Determining chemotherapy tolerance in older patients with cancer

Outcomes following IMRT alone in head and neck squamous cell carcinoma ordinarily managed with concurrent chemo-radiotherapy

PURPOSE/OBJECTIVE(S)

We report outcomes following IMRT-alone in patients with head-and-neck squamous cell carcinoma (HNSCC) ordinarily managed with concurrent chemo-radiotherapy.

MATERIALS/METHODS

HNSCC (excluding T1-2 N0) patients treated with IMRT-alone from 2005 to 2019 were included and restaged according to TNM-8. Overall survival (OS) was stratified by TNM-8 stage subgroups within HPV-positive (HPV + ) and separately within HPV-negative (HPV-) HNSCC. Multivariable analysis (MVA) identified prognostic factors for OS.

RESULTS

A total of 460 patients with HPV + and 623 HPV- HNSCC were identified. Reasons for chemotherapy omission were: age > 70 years and/or frailty (n = 551, 51 %), cisplatin contraindication (n = 241, 22 %), patient' preference (n = 106, 10 %), and clinician's decision (n = 185, 17 %). IMRT was delivered mostly using altered-fractionation: moderately-accelerated (70 Gy/35 fractions [f]/6 weeks [w], 55 %), hypofractionated (60 Gy/25f/5w, 14 %), and hyperfractionated-accelerated (64 Gy/40f/4w, 25 %). Median follow-up was 5.0 years. Five-year OS for HPV + stage-I-single node, stage-I-multiple nodes, stage-II-T1-2 N2, stage-II-T3 N0-N2, and stage-III were 90 %, 79 %%, 80 %, 64 %, and 33 %, and for HPV- stage III, IVA, and IVB were 47 %, 27 %, and 13 %, respectively. MVA confirmed lower OS in HPV + stage-I-multiple nodes (p = 0.03), II-T3 N0-N2 and III (vs stage-I-single node) and HPV- stage IVA/IVB (vs III) (p < 0.01), and marginally lower OS in HPV + stage-II-T3 N0-2 (vs I-single node) (p = 0.07).

CONCLUSION

Altered fractionated IMRT-alone is a valid option for patients with HPV + stage I-single node HNSCC, and an acceptable alternative for elderly/frail or cisplatin ineligible patients with HPV + stage I-multiple nodes and T1-2 N2 HNSCC. Patients with HPV + T3-T4 or N3 and HPV- stage III/IV HNSCC had unsatisfactory OS, requiring further research into alternative options.

Identification of non-charged 7.44 analogs interacting with the NHR2 domain of RUNX1-ETO with improved antiproliferative effect in RUNX-ETO positive cells

The RUNX1/ETO fusion protein is a chimeric transcription factor in acute myeloid leukemia (AML) created by chromosomal translocation t(8;21)(q22;q22). t(8;21) abnormality is associated with 12% of de novo AML cases and up to 40% in the AML subtype M2. Previously, we identified the small-molecule inhibitor 7.44, which interferes with NHR2 domain tetramerization of RUNX1/ETO, restores gene expression down-regulated by RUNX1/ETO, inhibits proliferation, and reduces RUNX1/ETO-related tumor growth in a mouse model. However, despite favorable properties, 7.44 is negatively charged at physiological pH and was predicted to have low to medium membrane permeability. Here, we identified M23, M27, and M10 as non-charged analogs of 7.44 using ligand-based virtual screening, in vivo hit identification, biophysical and in vivo hit validation, and integrative modeling and ADMET predictions. All three compounds interact with the NHR2 domain, have KD, app values of 39-114 µM in Microscale Thermophoresis experiments, and IC50 values of 33-77 µM as to cell viability in RUNX1/ETO-positive KASUMI cells, i.e., are ~ 5 to 10-fold more potent than 7.44. M23 is ~ 10-fold more potent than 7.44 in inhibiting cell proliferation of RUNX1/ETO-positive cells. Biological characterization of M23 in relevant RUNX1/ETO-positive -and negative cell lines indicates that M23 induces apoptosis and promotes differentiation in RUNX1/ETO-positive AML cells. M23 and M27 are negligibly protonated or in a ~ 1:1 ratio at physiological pH, while M10 has no (de-)protonatable group. The non-protonated species are predicted to be highly membrane-permeable, along with other favorable pharmacokinetic and toxicological properties. These compounds might serve as lead structures for compounds inhibiting RUNX1/ETO oncogenic function in t(8;21) AML.

Restricted cubic spline analysis: Age-dependent relationship between MAGEA12 and hepatocellular carcinoma prognosis

OBJECTIVES

Currently, understanding of the nonlinear relationship between age and hepatocellular carcinoma (HCC) prognosis is insufficient. Thus, this study aimed to analyze the relationship between age at HCC diagnosis and overall survival (OS) and identify possible influencing mechanisms.

METHODS

Clinical data from the TCGA public database were analyzed. Restricted cubic spline and segmented logistic regression were employed to explore the nonlinear relationship between age at diagnosis and mortality risk following hepatectomy. Furthermore, bioinformatics methods were employed to understand the possible mechanisms of this nonlinear relationship at the genetic level.

RESULTS

The results indicated a nonlinear relationship between age at diagnosis and OS, with the age of 60 years identified as a critical point. Segmented regression showed that age ≥60 years is an unfavorable prognostic factor. The "DNA mismatch repair" pathway was considerably enriched in patients aged <60 years. However, the gene mutation rate of "APOB," "MUC16," "ALB," and "PCLO" and the median tumor mutation burden were relatively more evident in patients aged ≥60 years. MGEA12 was more highly expressed in tumor tissues than in normal ones, particularly in patients aged ≥60 years. The survival rate of the high-expression group was lower than that of the low-expression group. At the mRNA level, the MGEA12 expression in Huh-7 and SUN449 was higher than that in the HSC-LX2 cell line.

CONCLUSION

A nonlinear relationship was found between age at HCC diagnosis and OS, with the age of 60 years being the critical point. MGEA12 may affect the prognosis of elderly people.

Cost-Effectiveness of Enfortumab Vedotin and Pembrolizumab for First-Line Metastatic Urothelial Cancer in the United States

OBJECTIVES

The EV-302 trial demonstrated that the combination of enfortumab vedotin and pembrolizumab (EV+P) significantly improved progression-free and overall survival in patients with metastatic urothelial cancer. However, the economic value of this regimen remains uncertain. Our study aims to evaluate the cost-effectiveness of EV+P versus platinum-based chemotherapy as first-line treatment for metastatic urothelial cancer from the US payer perspective.

METHODS

We developed a cohort state-transition model to simulate the lifetime costs and effectiveness of a cohort of 69-year-olds with metastatic urothelial cancer, resembling those in the EV-302 trial. Costs and utilities were derived from published literature to calculate the quality-adjusted life years (QALYs) and the incremental cost-effectiveness ratio for EV+P relative to chemotherapy. We conducted deterministic and probabilistic sensitivity analyses to identify factors influencing the cost-effectiveness.

RESULTS

In the base case, the chemotherapy strategy costs $80 874, yielding 1.26 QALYs and 1.69 life years. The EV+P strategy costs $752 637, yielding 2.54 QALYs and 3.31 life years. This resulted in an incremental cost-effectiveness ratio of $525 239/QALY and $414 927/life year. To achieve cost-effectiveness at a $150 000/QALY threshold, the price of the combination therapy would need to be reduced by 76%. A probabilistic sensitivity analysis indicated that EV+P was cost-effective in 0% of the simulations.

