A Digital Solution for an Advanced Breast Tumor Board: Pilot Application Cocreation and Implementation Study

BACKGROUND

Cancer treatment is constantly evolving toward a more personalized approach based on clinical features, imaging, and genomic pathology information. To ensure the best care for patients, multidisciplinary teams (MDTs) meet regularly to review cases. Notwithstanding, the conduction of MDT meetings is challenged by medical time restrictions, the unavailability of critical MDT members, and the additional administrative work required. These issues may result in members missing information during MDT meetings and postponed treatment. To explore and facilitate improved approaches for MDT meetings in France, using advanced breast cancers (ABCs) as a model, Centre Léon Bérard (CLB) and ROCHE Diagnostics cocreated an MDT application prototype based on structured data.

OBJECTIVE

In this paper, we want to describe how an application prototype was implemented for ABC MDT meetings at CLB to support clinical decisions.

METHODS

Prior to the initiation of cocreation activities, an organizational audit of ABC MDT meetings identified the following four key phases for the MDT: the instigation, preparation, execution, and follow-up phases. For each phase, challenges and opportunities were identified that informed the new cocreation activities. The MDT application prototype became software that integrated structured data from medical files for the visualization of the neoplastic history of a patient. The digital solution was assessed via a before-and-after audit and a survey questionnaire that was administered to health care professionals involved in the MDT.

RESULTS

The ABC MDT meeting audit was carried out during 3 MDT meetings, including 70 discussions of clinical cases before and 58 such discussions after the implementation of the MDT application prototype. We identified 33 pain points related to the preparation, execution, and follow-up phases. No issues were identified related to the instigation phase. Difficulties were grouped as follows: process challenges (n=18), technological limitations (n=9), and the lack of available resources (n=6). The preparation of MDT meetings was the phase in which the most issues (n=16) were seen. A repeat audit, which was undertaken after the implementation of the MDT application, demonstrated that (1) the discussion times per case remained comparable (2 min and 22 s vs 2 min and 14 s), (2) the capture of MDT decisions improved (all cases included a therapeutic proposal), (3) there was no postponement of treatment decisions, and (4) the mean confidence of medical oncologists in decision-making increased.

CONCLUSIONS

The introduction of the MDT application prototype at CLB to support the ABC MDT seemed to improve the quality of and confidence in clinical decisions. The integration of an MDT application with the local electronic medical record and the utilization of structured data conforming to international terminologies could enable a national network of MDTs to support sustained improvements to patient care.

Impact of Limited E-Health Literacy on the Overall Survival of Patients With Cancer

PURPOSE

Digitalization of the health care system is transforming cancer patient care. Although many studies have investigated the determinants of a limited digital health literacy, the association between frailty factors and overall survival (OS) of these patients has never been assessed.

METHODS

A retrospective noninterventional study included 15,244 adult patients with cancer diagnosed between January 1, 2015, and December 31, 2017, and treated at the Centre Léon Bérard. Limited e-health literacy was defined as the absence of an e-mail address in the electronic patient record. An Inverse Probability of Treatment-Weighted Kaplan-Meier estimate and a multivariate Cox proportional hazards model including interaction terms were used to adjust for confounding on measured covariates.

RESULTS

In total, 15,244 adults with cancer were included: 55% women, with a median age of 62 years (19-103), and 35.5% had a metastatic disease. More than half (n = 8,771, 57.5%) had entered their e-mail address in their electronic patient record, and 4,020 (26.4%) opened their own patient portal. The median follow-up was 3.6 years (range: 0-6.8). Inverse Probability of Treatment-weighted Kaplan-Meier estimates showed a significantly better OS for patients with an e-mail address (P < .001). In multivariate analysis integrating interaction terms, male gender (hazard ratio [HR] = 1.27; 95% CI, 1.15 to 1.41; P < .001), older age (HR = 1.02; 95% CI, 1.02 to 1.03; P < .001), de novo metastatic setting (HR = 2.63; 95% CI, 2.47 to 2.79; P < .001), and no e-mail address (HR = 1.63; 95% CI, 1.33 to 2.00; P < .001) were significantly associated with worse OS.

