Reliability and validity of PRO-CTCAE® daily reporting with a 24-hour recall period

PURPOSE

The standard recall period for the patient-reported outcomes version of the common terminology criteria for adverse events (PRO-CTCAE®) is the past 7 days, but there are contexts where a 24-hour recall may be desirable. The purpose of this analysis was to investigate the reliability and validity of a subset of PRO-CTCAE items captured using a 24-hour recall.

METHODS

27 PRO-CTCAE items representing 14 symptomatic adverse events (AEs) were collected using both a 24-hour recall (24 h) and the standard 7 day recall (7d) in a sample of patients receiving active cancer treatment (n = 113). Using data captured with a PRO-CTCAE-24h on days 6 and 7, and 20 and 21, we computed intra-class correlation coefficients (ICC); an ICC ≥ 0.70 was interpreted as demonstrating high test-retest reliability. Correlations between PRO-CTCAE-24h items on day 7 and conceptually relevant EORTC QLQ-C30 domains were examined. In responsiveness analysis, patients were deemed changed if they had a one-point or greater change in the corresponding PRO-CTCAE-7d item (from week 0 to week 1).

RESULTS

PRO-CTCAE-24h captured on two consecutive days demonstrated that 21 of 27 items (78%) had ICCs ≥ 0.70 (day 6/7 median ICC 0.76), (day 20/21 median ICC 0.84). Median correlation between attributes within a common AE was 0.75, and the median correlation between conceptually relevant EORTC QLQ-C30 domains and PRO-CTCAE-24 h items captured on day 7 was 0.44. In the analysis of responsiveness to change, the median standardized response mean (SRM) for patients with improvement was - 0.52 and that for patients with worsening was 0.71.

CONCLUSION

A 24-hour recall period for PRO-CTCAE items has acceptable measurement properties and can inform day-to-day variations in symptomatic AEs when daily PRO-CTCAE administration is implemented in a clinical trial.

Abstract P5-15-02: Withdrawn

This abstract was withdrawn by the authors.

Abstract GS4-04: Randomized blinded sham- and waitlist-controlled trial of acupuncture for joint symptoms related to aromatase inhibitors in women with early stage breast cancer (S1200)

Background: Musculoskeletal symptoms are the most common side effect of aromatase inhibitors (AIs) and can result in decreased quality of life and discontinuation of therapy. Pilot data from two prior single institution studies showed that acupuncture decreased AI-induced joint symptoms in breast cancer (BC) patients.

Methods: We conducted a SWOG multicenter randomized controlled trial among postmenopausal women with early stage BC. Patients taking an AI for ≥30 days and having a worst pain score of ≥3 out of 10 using the Brief Pain Inventory (BPI-WP) were eligible. Subjects were randomized at a 2:1:1 ratio to true acupuncture (TA) vs. sham acupuncture (SA) vs. waitlist control (WC). The TA protocol used a standardized protocol of body and auricular acupoints tailored to joint symptoms. The similarly standardized SA protocol utilized superficial needling of non-acupoints. Both the TA and SA protocols consisted of a 12 week intervention, with 12 sessions administered over 6 weeks, followed by 1 session per week for 6 additional weeks. The primary endpoint was change in the BPI-WP (worst pain) score at 6 weeks. Secondary outcomes included other BPI scores, the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) for the hips and knees, the Modified Score for the Assessment of Chronic Rheumatoid Affections of the Hands (M-SACRAH), and functional testing with grip strength and "Timed Get Up and Go" (TGUG). The design specified alpha=.025 two-sided tests to account for two independent comparisons (TA vs. SA and TA vs. WC).

Results: Among 226 patients registered, 110 were randomized to TA, 59 to SA and 57 to WC. Baseline characteristics were similar between the groups. In a linear regression adjusting for the baseline score and stratification factors, 6-week mean BPI-WP scores were 0.92 points lower (correlating with less pain) in the TA compared to SA arm (95% CI: 0.20-1.65, p=.01), and were 0.96 points lower in the TA compared to WC arm (95% CI: 0.24-1.67, p=.01). The proportion of patients experiencing a clinically meaningful (>2) reduction (i.e. improvement) in BPI-WP was 58% for TA compared to 33% on SA and 31% on WC. Patients randomized to TA had improved symptoms compared to SA at week 6 according to all other BPI pain measures (average pain, p=.04; pain interference, p=.02; pain severity, p=.05; worst stiffness, p=.02). Results were similar compared to WC. Patients randomized to TA compared to SA or WC had statistically significant or marginally statistically significant improvements in BPI pain measures at week 12. Patients randomized to TA had generally improved symptoms compared to SA or WC at week 6 and at week 12 according to the M-SACRAH and WOMAC measures (p<0.05). With regard to adverse events, more patients on the TA arm experienced Grade 1 bruising compared to SA (47% vs. 25%, p=.01). No other differences by arm for selected adverse events were observed.

