Genomic Predictors Associated With Exceptional Response to Systemic Therapy in Advanced Pancreatic Cancer

INTRODUCTION

Exceptional response to therapy is rare in patients with advanced pancreatic cancer. This study explored potential genomic differences between typical and exceptional responses that could confer more favorable biology.

METHODS

We included exceptional responders and controls with advanced pancreatic cancer from Cleveland Clinic from April 2013 to August 2017. Exceptional responders were defined as patients with an overall survival of more than 18 months for metastatic disease and more than 24 months for locally advanced disease. Clinical data were obtained, and next-generation sequencing was performed. Statistical analyses comparing the 2 groups were performed using descriptive statistics, the Kaplan-Meier method, and the log-rank test.

RESULTS

The study comprised 4 exceptional responders and 6 controls. Both groups were well balanced in age, sex, race, and treatment regimens. Exceptional responders had significantly fewer nonsynonymous mutations than controls (2.25 vs 5.17; P = .014). A mutation count of less than 3 was associated with significantly better progression-free survival (17.2 vs 2.3 months; P = .002) and overall survival (29.4 vs 4.6 months; P = .013). Tumor mutational burden did not differ between exceptional responders and controls (4.88 vs 5.70 mut/Mb; P = .39).

CONCLUSION

A lower number of nonsynonymous mutations may correlate with exceptional outcomes in patients with pancreatic cancer. These findings should encourage future studies into genomic signatures of exceptional response.

Comparison of characteristics and outcomes of young-onset versus average onset pancreatico-biliary adenocarcinoma

BACKGROUND

Young-onset gastrointestinal malignancies appear to be increasing in incidence. There are limited data on young-onset pancreaticobiliary adenocarcinoma (YO-PBA).

METHODS

The study comprised patients with PBA (pancreatic adenocarcinoma, intra-, and extra-hepatic cholangiocarcinoma) and included in the National Cancer Database (NCDB) between 2004 and 2017. YO-PBA was defined as a diagnosis at age less than 50 years. Logistic regression to assess factors associated with YO-PBA status, and cox proportional hazards modeling to associate relevant factors with overall survival was performed.

RESULTS

The study cohort comprised 360,764 patients, with 20,822 (5.8%) YO-PBA. YO-PBA was associated with (p-values<0.0001 for all): male sex (6.3% YO-male out of all male patients vs. 5.2% YO-female, OR 1.29, 95% CI 1.25-1.33), Black race (7.9% YO-Black vs. 5.0% YO-White, OR 1.72, 95% CI 1.64-1.80), lower income (6.4% YO-lowest household income based group vs. 5.5% highest, OR 1.08, 95% CI 1.03-1.13). YO-PBA were more likely to present with stage-IV disease (6.4% YO-Stage IV of all stage IV vs. 5.4% YO-Stage I-III, OR 1.25, 95% CI 1.21-1.29 p-value < 0.0001). Factors associated with overall survival (OS) in non-operable patients included-sex - male vs. female, HR 1.12 (95% CI 1.08-1.15); race - Black vs. White, HR 1.23 (95% CI 1.06-1.42); income group - lowest vs. highest, HR 1.33 (95% CI 1.27-1.39), and treatment center type - academic vs. nonacademic center, HR 0.87 (95% CI 0.85-0.90).

CONCLUSIONS

Socioeconomic factors significantly impact incidence and outcomes for young-onset pancreaticobiliary adenocarcinoma (YO-PBA). More work is needed to help understand the mechanisms involved while addressing the disparities.

Improving plan-of-care visit completion

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Background: Plan of Care Visits (POCV) facilitate communicating daily plan of care among providers, nursing, and patients and their families together at the bedside. This discussion standardizes how patients and caregivers collaboratively develop treatment plans that provide the highest quality of care. Daily Plan of Care Visit Completion is expected to improve patient experience with regards to provider effectiveness and interaction. Improved opportunities for understanding, communication, and patient care planning amongst patients, patient family members, and caregivers are a function of Plan of Care Visits. The documented completion of daily POCV in 2020 on the inpatient solid oncology unit was 42% compared to an expected target of 80%. Methods: Team utilized A3 thinking and tools including process mapping, trips to gemba, brainstorming, 5 Whys and fishbone to determine which Potential Root Causes drove failure to complete POCV. Results: Team identified multiple root causes including: Lack of awareness amongst providers that POCV needs to be completed Lack of provider understanding of how to complete a POCV Inconsistent notification of the nurse and staff of when POCV are occurring. Providers unaware of the results of their POCV documentation completion rate Physician attestation templates do not include an option for proper POCV documentation. By implementing retraining and standard procedures for handoff and setting expectations at the start of each change of provider, the team was able increase POCV completion. The subsequent development of a routine to notify staff of their performance daily (and later weekly), and the integration of the POCV completion documentation option into their attestation enhanced completion from 42% in 2020 to 74% in 2021 to 85% in 2022. Conclusions: Following our QI project, POCV completion exceeded the original enterprise target of 55% and revised target of 80%. Improvement in POCV has been sustained for over a year. POCV completion led to improved communication between physicians and nurses on the inpatient unit. The standardization of the process led to consistent completion and improved interaction with the patient. The interdisciplinary care and team were a large contributor to the success of this process.

Epstein-Barr virus-associated smooth muscle tumors in immunocompromised patients: Six case reports

BACKGROUND

Epstein-Barr virus associated smooth muscle tumor (EBV-SMT) is a rare oncological entity. However, there is an increasing incidence of EBV-SMTs, as the frequency of organ transplantation and immunosuppression grows. EBV-SMT diagnosis relies on histopathology and immunochemical staining to distinguish it from post-transplant lymphoproliferative disorder (PTLD). There is no clear consensus on the treatment of EBV-SMTs. However, surgical resection, chemotherapy, radiation therapy, and immunosuppression reduction have been explored with varying degrees of success.

CASE SUMMARY

Our case series includes six cases of EBV-SMTs across different age groups, with different treatment modalities, adding to the limited existing literature on this rare tumor. The median latency time between immunosuppression and disease diagnosis is four years. EBV-SMTs present with variable degrees of aggressiveness and seem to have worse clinical outcomes in patients with tumor multiplicity and worse immunocompetency.

CONCLUSION

It is imperative to continue building on this knowledge and keeping EBV-SMTs on the differential in immunocompromised individuals.

