Telehealth Preferences Among Patients With Advanced Cancer in the Post COVID-19 Vaccine Era

BACKGROUND

Few studies have examined patient preferences for telehealth in palliative care after the availability of COVID-19 vaccines. We examined patient preferences for video versus in-person visits and factors contributing to preferences in the postvaccine era.

METHODS

This is a cross-sectional survey of patients who were seen at our palliative care clinic between April 2021 and March 2022. Patients were surveyed directly their preference for either video or in-person visits for outpatient palliative care (primary outcome). We also surveyed preferences including convenience, cost, wait time, and perceptions of COVID-19 safety regarding their palliative virtual-video visit. We examined clinical factors associated with preferences with multivariate logistic regression.

RESULTS

About 200 patients completed the survey. 132 (67%, 95% confidence interval [CI]: 60%, 74%) preferred virtual-video, while 16 (8%) preferred in-person visits during the COVID-19 pandemic. About 120 (61%, 95%CI: 54%, 68%) preferred virtual-video after the pandemic. Patients perceived virtual-video favorably regarding travel and related costs (179 [91%]), convenience (175 [88%]), and wait time (136 [69%]). Multivariable analysis showed concerns for catching COVID-19 from healthcare providers (odds ratio [OR]: 4.20; 95%CI: 1.24-14.25; P = 0.02) and feeling comfortable with computers or mobile devices (OR: 4.59; 95%CI: 1.02, 20.60; P = 0.047) were significantly associated with preferring virtual-video. Patients who were of Hispanic or Latino ethnicity (OR: 0.25; 95%CI: 0.09, 0.71) and had increased dypsnea (OR: 0.74; 95%CI: 0.59, 0.93) were less likely to prefer video over in-person.

CONCLUSION

Patients expressed strong preference for video over in-person visits in the outpatient palliative care setting.

Impact of Dosing and Duration of Dexamethasone on Serious Corticosteroid-Related Adverse Events

CONTEXT

Corticosteroids are commonly prescribed in oncology, but few studies have examined its adverse events (AEs) compared to placebo control.

OBJECTIVES

Using data from a double-blind, placebo-controlled randomized trial, we evaluated the association between the dose and duration of dexamethasone and serious AEs.

METHODS

This is a pre-planned secondary analysis of the Alleviating Breathlessness in Cancer Patients with Dexamethasone (ABCD) trial in which patients were randomized to dexamethasone 8 mg BID x1 week, then 4 mg BID x1 week or placebo, followed by an optional open-label phase with 4 mg BID x1 week, then 2 mg BID x1 week. The primary outcome was Grade 3+ AEs (CTCAE v4.03). We evaluated the association between AEs and dexamethasone exposure using multivariable logistic regression.

RESULTS

Among 119 cancer patients, 32 received intervention followed by open label (mean exposure 243 mg over 27 days), 47 received intervention with no open label, 20 received placebo followed by open label, and 20 received no dexamethasone. The most common AEs included insomnia (31%), dyspepsia (21%), neuropsychiatric symptoms (18%), and infections (17%). Overall, 38 (32%) had Grade 3+ AEs and 27 (23%) were hospitalized. Patients with the greatest exposure to dexamethasone experienced more Grade 3+ AEs compared to those with no exposure (65% vs. 15%); odds ratio of 15.1 (95% CI 1.4-160.8, P = 0.01).

CONCLUSION

Greater dexamethasone exposure, even at moderate doses, was associated with more serious AEs. Prescribers should cautiously weigh the risks and benefits of dexamethasone use, especially when considering for palliation of symptoms.

Postvaccine Era COVID-19 Pandemic-Related Distress in Palliative Care Patients With Advanced Cancer

CONTEXT

The COVID-19 pandemic represents a source of distress in patients with advanced cancer; however, few studies have examined the extent of pandemic-related distress in the postvaccine era.

OBJECTIVES

We conducted a cross-sectional survey to examine pandemic-related distress among patients seen by palliative care after vaccine availability.

METHODS

Patients at our palliative care clinic were surveyed from April 2021 to March 2022 regarding 1) pandemic-related distress level, 2) potential contributors to pandemic-related distress, 3) coping strategies, 4) demographic factors and symptom burden. Univariate and multivariate analyses identified factors associated with pandemic-related distress.

RESULTS

A total of 200 patients completed the survey. Of 79 (40%, 95% confidence interval [CI]: 33%, 46%) reported worse pandemic-related distress. Patients who reported greater distress were more likely to report worse social isolation (67 [86%] vs. 52 [43%]), staying home more often (75 [95%] vs. 95 [79%]), more negative experience staying at home (26 [33%] vs. 11 [9%]), worse stress with child-care duties (14 [19%] vs. 4 [3%]), less seeing family/friends (63 [81%] vs. 72 [60%]), and more difficulty traveling to medical appointments (27 [35%] vs. 20 [17%]). Thirty-seven patients (19%) reported more difficulty getting medical appointments. In multivariable analysis, younger age (odds ratio [OR], 0.97; 95% CI, 0.92-0.99; P = 0.01), worse isolation status (OR, 6.87; 95% CI, 2.76-17.12; P < 0.001), and more negative attitude towards staying home (OR, 4.49; 95% CI, 1.6-12.57; P = 0.004) were associated with pandemic-related distress.

CONCLUSIONS

Patients with advanced cancer continued to experience pandemic-related distress in the postvaccine era. Our findings highlight potential opportunities to support patients.

Characterization of industry relationships in oncology

BACKGROUND

Collaborative relationships between academic oncology and industry (pharmaceutical, biotechnology, "omic," and medical device companies) are essential for therapeutic development in oncology; however, limited research on engagement in and perceptions of these relationships has been done.

METHODS

Survey questions were developed to evaluate relationships between academic oncology and industry. An electronic survey was delivered to 1000 randomly selected members of the American Society of Clinical Oncology, a professional organization for oncologists, eliciting respondents' views around oncology-industry collaborations. The responses were analyzed according to prespecified plans.

RESULTS

There were 225 survey respondents. Most were from the United States (70.0%), worked at an academic institution (60.1%), worked in medical oncology (81.2%), and had an active relationship with industry (85.8%). One quarter (26.7%) of respondents reported difficulty establishing a relationship with industry collaborators, and most respondents (75%) did not report having had mentorship in developing these relationships. The majority (85.3%) of respondents considered these collaborations important to their careers. Respondents generally thought that scientific integrity was preserved (92%), and most respondents (95%) had little concern over the quality of the collaborative product. Many (60%) shared concerns over potential conflict of interest if an individual with a compensated relationship promoted an industry product for clinical care/research, yet most respondents (67%) stated these relationships did not shape their interactions with patients.

CONCLUSIONS

This study provides novel data characterizing the nature of collaborative relationships between clinicians, researchers, and industry in oncology. Although respondents considered these collaborations an important part of clinical and academic oncology, formal education or mentorship around these relationships was rare. Conflicting findings around conflict of interest highlight the importance of more dedicated research in this area.

PLAIN LANGUAGE SUMMARY

Business enterprises in health care play a central role in cancer research and care, driving the development of new medical testing, drugs, and devices. Effective working relationships among clinicians, researchers, and these industry partners can promote innovative research and enhance patient care. Study of these collaborations has been limited to date. Through distribution of a questionnaire to cancer clinicians and researchers, we found that most participants consider these relationships valuable, though they find establishing such relationships challenging partly because of gaps in educational programs in this area. Our findings also highlight the need for further policy around the potential bias these relationships can introduce.

Attitudes of Palliative Care Specialists Toward Assessing Sexual Dysfunction in Patients With Cancer

CONTEXT

The sexual health of patients is frequently neglected.

OBJECTIVES

To evaluate the attitudes and beliefs of palliative care providers toward discussing the presence of sexual dysfunction (SD) in patients with cancer METHODS: In this pilot study, an anonymous survey was conducted among palliative care professionals about their attitudes toward discussing SD RESULTS: Forty-nine (89%) palliative care providers completed the survey. Thirty-four (69%) responded that they rarely or never discussed sexuality with their patients and most believed it is the oncologist's responsibility. The top reasons for not discussing SD were that the patient did not raise the issue, lack of time and the presence of a third party. The majority acknowledged the need of more training and that printed materials would be helpful.

CONCLUSION

Palliative care providers infrequently address the presence of SD among patients with cancer. Additional training and routine screening for SD might help addressing this problem.

Endometrial cancer patients understanding and interest in weight loss surgery

OBJECTIVE

Obesity is a risk factor for endometrial hyperplasia (EH), endometrial intraepithelial neoplasia (EIN), and early type 1 endometrial cancer (EC) in 70%-90% of patients and is often a significant contributor to overall morbidity and mortality due to comorbidities. In 2011, bariatric surgery (BS) with lifestyle modification was identified as an intervention for reduction in overall mortality as well as risk for gynecologic cancers (Tsui et al., 2021). Our aim was to assess awareness of obesity as a risk factor and understanding of BS in an underinsured obese patient population with EC or EH.

METHOD

This IRB-approved survey was distributed to patients with type I EC or EH within the past 5 years and a BMI >30. Questions addressed demographics, health habits, cancer and obesity awareness, as well as benefits and concerns about undergoing BS. Information was provided about dietary requirements after BS, and then interest in BS was surveyed.

RESULTS

61.2% of surveyed patients were interested in bariatric surgery for weight loss after receiving education about the procedure. Interest in bariatric surgery was correlated with higher BMI, higher ideal and comfortable weight loss in pounds and higher estimated weight loss that could be obtained with bariatric surgery. Additionally, patients who were interested in BS had better understanding of the risks of obesity with cancer overall.

CONCLUSION

Obese patients with history of EC/EIN/EH are aware of hazards associated with excess weight and understand the relationship between EC/EIN/EH diagnosis and obesity, and overall are very interested in BS as a modality to improve their health.

Evaluation of a Daily Nine-Item "Handbook for Self-Care at Work" for Palliative Care Clinicians

Context: A daily nine-item "Handbook for Self-Care at Work" was created to increase the well-being and satisfaction of the staff at the department of palliative care of a tertiary oncological center in the United States. Objectives: To evaluate the perceived usefulness of and adherence to the Handbook. Design, Setting and Participants: An anonymous survey was conducted among the palliative care staff asking for the frequency of utilization and the perception of usefulness of the Handbook. Additional data collected included demographics, satisfaction with professional life, frequency of burnout, and frequency of callousness toward people. We also compared the use and perception of the Handbook before and during the COVID-19 pandemic. Results: Of 52 palliative care clinicians, 39 (75%) completed the survey. Most participants were women and were <49 years. Most respondents (59%) found the Handbook useful or very useful. Offer help, ask for help, and hydration were perceived as the most useful items. The items most frequently achieved were movement, hydration, and eat light. The least useful perceived item was nap time, which was rarely achieved. During the COVID-19 pandemic, 32 (82%) respondents found the Handbook to be as/somewhat more/much more useful, and 29 (75%) were able to adhere to the items as/somewhat more/much more often than before. Conclusion: Most respondents found the Handbook useful and were able to accomplish the items most of the days. During the COVID-19 pandemic, the staff felt that the Handbook was more useful.

