Fear of Cancer Recurrence (FCR) in Human Papillomavirus-Associated Oropharyngeal Cancer (HPVOPC) Patients 12 months (12m) after (Chemo)Radiation (RT/CRT)

PURPOSE/OBJECTIVE(S)

This study constitutes a planned secondary endpoint analysis from a longitudinal unmet needs study. The aim was to: (1) describe FCR outcomes 12m after RT/CRT; (2) examine associations between FCR severity scores 12m after RT/CRT and patient and disease characteristics and other patient-reported outcomes (PROs); and (3) to evaluate preferred FCR referral pathways.

MATERIALS/METHODS

Eligible HPVOPC patients scheduled for curative RT/CRT were approached for enrolment. FCR was assessed with the 42-item Fear of Cancer Recurrence Inventory (FCRI) 12m after RT/CRT, as were patients' preferences for FCR referral pathways, using customized questions. Optimism (LOT-R) and resilience (Connor-Davidson Resilience Scale) were assessed at enrolment. Health-related quality of life (HRQL, EORTC QLQ-C30), disease-specific symptom severity and interference (MDASI-HN) and emotional distress (PROMIS Anxiety 7a, Depression 8a) were assessed 12m after RT/CRT.

RESULTS

A total of 100/129 eligible patients were enrolled between October 2020 and November 2021. 85/93 (91%) alive patients without recurrence completed the FCRI; patients were mostly men (n = 73, 86%), with a median age of 60 years (range 44-77). A majority had stage I disease (n = 46, 54%) and received CRT (n = 82, 96%). The mean FCRI total score was 45.4 (SD = 26.3, range 0-102, possible range 0-168). The mean FCRI severity score was 12.1 (SD = 7.4, median = 11.0, range 0-29); 13%, 31% and 56% of respondents scored in the severe (≥22), moderate (>12-22) and low (≤12) range, respectively. Univariable regression analysis indicated that lower resilience, lower HRQL (global health status, all functional domains), higher emotional distress (anxiety, depression), and higher symptom severity and interference were associated with higher FCR severity scores 12m after RT/CRT. Apart from lower levels of education, associations between FCRI severity scores and other patient and disease factors were not statistically significant. If FCR had been a problem (n = 66), 86%, 44%, 14% and 5% of patients indicated they would like to discuss it with their oncologist, primary care physician, a psychologist or nurse, respectively (multiple responses allowed). If specific FCR interventions were available, 70/85 indicated their preferred sources for delivery (ordered by median rank) were oncologist, primary care physician, psychologist or nurse (tied), self-management or group sessions (tied).

CONCLUSION

Almost half of HPVOPC patients reported moderate-to-severe FCR 12m after RT/CRT. Increased FCR severity was associated with education and self-reported resilience at baseline and with other measures of HRQL, toxicity and emotional distress at 12m. While patients view oncologists as central in FCR management, education about the benefits of other FCR-reducing approaches may be necessary.

A Prospective Study Evaluating Sexual Health Outcomes in Patients Undergoing (Chemo)Radiation (CRT/RT) for Human Papillomavirus-Associated Oropharyngeal Cancer (HPVOPC)

PURPOSE/OBJECTIVE(S)

The primary endpoint of this study was to describe the course of sexual health outcomes prior to, during and following CRT/RT and to determine the importance of sexual function in a broader context of other oncological and functional outcomes.

MATERIALS/METHODS

Eligible patients with locoregionally confined HPVOPC suitable for curative CRT/RT were approached for enrolment. Patients were assessed before treatment (baseline), week 7 of treatment (FU1), and 3- and 12-months post-treatment (FU2 and FU3, respectively). Study outcomes included sexual health (EORTC SHQ-22), quality of life (EORTC QLQ-C30), symptom burden (MDASI-HN), emotional distress (PROMIS Anxiety 7a, Depression 8b) and facial appearance and appearance distress (FACE-Q). Patient preferences were elicited using a modified version ('keeping sexual function' added) of the Chicago Priorities Scale (CPS) at baseline and FU3; items were sorted into top, middle or lower priorities; then ranked from 1-13.

