A real-world study of treatment sequences and second-line clinical outcomes in patients with HER2-positive metastatic breast cancer in US community practice

PURPOSE

Standard-of-care for HER2-positive metastatic breast cancer (HER2 + mBC) patients consists of trastuzumab ± pertuzumab with chemotherapy in first-line (1L), and ado-trastuzumab emtansine (T-DM1) or the more recently approved trastuzumab deruxtecan (T-DXd) in second-line (2L). Contemporary data on treatment sequencing and real-world effectiveness is limited. This study aims to report 2L treatments and outcomes among HER2 + mBC patients in the United States (US).

METHODS

HER2 + mBC patients initiating 2L treatment (index date) between January 2014 and February 2021 were identified from the Syapse Learning Health Network (LHN) database. Summary statistics for patient characteristics, treatment received, reasons for 2L discontinuation and time to 2L-clinical outcomes are reported.

RESULTS

Of the 312 patients initiating 2L treatment, had a median age of 59 years (interquartile range [IQR], 50-66) at the start of 2L. The majority were white (69%) and had de novo mBC (62%). Top three 2L regimens included T-DM1 ± endocrine therapy (29%), trastuzumab/pertuzumab/taxane (10%) and T-DM1/trastuzumab (8%). Around 88% discontinued 2L and 63% received subsequent treatment. Median time-to-next-treatment was 10.6 months (95% CI, 8.8-13.3) and real-world progression-free-survival was 7.9 months (95% CI, 7.0-9.9). Among 274 patients who discontinued 2L, 47% discontinued due to progression and 17% because of intolerance/toxicity, respectively.

CONCLUSION

This real-world US study showed that approximately two-thirds of 2L patients received subsequent therapy and disease progression was the most common reason for 2L discontinuation highlighting the need for timely 2L treatment with the most efficacious drug to allow patients to achieve longer treatment duration and delayed progression.

Retrospective study to estimate the prevalence and describe the clinicopathological characteristics, treatments received, and outcomes of HER2-low breast cancer

BACKGROUND

Approximately 80% of all breast cancers (BCs) are currently categorized as human epidermal growth factor receptor 2 (HER2)-negative [immunohistochemistry (IHC) 0, 1+, or 2+/in situ hybridization (ISH) negative]; approximately 60% of BCs traditionally categorized as HER2-negative express low levels of HER2. HER2-low (IHC 1+ or IHC 2+/ISH-) status became clinically actionable with approval of trastuzumab deruxtecan to treat unresectable/metastatic HER2-low BC. Greater understanding of patients with HER2-low disease is urgently needed.

PATIENTS AND METHODS

This global, multicenter, retrospective study (NCT04807595) included tissue samples from patients with confirmed HER2-negative unresectable/metastatic BC [any hormone receptor (HR) status] diagnosed from 2014 to 2017. Pathologists rescored HER2 IHC-stained slides as HER2-low (IHC 1+ or IHC 2+/ISH-) or HER2 IHC 0 after training on low-end expression scoring using Ventana 4B5 and other assays at local laboratories (13 sites; 10 countries) blinded to historical scores. HER2-low prevalence and concordance between historical scores and rescores were assessed. Demographics, clinicopathological characteristics, treatments, and outcomes were examined.

RESULTS

In rescored samples from 789 patients with HER2-negative unresectable/metastatic BC, the overall HER2-low prevalence was 67.2% (HR positive, 71.1%; HR negative, 52.8%). Concordance was moderate between historical and rescored HER2 statuses (81.3%; κ = 0.583); positive agreement was numerically higher for HER2-low (87.5%) than HER2 IHC 0 (69.9%). More than 30% of historical IHC 0 cases were rescored as HER2-low overall (all assays) and using Ventana 4B5. There were no notable differences between HER2-low and HER2 IHC 0 in patient characteristics, treatments received, or clinical outcomes.

CONCLUSIONS

Approximately two-thirds of patients with historically HER2-negative unresectable/metastatic BC may benefit from HER2-low-directed treatments. Our data suggest that HER2 reassessment in patients with historical IHC 0 scores may be considered to help optimize selection of patients for treatment. Further, accurate identification of patients with HER2-low BC may be achieved with standardized pathologist training.

Abstract HER2-15: HER2-15 Retrospective Study to Estimate the Prevalence and Describe the Clinicopathological Characteristics, Treatment Patterns, and Outcomes of HER2-Low Breast Cancer

