A randomized clinical trial testing two implementation strategies to promote the treatment of tobacco dependence in community mental healthcare

INTRODUCTION

People with serious mental illness (SMI) are more likely to smoke and less likely to receive tobacco treatment. Implementation strategies may address clinician and organizational barriers to treating tobacco in mental healthcare.

METHODS

A cluster-randomized trial (Clinic N=13, Client N=610, Staff N=222) tested two models to promote tobacco treatment in community mental healthcare: standard didactic training vs. Addressing Tobacco Through Organizational Change (ATTOC), an organizational model that provides clinician and leadership training and addresses system barriers to tobacco treatment. Primary outcomes were changes in tobacco treatment from clients, staff, and medical records. Secondary outcomes were changes in smoking, mental health, and quality of life (QOL), and staff skills and barriers to treat tobacco.

RESULTS

Clients at ATTOC sites reported a significant increase in receiving tobacco treatment from clinician at weeks 12 and 24 (ps<0.05) and tobacco treatments and policies from clinics at weeks 12, 24, 36, and 52 (ps<0.05), vs. standard sites. ATTOC staff reported a significant increase in skills to treat tobacco at week 36 (p=0.05), vs. standard sites. For both models, tobacco use medications, from clients (week 52) and medical records (week 36), increased (ps<0.05), while perceived barriers decreased at weeks 24 and 52 (ps<0.05); 4.3% of clients quit smoking which was not associated with model. QOL and mental health improved over 24 weeks for both models (ps<0.05).

CONCLUSIONS

Standard training and ATTOC improve use of evidence-based tobacco treatments in community mental healthcare without worsening mental health, but ATTOC may more effectively address this practice gap.

CD8+ T cells contribute to survival in patients with COVID-19 and hematologic cancer

Patients with cancer have high mortality from coronavirus disease 2019 (COVID-19), and the immune parameters that dictate clinical outcomes remain unknown. In a cohort of 100 patients with cancer who were hospitalized for COVID-19, patients with hematologic cancer had higher mortality relative to patients with solid cancer. In two additional cohorts, flow cytometric and serologic analyses demonstrated that patients with solid cancer and patients without cancer had a similar immune phenotype during acute COVID-19, whereas patients with hematologic cancer had impairment of B cells and severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)-specific antibody responses. Despite the impaired humoral immunity and high mortality in patients with hematologic cancer who also have COVID-19, those with a greater number of CD8 T cells had improved survival, including those treated with anti-CD20 therapy. Furthermore, 77% of patients with hematologic cancer had detectable SARS-CoV-2-specific T cell responses. Thus, CD8 T cells might influence recovery from COVID-19 when humoral immunity is deficient. These observations suggest that CD8 T cell responses to vaccination might provide protection in patients with hematologic cancer even in the setting of limited humoral responses.

Abstract LB052: Cell cycle synchronization: Biomarker analysis in a phase I trial of alternating ribociclib and paclitaxel in advanced breast cancer

Background:Cyclin dependent kinase 4/6 inhibitors (CDK 4/6i) are standard of care for hormone receptor positive, HER2 negative metastatic breast cancer (MBC), alone or in combination with endocrine therapy. Combination with paclitaxel (P) is possible with an intermittent, alternating dosing schedule in order to synchronize (sync) the cell cycle (cc) with a short burst of CDKi. To optimize this strategy, we measured cc biomarkers before, during and after a 4 day run in of ribociclib (R) in patients (pts) receiving R with P in a phase I clinical trial (NCT02599363). Methods:Eligible pts with Rb-positive MBC of any subtype and measurable disease were treated with 200, 400 or 600 mg of R on Days (D) 2-5, 9-12 and 16-19, and P 80mg/m2 on D1, 8, 15 and 22 in 28-day cycles (C). Skin biopsies, blood samples and FLT-PET CT were assessed at baseline (pre- R burst), D-3 (post R burst) and C1D1 P (after cc re-entry). Skin biopsies were analyzed for Ki-67 (Dako Santa Clara, CA), phospho-Rb (Ser807/811; Cell Signaling, Danvers, MA) and Rb (clone 1F8, Thermo Scientific, Waltham, MA) by IHC. Serum and plasma were analyzed for thymidine kinase (TK, Biovica, Sweden) and R pharmacokinetics (PK, WuXi, China) respectively.P-Rb and Rb results were binned for intensity and pattern of staining.Intensity was defined as None (0), Weak (W, 1+), Moderate (M, 2+), Strong (S, 3+). Pattern was defined as: Rare (R, &lt;10%), Focal (F, 10-50%) and Diffuse (D, &gt;50%). SUV max was averaged over the 5 brightest lesions.Results:13 pts enrolled to the Phase I trial. Nine pts had at least 1 skin biopsy; 8 had ≥2. Five pts had at least one FLT-PET. Biomarker results are summarized in table. Ki-67 (skin) and TK and FLT (tumor) drop after 4 days of R treatment, when R PK levels are highest. Decreases in P-Rb, were less consistent, observed in 4/8 (50%) pts. While R PK levels drop after 2 days off treatment, only 2/8 (25%) subjects had higher cell cycle measurements on C1D1 compared to baseline.Conclusions:CC synchronization with intermittent dosing is possible, and allows safe administration of P. More time off R is needed for cc re-entry. Future trials should give more time off of R before P delivery.