Comparison of characteristics and outcomes of young onset versus average onset pancreatobiliary adenocarcinoma

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Background: Young-onset gastrointestinal malignancies appear to be increasing in incidence but most investigations have focused on colorectal cancer and there are limited data on young-onset pancreatobiliary cancers (YO-PBA). We evaluated trends and characteristics of YO-PBA in comparison to average-onset disease (AO-PBA). Methods: The study cohort comprised patients with PBA (pancreatic adenocarcinoma, intra- and extra-hepatic cholangiocarcinoma) diagnosed between 2004 and 2017 from the National Cancer Database. YO-PBA was defined as diagnosis at age < 50 years and AO-PBA as >50 years. Logistic regression was used to assess factors associated with YO-PBA status, and cox proportional hazards modeling was performed to associate demographic and clinical factors with overall survival. Results: Of 360,764 patients analyzed, 20,822 (5.8%) were YO-PBA with a median age at diagnosis of 45 years (IQR 42 – 48) vs 70 (62-78) years for AO-PBA. The number of patients with YO-PBA increased by 33.3% during the study period compared to 111.8% for AO-PBA. Characteristics associated with YO-PBA were (p-values<0.001 for all): male sex (6.3% YO-male out of all male patients vs 5.2% YO-female out of all female patients, OR 1.2), Black race (7.9% YO-Black vs 5.0% YO-White, OR 1.4), lower income (6.4% YO-lowest household income based category vs 5.5% highest, OR 1.3), and lower education (6.9% YO-lowest educational status category vs. 4.9% highest, OR 1.4). YO-PBA were more likely to present with stage-IV disease (6.4% YO-Stage IV of all stage IV vs 5.4% YO-Stage I-III, OR 1.2, p-value<0.0001), but more likely to undergo surgery (7.4% YO-surgery patients vs 5.4% YO no-surgery patients). Median OS was YO 11.0 (95% CI 10.8 – 11.3) vs. AO 7.1 months (95% CI 7.0 – 7.1). Effects of patients’ characteristics on OS differed significantly between YO and AO-PBA cohorts (interaction p-values < 0.001), and were analyzed separately (table). Notably, Black patients experienced worse outcomes in both age groups. Conclusions: Young-onset pancreatobiliary cancers (YO-PBA) reported in NCDB have increased over the years. YO-PBA is associated with better survival compared to AO-PBA. Socioeconomic disparities significantly impact incidence and outcomes. More work is needed to help address these health disparities, especially for those with young-onset cancer. [Table: see text]

Recipient and Donor Outcomes After Living-Donor Liver Transplant for Unresectable Colorectal Liver Metastases

Question

What are the estimated overall and recurrence-free survival outcomes after living-donor liver transplant (LDLT) in patients with liver-confined, unresectable colorectal cancer liver metastasis (CRLM)?

Findings

In this cohort study of 10 adults with CRLM who received LDLT, Kaplan-Meier estimates of recurrence-free and overall survival at a median follow-up of 1.5 years were 62% and 100%, respectively. Perioperative outcomes for both recipients and donors were consistent with established benchmarks.

Meaning

The results suggest that LDLT may be a viable treatment option for select patients with unresectable CRLMs with favorable tumor biology.

Importance

Colorectal cancer is a leading cause of cancer-related death, and nearly 70% of patients with this cancer have unresectable colorectal cancer liver metastases (CRLMs). Compared with chemotherapy, liver transplant has been reported to improve survival in patients with CRLMs, but in North America, liver allograft shortages make the use of deceased-donor allografts for this indication problematic.

Objective

To examine survival outcomes of living-donor liver transplant (LDLT) for unresectable, liver-confined CRLMs.

Design, Setting, and Participants

This prospective cohort study included patients at 3 North American liver transplant centers with established LDLT programs, 2 in the US and 1 in Canada. Patients with liver-confined, unresectable CRLMs who had demonstrated sustained disease control on oncologic therapy met the inclusion criteria for LDLT. Patients included in this study underwent an LDLT between July 2017 and October 2020 and were followed up until May 1, 2021.

Exposures

Living-donor liver transplant.

Main Outcomes and Measures

Perioperative morbidity and mortality of treated patients and donors, assessed by univariate statistics, and 1.5-year Kaplan-Meier estimates of recurrence-free and overall survival for transplant recipients.

Results

Of 91 evaluated patients, 10 (11%) underwent LDLT (6 [60%] male; median age, 45 years [range, 35-58 years]). Among the 10 living donors, 7 (70%) were male, and the median age was 40.5 years (range, 27-50 years). Kaplan-Meier estimates for recurrence-free and overall survival at 1.5 years after LDLT were 62% and 100%, respectively. Perioperative morbidity for both donors and recipients was consistent with established standards (Clavien-Dindo complications among recipients: 3 [10%] had none, 3 [30%] had grade II, and 4 [40%] had grade III; donors: 5 [50%] had none, 4 [40%] had grade I, and 1 had grade III).

Conclusions and Relevance

This study’s findings of recurrence-free and overall survival rates suggest that select patients with unresectable, liver-confined CRLMs may benefit from total hepatectomy and LDLT.

Incidence and patterns of secondary malignancies in patients with neuroendocrine neoplasms: A SEER database analysis

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Background: Neuroendocrine neoplasms (NENs) are a group of biologically and clinically heterogenous malignancies of different anatomic sites, the majority of which lie within the gastrointestinal (GI) tract. Prior literature has reported on the association between NENs and other primary malignancies (OPM), but these studies are limited by small sample sizes. We aim to further analyze the association of NENs and OPM on a larger scale using a population-based cancer registry. Methods: Primary malignancies with NEN features were identified from the Surveillance Epidemiology and Ends Results registry between 1975-2017. The histology/behavior of NEN included carcinoid tumor, neuroendocrine carcinoma (NEC), pancreatic endocrine tumor, atypical carcinoid tumor, and other (insulinoma, glucagonoma, gastrinoma, VIPoma, somatostatinoma and enterochromaffin cell carcinoid). First NEN observation from each patient was examined. Patients with NEN were grouped into 3 categories: NEN only, NEN first followed by OPM, and non-NEN first followed by NEN based on sequence number of primary cancer. Secondary malignancy sites were analyzed. Distribution of NEN between GI and non-GI sites was described. Demographics were compared by NEN sequence groups and between GI and non-GI sites. Results: 45,896 patients with NEN were analyzed (77.9% Caucasian, 47.0% male, median age 62.0 yrs). 65.7% of NENs were observed in GI sites. Within the GI tract, 31.3% were small intestine, 25.1% rectum, 16.6% pancreatobiliary, and < 11% in other GI locations. Age at NEN diagnosis was younger in those with GI NENs (median 60.0 vs 65.0, p < 0.001). 71.2% of patients had NEN only, 10.4% had NEN first followed by OPM, and 18.4% had a non-NEN primary followed by NEN. Mean age was 58.9 for NEN primary only, 61.0 for NEN primary first and 68.3 for non-NEN primary first (p < 0.0001). More Caucasian patients had non-NEN primary first (82.3%) compared to NEN primary only (76.9%) and NEN primary first (75.5%). There were no gender differences amongst the three groups. Carcinoid tumor histology was more prevalent in NEN primary first (78.6%) compared to NEN primary only (67.3%) and non-NEN primary first (66.6%), while NEC histology was more prevalent in NEN only (27.4%) and non-NEN first (29.3%) compared to NEN first. Among patients with NEN first followed by a second primary malignancy (SPM), 23.6% of females had a secondary breast malignancy and 28.9% of males had a secondary prostate malignancy. Conclusions: 28.8% of patients with NENs were found to have OPM, either preceding or following their NEN diagnosis. Of those with a SPM following NEN, breast and prostate were the most common sites for women and men, respectively. It is imperative that patients with NEN undergo age-appropriate cancer screening to help identify any concurrent malignancies. Further research is warranted to identify the timeframe in which they occur in relation to the NEN.