Background: About 60% of breast cancers (BCs) traditionally categorized as HER2 negative (HER2-neg; immunohistochemistry [IHC] 0, IHC 1+ or IHC 2+/in situ hybridization [ISH]–) express low levels of HER2 (HER2-low; IHC 1+ or IHC 2+/ISH–; Schettini, NPJ Breast Cancer 2021). In the phase 3 DESTINY-Breast04 trial (NCT03734029), trastuzumab deruxtecan (T-DXd) showed significantly longer progression-free survival and overall survival (OS) vs physician’s choice of chemotherapy in patients (pts) with HER2-low metastatic BC (mBC) who previously received chemotherapy (Modi, NEJM 2022). As HER2-low becomes a clinically relevant HER2 status among pts with BC, greater understanding of pts with HER2-low disease is needed, including identification of these pts using conventional IHC assays. Our objectives were to assess the prevalence of HER2-low among HER2-neg mBC based on rescored HER2 IHC slides, to describe characteristics of pts with HER2-low mBC, and to characterize concordance between historical HER2 scores and rescores. Methods: This global, multicenter, retrospective study (NCT04807595) included pts with confirmed HER2-neg (HER2 IHC 0, 1+, or 2+/ISH−) unresectable/mBC diagnosed from 2014 through 2017. HER2 IHC-stained slides were rescored after training on low-end expression scoring using Ventana 4B5 and other assays by local laboratories at 13 sites in 10 countries blinded to historical HER2 scores. BCs were categorized as HER2-low (IHC 1+ or IHC 2+/ISH−) or HER2 IHC 0 (IHC 0 or >0< 1+). Prevalence of HER2-low and concordance between historical HER2 scores and rescores were assessed. Demographics, clinicopathological characteristics, treatment patterns, and outcomes were examined via data from medical charts/health records. Results: HER2 rescores were obtained for 781 pts with HER2-neg mBC. HER2-low prevalence was 67.1% overall; 71.1% in hormone receptor (HR)–positive (HR+) and 52.5% in HR–negative (HR−) subgroups. There were no notable differences in characteristics (Table) or treatment patterns between pts with HER2-low and HER2 IHC 0. The most frequent therapies used in the first treatment in the metastatic setting were endocrine therapy (64.1%) for pts with HR+ mBC and chemotherapy (94.4%) for pts with HR− mBC. Among pts with HR+ mBC, 10.2% received cyclin-dependent kinase 4/6 inhibitors as part of their first treatment. There were no statistically significant differences in clinical outcomes between the HER2-low and HER2 IHC 0 groups within each HR subgroup. For pts with HR+ mBC, median time to first subsequent treatment was 10 and 8 months for the HER2-low and HER2 IHC 0 groups, respectively. Overall, concordance was 81.2% (kappa=0.582). Concordance between historical HER2 scores and rescores was 87.3% for HER2-low and 70.1% for HER2 IHC 0 samples. Conclusions: The prevalence of HER2-low (67.1%) among pts previously categorized as HER2-neg mBC in this study was similar to that of an earlier study (≈60%). No obvious differences in patient characteristics or clinical presentation were seen between pts with HER2-low and HER2 IHC 0 mBC. Overall percentage agreement between rescored and historical HER2 scores was 81.2%; agreement was numerically greater for HER2-low than HER2 IHC 0. As HER2-targeted therapies such as T-DXd for the treatment of pts with HER2-low BC are emerging, a greater understanding of pts with HER2-low expression who may benefit from these therapies is important.

Citation Format: Giuseppe Viale, Mark Basik, Naoki Niikura, Eriko Tokunaga, Sara Brucker, Frédérique Penault-Llorca, Naoki Hayashi, Joo Hyuk Sohn, Rita Teixeira de Sousa, Adam M. Brufsky, Ciara S. O’Brien, Fernando Schmitt, Gavin Higgins, Della Varghese, Gareth D. James, Akira Moh, Andrew Livingston, Victoria de Giorgio-Miller. HER2-15 Retrospective Study to Estimate the Prevalence and Describe the Clinicopathological Characteristics, Treatment Patterns, and Outcomes of HER2-Low Breast Cancer [abstract]. In: Proceedings of the 2022 San Antonio Breast Cancer Symposium; 2022 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2023;83(5 Suppl):Abstract nr HER2-15.

Abstract P6-04-03: Computational pathology based HER2 expression quantification in HER2-low breast cancer

Background HER2 directed therapies for breast cancer (BC) rely on accurate estimation of HER2 expression by pathologist scoring of immunohistochemically (IHC) stained tissue according to ASCO/CAP guidelines Emerging HER2-targeted antibody drug conjugates (ADCs) like trastuzumab deruxtecan (T-DXd), have demonstrated efficacy in the HER2-low (IHC 1+ or IHC 2+/ISH-) population (Modi, NEJM 2022). A deeper understanding of the spectrum of HER2 expression and its spatial distribution could provide insights about the mode of action of ADCs, including potential bystander activity. Computational pathology-based methods like Quantitative Continuous Scoring (QCS) can help here by objectively quantifying HER2 expression levels on a per cell basis from digitized HER2 IHC slides (Gustavson, SABCS 2020). We applied QCS to a cohort of HER2-negative (HER2-neg) patients (pts) from a retrospective study (NCT04807595) to quantify the prevalence of HER2 expression in this population and investigate the relationship with manual scoring. Methods To analyze the prevalence of HER2 expression in the HER2-neg population, we used available digital images (N=207 pts) from retrospectively rescored HER2 slides from tumors categorized as HER2-low or IHC 0 (IHC 0 or >0< 1+). QCS algorithm was applied to perform an instance segmentation of each tumor cell into the membrane, cytoplasmic and nuclear sub-compartments. HER2 expression levels on the membrane were estimated from a Hue-Saturation-Density model (Van der Laak, JQCS 2000) in terms of optical density (OD). Descriptive statistics and spatial modelling were used to aggregate cell-level information to a slide level score using the membrane OD values and tumor cell locations. A novel Spatial Proximity Score (SPS) was used to mathematically model the proportion of tumor cells that could potentially be targeted either directly or via bystander activity of ADCs. The analysis is ongoing, complete results with additional patient data to be presented. Analytical validation of the QCS algorithm demonstrated high correlation between OD values as measured on the automatically detected membranes from QCS and those measured on consolidated manual membrane annotations (N=2157 cells) from three pathologists (R = 0.993). This is very similar to the correlation observed between individual pathologists (R = 0.995). Results In the analyzed cohort (N=207), median OD of HER2-low tumors was significantly higher compared to IHC 0 tumors (one-sided Wilcoxon p-value < 0.001). A significant increase of OD values was observed for increasing IHC categories from 0 through >0 < 1+ and 1+ to 2+/ISH- (one-sided Jonckheere-Terpstra p-value < 0.001). OD values within each IHC category showed considerable variability, particularly in IHC 1+ and IHC 2+. In 49% of pts (N=101), greater than 88% of tumor cells expressed HER2 at any intensity (OD≥10). Among the remaining 106 pts, the number of potentially ADC-susceptible cells (within 25μm radius of HER2 expressing cells) as estimated by SPS was at least double the amount estimated by single cell-based scores alone in 45 cases (42%) and increased by at least 50% in another 12 cases (11%). Conclusions Computational approaches such as QCS can help us to objectively characterize the spectrum and spatial distribution of HER2 expression. These mathematical models contribute to our understanding of potential mechanisms of action of ADCs. While this study confirmed a general association of QCS-based scores with manual IHC categories, we also saw considerable variation, as some IHC 1+ or 2+ samples had low OD. Building on these and other promising initial results (Gustavson et al, SABCS 2020), we will further explore clinical relevance of QCS-based scoring. Eventually, digital scoring may be able to define data-driven signatures to select HER2-low pts that might benefit from HER2 targeted therapies.