Pt ID (Dose(mg))TKi-67 (%)P-RbIntensity- PatternRbIntensity- PatternR PKR PKTK (Du/L)FLT(SUV*)LEE011(ng/mL)LEQ803(ng/mL)002 (200)B22M-FM-D002045n/a004 (200)B8M-RM-D00190311.6D-34NM-D69.612.01459.55.2C1D15M-RM-D16.96.5165310005 (200)B11M-RW-F0083212.4D-32M-RW-D83.013.8122.55.1C1D161M-FM-F17.56.18234.514.8006 (200)Bn/an/an/a009030.512.3D-3n/an/an/a15412.37429.59.6013 (200)B19M-FM-D008566.0D-33M-FW-F15815.8767.55.2007 (400)B8M-FM-D003070.5n/aD-31NM-D33230.82009.5n/a010 (400)B23M-FM-D001964.7D-30.5NM-F35929.322.74.1C1D14M-RM-D78.516.4&lt;204.0016 (400)B30M-RW-Dn/an/a75.56.4D-312W-FW-Dn/an/an/a4.1C1D110M-FW-Dn/an/a21.65.1017 (400)B17M-RW-Fn/an/a46.6n/aD-314M-RW-Dn/an/a23n/aC1D116M-RW-Fn/an/a&lt;20n/a014 (600)B15M-RW-D0n/an/an/aD-312M-RW-Dn/a106&lt;20n/aC1D126M-FW-Dn/an/a&lt;20n/a

Citation Format: Amy Clark, Azadeh Elmi, Nicholas P. McAndrew, Paul Wileyto, Natalie Shih, Michael Feldman, Mark Rosen, Jessica Savage, Robin Holmes, Nancy Dinubile, Theresa Berger, Erin Schubert, Alice Matthai, Melissa Volpe, Payal Shah, Susan Domchek, David Mankoff, Angela DeMichele. Cell cycle synchronization: Biomarker analysis in a phase I trial of alternating ribociclib and paclitaxel in advanced breast cancer [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2021; 2021 Apr 10-15 and May 17-21. Philadelphia (PA): AACR; Cancer Res 2021;81(13_Suppl):Abstract nr LB052.

Environmental exposomics and lung cancer risk assessment in the Philadelphia metropolitan area using ZIP code-level hazard indices

To illustrate methods for assessing environmental exposures associated with lung cancer risk, we investigated anthropogenic based air pollutant data in a major metropolitan area using United States-Environmental Protection Agency (US-EPA) Toxic Release Inventory (TRI) (1987-2017), and PM2.5 (1998-2016) and NO2 (1996-2012) concentrations from NASA satellite data. We studied chemicals reported according to the following five exposome features: (1) International Agency for Research on Cancer (IARC) cancer grouping; (2) priority EPA polycyclic aromatic hydrocarbons (PAHs); (3) component of diesel exhaust; (4) status as a volatile organic compound (VOC); and (5) evidence of lung carcinogenesis. Published articles from PubChem were tallied for occurrences of 10 key characteristics of cancer-causing agents on those chemicals. Zone Improvement Plan (ZIP) codes with higher exposures were identified in two ways: (1) combined mean exposure from all features, and (2) hazard index derived through a multi-step multi-criteria decision analysis (MMCDA) process. VOCs, IARC Group 1 carcinogens consisted 82.3% and 11.5% of the reported TRI emissions, respectively. ZIP codes along major highways tended to have greater exposure. The MMCDA approach yielded hazard indices based on imputed toxicity, occurrence, and persistence for risk assessment. Despite many studies describing environmental exposures and lung cancer risk, this study develops a method to integrate these exposures into population-based exposure estimates that could be incorporated into future lung cancer screening trials and benefit public health surveillance of lung cancer incidence. Our methodology may be applied to probe other hazardous exposures for other cancers.

Abstract PD9-10: Investigating the clinical utility of tumor mutational burden in predicting rapid progression and death in patients with metastatic breast cancer

Background Up to 30% of breast cancer patients will eventually relapse with metastatic disease. With an increasing array of therapeutic options, there is an ongoing need for predictive biomarkers to help guide treatment strategies including sequencing of therapies in the metastatic setting. We sought to evaluate the prognostic and predictive potential of a panel-specific tumor mutational burden (TMB) in metastatic breast cancer patients.

Methods METAMORPH is a prospective, longitudinal cohort study. Eligible patients (pts) had newly diagnosed or progressive metastatic breast cancer and enrolled prior to starting a new line of therapy (physician’s choice) at the University of Pennsylvania. Pts underwent tissue biopsy of a suspected metastatic site. Tumor samples were analyzed for mutations and copy number alterations (CNA’s) using our institution’s CLIA-certified Center for Personalized Diagnostics (CPD) targeted gene panel, which evolved over the course of the study from 20 genes to 152 genes. TMB-high (TMB-H) was defined as ≥3 mutations and/or copy-number gains (CNG) among 18 genes shared across all panel versions. Pts were followed for time to progression (TTP), progression-free survival (PFS), and overall survival (OS). The frequency of rapid progressors and rapid death (defined as having progressed or died within 3 months of enrollment, respectively) was assessed.

