EULAR recommendations for the management of systemic lupus erythematosus: 2023 update

OBJECTIVES

To update the EULAR recommendations for the management of systemic lupus erythematosus (SLE) based on emerging new evidence.

METHODS

An international Task Force formed the questions for the systematic literature reviews (January 2018-December 2022), followed by formulation and finalisation of the statements after a series of meetings. A predefined voting process was applied to each overarching principle and recommendation. Levels of evidence and strengths of recommendation were assigned, and participants finally provided their level of agreement with each item.

RESULTS

The Task Force agreed on 5 overarching principles and 13 recommendations, concerning the use of hydroxychloroquine (HCQ), glucocorticoids (GC), immunosuppressive drugs (ISDs) (including methotrexate, mycophenolate, azathioprine, cyclophosphamide (CYC)), calcineurin inhibitors (CNIs, cyclosporine, tacrolimus, voclosporin) and biologics (belimumab, anifrolumab, rituximab). Advice is also provided on treatment strategies and targets of therapy, assessment of response, combination and sequential therapies, and tapering of therapy. HCQ is recommended for all patients with lupus at a target dose 5 mg/kg real body weight/day, considering the individual's risk for flares and retinal toxicity. GC are used as 'bridging therapy' during periods of disease activity; for maintenance treatment, they should be minimised to equal or less than 5 mg/day (prednisone equivalent) and, when possible, withdrawn. Prompt initiation of ISDs (methotrexate, azathioprine, mycophenolate) and/or biological agents (anifrolumab, belimumab) should be considered to control the disease and facilitate GC tapering/discontinuation. CYC and rituximab should be considered in organ-threatening and refractory disease, respectively. For active lupus nephritis, GC, mycophenolate or low-dose intravenous CYC are recommended as anchor drugs, and add-on therapy with belimumab or CNIs (voclosporin or tacrolimus) should be considered. Updated specific recommendations are also provided for cutaneous, neuropsychiatric and haematological disease, SLE-associated antiphospholipid syndrome, kidney protection, as well as preventative measures for infections, osteoporosis, cardiovascular disease.

CONCLUSION

The updated recommendations provide consensus guidance on the management of SLE, combining evidence and expert opinion.

Improvements in Survival and Clinical Benefit With Gemcitabine as First-Line Therapy for Patients With Advanced Pancreas Cancer: A Randomized Trial

PURPOSE

Most patients with advanced pancreas cancer experience pain and must limit their daily activities because of tumor-related symptoms. To date, no treatment has had a significant impact on the disease. In early studies with gemcitabine, patients with pancreas cancer experienced an improvement in disease-related symptoms. Based on those findings, a definitive trial was performed to assess the effectiveness of gemcitabine in patients with newly diagnosed advanced pancreas cancer.

PATIENTS AND METHODS

One hundred twenty-six patients with advanced symptomatic pancreas cancer completed a lead-in period to characterize and stabilize pain and were randomized to receive either gemcitabine 1,000 mg/m2 weekly x 7 followed by 1 week of rest, then weekly x 3 every 4 weeks thereafter (63 patients), or to fluorouracil (5-FU) 600 mg/m2 once weekly (63 patients). The primary efficacy measure was clinical benefit response, which was a composite of measurements of pain (analgesic consumption and pain intensity), Karnofsky performance status, and weight. Clinical benefit required a sustained (> or = 4 weeks) improvement in at least one parameter without worsening in any others. Other measures of efficacy included response rate, time to progressive disease, and survival.

RESULTS

Clinical benefit response was experienced by 23.8% of gemcitabine-treated patients compared with 4.8% of 5-FU-treated patients (P = .0022). The median survival durations were 5.65 and 4.41 months for gemcitabine-treated and 5-FU-treated patients, respectively (P = .0025). The survival rate at 12 months was 18% for gemcitabine patients and 2% for 5-FU patients. Treatment was well tolerated.

CONCLUSION

This study demonstrates that gemcitabine is more effective than 5-FU in alleviation of some disease-related symptoms in patients with advanced, symptomatic pancreas cancer. Gemcitabine also confers a modest survival advantage over treatment with 5-FU.

Towards a novel clinical outcome assessment for systemic lupus erythematosus: first outcomes of an international taskforce

Systemic lupus erythematosus (SLE) is a disease of high unmet therapeutic need. The challenge of accurately measuring clinically meaningful responses to treatment has hindered progress towards positive outcomes in SLE trials, impeding the approval of potential new therapies. Current primary end points used in SLE trials are based on legacy disease activity measures that were neither specifically designed for the clinical trial context, nor developed according to contemporary recommendations for clinical outcome assessments (COAs), such as that substantial patient input should be incorporated into their design. The Treatment Response Measure for SLE (TRM-SLE) Taskforce is a global collaboration of SLE clinician-academics, patients and patient representatives, industry partners and regulatory experts, established to realize the goal of developing a new COA for SLE clinical trials. The aim of this project is a novel COA designed specifically to measure treatment effects that are clinically meaningful to patients and clinicians, and intended for implementation in a trial end point that supports regulatory approval of novel therapeutic agents in SLE. This Consensus Statement reports the first outcomes of the TRM-SLE project, including a structured process for TRM-SLE development.

ERN ReCONNET points to consider for treating patients living with autoimmune rheumatic diseases with antiviral therapies and anti-SARS-CoV-2 antibody products

Recent studies have shown that people who are immunocompromised may inadvertently play a role in spurring the mutations of the virus that create new variants. This is because some immunocompromised individuals remain at risk of getting COVID-19 despite vaccination, experience more severe disease, are susceptible to being chronically infected and remain contagious for longer if they become infected and considering that immunocompromised individuals represent approximately 2% of the overall population, this aspect should be carefully considered. So far, some autoimmune rheumatic disease (ARD) patients with COVID-19 have been treated with antiviral therapies or anti-SARS-CoV-2 antibody products. However, there is no homogeneous approach to these treatment strategies. This issue was addressed within the European Reference Network (ERN) on Rare and Complex Connective Tissue and Musculoskeletal Diseases (ReCONNET) in a discussion among experts and patient's representatives in the context of the rare and complex connective tissue diseases (rCTDs) covered by the Network. ERN ReCONNET is one of the 24 ERNs launched by the European Commission in 2017 with the aim of tackling low prevalence and rare diseases that require highly specialised treatment and promoting concentration of knowledge and resources through virtual networks involving healthcare providers (HCPs) across the European Union (EU). Considering the urgent need to provide guidance not only to the rCTDs community, but also to the whole ARDs community, a multidisciplinary Task Force, including expert clinicians and European Patient Advocacy Group (ePAG) Advocates, was created in the framework of ERN ReCONNET with the aim of developing overarching principles (OP) and points-to-consider (PtC) on a homogenous approach to treat immunocompromised patients with ARDs (with a particular focus on CTDs) affected by COVID-19 using antiviral therapies and anti-SARS-CoV-2 antibody products. The present work reports the final OP and PtC agreed by the Task Force.

