Geographic Origin may Affect Outcomes for Hispanic Patients with Non-Small Cell Lung Cancer in the United States

BACKGROUND

Social determinants of health thoroughly explored in the literature include insurance status, race, and ethnicity. There are over 50 million self-identifying Hispanics in the United States. This, however, represents a heterogeneous population. We used a national registry to investigate for significant differences in outcomes of Hispanic patients with non-small cell lung cancer (NSCLC) in the Unites states, by geographic region of origin.

MATERIALS AND METHODS

We identified a cohort of Hispanic patients in the Unites states with NSCLC for which region of origin was documented within the 2004 to 2016 National Cancer Database (NCDB) registry. This included patients from Cuba, Puerto Rico, Mexico, South and Central America, and the Dominican Republic. We performed multivariate logistic regression modeling to determine whether origin was a significant predictor of cancer staging at diagnosis, adjusting for age, sex, histology, grade, insurance status, and facility type. Race was not included due to a nonsignificant association with stage at diagnosis at the bivariate level in this cohort. Subsequently, we used Kaplan-Meier modeling to identify whether overall survival (OS) of Hispanic patients differed by origin.

RESULTS

A total of 12,557 Hispanic patients with NSCLC were included in this analysis. The breakdown by origin was as follows: n = 2071 (16.5%) Cuban, n = 2360 (18.8%) Puerto Rican, n = 4950 (39.4%) Mexican, n = 2329 (18.5%) from South or Central America, and n = 847 (6.7%) from the Dominican Republic. After controlling for age, sex, histology, grade, insurance status and treating facility type, we found that geographic origin was a significant predictor of advanced stage at diagnosis (P = .015). Compared to Cubans, patients of Puerto Rican origin were less likely to present with advanced disease (68.4% vs. 71.9%; OR: 0.82; 95%CI: 0.69-0.98; P = .026). We also identified a significant (log-rank P-value<.001) difference in OS by geographic origin, even at early-stages of diagnosis. Dominican patients with NSCLC exhibited the highest 5-year OS rate (63.3%), followed by patients from South/Central America (59.7%), Puerto Rico (52.3%), Mexico (45.9%), and Cuba (43.8%).

CONCLUSION

This study showed that for Hispanic individuals living in the Unites states, region/country of origin is significantly associated with outcomes, even after accounting for other known determinants of health. We suggest that region of origin should be studied further as a potential determinant of outcomes in patients with cancer.

Social disparities in pain management provision in stage IV lung cancer: A national registry analysis

A strong association exists between pain and lung cancer (LC). Focusing on the disparities in pain referral in LC patients, we are aiming to characterize the prevalence and patterns of referrals to pain management (PM) in Stage IV non-small-cell LC (NSLC) and small-cell LC (SCLC). We sampled the National Cancer Database for de novo stage IV LC (2004-2016). We analyzed trends of pain referral using the Cochran-Armitage test. Chi-squared statistics were used to identify the sociodemographic and clinico-pathologic determinants of referral to PM, and significant variables (P < .05) were included in one multivariable regression model predicting the likelihood of pain referral. A total N = 17,620 (3.1%) of NSLC and N = 4305 (2.9%) SCLC patients were referred to PM. A significant increase in referrals was observed between 2004 and 2016 (NSLC: 1.7%-4.1%, P < .001; SCLC: 1.6%-4.2%, P < .001). Patient and disease factors played a significant role in likelihood of referral in both groups. Demographic factors such as gender, age, and facility type played a role in the likelihood of pain referrals, highlighting the gap and need for multidisciplinary PM in patients with LC. Despite an increase in the proportion of referrals to PM issued for terminal stage LC, the overall proportion remains low. To ensure better of quality of life for patients, oncologists need to be made aware of existent disparities and implicit biases.

Efficacy of chemotherapy in patients with HR+/HER2-Invasive lobular breast cancer

INTRODUCTION

Invasive Lobular Breast Cancer (ILC) harbors unique clinicopathologic features. Data on optimal treatment modalities focusing on ILC remain scarce. We aim to investigate the benefit of chemotherapy in early-stage hormone receptor-positive (HR+) and human epidermal growth factor receptor-2 negative (HER2-) ILC.

METHODS

Female patients with early HR+/HER2- ILC (stages I-III) who underwent surgery were selected from the National Cancer Database (2010-2016) and grouped into four treatment cohorts: surgery only(S), chemotherapy alone (CT), endocrine therapy alone (ET), and combined chemotherapy followed by endocrine therapy (CET). Descriptive and bi-variate statistics summarized baseline characteristics and compared them across cohorts. A secondary analysis accounting for OncotypeDX (ODX) information was performed, stratifying for low (<26) and high (≥26) ODX. Kaplan-Meier (KM) and Cox proportional hazard models evaluated the relationship between treatment modality and overall survival (OS), stratifying for ODX scoring.

RESULTS

N = 15,271 patients were included. The CET cohort (29.8%) was more likely to be younger and have no co-morbidities, advanced tumor stage or high ODX score (≥26). No significant difference in OS comparing ET to CET (HR:1.08, 95%CI:0.93-1.26, p = 0.31) was observed, adjusting for confounders. N = 5,561 patients had ODX results available. No significant difference in 5-year OS was observed comparing the ET to CET cohorts, both in patients an ODX score <26 (HR:1.10; 95%CI:0.69-1.76, p = 0.69) and ODX score ≥26 (HR:1.18; 95%CI:0.51-2.75, p = 0.69).

CONCLUSION

Chemotherapy demonstrated no added survival benefit in HR+/HER2- ILC, even in tumors with ODX ≥26. Prospective trials identifying potential subgroups of patients with ILC who could benefit from chemotherapy are needed.

Does the 21-gene recurrence score have clinical utility in HR+/HER2+ breast cancer?

The 21-gene recurrence score assay has been validated as a predictive biomarker in early-stage HR+ and HER2-breast cancer. It is not indicated for use in HER2+ disease based on national guidelines. In this study, we assessed the value of 21-gene recurrence score (RS), or OncotypeDX (ODX), testing in HR+/HER2+ breast cancer. We used the National Cancer Database to identify patients with stages I-II, HR+/HER2+ breast cancer who received multi-gene testing with ODX. We then explored the prognostic and predictive value of this biomarker through various forms of survival modeling. ODX testing was performed in n = 5,280 patients. N = 2,678 patients (50.7%) had a RS < 26, while n = 2,602 (49.3%) had a RS ≥26. In Kaplan-Meier survival modeling for patients with recurrence scores <26, there was no significant difference in overall survival (p = 0.445) between patients receiving different systemic treatment regimens. However, when recurrence scores were ≥26, there was a statistically-significant difference in overall survival between systemic treatment regimens (p < 0.001). 5-year overall survival was highest (97.4%) for patients receiving triple therapy (anti-HER2 with chemotherapy and endocrine therapy), followed by those receiving dual therapy with endocrine and anti-HER2 (96.7%), and endocrine with chemotherapy (94.9%). Patients receiving endocrine therapy alone exhibited the lowest 5-year overall survival (88.5%). RESULTS: Analysis from this large national cancer registry suggests that multigene testing may have predictive value in treatment selection for patients with early-stage, HR+/HER2+ breast cancer. Prospective trials are warranted to identify subgroups of patients with HR+/HER2+ breast cancer who can be spared anti-HER2 treatments and cytotoxic chemotherapy.

Management of HR+/HER2+ lobular breast cancer and trends do not mirror better outcomes

Purpose

Treatment protocols for invasive lobular breast cancer (ILC) have largely followed those for invasive ductal breast cancer. This study compares treatment outcomes of endocrine therapy versus combined chemo-endocrine therapy in hormone-receptor-positive (HR+), HER2-positive (HER2+) ILC tumors in a large national registry.

Methods

We sampled the National Cancer Database (2010–2016) for female patients with stages I-III, HR+/HER2+ ILC who underwent surgery. Cochran-Armitage trend test examined trends of treatment regimen administration: Surgery only (S), chemotherapy (C), endocrine therapy (ET), and combined chemo-endocrine therapy (CET), with or without anti-HER2 therapy. Cox proportional hazard model were used to compare overall survival (OS) across ET and CET cohorts, stratifying for anti-HER2 therapy, before and after propensity score match of cohorts (2013–2016). Kaplan-Meier (KM) survival curves were also produced.

Results

N=11,421 were included. 58.7% of patients received Anti-Her2 therapy after 2013. CET conferred better OS over ET in the unmatched (adjusted-5-year-OS: 92.5% vs. 81.1%, p<0.001) and PS-matched (90.4% vs. 84.5%, p=0.001) samples. ET caused lower OS in patients who received Anti-Her2 therapy (HR: 2.56, 95% CI: 1.60–4.12, p<0.001) and patients who did not (HR: 1.84, 95% CI: 1.21–2.78, p=0.004), as compared to CET on multivariable analysis. KM modeling showed highest OS in the CET cohort who received Anti-Her2 (93.0%), followed by the CET cohort who did not receive Anti-Her2 (90.2%) (p=0.06).

Conclusion

Chemotherapy followed by endocrine therapy and Anti-Her2 therapy was shown to be the most effective treatment modality in HR+/HER2+ ILC, contrasting previous data on the inconclusive benefit of chemotherapy in patients with ILC.

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Less chemotherapy (CT) is used in favor of endocrine therapy (ET) alone for HR+/HER2+ ILBC at the expense of efficacy.

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CT followed by ET remains an effective treatment in HR+/HER2+ ILBC, specifically for larger and locally advanced tumors.

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Research investigating subgroups of lobular BC who would benefit from CT de-escalation, or ET alone without CT is needed.