CONCLUSIONS

Although EV+P therapy is effective, it is not cost-effective at its current price as a first-line therapy in the United States at a cost-effectiveness threshold of $150 000/QALY. A substantial reduction in its drug cost is required to be cost-effective at commonly accepted willingness-to-pay thresholds.

Optimal lung cancer care pathways: a Tasmanian perspective

Objective In Australia, Tasmania has the second highest rate of incident lung cancer cases at 44.0 per 100,000 population, with an overall 5year relative survival rate of 20%. The aim of this retrospective study was to map and compare patient transit timelines from referral, diagnosis and treatment, to national care quality indicators (NCQI) and optimal care pathway (OCP) benchmarks. Methods Data were extracted from the weekly lung cancer multidisciplinary team meeting minutes, digital medical records and the ARIA Oncology-Information System for newly diagnosed small cell and non-small cell lung cancer cases between 2019 and 2022, at a regional, university-affiliated tertiary hospital in Tasmania. Sociodemographic data and key dates were extracted, including first general practitioner (GP) referral, specialist appointments (respiratory, medical oncology, radiation oncology and cardiothoracic), investigations, diagnosis, staging and treatment of any intent. Timelines were benchmarked against NCQI and the OCP. Results A total of 165 cases were included; mean patient age was 72years, and 57% were male. A total of 153 patients (93%) were diagnosed with non-small cell cancer and 12 (7%) with small cell lung cancer. Results for all years showed that 93% of patients were seen by the respiratory service within 14days of their GP referral and 71% diagnosed within 28days of their referral, in accordance with current standards. The time taken between GP referrals and diagnosis to any treatment was greater than the required standards, with on average 7% of patients meeting the quality standards (range, 0-16%) for all treatment intents. Conclusion Current national benchmarks have proven challenging to achieve, with prolonged time to treatment of any intent. Challenges both at a patient and systemic level will need to be assessed to improve clinical indicator outcomes.

Evaluating Treatment Outcomes in Women with Node-Negative T1 Breast Cancers

BACKGROUND

With greater awareness and increased screening, cancers are increasingly being diagnosed at stage I. Women with these small node-negative tumours have excellent survival prospects after surgery, but many women, especially those with triple-negative and human epidermal growth factor receptor (HER)-2-positive tumours, still receive adjuvant systemic treatments to reduce the recurrence risk.

AIMS

We review the outcomes of women diagnosed with stage I (T1N0M0) tumours in our unit and examine the effect of systemic chemotherapy with/without targeted therapy on recurrence patterns and survival outcomes.

RESULTS

We reviewed 643 women diagnosed with T1N0M0 disease over a 10-year period. Five-year recurrence-free survival (RFS) was 96.6% and the 10-year RFS was 95.5%. Recurrence occurred in 4.7% of the women and was limited to locoregional sites in two-thirds of the instances. Systemic recurrences developed in 12 women, all of whom had ER-positive/HER2-negative disease. The mode of surgery emerged as the only independent predictor of recurrence. Recurrence was highest in women treated with wide local excision (WLE) alone (p < 0.05), but not in those who had received breast radiation after WLE (p = 0.112). Systemic chemotherapy, with or without anti-HER2 therapy, was discussed with 334 women, of whom 50.6% received the treatment; these women were more often younger and had triple-negative or HER2-positive tumours (p < 0.001). Women who received chemotherapy showed a non-significant tendency to develop locoregional recurrence (p = 0.104), but the number of systemic recurrences were similar to those documented in women who had not received chemotherapy. Chemotherapy and/or targeted treatment was not observed to have a significant effect on 5-year recurrence-free survival (p = 0.444).

CONCLUSIONS

Stage I cancers have excellent survival outcomes. An optimal local surgical treatment is important and we did not find chemotherapy and/or targeted therapy to produce any significant differences in survival.

Hemoglobin, albumin, lymphocytes and platelets (HALP) score as a predictor of survival in patients with glioblastoma (GBM)

BACKGROUND

We aimed to investigate whether the HALP score was a predictor of survival in patients with Glioblastoma (GBM).

METHODS

A total of 84 Glioblastoma (GBM) patients followed in our clinic were included in the study. HALP scores were calculated using the preoperative hemoglobin, albumin, lymphocyte and platelet results of the patients. For the HALP score, a cut-off value was found by examining the area below the receiver operating characteristic (ROC) curve. Patients were divided into two groups as low and high according to this cut-off value. The relationships among the clinical, dermographic and laboratory parameters of the patients were examined using these two groups.

RESULTS

Median OS, PFS, HALP score, NLR, PLR were 15 months (1.0-78.0), 8 months (1.0-66.0), 37.39 ± 23.84 (min 6.00-max 132.31), 4.14, 145.07 respectively. A statistically significant correlation was found between HALP score and OS, PFS, NLR, PLR, ECOG-PS status using Spearman's rho test (p = 0.001, p < 0.001, p < 0.001, p < 0.001, p = 0.026 respectively). For the HALP score, a cut-off value of = 37.39 (AUC = 0.698, 95% CI, p < 0.002) was found using ROC analysis. Median OS was 12 (6.99-17.01) months in the low HALP group and 21 (11.37-30.63) months in the high HALP group (p = 0.117). NLR and PLR were significantly lower in the HALP high group (p < 0.001, p < 0.001 respectively). The ratio of receiving treatment was significantly higher in the high HALP group (p < 0.05). In Multivariate analysis, significant results were found for treatment status and ECOG-PS status (p < 0.001, p = 0.038 respectively).

CONCLUSIONS

The HALP score measured at the beginning of treatment seems to have predictive importance in the prognosis of GBM patients. A HALP score of > 37.39 was associated with prolonged survival in high-grade brain tumors.

Magnetic resonance imaging radiomics-based prediction of severe inflammatory response in locally advanced rectal cancer patients after neoadjuvant radiochemotherapy

PURPOSE

To predict severe inflammatory response after neoadjuvant radiochemotherapy in locally advanced rectal cancer (RC) patients using magnetic resonance imaging (MRI) radiomics models.

METHODS

This retrospective study included patients who underwent radical surgery for RC cancer after neoadjuvant radiochemotherapy between July 2017 and December 2019 at XXX Hospital. MRI radiomics features were extracted from T2WI images before (pre-nRCT-RF) and after (post-nRCT-RF) neoadjuvant radiochemotherapy, and the variation of radiomics features before and after neoadjuvant radiochemotherapy (delta-RF) were calculated. Eight, eight, and five most relevant features were identified for pre-nRCT-RF, post-nRCT-RF, and delta-RF, respectively.

RESULTS

Eighty-six patients were included and randomized 3:1 to the training and test set (n = 65 and n = 21, respectively). The prediction model based on delta-RF had areas under the curve (AUCs) of 0.80 and 0.85 in the training and test set, respectively. A higher rate of difficult operations was observed in patients with severe inflammation (65.5% vs. 42.9%, P = 0.045).

CONCLUSION

The prediction model based on MRI delta-RF may be a useful tool for predicting severe inflammatory response after neoadjuvant radiochemotherapy in locally advanced RC patients.