Coping with systemic lupus erythematosus in patients' words

OBJECTIVE

Previous research on coping strategies of patients with SLE showed that there are no absolute adaptive or maladaptive strategies and that the range of potential coping strategies is large and heterogeneous. In this paper, we aimed to identify, in a large sample of patients with SLE (N=3222), the most frequent words used by patients to describe their coping strategies, to group them into significant themes and to test their possible association with specific patient characteristics.

METHODS

Our analyses were based on the data set of the European survey 'Living with Lupus in 2020' (N=3222). Through the T-LAB software, we analysed the answers that adult participants gave to an open-ended question about how they cope with the disease. We identified the most frequent words, and with hierarchical cluster analysis we grouped them into semantic clusters (ie, themes) that were characterised by specific patterns of words. Finally, we tested the possible association between clusters and illustrative variables (sociodemographics, disease characteristics, quality of life).

RESULTS

Five coping strategies were identified, each of them constituting an important percentage of the total word occurrences: positive attitude (22.58%), social support (25.46%), medical treatments (10.77%), healthy habits (20.74%) and avoid stress (20.45%). Each strategy was statistically associated with specific patient characteristics, such as age and organ involvement.

CONCLUSIONS

Learning to adapt to a lifetime of having SLE may require replacing old coping strategies with more effective ones. Investigating patients' coping strategies in relation to different patient characteristics represents a useful starting point for developing more targeted and efficacious interventions.

Socioeconomic position and initiation of SGLT-2 inhibitors or GLP-1 receptor agonists in patients with type 2 diabetes – a Danish nationwide observational study

Background

Between 2015 and 2017, Sodium-glucose cotransporter-2 (SGLT-2) inhibitors and glucacon-like-peptide-1 receptor agonists (GLP-1 RA) were shown to reduce cardiovascular events in patients with type 2 diabetes and cardiovascular disease. Thus, in 2018, guidelines were updated to favor these drugs in patients with cardiovascular disease and type 2 diabetes. Lower socioeconomic position may adversely affect use of SGLT-2 inhibitors and GLP-1 RA.

Purpose

We aimed to examine socioeconomic differences in initiation of SGLT-2 inhibitors and GLP-1 RA in a contemporary population of patients with type 2 diabetes.

Methods

Through the Danish nationwide registers, we identified all patients with type 2 diabetes who initiated second-line add-on therapy after metformin monotherapy between December 10, 2012, and December 31, 2018. Patients aged 40–79 years and without a history of end-stage renal disease were included. We measured socioeconomic position according to level of income: Low = 1st quartile; Middle = 2nd and 3rd quartile; High = 4th quartile. Based on multivariable logistic regression models adjusted for age, sex, cohabitation status, duration of type 2 diabetes, comorbidities, and cardiovascular medications, we reported the standardised probabilities of initiating each drug class at time of first intensification according to income group and time period: 2012–2014, 2015–2017, and 2018.

Results

The 33,201 patients had a median age of 63 years (interquartile range 53–69). The probability of initiating a SGLT-2 inhibitor or a GLP-1 RA increased over time in all income-groups. In each time period, the standardised probability of initiating a SGLT-2 inhibitor or a GLP-1 RA at time of first intensification increased with increasing income (Figure): in 2012–2014, from 9.6% (95% confidence interval (CI) 8.4–10.9) in the lowest income group to 14.4% (CI 12.9–15.9) in the highest income group; in 2015–2017, from 19.5% (CI 18.3–20.7) to 24.6% (CI 23.3–25.9); in 2018, from 39.9% (CI 37.5–42.3) to 50.7% (CI 48.2–53.1). The absolute difference between high and low income groups increased over time, reaching 10.8% (CI 7.3–14.3) in 2018. A similar trend was observed in both subgroups of patients with and without established cardiovascular disease (data not shown). Initiation of a dipeptidyl peptidase-4 (DPP-4) inhibitor increased with income in the early time periods, but this trend reversed in 2018 (Figure). Initiation of sulfonylureas (SU) showed a consistent inverse association with income in each time period.

Conclusions

Low socioeconomic position was consistently associated with a lower probability of initiation of a GLP-1 RA or a SLGT-2 inhibitor at time of first intensification of antidiabetic treatment, even after guidelines recommended these drugs to patients with established cardiovascular disease. These disparities may adversely affect cardiovascular outcomes in patients with low socioeconomic position.

Funding Acknowledgement

Type of funding sources: None.

What are the topics you care about making trials in lupus more effective? Results of an Open Space meeting of international lupus experts

Despite promising candidates for new therapeutic options in the treatment of systemic lupus erythematosus (SLE), many clinical trials have failed in the past few years. The disappointing results have been at least partly be attributed to trial designs. With the aim of stimulating new developments in SLE trial design, an international open space meeting was held on occasion of the European Lupus Meeting 2018 in Duesseldorf, Germany about ‘What are the topics you care about for making trials in lupus more effective?’. The Open Space is a participant-driven technology, where the discussion topics and schedule are selected during the meeting by all participants and discussion rounds are led by the people attending encouraging active contributions. Eleven topics were selected for further discussion, of which 6 were voted to be more intensively discussed in two consecutive rounds. Major topics were the optimal handling of glucocorticoids in clinical trials, the improvement of outcome measures, reducing or controlling the placebo response and the identification of biomarkers and stratification parameters. Further, the importance of local and international networks was emphasised. By networking, collaborations are facilitated, patient recruitment is more efficient and treatment can be harmonised thus lead to more successful SLE trials. Further discussions are needed to substantiate the results and develop new trial designs.

Hydroxychloroquine availability during COVID-19 crisis and its effect on patient anxiety

OBJECTIVE

To report the results of a survey exploring the experience of patients with SLE facing hydroxychloroquine (HCQ) shortage that occurred during the early phases of the COVID-19 pandemic.

