Bridging the gaps between tertiary and community care networks: Results from a southern California survey research analysis

1538

Background: Although many tertiary cancer centers offer access to myriad research protocols, the majority of patients nevertheless receive treatment at community practices. We sought to examine the barriers that hamper clinical collaboration between tertiary and community practice environments in Southern California. Methods: A 31-item survey was distributed to community and tertiary oncologists using REDCap, a browser-based electronic data capture system. Survey questions assessed the following attributes: demographics and features of clinical practice, referral patterns, availability and knowledge pertaining to clinical trials, strategies for knowledge acquisition, and integration of community and tertiary practices. Results: The survey was distributed to 98 oncologists, 85 (87%) of whom completed it in full. The most common institutional affiliations were City of Hope Comprehensive Cancer Center (58%), University of California, Los Angeles (10%), and Cedars Sinai Medical Center (8%). In total, 52 (61%) respondents were community practitioners and 33 (38%) were tertiary oncologists. A majority (56%) of community oncologists defined themselves as general oncologists whereas almost all (97%) tertiary oncologists reported a subspecialty. Clinical trial availability was the most common reason for pt referrals to tertiary centers (73%). The most frequent barrier to tertiary referral was financial considerations (59%). Clinical trials were offered by 97% of tertiary practitioners as compared to 67% of community oncologists (p = 0.001). Of note, while a majority of tertiary center providers (52%) described the primary value of community practices to be a source of referrals for clinical trials, most community oncologists (82%) reported only a minimal-to-moderate understanding of clinical trials available at regional tertiary centers. Conclusions: Community oncologists refer patients to tertiary centers primarily with the intent of clinical trial enrollment; however, significant gaps exist in their knowledge of trial availability. Our results identify the need for enhanced communication and collaboration between community and tertiary providers to expand patients’ access to clinical trials.

A multidisciplinary team approach to efficient breast cancer diagnosis

88

Background: System inefficiencies result in delayed breast cancer diagnoses. Inefficiencies include any non-value added steps between symptom onset/imaging abnormality to cancer diagnosis and treatment. Diagnostic delays can lead to more advanced disease and may negatively impact survival. Further, optimizing the efficiency of diagnostic evaluation models can reduce barriers to care and improve patient satisfaction. To achieve these efficiency goals, Banner MD Anderson Cancer Center (BMDACC) instituted the Undiagnosed Breast Clinic (UBC). The UBC expedites patient evaluation through a multidisciplinary diagnostic team of internists, surgeons, pathologists and radiologists. Patients with an abnormality on physical exam or imaging are promptly evaluated by the UBC team and any necessary diagnostic tests are performed. If malignancy is diagnosed, the BMDACC breast team swiftly institutes multidisciplinary care. Methods: We conducted a retrospective chart review of patients seen in the UBC from 12/2012 - 12/2013. We tallied patient demographics, diagnostic data, and treatment information. Results: 177 patients (174 females; 3 males) were identified. Mean age was 54 years (range: 16-91). Patient racial breakdown was 144 (81%) Caucasian; 8 (5%) Black, 6 (3%) Latina, 4 (2%) Asian, and 15 (8%) Other. Malignant diagnoses (invasive carcinoma or ductal carcinoma in situ) were found in 28 patients (16%), and high-risk lesions (atypia or lobular carcinoma in situ) were found in 8 patients (5%). Of the 46 patients who underwent needle biopsy as part of the UBC evaluation, 28 (61%) underwent biopsy the same day as the initial visit. An additional 5 patients (11%) underwent biopsy the next day.Genetics consults were obtained in 11 patients (6%). Of these 11 patients, one tested positive for BRCA 1 and one for BRCA2. Conclusions: A multidisciplinary team approach to breast cancer diagnosis is feasible. The resultant evaluation eliminates non-value added steps in the patients’ workup, thereby expediting time from presentation to diagnosis and, if needed, treatment.