Impact of an Interdisciplinary Goals-of-Care Program Among Medical Inpatients at a Comprehensive Cancer Center During the COVID-19 Pandemic: A Propensity Score Analysis

PURPOSE

Many hospitals have established goals-of-care programs in response to the coronavirus disease 2019 pandemic; however, few have reported their outcomes. We examined the impact of a multicomponent interdisciplinary goals-of-care program on intensive care unit (ICU) mortality and hospital outcomes for medical inpatients with cancer.

METHODS

This single-center study with a quasi-experimental design included consecutive adult patients with cancer admitted to medical units at the MD Anderson Cancer Center, TX, during the 8-month preimplementation (May 1, 2019-December 31, 2019) and postimplementation period (May 1, 2020-December 31, 2020). The primary outcome was ICU mortality. Secondary outcomes included ICU length of stay, hospital mortality, and proportion/timing of care plan documentation. Propensity score weighting was used to adjust for differences in potential covariates, including age, sex, cancer diagnosis, race/ethnicity, and Sequential Organ Failure Assessment score.

RESULTS

This study involved 12,941 hospitalized patients with cancer (pre n = 6,977; post n = 5,964) including 1,365 ICU admissions (pre n = 727; post n = 638). After multicomponent goals-of-care program initiation, we observed a significant reduction in ICU mortality (28.2% v 21.9%; change -6.3%, 95% CI, -9.6 to -3.1; P = .0001). We also observed significant decreases in length of ICU stay (mean change -1.4 days, 95% CI, -2.0 to -0.7; P < .0001) and in-hospital mortality (7% v 6.1%, mean change -0.9%, 95% CI, -1.5 to -0.3; P = .004). The proportion of hospitalized patients with an in-hospital do-not-resuscitate order increased significantly from 14.7% to 19.6% after implementation (odds ratio, 1.4; 95% CI, 1.3 to 1.5; P < .0001), and do-not-resuscitate order was established earlier (mean difference -3.0 days, 95% CI, -3.9 to -2.1; P < .0001).

CONCLUSION

This study showed improvement in hospital outcomes and care plan documentation after implementation of a system-wide, multicomponent goals-of-care intervention.

Effect of dexamethasone on dyspnoea in patients with cancer (ABCD): a parallel-group, double-blind, randomised, controlled trial

BACKGROUND

Systemic corticosteroids are commonly prescribed for palliation of dyspnoea in patients with cancer, despite scarce evidence to support their use. We aimed to assess the effect of high-dose dexamethasone versus placebo on cancer-related dyspnoea.

METHODS

The parallel-group, double-blind, randomised, controlled ABCD (Alleviating Breathlessness in Cancer Patients with Dexamethasone) trial was done at the at the University of Texas MD Anderson Cancer Center and the general oncology clinic at Lyndon B Johnson General Hospital (both in Houston, TX, USA). Ambulatory patients with cancer, aged 18 years or older, and with an average dyspnoea intensity score on an 11-point numerical rating scale (NRS; 0=none, 10=worst) over the past week of 4 or higher were randomly assigned (2:1) to receive dexamethasone 8 mg orally every 12 h for 7 days followed by 4 mg orally every 12 h for 7 days, or matching placebo capsules for 14 days. Pharmacists did permuted block randomisation with a block size of six, and patients were stratified by baseline dyspnoea score (4-6 vs 7-10) and study site. Patients, research staff, and clinicians were masked to group assignment. The primary outcome was change in dyspnoea NRS intensity over the past 24 h from baseline to day 7 (±2 days). Analyses were done by modified intention-to-treat (ie, including all patients who were randomly assigned and started the study treatment, regardless of whether they completed the study). Enrolment was stopped after the second preplanned interim analysis, when the futility criterion was met. This study is registered with ClinicalTrials.gov (NCT03367156) and is now completed.

FINDINGS

Between Jan 11, 2018, and April 23, 2021, we screened 2867 patients, enrolled 149 patients, and randomly assigned 128 to dexamethasone (n=85) or placebo (n=43). The mean change in dyspnoea NRS intensity from baseline to day 7 (±2 days) was -1·6 (95% CI -2·0 to -1·2) in the dexamethasone group and -1·6 (-2·3 to -0·9) in the placebo group, with no significant between-group difference (mean 0 [95% CI -0·8 to 0·7]; p=0·48). The most common all-cause grade 3-4 adverse events were infections (nine [11%] of 85 patients in the dexamethasone group vs three [7%] of 43 in the placebo group), insomnia (seven [8%] vs one [2%]), and neuropsychiatric symptoms (three [4%] vs none [0%]). Serious adverse events, all resulting in hospital admissions, were reported in 24 (28%) of 85 patients in the dexamethasone group and in three (7%) of 43 patients in the placebo group. No treatment-related deaths occurred in either group.

INTERPRETATION

High-dose dexamethasone did not improve dyspnoea in patients with cancer more effectively than placebo and was associated with a higher frequency of adverse events. These data suggest that dexamethasone should not be routinely given to unselected patients with cancer for palliation of dyspnoea.

FUNDING

US National Cancer Institute.

Open-Label Placebo for the Treatment of Cancer-Related Fatigue in Patients with Advanced Cancer: A Randomized Controlled Trial

BACKGROUND

The purpose of this study was to determine the effects of an open-labeled placebo (OLP) compared to a waitlist control (WL) in reducing cancer-related fatigue (CRF) in patients with advanced cancer using Functional Assessment of Chronic Illness Therapy-Fatigue (FACIT-F).

MATERIALS AND METHODS

In this randomized controlled trial, patients with fatigue ≥4/10 on Edmonton Symptom Assessment Scale (ESAS) were randomized to OLP one tablet twice a day or WL for 7 days. On day 8, patients of both arms received a placebo for 3 weeks. Changes in FACIT-F from baseline to day 8 (primary outcome) and at day 29, were assessed. Secondary outcomes included FACT-G, Multidimensional Fatigue Symptom Inventory-SF, Fatigue cluster (defined as a composite of ESAS fatigue, pain, and depression), Center for epidemiologic studies-depression, Godin leisure-time physical activity questionnaire, and global symptom evaluation.

RESULTS

A total of 84/90 (93%) patients were evaluable. The mean (SD) FACIT-F change at day 8 was 6.6 (7.6) after OLP, vs. 2.1 (9.4) after WL (P = .016). On days 15 and 29, when all patients received OLP, there was a significant improvement in CRF and no difference between arms. There was also a significant improvement in ESAS fatigue, and fatigue cluster score in the OLP arm on day 8 of the study (0.029, and 0.044, respectively). There were no significant differences in other secondary outcomes and adverse events between groups.

CONCLUSIONS

Open-labeled placebo was efficacious in reducing CRF and fatigue clusters in fatigued advanced cancer patients at the end of 1 week. The improvement in fatigue was maintained for 4 weeks. Further studies are needed.

Open-labeled placebo for the treatment of cancer-related-fatigue in patients with advanced cancer: Results of a randomized controlled trial

12006

Background: Despite the high frequency of cancer related fatigue (CRF) in patients with advanced cancer (PAdC), there are no effective pharmacological treatments. Our group previously found that the placebo response was 56% among PAdC participating in CRF trials. There are no clinical trials using open label placebo for CRF in PAdC. The purpose of this study was to determine the effects of open labeled placebo (OLP) compared to waitlist control (WLC) in reducing CRF in PAdC using Functional Assessment of Chronic Illness Therapy-Fatigue subscale (FACIT-F). Methods: In this randomized controlled trial, PAdC with fatigue ≥ 4/10 on ESAS were randomized to OLP one tablet twice a day or WLC for seven days (primary end point). After week 1 in patients of both arms received placebo for 3 weeks. Changes in FACIT-F from baseline to Day 8 (primary outcome), and changes after 21 days of placebo in both arms were assessed. Secondary outcomes included quality of life (QOL)[FACT-G], fatigue dimensions(MFSI-SF), depression(CES-D), and Fatigue cluster(ESAS fatigue, pain, and depression). Results: 82/90(91%) patients were evaluable. The adherence to placebo [mean%(SD)], was 93.6(18.6), and 88.1(20.2) at Day 8 and Day 29 respectively in OLP arm, and 89.9 (73) at Day 29 in WLC arm. The mean(SD) FACIT-F change at day 8 was 6.6 (7.6) after OLP, 2.1 (9.4) after WLC (p = 0.016). On days 15 and 29, when all patients received OLP, there was significant improvement of CRF but not difference between arms. FACT-G Total Score, FACT-G EWB, ESAS Fatigue, and Fatigue cluster score, all showed significant evidence of reduced CRF in the OLP arm on Day 8 of the study (p = 0.002, 0.030, 0.029, and 0.044, respectively). There was no significant difference in adverse events between the two groups. Conclusions: Open labeled placebo was efficacious in reducing CRF, fatigue cluster, and QOL in fatigued advanced cancer patients at the end of one week. The improvement in fatigue was maintained for 4 weeks. Further studies of this intervention are justified. Clinical trial information: NCT03927885.

Characterization of industry relationships in oncology

11025

Background: Collaborative relationships between academic oncology and the pharmaceutical industry are essential for therapeutic development in oncology. Despite this, formal training and mentorship in developing productive industry collaborations are not routinely included in oncology training. Since little research has been done to characterize and optimize the efficiency of these relationships, we sought to better understand the nature of such collaborations in order to identify areas for optimization. Methods: An electronic survey was administered to 1000 randomly selected ASCO members. The survey included 23 questions eliciting demographic and practice information, and 26 questions eliciting respondents’ views around oncology-industry collaborations. Survey results were analyzed using descriptive statistics. Results: There were 225 survey respondents. Most were from the United States (70%), worked at an academic institution (60.1%), worked in medical oncology (81.2%), and had an active relationship with industry (85.8%). 26.7 % of respondents reported difficulty establishing a relationship with industry collaborators. Many relied on federal (39.5%) or departmental (30.2%) funding to supplement their research ventures. Partnerships were initiated by the respondents themselves (34.6%) or industry partners (31.9%) with similar frequency, whereas institutional affiliations (15.7%) and collaborative groups (5.8%) were reported as less common means for establishing collaborations. The majority (85.3%) of respondents stated these collaborations were of importance to their career. Inclusion in industry sponsored trials (71.1%) and commitment to research funding (66.3%) were considered early signs of a productive relationship, whereas lack of effective communication (86.1%) or little engagement by senior industry leadership (63.1%) were early red flags. Most respondents (75%) did not report having had mentorship in developing these relationships. Scientific integrity was generally thought to be preserved (92%) and there was little concern over the quality of the collaborative product (95%). Many shared concern over potential conflict of interest if a compensated relationship promoted an industry product for clinical care/research (60%), yet also stated these relationships did not shape their interactions with patients (67%). Conclusions: This study provides novel data characterizing the nature of collaborative industry-academia relationships in oncology. While respondents considered these collaborations an important part of clinical and academic oncology, formal education or mentorship around these relationships is rare. Further study exploring the structure of effective industry collaborations, optimizing methods to provide education in this area at all career stages, navigating conflict of interest issues in these relationships, and understanding industry perspectives is warranted.