Five-year survival stratification using “the Cancer Of the Bladder Risk Assessment” (COBRA) score for micropapillary and sarcomatoid urothelial carcinoma of the bladder variants

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Background: The Cancer of the Bladder Risk Assessment (COBRA) score is a validated risk stratification tool for patients with urothelial carcinoma of the bladder (UCB) after cystectomy. Radical cystectomy with or without neoadjuvant chemotherapy is the standard of care for patients with muscle-invasive bladder cancer (MIBC). Lymph node density and the presence of positive lymph nodes have been demonstrated to be critical prognostic tools. Our goal was to evaluate 5-year overall survival (OS) on UCB variants: micropapillary and sarcomatoid, stratified by COBRA score and the presence of lymph nodes. Methods: We sampled the National Cancer Database (NCDB) for bladder cancer patients diagnosed with de novo micropapillary and sarcomatoid UCB between 2004 and 2018 and treated with radical cystectomy. 5-year Kaplan-Meier survival plots were utilized to assess OS differences amongst different COBRA score groups and stratified by the presence of lymph nodes (LNs). A multivariable Cox regression model was used to compare hazard ratios, adjusting for significantly unbalanced factors. A p-value < 0.05 was considered statistically significant. Results: A total of 1382 patients met the inclusion criteria. The average age was 68.10 + 10.31 years. 75% were male. Micropapillary represented 50.1% of selected histologies, followed by 49.5% sarcomatoid. For all combined histologies, 5-year OS percentage for patients with cystectomy and stratified by COBRA score (0-7) were 66% COBRA 0, 54% COBRA 1, 34% COBRA 2, 29% COBRA3, 15% COBRA > 4) (p < 0.001). 5-year OS for patients with cystectomy stratified by LN status was 54% for LN negative and 24% for LN positive (p < 0.001). Substratification of the cohort according to the presence of LNs and COBRA score have shown a numerical drop in 5-year survival and a notable decrease in median survival amongst compared groups. The risk of death was almost 5 times higher in patients with a high COBRA score (> 4) than in patients with a COBRA score of 0 (HR = 5.15, p < 0.001). Conclusions: COBRA score could contribute to clinical decision-making as a risk stratification tool for patients with UCB variants, micropapillary and sarcomatoid. 5-year OS decreases with higher COBRA scores, and LN status plays a major role in 5-year OS for these two UCB variants.[Table: see text]

Five-year survival comparison of different treatment modalities for muscle invasive urothelial carcinoma, squamous cell carcinoma and adenocarcinoma of the bladder: An analysis of the National Cancer Database

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Background: Localized muscle invasive bladder cancer carries a significant recurrence and mortality rate. The purpose of this study was to compare 5-year overall survival (OS) of neoadjuvant chemotherapy (NAC) followed by radical cystectomy (RC), RC alone, bladder preserving chemoradiotherapy (BPCRT) and radiation alone (RT) on selected histologies. Methods: We sampled the National Cancer Database (NCDB) for bladder cancer patients diagnosed with AJCC 7th Stage 2 and 3 for urothelial carcinoma (UC) including variant histologies, squamous cell carcinoma (SCC) and adenocarcinoma (AC) from 2004-2018 with definitive intent treatment. 5-year Kaplan-Meier survival plots were utilized to assess survival differences amongst treatment modalities and stratified by selected histologies. Multivariate cox regression models were used to compare hazard ratios and logistic regression analysis was performed for covariate analysis. A p-value <0.05 was considered statistically significant. Results: A total of 20,629 patients met inclusion criteria. The average age was 69.51 + 11.02 years, 68% were male. UC represented 94.1% of selected histologies, followed by 4.6% SCC and 1.3% AC. For all combined histologies, 5-year OS for patients with NAC followed by RC was 58%, 48% for RC alone, 33% for BPCRT and 10% for RT alone. RC alone provided a longer OS in the SCC and AC groups, 48% and 47% respectively (p<0.001). NAC followed by RC showed superior OS in the UC group (58%, p<0.001), with OS decreasing to 43% in SCC and 44% in AC. BPCRT showed lower 5-year OS in all selected histologies when compared to NAC followed by RC and RC alone (33% in UC, 27% in SCC and 24% in AC group). In all selected histologies, RT showed the lowest 5-year OS (10% in UC, 8% in SCC and 17% in AC group; p<0.001). Furthermore, covariables associated with lower 5-year survival were male sex (p<0.001) and TNM Stage 3 (p<0.001). Conclusions: NAC followed by RC showed improved 5-year OS for UC. The benefit of NAC was marginal for SCC and AC histology. RC is better than BPCRT for all histologies. RT alone showed inferior 5-year OS for all histologies.[Table: see text]

Abstract P2-07-07: Does OncotypeDX have predictive value in HER2+ breast cancer?

Background: The 21-gene OncotypeDX (ODX) assay has been validated as a predictive biomarker in early-stage hormone receptor positive (HR+) and HER2- breast cancer. This multigene panel identifies patients with a high risk of recurrence who would benefit systemic treatment involving both chemotherapy and endocrine therapy, versus endocrine therapy alone. ODX is not indicated in HER2 + breast cancer. Not all patients with HER2+ breast cancer are candidates for anti-HER2 treatments due to the potential for cardiotoxicity. We were interested to assess the value of ODX in predicting benefit of anti-HER2 treatment in HR+ and HER2+ breast cancer. Methods: We used the National Cancer Database to identify patients with early-stage (AJCC clinical staging I-II), HR+/HER2+ breast cancer who happen to have received multigene testing with ODX. We described this cohort using univariate descriptive statistics. We then explored the predictive value of this biomarker by constructing two Kaplan-Meier models for overall survival (OS) with log-rank testing. The first model generates OS curves associated with different approaches to systemic treatment (a. endocrine therapy alone, versus b. endocrine therapy + anti-HER2 targeted treatment, versus c. endocrine therapy + chemotherapy, versus d. endocrine therapy + anti-HER2 targeted treatment + chemotherapy) in patients with a recurrence score (RS) &lt; 26. The second model explores for differences in these systemic therapy approaches for those with a RS ≥ 26. Results: N=107,132 patients with early-stage, HR+/HER2+ breast cancer were included in this analysis. ODX testing was performed in n=5,280 (4.93%). The age distribution of this cohort was as follows: n=1,120 (21.2%) &lt; 50 years, n=3,195 (60.5%) between 50-70 years, and n=965 (18.3%) were &gt;70 years. The majority were White (84.9%), 9.6% were Black, and 3.3% were Asian. N=701 patients (13.3%) had a RS &lt; 26, while n=4,353 (82.4%) had a RS &gt;=26. The first Kaplan-Meier survival model indicated no significant difference in OS (p=0.445) between patients receiving different systemic treatment regimens when patients had a low risk of recurrence. However, the second Kaplan-Meier model indicates that when the ODX RS was ≥ 26, there was a statistically-significant difference in OS between systemic treatment regimens (p&lt;0.001). 5-year OS was highest (97.4%) for patients receiving triple therapy (anti-HER2 + chemotherapy + endocrine therapy), followed by those receiving dual therapy with endocrine + anti-HER2 (96.7%), and endocrine + chemotherapy (94.9%). Patients receiving endocrine therapy alone exhibited the lowest 5-year OS (88.5%). Conclusion: Results from this large national cancer registry suggest that multi-gene testing with ODX may have predictive value in treatment selection of patients with early-stage, HR+/HER2+ breast cancer. Prospective trials are warranted to identify subgroups of patients with HR+/HER2+ breast cancer who can be spared anti-HER2 treatments and cytotoxic chemotherapy.

Citation Format: Nadeem Bilani, Marita Yaghi, Diana Saravia, Iktej Jabbal, Maroun Bou Zerdan, Leah Elson, Hong Liang, Zeina Nahleh. Does OncotypeDX have predictive value in HER2+ breast cancer? [abstract]. In: Proceedings of the 2021 San Antonio Breast Cancer Symposium; 2021 Dec 7-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2022;82(4 Suppl):Abstract nr P2-07-07.

Abstract P4-05-10: Composite score combining multi-gene testing with liquid biopsy may have stronger prognostic value in HR+/HER2- breast cancer

Background: For patients with early-stage, hormone receptor-positive (HR+) and HER2-negative breast cancer, multigene testing (MGT) is commonly used to personalize treatment. Published data suggests that the 70-gene MammaPrint (MP) assay, while used less commonly, may be superior to the 21-gene OncotypeDX panel at identifying high-risk patients requiring chemotherapy adjunct to endocrine therapy, versus endocrine therapy alone. We previously showed that the presence of circulating tumor cells (CTCs) has prognostic and predictive value in breast cancer. We assess the prognostic value of composite scoring combining liquid biopsy data with MGT. Methods: This retrospective analysis of the National Cancer Database explores the prognostic value of ODX, MP and liquid biopsy identifying CTCs in patients diagnosed between 2004-2017 with early-stage (AJCC clinical stage I-II), HR+/HER- breast cancer. We examined the prognostic value of the following models: 1) ODX alone, 2) MP alone, and 3) ODX-liquid biopsy composite score. The ODX-liquid biopsy composite score was created to be a binary risk stratification as follows: when circulating tumor cells were present, intermediate-risk as per ODX was upstaged to high-risk, but when absent, intermediate-risk was down-staged to low-risk. We compared the effect size of hazard ratios generated by each model’s inclusion in Cox regressions for overall survival that controlled for age and race. We also evaluated the prognostic value of each model through generated Harrell’s C-indices (i.e. area under ROC curve), with a C-index closer to 1 indicating superiority of a model in differentiating high- from low-risk groups. Results: Among early-stage, HR+/HER2- patients (n=841,716), n=271,416 (32.2%) had documented ODX data, n=12,417 (1.5%) had MP data, and n=1,141 (0.14%) had both ODX and CTC data. Based on liquid biopsy results, n=63 patients were upstaged from intermediate- to high-risk in the partial composite ODX-CTC model (20.5% of all intermediate-risk), while the rest (79.5%) were down-staged. A comparison of effect sizes for HRs corroborates preliminary data in the literature that MP alone (HR 2.49, 95% CI 1.94-3.19) may be superior to ODX alone (HR 2.23, 95% CI 2.07-2.39) at prognosticating overall survival. Additionally, we show that a binary composite score of ODX with liquid biopsy may better identify patients with a higher risk of mortality (HR 3.46, 95% CI 1.63-7.31). Comparison of C-indices was not possible for MP scoring or ODX-liquid biopsy scoring, likely due to an inadequate sample size leading to non-significance. Conclusion: Composite scoring based on ODX and liquid biopsy using CTCs may be superior to ODX/MP alone to differentiate high-risk from low-risk prognosis in patients with early-stage, HR+/HER2- BC. If confirmed in larger studies, this composite scoring would be useful in practice to more accurately identify a higher risk patient population to target for additional treatment and close monitoring.

