A multicenter, randomized phase 2 study to establish combinations of CBP501, cisplatin and nivolumab for ≥3rd-line treatment of patients with advanced pancreatic adenocarcinoma

BACKGROUND

There is no standard of care for ≥ 3rd-line treatment of metastatic pancreatic adenocarcinoma (PDAC). CBP501 is a novel calmodulin-binding peptide that has been shown to enhance the influx of platinum agents into tumor cells and tumor immunogenicity. This study aimed to (1) confirm efficacy of CBP501/cisplatin/nivolumab for metastatic PDAC observed in a previous phase 1 study, (2) identify combinations that yield 35% 3-month progression-free survival rate (3MPFS) and (3) define the contribution of CBP501 to the effects of combination therapy.

METHODS

CBP501 16 or 25 mg/m2 (CBP(16) or CBP(25)) was combined with 60 mg/m2 cisplatin (CDDP) and 240 mg nivolumab (nivo), administered at 3-week intervals. Patients were randomized 1:1:1:1 to (1) CBP(25)/CDDP/nivo, (2) CBP(16)/CDDP/nivo, (3) CBP(25)/CDDP and (4) CDDP/nivo, with randomization stratified by ECOG PS and liver metastases. A Fleming two-stage design was used, yielding a one-sided type I error rate of 2.5% and 80% power when the true 3MPFS is 35%.

RESULTS

Among 36 patients, 3MPFS was 44.4% in arms 1 and 2, 11.1% in arm 3% and 33.3% in arm 4. Two patients achieved a partial response in arm 1 (ORR 22.2%; none in other arms). Median PFS and OS were 2.4, 2.1, 1.5 and 1.5 months and 6.3, 5.3, 3.7 and 4.9 months, respectively. Overall, all treatment combinations were well tolerated. Most treatment-related adverse events were grade 1-2.

CONCLUSIONS

The combination CBP(25)/(16)/CDDP/nivo demonstrated promising signs of efficacy and a manageable safety profile for the treatment of advanced PDAC.

CLINICAL TRIAL REGISTRATION

NCT04953962.

Performance of a Cell-Free DNA-Based Multi-cancer Detection Test in Individuals Presenting With Symptoms Suspicious for Cancers

PURPOSE

A multi-cancer detection test using a targeted methylation assay and machine learning classifiers was validated and optimized for screening in prospective, case-controlled Circulating Cell-free Genome Atlas (ClinicalTrials.gov identifier: NCT02889978) substudy 3. Here, we report test performance in a subgroup of participants with symptoms suspicious for cancer to assess the test's ability to potentially facilitate efficient diagnostic evaluation in symptomatic individuals.

METHODS

We evaluated test performance (sensitivity, specificity, and accuracy of cancer signal origin [CSO] prediction accuracy) in participants with clinically presenting cancers (CPCs) and noncancer with underlying medical conditions and among two subgroups (65 years and older and GI cancers). Overall survival (OS) of participants who had a cancer signal detected/not detected was compared with SEER-based expected survival.

RESULTS

A total of 2,036 cancer and 1,472 noncancer participants were included. Specificity was high in all noncancer participants (99.5% [95% CI, 98.4 to 99.8]). In participants with CPCs, the overall sensitivity was 64.3% (95% CI, 62.2 to 66.4) and the overall accuracy of CSO prediction in true positives was 90.3%. For GI cancers, the overall sensitivity was 84.1% (95% CI, 80.6 to 87.1). In participants 65 years and older, test performance was similar to that of all participants. Individuals with cancers not detected had a significantly better OS than that expected from SEER (P < .01).

CONCLUSION

This test detected a cancer signal with high specificity and CSO prediction accuracy and moderate sensitivity in symptomatic individuals, with especially high performance in participants with GI cancers. The survival analysis implied that the cancers not detected were less clinically aggressive than cancers detected by the test, providing prognostic insights to physicians. This multi-cancer detection test could facilitate efficient workup and stratify cancer risk in symptomatic individuals.

Hemodynamic Gain Index and Exercise Capacity in Heart Failure With Preserved Ejection Fraction

Decreased exercise capacity portends a poor prognosis in heart failure with preserved ejection fraction (HFpEF). The hemodynamic gain index (HGI) is an integrated marker of hemodynamic reserve measured during exercise stress testing and is associated with survival. The goal of this study was to establish the association of HGI with exercise capacity, serum biomarkers, and echocardiography features in subjects with HFpEF. In 209 subjects with HFpEF enrolled in the RELAX (Phosphodiesterase-5 Inhibition to Improve Clinical Status and Exercise Capacity in Diastolic Heart Failure) trial who underwent cardiopulmonary exercise testing, we calculated the HGI ([peak heart rate [HR] × peak systolic blood pressure [SBP]-[HR at rest × SBP at rest])/(HR at rest × SBP at rest) and tested associations with outcomes of interest. The median (interquartile range) HGI was 0.94 (0.5 to 1.3) beats per min/mm Hg. In multivariable-adjusted linear regression, higher HGI was associated with greater peak oxygen consumption (VO₂), VO₂ at anaerobic threshold, peak minute ventilation, and 6-minute walk distance (all p <0.001). Higher HGI was associated with lower serum high-sensitivity troponin I, pro-collagen III, N-terminal pro-B-type natriuretic peptide, and creatinine (all p <0.05) and with longer deceleration time, lower E/A ratio, and lower left atrial volume index by echocardiography (all p <0.05). In conclusion, higher HGI in stable HFpEF was associated with greater exercise capacity, a biomarker profile indicating less myocardial injury and fibrosis and less kidney dysfunction, and with less severe diastolic dysfunction. These results suggest that HGI, an easily calculated metric from routine exercise testing, is a marker of functional capacity and disease severity in HFpEF and may serve as a surrogate for VO₂ parameters for use in treadmill testing without gas exchange capability.

Silmitasertib plus gemcitabine and cisplatin first-line therapy in locally advanced/metastatic cholangiocarcinoma: A Phase 1b/2 study

BACKGROUND AND AIMS

This study aimed to investigate safety and efficacy of silmitasertib, an oral small molecule casein kinase 2 inhibitor, plus gemcitabine and cisplatin (G+C) versus G+C in locally advanced/metastatic cholangiocarcinoma.

APPROACH AND RESULTS

This work is a Phase 1b/2 study (S4-13-001). In Phase 2, patients received silmitasertib 1000 mg twice daily for 10 days with G+C on Days 1 and 8 of a 21-day cycle. Primary efficacy endpoint was progression-free survival (PFS) in the modified intent-to-treat population (defined as patients who completed at least one cycle of silmitasertib without dose interruption/reduction) from both phases (silmitasertib/G+C n = 55, G+C n = 29). The response was assessed by Response Evaluation Criteria in Solid Tumors v1.1. The median PFS was 11.2 months (95% confidence interval [CI], 7.6, 14.7) versus 5.8 months (95% CI, 3.1, not evaluable [NE]) ( p  = 0.0496); 10-month PFS was 56.1% (95% CI, 38.8%, 70.2%) versus 22.2% (95% CI, 1.8%, 56.7%); and median overall survival was 17.4 months (95% CI, 13.4, 25.7) versus 14.9 months (95% CI, 9.9, NE) with silmitasertib/G+C versus G+C. Overall response rate was 34.0% versus 30.8%; the disease control rate was 86.0% versus 88.5% with silmitasertib/G+C versus G+C. Almost all silmitasertib/G+C (99%) and G+C (93%) patients reported at least one treatment emergent adverse event (TEAE). The most common TEAEs (all grades) with silmitasertib/G+C versus G+C were diarrhea (70% versus 13%), nausea (59% vs. 30%), fatigue (47% vs. 47%), vomiting (39% vs. 7%), and anemia (39% vs. 30%). Twelve patients (10%) discontinued treatment because of TEAEs during the study.

CONCLUSIONS

Silmitasertib/G+C demonstrated promising preliminary evidence of efficacy for the first-line treatment of patients with locally advanced/metastatic cholangiocarcinoma.

Search for Subsolar-Mass Binaries in the First Half of Advanced LIGO's and Advanced Virgo's Third Observing Run

We report on a search for compact binary coalescences where at least one binary component has a mass between 0.2  M_{⊙} and 1.0  M_{⊙} in Advanced LIGO and Advanced Virgo data collected between 1 April 2019 1500 UTC and 1 October 2019 1500 UTC. We extend our previous analyses in two main ways: we include data from the Virgo detector and we allow for more unequal mass systems, with mass ratio q≥0.1. We do not report any gravitational-wave candidates. The most significant trigger has a false alarm rate of 0.14  yr^{-1}. This implies an upper limit on the merger rate of subsolar binaries in the range [220-24200]  Gpc^{-3} yr^{-1}, depending on the chirp mass of the binary. We use this upper limit to derive astrophysical constraints on two phenomenological models that could produce subsolar-mass compact objects. One is an isotropic distribution of equal-mass primordial black holes. Using this model, we find that the fraction of dark matter in primordial black holes in the mass range 0.2  M_{⊙}<m_{PBH}<1.0  M_{⊙} is f_{PBH}≡Ω_{PBH}/Ω_{DM}≲6%. This improves existing constraints on primordial black hole abundance by a factor of ∼3. The other is a dissipative dark matter model, in which fermionic dark matter can collapse and form black holes. The upper limit on the fraction of dark matter black holes depends on the minimum mass of the black holes that can be formed: the most constraining result is obtained at M_{min}=1  M_{⊙}, where f_{DBH}≡Ω_{DBH}/Ω_{DM}≲0.003%. These are the first constraints placed on dissipative dark models by subsolar-mass analyses.