Results Three hundred pts enrolled from 2013-2020, of whom 200 pts had CPD reports generated. Of these, 12 pts were excluded due to either no treatment change on enrollment (n=11) or different primary cancer on biopsy (n=1). Thus 188 pts were included in this analysis. The median age was 55 years (range 28-79). 77% of pts identified as white, 18% as Black or African American, and 3.2% as Asian. Pts had a median of 1 line (range 0-12) of prior systemic therapy in the metastatic setting. 46.8% had no prior therapies for MBC, while 31% had ≥3 prior lines of therapy. 74.4% were HR+, 22.8% TNBC, and 2.7% HR-/HER2+. 6.9% of the cohort were classified as TMB-H. The average mutation/CNG rate was 2.2/sample, and 22.5% had no mutations or CNA’s. The most common mutations were TP53 (35%) and PIK3CA (26%).

While TMB-H patients showed a statistically non-significant trend towards shorter median TTP and PFS compared with TMB-L, they comprised a significantly greater proportion of rapid progressors (54.5% vs 24.1%, p=0.027), with an odds ratio for rapid progression of 3.8 (95% CI 1.08-13.2). In a multivariate logistic regression analysis, TMB-H remained independently associated with rapid progression when adjusted for receptor subtype and next line of therapy. Receptor subtype analysis revealed that ER- (including ER-/PR+) patients with TMB-H had a shorter median TTP compared to ER- TMB-L (147 vs 68 days, p=0.03). TMB-H was also associated with significantly shorter OS compared with TMB-L (587 vs 648 days, p=0.02; HR 2.2 [95% CI 1.11-4.41]). 44.4% of TMB-H pts died within 3 months of enrollment, as compared to 11.0% of TMB-L pts (p=0.005), with an odds ratio for rapid death, adjusted for number of previous lines of therapy and receptor subtype, of 6.7 (95% CI 1.5-31.0).

Conclusion MBC pts who are TMB-H represent a population who are highly resistant to standard therapies, progress rapidly, and have significantly shorter overall survival with more rapid time to death. Our data support further studies investigating the utility of TMB as a predictive biomarker in directing patients away from standard treatment options and towards novel approaches e.g. immunotherapy.

Citation Format: Igor Makhlin, Amy S Clark, Paul Wileyto, Noah Goodman, John Ndicu, Shannon DeLuca, Candace Clark, S. William Stavropoulos, Natalie Shih, Michael D Feldman, Susan M Domchek, Jennifer M Matro, Payal D Shah, Hayley M Knollman, Kevin R Fox, Kara N Maxwell, Lewis A Chodosh, Angela DeMichele. Investigating the clinical utility of tumor mutational burden in predicting rapid progression and death in patients with metastatic breast cancer [abstract]. In: Proceedings of the 2020 San Antonio Breast Cancer Virtual Symposium; 2020 Dec 8-11; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2021;81(4 Suppl):Abstract nr PD9-10.

Abstract OT-33-01: Combination ipatasertib and atezolizumab to prevent recurrence in triple negative breast cancer(TNBC): A phase II single arm trial