Improved overall survival for patients with early-onset pancreatic ductal adenocarcinoma

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Background: The median age of diagnosis of pancreatic ductal adenocarcinomas (PDAC) is 70 years. Only about 20% of patients are diagnosed prior to the age of 60. We sought to identify clinical characteristics and outcomes of patients with early-onset PDAC as compared to later-onset PDAC. Methods: We identified histologically confirmed cases of pancreatic adenocarcinoma with information about age and overall survival (OS) diagnosed between 2004 and 2016 from the National Cancer Database (NCDB). Differences in demographic, disease and treatment characteristics and socioeconomic factors between younger and older patients were assessed by Chi-square test. The effect of age, race, insurance status, community median income and community educational attainment on overall survival (OS) were assessed using log rank test. Results: Of 321,896 patients who met inclusion criteria, 71,263 (22%) were younger than 60 years and 250,633 were 60 years of age or older at diagnosis. Median OS for younger patients was 9.5 months, compared to 5.6 months for older patients ( p< 0.0001). Younger patients were more likely to be diagnosed with stage IV disease (47.8% vs 43.4%), to be Black (16.1% vs 10.7%) or Hispanic (6.4% vs 4.5%), have a Charlson-Deyo comorbidity index of 0 (73.5% vs 63.3%), have private insurance (65.1% vs 20.5%), and receive treatment at academic centers (45.9% vs 40.9) (all p< 0.0001). Younger patients were also more likely to receive surgery (26.2% vs 19.5%), radiation (23.0% vs 15.9%), and chemotherapy (65.9% vs 46.7%) (all p< 0.0001). Conclusions: Survival for patients with early-onset PDAC is significantly better than older patients despite more patients being diagnosed with stage IV disease. This may be attributable to younger patients having less comorbidities and receiving more treatment. Concerningly, Black and Hispanic patients make up a larger proportion of younger patients with PDAC, and further work is needed to investigate these differences and underlying causes.

Incidence and patterns of secondary malignancies in patients with neuroendocrine neoplasms: A SEER database analysis

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Background: Neuroendocrine tumors (NETs) are comprised of a group of biologically and clinically heterogenous malignancies arising from a variety of anatomic sites, the majority of which lie within the gastrointestinal tract. Prior literature has reported on the association between NETs and other primary malignancies (OPM), most of which also end up being within the gastrointestinal tract, but these studies are limited by small sample sizes. We aim to further analyze the association of NETs and OPM on a larger scale using a population-based cancer registry. Methods: Malignant primary cancer with NET features were identified from the Surveillance Epidemiology and Ends Results (SEER) registry between 1975 and 2017. The histology/behavior of NET included carcinoid tumor, neuroendocrine carcinoma, pancreatic endocrine tumor, atypical carcinoid tumor, and other including insulinoma, glucagonoma, gastrinoma, VIPoma, somatostatinoma and enterochromaffin cell carcinoid. First NET observation from each patient was examined. Patients with NET were grouped into three categories: only one primary cancer with NET, first primary cancer with NET and first primary cancer without NET based on sequence number of primary cancer recorded in SEER. Distribution of NET between gastrointestinal (GI) and non-GI sites was described. Demographics were compared by NET sequence group and between GI and non-GI sites. Results: 45,896 patients with NET were analyzed (77.9% Caucasian, 47.0% male, median age 62.0 years). More than half (65.7%) of the NETs were observed in GI sites. Within the GI tract, 31.3% were in the small intestine, 25.1% in the rectum, 16.6% in pancreatobiliary, and < 11% in other GI locations. Age at NET diagnosis was younger in those with GI NETs (median 60.0 vs 65.0, p < 0.001 ). 71.2% of NET found in only cancer diagnosis, 10.4% of NET in first followed by a second primary malignancy, and 18.4% in a non-NET primary followed by NET. Mean age was 58.9 for NET primary only, 61.0 for NET primary first and 68.3 for non-NET primary first (p < 0.0001). More Caucasian patients had non-NET primary first (82.3%) compared to NET primary only (76.9%) and NET primary first (75.5%). No gender differences were observed amongst the three groups. Carcinoid tumor histology was more prevalent in NET primary first (78.6%) compared to NET primary only (67.3%) and non-NET primary first (66.6%), while neuroendocrine carcinoma histology was more prevalent in NET only (27.4%) and non-NET first (29.3%) compared to NET first. Conclusions: 28.8% of patients with NETs were found to have OPM, either preceding or following their NET diagnosis. It is imperative that patients with NET undergo age-appropriate cancer screening to help identify any concurrent malignancies. Further research is warranted to identify the location of such additional malignancies and the timeframe in which they occur in relation to the NET.

Number of nonsynonymous genomic variants may correlate with prognosis in advanced pancreatic cancer

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Background: Pancreatic cancer is associated with poor outcomes at any stage. A very small number of patients - approximately 3% of those with metastatic disease - experience long-term survival through 5 years but the biologic mechanisms underlying the benefit observed with these “exceptional responders” are incompletely understood. We explored potential genomic differences between exceptional responders and typical responders to treatment for advanced pancreatic cancer that could confer a more favorable biology. Methods: We included consecutive exceptional responders and matched controls (MCs) with advanced pancreatic cancer in a 1:3 ratio from the Cleveland Clinic from April, 2013 – August, 2017. ERs were defined as patients with overall survival (OS) > 18 months for metastatic disease and > 24 months for locally advanced disease. Controls were matched by age, gender, stage and type of chemotherapy given and experienced OS at or below median survival for their stages. Clinical variables including demographics, comorbidities, stage, histology and treatment history were collected. Next generation sequencing (NGS) was performed for DNA sequencing of 648 genes and tumor mutation burden (TMB) on available tissue. The study population initially comprised of 14 exceptional responders and 42 MCs. However, only 4 exceptional responders and 6 MCs were included for analysis due to insufficient tissue for NGS for the remaining patients. Descriptive statistics were used for statistical analysis. Differences in survival outcomes were assessed using the Kaplan-Meier method and log-rank test. Results: The median ages for the exceptional responders and MCs were 69 and 67.5 years, respectively. Both groups were at least 75% male and white. Of the exceptional responders, 50% had pancreatic tail primaries compared to 0% of the MCs. There were no differences between groups in first-line chemotherapy used. Exceptional responders had significantly fewer non-synonymous mutations compared to MCs (2.25 vs. 5.17, p = 0.014). Mutation count < 3 was associated with significantly better progression-free survival (PFS) and OS as shown in the Table. TMB did not differ between exceptional responders and MCs (4.88 vs. 5.70 Muts/Mb, p = 0.39). Of the exceptional responders, 50% had alterations in BAGE2 versus 0% of MCs. Conversely, 50% of MCs had alterations in LRP1B, CUL4B or APC vs. 0% of exceptional responders. Conclusions: Having a lower number of non-synonymous mutations may correlate with exceptional response to systemic therapy and therefore with improved survival in pancreatic cancer. Pancreatic tail primary may also be associated with improved outcomes. These findings, though limited by small sample size, should encourage future study into genomic signatures of exceptional response. [Table: see text]

Epidemiology of Cholangiocarcinoma; United States Incidence and Mortality Trends

BACKGROUND

Cholangiocarcinoma is an aggressive malignancy with few available studies assessing incidence and mortality. In this study, we aim to investigate trends of incidence and mortality in a large nation-wide epidemiologic study.