Anastrozole versus tamoxifen in postmenopausal women with ductal carcinoma in situ undergoing lumpectomy plus radiotherapy (NSABP B-35): a randomised, double-blind, phase 3 clinical trial

BACKGROUND

Ductal carcinoma in situ is currently managed with excision, radiotherapy, and adjuvant hormone therapy, usually tamoxifen. We postulated that an aromatase inhibitor would be safer and more effective. We therefore undertook this trial to compare anastrozole versus tamoxifen in postmenopausal women with ductal carcinoma in situ undergoing lumpectomy plus radiotherapy.

METHODS

The double-blind, randomised, phase 3 National Surgical Adjuvant Breast and Bowel Project (NSABP) B-35 trial was done in 333 participating NSABP centres in the USA and Canada. Postmenopausal women with hormone-positive ductal carcinoma in situ treated by lumpectomy with clear resection margins and whole-breast irradiation were enrolled and randomly assigned (1:1) to receive either oral tamoxifen 20 mg per day (with matching placebo in place of anastrozole) or oral anastrozole 1 mg per day (with matching placebo in place of tamoxifen) for 5 years. Randomisation was stratified by age (<60 vs ≥60 years) and patients and investigators were masked to treatment allocation. The primary outcome was breast cancer-free interval, defined as time from randomisation to any breast cancer event (local, regional, or distant recurrence, or contralateral breast cancer, invasive disease, or ductal carcinoma in situ), analysed by intention to treat. This study is registered with ClinicalTrials.gov, number NCT00053898, and is complete.

FINDINGS

Between Jan 1, 2003, and June 15, 2006, 3104 eligible patients were enrolled and randomly assigned to the two treatment groups (1552 to tamoxifen and 1552 to anastrozole). As of Feb 28, 2015, follow-up information was available for 3083 patients for overall survival and 3077 for all other disease-free endpoints, with median follow-up of 9·0 years (IQR 8·2-10·0). In total, 212 breast cancer-free interval events occurred: 122 in the tamoxifen group and 90 in the anastrozole group (HR 0·73 [95% CI 0·56-0·96], p=0·0234). A significant time-by-treatment interaction (p=0·0410) became evident later in the study. There was also a significant interaction between treatment and age group (p=0·0379), showing that anastrozole is superior only in women younger than 60 years of age. Adverse events did not differ between the groups, except for thrombosis or embolism--a known side-effect of tamoxifen-for which there were 17 grade 4 or worse events in the tamoxifen group versus four in the anastrozole group.

INTERPRETATION

Compared with tamoxifen, anastrozole treatment provided a significant improvement in breast cancer-free interval, mainly in women younger than 60 years of age. This finding means that women will benefit from having a choice of effective agents for ductal carcinoma in situ.

FUNDING

US National Cancer Institute and AstraZeneca Pharmaceuticals LP.

Patient-reported outcomes with anastrozole versus tamoxifen for postmenopausal patients with ductal carcinoma in situ treated with lumpectomy plus radiotherapy (NSABP B-35): a randomised, double-blind, phase 3 clinical trial

BACKGROUND

The NSABP B-35 trial compared 5 years of treatment with anastrozole versus tamoxifen for reducing subsequent occurrence of breast cancer in postmenopausal patients with ductal carcinoma in situ. This report assesses the effect of these drugs on quality of life and symptoms.

METHODS

The study was done at 333 hospitals in North America. Postmenopausal women with hormone-positive ductal carcinoma in situ treated by lumpectomy with clear resection margins and whole breast irradiation were randomly assigned to receive either tamoxifen (20 mg/day) or anastrazole (1 mg/day) for 5 years, stratified by age (<60 years vs ≥60 years). Patients and investigators were masked to treatment allocation. Patients completed questionnaires at baseline and every 6 months thereafter for 6 years. The primary outcomes were SF-12 physical and mental health component scale scores, and vasomotor symptoms (as per the BCPT symptom scale). Secondary outcomes were vaginal symptoms and sexual functioning. Exploratory outcomes were musculoskeletal pain, bladder symptoms, gynaecological symptoms, cognitive symptoms, weight problems, vitality, and depression. We did the analyses by intention to treat, including patients who completed questionnaires at baseline and at least once during follow-up. This study is registered with ClinicalTrials.gov, NCT00053898.