Clinical and pathological factors associated with survival in patients with pancreatic cancer who receive adjuvant therapy after neoadjuvant therapy: A retrospective multi-institutional analysis

BACKGROUND

Neoadjuvant therapy is being increasingly used for patients with pancreatic cancer. The role of adjuvant therapy in these patients is unclear. The purpose of this study was to identify clinical and pathologic characteristics that are associated with longer overall survival in patients with pancreatic cancer who receive adjuvant therapy after neoadjuvant therapy.

METHODS

This study was conducted using multi-institutional data. All patients underwent surgery after at least 1 cycle of neoadjuvant therapy for pancreatic cancer. Patients who died within 3 months after surgery and were known to have distant metastasis or macroscopic residual disease were excluded. Mann-Whitney U test, χ2 analysis, Kaplan-Meier plot, and univariate and multivariate Cox regression analysis were performed as statistical analyses.

RESULTS

In the present study, 529 patients with resected pancreatic cancer after neoadjuvant therapy were reviewed. For neoadjuvant therapy, 177 (33.5%) patients received neoadjuvant chemotherapy, and 352 (66.5%) patients received neoadjuvant chemoradiotherapy. The median duration of neoadjuvant therapy was 7.0 months (interquartile range, 5.0-8.7). Patients were followed for a median of 23.0 months after surgery. Adjuvant therapy was administered to 297 (56.1%) patients and was not associated with longer overall survival for the entire cohort (24 vs 22 months, P = .31). Interaction analysis showed that adjuvant therapy was associated with longer overall survival in patients who received less than 4 months neoadjuvant therapy (hazard ratio 0.40; 95% confidence interval 0.17-0.95; P = .03) or who had microscopic margin positive surgical resections (hazard ratio 0.56; 95% confidence interval 0.33-0.93; P = .03).

CONCLUSION

In this retrospective study, there was a survival benefit associated with adjuvant therapy for patients who received less than 4 months of neoadjuvant therapy or had microscopic positive margins.

Subgroup analyses from the phase 3 ASCENT study of sacituzumab govitecan in metastatic triple-negative breast cancer

In this post hoc analysis of the ASCENT study, we compared outcomes with sacituzumab govitecan (SG) vs single-agent chemotherapy in clinically important subgroups of patients with metastatic triple-negative breast cancer (mTNBC). Patients with mTNBC refractory to/relapsing after ≥2 prior chemotherapies (≥1 in the metastatic setting) were randomized 1:1 to receive SG or treatment of physician's choice (TPC) until unacceptable toxicity/progression. The primary endpoint was progression-free survival (PFS) per RECIST 1.1 by central review in patients without brain metastases. Patients with brain metastases were allowed if metastases were stable ≥4 weeks. In the intention-to-treat (ITT) population, 19% of patients were age ≥65 years; 12% were Black, and 12% had brain metastases. SG improved PFS and overall survival (OS), respectively, vs TPC in patients age ≥65 years (7.1 vs 2.4 months and 14.7 vs 8.9 months), or of Black race (5.4 vs 2.2 months and 13.8 vs 8.5 months), consistent with outcomes in the ITT population. Patients with brain metastases had numerically higher median PFS with SG vs TPC, but median OS was similar between treatment groups. SG was well tolerated and had a manageable safety profile consistent with the full safety population across all subgroups; neutropenia and diarrhea were the most common treatment-emergent adverse events. These findings confirm the meaningful clinical benefit of SG vs standard chemotherapy in patient subgroups with high unmet needs. SG should be considered an effective and safe treatment option for patients with mTNBC eligible for second-line or later therapy. ClinicalTrials.gov Number: NCT02574455.

Addressing controversial areas in the management of advanced prostate cancer in Canada Areas of consensus and controversy from the third Canadian consensus forum

INTRODUCTION

The management of prostate cancer (PCa) is rapidly evolving. Treatment and diagnostic options grow annually, however, high-level evidence for the use of new therapeutics and diagnostics is lacking. In November 2022, the Genitourinary Research Consortium held its 3rd Canadian Consensus Forum (CCF3) to provide guidance on key controversial areas for management of PCa.

METHODS

A steering committee of eight multidisciplinary physicians identified topics for discussion and adapted questions from the Advanced Prostate Cancer Consensus Conference 2022 for CCF3. Questions focused on management of metastatic castration-sensitive prostate cancer (mCSPC); use of novel imaging, germline testing, and genomic profiling; and areas of non-consensus from CCF2. Fifty-eight questions were voted on during a live forum, with threshold for "consensus agreement" set at 75%.

RESULTS

The voting panel consisted of 26 physicians: 13 urologists/uro-oncologists, nine medical oncologists, and four radiation oncologists. Consensus was reached for 32 of 58 questions (one ad-hoc). Consensus was seen in the use of local treatment, to not use metastasis-directed therapy for low-volume mCSPC, and to use triplet therapy for synchronous high-volume mCSPC (low prostate-specific antigen). Consensus was also reached on sufficiency of conventional imaging to manage disease, use of germline testing and genomic profiling for metastatic disease, and poly (ADP-ribose) polymerase (PARP) inhibitors for BRCA-positive prostate cancer.

CONCLUSIONS

CCF3 identified consensus agreement and provides guidance on >30 practice scenarios related to management of PCa and nine areas of controversy, which represent opportunities for research and education to improve patient care. Consensus initiatives provide valuable guidance on areas of controversy as clinicians await high-level evidence.

Associations of Age and Sex with the Efficacy of Inpatient Cancer Rehabilitation: Results from a Longitudinal Observational Study Using Electronic Patient-Reported Outcomes

Cancer rehabilitation is thought to increase the quality of life (QOL) and functioning of cancer survivors. It remains, however, uncertain whether subgroups benefit equally from rehabilitation. We wished to investigate the outcomes of multimodal rehabilitation according to age, sex and functioning. Patients of an Austrian rehabilitation center routinely completed the EORTC QLQ-C30 and the hospital anxiety and depression scale (HADS) questionnaires prior to (T1), and after rehabilitation (T2). To compare the outcomes between age groups (i.e., <40, 41–69, and ≥70 years), sex, and the Norton scale risk status, repeated measures of analyses of variance were calculated. A total of 5567 patients with an average age of 60.7 years were included, of which 62.7% were female. With T1 indicating the cancer survivors’ needs, older and high-risk patients reported lower functioning (all p < 0.001) and a higher symptom burden for most scales (all p < 0.05) before rehabilitation. Regardless of age, sex or risk status, the patients showed at a least small to medium improvement during rehabilitation for anxiety, depression, and most functioning and symptom scales. Some between-group differences were observed, none of which being of a relevant effect size as determined with the Cohen’s d. In conclusion, QOL is improved by rehabilitation in all patients groups, independently from age, sex, or the risk status.

Personalised Assessment and Rapid Intervention in Frail Patients with Lung Cancer: The Impact of an Outpatient Occupational Therapy Service

INTRODUCTION

Lung cancer and its treatments cause or accelerate frailty, detrimentally affecting function and quality of life. Occupational therapists (OTs) provide global assessments and interventions, but services are often available for inpatients. The impact of holistic assessment and early intervention in the outpatient setting is unknown.

MATERIALS AND METHODS

A tertiary cancer center in North East England piloted a Lung Cancer Outpatient OT Service for patients with thoracic malignancy and a Clinical Frailty Scale Score (CFS) ≥ 5. Service effectiveness was evaluated through calculation of admission avoidance, hospital length-of-stay reduction, completion/impact of advance care planning and patient/family feedback. Demographics, frailty level, required interventions, and onward referrals were recorded.