Table 1. Summary of prognostic parameters (HR and C-index) of 3 scoring systems.Prognostic ModelCOX RegressionROC AnalysisHR* (95% CI)C-index (95% CI)p-value1. ODX scoring alone (n=182,861)2.23 (2.07-2.39)0.566 (0.558-0.573)&lt;0.0012. MP scoring alone (n=8,643)2.49 (1.94-3.19)0.527 (0.492-0.562)0.1213. ODX-liquid biopsy composite scoring (n=685) 3.46 (1.63-7.31)0.497 (0.391-0.602)0.952*HRs comparing high-risk to low-risk stratifications, calculated from COX regression for overall survival after controlling for age (5-70) and race (White).

Citation Format: Nadeem Bilani, Marita Yaghi, Diana Saravia, Iktej Jabbal, Maroun Bou Zerdan, Leah Elson, Hong Liang, Zeina Nahleh. Composite score combining multi-gene testing with liquid biopsy may have stronger prognostic value in HR+/HER2- breast cancer [abstract]. In: Proceedings of the 2021 San Antonio Breast Cancer Symposium; 2021 Dec 7-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2022;82(4 Suppl):Abstract nr P4-05-10.

Abstract PD14-06: Does chemotherapy benefit patients with HR+/HER2- invasive lobular breast cancer?

Introduction Invasive lobular breast cancer (ILBC) is the second most common subtype of breast cancer. More evidence is emerging on the unique clinical features of ILBC. However, most systemic therapy guidelines for ILBC are derived from clinical trials with no specific focus on ILBC. Also, the benefit of chemotherapy for the treatment ILBC has been questioned. Using a large national registry, we aimed at comparing outcomes of various systemic therapy regimens in hormone receptor-positive (HR+) and HER2- ILBC. Methods We performed a year-stratified simple random sampling method to select 10% of ER+ or PR+ (HR+) and HER2- female patients with ILBC with AJCC stages I-III who underwent surgery from the National Cancer Database (NCDB) (2010-2017). Patients were grouped into four treatment cohorts: surgery only (S), chemotherapy alone (CT), endocrine therapy alone (ET), combined chemotherapy followed by endocrine therapy (CET). Overall survival (OS) among groups was first examined using the Kaplan-Meier method and Cox proportional hazard modeling. Focusing on ET and CET, propensity score (PS) match in logistic regression was performed to reduce selection biases due to demographical and clinical characteristics. OS between PS matched ET and CET pairs were evaluated again using the same methods. OS differences between ET and CET by lobular histology group and by disease stage were also examined. Results Approximately 90% of ILBC were HR+ and HER2+. N=17,789 patients were included in this analysis: 59.7% received ET, 26.2% CET, 2.3% CT and 11.9% S. 5-years OS was significantly better for patients who received ET (90.7%) or CET (90.4%) as compared to CT (79.4%) or S only (79.7%) (p&lt;.001). Of interest, after adjusting for other demographic and clinical characteristics, 5-years OS was similar for both ET and CET (p=.064). Increased ET administration (52.6% to 67.4%, p for trend &lt;.001) and decreased CET (30.4% to 20.2%, p for trend &lt;0.001) were observed from 2010 to 2017. Among n=15,273 patients who underwent ET (n=10,616; 69.5%) or CET (n=4,657; 30.5%), both groups had similar histology findings (45.5% vs 47.7% lobular histology mixed with other features). However, significant demographic and clinical characteristics differences were identified between both cohorts. Patients in the CET group were younger (mean age 56.9±10.5 vs. 65.5±11.6) (p&lt;.001), had a higher stage at diagnosis (34.8% stage III vs. 4.2%), more positive regional LN (67.5% vs. 13.7%), and received more radiation therapy (74.1% vs. 58.5%) as compared to those in the ET group. 5-years OS remained similar between ET and CET when adjusting for age, stage, LN involvement, histology, and radiation therapy (adjusted HR, 95% CI: 1.04, 0.89-1.20). Importantly, OS was similar between ET and ECT among patients with OncotypeDX (ODX) score &lt; 26 (96.4% vs 97.5%) and ODX score ≥ 26 (5-year OS: 92.2% vs 91.4%). PS match yielded 3,002 pairs; 5-years OS remained similar between ET (92.6%) and CET (91.6%) (p=0.94). In addition, no significant difference was detected when stratifying by disease stage and histology. Conclusion In this large analysis , chemotherapy did not improve survival in patients with HR+ and HER2- lobular cancer treated with ET, regardless of stage or lymph node involvement, or ODX score. The majority of patients with early stage HR+/HER2- with ILBC in the US receive ET, and one-fourth receive CET. Research investigating de-escalated chemotherapy-free regimens for ILBC are warranted. Exploring biomarkers-based approach to identify subgroups who would benefit from chemotherapy would better define systemic treatment options for ILBC.

Citation Format: Marita Yaghi, Iktej Jabbal, Nadeem Bilani, Maroun Bou Zerdan, Leah Elson, Hong Li, Diana Saravia, Elizabeth Stone, Zeina Nahleh. Does chemotherapy benefit patients with HR+/HER2- invasive lobular breast cancer? [abstract]. In: Proceedings of the 2021 San Antonio Breast Cancer Symposium; 2021 Dec 7-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2022;82(4 Suppl):Abstract nr PD14-06.

Abstract P1-08-33: Disparities in the practice of precision medicine? Using multi-gene testing in early-stage, HR+/HER2- breast cancer

Background: Multi-gene testing (MGT) can be used to identify patients with early-stage, hormone receptor-positive (HR+), HER2-negative (HER2-) breast cancer that are likely to benefit from treatment regimens with chemotherapy and endocrine therapy, compared to endocrine therapy alone. Two examples of genomic panels include OncotypeDX (ODX) MammaPrint (MP). Tailoring practice to the unique profile of each patient, known as ‘precision medicine’, has significantly refined the treatment approach in breast cancer, while decreasing toxicity and cost. In this analysis, we explore disparities in the access to precision medicine among several socio-demographic groups. Methods: We conducted a retrospective analysis of the National Cancer Database, using the 2004-2017 breast cancer dataset. We included patients with HR+/HER2-, stage I-II breast cancer. We excluded patients with stage III disease as many would still receive chemotherapy with less use of MGT. Using chi-squared statistics, we identified socio-demographic, clinical and pathologic factors associated with the use MGT - either ODX or MP - in this group. We then included significant variables (p&lt;0.05) in one multiple logistic regression model predicting the use of either genomic panel. Results: A total of n=841,716 patients who were candidates for MGT (early-stage, HR+/HER2- breast cancer) were included in this analysis. N=283,833 (n=33.7%) underwent MGT (32.2% used ODX while 1.5% used MP). Use of genomic assays has increased significantly over time (11.5% for patients diagnosed between 2007-2009, to 39.4% between 2016-2017). Variables significantly associated with the use of either ODX/MP at the multivariate level (p&lt;0.05) included: age, race, insurance status, education level, facility type, year of diagnosis, geographic location, tumor grade, and tumor histology. Elderly patients (&gt;70) were less likely than those &lt;50 to undergo MGT (OR 0.32, 95% CI 0.32-0.33, p&lt;0.001). Black patients were also less likely to receive a genomic assay compared to White patients (OR 0.80, 95% CI 0.78-0.82, p&lt;0.001). Insurance status was another significant predictor, with uninsured patients being the least likely to receive ODX or MP (OR 0.69, 95% CI 0.66-0.72, p&lt;0.001), compared to those with private insurance. Conversely, patients treated at academic/research cancer programs were more likely to undergo MGT than those treated at community cancer programs (OR 1.13, 95% CI 1.10-1.15, p&lt;0.001). Geographic discordance in use of MGT was also identified: with highest rates of use (39.2%) in the Middle Atlantic (NJ, NY, PA), and lowest rates (23.5%) in West South-Central states (AR, LA, OK, TX). Conclusions: This large analysis of real world, national data identified several social determinants of health predictive of disparity in the implementation of precision medicine practices for early-stage, HR+/HER2- breast cancer. Improving access to innovative, diagnostic and prognostic tools, among black and underinsured patients, as well as those treated in community practices, is needed.

Citation Format: Nadeem Bilani, Marita Yaghi, Diana Saravia, Iktej Jabbal, Maroun Bou Zerdan, Leah Elson, Liang Hong, Zeina Nahleh. Disparities in the practice of precision medicine? Using multi-gene testing in early-stage, HR+/HER2- breast cancer [abstract]. In: Proceedings of the 2021 San Antonio Breast Cancer Symposium; 2021 Dec 7-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2022;82(4 Suppl):Abstract nr P1-08-33.