FINDINGS

Between Jan 6, 2003, and June 15, 2006, 3104 patients were enrolled in the study, of whom 1193 were included in the quality-of-life substudy: 601 assigned to tamoxifen and 592 assigned to anastrozole. We detected no significant difference between treatment groups for: physical health scores (mean severity score 46·72 for tamoxifen vs 45·85 for anastrozole; p=0·20), mental health scores (52·38 vs 51·48; p=0·38), energy and fatigue (58·34 vs 57·54; p=0·86), or symptoms of depression (6·19 vs 6·39; p=0·46) over 5 years. Vasomotor symptoms (1·33 vs 1·17; p=0·011), difficulty with bladder control (0·96 vs 0·80; p=0·0002), and gynaecological symptoms (0·29 vs 0·18; p<0·0001) were significantly more severe in the tamoxifen group than in the anastrozole group. Musculoskeletal pain (1·50 vs 1·72; p=0·0006) and vaginal symptoms (0·76 vs 0·86; p=0·035) were significantly worse in the anastrozole group than in the tamoxifen group. Sexual functioning did not differ significantly between the two treatments (43·65 vs 45·29; p=0·56). Younger age was significantly associated with more severe vasomotor symptoms (mean severity score 1·45 for age <60 years vs 0·65 for age ≥60 years; p=0·0006), vaginal symptoms (0·98 vs 0·65; p<0·0001), weight problems (1·32 vs 1·02; p<0·0001), and gynaecological symptoms (0·26 vs 0·22; p=0·014).

INTERPRETATION

Given the similar efficacy of tamoxifen and anastrozole for women older than age 60 years, decisions about treatment should be informed by the risk for serious adverse health effects and the symptoms associated with each drug. For women younger than 60 years old, treatment decisions might be driven by efficacy (favouring anastrozole); however, if the side-effects of anastrozole are intolerable, then switching to tamoxifen is a good alternative.

FUNDING

US National Cancer Institute, AstraZeneca Pharmaceuticals.

Abstract S6-04: Patient-reported outcome (PRO) results, NRG Oncology/NSABP B-35: A clinical trial of anastrozole (A) vs tamoxifen (tam) in postmenopausal patients with DCIS undergoing lumpectomy plus radiotherapy

Background

The clinical results of NSABP B-35, phase III trial comparing 1 mg/day A to 20 mg/day tam, each given for 5 years, were reported at ASCO 2015. B-35 demonstrated a statistically significant benefit in breast cancer free interval for women assigned to A, primarily in women &lt;60 years. A secondary endpoint of B-35 was quality of life (QOL) and symptom (SX) outcomes in the two treatment groups. The primary hypotheses of the PRO study were that there would be no differences in QOL between the two treatments, and that patients receiving A would report higher rates of hot flashes compared to patients receiving tam. Other SX comparisons were secondary endpoints.

Methods

QOL and SX were assessed at baseline (prior to randomization), and every 6 months thereafter for 5 years of treatment and in the following 12 months. QOL was measured with the SF-12 Physical Component Summary (PCS) and Mental Component Summary (MCS). SX were measured with selected scales from the BCPT symptom-checklist, and other standardized instruments. Stratification was by age (&lt;60 v ≥60) as in the main trial. Study hypotheses and endpoints were examined by comparing PROs in the two treatment arms using a mixed model for repeated measures analysis with adjustment for the baseline scores, time point and age category, using an intention-to-treat principle and including only patients who completed the baseline and at least one follow-up questionnaire. Patients with protocol events were censored. Only data through 60 months are reported here. The accrual goal for the sub-study was 1,150 consecutive patients.

Results

Between January 6, 2003 and June 15, 2006, a total of 3,104 patients were entered and randomly assigned to NSABP Protocol B-35. Accrual to the PRO study of B-35 closed on December 28, 2004, at which time 1,275 patients were entered, with 1,193 patients included in this analysis. There were no medical or demographic differences between patients assigned to A or tam in the PRO sub-study, and they reflected the characteristics of the parent trial. Adherence to data collection across the 60 months was 87%. There were no significant differences in QOL outcomes by treatment for the PCS (p=0.16) or the MCS (p=0.38). SX subscales: hot flash scale was greater in tam group and this difference varied over time (p=0.001); musculoskeletal pain was significantly greater in A group for time points 6-24 months (all p&lt;.001); vaginal problems were greater in A group (p=0.03). Hot flash and vaginal problems were significantly worse in women &lt;60 years. Additional SX outcomes (depression, fatigue, sexual function) will be reported at presentation.

