Increased expression of CD70 in relapsed acute myeloid leukemia after hypomethylating agents

Acute myeloid leukemia (AML) is the most common acute leukemia in adults. While induction chemotherapy leads to remission in most patients, a significant number will experience relapse. Therefore, there is a need for novel therapies that can improve remission rates in patients with relapsed and refractory AML. CD70 is the natural ligand for CD27 (a member of the TNF superfamily) and appears to be a promising therapeutic target. Consequently, there is considerable interest in developing chimeric antigen receptor (CAR) T-cell therapy products that can specifically target CD70 in various neoplasms, including AML. In this study, we employed routine diagnostic techniques, such as immunohistochemistry and flow cytometry, to investigate the expression of CD70 in bone marrow samples from treatment-naïve and relapsed AML patients after hypomethylating agents (HMA). Also, we evaluated the impact of HMA on CD70 expression and examined CD70 expression in various leukemic cell subsets and normal hematopoietic progenitors.

Detection of chromosomal alteration after infusion of gene-edited allogeneic CAR T cells

A chromosome 14 inversion was found in a patient who developed bone marrow aplasia following treatment with allogeneic chimeric antigen receptor (CAR) Tcells containing gene edits made with transcription activator-like effector nucleases (TALEN). TALEN editing sites were not involved at either breakpoint. Recombination signal sequences (RSSs) were found suggesting recombination-activating gene (RAG)-mediated activity. The inversion represented a dominant clone detected in the context of decreasing absolute CAR Tcell and overall lymphocyte counts. The inversion was not associated with clinical consequences and wasnot detected in the drug product administered to this patient or in any drug product used in this or other trials using the same manufacturing processes. Neither was the inversion detected in this patient at earlier time points or in any other patient enrolled in this or other trials treated with this or other product lots. This case illustrates that spontaneous, possibly RAG-mediated, recombination events unrelated to gene editing can occur in adoptive cell therapy studies, emphasizes the need for ruling out off-target gene editing sites, and illustrates that other processes, such as spontaneous V(D)J recombination, can lead to chromosomal alterations in infused cells independent of gene editing.

Pembrolizumab in Relapsed or Refractory Primary Mediastinal Large B-Cell Lymphoma

PURPOSE

Patients with relapsed or refractory primary mediastinal large B-cell lymphoma (rrPMBCL) have a poor prognosis, and their treatment represents an urgent and unmet need. Because PMBCL is associated with genetic aberrations at 9p24 and overexpression of programmed cell death-1 (PD-1) ligands (PD-L1), it is hypothesized to be susceptible to PD-1 blockade.

METHODS

In the phase IB KEYNOTE-013 (ClinicalTrials.gov identifier: NCT01953692) and phase II KEYNOTE-170 (ClinicalTrials.gov identifier: NCT02576990) studies, adults with rrPMBCL received pembrolizumab for up to 2 years or until disease progression or unacceptable toxicity. The primary end points were safety and objective response rate in KEYNOTE-013 and objective response rate in KEYNOTE-170. Secondary end points included duration of response, progression-free survival, overall survival, and safety. Exploratory end points included association between biomarkers and pembrolizumab activity.

RESULTS

The objective response rate was 48% (7 complete responses; 33%) among 21 patients in KEYNOTE-013 and 45% (7 complete responses; 13%) among 53 patients in KEYNOTE-170. After a median follow-up time of 29.1 months in KEYNOTE-013 and 12.5 months in KEYNOTE-170, the median duration of response was not reached in either study. No patient with complete response experienced progression, including 2 patients with complete response for at least 1 year off therapy. Treatment-related adverse events occurred in 24% of patients in KEYNOTE-013 and 23% of patients in KEYNOTE-170. There were no treatment-related deaths. Among 42 evaluable patients, the magnitude of the 9p24 gene abnormality was associated with PD-L1 expression, which was itself significantly associated with progression-free survival.

CONCLUSION

Pembrolizumab is associated with high response rate, durable activity, and a manageable safety profile in patients with rrPMBCL.

Patient-reported outcomes in KEYNOTE-087, a phase 2 study of pembrolizumab in patients with classical Hodgkin lymphoma

In KEYNOTE-087, pembrolizumab had a 69% overall response rate and acceptable safety in patients with relapsed/refractory classical Hodgkin lymphoma (rrHL). We assessed health-related quality of life (HRQoL) in KEYNOTE-087. The European Organization for Research and Treatment of Cancer Quality of Life Questionnaire-Core 30 (QLQ-C30) and the EuroQoL Five Dimensions Questionnaire 3-level version (EQ-5D) were administered to 206 patients across three cohorts defined by lymphoma progression after: (1) autologous stem cell transplantation (ASCT) and subsequent brentuximab vedotin (BV) (n = 69); (2) salvage chemotherapy and BV (n = 79); and (3) ASCT without post-transplantation BV (n = 58). Compliance/completion rates were ≥90% at week 12 and ≥70% at week 24. QLQ-C30 global health status/QoL and EQ-5D visual analog scale scores showed mean increases from baseline in overall health at all assessed timepoints. With few exceptions, mean improvements from baseline to weeks 12 and 24 in QLQ-C30 functional and symptom scores occurred in all cohorts.Clinicaltrials.gov identifier: NCT02453594.

ACCELERATE and European Medicine Agency Paediatric Strategy Forum for medicinal product development for mature B-cell malignancies in children

Paediatric Strategy Forums have been created by the multistakeholder organisation, ACCELERATE, and the European Medicines Agency to facilitate dialogue between all relevant stakeholders and suggest strategies in critical areas of paediatric oncology drug development. As there are many medicines being developed for B-cell malignancies in adults but comparatively few in children with these malignancies, a Paediatric Strategy Forum was held to discuss the best approach to develop these products for children. It was concluded that as current frontline therapy is highly successful, despite associated acute toxicity, de-escalation of this or substitution of presently used drugs with new medicines can only be undertaken when there is an effective salvage regimen, which is currently not available. Therefore priority should be given to developing treatment for patients with relapsed and refractory mature B-cell lymphomas. The consensus of the clinicians attending the meeting was that CAR T-cells, T-cell engagers and antibody drug conjugates (excluding those with a vinca alkaloid-like drug) presently have the greatest probability of providing benefit in relapse in view of their mechanism of action. However, as producing autologous CAR T-cells currently takes at least 4 weeks, they are not products which could be quickly employed initially at relapse in rapidly progressing mature B-cell malignancies but only for the consolidation phase of the treatment. Global, industry-supported, academic-sponsored studies testing compounds from different pharmaceutical companies simultaneously should be considered in rare populations, and it was proposed that an international working group be formed to develop an overarching clinical trials strategy for these disease groups. Future Forums are planned for other relevant paediatric oncologic diseases with a high unmet medical need and relevant molecular targets.