Abstract CT119: A randomized, double-blind phase 2 evaluation of the anti-IL-8 monoclonal antibody BMS-986253 + nivolumab + ipilimumab vs nivolumab + ipilimumab in patients with advanced melanoma that progressed on/after anti-PD-(L)1 therapy

Purpose: This phase 1/2 trial evaluates the novel immunotherapy BMS-986253 in combination with immune checkpoint inhibitors (NCT03400332). Interleukin-8 (IL-8) is an immunosuppressive chemokine often elevated in the serum of patients with cancer. High serum IL-8 concentration is associated with poor prognoses and resistance to immunotherapies, including anti-programmed death-1 (PD-1) and anti-cytotoxic T lymphocyte antigen-4 (CTLA-4) agents (Schalper et al. Nat Med 2020;26:688). The addition of anti-IL-8 therapy to anti-PD-1 nivolumab (NIVO) and anti-CTLA-4 ipilimumab (IPI) may sensitize patients with high serum IL-8 levels to immune checkpoint inhibition. BMS-986253, a fully human IgG1 anti-IL-8 monoclonal antibody, in combination with NIVO ± IPI is under investigation in a phase 1/2 trial of patients with advanced solid tumors. Initial results from part 1 indicate BMS-986253 + NIVO was well tolerated with no dose-limiting toxicities (Davar et al. J Immunother Cancer 2020;8. Abstract 394). Preliminary antitumor activity was observed, including partial responses in 5 of 28 patients with melanoma that had progressed on or after prior anti-PD-(L)1 therapy, a population with high unmet medical need. Part 2 is a randomized, double-blind phase 2 study comparing the efficacy of BMS-986253 in combination with NIVO + IPI vs NIVO + IPI in patients with advanced melanoma that progressed on or after prior anti-PD-(L)1 therapy.

Trial Design: Patients eligible for part 2 have histologically confirmed, unresectable, stage III/IV melanoma, have progressed on or after anti-PD-(L)1 treatment, had an anti-PD-(L)1 agent as their most recent therapy, and have not received anti-CTLA-4 treatment. PD-L1 and BRAFV600 mutation status (wild-type and BRAF mutations permitted) must be documented, and serum IL-8 levels will be measured at screening. Patients will be randomized 1:1 to receive BMS-986253 + NIVO + IPI or placebo + NIVO + IPI and stratified by serum IL-8 level, BRAF V600E status, and lactate dehydrogenase level. The dose and frequency of BMS-986253, NIVO, and IPI will be determined by part 1 data. Treatment with BMS-986253 or placebo and NIVO will continue ≤ 3 years or until disease progression or intolerance. The primary objective is to compare progression-free survival (PFS) by blinded independent central review (BICR) per RECIST v1.1 between treatment arms in patients with baseline serum IL-8 levels &gt; 10 pg/mL. Secondary objectives include PFS by BICR in all randomized patients, overall response rates by BICR per RECIST v1.1, overall survival, safety, pharmacokinetic profile, immunogenicity of BMS-986253, and associations of baseline factors with response. Recruitment will continue until ≈170 patients are enrolled.

Citation Format: Matteo Simonelli, Emiliano Calvo, Diwakar Davar, Jason Melear, Donald Richards, Matthew Dallos, Martin Gutierrez, Victor Moreno, Thomas Marron, Sylvie Rottey, Angela Orcurto, Susana Barriga, Jessy Fan, Elizabeth Gibson, Santanu Dutta, Vivek Arora, Ignacio Melero. A randomized, double-blind phase 2 evaluation of the anti-IL-8 monoclonal antibody BMS-986253 + nivolumab + ipilimumab vs nivolumab + ipilimumab in patients with advanced melanoma that progressed on/after anti-PD-(L)1 therapy [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2022; 2022 Apr 8-13. Philadelphia (PA): AACR; Cancer Res 2022;82(12_Suppl):Abstract nr CT119.

Abstract LB013: Clinical validation of a targeted methylation-based multi-cancer early detection test

Introduction: A multi-cancer early detection (MCED) test as a complement to existing screening tests could increase the number of cancer cases detected in a population, potentially improving patient outcomes and survival as well as decreasing harmful and aggressive treatments. The Circulating Cell-free Genome Atlas study (CCGA; NCT02889978) was designed to develop and validate a blood-based MCED test analyzing plasma cell-free DNA (cfDNA) to detect cancer signals across multiple cancer types and simultaneously predict their signal origin. Here, the results of the third and final pre-specified CCGA validation sub-study for a refined MCED test in a large cohort in preparation for clinical use are reported. Methods: CCGA is a prospective, multicenter, case-control, observational study with longitudinal follow-up (overall population N=15,254). In this sub-study (n=5309), key primary objectives were to evaluate test performance for cancer signal detection (specificity, overall sensitivity, sensitivity by clinical stage) and signal origin prediction (accuracy). cfDNA from evaluable samples was analyzed using a targeted methylation bisulfite sequencing assay and a machine learning algorithm. The classifier was trained to target a specificity of 99.4% and locked before analysis of the independent validation set. Overall, 4077 participants comprised the independent validation set with confirmed status (cancer: n=2823; non-cancer: n=1254 with non-cancer status confirmed at year-one follow-up). MCED test results are reported for this confirmed status set. Results: Mean (SD) age in the cancer and non-cancer groups was 62.6 (11.76) and 56.2 (12.63) years, respectively. Specificity for cancer signal detection was 99.5% (1248/1254; 95% confidence interval: 99.0-99.8%). Overall sensitivity for cancer signal detection was 51.5% (1453/2823; 49.6-53.3%); sensitivity increased with stage (Stage I: 16.8% [14.5-19.5%], Stage II: 40.4% [36.8-44.1%], Stage III: 77.0% [73.4-80.3%], Stage IV: 90.1% [87.5-92.2%]). Stage I-III sensitivity was 67.6% (593/877; 64.4-70.6%) in a pre-specified set of 12 high-signal cancers accounting for ~63% of annual US cancer deaths [1] and was 40.7% (863/2118; 38.7-42.9%) in all cancers. Cancer signals were detected across &gt;50 cancer types [2]. Overall accuracy of signal origin prediction in true positives was 88.7% (87.0-90.2%). Conclusions: In this pre-specified, large-scale, clinical validation sub-study of CCGA, the MCED test detected cancer signals across &gt;50 cancer types, which is critical to maximize the number of cancer cases detected in a population. This MCED test performed with high specificity and high accuracy of signal origin prediction. These data lay the foundation for population-scale clinical implementation of this test. 1.US Mortality Data 1969-2016 (www.seer.cancer.gov); based on 2015-2016. 2.Amin et al. CA Cancer J Clin. 2017;67:93e99.

Citation Format: Eric A. Klein, Donald Richards, Allen Cohn, Mohan Tummala, Rosanna Lapham, David Cosgrove, Gina Chung, Jessica Clement, Jingjing Gao, Nathan Hunkapiller, Arash Jamshidi, Kathryn Kurtzman, Michael V. Seiden, Charles Swanton, Minetta C. Liu. Clinical validation of a targeted methylation-based multi-cancer early detection test [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2021; 2021 Apr 10-15 and May 17-21. Philadelphia (PA): AACR; Cancer Res 2021;81(13_Suppl):Abstract nr LB013.