Conclusion

In this large, double-blind, placebo-controlled trial comparing A to tam in patients with DCIS, there was no significant difference in QOL between the two treatments. However, there were important treatment differences in SX outcomes, which should be considered as part of treatment decision-making discussions, along with the clinical breast cancer outcome results.

Support: CA-180868, 180822, 189867, 196067, 114732; AstraZeneca Pharmaceuticals LP.

Citation Format: Ganz PA, Cecchini RS, Julian TB, Margolese RG, Costantino JP, Vallow LA, Albain KS, Whitworth PW, Cianfrocca ME, Brufsky A, Gross HM, Soori GS, Hopkins JO, Fehrenbacher L, Sturtz K, Wozniak TF, Seay TE, Mamounas EP, Wolmark N. Patient-reported outcome (PRO) results, NRG Oncology/NSABP B-35: A clinical trial of anastrozole (A) vs tamoxifen (tam) in postmenopausal patients with DCIS undergoing lumpectomy plus radiotherapy. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr S6-04.

Primary results, NRG Oncology/NSABP B-35: A clinical trial of anastrozole (A) versus tamoxifen (tam) in postmenopausal patients with DCIS undergoing lumpectomy plus radiotherapy

LBA500

Background: The primary endpoint of NSABP B-35, a phase III trial comparing 1 mg/day anastrozole to 20 mg/day tamoxifen, each given for 5 years, was breast cancer-free interval (BCFI), defined as the time from randomization to any breast cancer (BC) event including local, regional, or distant recurrence or contralateral disease, invasive or DCIS. Methods: Postmenopausal women with ER-receptor or PgR-receptor positive (by IHC analysis) DCIS and no invasive BC who had undergone a lumpectomy with clear resection margins were randomly assigned to receive either 20 mg/day tam or 1 mg/day A (blinded) for 5 years. Stratification was by age (<60 v ≥60). Results: From 1/6/2003 to 6/15/2006, 3,104 pts were entered and randomized (1552 in groups tam and A each). As of 2/28/15, follow-up information was available on 3,083 pts for OS and on 3,077 pts for all other disease-free endpoints, with mean time of follow-up of 8.6 years. There were 198 BCFI events, 114 in the tam group and 84 in the A group (HR, 0.73; p=0.03). 10-year point estimates for BCFI were 89.2% for tam and 93.5% for A. A significant time-by-treatment interaction (p=0.02) indicated that the effect was not evident until later in the study. There was a significant interaction between treatment and age group (p=0.04); benefit of A is only in women <60 years old. As to secondary endpoints, there were 495 DFS events, 260 in the tam group and 235 in the A group (HR, 0.89; p=0.21). 10-year point estimates for DFS were 77.9% for tam and 82.7% for A. There were 186 deaths, 88 in the tam group and 98 in the A group (HR, 1.11; p=0.48). 10-year point estimates for OS were 92.1% for tam, 92.5% for A. There were 8 deaths due to breast cancer in the tam group and 5 in the A group. There were 63 cases of invasive breast cancer in the tam group and 39 in the A group (HR, 0.61; p=0.02). There was a non-significant trend for a reduction in breast second primary cancers with A (HR, 0.68; p=0.07). Conclusions: Anastrozole provided a significant improvement compared to tamoxifen for BCFI, which was seen later in the study, primarily in women <60 years. Support: CA12027, 37377, 69651, 69974; 180868, 180822, 189867 196067, 114732; AstraZeneca Pharmaceuticals LP. Clinical trial information: NCT00053898.