Conclusions: This study was the first large multicenter trial to investigate the effect of acupuncture in treating AI-induced joint symptoms in BC patients. According to multiple measures, TA generated better outcomes than either SA or WC with minimal toxicity.

Citation Format: Hershman DL, Unger JM, Greenlee H, Capodice J, Lew DL, Kengla AT, Melnik MK, Jorgensen CW, Kreisle WH, Minasian LM, Fisch MJ, Henry L, Crew KD. Randomized blinded sham- and waitlist-controlled trial of acupuncture for joint symptoms related to aromatase inhibitors in women with early stage breast cancer (S1200) [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr GS4-04.

Retention of Black and White Populations in the Selenium and Vitamin E Cancer Prevention Trial

Background: Adequate retention of Black (African-American) participants in long-term, randomized trials is important for achieving broadly applicable results. Purpose: To determine the incidence of retention failures and the individual and study site factors associated with retention failure among White and Black participants from the Selenium and Vitamin E Cancer Prevention Trial (SELECT), a phase III study of selenium and vitamin E for prevention of prostate cancer. Methods: SELECT randomized 35,533 participants from 427 study sites. Age eligibility was >55 years for Whites, >50 years for Blacks; race was determined by self-report. The primary analysis included 28,118 (87%) White and 4,322 (13%) Black men. Time to retention failure was defined as days to the earliest of either (1) the second consecutive missed in-person or phone visit or (2) refusal of future contact with study staff. Covariates included participant demographic and clinical characteristics, reasons for participating in SELECT and study site characteristics. Results: In SELECT, Blacks had a higher age-adjusted risk of disengagement than Whites [HR = 1.9; 95% CI 1.7–2.0; p-value < .0001]. Younger Black participants, age 50–54, representing 32% of Black participants, were at three times the risk of disengagement than those age 65+ [HR = 3.34, 95%CI 2.24,4.94, p < .0001]. Blacks age 65+ had 1.6 times the risk of disengagement than Whites age 65+ [HR = 1.58, 95%CI 1.37, 1.83, p < .0001]. By six years post-randomization, 83% of Whites were still retained on the study compared to 68% of Blacks. Among Whites, participant risk factors for disengagement were Hispanic ethnicity, graduate degree, living alone or current smoking; among Blacks, younger age and current smoking were risk factors. The site characteristic associated with disengagement among both racial groups was staff missing SELECT training sessions. Sites with a low staff attendance at training sessions had a high percentage of disengaged participants of either race. Both Whites and Blacks at sites receiving SELECT retention and adherence grants had lower risks for retention failure. Conclusion: These results may be useful in identifying personal and study site characteristics to guide recruitment and enhance retention of both Black and White men in long-term prevention trials.

OT2-07-02: SWOG S0927: A Randomized Double Blind Placebo-Controlled Trial of Omega-3-Fatty Acid for the Control of Aromatase Inhibitor (AI)-Induced Musculoskeletal Pain in Women with Early Stage Breast Cancer

Background: Despite the well-proven efficacy of aromatase inhibitors(AIs) for the treatment of hormone-sensitive breast cancer, a significant number of women suffer from musculoskeletal side-effects which can result in early discontinuation of this important medication. Given the proposed anti-inflammatory effects of omega-3-fatty acid and the paucity of therapeutic options for AI-induced arthralgia, it is therefore reasonable to test the efficacy of omega-3-fatty acid in women with breast cancer who have developed moderate to severe joint symptoms after initiating AIs.

Specific aims: To assess if omega-3-fatty acid as compared to placebo causes a reduction in worst joint pain/stiffness in women with AI-associated arthralgias at 12weeks as measured by the modified Brief Pain Inventory (BPI). Additional measures will include the WOMAC, M-SACRAH, FACT-ES and global rating of change, which will be assessed at baseline, 6, 12 and 24 weeks. We will evaluate fasting lipids, hormone levels, serum inflammatory markers (TNF, IL2, CRP), and markers of joint destruction (CTX-II) at baseline, 12 and 24 weeks.

