Identification of patient subgroups who benefit from a behavioral intervention to improve adjuvant endocrine therapy adherence: a randomized-controlled trial

PURPOSE

Adjuvant endocrine therapy (AET) reduces breast cancer morbidity and mortality; however, adherence is suboptimal. Interventions exist, yet few have improved adherence. Patient characteristics may alter uptake of an intervention to boost adherence. We examined moderators of the effect of a virtual intervention (STRIDE; #NCT03837496) on AET adherence after breast cancer.

METHODS

At a large academic medical center, patients taking AET (N = 100; Mage = 56.1, 91% White) were randomized to receive STRIDE versus medication monitoring. All stored their medication in digital pill bottles (MEMS Caps) which captured objective adherence. Participants self-reported adherence (Medication Adherence Report Scale) at 12 weeks post-baseline. Moderators included age, anxiety, and depressive symptoms (Hospital Anxiety and Depression Scale), AET-related symptom distress (Breast Cancer Prevention Trial Symptom Scale), and AET-specific concerns (Beliefs about Medications Questionnaire). We used hierarchical linear modeling (time × condition × moderator) and multiple regression (condition × moderator) to test the interaction effects on adherence.

RESULTS

Age (B = 0.05, SE = 0.02, p = 0.003) and AET-related symptom distress (B = -0.04, SE = 0.02, p = 0.02) moderated condition effect on self-reported adherence while anxiety (B = -1.20, SE = 0.53, p = 0.03) and depressive symptoms (B = -1.65, SE = 0.65, p = 0.01) moderated objective adherence effects. AET-specific concerns approached significance (B = 0.91, SE = 0.57, p = 0.12). Participants who received STRIDE and were older or presented with lower anxiety and depressive symptoms or AET-related symptom distress exhibited improved adherence. Post hoc analyses revealed high correlations among most moderators.

CONCLUSIONS

A subgroup of patients who received STRIDE exhibited improvements in AET adherence. The interrelatedness of moderators suggests an underlying profile of patients with lower symptom burden who benefitted most from the intervention.

STUDY REGISTRATION

NCT03837496.

Gut microbiota and metabolite interface-mediated hepatic inflammation

Immunologic and metabolic signals regulated by gut microbiota and relevant metabolites mediate bidirectional interaction between the gut and liver. Gut microbiota dysbiosis, due to diet, lifestyle, bile acids, and genetic and environmental factors, can advance the progression of chronic liver disease. Commensal gut bacteria have both pro- and anti-inflammatory effects depending on their species and relative abundance in the intestine. Components and metabolites derived from gut microbiota-diet interaction can regulate hepatic innate and adaptive immune cells, as well as liver parenchymal cells, significantly impacting liver inflammation. In this mini review, recent findings of specific bacterial species and metabolites with functions in regulating liver inflammation are first reviewed. In addition, socioeconomic and environmental factors, hormones, and genetics that shape the profile of gut microbiota and microbial metabolites and components with the function of priming or dampening liver inflammation are discussed. Finally, current clinical trials evaluating the factors that manipulate gut microbiota to treat liver inflammation and chronic liver disease are reviewed. Overall, the discussion of microbial and metabolic mediators contributing to liver inflammation will help direct our future studies on liver disease.

A telehealth intervention for symptom management, distress, and adherence to adjuvant endocrine therapy: A randomized controlled trial

BACKGROUND

Patients taking adjuvant endocrine therapy (AET) after breast cancer face adherence challenges and symptom-related distress. We conducted a randomized trial to evaluate the feasibility, acceptability, and preliminary efficacy of a telehealth intervention (Symptom-Targeted Randomized Intervention for Distress and Adherence to Adjuvant Endocrine Therapy [STRIDE]) for patients taking AET.

METHODS

From October 2019 to June 2021, 100 patients reporting difficulty with AET were randomly assigned to either STRIDE or a medication monitoring (MedMon) control group. STRIDE included six weekly small-group videoconferencing sessions and two individual calls. We defined feasibility as having >50% of eligible patients enroll, >70% complete the 12-week assessment, and > 70% of STRIDE patients complete ≥4/6 sessions. We monitored adherence with the Medication Event Monitoring System Caps (MEMS Caps). At baseline and 12- and 24-weeks after baseline, patients self-reported adherence (Medication Adherence Report Scale), AET satisfaction (Cancer Therapy Satisfaction Questionnaire), symptom distress (Breast Cancer Prevention Trial-Symptom Checklist), self-management of symptoms (Self-efficacy for Symptom Management-AET), coping (Measure of Current Status), quality of life (QOL; Functional Assessment of Cancer Therapy-Breast), and mood (Hospital Anxiety and Depression Scale). We used linear mixed effects models to assess the effect of STRIDE on longitudinal outcomes.