Cost-effectiveness of pembrolizumab versus brentuximab vedotin for patients with relapsed or refractory classical Hodgkin's lymphoma: a United States payer perspective

AIMS

Patients with classical Hodgkin's lymphoma (cHL) who have relapsed after or are ineligible for autologous stem cell transplantation (ASCT) have limited treatment options and generally a poor prognosis. Pembrolizumab was recently approved in the US for the treatment of such patients having demonstrated clinical benefit and tolerability in relapsed/refractory cHL; however, the cost-effectiveness of pembrolizumab in this population is currently unknown.

MATERIALS AND METHODS

A three-state Markov model (progression-free [PF], progressed disease, and death) was developed to assess the cost-effectiveness of pembrolizumab (200 mg) vs brentuximab vedotin (BV; 1.8 mg/kg) in patients with relapsed/refractory cHL after ASCT who have not received BV post-ASCT over a 20-year time horizon from a US payer perspective. PF survival was modeled using a naïve indirect treatment comparison of data from KEYNOTE-087 and the SG035-003 trial. Post-progression survival was modeled using data from published literature. Costs (drug acquisition and administration, disease management, subsequent treatment, and adverse events) and outcomes were discounted at an annual rate of 3.0%. Uncertainty surrounding cost-effectiveness was assessed via probabilistic, deterministic, and scenario analyses.

RESULTS

In the base case, pembrolizumab was predicted to yield an additional 0.574 life-years (LYs) and 0.500 quality-adjusted life-years (QALYs) vs BV and cost savings of $63,278. Drug acquisition costs were the biggest driver of incremental costs between strategies. Pembrolizumab had a 99.6% probability of being cost-effective compared with BV at a willingness-to-pay threshold of $20,000/QALY and dominated BV in all scenarios tested.

LIMITATIONS

The analysis was subject to potential bias due to the use of a naïve indirect treatment comparison and, given the current immaturity of OS in KEYNOTE-087, PPS was assumed equivalent across both treatments.

CONCLUSION

Pembrolizumab is a cost-effective alternative to BV for patients with relapsed/refractory cHL after ASCT.

Treatment patterns, health care resource utilization, and costs in patients with relapsed/refractory Hodgkin lymphoma treated with brentuximab vedotin

Data are limited on the real-world utilization and costs of brentuximab vedotin (BV) among patients with relapsed/refractory Hodgkin lymphoma (rrHL) in the United States. A total of 219 BV patients identified from the Truven MarketScan^® databases were followed up for a median of 2.9 years before and 1.0 year after initiation of BV. Of these patients, 109 (50.6%) received systemic therapy after BV (post-BV ST). Median duration of treatment was short for BV (2.1 months) and post-BV ST treatment (1.3 months); time to next treatment was 6.2 and 9.1 months, respectively. Average total US dollar 2014 costs/person for BV and post-BV ST line of therapy were $167,152 and $132,115, respectively; mean per-patient-per-month costs for BV and post-BV ST were $30,434 and $29,138, respectively. Findings underscore the unmet medical need and substantial economic burden in BV-treated patients with rrHL.

Pembrolizumab versus the standard of care for relapsed and refractory classical Hodgkin's lymphoma progressing after brentuximab vedotin: an indirect treatment comparison

BACKGROUND

There is significant unmet need among patients with relapsed and refractory classical Hodgkin's lymphoma (RRcHL) who have failed multiple lines of therapy, including brentuximab vedotin (BV). Pembrolizumab, an immune checkpoint inhibitor, is one possible treatment solution for this population.

RESEARCH METHODS

The objective of this study was to compare progression-free survival (PFS) with standard of care (SOC) versus pembrolizumab in previously BV treated RRcHL patients. A systematic literature review identified one observational study of SOC that was suitable for comparison with KEYNOTE-087, the principal trial of pembrolizumab in this population. Both naïve and population-adjusted (using outcomes regression) pairwise indirect comparisons were conducted. The primary analysis included all patients who had failed BV, with a secondary analysis conducted including only those known to have failed BV that was part of definitive treatment.

RESULTS

In the primary analysis, SOC was inferior to pembrolizumab in both the unadjusted comparison (HR 5.00 [95% confidence interval (CI) 3.56-7.01]) and the adjusted comparison (HR 6.35 [95% CI 4.04-9.98]). These HRs increased to 5.16 (95% CI 3.61-7.38) and 6.56 (95% CI 4.01-10.72), respectively, in the secondary analysis.

CONCLUSION

Pembrolizumab offers a significant improvement in PFS compared to SOC in this population.

