Evolving Project ECHO: delivery of pediatric pain core competency learning for interprofessional healthcare providers

Introduction

Healthcare providers (HCPs) practicing in community settings are critical to improving access to pain care, yet there are significant gaps in training opportunities designed for interprofessional learners. Project Extension for Community Healthcare Outcomes (Project ECHO®) is an established model for delivering online HCP education through virtual clinics and cultivating a community of practice. However, to our knowledge, the integration of pain core competency education into the ECHO® model has not been previously attempted. This innovation could enhance the ECHO® model while also addressing the growing calls for more accessible interprofessional pain curricula. This paper describes efforts to implement and evaluate core competency curricula within the context of Pediatric Project ECHO for Pain, one of the first pediatric-pain focused ECHO programs in the world.

Methods

Needs assessments informed curricula development. The first delivered core competency model consisted of synchronous webinar-style sessions while the second model included a mixture of asynchronous (eLearning course) and synchronous (virtual clinical debrief) elements. A convenience sample of HCPs was recruited from ECHO program registrants. Participants completed baseline and follow-up surveys to assess core competency acceptability as well as impact on knowledge and self-efficacy related to managing pediatric pain. Usability of the eLearning platform (model 2 only) was also evaluated. Surveys used 5-point Likert scales to capture outcomes. A priori targets included mean scores ≥4/5 for acceptability and ≥80% of learners reporting knowledge and self-efficacy improvements. The study received local research ethics approval.

Results

The core competency was found to be highly acceptable to interprofessional learners (n = 31) across delivery models, surpassing a priori targets. Specifically, it was characterized as a worthwhile and satisfactory experience that was helpful in supporting learning. The core competency was also associated with improvements in knowledge and self-efficacy by 97% and 90% of learners, respectively. The eLearning platform was reported to have high usability with clinically realistic cases (100% of respondents) that were helpful to inform care delivery (94% of respondents).

Conclusion

The integration of core competency learning within the Project ECHO® model was a successful approach to deliver pediatric pain education to interprofessional HCPs.

Pediatric Project ECHO® for Pain: implementation and mixed methods evaluation of a virtual medical education program to support interprofessional pain management in children and youth

BACKGROUND

Pediatric pain is a complex health challenge requiring a multi-modal management approach. It is critical that healthcare providers (HCPs) have access to ongoing, flexible education and mentorship specific to pediatric pain. However, there are significant gaps in available pain education and a need for more opportunities to support interprofessional training. Project Extension for Community Healthcare Outcomes (Project ECHO®) is a model for delivering online HCP education and cultivating a virtual community of practice. Within the pediatric pain setting, ECHO® has potential to improve local access to specialized pain knowledge, particularly among the physicians, nurses, and allied health providers who primarily manage these cases in community and hospital settings across rural and urban environments. The purpose of this study was three-fold. First, to evaluate the feasibility (participation levels, acceptability) of implementing Project ECHO® in the context of pediatric pain. Second, to measure preliminary program impacts on HCP knowledge, self-efficacy, and clinical practice. Third, to characterize HCP program engagement levels before and after onset of the COVID-19 pandemic.

METHODS

A needs assessment was conducted to identify interprofessional education gaps and inform the program curriculum. The no-cost Pediatric ECHO® for Pain program offered TeleECHO sessions (didactic and case-based learning) as well as foundational education. Surveys were distributed at baseline and 6 months to assess outcomes using 7-point Likert scales. Participant engagement was assessed for periods prior to and during the COVID-19 pandemic. Descriptive and inferential statistical analyses were conducted.

RESULTS

Eighty-five TeleECHO sessions were hosted, with a mean attendance of 34.1 ± 23.4 HCPs. Acceptability scores at 6 months (n = 33) ranged from 5.0 ± 1.4 to 6.5 ± 0.5. Participants reported statistically significant (p < 0.05) improvements in knowledge (7 out of 7 topics) and self-efficacy (8 out of 9 skills). Most participants reported positive practice impacts, including improved satisfaction with managing children with pain. Exploratory analyses showed a trend of greater engagement from ECHO® learners after onset of the COVID-19 pandemic.

CONCLUSIONS

Project ECHO® is a feasible and impactful model for virtual education of interprofessional HCPs in managing pediatric pain.

Children's and young People's diabetes services: What works well and what doesn't?

Objectives

Study design

Methods

Results

Conclusions

Cambridge hybrid closed-loop algorithm in children and adolescents with type 1 diabetes: a multicentre 6-month randomised controlled trial

BACKGROUND

Closed-loop insulin delivery systems have the potential to address suboptimal glucose control in children and adolescents with type 1 diabetes. We compared safety and efficacy of the Cambridge hybrid closed-loop algorithm with usual care over 6 months in this population.

METHODS

In a multicentre, multinational, parallel randomised controlled trial, participants aged 6-18 years using insulin pump therapy were recruited at seven UK and five US paediatric diabetes centres. Key inclusion criteria were diagnosis of type 1 diabetes for at least 12 months, insulin pump therapy for at least 3 months, and screening HbA1c levels between 53 and 86 mmol/mol (7·0-10·0%). Using block randomisation and central randomisation software, we randomly assigned participants to either closed-loop insulin delivery (closed-loop group) or to usual care with insulin pump therapy (control group) for 6 months. Randomisation was stratified at each centre by local baseline HbA1c. The Cambridge closed-loop algorithm running on a smartphone was used with either (1) a modified Medtronic 640G pump, Medtronic Guardian 3 sensor, and Medtronic prototype phone enclosure (FlorenceM configuration), or (2) a Sooil Dana RS pump and Dexcom G6 sensor (CamAPS FX configuration). The primary endpoint was change in HbA1c at 6 months combining data from both configurations. The primary analysis was done in all randomised patients (intention to treat). Trial registration ClinicalTrials.gov, NCT02925299.

FINDINGS

Of 147 people initially screened, 133 participants (mean age 13·0 years [SD 2·8]; 57% female, 43% male) were randomly assigned to either the closed-loop group (n=65) or the control group (n=68). Mean baseline HbA1c was 8·2% (SD 0·7) in the closed-loop group and 8·3% (0·7) in the control group. At 6 months, HbA1c was lower in the closed-loop group than in the control group (between-group difference -3·5 mmol/mol (95% CI -6·5 to -0·5 [-0·32 percentage points, -0·59 to -0·04]; p=0·023). Closed-loop usage was low with FlorenceM due to failing phone enclosures (median 40% [IQR 26-53]), but consistently high with CamAPS FX (93% [88-96]), impacting efficacy. A total of 155 adverse events occurred after randomisation (67 in the closed-loop group, 88 in the control group), including seven severe hypoglycaemia events (four in the closed-loop group, three in the control group), two diabetic ketoacidosis events (both in the closed-loop group), and two non-treatment-related serious adverse events. There were 23 reportable hyperglycaemia events (11 in the closed-loop group, 12 in the control group), which did not meet criteria for diabetic ketoacidosis.

INTERPRETATION

The Cambridge hybrid closed-loop algorithm had an acceptable safety profile, and improved glycaemic control in children and adolescents with type 1 diabetes. To ensure optimal efficacy of the closed-loop system, usage needs to be consistently high, as demonstrated with CamAPS FX.

FUNDING

National Institute of Diabetes and Digestive and Kidney Diseases.

Health professionals' views about who would benefit from using a closed-loop system: a qualitative study

AIM

To explore health professionals' views about who would benefit from using a closed-loop system and who should be prioritized for access to the technology in routine clinical care.

METHODS

Health professionals (n = 22) delivering the Closed Loop from Onset in type 1 Diabetes (CLOuD) trial were interviewed after they had ≥ 6 months' experience supporting participants using a closed-loop system. Data were analysed thematically.

RESULTS

Interviewees described holding strong assumptions about the types of people who would use the technology effectively prior to the trial. Interviewees described changing their views as a result of observing individuals engaging with the closed-loop system in ways they had not anticipated. This included educated, technologically competent individuals who over-interacted with the system in ways which could compromise glycaemic control. Other individuals, who health professionals assumed would struggle to understand and use the technology, were reported to have benefitted from it because they stood back and allowed the system to operate without interference. Interviewees concluded that individual, family and psychological attributes cannot be used as pre-selection criteria and, ideally, all individuals should be given the chance to try the technology. However, it was recognized that clinical guidelines will be needed to inform difficult decisions about treatment allocation (and withdrawal), with young children and infants being considered priority groups.

CONCLUSIONS

To ensure fair and equitable access to closed-loop systems, prejudicial assumptions held by health professionals may need to be addressed. To support their decision-making, clinical guidelines need to be made available in a timely manner.

The Cochrane 2018 Review on Brief Interventions in Primary Care for Hazardous and Harmful Alcohol Consumption: A Distillation for Clinicians and Policy Makers

AIMS

An updated Cochrane systematic review assessed effectiveness of screening and brief intervention to reduce hazardous or harmful alcohol consumption in general practice or emergency care settings. This paper summarises the implications of the review for clinicians.