Eligibility criteria:Pts. must have histologically-confirmed stages I-III breast cancer, with no evidence of metastatic disease and undergone definitive breast cancer surgery. Pts must be post-menopausal and currently be taking a third-generation AI —anastrazole(Arimidex®), letrozole (Femara®), or exemestane (Aromasin®) for at least the previous 90 days prior to registration with plans to continue for at least an additional 180 days after registration.The patient must have a worse joint pain/stiffness score of 5 or greater on the 10-point scale of the BPI which started or increased after initiation of AI. Pts must not have taken omega-3-fatty acid supplements within the past 3 months prior to registration.Pts will be randomized to receive 6 capsules daily (at 1,000 mg each; ∼600mg combination of ethyl esters EPA/DHA) of omega-3-fattyacid or matching placebo daily for 24 weeks. Statistical methods:We stipulate an alpha=.05 two-sided test, with an estimated 5% non-adherenceand 20% dropout rate at the primary endpoint evaluation time of 12 weeks after randomization. For a two point difference in worst joint pain/stiffness and a 3.5 point SD at 12 weeks, 222 eligible patients would be required for 90% power under a two-arm normal design. To allow ineligibility rate of 10%, 246 total pts will be enrolled. The study should be activated September 2011. Funding: Supported by National Cancer Institute grant CA037429

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr OT2-07-02.

Increased efficacy and toxicity with combination anti-VEGF therapy using sorafenib and bevacizumab

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Background: The multikinase inhibitor, sorafenib (sor), targets raf-kinase and vascular endothelial growth factor receptor 2 (VEGFR2). Bevacizumab (bev) is a monoclonal antibody against VEGF. We theorized that combining the two agents would have synergistic therapeutic effects. Methods: Eligible pts had advanced solid tumors, good end organ function, and PS ≤ 1. A phase I dose-escalation study (cohort 1) used sor 200 mg po BID, and bev 5 mg/kg q2 wks IV (dose level, DL1) or 10 mg/kg (DL2). After DLT was reached, DL4 was added to cohort 1 which tested sor 200 mg po BID on days 1–5 q wk with bev IV 5 mg/kg q 2 wks in an attempt to minimize toxicity. Cohort 2 is an expansion phase at MTD (DL1: sor 200 mg po BID daily with bev IV 5 mg/kg), randomized to start with single drug for 4 wks. Cohort 2 has extensive translational endpoints, including imaging. Results: 34 pts have enrolled, 16 in cohort 1 and 18 in cohort 2. Tumor types include ovarian cancer (13), melanoma (4), and renal cell carcinoma (3). The median age was 58 yrs (30–76); pts received a median of 6.5 (1–15) prior regimens. In cohort 1, 3/16 pts had PR (19%; duration 4, 5+, 12+ mos), all with ovarian cancer, and 11/16 had stable disease (SD; 69%; 3+ - 13+ mos). 10/13 assessable cohort 2 pts had SD (77%; 3+ - 6.5+ mos). The most common DL1 AEs Gr ≥ 2 were hypertension (HTN; 6/6) and hand-foot syndrome (4/6). Other Gr 3 AEs in DL1 were leukopenia and infection (2; 2). DLT was reached at DL2 when 2/6 patients developed Gr 3 proteinuria (4, 5 gm/24 hr) and 3/6 developed uncontrolled Gr 3 HTN. Dose reduction on daily sor (DL1 and DL2) occurred for 11/12 pts at a median of 2 cycles, but is delayed on the intermittent schedule (DL4). In all pts, common Gr 1–2 AEs were elevated AST/ALT (18), rhinorrhea (12), fatigue (10), and anorexia (4). 4 pts developed Gr 2–3 diarrhea and 4 Gr 2–3 nausea/vomiting. Gastrointestinal fistulae occurred in two pts with PR, occurring within 4 wk of initiation of therapy, both in areas of tumor regression. Serial PET and DCE-MRI results and proteomic signal pathway analysis will be reported. Conclusions: The combination of sorafenib and bevacizumab appeared to increase both clinical effect and toxicity at below recognized single agent doses. Sor 200 mg po BID d1–5 qwk and bev of 5 mg/kg q2 wks is suggested for further study, pending further dose escalation.

No significant financial relationships to disclose.