A trial-based EuroQol EQ-5D health utility analysis in patients with classical Hodgkin lymphoma

e19011

Background: Pembrolizumab has shown a high response in patients classic Hodgkin lymphoma (cHL) patients who have experienced disease progression after brentuximab vedotin in KEYNOTE (KN)-087 and the results have been presented. This study aimed to evaluate the health-related quality of life (HRQoL) of the trial patients in KN087. Methods: KN-087 is an ongoing single-arm multi-center, non-randomized Phase II trial evaluating pembrolizumab 200mg Q3W IV in patients with relapsed or refractory cHL. In KN-087, HRQoL data were collected at baseline and every drug administration over the 18 months of follow-up. HRQoL was assessed using both the EQ-5D and EORTC QLQ-C30 instruments. The generic health statuses assessed from both instrument were converted to population-based utility values using published algorithms. More specifically, US-based scoring was applied to US patients, UK-based scoring for UK patients and EU-based scoring for all other patients. HRQoL was reported by status of respond and disease progression. Response was defined based upon IWG criteria. Furthermore, stratified analyses were conducted to examine the health disabilities of the patients who experienced grade 3+ adverse events (AEs), and by ECOG performance and the number of prior therapies. Results: Among 210 trial patients, HRQoL data were collected for 205 patients at baseline and the mean health utility score was 0.759 (95% CI 0.730-0.788). Mean health utility score among responders and non-responders was 0.826 (95% CI 0.811-0.842) and 0.760 (95% CI 0.718-0.801), respectively. The difference is considered clinically significant. Mean utility decreased from 0.820 (95% CI 0.807-0.833) for time spent prior to progression to 0.806 (95% CI 0.780-0.832) post disease progression. Progression-free patients who experienced grade 3+ AEs (N=17) had a mean health utility of 0.736 (95% CI 0.662-0.811), compared with 0.825 (95% CI 0.811-0.838) among those did not. Conclusions: The results showed a substantial HRQoL impact of R/R cHL. Treatment response was associated with significant clinically meaningful improvement in HRQoL. The utility estimates from the study are important for economic evaluations of treatments in R/R cHL patients. Clinical trial information: NCT02453594.

Phase II Study of the Efficacy and Safety of Pembrolizumab for Relapsed/Refractory Classic Hodgkin Lymphoma

Purpose Hodgkin Reed-Sternberg cells harbor alterations in chromosome 9p24.1, leading to overexpression of programmed death-ligand 1 (PD-L1) and PD-L2. Pembrolizumab, a programmed death 1-blocking antibody, demonstrated a high overall response rate (ORR) in patients with relapsed or refractory classic Hodgkin lymphoma (rrHL) in phase I testing. Methods KEYNOTE-087 ( ClinicalTrials.gov identifier, NCT02453594) was a single-arm phase II study of pembrolizumab in three cohorts of patients with rrHL, defined on the basis of lymphoma progression after (1) autologous stem cell transplantation (ASCT) and subsequent brentuximab vedotin (BV); (2) salvage chemotherapy and BV, and thus, ineligible for ASCT because of chemoresistant disease; and (3) ASCT, but without BV after transplantation. Patients received pembrolizumab 200 mg once every 3 weeks. Response was assessed every 12 weeks. The primary end points were ORR by central review and safety. Results A total of 210 patients were enrolled and treated (69 in cohort 1, 81 in cohort 2, and 60 in cohort 3). At the time of analysis, patients received a median of 13 treatment cycles. Per central review, the ORR was 69.0% (95% CI, 62.3% to 75.2%), and the complete response rate was 22.4% (95% CI, 16.9% to 28.6%). By cohort, ORRs were 73.9% for cohort 1, 64.2% for cohort 2, and 70.0% for cohort 3. Thirty-one patients had a response ≥ 6 months. The safety profile was largely consistent with previous pembrolizumab studies. Conclusion Pembrolizumab was associated with high response rates and an acceptable safety profile in patients with rrHL, offering a new treatment paradigm for this disease.

Programmed Death-1 Blockade With Pembrolizumab in Patients With Classical Hodgkin Lymphoma After Brentuximab Vedotin Failure

Purpose Classical Hodgkin lymphoma (HL) frequently exhibits genetic alterations leading to overexpression of the programmed death-1 (PD-1) ligands, suggesting a possible vulnerability to PD-1 blockade. The phase Ib study KEYNOTE-013 (NCT01953692) tested the safety and efficacy of the anti-PD-1 antibody pembrolizumab in patients with hematologic malignancies. Based on its genetics, HL was included as an independent cohort. Methods We enrolled patients with relapsed or refractory HL whose disease progressed on or after treatment with brentuximab vedotin. Patients received pembrolizumab, 10 mg/kg every 2 weeks, until disease progression occurred. Response to treatment was assessed at week 12 and every 8 weeks thereafter. Principal end points were safety and complete remission (CR) rate. Results Thirty-one patients were enrolled; 55% had more than four lines of prior therapy, and 71% had relapsed after autologous stem cell transplantation. Five patients (16%) experienced grade 3 drug-related adverse events (AEs); there were no grade 4 AEs or deaths related to treatment. The CR rate was 16% (90% CI, 7% to 31%). In addition, 48% of patients achieved a partial remission, for an overall response rate of 65% (90% CI, 48% to 79%). Most of the responses (70%) lasted longer than 24 weeks (range, 0.14+ to 74+ weeks), with a median follow-up of 17 months. The progression-free survival rate was 69% at 24 weeks and 46% at 52 weeks. Biomarker analyses demonstrated a high prevalence of PD-L1 and PD-L2 expression, treatment-induced expansion of T cells and natural killer cells, and activation of interferon-γ, T-cell receptor, and expanded immune-related signaling pathways. Conclusions Pembrolizumab was associated with a favorable safety profile. Pembrolizumab treatment induced favorable responses in a heavily pretreated patient cohort, justifying further studies.

Immunomodulatory antibodies for the treatment of lymphoma: Report on the CALYM Workshop

In November 2015, the CALYM Carnot Institute held a 2-d workshop to discuss the current and future development of immunomodulatory antibodies for the treatment of lymphoma. Highlights from the workshop are presented in this article.

Burden of symptoms associated with development of metastatic bone disease in patients with breast cancer

Purpose

Women with breast cancer frequently develop painful bone metastases. This retrospective study was designed to longitudinally characterize patterns of patient-reported symptoms among patients with breast cancer relative to the diagnosis of bone metastases.

Methods

Patient records were identified from the Oncology Services Comprehensive Electronic Records (OSCER) database which includes outpatient oncology practices across the USA. Symptom burden was assessed by Patient Care Monitor (PCM) assessments, which are administered as part of routine care in a subset of these practices. Eligible patients were women diagnosed with breast cancer (ICD-9-CM 174.xx) who developed bone metastases (ICD-9-CM 198.5) and had ≥1 PCM assessment between January 2007 and December 2012. The pre-specified endpoint was the occurrence of moderate to severe symptom burden, defined as PCM score ≥4 (0–10 scale).