RESULTS

We enrolled 70.9% (100/141) of eligible patients; 92% completed the 12-week assessment, and 86% completed ≥4/6 STRIDE sessions. Compared with MedMon, STRIDE patients reported less symptom distress (B[difference] = -1.91; 95% CI, -3.29 to -0.52; p = .007) and better self-management of AET symptoms, coping, QOL, and mood. We did not observe significant differences in AET satisfaction or adherence.

CONCLUSIONS

STRIDE is feasible and acceptable, showing promise for improving outcomes in patients taking AET after breast cancer.

LAY SUMMARY

Patients taking adjuvant endocrine therapy (AET) after breast cancer may face challenges while following their treatment regimen. In this randomized controlled trial of 100 patients taking AET, a brief, small-group virtual intervention (STRIDE) was well-received by patients and led to improvements in how upset patients were due to symptoms, how confident they were in managing symptoms, and how well they could cope with stress. Thus, STRIDE is a promising intervention and should be tested in future multi-site trials.

Development of a virtual intervention for patients with lung cancer transitioning to surveillance after curative treatment

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Background: Patients with lung cancer who are treated with curative intent are rarely included in quality-of-life (QOL) intervention research in cancer, and the transition from treatment to surveillance is an understudied phase in lung cancer. Given the high risk of recurrence in this population, we aimed to 1) characterize the QOL challenges of patients with lung cancer who complete curative treatment and 2) develop and refine an intervention to support patients during their transition to surveillance. Methods: We first conducted semi-structured interviews to explore the QOL challenges of patients in transition from lung cancer treatment to surveillance (n = 12). Interviews were transcribed, coded, and analyzed using a thematic analysis approach. Results were used to develop the content, timing, and delivery of a cognitive behavioral intervention to enhance patient QOL during the transition to surveillance. We conducted an open pilot with patients within 3 weeks of completing lung cancer treatment (systemic therapy +/- radiation) to test and refine the intervention (n = 5). Mixed methods data were collected to evaluate intervention feasibility, acceptability, and areas for refinement. All study procedures were conducted at an academic medical center in the New England region. Results: Qualitative study results indicated that during the transition to surveillance, patients with lung cancer (6 female, 6 male; age range: 26-76) faced unexpected challenges in coping with residual symptoms (e.g., dyspnea, fatigue), uncertainty about future health, and changes in close relationships. Results were used to develop a 5-session intervention to address patient challenges with a coping skills framework that balanced acceptance-and change-oriented approaches. Study clinicians delivered intervention sessions remotely (video or telephone). Of 6 patients approached, 5 enrolled in the pilot (all female; age range: 62-73; 1 declined due to time commitment). Pilot patient feedback indicated that the intervention timing and content targeted patients’ current needs and concerns. Patients valued the opportunity to normalize and address current challenges and to cope with difficult emotions. Results suggested further refinements to the timing for patient recruitment and the order of session content to enhance skills uptake. Conclusions: Patients who are treated for lung cancer with curative intent may face unexpected QOL challenges related to residual symptoms, health uncertainty, and changes in close relationships during the transition to surveillance. Results enhance our understanding of lung cancer survivorship and provide a framework for addressing QOL challenges in this population. Remote delivery of this manualized intervention supports scalability for survivors of cancers with high risk of recurrence. This model will be tested further in a larger scale efficacy trial. Clinical trial information: 04450043.

Abstract AP20: STROMAL CELL EXPRESSION OF THE RECEPTOR TYROSINE KINASE DDR2 PROMOTES OVARIAN CANCER METASTASIS

OBJECTIVES: Understand the role of stromal discoid domain receptor 2 (DDR2) expression in ovarian cancer metastasis

METHODS: 111 high-grade serous ovarian cancer specimens were examined for stromal DDR2 protein expression by immunohistochemistry (IHC) and correlated with survival. The stromal cell contribution of DDR2 for the steps of metastasis were evaluated through mesothelial cell clearance, Matrigel invasion assays, and germline knock-out mice. DDR2 low versus DDR2 high primary stromal cells were cultured from normal omenutum: human peritoneal mesothelial cells (HPMC) and normal omental fibroblasts (NOF). DDR2 knock-out (KO) and wild-type (WT) mice were used to evaluate metastasis. DDR2 positive (ID8Trp53-/-BRCA2-/- and ES2) tumor cells were used. Mesothelial cell clearance area was evaluated by measuring the size of the clearance area, invasion was evaluated by the number of tumor cells per high power field (hpf), and metastatic spread evaluated by number of tumors nodules and tumor weight. Collagen contribution was evaluated with Masson's trichrome stain and second harmonic generation (SHG). In addition, the media of genetically inhibited DDR2 or therapeutic inhibition of DDR2 in the NOFs (siControl vs siDDR2) was removed and then added to tumor cells to evaluate for invasion. Therapeutic inhibition was performed with a small molecule developed in a collaborating lab, WRG-R28.