METHODS

A survey was designed by Lupus Europe's patient advisory network and distributed through its social media, newsflash and members' network. People with lupus were asked about their last HCQ purchases and their level of anxiety (on a 0-10 scale) with regard to not being able to have access to HCQ, once in April 2020 (first wave) and after 11 August (second wave). The results were compared.

RESULTS

2075 patients responded during the first wave; 1001 (48.2%) could get HCQ from the first place they asked, 230 (11.1%) could get the drug by going to more than one pharmacy, 498 (24.0%) obtained HCQ later from their usual pharmacy and 126 (6.1%) from other sources. 188 (9.1%) could not get any; 32 (1.5%) did not respond to this question. All countries showed significant improvement in HCQ availability during the second wave. 562 (27.4%) patients reported an extremely high level of anxiety in wave 1 and 162 (10.3%) patients in wave 2; 589 (28.7%) and 268 (17.1%) patients reported a high level of anxiety in wave 1 and wave 2, respectively.

CONCLUSIONS

The HCQ shortage had a significant impact on patients with SLE and has been responsible for psychological consequences including anxiety. Indeed, despite an objective improvement in drug availability, the event is leaving significant traces in patients' mind and behaviours.

Living with systemic lupus erythematosus in 2020: a European patient survey

Objective

The aim of this study was to analyse the 2020 burden of Systemic Lupus Erythematosus (SLE) in Europe, from the patients’ perspective.

Methods

In May 2020, Lupus Europe, the European umbrella patient association for SLE, designed and disseminated a multilingual anonymous online survey to individuals with a self-reported physician’s diagnosis of SLE living in Europe.

Results

Data from 4375 SLE survey respondents (95.9% women, median age: 45 (IQR: 36–54) years, 70.7% Caucasians) from 35 European countries were analysed. The median age at SLE diagnosis was 30 years (IQR: 22–40) and the median diagnosis delay was 2 years (IQR: 0–6). The most commonly affected organ-systems included the joints (81.8%) and skin (59.4%), with renal involvement in 30%. Another diagnosis was given before that of SLE in 45.0%, including psychological/mental disorders in 9.1% and fibromyalgia in 5.9%. The median number of symptoms reported was 9 (IQR: 6–11) out of 21, with fatigue most common (85.3%) and most bothersome. The median number of SLE-related medications was 5 (IQR: 3–7), including antimalarials (75%), oral glucocorticoids (52.4%), immunosuppressants (39.8%) and biologics (10.9%). Respondents reported significant impact over their studies, career and emotional/sexual life in 50.7%, 57.9% and 38.2%, respectively. Appropriate access to care was highly variable across countries and care component.

Conclusion

This survey underlines the 2020 burden and strong heterogeneity in the care of SLE across Europe, from the patient’s perspective. Altogether, these data may prove crucial to physicians, patients and policy-makers to improve the diagnosis and management of this rare and complex disease.

Hydroxychloroquine treatment in European patients with lupus erythematosus: dosing, retinopathy screening and adherence

BACKGROUND

Use of hydroxychloroquine (HCQ) is common in patients with lupus erythematosus. Long-term use (ie, ≥5 years) and high-dose HCQ (ie, >5 mg/kg/day) are both risk factors for developing HCQ retinopathy. Advances in our understanding of HCQ retinopathy have led to changes in the recommendations for HCQ dosing and retinopathy screening. The latest EULAR guidelines for the management of SLE recommend a maximum HCQ dose of 5 mg/kg/day and ophthalmological screening at baseline and annually after 5 years of HCQ treatment.

OBJECTIVES

This study aimed to assess whether the EULAR guidelines are affecting HCQ prescription patterns and screening frequencies in Europe. Furthermore, we inventoried adherence to HCQ.

RESULTS

The online questionnaire was completed by 2936 patients with systemic, cutaneous or juvenile lupus from 33 countries. The majority were female (86.5%) and diagnosed with SLE (81.2%). Among those taking HCQ, the median HCQ dose reported was 4.26 mg/kg/day. More than one-third of respondents (36.8%) exceeded the recommended maximal HCQ dose of 5 mg/kg/day. Baseline ophthalmological screening had been done in 857 out of 1017 respondents diagnosed in the past 10 years (84.3%). Of patients using HCQ ≥5 years, 69.2% reported yearly retinopathy screening. Lastly, 17.3% of patients reported that they skipped HCQ once a week or more often.

CONCLUSION

The results of our study demonstrate that higher than recommended dosages of HCQ are prescribed to more than one-third of patients with lupus in Europe. Recent recommendations regarding screening for retinopathy are incompletely implemented.

Both soap and ozone more effective and better tolerated than alcohol hand disinfection?

Background

Preventing the transfer of virulent microorganisms is an essential part of infection control programs and clinical practice. Hand disinfection using alcohol from dispensers has become a standard practice worldwide; however, consequent skin irritation is frequently reported. Thus, alternative methods for hand sanitization are needed.

Objectives

We used a modified European Standard procedure (EN 1500:2013) with the aim of comparing the efficiency of alcohol, ozonated water and soap for eradicating transient Escherichia coli from artificially contaminated hands.

Methods

We applied a crossover design for testing alcohol and ozone (20 participants/product; 40 participants in total). The participants were mostly nursing students. We have merged the results from two separate crossover studies with altogether 35 participants, and also included 20 non-crossover participants for soap washing.

Results

Both ozonated tap water and soap & water were more effective than alcohol disinfection; and washing hands with soap the most effective. In some participants, disinfection with alcohol seemed to fail at eradicating transient E. coli from the hands, particularly from one side. The pre-test CFU/mL values were ≥30,000 in 52 of 55 participants. After disinfection of both the hands with 85% alcohol, 0.8 ppm ozonated tap water and soap & water, the mean/median (range) values were 2330/300 (14,000), 538/250 (3450) and 98/50 (450), respectively. The majority of the participants (66%) stated that they would prefer using ozonated tap water if the disinfection effect was the same as that of other agents.

Conclusions

We hypothesize that hand disinfection with alcohol is more difficult, and that the flow rate of water may play a pivotal role in eradicating microorganisms in addition to the choice of disinfectant. Ozonated tap water had no adverse effects on the skin and was preferred by most participants.

Key messages

Ozonized water as hand disinfection. Alcohol hand disinfection problems.