Alleviating breathlessness in patients with cancer with dexamethasone (ABCD): A parallel-group, double-blind, randomized clinical trial (RCT)

12112

Background: Systemic corticosteroids are commonly prescribed for palliation of dyspnea in patients with cancer; however, evidence to support their use is limited. A small RCT suggested that dexamethasone may be efficacious. In this confirmatory RCT, we compared the effect of high dose dexamethasone and placebo on dyspnea in patients with cancer. Methods: This NCI-funded, multi-site, double-blind, parallel group RCT enrolled ambulatory patients with cancer, age ≥18, dyspnea ≥4/10 and randomly assigned them to receive dexamethasone 8 mg orally every 12 hours for 7 days followed by 4 mg orally every 12 hours for 7 days or matching placebo capsules. Permuted block randomization (block size = 6, 2:1) was conducted, stratified by baseline dyspnea and study site. Patients, research staff and clinicians were blinded. The primary outcome was change in average dyspnea intensity assessed with a 0-10 numeric rating scale (0 = none, 10 = worst) between baseline and day 7. Secondary outcomes included the Edmonton Symptom Assessment Scale (ESAS) and adverse effects (CTCAE v4.02). Intention-to-treat analysis was conducted with linear models to compare between groups. The planned sample size of 201 patients provided 80% power to detect a mean difference of 1.0 between treatment groups with a two-sided α of 5%, assuming a standard deviation of 2.0 and 15% attrition. (Clinicaltrials.gov NCT03367156). Results: Between 1/11/2017 and 4/23/2021, we enrolled 149 patients and 128 received the blinded study interventions (dexamethasone n = 85, placebo n = 43). Enrollment was terminated early by the Data Safety Monitoring Board when futility criterion was met in pre-planned interim analysis. The mean change in dyspnea NRS intensity between baseline and day 7 was -1.6 (95% CI -2, -1.2) in the dexamethasone group and -1.6 (95% CI -2.3, -0.9) in the placebo group, with no significant between-group difference (mean 0, 95% CI -0.8, 0.7; P = 0.91). Secondary analyses showed that the dexamethasone group had a significantly better ESAS appetite (mean difference -1.2, 95% CI -2.2, -0.1; P = 0.03) and well being (mean -1, 95% CI -1.8, -0.2; P = 0.02), and worse ESAS anxiety (mean 1.1, 95% CI 0.3, 1.9; P = 0.01) and depression (mean 0.9, 95% CI 0.1, 1.7; P = 0.02) compared to placebo. Similar magnitude of changes in dyspnea and ESAS symptoms were observed by day 14. Adverse effects were reported more frequently in the dexamethasone group (any grade): insomnia (38% v. 12%), neuropsychiatric symptoms (31% vs. 7%), infections (21% v. 12%), dyspepsia (26% v. 12%), edema (18% v. 9%), hiccups (12% v. 7%), flushing (9% v. 5%) and respiratory distress (6% v. 0%). More patients in the dexamethasone group required hospitalization within 30 d of last study medication (25% vs. 7%, P = 0.02). Conclusions: High dose dexamethasone did not improve dyspnea in patients with cancer more than placebo and was associated with more adverse events. Clinical trial information: NCT03367156.

Impact of an interdisciplinary goals of care program on hospital outcomes at a comprehensive cancer center during the COVID-19 pandemic: A propensity score analysis

6502

Background: Many hospitals have established goals-of-care (GOC) programs in response to the COVID-19 pandemic; however, few have reported their outcomes. MD Anderson Cancer Center launched a multicomponent interdisciplinary GOC (myGOC) program in March 2020 that involved risk stratification, team huddles to discuss care planning, oncologist-initiated GOC discussions, communication training, palliative care involvement, rapid-response GOC team deployment, and daily monitoring with immediate feedback. We examined the impact of this myGOC program among medical inpatients. Methods: This single-center study with a quasi-experimental design included consecutive adult patients with cancer admitted to medical units at MD Anderson Cancer Center, Texas during an 8-month pre-implementation (May 1, 2019 to December 31, 2019) and post-implementation period (May 1, 2020 to December 31, 2020). The primary outcome was intensive care unit (ICU) mortality. Secondary outcomes included ICU length of stay, hospital mortality, and proportion/timing of patients with in-hospital do-not-resuscitate (DNR) orders, medical power of attorney (MPOA), living will (LW) and out-of-hospital DNR (OOHDNR). Propensity score weighting was used to adjust for differences in potential covariates, including age, sex, cancer diagnosis, race/ethnicity, and Sequential Organ Failure Assessment (SOFA) Score. With a sample size of 600 ICU patients over each time period and a baseline ICU mortality of 28%, we had 80% power to detect a 5% reduction in mortality using a two-tailed test at 5% significance level. Results: This study involved 12,941 hospitalized patients with cancer (Pre n = 6,977; Post n = 5,964) including 1365 ICU admissions (Pre n = 727; Post n = 638). After myGOC initiation, we observed a significant reduction in ICU mortality (28.2% vs. 21.9%; change -6.3%, 95% CI -9.6, -3.1; P = 0.0001). We also observed significant decreases in length of ICU stay (mean change -1.4 days, 95% CI -2.0, -0.7 days; P < 0.0001) and in-hospital mortality (7% vs. 6.1%, mean change -0.9%, 95% CI -1.5%, -0.3%; P = 0.004). The proportion of hospitalized patients with an in-hospital DNR order increased significantly from 14.7% to 19.6% after implementation (odds ratio [OR] 1.4, 95% CI 1.3, 1.5; P < 0.0001) and DNR was established earlier (mean difference -3.0 d, 95% CI -3.9 d, -2.1 d; P < 0.0001). OOHDNR (OR 1.3, 95% CI 1.1, 1.6, P < 0.0007) also increased post-implementation but not MPOA and LW. MPOA, LW and OOHDNR were documented significantly earlier relative to the index hospitalization in the post-implementation period (P < 0.005 for all). Conclusions: This study showed improvement in hospital outcomes and care plan documentation after implementation of a system-wide, multicomponent GOC intervention. Our findings may have implications for GOC programs during the pandemic and beyond.

Personalized sedation goal for agitated delirium in patients with cancer: Balancing comfort and communication

BACKGROUND

Agitated delirium is common and highly distressing. Medications are often needed to reduce agitation, but it is unclear what the desired level of sedation is. This study assessed personalized sedation goals (PSGs) and their predictors for patients in a delirium clinical trial and in clinical vignettes.

METHODS

This was a preplanned secondary analysis of a double-blind randomized clinical trial examining the sedative effect of chlorpromazine and/or haloperidol in patients with agitated delirium. At the baseline, caregivers and nurses were independently asked to select the PSG for the trial patient from 5 choices corresponding to Richmond Agitation Sedation Scale (RASS) scores of 0 or higher (no sedation), -1 to -2, -3, -4, and -5 (deep sedation). Respondents also selected a PSG for 6 vignettes that differed by the level of agitation, ability to communicate, and survival.

RESULTS

Forty-two caregivers and 39 nurses answered questions regarding PSGs. For the trial patient, caregivers preferred RASS scores of -1 to -2 most often (36%), whereas nurses preferred an RASS score of -3 most often (51 %). Caregivers were significantly more likely than nurses to choose lighter sedation (odds ratio [OR], 4.8; P = .01) despite reporting greater delirium-related distress (P = .0006). Patients were undersedated 33% to 53% of the time and oversedated 0% to 15% of the time according to the PSG response criteria. In the case vignettes, deeper sedation was preferred by nurses (P < .0001) and for patients who were unable to communicate (OR, 3.1-4.4; P < .0001) and had a shorter life expectancy (OR, 1.7; P = .002).

CONCLUSIONS

Caregivers often preferred lighter sedation than nurses. Many patients were undersedated in comparison with caregivers' PSGs, and this highlights room for improvement.

LAY SUMMARY

In the last days of life, many patients with cancer develop delirium and become restless/agitated; this can be highly distressing. Caregivers and physicians alike are often concerned about the use of sedatives for agitated delirium and try to find a balance between maximizing comfort and maintaining communication. This study examined the concept of a personalized sedation goal for setting an individualized target for the level of sedation. Caregivers often preferred lighter sedation than nurses. Many patients were undersedated in comparison with caregivers' stated goals, and this highlights room for improvement.

MEK inhibition overcomes resistance to EphA2-targeted therapy in uterine cancer

BACKGROUND

Our pilot clinical study of EphA2 inhibitor (dasatinib) plus paclitaxel and carboplatin showed interesting clinical activity in endometrial cancer with manageable toxicity. However, the underlying mechanisms of dasatinib resistance in uterine cancer are unknown. Here, we investigated potential mechanisms underlying resistance to EphA2 inhibitors in uterine cancer and examined the anti-tumor activity of EphA2 inhibitors alone and in combination with a MEK inhibitor.

METHODS

We evaluated the antitumor activity of EphA2 inhibitors plus a MEK inhibitor using in vitro and in vivo orthotopic models of uterine cancer.

RESULTS

EphA2 inhibitor induced MAPK in dasatinib-resistant uterine cancer cells (HEC-1A and Ishikawa) and BRAF/CRAF heterodimerization in HEC-1A cells. EphA2 inhibitor and trametinib significantly increased apoptosis in cancer cells resistant to EphA2 inhibitors compared with controls (p < 0.01). An in vivo study with the orthotopic HEC-1A model showed significantly greater antitumor response to combination treatment compared with dasatinib alone (p < 0.01). Combination treatment increased EphrinA1 and BIM along with decreased pMAPK, Jagged 1, and c-MYC expression in dasatinib-resistant cells. In addition, Spearman analysis using the TCGA data revealed that upregulation of EphA2 was significantly correlated with JAG1, MYC, NOTCH1, NOTCH3 and HES1 expression (p < 0.001, r = 0.25-0.43). Specifically, MAP3K15 and the NOTCH family genes were significantly related to poor clinical outcome in patients with uterine cancer.