Abstract LB058: Performance of a cell-free DNA-based multi-cancer detection test as a tool for diagnostic resolution of symptomatic cancers

Introduction: A test that detects cancer signal across multiple cancer types and predicts signal (tissue) origin (SO) could aid in more efficient diagnostic workup and shorten time to cancer diagnosis in individuals with signs and symptoms.Methods: The Circulating Cell-free Genome Atlas (CCGA; NCT02889978) study is a prospective, longitudinal, multicenter, case-control study to develop and validate a multi-cancer detection test. The 2nd CCGA substudy utilized a targeted methylation-based cell-free DNA assay and machine learning algorithm and included assessment of test performance (sensitivity and SO prediction accuracy) in a subgroup of participants with clinically presenting cancers (CPCs) that were undiagnosed prior to blood draw. Specificity was assessed in the noncancer group and subgroups with confounding (nonmalignant) conditions (CCs; eg, cirrhosis) and noncancer participants enrolled in hematology clinics (HCs).Results: Specificity was 99.5% (95% confidence interval: 98.2-99.9%; 396/398), 93.8% (71.7-99.7%; 15/16), and 99.3% (96.0-100.0%; 136/137) for the noncancer group, CCs subgroup, and HCs subgroup, respectively. Overall sensitivity among those with CPCs was 66.4% (62.2-70.3%; 344/518). Sensitivity of cancer signal detection increased with increasing clinical stage (Table). SO prediction accuracy was 91.7% (88.3-94.3%; 300/327) among CPC participants with cancers detected, excluding those with multiple or unknown primaries. The test demonstrated prognostic value as detected cancer participants had worse survival probability than those not detected. Conclusions: This multi-cancer detection test detected cancer signals and predicted SO in individuals with CPCs with high specificity. These findings support further clinical development of this multi-cancer detection test that could accelerate the diagnostic resolution of symptomatic cancers.

Table. Sensitivity by Clinical Stage Across Cancer Type in Clinically Presenting CancersClinical StagePositive Test/Total Cancer; Sensitivity (95% CI)All*344/518; 66.4% (62.2-70.3%)I33/122; 27.0% (20.0-35.5%)II60/102; 58.8% (49.1-67.9%)III103/121; 85.1% (77.7-90.4%)IV136/147; 92.5% (87.1-95.8%)Not expected to be staged9/21; 42.9% (24.5-63.5%)Non-informative2/4; 50.0% (15.0-85.0%)CI, confidence interval.*One participant who had a positive test result had multiple primaries with clinical stage I and not-expected-to-be-staged.

Citation Format: Alan H. Bryce, Minetta C. Liu, Michael V. Seiden, David D. Thiel, Donald Richards, Carlos Becerra, Kathryn N. Kurtzman, Xiaoji Chen, Tony Wu, Quan Zhang, Jingjing Gao, Nan Zhang, Earl Hubbell, Arash Jamshidi, Eric T. Fung, Eric A. Klein. Performance of a cell-free DNA-based multi-cancer detection test as a tool for diagnostic resolution of symptomatic cancers [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2021; 2021 Apr 10-15 and May 17-21. Philadelphia (PA): AACR; Cancer Res 2021;81(13_Suppl):Abstract nr LB058.

Clinical validation of a targeted methylation-based multi-cancer early detection test using an independent validation set

BACKGROUND

A multi-cancer early detection (MCED) test used to complement existing screening could increase the number of cancers detected through population screening, potentially improving clinical outcomes. The Circulating Cell-free Genome Atlas study (CCGA; NCT02889978) was a prospective, case-controlled, observational study and demonstrated that a blood-based MCED test utilizing cell-free DNA (cfDNA) sequencing in combination with machine learning could detect cancer signals across multiple cancer types and predict cancer signal origin (CSO) with high accuracy. The objective of this third and final CCGA substudy was to validate an MCED test version further refined for use as a screening tool.

PATIENTS AND METHODS

This pre-specified substudy included 4077 participants in an independent validation set (cancer: n = 2823; non-cancer: n = 1254, non-cancer status confirmed at year-one follow-up). Specificity, sensitivity, and CSO prediction accuracy were measured.

RESULTS

Specificity for cancer signal detection was 99.5% [95% confidence interval (CI): 99.0% to 99.8%]. Overall sensitivity for cancer signal detection was 51.5% (49.6% to 53.3%); sensitivity increased with stage [stage I: 16.8% (14.5% to 19.5%), stage II: 40.4% (36.8% to 44.1%), stage III: 77.0% (73.4% to 80.3%), stage IV: 90.1% (87.5% to 92.2%)]. Stage I-III sensitivity was 67.6% (64.4% to 70.6%) in 12 pre-specified cancers that account for approximately two-thirds of annual USA cancer deaths and was 40.7% (38.7% to 42.9%) in all cancers. Cancer signals were detected across >50 cancer types. Overall accuracy of CSO prediction in true positives was 88.7% (87.0% to 90.2%).

CONCLUSION

In this pre-specified, large-scale, clinical validation substudy, the MCED test demonstrated high specificity and accuracy of CSO prediction and detected cancer signals across a wide diversity of cancers. These results support the feasibility of this blood-based MCED test as a complement to existing single-cancer screening tests.

CLINICAL TRIAL NUMBER

NCT02889978.

Lenvatinib plus pembrolizumab in patients with either treatment-naive or previously treated metastatic renal cell carcinoma (Study 111/KEYNOTE-146): a phase 1b/2 study

BACKGROUND

Despite advances in the first-line treatment of metastatic renal cell carcinoma (RCC), there is an unmet need for options to address disease progression during or after treatment with immune checkpoint inhibitors (ICIs). Pembrolizumab and lenvatinib are active as monotherapies in RCC; thus, we aimed to evaluate the combination of lenvatinib plus pembrolizumab in these patients.

METHODS

We report results of the metastatic RCC cohort from an open-label phase 1b/2 study of lenvatinib plus pembrolizumab in patients aged at least 18 years with selected solid tumours and an Eastern Cooperative Oncology Group performance status of 0-1. Oral lenvatinib at 20 mg was given once daily along with intravenous pembrolizumab at 200 mg once every 3 weeks. Patients remained on study drug treatment until disease progression, development of unacceptable toxicity, or withdrawal of consent. Efficacy was analysed in patients with clear cell metastatic RCC receiving study drug by previous therapy grouping: treatment naive, previously treated ICI naive (previously treated with at least one line of therapy but not with an anti-PD-1 or anti-PD-L1 ICI), and ICI pretreated (ie, anti-PD-1 or anti-PD-L1) patients. Safety was analysed in all enrolled and treated patients. The primary endpoint was the objective response rate at week 24 per immune-related Response Evaluation Criteria In Solid Tumors (irRECIST) by investigator assessment. This trial is registered with ClinicalTrials.gov (NCT02501096) and with the EU Clinical Trials Register (EudraCT2017-000300-26), and is closed to new participants.

FINDINGS

Between July 21, 2015, and Oct 16, 2019, 145 patients were enrolled in the study. Two patients had non-clear cell RCC and were excluded from the efficacy analysis (one in the treatment-naive group and one in the ICI-pretreated group); thus, the population evaluated for efficacy comprised 143 patients (n=22 in the treatment-naive group, n=17 in the previously treated ICI-naive group, and n=104 in the ICI-pretreated group). All 145 enrolled patients were included in the safety analysis. The median follow-up was 19·8 months (IQR 14·3-28·4). The number of patients with an objective response at week 24 by irRECIST was 16 (72·7%, 95% CI 49·8-89·3) of 22 treatment-naive patients, seven (41·2%, 18·4-67·1) of 17 previously treated ICI-naive patients, and 58 (55·8%, 45·7-65·5) of 104 ICI-pretreated patients. Of 145 patients, 82 (57%) had grade 3 treatment-related adverse events and ten (7%) had grade 4 treatment-related adverse events. The most common grade 3 treatment-related adverse event was hypertension (30 [21%] of 145 patients). Treatment-related serious adverse events occurred in 36 (25%) patients, and there were three treatment-related deaths (upper gastrointestinal haemorrhage, sudden death, and pneumonia).

INTERPRETATION

Lenvatinib plus pembrolizumab showed encouraging antitumour activity and a manageable safety profile and might be an option for post-ICI treatment of metastatic RCC.

FUNDING

Eisai and Merck Sharp & Dohme.

Role of age, gender and marital status in prognosis for adults with depression: An individual patient data meta-analysis

AIMS

To determine whether age, gender and marital status are associated with prognosis for adults with depression who sought treatment in primary care.

METHODS

Medline, Embase, PsycINFO and Cochrane Central were searched from inception to 1st December 2020 for randomised controlled trials (RCTs) of adults seeking treatment for depression from their general practitioners, that used the Revised Clinical Interview Schedule so that there was uniformity in the measurement of clinical prognostic factors, and that reported on age, gender and marital status. Individual participant data were gathered from all nine eligible RCTs (N = 4864). Two-stage random-effects meta-analyses were conducted to ascertain the independent association between: (i) age, (ii) gender and (iii) marital status, and depressive symptoms at 3-4, 6-8, and 9-12 months post-baseline and remission at 3-4 months. Risk of bias was evaluated using QUIPS and quality was assessed using GRADE. PROSPERO registration: CRD42019129512. Pre-registered protocol https://osf.io/e5zup/.