Citation Format: Andreas Spitzmüller, Ansh Kapil, Anatoliy Shumilov, Jessica Chan, Lemonia Konstantinidou, Zonera Hassan, Mark Gustavson, Danielle Carroll, Della Varghese, Gareth D. James, Akira Moh, Andrew Livingston, Victoria de Giorgio-Miller. Computational pathology based HER2 expression quantification in HER2-low breast cancer [abstract]. In: Proceedings of the 2022 San Antonio Breast Cancer Symposium; 2022 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2023;83(5 Suppl):Abstract nr P6-04-03.

Abstract P1-11-19: A real-world evidence study of treatment patterns in patients with HER2-positive metastatic breast cancer who have received at least 2-lines of therapy

Background. Standard-of-care treatment for HER2-positive metastatic breast cancer (HER2+ mBC) patients has traditionally included targeted therapies such as trastuzumab and/or pertuzumab in first line (1L) and ado-trastuzumab emtansine (T-DM1) in the second line (2L). In 2021, fam-trastuzumab deruxtecan-nxki (T-DXd, Enhertu®) was approved following DESTINY-Breast 03 trial results, demonstrating a significant reduction in the risk of progression compared to T-DM1 in 2L. Contemporary data on treatment patterns and clinical outcomes for HER2+ mBC patients after their 1L therapy in a real-world setting is limited and would help understand whether all eligible patients receive optimal and timely targeted therapies. This study aimed to report 2L treatment patterns and outcomes among HER2+ mBC patients in the United States (US). Methods. Adult HER2+ mBC patients with ≥2 lines of therapy were identified from the Syapse Learning Health Network (LHN) database; a longitudinal US oncology database integrating data from community health systems, labs and other external sources. Included patients initiated 2L treatment for metastatic disease between January 2014-February 2021 (index date), allowing for 12-months of follow-up. Descriptive statistics for patient characteristics, treatment patterns including prior metastatic treatments, time to treatment discontinuation (TTD), and reasons for 2L discontinuation were reported. Results. Of the 15,241 breast cancer patients in the LHN with abstracted data, 312 HER2+ mBC patients received ≥2L treatment. The patients were mostly White (69%) or African American (21%), median age of 59 years (interquartile range [IQR], 50-66) at start of 2L. The African American population was typically diagnosed young (median age 50 [IQR, 44-61] vs. 54 [IQR, 46-62] years) with stage IV disease at initial diagnosis (69% vs 62%) versus Whites. Majority of the 312 patients had stage IV disease at initial diagnosis (62%); most common sites of metastasis at mBC diagnosis were bone (52%), distant lymph node(s) (38%), liver (36%) and brain (10%). The median length of follow-up was 22 months (IQR, 13-37), 54% had initiated their 2L therapy since 2018. Majority of the 312 patients had received a trastuzumab-based (T-based) regimen in 1L (78%). Among the 312 patients, 37% had received only 2 lines of therapy in the metastatic setting, 28% received 3 and 35% received ≥4 lines of therapy. In 2L, 89% of the 312 patients received a HER2-targeted treatment (monotherapy or combination); the most frequent 2L regimens included T-DM1 monotherapy (29%), trastuzumab/pertuzumab/taxane (10%) and T-DM1/trastuzumab (8%). Subsequently, 197 of the 312 patients (63%) received 3L therapy. Among these 197 patients, T-DM1 monotherapy (19%), T-DXd monotherapy (10%) and capecitabine/lapatinib (8%) were the most frequently reported 3L regimens. Around 88% (n=274) of the 312 patients discontinued their 2L therapy. Median TTD of 2L from index date was 7.2 months (95% CI, 6.5-8.9); median TTD was 10.6 months (95% CI, 7.4-14.0) among a sub-group of patients who received a T-based regimen in their 2L (N=116). Approximately 47% of patients discontinued their 2L regimen due to progression/worsening of cancer, 17% discontinued from intolerance/toxicity in the absence of progression. Conclusions. This study suggests the treatment trajectory of US HER2+ mBC patients is variable in the real world clinical practice. Approximately two-thirds of the 2L patients had to receive a subsequent therapy and disease progression was the most common reason for 2L treatment discontinuation, reflecting a remaining need to improve outcomes for patients in 2L HER2+ disease.