[Hydroxychloroquine treatment rarely causes eye damage when used correctly]

Hydroxychloroquine (HCQ) is used in the treatment of rheumatologic diseases including systemic lupus erythematosus, rheumatoid arthritis and other conditions. Besides reducing joint and skin inflammation, growing evidence shows other beneficial effects of HCQ, e.g. a positive effect on cardiovascular risk, pregnancy outcome, and flare reduction. In this review, we wish to emphasise "best practice" in the use of HCQ based on the present literature, to show the typical eye damage, which may occur, and to highlight which precautions should be made, so that retinal injury does not occur.

FAIRLANE, a double-blind placebo-controlled randomized phase II trial of neoadjuvant ipatasertib plus paclitaxel for early triple-negative breast cancer

BACKGROUND

This hypothesis-generating trial evaluated neoadjuvant ipatasertib-paclitaxel for early triple-negative breast cancer (TNBC).

PATIENTS AND METHODS

In this randomized phase II trial, patients with early TNBC (T ≥ 1.5 cm, N0-2) were randomized 1 : 1 to receive weekly paclitaxel 80 mg/m2 with ipatasertib 400 mg or placebo (days 1-21 every 28 days) for 12 weeks before surgery. Co-primary end points were pathologic complete response (pCR) rate (ypT0/TisN0) in the intention-to-treat (ITT) and immunohistochemistry phosphatase and tensin homolog (PTEN)-low populations. Secondary end points included pCR rate in patients with PIK3CA/AKT1/PTEN-altered tumors and pre-surgery response rates by magnetic resonance imaging (MRI).

RESULTS

pCR rates with ipatasertib versus placebo were 17% versus 13%, respectively, in the ITT population (N = 151), 16% versus 13% in the immunohistochemistry PTEN-low population (N = 35), and 18% versus 12% in the PIK3CA/AKT1/PTEN-altered subgroup (N = 62). Rates of overall and complete response (CR) by MRI favored ipatasertib in all three populations (CR rate 39% versus 9% in the PIK3CA/AKT1/PTEN-altered subgroup). Ipatasertib was associated with more grade ≥3 adverse events (32% versus 16% with placebo), especially diarrhea (17% versus 1%). Higher cycle 1 day 8 (C1D8) immune score was significantly associated with better response only in placebo-treated patients. All ipatasertib-treated patients with low immune scores and a CR had PIK3CA/AKT1/PTEN-altered tumors.

CONCLUSIONS

Adding ipatasertib to 12 weeks of paclitaxel for early TNBC did not clinically or statistically significantly increase pCR rate, although overall response rate by MRI was numerically higher with ipatasertib. The antitumor effect of ipatasertib was most pronounced in biomarker-selected patients. Safety was consistent with prior experience of ipatasertib-paclitaxel. A T-cell-rich environment at C1D8 had a stronger association with improved outcomes in paclitaxel-treated patients than seen for baseline tumor-infiltrating lymphocytes. This dependency may be overcome with the addition of AKT inhibition, especially in patients with PIK3CA/AKT1/PTEN-altered tumors.

CLINICALTRIALS.GOV

NCT02301988.

AB0856 A PLACEBO-CONTROLLED, DOUBLE-BLIND, RANDOMIZED, TRIAL OF AMZ001 – A NOVEL DICLOFENAC SODIUM 3.06% GEL - FOR THE TREATMENT OF KNEE OSTEOARTHRITIS SYMPTOMS

Background:

Development of improved topical treatments of painful joints is warranted. A novel diclofenac sodium gel formulation, AMZ001, has been developed with the purpose of improving 1) The onset and duration of pain relief, and 2) The ease of use by reducing the required daily frequency of gel application. Previous trials in human subjects have confirmed improved permeability of a reduced volume of AMZ001 gel as compared to approved diclofenac topical products with a comparable safety and tolerability profile, supporting trials to evaluate the efficacy and safety of AMZ001 in painful joint conditions.

Objectives:

The current abstract reports the main results of a randomized trial of AMZ001 once or twice daily application versus placebo in symptomatic knee osteoarthritis.

Methods:

The trial was a placebo-controlled, parallel group, double-blind, randomized trial to evaluate the efficacy and safety of AMZ001 or placebo in subjects with knee osteoarthritis. The main inclusion criteria were Kellgren-Lawrence radiographic severity of 1-3, and pain ≥40 and ≤90 out of 100 using the WOMAC pain subscale (5 questions) at the time of screening. The subjects were randomized to apply AMZ001 gel once (QD) or twice (BID) daily or placebo twice daily per OA knee for a period of 28 days, or to apply Voltaren® Gel 1 % four times daily (QID) in a single-blind fashion for exploratory comparison. The primary endpoint was change from baseline at week 4 in WOMAC pain (5 questions). The main secondary endpoints included WOMAC subscales, Patient Global Assessment (PGA) and quality of life using the EQ-5D. In addition to the main analysis, a post-hoc subgroup analysis of subjects meeting the pain criterion at both screening and baseline was performed.

Results:

A total of 444 subjects were randomized. The main baseline characteristics were well balanced between treatment groups.

AMZ001 QD and BID led to statistically significant reductions in pain compared to baseline with an estimated difference (95% CI) normalized to 0-100 at week 4 of -27.33 (-30.50, -24.17), and -26.49 (-29.60, -23.38), respectively. Reduction in pain at week 4 was statistically significantly superior to placebo for AMZ001 QD (p=0.04), and borderline significant for AMZ001 BID (p<0.10) as shown in Figure 1.

Both AMZ001 QD and BID led to statistically significant improvements in PGA at week 4 compared to placebo (p<0.05 for both), and AMZ001 BID led to significantly improved quality of life (p<0.05) compared to placebo. There were no statistically significant differences between AMZ001 QD or BID in any of the endpoints. In the post-hoc analysis of subjects meeting the pain criterion at both screening and baseline the differentiation to placebo was strengthened for all efficacy endpoints, as shown in Figure 2.

While the study design and differences in sample sizes does not allow formal comparisons between the double- and single blinded groups, the exploratory comparator, Voltaren QID, did not reach statistically significant differences to placebo or AMZ001 in any of the endpoints, in neither the ITT nor the subgroup analyses.

The safety and tolerability of AMZ001 was favorable, as the frequency of AEs leading to discontinuation of treatment was similarly low (ranging between 2.8 % to 6.6 %) between AMZ001 once or twice daily and placebo or Voltaren Gel 1%. The most common treatment-emergent AEs were application site dryness, and application site erythema. No serious adverse events were reported during the trial.

Conclusion:

AMZ001, a novel topical diclofenac formulation, either once or twice daily was efficacious in the treatment of knee OA pain with a good tolerability and safety profile, suggesting AMZ001 may be a promising alternative to existing pain-relieving treatments in knee OA.