RESULTS

A total of 153 patients (median age of 71 (range 46-90) received OT assessment and intervention. 48% were in the lowest socioeconomic quintile. Median CFS score was 5 (mildly frail (range: 4-7)) at initial assessment. Total of 918 interventions were delivered (median: 5, IQR: 3-7, Range 0-22). 48% of patients engaged in future planning (national average: 10%-15% P < .0001) and 78.5% achieved preferred place of death (national average 30%). An estimated 37 hospital admissions were avoided. In admitted patients, average inpatient stay when known to the service was 6.5 days less than other frail lung cancer patients in our unit (95% CI 4-9.1 days P < .0001). Higher CFS was associated with poor survival (P < .05).

CONCLUSION

Outpatient OT services can avoid and shorten hospital admissions through advance care planning, management of functional disruption, onward referral to other allied health professionals and palliative care. A comprehensive multidisciplinary outpatient service may benefit patients further and should be the focus of future research.

FOxTROT2: innovative trial design to evaluate the role of neoadjuvant chemotherapy for treating locally advanced colon cancer in older adults or those with frailty

Treating older adults with cancer is increasingly important in modern oncology practice. However, we currently lack the high-quality evidence needed to guide optimal management of this heterogeneous group. Principally, historic under-recruitment of older adults to clinical trials limits our understanding of how existing evidence can be applied to this group. Such uncertainty is particularly prevalent in the management of colon cancer (CC). With CC being most common in older adults, many patients also suffer from frailty, which is recognised as being strongly associated with poor clinical outcomes. Conducting clinical trials in older adults presents several major challenges, many of which impact the clinical relevance of results to a real-world population. When considering this heterogeneous group, it may be difficult to define the target population, recruit participants effectively, choose an appropriate trial design, and ensure participants remain engaged with the trial during follow-up. Furthermore, after overcoming these challenges, clinical trials tend to enrol highly selected patient cohorts that comprise only the fittest older patients, which are not representative of the wider population. FOxTROT1 was the first phase III randomised controlled trial to illustrate the benefit of neoadjuvant chemotherapy (NAC) in the treatment of CC. Patients receiving NAC had greater 2-year disease-free survival compared to those proceeding straight to surgery. Outcomes for older adults in FOxTROT1 were similarly impressive when compared to their younger counterparts. Yet, this group inevitably represents a fitter subgroup of the older patient population. FOxTROT2 has been designed to investigate NAC in a full range of older adults with CC, including those with frailty. In this review, we describe the key challenges to conducting a robust clinical trial in this heterogeneous patient group, highlight our strategies for overcoming these challenges in FOxTROT2, and explain how we hope to provide clarity on the optimal treatment of CC in older adults.

CT-derived body composition measurements as predictors for neoadjuvant treatment tolerance and survival in gastroesophageal adenocarcinoma

PURPOSE

Treatment for gastroesophageal adenocarcinomas can result in significant morbidity and mortality. The purpose of this study is to supplement methods for choosing treatment strategy by assessing the relationship between CT-derived body composition, patient, and tumor features, and clinical outcomes in this population.

METHODS

Patients with neoadjuvant treatment, biopsy-proven gastroesophageal adenocarcinoma, and initial staging CTs were retrospectively identified from institutional clinic encounters between 2000 and 2019. Details about patient, disease, treatment, and outcomes (including therapy tolerance and survival) were extracted from electronic medical records. A deep learning semantic segmentation algorithm was utilized to measure cross-sectional areas of skeletal muscle (SM), visceral fat (VF), and subcutaneous fat (SF) at the L3 vertebra level on staging CTs. Univariate and multivariate analyses were performed to assess the relationships between predictors and outcomes.

RESULTS

142 patients were evaluated. Median survival was 52 months. Univariate and multivariate analysis showed significant associations between treatment tolerance and SM and VF area, SM to fat and VF to SF ratios, and skeletal muscle index (SMI) (p = 0.004-0.04). Increased survival was associated with increased body mass index (BMI) (p = 0.01) and increased SMI (p = 0.004). A multivariate Cox model consisting of BMI, SMI, age, gender, and stage demonstrated that patients in the high-risk group had significantly lower survival (HR = 1.77, 95% CI = 1.13-2.78, p = 0.008).

CONCLUSION

CT-based measures of body composition in patients with gastroesophageal adenocarcinoma may be independent predictors of treatment complications and survival and can supplement methods for assessing functional status during treatment planning.

Refining patient selection of MET-activated non-small cell lung cancer through biomarker precision

Dysregulated MET signaling plays an important role in lung oncogenesis, tumor growth and invasiveness. It may occur through various mechanisms, such as MET overexpression or gene amplification or mutation, all of which can be detected by specific methods. The utility of MET overexpression as a biomarker remains unclear due to discrepancies in its occurrence and non-standardized cut-off thresholds. MET exon 14 skipping mutation (METex14) was established as a strong predictor of response to selective MET tyrosine kinase inhibitors (TKIs), and clinical trial results in patients with non-small cell lung cancer (NSCLC) harboring METex14 led to the approval of capmatinib and tepotinib by regulatory agencies worldwide. MET amplification is an emerging biomarker, with clinical data indicating an association between MET gene copy number and response to MET-TKIs. Additionally, MET amplification represents an important mechanism of resistance to TKIs in oncogene-driven NSCLC. The identification of molecular alterations for which targeted therapies are available is important, and high-throughput next-generation sequencing techniques can provide information on multiple genes at the same time, helping to provide valuable predictive information for oncogene-driven cancers. This review summarizes the current methods used for the detection of METex14, MET amplification and MET overexpression, and discusses the evidence for the use of MET-TKIs in patients with NSCLC with MET dysregulation. We discuss the practical challenges that impact the use of METex14 in the clinic and the evidence gaps that need to be addressed to validate additional genomic markers for MET-dependent cancers.

Safety analyses from the phase 3 ASCENT trial of sacituzumab govitecan in metastatic triple-negative breast cancer

Sacituzumab govitecan (SG) is an anti-Trop-2 antibody-drug conjugate with an SN-38 payload. In the ASCENT study, patients with metastatic triple-negative breast cancer (mTNBC) relapsed/refractory to ≥2 prior chemotherapy regimens (≥1 in the metastatic setting), received SG or single-agent treatment of physician's choice (eribulin, vinorelbine, capecitabine, or gemcitabine). This ASCENT safety analysis includes the impact of age and UGT1A1 polymorphisms, which hinder SN-38 detoxification. SG demonstrated a manageable safety profile in patients with mTNBC, including those ≥65 years; neutropenia/diarrhea are key adverse events (AE). Patients with UGT1A1 *28/*28 genotype versus those with 1/*28 and *1/*1 genotypes had higher rates of grade ≥3 SG-related neutropenia (59% vs 47% and 53%), febrile neutropenia (18% vs 5% and 3%), anemia (15% vs 6% and 4%), and diarrhea (15% vs 9% and 10%), respectively. Individuals with UGT1A1 *28/*28 genotype should be monitored closely; active monitoring and routine AE management allow optimal therapeutic exposure of SG.

