Genome-matched treatments and patient outcomes in the Maine Cancer Genomics Initiative (MCGI)

Genomic tumor testing (GTT) is an emerging technology aimed at identifying variants in tumors that can be targeted with genomically matched drugs. Due to limited resources, rural patients receiving care in community oncology settings may be less likely to benefit from GTT. We analyzed GTT results and observational clinical outcomes data from patients enrolled in the Maine Cancer Genomics Initiative (MCGI), which provided access to GTTs; clinician educational resources; and genomic tumor boards in community practices in a predominantly rural state. 1603 adult cancer patients completed enrollment; 1258 had at least one potentially actionable variant identified. 206 (16.4%) patients received a total of 240 genome matched treatments, of those treatments, 64% were FDA-approved in the tumor type, 27% FDA-approved in a different tumor type and 9% were given on a clinical trial. Using Inverse Probability of Treatment Weighting to adjust for baseline characteristics, a Cox proportional hazards model demonstrated that patients who received genome matched treatment were 31% less likely to die within 1 year compared to those who did not receive genome matched treatment (HR: 0.69; 95% CI: 0.52-0.90; p-value: 0.006). Overall, GTT through this initiative resulted in levels of genome matched treatment that were similar to other initiatives, however, clinical trials represented a smaller share of treatments than previously reported, and "off-label" treatments represented a greater share. Although this was an observational study, we found evidence for a potential 1-year survival benefit for patients who received genome matched treatments. These findings suggest that when disseminated and implemented with a supportive infrastructure, GTT may benefit cancer patients in rural community oncology settings, with further work remaining on providing genome-matched clinical trials.

The Maine Cancer Genomics Initiative: Implementing a Community Cancer Genomics Program Across an Entire Rural State

PURPOSE

The Maine Cancer Genomics Initiative (MCGI) aimed to overcome patient- and provider-level barriers to using genomic tumor testing (GTT) in rural practices by providing genomic tumor boards (GTBs), clinician education, and access to comprehensive large-panel next-generation sequencing to all patients with cancer in Maine. This paper describes the successful implementation of the initiative and three key services made operative between 2016 and 2020.

METHODS

A community-inclusive, hub-and-spoke approach was taken to implement the three program components: (1) a centralized GTB program; (2) a modular online education program, designed using an iterative approach with broad clinical stakeholders; and (3) GTT free of charge to clinicians and patients. Implementation timelines, participation metrics, and survey data were used to describe the rollout.

RESULTS

The MCGI was launched over an 18-month period at all 19 oncology practices in the State. Seventy-nine physicians (66 medical oncologists, 5 gynecologic oncologists, 1 neuro-oncologist, and 7 pediatric oncologists) enrolled on the study, representing 100% of all practicing oncologists in Maine. Between July 2017 and September 2020, 1610 patients were enrolled. A total of 515 cases were discussed by 47 (73%) clinicians in 196 GTBs. Clinicians who participated in the GTBs enrolled significantly more patients on the study, stayed in Maine, and reported less time spent in clinical patient care.

CONCLUSION

The MCGI was able to engage geographically and culturally disparate cancer care practices in a precision oncology program using a hub-and-spoke model. By facilitating access to GTT, structured education, and GTBs, we narrowed the gap in the implementation of precision oncology in one of the most rural states in the country.

Structure and expression of the quinolinate phosphoribosyltransferase (QPT) gene family in Nicotiana