METHODS

We used SEER 18 database to study cholangiocarcinoma cases in the US during 2000-2015. Incidence and mortality rates of cholangiocarcinoma were calculated by race and were expressed by 1,000,000 person-years. Annual percent change (APC) was calculated using joinpoint regression software.

RESULTS

We reviewed 16,189 patients with cholangiocarcinoma, of which 64.4% were intrahepatic. Most patients were whites (78.4%), males (51.3%), and older than 65 years (63%). A total of 13,121 patients died of cholangiocarcinoma during the study period. Cholangiocarcinoma incidence and mortality were 11.977 and 10.295 and were both higher among Asians, males, and individuals older than 65 years. Incidence rates have significantly increased over the study period (APC=5.063%, P<.001), while mortality increased significantly over the study period (APC=5.964%, P<.001), but decreased after 2013 (APC=-25.029, P<.001).

CONCLUSION

The incidence and mortality of cholangiocarcinoma were increasing in the study period with significant observed disparities based on race and gender.

Improving the referral rate of universal genetic counseling for pancreatic ductal adenocarcinoma (PDAC) at the Cleveland Clinic Taussig Cancer Center: A quality improvement project

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Background: While most PDAC are sporadic, up to 10% are inherited. In 2018, ASCO and NCCN guidelines were updated to recommend that all patients with PDAC be considered for genetic counseling (GC) and germline testing. Furthermore, interest in treating patients with targeted therapy, such as olaparib, for germline mutations is increasing. We implemented a quality improvement project to identify the referral rate to GC for patients with PDAC, with the goal of improving the referral rate to 60%. Methods: Barriers to GC referral were identified using quality improvement tools developed at the ASCO Quality Training Program. Three “plan, do, study, act” (PDSA) cycles were implemented: 1) updating the electronic order and tumor board template to include GC recommendation (Aug–Oct 2019), 2) physician education (Nov–Dec 2019) and 3) patient education and physician reinforcement (Jan–Feb 2020). Baseline data to evaluate impact of PDSA intervention (from April to June 2019) on documented discussions about GC and placement of the referral order was completed via chart review. Results: Between April 2019 to January 2020, 199 patients with PDAC were seen in medical oncology clinic as new patient visits. Thirteen patients had previously completed GC. For the remainder, baseline discussion and referral rates were 25% and 9%, respectively. Discussion and referral rates improved to 55% and 30% after PDSA 1, to 73% and 33% after PDSA 2, and to 95% and 58% after PDSA 3, respectively. Forty-nine patients were referred at the first visit and 23 were referred at a subsequent visit. Forty-six patients underwent GC. In patients who completed germline testing 8.9% (4/45) were found to have a pathogenic variant in BRCA2, TP53, ATM, and MUTYH. Conclusions: With increased physician and patient education, we were able to improve the GC discussion rate from 25% to 95% and referral rate from 9% to 58%. While we did not meet our aim of 60% GC referral rate, we identified obstacles and outlined an improved process for early GC referrals. Enacting processes to reinforce GC referrals for patients with PDAC is likely to increase detection of germline mutations in this population.

Profiling and prognostic implications of variants of unknown significance (VUS) in solid tumors

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Background: While precision oncology is becoming increasingly integrated into standard of care for most incurable solid tumor malignancies, there is paucity of data regarding the clinical significance of VUS. In this study, we aim to evaluate whether the number of VUS is associated with overall survival (OS). We also analyze racial disparities pertaining to the number of VUS present and identify which, if any, genes possess prognostic implications. Methods: This is a retrospective review of 389 consecutive patients seen at Cleveland Clinic from 2014 to 2016 with incurable solid tumor malignancies, for whom next-generation sequencing (NGS) was ordered using Foundation One™ (Cambridge, MA). Demographics, number of VUS, genes involved, and race were summarized. OS was estimated by Kaplan-Meier and compared by log rank test. Results: Median age was 60 years, 202 (52%) patients were female, 338 (86.7%) were Caucasian, and 31 (8.0%) were African American. On NGS, 376 (97%) patients had VUS reported. The median number of VUS was 9 (range 1-116). When dichotomized at the median, the number of VUS did not affect OS. Genes most commonly implicated in reported VUS were LRP1B (88, 22.6%), MLL3 (83, 21.3%), MLL2 (73, 18.8%), ARID1B (70, 18.0%), PRKDC (60, 15.4%), PREX2 (58, 18.7%), and SPTA1 (56, 14.4%). Patients found to have a variant of unknown significance in MLL2 had worse median OS as compared to those who did not (2.61 vs 3.76 years respectively; p = 0.033). When profiled by race, Caucasians had lower numbers of VUS (p = 0.002; Table). Conclusions: We did not find a clear association between the number of VUS and OS. MLL2, a gene known to predict poor prognosis as a pathogenic variant, was seen in our study to have similarly poor prognostic implications as a variant of unknown significance. Racial disparities in genomics exist as African Americans are under-represented and have greater numbers of VUS as compared to Caucasians. Further research is warranted to elucidate these disparities. [Table: see text]

Outcomes of appendiceal adenocarcinomas compared to right and left-sided colorectal adenocarcinomas: An analysis from the National Cancer Database (NCDB)

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Background: Appendiceal carcinomas (AC) account for 1-2% of colorectal cancers (CRC) and are generally treated like other CRC. However, there is limited data to guide treatment. While AC originate on the right side of the colon, it is unclear if they behave like as right-sided CRC (R-CRC). We seek to learn how AC differ from right versus left-sided CRC (L-CRC). Methods: We identified histologically confirmed cases of appendiceal and colorectal adenocarcinomas with information about stage and overall survival (OS) diagnosed between 2004 and 2016 from the National Cancer Database. Kaplan-Meier method and log-rank test were used to estimate and compare OS. Results: 833,939 patients met our inclusion criteria: 15,138 (1.8%) AC, 447,551 (53.7%) L-CRC, 308,794 (37.0%) R-CRC, and 62,456 (7.5%) transverse CRC (T-CRC). Median age at diagnosis of all patients was 68 years (range:18-90); AC was lowest at 61 years for stage I-III disease and 58 years for stage IV disease. Stage IV AC was more common in females 3628/5739 (63.22%). AC had the best OS among site groups in stage I-III. Median OS for stage I-III AC was 128.8 months (95% CI: 117.9-139.0), with 5-year OS rate of 0.69 (95% CI: 0.67-0.70); L-CRC median OS was 111.6 months (95% CI: 110.9-112.4), with 5-year OS rate of 0.681 (95% CI: 0.680-0.683); R-CRC median OS was 88.5 months (95% CI: 87.8-89.1), with 5-year OS rate of 0.613 (95% CI: 0.611-0.615); and T-CRC median OS was 86.2 months (95% CI: 84.7-87.6), with 5-year OS rate of 0.608 (95% CI: 0.604-0.613) (p <0.0001) (Table). Similar difference was observed in stage IV patients (Table). Conclusions: Patients with AC had significantly better OS for stages I-III and stage IV compared to patients with L-CRC, R-CRC, and T-CRC, though outcomes were more similar to L-CRC. The difference is more evidence for patients with stage IV disease. T-CRC had similar OS to R-CRC, as anticipated.