Abstract P2-12-12: The effect of Neoadjuvant Chemotherapy in reducing the need for axillary lymph node dissection in HR+/HER2- node positive breast cancers

Background In recent years, indications for neoadjuvant treatment (NAC) have been extended to patients with operable disease at diagnosis and it is increasingly being used in patients to reduce extent of axillary involvement and allow for more limited surgery in the breast and axilla. The increasing use of this therapy however has raised questions about optimal surgical exploration of the axilla post-chemotherapy. In this study therefore, we aimed to analyze the effect of NAC in reducing the need for axillary lymph node dissection (ALND), regardless of pathologic nodal status, in those who present with clinically node positive disease at diagnosis. Methods We sampled the National Cancer Database (NCDB) (2004-2016) for female patients with hormone receptor (HR) positive [estrogen receptor (ER) positive and/or progesterone receptor) (PR) positive], human epidermal growth factor receptor 2 (HER 2) negative, clinically node positive breast cancers. We then performed a multivariate logistic regression analysis to evaluate associations between chemotherapy regimen, disease, demographic, and geographic characteristics with the patients undergoing ALND. Statistics were performed using SPSS version 28.0 (190). Results N= 134704 female patients were included in the analysis; 79.2% Caucasian, mean age 59.13 years (SD = 13.95). Receiving NAC was associated with lower odds of undergoing ALND (OR = 0.849, 95% CI = 0.822 - 0.879, p &lt;0.001) as compared to adjuvant chemotherapy (AC). On multivariate analysis, patients younger than 50 years old (ref, p = 0.005), black (OR = 0.824, 95% CI = 0.788 - 0.862, p &lt;0.001), and uninsured (ref, p&lt;0.001) were associated with lower odds of undergoing ALND as compared to their counterparts. In contrast, receiving care at Integrated Network Cancer Programs (OR = 1.182, 95% CI = 1.107 -1.261, p &lt; 0.001) and residing in the Pacific region (OR = 1.519, 95% CI = 1.402 - 1.646, p &lt; 0.001) was associated with a higher odds of patients undergoing ALND as compared to their counterparts. Conclusion Our findings indicate that for HR+/HER2-, node positive breast cancer, receiving chemotherapy in the neoadjuvant setting is associated with lower odds of ALND compared to when chemotherapy is received adjuvantly. Further studies exploring the effect of NAC on the nodal status post operatively, would help strengthen our findings. Additionally, while the use of chemotherapy remains a clinical decision, our study highlights that disparities in terms of sociodemographic and geographic factors may influence the receipt of such treatment in this cohort of patients.

Citation Format: Iktej Singh Jabbal, Diana Saravia, Marita Yaghi, Nadeem Bilani, Leah Elson, Hong Liang, Zeina Nahleh. The effect of Neoadjuvant Chemotherapy in reducing the need for axillary lymph node dissection in HR+/HER2- node positive breast cancers [abstract]. In: Proceedings of the 2021 San Antonio Breast Cancer Symposium; 2021 Dec 7-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2022;82(4 Suppl):Abstract nr P2-12-12.

Abstract P2-12-17: Comparative outcomes of Neoadjuvant versus Adjuvant chemotherapy in HR+/HER2- node positive breast cancer

Background Neoadjuvant therapy is considered for patients with hormone receptor (HR) positive/Human Epidermal Growth factor Receptor (HER) 2 negative breast cancers primarily to reduce tumor size and optimize surgical outcomes, and improve the chances for breast conservation. This approach rarely leads to pathological complete response and raises concerns about potential adverse outcomes due to delaying surgery. The objective of this study was to compare long term outcomes in patients receiving neoadjuvant (NAC) versus adjuvant chemotherapy (AC) for node positive breast cancer and to analyze survival in these groups when stratified by clinical stage. Methods We sampled the National Cancer Database (NCDB) (2004-2016) for patients with HR positive [estrogen receptor (ER) positive and/or progesterone receptor (PR) positive], HER2 negative, clinically diagnosed node positive breast cancers. We performed a multivariate logistic regression analysis to summarize demographic, geographic, and disease characteristics associated with the specific chemotherapy regimen. We then used multivariate cox regression models to compare hazard ratios for the same variables and plotted Kaplan-Meier survival plots to look for survival rate differences (S) between NAC and AC stratified by stage IIA, IIB, IIIA, and IIIB. Results Out of the 134,704 female patients who were included in this analysis (79.2% Caucasian, mean age 59.13 years), 24.9% received NAC, and 46.3% AC. In our study, patients older than 70 years had lower odds of receiving either NAC or AC (NAC: OR = 0.33, 95% CI = 0.31 - 0.35, p &lt;0.001 and AC: OR = 0.31, 95% CI = 0.29 - 0.32, p &lt; 0.0001) while those on private insurance had increased odds of getting either NAC or AC (NAC: 1.33, 95% CI = 1.23 - 1.45, p &lt; 0.001 and AC: OR = 1.13, 95% CI = 1.06 - 1.21, p = &lt;0.001) as compared to their counterparts. Patients with higher income (OR = 1.134, 95% CI = 1.064 - 1.209, p = &lt;0.001), and those receiving treatment at an Integrated Network Cancer Program (OR = 1.405, 95% CI = 1.318 - 1.498, p &lt; 0.001) were associated with higher odds of receiving NAC as compared to AC. However, patients were less to receive AC at an Integrated Network Cancer Program (OR = 0.784, 95% CI = 0.743 - 0.828, p &lt;0.001), and with a Charlson/Deyo score of 3 or more (OR = 0.632, 95% CI = 0.561 - 0.712, p &lt;0.001). Upon stratification, NAC as opposed to AC was associated with a longer S for patients with Stage IIIB (NAC: median S = 108.19 months, 95% CI = 101.71 - 114.67, and AC: median S = 89.63, 95% CI = 82.78 - 96.48, p &lt;0.001). While data for stage IIA showed similar survival rates for both NAC and AC, it favored AC for other stages (IIB and IIIA). We analyzed characteristics associated with the benefit from chemotherapy overall, and noted that in patients with HR+, HER2 negative and node positive breast cancer, patients who received chemotherapy had a predicted greater survival as opposed to those who did not receive any chemotherapy whether NAC (HR = 0.565, 95% CI = 0.545 - 0.586, p &lt; 0.001) or AC (HR = 0.545, 95% CI = 0.529 - 0.561, p &lt; 0.0001). Hispanic ethnicity ( HR = 0.721, 95% CI = 0.661 - 0.787, p &lt;0.001), private insurance (HR = 0.510, 95% CI = 0.479 - 0.544, p &lt; 0.001), higher income (HR = 0.869, 95% CI = 0.826 - 0.914, p &lt;0.001), care at an academic program (HR = 0.870, 95% CI = 0.833 - 0.908, p &lt;0.001) and being located in the West South Central region (HR = 0.860, 95% CI = 0.803 - 0.921, p &lt;0.001) were associated with greater S as compared to their counterparts in their respective subgroups. Conclusions In this large database, our data suggests that AC confers superior survival, compared to NAC in patients with HR positive, HER2 negative, and node positive breast cancer except for patients with Stage IIIB breast cancer. Also, chemotherapy given in any setting appears to improve survival overall.

Citation Format: Iktej Singh Jabbal, Diana Saravia, Marita Yaghi, Nadeem Bilani, Leah Elson, Hong Liang, Zeina Nahleh. Comparative outcomes of Neoadjuvant versus Adjuvant chemotherapy in HR+/HER2- node positive breast cancer [abstract]. In: Proceedings of the 2021 San Antonio Breast Cancer Symposium; 2021 Dec 7-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2022;82(4 Suppl):Abstract nr P2-12-17.

Metastasectomy versus radiation of secondary sites in stage IV breast cancer: Analysis from a national cancer registry

PURPOSE

Locoregional therapy at primary or secondary sites in breast cancer may be associated with improved survival as compared to systemic therapy alone. We explored the sociodemographic and clinicopathologic factors associated with the use of radiation versus surgical resection of metastatic sites (metastasectomy) in patients with de novo stage IV breast cancer, followed by the associated overall survival.

METHODS

We sampled the National Cancer Database for patients with de novo stage IV breast cancer, (2010-2017) and described cohort's characteristics using univariate analyses. We identified 5 subgroups based on malignant site involvement: 1. Bone only, 2. Brain only, 3. Liver only, 4. Lung only, and 5. Metastasis involving >1 site. Kaplan-Meier modeling with log-rank testing and multivariate Cox Regression analysis were used to explore differences in overall survival between those that received radiation at secondary sites and those that underwent metastasectomy.

RESULTS

N = 22,749patients were included in this analysis. Radiation (81.2%) was used more commonly than metastasectomy (28.8%). Metastasectomy was associated with better median overall survival across all 5 cohorts (p < .001), with the survival benefit being the most pronounced with lung only (OS: 56.9 months; HR 0.8, 95% CI 0.7-0.9, p = .032), or liver only (OS: 41.6 months; HR: 0.9; 95% CI: 0.7-1.1, p < .001) metastasis.

CONCLUSION

Metastasectomy in patients with de novo stage IV breast cancer may be associated with improved overall survival as compared to radiation of secondary lesions, particularly in those with only liver or lung involvement. Prospective randomized controlled trials investigating surgical resection of metastatic sites in patients with breast cancer are warranted.