Citation Format: Della Varghese, Giovanna I. Cruz, Colden Johanson, Liz Toland, Miguel Miranda, Eleanor C. Faherty, David Harland, Henry G. Kaplan. A real-world evidence study of treatment patterns in patients with HER2-positive metastatic breast cancer who have received at least 2-lines of therapy [abstract]. In: Proceedings of the 2022 San Antonio Breast Cancer Symposium; 2022 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2023;83(5 Suppl):Abstract nr P1-11-19.

The potential of bacteriophage therapy in the treatment of paediatric respiratory infections

The looming antibiotic resistance crisis is forcing clinicians to consider alternative approaches to treating bacterial infections. As the window of use for current antimicrobial agents becomes ever narrower, we consider if looking back will now be the way forward. Conceptually, phage therapy is simple and specific; a targeted treatment to control bacterial overgrowth. In this article we discuss bacteriophage and potential use in future therapy.

Retrospective study to estimate the prevalence of HER2-low breast cancer (BC) and describe its clinicopathological characteristics

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Background: Approximately 50% of BCs traditionally categorized as HER2 negative (HER2-neg) express low levels of HER2 (IHC 1+ or IHC 2+/ISH-; Miglietta, NPJ Breast Cancer 2021). HER2-targeted therapies for HER2-low metastatic BC (mBC) are under investigation (eg, T-DXd in the phase 3 DESTINY-Breast04 study; NCT03734029), but HER2 assays currently used to select patients (pts) for approved anti-HER2 therapies are optimized for high HER2 expression and are not validated for HER2-low detection. A recent study found relatively poor agreement (<70% interrater agreement) in evaluation of IHC scores of 0 and 1+ using current HER2 assays (Fernandez, JAMA Oncol 2022). Our objectives were to assess the prevalence of HER2-low among HER2-neg based on rescored HER2 IHC slides after training on low-end expression scoring and to describe pt characteristics of HER2-low vs HER2 IHC 0 mBC. Preliminary results are reported for 233 of 1000 planned pts. Methods: This multicenter, retrospective study (NCT04807595) included pts with confirmed HER2-neg unresectable/mBC diagnosed between 2015 and 2017. Local laboratories, blinded to historical HER2 scores, rescored HER2 IHC-stained slides. HER2 was assessed using Ventana 4B5 and other assays. BCs were categorized as HER2-low or HER2 IHC 0. The prevalence of HER2-low BC among pts originally scored as HER2-neg was measured. Demographics (eg, age, country, race) and clinicopathological characteristics were examined via medical charts/electronic health records. Concordance between historical HER2 scores and rescores was assessed. Results: HER2 rescores were obtained for 233 pts (mean age, 54 y). HER2-low prevalence was 63.2% overall and numerically greater in hormone receptor (HR)–positive vs HR-negative subgroups (66.1% vs 54.8%; Table). No notable differences in prevalence were seen among different HER2 assays or in demographic/baseline disease characteristics between the HER2-low and HER2 IHC 0 groups. Concordance rate between historical and rescored slides for HER2-status classification was 82.3%. The presentation will include an expanded data set (≈400 pts) with additional results. Conclusions: Data on HER2-low prevalence in BC is limited. Preliminary data from this study of mBC samples suggest a somewhat higher prevalence estimate (≈63%) than a previous study of primary BC samples (≈50%). Concordance was 82%; ongoing analyses with updated data will clarify the concordance between rescored and historical HER2 slides. These data can support development of best practices for identifying pts with HER2-low expression who may benefit from HER2-targeted therapies. Clinical trial information: NCT04807595. [Table: see text]

Real-world burden of adverse events for apalutamide- or enzalutamide-treated non-metastatic castration-resistant prostate cancer patients in the United States

Background

Second-generation androgen receptor inhibitors (ARIs) have been associated with adverse events (AEs) such as fatigue, falls, fractures, and rash in non-metastatic castration-resistant prostate cancer (nmCRPC) patients as identified in clinical trials. The objectives of this study were to describe the incidence and management of AEs in patients receiving apalutamide and enzalutamide.

Methods

This retrospective chart review study was conducted in nmCRPC-treating sites in the United States. Patients starting apalutamide or enzalutamide between February 1, 2018 and December 31, 2018 were included and any AEs they experienced were recorded. AEs, including those considered to be of special interest as defined in the pivotal clinical trials of the second-generation ARIs, were analyzed and grouped retrospectively in this study. Detailed chart data (patient demographics, clinical characteristics, treatment history, type of AE, outcomes, and resource utilization) were then collected for a randomly selected subset among patients with ≥1 AE to characterize AEs and their management. Descriptive results were summarized.

Results

Forty-three sites participated in the study. A total of 699 patients were included, of whom 525 (75.1%) experienced ≥1 AE. The most common AEs were fatigue/asthenia (34.3%), hot flush (13.9%), and arthralgia (13.6%). In the subset of 250 patients randomly selected from those who experienced ≥1 AE, patients were primarily White (72.0%), the mean age was 71 years, 86.0% had an Eastern Cooperative Oncology Group score of 0–1 at nmCRPC diagnosis, and the average prostate specific antigen (PSA) value at diagnosis was 23.2 ng/mL. PSA-doubling time < 10 months was chosen as reason to initiate treatment in 40% of patients. The median duration of follow-up was 1.1 years, with 14.4% of patients progressing to metastasis by end of study period. Grade 3–4 and Grade 5 AEs occurred in 14.4 and 0.4% of patients, respectively. Actions taken to manage AEs included AE-directed treatment (38.0%), ARI discontinuation (10.4%), dose reduction (7.6%), and AE-related hospitalization (4.8%).