METHODS

Cochrane methods were followed. Reporting accords with PRISMA guidance. We searched multiple resources to September 2017, seeking randomised controlled trials of brief interventions to reduce hazardous or harmful alcohol consumption in people attending general practice, emergency care or other primary care settings for reasons other than alcohol treatment. Brief intervention was defined as a conversation comprising five or fewer sessions of brief advice or brief lifestyle counselling and a total duration of less than 60 min. Our primary outcome was alcohol consumption, measured as or convertible to grams per week. We conducted meta-analyses to assess change in consumption, and subgroup analyses to explore the impact of participant and intervention characteristics.

RESULTS

We included 69 studies, of which 42 were added for this update. Most studies (88%) compared brief intervention to control. The primary meta-analysis included 34 studies and provided moderate-quality evidence that brief intervention reduced consumption compared to control after one year (mean difference -20 g/wk, 95% confidence interval -28 to -12). Subgroup analysis showed a similar effect for men and women.

CONCLUSIONS

Brief interventions can reduce harmful and hazardous alcohol consumption in men and women. Short, advice-based interventions may be as effective as extended, counselling-based interventions for patients with harmful levels of alcohol use who are presenting for the first time in a primary care setting.

The Liverpool duodenum-and spleen-preserving near-total pancreatectomy can provide long-term pain relief in patients with end-stage chronic pancreatitis

PURPOSE

Total pancreatectomy may improve symptoms in patients with severe end-stage chronic pancreatitis. This might be achieved whilst preserving both the duodenum- and spleen-(DPSPTP). Mature clinical outcomes of this approach are presented.

METHODS

Single-centre prospective cohort study performed between September 1996 and May 2016. Demographic, clinical details, pain scores and employment status were prospectively recorded during clinic attendance.

RESULTS

Fifty-one patients (33 men, 18 women) with a median (interquartile range) age of 40.8 (35.3-49.4) years, a median weight of 69.8 (61.0-81.5) Kg and a median body mass index of 23.8 (21.5-27.8), underwent intended duodenum-and spleen-preserving near-total pancreatectomy for end-stage chronic pancreatitis. Aetiology was excess alcohol in 25, idiopathic (no mutation) in 15, idiopathic (SPINK-1/CFTR mutations) in two, hereditary (PRSS1 mutation) in seven and one each post-necrotising pancreatitis and obstructive pancreatic duct divisum in 1. The main indication for surgery was severe pain. Findings included parenchymal calcification in 79% and ductal calculi in 24%, a dilated main pancreatic duct in 57% and a dilated main bile duct in 17%, major vascular involvement in 27% and pancreato-peritoneal fistula in 2%. Postoperative complications occurred in 20 patients with two deaths. Median pain scores were 8 (7-8) preoperatively and 3 (0.25-5.75) at 5 years (p = 0.013). Opiate analgesic use was significantly reduced postoperatively (p = 0.048). Following surgery, 22 (63%) of 38 patients of working age re-entered employment compared with 12 (33%) working preoperatively (p = 0.016).

CONCLUSION

Duodenum-and spleen-preserving near-total pancreatectomy provided long-term relief in adult patients with intractable chronic pancreatitis pain, with improved employment prospects.

Working with Insulin, Carbohydrates, Ketones and Exercise to Manage Diabetes (WICKED): evaluation of a self-management course for young people with Type 1 diabetes

AIMS

To evaluate a 5-day self-management education course for young people with Type 1 diabetes and assess its effects on knowledge, self-efficacy, beliefs, distress, self-management behaviours and HbA_1c .

METHODS

This is an evaluation of a structured education course. Young people (aged 16-24 years) with Type 1 diabetes were recruited from three diabetes centres. In the first centre, participants completed self-report measures of knowledge, self-efficacy, positive and negative outcome expectancies, and hypoglycaemic worries at baseline (n=47) and the end of the course (n=42). In two additional centres, participants completed these and other measures assessing self-management behaviours, cognitive adaptation to diabetes and diabetes distress at baseline (n=32), the end of the course (n=27) and 3-month follow-up (n = 27). HbA_1c levels were recorded at baseline (n=79), 6 months (n=77) and 12 months (n=65).

RESULTS

There were statistically significant increases in self-report knowledge, self-efficacy, positive outcome expectancies and self-management behaviours, and a statistically significant decrease in negative outcome expectances, between baseline and the end of the course. There were also statistically significant increases in self-report knowledge, self-efficacy, self-management behaviours and cognitive adaptation to diabetes between baseline and 3-month follow-up. Compared with baseline, HbA_1c levels decreased by a mean (sd) of 5.44 (19.93) mmol/mol (0.48%) at 6 months (P=0.019), and by 5.98 (23.32) mmol/mol (0.54%) at 12 months (P =0.043).

DISCUSSION

The results indicate the potential benefits of a self-management course designed to address the developmental needs and challenges faced by young people with Type 1 diabetes. Further studies with larger numbers and appropriate controls are required to confirm these initial findings.

Use of sensor-integrated pump therapy to reduce hypoglycaemia in people with Type 1 diabetes: a real-world study in the UK

AIMS

To assess the efficacy of insulin pumps with automated insulin suspension systems in a real-world setting.

METHODS

We analysed anonymized data uploaded to CareLink^™ by people (n=920) with Type 1 diabetes using the MiniMed Paradigm Veo system and the MiniMed 640G system (Medtronic International Trading Sàrl, Tolochanez, Switzerland) with SmartGuard technology, with or without automated insulin suspension enabled, between February 2016 and June 2018. Users with ≥15 days of sensor data and ≥70% sensor-wear time were classified as sensor-augmented pump alone, sensor-integrated pump with low glucose suspend enabled or sensor-integrated pump with predictive low glucose management enabled.

RESULTS

The median (25^th -75^th percentile) system use was 161 (58-348) days. The median time spent with sensor glucose values ≤3 mmol/l was 0.8 (0.3-1.7)% in the sensor-augmented pump group, 0.3 (0.1-0.7)% in the sensor-integrated pump with low glucose suspend group, and 0.3 (0.1-0.5)% in the sensor-integrated pump with predictive low glucose management group. In individuals switching from sensor-augmented pump to sensor-integrated pump with low glucose suspend (n=31), there were significant reductions in the monthly rate of hypoglycaemic events <3 mmol/l (rate ratio 0.63, 95% CI 0.45-0.89; P=0.009) and in the percentage of time with glucose values ≤3 mmol/l [sensor-augmented pump: 0.63% (95% CI 0.34-1.29), sensor-integrated pump with low glucose suspend: 0.33% (95% CI 0.16-0.64); P=0.001]. The monthly rate of hypoglycaemic events decreased further in individuals (n=139) switching from sensor-integrated pump with low glucose suspend to sensor-integrated pump with predictive low glucose management [rate ratio 0.82 (95% CI 0.69-0.98); P<0.0274]. Similar results were seen for events <3.9 mmol/l. There was no difference in median time spent in target glucose range.

CONCLUSION

Real-world UK data show that increasing automation of insulin suspension reduces hypoglycaemia exposure in people with Type 1 diabetes.

Tumour stage and resection margin status are independent survival factors following partial pancreatoduodenectomy for duodenal adenocarcinoma

INTRODUCTION

There is limited published evidence on duodenal carcinoma due to its rarity. This study aimed to evaluate gastric outlet obstruction and obstructive jaundice along with pathological variables as survival factors in patients with duodenal adenocarcinoma following resection.

METHODS

Survival factor analysis was undertaken in patients undergoing duodenal cancer surgery from 1997 to 2015 in a single centre.

RESULTS

There were 57 patients of whom 18 had gastric outlet obstruction and 14 had obstructive jaundice. Fifty-three had a partial pancreatoduodenectomy and four had palliative bypass. Perioperative mortality and morbidity were 4% (2/53) and 47% (25/53) respectively in resected patients. With a median (95% confidence interval, CI) follow-up of 72 (57-86) months, median overall and recurrence-free survival was 38 months (95% CI 28-113) and 27 months (95% CI 18-83) respectively. The 1 and 3-year overall survival rates were 84% (95% CI 74-95) and 52% (95% CI 39-69) respectively. Median overall survival was 19 months in patients with gastric outlet obstruction vs 53 months in those without (p = 0.026) and 28 months in patients with obstructive jaundice vs 38 months in those without (p = 0.611). Univariate analysis revealed that tumour stage, resection margin status, pre-operative albumin status, gastric outlet obstruction and age were associated with poorer overall and recurrence-free survival but multivariate analysis confirmed only tumour stage and resection margin status to be significant.

CONCLUSION

Whereas gastric outlet obstruction in duodenal cancer appeared to be an important survival factor following partial pancreatoduodenectomy, multivariate analysis showed that only tumour stage and resection margin status were the key independent survival factors. Further multicentre studies are required to elucidate further characteristics of duodenal carcinoma and develop neoadjuvant/adjuvant management strategies.