[Table: see text]

Patient reported outcomes in cancer patients: Psychological, physical and functional importance

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Background: Patient-reported outcomes (PROs) allow consistent monitoring of patients’ symptoms and quality of life. We evaluated their prevalence among cancer patients. We also evaluated the association of PROs, Emotional Thermometer (ET) distress with demographic and disease characteristics. Methods: PROs were prospectively collected as cross sectional data. This was later combined with retrospectively obtained clinical data from the EMR. Predictors of ET component (Distress, Anxiety, Anger, Depression) was determined by linear regression analysis. The predictors of those who required Help with tablet computers was determined by logistic regression. Results: The mean age was 58 (±14) years; 54% male. The common cancer diagnoses were breast 17%, hematological (leukemia) 17% and lymphoma 12%. Few (7%) participants required help (N = 1076) with the tablet-based surveys. Age ≤ 30 and 51–70 years scored lower in mean depression ET. African Americans had higher ET Anger scale. African Americans scored higher in need of Help –ET. Age 31-50 years was at 13% lower risk and 51–70 years was at 72% lower risk of requiring help. Those with self-care problems were at higher risk of requiring Help with tablet computer. Conclusions: Many cancer patients visiting the cancer center had high pain/discomfort, anxiety/depression, problems with usual activities and mobility problems. Younger patients (31-50 years) had more distress and depression (ET). African Americans reported more problems with mobility, self-care, usual activities, pain/discomfort and anxiety/depression (EQ5D). Those with self-care problems were at risk to require help with tablet-based surveys.

Swallow screen and test in cancer patients

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Background: Swallowing is a complex process with four phases. It initiates digestion and is essential for proper nutrition. Difficulty swallowing independently correlated with cancer survival. We retrospectively evaluated the prevalence and incidence of difficulty swallowing in an acute care palliative medicine unit. BMI and survival were also examined. Methods: Electronic Medical Records (EMR) 2010-2012 was reviewed. Assessment comprised of 3 steps: nurse survey on patient condition (coma, intubation, PEG/feeing tube, respiratory distress), screening questionnaire and clinical swallowing test. Change in BMI from the day of admission to discharge calculated. Survival calculated from EMR and Social Security Death Index. Results: N = 261 with cancer identified; 47% known metastases. The mean age (± SD) was 68 ± 13 years. 55% females. 71% Caucasians and 25% African Americans. It was common in lung, gastrointestinal (GI) and genitourinary (GU) cancers. Clinical swallowing test was indicated in 94%. Prevalence of difficulty swallowing = 6%. Incidence of difficulty swallowing = 21%. Change in Body Mass Index (BMI) from 26 ± 7 (Mean ± SD) to 26 ± 6 on admission to discharge respectively. Median (25th, 75th percentile) survival: 25(13, 62) days. Conclusions: Difficulty swallowing was common in lung, GI and GU cancers. The incidence of difficulty swallowing in acute care palliative medicine unit was 21% and prevalence 6%. 75% with difficulty swallowing identified by nurse’s initial survey, 19% through screening questionnaires and 6% clinical swallowing test. Pneumonia/respiratory and GI problems were common. Swallowing evaluation critical for comprehensive cancer care.

Precision oncology in pancreatobiliary cancers: A longitudinal study

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Background: Precision oncology – the use of next-generation sequencing (NGS) to identify therapeutic options for advanced cancer patients – is being used widely, but its utility in patients with pancreatobiliary (PB) cancers has not been studied systematically. We evaluated the prevalence of actionable alterations and their impact on therapeutic decision-making in patients with PB cancers. Methods: We conducted a retrospective cohort study of consecutive patients seen at the Cleveland Clinic between 2013 and 2016 with incurable solid tumor malignancies, in whom FoundationOne™ (Cambridge, MA) NGS was ordered. All results were reviewed at a multidisciplinary genomics tumor board (GTB), which determined actionability and made therapeutic recommendations. Treatment decisions (on label, off label, or clinical trials) based on said recommendations were reviewed. Results: The study population was 600 patients, of whom 53 had PB cancers. For these 53, median age was 59.6 years; 62.2% (33/53) were female; 86.8% (46/53) were Caucasian. Eight samples (15.1%) had inadequate tissue; of 45 resulted cases, 21 (46.7%) were recommended treatment, including clinical trials (n = 19) and off-label drugs (n = 2). The most common targets for therapy were FGFR (5/21) and CDKN2 (3/21). Of 21 patients with recommendations, only two (9.5%) received genomics-driven therapy, compared with 31.7% (86/271) of patients with other solid tumor malignancies (p = 0.03). One received an IDH1 inhibitor, and one received dabrafenib and trametinib for a BRAF alteration; both on clinical trials. At time of last follow-up, best responses were unknown and partial response, respectively. Unavailability of clinical trials in the vicinity (9.5%), and clinical trial ineligibility, mainly due to poor performance status (9.5%), were common reasons for lack of actionability. Conclusions: Benefit from precision oncology in the PB population is low, with only 4.4% (2/45) of patients with NGS results eventually receiving genomics-driven therapy. Benefit to patients will not improve until access to clinical trials is enhanced and patients are evaluated for these trials earlier in the course of their disease, when their performance status is likely to be higher.