RESULTS: Patients with high stromal cell DDR2 expression had a median overall survival (OS) of 171 months vs. low stromal cell DDR2 expression (OS) of 28 months (p<0.0001). Mesothelial cell clearance was performed with HPMCsiControl vs siDDR2 and found to have decreased tumor cell clearance with HPMCsiDDR2 when compared to HPMCsiControl. Additionally, tumor cell invasion was decreased by 2-fold in the NOFsiDDR2 compared to NOFsiControl in two discrete NOFs. Furthermore, media from NOFsiControl vs NOFsiDDR2 was removed and co-cultured with DDR2+ tumor cells and found to have 50% less invasion for tumor cells co-cultured with NOFsiDDR2 compared to NOFsiControl. DDR2 KO mice had significantly less tumor weight (0.025g vs 0.05, p<0.05) than DDR2 WT mice. Collagen content was found to be less intense at 45% compared to 80%, p<0.0001 in the DDR2KO vs DDR2WT. SHG analysis showed DDR2 WT tumors to be more perpendicular than DDR2 KO tumors were more parallel to the tumor-stromal border. Therapeutic inhibition with WRG-R28 treatment of the NOFs resulted in 2-fold decrease in invasive tumor cells (150 vs 75 cells/hpf, p<0.01) as well as inhibition of mesothelial cell clearance by the tumor cells treated with WRG-R28 compared to DMSO.

CONCLUSIONS: The stromal contribution of DDR2 promotes tumor cell clearance of mesothelial cells and metastatic spread. This suggests that stromal expression of DDR2 may be a potential target to guide future therapy particularly in the maintenance setting.

Citation Format: Molly Greenwade, Holly Beck, Whitney Grither, Daniel Wilke, Katina Massad, Lei Guo, Greg Longmore, Katherine Fuh. STROMAL CELL EXPRESSION OF THE RECEPTOR TYROSINE KINASE DDR2 PROMOTES OVARIAN CANCER METASTASIS [abstract]. In: Proceedings of the 12th Biennial Ovarian Cancer Research Symposium; Sep 13-15, 2018; Seattle, WA. Philadelphia (PA): AACR; Clin Cancer Res 2019;25(22 Suppl):Abstract nr AP20.

Therapeutic Inhibition of the Receptor Tyrosine Kinase AXL Improves Sensitivity to Platinum and Taxane in Ovarian Cancer

Ovarian cancer, one of the deadliest malignancies in female cancer patients, is characterized by recurrence and poor response to cytotoxic chemotherapies. Fewer than 30% of patients with resistant disease will respond to additional chemotherapy treatments. This study aims to determine whether and how inhibition of the receptor tyrosine kinase AXL can restore sensitivity to first-line platinum and taxane therapy in ovarian cancer. AXL staining was quantified in a patient tissue microarray and correlated with chemoresponse of patients. We used small hairpin RNAs to knock down AXL expression and the small-molecule inhibitor BGB324 to inhibit AXL and assessed sensitivity of cell lines and primary patient-derived cells to chemotherapy. We quantified platinum accumulation by inductivity-coupled plasma phase mass spectrometry. Finally, we treated chemoresistant patient-derived xenografts with chemotherapy, BGB324, or chemotherapy plus BGB324 and monitored tumor burden. AXL expression was higher in chemoresistant patient tumors and cell lines than in chemosensitive tumors and cell lines. AXL staining significantly predicted chemoresponse. Knockdown and inhibition of AXL dose-dependently improved response to paclitaxel and carboplatin in both cell lines and primary cells. AXL inhibition increased platinum accumulation by 2-fold (*, P < 0.05). In vivo studies indicated that AXL inhibition enhanced the ability of chemotherapy to prevent tumor growth (****, P < 0.0001). AXL contributes to platinum and taxane resistance in ovarian cancer, and inhibition of AXL improves chemoresponse and accumulation of chemotherapy drugs. This study supports continued investigation into AXL as a clinical target.