The impact of using a closed-loop system on food choices and eating practices among people with Type 1 diabetes: a qualitative study involving adults, teenagers and parents

AIMS

We explored whether, how and why moving onto and using a hybrid day-and-night closed-loop system affected people's food choices and dietary practices to better understand the impact of this technology on everyday life and inform recommendations for training and support given to future users.

METHODS

Twenty-four adults, adolescents and parents were interviewed before commencing use of the closed-loop system and following its 3-month use. Data were analysed thematically and longitudinally.

RESULTS

While participants described preparing and/or eating similar meals to those consumed prior to using a closed-loop, many described feeling more normal and less burdened by diabetes in dietary situations. Individuals also noted how the use of this technology could lead to deskilling (less precise carbohydrate counting) and less healthy eating (increased snacking and portion sizes and consumption of fatty, energy-dense foods) because of the perceived ability of the system to deal with errors in carbohydrate counting and address small rises in blood glucose without a corrective dose needing to be administered.

CONCLUSIONS

While there may be quality-of-life benefits to using a closed-loop, individuals might benefit from additional nutritional and behavioural education to help promote healthy eating. Refresher training in carbohydrate counting may also be necessary to help ensure that users are able to undertake diabetes management in situations where the technology might fail or that they take a break from using it.

Differentiation of Autoimmune Pancreatitis from Pancreatic Cancer Remains Challenging

BACKGROUND

Autoimmune pancreatitis (AIP) is an uncommon form of chronic pancreatitis. Whilst being corticosteroid responsive, AIP often masquerades radiologically as pancreatic neoplasia. Our aim is to appraise demographic, radiological and histological features in our cohort in order to differentiate AIP from pancreatic malignancy.

METHODS

Clinical, biochemical, histological and radiological details of all AIP patients 1997-2016 were analysed. The initial imaging was re-reviewed according to international guidelines by three blinded independent radiologists to evaluate features associated with autoimmune pancreatitis and pancreatic cancer.

RESULTS

There were a total of 45 patients: 25 in type 1 (55.5%), 14 type 2 (31.1%) and 6 AIP otherwise not specified (13.3%). The median (IQR) age was 57 (51-70) years. Thirty patients (66.6%) were male. Twenty-six patients (57.8%) had resection for suspected malignancy and one for symptomatic chronic pancreatitis. Three had histologically proven malignancy with concurrent AIP. Two patients died from recurrent pancreatic cancer following resection. Multidisciplinary team review based on radiology and clinical history dictated management. Resected patients (vs. non-resected group) were older (64 vs. 53, p = 0.003) and more frequently had co-existing autoimmune pathologies (22.2 vs. 55.6%, p = 0.022). Resected patients also presented with less classical radiological features of AIP, which are halo sign (0/25 vs. 3/17, p = 0.029) and loss of pancreatic clefts (18/25 vs. 17/17, p = 0.017). There were no differences in demographic features other than age.

CONCLUSION

Despite international guidelines for diagnosing AIP, differentiation from pancreatic cancer remains challenging. Resection remains an important treatment option in suspected cancer or where conservative treatment fails.

A Type 1 diabetes technology pathway: consensus statement for the use of technology in Type 1 diabetes

In both adults and children with diabetes, technologies such as continuous subcutaneous insulin infusion using insulin pumps and continuous glucose monitoring can help improve diabetes control, reduce hypoglycaemia and improve quality of life. Access to these technologies in the UK is very variable. Some technologies are recommended by the National Institute for Health and Care Excellence, while others have not been appraised, and new technologies are emerging all the time. Additionally, different guidelines for adults and children further complicate access to diabetes technology in the transition from paediatric to adult care. Against this background, Diabetes UK and NHS England have brought together a multidisciplinary group of experts, including clinicians and people with diabetes, to develop this consensus guideline, combining the different technologies into a common pathway to aid clinical and policy decision-making. We created a pathway that supports the incremental addition of technology as monotherapy and then dual therapy in the same way that we incrementally add in therapeutic agents to support people with Type 2 diabetes to achieve their personalized glycaemic targets. The pathway emphasizes the importance of structured education, specialist support and appropriate access to psychological therapies, as essential pillars for optimized use of diabetes-related technology, and recommends the re-evaluation of its use when the individual is unable either to use the technology appropriately or to achieve the intended outcomes. This pathway is endorsed by UK-wide clinical and patient associations and we recommend that providers and commissioners use it to ensure the right individual with diabetes has access to the right technology in a timely way to help achieve better outcomes.

HbA1c values and hospital admissions in children and adolescents receiving continuous subcutaneous insulin infusion therapy

AIMS

To assess HbA_1c values and hospitalization rates before, during and after continuous subcutaneous insulin infusion (CSII) therapy.

METHODS

Demographic and hospitalization data were extracted from 161 individuals with Type 1 diabetes who received continuous subcutaneous insulin infusion (CSII) therapy between 2002 and 2013 at the Leeds Children and Young People's Diabetes Service for those aged < 20 years. The median (range) age at CSII start was 11.9 (1.1-17.6) years. The median (range) follow-up time was 2.3 (0-8.1) years. Random intercept models were used to compare HbA_1c values before and during CSII initiation (and after CSII for those who discontinued it). Hospitalization rates were calculated for diabetic ketoacidosis and severe hypoglycaemia.

RESULTS

The mean HbA_1c concentration decreased by 7 mmol/mol [95% CI 6-8; 0.6% (95% CI 0.5-0.7%)]. For the discontinued group (n=30), mean HbA_1c decreased by 5 mmol/mol [95% CI 2-8; 0.4% (95% CI 0.2-0.7%)]. HbA_1c returned to pre-CSII start levels at the end of this therapy. Diabetic ketoacidosis admissions increased threefold during CSII compared with before CSII start [2.2 per 100 person-years (95% CI 1.3 to 3.6) vs 7.4 per 100 person-years (95% CI 5.1 to 10.8)] and was highest during the first year of CSII. No difference in severe hypoglycaemia incidence rate was found during CSII compared with the pre-CSII period.

CONCLUSIONS

Despite significant reductions in HbA_1c levels for individuals treated with CSII, improvements are needed to reduce diabetic ketoacidosis hospitalizations for those new to the therapy.

Intratumoural expression of deoxycytidylate deaminase or ribonuceotide reductase subunit M1 expression are not related to survival in patients with resected pancreatic cancer given adjuvant chemotherapy

BACKGROUND

Deoxycytidylate deaminase (DCTD) and ribonucleotide reductase subunit M1 (RRM1) are potential prognostic and predictive biomarkers for pyrimidine-based chemotherapy in pancreatic adenocarcinoma.

METHODS

Immunohistochemical staining of DCTD and RRM1 was performed on tissue microarrays representing tumour samples from 303 patients in European Study Group for Pancreatic Cancer (ESPAC)-randomised adjuvant trials following pancreatic resection, 272 of whom had received gemcitabine or 5-fluorouracil with folinic acid in ESPAC-3(v2), and 31 patients from the combined ESPAC-3(v1) and ESPAC-1 post-operative pure observational groups.

RESULTS

Neither log-rank testing on dichotomised strata or Cox proportional hazard regression showed any relationship of DCTD or RRM1 expression levels to survival overall or by treatment group.

CONCLUSIONS

Expression of either DCTD or RRM1 was not prognostic or predictive in patients with pancreatic adenocarcinoma who had had post-operative chemotherapy with either gemcitabine or 5-fluorouracil with folinic acid.

Expression of dihydropyrimidine dehydrogenase (DPD) and hENT1 predicts survival in pancreatic cancer

BACKGROUND

Dihydropyrimidine dehydrogenase (DPD) tumour expression may provide added value to human equilibrative nucleoside transporter-1 (hENT1) tumour expression in predicting survival following pyrimidine-based adjuvant chemotherapy.

METHODS

DPD and hENT1 immunohistochemistry and scoring was completed on tumour cores from 238 patients with pancreatic cancer in the ESPAC-3(v2) trial, randomised to either postoperative gemcitabine or 5-fluorouracil/folinic acid (5FU/FA).

RESULTS

DPD tumour expression was associated with reduced overall survival (hazard ratio, HR = 1.73 [95% confidence interval, CI = 1.21-2.49], p = 0.003). This was significant in the 5FU/FA arm (HR = 2.07 [95% CI = 1.22-3.53], p = 0.007), but not in the gemcitabine arm (HR = 1.47 [0.91-3.37], p = 0.119). High hENT1 tumour expression was associated with increased survival in gemcitabine treated (HR = 0.56 [0.38-0.82], p = 0.003) but not in 5FU/FA treated patients (HR = 1.19 [0.80-1.78], p = 0.390). In patients with low hENT1 tumour expression, high DPD tumour expression was associated with a worse median [95% CI] survival in the 5FU/FA arm (9.7 [5.3-30.4] vs 29.2 [19.5-41.9] months, p = 0.002) but not in the gemcitabine arm (14.0 [9.1-15.7] vs. 18.0 [7.6-15.3] months, p = 1.000). The interaction of treatment arm and DPD expression was not significant (p = 0.303), but the interaction of treatment arm and hENT1 expression was (p = 0.009).