Differential responses to therapy in Hispanic NSCLC patients with EGFR, KRAS, or TP53 mutations

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Background: Hispanic (H) patients with non-small cell lung cancer (NSCLC) tend to have more advanced disease at time of diagnosis and less likely to receive treatment compared to non-Hispanic white (NHW) Americans. While survival outcomes do not differ greatly, Hispanic patients tend to have lower response rates to immunotherapy and to targeted therapy with known EGFR mutations. We sought to determine if Hispanic patients with other common mutations present in NSCLC also demonstrate suboptimal responses to therapy compared to NHW patients. Methods: We performed a retrospective review of 468 patients with advanced stage NSCLC at the University of Miami / Sylvester Comprehensive Cancer Center who underwent next-generation sequencing (NGS) for whom treatment outcomes could be identified. Genomic results were obtained from Guardant360 and Foundation One testing in blood or tissue, respectively. Results: In our cohort, 154 patients (33%) were of Hispanic ethnicity, while 279 patients (60%) were NHW. Median age at time of diagnosis was 59, and 50% were male. PD-L1 status was known for 217 patients, with 110 expressing some level of PD-L1. EGFR mutations were present in 25% of all patients, KRAS mutations in 25%, and TP53 mutations in 61%. Average tumor mutational burden was 4.0 in Hispanic patients and 3.6 in NHW patients. We compared outcomes in patients receiving any therapy as well as those specifically receiving immune checkpoint inhibitors (ICI). No differences in OS were observed in our overall patient cohort between H and NHW patients. However, when stratifying patients with EGFR or KRAS mutations, Hispanic patients exhibit significantly shorter OS than their NHW counterparts. In patients with TP53 mutations, we observed no differences between H and NHW outcomes considering all therapy, but Hispanic patients exhibited improved OS with the use of ICI. Conclusions: Our data suggest that the presence of certain mutations in Hispanic patients with advanced NSCLC may serve some prognostic value in predicting responses to therapy, specifically the use of ICI. Further investigation is indicated to determine mechanisms leading to inferior responses after ICI therapy in Hispanic patients.[Table: see text]

A national analysis of untreated stage III non-small cell lung cancer in black and white patients

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Background: Stage III non-small cell lung cancer (NSCLC) is treatable and potentially curable with surgical resection and/or chemoradiotherapy (CRT). Factors such as medical comorbidities and access to care may impact treatment decisions, including the decision to give no treatment. Using the National Cancer Database (NCDB), we analyzed the clinical presentation and proportion of Black and White Stage III NSCLC patients who received no form of treatment and compared their overall survival to patients who received other forms of management. Methods: Black and White stage III NSCLC’s diagnosed between 2004 and 2015 in the NCDB were included. Cases with multiple tumors and who received surgery were excluded. Patients who received no form of treatment (No-RT-nor-CT) were compared to patients treated with (CRT), RT only (RT), and CT only (CT). Univariate, multivariate, and Kaplan-Meier models were performed. Results: A total of n=22,459 Black and n=138,477 White stage III NSCLC patients were analyzed. Concurrent CRT given within 0-30 days was the most common management for Black (42.3%) and White patients (43.9%). No-RT-nor-CT was the second largest management group among Black (21.2%) and White patients (21.5%). A higher proportion of Black patients (14.2%) had a contraindication to CT than White patients (12.9%), p=0.0016; the same was true for those not managed with RT (6.1% vs. 5.3%, p=0.0051). Among patients managed without CT, the most common reason for not receiving CT among Black (63.31%) and White patients (63.0%) was that CT was not part of the planned 1st treatment course. Among patients managed without RT, the most common reason for not receiving RT among Black (77.0%) and White patients (78.2%) was that RT was not part of the planned 1st treatment course. A higher proportion of White patients versus Black patients did not receive CT (17.4% vs 14.0%, p<0.0001) nor RT (8.8% vs 7.7%, p=0.0013) because it was refused by the patient or guardian. The 2- and 5-year overall survival (OS) rates were lowest among the No-RT-nor-CT cohort of Black (13.9%, 5.4%, respectively) and White (12.1%, 4.6%, respectively) patients versus all other treatments. Median OS with No-RT-nor-CT was 4 months for Black patients and 3 months for White patients (p<0.0001). Conclusions: Concurrent CRT with or without surgery is an established standard of care for stage III NSCLC, but a significant proportion of White and Black patients are not receiving potentially curative therapy. A higher proportion of Black patients had contraindications to CT and RT than a similar cohort of White patients, which may reflect a higher rate of medical comorbidities. A higher proportion of White patients or their guardians refused CT and RT than a similar cohort of Black patients. Assessing and addressing the challenges that affect access to care and the type of care delivered remains an essential component of health care in America and influences survival outcomes.

Patterns of survival in NSCLC with de novo brain metastasis: SRS, WBRT, and no radiotherapy cohorts

9122

Background: Prognostic determinants in metastatic non-small cell lung cancer (mNSCLC) include numerous sociodemographic and clinical characteristics. We provide granular, real-world survival data in different cohorts of this heterogeneous population, stratifying by: age, Charlson/Deyo scoring (CDS) of comorbidity, tumor histology, and use of immunotherapy. Methods: This retrospective analysis uses the National Cancer Database (NCDB) to explore patterns of survival in patients diagnosed between 2010-2016 with mNSCLC involving the brain. Kaplan-Meier (KM) modeling was used to evaluate for differences in overall survival (OS) between 3 cohorts of patients: those undergoing 1) stereotactic radiosurgery (SRS), 2) whole-brain radiotherapy (WBRT), and 3) those not undergoing brain radiotherapy (NR) as part of the first course of treatment. As per Table, we ran 8 KM models to generate median OS (mOS) data across stratifications for age (<70 vs. ≥70), CDS (0-1 vs. 2-3), tumor histology (adenocarcinoma vs. squamous), and use of immunotherapy (yes vs. no). We provide a ranked order of these 3 cohorts by mOS (‘survival sequence’, or ‘SS’), as well as differences in mOS (‘ΔmOS’) between NR and WBRT – the two cohorts most comparable in life expectancy. Results: A total of n=38,119 patients were included in this study. Most received WBRT (n=18,052, 47.4%), n=6,562 (17.2%) received SRS, while n=13,505 (35.4%) did not receive brain radiation as part of their first course of treatment. In all subgroups, patients treated with SRS for brain metastasis had the highest mOS. Survival for those receiving WBRT was better or comparable (difference in mOS <0.5 months) to those that did not receive radiotherapy, except in patients aged ≥70 (SS: NR > WBRT; KM p-value <0.05; ΔmOS of 1.6 months), those with Charlson-Deyo comorbidity scores of 2-3 (SS: NR > WBRT; KM p-value <0.05; ΔmOS: 0.6 months), those with squamous carcinoma (SS: NR > WBRT; KM p-value <0.05; ΔmOS: 0.7 months), and those already receiving immunotherapy (SS: NR > WBRT; KM p-value <0.05; ΔmOS: 0.6 months). Conclusions: SRS for de novo brain metastases is associated with improved OS in mNSCLC. In contrast, the burden of WBRT may outweigh the survival benefit it affords in patients ≥70, and those with comorbidities. Squamous cell carcinomas may be associated with more radio-resistance than adenocarcinomas to WBRT. Finally, as previously described in melanoma, the survival benefit afforded by brain radiotherapy may be lower in patients on immunotherapy.[Table: see text]

A comparative analysis of mortality between black and white stage III non–small cell lung cancer patients in the United States

8552

Background: Lung cancer remains the leading cause of cancer death in the United States (U.S.). For stage III non-small cell lung cancer (NSCLC), concurrent chemotherapy (CT) plus radiotherapy (RT) within 30 days (CCRT) confers a survival benefit. The proportion of Black and White NSCLC patients not receiving CCRT and their outcomes have not been explored. Methods: Stage III NSCLC in Black and White patients diagnosed between 2004 and 2015 from the U.S. NCDB were included. Those with multiple tumors and who received surgery were excluded. Six groups were analyzed: CCRT (0-30 days between CT and RT), SCRT (31-120 days between CT and RT), RT (only RT), CT (only CT), No-RT-nor-CT (didn’t receive RT nor CT), and other (uncategorized). Univariate, multivariate, and Kaplan-Meier analyses were utilized (p<0.05). Results: A total of 22,459 Black (CCRT 42.3%, SCRT 7.6%, RT 13.8%, CT 15.1%, and No-RT-nor-CT 21.2%) and 138,477 White (CCRT 43.9%, SCRT 7.0%, RT 12.7%, CT 14.9%, and No-RT-nor-CT 21.5%) stage III NSCLCs were analyzed. Male gender and White race were positive predictive factors for receiving CCRT (Table). In Black patients SCRT (HR 1.1; 95% CI 1.04-1.17), RT only (HR 1.2; 95% CI 1.81-1.99), CT only (HR 1.4; 95% CI 1.36-1.49), and No RT or CT (HR 2.6; 95% CI 2.49-2.69) was associated with decreased overall survival (OS) compared to CCRT. In White patients, SCRT (HR, 1.0; 95% CI, 0.99-1.03) did not decrease OS compared to CCRT, whereas RT only (HR 1.8; 95% CI, 1.74-1.80), CT only (HR 1.3; 95% CI, 1.29-1.34), and No RT or CT (HR 2.6; 95% CI, 2.59-2.67) were associated with decreased OS. Median OS with CCRT was 18 months for Black patients, versus 16 months for White patients (p<0.0001). Conclusions: OS was highest when CCRT was given. A lower proportion of Black cases were managed with CCRT, but Black patients benefit more from CCRT and had improved OS than White patients. Despite the known benefits of CT and RT in stage III NSCLC, the second largest management cohort received neither RT nor CT.[Table: see text]

