Early Prophylactic Gastrectomy for the Management of Gastric Adenomatous Proximal Polyposis Syndrome (GAPPS)

Background

Gastric adenomatous proximal polyposis syndrome (GAPPS) is a recently described, rare, autosomal dominant condition characterized by the extensive involvement of the proximal stomach with hundreds of heterogeneous fundic gland polyps with antral and duodenal sparing. GAPPS is caused by a point mutation of the APC gene promoter 1B and is associated with a risk of malignant transformation, distant metastasis, and death. There are no surveillance, screening, or treatment guidelines for managing GAPPS. The few reported cases have been variably managed with endoscopic surveillance or prophylactic gastrectomy. However, there is no consensus on the optimal management approach.

Summary

In this case series, we review the relevant literature on GAPPS and present two siblings who underwent early prophylactic total gastrectomies with good outcomes.

Conclusion

Due to the poor correlation between the endoscopic findings on sampled polyps and the risk of harboring invasive gastric cancer, patients with GAPPS should be strongly considered for early prophylactic total gastrectomies in the absence of prohibitive comorbidities.

Access to internet, smartphone usage, and acceptability of mobile health technology among cancer patients

PURPOSE

The use of mobile health (mHealth) technologies to augment patient care enables providers to communicate remotely with patients enhancing the quality of care and patient engagement. Few studies evaluated predictive factors of its acceptance and subsequent implementation, especially in medically underserved populations.

METHODS

A cross-sectional study of 151 cancer patients was conducted at an academic medical center in the USA. A trained interviewer performed structured interviews regarding the barriers and facilitators of patients' current and desired use of mHealth technology for healthcare services.

RESULTS

Of the 151 participants, 35.8% were male and ages ranged from 21 to 104 years. 73.5% of participants currently have daily access to internet, and 68.2% currently own a smartphone capable of displaying mobile applications. Among all participants, acceptability of a daily mHealth application was significantly higher in patients with a college-level degree (OR 2.78, CI_95% 1.25-5.88) and lower in patients > 80 years of age (OR 0.05, CI_95% 0.01-0.23). Differences in acceptability when adjusted for current smartphone use and daily access to internet were nonsignificant. Among smartphone users, the desire to increase cancer knowledge was associated with a higher likelihood of utilizing a mHealth application (OR 261.53, CI_95% 10.13-6748.71).

CONCLUSION

The study suggests that factors such as age, educational achievement, and access to internet are significant predictors of acceptability of a mHealth application among cancer patients. Healthcare organizations should consider these factors when launching patient engagement platforms.

Acceptability of mobile health technology among cancer patients

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Background: Advances in wireless technology have led to the increasing use of mobile health platforms. This approach, tele-medicine, enables healthcare providers to communicate remotely with patients, thereby enhancing timeliness and quality of care, and patient engagement. However, few studies address barriers to its implementation, especially in medically under served populations. Methods: A cross-sectional survey of 151 cancer patients was conducted at an academic medical center in North Philadelphia, PA. A trained interviewer performed structured interviews regarding the barriers and facilitators of patients’ current and desired utilization of technology for healthcare services. Statistical significance was defined as p < 0.05 on a two-tailed distribution. Chi-Square test was used for categorical variables. Odds ratios from logistic regression analysis were used to identify the relationship between demographic factors and willingness to utilize a mobile application for health surveillance. Results: Of the 151 patients who completed the survey, 35.8% were male; ages ranged from 21-104 years. Forty-two percent were married, 49.0% were single, and 9% were divorced at the time of the survey. No significant associations existed between the willingness to utilize a mobile health application and gender ( p = 0.73) or marital status ( p = 0.97). After controlling for other demographic variables, patients older than 70 were significantly less likely to utilize a mobile application. Conversely, patients with a college-level education or more were significantly more likely to utilize a mobile application [OR = 2.78, p = 0.01]. Conclusions: Age and education level represent potential barriers to mobile health applications for cancer patients in socioeconomically diverse community. Health networks should consider these factors when launching patient engagement platforms. [Table: see text]

Abstract P5-18-09: Performance of Oncotype DX DCIS score across diverse ethnic populations

There is a paucity of data on Oncotype DX DCIS Score and ethnic variation. It has been postulated that there are different molecular features /drivers among different ethnic populations. The Oncotype DX DCIS Score is a genomic test designed to analyze the expression of a group of 12 genes which can quantify 10-year local recurrence risk after surgery. The purpose of this study is to evaluate diverse ethnic patients with DCIS relative to traditional clinical pathologic factors and Oncotype DX DCIS Score

We analyzed consecutive cases of DCIS from 2011-2017 who underwent Oncotype DX DCIS Score testing at a single institution. Eighty-four female patients were divided into 5 groups based on self-reported ethnicity: White (36%), African American (AA) (48%), Asian (8%), Hispanic (4%) and Other (4%). Clinical and traditional pathologic factors were collected including age, nuclear grade (NG), ER/PR status and Oncotype DX DCIS Score. The distribution of NG and Oncotype DX DCIS Score was analyzed across ethnic groups.