CONCLUSIONS

These findings indicate that the MAPK pathway is activated in dasatinib-resistant uterine cancer cells and that EphrinA1-mediated MEK inhibition overcomes dasatinib resistance. Dual targeting of both EphA2 and MEK, combined with chemotherapy, should be considered for future clinical development.

Recommendations for supportive care and best supportive care in NCCN clinical practice guidelines for treatment of cancer: Differences between solid tumor and hematologic malignancy guidelines

PURPOSE

It is unclear how NCCN guidelines recommend "supportive care" and "best supportive care" in oncology practice. We examined the usage of "supportive care" and "best supportive care" in NCCN guidelines and compared between solid tumor and hematologic malignancy guidelines.

METHODS

We reviewed all updated NCCN Guidelines for Treatment of Cancer in October 2019. We documented the frequency of occurrence, definition, and timing of introduction of each term. We compared between solid tumor and hematologic malignancy guidelines.

RESULTS

We identified a total of 37 solid tumor and 16 hematologic guidelines. Thirty-seven (70%) guidelines mentioned "supportive care" and 36 (68%) mentioned "best supportive care." Hematologic guidelines were significantly more likely than solid tumor guidelines to use the term "supportive care" (median occurrence 19 vs. 2; P = 0.001) and to describe "supportive care" as management of cancer-related complications (N = 11/15, 73% vs. N = 2/22, 9%; P < 0.001). Domains of specialist palliative care were infrequently mentioned (N = 10/37, 27%). In contrast, solid tumor guidelines were significantly more likely than hematologic guidelines to mention "best supportive care" (median occurrence 6 vs. 0; P = 0.016). This term was rarely defined and mostly used in the advanced disease setting.

CONCLUSION

"Supportive care" and "best supportive care" were frequently used in NCCN guidelines, with significant variations in usage between solid tumor and hematologic oncologists. "Supportive care" was mostly limited to management of cancer-related complications and treatment adverse effects in NCCN guidelines, highlighting the need to go beyond the traditional biomedical model to more a patient-centered care model with greater integration of palliative care.

Personalized delirium sedation goal (PDSG): Balancing comfort and communication in the last days of life

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Background: Management of patients with agitated terminal delirium is challenging as clinicians try to find a balance between adequate sedation to maximize comfort while retaining communication abilities. A novel approach to tailor care is to ask caregivers for a PDSG by setting an individualized target for sedation. In this study, we examined PDSG using (1) clinical vignettes and (2) as a clinical response criteria in patients enrolled onto a randomized clinical trial. Methods: This is a pre-planned secondary analysis of a double-blind randomized clinical trial examining the sedative effect of chlorpromazine and/or haloperidol in patients with agitated terminal delirium refractory to low dose haloperidol (clinicaltrials.gov: NCT03021486; Lancet Oncol 2020 21:7 989-998). At baseline, caregivers and bedside nurses were independently asked to select the PDSG for 6 patient vignettes that differed by level of agitation (high vs. moderate), ability to communicate (yes or no), and survival (days vs. weeks). There were 5 choices for PDSG, corresponding to RASS scores of 0 (no sedation), -1 to -2, -3, -4 and -5 (deep sedation). Respondents were also asked to select the PDSG for the enrolled study patient, which were assessed against actual RASS scores over the first 24 hours to determine a response. We examined the association between PDSG levels and various patient and respondent characteristics with multi-level cumulative logits models. Results: 68 patients were enrolled and 45 received the masked study interventions (median survival 73 h [95% CI 49,106 h]). 42 caregivers and 40 nurses provided PDSG data. For the case vignettes, 7-31% of caregivers and 20-55% of nurses chose RASS -4 or -5 as PDSG. PDSG was significantly lower for patients who were unable to communicate (odds ratio [OR] 3.1-4.4, P < 0.0001), patients with only days of survival vs. weeks (OR 1.7, 95% confidence interval [CI] 1.2-2.5; P = 0.002) and if the respondent was a bedside nurse (OR = 2.5, 95% CI 1.8-3.6; P < 0.0001). For study patients, 12 (29%) of caregivers and 13 (33%) of nurses selected RASS -4 or -5 as PDSG. After the first 2 hours, 40-61% of patients achieved RASS scores that were within ±1 point of caregiver’s PDSG, with no significant difference detected among treatment groups (P = 0.45). PDSG for study patients was significantly lower if the respondent perceived severe distress related to agitation (OR = 4.4, 95% CI 1.1-17.2; P = 0.03), particularly if the respondent was a bedside nurse (OR = 4.8, 95% CI 1.4-16.2; P = 0.01). Conclusions: PDSG represents a novel response criterion to tailor care for patients with agitated terminal delirium. Lighter sedation was preferred by caregivers compared to nurses, particularly for patients with less agitation, ability to communicate, and longer expected survival. These findings may allow clinicians to better tailor the level of sedation for patients with restlessness/agitation in the last days of life. Clinical trial information: NCT03021486.

Futility and toxicity monitoring without halting for interim analyses

e13579

Background: Many trial designs with futility or toxicity monitoring require that accrual halt to wait for currently enrolled patients to complete their assessment window. However, logistics often prevent this. In these cases, the performance of those designs might be compromised. This study examines the performance of 2 popular designs when enrollment is not halted at interim. Methods: Simulations were run to examine the effect of continuous enrollment on the operating characteristics (OCs) of a Simon’s 2-stage design for futility monitoring and a design using Bayesian posterior probabilities for toxicity monitoring. Both sets of 10,000 simulations examined the OCs when accrual rate was 0.5, 1.5, 3 and 5 patients/month with an assessment window of 30, 60 and 180 days. Results: The first scenario examined the OCs of a Simon design with 12 patients in the first stage and 21 at the end of the second stage. Regardless of accrual rate, the expected number of patients (EN0) increased and probability of early termination (PET0) decreased under the null hypothesis. Rate of change increased as assessment window increased. EN0 was 16 and PET0 was 54% when halting enrollment between stages. With continuous enrollment, EN0 ranged from 16-19, 17-21, and 18-21 patients for the 30-, 90- and 180-day assessment windows. PET0 ranged from 54%-50% with a 30-day assessment window. It halved to 24% with 3 patients/month enrolled and a 90-day window. PET0 was essentially 0 with a 180-day window and an enrollment of 3 patients/month. OCs for toxicity monitoring were examined for the early stopping rule Pr(toxicity rate > 0.3 | data) > 0.85 with toxicity rate ̃ beta(1, 1) with a maximum sample size of 20 and cohort size of 5. Expected number of patients (EN) increased and probability of early termination (PET) decreased as accrual rate increased, with rate of change increasing as assessment window increased. When the true probability of toxicity was 50% and enrollment halted between cohorts, EN was 10 patients and PET was 78%. EN was 17 and PET 54% with an assessment window of 30 days and 5 patients were enrolled per month. With a 90-day assessment window and 3 patients/month enrolled, EN was 16 and PET 59%. EN was 20 and PET was 12% with a 180-day assessment window and 3 patients were enrolled per month. Similar results were noted for cohorts of size 10 and a maximum number of 40 patients. Conclusions: The performance of designs that require halting enrollment while waiting for results of an interim analysis can be compromised by continuous accrual when assessment windows are lengthy and the accrual is fast. In these circumstances, consideration should be given to designs, such as Bayesian multiple imputation for delayed outcomes (Cai et al Stat Med 2014) and TOP2 (Lin et al JNCI 2019), that do not require accrual halt to make real-time interim analysis in the presence of pending patients, which protects patients from excessive toxicity or a futile intervention.

Facilitated cascade testing (FaCT): a randomized controlled trial

BACKGROUND

Identifying mutation-carrying relatives of patients with hereditary cancer syndromes via cascade testing is an underused first step in primary cancer prevention. A feasibility study of facilitated genetic testing of at-risk relatives of patients with a known pathogenic mutation demonstrated encouraging uptake of cascade testing.

PRIMARY OBJECTIVE

Our primary objective is to compare the proportion of genetic testing of identified first-degree relatives of probands with a confirmed BRCA1/2 mutation randomized to a facilitated cascade testing strategy versus standard of care, proband-mediated, information sharing.

STUDY HYPOTHESIS

We hypothesize that facilitated cascade testing will drive significantly higher uptake of genetic testing than the standard of care.

TRIAL DESIGN

The FaCT (Facilitated Cascade Testing) trial is a prospective multi-institutional randomized study comparing the efficacy of a multicomponent facilitated cascade testing intervention with the standard of care. Patients with a known BRCA1/2 mutation (probands) cared for at participating sites will be randomized. Probands randomized to the standard of care group will be instructed to share a family letter with their first-degree relatives and encourage them to complete genetic testing. First-degree relatives of probands randomized to the intervention arm will receive engagement strategies with a patient navigator, an educational video, and accessible genetic testing services.

MAJOR INCLUSION/EXCLUSION CRITERIA

Adult participants who are first-degree relatives of a patient with a BRCA1/2 mutation and have not had prior genetic testing will be included.

PRIMARY ENDPOINT

Analyses will assess the proportion of first-degree relatives identified by the proband who complete genetic testing by 6 months in the intervention arm versus the control arm.

SAMPLE SIZE

One hundred and fifty probands with a BRCA1/2 mutation will be randomized. Each proband is expected to provide an average of 3 relatives, for an expected 450 participants.

ESTIMATED DATES FOR COMPLETING ACCRUAL AND PRESENTING RESULTS

January 2024.

TRIAL REGISTRATION

NCT04613440.

Recommendations for Palliative and Hospice Care in NCCN Guidelines for Treatment of Cancer

BACKGROUND

Integration of specialist palliative care into routine oncologic care improves patients' quality of life and survival. National Comprehensive Cancer Network (NCCN) cancer treatment guidelines are instrumental in standardizing cancer care, yet it is unclear how palliative and hospice care are integrated in these guidelines. In this study, we examined the frequency of occurrence of "palliative care" and "hospice care" in NCCN guidelines and compared between solid tumor and hematologic malignancy guidelines.

MATERIALS AND METHODS

We reviewed all 53 updated NCCN Guidelines for Treatment of Cancer. We documented the frequency of occurrence of "palliative care" and "hospice care," the definitions for these terms if available, and the recommended timing for these services.