References:

NA

Disclosure of Interests:

Asger Bihlet Shareholder of: Nordic Bioscience, Consultant of: Amzell BV, Medivir AB, Xintela AB, Merck KGaA, Employee of: Nordic Bioscience, Inger Byrjalsen Employee of: Nordic Bioscience, Henning Bay Nielsen: None declared, Jeppe Andersen Shareholder of: Minor shareholder of Nordic Bioscience, Consultant of: Medivir AB, Xintela AB, Employee of: Nordic Bioscience, Laetitia Delpy Employee of: Amzell BV, Caroline Derne Employee of: Amzell BV, Dario Carrara Employee of: Amzell BV

P765One-year mortality risk after intensification of outpatient diuretics

Background

Mortality is increased following a hospitalization for heart failure (HF). It is not clear whether outpatient intensification of diuretic confers the same increased risk in the general population with heart failure

Purpose

This study sought to assess 1-year mortality risk after worsening HF, defined either as hospitalization due to HF or as intensified diuretic therapy in an outpatient setting, in a complete nationwide cohort of patients with HF on angiotensin converting enzyme inhibitors/ angiotensin receptor blocker and beta blockers.

Methods

From nationwide administrative registers, we identified all patients in Denmark diagnosed with HF in 2001–2016 and prescribed angiotensin converting enzyme inhibitor/ angiotensin receptor blocker and beta blocker within 120 days. During follow-up we defined worsening HF by the following events: Inpatient worsening (HF readmission) and outpatient worsening (intensified diuretic therapy, defined as the first event of new addition or doubled dosage of loop diuretic therapy or new onset addition of thiazide to loop diuretic therapy). Patients with a worsening event were risk set matched to two HF controls each at time of the event – based on age, sex and calendar year. One-year mortality risk was estimated with Kaplan-Meier and multivariable Cox regression models.

Results

We included 74,990 patients, median age 71 years (interquartile range: 62–79), 36% women. During five years of follow up, 8,727 patients had an inpatient worsening event, and 12,290 had an outpatient worsening event as first event. Absolute risk of 1-year mortality was 22.6% (95%-confidence interval (95%-CI): 21.7%-23.5%) after inpatient worsening, 18.0% (95%-CI: 17.3%-18.7%) after outpatient worsening compared to 9.8% (95%-CI: 9.5%-10.1%) for the matched controls. In a multivariable Cox model adjusted ischemic heart disease, atrial fibrillation, chronic obstructive pulmonary disease and diabetes, the hazard ratio for mortality among patients experiencing inpatient worsening was 2.46 (95%-CI: 2.33–2.60) and for outpatient worsening was 1.87 (95%-CI: 1.77–1.97), compared with the matched HF controls as reference (figure 1). Among patients who had an outpatient worsening as first event, 1,245 (10.1%) had a subsequent HF readmission within one year.

Conclusion

In a nationwide cohort of patients with HF, outpatient worsening defined by a diuretic intensification was associated with almost 2-fold risk of mortality during the next year. Although HF hospitalization is associated with a higher risk, the need to intensify diuretics in the outpatient setting is a signal to review and intensify efforts to improve HF outcomes.

Acknowledgement/Funding

The Danish Heart Foundation, (grant number 17-R116-A7610-22048)

Abstract P2-08-19: Exploratory biomarker analyses of FAIRLANE, a double-blind placebo (PBO)-controlled randomized phase II trial of neoadjuvant ipatasertib (IPAT) + paclitaxel (PAC) for early triple-negative breast cancer (TNBC)

Background: The oral AKT inhibitor IPAT is being evaluated in cancers with a high prevalence of PI3K/AKT pathway activation. In the PBO-controlled randomized phase II FAIRLANE trial (NCT02301988), adding IPAT to PAC as neoadjuvant therapy for TNBC led to a numerical increase in pathologic complete response (pCR) in unselected patients (17.1% vs 13.3%), with a greater treatment effect in patients with PIK3CA/AKT1/PTEN-altered tumors (17.9% vs 11.8%). The addition of IPAT also led to an increase in complete response (CR) by MRI (27.6% vs 13.3%) that was enhanced in patients with PIK3CA/AKT1/PTEN-altered tumors (39.3% vs 8.8%) [Oliveira, AACR 2018]. We report an exploratory analysis performed to provide better understanding of potential biomarkers for response.

Methods: Pretreatment tumor samples were evaluated for genomic alterations using the FoundationOne® (Foundation Medicine) assay (n=144) and gene expression by RNA-Seq (n=92). Samples were classified into TNBC subtypes based on the method developed by Lehmann and Pietenpol [Lehmann, J Clin Invest 2011]. Tumor-infiltrating lymphocytes (TILs) were quantified using the Salgado method [Salgado, Ann Oncol 2015] (n=135).

Results: Of 62 patients (43%) with PIK3CA/AKT1/PTEN-altered tumors, 21 had an activating mutation in PIK3CA or AKT1 and 47 had an alteration in PTEN (6 [3 in each arm] had both PIK3CA mutation and PTEN alteration). Although only 3 patients with PIK3CA/AKT1-mutant tumors achieved a pCR, there was an increased rate of MRI CR with the addition of IPAT to PAC [Table]. In patients with PTEN alterations, both pCR rate and MRI CR rate were increased with IPAT. In patients treated with PBO + PAC, all 4 pCR patients evaluable by RNA-Seq were of the immunomodulatory (IM) subtype. However, in the IPAT + PAC arm, pCRs were also seen in patients with basal-like 1 (BL-1), mesenchymal (M), and mesenchymal stem-like (MSL) subtypes. Consistent with this observation, in the PBO + PAC arm, samples from patients achieving a pCR had significantly higher levels of stromal TILs than those from patients who did not have a pCR, while no difference was observed in the IPAT + PAC arm.

Response, n (%)PIK3CA/AKT mutation (n=21)PTEN alteration (n=47) IPAT + PAC (n=11)PBO + PAC (n=10)IPAT + PAC (n=21)PBO + PAC (n=26)pCR1 (9%)2 (20%)4 (19%)3 (12%)CR by MRI5 (45%)1 (10%)8 (38%)2 (8%)

Conclusions: This retrospective exploratory biomarker analysis of the phase II FAIRLANE trial of neoadjuvant IPAT for TNBC provides insight into the potential heterogeneity of response and resistance to taxane therapy. The results also hint that response to PAC alone is dependent on baseline immune infiltration and that this dependency might be relieved with the addition of AKT inhibition.