The mean age at diagnosis was 63. Overall 99 % of cases were hormone positive. Comparison of White and AA patients revealed a correlation between ethnic group and DCIS Score, with a p value of 0.0087 (Table 1). Similarly, we looked at all five ethnic groups and Oncotype DX DCIS Score and found a p value of 0.022. We evaluated ethnicity with White and AA patients versus NG and obtained a p value of 0.084 (Table 2). In addition, we assessed all five ethnic groups and NG. We obtained a p value of 0.068. No AA patients with DCIS had a high DCIS Score. No patients with low NG DCIS had a high DCIS Score. Analysis of the three factors (NG, ethnicity and DCIS Score) concurrently showed that they are not independent.

In summary, our study provides valuable data on Oncotype DX DCIS Score and NG across a diverse patient population. These data highlight the importance of incorporating both traditional clinical pathologic factors and DCIS Score molecular testing for making treatment decision across different ethnic patient populations.

Table 1.Comparison of DCIS Score and Ethnic GroupEthnic GroupLow DCIS ScoreIntermediate DCIS ScoreHigh DCIS ScoreAA3730White2704p=0.0087

Table 2.Comparison of Nuclear Grade and Ethnic GroupEthnic GroupNuclear Grade 1Nuclear Grade 2Nuclear Grade 3AA17194White1399p=0.084

Citation Format: Mittar P, Casella S, Bombonati A, Emiloju O, Jablon L, Schultz D, Leighton JC, Solin LJ. Performance of Oncotype DX DCIS score across diverse ethnic populations [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 P5-18-09.

Proteinuria monitoring in patients receiving bevacizumab at a community cancer center

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Background: The use of bevacizumab has been associated with the development of proteinuria. The manufacturer suggests monitoring for proteinuria with serial urine dipsticks. We set to evaluate the relevance and cost of this practice in a Community Cancer Center in Philadelphia. Methods: We performed a retrospective chart review at Albert Einstein Cancer Center. Consecutive patients treated with bevacizumab from January 2011 to March 2014 were included in the study. Primary endpoints were the incidence and grade of proteinuria under bevacizumab therapy and the implication of proteinuria in treatment (holding or cessation of bevacizumab). Secondary objectives included the association between the number of bevacizumab infusions or patient’s comorbidities (diabetes, hypertension, chronic kidney disease) and the development or worsening of proteinuria. We also calculated the cost of monitoring for proteinuria in our cohort. Results: 71 patients were screened. A total of 66 patients (corresponding to 738 infusions) were included in the analysis. Typical monitoring interval was every 2 cycles. None developed nephrotic range proteinuria. One patient (1.5%) developed grade 2 proteinuria. Bevaciuzumab was discontinued due to proteinuria in 2 patients (3%): neither of them developed permanent kidney damage or required an intervention as a consequence of the proteinuria. The most common reason of bevacizumab discontinuation was progression of disease (75%). Neither the number of infusions nor concomitant comorbidities were significantly associated with the development or worsening of proteinuria (p=0.8, p>0.05 respectively). The cost of monitoring for proteinuria in our cohort was estimated at $3980. Conclusions: These results show that the development of grade 2 proteinuria, let alone grade 3, with bevacizumab is uncommon and rarely affects treatment decisions in our Community Cancer Center. We therefore question the necessity of routine monitoring for proteinuria during bevacizumab treatment.