Conclusions

This study highlights the burden of AEs among nmCRPC patients treated with apalutamide or enzalutamide, providing a relevant real-world benchmark as clinical trial evidence and the treatment landcape for nmCRPC continues to evolve.

Frequency, management, and resource use of adverse events (AEs) in nonmetastatic castrate-resistant prostate cancer (nmCRPC) patients receiving apalutamide or enzalutamide: A real-world study

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Background: Second generation androgen receptor inhibitors (SGARIs), apalutamide (APA) and enzalutamide (ENZ) and darolutamide, are approved in the United States (US) for the treatment of nmCRPC. The objectives of this study were to describe the frequency of AEs and actions taken to manage AEs among nmCRPC patients treated with APA or ENZ and their downstream resource implications. Methods: This is a further descriptive analysis of a retrospective chart review study conducted in 43 US nmCRPC-treating sites. In our sample, the 43 physicians identified 699 nmCRPC patients initiating treatment with APA (N = 368) or ENZ (N = 333) with 2 patients receiving both, between February 1, 2018 and December 31, 2018 and AEs were collected as reported in regular clinical practice. A representative subset of patients, experiencing at least 1 AE for either APA (N = 125) or ENZ (N = 125), were selected randomly from the initial cohort, and their detailed chart data were extracted to understand the actions taken to manage AEs. Results: Of the initial cohort of nmCRPC patients, 72.0% and 78.7% of men receiving APA (N = 368) and ENZ (N = 333) experienced ≥1 AE, respectively. The three most common AEs reported were fatigue/asthenia (APA, 30.2%; ENZ, 38.7%), hot flush (APA, 14.1%; ENZ, 13.5%), and arthralgia (APA, 14.4%; ENZ, 12.9%). Cognitive and mental changes were observed in 5.4% (APA) and 7.8% (ENZA) men. The subset analysis of randomly selected patients experiencing ≥1 AE (APA, 125; ENZ, 125) were mostly Caucasian (APA, 72.8%; ENZ, 71.2%), ECOG score 0-1 (APA, 84%; ENZ, 88%), median prostate specific antigen (PSA) value 13 ng/ml and 11 ng/ml (APA, ENZ; respectively). Actions to address AEs included treatment of AE, SGARI discontinuation, dose reduction and hospitalization (Table). Specifically, treatment discontinuation due to AE was observed in 8.0% (APA) and 12.8 (%) of men. AEs were often not resolved (APA, 43.6%; ENZ, 39.4%), and the median duration of days to resolve AEs were 60.0 for APA and 56.0 for ENZ. Conclusions: This real-world study highlights the clinical and resource use burden of AEs among nmCRPC patients treated with APA and ENZ. The results demonstrate the importance of safety and tolerability as key considerations in shared clinician-patient decision-making regarding SGARI therapy in nmCRPC. [Table: see text]

Patient-reported outcomes in schizophrenia patients treated with once-monthly extended-release risperidone in a long-term clinical study

PURPOSE

RBP-7000 (PERSERIS™) is a once-monthly subcutaneous extended-release risperidone formulation approved by the United States Food and Drug Administration for the treatment of schizophrenia in adults. The objective of this study was to describe the long-term impact of RBP-7000 on health-related quality of life (HRQoL), subjective well-being, treatment satisfaction and medication preference in patients with schizophrenia.

PATIENTS AND METHODS

HRQoL was derived from a 52-week multicentre Phase III single-arm open-label outpatient study that assessed the safety and efficacy of RBP-7000 (120 mg) in patients with schizophrenia. HRQoL was measured using the EuroQol EQ-5D-5L and Short-Form Survey SF-36 version 2; well-being using the Subjective Well-being Under Neuroleptic Treatment - Short Version (SWN-S); satisfaction using the Medication Satisfaction Questionnaire and medication preference using the Preference of Medication questionnaire.

RESULTS

Of 482 participants at baseline, 234 remained through the end of study (EOS; week 52). Mean HRQoL and well-being scores remained stable between baseline (EQ-5D-5L index: 0.83; SF-36v2 Physical Component Score: 50; SF-36v2 Mental Component Score: 46; total SWN-S score: 89) and EOS (EQ-5D-5L index: 0.86; SF-36v2 Physical Component Score: 49; SF-36v2 Mental Component Score: 47; total SWN-S score: 90). The proportion of participants reporting satisfaction increased between week 4 (66%) and EOS (81%), with a similar trend for the preference of RBP-7000 over previous treatment (week 4: 66%; EOS: 72%). Sensitivity analyses suggested a minor effect of dropout on characterization of change over time in patient-reported outcomes (PRO) measures.

CONCLUSION

Study participants attained mean HRQoL scores near that of the general US population. Over two-thirds reported high satisfaction with and preference for RBP-7000 across the study period. Additional research is needed to confirm whether these PRO translate into improved outcomes such as adherence and ultimately fewer relapses in patients with schizophrenia.