Citation Format: Wongchenko MJ, Oliveira M, Saura C, Nuciforo P, Calvo I, Andersen J, Passos Coelho JI, Gil Gil M, Bermejo B, Patt DA, Ciruelos E, Singel SM, Maslyar DJ, Xu N, de la Peña L, Baselga J, Gendreau S, Isakoff SJ. Exploratory biomarker analyses of FAIRLANE, a double-blind placebo (PBO)-controlled randomized phase II trial of neoadjuvant ipatasertib (IPAT) + paclitaxel (PAC) for early triple-negative breast cancer (TNBC) [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P2-08-19.

Highly localized H2O librational motion as a far-infrared spectroscopic probe for microsolvation of organic molecules

The most prominent spectroscopic observable for the hydrogen bonding between individual molecules in liquid water is the broad absorption band detected in the spectral region between 300 and 900 cm-1. The present work demonstrates how the associated large-amplitude out-of-plane OH librational motion of H2O molecules also directly reflects the microsolvation of organic compounds. This highly localized OH librational motion of the first solvating H2O molecule causes a significant change of dipole moment and gives rise to a strong characteristic band in the far-infrared spectral region, which is correlated quantitatively with the complexation energy. The out-of-plane OH librational band origins ranging from 324.5 to 658.9 cm-1 have been assigned experimentally for a series of four binary hydrogen-bonded H2O complexes embedded in solid neon involving S-, O- and N-containing compounds with increasing hydrogen bond acceptor capability. The hydrogen bond energies for altogether eight binary H2O complexes relative to the experimental value of 13.2 ± 0.12 kJ mol-1 for the prototypical (H2O)2 system [Rocher-Casterline et al., J. Chem. Phys., 2011, 134, 211101] are revealed directly by these far-infrared spectroscopic observables. The far-infrared spectral signatures are able to capture even minor differences in the hydrogen bond acceptor capability of O atoms with slightly different alkyl substituents in the order H-O-C(CH3)3 > CH3-O-CH3 > H-O-CH(CH3)2 > H-O-CH2CH3.

Causal Probabilistic Network and Power Spectral Estimation Used in Sleep Stage Classification

A new method for sleep-stage classification using a causal probabilistic network as automatic classifier has been implemented and validated. The system uses features from the primary sleep signals from the brain (EEG) and the eyes (AOG) as input. From the EEG, features are derived containing spectral information which is used to classify power in the classical spectral bands, sleep spindles and K-complexes. From AOG, information on rapid eye movements is derived. Features are extracted every 2 seconds. The CPN-based sleep classifier was implemented using the HUGIN system, an application tool to handle causal probabilistic networks. The results obtained using different training approaches show agreements ranging from 68.7 to 70.7% between the system and the two experts when a pooled agreement is computed over the six subjects. As a comparison, the interrater agreement between the two experts was found to be 71.4%, measured also over the six subjects.

Geotechnical and mineralogical characterisations of marine-dredged sediments before and after stabilisation to optimise their use as a road material

Dredging activities to extend, deepen and maintain access to harbours generate significant volumes of waste dredged material. Some ways are investigated to add value to these sediments. One solution described here is their use in road construction following treatment with hydraulic binders. This paper presents the characterisation of four sediments, in their raw state and after 90 days of curing following stabilisation treatment with lime and cement, using a combination of novel and established analytical techniques to investigate subsequent changes in mineralogy. These sediments are classified as fine, moderately to highly organic and highly plastic and their behaviour is linked to the presence of smectite clays. The main minerals found in the sediments using X-ray diffraction (XRD) and automated mineralogy are quartz, calcite, feldspars, aluminium silicates, pyrite and halite. Stabilisation was found to improve the mechanical performances of all the sediments. The formation of cementitious hydrates was not specifically detected using automated mineralogy or XRD. However, a decrease in the percentage volume of aluminium silicates and aluminium-iron silicates and an increase of the percentage volume of feldspars and carbonates was observed.

Drug-resistant tuberculosis clinical trials: proposed core research definitions in adults

Drug-resistant tuberculosis (DR-TB) is a growing public health problem, and for the first time in decades, new drugs for the treatment of this disease have been developed. These new drugs have prompted strengthened efforts in DR-TB clinical trials research, and there are now multiple ongoing and planned DR-TB clinical trials. To facilitate comparability and maximise policy impact, a common set of core research definitions is needed, and this paper presents a core set of efficacy and safety definitions as well as other important considerations in DR-TB clinical trials work. To elaborate these definitions, a search of clinical trials registries, published manuscripts and conference proceedings was undertaken to identify groups conducting trials of new regimens for the treatment of DR-TB. Individuals from these groups developed the core set of definitions presented here. Further work is needed to validate and assess the utility of these definitions but they represent an important first step to ensure there is comparability in clinical trials on multidrug-resistant TB.

Spectroscopic identification of ethanol-water conformers by large-amplitude hydrogen bond librational modes

The far-infrared absorption spectra have been recorded for hydrogen-bonded complexes of water with ethanol embedded in cryogenic neon matrices at 2.8 K. The partial isotopic H/D-substitution of the ethanol subunit enabled by a dual inlet deposition procedure enables the observation and unambiguous assignment of the intermolecular high-frequency out-of-plane and the low-frequency in-plane donor OH librational modes for two different conformations of the mixed binary ethanol/water complex. The resolved donor OH librational bands confirm directly previous experimental evidence that ethanol acts as the O⋯HO hydrogen bond acceptor in the two most stable conformations. In the most stable conformation, the water subunit forces the ethanol molecule into its less stable gauche configuration upon dimerization owing to a cooperative secondary weak O⋯HC hydrogen bond interaction evidenced by a significantly blue-shift of the low-frequency in-plane donor OH librational band origin. The strong correlation between the low-frequency in-plane donor OH librational motion and the secondary intermolecular O⋯HC hydrogen bond is demonstrated by electronic structure calculations. The experimental findings are further supported by CCSD(T)-F12/aug-cc-pVQZ calculations of the conformational energy differences together with second-order vibrational perturbation theory calculations of the large-amplitude donor OH librational band origins.