A retrospective analysis of the demographic profile and clinical outcomes of stage III colon cancer patients treated with adjuvant chemotherapy in a real-world perspective

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Background: It is standard to use results of randomized controlled trials (RCT’s) for therapeutic decisions in community oncology. However participant selection in trial environments may not reflect real-world scenario. We aim to perform a retrospective analysis of patient profile and treatment outcomes in a community cancer center. Methods: Patients with stage III colon cancer offered adjuvant chemotherapy after curative resection from 2003-2010 (N=177) were reviewed. Eighty-seven patients with complete medical records were analyzed. Patient eligibility was assessed on criteria from the MOSAIC and NSABP C-07 trials. Eligible and ineligible patients were compared using Fisher’s exact test, Student’s t-test and Kaplan-Meier survival analysis. Results: The study group (females: 53%) with mean age of 65 years, was predominantly African American (60%). ECOG performance status was ≥ 2 in 13% patients. Only 29% satisfied all standard eligibility criteria. Ineligibility characteristics included age > 75 years (21%), non-malignant severe systemic disease (10%) and > 42 days from surgery to chemotherapy (39%). Seventy-five patients (86%) received chemotherapy. Chemotherapy regimens included FOLFOX (51%), FLOX (10%), FL (29%) and Capecitabine (8%). Total planned dose had to be modified in 64% patients with mean doses of 89% 5-fluorouracil and 79% oxaliplatin employed. The 3-year disease free survival (DFS) was 53% and 5-year overall survival (OS) was 56%. Age ≥ 69 years was significantly associated with poor 3-year DFS (P=0.013). On Kaplan-Meier survival analysis, the ineligible patient group had significantly reduced overall survival (hazard ratio, 2.88; 95% CI, 1.05-4.82; P= 0.037). Conclusions: This pilot venture studied adjuvant management of Stage III colon cancer in a real-world setting. Our results reveal that over 70% patients did not meet standard eligibility criteria and show decreased 5-year OS among these patients that needs to be addressed in future prospective RCT’s.

Angiotensin converting enzyme inhibitor and angiotensin receptor blocker use and outcomes in patients with colorectal cancer

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Background: Increasing evidence implicates angiotensin in the pathophysiology of carcinogenesis. Both Angiotensin Converting Enzyme Inhibitors (ACEIs) and Angiotensin Receptor Blockers (ARBs) have shown in-vitro activity in Colorectal Cancer (CRC) via inhibition of both VEGF and IGF-1 and present a novel therapeutic strategy. This study aimed to investigate the association of these agents in outcomes of patients with CRC. Methods: We reviewed the medical records of patients with stage I-III CRC from 2004-2008. ACEI and ARB use was defined as consumption for at least 3 months in patients with no evidence of disease after initial diagnosis and treatment. Outcomes were Disease Free Survival (DFS) and Overall Survival (OS). Kaplan-Meier and Cox proportional hazards regression were used. Results: A total of 222 patients were included, with a median follow up of 39 months. A total of 105 (47%) were identified as users of ACEI/ARBs. Multivariate analysis, adjusted to age, sex, race, stage, grade, tumor location, adjuvant chemotherapy, radiotherapy, statin and ASA use showed significantly improved DFS among users of ACEI and/or ARBs compared to non-users (HR = 0.44, p = 0.003). Considered separately, users of ACEIs only and users of ARBs only had better DFS than non-users (HR = 0.43 and 0.53, respectively). Compared directly, users of ACEIs did not have significantly different DFS than users of ARBs (HR = 0.81, p = 0.678). With regards to OS, multivariate analysis showed that, compared to non-users, patients with ACEI or ARB use had better OS, although non-significantly (HR = 0.59, p = 0.219). However, the magnitude of the impact on OS was comparable to that seen for DFS. Conclusions: The use of ACEIs and/or ARBs is associated with improved disease-free survival in CRC patients. There was a statistically insignificant trend toward improved OS, which may be related to the low power to the study. This observation warrants further exploration.

Early-phase (EP) clinical trials (CTs) in the community: Results from the National Cancer Institute (NCI) Community Cancer Centers Program (NCCCP) Early-Phase Working Group (EPWG) Baseline Assessment Study (BAS)