RESULTS

From October 2020 to November 2021, 100/129 eligible patients were enrolled from 3 centers: median age 61 (range 44-79), male (n = 87, 87%), partnered (n = 75, 77%), heterosexual (n = 95, 95%). Most patients received CRT (n = 97, 97%), 52% had stage I disease (n = 52). Compliance with SHQ-22 at FU3 was 89/98 alive patients. Mean sexual satisfaction scores were 52 (SD = 27, range 0-100) at baseline, 27 (SD = 20) at FU1, 40 (SD = 24) at FU2 and 48 (SD = 28) at FU3. Mixed model results indicated a clinically significant reduction in sexual satisfaction at FU1 (-25, 95% CI = -31, -20; p < 0.001) and FU2 (-12, 95% CI = -17, -7; p<0.001) from baseline, but not FU3 (-4, 95% CI = -9, 1; p = 0.15). Univariable regression analysis indicated that patient factors (cohabiting, having a sexual partner, being sexually active, non-smoker), higher global health status, other SHQ-22 items (higher importance of sex life, libido, security with satisfying their partner, erection confidence, lower fatigue affecting sex life), lower depression, as well as 'keeping sexual function' being a top priority were associated with higher sexual satisfaction at FU3. Associations with MDASI-HN symptom and interference scales, and oral toxicity measures (pain, dry mouth, taste, mouth/throat sores) were not statistically significant. For 30/87 patients, treatment affected their sexual activity quite a bit or very much. Amongst the 13 CPS priorities, 'keeping sexual function' had a median rank of 10 and 9 at baseline and FU3, respectively; 24% and 26% identified it as a top priority at these assessments.

CONCLUSION

Sexual satisfaction is affected during and after CRT/RT for HPVOPC; however, on average, score differences before and 12 months after treatment are not clinically significant. Approximately one-quarter of patients consider sexual function a 'top' priority during survivorship.

Prognostic stratification of HPV-associated oropharyngeal cancer based on CD103+ immune cell abundance in patients treated on TROG 12.01 and De-ESCALaTE randomized trials

BACKGROUND

High CD103+ intratumoral immune cell (ITIC) abundance is associated with better prognosis in unselected patients with human papilloma virus-associated oropharyngeal squamous cell carcinoma (HPV-associated OPSCC) treated with cisplatin and radiotherapy (CIS/RT). Substituting cetuximab (CETUX) for CIS with RT in HPV-associated OPSCC resulted in inferior efficacy. Our aim was to determine whether quantification of CD103 ITIC could be used to identify a population of HPV-associated OPSCC with superior prognosis.

PATIENTS AND METHODS

We pooled data from the TROG 12.01 and De-ESCALaTE randomized trials that compared CETUX/70GyRT with CIS/70GyRT in low-risk HPV-associated OPSCC: American Joint Committee on Cancer 7 stage III (excluding T1-2N1) or stage IV (excluding N2b-c if smoking history >10 pack-years and/or distant metastases), including all patients with available tumor samples. The primary endpoint was failure-free survival (FFS) in patients receiving CETUX/RT comparing CD103+ ITIC high (≥30%) versus low (<30%). High and low CD103 were compared using Cox regression adjusting for age, stage and trial.

RESULTS

Tumor samples were available in 159/182 patients on TROG 12.01 and 145/334 on De-ESCALaTE. CD103+ ITIC abundance was high in 27% of patients. The median follow-up was 3.2 years. The 3-year FFS in patients treated with CETUX/RT was 93% [95% confidence interval (CI) 79% to 98%] in high CD103 and 74% (95% CI 63% to 81%) in low CD103 [adjusted hazard ratio = 0.22 (95% CI 0.12-0.41), P < 0.001]. The 3-year overall survival in patients treated with CETUX/RT was 100% in high CD103 and 86% (95% CI 76% to 92%) in low CD103, P < 0.001. In patients treated with CIS/RT, there was no significant difference in FFS.