Abstract P5-19-15: Prescribing preferences of US-based medical oncology physicians for patients with hormone receptor positive, HER2 negative metastatic breast cancer following prior endocrine therapies

Background: Non-steroidal aromatase inhibitors (NSAI) are a standard first-line therapy (Rx) for post-menopausal pts with hormone receptor positive (HR+), HER2 negative (HER2-) advanced and recurrent metastatic breast cancer (mBC). When studied in phase III clinical trials, combination hormonal Rx regimens have not consistently produced significant improvements in time to event measures compared to sequential single agents. However recent phase II and III studies combining hormonal and targeted agents have shown significant extensions in PFS and potential increases in OS. Due to the emergence of several targeted agents, standards of care for treatment after failure on a NSAI are evolving.

Methods: Prescribing preferences (PPrefs) of 187 U.S.-based medical oncology physicians (MOPs) were studied using a validated, proprietary, live, case-based market research tool (Challenging Cases®). Data were acquired using blinded, audience-response iPad technology and acquisition events took place in March and May 2014. A core case was constructed and PPrefs for three 1st, three 2nd, and one 3rd failure scenario were assessed. Core case: 60-year-old female; History of mild hypertension well-controlled by medication; diagnosed with stage 2B HR+, HER2-, grade 3, invasive ductal carcinoma; Primary Rx included lumpectomy+ sentinel node biopsy/axillary dissection, chemotherapy (CT) and radiotherapy (RT) followed by anastrozole with plans for 5 years (yrs) of Rx. Question posed: What systemic Rx would you recommend now?

Results:

Figure 1: PPrefs for Rx for first recurrent disease during or after 5 yrs of adjuvant anastrozoleScenarioEndocrine Rx Targeted StrategyCTOther Time to Recurrence(REC) Met sitesAnother NSAIFulvestrant (F)Exemestane (EXE)EXE + Everolimus (EVE)Single agent(SA)/ comboOther/ Clinical Trial (CLT)/Continue NSAI and add FS1a, N=18718 mths while on NSAI Non-Visceral (N-VIS) and Visceral (VIS)10%28%6%35%14%7%S1b, N=9718 mths while on NSAI N-VIS, Unproven VIS7%46%5%28%7%6%S2, N=1872 yrs post 5 yrs NSAI N-VIS25%35%18%17%3%5%

Figure 2: PPrefs for next Rx following adjuvant anastrozole and then letrozole (LET) at first failure.ScenarioEndocrine RxTSCTOther Time to REC after TX with LET Met sitesFEXEEXE + EVESA/ComboCLT/RT to rib + no Rx change, Continue current NSAI + add FS3, N=1875 mths N-VIS42%6%37%7%9%S4, N=18612 mths N-VIS46%6%36%5%9%S5, N=9418 mths N-VIS65%5%21%3%6% Time to REC on FFEXEEXE + EVESA/ComboOther/CLTS6, N= 1866 mths N-VIS, VISN/O3%40%55%2%N/O - not offered

Conclusion:

MOPs PPrefs for management of pts with ER+, HER2- mBC are dictated by time to REC, number of RECs, and presence/absence of VIS disease. EXE and EVE has substantial traction in all scenarios studied. Since these PPref data were acquired, OS findings from the BOLERO-2 trial of EXE alone or EXE + EVE have been presented. PPrefs using these case scenarios will be studied at 2 additional events prior to SABCS, allowing more robust data and insights into the early impact of the BOLERO-2 survival data on PPrefs to be available at the meeting.

Citation Format: Mary E Cianfrocca, Arden D Buettner, Susan L Britton, Maria L Lankford, Mark R Green. Prescribing preferences of US-based medical oncology physicians for patients with hormone receptor positive, HER2 negative metastatic breast cancer following prior endocrine therapies [abstract]. In: Proceedings of the Thirty-Seventh Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2014 Dec 9-13; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2015;75(9 Suppl):Abstract nr P5-19-15.

A phase 1/pharmacokinetic study of sunitinib in combination with highly active antiretroviral therapy in human immunodeficiency virus-positive patients with cancer: AIDS Malignancy Consortium trial AMC 061

BACKGROUND

The treatment of non-acquired immunodeficiency syndrome-defining cancers may be complicated by drug interactions between highly active antiretroviral therapy (HAART) and chemotherapy. This trial is the first by the AIDS Malignancy Consortium to assess targeted therapies and HAART in human immunodeficiency virus-positive patients (ClinicalTrials.gov identifier: NCT00890747).