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Background: The NCCCP is a network of 30 community cancer center (CCC) sites that strive to expand cancer research capacity and deliver advanced care in the community. The EPWG was formed to facilitate NCCCP site participation in EP (phase I-II) CTs, thus allowing patients (pts) to be treated within their communities. This study describes the CT infrastructure at NCCCP sites and its association with EP accrual. Methods: A BAS was conducted to obtain data on NCCCP site CT infrastructure, funding, sponsor affiliations, and barriers to EP CTs. To evaluate EP performance, EP accruals during July 2010-June 2011 were obtained. High accruing sites were those with EP accrual above the median EP accrual per 1,000 new analytical cases seen in 2009 or 2010. Results: 27 sites, caring for ~56,000 new cancer pts annually, participated in the study. Median number of accruing EP trials/site was 6 (mean 7.4). Median EP accrual/site was 14 (mean 16). Median EP accrual rate was 7/1,000. Trials with a phase I component were open at 21 sites. Most sites (24) are members of multiple CGs (median 4) and enroll pts via the CTSU (70%). The more common barriers to EP trial implementation were related to infrastructure (59%), cost (52%), and access to trials (41%). When accrual rates to NCCCP CTEP EP trials only were analyzed, we found that between high vs low accruing sites, respectively, higher accrual rates were associated with higher number of CRAs devoted to EP trials (median 3.25 vs 1; P= .05) and lower proportion of funding from industry (median 18% vs 40%; P=.02). We did not, however, find significant associations when EP trials were examined across all sponsors. Conclusions: CCCs are capable of conducting, and actively participating in, EP trials. Infrastructure and collaborations are critical components of success. Our study provides useful information for those planning to begin EP trials in the community setting. [Table: see text]

Quantitative reverse transcriptase-polymerase chain reaction measured expression of MDR1 and MRP in primary breast carcinoma

To evaluate the clinical significance of drug resistance mechanisms in breast cancer, we examined the expression of MDR1 and MRP in primary breast carcinoma and normal adjacent tissue using a highly quantitative and reproducible reverse transcription-PCR assay. Expression of both genes was observed in all specimens examined, both tumor (n = 74) and normal adjacent tissue (n = 55). The expression of MDR1, however, was low, with the level of expression being 25 times less than the drug-resistant control cell line KB 8-5. Immunohistochemical analysis of P-glycoprotein corroborated the PCR results; only 6% (2 of 31) were positive for JSB1 staining, and 0 of 32 were positive for for UIC2. MRP expression did not exceed control cell line levels, and immunohistochemistry detected moderate levels of expression. MDR1 expression was independent of grade, stage, tumor size, nodal status, metastasis, and estrogen receptor and progesterone receptor status. There was, however, a significant correlation of MDR1 expression with age and histology. Approximately twice the expression of MDR1 was observed in the < 50 age group compared to the > 50 age group, and lobular carcinoma had 4 times the expression of MDR1 of other histological types. MRP expression was independent of all other clinical parameters. Thus, these results show that although MDR1 expression is detectable in primary breast carcinoma by PCR, this expression as measured by quantitative reverse transcriptase-PCR is extremely low. The significance of these low levels is yet to be determined. MDR1 expression was higher in < 50 age group and lobular carcinoma, which may contribute to poor prognosis associated with young age and lobular histology.

Paclitaxel and carboplatin in combination in the treatment of advanced non-small-cell lung cancer: a phase II toxicity, response, and survival analysis

PURPOSE

To determine the activity and toxicity of combination paclitaxel (24 hours) and carboplatin in advanced non-small-cell lung cancer (NSCLC).

PATIENTS AND METHODS

Eligibility required measurable disease (stage IV or stage IIIB with malignant pleural effusion), Eastern Cooperative Oncology Group (ECOG) performance status 0 or 1, absolute neutrophil count > or = 2,000/microL, platelet count > or = 100,000/microL serum creatinine concentration < or = 1.5 mg/dL, and bilirubin level < or = 2 mg/dL. Paclitaxel was initially administered at a dose of 135 mg/m2/d, followed by carboplatin on day 2 at a targeted area under the concentration-time curve (AUC) of 7.5 using the Calvert formula. Granulocyte colony-stimulating factor (G-CSF) 5 micrograms/kg subcutaneously (SC) on days 3 to 17 was introduced during the second and subsequent cycles. In patients who sustained less than grade 4 myelosuppression, the paclitaxel dose was sequentially escalated 40 mg/m2 per cycle to a maximum of 215 mg/m2. Treatment was repeated at 3-week intervals for six cycles.