Longitudinal treatment patterns and adverse events (AEs) in younger patients (Pts) with metastatic triple-negative breast cancer (mTNBC): A real-world landscape analysis

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Background: While no uniform standard of care exists for mTNBC, conventional chemotherapy remains the treatment mainstay. This retrospective analysis of U.S. commercial claims data was conducted to characterize real-world longitudinal chemotherapy treatment patterns and predictors of AEs in mTNBC. Methods: We assessed all pts with mTNBC aged 18-60 years starting first-line (1L) chemotherapy from 01/01/2011 to 12/31/2015 in the IMS LifeLink database, which does not report on investigational therapies. Longitudinal treatment patterns, treatment duration, and AEs were characterized by line-of-therapy (LOT). The primary and secondary endpoints were any AE and treatment duration. Multivariable logistic and Cox regression analyses were used to identify clinical risk factors for AEs and predictors of longer treatment duration, respectively. Results: 1,447 mTNBC pts receiving ≥1 LOT were identified (median [range] age, 51 [24-60] years), of which 54% received ≥2 and 8% ≥3 LOT. Combination therapy (combi-Tx) was used as 1L for 73%, second-line (2L) for 22%, and third-line (3L) for 32% of pts. The most common combi-Tx was cyclophosphamide/doxorubicin (1L: 40%; 2L: 5%), and carboplatin/gemcitabine in 3L (17%). The most common 1L and 2L monotherapies (mono-Tx) were taxanes (10% and 66%), and 3L capecitabine (13%). Median treatment duration for 1L to 3L was 56-58 days, and for combi- vs mono-Tx in 1L, 50 vs 71 days. The proportion of pts experiencing any AE was 34% during 1L, 38% during 2L, and 56% during 3L therapy. After adjusting for key confounders including Charlson comorbidity index, independent risk factors for AEs were later LOT, 3L vs 1L (OR = 3.20, 95%CI: 2.13-4.79), and younger age groups vs age 55-60 (OR = 1.94, 95%CI: 1.48-2.55). Additional analysis will assess independent predictors of treatment duration. Conclusions: This real-world study reveals considerable treatment heterogeneity and short treatment durations even with conventional combination chemotherapies. Among non-Medicare mTNBC pts, younger age is a risk factor for AEs possibly due to more aggressive therapies. More treatment options are needed for pts with mTNBC.

Value of hospital antimicrobial stewardship programs [ASPs]: a systematic review

Background

Hospital antimicrobial stewardship programs (ASPs) aim to promote judicious use of antimicrobials to combat antimicrobial resistance. For ASPs to be developed, adopted, and implemented, an economic value assessment is essential. Few studies demonstrate the cost-effectiveness of ASPs. This systematic review aimed to evaluate the economic and clinical impact of ASPs.

Methods

An update to the Dik et al. systematic review (2000–2014) was conducted on EMBASE and Medline using PRISMA guidelines. The updated search was limited to primary research studies in English (30 September 2014–31 December 2017) that evaluated patient and/or economic outcomes after implementation of hospital ASPs including length of stay (LOS), antimicrobial use, and total (including operational and implementation) costs.

Results

One hundred forty-six studies meeting inclusion criteria were included. The majority of these studies were conducted within the last 5 years in North America (49%), Europe (25%), and Asia (14%), with few studies conducted in Africa (3%), South America (3%), and Australia (3%). Most studies were conducted in hospitals with 500–1000 beds and evaluated LOS and change in antibiotic expenditure, the majority of which showed a decrease in LOS (85%) and antibiotic expenditure (92%). The mean cost-savings varied by hospital size and region after implementation of ASPs. Average cost savings in US studies were $732 per patient (range: $2.50 to $2640), with similar trends exhibited in European studies. The key driver of cost savings was from reduction in LOS. Savings were higher among hospitals with comprehensive ASPs which included therapy review and antibiotic restrictions.

Conclusions

Our data indicates that hospital ASPs have significant value with beneficial clinical and economic impacts. More robust published data is required in terms of implementation, LOS, and overall costs so that decision-makers can make a stronger case for investing in ASPs, considering competing priorities. Such data on ASPs in lower- and middle-income countries is limited and requires urgent attention.

Treatment patterns in metastatic triple-negative breast cancer (mTNBC)

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Background: Real-world treatment patterns have not been extensively described in mTNBC. There is no generally accepted standard of care (SoC) in mTNBC or consensus regarding the use of multidrug regimens. We assessed drug-utilization patterns in commercially-insured US patients (pts) with mTNBC. Methods: Adult females with ≥1 breast cancer and ≥1 distant secondary malignant neoplasm diagnosis codes (2011-2015) were identified from the IMS LifeLink claims database. mTNBC status was approximated via receipt of any chemotherapy (chemo) post-metastatic diagnosis (mDx) in absence of pre-/post-mDx hormone replacement therapy/contraceptives or trastuzumab usage. First regimen (FR) was defined as the first chemo agent used post-mDx; chemo agents started ≤30 days of this first agent were counted as combination (combo) FR. Second regimen (SR) was defined as the chemo agent following FR by >30 days, or the same agent if there was a ≥90-day gap after FR. Kaplan-Meier survival curves were used to estimate time to SR initiation. Predictors of FR combo therapy and SR initiation were identified via logistic and Cox proportional hazard (CPH) regressions, respectively. Results: 2,949 pts received FR (median age: 53 years). Progression to SR occurred in 54% and 68% of pts at 12 and 36 months post-FR initiation, respectively. Median (95% CI) time between FR and SR was 81 (75-87) days. 39% and 27% of pts in FR and SR received combo therapy. Patients with age <55, surgery, no radiation, or more comorbidities during the pre-metastatic period were more likely to receive combo FR (Table). Pts with no surgery, more comorbidities, or combo FR, were more likely to start SR. Conclusions: There is no generally accepted SOC in mTNBC.Over half of mTNBC pts do not receive combo therapy and a majority progress to a SR within 1 year. [Table: see text]

Prevalence of Antidiabetic and Antilipidemic Medications in Children and Adolescents Treated With Atypical Antipsychotics in a Virginia Medicaid Population

BACKGROUND

Atypical antipsychotic use among children and adolescents is a cause for concern secondary to metabolic adverse effects. There have been reports of weight gain, metabolic syndrome, dyslipidemia, glucose abnormalities, and decreased insulin sensitivity in children aged 4 to 19 years using atypical antipsychotics.