RESULTS

There was no evidence of an association between age and prognosis before or after adjusting for depressive 'disorder characteristics' that are associated with prognosis (symptom severity, durations of depression and anxiety, comorbid panic disorderand a history of antidepressant treatment). Difference in mean depressive symptom score at 3-4 months post-baseline per-5-year increase in age = 0(95% CI: -0.02 to 0.02). There was no evidence for a difference in prognoses for men and women at 3-4 months or 9-12 months post-baseline, but men had worse prognoses at 6-8 months (percentage difference in depressive symptoms for men compared to women: 15.08% (95% CI: 4.82 to 26.35)). However, this was largely driven by a single study that contributed data at 6-8 months and not the other time points. Further, there was little evidence for an association after adjusting for depressive 'disorder characteristics' and employment status (12.23% (-1.69 to 28.12)). Participants that were either single (percentage difference in depressive symptoms for single participants: 9.25% (95% CI: 2.78 to 16.13) or no longer married (8.02% (95% CI: 1.31 to 15.18)) had worse prognoses than those that were married, even after adjusting for depressive 'disorder characteristics' and all available confounders.

CONCLUSION

Clinicians and researchers will continue to routinely record age and gender, but despite their importance for incidence and prevalence of depression, they appear to offer little information regarding prognosis. Patients that are single or no longer married may be expected to have slightly worse prognoses than those that are married. Ensuring this is recorded routinely alongside depressive 'disorder characteristics' in clinic may be important.

Nurses' and physicians' experiences with diabetes consultations and the use of dialogue tools in the DiaPROM pilot trial: A qualitative study

AIM

To explore nurses' and physicians' experiences with diabetes consultations in general and the use of dialogue tools in the Diabetes Patient-Related Outcome Measures (DiaPROM) pilot trial.

METHODS

We used a qualitative explorative design by conducting semi-structured in-depth interviews with five nurses and nine physicians engaged in the DiaPROM pilot trial. The pilot trial aimed to test an intervention utilizing the patient-reported Problem Areas In Diabetes (PAID) scale and person-centred communication skills as dialogue tools in clinical consultations with adults with type 1 diabetes. We used thematic analysis to analyse the data.

RESULTS

We generated three themes (each including two subthemes) from the analysis of participants' experiences: (1) 'Conflicting demands and priorities' (subthemes: 'Balancing guideline recommendations with patients' main concerns' and 'Experiencing that patients need more support to disclose their emotional concerns'); (2) 'Insights about using dialogue tools' (subthemes: 'The benefits and challenges of using the PAID as a dialogue tool' and 'Communication techniques are helpful'); and (3) 'Facilitating new interventions is challenging' (subthemes: 'Unclear roles and responsibilities in the multidisciplinary teamwork' and 'The capacity sets the limit, not the willingness').

CONCLUSIONS

Our findings indicate that the physicians and nurses experienced substantial challenges related to time and resources in the use of dialogue tools to support people's emotional concerns in clinical diabetes consultations. Thus, there is a need for healthcare organizations to adjust priorities to focus on the emotional burden of diabetes if the multidisciplinary diabetes teams are to successfully integrate psychosocial support into routine diabetes care.

Phase I Study of Elacestrant (RAD1901), a Novel Selective Estrogen Receptor Degrader, in ER-Positive, HER2-Negative Advanced Breast Cancer

PURPOSE

This phase I study (RAD1901-005; NCT02338349) evaluated elacestrant, an investigational oral selective estrogen receptor degrader (SERD), in heavily pretreated women with estrogen receptor-positive, human epidermal growth factor receptor 2-negative metastatic breast cancer, including those with estrogen receptor gene alpha (ESR1) mutation. The primary objective was to determine the maximum tolerated dose and/or recommended phase II dose (RP2D).

METHODS

The study consisted of a 3 + 3 design (elacestrant capsules) followed by expansion at RP2D (400-mg capsules, then 400-mg tablets) for the evaluation of safety and antitumor activity. Elacestrant was taken once daily until progression or intolerability.

RESULTS

Of 57 postmenopausal women enrolled, 50 received RP2D (400 mg once daily): median age, 63 years; median three prior anticancer therapies, including cyclin-dependent kinase 4,6 inhibitors (CDK4/6i; 52%), SERD (52%), and ESR1 mutation (circulating tumor DNA; 50%). No dose-limiting toxicities occurred; the most common adverse events at RP2D (400-mg tablet; n = 24) were nausea (33.3%) and increased blood triglycerides and decreased blood phosphorus (25.0% each). Most adverse events were grade 1-2 in severity. The objective response rate was 19.4% (n = 31 evaluable patients receiving RP2D), 15.0% in patients with prior SERD, 16.7% in patients with prior CDK4/6i, and 33.3% in patients with ESR1 mutation (n = 5/15). The clinical benefit rate (24-week) was 42.6% overall (n = 47 patients receiving RP2D), 56.5% (n = 23, ESR1 mutation), and 30.4% (n = 23, prior CDK4/6i). Elacestrant clinical benefit was associated with decline in ESR1 mutant allele fraction.

CONCLUSION

Elacestrant 400 mg orally once daily has an acceptable safety profile and demonstrated single-agent activity with confirmed partial responses in heavily pretreated patients with estrogen receptor-positive metastatic breast cancer. Notably, responses were observed in patients with ESR1 mutation as well as those with prior CDK4/6i and prior SERD. A phase III trial investigating elacestrant versus standard endocrine therapy is ongoing.

Efficacy and safety of ofatumumab and bendamustine followed by ofatumumab maintenance in patients with relapsed indolent non-Hodgkin lymphoma after prior rituximab

In indolent non-Hodgkin's lymphoma (iNHL), patients treated with rituximab, alone or in combination with various chemotherapeutic agents eventually relapse. This study evaluated the combination of ofatumumab and bendamustine, followed by maintenance ofatumumab in patients with relapsed iNHL with prior sensitivity to rituximab. Among the 49 patients enrolled, 24.5% achieved a complete response (CR) and 42.9% achieved a partial response (PR), with an overall response rate of 67.3% at the end of the induction therapy. Additionally, six patients with PR during induction phase achieved CR during the maintenance phase. Treatment-related adverse event was observed in 95.9% patients. The most common hematologic and biochemical abnormalities were decrease in lymphocytes (85.7%) and increase in glucose (91.8%), respectively. Overall, 42.9% progressed and 14.3% died during the study. Thus, ofatumumab in combination with bendamustine, followed by ofatumumab maintenance, was effective in the treatment of patients with iNHL with a manageable safety profile (NCT01294579).

Phase Ib Trial of the PI3K Inhibitor Copanlisib Combined with the Allosteric MEK Inhibitor Refametinib in Patients with Advanced Cancer

Background

Dual inhibition of PI3K and MAPK signaling is conceptually a promising anticancer therapy.

Objective

This phase 1b trial investigated the safety, maximum tolerated dose (MTD), recommended phase II dose, pharmacokinetics, tumor response, fluorodeoxyglucose positron emission tomography (FDG-PET) pharmacodynamics, and biomarker explorations for the combination of pan-PI3K inhibitor copanlisib and allosteric MEK inhibitor refametinib in patients with advanced solid tumors.

Patients and methods

This was an adaptive trial with eight dose cohorts combining dose escalation and varying schedules in repeated 28-day cycles. Patients received copanlisib (0.2–0.8 mg/kg intravenously) intermittently (days 1, 8, 15) or weekly (days 1, 8, 15, 22) each cycle, and refametinib (30–50 mg twice daily orally) continuously or 4 days on/3 days off. Patients with KRAS, NRAS, BRAF, or PI3KCA mutations were eligible for the expansion cohort.

Results

In the dose-escalation (n = 49) and expansion (n = 15) cohorts, the most common treatment-emergent adverse events included diarrhea (59.4%), nausea, acneiform rash, and fatigue (51.6% each). Dose-limiting toxicities included oral mucositis (n = 4), increased alanine aminotransferase/aspartate aminotransferase (n = 3), acneiform rash, hypertension (n = 2 each), and diarrhea (n = 1). MTD was copanlisib 0.4 mg/kg weekly and refametinib 30 mg twice daily. No pharmacokinetic interactions were identified. Decreased tumor FDG uptake and MEK-ERK signaling inhibition were demonstrated during treatment. Best response was stable disease (n = 21); median treatment duration was 6 weeks.

Conclusions

Despite sound rationale and demonstrable pharmacodynamic tumor activity in relevant tumor populations, a dose and schedule could not be identified for this drug combination that were both tolerable and offered clear efficacy in the population assessed.

Clinicaltrials.gov identifier

NCT01392521.

Electronic supplementary material

The online version of this article (10.1007/s11523-020-00714-0) contains supplementary material, which is available to authorized users.

Cardiac magnetic resonance derived left atrial function after ST-elevation myocardial infarction: an important prognostic indicator

Background

The prognostic value of cardiac magnetic resonance (CMR) derived left atrial (LA) strain, ejection fraction (LAEF) and volumes (LAVImax and LAVImin) after STEMI is controversial.

Aim

To assess the relationship between LA function and major adverse cardiovascular events (MACE) within 2 years after STEMI.