RESULTS

From June 1993 through February 1994, 54 patients were enrolled; 53 are assessable for toxicity and response. The median age was 62 years (range, 34 to 84). Sixty-nine percent were male, 65% had adenocarcinoma, and 93% had stage IV disease. Two hundred sixty-eight cycles were administered; 32 patients (59%) completed all six cycles. Twenty-five unanticipated hospitalizations occurred during treatment (9.3% of cycles) in 20 patients (37%). Myelosuppression was the principal toxicity; grade 3 or 4 granulocytopenia occurred in 57% of patients after the first cycle, but decreased to 35% during the second cycle after introduction of G-CSF and consistently remained < or = 22% during subsequent cycles. Seven episodes of neutropenic fever occurred, all during the first cycle. Grade 3 or 4 thrombocytopenia and anemia occurred in 47% and 33% of patients, respectively. Eight patients (15%) required platelet transfusions and 16 (30%) required packed RBC support. Neuropathy, myalgias/arthralgias, and thrombocytopenia, although generally mild, were cumulative. The paclitaxel dose was boosted to 215 mg/m2 in > or = 70% of patients who received three or more cycles. At an AUC of 7.5, the median first-cycle carboplatin dose was 424 mg/m2 (range, 273 to 709 mg/m2). The objective response rate was 62%, with five (9%) complete responses and 28 (53%) partial responses. The median progression-free survival time was 28 weeks and the median survival time 53 weeks. The 1-year survival rate is 54%.

CONCLUSION

The paclitaxel-carboplatin combination is active in advanced NSCLC and may enhance survival; it merits further investigation in phase III trials.

Paclitaxel by 24- or 1-hour infusion n combination with carboplatin in advanced non-small cell lung cancer: the Fox Chase Cancer Center experience

A phase II trial of combination paclitaxel (Taxol; Bristol-Myers Squibb Company, Princeton, NJ) and carboplatin included 54 chemotherapy-naive patients with advanced non-small cell lung cancer. Eligibility mandated Eastern Cooperative Oncology Group performance status of 0 or 1 and adequate hematologic, renal, and hepatic function. Paclitaxel 135 mg/m2 over 24 hours preceded carboplatin dosed to an area under the concentration-time curve of 7.5. Six planned courses were given every 3 weeks. Granulocyte colony-stimulating factor was introduced during the second and subsequent cycles, and paclitaxel increased 40 mg/m2/cycle (maximum, 215 mg/m2) in patients with absolute neutrophil and platelet nadirs exceeding 500/microL and 50,000/microL, respectively. Grade 3 or 4 neutropenia, observed in 54% of patients during cycle 1, declined to 35% during cycle 2 and to 22% or less during cycles 3 through 6. Neuropathy, myalgias/arthralgias, and thrombocytopenia were mild but cumulative. In 53 evaluable patients, the objective response rate was 62%, with 9% complete remissions and a median response duration of 6 months (range, 1 to 19+ months). At median potential follow-up of 16 months, 9% of patients remain progression free (52+ to 80+ weeks). Median survival is 12.5 months; 1-year survival is 54%. Paclitaxel/carboplatin is highly active in advanced non-small cell lung cancer; granulocyte colony-stimulating factor abrogates neutropenia as the dose-limiting toxicity, but has no effect on the cumulative incidence of thrombocytopenia or treatment delays. One-hour paclitaxel infusion is minimally myelosuppressive, logistically easier, and less costly. A follow-up study combined paclitaxel (175 mg/m2) over 1 hour followed by carboplatin (area under the concentration-time curve, 7.5). In the absence of grade 4 myelosuppression, paclitaxel was increased 35 mg/m2/cycle (maximum, 280 mg/m2). Granulocyte colony-stimulating factor was implemented only after neutropenic fever or grade 4 neutropenia. Of 17 patients entered, 13 are evaluable for toxicity and seven for response. Four patients have sustained a partial response, two a minor response, and one stable disease. The incidence of grade 3 or 4 neutropenia, thrombocytopenia, and anemia in cycle 1 was 38%, 16%, and 0%, respectively, and 72%, 28%, and 28%, respectively, during cycle 2. Major nonhematologic toxicities include myalgias and arthralgias (54%) and fatigue and neuropathy (78%), the latter cumulative and progressive over successive cycles. Preliminary data suggest comparable activity for the 1- and 24 hour paclitaxel infusions in combination with carboplatin. The more severe neuropathy of the 1-hour paclitaxel/carboplatin combination may be related to the paclitaxel dosing schema (175 mg/m2 to as high as 280 mg/m2).(ABSTRACT TRUNCATED AT 400 WORDS)

P-glycoprotein in adult solid tumors. Expression and prognostic significance

Several potential mechanisms of chemotherapy resistance have been identified in adult solid tumors. The multidrug resistance (MDR) phenotype is one mechanism by which tumors may simultaneously develop resistance to multiple chemotherapeutic agents and is associated with P-glycoprotein expression. In this article, the authors examine the literature and summarize the various techniques used to measure MDR1 gene expression, patterns of expression in adult solid tumors.