Results

One thousand one hundred five women (median age, 61) met the eligibility criteria. Worsening of symptoms, particularly fatigue and pain, occurred in the months leading up to the diagnosis of bone metastases. After bone metastases diagnosis, the rate of increase in the proportion of patients experiencing moderate/severe symptoms slowed, but continued to climb during follow-up. Median time to moderate/severe symptoms was 0.9 month for fatigue, 1 month for pain, 2.9 months for trouble sleeping, and 7.7 months for numbness/tingling. Half of the patients received bone-targeted agents after diagnosis of bone metastases.

Conclusions

Symptom burden, especially pain and fatigue, increased both before and after the diagnosis of bone metastases, highlighting the need for proactive monitoring and management of symptoms in breast cancer patients.

Electronic supplementary material

The online version of this article (doi:10.1007/s00520-016-3154-x) contains supplementary material, which is available to authorized users.

Pain and analgesic use associated with skeletal-related events in patients with advanced cancer and bone metastases

PURPOSE

Bone metastases secondary to solid tumors increase the risk of skeletal-related events (SREs), including the occurrence of pathological fracture (PF), radiation to bone (RB), surgery to bone (SB), and spinal cord compression (SCC). The aim of this study was to evaluate the impact of SREs on patients' pain, analgesic use, and pain interference with daily functioning.

METHODS

Data were combined from patients with solid tumors and bone metastases who received denosumab or zoledronic acid across three identically designed phase 3 trials (N = 5543). Pain severity (worst pain) and pain interference were assessed using the Brief Pain Inventory at baseline and each monthly visit. Analgesic use was quantified using the Analgesic Quantification Algorithm.

RESULTS

The proportion of patients with moderate/severe pain and strong opioid use generally increased in the 6 months preceding an SRE and remained elevated, while they remained relatively consistent over time in patients without an SRE. Regression analysis indicated that all SRE types were significantly associated with an increased risk of progression to moderate/severe pain and strong opioid use. PF, RB, and SCC were associated with significantly greater risk of pain interference overall. Results were similar for pain interference with emotional well-being. All SRE types were associated with significantly greater risk of pain interference with physical function.

CONCLUSIONS

SREs are associated with increased pain and analgesic use in patients with bone metastases. Treatments that prevent SREs may decrease pain and the need for opioid analgesics and reduce the impact of pain on daily functioning.

Measurement of skeletal related events in SEER-Medicare: a comparison of claims-based methods

Background

Skeletal related events (SREs) are common in men with metastatic prostate cancer (mPC). Various methods have been used to identify SREs from claims data. The objective of this study was to provide a framework for measuring SREs from claims and compare SRE prevalence and cumulative incidence estimates based on alternative approaches in men with mPC.

Methods

Several claims-based approaches for identifying SREs were developed and applied to data for men aged [greater than or equal to] 66 years newly diagnosed with mPC between 2000 and 2009 in the SEER-Medicare datasets and followed through 2010 or until censoring. Post-diagnosis SREs were identified using claims that indicated spinal cord compression (SCC), pathologic fracture (PF), surgery to bone (BS), or radiation (suggestive of bone palliative radiation, RAD). To measure SRE prevalence, two SRE definitions were created: ‘base case’ (most commonly used in the literature) and ‘alternative’ in which different claims were used to identify each type of SRE. To measure cumulative incidence, we used the ‘base case’ definition and applied three periods in which claims were clustered to episodes: 14-, 21-, and 28-day windows.

Results

Among 8997 mPC patients, 46 % experienced an SRE according to the ‘base case’ definition and 43 % patients experienced an SRE according to the ‘alternative’ definition. Varying the code definition from ‘base case’ to ‘alternative’ resulted in an 8 % increase in the overall SRE prevalence. Using the 21-day window, a total of 12,930 SRE episodes were observed during follow up. Varying the window length from 21 to 28 days resulted in an 8 % decrease in SRE cumulative incidence (RAD: 10 %, PF: 8 %, SCC: 6 %, BS: 0.2 %).

Conclusions

SRE prevalence was affected by the codes used, with PF being most impacted. The overall SRE cumulative incidence was affected by the window length used, with RAD being most affected. These results underscore the importance of the baseline definitions used to study claims data when attempting to understand relevant clinical events such as SREs in the real world setting.

Abstract P5-16-03: The impact of skeletal-related events on pain interference in patients with advanced breast cancer and bone metastases

Background: Patients with advanced breast cancer and bone metastases are at an increased risk for experiencing skeletal-related events (SREs), which include pathological fracture (PF), surgery to bone (SB) radiation to bone (RB), and spinal cord compression (SCC). The pain of SREs can be severe enough to interfere with daily functioning. Here we evaluated the impact of SREs on pain interference in patients with advanced breast cancer and bone metastases.

Methods: In a double-blind, double-dummy, placebo-controlled trial, patients were evenly randomized to receive monthly denosumab 120 mg SC or zoledronic acid 4 mg IV, (adjusted for renal function). Pain interference (overall, emotional well-being, and physical function) was assessed at baseline and each study visit using the Brief Pain Inventory-Short Form (BPI-SF) with scores that ranged from 0 (no interference) to 10 (complete interference). A change of ≥ 2 points from baseline was considered clinically meaningful. To evaluate the overall impact of SREs on pain interference, we conducted a post-hoc analysis using a Cox Proportional Hazards model adjusting for SREs as time-dependent covariates and stratified by treatment and randomized stratification factors. The impact of on-study SREs was evaluated using patients’ first on-study SRE, starting 28 days before the SRE occurrence.

Results: 687 first on-study SREs were reported (450 PF, 201 RB, 20 SB, 16 SCC). SCC, RB, and PF were associated with a greater risk of a clinically meaningful increase in overall pain interference (Table 1). For the subdomains, RB and SCC were associated with an increased risk of pain interference with emotional well-being, while PF, RB, and SB were associated with an increased risk of pain interference with physical function.