CONCLUSIONS

CD103+ ITIC expression separates CETUX/RT-treated low-risk HPV-associated OPSCC into excellent and poor prognosis subgroups. The high CD103 population is a rational target for de-intensification trials.

Identification of an excellent prognosis subset of human papillomavirus-associated oropharyngeal cancer patients by quantification of intratumoral CD103+ immune cell abundance

BACKGROUND

Accurate prognostic stratification of human papillomavirus-associated oropharyngeal cancers (HPV+OPSCC) is required to identify patients potentially suitable for treatment deintensification. We evaluated the prognostic significance of CD103, a surface marker associated with tissue-resident memory T cells (TRMs), in two independent cohorts of patients with HPV+OPSCC.

PATIENTS AND METHODS

The abundance and distribution of CD103+ immune cells were quantified using immunohistochemistry in a cohort of 189 HPV+OPSCC patients treated with curative intent and correlated with outcome. Findings were then validated in an independent cohort comprising 177 HPV+OPSCCs using univariable and multivariable analysis. Intratumoral CD103+ immune cells were characterized by multispectral fluorescence immunohistochemistry and gene expression analysis.

RESULTS

High intratumoral abundance of CD103+ immune cells using a  ≥30% cut-off was found in 19.8% of tumors in the training cohort of HPV+OPSCC patients and associated with excellent prognosis for overall survival (OS) with adjusted hazard ratio (HR) of 0.13 [95% confidence interval (CI) 0.02-0.94, P = 0.004]. In the independent cohort of HPV+OPSCCs, 20.4% had high intratumoral CD103+ abundance and an adjusted HR for OS of 0.16 (95% CI 0.02-1.22, P = 0.02). Five year OS of patients with high intratumoral CD103 was 100% across both cohorts. The C-statistic for the multivariate prognostic model with stage and age was significantly improved in both cohorts with the addition of intratumoral CD103+ cell abundance. On the basis of spatial location, co-expression of CD8 and CD69, and gene expression profiles, intratumoral CD103+ cells were consistent with TRMs.

CONCLUSION

Quantification of intratumoral CD103+ immune cell abundance provides prognostic information beyond that provided by clinical parameters such as TNM-staging, identifying a population of low risk HPV+OPSCC patients who are good candidates for trials of deintensification strategies.

Diabetes associated with immune checkpoint inhibition: presentation and management challenges

BACKGROUND

In recent years, immune checkpoint blockade has become a standard therapy for a wide range of cancers. Adverse events including endocrinopathies result from the induction of autoimmunity.

CASE REPORT

We report a case series of nine individuals who presented with immunotherapy-induced type 1 diabetes between 2015-2017.

DISCUSSION

Onset of diabetes occurred within 12 weeks of commencing therapy. Anti- GAD antibodies were present in six people. Retrospective testing of islet antibodies in pre-treatment samples was possible in two people and this revealed anti-GAD seroconversion in the first and high anti-GAD titres pre and post-treatment in the second person. Six people had high risk HLA haplotypes. Clinical and genetic factors are described and compared with previously published cases. This article is protected by copyright. All rights reserved.

Frequency and prognostic significance of p16(INK4A) protein overexpression and transcriptionally active human papillomavirus infection in laryngeal squamous cell carcinoma

Background:

Human papillomavirus (HPV) infection is a powerful prognostic biomarker in a subset of head and neck squamous cell carcinomas, specifically oropharyngeal cancers. However, the role of HPV in non-oropharyngeal sites, such as the larynx, remains unconfirmed.