Background: TNBC patients with residual disease after neoadjuvant chemotherapy (NAC) have high recurrence rates. Targetable mechanisms likely responsible for NAC resistance must therefore be identified to identify new therapeutic options. Alterations in the PI3K/mTOR pathway as well as expression of the immune checkpoint PD-L1 have emerged as potential targets, with significant frequency of alteration in TNBC. Importantly, the AKT inhibitor ipatasertib (ipat) and the anti-PD-L1 antibody atezolizumab (atezo) have demonstrated activity against TNBC. Recent data suggests that the presence of circulating tumor cell-free DNA (cfDNA) following NAC correlates with residual disease and a higher recurrence risk. We have hypothesized that combination therapy with ipat and atezo will target micrometastatic disease, as determined by the presence of cfDNA after NAC, in TNBC patients. Trial design:Open label single-arm phase II study to evaluate combination therapy with ipat and atezo, in TNBC patients with detectable cfDNA after completion of NAC, definitive surgery, and adjuvant radiation and/or chemotherapy. Eligible patients will receive: atezo [840mg IV days 1 and 15 and ipat [400 mg orally daily on days 1-21, followed by one week off] in a 28-day cycle for 6 cycles; cfDNA will be evaluated after 3 and 6 cycles. Biomarkers including PD-L1 expression on tumor cells or infiltrating immune cells in the primary tumor or PD-L1 expression on circulating tumor cells will be assessed. Eligibility criteria:Patients ≥ 18 yrs of age with pathologically confirmed residual invasive TNBC (ER and PR negative defined as &lt;10% of cells expressing ER/PR by local assessment; HER2 negative according to ASCO/CAP guidelines) following NAC with evidence of cfDNA after completion of all local and systemic neoadjuvant and adjuvant therapy. Patients must enroll within 12 months of last therapy (definitive breast surgery, radiation and/or all intended adjuvant therapy). Prior treatment with immunotherapeutic agents is allowed. Specific aims:The primary objective is to evaluate the efficacy of 6 cycles of ipat + atezo in reducing micrometastatic disease (detectable cfDNA) in patients with residual breast and/or axillary disease after NAC and completion of all locoregional and/or systemic adjuvant therapy. Secondary objectives include: evaluating efficacy of ipat + atezo in reducing micrometastatic disease after 3 cycles; determining the recurrence risk after treatment with ipat + atezo; and determining the safety and tolerability of the combination. Correlative objectives include determining whether: 1) pretreatment circulating markers (mutations or copy number changes in PTEN/PI3K/AKT) are associated with response; 2) PD-L1 expression on tumor cells or infiltrating tumor cells in the primary tumor is associated with response; 3) PD-L1 expression on circulating tumor cells has utility as a pharmacodynamic biomarker; and 4) stool microbiome profiles are associated with response and/or survival. As an exploratory objective, patient attitudes and experience surrounding testing for tumor cfDNA and, for those testing positive, participation in a trial targeting cfDNA, will be assessed. Statistical methods:The primary objective is to determine the response rate defined as the proportion of patients with detectable cfDNA who become undetectable. We anticipate that 30% of patients screened will be tumor cfDNA-positive, thus anticipate screening ~ 120 patients to enroll 40. With 40 patients enrolled (assuming a one-sided alpha of 0.05), we will have 80% power to detect a 19.0% (81% positive versus 93% positive) clearance rate using a one-sample binomial exact test. Target Accrual:40 patients Contact:A. DeMichele (angela.demichele@pennmedicine.upenn,edu) Clinicaltrials.gov #: NCT04434040

Citation Format: Elizabeth Mittendorf, Sara Tolaney, Paul Wileyto, Michelle DeMeo, Hope Rugo, Rita Nanda, Ingrid Mayer, Ben Park, Heather MacArthur, Angela DeMichelle. Combination ipatasertib and atezolizumab to prevent recurrence in triple negative breast cancer(TNBC): A phase II single arm trial [abstract]. In: Proceedings of the 2020 San Antonio Breast Cancer Virtual Symposium; 2020 Dec 8-11; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2021;81(4 Suppl):Abstract nr OT-33-01.

CD8 T cells compensate for impaired humoral immunity in COVID-19 patients with hematologic cancer

Cancer patients have increased morbidity and mortality from Coronavirus Disease 2019 (COVID-19), but the underlying immune mechanisms are unknown. In a cohort of 100 cancer patients hospitalized for COVID-19 at the University of Pennsylvania Health System, we found that patients with hematologic cancers had a significantly higher mortality relative to patients with solid cancers after accounting for confounders including ECOG performance status and active cancer status. We performed flow cytometric and serologic analyses of 106 cancer patients and 113 non-cancer controls from two additional cohorts at Penn and Memorial Sloan Kettering Cancer Center. Patients with solid cancers exhibited an immune phenotype similar to non-cancer patients during acute COVID-19 whereas patients with hematologic cancers had significant impairment of B cells and SARS-CoV-2-specific antibody responses. High dimensional analysis of flow cytometric data revealed 5 distinct immune phenotypes. An immune phenotype characterized by CD8 T cell depletion was associated with a high viral load and the highest mortality of 71%, among all cancer patients. In contrast, despite impaired B cell responses, patients with hematologic cancers and preserved CD8 T cells had a lower viral load and mortality. These data highlight the importance of CD8 T cells in acute COVID-19, particularly in the setting of impaired humoral immunity. Further, depletion of B cells with anti-CD20 therapy resulted in almost complete abrogation of SARS-CoV-2-specific IgG and IgM antibodies, but was not associated with increased mortality compared to other hematologic cancers, when adequate CD8 T cells were present. Finally, higher CD8 T cell counts were associated with improved overall survival in patients with hematologic cancers. Thus, CD8 T cells likely compensate for deficient humoral immunity and influence clinical recovery of COVID-19. These observations have important implications for cancer and COVID-19-directed treatments, immunosuppressive therapies, and for understanding the role of B and T cells in acute COVID-19.

Abstract PR06: Geocoding and integrating multiple environmental exposomics sources: Assessing population hazard to lung carcinogens in 421 zip codes of a cancer center catchment area