Impact of on-study SREs on time to ≥ 2-point increase from baseline in pain interference BPI score PFRBSBSCCPain interference - overall (n = 1829)    HR (95% CI)1.31 (1.05, 1.63)2.41 (1.80, 3.23)1.85 (0.68, 5.05)4.26 (1.38, 13.19) P value0.0159< 0.00010.23220.0120Pain interference - emotional well being (n = 1806)    HR (95% CI)1.20 (0.97, 1.48)2.25 (1.72, 2.95)1.11 (0.41, 3.00)4.74 (2.15, 10.44) P value0.1003< 0.00010.84320.0001Pain interference - physical activity (n = 1690)    HR (95% CI)1.35 (1.09, 1.69)2.30 (1.70, 3.10)2.86 (1.09, 7.47)2.26 (0.45, 11.37) P value0.0070< 0.00010.03260.3232Includes patients with baseline BPI score ≤8; HR = hazard ratio; CI = confidence interval.

Conclusions: In patients with advanced breast cancer, SREs are associated with an increase in pain interference. Effective treatments that prevent SREs may reduce the burden of pain on patients’ daily functioning.

Citation Format: Lesley Fallowfield, Donald L Patrick, Roger Von Moos, Charles S Cleeland, Ying Zhou, Arun Balakumaran, Yi Qian. The impact of skeletal-related events on pain interference in patients with advanced breast cancer and bone metastases [abstract]. In: Proceedings of the Thirty-Seventh Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2014 Dec 9-13; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2015;75(9 Suppl):Abstract nr P5-16-03.

Short-term disability in solid tumor patients with bone metastases and skeletal-related events

OBJECTIVE

The skeleton is a common site of metastasis in patients with solid tumors. These patients often experience pain and reduced quality-of-life. This analysis evaluated the time and costs associated with short-term disability use among solid tumor patients with bone metastases (BM) and skeletal-related events (SREs).

METHODS

Data from patients 18-64 years old with solid tumors and BM, eligible for short-term disability benefits between January 1, 2002 and December 31, 2010, were extracted from MarketScan Research Databases. Short-term disability hours and costs associated with BM and SREs were evaluated.

RESULTS

Overall, 1098 patients met the criteria. For all patients with BM, the monthly mean short-term disability hours were 17.7 h pre-BM diagnosis and increased to 60.2 h post-BM diagnosis (p < 0.001). The corresponding mean monthly short-term disability costs were $277 and $963 in the pre- and post-BM diagnosis periods, respectively (p < 0.001). Monthly mean short-term disability hours were higher for the cohort of patients with SREs (21.2 h pre-SRE diagnosis and 67.4 h post-SRE diagnosis) than for those without an SRE (8.6 h pre-SRE diagnosis and 14.4 h post-SRE diagnosis) (p < 0.001). Similarly, the corresponding monthly mean short-term disability costs were higher for patients with SREs ($625 and $1259 pre- and post-SRE diagnosis, respectively) than for patients without an SRE ($452 and $612 pre- and post-SRE diagnosis, respectively) (p < 0.001). RESULTS of a multivariate analysis indicated that SREs were associated with an additional 39.4 short-term disability hours and $613 in short-term disability costs per month (p < 0.001).

CONCLUSION

Short-term disability hours and costs increased significantly when patients with solid tumors developed BM and SRE.

Molecular profile of clonal strains of human skeletal stem/progenitor cells with different potencies

Bone marrow stromal cells (BMSCs, also known as bone marrow-derived mesenchymal stem cells) are fibroblastic reticular cells, a subset of which is composed of multipotent skeletal stem cells (SSCs). SSCs/BMSCs are able to recreate a bone/marrow organ in vivo. To determine differences between clonogenic multipotent SSCs and similarly clonogenic but non-multipotent BMSCs, we established single colony-derived strains (SCDSs, initiated by individual Colony Forming Unit-Fibroblasts) and determined their differentiation capacity by vivo transplantation. In this series of human SCDSs (N=24), 20.8% formed fibrous tissue (F), 66.7% formed bone (B), and 12.5% formed a bone/marrow organ, and thus were multipotent (M). RNA isolated from 12 SCDSs just prior to transplantation was analyzed by microarray. Although highly similar, there was variability from one SCDS to another, and SCDSs did not strictly segregate into the three functional groups (F, B or M) by unsupervised hierarchical clustering. We then compared 3 F-SCDSs to 3 M-SCDSs that did segregate. Genes associated with skeletogenesis, osteoblastogeneis, hematopoiesis, and extracellular matrix were over-represented in M-SCDSs compared with F-SCDSs. These results highlight the heterogeneity of SSCs/BMSCs, even between functionally similar SCDSs, but also indicate that differences can be detected that may shed light on the character of the SSC.

Denosumab for the prevention of skeletal complications in metastatic castration-resistant prostate cancer: comparison of skeletal-related events and symptomatic skeletal events

In this analysis of a phase III trial in patients with castration-resistant prostate cancer and bone metastases, treatment with denosumab reduced the risk of skeletal complications vs zoledronic acid regardless of whether the end point was defined as SSE or SRE. Both SSEs and SREs were associated with development of moderate/severe pain among patients with no/mild pain at baseline.

Background

In a phase III trial in patients with castration-resistant prostate cancer (CRPC) and bone metastases, denosumab was superior to zoledronic acid in reducing skeletal-related events (SREs; radiation to bone, pathologic fracture, surgery to bone, or spinal cord compression). This study reassessed the efficacy of denosumab using symptomatic skeletal events (SSEs) as a prespecified exploratory end point.

Patients and methods

Patients with CRPC, no previous bisphosphonate exposure, and radiographic evidence of bone metastasis were randomized to subcutaneous denosumab 120 mg plus i.v. placebo every 4 weeks (Q4W), or i.v. zoledronic acid 4 mg plus subcutaneous placebo Q4W during the blinded treatment phase. SSEs were defined as radiation to bone, symptomatic pathologic fracture, surgery to bone, or symptomatic spinal cord compression. The relationship between SSE or SRE and time to moderate/severe pain was assessed using the Brief Pain Inventory Short Form.