Metastasectomy versus radiation of secondary sites in stage IV breast cancer

1094

Background: Prospective trials have yielded mixed results on the utility of surgery in metastatic breast cancer (mBC). Thus far, however, studies have focused primarily on the impact of lumpectomy or mastectomy. We previously showed that a combined approach involving resection of primary and secondary sites (i.e. ‘metastasectomy’) in patients with limited mBC was associated with improved overall survival (OS). We sought to evaluate the effect on OS of two approaches to loco-regional therapy (LRT) at secondary sites: metastasectomy versus radiation therapy. Methods: This is a retrospective analysis of patients diagnosed with mBC from 2010-2017 using the National Cancer Database. We identified 5 cohorts of patients by site of metastasis: mBC involving only 1) bone, 2) brain, 3) liver, or 4) lung; and 5) patients with metastasis involving >1 site. For each cohort, we used Kaplan-Meier (KM) models with log-rank testing to evaluate differences in OS, by the LRT approach at secondary sites (radiation versus metastasectomy). Prior to KM modeling, chi-squared statistics were used in each cohort to assess whether age, race, Charlson/Deyo score (CDS) for comorbidity, and receptor subtype were potential confounders of survival. The KM models were adjusted accordingly, as per the table below. Results: 53.4%) were between 50-70 years old, White (n=53,409, 78.9%), and had hormone receptor (HR)-positive/HER2 receptor-negative breast cancer. N=12,362 patients received radiation therapy at either the bone, brain, liver, or lung; while n=2674 underwent surgical resection of a metastatic site. Of patients with metastasis to 1 site (n=44,451), n=30,341(68.3%) involved the bone, n=1,119 (2.5%) involved the brain, n=5,227 (11.8%) involved the liver, and n=7,764 (17.5%) involved the lung. N=24,017 patients had metastatic disease involving > 1 site. KM modeling revealed superior OS of patients undergoing metastasectomy versus radiation of secondary sites in all 5 cohorts (p<0.05). The difference in median OS (ΔmOS) by LRT approach was more pronounced when metastasis involved only the liver (41.6 months) or lung (48.6 months), versus only the brain (9.7 months) or bone (8.7 months). Conclusions: Metastasectomy appears to confer a superior benefit for OS compared to radiation of secondary sites, particularly in patients with secondary site involvement limited to the liver or lung. More research is needed from prospective trials investigating surgical resection of metastatic sites.[Table: see text]

Prognostic value of systemic inflammatory markers in first- and subsequent-line immunotherapy and durability of response in NSCLC

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Background: Treatment of advanced non-small cell lung cancer with immune checkpoint inhibitors (ICI) has been shown to yield durable responses. High neutrophil-to-lymphocyte ratios (NLR), low lymphocyte-to-monocyte ratios (LMR) and high platelet-to-lymphocyte ratios (PLRs) have been used as surrogates for increased levels of inflammation in the tumor microenvironment that can predict cancer progression and response to therapy. However, the comparative prognostic role of these markers account for when immunotherapy is utilized has not been explicitly determined. Methods: We performed a retrospective review of 233 patients with advanced stage NSCLC at the University of Miami / Sylvester Comprehensive Cancer Center who received ICI either as first-line (1L) or second-line (2L) therapy and for whom laboratory data, in particular absolute neutrophil, lymphocyte, monocyte, and platelet counts, were available pre-treatment and 4 weeks after initiation of immunotherapy. Results: Using receiver operating characteristic (ROC) curves, we identified cutoff values with optimal prognostic value for NLR (4), LMR (2), and PLR (200). Median age, histology, and smoking history were equivalent across each group. Improved OS was observed in our cohort for patients in which pre-treatment NLR < 4 (54.4m vs. 35.9m, p = 0.0069), LMR > 2 (54.4m vs. 32.3m, p = 0.0016), and PLR < 200 (54.4m vs. 27.5m, p = 0.0007), while PFS was unaffected when looking strictly at these cutoffs. We then observed that PFS could be better predicted after stratifying NLR, LMR, or PLR when taking into account whether ICI was administered as 1L or 2L. We also determined that changes in (Δ) NLR or LMR (but not PLR) by at least 20% between baseline and 4 weeks after initiation of ICI could predict duration of response to ICI. Conclusions: In conclusion, the NLR, LMR, and PLR are powerful surrogates for the tumor microenvironment and can predict responses to ICI in advanced NSCLC when used in the context of previous lines of therapy and subsequent pro-inflammatory changes. Our study shows that ICI used in the first-line setting results in more durable responses, and can overcome an unfavorable tumor microenvironment. In addition, we demonstrate that in NSCLC, durability of responses can be predicted by changes in these systemic inflammatory response markers early after the initiation of ICI.[Table: see text]

Stage migration in breast cancer: Better detection or semantics in staging?

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Background: As oncology treatment has evolved to become more individualized, prognostic rationale has also undergone important changes. In breast cancer, disease staging was historically based upon anatomic features of the primary tumor, in combination with involvement of adjacent/distant tissues. However, as the understanding of molecular/genomic involvement became more advanced, staging definitions were redefined to incorporate receptors, histologic grade, and genetic expression. In this analysis, we use autoregressive integrated moving average (ARIMA) forecasting to understand how AJCC updates to prognostic definitions have contributed to stage migration, and to comment on whether better detection, or definitional changes, may be responsible for the increasing incidence in early stage breast cancer. Methods: In this time series forecast, ARIMA models, per stage (early: stage I/II vs. late: stage III/IV) were constructed based on 2004-2016 historic breast cancer incidence rates, as reported by the NCDB. Multiple models were generated, using differing autoregressive parameters; the most predictive model was chosen using the lowest Bayesian Information Criteria (BIC), and mean absolute percentage error (MAPE) to ensure best fit. Similar methodology has already been published to predict prostate cancer incidence. The best fit models were applied to forecast annual incidence, in the NCDB, in 2017. These data were compared to the real-world data captured in 2017. Statistics were performed using modeling systems in SPSS, version 27. Results: n=1,661,971 cases were included for these models, and 12 years of pre-AJCC updated NCDB breast cancer data were used. Using ARIMA modeling, best fit, stationary averages were identified, with autoregressive and difference terms which contributed to the lowest BIC, and MAPE < 5%, for both models. The best fit models forecasted 2017 incidence, by stage, without AJCC updates to staging criteria, and this data is compared to actual 2017 incidence with current updated AJCC 8th staging criteria (Table). Conclusions: During 2017, the first year of AJCC staging updates, there was an observed decrease in late stage diagnoses, and increase in early stage diagnoses, when compared with incidence rates that were forecasted using the old, anatomic AJCC criteria. Therefore, part of the stage migration noted may be a product of staging semantics, using updated definitions. Confirming appropriate improvement in long-term outcomes, based on new staging would be helpful. It is also important for clinicians and public health officials to bear this in-mind when interpreting epidemiologic data, for allocating resources, as shifts in staging may be a product of guideline changes, and not necessarily screening efficacy or early detection only.[Table: see text]

Cancer disparities among patients with advanced metastatic breast cancer

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Background: We previously elucidated sociodemographic factors associated with risk-of-death, in a subgroup of patients with Stage IV human epidermal growth factor 2 (HER)+ breast cancer. To further understand determinants of disparities in all subgroups of stage IV breast cancer, this study sought to evaluate factors which are predictive of overall survival (OS) in a cohort of patients with metastatic breast cancer (MBC), according to the following subtypes: 1) estrogen receptor (ER)+ or progesterone receptor (PR)+ and (HER)-, (2) (ER+ or PR+) and HER+, (3) (ER- and PR-) and HER-, or (4) (ER- and PR-) and HER+. Methods: Study population included patients with MBC, extracted from the National Cancer Database, treated between 2010 and 2016. Descriptive statistics were used to summarize patient characteristics, and chi-square tests were performed to compare patient characteristics, by ethnic group (white, black, Hispanic, Asian, and other). Multivariate Cox regression models with backward elimination (using significance level of p<0.05) were utilized to compare overall survival among patient cohorts. In addition, Kaplan-Meier survival curves of patient cohort were also produced. Statistics were performed using SAS. Results: Records from n= 47,032 patients were included, the majority were 50 years or older, white, and treated with hormonal therapy. With a median follow-up time of 2.3 years, disparities in OS were observed; black patients were more likely to suffer death (HR=1.12 (1.08-1.16), p<0.0001), compared to white patients. Additional factors contributing to risk of death in MBC included: being male (HR=1.12, (1.02-1.23), p=0.019), having visceral involvement compared to bone only (HR=1.52, (1.05-1.28), p<0.0001), income < $38,000 (HR=1.13 (1.09-1.17), p<0.0001), being on government insurance (HR=1.24, (1.20-1.27), p<0.0001, and having Triple Negative Breast Cancer (ER- and PR-) and HER- status (HR=1.68 (1.60-1.75) p<0.0001). Patients who receive chemotherapy, not hormonal therapy (HR=1.25 (1.2 – 1.3), p<0.0001), were found to have worse prognosis possibly reflecting biology of disease at presentation and lack of specific targeted therapy. Conclusions: This study confirms that sociodemographic disparities exist in OS among patients within the same stage of MBC, and regardless of receptor status subtypes. Clinical practice should focus on closing disparities gaps for those with advanced and MBC, especially among Black, impoverished, and male patients. Better treatment approaches should be sought for patients with visceral metastasis and those diagnosed with triple negative receptor status, who continue to suffer from worse outcomes.