Methods

We prospectively recruited 213 consecutive STEMI patients who underwent CMR at median day 4. 202 patients had complete CMR data for feature tracking assessment. LA reservoir and booster strain were quantified by one blinded observer based on the average of three independently repeated measurements from two- and four-chamber views. MACE was a composite of all-cause mortality, reinfarction, new or worsening heart failure, stroke and sustained ventricular arrhythmias.

Results

The cohort included 174 (86.1%) males, median age 56 years (IQR 50–65 years). MACE occurred in 35 (17.3%) patients. Patients with MACE had lower median reservoir strain (18.9 vs 29.4%, p&lt;0.001), booster strain (9.4 vs 13.0%, p=0.002) and LAEF (41.5 vs 49.2%, p&lt;0.001), and higher LAVImax (43.5 vs 38.6ml/m2, p=0.019) and LAVImin (23.7 vs 19.3ml/m2, p&lt;0.001) than patients without MACE. Patients with reduced left ventricular ejection fraction (LVEF≤40%) had lower median reservoir strain (22.5 vs 30.1%, p&lt;0.001), booster strain (11.3 vs 12.9%, p=0.021) and LAEF (43.3 vs 50.3%, p&lt;0.001) than patients with LVEF&gt;40%. AUC analyses showed reservoir strain (AUC 0.769; 95% CI 0.676–0.861, p&lt;0.001), booster strain (AUC 0.684; 95% CI 0.558–0.810, p=0.002) and LAEF (AUC 0.698; 95% CI 0.596–0.800, p&lt;0.001) predicted MACE. Kaplan Meier analyses showed a difference in MACE between high- and low-risk groups for reservoir strain (cutoff 21%, p&lt;0.001), booster strain (cutoff 9.6%, p&lt;0.001) and LAEF (cutoff 41%, p&lt;0.001). Univariate Cox regression analyses showed all LA parameters had a significant effect on MACE, while multivariate analyses found additional prognostic utility using reservoir strain.

Conclusion

LA reservoir strain provided incremental prognostic value beyond established clinical and CMR parameters for predicting MACE after STEMI.

Kaplan Meier analyses

Funding Acknowledgement

Type of funding source: None

Phase Ib clinical trial of the anti-frizzled antibody vantictumab (OMP-18R5) plus paclitaxel in patients with locally advanced or metastatic HER2-negative breast cancer

PURPOSE

Vantictumab is a monoclonal antibody that binds to frizzled (FZD) receptors and inhibits canonical WNT signaling. This phase Ib dose escalation study enrolled patients with locally recurrent or metastatic HER2-negative breast cancer who were treated with weekly paclitaxel in combination with escalating doses of vantictumab.

METHODS

Patients were enrolled in dose escalation cohorts treated with weekly paclitaxel 90 mg/m² on days 1, 8 and 15 in combination with vantictumab 3.5-14 mg/kg days 1 and 15 or 3-8 mg/kg day 1 of every 28-day cycle. Primary endpoints were safety, dose-limiting toxicities (DLTs). Secondary endpoints included pharmacokinetics, efficacy and an exploratory biomarker analysis.

RESULTS

Forty-eight female patients with a mean age of 54 were enrolled. The majority (66.6%) received prior chemotherapy for recurrent or metastatic disease; 45.8% were hormone receptor (HR)-positive, HER2-negative and 54.2% triple-negative. The most frequent adverse events related to any study treatment were nausea (54.2%), alopecia (52.1%), fatigue (47.9%), and peripheral neuropathy (43.8%). No DLTs occurred; however, 6 patients experienced fractures outside of the DLT window. The overall response rate was 31.3% and the clinical benefit rate was 68.8%. A 6-gene WNT pathway signature showed significant association with progression-free survival (PFS) and overall survival (OS) for the biomarker high versus biomarker low groups (PFS: p = 0.029 and OS: p = 0.00045, respectively).

CONCLUSIONS

The combination of vantictumab and weekly paclitaxel was generally well tolerated with promising efficacy; however, the incidence of fractures limits future clinical development of this particular WNT inhibitor in metastatic breast cancer.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov registration: NCT01973309.

Abstract IA02: Multicancer detection of early-stage cancers with simultaneous tissue localization using a plasma cfDNA-based targeted methylation assay

Background: Earlier cancer detection could identify tumors when they are more treatable and thus may improve clinical outcomes. A blood-based multicancer early detection test using circulating tumor cell-free DNA (cfDNA) offers the potential to address this unmet need. Our previous discovery work identified whole-genome bisulfite sequencing as outperforming whole-genome and targeted sequencing approaches for multicancer detection across stages. We thus developed a targeted methylation (TM) assay for multicancer detection and tissue-of-origin (TOO) localization.

Methods: Participants were from the Circulating Cell-free Genome Atlas (CCGA; NCT02889978) and STRIVE (NCT03085888) studies, both prospective, multicenter, observational studies with longitudinal follow-up. cfDNA samples spanning &gt;20 cancer types of all stages were divided into a cross-validated training set and an independent validation set; there were 3,583 evaluable samples in training (1,530 cancer; 2,053 noncancer) and 1,803 in validation (678 cancer; 1,125 noncancer). Performance in a prespecified set of 12 high-signal cancers was also reported (anus, bladder, colon/rectum, esophagus, head and neck, liver/bile-duct, lung, lymphoma, ovary, pancreas, plasma cell neoplasm, stomach). This multicancer early detection test evaluated cfDNA for the presence of cancer and localization of TOO; the TM classifier was trained to target &gt;99% specificity. Precision was defined as the fraction of correct calls.

Results: Participants with and without cancer were similar in age. Specificity across all cancer types in the training and validation sets was 99.8% (95% CI, 99.2-99.9%) and 99.3% (98.3-99.8%), respectively, which reflects a consistent (P=0.292) false positive rate of &lt;1%. Across all cancer types, aggregate sensitivity was also consistent between the training and validation sets (55% [53-58%] and 55% [51-59], respectively; P=0.897). In the validation set, aggregate sensitivity in the prespecified group was 76% (73-78%); detection was 39% (27–52%) in stage I (n=62), 69% (56–80%) in stage II (n=62), 83% (75–90%) in stage III (n=102), and 92% (86–96%) in stage IV (n=130). Overall, the classifier assigned a TOO across &gt;20 cancer types in 96% of samples (344/359); of these, the TOO was correct in 93% (321/344) of cases, which was consistent with training set analyses.

Conclusions: This multicancer early detection test detected cancer signal across &gt;20 cancer types with a single, fixed, low false positive rate and highly accurate TOO localization. Importantly, results in the independent validation set were consistent with the training set, demonstrating the robustness of machine learning classifier training, and confirms that data were not overfitted. These data support the feasibility of a single blood-based test that can detect multiple cancers, supporting further clinical development in preparation for the return of results.

Citation Format: Anne-Renee Hartman, Geoffrey Oxnard, Eric Klein, Michael Seiden, Earl Hubbell, Oliver Venn, Arash Jamshidi, Nan Zhang, John Beausang, Samuel Gross, Kathryn Kurtzman, Eric Fung, Brian Allen, Alexander Fields, Hai Liu, Mikkael Sekeres, Donald Richards, Peter Yu, Alexander Aravanis, Minetta Liu. Multicancer detection of early-stage cancers with simultaneous tissue localization using a plasma cfDNA-based targeted methylation assay [abstract]. In: Proceedings of the AACR Special Conference on Advances in Liquid Biopsies; Jan 13-16, 2020; Miami, FL. Philadelphia (PA): AACR; Clin Cancer Res 2020;26(11_Suppl):Abstract nr IA02.

OP0196-PARE #ARTHRITISATWORK: USING TWITTER TO ENGAGE THE INTERNATIONAL ARTHRITIS COMMUNITY

Background:

In 2019, EULAR launched the #Time2Work campaign [1] to raise awareness of the impact of rheumatic and musculoskeletal diseases on individuals, society, and the economy. Building on this theme, the Canadian Arthritis Patient Alliance (CAPA) developed a social media campaign and Twitter chat in collaboration with international patient advocates and organizations. The Twitter chat built upon CAPA’s successful development of workplace resources for people living with arthritis [2].

Objectives:

To deliver an international #ArthritisAtWork social media campaign on Twitter, in support of the #Time2Work campaign.

Methods:

A one-hour Twitter Chat was held on World Arthritis Day (October 12, 2019) on arthritis in the workplace (#ArthritisAtWork) from 18:00 to 19:00 UTC. The chat was hosted by CAPA and co-hosted by Simon Stones, a patient advocate from the United Kingdom (UK) and CreakyJoints, patient-driven arthritis organization in the United States (US). The Twitter Chat questions were co-developed in advance by the hosts, and blog posts were shared from CAPA’s website. Each host also promoted the Twitter Chat through their websites, newsletters and online communities. A social media analytical tool, Symplur, was used to measure audience engagement using the hashtag #ArthritisAtWork. In addition, pertinent Tweets before, during, and after the chat were obtained. The analysis of themes was undertaken to identify common issues and questions.