To assess risk factors that contribute to lung cancer burden in the Abramson Cancer Center (ACC) catchment area, we integrated geospatial data of exposure to pollutants from publicly available EPA and NASA datasets. The study area covers the 421 zip codes that make up the 12 counties of the catchment area from which most of the ACC patients come. The counties include 5 that surround Philadelphia, 6 in New Jersey, and 1 in Delaware. Environmental exposure data, sourced from US-EPA Air Quality System (AQS) Data Mart, were focused on air pollutants since air pollution is recognized by the International Agency on Cancer (IARC) as a Group 1 human carcinogen. Exposomics data included: hourly, daily, and annual (1980 -2018) PM2.5, PM10, NO2; Hazardous Air Pollutants (HAPS); Volatile Organic Compounds (VOCs); (Air Quality Index) AQI; NONOxNOy monitoring; and annual Toxic Release Inventory (TRI) air emissions by chemical classifier and point source (1987 -2017). Annual NASA satellite-derived grids were incorporated for PM2.5 (1998-2016; 1 km resolution) and NOx (1997 - 2012; 10 km resolution). ESRI’s ArcGIS was used to develop programming scripts to automate the process of data integration, geocoding, and classifying chemical parameters by (1) status as a lung carcinogen with sufficient evidence of lung carcinogenesis; (2) status as one of the priority 16 EPA polycyclic aromatic hydrocarbons, as a surrogate marker of exposure to carcinogens; (3) status in the IARC rankings for Cancer Group; (4) status as a component of diesel exhaust; and (5) status as a VOC. 1-km search radius kernel density grids were generated for each air pollutant. We sliced the density estimates into ordinal rankings ranging from “10 = high” to “1 = low.” A hazard index may be generated by summing data layers of cumulative environmental exposomics in a process called map algebra. Spatial sorting and merging of exposome releases by facility, year, chemical and zip code concentration allow for addressing “low-hanging fruit” through summary statistics. Although the focus of this investigation is on lung cancer, the utility of the methodology may be applied to probe exposures related to other cancers. Incorporating more years or larger geographic areas of study may make exploring the risk of exposure possible for less prevalent cancers. In future studies, we are conducting statistical analysis to determine whether geocoded exposure data predict lung cancer risks in those vulnerable zip codes using electronic health record data of geolocations of lung cancer patients. This novel approach will help determine whether geocoded exposomics data are associated with cancer incidence. The hazard index was used to identify zip codes that are the most vulnerable to carcinogen exposure. Zip codes 19720, 19061, 08066, 08027, 19153, and 19145 scored highest on the hazard index based on cumulative exposure. (Supported by P30-CA-016520 and P30-ES013508.)

This abstract is also being presented as Poster A08.

Citation Format: Thomas P. McKeon, Vicky Tam, Wei-Ting Hwang, Paul Wileyto, Karen Glanz, Trevor M. Penning. Geocoding and integrating multiple environmental exposomics sources: Assessing population hazard to lung carcinogens in 421 zip codes of a cancer center catchment area [abstract]. In: Proceedings of the AACR Special Conference on Modernizing Population Sciences in the Digital Age; 2019 Feb 19-22; San Diego, CA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(9 Suppl):Abstract nr PR06.

Understanding Respiratory Restrictions as a Function of the Scoliotic Spinal Curve in Thoracic Insufficiency Syndrome: A 4D Dynamic MR Imaging Study

BACKGROUND

Over the past 100 years, many procedures have been developed for correcting restrictive thoracic deformities which cause thoracic insufficiency syndrome. However, none of them have been assessed by a robust metric incorporating thoracic dynamics. In this paper, we investigate the relationship between radiographic spinal curve and lung volumes derived from thoracic dynamic magnetic resonance imaging (dMRI). Our central hypothesis is that different anteroposterior major spinal curve types induce different restrictions on the left and right lungs and their dynamics.

METHODS

Retrospectively, we included 25 consecutive patients with thoracic insufficiency syndrome (14 neuromuscular, 7 congenital, 4 other) who underwent vertical expandable prosthetic titanium rib surgery and received preimplantation and postimplantation thoracic dMRI for clinical care. We measured thoracic and lumbar major curves by the Cobb measurement method from anteroposterior radiographs and classified the curves as per Scoliosis Research Society (SRS)-defined curve types. From 4D dMRI images, we derived static volumes and tidal volumes of left and right lung, along with left and right chest wall and left and right diaphragm tidal volumes (excursions), and analyzed their association with curve type and major curve angles.

RESULTS

Thoracic and lumbar major curve angles ranged from 0 to 136 and 0 to 116 degrees, respectively. A dramatic postoperative increase in chest wall and diaphragmatic excursion was seen qualitatively. All components of volume increased postoperatively by up to 533%, with a mean of 70%. As the major curve, main thoracic curve (MTC) was associated with higher tidal volumes (effect size range: 0.7 to 1.0) than thoracolumbar curve (TLC) in preoperative and postoperative situation. Neither MTC nor TLC showed any meaningful correlation between volumes and major curve angles preoperatively or postoperatively. Moderate correlations (0.65) were observed for specific conditions like volumes at end-inspiration or end-expiration.

CONCLUSIONS

The relationships between component tidal volumes and the spinal curve type are complex and are beyond intuitive reasoning and guessing. TLC has a much greater influence on restricting chest wall and diaphragm tidal volumes than MTC. Major curve angles are not indicative of passive resting volumes or tidal volumes.

LEVEL OF EVIDENCE

Level II-diagnostic.