CONCLUSION

Our results support a strong association between the limited level of literacy and OS. A more in-depth study integrating variables such as socioeconomic level and location of residence would enrich these results.

TP53 Mutation as a Prognostic and Predictive Marker in Sarcoma: Pooled Analysis of MOSCATO and ProfiLER Precision Medicine Trials

(1) Background: locally resected high-grade sarcomas relapse in 40% of cases. There is no prognostic or predictive genomic marker for response to peri-operative chemotherapy. (2) Methods: MOSCATO and ProfiLER are pan-tumor prospective precision medicine trials for advanced tumors. Molecular analysis in both trials comprised targeted next-generation sequencing and comparative genomic hybridization array. We investigated if molecular alterations identified in these trials in sarcomas were associated with disease-free survival (DFS) and response to anthracyclines. (3) Results: this analysis included 215 sarcomas, amongst which 53 leiomyosarcomas, 27 rhabdomyosarcomas, 20 undifferentiated pleomorphic sarcomas, and 17 liposarcomas. The most frequently altered gene was TP53 (46 mutations and eight deletions). There were 149 surgically resected localized sarcomas. Median DFS in TP53 wild type (WT), deleted, and mutated sarcomas was 16, 10, and 10 months, respectively (p = 0.028; deletions: HR = 1.55; 95% CI = 0.75-3.19; mutations: HR = 1.70; 95%CI = 1.13-2.64). In multivariate analysis, TP53 mutations remained associated with shorter DFS (p = 0.027; HR = 2.30; 95%CI = 1.10-4.82). There were 161 localized and advanced sarcomas evaluable for response to anthracyclines. Objective response rates were 35% and 55% in TP53 WT and mutated sarcomas, respectively (OR = 2.24; 95%CI = 1.01-5.03; p = 0.05). In multivariate analysis, TP53 mutations remained associated with increased response (OR = 3.24; 95%CI = 1.30-8.45; p = 0.01). (4) Conclusions: TP53 mutations are associated with shorter DFS and increased response to anthracyclines. Post-validation, these findings could assist in decision-making for peri-operative treatments.

Issues and limitations of available biomarkers for fluoropyrimidine-based chemotherapy toxicity, a narrative review of the literature

Fluoropyrimidine-based chemotherapies are widely used to treat gastrointestinal tract, head and neck, and breast carcinomas. Severe toxicities mostly impact rapidly dividing cell lines and can occur due to the partial or complete deficiency in dihydropyrimidine dehydrogenase (DPD) catabolism. Since April 2020, the European Medicines Agency (EMA) recommends DPD testing before any fluoropyrimidine-based treatment. Currently, different assays are used to predict DPD deficiency; the two main approaches consist of either phenotyping the enzyme activity (directly or indirectly) or genotyping the four main deficiency-related polymorphisms associated with 5-fluorouracil (5-FU) toxicity. In this review, we focused on the advantages and limitations of these diagnostic methods: direct phenotyping by evaluation of peripheral mononuclear cell DPD activity (PBMC-DPD activity), indirect phenotyping assessed by uracil levels or UH2/U ratio, and genotyping DPD of four variants directly associated with 5-FU toxicity. The risk of 5-FU toxicity increases with uracil concentration. Having a pyrimidine-related structure, 5-FU is catabolised by the same physiological pathway. By assessing uracil concentration in plasma, indirect phenotyping of DPD is then measured. With this approach, in France, a decreased 5-FU dose is systematically recommended at a uracil concentration of 16 ng/ml, which may lead to chemotherapy under-exposure as uracil concentration is a continuous variable and the association between uracil levels and DPD activity is not clear. We aim herein to describe the different available strategies developed to improve fluoropyrimidine-based chemotherapy safety, how they are implemented in routine clinical practice, and the possible relationship with inefficacy mechanisms.