Abstract OT1-03-09: FAIRLANE: A phase II randomized, double-blind, study of the Akt inhibitor ipatasertib (Ipat, GDC-0068) in combination with paclitaxel (Pac) as neoadjuvant treatment for early stage triple-negative breast cancer (TNBC)

Background: TNBC often exhibits activation of PI3K/Akt signaling, associated with loss of PTEN expression, low INPP4B expression, and/or increased AKT3 amplification. Inhibition of the PI3K/Akt pathway in diverse cancers leads to radiosensitization and/or chemosensitization. Ipat is an oral, potent ATP-competitive small molecule inhibitor of all three isoforms of Akt. The combination of ipat with taxanes in preclinical models resulted in enhanced efficacy relative to either ipat or chemotherapy alone. In a Phase Ib clinical study, the combination of ipat with diverse chemotherapy regimens was well-tolerated and resulted in RECIST responses, particularly pts with tumors having PI3K/Akt activation.

Methods: FAIRLANE is a randomized, double-blind, placebo controlled, multicenter, neoadjuvant Phase II study designed to estimate the efficacy of ipat combined with pac versus placebo combined with pac in women with Stage Ia  IIIa TNBC. Approximately 150 pts (Pts) will be enrolled, randomized in a 1:1 ratio, and stratified by PTEN status, node involvement, and tumor size. Pts will receive 3 cycles of ipat 400 mg or placebo orally once daily on Days 1 to 21 of each 28-day cycle, along with pac 80 mg/m2 every 7 days for a total of 12 doses. All pts will undergo pretreatment and Day 8 tumor tissue acquisition to evaluate pathway biomarkers. Following three cycles of treatment, pts will undergo surgery. The primary efficacy endpoint, pCR within the breast and axilla (ypT0/Tis ypN0) in all pts and in pts with PTEN low tumors, will be assessed by local pathology evaluation following completion of neoadjuvant therapy and surgery. Additional endpoints include objective response rate, safety, BCS rate, pharmacokinetics, and pathway biomarkers. Following surgical resection of primary tumor, pts are expected to continue post-operative treatment with a standard adjuvant chemotherapy regimen at physician's discretion. The study is open for accrual. Clinical trial information: NCT02301988.

Citation Format: Saura C, Isakoff SJ, Calvo I, Patt D, Andersen J, Gonzalez-Martin A, Fisher J, Ciruelos E, Gil-Gil M, De la Peña L, Choi Y, Jia S, Singel S, Patel PH, Baselga J, Oliveira M. FAIRLANE: A phase II randomized, double-blind, study of the Akt inhibitor ipatasertib (Ipat, GDC-0068) in combination with paclitaxel (Pac) as neoadjuvant treatment for early stage triple-negative breast cancer (TNBC). [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr OT1-03-09.

The donor OH stretching–libration dynamics of hydrogen-bonded methanol dimers in cryogenic matrices

FTIR spectra of the methanol dimer trapped in neon matrices are presented.

The Safety of Discontinuation of Maintenance Therapy for Cytomegalovirus (CMV) Retinitis and Incidence of Immune Recovery Uveitis Following Potent Antiretroviral Therapy

BACKGROUND

Reconstitution of immune function during potent antiretroviral therapy can prompt discontinuation of maintenance cytomegalovirus (CMV) therapy but has also been associated with sight-threatening inflammatory conditions including immune recovery uveitis (IRU).

METHOD

Patients with inactive CMV retinitis and a CD4+ cell count above 100/mm3, receiving CMV therapy and stable combination antiretroviral therapy, were assigned to one of two groups based on willingness to discontinue CMV therapy.

RESULTS

Thirty-eight participants were enrolled: 28 discontinued anti-CMV therapy (Group 1) and 10 continued CMV treatment (Group 2). Median on-study follow-up was 16 months. One Group 1 participant who experienced an increase in plasma HIV viral load and a decline in CD4+ cell count developed confirmed progression of CMV retinitis. Progression or reactivation CMV retinitis was not observed among Group 2. IRU was present at study entry in 3 participants. Six participants in Group 1 and 3 participants in Group 2 developed IRU on-study. CMV viremia was not detected in any participants, and urinary shedding of CMV was intermittent.

CONCLUSION

Recurrence of CMV retinitis following discontinuation of anti-CMV therapy among patients with antiretroviral-induced increases in CD4+ cell count was rare. However, IRU was common in both those who maintained and discontinued anti-CMV therapy.

The influence of large-amplitude librational motion on the hydrogen bond energy for alcohol–water complexes

The intermolecular large-amplitude OH librational modes for mixed hydrogen-bonded complexes of water with methanol and t-butanol are unambiguously assigned for the first time.

A skin disease, a blood disease or something in between? An exploratory focus group study of patients' experiences with porphyria cutanea tarda

Background

Porphyria cutanea tarda (PCT) is characterized by fragile skin with blistering on sun-exposed areas. Symptoms typically develop in late adulthood and can be triggered by iron overload, alcohol intake, oestrogens and various liver diseases. Treatment consists of phlebotomy to reduce iron, or increasing urinary porphyrin excretion by administering chlorochin. To optimize patient care, health personnel need to understand the subjective experiences of PCT.

Objectives

To explore the experiences of persons with PCT with regard to symptoms, treatment, follow-up and prevention of the disease.

Methods

Interpretive description was used as a qualitative approach. Twenty-one participants attended three focus groups. All participants had experienced PCT symptoms during the last 5 years.

Results

Participants' experiences varied from trivializing symptoms and fragile skin to what was described as a desperate situation, with huge blisters, skin falling off and feeling as if one was in a ‘horror movie’. For some, itching was very troublesome, preventing sleep and delaying skin healing. In managing PCT a shift in focus from skin to blood was described. PCT was perceived as a chronic and systemic disease causing a range of health problems. Strategies for preventing symptoms ranged from doing nothing to frequent controls and check-ups.

Conclusions

Participants had a systemic perception of PCT, and a tendency to attribute a range of health problems to the condition. This study adds insight into the experiences patients have with PCT.

Communication: THz absorption spectrum of the CO2-H2O complex: observation and assignment of intermolecular van der Waals vibrations

Terahertz absorption spectra have been recorded for the weakly bound CO2-H2O complex embedded in cryogenic neon matrices at 2.8 K. The three high-frequency van der Waals vibrational transitions associated with out-of-plane wagging, in-plane rocking, and torsional motion of the isotopic H2O subunit have been assigned and provide crucial observables for benchmark theoretical descriptions of this systems' flat intermolecular potential energy surface. A (semi)-empirical value for the zero-point energy of 273 ± 15 cm(-1) from the class of intermolecular van der Waals vibrations is proposed and the combination with high-level quantum chemical calculations provides a value of 726 ± 15 cm(-1) for the dissociation energy D0.