Abstract OT2-07-09: Detection and targeting of minimal residual disease in breast cancer to reduce recurrence: The PENN-SURMOUNT and CLEVER trials

Background:

Recurrent breast cancers arise from minimal residual disease (MRD): the pool of disseminated and circulating tumor cells (DTCs and CTCs) that survive in their host following treatment of primary breast cancer. Detection of DTCs in the bone marrow (BM) after treatment is strongly associated with an increased risk of recurrence. Through the analysis of novel genetically-engineered mouse models, we have generated a substantial body of evidence that autophagy and mTOR signaling play key roles in the survival of DTCs. Moreover, administration of agents that block these pathways in mice harboring MRD reduces DTC burden and concomitantly reduces tumor recurrence, providing the rationale for translating these findings to patients (pts).

Trial Design:

The PENN-SURMOUNT screening study uses a clinically validated IHC assay (DTC-IHC) to identify at-risk pts who harbor DTCs. DTC+ pts are eligible for enrollment on the CLEVER trial, which will determine the feasibility, safety and efficacy of administering hydroxychloroquine (HCQ) and/or everolimus (EVE) in DTC+ patients to target MRD and prevent recurrence. PENN-SURMOUNT is single center, prospective cohort study of pts who have completed therapy for primary breast cancer, are within 5 yrs of diagnosis and are at increased risk for relapse by virtue of nodal positivity, triple negative disease, ER+/Oncotype DX RS ≥ 25, or residual disease after neoadjuvant therapy. Pts undergo screening BM aspirate to test for DTCs following completion of adjuvant chemo and radiotherapy. The primary objective of the study is to determine the incidence and frequency of MRD in pts who have completed primary treatment for breast cancer and to ascertain eligibility for the CLEVER recurrence prevention trial.

CLEVER is a randomized, controlled, open label phase II pilot trial. Target enrollment is 60 pts, with 15 pts allocated to each of 4 treatment arms: HCQ (600 mg BID), EVE (10mg daily), combination HCQ/EVE, or control/observation. A cycle is 28 days of continuous dosing. After a 3-month observation period, control pts will be offered HCQ/EVE therapy for 6 cycles; thus, the control group is actually a delayed treatment group and all pts will receive treatment. Pts who demonstrate persistent DTCs after 6 cycles will continue on combination therapy for an additional 6 cycles. The primary endpoint is feasibility of administering HCQ, EVE or the combination in this population. Secondary objectives include safety, efficacy (DTC reduction), and 3-year RFS. The principal translational objective is to assess the utility of a novel DTC assay, "DTC-Flow", for more sensitive detection and response to study therapy, compared to DTC-IHC. Additional translational objectives include determining whether patient DTCs, CTCs, and cell-free circulating plasma tumor DNA (ptDNA) biologically reflect the primary tumor and predict response.

As of 5/23/17, 58 patients have been enrolled to PENN SURMOUNT, with a DTC-positivity rate of 22.6%; CLEVER opened in 2/2017; 11 patients are currently enrolled. Contact information: angela.demichele@uphs.upenn.edu

Key words: Recurrence, disseminated tumor cells, dormancy, minimal residual disease, autophagy, mTOR, Everolimus, hydroxychloroquine

Citation Format: Bayne LJ, Nivar I, Goodspeed B, Wileyto P, Savage J, Shih NNC, Feldman MD, Edwards J, Clark AS, Fox KR, Matro JM, Domchek SM, Bradbury AR, Shah PD, Chislock EM, Belka GK, Wang J, Amaravadi R, Chodosh LA, DeMichele AM. Detection and targeting of minimal residual disease in breast cancer to reduce recurrence: The PENN-SURMOUNT and CLEVER trials [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 OT2-07-09.

Effect of Eischens Yoga During Radiation Therapy on Prostate Cancer Patient Symptoms and Quality of Life: A Randomized Phase II Trial

PURPOSE

A randomized phase II study was performed to measure the potential therapeutic effects of yoga on fatigue, erectile dysfunction, urinary incontinence, and overall quality of life (QOL) in prostate cancer (PCa) patients undergoing external beam radiation therapy (RT).

METHODS AND MATERIALS

The participants were randomized to yoga and no-yoga cohorts (1:1). Twice-weekly yoga interventions were offered throughout the 6- to 9-week courses of RT. Comparisons of standardized assessments were performed between the 2 cohorts for the primary endpoint of fatigue and the secondary endpoints of erectile dysfunction, urinary incontinence, and QOL before, during, and after RT.

RESULTS

From October 2014 to January 2016, 68 eligible PCa patients underwent informed consent and agreed to participate in the study. Of the 68 patients, 18 withdrew early, mostly because of treatment schedule-related time constraints, resulting in 22 and 28 patients in the yoga and no-yoga groups, respectively. Throughout treatment, those in the yoga arm reported less fatigue than those in the control arm, with global fatigue, effect of fatigue, and severity of fatigue subscales showing statistically significant interactions (P<.0001). The sexual health scores (International Index of Erectile Function Questionnaire) also displayed a statistically significant interaction (P=.0333). The International Prostate Symptom Score revealed a statistically significant effect of time (P<.0001) but no significant effect of treatment (P=.1022). The QOL measures had mixed results, with yoga having a significant time by treatment effect on the emotional, physical, and social scores but not on functional scores.