Use of brain radiotherapy as part of first course of treatment for NSCLC with de novo brain metastasis

9118

Background: Loco-regional management of brain metastases from non-small cell lung cancer (NSCLC) are surgery and/or brain radiotherapy, either whole brain (WBRT) or stereotactic (SRS). We used a national registry to evaluate trends in the use of brain radiotherapy as part of the first course of management in patients diagnosed with de novo brain metastasis. Methods: We retrospectively analyzed the National Cancer Database (NCDB) to identify patients with NSCLC and de novo brain metastasis diagnosed from 2004-2016. We described the socio-demographic and clinical characteristics of this population, then used chi-squared testing to evaluate for an association between these variables and the use of brain radiotherapy (either SRS or WBRT). Significant variables (p < 0.05) were included in a multiple logistic regression model. Results: Of n = 41,454 patients with NSCLC and de novo brain metastasis, n = 27,949 (67.4%) received either SRS or WBRT as part of their first course of treatment, while n = 13,505 (32.6%) did not receive primary brain radiation. Of those that did not receive radiation: n = 9,927 (73.5%) were < 70 years old while n = 3,578 (26.5%) were ≥70. N = 11,081 (82.7%) were White, n = 1,550 (11.6%) were Black and n = 768 (5.7%) were Asian. Variables significantly associated with the use of primary brain radiotherapy at the multivariate level were: treatment facility type (p = 0.004), tumor histology (p < 0.001), clinical T-staging (p < 0.001), and clinical N-staging (p < 0.001). Age, sex, race, comorbidity, grade, insurance status, and setting (metro vs. rural vs. urban) were not significantly associated with the use of radiotherapy. Compared to patients treated at community cancer programs (CPs), those treated at comprehensive community CPs (OR 1.152, 95% CI 1.027-1.291, p = 0.015) and academic CPs (OR 1.242, 95% CI 1.104-1.398, p < 0.001) were more likely to receive primary brain radiotherapy. Patients with squamous NSCLC were less likely (OR 0.680, 95% CI 0.619-0.747, p < 0.001) to receive brain radiotherapy compared to those with adenocarcinoma. Finally, patients with advanced T-staging (p < 0.001) and N-staging (p < 0.001) were less likely (OR < 1) to receive brain radiotherapy as part of the first course of treatment. Conclusions: While insurance status and setting were not significantly associated with the use of brain radiotherapy, facility type was. Further research is needed to evaluate whether this is a true disparity in medical practice, or the differences can be explained by characteristics of the patient population undocumented by the NCDB (e.g. severity of brain metastasis). Additionally, patients with larger primary tumors were less likely to receive brain radiation as part of the first course of treatment, which may reflect the need for local therapy prior to treating metastatic sites.

Predicting immunotherapy outcomes under therapy in patients with advanced NSCLC using dNLR and its early dynamics

BACKGROUND

dNLR at the baseline (B), defined by neutrophils/[leucocytes-neutrophils], correlates with immune-checkpoint inhibitor (ICI) outcomes in advanced non-small-cell lung cancer (aNSCLC). However, dNLR is dynamic under therapy and its longitudinal assessment may provide data predicting efficacy. We sought to examine the impact of dNLR dynamics on ICI efficacy and understand its biological significance.

PATIENTS AND METHODS

aNSCLC patients receiving ICI at 17 EU/US centres were included [Feb/13-Jun/18]. As chemotherapy-only group was evaluated (NCT02105168). dNLR was determined at (B) and at cycle2 (C2) [dNLR≤3 = low]. B+C2 dNLR were combined in one score: good = low (B+C2), poor = high (B+C2), intermediate = other situations. In 57 patients, we prospectively explored the immunophenotype of circulating neutrophils, particularly the CD15+CD244-CD16^lowcells (immature) by flow cytometry.

RESULTS

About 1485 patients treatment with ICI were analysed. In ICI-treated patients, high dNLR (B) (~1/3rd) associated with worse progression-free (PFS)/overall survival (OS) (HR 1.56/HR 2.02, P < 0.0001) but not with chemotherapy alone (N = 173). High dNLR at C2 was associated with worse PFS/OS (HR 1.64/HR 2.15, P < 0.0001). When dNLR at both time points were considered together, those with persistently high dNLR (23%) had poor survival (mOS = 5 months (mo)), compared with high dNLR at one time point (22%; mOS = 9.2mo) and persistently low dNLR (55%; mOS = 18.6mo) (P < 0.0001). The dNLR impact remained significant after PD-L1 adjustment. By cytometry, high rate of immature neutrophils (B) (30/57) correlated with poor PFS/OS (P = 0.04; P = 0.0007), with a 12-week death rate of 49%.

CONCLUSION

The dNLR (B) and its dynamics (C2) under ICI associate with ICI outcomes in aNSCLC. Persistently high dNLR (B+C2) correlated with early ICI failure. Immature neutrophils may be a key subpopulation on ICI resistance.

Impact of STK11 and KRAS co-mutations on outcomes with immunotherapy in non-small cell lung cancer

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Background: While the use of monoclonal antibodies targeting the PD-1 axis in metastatic non-small cell lung cancer (NSCLC) continues to expand since initial FDA approval in 2015, factors predictive of response still remain to be determined. Mutation status may provide insight as to which subgroups exhibit resistance to checkpoint inhibitor therapy. Methods: We conducted a single center retrospective analysis of patients with metastatic NSCLC treated at the University of Miami / Sylvester Comprehensive Cancer Center who underwent next-generation sequencing (NGS) and identified patients that harbor either STK11 mutation alone (S) or co-mutations with STK11 and KRAS (S/K). Genomic results were obtained from Guardant360 and Foundation One testing in blood and tissue, respectively. Results: We identified 37 S patients and 36 S/K patients and determined no significant differences in progression-free survival (PFS). However, overall survival (OS) was significantly increased in patients with S/K co-mutation (20.3 ± 4.1 months) vs. patients with S alone (11.9 ± 1.9 months, p = 0.028). Furthermore, S/K patients who received immunotherapy had longer OS (20.7 ± 5.6 months) vs. S patients (13.6 ± 3.4 months, p = 0.049). We further investigated any population-specific factors that may contribute to the enhanced survival in the S/K cohort that had received immunotherapy, as previous studies have reported that STK11/KRAS co-mutations may confer a resistance to PD-1 axis-directed therapy. We found that S/K patients were older at diagnosis and were more likely to have received nivolumab (as compared to newer therapies pembrolizumab and atezolizumab). In addition, S/K patients were more likely to have longer smoking histories (81% smoked more than 30 pack-years at diagnosis) vs. S patients (53%, p = 0.01) and also had a higher number of additional targetable mutations found on NGS (4.7 ± 0.4 vs. 2.9 ± 0.3, p = 0.001). The most commonly identified mutations were TP53 (30%), KEAP1 (19%), CDKN2A/B (18%), SMARCA4/BRG1 (16%), and ARID1A (11%). Conclusions: Our study reveals an interesting analysis of potential predictors of resistance to immunotherapy with the utilization of precision medicine in combination with patient characteristics to identify the most appropriate treatment regimens for patients with NSCLC. Further studies will explore whether patients receiving immunotherapy as first line could overcome any inherent resistance to PD-1 axis-directed therapy from non-modifiable factors at diagnosis.

Concordance of next-generation sequencing between tissue and liquid biopsies in non-small cell lung cancer

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Background: While genetic profiling has become standard of care for patients diagnosed with non-small cell lung cancer (NSCLC), next-generation sequencing (NGS) provides a wealth of information about targetable mutations. Advances in genetic testing have led to sequencing platforms that utilize tissue itself or extracellular circulating tumor DNA in the blood, known as a “liquid biopsy.” Methods: We identified 55 patients with NSCLC who had undergone both tissue and liquid biopsy, using Foundation One and Guardant 360 at the University of Miami / Sylvester Comprehensive Cancer Center between January 2016 and December 2018, and performed retrospective analysis to determine patient characteristics as well concordance between different NGS platforms. Results: In our patient population, 34% of patients had never smoked prior to diagnosis, while 22% had more than a 30 pack-year smoking history. 64% of patients had no treatment prior to initial NGS. 40% of patients had both testing done essentially simultaneously, while 60% of patients had one test done after disease progression. Of these patients, therapy was changed as a result in 73%. Median number of days between tests was 21 days, with 56% of testing done within 90 days of the previous testing. Nine patients had an additional Foundation One tissue NGS performed. Concordance across all genes tested in both platforms was 98 ± 0.2%. Concordance with consideration of genetic alterations detected in both assays was 24.5 ± 3.0%. The median number of gene alterations determined by Foundation One testing was 4 (range 1-9), while the median for gene alterations detected by Guardant 360 was 3 (range 1-13). The median number of variants of unknown significance (VUS) was 10 (range 5-25). Conclusions: Our analysis indicates a role for both tissue-based and circulating tumor DNA-based NGS for determination of targetable mutations and thus appropriate treatment regimens. Low levels of concordance are potentially related to post-treatment changes in the tumor genetic profile as well as evolution in the testing itself.

Association of the prognostic model iSEND with PD-1/L1 monotherapy outcome in non-small-cell lung cancer

Background

Accessible biomarkers are needed for immunotherapy in advanced non-small-cell lung cancer (NSCLC). We previously described a multivariate risk prediction model, the iSEND, which categorises advanced NSCLC patients treated with nivolumab into Good, Intermediate or Poor groups. This model was developed by using only clinical and analytical variables (sex, ECOG-performance status, neutrophil-to-lymphocyte ratio [NLR] and post-treatment delta NLR).

Methods

An international database of 439 patients who received post-platinum PD-1/L1 monotherapies was collected for validation. Performance of the iSEND to different PD-L1 groups was compared by using time-dependent positive predictive value (PPV) for their mortality events.

Results

Median follow-up was 18.2 months (95% CI: 15.9–19.6). The overall survival of the iSEND Good (HR = 0.31, 95% CI: 0.22–0.43, p < 0.0001) was superior to the iSEND Poor. Time-dependent PPV for mortality of iSEND Poor was superior to PD-L1 = 0% group at 12 (75 vs. 53%, p = 0.01) and 18 months (85 vs. 46%, p = 0.03). However, female gender did not independently associate with better outcome in the validation cohort.

Conclusion

The iSEND model is associated with the outcome of post-platinum PD-1/L1 monotherapy in advanced NSCLC patients. The iSEND Poor demonstrated a superior performance to PD-L1 = 0% in negative prognostication. Prospective investigation and modelling with other significant parameters in a larger cohort are warranted.

Clinical and Immunological Implications of Frameshift Mutations in Lung Cancer

INTRODUCTION

Presently, programmed death ligand 1 is the most commonly used biomarker to predict response to immune checkpoint inhibitors (ICIs) in NSCLC. Owing to its several limitations, there is continuous search for more precise and reliable markers. Frameshift mutations by insertion or deletion (fsindels) are suggested to induce more immunogenic tumor-specific neoantigens, conferring better response to ICIs. Positive correlation of fsindels with ICI response has been studied in melanoma and renal cell carcinoma. We investigated the implication of fsindels in the clinical outcomes and immune landscape of patients with NSCLC treated with ICIs.