Phase 1b/2 study of tivozanib in patients with advanced inoperable hepatocellular carcinoma

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Background: Sorafenib has been the only FDA-approved medication for inoperable HCC (iHCC) as first line. Agents with better tolerability and potential to improve progression-free-survival (PFS) are needed. Tivozanib (TIVO) is an inhibitor of vascular endothelial growth factor (VEGF) tyrosine kinase, inhibiting angiogenesis critical in HCC. Methods: This is a phase 1b/2 study with HCC patients (pts) having a measurable disease, Child-Pugh class A, and no prior systemic therapy. Phase 1b portion followed a modified 3 + 3 design; phase 2 portion was a two-stage, single arm, un-blinded study. Adverse events were categorized based on CTCAE, and tumor imaging was assessed per RECIST. Results: At 3 centers with IRB approval, 21 eligible pts were enrolled. In phase 1b, 8 pts were enrolled at a starting dose of 1mg once daily q21days with one week off. Upon escalation to 1.5mg, two pts had dose limiting toxicities (DLTs, grade 3 mucositis and hypertension) and came off study without completing the DLT period. The dose of TIVO was de-escalated to 1 mg, and the accrual of remaining patients to phase 2 portion occurred at 1 mg. In a total of 19 pts, median follow up was 16.9 months (mo). The primary endpoint of median PFS was 5.5 mo. Partial response (PR) was seen in 4/19 (21%) and stable disease (SD) in 8/19 (42%): disease control rate was 63%. Overall survival (OS) at 6 and 12 mo was 58% and 25%. Median OS was 7.5 mo. Three pts have remained on TIVO for > 2 years. Viral loads of hepatitis B and C remained stable during the study. Adverse events (AEs) related to TIVO included grade 3 fatigue (15.7%), decreased appetite (5.3%), pulmonary embolism (5.3%), hand-foot syndrome (5.3%), elevated LFT (10.5%), and grade 4 hypertension (5.3%). Conclusions: TIVO is tolerable at 1 mg in iHCC. In few pts, TIVO had deep and durable responses. Biomarker driven studies of TIVO in the context of immunotherapy are warranted. Acknowledgment: We appreciate support from NCCN. Clinical trial information: NCT01835223.

Analysis of Origins of Admission for Solid Tumor Oncology Inpatients: Disease Severity and Outcomes

PURPOSE

Hospital transfers may affect clinical outcomes. Evaluation of admission by source of transfer, time of admission, and provider type may identify opportunities to improve inpatient outcomes.

METHODS

We reviewed charts of patients admitted to the solid tumor oncology service between July and December 2014 from the Cleveland Clinic Foundation (CCF) Main Campus emergency department (ED), CCF Regional EDs, outside hospital (OSH) ED, OSH inpatient services, and CCF outpatient clinics. Data collected included time of admission, mortality and severity risk scores, and provider type. Risk factors were assessed for clinical outcomes, including activations of the Adult Medical Emergency Team, intensive care unit transfers, in-hospital mortality, and length of stay (LOS).

RESULTS

Five hundred admissions were included. OSH inpatient transfers had significantly higher disease severity compared with all other origins of admission. OSH inpatient transfers demonstrated significantly longer LOS compared with all other origins of admission, and higher mortality rates compared with the outpatient direct admits and CCF Main Campus ED admits. After adjusting for disease severity and risk of mortality, OSH ED patients remained at higher risk for Adult Medical Emergency Team activation, OSH inpatient transfers had the longest LOS, and CCF Main Campus ED patients had the lowest risk of mortality. Time of admission and provider type were not associated with any of the outcomes.

CONCLUSION

Oncology inpatients transferred from an outside health care facility are at higher risk for adverse outcomes. The magnitude of difference is lessened, but still significant, after adjustment for disease severity and risk of mortality.

Precision oncology experience at a tertiary care center

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Background: Precision oncology – use of tumor genomic profiling to guide therapies – is widely discussed but with limited real-world data. We have previously reported our prospective study on feasibility and clinical utility of routine somatic genomic testing of solid tumors [ J Natl Cancer Inst. 2015; 108(3)], and here we report our longitudinal experience, focusing on therapeutic impact. Methods: Records were reviewed for consecutive adult patients seen at Cleveland Clinic for a solid tumor malignancy without known curative options where tumor genomic profiling was ordered using FoundationOne™ (Cambridge, MA). Results were discussed at the Cleveland Clinic Genomics Tumor Board, and therapeutic recommendations were conveyed to the primary oncologist. Data for this cohort study approved by the Cleveland Clinic IRB included subsequent therapies and clinical outcomes. Results: From 2013 to 2016, 330 patients had tumor genomic testing ordered. Median age was 61 years (range, 24-94); 170 (51.5%) were female; 289 (87.6%) were Caucasian. Colorectal (21.5%), breast (17%), lung (16.1%), and pancreatobiliary (11.5%) cancers were the most common diagnoses. In 300 resulted cases, a median of 4 (0-20) alterations per specimen were noted; the most commonly altered genes were TP53 (n = 174), KRAS (n = 75), APC (n = 65), CDKN2A/B (n = 49), and PIK3CA/ PIK3R (n = 46). A specific therapy targeting an actionable alteration was recommended in 51% (153/300) of patients, and 11.7% (n = 35) received such therapy: 14 on clinical trials, 5 on-label, and 16 off-label. Most common targets for therapy were PIK3CA/PIK3R/PTEN (n = 7), HER2 (6), BRAF (3), EGFR (3), and ALK, FLT3, NTRK1 and RET (2 each). At last follow-up, of 35 patients receiving targeted therapy, best responses were: complete response (n = 1, 2.9%), partial response (n = 5, 14.3%), stable disease (n = 14, 40%), progressive disease (n = 11, 31.4%); data not available for 4 patients. Non-availability of clinical trials was a common reason for non-receipt of targeted therapy. Conclusions: Tumor genomic profiling influenced treatment in 11.7% of patients in this cohort, and 57% of those receiving targeted therapy experienced clinical benefit. These data can help guide real-world discussions of precision oncology.

Clinical outcomes in borderline resectable pancreatic cancer: A cohort study

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Background: The management of borderline resectable pancreatic cancer (BRPC) remains unsettled and the predictors of outcome are uncertain. We evaluated the role of neoadjuvant therapy (nRx) and outcomes in patients with BRPC. Methods: We conducted a retrospective cohort study of consecutive patients with BRPC who received nRx and were followed at the Cleveland Clinic. A histopathologic diagnosis of pancreatic carcinoma was required. Tumor anatomy was assessed by contrast-enhanced cross-sectional imaging (CT or MRI), and BRPC was defined as a tumor-vessel wall interface involving one or more of: celiac artery, superior mesenteric artery, common hepatic artery, main portal vein, superior mesenteric vein; making margin-negative resection unlikely. Baseline laparoscopy was performed to rule out occult metastatic disease. Chemotherapy (CT), radiation (RT), surgery details, and pathologic and survival outcomes were evaluated. Hazard ratios (HR) with 95% confidence intervals (CI) and 2-sided p-values are presented. Results: The study population comprised 79 patients from 2009 to 2014. Median age was 64 years; 52% were male; 85% were Caucasian. Pancreatic head/neck were the primary site in 81%; body/tail in 19%. Vascular involvement included arterial in 32 (41%), and venous in 65 (82%) patients. nRx included RT in all patients; 77 (97%) received CT; gemcitabine (n = 50, 63%) was the most common agent. After CT/RT, 36 (46%) patients had unresectable/inoperable disease: 29 (37%) for anatomic reasons, 4 (5%) for physiologic reasons, and 3 (4%) for both. Surgical resection was performed in 43 (54%) patients; 38 (88%) had negative margins; 30 (70%) had negative nodes; 32 (74%) received adjuvant CT. There were no statistically significant predictors of resection. After median follow-up of 27 mths, there have been 45 deaths (57%); median overall survival (mOS) is 23.5 mths (95% CI: 16-28 mths). Only cancer resection was associated with survival (mOS, resected: not reached; mOS, not resected: 12.8 mths; HR: 0.30, 95% CI: 0.16-0.56, p = 0.0002). Conclusions: Surgical resection, if feasible, of BRPC is associated with improved OS. Strategies to improve the odds of resection should be evaluated in prospective studies.