Outcomes of Geriatric Patients with Hepatocellular Carcinoma

Background: The treatment modalities and outcomes of geriatric patients with hepatocellular carcinoma (HCC) remain controversial. This retrospective observational cohort study compared the outcomes of HCC between geriatric and younger patients. Methods: The medical records of patients with HCC managed between January 2001 and December 2017 were retrieved from the Chang Gung Memorial Hospital Research Database. Patients were stratified by age into two groups: a geriatric group (65−75 years) and a younger group (<65 years). The two groups were matched through 1:2 propensity score matching (PSM) according to sex, cardiovascular disease, cerebrovascular attack, diabetes mellitus, cirrhosis, hepatitis, and hypertension. Results: Of the 11,033 patients with HCC, 2147 patients aged 65−75 years and 4294 patients aged <65 years were identified after 1:2 PSM. The Kaplan−Meier model revealed that the HCC outcomes in patients older than 65 years were not significantly different after 3 years (p = 0.060). Consistent results were also obtained when the laboratory data associated with HCC incidence were included in the Fine−Gray competing risk model after 1:2 PSM (p = 0.1695). The major risk factors for HCC survival were systemic immune-inflammation index (SII) ≥ 610 × 109 cells/L, advanced tumor stage, and model for end-stage liver disease (MELD) score, etc. Conclusion: Age was not an independent factor for mortality in patients with HCC in the first 3 years. Geriatric patients with HCC should be as aggressively managed as younger patients.

Survival of Adolescents and Young Adults with Prevalent Poor-Prognosis Metastatic Cancers: A Population-Based Study of Contemporary Patterns and Their Implications

BACKGROUND

Although survival has improved dramatically for most adolescents and young adults (AYA; 15-39 years old) with cancer, it remains poor for those presenting with metastatic disease. To better characterize this subset, we conducted a landscape survival comparison with older adults (40-79 years).

METHODS

Using Surveillance, Epidemiology, and End Results Program data from 2000 to 2016, we examined incident cases of poor-prognosis metastatic cancers (5-year survival < 50%) among AYAs (n = 11,518) and older adults (n = 345,681) and compared cause-specific survival by sociodemographic characteristics (race/ethnicity, sex, and socioeconomic status). Adjusted HRs (aHR) for death from metastatic disease [95% confidence intervals (95% CI)] were compared between AYAs and older adults (Pint).

RESULTS

AYAs had significantly better survival than older adults for every cancer site except kidney, where it was equivalent (range of aHRs = 0.91; 95% CI, 0.82-1.02 for kidney cancer to aHR = 0.33; 95% CI, 0.26-0.42 for rhabdomyosarcoma). Compared with their older adult counterparts, greater survival disparities existed for AYAs who were non-Hispanic Black with uterine cancer (aHR = 2.20; 95% CI, 1.25-3.86 versus aHR = 1.40; 95% CI, 1.28-1.54; Pint = 0.049) and kidney cancer (aHR = 1.51; 95% CI, 1.15-1.98 versus aHR = 1.10; 95% CI, 1.03-1.17; Pint = 0.04); non-Hispanic Asian/Pacific Islanders with ovarian cancer (aHR = 1.47; 95% CI, 1.12-1.93 versus aHR = 0.89; 95% CI, 0.84-0.95; Pint<0.001); and males with colorectal cancer (aHR = 1.21; 95% CI, 1.10-1.32 versus aHR = 1.08; 95% CI, 1.06-1.10; Pint = 0.045).

CONCLUSIONS

AYAs diagnosed with these metastatic cancers have better survival than older adults, but outcomes remain dismal.

IMPACT

Overcoming the impact of metastasis in these cancers is necessary for continuing progress in AYA oncology. Sociodemographic disparities affecting AYAs within kidney, uterine, ovarian, and colorectal cancer could indicate plausible effects of biology, environment, and/or access and should be explored.

OUP accepted manuscript

Background

Methods

Results

Conclusions

Excess mortality and undertreatment in elderly lung cancer patients: treatment nihilism in the modern era?

Treatment of elderly patients with lung cancer is significantly hindered by concerns about treatment tolerability, toxicity and limited clinical trial data in the elderly; potentially giving rise to treatment nihilism amongst clinicians. This study aims to describe survival in elderly patients with lung cancer and explore potential causes for excess mortality.

Patients diagnosed with lung cancer in the Victorian Lung Cancer Registry between 2011–2018 were analysed (n=3481). Patients were age-categorised and compared using Cox-regression modelling to determine mortality risk, after adjusting for confounding. Probability of being offered cancer treatments was also determined, further stratified by disease stage.

The eldest patients (≥80 years old) had significantly shorter median survival compared with younger age groups (<60 years: 2.0 years; 60–69 years: 1.5 years; 70–79 years: 1.6 years; ≥80 years: 1.0 years; p<0.001). Amongst those diagnosed with stage 1 or 2 lung cancer, there was no significant difference in adjusted-mortality between age groups. However, in those diagnosed with stage 3 or 4 disease, the eldest patients had an increased adjusted-mortality risk of 28% compared with patients younger than 60 years old (p=0.005), associated with markedly reduced probability of cancer treatment, after controlling for sex, performance status, comorbidities and histology type (OR 0.24, compared with <60 years old strata; p<0.001).

Compared to younger patients, older patients with advanced-stage lung cancer have a disproportionately higher risk of mortality and lower likelihood of receiving cancer treatments, even when performance status and comorbidity are equivalent. These healthcare inequities could be indicative of widespread treatment nihilism towards elderly patients.

Treatment strongly determines lung cancer survival, yet nihilism may threaten treatment provision and survival outcomes. Older patients in this cohort had reduced multidisciplinary presentation, less treatment (OR 0.24) and 28% increased mortality risk.https://bit.ly/2ZGotj0

Curcumin restores the engraftment capacity of aged hematopoietic stem cells and also reduces PD-1 expression on cytotoxic T cells

Aging affects the functionality of hematopoietic stem cells (HSCs), and therefore, aged individuals are not preferred as donors in HSC transplantation. Such elimination leads to the restriction of donor cohort. Several efforts are being done to rejuvenate aged HSCs. Here, we show that treatment of aged mice with curcumin rejuvenates their HSCs by restoring the expression of autophagy-inducing messenger RNAs in them, and improves their engraftment capacity. Importantly, we show that curcumin is effective in rejuvenation of HSCs when administered via both, intraperitoneal as well as oral routes. Aging also affects the immune system. While elderly individuals are not immuno-deficient, they do not respond optimally to immunizations, and hence, a strategy needs to be developed to make them immunologically responsive. Programmed cell death 1 (PD-1), one of the inhibitory coreceptors, plays an important role in the regulation of autoimmunity, infectious immunity, and cancer immunity. Its expression on T cells is indicative of their exhaustion. Here, we show that curcumin reduces the frequency of PD1+ cytotoxic T cells in the spleens of aged mice. Curcumin has a proven safety profile, and hence, can be used to treat aged donors to boost the functionality of their HSCs and also to improve the immunological profile of aged individuals. These data could have implications in various other regenerative medicine protocols as well.