Results

Treatment with denosumab significantly reduced the risk of developing first SSE [HR, 0.78; 95% confidence interval (CI) 0.66–0.93; P = 0.005] and first and subsequent SSEs (rate ratio, 0.78; 95% CI 0.65–0.92; P = 0.004) compared with zoledronic acid. The treatment differences in the number of patients with SSEs or SREs were similar (n = 48 and n = 45, respectively). Among patients with no/mild pain at baseline, both SSEs and SREs were associated with moderate/severe pain development (P < 0.0001). Fewer patients had skeletal complications, particularly fractures, when defined as SSE versus SRE.

Conclusion

In patients with CRPC and bone metastases, denosumab reduced the risk of skeletal complications versus zoledronic acid regardless of whether the end point was defined as SSE or SRE.

Physician referral patterns among men with advanced prostate cancer

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Background: Among men diagnosed with localized prostate cancer (PC), the type of specialist visited has been shown to influence the type of treatment regimen prescribed. There is limited data on referral patterns among men diagnosed with advanced PC. The objective of this study was to characterize referral patterns across physician types who treat men with stage IV nonmetastatic (M0) and metastatic (M1) PC. Methods: Using the linked US SEER (Surveillance, Epidemiology, and End Results) and Medicare database, we identified men aged 66 or older who were diagnosed with incident stage IV M0 or M1 PC between 2000 and 2007. We evaluated patterns of the first and second type of physicians visited after diagnosis of PC for men with visits to the following physician types: urologist, medical oncologist (medonc), radiation oncologist (radonc), or primary care physician (PCP). Results were stratified by M0 and M1 disease. Results: We identified 9,826 men with stage IV PC (median age=77 years). Of these 9,826 men, 8,736 (89%) visited at least two physician types (93% among men with M0 and 87% among men with M1). Across the physician types of interest, 94% of men initially visited a urologist (52%) or PCP (42%). Among men who visited a urologist first, most were referred to a PCP, while smaller percentages were referred to a medonc or radonc (Table). Among men who saw a PCP first, most were referred to a urologist next; smaller proportions were referred to a medonc or radonc. Men with M1 PC had more referrals to medonc and fewer referrals to radonc than men with M0 PC. Conclusions: In this analysis of nearly 10,000 men aged 66 or older with stage IV PC in the US, most men initially visited a urologist or PCP regardless of whether or not they had distant metastasis. Based on the patterns observed, the most frequent referral pattern occurred between urologists and PCPs. More referrals to a medonc were evident if the men had M1 disease. [Table: see text]

Prevalence of fractures among men with stage IV prostate cancer (S4PC)

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Background: Fractures (fx) are common in men with stage 4 prostate cancer (S4PC), resulting in significant clinical consequences, such as increased pain and decreased quality of life. The aim of this study was to estimate the prevalence of fx among men diagnosed with non-metastatic (M0) or metastatic (M1) S4PC and evaluate risk factors associated with fx. Methods: We estimated the prevalence of fx among men age 66 or older diagnosed with M0 or M1 S4PC using data from the U.S. SEER-Medicare datasets between 2000 to 2007. Men were followed through December 2009 or until they were lost to follow up. Codes indicating “pathologic fracture” or “fracture,” excluding codes suggesting accidents/falls in the 14 days prior to the fx, were used to identify fx. Results: Among 9,826 men with S4PC (M1 = 7301; M0 = 2525), 12.9% experienced a post-diagnosis fx based on the codes used. The prevalence of fx was nearly twice as high in men with M1 versus M0 S4PC (M1 = 14.7%; M0 = 7.5%). The median time from diagnosis of S4PC to first fx was five months for men with M1 S4PC versus 34 months for men with M0 S4PC. Compared to men with no fx, men who experienced fx were more likely to be older (20.3% vs. 17.8%), of white/non-Hispanic race (81.1% vs. 75.3%), have well (cancer grade 1) or moderately (cancer grade 2) differentiated tumors (48.7% vs. 41.7%), have a claim of osteoporosis (2.4% vs. 0.6%) or osteoarthritis (9.3% vs. 6.5%) in the year prior to S4PC diagnosis, and to have taken a bone mineral density (BMD) test (13.5% vs. 8.1%). All differences were significant at p<0.05 level. Overall, 92% of men did not receive BMD testing at any time post diagnosis despite the fact that 67% of the men received ADT. Conclusions: In men with M1 S4PC at diagnosis, the prevalence of fx is higher and the time to fx is substantially shorter than in men with M0 S4PC at diagnosis. Furthermore, most men with S4PC do not receive BMD testing. A significant need remains to monitor bone health and treat fx, particularly among M1 S4PC patients.

Denosumab for the prevention of symptomatic skeletal events in patients with castration-resistant advanced prostate cancer: A comparison with skeletal-related events

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Background: In a randomized controlled trial of men with castration-resistant prostate cancer (CRPC) and bone metastases, denosumab was superior to zoledronic acid (ZA) for reducing skeletal-related events (SRE, defined as pathological fracture, surgery or radiation to bone [including the use of radioisotopes], or spinal cord compression) (Fizazi, et al. Lancet 2011;377:813-822.). Recently, the composite endpoint of symptomatic skeletal event (SSE, defined as symptomatic fracture, surgery or radiation to bone, or spinal cord compression) was introduced as an alternative term/clinical trial endpoint to describe skeletal morbidity. Methods: Men with CRPC, ≥ 1 bone metastasis, and no prior IV bisphosphonate use received either SC denosumab 120 mg or IV ZA 4 mg (adjusted for creatinine clearance) in a blinded fashion every 4 weeks. Oral calcium and vitamin D supplements were recommended. SSEs included pathologic fractures considered symptomatic by the investigator, spinal cord compression and surgery and radiation to bone. Results: As previously reported, fewer men who received denosumab than ZA had confirmed first SREs, and experienced multiple SREs (Table). Similarly, fewer patients in the denosumab group than the ZA group had confirmed first SSE and multiple SSEs. The median (95% CI) estimate of time to first SSE (superiority analysis) for denosumab was not reached (28.8 mo, not estimable), and for ZA it was 24.2 (20.7, 30.2) mo (HR = 0.78 (0.66, 0.93) P = 0.01). Conclusions: Denosumab reduced the risk of skeletal events in men with CRPC regardless of endpoint definition as SRE or SSE. The risk of developing SSEs was reduced by up to 22% when comparing denosumab with ZA. Clinical trial information: NCT00321620. [Table: see text]