Results:

One hundred and ten users participated in the Twitter chat between 17:20 and 19:20 UTC. Participants included people living with arthritis, researchers, patient organizations, health information outlets and academic institutions. During this period, 565 tweets were shared between participants in Australia, Canada, Ireland, Spain, UK and US. There were 3.352 million Twitter impressions. This represents the number of times a tweet appears to users in either their timeline or search results. Emergent themes of the analysis include:

Conclusion:

The social media campaign was successful in reaching a diverse audience and supporting the #Time2Work campaign. Social media tools can provide an important social support for people living with arthritis as they navigate workplace challenges. It also offers a more contemporary platform to engage the international community on issues of common interest. Working together, internationally helps expand reach and reduce barriers in communication. Research can be conducted to measure potential behavior change that leverages digital social support for people living with arthritis.

References:

[1]EULAR (2019). Press release “EULAR launches Time2Work campaign to highlight the importance of keeping people with rheumatic and musculoskeletal diseases in work. Available from:https://www.eular.org/sysModules/obxContent/files/www.eular.2015/1_42291DEB-50E5-49AE-5726D0FAAA83A7D4/time2work_campaign_press_release_final.pdf2. CAPA (2019). Arthritis in the Workplace: Resources for Patients by Patients. Available from:http://arthritispatient.ca/arthritis-in-the-workplace-resources-for-patients-by-patients/

Disclosure of Interests:

Laurie Proulx Grant/research support from: Sources of grants and support received by the Canadian Arthritis Patient Alliance (including in-kind support) in the last two years include: AbbVie Canada, Alliance for Safe Biologic Medicines, Amgen Canada, Arthritis Alliance of Canada, The Arthritis Society, Best Medicines Coalition, CADTH, Canadian Rheumatology Association, Eli Lilly Canada, European League Against Rheumatism, Janssen Canada, Manulife, Novartis Canada, Ontario Rheumatology Association, Pfizer Canada (including Pfizer Hospira), Purdue Pharma Canada, Sanofi, and UCB Pharma., Speakers bureau: I have provided speaking services to Sanofi and Eli Lilly. These engagements do not relate to this abstract., Simon Stones Consultant of: I have been a paid consultant for Envision Pharma Group and Parexel. This does not relate to this abstract., Speakers bureau: I have been a paid speaker for Actelion and Janssen. These do not relate to this abstract., Joseph Coe: None declared, Dawn Richards Grant/research support from: Sources of grants and support received by the Canadian Arthritis Patient Alliance (including in-kind support) in the last two years include: AbbVie Canada, Alliance for Safe Biologic Medicines, Amgen Canada, Arthritis Alliance of Canada, The Arthritis Society, Best Medicines Coalition, CADTH, Canadian Rheumatology Association, Eli Lilly Canada, European League Against Rheumatism, Janssen Canada, Manulife, Novartis Canada, Ontario Rheumatology Association, Pfizer Canada (including Pfizer Hospira), Purdue Pharma Canada, Sanofi, and UCB Pharma., Consultant of: Dawn has done small consulting projects on patient engagement for companies., Speakers bureau: Dawn has been a paid speaker for several companies., Linda Wilhelm Grant/research support from: Sources of grants and support received by the Canadian Arthritis Patient Alliance (including in-kind support) in the last two years include: AbbVie Canada, Alliance for Safe Biologic Medicines, Amgen Canada, Arthritis Alliance of Canada, The Arthritis Society, Best Medicines Coalition, CADTH, Canadian Rheumatology Association, Eli Lilly Canada, European League Against Rheumatism, Janssen Canada, Manulife, Novartis Canada, Ontario Rheumatology Association, Pfizer Canada (including Pfizer Hospira), Purdue Pharma Canada, Sanofi, and UCB Pharma., Nathalie Robertson Grant/research support from: Sources of grants and support received by the Canadian Arthritis Patient Alliance (including in-kind support) in the last two years include: AbbVie Canada, Alliance for Safe Biologic Medicines, Amgen Canada, Arthritis Alliance of Canada, The Arthritis Society, Best Medicines Coalition, CADTH, Canadian Rheumatology Association, Eli Lilly Canada, European League Against Rheumatism, Janssen Canada, Manulife, Novartis Canada, Ontario Rheumatology Association, Pfizer Canada (including Pfizer Hospira), Purdue Pharma Canada, Sanofi, and UCB Pharma., Janet Gunderson Grant/research support from: Sources of grants and support received by the Canadian Arthritis Patient Alliance (including in-kind support) in the last two years include: AbbVie Canada, Alliance for Safe Biologic Medicines, Amgen Canada, Arthritis Alliance of Canada, The Arthritis Society, Best Medicines Coalition, CADTH, Canadian Rheumatology Association, Eli Lilly Canada, European League Against Rheumatism, Janssen Canada, Manulife, Novartis Canada, Ontario Rheumatology Association, Pfizer Canada (including Pfizer Hospira), Purdue Pharma Canada, Sanofi, and UCB Pharma., Alexandra Sirois Grant/research support from: Sources of grants and support received by the Canadian Arthritis Patient Alliance (including in-kind support) in the last two years include: AbbVie Canada, Alliance for Safe Biologic Medicines, Amgen Canada, Arthritis Alliance of Canada, The Arthritis Society, Best Medicines Coalition, CADTH, Canadian Rheumatology Association, Eli Lilly Canada, European League Against Rheumatism, Janssen Canada, Manulife, Novartis Canada, Ontario Rheumatology Association, Pfizer Canada (including Pfizer Hospira), Purdue Pharma Canada, Sanofi, and UCB Pharma., Annette McKinnon Grant/research support from: Sources of grants and support received by the Canadian Arthritis Patient Alliance (including in-kind support) in the last two years include: AbbVie Canada, Alliance for Safe Biologic Medicines, Amgen Canada, Arthritis Alliance of Canada, The Arthritis Society, Best Medicines Coalition, CADTH, Canadian Rheumatology Association, Eli Lilly Canada, European League Against Rheumatism, Janssen Canada, Manulife, Novartis Canada, Ontario Rheumatology Association, Pfizer Canada (including Pfizer Hospira), Purdue Pharma Canada, Sanofi, and UCB Pharma.

AB0488 CAN A GCA RISK STRATIFICATION SCORE BE HELPFUL IN CLINICAL PRACTICE?

Background:

Giant cell arteritis (GCA) is the most common type of large vessel vasculitis. Typically it presents in patients over the age of 50 with a combination of temporal headaches, scalp tenderness, jaw claudication, raised inflammatory markers and visual disturbance. The diagnosis of GCA is often challenging and there is a difficult balance of over and under investigation. There have been several proposed scoring systems to help clinicians risk stratify patients who may present with suspected GCA. One such scoring system, published in 2017, showed clinical utility in a large international multi-centre study. Following analysis by logistic regression on data from 530 biopsies, Ing et al. developed a parsimonious prediction model comprising 5 candidate criteria: age, jaw claudication, ischemia-related loss of visual acuity, platelet count and logCRP (Figure 1).[1]

Objectives:

Increasingly, ultrasound doppler imaging is recognised and accepted as satisfactory means of confirming the diagnosis of GCA, with the presence of the halo sign characteristic for GCA. The aim of our study was to determine whether this GCA prediction model accurately predicts positive temporal artery biopsies in a large, real world UK cohort. In addition, we assessed whether this model accurately predicts positive temporal artery ultrasounds.

Methods:

A retrospective cohort study was performed using electronic medical records of patients referred for temporal artery biopsy (TAB) and temporal artery ultrasound (USTA) for suspected GCA. All TAB performed at the Royal Wolverhampton NHS Trust between June 2014 - June 2018 and all USTA performed between January 2015 - January 2019 were analysed. Patients who undergo USTA for suspected GCA at our centre routinely have bilateral temporal and axillary arteries scanned. Patients were excluded if they already had a previous diagnosis of GCA (and the clinical question was suspected flare), or if there was insufficient information available.

Results:

The total number of patients who underwent a confirmatory diagnostic test (either TAB or USTA) for suspected GCA was 187. Thirteen of these patients met the exclusion criteria, the remaining 174 patients were included for analysis. 126/174 patients underwent a TAB, 63/174 had an USTA. 15/174 had both these were included in the USS cohort because for all these patients the ultrasound was the first diagnostic test performed (Table 1). Our results appear to closely mirror the original multi-centre results with regards to prediction of biopsy positive GCA, with the centiles closely following those in the inception cohort. 0% of the ‘low’ risk probability biopsy cohort were misclassified - none had a positive biopsy. However, 8% of the ‘low’ risk probability ultrasound cohort were misclassified - 2 had a positive ultrasound.

Table 1.