Abstract P1-13-03: ER, PR, HER2, and Ki67 index and responsiveness to adjuvant tamoxifen in postmenopausal high-risk breast cancer patients enrolled in the DBCG 77C trial

PURPOSE: The DBCG 77C trial compared one year of tamoxifen in postmenopausal, steroid-receptor unknown, high-risk breast cancer patients to no adjuvant systemic therapy. After a potential follow-up of 30 years we report overall efficacy for the study and results according to subtypes subsequently assessed by immunohistochemistry and FISH.

METHODS: Between 1977 and 1982, 1716 postmenopausal patients with tumors larger than 5 cm or positive axillary nodes were randomly assigned to no systemic therapy or tamoxifen 30 mg daily for one year. The main study is reported as an ITT analysis with the predefined DFS and BCM as endpoint. For multivariate analysis the Cox proportional hazards regression model was applied to assess the adjusted hazard ratio of treatment regimen, and to explore interactions. Formalin-fixed, paraffin-embedded primary breast tumor tissue blocks were available from 1548 (90%) of the 1716 participants enrolled and 1428 were assessable for ER, PR, HER2 and Ki67. The hormone receptor positive (ER and/or PR) cancers were defined as luminal A if Ki67 low and HER2-negative; as luminal B if Ki67 high or HER2-positive; and otherwise as HER2 positive or triple negative.

RESULTS: In the intent-to-treat (ITT) population one year of tamoxifen improved the disease-free-survival (DFS) (Hazard ratio (HR) = 0.87; 95% CI 0.77-0.98), the recurrence-free-survival (RFS) (HR = 0.79; 0.69-0.90) and reduced the breast-cancer-specific-mortality (BCM) (HR = 0.83; 0.73-0.93). Recurrence-free survivals were improved significantly by tamoxifen in luminal A (HR = 0.66; 0.53-0.84) and luminal B/HER2- (HR = 0.54; 0.39-0.74) but not in the other subsets, and with similar results for BCM with 30 years follow-up.

CONCLUSION: One year of treatment with tamoxifen significantly improves RFS and BCM in postmenopausal patients with ER positive breast cancers. The benefit from tamoxifen was not significantly different in luminal A and B subtypes.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P1-13-03.

Screening for pulmonary tuberculosis in HIV-infected individuals: AIDS Clinical Trials Group Protocol A5253

BACKGROUND

Improved tuberculosis (TB) screening is urgently needed for human immunodeficiency virus (HIV) infected patients.

METHODS

An observational, multi-country, cross-sectional study of HIV-infected patients to compare a standardized diagnostic evaluation (SDE) for TB with standard of care (SOC). SOC evaluations included TB symptom review (current cough, fever, night sweats and/or weight loss), sputum Ziehl-Neelsen staining and chest radiography. SDE screening added extended clinical signs and symptoms and fluorescent microscopy (FM). All participants underwent all evaluations. Mycobacterium tuberculosis on sputum culture was the primary outcome.

RESULTS

A total of 801 participants were enrolled from Botswana, Malawi, South Africa, Zimbabwe, India, Peru and Brazil. The median age was 33 years; 37% were male, and median CD4 count was 275 cells/mm(3). Thirty-one participants (4%) had a positive culture on Löwenstein-Jensen media and 54 (8%) on MGIT. All but one positive culture came from sub-Saharan Africa, where the prevalence of TB was 54/445 (12%). SOC screening had 54% sensitivity (95%CI 40-67) and 76% specificity (95%CI 72-80). Positive and negative predictive values were respectively 24% and 92%. No elements of the SDE improved the predictive values of SOC.

CONCLUSIONS

Symptom-based screening with smear microscopy was insufficiently sensitive. More sensitive diagnostic testing is required for HIV-infected patients.

Safety of intralesional cidofovir in patients with recurrent respiratory papillomatosis: an international retrospective study on 635 RRP patients

Intralesional use of cidofovir (Vistide(®)) has been one of the mainstays of adjuvant therapy in patients with recurrent respiratory papillomatosis (RRP) since 1998. In 2011, a communication provided by the producer of cidofovir addressed very serious side effects concerning its off-label use. As this was a general warning, it was inconclusive whether this would account for its use in RRP. The aim of this study is to determine whether nephrotoxic, neutropenic, or oncogenic side effects have occurred after intralesional use of cidofovir in patients with RRP. Update of recent developments in RRP, a multicentre questionnaire and a multicentre retrospective chart review. Sixteen hospitals from eleven countries worldwide submitted records of 635 RRP patients, of whom 275 were treated with cidofovir. RRP patients received a median of three intralesional injections (interquartile range 2-6). There were no statistical differences in occurrence of neutropenia or renal dysfunction before and after cidofovir. There was no statistical difference in occurrence of upper airway and tracheal malignancies between the cidofovir and the non-cidofovir group. In this retrospective patient chart review, no clinical evidence was found for more long-term nephrotoxicity, neutropenia or laryngeal malignancies after the administration of intralesional cidofovir in RRP patients.

Abstract P4-11-04: A Structured Genetic Risk Evaluation and Testing Program in the Community Oncology Practice Increases Identification of Individuals at Risk for BRCA Mutations

Background: Genetic risk assessment is an important component of the care of the community oncology breast cancer patient. However, identification of at-risk patients is largely an ad-hoc process and practices lack a systematic approach to genetic risk evaluation. The US Oncology Network Genetic Risk Evaluation and Testing (USON GREAT) Program provides a structured approach to implementation of genetic risk evaluation, testing, and triage for appropriate intervention.

Methods: In 2009, our multi-disciplinary community oncology practice implemented the USON GREAT Program. The practice's program has a single dedicated nurse practitioner and physician lead, trained in part through a core educational curriculum and utilizing US Oncology Network-wide genetics resources (web-based MD, midlevel, and genetic counselor conferencing; discussion Portal; published guidelines and office procedures). NCCN guidelines were used to guide testing recommendations. Sequential risk evaluations were documented prospectively. We retrospectively analyzed how evaluation patterns changed over a 4 year time period. We also sought to capture descriptive characteristics of the evaluated population.

Results: Overall, between 2008 and 2011, our practice evaluated 1018 patients at potential risk for a BRCA mutation (mut), based on personal history of breast cancer under age 50; ovarian, fallopian or peritoneal cancer; known family history of malignancy; or known BRCA mutation in the family.