METHODS

We utilized The Cancer Genome Atlas data set to analyze tumor mutational burden, neoantigen burden, and immune landscape in relation to fsindel status. In addition, utilizing the clinical data from 122 patients treated with ICIs, we evaluated the influence of fsindels on disease response rates and survival outcomes.

RESULTS

A positive correlation between fsindel burden and tumor mutational burden and activated CD4/CD8 T-cell infiltration was shown. Presence of fsindels was also associated with significant prolongation of progression-free survival in patients treated with ICIs (median 6.2 versus 2.7 months [p = 0.01]). In addition, significant differences in the overall response rates (26% versus 12% [p = 0.04]) and disease control rates (68% versus 48% [p = 0.02]) were observed in patients with fsindels.

CONCLUSION

Our findings suggest that fsindels may have a predictive role for ICI response in NSCLC.

Clinical responses and survival in Hispanic patients with non-small cell lung cancer treated with immunotherapy compared with non-Hispanic whites

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Background: The main immunotherapy (IMMUNO) trials that led to the approval of these agents for non-small cell lung cancer (NSCLC) accrued a minimum number of Hispanic (HISP) patients (pts) or, in some studies, no HISP pts at all. Additional data is thus needed to validate outcomes in HISP pts with NSCLC treated with IMMUNO. While it is known that genomic profiles and cancer survivals are different between HISP, Non-Hispanic Whites (NHW), and African-Americans; no study has yet looked at differences in IMMUNO outcomes between these populations. Methods: We present data in 436 NSCLC pts treated with IMMUNO at 5 large institutions (3 in the US, 2 in Latin America). The agents evaluated include: nivolumab, pembrolizumab and atezolizumab. 256 pts were HISP and 180 pts were NHW. Most of the pts were treated with single agent therapy as second line (or beyond) while a small group of pts were treated as first line. The primary endpoints of the study were: response rate (ORR), progression free survival (PFS) and overall survival (OS). Results: Among NHW pts, disease control rate (DCR) was 67% for Adenocarcinomas (Adeno) and 46% for squamous cell carcinomas (SQCC). In HISP pts there were no differences in DCR rates between both histologies: 68% for Adeno and 67% SQCC. There were no statistical significant differences among HISP and NHW pts regarding ORR, PFS, OS, and responses according to PD-L1 status. Conclusions: This is the largest publication and comparison of NSCLC immunotherapy outcomes in HISP vs NHW pts. No significant differences were found in the clinical outcomes between these 2 ethnic groups despite expected genomic differences. Pts with actionable mutations were excluded as they usually do not get IMMUNO as first or second line; an approach that might change after IMPOWER 150. These results are comparable to the ones seen in Checkmate and Keynote studies. As expected, higher response rates were seen in first line therapy and pts with PD-L1 (+) status. Further comparisons will be better addressed by a larger prospective study.[Table: see text]

Can texture analysis of pre-immunotherapy CT imaging predict clinical outcomes for patients with advanced NSCLC treated with Nivolumab?

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Background: Targeted therapies are ineffective in most NSCLC patients and response rates remain < 20% for patients with advanced NSCLC on immuno-monotherapy. Predictive models that distinguish responders from non-responders to immunotherapy could help guide clinical practice. Texture analysis is a data-mining tool used to identify intensity patterns in diagnostic imaging. We hypothesized that texture features on pre-immunotherapy CT imaging can be associated with clinical outcomes for patients with advanced NSCLC treated with Nivolumab. Methods: In an IRB-approved database containing 159 patients with advanced NSCLC treated with Nivolumab monotherapy, 20 patients with the longest overall survival (OS) and 20 with the shortest were selected for retrospective analysis. Patient characteristics were compared using paired t-tests. The last pre-immunotherapy PET CT for each patient was transferred to MIM software for segmentation. All FDG-avid intrathoracic tumors were delineated on the CT scan per RTOG contouring guidelines. Ninety-two texture features within each tumor were analyzed for association with the primary endpoint, OS. OS time was dichotomized to less than 1 year vs. more than 1 year. A univariate logistic regression model was used to estimate odds ratio (OR), 95% confidence interval and p-value for each feature. Multiple testing adjustments were performed using false discovery rate. Results: Eleven out of 92 texture features showed significant association with OS time (p-values from 0.009 to 0.044), of which 7 exhibited large effect (OR < 0.5 or > 1.5). Fifteen additional texture features trended toward statistical significance with p-values from .05 to .10. In all, 26 out of the 92 texture features showed significant association or trended toward significance with duration of OS. Conclusions: This preliminary study suggests that texture features on pre-immunotherapy CT imaging may help in predicting OS duration for patients with advanced NSCLC treated with Nivolumab monotherapy. We are in the process of validating a multivariate predictive model. Future directions include expansion of this study across the full database, survival analyses and correlation of texture features with tissue biology.

Abstract 701: An inflammation paradox: Obesity vs. neutrophil-lymphocyte ratio in immunotherapy

Background: The dual roles of inflammation in malignancy has been well-described. Neutrophils play a key role in inflammation and carcinogenesis. We previously showed that high NLR may confer resistance to PD1/PDL1 inhibitors in lung cancer patients. In addition, obesity has been shown to produce chronic inflammation and neutrophil dysfunction have been described. The interplay between obesity and neutrophil in solid tumor patients treated with immunotherapy is unknown. Methods: We retrospectively evaluated 408 patients with solid tumors who treated with immunotherapies at the University of Miami. Cox regression was performed to evaluate correlation of obesity (BMI &gt;30) and NLR &lt;5 with Progression Free Survival (PFS) and Overall Survival (OS). Pearson Correlation was used for correlation between BMI and NLR. Results: Median follow-up was 8.6 months. There were head, neck and thoracic (n=257), gastrointestinal (n=32), genitourinary (n=58), skin and musculoskeletal (n=61). There were 230 males, mean age was 65.8. Treatments include nivolumab (n=204), pembrolizumab (n=128), atezolizumab (n=35), and combination with ipilimumab (n=41). There were underweight (BMI&lt;18.5, n=27), normal weight (18.5≤BMI&lt;25, n=186), overweight (25≤BMI&lt;30, n=117), and obese patients (BMI≥30, n=78). Obesity (BMI≥30) and NLR &lt;5 were strongly correlated with better OS with HR: 3.031 and HR: 2.424, respectively. (Table 1) There was trend of better PFS in obese patients, however it was not statistically significant. BMI and NLR showed inverse correlation. (r= -0.172, p=0.001) Conclusions: Surrogates of inflammation, such as obesity and NLR in patients with solid cancer may predict immunotherapy responses. High NLR was associated with adverse clinical outcomes and failure to checkpoint inhibitors, perhaps due to unfavorable tumor-associated neutrophil phenotypes. There was also a strong correlation between obesity and overall survival in these solid tumor patients.

Table 1. Multivariate analysisPFSOSFactorHR95% C.I.p-valueHR95% C.I.p-valueECOG&gt;12.188(1.561-3.068)0.00013.031(1.937-4.742)0.0001BMI&lt;301.136(0.806-1.601)0.4682.934(1.484-5.801)0.002NLR≥51.704(1.301-2.230)0.00012.424(1.661-3.538)0.0001

Citation Format: Wungki Park, Vaia Florou, Alfredo Torres, Diana Saravia, Sandra Algaze, Gilberto Lopes, University of Miami. An inflammation paradox: Obesity vs. neutrophil-lymphocyte ratio in immunotherapy [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2018; 2018 Apr 14-18; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2018;78(13 Suppl):Abstract nr 701.

Developing a Predictive Model for Clinical Outcomes of Advanced Non-Small Cell Lung Cancer Patients Treated With Nivolumab

INTRODUCTION

Despite significant improvement of clinical outcomes of advanced non-small-cell lung cancer (NSCLC) patients treated with immunotherapy, our knowledge of optimal biomarkers is still limited.

PATIENTS AND METHODS

We retrospectively evaluated 159 advanced NSCLC patients in our institution treated with nivolumab after disease progression during platinum-based chemotherapy. We correlated several variables with progression-free survival (PFS) to develop the immunotherapy, Sex, Eastern Cooperative Oncology Group performance status, Neutrophil-to-lymphocyte ratio (NLR), and Delta NLR (iSEND) model. We categorized patients into iSEND good, intermediate, and poor risk groups and evaluated their clinical outcomes. Performance of iSEND at 3, 6, 9, and 12 months was evaluated according to receiver operating characteristic (ROC) curves and internally validated using bootstrapping. The association of iSEND risk groups with clinical benefit was evaluated using logistic regression.

RESULTS

Median follow-up was 11.5 months (95% confidence interval [CI], 9.4-13.1). There were 50 deaths and 43 with disease progression without death. PFS rates at 3, 6, 9, and 12 months were 78.4%, 63.7%, 55.3%, and 52.2% in iSEND good; 79.4%, 44.3%, 25.9%, and 19.2% in iSEND intermediate; and 65%, 25.9%, 22.8%, and 17.8% in iSEND poor. Time-dependent area under ROC curves of iSEND for PFS at 3, 6, 9, and 12 months were 0.718, 0.74, 0.746, and 0.774. The iSEND poor group was significantly associated with progressive disease at 12 ± 2 weeks (odds ratio, 9.59; 95% CI, 3.8-26.9; P < .0001).

CONCLUSION

The iSEND model is an algorithmic model that can characterize clinical outcomes of advanced NSCLC patients receiving nivolumab into good, intermediate, or poor risk groups and might be useful as a predictive model if validated independently.