Use of intravenous bisphosphonates in patients with breast, lung, or prostate cancer and metastases to bone: a 15-year study in two large US health systems

PURPOSE

The purpose of this paper is to document the use of intravenous (IV) bisphosphonates for prevention of skeletal-related events (SREs) in patients with bone metastases (BM) due to breast cancer (BC), lung cancer (LC), or prostate cancer (PC).

METHODS

Using data from two large US health systems, we identified all patients aged ≥ 18 years with primary BC, LC, or PC and newly diagnosed BM between 1/1/1995 and 12/31/2009. Starting with the diagnosis of BM, we reviewed medical and administrative records for evidence of receipt of IV bisphosphonates (zoledronic acid or pamidronate) and occurrence of SREs. Initiation of IV bisphosphonates prior to occurrence of an SRE was designated "primary prophylaxis"; use following an SRE was designated "secondary prophylaxis".

RESULTS

We identified a total of 1,193 patients with newly diagnosed BM, including 400 with BC, 332 with LC, and 461 with PC. Use of IV bisphosphonates was substantially higher in BC (55.8 % of all patients) than in LC (14.8 %) or PC (20.2 %). Use of IV bisphosphonates was fairly evenly split between primary and secondary prophylaxis in BC (26.3 vs. 29.5 %, respectively) and PC (10.6 vs 9.5 %); in LC, however, primary prophylaxis was much less common than secondary prophylaxis (4.8 vs 9.9 %).

CONCLUSIONS

Almost one half of all patients with BM due to BC, and substantially more with LC and PC, do not receive IV bisphosphonates. Among patients receiving such therapy, treatment often is not initiated until after the occurrence of an SRE. Our study suggests that IV bisphosphonates may be substantially underutilized in patients with BM due to these common cancers.

Abstract P3-10-01: Burden of symptoms associated with development of metastatic bone disease in patients with breast cancer

Background: Bone is the most common site of distant metastasis in advanced breast cancer patients (pts). Development of bone metastases (mets) is associated with substantial morbidity including skeletal complications, decreased quality of life, increased pain, and shortened lifespan. Pt burden of symptoms associated with bone mets has been assessed in tumor types other than breast or in metastatic disease not specific to bone. This study characterizes patterns of pt-reported symptoms over time among breast cancer pts with bone mets.

Methods: The Oncology Services Comprehensive Electronic Records (OSCER) database was used to retrospectively identify women with breast cancer who developed bone mets during their care and had ≥1 ACORN Patient Care Monitor (PCM) assessment. The PCM summarizes symptoms on an 11-point scale (0 = not a problem to 10 = as bad as possible). Moderate/severe symptoms were defined by a PCM score ≥4. PCM items relevant to metastatic disease (fatigue, physical pain, trouble sleeping, numbness/tingling, anxious, loss of interest in others) were assessed. A generalized linear mixed model was used to evaluate symptom progression before and after bone mets diagnosis (dx). Kaplan-Meier methods were used to estimate time to development of and proportion of pts with moderate/severe symptoms after bone mets dx.

Results: 1105 pts with breast cancer and bone mets were included. In general, the proportion of pts with moderate/severe symptom burden increased in the months (mos) before bone mets dx (Table 1). The odds (risk) of pts experiencing moderate/severe symptom burden increased in the mos leading up to bone mets dx, with a 9% increase per mo for both fatigue and physical pain, and a 19% increase per mo for numbness/tingling (P&lt;0.001 for all). Non-significant changes were observed in the risk of pts experiencing trouble sleeping (3%), anxiousness (0%), or loss of interest in others (16%). After bone mets dx, the cumulative proportion of pts with moderate/severe symptom burden increased with time (Table 2). Median time to moderate/severe symptoms after bone mets dx was 1.4 mos for fatigue, 1.9 mos for physical pain, 3.9 mos for trouble sleeping, 9.3 mos for numbness/tingling, 20.6 mos for anxious, and was not reached for loss of interest in others.

Table 1. Unadjusted proportion of pts with moderate/severe symptom burden before or at time of bone mets dxSymptom12 mos before dx6 mos before dxAt bone mets dxFatigue35%37%52%Physical pain29%34%47%Trouble sleeping22%25%28%Numbness/tingling16%18%19%Anxious14%16%23%Loss of interest in others4%6%6%

Conclusions: These data from a large number of breast cancer pts treated at community oncology practices show that pts experience increasing symptom burden for a substantial period of time before bone mets dx. Most pts continue to experience burdensome symptoms after bone mets dx. These findings reinforce the need for multiple symptoms to be proactively monitored and managed in these pts.

Table 2. KM estimate: cumulative proportion of pts with moderate/severe symptom burden after bone mets dxSymptom2 mos after dx12 mos after dxFatigue58%82%Physical pain51%74%Trouble sleeping39%64%Numbness/tingling26%53%Anxious27%46%Loss of interest in others9%22%

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P3-10-01.

Natural history of skeletal-related events in patients with breast, lung, or prostate cancer and metastases to bone: a 15-year study in two large US health systems

PURPOSE

To document the risk of skeletal complications in patients with bone metastases from breast cancer (BC), lung cancer (LC), or prostate cancer (PC) in routine clinical practice.