Interleukin-37 improves T-cell-mediated immunity and chimeric antigen receptor T-cell therapy in aged backgrounds

Aging‐associated declines in innate and adaptive immune responses are well documented and pose a risk for the growing aging population, which is predicted to comprise greater than 40 percent of the world's population by 2050. Efforts have been made to improve immunity in aged populations; however, safe and effective protocols to accomplish this goal have not been universally established. Aging‐associated chronic inflammation is postulated to compromise immunity in aged mice and humans. Interleukin‐37 (IL‐37) is a potent anti‐inflammatory cytokine, and we present data demonstrating that IL‐37 gene expression levels in human monocytes significantly decline with age. Furthermore, we demonstrate that transgenic expression of interleukin‐37 (IL‐37) in aged mice reduces or prevents aging‐associated chronic inflammation, splenomegaly, and accumulation of myeloid cells (macrophages and dendritic cells) in the bone marrow and spleen. Additionally, we show that IL‐37 expression decreases the surface expression of programmed cell death protein 1 (PD‐1) and augments cytokine production from aged T‐cells. Improved T‐cell function coincided with a youthful restoration of Pdcd1, Lat, and Stat4 gene expression levels in CD4⁺ T‐cells and Lat in CD8⁺ T‐cells when aged mice were treated with recombinant IL‐37 (rIL‐37) but not control immunoglobin (Control Ig). Importantly, IL‐37‐mediated rejuvenation of aged endogenous T‐cells was also observed in aged chimeric antigen receptor (CAR) T‐cells, where improved function significantly extended the survival of mice transplanted with leukemia cells. Collectively, these data demonstrate the potency of IL‐37 in boosting the function of aged T‐cells and highlight its therapeutic potential to overcome aging‐associated immunosenescence.

Bridging the Age Gap in breast cancer: Impact of chemotherapy on quality of life in older women with early breast cancer

INTRODUCTION

Older patients with early breast cancer (EBC) derive modest survival benefit from chemotherapy but have increased toxicity risk. Data on the impact of chemotherapy for EBC on quality of life in older patients are limited, but this is a key determinant of treatment acceptance. We aimed to investigate its effect on quality of life in older patients enrolled in the Bridging the Age Gap study.

MATERIALS AND METHODS

A prospective, multicentre, observational study of EBC patients ≥70 years old was conducted in 2013-2018 at 56 UK hospitals. Demographics, patient, tumour characteristics, treatments and adverse events were recorded. Quality of life was assessed using the European Organisation for Research and Treatment of Cancer Quality-of-Life Questionnaires (EORTC-QLQ) C30, BR23 and ELD 15 plus the Euroqol-5D (eq-5d) over 24 months and analysed at each time point using baseline adjusted linear regression analysis and propensity score-matching.

RESULTS

Three thousand and four hundred sixteen patients were enrolled in the study; 1520 patients undergoing surgery and who had high-risk EBC were included in this analysis. 376/1520 (24.7%) received chemotherapy. At 6 months, chemotherapy had a significant negative impact in several EORTC-QLQ-C30 domains, including global health score, physical, role, social functioning, cognition, fatigue, nausea/vomiting, dyspnoea, appetite loss, diarrhoea and constipation. Similar trends were documented on other scales (EORTC-QLQ-BR23, EORTC-QLQ-ELD15 and EQ-5D-5L). Its impact was no longer significant at 18-24 months in unmatched and matched cohorts.

CONCLUSIONS

The negative impact of chemotherapy on quality-of-life is clinically and statistically significant at 6 months but resolves by 18 months, which is crucial to inform decision-making for older patients contemplating chemotherapy.

TRIAL REGISTRATION NUMBER ISRCTN

46099296.

Low Pretreatment Albumin-to-Globulin Ratio Predicts Poor Prognosis in Gastric Cancer: Insight From a Meta-Analysis

BACKGROUND

In recent five years, reports regarding albumin-to-globulin ratio (AGR) and the survival of gastric cancer (GC) have emerged rapidly, yet their association remains controversial. This meta-analysis was aimed to provide an insight into the prognostic significance of pretreatment AGR in GC.

METHODS

PubMed, Embase, Cochrane library, Web of Science, WanFang, China National Knowledge Infrastructure (CNKI) and VIP databases were searched for relevant studies, from inception to September 30, 2020. Individual hazard ratios (HRs) with their 95% confidence intervals (CIs) were combined by Stata 12.0 software to evaluate the association between pretreatment AGR and overall survival (OS) and disease-free survival/progression-free survival (DFS/PFS).

RESULTS

A total of 8,305 patients with GC from 12 studies were included for further analysis. Pooled analyses indicated that low AGR was closely associated with worse OS (HR = 1.531, 95% CI: 1.300-1.803, P < 0.001) and worse DFS/PFS (HR = 2.008, 95% CI: 1.162-3.470, P = 0.012) in GC patients. Moreover, subgroup analyses demonstrated that the association between low AGR and worse OS remained constant despite variations in country, tumor stage, cut-off value, cut-off selection and treatment method.

CONCLUSION

AGR could act as an efficient prognostic indicator for GC, and that low pretreatment AGR predicts poor prognosis in GC.

Pretreatment Geriatric Assessments of Elderly Patients with Glioma: Development and Implications

Glioma is the most frequent primary brain tumor affecting adults, and the most lethal type is glioblastoma (GBM); currently, the available therapies only provide palliation. The treatments for low-grade glioma (LGG) include neurosurgical resection, watchful waiting, radiotherapy and chemotherapy, while the therapeutic strategies for high-grade glioma (HGG), particularly in elderly patients, have evolved to include radiotherapy, chemotherapy, and targeted monotherapy based on the characteristics of the investigated patients. Proper assessments aiming to predict and achieve the most satisfying prognosis among patients prior to surgery, radiotherapy, chemotherapy, targeted therapy or immunotherapy help summarize the pretreatment characteristics of patients, providing doctors comprehensive information to consider while determining whether the patients could benefit from ongoing treatments and deciding the proper treatment strategy for subsequent phases. This article aims to rigorously review the most recent evidence and discuss current mainstream assessments before the initiation of proper treatments for glioma, thus highlighting the potential necessity of pretreatment assessments.

Follicular lymphoma treatment patterns between 2000 and 2014: a SEER-Medicare analysis of elderly patients

Aim: Characterize follicular lymphoma (FL) treatment patterns among elderly patients using a dataset with longer follow-up time. Materials & methods: Using the linked Surveillance, Epidemiology and End Results-Medicare data, we identified patients diagnosed with FL between 2000 and 2013 with claims data until 2014. We investigated the treatments received and assigned them to lines of treatment. Results: We identified 10,238 elderly patients. Over a 4.7-year median follow-up, 78% of the patients received at least first-line treatment. Fewer individuals received second-line (47%) and third-line (30%) treatments. RCHOP (rituximab, cyclophosphamide, doxorubicin, vincristine and prednisolone), RCVP (rituximab, cyclophosphamide, vincristine and prednisolone) and rituximab monotherapy were the most common treatment regimens. Conclusion: One in five elderly patients did not receive FL-directed therapy. The most common treatment regimens were limited to RCHOP, RCVP and rituximab monotherapy.

Assessing the tolerability and efficacy of first-line chemotherapy in elderly patients with metastatic HER2-ve breast cancer

Background

In metastatic breast cancer (MBC), there is no consensus regarding the optimal regimen sequence and whether adults >65 years old (OA) are at increased risk from chemotherapy toxicity. Treatment decisions are often driven by the ability to tolerate treatment and maintain the quality of life. This study was designed to assess current practice in an oncology hospital in the UK.

Methods

Retrospective data were collected about treatments used for 87 OA with MBC in a single centre between 2009 and 2016 to assess the tolerability and efficacy of first-line chemotherapy. Student’s T-tests and Kaplan-Meier statistical methods were applied.

