at WCI in 2015 ( N= 12358) (49.7% F, 50.3% M), grouped race distribution was 64.0% W, 28.2% B, 8% O. Atlanta 2015 SEER patients ( N= 31101) (50.3%F, 49.7%M) showed grouped race distribution 58.4% W, 37.2% B, 4.3% O. Mean age at diagnosis was 62.9. GA 2015 SEER patients ( N= 99487) (48.6%F, 51.4%M) showed grouped race distribution 71.2% W, 26.7% B, 2.1% O. Mean age at diagnosis was 64.2. The race and sex distribution of phase 1 patients was significantly different than proportions calculated from new patient registrations at WCI and SEER data from patients in Atlanta ( p< 0.001). Sex distribution was significantly different than GA SEER patients. Conclusions: Phase 1 patients were significantly more likely to be white and male, compared with patients treated at the cancer center, as well as patients with cancer in Atlanta. Race distribution was not significantly different from patients with cancer in GA. Our intent is to characterize existing disparities in order to increase representation of patients from racial and ethnic minority backgrounds in phase 1 clinical trials.

Accounting for the high enrollment of African Americans in Winship Cancer Institute’s myeloma clinical trials

12016

Background: Multiple myeloma (MM) is twice as common in African Americans (AA) as in Whites, yet AA make up only 5% of multiple myeloma (MM) clinical trial participants nationwide. Multiple studies have attempted to identify the reasons why AA are underrepresented in clinical trials and have discovered that sociodemographic factors, a lack of understanding, mistrust of sponsors, and a variety of opportunity barriers all contribute to AA underrepresentation in clinical trials. At one cancer center, African Americans make up 33% of those enrolled in MM clinical trials. To begin to account for this success in enrolling AA in myeloma clinical trials, a survey was designed to determine whether the major barriers to AA clinical trial participation existed at this cancer center. Methods: The survey was open to any AA patient who had consented to a clinical trial. The Trust in Medical Research scale (TMR) developed by Hall et al., the Human Connection (THC) scale developed by Mack et al., and the Duke Intrinsic Religiosity Scale (DUREL) were the three main scales used in the survey. Adapted assessment questions from Advani et al were used to assess the importance of side effects in deciding to participate in clinical trials. Results: We offered the study to 76 patients and 80% (61/76) participated. The mean TMR score was 15.0 which is significantly greater than the 11.6 score observed for AAs at other institutions (p < 0.001). The mean human connection score was 57.7 which is significantly greater than the 54.6 observed in the population of the Mack study, which accrued mostly white participants (p < 0.001). The Pearson correlation coefficient between the TMR score and the human connection score is 0.37, indicating a significant positive correlation between human connection scores and trust scores (p-value = 0.002). The average score for the intrinsic religiosity section of the DUREL scale was 13 (score of 15 indicates high religiosity). The average score of importance of side effects was 8.574, significantly higher than the Advani AA response of 6.7 (p-value < 0.001). Conclusions: African Americans enrolled in clinical trials at the high enrolling cancer center had higher THC and TMR scale scores than reported nationally, both helping to facilitate trial enrollment. The high intrinsic religiosity score observed suggests that high religiosity had no impact on clinical trial participation, nor did concern about side effects. Furthermore, a high THC score was associated with a high trust score. Since this THC scale assesses whether participants believe their doctors listen carefully, care about them, offer hope, provide clear explanations, and so on, establishing a human connection may be one way to increase AA trust in providers, increase AA clinical trial enrollment and overcome other barriers.

Real-world outcomes of Black women versus non-Hispanic White women with advanced triple-negative breast cancer treated with immune checkpoint inhibitors at an urban cancer center

1074

Background: Black women (BW) are disproportionately diagnosed with metastatic triple negative breast cancer (mTNBC) compared to Non-Hispanic White women (NHW). Median overall survival (OS) in mTNBC remains poor at 12-18 months. While immune checkpoint inhibitors (ICIs) are a promising treatment strategy, BW were significantly underrepresented in pivotal clinical trials that led to the approval of ICIs in mTNBC. Therefore, the efficacy, safety, and optimal biomarkers of ICI response in BW remain unknown. We sought to compare baseline characteristics and outcomes between BW and NHW with mTNBC treated with an ICI and chemotherapy at an urban tertiary care institution. Methods: BW and NHW with advanced unresectable or mTNBC treated with an ICI plus chemotherapy at Emory University between 2019 and 2021 were retrospectively evaluated. Baseline characteristics, including next generation sequencing (NGS), as well as clinical outcomes between BW and NHW were compared using Kruskal-Wallis tests and Fisher’s exact tests. Progression free survival (PFS) and OS were analyzed with the Kaplan-Meir method. Results: Forty-one women with PDL-1 positive mTNBC treated with an ICI and chemotherapy were identified [BW, n = 26 (63%) and NHW, n = 15 (37%)]. A majority of patients had relapsed disease (73%); however BW were more likely to have de novo metastatic disease compared to NHW (38% vs 7%, p = 0.03). Twenty-seven (66%) patients received atezolizumab and 14 (34%) were treated with pembrolizumab. Of the 23 (56%) patients with NGS testing, alterations in TP53, PIK3CA, and BRCA were seen in 23 (100%), 5 (31%), and 1 (6%) patient, respectively. Median tumor mutational burden was similar between BW and NHW (5 vs 7, p = 0.8). BW had numerically lower median PDL-1 (SP142) compared to NHW (1% vs 2%, p = 0.5). Rates of immune and dose-limiting chemotherapy-related adverse events were similar between BW and NHW (Table). There were no differences in ICI response between groups, though BW had fewer complete responses and a shorter median PFS compared to NHW. Median OS was 12 months in BW compared to 28 months in NHW (p = 0.1). Conclusions: Our experience with real-world use of this regimen showed that BW had fewer complete responses and a trend towards worse OS compared to NHW. BW had numerically lower median PDL-1 expression compared to NHW, suggesting further investigation of biomarkers, potentially by Race, are needed to better identify responders to ICI in mTNBC. [Table: see text]

Improving eligibility criteria for first-line trials for patients with DLBCL using a US-based Delphi-method survey

Recent first-line randomized controlled trials (RCTs) for patients with diffuse large B-cell lymphoma (DLBCL) have shown negative results, which may be due in part to onerous eligibility criteria limiting enrollment of poor-risk patients who require immediate treatment. We conducted a Delphi-method survey with lymphoma experts in the United States to define recommendations for essential and potentially unnecessary enrollment criteria for modern first-line DLBCL RCTs aimed at increasing clinical diversity of ensuing study groups. We first tabulated enrollment criteria from 19 DLBCL RCTs spanning the rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone (R-CHOP) era to identify common eligibility criteria from prior DLBCL RCTs for inclusion in the Delphi-method survey. We tabulated 451 total eligibility criteria comprising 51 criterion categories across 19 first-line DLBCL RCTs in the R-CHOP era. We then surveyed lymphoma clinical trial experts representing 8 academic medical centers in the United States regarding essential and unnecessary eligibility criteria for modern DLBCL RCTs. Seventeen of 29 invited clinical investigators completed the round-1 questionnaire (response rate, of 58.6%), 15 of 17 round-1 participants (88.2%) completed the round-2 survey, and all round-1 participants reviewed finalized recommendations for eligibility criteria for modern first-line DLBCL RCTs. We defined consensus recommendations for 31 modernized eligibility criteria including threshold values for 10 quantitative eligibility criteria aimed at facilitating enrollment of a clinically diverse study population in first-line DLBCL RCTs designed to improve standard-of-care therapy.