RESULTS

We identified a total of 37 solid tumor and 16 hematologic malignancy guidelines. Palliative care was mentioned in 30 (57%) guidelines (24 solid tumor, 6 hematologic). Palliative care was mentioned more frequently in solid tumor than hematologic guidelines (median, 2 vs. 0; p = .04). Among the guidelines that included palliative care in the treatment recommendation, 25 (83%) only referred to NCCN palliative care guideline. Specialist palliative care referral was specifically mentioned in 5 of 30 (17%) guidelines. Only 14 of 24 (58%) solid tumor guidelines and 2 of 6 (33%) hematologic guidelines recommended palliative care in the front line setting for advanced malignancy. Few guidelines (n = 3/53, 6%) mentioned hospice care.

CONCLUSION

"Palliative care" was absent in almost half of NCCN cancer treatment guidelines and was rarely discussed in guidelines for hematologic malignancies. Our findings underscored opportunities to standardize timely palliative care access across NCCN guidelines.

IMPLICATIONS FOR PRACTICE

Integration of specialist palliative care into routine oncologic care is associated with improved patient outcomes. National Comprehensive Cancer Network (NCCN) Clinical Practice Guidelines in Oncology have an important role to standardize palliative care involvement for cancer patients. It is unclear how often palliative care referral is recommended in these guidelines. In this study involving 53 NCCN Guidelines for Treatment of Cancer, the researchers found that palliative care was not mentioned in over 40% of NCCN guidelines and was rarely discussed in guidelines for hematologic malignancies. These findings underscored opportunities to standardize timely palliative care access across NCCN guidelines.

Abstract A17: An innovative physical activity intervention in overweight and obese adults using continuous glucose monitor

Introduction: Regular physical activity (PA) lowers the risk of endometrial, breast, and colorectal cancer. However, nearly half of American adults are not sufficiently active. The physical inactivity rate is even higher among the overweight and obese population, which, in combination with the unfavorable effect of excess body weight, puts this population at a greater risk for cancer. Advancements in wearable sensor technology provide opportunities for personalized approaches to increase motivation to be active. The current pilot study used continuous glucose monitors (CGM) to demonstrate the immediate, physiologic benefits of PA.

Methods: Insufficiently active (&lt;150 mins of moderate intensity PA per week) overweight and obese (body mass index &gt;= 25 kg/m2) adults (18-65 years old) without diabetes are being recruited to participate in this pilot intervention. Upon enrollment, participants go through a one-on-one PA education session that includes a discussion about the health benefits of recommended PA levels, demonstration of the acute effect of PA on daily glucose patterns using a web-based glucose simulator, calculation of personal heart rate zones for moderate intensity PA, and development of an exercise plan. After the education session, participants are given a Fitbit Alta HR wristband and are instructed to wear it over the next 10 days. Participants are also given a Freestyle Libre CGM, which consists of a sensor and a reader. The sensor is inserted into the back of the upper arm to collect interstitial glucose data every 15 minutes for 10 days after activation. The reader displays current glucose readings and a graph of the 8 previous hours of glucose data upon scanning the sensor. Participants are instructed to scan the sensor at least 4 times a day and are encouraged to achieve at least 150 minutes of moderate-intensity PA each week. At the end of the self-monitoring period, participants return their Fitbit and have their CGM sensor removed.

Results: Thus far, 10 of 20 participants have enrolled in and completed the study. These participants have been 100% female, 70% obese, and 20% Hispanic with a mean age of 41.5 (SD = 8.6) years old. On average, participants scanned their sensor 6 times each day and wore the Fitbit for all 10 days. On average, participants highly rated each component of the education session (on a 5-point scale) for improving their PA knowledge (mean = 4.4), increasing their PA motivation (mean = 4.4), and providing personally relevant information (mean = 4.6). Participants also reported a very positive experience wearing the CGM, with mean ratings (on a 5-point scale) of 4.8 for usability, 4.6 for convenience, 4.9 for value, 4.9 for relevance, and 4.7 for motivating.

Conclusion: These preliminary data suggest that using a CGM to motivate PA among nondiabetic adults is feasible and acceptable. Future research will be conducted to examine the effect a CGM-based PA intervention has on changing PA behavior.

Citation Format: Yue Liao, Christopher J. Miller, Diana L. Urbauer, Therese B. Bevers, Ernest Hawk, Karen M. Basen-Engquist, Susan M. Schembre. An innovative physical activity intervention in overweight and obese adults using continuous glucose monitor [abstract]. In: Proceedings of the AACR Special Conference on Modernizing Population Sciences in the Digital Age; 2019 Feb 19-22; San Diego, CA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(9 Suppl):Abstract nr A17.

Using Continuous Glucose Monitoring to Motivate Physical Activity in Overweight and Obese Adults: A Pilot Study

BACKGROUND

Regular physical activity (PA) is associated with a lower risk of several types of cancers. However, two-thirds of overweight/obese adults are not sufficiently active; this, in combination with the unfavorable effect of excess body weight, puts them at a greater risk for cancer. One reason that these individuals do not engage in enough PA may be their lack of motivation to change their current behavior due to the perception of putting in effort for possible future gain without obvious short-term benefits. There is a need for innovative ways to help individuals recognize the immediate health benefits of PA and thus increase their motivation.

METHODS

This pilot intervention tested a PA education module that included a one-on-one counseling session highlighting the acute effects of PA on glucose patterns, followed by a 10-day self-monitoring period with a continuous glucose monitor (CGM) and a Fitbit tracker. Participants rated the acceptability of the education module on a 5-point Likert scale and completed surveys assessing stages of change for motivational readiness.

RESULTS

Nineteen overweight/obese adults (84% female) completed the study. Participants gave high ratings to the counseling session for improving their PA-related knowledge (mean = 4.22), increasing motivation (mean = 4.29), and providing personally relevant information (mean = 4.35). The summary acceptability scores for the self-monitoring period were 4.46 for CGM and 4.51 for Fitbit. Participants reported a significant decrease in the precontemplation stage and an increase in the action stage (P < 0.05).

CONCLUSIONS

CGM is a feasible tool for PA interventions.

IMPACT

Information from CGM could be used as biological-based feedback to motivate PA.See all articles in this CEBP Focus section, "Modernizing Population Science."

Phase I study of the PARP inhibitor talazoparib with radiation therapy for locally recurrent gynecologic cancers

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PARP inhibitors combined with radiotherapy may be promising for solid tumors.

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PARP inhibitors radiosensitize ovarian cancer cells both in vitro and in vivo.

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Talazoparib is a novel PARP-inhibitor with confirmed response in ovarian cancer.

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We propose a phase I study of talazoparib and concurrent radiation therapy.

PARP inhibitors have been shown to radiosensitize tumor cells in both in vitro and in vivo studies. This is a phase I study that aims to determine the safety, tolerability, and maximally tolerated dose of talazoparib, a PARP inhibitor, when delivered concurrently with radiotherapy in women with recurrent gynecologic cancers.

Prospective pilot trial with combination of propranolol with chemotherapy in patients with epithelial ovarian cancer and evaluation on circulating immune cell gene expression

OBJECTIVE

To determine the feasibility of pharmacologic beta-adrenergic blockade in women with newly diagnosed stage II-IV epithelial ovarian cancer (EOC) throughout primary treatment.

METHODS

Patients initiated propranolol prior to beginning chemotherapy or surgery. Feasibility was assessed as proportion able to complete 6 chemotherapy cycles while on adrenergic suppression. Descriptive statistics summarized surveys, and paired changes were analyzed using signed rank tests. Random-intercept Tobit models examined immune response.

RESULTS

Median age was 59.9; 88.5% were stage IIIC/IV; and 38.5% underwent primary debulking. Thirty-two patients were enrolled; 3 excluded because they never took propranolol; an additional 3 didn't meet inclusion criteria, leaving 26 evaluable. Eighteen of 26 (69%), 90% credible interval (CI) of 53-81%, completed 6 chemotherapy cycles plus propranolol (an 82% posterior probability that the true proportion of success is ≥60%). Among the 23 patients with baseline and six month follow up data, overall QOL, anxiety, and depression improved (P < 0.05) and leukocyte expression of pro-inflammatory genes declined (P = 0.03) after completion of therapy. Decrease from baseline of serum IL-6 and IL-8 preceded response to chemotherapy (P < 0.0014). Change from baseline IL-10 preceded complete response.

CONCLUSION

Use of propranolol during primary treatment of EOC is feasible and treatment resulted in decrease in markers of adrenergic stress response. In combination with chemotherapy, propranolol potentially results in improved QOL over baseline.

A snapshot of medical physics practice patterns

A large number of surveys have been sent to the medical physics community addressing many clinical topics for which the medical physicist is, or may be, responsible. Each survey provides an insight into clinical practice relevant to the medical physics community. The goal of this study was to create a summary of these surveys giving a snapshot of clinical practice patterns. Surveys used in this study were created using SurveyMonkey and distributed between February 6, 2013 and January 2, 2018 via the MEDPHYS and MEDDOS listserv groups. The format of the surveys included questions that were multiple choice and free response. Surveys were included in this analysis if they met the following criteria: more than 20 responses, relevant to radiation therapy physics practice, not single‐vendor specific, and formatted as multiple‐choice questions (i.e., not exclusively free‐text responses). Although the results of free response questions were not explicitly reported, they were carefully reviewed, and the responses were considered in the discussion of each topic. Two‐hundred and fifty‐two surveys were available, of which 139 passed the inclusion criteria. The mean number of questions per survey was 4. The mean number of respondents per survey was 63. Summaries were made for the following topics: simulation, treatment planning, electron treatments, linac commissioning and quality assurance, setup and treatment verification, IMRT and VMAT treatments, SRS/SBRT, breast treatments, prostate treatments, brachytherapy, TBI, facial lesion treatments, clinical workflow, and after‐hours/emergent treatments. We have provided a coherent overview of medical physics practice according to surveys conducted over the last 5 yr, which will be instructive for medical physicists.

Predicting treatment Response based on Dual assessment of magnetic resonance Imaging kinetics and Circulating Tumor cells in patients with Head and Neck cancer (PREDICT-HN): matching 'liquid biopsy' and quantitative tumor modeling

Background

Magnetic resonance imaging (MRI) has improved capacity to visualize tumor and soft tissue involvement in head and neck cancers. Using advanced MRI, we can interrogate cell density using diffusion weighted imaging, a quantitative imaging that can be used during radiotherapy, when diffuse inflammatory reaction precludes PET imaging, and can assist with target delineation as well. Correlation of circulating tumor cells (CTCs) measurements with 3D quantitative tumor characterization could potentially allow selective, patient-specific response-adapted escalation or de-escalation of local therapy, and improve the therapeutic ratio, curing the greatest number of patients with the least toxicity.

