Management of hepatocellular carcinoma from diagnosis in routine clinical practice

Aim: To assess real-world management of patients diagnosed with hepatocellular carcinoma (HCC) within an integrated delivery network. Materials & methods: A retrospective cohort analysis of adults newly diagnosed with HCC from January 2014 to March 2019. Overall survival and treatment journey were assessed over the entire available follow-up period per patient. Results: Of the 462 patients, 85% had ≥1 treatment. The 24-month overall survival rate (95% CI) from first treatment was 77% (72–82%). Majority of Child-Pugh class A (71%) and B (60%) patients received locoregional therapy first. Half (53.6%) of the patients with liver transplantation first were Child-Pugh class C patients. Sorafenib was the predominant systemic therapy. Conclusion: This integrated delivery network data analysis offers a comprehensive insight into the real-world management of HCC.

Biomarker testing patterns in patients with stage IV non-small cell lung cancer (NSCLC) in U.S. community-based oncology practice setting

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Background: This study evaluated rates of biomarker testing for patients with stage IV non-squamous NSCLC, which is known to have a ̃40% biomarker-positive rate (AMP, 2020), in a community-based oncology practice setting in the United States (US). Methods: A retrospective study was performed using data from a US electronic medical record database of patients aged ≥18 years with an initial diagnosis (index dx) of stage IV non-squamous NSCLC between Jan 1, 2015 and Dec 31, 2019. Unstructured data on molecular biomarker testing (single-gene and next-generation sequencing [NGS]-based) were abstracted from patient charts utilizing Natural Language Processing for EGFR mutation, ALK rearrangement, BRAF mutation, ROS1 rearrangement, MET exon14 mutation, RET fusion, NTRK fusion, and PD-L1 expression. Systemic therapy was obtained from structured data. Data were summarized using descriptive statistics. This study received a waiver of consent from Advarra IRB. Results: Of 646 patients identified in the database, 500 met all inclusion criteria and are included in this analysis. The majority (73.8%) were diagnosed in 2018 (n = 162; 32.4%) and 2019 (n = 207; 41.4%). Mean age (SD) was 70.0 (10.1) years, with 53.2% female. A total of 447 (89.4%) were tested for at least one biomarker after index diagnosis of which 81.2% (n = 406) had at least one single-gene test; 54.8% (n = 274) had an NGS test and 66.8% were tested for PD-L1. Single-gene or NGS-based testing was > 85% of patients across all index years. The use of NGS-based tests ranged from 35.0% among patients whose first diagnosis was in 2015 to 59.4% in 2019. Overall, 85.4% (n = 427) of the cohort received first-line treatment with chemotherapy (53.6%), immunotherapy (48.2%), or targeted therapy (14.2%). Among patients who received biomarker tests, 15.4% received targeted treatment and 49.7% received immunotherapy treatment, including checkpoint inhibitors, during first-line treatment. Conclusions: NGS testing utilization increased during the study period and by 2019, 59% of patients received NGS-based testing. Opportunities persist for practices to improve testing and achieve guideline recommendations. PD-L1 biomarker testing was performed amongst the highest proportion of patients in this study and nearly 50% of all patients received immunotherapy, including checkpoint inhibitors. Targeted therapy was used in 14.2% of this population, suggesting that patients with actionable biomarkers may not be receiving targeted treatment for their disease, potentially due to gaps in testing among patients in this dataset.

Expectations of overall survival for patients with metastatic pancreatic cancer (mPC)

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Background: Pancreatic cancer is the 4th leading cause of cancer-related death in the U.S. Metastatic pancreatic cancer has typically had a poor prognosis. However, the use of combination chemotherapy with novel agents have improved outcomes. First line therapy with either FOLFIRINOX (2011) or gemcitabine (gem)/nab-paclitaxel (2013) improved response rates (RR), progression-free survival (PFS) and OS versus (vs) gem alone. In 2015, second-line therapy with nanoliposomal irinotecan and fluorouracil (5FU) also improved RR, PFS, and OS vs 5FU. Since 2017, several newer agents have been approved for targeted patient populations – pembrolizumab for MSI-H/dMMR tumors, larotrectinib and entrectinib for NTRK gene fusion positive pts, and olaparib for germline BRCA-mutated pts. As more treatment (Tx) options become available, pts are more likely to receive Tx in later lines. A population-based study found that of mPC pts who completed 1st-line (1L) chemotherapy prior to December 31, 2014, 49% went on to receive 2nd-line (2L) Tx and 17% received 3rd-line (3L) Tx6. Methods: Prescribing patterns of 569 U.S.-based oncologists were studied using a validated, proprietary, case-based market research tool (Challenging Cases). Data were acquired using blinded, audience-response iPad technology at 8 live events during 2018-2019. Results: Estimate of mPC patients treated with 2L and 3L Tx in 2019 Estimates for mPC pts treated with 2L therapy rose from 2018 to 2019, with 46% treating > 60% of mPC patients with 2L in 2018 compared to 54% in 2019. Oncologists estimated median survivals to be 7.4 months (mos) from the regimens they prescribe in 1L, 4.3 mos in 2L, and 2.3 mos in 3L. Conclusions: With the addition of new and more effective treatments for mPC, more patients are treated in the 2L and 3L settings. However, oncologists may underestimate the survival expectation with novel agents or regimens, particularly in later lines of therapy. [Table: see text]