OBJECTIVE

To determine the prevalence of antidiabetic and antilipidemic medication use among children and adolescents receiving atypical antipsychotics and to evaluate whether the odds of receiving antidiabetic and antilipidemic medication differs among atypical antipsychotic agents.

METHODS

This retrospective cross-sectional study included Virginia Medicaid beneficiaries (2-17 years) continuously enrolled from August 1, 2010, to July 31, 2011. The participants were categorized into atypical antipsychotic exposed and unexposed. The prevalence of antidiabetic and antilipidemic medication use within the groups was computed. Logistic regression was used to calculate the odds of receiving antidiabetic or antilipidemic medication after controlling for age, sex, and race.

RESULTS

A total of 299593 and 4922 beneficiaries were identified in unexposed and exposed groups, respectively. The prevalence of antidiabetic medication use was 0.32% in the unexposed and 1.40% in the exposed group (P < 0.0001). Prevalence of antilipidemic medication use was 0.09% in the unexposed and 0.35% in the exposed group (P < 0.0001). Risperidone and quetiapine users had lower odds than olanzapine users of receiving antidiabetic medication. No differences between the odds of receiving antilipidemic medication among the different antipsychotics (P = 0.1653) were observed.

CONCLUSIONS

Prevalence of antidiabetic and antilipidemic medication use was significantly higher among children and adolescent atypical antipsychotic users in a Virginia Medicaid population.

Effectiveness of a Pharmacist-Physician Team-Based Collaboration to Improve Long-Term Blood Pressure Control at an Inner-City Safety-Net Clinic

PURPOSE

To evaluate the effectiveness of a pharmacist-physician collaborative practice model (PPCPM) to improve long-term blood pressure (BP) control rates in a primarily African-American underserved urban population.

PRACTICE INNOVATION

Volunteer physicians established initial diagnoses, whereas pharmacists provided most (more than 70%) of the medication management. During each scheduled visit, the pharmacist reconciled the medication list, completed a clinical interview, conducted a focused physical examination, developed and implemented a treatment plan, and provided documentation in a shared medical record.

EVALUATION

A retrospective chart review was performed to collect data for a longitudinal cohort of patients managed by the PPCPM from 2010-2013.

RESULTS

Of 385 patients with at least two pharmacist visits during 2009, 172 patients received continuous care over the study period. At baseline, the mean age of the cohort was 51.3 years, 62% were female, and 76% were African-American. Approximately 65% were obese (body mass index 30 kg/m(2) or higher), and 39% were cigarette smokers. Mean baseline BP was 156/98 mm Hg, with only 17% of the cohort at their BP goal of lower than 140/90 mm Hg. The BP control rate improved to 66% during the first year and persisted throughout the study period, with 68% of patients at goal in 2013 (p<0.05 compared with baseline).

CONCLUSION

The PPCPM BP control rate ranks in the 90th percentile of National Committee for Quality Assurance benchmarks and was superior even to the 2013 reported mean for commercial insurers. The PPCPM effectively improved hypertension control in an uninsured, primarily African-American, urban population despite significant health barriers. Key elements of this asynchronous care model included access to a common medical record, optimization of distinct interprofessional roles, frequent follow-up with evaluation, and collaborative practice agreement with sufficient scope of practice to implement medication changes at the time of the visit.

The heritability of delusional-like experiences

OBJECTIVE

Delusional-like experiences (DLE) are common in the general community and are associated with a family history of mental illness. The aim of this study was to estimate the heritability of DLE.

METHOD

The Peter's Delusional Inventory (PDI) was administered to a population-based cohort of mothers (n = 2861, aged 35-67 years) and their adult offspring (n = 3079, aged 18-23 years). Heritability of DLE was estimated from the sum scores of the 21 item PDI under the assumption that the covariance between mother-offspring scores is attributable to shared additive genetic factors.

RESULTS

The means (medians and standard deviations) for the total PDI scores for the mothers and their offspring were 3.6 (3.0, 3.0) and 5.0 (4.0, 3.5), respectively. The Pearson correlation coefficient between mother and offspring PDI scores was 0.17 (P < 0.001). The heritability was estimated to be 0.35 (standard error 0.04).

CONCLUSION

Heritable factors contribute to over a third of the variance of PDI scores in this population. In light of the association between a family history of a wide range of mental disorders and DLE, these experiences may represent a useful quantitative endophenotype for genetic studies of common mental disorders in population settings.

Socio-economic disadvantage and delusional-like experiences: a nationwide population-based study

PURPOSE

Delusional-like experiences (DLE) have been associated with low income, suggesting that more broadly defined socio-economic disadvantage may be associated with these experiences. We had the opportunity to explore the association between DLE and both individual- and area-level measures of socio-economic disadvantage.

METHOD

Subjects were drawn from the Australian National Survey of Mental Health and Wellbeing 2007. The Composite International Diagnostic Interview was used to identify DLE, common psychiatric disorders, and physical disorders. Individual-level and area-level socio-economic disadvantage measures were available based on variables including income, educational attainment, employment status, and housing. We examined the relationship between the variables of interest using logistic regression, adjusting for potential confounding factors.