Investigation outcome summary

Total number of patients who underwent TAB +/or USS TA for?GCA187 - 13 patients rejectedN = 174TAB = 111USS = 63Of these 15 patients hadbothUSS & TABPositive TAB =31 (28%)Negative TAB =80 (72%)Positive USS =24 (38%)Negative USS =39 (62%)

Conclusion:

Our study, highlights that a probability score for GCA derived from a large multi-centre cohort of patients who were biopsy positive, predicts ultrasound positivity with similar accuracy. Our work reveals that scoring systems are not infallible but can be helpful in guiding clinical decision making

References:

[1]Ing EB, Lahaie Luna G, Toren A, et al. Multivariable prediction model for suspected giant cell arteritis: development and validation.Clin Ophthalmol. 2017;11:2031–2042. Published 2017 Nov 22.

Acknowledgments:

Many thanks to the Rheumatology, Opthalmology & Ultrasound teams at Royal Wolverhampton NHS Trust

Disclosure of Interests:

None declared

Interlaboratory Study of a Thermospray-Liquid Chromatographic/Mass Spectrometric Method for Selected N-Methyl Carbamates, N-Methyl Carbamoyloximes, and Substituted Urea Pesticides

A thermospray-liquid chromatographic/mass spectrometric (TS-LC/MS) method was evaluated in an interlaboratory study for determining 3 N-methyl carbamates (bendiocarb, carbaryl, and carbofuran), 3 N-methyl carbamoyloximes (aldicarb, methomyl, and oxamyl), 2 substituted urea pesticides (diuron and linuron), and 1 ester of a substituted carbamic acid (carbendazim). The purpose of this study was to establish whether these 9 compounds can be reliably detected and quantitated with this method, and to establish the interlaboratory precision and accuracy of the method with currently available instrumentation. The study design was based on AOAC INTERNATIONAL’S blind replicate design with balanced replicates. The samples consisted of solutions of the 9 test compounds in methanol at 3 concentrations that were unknown to the participating laboratories and that covered the linear range of the method. Nine volunteer laboratories participated in the study. Linear regression equations are presented that calculate the accuracy of the method, i.e., the percent recovery of each of the 9 compounds at any concentration within the range of concentrations tested (5–90 (μg/mL for each compound, except carbendazim, for which the range was 1.25–22.5 μg/mL). The intra laboratory precisions of the TS-LC/MS method ranged from 6.5 to 33.1 % relative standard deviation, depending on the compound. The interlaboratory method precisions ranged from 29.8 to 98.2% relative standard deviation over the concentration range tested. Analysis of variance indicates that for all compounds tested, the variation from laboratory to laboratory is greater than that attributed to analytical error displayed within laboratories. There are many operational parameters that could contribute to interlaboratory variability; one of them, the thermospray tip temperature, can play a major role in adduct formation and ion fragmentation in the case of thermally labile carbamate pesticides and, therefore, needs to be monitored and controlled carefully. The correlation of mass spectral data with the thermospray tip temperature was attempted using principal component analysis.

P309 The use of echocardiographic parameters to predict clinical outcomes in AL-amyloidosis cardiomyopathy

Background

AL-amyloidosis has a rapid clinical progression, with cardiac involvement associated with a particularly poor prognosis. Cardiac amyloidosis is diagnosed by either invasive biopsy or conventional echocardiographic parameters such as increased wall thickness, in the absence of other causes. More recently, novel parameters including 2D longitudinal strain have demonstrated diagnostic utility in a range of infiltrative cardiomyopathies including cardiac amyloidosis.

Aim/Method: We sought to evaluate traditional and novel echocardiographic parameters in their ability to predict adverse outcomes in a cohort of AL-amyloid patients. 80 patients who had transthoracic echocardiograms at a single centre were included. Comprehensive echocardiographic assessment was performed, including left ventricular ejection fraction (LVEF), LV Global Longitudinal Strain (GLS), LV mass (indexed to BSA). The primary endpoint was a composite of of major adverse cardiac events (MACE) and all-cause mortality, that was assessed by interrogation of the medical records on a specified censor date.

Results

At a mean follow-up (time from echo to censor date) of 5.4 ± 2.6years, 38/80 (47.5%) of patients experienced the primary endpoint of MACE or death, of which 25/80 (31%) were deaths. LVEF (59 ± 5.6%vs56 ± 6.4%, p = 0.04), GLS (17.4 ± 3.9%vs14.8 ± 4.9%, p = 0.01) basal longitudinal strain (12.3 ± 3.2%vs9.6 ± 3.9%, p = 0.002), indexed LV mass (107 ± 36g/m2vs130 ± 34g/m2, p = 0.06) and E/E’ (13.7 ± 4.9vs20.6 ± 9.6, p &lt; 0.001) were all significantly different between patients who experienced the primary endpoint and those that didn’t. The strongest predictors of outcome were E/E’ (AUC 0.74), LV mass (AUC 0.73) and the ratio GLS:LV mass (AUC 0.73). An E/E’ of 15 had a sensitivity of 71% and specificity of 69%, while an indexed LV mass of 108 had a sensitivity and specificity of 74% and 67% respectively. GLS to LV mass as a cutoff of 0.16 had a sensitivity and specificity of 70% and 69% respectively.

Conclusion

In a cohort of 80 patients with AL-amyloid cardiomyopathy, almost half (47.5%) reached the primary composite endpoint. Diastolic dysfunction as expressed as E/E’, and LV mass were the most powerful predictors of outcome, while global longitudinal strain and LV basal strain were also reduced, and showed superiority over LV ejection fraction in predicting prognosis.

P1543 The assessment of regional myocardial strain in classifying amyloid cardiomyopathy

Background

An infiltrative cardiomyopathy is a common manifestation of AL-amyloidosis, with cardiac involvement associated with a poor prognosis. Wild-type transthyretin amyloidosis (wt-TTR), is a distinct clinical entity occurring predominantly in men &gt; 65 yrs, that has gained interest recently due to novel treatment options. Regional strain analysis has been shown to discriminate both forms of cardiac amyloidosis from other causes of concentric left ventricular hypertrophy, with a characteristic pattern of ‘apical sparing’. Due to the significant difference in both the course of the disease and treatment options between groups, a non-invasive echocardiographic method of determining subtype would be valuable.

Aim/Method: We sought to compare traditional and novel echocardiographic parameters in a cohort of AL ( n = 80) and wild type (wt-TTR) amyloid ( n = 32) patients. All amyloid patients underwent comprehensive transthoracic echocardiography, including both conventional parameters and LV longitudinal strain. Further novel parameters were computed including the ratio of global longitudinal strain (GLS) to LV ejection fraction (LVEF), as well as GLS to indexed LV mass.

Results

wt-TTR patients had significantly greater LV mass (176 ± 59g/m2vs118 ± 37g/m2, p &lt; 0.001), and worse diastolic dysfunction as expressed as E/E’ (21.5 ± 11vs17 ± 8, p = 0.04). LVEF was significantly lower in wt-TTR patients however remained in the normal range in both groups (53 ± 6%vs57 ± 6%, p = 0.001), whilst GLS was significantly reduced compared to AL-amyloid patients (11.5 ± 3.4%vs16.2 ± 4.6%, p &lt; 0.001). LVEF:GLS was significantly higher in wt-TTR patients (4.93 ± 1.4vs3.87 ± 1.3, p = 0.001) reflecting a more profound reduction in strain with a relatively preserved ejection fraction. Similarly, the ratio of GLS to LV mass was significantly lower in wt-TTR amyloidosis (0.078 ± 0.05vs0.155 ± 0.07, p &lt; 0.001), reflecting a more significant reduction in strain for a given wall thickness in wt-TTR patients. GLS:LV mass was the strongest discriminator between subtypes (AUC 0.82), with a cutoff of 0.09 giving a sensitivity and specificity of 71% and 80% respectively, for detecting wt-TTR.

Conclusion

In this cohort, patients with wt-TTR had significantly greater increase in LV wall thickness and diastolic dysfunction, which may in part reflect their increased age (77vs62). However, GLS was also significantly reduced compared to AL-amyloid, even when accounting for LV ejection fraction and LV mass, suggesting these composite parameters may have value in determining the subtype of cardiac amyloidosis.

4938Left ventricular global longitudinal strain recovery predicts scar size reduction and systolic remodelling post ST-elevation myocardial infarction

Background

Left ventricular (LV) strain has prognostic utility following ST-elevation myocardial infarction (STEMI); however, serial changes in LV strain has not been evaluated post-infarct. We sought to determine the relationship between post-STEMI transthoracic echocardiographic (TTE) LV global longitudinal strain (GLS) and cardiac magnetic resonance (CMR) imaging derived scar size and LV systolic remodelling.