Embedded palliative medicine model for inpatient solid tumor oncology patients utilizing corounding and consultation criteria: A quality improvement pilot

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Background: Hospitalized patients (pts) on solid tumor oncology (STO) services have palliative needs including pain management. This quality improvement project sought to establish a new STO-specific co-rounding PM consult service, evaluate the use of consult criteria for STO inpatients, assess the impact/interest in an embedded service, improve access to PM for STO pts and improve palliative education to STO teams. Methods: During October 2015 to January 2016, a new PM consult service was established for the 2 STO inpatient services at Cleveland Clinic. The PM attending physician (MD) rounded with each of the STO teams twice a week. On weekdays, the PM MD chart-screened all STO pts for palliative needs such as uncontrolled pain (2 pain scores ≥ 6 out of 10 in 24 hours), unplanned readmission within 30 days or contact with a PM MD as an outpatient. Other PM needs were assessed on rounds. PM consults were offered for pts who screened positive and were performed if approved by the STO team. STO MDs were surveyed anonymously regarding acceptance of the embedded service. Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) data regarding pain management during the pilot period was reviewed. Results: Average daily census for the 2 STO teams was 28 pts. There were 282 positive palliative screens in 4 months, 119 of whom were seen in consultation (42%.) The embedded service saw 42-45 new consults per month. The PM team followed 22-35% of all STO inpatients. 14-18 pts/month new to PM were referred to the outpatient PM clinic after discharge. STO MDs indicated strong acceptance of the embedded PM team for pain management, STO team education and coordination of care. All STO MDs wanted the service to continue. HCAHPS pain scores for the entire STO floor improved from a baseline 39th percentile to 98thpercentile. Conclusions: PM was integrated successfully into daily hospital care of STO pts at our institution using a co-rounding model and consult criteria. The service was busy and well received by STO MDs. Continuity with outpatient PM was provided. HCAHPS pain scores improved for the entire STO floor, including pts not directly seen by PM.

Effects of admission (adm) source, time, and provider on inpatient (inpt) oncology (onc) outcomes at the Cleveland Clinic Foundation (CCF)

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Background: The quality of care transfers is known to influence clinical outcomes. In an inpt onc setting at a major tertiary care referral center, patient (pt) adm originate from many different areas and times. A detailed evaluation of onc adm by source of transfer, admission time, and provider type, may identify opportunities to improve inpt clinical outcomes. Methods: We retrospectively reviewed all adm to the inpt solid tumor onc service from July - December 2014 from CCF regional hospital emergency departments (ED), outside hospital (OSH) ED, OSH inpt services, and CCF outpt clinics. Pts were excluded if the adm was planned or if admitted from the CCF Main Campus ED. Data collected included pt and encounter characteristics and provider type (house-staff or nocturnal hospitalist). Clinical outcomes, including activation of the adult medical emergency team (AMET), ICU transfers, length of stay (LOS), and in-hospital mortality were compared using chi-squared test; ECOG PS and LOS with the Kruskal-Wallis tests and Wilcoxon rank sum test. Results: A total of 413 unique pt admissions were reviewed. 213 were included after exclusion criteria were applied. The probability of AMET activation, mortality, and LOS differed by origin of transfer. Pts admitted from CCF regional EDs had the lowest median LOS and no deaths. OSH int transfers demonstrated significantly higher mortality vs other origins of transfer. Pts whose first orders were placed after 5pm had no significant differences in AMET activation, ICU transfers, LOS, or mortality vs daytime adm. There were no differences in adverse outcomes by the type of admitting provider. Conclusions: Onc inpts transferred from an outside healthcare setting were at highest risk for adverse outcomes (AMETs, increased LOS, and mortality) include those originating from OSH inpt services. Process and communication interventions focused on transfers from outside inpt facilities may improve safety and outcomes in this population. [Table: see text]

Predictors and prognostic importance of weight change in adult solid tumors

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Background: Body weight change in adults with solid tumors was examined in outpatients. Objective was to determine if demographics, clinical and biochemical characteristics were associated with change in weight between visit 1 and visit 2. Examine if weight change and related parameters were associated with survival. Methods: Electronic medical records (EMR) from a tertiary cancer center retrospectively reviewed from 2009-2011. Body weight and other clinical parameters on visit 1 - within a year post diagnosis; visit 2 ≥3 weeks after visit 1. Weight change categorized as: weight gain, 0-5%, 5.01-10%, >10%. Ordinal logistic regression and Cox proportional hazards utilized for WL predictors and prognostic factors respectively. Results: N = 5,901; Mean age (±SD): 61 ± 12 years; 82% were Caucasians; 16% African Americans. Common cancers were prostate 19%; breast 15%; lung 15%; head and neck 6%; colorectal 6%; others 12%. Metastatic disease was present in 18%. Bone, brain, lymph nodes – were common metastatic sites. 45% had radiotherapy; 41% chemotherapy. Median weight change from visit 1 to visit 2 = -1 (-48, 66) kgs. Weight loss (WL) in 57% (≤5%: 30%, 5.01-10%: 13%, >10%: 14%). Different primary cancer sites, number of metastatic sites, radiotherapy/chemotherapy/hormonal therapies, older age, body mass index (BMI), and albumin predicted weight change. Median survival in 5.01-10.0% WL= 9.4 months, >10.0% = 5.3 months, and not observed ≤ 5%. Conclusions: 1. Majority lost ≤5% of body weight by visit 2. 2. Esophagus, head and neck, and pancreas (primary) - the greatest risk of WL; prostate – lowest. 3. High BMI predicted greater WL compared to normal or underweight. 4. ≤5% WL had a survival advantage compared to 5.01-10% and >10%. 5. WL remained prognostic for survival after adjusting for other prognostic factors.