CONCLUSION

DPD tumour expression was a negative prognostic biomarker. Together with tumour expression of hENT1, DPD tumour expression defined patient subgroups that might benefit from either postoperative 5FU/FA or gemcitabine.

Patients' and caregivers' experiences of using continuous glucose monitoring to support diabetes self-management: qualitative study

BACKGROUND

Continuous glucose monitoring (CGM) enables users to view real-time interstitial glucose readings and provides information on the direction and rate of change of blood glucose levels. Users can also access historical data to inform treatment decisions. While the clinical and psychological benefits of CGM are well established, little is known about how individuals use CGM to inform diabetes self-management. We explored participants' experiences of using CGM in order to provide recommendations for supporting individuals to make optimal use of this technology.

METHODS

In-depth interviews (n = 24) with adults, adolescents and parents who had used CGM for ≥4 weeks; data were analysed thematically.

RESULTS

Participants found CGM an empowering tool because they could access blood glucose data effortlessly, and trend arrows enabled them to see whether blood glucose was rising or dropping and at what speed. This predicative information aided short-term lifestyle planning and enabled individuals to take action to prevent hypoglycaemia and hyperglycaemia. Having easy access to blood glucose data on a continuous basis also allowed participants to develop a better understanding of how insulin, activity and food impacted on blood glucose. This understanding was described as motivating individuals to make dietary changes and break cycles of over-treating hypoglycaemia and hyperglycaemia. Participants also described how historical CGM data provided a more nuanced picture of blood glucose control than was possible with blood glucose self-monitoring and, hence, better information to inform changes to background insulin doses and mealtime ratios. However, while participants expressed confidence making immediate adjustments to insulin and lifestyle to address impending hypoglycaemia and hypoglycaemia, most described needing and expecting health professionals to interpret historical CGM data and determine changes to background insulin doses and mealtime ratios. While alarms could reinforce a sense of hypoglycaemic safety, some individuals expressed ambivalent views, especially those who perceived alarms as signalling personal failure to achieve optimal glycaemic control.

CONCLUSIONS

CGM can be an empowering and motivational tool which enables participants to fine-tune and optimize their blood glucose control. However, individuals may benefit from psycho-social education, training and/or technological support to make optimal use of CGM data and use alarms appropriately.

A survey of staffing levels in paediatric diabetes services throughout the UK

AIMS

To assess staffing levels of healthcare professionals involved in the care of children and young people with diabetes in the UK.

METHODS

A web-based questionnaire was distributed to lead consultant paediatricians from all paediatric diabetes services in the UK between October and December 2014. Data on staffing levels and other aspects of diabetes services were collected and differences between the four nations of the UK and across the 10 English diabetes networks were explored.

RESULTS

Some 175 services (93%) caring for 29 711 children and young people aged ≤ 24 years with diabetes participated in the survey. Northern Ireland and Wales had the lowest ratio of total staff to patient population. Nursing caseloads per one whole-time equivalent (WTE) nurse ranged from 71 patients in England to 110 patients in Northern Ireland with only 52% of the UK services meeting the Royal College of Nursing recommended nurse-to-patient ratio of > 1 : 70. Scotland and Northern Ireland had the highest ratio of consultants and fully trained doctors per 1000 patients (3.5 WTE). Overall, 17% of consultants had a Certificate of Completion of Training in Endocrinology and Diabetes. Some 44% of dietitians were able to adjust insulin dose. Only 43% of services provided 24-h access to advice from the diabetes team and 82% of services had access to a psychologist. Staffing levels adjusted for volume were not directly related to glycaemic performance of services in England and Wales.

CONCLUSIONS

Wide variations in staffing levels existed across the four nations of the UK and important gaps were present in key areas.

Is there a relationship between surgical case volume and mortality in congenital heart disease services? A rapid evidence review

OBJECTIVE

To identify and synthesise the evidence on the relationship between surgical volume and patient outcomes for adults and children with congenital heart disease.

DESIGN

Evidence synthesis of interventional and observational studies.

DATA SOURCES

MEDLINE, EMBASE, CINAHL, Cochrane Library and Web of Science (2009-2014) and citation searching, reference lists and recommendations from stakeholders (2003-2014) were used to identify evidence.

STUDY SELECTION

Quantitative observational and interventional studies with information on volume of surgical procedures and patient outcomes were included.

RESULTS

31 of the 34 papers identified (91.2%) included only paediatric patients. 25 (73.5%) investigated the relationship between volume and mortality, 7 (20.6%) mortality and other outcomes and 2 (5.9%) non-mortality outcomes only. 88.2% were from the US, 97% were multicentre studies and all were retrospective observational studies. 20 studies (58.8%) included all congenital heart disease conditions and 14 (41.2%) single conditions or procedures. No UK studies were identified. Most studies showed a relationship between volume and outcome but this relationship was not consistent. The relationship was stronger for single complex conditions or procedures. We found limited evidence about the impact of volume on non-mortality outcomes. A mixed picture emerged revealing a range of factors, in addition to volume, that influence outcome including condition severity, individual centre and surgeon effects and clinical advances over time.

CONCLUSIONS

The heterogeneity of findings from observational studies suggests that, while a relationship between volume and outcome exists, this is unlikely to be a simple, independent and directly causal relationship. The effect of volume on outcome relative to the effect of other, as yet undetermined, health system factors remains a complex and unresolved research question.

Home Use of an Artificial Beta Cell in Type 1 Diabetes

BACKGROUND

The feasibility, safety, and efficacy of prolonged use of an artificial beta cell (closed-loop insulin-delivery system) in the home setting have not been established.

METHODS

In two multicenter, crossover, randomized, controlled studies conducted under free-living home conditions, we compared closed-loop insulin delivery with sensor-augmented pump therapy in 58 patients with type 1 diabetes. The closed-loop system was used day and night by 33 adults and overnight by 25 children and adolescents. Participants used the closed-loop system for a 12-week period and sensor-augmented pump therapy (control) for a similar period. The primary end point was the proportion of time that the glucose level was between 70 mg and 180 mg per deciliter for adults and between 70 mg and 145 mg per deciliter for children and adolescents.

RESULTS

Among adults, the proportion of time that the glucose level was in the target range was 11.0 percentage points (95% confidence interval [CI], 8.1 to 13.8) greater with the use of the closed-loop system day and night than with control therapy (P<0.001). The mean glucose level was lower during the closed-loop phase than during the control phase (difference, -11 mg per deciliter; 95% CI, -17 to -6; P<0.001), as were the area under the curve for the period when the glucose level was less than 63 mg per deciliter (39% lower; 95% CI, 24 to 51; P<0.001) and the mean glycated hemoglobin level (difference, -0.3%; 95% CI, -0.5 to -0.1; P=0.002). Among children and adolescents, the proportion of time with the nighttime glucose level in the target range was higher during the closed-loop phase than during the control phase (by 24.7 percentage points; 95% CI, 20.6 to 28.7; P<0.001), and the mean nighttime glucose level was lower (difference, -29 mg per deciliter; 95% CI, -39 to -20; P<0.001). The area under the curve for the period in which the day-and-night glucose levels were less than 63 mg per deciliter was lower by 42% (95% CI, 4 to 65; P=0.03). Three severe hypoglycemic episodes occurred during the closed-loop phase when the closed-loop system was not in use.

CONCLUSIONS

Among patients with type 1 diabetes, 12-week use of a closed-loop system, as compared with sensor-augmented pump therapy, improved glucose control, reduced hypoglycemia, and, in adults, resulted in a lower glycated hemoglobin level. (Funded by the JDRF and others; AP@home04 and APCam08 ClinicalTrials.gov numbers, NCT01961622 and NCT01778348.).

Expression of human cationic trypsinogen (PRSS1) in murine acinar cells promotes pancreatitis and apoptotic cell death

Hereditary pancreatitis (HP) is an autosomal dominant disease that displays the features of both acute and chronic pancreatitis. Mutations in human cationic trypsinogen (PRSS1) are associated with HP and have provided some insight into the pathogenesis of pancreatitis, but mechanisms responsible for the initiation of pancreatitis have not been elucidated and the role of apoptosis and necrosis has been much debated. However, it has been generally accepted that trypsinogen, prematurely activated within the pancreatic acinar cell, has a major role in the initiation process. Functional studies of HP have been limited by the absence of an experimental system that authentically mimics disease development. We therefore developed a novel transgenic murine model system using wild-type (WT) human PRSS1 or two HP-associated mutants (R122H and N29I) to determine whether expression of human cationic trypsinogen in murine acinar cells promotes pancreatitis. The rat elastase promoter was used to target transgene expression to pancreatic acinar cells in three transgenic strains that were generated: Tg(Ela-PRSS1)NV, Tg(Ela-PRSS1*R122H)NV and Tg(Ela-PRSS1*N29I)NV. Mice were analysed histologically, immunohistochemically and biochemically. We found that transgene expression is restricted to pancreatic acinar cells and transgenic PRSS1 proteins are targeted to the pancreatic secretory pathway. Animals from all transgenic strains developed pancreatitis characterised by acinar cell vacuolisation, inflammatory infiltrates and fibrosis. Transgenic animals also developed more severe pancreatitis upon treatment with low-dose cerulein than controls, displaying significantly higher scores for oedema, inflammation and overall histopathology. Expression of PRSS1, WT or mutant, in acinar cells increased apoptosis in pancreatic tissues and isolated acinar cells. Moreover, studies of isolated acinar cells demonstrated that transgene expression promotes apoptosis rather than necrosis. We therefore conclude that expression of WT or mutant human PRSS1 in murine acinar cells induces apoptosis and is sufficient to promote spontaneous pancreatitis, which is enhanced in response to cellular insult.