Results

70% of patients were commenced on standard dose (SD) of chemotherapy; 84% (21/25) of the anthracycline group (AG), 65% (20/31) of the capecitabine group (CG), 48% (10/21) of the taxane group (TG) and 100% (10/10) of other agents. 32% of patients had dose reductions; 16% in AG, 19% in TG and 58% in CG. Overall 30% of patients received six cycles of SD of chemotherapy; 36% in AG, 29% in CG and 14% in TG. 23% of patients suffered ≥grade 3 toxicity; 28% in AG, 29% in CG and 10% in TG. There were four treatment-related deaths; two in AG and one in both CG and TG. 61% of the CG received 6+ cycles with a mean on treatment time of 445 days (1–2,150). There was no statistical significance in progression- free survival (PFS) between groups. The median PFS for all patients was 244 days (87–381). Performance status, haemoglobin and estimated glomerular filtration rates prior to starting chemotherapy were all useful in predicting PFS.

Conclusions

A relevant number of patients required dose reduction but dose-reduced chemotherapy was tolerated well. Anthracycline-based regimens were used in patients who had not received adjuvant chemotherapy. Capecitabine required the most dose reductions. Taxanes were generally started at reduced doses, resulting in fewer grade 3+ toxicities. As well as age, underlying physiological reserve, current performance status and co-morbidities should guide physicians who should consider lower starting doses in OA and recognise that dose reductions may be required to improve tolerability. The PFS of all regimens were similar in this study. This study highlights the need for further research to define the optimal first-line chemotherapy and starting dose in OA with MBC.

[Risk assessment in medical geriatric oncology]

The assessment of risks in medical geriatric oncology requires close collaboration between oncologists and geriatricians. Vulnerability, death and severe chemotoxicity during cancer treatment represent the main risks to be assessed before making a decision regarding treatment in elderly patients with cancer. A comprehensive geriatric assessment and predictive scores enable a multidimensional assessment of the elderly cancer patient to be carried out.

Using a geriatric oncology assessment to link with services (GOAL)

OBJECTIVE

Geriatric screening tools assess functional limitations and inform clinical decision-making for older adults with cancer. Our objective was to evaluate the feasibility and effectiveness of a screener in community-based oncology clinics.

MATERIALS AND METHODS

Eligible patients were from two rural, underserved community-based cancer clinics; within 12 months of a cancer diagnosis (breast, lung, colorectal, pancreas, esophageal); aged ≥60 years; and not exclusively pursuing palliative care. We used a previously validated tool that was embedded in the electronic health record (EHR). Patient-reported responses identified memory impairment, depressive symptoms, deficits in activities of daily living, poor nutrition, and polypharmacy. At the discretion of the oncologist, responses prompted service referrals. From the EHR, we extracted information about referrals and completion of planned therapy. We present descriptive statistics.

RESULTS

Enrolled patients (n = 44) had a mean age of 71.5 years (SD = 6.9). Most were non-white (61%), women (66%), with government-sponsored health insurance (80%). The most commonly identified geriatric syndromes: polypharmacy (89%), reduced quality of life (39%), and poor nutrition (39%). The screener triggered a referral in 98% of patients. Generated referrals were for depressive symptoms (52% needed, 39% received), nutrition (43% needed, 37% received), and polypharmacy (89% needed, 26% received). Patients were referred to social work (56%), nutrition (44%), and pharmacy (25%). Many patients completed planned radiation therapy (100%), surgery (70%), and chemotherapy (60%).

CONCLUSIONS

Use of an EHR-embedded brief geriatric oncology assessment in rural oncology clinics identified geriatric syndromes that would benefit from provision of services in nearly all enrolled patients.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02906592.

Frailty status but not age predicts complications in elderly cancer patients: a follow-up study

OBJECTIVES

The purposes were to investigate the health status of elderly cancer patients by comprehensive geriatric assessment (CGA) and to compare the complications with respect to baseline CGA and to evaluate the need for geriatric interventions in an elderly cancer patients' population.

MATERIAL

Patients aged ≥70 years with lung cancer (LC), cancer of the head and neck (HNC), colorectal cancer (CRC), or upper gastro-intestinal cancer (UGIC) are referred to the Department of Oncology for cancer treatment.

METHODS

CGA was performed prior to cancer treatment and addressed the following domains: Activities of daily living (ADL), instrumental ADL (IADL), comorbidity, polypharmacy, nutrition, cognition, and depression. Complications, defined as dose reduction and discontinuation of treatment due to grade 3-4 toxicity, hospital admission, shift to palliative treatment, or death within 90 days, were identified from the medical files. Patients were classified as fit, vulnerable, or frail by CGA.

PRINCIPAL RESULTS

Patients (N = 217) with a median age of 75 years (range: 70-93 yeas) were included: 13% were fit, 35% vulnerable, and 52% frail. CGA significantly predicted admittance to hospital in frail and vulnerable patients compared to fit patients: risk ratio (RR) 2.12 (95% CI: 1.01; 4.46). Vulnerable and frail patients had higher absolute risk of death within 90 days compared to fit patients: 7% and 23% versus 0%. HR for death within 90 days in frail patients as compared to vulnerable patients was 3.50 (95% CI: 1.34; 9.15). More frail patients (88%) needed geriatric interventions than the vulnerable (46%) and fit patients (32%). Major conclusion: Few elderly cancer patients seem to be fit. CGA predicts admittance to hospital in a population of elderly patients with mixed cancer diseases. Frail and vulnerable patients have higher risk of death within 90 days as compared to fit patients.

Ginkgolic acids induce HepG2 cell death via a combination of apoptosis, autophagy and the mitochondrial pathway

Ginkgolic acids may induce malignant cell death via the B-cell lymphoma 2 (Bcl-2)-associated X protein (Bax)/Bcl-2 apoptosis pathway. Concurrently, apoptosis, autophagy and mitochondrial dysfunction may also be involved in bringing about this endpoint. The anticancer effect of Ginkgolic acids (GAs) was investigated using the HepG2 cell line. The median lethal dose of the GAs of the HepG2 was measured via an MTT assay, the dose-response curves were evaluated and changes in cell morphology were monitored by microscopy. Autophagy in HepG2 cells was down regulated using 3-methyladenine (3-MA) or Beclin-1-specific small interfering RNA (siRNA) and the expression of apoptosis associated proteins caspase-3, Bax/Bcl-2, and the autophagy-associated protein 5 and microtubule-associated protein 1A/1B-light chain 3 in the GA-treated HepG2 cells were all measured by western blot analysis. The level of apoptosis in the GA-treated cells was also assessed using terminal deoxynucleotidyl-transferase-mediated dUTP nick-end labeling (TUNEL) assay, and the mitochondrial membrane potential (Δψ_m) was detected by immunofluorescence. The results of the MTT and TUNEL assays indicated that the proliferation of HepG2 cells treated with GAs was significantly reduced compared with the control group, and the rate of the inhibition was dose-dependent. Western blot analysis indicated that treatment with the Gas induced apoptosis and autophagy in the HepG2 cells. The Δψ_m of the GA-treated HepG2 cells was decreased compared with the control, as monitored by immunofluorescence. However, upon the administration of 3-MA or Beclin-1-specific siRNAs (inhibitors of the autophagy), the expression levels of the apoptosis- and autophagy-associated proteins were decreased. In conclusion, the results of the present study indicated that GAs are potent anticancer agents that function through a combination of the apoptosis, autophagy and mitochondrial pathways.