Methods:

We evaluated a cohort of 324 laryngeal squamous cell carcinoma (LSCC) patients for the expression of p16^INK4A (p16) protein by immunohistochemistry (IHC) and for high-risk HPV E6 and E7 mRNA transcripts by RNA in situ hybridisation (ISH). p16 expression and HPV status were correlated with clinicopathological features and outcomes.

Results:

Of 307 patients assessable for p16 IHC, 20 (6.5%) were p16 positive. Females and node-positive patients were more likely to be p16 positive (P<0.05). There were no other significant clinical or demographic differences between p16-positive and -negative cases. There was no difference in overall survival (OS) between p16-positive and -negative patients with 2-year survival of 79% in each group (HR=0.83, 95% CI 0.36–1.89, P=0.65). There was no statistically significant difference in failure-free survival (FFS) with 2-year FFS of 79% and 66% for p16-positive and -negative patients, respectively (HR=0.60, 95% CI 0.26–1.36, P=0.22). Only seven cases were found to be HPV RNA ISH positive, all of which were p16 IHC positive. There was no statistically significant difference in OS between patients with HPV RNA ISH-positive tumours compared with -negative tumours with 2-year survival of 86% and 71%, respectively (HR=0.76, 95% CI 0.23–2.5, P=0.65). The 2-year FFS was 86% and 59%, respectively (HR=0.62, 95% CI 0.19–2.03, P=0.43).

Conclusions:

p16 overexpression is infrequent in LSCC and the proportion of cases with high-risk HPV transcripts is even lower. There are no statistically significant correlations between p16 IHC or HPV RNA ISH status and OS or disease outcomes.

Dosing of cytotoxic chemotherapy: impact of renal function estimates on dose

BACKGROUND

Oncology clinicians are now routinely provided with an estimated glomerular filtration rate on pathology reports whenever serum creatinine is requested. The utility of using this for the dose determination of renally excreted drugs compared with other existing methods is needed to inform practice.

PATIENTS AND METHODS

Renal function was determined by [Tc(99m)]DTPA clearance in adult patients presenting for chemotherapy. Renal function was calculated using the 4-variable Modification of Diet in Renal Disease (4v-MDRD), Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI), Cockcroft and Gault (CG), Wright and Martin formulae. Doses for renal excreted cytotoxic drugs, including carboplatin, were calculated.

RESULTS

The concordance of the renal function estimates according to the CKD classification with measured Tc(99m)DPTA clearance in 455 adults (median age 64.0 years: range 17-87 years) for the 4v-MDRD, CKD-EPI, CG, Martin and Wright formulae was 47.7%, 56.3%, 46.2%, 56.5% and 60.2%, respectively. Concordance for chemotherapy dose for these formulae was 89.0%, 89.5%, 85.1%, 89.9% and 89.9%, respectively. Concordance for carboplatin dose specifically was 66.4%, 71.4%, 64.0%, 73.8% and 73.2%.

CONCLUSION

All bedside formulae provide similar levels of concordance in dosage selection for the renal excreted chemotherapy drugs when compared with the use of a direct measure of renal function.

Role of FDG-PET/CT in staging and follow-up of head and neck squamous cell carcinoma

The established and emerging roles of FDG positron-emission tomography/computed tomography (PET/CT) in the evaluation of squamous cell carcinoma of head and neck region is reviewed with a strong clinical focus on recommended applications and methodologies. In the staging of newly diagnosed disease, detection of cervical nodal involvement is the major indication but exclusion of distant metastases and of synchronous primary malignancy is also a valuable adjunct. Use in radiotherapy planning is advantageous for locally-advanced disease. Although there are few data yet to assess the use of FDG PET/CT to assess response during therapy, there is good evidence that this technique can accurately assess the post-treatment neck to identify those who might benefit from salvage therapy and those in whom observation or palliative treatment might be more appropriate. Although more expensive than other imaging modalities used for assessing this disease, the superior diagnostic accuracy and impact of incremental information provided by this technology has been shown to be cost-effective in several clinical scenarios.