Arachidonic acid uptake by human platelets is mediated by CD36

The involvement of glycoprotein (GP) IV (CD36) in arachidonic acid uptake by human platelets was investigated using an anti-CD36 monoclonal antibody (MAB). The binding of [(14)C]arachidonic acid to MAB-treated platelets was significantly reduced compared with untreated platelets. The MAB also inhibited arachidonic acid-induced platelet aggregation and thromboxane A(2) synthesis in a dose-dependent manner. Pre-incubation of gel-filtered platelets with the MAB (10mg/I) inhibited arachidonic acid-induced platelet aggregation by 50% and collagen-induced platelet aggregation by 7-8% and the lag time was increased by 200%. Although the mechanism of platelet aggregation is not fully understood yet, the inhibition of arachidonic acid-induced platelet aggregation by the MAB could be the result of a reduced uptake of exogeneously added arachidonic acid by the MAB-treated platelets. Our data clearly indicate that arachidonic acid uptake by platelets is mediated, at least in part, by CD36.

The clinical effectiveness and cost-effectiveness of home-based, nurse-led health promotion for older people: a systematic review

BACKGROUND

In older age, reduction in physical function can lead to loss of independence, the need for hospital and long-term nursing or residential home care, and premature death. Home-visiting programmes for older people, carried out by nurses and other health-care professionals (e.g. occupational therapists and physiotherapists), aim to positively affect health and functional status, and may promote independent functioning of older people.

OBJECTIVE

The main research question addressed by this assessment is 'What is the clinical effectiveness and cost-effectiveness of home-based, nurse-led health promotion intervention for older people in the UK?'

DATA SOURCES

A comprehensive literature search was undertaken across 12 different databases and research registries from the year 2001 onwards (including MEDLINE, MEDLINE in Process & Other Non-Indexed Citations, EMBASE, Science Citation Index Expanded, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, NHS Health Economic Evaluation Database, Health Technology Assessment Database, Database of Abstracts of Reviews of Effects, Cumulative Index to Nursing and Allied Health Literature). Published systematic reviews were also hand searched to identify other trials previously published.

REVIEW METHODS

Potentially relevant studies were sifted by one reviewer, and inclusion decisions were agreed among the broader research team. The methodological quality of included studies was assessed using the Cochrane Risk of Bias tool. The results of included studies were synthesised using narrative and statistical methods. A separate systematic search was undertaken to identify existing health economic analyses of home-based, nurse-led health promotion programmes. Included studies were critically appraised using a published checklist. Owing to resource constraints, a de novo health economic model was not developed.

RESULTS

Eleven studies were included in the systematic review of clinical effectiveness. There was considerable heterogeneity among the studies with respect to the nature of the intervention, the nurses delivering the programmes and the populations in which the interventions were assessed. Overall, the quality of the included studies was good: all but one of the included studies were judged to be at medium or low risk of bias. Meta-analysis of eight studies suggested a statistically significant mortality benefit for the home-based health promotion groups, whereas a meta-analysis of four studies suggested non-significant benefits in terms of fewer falls in the intervention groups than in the control groups. Positive outcomes for home-based, nurse-led health promotion interventions were also reported within individual studies across several other outcomes. Only three economic studies met the criteria for inclusion in the review of cost-effectiveness. This evidence base consists of one non-randomised cost minimisation analysis and two economic evaluations undertaken alongside randomised controlled trials. Two of these studies involved an intervention targeted specifically at patients with a known underlying incurable disease, whereas the third study examined the clinical effectiveness and cost-effectiveness of early discharge in patients with a range of conditions, including fractures, neurological conditions and cardiorespiratory conditions. Each study indicated some likelihood that home-based, nurse-led health promotion may offer cost savings to the NHS and associated sectors, such as social services. However, one study did not report any comparison of health outcomes and instead simply assumed equivalence between the intervention and comparator groups, whereas the other two studies suggested at best a negligible incremental benefit in terms of preference-based health-related quality-of-life measures.

LIMITATIONS

The evidence base for clinical effectiveness is subject to considerable heterogeneity. The UK economic evidence base is limited to three studies.

CONCLUSIONS

On the basis of the evidence included in this systematic review, home-based, nurse-led health promotion may offer clinical benefits across a number of important health dimensions. However, it is generally unclear from the available studies which components of this type of complex intervention contribute towards individual aspects of benefit for older people. Given the limitations of the current evidence base, it remains unclear whether or not home-based health promotion interventions offer good value for money for the NHS and associated sectors. Given the considerable uncertainties in the available evidence base, it is difficult to isolate the key areas in which future research would be valuable or the exact study design required. Although this report does not identify specific studies that should be undertaken, it does set out a number of key considerations for the design of future research in this area.

STUDY REGISTRATION

PROSPERO number: CRD42012002133.

Incidence rate trends in childhood type 1 diabetes in Yorkshire, UK 1978-2007: effects of deprivation and age at diagnosis in the South Asian and non-South Asian populations

AIMS

Incidence of Type 1 diabetes in children is increasing worldwide. Earlier studies suggest that UK south Asian immigrants develop similar rates to the overall UK population, although incidence is lower in their country of origin. This study examines incidence rate trends of childhood Type 1 diabetes in Yorkshire 1978-2007, focusing on differences between south Asians and non-south Asians.

METHODS

Data from the population-based Yorkshire Register of Diabetes in Children and Young People were used to estimate incidence (per 100,000 childhood population < 15 years per year) of Type 1 diabetes, stratified by sex, age and ethnicity validated using two name-recognition programs. Age-sex standardized rates were calculated for 1978-2007 and assessed by ethnic-group and deprivation for 1990-2007. We used Poisson regression to assess incidence trends and predict rates until 2020.

RESULTS

From 1978-2007, 3912 children were diagnosed. Overall incidence was 18.1 per 100,000 childhood population (< 15 years) per year (95% CI17.6-18.7) and increased significantly over time: 13.2 (1978-1987) to 17.3 (1988-1997) to 24.2 (1998-2007). Average annual percentage change was 2.8% (2.5-3.2). Incidence for non-south Asians (21.5; 20.7-22.4) was significantly higher than for south Asians (14.7; 12.4-17.1). Average annual percentage change increased significantly over 18 years (1990-2007) in non-south Asians (3.4%; 2.7-4.2) compared with a non-significant rise of 1.5% (-1.5 to 4.6) in south Asians. Deprivation score did not affect overall incidence.

CONCLUSIONS

Type 1 diabetes incidence rose almost uniformly for non-south Asians, but not for south Asians, contrary to previous studies. Overall rates are predicted to rise by 52% from 2007 to 2020 to 39.0 per 100,000 per year.

Defining the endoscopic appearances of tylosis using conventional and narrow-band imaging: a case series

Tylosis is an autosomal dominant skin disorder strongly associated with esophageal squamous cell cancer. We present a single-operator experience of utilizing conventional endoscopy and narrow-band imaging with magnification to characterize esophageal appearances in tylosis. Nineteen consecutive patients with tylosis attending for surveillance endoscopy were studied. White-light imaging (WLI) and narrow-band imaging (NBI) were undertaken, with magnification being performed as necessary. On WLI, we classified 12 patients as having mild change, 5 moderate change, and 2 severe change. WLI can define changes to the esophageal mucosa of variable hyperkeratosis and identify more significant focal abnormalities. NBI enhances these mucosal changes, and NBI with magnification can demonstrate intrapapillary capillary loop changes compatible with dysplasia, prompting consideration of surgery. This report is the first to characterize the endoscopic appearances in tylosis.

Apical node metastasis independently predicts poor survival in Dukes C colorectal cancer

AIM

The prognostic significance of apical node metastasis in node-positive colorectal cancer (CRC) is disregarded by the Fourth American Joint Committee on Cancer and the International Union Against Cancer (AJCC/UICC) TNM classification system. The influence of apical node metastases on overall 5-year survival among patients with Dukes stage C CRC was examined.

METHOD

Patients who underwent operative resection for CRC between 1999 and 2003 were reviewed.