Methods

The proposed study is designed as a prospective observational study and will collect pretreatment CT, MRI and PET/CT images, weekly serial MR imaging during RT and post treatment CT, MRI and PET/CT images. In addition, blood sample will be collected for biomarker analysis at those time intervals. CTC assessments will be performed on the CellSave tube using the FDA-approved CellSearch® Circulating Tumor Cell Kit (Janssen Diagnostics), and plasma from the EDTA blood samples will be collected, labeled with a de-identifying number, and stored at − 80 °C for future analyses.

Discussion

The primary objective of the study is to evaluate the prognostic value and correlation of weekly tumor response kinetics (gross tumor volume and MR signal changes) and circulating tumor cells of mucosal head and neck cancers during radiation therapy using MRI in predicting treatment response and clinical outcomes. This study will provide landmark information as to the utility of CTCs (‘liquid biopsy) and tumor-specific functional quantitative imaging changes during treatment to guide personalization of treatment for future patients. Combining the biological information from CTCs and the structural information from MRI may provide more information than either modality alone. In addition, this study could potentially allow us to determine the optimal time to obtain MR imaging and/ or CTCs during radiotherapy to assess tumor response and provide guidance for patient selection and stratification for future dose escalation or de-escalation strategies.

Trial registration

Clinicaltrials.gov (NCT03491176). Date of registration: 9^th April 2018. (retrospectively registered). Date of enrolment of the first participant: 30^th May 2017.

Treatment of Low-Risk Endometrial Cancer and Complex Atypical Hyperplasia With the Levonorgestrel-Releasing Intrauterine Device

OBJECTIVE

To assess efficacy of the levonorgestrel-releasing intrauterine device (LNG-IUD) for treatment of complex atypical hyperplasia or low-grade endometrial cancer.

METHODS

This retrospective case series included all patients treated with the LNG-IUD for complex atypical hyperplasia or early-grade endometrial cancer from January 2003 to June 2013. Response rates were calculated and the association of response with clinicopathologic factors, including age, body mass index, and uterine size, was determined.

RESULTS

Forty-six patients diagnosed with complex atypical hyperplasia or early-grade endometrial cancer were treated with the LNG-IUD. Of 32 evaluable patients at the 6-month time point, 15 had complex atypical hyperplasia (47%), nine had G1 endometrial cancer (28%), and eight had grade 2 endometrial cancer (25%). Overall response rate was 75% (95% CI 57-89) at 6 months; 80% (95% CI 52-96) in complex atypical hyperplasia, 67% (95% CI 30-93) in grade 1 endometrial cancer, and 75% (CI 35-97) in grade 2 endometrial cancer. Of the clinicopathologic features evaluated, there was a trend toward the association of lack of exogenous progesterone effect in the pathology specimen with nonresponse to the IUD (P=.05). Median uterine diameter was 1.3 cm larger in women who did not respond to the IUD (P=.04).

CONCLUSION

Levonorgestrel-releasing IUD therapy for the conservative treatment of complex atypical hyperplasia or early-grade endometrial cancer resulted in return to normal histology in a majority of patients.

Programmed cell death ligand 1 and tumor-infiltrating lymphocyte status in patients with renal cell carcinoma and sarcomatoid dedifferentiation

BACKGROUND

The immune profile of sarcomatoid renal cell carcinoma (sRCC), including the programmed cell death ligand 1 (PD-L1) and programmed cell death 1 (PD-1) status, has not been well characterized.

METHODS

An immunohistochemical digital analysis of PD-L1, PD-1, CD4, and CD8 was performed on nephrectomy specimens from 118 sRCC patients and 92 nonsarcomatoid clear cell renal cell carcinoma (ccRCC) patients. The clinical characteristics of the population were compared between sRCC and ccRCC. Overall survival was estimated, and comparisons were made between PD-L1-positive and PD-L1-negative groups as well as tumor-infiltrating lymphocyte (TIL)-high and TIL-low groups.

RESULTS

The PD-L1 H-score of sRCC (mean, 3.7; range, 0-192.1) was significantly higher than the score of grade 4 ccRCC (P = .001), and 41.3% of sRCC cases showed a PD-L1 H-score ≥ 10. The PD-1-positive cell density was significantly higher in sRCC versus ccRCC within the tumor and at the invasive front. The intratumoral CD8-positive cell density was significantly higher in sRCC versus ccRCC. Forty-one percent in the sarcomatoid component of sRCC and 8% in the epithelioid component of sRCC had an adaptive immune resistance phenotype (PD-L1-positive and TIL-positive), whereas only 1% in ccRCC had the type I phenotype.

CONCLUSIONS

sRCC showed higher PD-L1 expression and higher PD-1- and CD8-positive cell density than grade 4 ccRCC. The results indicate a notable immunosuppressive environment in sRCC. Despite advances in the treatment of advanced-stage renal cell carcinoma, sRCC still has a poor prognosis. This work describes highly immunosuppressive characteristics of sRCC in comparison with an appropriate ccRCC control. The results suggest PD-1/PD-L1 blockade therapy as a potential therapeutic approach for sRCC. Cancer 2017;123:4823-31. © 2017 American Cancer Society.

The Effects of Neoadjuvant Axitinib on Anthropometric Parameters in Patients With Locally Advanced Non-metastatic Renal Cell Carcinoma

OBJECTIVE

To examine the effect that neoadjuvant axitinib for the treatment of localized renal cell carcinoma has on body compartment composition.

MATERIALS AND METHODS

The study was based on a single-institution, single-arm clinical trial that enrolled 24 patients with locally advanced non-metastatic biopsy-proven clear cell renal cell carcinoma. Patients received axitinib orally for up to 12 weeks. Computed tomography scans were completed before the start of treatment, after 7 weeks of treatment and at the completion of 12 weeks of treatment. Patients underwent nephrectomy after axitinib treatment. The primary outcome of the current study was change in body compartment composition. Secondary outcomes included development of new-onset sarcopenia and changes in body weight.

RESULTS

A total of 23 patients had a complete set of imaging for evaluation, of which 19 (82.6%) lost weight. Median weight loss was 4.5 kg (P <.001). Seven patients (30.4%) had sarcopenia before treatment, with an additional 5 (21.7%) developing sarcopenia during treatment. Median decrease in skeletal muscle was 2.9 cm²/m² (P <.001), visceral adipose tissue was 4.9 cm²/m² (P = .132), and subcutaneous adipose tissue was 1.0 cm²/m² (P = .043). Ten of the 16 patients (62.5%) without baseline sarcopenia achieved a partial response, whereas only 1 of the 7 patients (14.3%) with baseline pretreatment sarcopenia achieved a partial response (P = .069).

CONCLUSION

Neoadjuvant axitinib resulted in a decrease in skeletal muscle and subcutaneous adipose tissue, as well as weight loss. Patients with baseline sarcopenia tended to have a lower response rate to neoadjuvant axitinib.

Prospective randomized biomarker study of metformin and lifestyle intervention for prevention in obese postmenopausal women at increased risk for endometrial cancer

1551

Background: Obesity significantly increases risk of endometrial cancer (EC) through systemic metabolic effects and local tissue action, driven by estrogen and dysregulated insulin signaling. EC is most commonly diagnosed in postmenopausal women. Metformin, an antidiabetes drug, and lifestyle intervention were evaluated for effects on endometrial proliferation and serum biomarkers, in parallel with weight loss. Methods: Obese postmenopausal women were randomized into 4 groups for a 16 week intervention using a 2 (metformin 1700 mg/day vs placebo) x 2 (lifestyle intervention vs no lifestyle intervention) factorial design based on the Diabetes Prevention Program. Pre- and post-intervention endometrial biopsies were assessed for proliferation (% Ki67+). Body weight and serum markers were measured pre- and post-intervention (estrone, FSH, DHEA-S, SHBG, IGF-1, adiponectin, omentin, insulin, glucose, A1C, ALT, triglycerides, and others). Results: Of 576 women approached for the study, 29 women were randomized and 26 completed the study. Similar adherence was seen for placebo and metformin, with 88% and 94% of doses taken, respectively. Adverse events were grade 1 or 2, most commonly flatulence, headache, and diarrhea. Metformin+lifestyle group lost the most weight (-7.4%), followed by lifestyle (-5.2%), metformin only (-3.1%), and placebo (+0.1%). Endometrial proliferation was not changed. Overall proliferation was low (7.1% at baseline) with substantial variability even in this postmenopausal cohort. Biopsies produced limited endometrium, precluding evaluation of other tissue markers. Metformin significantly increased serum DHEA (p = 0.002). SHBG increased (p = 0.031) and insulin decreased with lifestyle intervention (p = 0.035) but were not statistically significant after multiple comparisons correction. Conclusions: Metformin and lifestyle intervention produced positive changes in serum markers and weight loss. While it is known that obese postmenopausal women are at increased risk for EC, improved biomarkers are needed to stratify risk and test prevention strategies, particularly at the endometrial tissue level. Clinical trial information: NCT01697566.

Clinical Challenges Associated with Universal Screening for Lynch Syndrome-Associated Endometrial Cancer

Universal testing for Lynch syndrome is now a routine component of the diagnostic work-up of endometrial cancer patients. The purpose of this study was to identify prospectively the barriers to universal screening based on a tissue testing approach [microsatellite instability (MSI) analysis, IHC for DNA mismatch repair proteins, and MLH1 methylation analysis]. Endometrial carcinoma patients (n = 213) prospectively underwent microsatellite instability and IHC testing for expression of DNA mismatch repair (MMR) proteins. Patients with low (MSI-L) or high (MSI-H) levels of tumor MSI or immunohistochemical loss of MLH1 (and absent MLH1 methylation), MSH2, MSH6, or PMS2 were referred to a genetic counselor for consideration of germline testing. Six discordances (3.1% of tested cases) between IHC and MSI were identified. Half of these exhibited heterogeneous immunohistochemical loss of MLH1/PMS2 and were microsatellite stable (MSS). Of the remaining cases, one was MSS with immunohistochemical loss of MSH6, one was MSS with immunohistochemical loss of MLH1/PMS2 and absent MLH1 promoter methylation, and one was MSI-H with intact expression of DNA MMR proteins. Four patients had MSI-L tumors with intact immunohistochemical protein expression; the clinical significance of MSI-L in endometrial cancer is unclear. Eight patients did not have germline mutations despite tissue testing suggesting Lynch syndrome. Including cases with insufficient tissue for testing and patients declining tissue or germline testing, we encountered significant barriers to universal screening in 13.6% of screened patients (29/213) that preclude designation of a tumor as sporadic or hereditary. Cancer Prev Res; 10(2); 108-15. ©2016 AACR.