Changing treatment patterns in patients with stage IV non-small cell lung cancer (NSCLC) from United States community-based oncology practices

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Background: This study evaluated the shift in treatment patterns in Stage IV NSCLC following the approval of immune-oncology (IO) agents in the US. Methods: A retrospective cohort study was performed using structured data from a US community-based oncology electronic medical record (EMR) database for care received from Jan 2015-May 2018. The study sample included patients with Stage IV NSCLC, ≥18 years of age initiating first-line (1L) treatment with chemotherapy (chemo) or IO agents and classified into 3 groups: chemo alone, IO alone, or chemo+IO. Treatment patterns in 1L and treatment switch patterns in second-line (2L) are reported. A sub-group analysis of patients initiating 1L therapy during the last 6 months of the study period (Dec 2017-May 2018) was conducted to explore changes in 1L treatment patterns in the post-IO approval setting. Chart reviews were done for a subset of patients initiating 1L from Jan 2017-May 2018 to extract information on programmed cell death ligand 1 (PD-L1) testing and evaluate the association of PD-L1 expression levels with receipt of IO therapy. Results: Between Jan 2015-May 2018, 1,969 patients received 1L therapy with a chemo or IO agent. Mean age (SD) was 69.0 (10.1) years, with 44.7% female. The majority of patients (79%, n = 1570) initiated 1L therapy with chemo alone and 21% initiated IO (alone [14%, n = 271] or in combination with chemo [7%, n = 128]). Of 1L patients, 41% (n = 809) were treated with 2L therapy. Of the 1L chemo alone group, 37% (n = 580) received IO in 2L. The use of IO agents in 1L increased from 21% to 48% (n = 147) in the sub-group analysis of 305 patients initiating therapy Dec 2017-May 2018. In the subset of 62 patients whose charts were reviewed, 87% (n = 54) had their tumor tested for PD-L1, of which 37% (n = 20) had high (≥50%) expression values. The majority of high-PD-L1 patients were treated in 1L with IO alone (80%, n = 16), followed by chemo+IO (15%; n = 3), and only 5% (n = 1) received chemo alone. Conclusions: Initially, IO was used as 2L treatment for Stage IV NSCLC, but IO use shifted to 1L setting in the US by the end of 2017. The use of IO therapy alone or with chemotherapy in 1L was more likely in patients with ≥50% PD-L1 expression level.

Molecular profiling (MP) for malignancies: Knowledge gaps and variable practice patterns among United States oncologists (Onc)

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Background: Clinically impactful therapies for malignancies require the identification of specific molecular alterations. Onc must be aware of these targets and how to interpret them to provide optimum care. The use of MP has become the standard of care for many cancers, and is recently FDA approved. Using 2 data sets, we assessed the current awareness and incorporation of MP in the treatment of cancer; comparing data from community based Onc (C) to academic Onc (A). Methods: C consisted of 292 physicians polled using an audience response system during 6 case-based research events across the US. Questions focused on various aspects of molecular testing. Data for A was obtained from a chart review focused on timing and extent of MP in disease specific academic practices (lung, breast, GI) (N = 59). Results: Within C, 257 (88%) were Onc from community-based practices. The frequency at which Onc ordered MP significantly varied depending on tumor type; 33% in lung cancer (LC), 18% in colorectal cancer (CRC) and less commonly in breast cancer (BC) (8%). In A, MP was ordered more frequently; 74% in LC, 27% in CRC and 0% in BC. These results reflect a gap in practice among community versus academic Onc, as C had lower utilization of MP for both LC and CRC. In C, Onc were also asked to match the molecular alteration with the appropriate targeted therapy. Onc incorrectly matched the molecular alteration to the targeted therapy or marked unknown in up to 69%. This reflects a large knowledge gap among community Onc with regards to the correct application of MP to currently FDA approved targeted therapies. Conclusions: Given the significant knowledge and practice gap, we conclude there is an urgent need for focused educational activities that facilitate improved knowledge of MP and corresponding personalized therapeutic strategies for Onc in the US.

Abstract P4-13-05: Evolving treatment patterns in hormone receptor-positive, HER2-negative metastatic breast cancer

Background: The last several years have seen the approval of multiple targeted agents for use alone or combined with standard endocrine therapies (ET) in the 1st, 2nd, and 3rd line hormone receptor positive (HR+), HER2 negative (HER2-) metastatic breast cancer (MBC) settings. Due to these new approvals, standards of care for treatment are evolving.

Methods: Prescribing preferences (PPrefs) of 592 U.S.-based medical oncologists were studied using a validated, proprietary, case-based market research tool (Challenging Cases®). Data were acquired using blinded, audience-response iPad technology at 8 live and virtual events during 2016-2018.