METHODS

We used data from two large US health systems to identify patients aged ≥18 years with primary BC, LC, or PC and newly diagnosed bone metastases between January 1, 1995 and December 31, 2009. Beginning with the date of diagnosis of bone metastasis, we estimated the cumulative incidence of skeletal-related events (SREs) (spinal cord compression, pathologic fracture, radiation to bone, bone surgery), based on review of medical records, accounting for death as a competing risk.

RESULTS

We identified a total of 621 BC, 477 LC, and 721 PC patients with newly diagnosed bone metastases. SREs were present at diagnosis of bone metastasis in 22.4, 22.4, and 10.0 % of BC, LC, and PC patients, respectively. Relatively few LC or PC patients received intravenous bisphosphonates (14.8 and 20.2 %, respectively); use was higher in patients with BC, however (55.8 %). In BC, cumulative incidence of SREs during follow-up was 38.7 % at 6 months, 45.4 % at 12 months, and 54.2 % at 24 months; in LC, it was 41.0, 45.4, and 47.7 %; and in PC, it was 21.5, 30.4, and 41.9 %. More than one half of patients with bone metastases had evidence of SREs (BC: 62.6 %; LC: 58.7 %; PC: 51.7 %), either at diagnosis of bone metastases or subsequently.

CONCLUSIONS

SREs are a frequent complication in patients with solid tumors and bone metastases, and are much more common than previously recognized in women with BC.

Evaluating results from the multiple myeloma subset of patients treated with denosumab or zoledronic acid (ZA) in a randomized phase III study

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Background: Denosumab (dmab) is a fully human monoclonal antibody against RANKL and is superior to ZA in preventing skeletal-related events (SREs) as shown in 3 identically designed phase 3 trials (N=5723). Overall survival (OS) was balanced between treatment groups in the overall study populations of these trials. In the trial of patients (pts) with solid tumors (excluding breast and prostate) and multiple myeloma (MM), OS was longer for dmab pts with lung cancer, shorter for pts with MM, and balanced for pts with other solid tumors. This analysis further characterizes the results from the MM subset of this trial. Methods: Pts with solid tumors or MM were randomized (1:1) to receive 120 mg of SC dmab or 4 mg of IV ZA Q4W. Daily calcium and vit D supplements were strongly recommended. The primary endpoint was the time to first on-study SRE; results from the primary endpoint and lung cancer subset were previously reported. Results: Of 1776 randomized pts, 10% had MM (93 ZA, 87 dmab). OS favored ZA (hazard ratio: 2.26; 10 subject difference in deaths). 1-year OS was 83% dmab, 97% ZA. Imbalances in baseline prognostic characteristics were observed. More pts in the dmab arm had low baseline renal function (CrCl < 40 mL/min) (ZA 2 [2%], dmab 9 [10%]) and more ZA pts underwent stem cell transplant (ZA 23 [25%], dmab 15 [17%]). Additionally, more ZA pts had stage I tumors at diagnosis (ZA 13 [14%], dmab 9 [10%]) and better performance status (ECOG = 0; ZA 30 [32%], dmab 21 [24%]). Study discontinuations due to consent withdrawal or lost to follow-up were also higher in the ZA group (ZA 17 [18%], dmab 11 [13%]) and occurred earlier in the ZA arm (ZA 59%, dmab 45% within 9 months of randomization). Conclusions: In this SRE study of dmab vs ZA, pts were stratified by baseline characteristics known to affect SRE outcomes, but not by prognostic factors or concurrent anticancer therapy that may impact survival in MM. OS results in the MM cohort are difficult to interpret due to small sample size and imbalances in baseline disease characteristics, stem cell transplant therapy, and consent withdrawal or loss of follow-up that favored ZA. A phase 3 trial is currently underway, which controls for these factors in pts with MM. Clinical trial information: NCT00330759.

Impact of skeletal-related events on pain and analgesic use in patients with solid tumors and bone metastases

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Background: Skeletal-related events (SREs) including pathological fracture (PF), surgery (SB) or radiotherapy to bone (RB), or spinal cord compression (SCC) occur frequently in patients (pts) with advanced cancer and bone metastases and may cause debilitating clinical sequelae for pts. Pooled results from 3 clinical trials showed denosumab was superior to zoledronic acid (ZA) for prevention of SREs. We now evaluate the burden of SREs through pt-reported pain and analgesic use. Methods: Randomized (1:1) pts in the phase III, double-blind, placebo-controlled trials received denosumab (120 mg SC) or ZA (4 mg IV, adjusted for renal function) monthly. In this posthoc analysis, data from pts with solid tumors in the 2 treatment arms were pooled. At baseline (BL) and each monthly visit, pain was assessed via the Brief Pain Inventory (BPI; 0 no pain to 10 severe pain), and pts’ analgesic use with the Analgesic Quantification Algorithm (AQA; 0 no analgesics to 7 > 600 mg oral morphine equivalent/day). Pain and analgesic use for pts with SREs were assessed from 6 months before to 6 months after the 1st on-study SRE. A control group was comprised of all pts without SREs; the index time was defined as the median time to each SRE type. SRE impact was assessed using a stratified Cox proportional hazards model adjusting for SREs, as time-dependent covariates, and other baseline characteristics, and reported as HR and 95% CI. Results: 1,925 pts had an on-study SRE (first SRE type: 923 PF; 829 RB, 119 SCC, 54 SB), and 3,618 pts did not. A greater proportion of pts with SREs had a BPI worst pain score > 4 (moderate/severe pain) or an AQA score ≥ 3 (strong opioid use) than did pts with no SREs. The development of SRE was associated with significantly greater risk of pain progression from no/mild pain at BL to moderate/severe pain on study (PF 1.29 [1.07, 1.57], P = 0.009; RB 2.51 [2.03, 3.10], P < 0.001; SCC 3.07 [1.83, 5.13], P < 0.001; and SB 2.75 [1.19, 6.33], P = 0.018). Conclusions: Pts who experienced on-study SREs had increased pain severity requiring stronger analgesic use. Effective treatments that delay or prevent SREs can reduce pain and the need for palliation with opioids. Clinical trial information: NCT00321464, NCT00321620, and NCT00330759.