RESULTS

Two-hundred and ninety patients were included in the study, including 203 with Dukes C apical node-negative cancers, 39 with Dukes C apical node-positive cancers and 48 with Dukes D cancers. The respective prevalence of extramural vascular invasion was 35%vs 64%vs 56% (P = 0.0005), T4-stage 24%vs 38%vs 48% (P = 0.013), positive resection margin 16%vs 41%vs 23% (P = 0.001), more than three positive nodes harvested 28%vs 85%vs 52% (P < 0.0001) and poorer tumour differentiation grade 9%vs 21%vs 23% (P = 0.009). Multivariate analyses of all Dukes C cancer patients (n = 242) showed a positive apical node to be a highly significant independent predictor of mortality (hazard ratio 2.281, 95% confidence interval 1.421-3.662, P = 0.0006). Extramural vascular invasion and a positive resection margin were also independent predictors of poor survival. Patients with Dukes C apical node-positive cancers had a significantly poorer overall 5-year survival compared to patients with Dukes C apical node-negative cancers (P < 0.0001) but survival was not significantly different compared to patients with distant metastases at initial presentation (P = 0.504).

CONCLUSION

  Apical node metastasis appears to be a strong independent, negative prognostic factor of poor survival in Dukes C CRC.

Abstract P3-10-21: Audit of the Accuracy of Immunohistochemical (IHC) Testing of HER2 Status of Breast Cancer in the United Kingdom: An Interim Analysis

Background: The analysis of the level and distribution of HER2 protein expressed by cancer cells (HER2 status) is of great clinical value in the management of breast cancer patients both for the determination of the prognosis of disease and for identification of those patients who are eligible for anti-HER2 therapy. Accurate assessment of the HER2 status is essential for identifying patients which will benefit from HER2 targeted therapy. HER2 status in the UK is established using a two tier strategy with IHC as the initial test and subsequent reflex of equivocal results to in situ hybridization (ISH). IHC staining of the HER2 protein is graded as 0- 3+ dependent upon the intensity of staining, cellular localisation and the percentage of cells positive in accordance with CAP/ASCO and UK guidelines. HER2 3+ cases are considered as positive, with HER2 2+ cases (equivocal) retested by ISH to ascertain the gene amplification status. Cases that are scored as 0 and 1+ by IHC have no additional testing and are classed as negative. The literature indicates that a subset of these IHC negative cases show HER2 gene amplification by FISH (range 1.1-10.7%). The aim of this audit is to evaluate the discordance rate of HER2 IHC negative, FISH positive breast cancer in the UK, with a secondary objective to resolve if this is related to the choice of antibody used. Materials and methods: This audit selected a total of 1000 sequential cases reported as HER2 negative on IHC, from three UK reference centres receiving cases from 29 different hospitals. The cases were given a unique identifying number and annonymised. Each of the three centres used a different IHC method for frontline HER2 testing with centre one using HercepTest™ (DAKO), centre two Pathway 4B5 (Roche), and centre three, Oracle (Leica Microsystems). HER2 gene amplification status was determined using dual colour FISH analysis, PathVysion (ABBOTT) fluorescence ISH (FISH) in a single centre to provide standardised methodology and assessment. HER2 was classed as amplified when the HER2/cep 17 ratio was two or greater in accordance with UK guidelines. All cases which showed discordance between IHC and FISH were retested with each of the HER2 IHC platforms to discover whether these are truly discordant results or if the discrepancy is a consequence of the choice of antibody.

Results: An interim analysis of 170 cases shows an overall IHC negative/FISH positive discordance rate of 2.37%. The discordance rate per antibody was 1.7% for HercepTest, 3.3% with 4B5 and 2.5% with Oracle. Of the FISH positive cases the HER2/cep 17 ratios ranged from 2.2 - 6.17. The overall discordance rate between IHC negative and FISH positive is in keeping with the literature and is comparable between the three IHC platforms.

Citation Information: Cancer Res 2010;70(24 Suppl):Abstract nr P3-10-21.

Abstract PD10-03: Is 5-50% of Amplified Cells a Suitable Cut Off To Define Heterogeneous Amplification of the HER2 Oncogene?

Background: A recent panel guideline, published on behalf of the College of American Pathologists, redefines heterogeneous amplification of HER2 as the presence of between 5-50% of cells with a HER2/CEP17 ratio ≥2.20[Vance et al., 2009]. We are unaware of pre-existing data auditing either the frequency of cells with this ratio in FISH analysis or of the clinical impact of this definition. Without such data it is difficult for clinicians to interpret the reporting of a breast cancer with 5% HER2 amplified in the context of therapeutic decision making.

Patients & Methods: An audit of FISH results from the Birmingham Heartlands Hospital (BHH) routine pathology laboratory was combined with data from analysis of the TEAM pathology study (TPS). All case reports were scanned and the percentage of amplified cells was reported in all cases with at least 20 cells scored as per UK guidelines. Interim data on 1050 cases from Birmingham & 1870 cases from the TEAM trial are reported and the impact of “heterogeneous amplification” on outcome will be presented at the meeting.

Results: Cohort 1: BHH: Of 1050 eligible cases 187 (17.8%) were amplified as defined by UK guidelines (HER2/CEP17 ratio ≥2.00). Of these 32 would be defined as “borderline” by the ASCO/CAP guidelines. All cases were referred due to equivocal IHC results (2+ etc). 147 cases exhibited ≥50% of cells with ratios &gt;2.20 “amplified” under the CAP panel guidelines; 51/147 exhibited at least 30% of “non-amplified” cells (ratio &lt;2.20). A further 381 cases (36.2%) exhibited between 5-50% of cells 5-50% of cells with a HER2/CEP17 ratio of greater than 2.20 and would under new CAP guidelines be regarded as exhibiting “Heterogeneous amplification”.

Cohort 2 TPS: Of 1870 eligible cases, 220 (11.2%) were amplified for HER2 as defined using conventional parameters of HER2/CEP17 ratios above 2.0(as per UK guidelines). Of these 16 cases would be defined as “borderline” by ASCO/CAP guidelines. All cases were ER+ve accounting for the lower frequency of HER2 amplification. 180 cases (9.6%) exhibited ≥50% of cells with ratios above 2.20 satisfying the new CAP guidelines for amplification (non-heterogeneous). Of these 72 (40%) exhibited at least 30% of cells with ratios &lt;2.20.

Conclusion: Using the new CAP panel guidelines for HER2 “heterogeneous amplification” in an audit of 2920 cases identified 955 (32.7%) of heterogeneous amplification, and raised the frequency of “HER2 amplification/heterogeneous amplification” to 44% of cases evaluated. Heterogeneous amplification of the HER2 oncogene is a real and challenging diagnostic finding Evidence relating to the prognostic impact and in particular response to HER2 therapies is currently lacking for these cases. Guidelines should reflect this and seek to gather such evidence before implementing changes to diagnostic practice.

Citation Information: Cancer Res 2010;70(24 Suppl):Abstract nr PD10-03.

Abstract P3-10-04: An Integration of Biological and Pathological Marker Panel in the TEAM Pathology Sub-Study: The Impact of Different Parameters on Risk Estimation of Relapse at Both 2.75 and 5 Years

Background: Recent evidence confirms the importance of both biological and pathological risk markers in predicting early relapse for breast cancer patients treated with endocrine therapy. Most studies use a two step process integrating biological markers into a “biological predictor (e.g. Oncotype Dx, “IHC4” etc) followed by assessment of the predictive value of such tests in the context of pathological markers (grade, nodal status etc). We have taken a one step process integrating both biological and pathological markers into a single model to assess key factors for predicting outcome at 2.75 years and 5 years of endocrine therapy; to inform choices between switching, upfront and extended adjuvant treatment with AIs. Patients & Methods: Pathology blocks from 4598 TEAM patients were collected and tissue microarrays constructed. Quantitative analysis ER, PgR, Ki67, HER1, HER2, and HER3 was performed centrally. A prognostic model, integrating data from biological and pathological markers was created to assess risk (disease-free survival) after 2.75 and 5 years of follow up in the TEAM trial.

Results: Of 4595 eligible cases samples received, 16 were excluded, and 3993 had complete biomarker data for all markers for the final biomarker analysis. In univariate analysis nodal status, grade, size, age at diagnosis, HER1, HER2, PgR, ER and Ki67 were all prognostic. At 2.75 years nodal status, age, PgR histoscore, size, grade, HER2, ER histoscore and HER1 positivity were significant prognostic variables (ranked by WaldX2 statistic), Ki67 and HER3 were not included in this model. At 5 years median follow up; age, nodal status, size, PgR histoscore, grade, Ki67, HER2, and HER1 positivity were significant prognostic variables (ranked by WaldX2 statistic), ER and HER3 were not included in this model. Conclusion: Combined biological and pathological marker panels are of significant value in predicting early relapse in breast cancer patients treated with endocrine therapy, however duration of follow-up may impact on the inclusion of variables in the model. This provides significant information relevant to the choice of different adjuvant endocrine therapies.

Citation Information: Cancer Res 2010;70(24 Suppl):Abstract nr P3-10-04.