METHODS

In a modified phase 1 study of sunitinib, patients were stratified into 2 treatment arms based on whether they were receiving therapy with ritonavir, a potent CYP3A4 inhibitor. Patients in treatment arm 1 (non-ritonavir HAART) received standard sunitinib dosing (50 mg/day). Treatment arm 2 (ritonavir-based HAART) used a phase 1, 3 + 3 dose escalation design (from 25 mg/day to 50 mg/day). Cycles were comprised of 4 weeks on treatment followed by a 2-week break (6 weeks total). The pharmacokinetics of sunitinib and its active metabolite (N-desethyl sunitinib) were assessed.

RESULTS

Nineteen patients were enrolled and were evaluable. Patients on treatment arm 1 tolerated treatment with no dose-limiting toxicity observed. In treatment arm 2, a dose-limiting toxicity was experienced at a dose of 37.5 mg, and an additional 3 of 5 patients experienced grade 3 neutropenia (toxicity graded as per National Cancer Institute Common Terminology Criteria for Adverse Events [version 4.0]), an uncommon toxicity of sunitinib. No patient achieved a response, but 10 patients had stable disease, including 8 with prolonged disease stability. Efavirenz, a potent inducer of CYP3A4, resulted in increased exposure of N-desethyl sunitinib, whereas ritonavir caused decreased exposure of the metabolite. Hand-foot syndrome was associated with higher steady-state trough concentrations of sunitinib.

CONCLUSIONS

Patients receiving non-ritonavir-based HAART regimens tolerated standard dosing of sunitinib. Patients receiving ritonavir-based therapy who were treated with a dose of 37.5 mg/day experienced higher toxicities. Dose reductions of sunitinib to 37.5 mg may be warranted in patients receiving ritonavir.

Randomized phase II trial of gemcitabine versus gemcitabine and imatinib mesylate in patients with previously treated metastatic breast cancer

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Background: Gemcitabine (GEM) as a standard 30-min infusion has activity as a single-agent in metastatic breast cancer (mbc). Prolonged infusion of GEM at a fixed dose rate (FDR) of 10 mg/m2/min is associated with greater formation of active metabolite and may result in improved antitumor activity. Imatinib mesylate (IM)-mediated inhibition of PDGFR reduces tumor interstitial fluid pressure allowing for improved chemotherapy penetration into tumors. We evaluated the addition of IM to FDR GEM in patients (pts) with previously treated mbc. Methods: This was a randomized phase II trial in mbc pts who progressed after 1 but no more than 2 prior cytotoxic regimens. Eligibility included measurable disease; no prior GEM or IM exposure. Group 1 received FDR GEM IV 1250 mg/m2 at 10 mg/m2/min (over 120 min) on days 3 and 10 every 21 days; Group 2 received the same FDR GEM dose and schedule plus IM 400 mg orally daily on days 1-5 and 8-12 every 21 days. Primary endpoint was time to progression (TTP). Sample size of 40 pts per group was needed to detect an 8 mo increase in TTP with the combination (80% power, α = .05, 2-sided). Secondary endpoints included ORR and safety. Results: Between 5/2006-4/2011, 44 pts were randomized (22 per group). Study closed early due to slow accrual. Median age 54 (31-75); median ECOG PS 1 (0-2); 52% were hormone receptor-positive and HER2-negative; 27% triple-negative, and 20% HER2-positive. Median number of cycles was 2 in Group 1 (range 1-12) and 3.5 in Group 2 (range 1-13). Most common adverse events (%) of any grade, Group 1 vs Group 2 were neutropenia (68 vs. 78), anemia (48 vs. 65), thrombocytopenia (24 vs. 47), nausea (40 vs. 52) and vomiting (24 vs. 21). One gr 4 thrombotic thrombocytopenic purpura occurred in Group 2. Median TTP were 2 mo (95% CI: 1-5 mo) in Group 1 and 2.5 mo (95% CI: 1-5 mo) in Group 2 (p = 0.3 log rank test). ORR was 9.1% in each group (95% CI: 1.6-30.6%), with 2 PRs in each group. Stable disease (≥ 3 mo) was 32% in Group 1 and 41% in Group 2. Conclusions: This study was underpowered to draw any conclusion regarding a difference in TTP between the two groups at the time it was prematurely closed. Combination of IM and FDR GEM showed a trend to increased toxicity compared to FDR GEM alone. Clinical trial information: NCT00323063.