RESULTS

Of the 8773 subjects, 8.4% (n=776) positively endorsed one or more DLE. DLE screen items were more likely to be endorsed by those who were (a) younger, (b) never married, or widowed, separated or divorced status, (c) migrants, or (d) living in rented houses. There were significant associations between socio-economic disadvantage and increased DLE endorsement, and this was found for both individual-level and area-level measures of socio-economic disadvantage. In general, the associations remained significant after adjusting for a range of potential confounding factors and in planned sensitivity analyses.

CONCLUSIONS

DLE are associated with socio-economic disadvantage in the general population. We speculate that the link between socio-economic disadvantage and DLE may be mediated by psychosocial stress and general psychological distress.

Cryopreservation of shoot tips of Trichilia emetica, a tropical recalcitrant-seeded species

This paper reports the successful cryopreservation of shoot tips of Trichilia emetica, a tropical tree species producing recalcitrant seeds. Preculture of shoot tips on MS medium with 0.7 M sucrose or with 0.3 M sucrose + 0.5 M glycerol followed by cryoprotection with a mixture of glycerol and DMSO or with PVS2 was crucial for successful recovery following cryostorage. Three cooling rates were applied to assess the effects on post-thaw regrowth of shoot tips. Slow cooling of the shoot tips (WC 1.24 g/g DW) precultured on medium with 0.3 M sucrose + 0.5 M glycerol and cryoprotected with PVS2 resulted in high shoot production (71 percent). Subsequent to relatively faster cooling, only 38 percent of the shoot tips developed shoots. Ultra-rapid cooling with PVS2 resulted in callus formation with 55 percent regrowth. We report one of the very few successful attempts to cryopreserve explants alternative to zygotic axes of tropical tree species producing recalcitrant seeds.

Quality-of-life study on four patients who underwent esophageal resection and delayed reconstruction for Boerhaave's syndrome

Boerhaave's syndrome is the condition of spontaneous rupture of the esophagus as a consequence of the strain of emesis with or without predisposing esophageal disease. It is a condition with high mortality. We describe four patients who underwent a transthoracic esophagectomy to remove the rupture of the intrathoracic esophagus, closure of the esophageal gastric junction, fashioning of a feeding gastrostomy, and formation of a left cervical esophagostomy. Three patients underwent reconstruction with subcutaneous colon. We suggest that this method of management may be considered where primary repair is impossible in those patients too ill for prolonged reconstruction or as a salvage procedure where other methods have failed. The poor quality of life after esophagectomy is improved by reconstruction. Other surgical options include covering the repaired opening with a circumferential wrap of pleura, chest wall muscle, or omentum or closing the repair around a T-tube of large caliber. Esophageal exclusion using absorbable staples is another approach.

Outcome of non-elective coronary artery bypass grafting without cardio-pulmonary bypass

OBJECTIVES

There is limited experience in the use of beating heart coronary artery bypass grafting (CABG) in emergency and urgent cases. The aim of this study was to retrospectively assess the safety and efficacy of this technique when used in a non-elective setting.

METHODS

We retrospectively reviewed all urgent and emergency cases of coronary artery bypass grafting performed without cardiopulmonary bypass (CPB) from July 1999 to February 2000. There were 35 patients in total. The mean age was 64.8+/-11.9. Twenty-six (74.3%) patients had Canadian Cardiovascular Society grade 4 angina. Twenty-six patients (74.3%) had triple vessel disease. Eleven patients (31.4%) were on preoperative IV nitrates and nine patients (25.7%) had a preoperative IABP (intra aortic balloon pump). Three patients (8.6%) had suffered a preoperative cardiac arrest during coronary angiography. Other associated significant risk factors were smoking (60%), hypertension (40%), hypercholesterolemia (57.1%) and previous Q wave myocardial infarction (31.4%).

RESULTS

Twenty-two patients (62.9%) were classified as being urgent and 13 patients (37.1%) were classified as emergencies. The mean number of anastomoses performed were 2.8+/-0.8 (range 1-4) with 68.6% of patients under going triple or quadruple vessel grafting. All patients (100%) received at least one arterial graft. There was no conversion to cardiopulmonary bypass. The main postoperative complications were--supraventricular arrhythmias eight (22.9%), low cardiac output seven (20%) and postoperative HF/dialysis two (5.7%). The median postoperative intensive care unit (ICU) stay was 27.5 h. The mean postoperative hospital stay was 8.3+/-3.1 days. One patient died (2.9%) at the eighth day after surgery due to postoperative myocardial infarction, multi-organ failure secondary to the septicaemia and ventricular arrest.

CONCLUSION

Non-elective CABG without CPB is feasible and safe with modern cardiac stabilization devices.

Repair of pulmonary vein rupture after deceleration injury

Injuries to the major pulmonary vessels are uncommon and are extremely difficult to manage. We report a case of an isolated pulmonary vein injury following a road traffic accident that was repaired successfully.

Improving senior house officer training in accident and emergency medicine: the benefits of a diploma

Accident and emergency is a fascinating specialty providing exposure to a wide range of acute and chronic conditions from all branches of medicine. To ensure a minimal standard of training nationally we propose the introduction of a diploma for junior doctors.

Surgical training for the next millennium

The Calman reforms in training have meant that surgical training now consists of a 2-year basic training period followed by a 6-year period of higher surgical training. This article addresses the problems faced by the new Calman surgical trainees and proposes some new measures which could be introduced for surgical training in the next millennium.

An inexpensive and easily constructed laparoscopic simulator

In this short article the authors describe a simple yet effective method to train surgical trainees in minimally invasive surgery. This method will allow trainees to freely practice and acquire the necessary basic skills required to both competently assist and perform laparoscopic surgery.