The mammalian target of rapamycin inhibitor everolimus (RAD001) in early breast cancer: results of a pre-operative study

mTOR plays a key role in tumor cell cycle control, proliferation, and survival. RAD001 (everolimus) is a novel macrolide that inhibits mTOR and thus downstream signaling pathways. 31 post-menopausal women with early breast cancer were given 5 mg RAD001 once daily for 14 days prior to surgery. Biopsies were taken at diagnosis and at surgery (post 14 days of treatment) and assessed for immunohistochemical changes in proliferation (Ki67), apoptosis (active caspase-3), p-AKT (s473), p-S6 (s235/236 and s240/244), p-mTOR (s2448), ER, and PR. Five patients did not complete the 2-week treatment period due to adverse events. All adverse events were grade 1 or 2 (NCIC-CTC scale). RAD001 treatment significantly decreased proliferation (geometric mean reduction 74% from baseline (p = 0.019)), particularly in HER-2 positive tumors. High Ki67 pre-treatment correlated with reduction in Ki67, an increase in apoptosis, a reduction in p-AKT (cytoplasmic) and reduction in p-mTOR following treatment. Nuclear expression of p-AKT was significantly reduced with treatment. Tumors that had a reduction in Ki67 with treatment exhibited a significant reduction in cytoplasmic p-AKT. p-S6 staining was significantly reduced independently of Ki67 (p < 0.001 for two sites of phosphorylation). RAD001 5 mg/daily is safe and tolerable in postmenopausal early breast cancer patients and inhibits the mTOR pathway and its downstream effectors, significantly reducing tumor cell proliferation. Tumors with high Ki67, high p-AKT, and HER-2 positivity may be more responsive to mTOR inhibition with RAD001. This is the first study to report results of RAD001 5 mg as a single agent in early breast cancer.

Considerations for the use of plasma cytokeratin 18 as a biomarker in pancreatic cancer

BACKGROUND

Enzyme-linked immunoassays of full-length (M65) and/or caspase-cleaved (M30) cytokeratin 18 (CK18) released from epithelial cells undergoing necrosis and/or apoptosis, respectively, may have prognostic or predictive biomarker utility in a range of solid tumour types. Characterisation of baseline levels of circulating full length and cleaved CK18 specifically in patients with pancreatic cancer.

METHODS

Plasma samples from 103 patients with pancreatic cancer stored at -80 degrees C were assayed for M65 and M30 levels. The median (inter-quartile range (IQR)) duration of plasma storage was 34 (23-57) months. Patients with metastatic disease (n=19) were found to have greater median (IQR) M65 levels (1145 (739-1698) U l(-1)) compared with the locally advanced (n=20; 748 (406-1150) U l(-1)) and resected (n=64; 612 (331-987) U l(-1)) patients (P=0.002). Elevated M65 levels were associated with poorer overall survival on univariate (P<0.001) but not multivariate (P=0.202) analysis. M65 concentrations also exhibited significant associations with concurrent serum-bilirubin levels (P<0.001) and the duration of plasma storage (P<0.001).

CONCLUSIONS

Baseline plasma CK18 levels in pancreatic cancer are affected by the presence of obstructive jaundice and prolonged plasma storage. Clinical biomarker studies utilising serial CK18 levels are warranted in pancreatic cancer, provided consideration is given to these potentially confounding factors.

External Quality Assurance Schemes: The Impact of Participation in the UK Versus Rest of the World: 5 Year Data from the UK National External Quality Assurance Scheme

The American Society of Clinical Oncology/College of American Pathologists guidelines highlighted the critical importance of quality assurance in diagnostic testing for HER2.Unstained formalin-fixed, paraffin-embedded human breast carcinoma cell line sections were circulated to scheme participants on 15 occasions over 5 years. “Reference laboratories” reported results for the HER2/chromosome 17 ratio and HER2 copy number for 5 years for each cell line. Results from the 5th years participants (3 runs 13, 14, 15) were assessed for the pass rate in UK versus rest of the world (EU, US, Asia, etc). The number of participants was 76-78 laboratories/run (UK 30-35, ROW 43-46).Results: The percentage of laboratories achieving “appropriate” results ranged from 78-82% overall. Significantly higher performance was observed over 3 runs for UK laboratories (91-97%, “appropriate” results) versus ROW laboratories (67-74% “appropriate” results), p = 0.004. All methods used by scheme participants in UK Laboratories had excellent performance rates (Pathvysion, PharmDx, Ventana SISH/Inform, Kreatech Posieden). However in the ROW there was evidence of poor performance, which may be related to the assay format, although numbers of comparisons are relatively small.Participation in external quality assurance schemes is a valuable mechanism for evaluation and benchmarking of performance between laboratories. It also serves to improve consistency of HER2 testing by in situ hybridization. Using data from the UK NEQAS scheme we identified that laboratories whose performance is monitored and linked to an intergrated corrective action component(UK laboratories) perform consistently better than laboratories where performance data alone is provided (ROW). In the UK both participation and adequate performance in a national EQA scheme is required for laboratory accreditation. Whilst, in the context of robust EQA there is no evidence that different methods affect performance, in the ROW implementation of some assays appears sub-optimal. This poor performance does not, however, identify fundamental flaws with these methods, which are currently very well controlled amongst UK users but suggests greater attention to EQA results and change to improve laboratory performance is required in the rest of the world.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 6010.

Expression Levels of Co-Regulators in Early Breast Cancer

Introduction: The p160 (SRC) family of estrogen receptor (ER) co-activators have important implications in tamoxifen resistance. The SRC family play a central role in ER mediated transcription. There are three family members; SRC-1, SRC-2 and AIB1. AIB1 is amplified in 5-10% of human breast cancers. SRC-1 expression is associated with HER2 expression, increased risk of recurrence and insensitivity to endocrine treatment. Co-factors interact with the ER and basal transcriptional machine to activate or repress ER-mediated transcription. To investigate the role of ER and its co-factors in breast cancer we have carried out quantitative RT-PCR (qRT-PCR) to measure the relative expression of ERa and its co-factors.Methods: In this study we examined patients which were untreated or treated with chemotherapy or hormonal therapy following breast conservation surgery. RNA was extracted from 340 early breast cancer specimens from the Edinburgh Breast Conserving Surgery cohort (BCS). The BCS is a fully documented consectutive cohort of breast cancers treated by conservation surgery, axillary node sampling or clearance, and whole breast radiotherapy between 1981-1998. Clinico-pathological features and complete follow up (duration &gt;10 years) is available for this cohort. qRT-PCR was carried out using primers for ER, SRC-1, SRC-2, AIB1, NCoR1 and SMRT.Results: This study demonstrated SRC-1 expression to be negatively correlated with both SRC-2 and AIB1 expression. SRC-1 expression was also negatively correlated with the co-repressors NCoR1 and SMRT expression. There was a strong correlation between the co-repressors, NCoR1 and SMRT and the co-activators SRC-2 and AIB1. Relapse-free survival (RFS) was estimated using Kaplan-Meier curves. Patients who had high expression of all three co-activators had reduced relapse-free survival (HR: 2.15 95%C.I. 1.175-3.921, p=0.01). No significant association was noted with overall survival. Exploratory subgroup analysis was under powered and showed no significant association with outcome.Conclusion: In conclusion, our study of expression levels of ER and its cofactors by quantitative RT-PCR in breast cancer samples revealed a correlation between the co-factors and co-repressors. These findings would suggest that ER and cofactors may play a synergistic role in the development and progression of breast cancer.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 2127.

The Expression of Insulin-Like Growth Factor-1 Receptor (IGF-1R) in Early Breast Cancer

Background: The insulin-like growth factor-1 receptor (IGF-1R) is expressed in normal breast epithelial cells and breast carcinomas. A number of studies have examined the over-expression of IGF-1R in breast cancer with the range of between 39% to 93%. However, many of these studies were carried out using ELISAs, radioimmunoassay with small patient cohorts. Phosphorylation of IGF-1R results in the activation of the MAPK and PI3K/Akt pathway. Activation of the PI3K/Akt pathway under the influence of IGF-1R plays an important role in maintaining the proliferation of breast cancer cells that are resistant to gefitnib, trastuzumab or chemoradiotherapy in vitro and in vivo. In the present study, we examined the expression of IGF-1R in early breast cancer and investigated the clinicopathological implications using immunohistochemistry and FISH.Methods: TMAs from a consecutive series (1981-98) of 1,812 women managed by wide local excision and postoperative radiotherapy (45Gy in 20-25 fractions) were collected following appropriate ethical review. Of 1686 cases stained, 198 received no adjuvant hormonal or chemotherapy, 1106 received tamoxifen only as adjuvant therapy and 144 received a combination of hormonal and chemotherapy. Median age at diagnosis was 56, 72% were post-menopausal, 23.9% node positive, median size was 1.5 cm. Samples were stained, using triplicate 0.6mm2 TMA cores for IGF-1R.Results: FISH for IGF1R gene amplification was successful in 343/408 cases (84%). Only 7 cases of IGF1R amplification were observed (2%). IGF1R expression was successfully evaluated in 1597 of 1686 (94.7%) cases. High levels of IGF-1R expression was weakly associated with tumour ER-a (correlation coefficient, 0.108; p=2.2 x 10-5) and PgR levels (correlation coefficient 0.162; p=1.86x10-10) and inversely correlated with EGFR expression (correlation coefficient -0.189; p=6.33x10-6). No association was noted between IGF1R expression and other molecular or clinical markers, such as tumour size. There was a trend for over-expression of IGF-1R to link with increased distant relapse free survival, particularly in ER positive breast cancers. This trend is time dependent, such that no difference in outcome is observed at 15 years.Conclusions: We have demonstrated in a large cohort of patients that IGF-1R gene amplification is a rare event, and over-expression is weakly associated with good prognostic features (ERa and PgR, lack of EGFR and better outcome).