Two core hypothetical cases were presented: 1st line MBC and recurrent (REC) MBC. For each core case the following variables were introduced: time from completion of adjuvant (adj) therapy (Tx) to REC disease, site of metastases [visceral (VIS) vs non-visceral (N-VIS)], and age for the 1st line case, and type of metastases and line of Tx for the recurrent case. Rx choices for which there are published phase 3 data were offered, as well as a category for “other.”

Results:

Table 1.Preferred Rx for recurrent disease during or after 5 yrs of adjuvant non-steroidal aromatase inhibitor (NSAI)*ScenarioExemestane (EXE) + Everolimus (EVE)NSAI + CDK inhibitor (CDKi)Fulvestrant (FUL) + CDKiChemotherapy (CT)Endocrine therapy (ET)OtherREC 18 months (mos) into adj AI Tx, VIS) and N-VIS mets, Age 635%25%63%3%4%0%REC post 5 yrs adj AI and 2 yr treatment free interval (TFI), N-VIS mets, Age 674%49%34%1%12%1%REC post 5 yrs adj AI and 2 yr TFI, N-VIS mets, Age 853%34%19%0%42%1%* May not equal 100% due to rounding.

Table 2.Preferred Rx for 2nd or 3rd recurrence*ScenarioEXE + EVENSAI + CDKiFUL + CDKiCTETAbemaciclibOtherREC post 5 yrs adj AI and 2 yr TFI, N-VIS mets, age 67 --> 12 mos 1st line Tx --> N-VIS mets31%12%38%6%12%1%1%REC post 5 yrs adj AI and 2 yr TFI, N-VIS mets, age 67 --> 12 mos 1st line NSAI + palbociclib Tx --> N-VIS mets38%1%33%9%15%0%3%REC 12 mos into adj AI, age 61,N-VIS mets -->12 mos Tx 1st line -->N-VIS mets21%9%53%9%6%0%1%REC post 5 yrs adj AI and 2 yr TFI, N-VIS mets, age 67 -->12 mos 1st line Tx, N-VIS mets --> 6 mos 2nd line Tx --> VIS and N-VIS mets23%1%9%59%5%2%1%* May not equal 100% due to rounding.

In the setting of a patient (pt), age 63 with early REC on an adj AI, the most preferred strategy was FUL + a CDKi. In a pt, age 67, who completed 5 years of an adj AI with a TFI of 2 years, the most common preference was NSAI + a CDKi. In an older pt (age 85) who completed 5 years of an adj AI and TFI of 2 years, the most common choice of TX was single agent ET. For a pt with N-VIS mets treated in the 2nd line setting, FUL + a CDKi was the most preferred strategy. In a 2nd line pt with REC at 12 mos on adj Tx and after 12 mos of 1st line Tx, FUL + a CDKi and EXE + EVE were the most preferred therapies. In a 3rd line pt, with VIS mets CT was the preferred choice.

Conclusion: Treatment patterns in HR+ HER2- MBC are evolving with the approval of several new agents and emerging data. Age, time to relapse, line of Tx, and type of mets may be some of the key factors that determine PPrefs in HR+, HER2- MBC.

Citation Format: Lankford ML, Britton SL, Buettner AD, Scharf M, Tiscione B, Willey JP, Mahtani RL. Evolving treatment patterns in hormone receptor-positive, HER2-negative metastatic breast cancer [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 P4-13-05.

Prescribing preferences of U.S. oncologists for patients (Pts) with metastatic urothelial carcinoma (mUC) at first recurrence: Impact of novel agents

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Background: In May 2016 atezolizumab (A) was approved for the treatment of pts with locally advanced or mUC who have disease progression during or following platinum-containing chemotherapy (PCCT), or within 12 months (mos) of neoadjuvant or adjuvant treatment with PCCT. We evaluated prescribing preferences (PPrefs) of 248 U.S-based oncologists for 1strecurrence treatment across a range of clinical scenarios prior to and following A approval. Methods: PPrefs were assessed through a validated, case-based market research tool (Challenging Cases). Assessment dates were 3/5 and 4/30 (PRE-) and 8/6 (POST-approval). Data were acquired using blinded, audience-response technology. A core scenario (CS) and 5 variant scenarios (V1, 2, 3, 4, 5) were utilized. CS: 69-year-old pt with muscle invasive bladder cancer, with a CrCl 62 ml/min, Hgb 12.5, and PS 1, recurs in the liver and bone 18 months after receiving neoadjuvant gemcitabine/cisplatin and a radical cystectomy. V1: Same as CS but with reduced CrCl 48 ml/min. V2: Same as CS but recurrence at 6 months. V3: Same as V2 but multiple comorbidities and PS 2. V4: Same as CS but age 79. V5: Same as V4 but multiple comorbidities. The same query was posed in each setting: What therapy would you choose? Results: See Table. Conclusions: Following the approval of A, overall PPref of most regimens offered decreased across nearly all 1st recurrence scenarios in favor of A. This is particularly stark in platinum unfit (older, comorbid, poor PS) pts. This highlights the previously unmet medical need in the PCCT pre-treated mUC pts. [Table: see text]