Efficacy and Safety of Ramucirumab With Docetaxel Versus Placebo With Docetaxel as Second-Line Treatment of Advanced Non-Small-Cell Lung Cancer: A Subgroup Analysis According to Patient Age in the REVEL Trial

INTRODUCTION

Ramucirumab, a recombinant human immunoglobulin G1 monoclonal antibody receptor antagonist designed to block the ligand-binding site of vascular endothelial growth factor receptor-2 (VEGFR-2), was evaluated as second-line treatment in combination with docetaxel in patients with non-small-cell lung cancer in the REVEL trial (NCT01168973). Ramucirumab significantly improved overall survival (OS) and progression-free survival (PFS). We report age subgroup analysis results primarily on the basis of a 65-year cutoff.

PATIENTS AND METHODS

Patients were randomized 1:1 to ramucirumab with docetaxel or placebo with docetaxel (n = 1253). Of these, 798 were younger than 65 years (ramucirumab, n = 391; control, n = 407) and 455 were 65 years or older (ramucirumab, n = 237; control, n = 218). Treatment comprised 21-day cycles of 75 mg/m2 docetaxel with 10 mg/kg ramucirumab or placebo. Prespecified age subgroup analyses were performed, including OS, PFS, and objective response rate. Quintiles age analysis was conducted to establish a relationship between efficacy and age. The Lung Cancer Symptom Scale (LCSS) measured quality of life outcomes. Safety was assessed according to adverse events (AEs).

RESULTS

Patients younger than 65 years showed favorable OS outcomes with ramucirumab treatment (hazard ratio [HR], 0.74; 95% confidence interval [CI], 0.62-0.87; P < .001) and PFS (HR, 0.68; 95% CI, 0.59-0.79; P < .001). In patients 65 years or older, benefits of ramucirumab were not as evident; after model adjustment for prognostic factors, OS and PFS HRs were 0.96 (95% CI, 0.77-1.21; P = .04) and 0.87 (95% CI, 0.71-1.05; P = .03), respectively. Age analysis according to quintiles showed HRs favoring ramucirumab for all age groupings. LCSS scores and AEs did not considerably differ between age groups.

CONCLUSION

In this subgroup analysis, true treatment effect differences on the basis of age have not been established, and treatment should not be deterred solely because of age.

Prognostic significance of the combination of preoperative hemoglobin, albumin, lymphocyte and platelet in patients with gastric carcinoma: a retrospective cohort study

Nutritional and immune status is important to the prognosis of patients with gastric carcinoma (GC). Here, we evaluated the prognostic significance of the combination of preoperative hemoglobin, albumin, lymphocyte and platelet (HALP) in patients with GC. From January 2005 to December 2011, 1332 patients with GC who underwent gastrectomy were randomly divided into the training (n = 888) and the validation sets (n = 444) by X-tile according to the sample size ratio 2:1. The cut-point of HALP was 56.8 and the patients were subsequently subdivided into HALP < 56.8 and HALP ≥ 56.8 groups in both two sets. Multivariate analysis revealed that gender (p < 0.001, p < 0.001), tumor size (p = 0.003, p = 0.035) and T stage (p < 0.001, p = 0.044) were independently related to HALP both in the training and the validation sets. Kaplan-Meier (p < 0.001, p = 0.003) and Cox regression (p = 0.043, p = 0.042) showed that the prognosis of HALP ≥ 56.8 group was significantly better than that of HALP < 56.8 group both in two sets (p < 0.001, p < 0.001). Nomograms of these two sets based on HALP were more accurate in prognostic prediction than TNM stage alone. Our findings suggested that HALP was closely associated with clinicopathological features and was an independent prognostic factor in GC patients. Nomogram based on HALP could accurately predict the prognosis of GC patients.

Management of Elderly Patients with Plasma Cell Myeloma

Plasma cell myeloma (PCM) is a hematologic malignancy that primarily affects the elderly. Approximately two-thirds of patients are aged 65 years or older at diagnosis. Major advances in testing, treatment, and supportive care have resulted in substantial improvement in overall survival in younger, standard-risk, PCM patients over the past 3 decades. However, this positive impact progressively diminishes with advancing age, with some studies showing no improvement in survival outcomes in the elderly. Slow improvement in survival for elderly PCM patients is likely multifactorial, influenced by factors such as age-related physiologic changes, increased comorbidities, decreased treatment tolerance, socioeconomic barriers, and possible differences in disease biology. The standard approach of basing treatment decisions on age and performance status does not account for this complexity, and can be insufficient to determine the risks and benefits of treatment. Comprehensive geriatric assessment (CGA) produces a more thorough iteration of the factors influencing an individual's treatment risk, and can potentially identify targets for intervention to lower risk. Ongoing studies are looking at developing and refining the tools available for risk screening and assessment. Treating elderly PCM patients with novel agent-based regimens with or without autologous stem cell transplantation has improved response rates and survival in some studies, but elderly PCM patients have benefitted less than their younger counterparts from recent advances in PCM treatment. Personalizing treatment decisions, based on predictions of risk, determined by geriatric assessment, and response, determined by precision medicine (our understanding of the genetic, molecular, and cellular pathways that drive an individual's cancer) will help maximize the benefit and minimize the risk of PCM treatment for each patient. Continued evaluation of new strategies and treatments for PCM in clinical trials specifically designed for elderly patients is needed to continue to improve outcomes for elderly PCM patients in the future.

Emerging uses of patient generated health data in clinical research

Recent advancements in consumer directed personal computing technology have led to the generation of biomedically-relevant data streams with potential health applications. This has catalyzed international interest in Patient Generated Health Data (PGHD), defined as "health-related data - including health history, symptoms, biometric data, treatment history, lifestyle choices, and other information-created, recorded, gathered, or inferred by or from patients or their designees (i.e. care partners or those who assist them) to help address a health concern."(Shapiro et al., 2012) PGHD offers several opportunities to improve the efficiency and output of clinical trials, particularly within oncology. These range from using PGHD to understand mechanisms of action of therapeutic strategies, to understanding and predicting treatment-related toxicity, to designing interventions to improve adherence and clinical outcomes. To facilitate the optimal use of PGHD, methodological research around considerations related to feasibility, validation, measure selection, and modeling of PGHD streams is needed. With successful integration, PGHD can catalyze the application of "big data" to cancer clinical research, creating both "n of 1" and population-level observations, and generating new insights into the nature of health and disease.

Comprehensive geriatric assessment in the older cancer patient: coming of age in clinical cancer care

Cancer care at the extremes of life, in the young and the old, is characterized by unique issues associated with pediatrics and geriatric medicine, accentuated by the special vulnerabilities of these groups. In response to these needs, the field of pediatric oncology has been well honed to deal with the special problems associated with juvenile cancer patients. While most adult oncologists consider themselves well prepared to deal with older cancer patients, the current expansion of the geriatric population - their variable levels of fitness, frailty and vulnerability, the fact that cancer is primarily a disease of older adults, the significant expansion of agents and approaches to treat cancer, as well as their resultant toxicities and complications - has led to the development of specialized geriatric oncologists. Moreover, the special characteristics and needs of these patients have led to the evolution of new guidelines for evaluation, management and the conduct of research in older patients with cancer.