Methods

Following revascularisation, 172 first STEMI patients (85% male, 56.9±10.7 years) had paired TTE for GLS, and CMR to evaluate scar size and LV systolic function at baseline (2–7 days) and follow-up (8–10 weeks). Patients were divided into 3 groups according to absolute baseline GLS: group 1 (GLS ≥16%), group 2 (12%< GLS <16%), group 3 (GLS ≤12%). GLS recovery was defined as ≥10% increase in GLS at follow-up, excluding patients with normal baseline GLS. LV systolic adverse remodelling was defined as ≥15% increase in LVESV. LV systolic reverse remodelling was defined as ≥15% decrease in LVESV. Scar reduction was defined as ≥30% decrease in scar size.

Results

Group 1 and 2 had smaller follow-up scar size and higher LVEF compared to group 3 (p<0.0001 for both, see table). There was no difference in scar size reduction or systolic reverse remodeling among the baseline GLS groups (p>0.05 for both). Importantly, no patients from group 1 demonstrated systolic adverse remodelling. Relative change in GLS is significantly correlated with changes in LVEF (r=0.354, p<0.0001) and scar size (r=−0.262, p<0.0001), see figure. On multivariate binary logistic analysis, patients who demonstrated GLS recovery had greater reduction in scar size (OR=2.77 (1.09–7.01), p=0.032) and LV systolic reverse remodelling (OR=9.63 (1.21–76.41), p=0.032).

Follow-up parameters within GLS groups All patients (n=172) Group 1 (n=47) Group 2 (n=72) Group 3 (n=53) Follow-up GLS, % 16.02±3.44 19.38±1.90 16.36±2.09 12.57±2.69 GLS recovery, n 110 (64%) 19 (40%) 53 (74%) 38 (72%) Follow-up scar size, % 7.67±5.40 5.01±3.38 6.27±3.73 12.02±6.24 Follow-up LVEF, % 51.80±10.20 57.83±6.95 54.14±8.02 43.26±9.83 Data presented as mean ± SD or n (%).

Correlation graphs for change in GLS

Conclusion

Stratification of STEMI patients by baseline GLS was a determinant of CMR scar size as well as LV systolic function. However, the evaluation of GLS recovery could provide additional insights into reduction in scar size and LV systolic remodelling, both important prognostic markers. Thus, echocardiographic serial GLS evaluation may be a relevant non-invasive parameter, that is cheaper and more widely available for monitoring STEMI patients and guiding therapy.

P1483Serial changes in peak left atrial strain predicts diastolic remodelling following percutaneous revascularisation for ST-segment elevation myocardial infarction

Background

Echocardiographic 2D speckle tracking peak left atrial (LA) strain reflects LA reservoir function. Limited studies have reported the relationship between peak LA strain and diastolic dysfunction. In addition, adverse diastolic remodeling (ADR) has been reported, to have better prognostic value than single diastolic function assessment following ST-elevation myocardial infarction (STEMI).

Purpose

We examined the relationship between serial changes in echocardiographic peak LA strain and diastolic function in STEMI patients.

Methods

186 percutaneously revascularized first presentation STEMI patients (87% male, 56.9±10.6 years) underwent serial TTE at baseline (2–7 days) and at follow-up (8–10 weeks) post-STEMI. Peak LA reservoir strain measurements were analysed from apical 2-, 3- and 4- chamber views. Diastolic function was graded as per 2016 guidelines: normal, grade 1, grade 2 and grade 3. ADR was defined as worsening of diastolic function grade (≥1) from baseline to follow-up, or persistent grade 3.

Results

Lower baseline peak LA strain was associated with grade 2 and grade 3 diastolic dysfunction compared to normal and grade 1 function at follow-up (p<0.05, see figure and table). Change in LA strain was less with worsening grades of diastolic function (see table). ADR was seen in 33 patients. Lower baseline peak LA strain predicted ADR (B=0.86 (0.80–0.92), p<0.0001). In addition, a reduction in peak LA strain at follow up was independently associated with ADR (B=0.91 (0.84–0.97), p=0.007) (see figure).

Diastolic function grades with LA strain Follow-up diastolic function Baseline peak LA strain (%) Follow-up peak LA strain (%) Change in peak LA strain (%) Normal (n=91) 35.70±6.38 40.97±8.10 5.26±6.07 Grade 1 (n=61) 30.70±6.97 34.54±8.77 3.84±6.32 Grade 2 (n=17) 23.95±6.11 25.49±5.93 1.54±4.70 Grade 3 (n=17) 23.66±8.07 23.49±10.64 −0.17±7.44 Data presented as mean ± SD.

Peak LA strain vs diastolic function

Conclusion

Peak LA strain is associated with diastolic function following STEMI and differentiates normal diastolic function from diastolic dysfunction. Serial changes in peak LA strain correlated with diastolic remodelling. Longer-term follow-up is required to determine the prognostic value of changes in peak LA strain, and diastolic remodelling.

Assessing the efficacy and acceptability of an internet-delivered intervention for resilience among college students: A pilot randomised control trial protocol

BACKGROUND

Exposure to new stressors places college students at increased risk for developing mental health problems. Preventive interventions aimed at enhancing resilience have the potential to improve mental health and well-being in college students and internet-delivery may improve access to these interventions. However, few studies have evaluated the efficacy of online interventions for resilience in college students. The present study seeks to assess the feasibility [initial efficacy and acceptability] of a newly developed internet-delivered intervention for resilience provided with human or automated support, in a sample of college students.

METHOD

A pilot randomised controlled trial including three groups: 1) an intervention group with human support; 2) an intervention group with automated support; and 3) a waiting list control group. The intervention, Space for Resilience, is based on positive psychology and consists of seven modules, delivered over a period of eight weeks. Primary outcomes measures will include the Connor-Davidson Resilience Scale (CD-RISC) and the Pemberton Happiness Index (PHI). Secondary outcomes measures will include the Brief Resilience Scale (BRS), the Patient Health Questionnaire - 4 items (PHQ-4), the Rosenberg Self-Esteem Scale (RSES), and the Perceived Stress Scale - 4 items (PSS-4). Acceptability will be examined using the Satisfaction with Treatment (SAT) questionnaire. Analysis will be conducted on an intention-to-treat basis.

DISCUSSION

The study seeks to establish the initial efficacy and acceptability of an internet-delivered intervention for resilience with human support and automated support. Apart from determining the impact of the intervention on acceptability and effectiveness, this study will be a first to explore more clearly the relative benefits of different support modes.

Generalized Fréchet Bounds for Cell Entries in Multidimensional Contingency Tables

We consider the lattice, $\mathcal{L}$, of all subsets of a multidimensional contingency table and establish the properties of monotonicity and supermodularity for the marginalization function, $n(\cdot)$, on $\mathcal{L}$.  We derive from the supermodularity of $n(\cdot)$ some generalized Fr\'echet inequalities complementing and extending inequalities of Dobra and Fienberg.  Further, we construct new monotonic and supermodular functions from $n(\cdot)$, and we remark on the connection between supermodularity and some correlation inequalities for probability distributions on lattices.  We also apply an inequality of Ky Fan to derive a new approach to Fr\'echet inequalities for multidimensional contingency tables.

Efficacy and Safety of Ribociclib With Letrozole in US Patients Enrolled in the MONALEESA-2 Study

BACKGROUND

In the Mammary Oncology Assessment of LEE011's (Ribociclib's) Efficacy and Safety (MONALEESA-2) study, combination treatment with the selective inhibitor of cyclin-dependent kinases 4/6 ribociclib with letrozole significantly improved progression-free survival (PFS) versus letrozole alone in postmenopausal women with hormone receptor-positive HR⁺/HER2^- advanced breast cancer (ABC). Herein we present results from the subset of US patients enrolled in MONALEESA-2.

PATIENTS AND METHODS

Postmenopausal women with HR⁺/HER2^- ABC without previous treatment for advanced disease were randomized (1:1) to ribociclib 600 mg/d (3 weeks on/1 week off) with letrozole 2.5 mg/d (continuous) or placebo with letrozole. The primary end point was locally assessed PFS.

RESULTS

Overall, 213 US patients were enrolled in MONALEESA-2 (ribociclib, n = 100; placebo, n = 113). Baseline characteristics were similar between treatment groups and consistent with the global population. With a median follow-up of 27 months, 38 (38%) and 29 (26%) patients in the ribociclib and placebo groups, respectively, had continued to receive treatment. Median PFS was 27.6 months with ribociclib and 15.0 months with placebo (hazard ratio, 0.53). The most common all-cause adverse events were neutropenia (ribociclib, 72.0% [n = 72]; placebo, 4.6% [n = 5]), nausea (ribociclib, 69.0% [n = 69]; placebo, 44.0% [n = 48]), and fatigue (ribociclib, 60.0% [n = 60]; placebo, 50.5% [n = 55]). Two patients (ribociclib, 2.0%; placebo, 0%) experienced febrile neutropenia.

CONCLUSION

In the US subset of MONALEESA-2, ribociclib with letrozole showed superior efficacy versus letrozole alone. These findings are consistent with the global population and support first-line use of ribociclib with letrozole in patients with HR⁺/HER2^- ABC.