CONCLUSIONS

A structured yoga intervention of twice-weekly classes during a course of RT was associated with a significant reduction in pre-existing and RT-related fatigue and urinary and sexual dysfunction in PCa patients.

Diffusion of an Evidence-Based Smoking Cessation Intervention Through Facebook: A Randomized Controlled Trial

OBJECTIVES

To examine the diffusion of an evidence-based smoking cessation application ("app") through Facebook social networks and identify specific intervention components that accelerate diffusion.

METHODS

Between December 2012 and October 2013, we recruited adult US smokers ("seeds") via Facebook advertising and randomized them to 1 of 12 app variants using a factorial design. App variants targeted components of diffusion: duration of use (t), "contagiousness" (β), and number of contacts (Z). The primary outcome was the reproductive ratio (R), defined as the number of individuals installing the app ("descendants") divided by the number of a seed participant's Facebook friends.

RESULTS

We randomized 9042 smokers. App utilization metrics demonstrated between-variant differences in expected directions. The highest level of diffusion (R = 0.087) occurred when we combined active contagion strategies with strategies to increase duration of use (incidence rate ratio = 9.99; 95% confidence interval = 5.58, 17.91; P < .001). Involving nonsmokers did not affect diffusion.

CONCLUSIONS

The maximal R value (0.087) is sufficient to increase the numbers of individuals receiving treatment if applied on a large scale. Online interventions can be designed a priori to spread through social networks.

The relationship between the nicotine metabolite ratio and three self-report measures of nicotine dependence across sex and race

RATIONALE

Variability in the rate of nicotine metabolism, measured by the nicotine metabolite ratio (NMR), is associated with smoking behavior. However, data linking the NMR with nicotine dependence measured by the Fagerström test for nicotine dependence (FTND) are mixed. Few past studies have examined alternative measures of nicotine dependence and how this relationship may vary by sex and race.

OBJECTIVE

Using data from smokers undergoing eligibility evaluation for a smoking cessation clinical trial (n = 833), this study examined variability in the relationship between NMR and nicotine dependence across sex and race and using three measures of nicotine dependence: FTND, time-to-first-cigarette (TTFC), and the heaviness of smoking index (HSI).

RESULTS

Controlling for sex and race, nicotine metabolism was associated with nicotine dependence only when using the HSI (p < 0.05). Male normal metabolizers of nicotine were more likely to have high nicotine dependence based on the FTND and HSI (p < 0.05), but NMR was not related to measures of nicotine dependence in women. For African Americans, the NMR was associated with nicotine dependence only for the TTFC (p < 0.05), but NMR was not associated with nicotine dependence among Caucasians. Post hoc analyses indicated that the NMR was associated with cigarettes per day, overall, and among men and Caucasians (p < 0.05).

CONCLUSIONS

While there was some variation in the relationship between nicotine metabolism and nicotine dependence across measures and sex and race, the results indicate that this relationship may be more attributable to the association between NMR and cigarettes per day.

Risk factors for recurrence amongst high intermediate risk patients with endometrioid adenocarcinoma

Objective

To determine risk factors associated with recurrence in patients with high intermediate risk (HIR) endometrioid adenocarcinoma.

Methods

A retrospective analysis of patients with HIR endometrioid adenocarcinoma who underwent hysterectomy, bilateral salpingo-oophorectomy, with or without pelvic/para-aortic lymphadenectomy at the University of Pennsylvania between 1990 and 2009 was performed.

Results

A total of 103 women with HIR endometrial cancer were identified. Multivariable analysis revealed that ≥2/3 myometrial invasion (HR, 4.79; p=0.010) and grade 3 disease (HR, 3.04; p=0.045) were independently predictive of distant metastases. The 5-year distant metastases free survival (DMFS) for patients with neither or one of these risk factors was 89%, and the 5-year DMFS for patients with both risk factors was 48% (p<0.001).

Conclusion

Patients with both grade 3 disease and deep third myometrial invasion have a high risk of distant metastases. Identifying these patients may be important in rationally selecting patients for systemic therapy.

Randomized controlled trial of a psychosocial telephone counseling intervention in BRCA1 and BRCA2 mutation carriers

BACKGROUND

Responses following BRCA1/2 genetic testing are relevant for the comprehension of risk status and may play a role in risk management decision making. The objective of this study was to evaluate a psychosocial telephone counseling (PTC) intervention delivered to BRCA1/2 mutation carriers following standard genetic counseling (SGC). We examined the effect of the intervention on distress and the concerns related to genetic testing.

METHODS

This prospective randomized clinical trial included 90 BRCA1/2 mutation carriers. We measured anxiety, depression, and genetic testing distress outcomes at intervention baseline and 6 and 12 months following disclosure. We evaluated the effects of SGC versus SGC plus PTC on psychological outcomes using intention-to-treat analyses through generalized estimating equations.