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 2128.

The TEAM Trial Pathology Study Identifies Potential Prognostic and Predictive Biomarker Models for Postmenopausal Patients Treated with Endocrine Therapy

Background: The Tamoxifen and Exemestane Adjuvant Multinational (TEAM) trial included prospectively planned biomarker studies to identify prognostic and predictive biomarkers for patients receiving endocrine therapy. Quantitative IHC data for ER/PgR (Can Res 69:83S, SABCS2008), HER2, HER3 and Ki67 was available for the current analysis relative to outcome of estrogen receptor–positive (ER+) early postmenopausal breast cancer (BC) patients treated with exemestane versus tamoxifen.Patients & Methods: Pathology blocks from 4598 TEAM patients were collected and tissue microarrays constructed. Quantitative analysis of hormone receptors (HER2/3) by conventional IHC, and image analysis derived continuous scores for Ki67/ER/PgR were analyzed relative to disease-free survival and treatment on an intent to treat basis using survival data for the first 2.75 years of the TEAM trial. Data on HER2FISH and EGF Receptor IHC will be presented.Results: Of 4595 eligible cases samples received, 16 were excluded, 271 had incomplete biomarker data, leaving 4308 patients for the final biomarker analysis. 1275 (30%) cases were HER2/3 positive.A significant treatment by marker effect was observed for exemestane versus tamoxifen with HER2/3 negative cases deriving benefit from aromatase inhibitor treatment (HER2/3-ve HR=0.69 95%CI, 0.53-0.88; HER2/3 pos HR, 1.13; 95%CI, 0.82–1.55; p=0.016 for interaction in multivariate analysis). By conventional and STEPP analysis no predictive effect of Ki67 was observed. In multivariate regression analysis increased HER2 expression (P=0.0001) decreased PgR expression (P&lt;0.0001) and increased percentage of Ki67 positive cells (P=0.004) as continuous IHC variables were independently prognostic as were size (P=0.0001), nodal status (P&lt;0.0001), grade (P=0.03) and age (P&lt;0.0001).Conclusion: Multiple biological parameters (HER2/PgR/Ki67) are independently prognostic in ER+ve early postmenopausal BC. Modelling will be explored to derive prognostic and potentially predictive biomarker signatures for application in BC. Preferential exemestane versus tamoxifen treatment benefit was seen in HER2/3 negative cases, whilst HER2/3 positive cases had a poor prognosis in this population receiving hormonal therapy (suggesting resistance to endocrine therapy), and no evidence of benefit from AIs versus tamoxifen. Type I receptor tyrosine kinases may identify breast cancers with relative resistance to all forms of endocrine therapy. Whilst Ki67 alone was not predictive of benefit from Ais, Ki67, HER2 and PgR were independent prognostic variables and modelling of predictive/prognostic effects may further inform treatment selection in early postmenopausal breast cancer.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 75.

Prelminary Results of a NEQAS Ring Study Evaluating the Ventana INFORM™ HER2 Dual Colour Single Slide ISH Assay

Background: Recent innovations in HER2 testing include the development of novel chromogenic in situ hybridisation tests. Most countries use FISH or ISH based testing for HER2 gene amplification in equivocal (IHC 2+) cases. Data on the reproducibility and portability of novel and even established HER2 ISH methods is sparse. We report initial results from the multicentre evaluation of intra and inter-observer/site variation in scoring HER2 results from 30 breast cancers measured in 5 laboratories using the Ventana Dual colour ISH assay.Methods: A commercially available tissue micro-array (TMA; Stretton Scientific UK) containing 2 replicate cores from 30 breast cancers was circulated to 5 UK NEQAS reference laboratories (numbered 1-5). All laboratories performed chromogenic ISH using a 60 core TMA and reported results for all assessable cores. For all cases 20 cells were scored and a further 20 cells scored on a separate occasion to check intra-observer variation. Results were collated centrally and compared with FISH peformed in a single laboratory. Concordance between FISH and CISH is reported on a core by core and case by case analysis. Intra and inter-observer variation between laboratories is also assessed. Finally regression analysis comparing results was performed. Results from a single laboratory are presented here and full results will be available for the meeting.Results: 93% of cores were successfully analysed by the Ventana dual colour ISH assay. 87% of cores were successfully analysed by PathyVision® FISH CISH was concordant with FISH in 96.4% of cores evaluated. In one sample FISH results were 2.05 & 1.93 vs CISH of 2.03 and 2.14. In a second sample FISH results were 1.60 & 1.53 versus CISH results of 2.00 & 1.65. When mean results were calculated (2 cores per case) concordance between FISH and CISH results for this laboratories was 96.7% (1 discordant case – mean FISH – 1.99, mean CISH 2.09). 48 cores were scored twice (20 cells x 2) by a single observer. Mean intra-observer variation (for HER2 ratio) was 1.72% (Range 0.0-7.42%). No difference in scores was observed for the first vs second 20 cells. Scoring 40 cells produced no advantage. For results from a single observer for 2 cores (intra-site variation) from 42 core pairs (each core counted twice) variation was 7.5%.Conclusions: Preliminary evidence from the current study suggest that the Ventana INFORM™ HER2 dual colour single slide ISH assay can be robustly evaluated using conventional scoring approaches (20 cells per case). Concordance with FISH was excellent in the single laboratory reporting results to date. Further evidence will be reported from the other 4 participating laboratories.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 6011.

Factors associated with regression of cervical dysplasia in adolescents: A retrospective study

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Background: Sexually active adolescents have high rates of infection with human papilloma virus (HPV) and abnormal pap smears. They are considered a special population as they are likely to regress to normal cytology. The aim of our study was to identify factors associated with regression of cervical dysplasia in adolescents. Methods: We identified adolescent patients (aged 12–21 years) who had abnormal pap smears at the Center for Women's Medicine at Lehigh Valley Hospital in Allentown, PA, by CPT code from a database between Jan 2004 and Dec 2006. A chart review was performed to capture demographic data, cytology, smoking history, number of sexual partners, parity, race, contraceptive choice, use of barrier contraception. Chi-square analysis with logistic regression and multivariate analysis were used to identify factors associated with regression of cervical dysplasia. Results: Two-hundred two patients were identified. Mean age was 18.84 years (14–22 years). One hundred twenty-two (57.8%) were Hispanic, 71 (33.6%) Caucasian, and 16 (7.6%) Black. Fifty-two (24.6%) were pregnant at the time of diagnosis. Seventy-six (36%) were smokers. There were 125 (61.9%) cases of ASCUS, 33.7% (68 cases) LGSIL and 4.5% (9 cases) HGSIL on initial pap smear. One hundred eighteen (55.9%) patients had colposcopy, and of these, 32 (15.2%) had surgical intervention. Follow-up demonstrated that 72 (57.6%) patients had disease regression, 24 (19.2%) persistence and 29 (23.2%) progression. On multivariate analysis, patients who did not smoke were significantly more likely to show regression of cervical dysplasia on pap smear than women who smoked (OR 2.17, 95% CI 1.03–4.55, p = 0.039). Other factors were not statistically significant in predicting regression of cervical dysplasia. Conclusions: Adolescents who smoke were more likely to have persistent cervical dysplasia than non-smoking adolescents, putting smokers at an increased risk of advanced disease. We suggest that this subset have follow-up at shorter intervals and be enrolled in a smoking cessation program.

No significant financial relationships to disclose.

Frequent amplifications and deletions of G1/S-phase transition genes, CCND1 and MYC in early breast cancers: a potential role in G1/S escape

Uncontrolled growth of cancer cells can be related to dysfunctional cell cycle control, including entry into S-phase, initiating cell division. Cyclin CCND3 and CCNE1 along with CDK2 and CDK6 regulate this checkpoint, and genetic changes, detectable by fluorescence in situ hybridization, are hypothesized to increase the aggressiveness of breast cancer, thereby influencing patient survival. Genomic change was investigated in 106 primary breast cancer samples, where the combined gene copy number changes in one of these four cell cycle regulatory factors was observed in 22% of the 98 tumors of successful analysis, distributed with 15 deletions and 7 amplifications. A trend towards decreased survival was observed with the aberrations, suggesting a prognostic potential of this set of markers, which was supported by an association with tumor grade. For validation of the new set of FISH probes for the G1/S-phase cell cycle factors, two additional markers, frequently amplified in breast cancers, were included in this study: The G1/S phase control gene CCND1 and the proliferation marker MYC. Both markers were amplified in 14% and deleted in 5% of the cases. This is the first report of genomic deletions of MYC in breast cancer.