Endometrial Cancer Associated Symptoms: A Case-Control Study

BACKGROUND

The majority of women with endometrial cancer (EC) present at an early stage with an associated 5-year survival rate of >90%. High rates of early detection are attributed to warning symptoms; however, the prevalence of such symptoms has not been well defined.

METHODS

A case-control study was conducted assessing the prevalence of symptoms in EC patients at a large cancer center compared with healthy controls. Controls included patients seen for an annual gynecologic care visit (AV) or for a gynecological problem-based visit (PV). A self-administered questionnaire was given to all participants addressing EC-associated symptoms, at the time of initial clinic visit. Odds ratios (ORs) were used to compare prevalence of symptoms between EC cases and controls. Logistic regression was used to determine the impact of menopausal status and obesity on symptom prevalence.

RESULTS

The cases (n = 75) were significantly older than the AV (n = 203) and PV (n = 151) controls (59.7 vs. 49.8 vs. 51.0 years, p < 0.01), had a higher body mass index (35.5 vs. 29.4 vs. 30.9 kg/m², p < 0.01), and were more likely to be postmenopausal (76% vs. 53.7% vs. 52.0%, p < 0.01). The cases were more likely to report postmenopausal bleeding (OR = 32.99 and 5.83, p < 0.01) and abnormal vaginal discharge (OR = 8.8 and 3.3, p < 0.01) compared with the AV and PV groups. Overall, 55.4% of cases reported abnormal vaginal discharge.

CONCLUSIONS

Symptoms of both postmenopausal bleeding and abnormal vaginal discharge were significantly higher in EC compared with controls. The presence of such symptoms should raise concern for malignant disease and prompt immediate gynecological evaluation.

Clinical impact of selective and nonselective beta-blockers on survival in patients with ovarian cancer

BACKGROUND

Preclinical evidence has suggested that sustained adrenergic activation can promote ovarian cancer growth and metastasis. The authors examined the impact of beta-adrenergic blockade on the clinical outcome of women with epithelial ovarian, primary peritoneal, or fallopian tube cancers (collectively, epithelial ovarian cancer [EOC]).

METHODS

A multicenter review of 1425 women with histopathologically confirmed EOC was performed. Comparisons were made between patients with documented beta-blocker use during chemotherapy and those without beta-blocker use.

RESULTS

The median age of patients in the current study was 63 years (range, 21-93 years). The sample included 269 patients who received beta-blockers. Of those, 193 (71.7%) were receiving beta-1-adrenergic receptor selective agents, and the remaining patients were receiving nonselective beta antagonists. The primary indication for beta-blocker use was hypertension but also included arrhythmia and postmyocardial infarction management. For patients receiving any beta-blocker, the median overall survival (OS) was 47.8 months versus 42 months for nonusers (P =.04). The median OS based on beta-blocker receptor selectivity was 94.9 months for those receiving nonselective beta-blockers versus 38 months for those receiving beta-1-adrenergic receptor selective agents (P<.001). Hypertension was associated with decreased OS compared with no hypertension across all groups. However, even among patients with hypertension, a longer median OS was observed among users of a nonselective beta-blocker compared with nonusers (38.2 months vs 90 months; P<.001).

CONCLUSIONS

Use of nonselective beta-blockers in patients with EOC was associated with longer OS. These findings may have implications for new therapeutic approaches. Cancer 2015;121:3435-43. © 2015 American Cancer Society.

Is it equivalent? Evaluation of the clinical activity of single agent Lipodox® compared to single agent Doxil® in ovarian cancer treatment

Background

In response to the critical shortage of liposomal doxorubicin (Doxil®) in the United States, the Food and Drug Administration (FDA) approved temporary importation of doxorubicin hydrochloride liposome (Lipodox®). The objective was to compare toxicity and clinical activity of Lipodox® with Doxil®.

Methods

Recurrent ovarian cancer patients who received Lipodox® were compared 3:1 to matched control Doxil® patients who had received Doxil®. Patients were matched based on age, stage, dose, platinum sensitivity, and prior treatments from an existing de-identified database. Patients receiving combination regimens were excluded.

Results

The data from 40 Lipodox® patients was compared to 120 matched control Doxil® patients. In this study, 17 (42.5%) of the Lipodox® patients were switched to Doxil®. The overall response rate Lipodox® was 4.3% (1/23) compared to 18% (20/111) in matched control Doxil® patients. In the platinum-sensitive patients, 100% progressed in the Lipodox® group compared to 78.4% in matched control Doxil® patients. The mean time to progression was 4.1 ± 2.8 months for Lipodox® and 6.2 ± 7.2 months in control Doxil®s ( p = 0·25). Toxicity was similar in the Lipodox® group and control Doxil® group.

Conclusion

Lipodox® for treatment of recurrent ovarian cancer did not appear to have equivalent efficacy compared to Doxil®. A prospective clinical study is warranted before Lipodox® can be deemed equivalent substitution for Doxil®.

Metastases to the kidney: a comprehensive analysis of 151 patients from a tertiary referral centre

OBJECTIVE

To describe the presentation, treatment and outcomes of patients with metastatic tumours to the kidney treated at a tertiary referral centre.

PATIENTS AND METHODS

We retrospectively identified 151 patients diagnosed with a primary non-renal malignancy with renal metastasis. Clinical, radiographic and pathological characteristics were assessed. Overall survival (OS) was calculated using Kaplan-Meier methods.

RESULTS

The median patient age was 56.7 years. The most common presenting symptoms were flank pain (30%), haematuria (16%) and weight loss (12%). Most primary cancers were carcinomas (80.8%). The most common primary tumour sites were lung (43.7%), colorectal (10.6%), head and neck (6%), breast (5.3%), soft tissue (5.3%) and thyroid (5.3%). Renal metastases were typically solitary (77.5%). Concordance between radiologist and clinician imaging assessment was 54.0%. Three ablations and 48 nephrectomies were performed. For non-surgical patients, renal metastasis diagnosis was made with fine-needle aspiration or biopsy. The median OS from primary tumour diagnosis was 3.08 years and the median OS from time of metastatic diagnosis was 1.13 years. For patients treated with surgery, median OS from primary tumour diagnosis was 4.81 years, and OS from metastatic diagnosis was 2.24 years.

CONCLUSIONS

Metastases to the kidney are a rare entity. Survival appears to be longer in patients who are candidates for and are treated with surgery. Surgical intervention in carefully selected patients with oligometastatic disease and good performance status should be considered. A multidisciplinary approach with input from urologists, oncologists, radiologists and pathologists is needed to achieve the optimum outcomes for this specific patient population.

Variability of inter-observer agreement on feasibility of partial nephrectomy before and after neoadjuvant axitinib for locally advanced renal cell carcinoma (RCC): independent analysis from a phase II trial

OBJECTIVE

To evaluate how many patients could have undergone partial nephrectomy (PN) rather than radical nephrectomy (RN) before and after neoadjuvant axitinib therapy, as assessed by five independent urological oncologists, and to study the variability of inter-observer agreement.

PATIENTS AND METHODS

Pre- and post-systemic treatment computed tomography scans from 22 patients with clear cell renal cell carcinoma in a phase II neoadjuvant axitinib trial were reviewed by five independent urological oncologists. R.E.N.A.L. nephrometry score and κ statistics were calculated.

RESULTS

The median R.E.N.A.L. nephrometry score changed from 11 before treatment to 10 after treatment (P = 0.002). Five tumours with moderate complexity before axitinib treatment remained moderate complexity after treatment. Of 17 tumours with high complexity before axitinib treatment, three became moderate complexity after treatment. The overall κ statistic was 0.611. Moderate-complexity κ was 0.611 vs a high-complexity κ of 0.428. Before axitinib treatment the κ was 0.550 vs 0.609 after treatment. After treatment with axitinib, all five reviewers agreed that only five patients required RN (instead of eight before treatment) and that 10 patients could now undergo PN (instead of three before treatment). The odds of PN feasibility were 22.8-times higher after treatment with axitinib.

CONCLUSIONS

There is considerable variability in inter-observer agreement on the feasibility of PN in patients treated with neoadjuvant targeted therapy. Although more patients were candidates for PN after neoadjuvant axitinib therapy, it remains difficult to identify these patients a priori.

Cytokine Panel for Response to Intravesical Therapy (CyPRIT): Nomogram of Changes in Urinary Cytokine Levels Predicts Patient Response to Bacillus Calmette-Guérin

The response of non-muscle-invasive bladder cancer (NMIBC) to intravesical immunotherapy with bacillus Calmette-Guérin (BCG) depends on adequate stimulation of an immune response. Although BCG has been used for decades, we lack tools to accurately predict response in individual patients. To address this deficiency, we initiated a clinical trial in patients with intermediate- and high-risk NMIBC. BCG was administered according to the Southwest Oncology Group protocol. Urine samples were collected for cytokine assay at baseline, immediately before and after BCG instillation at 6 wk, and immediately before and after the third BCG instillation of the first maintenance course. Levels of 12 cytokines were measured, and changes from baseline were calculated after treatment. A total of 130 patients were enrolled. Increases in single cytokines correlated with recurrence, but the best predictor of recurrence was changes in a combination of cytokines. A nomogram (CyPRIT) constructed using urinary levels of nine inducible cytokines (IL-2, IL-6, IL-8, IL-18, IL-1ra, TRAIL, IFN-γ, IL-12[p70], and TNF-α) predicted the likelihood of recurrence with 85.5% accuracy (95% confidence interval 77.9–93.1%).” This cytokine panel and nomogram have potential for identifying patients at risk of tumor recurrence during BCG treatment to guide modification of the dose and duration of BCG immunotherapy.

TRIAL REGISTRATION

Clinicaltrials.gov NCT01007058.

Primary prevention of bladder cancer: Does the public know the risk factors?

366

Background: Smoking is the single most significant modifiable risk factor for bladder cancer, yet this is not well known outside of the medical community. Previous studies from tertiary referral centers have found that 36-58% of urology patients can identify smoking as a risk factor for bladder cancer. Since those patients may not be representative of the general population, we studied the knowledge base of bladder cancer risk factors among people encountered in the general waiting room of an urban county hospital. Methods: 215 participants over 18 years of age were recruited from the waiting room of an urban county hospital to participate in a brief survey on risk factors for various cancers. Fisher’s exact test and McNemar’s test were used to detect differences in knowledge between bladder cancer and other cancers. Results: The survey participant population was mostly female (65.6%), Hispanic (54%), and middle-aged (67% age 35-64). Most (54.8%) had an annual household income of less than $20,000, attained a high school education (49.1%) or below (24.1%), and 40.3% were current or former smokers. An overwhelming majority of participants chose smoking as a risk factor for lung cancer (92.2%), with 80.7% identifying smoking as the primary risk factor for lung cancer. In contrast, only 31.6% of participants chose smoking as a risk factor for bladder cancer with 7.4% selecting it as the primary risk factor for bladder cancer. Knowledge of smoking as a risk factor for bladder cancer was not impacted by education, income, smoking status, or personal/family history of cancer. Male gender and exposure to industrial chemicals were identified as risk factors for bladder cancer by a minority of patients (19.3% and 28.0%, respectively). Almost half of all participants surveyed (49.1%) incorrectly identified alcohol use as a risk factor for bladder cancer. Conclusions: Among participants of low socioeconomic status presenting to an urban county hospital, there is a concerning lack of knowledge about the major risk factors for bladder cancer. Given that smoking is a modifiable risk factor, future public education initiatives to prevent bladder cancer should focus on populations with low socioeconomic status as high-yield targets to affect change.