A phase I study of anti-GD3 ganglioside monoclonal antibody R24 and recombinant human macrophage-colony stimulating factor in patients with metastatic melanoma

BACKGROUND

Macrophages activated by macrophage-colony stimulating factor (M-CSF) are potent immune effector cells and can mediate both in vitro cytotoxicity and antitumor effects in vivo. A Phase I trial combining M-CSF with R24, a mouse monoclonal antibody against GD3 ganglioside that has been shown to localize to melanoma tumors, induce inflammation at tumor sites, and result in major tumor responses in some patients with melanoma was performed.

METHODS

Nineteen patients with metastatic melanoma received a 14-day continuous intravenous infusion of 80 micrograms/kg/day of recombinant human M-CSF. R24 was administered daily by intravenous infusion on days 6-10 at doses of 1, 3, 10, 30, and 50 micrograms/m2/day.

RESULTS

All patients developed pruritus and urticaria; 13 patients developed transient thrombocytopenia less than 100,000/mm3. The maximum tolerated dose was not reached. All patients developed a monocytosis characterized by increased expression of the antigen HLA-DR and decreased expression of CD14, a phenotype reported to represent a subpopulation of monocytes active in mediating antibody-directed cellular cytotoxicity. Other biologic effects of treatment included marked but transient decreases in total cholesterol, low density lipoprotein, and high density lipoprotein. Three patients experienced tumor regression in breast, liver, and lymph node metastases and received a second course of therapy. Six of the 19 patients, one of whom received no further therapy, survived more than 2 years and 4 of these patients remain alive 24 to 37 months after treatment. Of the six patients with liver metastases, three (50%) survived more than 2.5 years and one remains alive at 37+ months.

CONCLUSIONS

Combination therapy with R24 and M-CSF resulted in both clinical and biologic effects that warrant further investigation of this combination.

Hemorrhagic tumor necrosis during a pilot trial of tumor necrosis factor-alpha and anti-GD3 ganglioside monoclonal antibody in patients with metastatic melanoma

Hemorrhagic tumor necrosis is an inflammatory event that leads to selective destruction of malignant tissues, with both potentially toxic and beneficial consequences. A pilot clinical trial was undertaken combining tumor necrosis factor-alpha (TNF-alpha) with the monoclonal antibody R24 (MoAb R24) against GD3 ganglioside in patients with metastatic melanoma. Patients received MoAb R24 to recruit leukocytes to the tumor followed by low doses of recombinant TNF-alpha to activate leukocytes. Eight patients were treated and seven patients had mild toxicity. One patient with extensive metastatic melanoma developed tumor lysis syndrome within hours after treatment with almost complete necrosis of bulky tumors in multiple visceral sites. To our knowledge, this is the first documented case of hemorrhagic tumor necrosis in a patient with metastatic cancer in multiple visceral sites.

Interferon alfa-2a in advanced renal cell carcinoma: treatment results and survival in 159 patients with long-term follow-up

PURPOSE

Three trials were conducted to define the efficacy and toxicity of interferon alfa-2a in the treatment of metastatic renal cell cancer. Univariate and multivariate analyses were performed to identify prognostic factors for survival.

PATIENTS AND METHODS

Prospectively, 159 patients were treated with interferon alfa-2a. In the first trial, 42 patients received 50 x 10(6) U/m2 intramuscularly three times per week. In the second trial, 64 patients received gradually escalating doses of interferon alfa-2a from 3 to 36 x 10(6) U subcutaneously administered daily. The third trial was randomized; 25 patients received daily interferon alfa-2a alone and 28 were treated with daily interferon alfa-2a and 0.15 mg/kg vinblastine every 3 weeks.

RESULTS

The overall response proportion was 10% (two complete and 14 partial responses). The median response duration was 12.2 months. The median survival duration was 11.4 months, with 3% of patients alive at 5 or more years. A univariate statistical analysis showed that a Karnofsky performance status > or = 80, prior nephrectomy, and interval from diagnosis to treatment of longer than 365 days were significant prognostic factors for survival. In a multivariate analysis, only prior nephrectomy and Karnofsky performance status > or = 80 were shown to be independent predictors of survival.

CONCLUSION

Interferon alfa-2a had minimal antitumor activity in patients with advanced renal cell carcinoma and long-term survival was achieved in a small proportion of patients. The need for continued investigation and the identification of more effective therapy for advanced renal cell carcinoma is evident from the poor overall survival rate observed in these 159 patients. The investigation of new agents and of interferon alfa-2a in combination with other agents remains a priority.