Challenges with genomic testing in pancreaticobiliary cancers: Results of a prospective cohort study

314

Background: Therapeutic options for advanced pancreaticobiliary (PB) malignancies may be improved by genomics-driven therapies. We conducted a prospective cohort study of outpatient genomic testing to identify prevalence of actionable alterations and therapeutic impact of such testing in PB cancers. Methods: Eligibility requirements included confirmed pathologic diagnosis of select solid tumor malignancies without a known curative option, age ≥ 18 years, and an ECOG performance status of 0-2. Data for the PB cancer subgroup are presented here. Tumor samples were sequenced for up to 315 candidate genes in collaboration with Foundation Medicine, Inc. (Cambridge, MA). Results were discussed at the Cleveland Clinic Genomics Tumor Board that made therapeutic recommendations to treating physicians. Results: From Aug 2013 to Aug 2014, samples from 228 patients were analyzed; 24 (11%) had PB cancers. For the latter subgroup, median age was 60 years; 14 (58%) were male; 20 (83%) were white. Twelve (50%) tumors were pancreatic, 11 (46%) from biliary tract/gallbladder, and 1 (4%) periampullary. Median time from consent to result was 24 (range, 3-84) days. Eight (33%) samples had inadequate tissue compared with 6/174 (3%) non-PB samples (p<0.001). Among patients with adequate tissue (n=16), a median of 3 (1-7) mutations were detected per sample; TP53 (50%), CDKN2A/p16 (44%) and KRAS (38%) were most common. A targeted therapy was recommended in 7 (44%) patients. Of these, 78% of recommendations were for specific clinical trials. To date, no patient with PB cancer has received a targeted therapy, compared with 6/45 (13%) patients with colorectal cancer (p=0.18). The most common reason for non-receipt of recommended targeted therapy was non-availability of clinical trials. Conclusions: Compared with other common solid tumors, genomic profiling in pancreaticobiliary cancers is challenged by paucity of diagnostic tissue collected during routine clinical care. Targeted therapy options (on-study or off-label) are few at this time. Precision oncology in pancreaticobiliary cancers will remain under-utilized until access to clinical trials is enhanced.

Genomic testing to enhance treatment choices and clinical trial accrual in metastatic colorectal cancer: Results of a prospective cohort study

593

Background: Tumor genome sequencing is being used widely in clinical settings but its value to individual patients has not been well-studied. A prospective cohort study of outpatient genomic testing to identify prevalence of actionable alterations and their impact on management decisions was conducted. Methods: Eligibility requirements included pathologic diagnosis of select solid tumor malignancies without a known curative option, age ≥18 years, and an ECOG PS of 0-2. Data for the colorectal cancer (CRC) subgroup are presented here. Tumor samples were sequenced for up to 315 candidate genes using FoundationOne (Cambridge, MA). Results were discussed at the Cleveland Clinic Genomics Tumor Board that made therapeutic recommendations to treating physicians. Results: From Aug 2013 to Aug 2014, samples from 45 patients with CRC were analyzed. Median age was 60 years; 23 (51%) were female; 38 (84%) were white. Median time from consent to result was 25 (range, 7-75) days. One (2%) sample had inadequate tissue. A median of 5 (range, 2-19) mutations were detected per sample; APC (89%), TP53 (73%) and KRAS (66%) were most common. A therapy targeting an actionable alteration was recommended in 22 (51%) patients; 88% of these recommendations were for clinical trials. To date, 6 (33%) of 18 patients who switched management after test results received genomics-driven therapies (Table). Previously unknown RAS (KRAS Q61H, NRAS) mutations were detected in an additional 3 patients, influencing EGFR antibody use decisions. The commonest reason for non-receipt of therapy based on the test result was non-availability of clinical trials. Conclusions: Routine tumor genome profiling in CRC patients is feasible and influenced treatment decisions in a third of patients. A genomics tumor board for the interpretation of rapidly evolving information, and improved access to clinical trials of targeted agents are critical to the success of precision oncology. [Table: see text]

Predicting early mortality in resectable pancreatic adenocarcinoma: A cohort study

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Background: Overall survival after pancreatic cancer resection remains poor. A subgroup of patients die early (<6 months) and understanding factors associated with early mortality may help identify high-risk patients. The Khorana Score, including baseline hemoglobin, leukocyte and platelet counts, and body mass index [Khorana et al, Blood, 2008], has been shown to be associated with early mortality in solid tumors [Ay et al; Kuderer et al]. We evaluated the role of this score and other prognostic variables in predicting early mortality following resection. Methods: We conducted a cohort study of consecutive patients who underwent surgical resection for pancreatic cancer from January 2006 through June 2013 and were followed at the Cleveland Clinic. Baseline (diagnosis +/- 30 days) parameters were used to define patients as high-risk (Score >=3). Statistically significant univariable associations and a priori prognostic variables were tested in multivariable models; adjusted hazard ratios (HR) are presented. Results: The study population comprised 334 patients. Median age was 67 years; 50% were female; 86% were Caucasian. Pancreatic head was the primary site for 73%; 67% were T3 and 63% were N1 tumors. Median Khorana score was 2; 152 patients (47%) were high-risk. Adjunctive treatment included chemotherapy (70%) and radiation (40%). Post-operative (30-day) mortality was 0.9%. Six-month mortality for the entire cohort was 9.4%, with significantly higher rates for high-risk patients (13.4% vs. 5.6%, p=0.02). In univariable analyses, Khorana score, low hemoglobin, and elevated blood urea nitrogen (BUN) were associated with early mortality; T- and N-stage, as well as margin status (R0/R1), were not. In multivariable analyses (n=326), Khorana score (HR high-risk = 2.31, p=0.039) and elevated BUN (HR = 4.34, p<0.001) were associated with early mortality. Conclusions: Patients at high risk for early mortality after resection of pancreatic adenocarcinoma can be identified using simple baseline patient-related clinical and laboratory parameters rather than tumor characteristics. Future studies could evaluate the benefit of pre-operative interventions targeting patients at high risk for early mortality.

Weight loss in solid tumors: Clinical features and prognostic importance

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Background: Large cancer databases provide valuable information on weight change and its impact on different clinical parameters. Body weight change in adults with solid tumors was examined in outpatients. The objective was to determine if demographics, clinical and biochemical indices are predictive of weight loss (WL). The effect of WL and other parameters on survival were also assessed. Methods: Electronic medical records (EMR) for outpatient visits from a tertiary cancer center were retrospectively reviewed. Body weight and other clinical parameters on first visit (V1) - within a year post diagnosis - last visit (V2) ≥3 weeks after V1. WL at V2 from V1 categorized as: ≤5%, 5.01-10%, >10%. Results summarized by descriptive statistics, level of association and survival analysis. Results: N = 5901; Mean age (±SD): 61 ± 12 years; 82% were Caucasians; 16% African Americans. Common cancers were genitourinary (GU) 31%; gastrointestinal (GI) 16%; breast 15%; lung 15%; head and neck 6%; brain 5% and others 12%. Metastatic disease in 18%. Bone, brain, lymph nodes – common. 45% had radiotherapy and 41% chemotherapy. Median (min, max) weight, kgs: V1=81(32.0, 223), V2=79.4(34, 221). Median duration (min, max), days V1→V2: 195 (22, 1080). Weight loss V1→V2: ≤5% (73%), 5.01-10% (13%) and >10% (14%). Median change in BMI V1→V2: -0.2 (-19, 13). Median change systolic/diastolic blood pressure (BP) V1→V2: -3(-99, 80)/-1(-57, 47). Change in REE V1→V2: -13(-890, 365). Median survival for 5.01-10.0% WL= 9.4 months, >10.0% = 5.3 months and not observed for ≤ 5%. Conclusions: Majority lost ≤ 5% of body weight by V2. WL maximum for head and neck cancer and GI. High BMI predicted greater WL compared to normal or underweight. ≤5% WL had a survival advantage 5.01-10% and >10%. WL remained prognostic for survival even after adjusting for other prognostic factors.