Utility of MLH1 methylation analysis in the clinical evaluation of Lynch Syndrome in women with endometrial cancer

Clinical screening criteria, such as young age of endometrial cancer diagnosis and family history of signature cancers, have traditionally been used to identify women with Lynch Syndrome, which is caused by mutation of a DNA mismatch repair gene. Immunohistochemistry and microsatellite instability analysis have evolved as important screening tools to evaluate endometrial cancer patients for Lynch Syndrome. A complicating factor is that 15-20% of sporadic endometrial cancers have immunohistochemical loss of the DNA mismatch repair protein MLH1 and high levels of microsatellite instability due to methylation of MLH1. The PCR-based MLH1 methylation assay potentially resolves this issue, yet many clinical laboratories do not perform this assay. The objective of this study was to determine if clinical and pathologic features help to distinguish sporadic endometrial carcinomas with MLH1 loss secondary to MLH1 methylation from Lynch Syndrome-associated endometrial carcinomas with MLH1 loss and absence of MLH1 methylation. Of 337 endometrial carcinomas examined, 54 had immunohistochemical loss of MLH1. 40/54 had MLH1 methylation and were designated as sporadic, while 14/54 lacked MLH1 methylation and were designated as Lynch Syndrome. Diabetes and deep myometrial invasion were associated with Lynch Syndrome; no other clinical or pathological variable distinguished the 2 groups. Combining Society of Gynecologic Oncology screening criteria with these 2 features accurately captured all Lynch Syndrome cases, but with low specificity. In summary, no single clinical/pathologic feature or screening criteria tool accurately identified all Lynch Syndrome-associated endometrial carcinomas, highlighting the importance of the MLH1 methylation assay in the clinical evaluation of these patients.

Overall survival after pelvic exenteration for gynecologic malignancy

BACKGROUND

Five-Year survival after pelvic exenteration for gynecologic malignancies has been reported as high as 60%. The objective of this study was to determine overall survival (OS) after pelvic exenteration and evaluate factors impacting outcome.

METHODS

A retrospective review of all women who underwent pelvic exenteration at our institution between February 1993 and December 2010 was performed. OS was defined as time from exenteration to date of death or last contact. Survival analysis was performed using the Kaplan Meyer method. Multivariate analysis was performed to determine the impact of clinical and pathologic factors on survival outcomes.

RESULTS

One hundred sixty patients with gynecologic malignancy underwent pelvic exenteration. Five-year recurrence free survival (RFS) was 33% (95%CI 0.25-0.40). Factors which negatively impacted RFS included shorter treatment-free interval (p=.050), vulvar primary (p=.032), positive margins (p<.001), lymphovascular space invasion (LVSI, p<.001), positive lymph nodes (p<.001) and perineural invasion (p=0.030). In multivariate analysis, positive margins (p=.040), positive nodes (p<.001) and lymphovascular space invasion (LVSI, p=.003) retained a significant impact on RFS. Five-year OS was 40% (95% CI 0.32-0.48). Factors which negatively impacted OS included vulvar primary (p=.04), positive margins (p<.001), LVSI (p<.001), positive lymph nodes (p<.001) and perineural invasion (p=.008). In multivariate analysis, positive nodes (p=.001) and LVSI (p=.001) retained a significant impact on OS.

CONCLUSION

Five-year OS after pelvic exenteration was 40%. Survival outcomes have not significantly improved despite improvements in technique and patient selection. Multiple non-modifiable factors at the time of exenteration are associated with poor survival.

Randomized controlled trial of a sun protection intervention for children of melanoma survivors

BACKGROUND

We studied whether a melanoma survivor-centered intervention was more effective than materials available to the general public in increasing children's sun protection.

METHODS

In a randomized controlled trial, melanoma survivors (n = 340) who had a child ≤ 12 years received a targeted sun protection intervention (DVD and booklets) or standard education. Primary outcomes were children's sunburns, children's sun protection, and survivors' psychosocial factors at baseline and postintervention (1 and 4 months).

RESULTS

The intervention increased children's sunscreen reapplication at 1 month (P = 0.002) and use of wide-brimmed hats at 4 months (P = 0.045). There were no effects on other behaviors or sunburns. The intervention improved survivors' hats/clothing self-efficacy at both follow-up assessments (P = 0.026, 0.009). At 4 months, the intervention improved survivors' clothing intentions (P = 0.029), knowledge (P = 0.010), and outcome expectations for hats (P = 0.002) and clothing (P = 0.037). Children's sun protection increased with survivors' intervention use. The intervention was less effective in survivors who were female or who had a family history, older children, or children with higher baseline sun protection scores.

CONCLUSIONS

A melanoma survivor-centered sun protection intervention can improve some child and survivor outcomes. The intervention may be more effective in survivors who have younger children or less experience with sun protection. Intervention delivery must be enhanced to maximize use.

IMPACT

This is the first study to examine a sun protection intervention for children of melanoma survivors. Findings will guide interventions for this important population at increased melanoma risk.

CGRRF1 as a novel biomarker of tissue response to metformin in the context of obesity

OBJECTIVE

Obesity-associated hyperestrogenism and hyperinsulinemia contribute significantly to the pathogenesis of endometrial cancer. We recently demonstrated that metformin, a drug long used for treatment of type 2 diabetes, attenuates both insulin- and estrogen-mediated proliferative signaling in the obese rat endometrium. In this study, we sought to identify tissue biomarkers that may prove clinically useful to predict tissue response for both prevention and therapeutic studies. We identified CGRRF1 (cell growth regulator with ring finger domain 1) as a novel metformin-responsive gene and characterized its possible role in endometrial cancer prevention.

METHODS

CGRRF1 mRNA expression was evaluated by RT-qPCR in the endometrium of obese and lean rats, and also in normal and malignant human endometrium. CGRRF1 levels were genetically manipulated in endometrial cancer cells, and its effects on proliferation and apoptosis were evaluated by MTT and Western blot.

RESULTS

CGRRF1 is significantly induced by metformin treatment in the obese rat endometrium. In vitro studies demonstrate that overexpression of CGRRF1 inhibits endometrial cancer cell proliferation. Analysis of human endometrial tumors reveals that CGRRF1 expression is significantly lower in hyperplasia, Grade 1, Grade 2, Grade 3, MMMT, and UPSC endometrial tumors compared to normal human endometrium (p<0.05), suggesting that loss of CGRRF1 is associated with the presence of disease.

CONCLUSION

CGRRF1 represents a novel, reproducible tissue marker of metformin response in the obese endometrium. Furthermore, our preliminary data suggests that up-regulation of CGRRF1 expression may prove clinically useful in the prevention or treatment of endometrial cancer.

Clinical significance of ureteric 'skip lesions' at the time of radical cystectomy: the M.D. Anderson experience and literature review

OBJECTIVE

To assess the incidence and clinical significance of 'skip lesions' that are present in proximal but not in distal ureteric sections, which are occasionally found during the pathological examination of ureteric margins during radical cystectomy (RC).

PATIENTS AND METHODS

We identified 660 patients who underwent a RC and had at least two permanent margins for a given ureter. In all, 1173 ureters were analysed and classified as follows: 'normal' (no tumour, reactive atypia, mild or moderate dysplasia) or 'abnormal' (severe dysplasia, carcinoma in situ (CIS), or tumour). Transitions from 'normal' distal pathology to 'abnormal' on proximal section(s) determined frequency of skip lesions. Fisher's exact test and the log-rank test were used to study correlations.

RESULTS

Ureteric skip lesions were found in 4.8% patients (2.9% ureters). Pathology of skip lesions was CIS in 55.9%, transitional cell carcinoma in 23.5% and severe dysplasia in 20.6%. Skip lesions were associated with lymphovascular invasion (34.4% vs 13.7%, P = 0.004) and advanced pT stage (P = 0.007). On multivariate analysis, skip lesions correlated with lower median overall survival (OS) (inestimable vs 8.2 years, P = 0.014) in patients with pT0 or pTa disease and a trend towards lower OS (2.7 vs 8.8 years, P = 0.066) in pTis disease. Concordance between frozen distal margin and permanent proximal margin varied; sensitivity was 80% in those without and 20% in those with skip lesions.

CONCLUSIONS

The presence of a ureteric skip lesion may be associated with lower survival in patients with pT0, pTa or pTis urothelial carcinoma. Thus, while uncommon, ureteric skip lesions should be reported in pathological findings.

Efficacy and safety of ibutilide for chemical cardioversion of atrial fibrillation and atrial flutter in cancer patients

BACKGROUND

Atrial fibrillation and atrial flutter (AF/AFL) are the most common arrhythmias encountered in clinical practice. Rate versus rhythm control remains a difficult decision, especially in the acute setting. Ibutilide is a class III antiarrhythmic indicated for pharmacological cardioversion of recent-onset AF/AFL. At the University of Texas MD Anderson Cancer Center, restoration of sinus rhythm is desirable because many patients have contraindications to anticoagulation. In addition, most are on multiple medications that prolong the QT interval; therefore, the objective of this study was to establish the safety and efficacy of ibutilide.

METHODS

This was a retrospective chart review of 81 patients who were identified via the pharmacy database as receiving ibutilide for AF/AFL from January 2002 to May 2006. Outcomes including cardioversion rates and effects on the QT interval were recorded.

RESULTS

Ibutilide use was associated with successful cardioversion in 75% of patients. Out of 81 patients, 68 patients (84%) were on at least 1 medication that prolonged the QT interval at the time of ibutilide administration. However, no significant changes in the corrected QT interval pre and post ibutilide cardioversion were noted in any group of patients.

CONCLUSIONS

Overall, ibutilide is safe and effective in cancer patients when used for acute cardioversion of AF/AFL. Despite the use of multiple medications that can potentially prolong the QT interval, no patient experienced serious life-threatening rhythm disturbances or significant QT prolongation during ibutilide administration.