Aligning cancer quality metrics across the continuum of community-based and academic medicine using a prioritization tool

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Background: The Accountable Care Act (ACA) created a foundation for value based purchasing to increase quality of care. This resulted in a request for metrics from multiple organizations at both national and state levels interested in improving healthcare delivery through measurement. Competing with these are internal disease specific metrics requested by organizational leaders to judge the quality of services in their area. In 2009, Banner Health created a partnership with MD Anderson to form Banner MD Anderson Cancer Center. This partnership includes ensuring care provided across both organizations is comparable, and meets evidence based guidelines, including the challenges of developing and tracking clinical metrics that represented quality and value for both a community hospital and an academic medical center. Methods: Banner and MD Anderson compiled a list of all relevant external and internal metrics currently collected plus those in development to create a unified approach for collecting and comparison of cancer specific, hospital, physician, and department specific measures. However, both institutions faced the challenge of resource constraints, competing priorities and appropriate informatics infrastructure. To address this issue, an objective metrics prioritization tool was created based on Failure Mode and Effect Analysis and Quality Function Deployment methods used in quality improvement. The tool provides the flexibility of adjustable weights in the components of Quality, Data, and Organizational Utility for each organization. Results: Prior to the tool, both sites had no basis for comparison or strategic alignment as to which measures to report. The tool was independently scored by institution, resulting in 90% alignment. The remaining difference was attributed to variation in informatics systems and resource allocation. Conclusions: Data while limited, demonstrates that the tool provides an objective measure of comparison between two organizations. While it continues to evolve and require further testing, it does provide an opportunity to facilitate harmonization between measures and alignment of various stakeholders both internally and externally.

Phase I trial of pegylated liposomal doxorubicin and lapatinib in the treatment of metastatic breast cancer (MBC): Final results

610

Background: Liposomal formulations including pegylated liposomal doxorubicin (PLD) were developed to improve the therapeutic index of anthracyclines (A). Lapatinib (L) is a selective, highly competitive inhibitor of ErbB1 and ErbB2 tyrosine kinases. Conventional doxorubicin plus trastuzumab was effective but with unacceptable cardiac toxicity. PLD plus L may be effective with less cardiac risk. Methods: This is a phase I, dose-escalation trial of PLD 20, 30, 45 and 60 mg/m2 IV every 4 weeks (maximum of 8 doses) and L, 1500 mg po daily until progression in patients (pts) with MBC. ErbB2 positivity was not required. Prior chemotherapy, endocrine therapy and trastuzumab were allowed. A subsequent amendment allowed prior L. Prior A use was limited to 240 mg/m2 of doxorubicin or 600 mg/m2 of epirubicin. Concomitant CYP3A4 inducers/ inhibitors were not allowed. A left ventricular ejection fraction (LVEF) of > 50% was required. The primary objective was to evaluate the safety (particularly cardiac), tolerability and feasibility of PLD and L. Results: 23 pts (PLD: 20 mg/m2 - 4 pts; 30 mg/m2 - 3 pts; 45 mg/m2 – 13 pts; 60 mg/m2- 3 pts) have been treated; total of 73 treatment cycles. Dose-limiting toxicity (DLT) was not reached. One pt had an LVEF drop to < 50% after 4 cycles accompanied by a pericardial effusion due to progressive disease. Treatment-related grade III/IV adverse events included: 4 pts with hand-foot-syndrome (HFS), 2 pts each with leukopenia, infection, and skin changes, 1 pt each with pain, fatigue, diarrhea, mucositis, hypoalbuminemia, anemia, cough, pleural effusion, and edema. Grade 3 HFS occurred in 2 of 3 pts in the 60 mg/m2 cohort. Response data in 21 evaluable pts: 4 PR, 5 SD, and 12 PD. Preliminary pharmacokinetic (PK) analyses (7 pts) indicate L has no effect on PLD (45 mg/m2) concentrations, but L concentrations were approximately 2-fold higher the day of PLD dosing. Conclusions: In 23 pts treated, PLD plus L was well tolerated with manageable toxicities and no treatment-related cardiac toxicity. DLT was not reached however grade 3 HFS occurred in 2 of 3 pts in the 60 mg/m2 cohort. Preliminary PK analyses demonstrate no effect of L on PLD, but an effect of PLD on L the day of PLD dosing.