RESULTS

At 6 months, PTC reduced depressive symptoms (Z = -2.25, P = 0.02) and genetic testing distress (Z = 2.18, P = 0.02) compared with SGC. Furthermore, women in the intervention condition reported less clinically significant anxiety at 6 months (chi(2)(1) = 4.11, P = 0.04) than women who received SGC. We found no differences in outcomes between the intervention groups at the 12-month follow-up.

CONCLUSIONS

As an adjunct to SGC, PTC delivered following disclosure of positive BRCA1/2 test results seems to offer modest short-term benefits for distress and anxiety. These results build upon a growing literature of psychosocial interventions for BRCA1/2 carriers and, given the potential impact of affect on risk management decision making, suggest that some carriers may derive benefits from adjuncts to traditional genetic counseling.

Distinguishing risk factors for the onset of cravings, withdrawal symptoms and tolerance in novice adolescent smokers

AIM

While many studies report determinants of adolescent cigarette smoking, few identify risk factors for nicotine dependence (ND). This study distinguished between risk factors for three hallmarks of ND including cravings, withdrawal symptoms and tolerance.

METHODS

A total of 319 novice smokers were followed every 3 months from first puff on a cigarette until the end of secondary school. Outcomes included time to first report of cravings, withdrawal symptoms and tolerance.

RESULTS

Female sex, inhalation, smoking a whole cigarette, weekly smoking, daily smoking and alcohol use each independently increased the incidence of the onset of cravings. Inhalation, weekly smoking, daily smoking and alcohol use predicted the onset of withdrawal symptoms. Withdrawal symptoms, smoking a whole cigarette, monthly smoking, daily smoking and friends and siblings smoking increased the incidence of the onset of tolerance. None of parental education, impulsivity, novelty seeking, self-esteem, depression, stress, parental smoking, physical activity, or participation in sports teams was associated with the outcomes.

CONCLUSION

The hallmarks of early ND are related to intensity and frequency of cigarette use. Avoidance of daily smoking may be particularly important in preventing the onset of ND symptoms and sustained smoking.

Effect of bupropion on depression symptoms in a smoking cessation clinical trial

Bupropion is an antidepressant shown to be efficacious for smoking cessation. This study examined the short- and long-term effects of bupropion (300 mg/day for 10 weeks) versus placebo on depression symptoms among 497 smokers attempting to quit in a randomized trial of bupropion plus behavioral counseling. Depression symptoms were assessed via the Center for Epidemiological Studies Depression Scale (L. Radloff, 1977) at baseline, end of treatment, and at 6-month follow-up. Baseline nicotine dependence level was assessed with the Fagerström Test for Nicotine Dependence (T. F. Heatherton, L. T. Kozlowski, R. C. Frecker, & K. O. Fagerstrom, 1991). A regression model of depression symptoms demonstrated a significant interaction between nicotine dependence and treatment for the treatment phase and during follow-up. Depression symptoms did not mediate the effects of bupropion on abstinence at either time point. Highly nicotine-dependent smokers who receive bupropion are more likely to experience a decrease in depressive symptoms during active treatment but are also more likely to experience a rebound in depressive symptoms when bupropion is discontinued.

Do small lapses predict relapse to smoking behavior under bupropion treatment?

Although bupropion is known to be an effective aid to smoking cessation, little is known about its mode of action. In the present study we tested the hypothesis that bupropion reduces the likelihood that a smoking lapse, or slip, leads to a subsequent relapse. This hypothesis was tested in the context of a clinical trial of bupropion as a smoking cessation aid, using Cox regression and representing lapse history as a discrete time-varying covariate. Bupropion treatment reduced the probability of relapse during the treatment phase (hazard ratio, or HR=.421, p< or =.000) but not during the follow-up phase (end of treatment to 6 months, HR=.896, p< or=.67). As anticipated, having small lapses during treatment contributed to or predicted subsequent relapse, both during treatment (HR=2.897, p< or =.000) and during follow-up (HR=2.320, p< or=.008). Although an interaction was found between drug treatment and lapse history in predicting subsequent failure during the treatment phase, the finding suggested that drug slightly increased the effect of lapse on eventual failure during treatment (HR=1.706, p<or=.012). No evidence was found that the effect of this interaction carried forward into follow-up (HR=1.500, p<or=.30). Although the mechanisms of action of bupropion may best be addressed in a human laboratory study, results from this clinical trial suggest that the effectiveness of bupropion treatment is not attributable to reducing the effect of a lapse in predicting relapse.

Individual differences in nicotine intake per cigarette

The increase in levels of blood nicotine that occurs from smoking a single cigarette, sometimes referred to as a "nicotine boost," is an individualized measure of how much nicotine has been extracted from smoking a cigarette. This study investigated the demographic, smoking status, and psychological predictors of nicotine boost in a sample of 190 treatment-seeking smokers. Boost was assessed by comparing plasma nicotine levels before and after participants smoked one of their own brand cigarettes ad libitum. Positive affect (mood) was a significant positive predictor of nicotine boost, controlling for baseline cotinine levels and cigarette brand (Federal Trade Commission) nicotine delivery. However the proportion of variability accounted for in the model was relatively small (5%). Future research on individual differences in nicotine boost is warranted to clarify the role of psychological, physiological, and cigarette-related determinants.