Molecular Characterization of Ovarian Yolk Sac Tumor (OYST)

Simple Summary

Ovarian yolk sac tumors (OYSTs) are rare and specific therapeutic strategies are needed after the failure of platinum-based first-line and salvage regimens. This retrospective study included ten patients with OYST, including patients with relapsed disease and disease-free patients. Three patients (33.3%) harbored oncogenic mutations in KRAS, KIT and ARID1A, which may be used as a target. Our series shows that relapsed patients with molecular analysis had clinically relevant molecular alterations. Future research with dedicated trials and multicenter international collaborations are needed to demonstrate the efficacy of specific therapeutic strategies after failure of platinum-based first-line and salvage regimens.

Abstract

Most patients with malignant ovarian germ cell tumors (MOGTCs) have a very good prognosis and chemotherapy provides curative treatment; however, patients with yolk sac tumors (OYSTs) have a significantly worse prognosis. OYSTs are rare tumors and promising results are expected with the use of specific therapeutic strategies after the failure of platinum-based first-line and salvage regimens. We initiated a project in collaboration with EORTC SPECTA, to explore the molecular characteristics of OYSTs. The pilot project used retrospective samples from ten OYST relapsed and disease-free patients. Each patient had a molecular analysis performed with FoundationOne CDx describing the following variables according to the Foundation Medicine Incorporation (FMI): alteration type (SNV, deletion), actionable gene alteration, therapies approved in EU (for patient’s tumor type and other tumor types), tumor mutational burden (TMB), and microsatellite instability (MSI) status. A total of 10 patients with OYST diagnosed between 2007 and 2017 had a molecular analysis. A molecular alteration was identified in four patients (40%). A subset of three patients (33.3% of all patients) harbored targetable oncogenic mutations in KRAS, KIT, ARID1A. Two patients at relapse harbored a targetable mutation. This retrospective study identifies clinically relevant molecular alterations for all relapsed patients with molecular analysis. Dedicated studies are needed to demonstrate the efficacy of specific therapeutic strategies after the failure of platinum-based first-line and salvage regimens and to explore the potential relationship of a molecular alteration and patient outcome.

OS5.4 Characteristics of adult diffuse H3K27M-mutant gliomas at recurrence

BACKGROUND

Adult diffuse H3K27M-mutant gliomas are rare and associated with a poor prognosis but could benefit in the next future from specific therapeutic strategies. In this context, the aim of the present study was to describe the characteristics of these tumors at recurrence.

MATERIAL AND METHODS

We retrospectively analyzed the characteristics of a series of 27 adult diffuse H3K27M-mutant gliomas at recurrence

RESULTS

Median age at diagnosis was 37 years. Initial treatment consisted of temozolomide radiochemotherapy (n=17, 62%), radiotherapy alone (n=1, 4%), chemotherapy alone (n=4, 15%), wait and see (n=1, 4%) and palliative care (n=4, 15%). Median PFS and median OS were 11 and 22 months in the whole series and 15 and 29 months in the patients who were treated with temozolomide radiochemotherapy. The pattern of recurrence could be analyzed in 19 patients. Ten patients (50%) demonstrated a local recurrence, five patients a local and distant recurrence (25%), two patients only a distant recurrence (10%) and two patients a leptomeningeal progression (10%). At recurrence, 15 patients received an oncological treatment that consisted of an alkylating chemotherapy (n=5), a bevacizumab based chemotherapy regimen (n=9) and of radiotherapy (n=1). Median PFS and OS after first recurrence in these patients were 6 and 14 months, respectively. An activating FGFR1 mutation was identified in 4 out of the 9 patients in whom it was assessed.

CONCLUSION

At recurrence, adult diffuse H3K27M-mutant gliomas are associated with a high rate of distant locations. A subset of patients harbor targetable FGFR1 activating mutations.