Phase 1 trial of the antiangiogenic peptide ATN-161 (Ac-PHSCN-NH(2)), a beta integrin antagonist, in patients with solid tumours

To evaluate the toxicity, pharmacological and biological properties of ATN-161, a five –amino-acid peptide derived from the synergy region of fibronectin, adult patients with advanced solid tumours were enrolled in eight sequential dose cohorts (0.1–16 mg kg⁻¹), receiving ATN-161 administered as a 10-min infusion thrice weekly. Pharmacokinetic sampling of blood and urine over 7 h was performed on Day 1. Twenty-six patients received from 1 to 14 4-week cycles of treatment. The total number of cycles administered to all patients was 86, without dose-limiting toxicities. At dose levels above 0.5 mg kg⁻¹, mean total clearance and volume of distribution showed dose-independent pharmacokinetics (PKs). At 8.0 and 16.0 mg kg⁻¹, clearance of ATN-161 was reduced, suggesting saturable PKs. Dose escalation was halted at 16 mg kg⁻¹ when drug exposure (area under the curve) exceeded that associated with efficacy in animal models. There were no objective responses. Six patients received more than four cycles of treatment (>112 days). Three patients received 10 or more cycles (⩾280 days). ATN-161 was well tolerated at all dose levels. Approximately, 1/3 of the patients in the study manifested prolonged stable disease. These findings suggest that ATN-161 should be investigated further as an antiangiogenic and antimetastatic cancer agent alone or with chemotherapy.

Routine mammography is associated with earlier stage disease and greater eligibility for breast conservation in breast carcinoma patients age 40 years and older

BACKGROUND

Reduction in breast carcinoma mortality is a major benefit of screening mammography and has been demonstrated in multiple randomized clinical trials and service screening programs. Another benefit from screening is that it allows the patient a wider choice of treatment options, particularly the possibility of conservation surgery. The current study analyzed the impact of mammography in the staging and treatment of breast carcinoma.

METHODS

A total of 1591 women aged > or = 40 years were treated for breast carcinoma between July 1995 and October 2001. Three subgroups were defined and compared. Group 1 had 192 patients with no previous mammography, Group 2 was comprised of 695 patients who underwent mammography on average less often than once yearly, and Group 3 was comprised of 704 patients who on average underwent mammography once yearly or more often.

RESULTS

The difference in tumor stage was found to be statistically significant between the groups (P < 0.0001). In Group 1, 15% of the patients had ductal carcinoma in situ (DCIS) compared with 21% of patients in Group 2 and 26% of patients in Group 3. In addition, 32% of patients in Group 1 had T1 tumors, whereas 50% of patients in Group 2 and 56% of patients in Group 3 had T1 tumors. The tumor size was < or = 1 cm in 8% of the patients in Group 1 compared with 20-23% of patients in Groups 2 and 3 (P = 0.0092). Breast conservation was an option for 41% of the patients in Group 1 but mastectomy was recommended in another 41% of patients. However, in Groups 2 and 3, 61% of patients were offered breast conservation and mastectomy was recommended to 28% (P < 0.0001).

CONCLUSIONS

In the current study, women age > or = 40 years with breast carcinoma who underwent mammography at least once yearly were diagnosed with DCIS more often compared with patients who underwent mammography less frequently or those who had no prior mammography. Women who underwent mammographic screening were found to have smaller tumors, which resulted in a majority of these patients being able to consider breast conservation as an alternative to mastectomy.