Synthesis of wound-inducible pyridine alkaloids is characteristic of species in the genus Nicotiana. The enzyme quinolinate phosphoribosyltransferase (QPT) plays a key role in facilitating the availability of precursors for alkaloid synthesis, in addition to its ubiquitous role in enabling NAD(P)(H) synthesis. In a previous study, we reported that Nicotiana tabacum L. var. NC 95 possesses a QPT RFLP pattern similar to its model paternal progenitor species, Nicotiana tomentosiformis Goodsp. Here we show that although some varieties of N. tabacum (e.g. NC 95 and LAFC 53) possess QPT genomic contributions from only its paternal progenitor species, this is not the case for many other N. tabacum varieties (e.g. Xanthi, Samsun, Petite Havana SR1 and SC 58) where genomic QPT sequences from both diploid progenitor species have been retained. We also report that QPT is encoded by duplicate genes (designated QPT1 and QPT2) not only in N. tabacum, but also its model progenitor species Nicotiana sylvestris Speg. and Comes and N. tomentosiformis as well as in the diploid species Nicotiana glauca Graham. Previous studies have demonstrated that the N. tabacum QPT2 gene encodes a functional enzyme via complementation of a nadC(-)Escherichia coli mutant. Using a similar experimental approach here, we demonstrate that the N. tabacum QPT1 gene also encodes a functional QPT protein. We observe too that QPT2 is the predominate transcript present in both alkaloid and non-alkaloid synthesising tissues in N. tabacum and that promoter regions of both QPT1 and QPT2 are able to produce GUS activity in reproductive tissues. In N. tabacum and in several other Nicotiana species tested, QPT2 transcript levels increase following wounding or methyl jasmonate treatment whilst QPT1 transcript levels remain largely unaltered by these treatments. Together with conclusions from recently published studies involving functional interaction of MYC2-bHLH and specific ERF-type and transcription factors with QPT2-promoter sequences from N. tabacum, our results suggest that whilst both members of the QPT gene family can contribute to the transcript pool in both alkaloid producing and non-producing tissues, it is QPT2 that is regulated in association with inducible defensive pyridine alkaloid synthesis in species across the genus Nicotiana.

Determinants of duration of disability and return-to-work after work-related injury and illness: challenges for future research

BACKGROUND

The purpose of this review was to identify critical data and research needs in addressing the following question: What are the primary factors that affect the time lost from work, return-to-work (RTW), subsequent unemployment, and changes in occupation after disabling illness or injury?

METHODS

Review of the literature to identify research challenges originating from the multitude of disciplines, data sources, outcome measures, and methodological and analytical problems.

RESULTS

About 100 different determinants of RTW outcomes were identified. Their impact varies across different phases of the disablement process. Recommendations are provided for addressing five selected research challenges.

CONCLUSION

Interdisciplinary research needs to develop a comprehensive conceptual framework. Priority should be given to studies on specific domains of risk factors meeting five selection criteria: amenability to change; relevance to users of research; generalizability across health conditions, disability phases, and settings; "degree of promise" as derived from qualitative exploratory studies; and capacity to improve measurement instruments. Combining qualitative and quantitative research methods is necessary to bridge existing knowledge gaps.

Molecular characterization of quinolinate phosphoribosyltransferase (QPRtase) in Nicotiana

Quinolate acid phosphoribosyltransferase (QPRTase), a key enzyme in nicotinamide adenine dinucleotide (NAD) biosynthesis, also plays an important role in ensuring nicotinic acid is available for the synthesis of defensive pyridine alkaloids in Nicotiana species. In this study, cDNAs for QPRTase were characterized from N. rustica and N. tabacum. Deduced proteins from both cDNAs are almost identical and contain a 24 amino acid N-terminal extension, not reported in other QPRTases, that has characteristics of a mitochondrial targeting sequence. In N. tabacum and N. sylvestris, both of which contain nicotine as the major pyridine alkaloid, QPRTase transcript was detected in roots, the site of nicotine synthesis, but not in leaves. QPRTase transcript levels increased markedly in roots of both species 12-24 h after damage to aerial tissues, with a concomitant rise in transcript levels of putrescine N-methyltransferase (PMT), another key enzyme in nicotine biosynthesis. In N. glauca, however, in which anabasine represents the major pyridine alkaloid, QPRTase transcript was detected in both leaf and root tissues. Moreover, wound induction of QPRTase but not PMT was observed in leaf tissues, and not in roots, 12-24 h after wounding. Southern analysis of genomic DNA from the Nicotiana species noted above, and also several others from within the genus, suggested that QPRTase is encoded by a small gene family in all the species investigated.

The effectiveness of an early active intervention program for workers with soft-tissue injuries. The Early Claimant Cohort Study

STUDY DESIGN

A prospective cohort of approximately 1600 injured workers off work because of soft-tissue musculoskeletal problems was followed for 1 year through a series of structured telephone interviews.

OBJECTIVE

To determine the effectiveness of a Workers' Compensation Board-sponsored early, active, exercise and education program based in the community in comparison to "usual" care.

SUMMARY OF BACKGROUND DATA

The program established in 1990 was available in more than 100 clinics. Results from an earlier pilot study indicated lower overall claims costs for workers attending the program compared with non-attenders.

METHODS

Subjects were recruited at the time of Workers' Compensation Board claim registration. Routinely collected data and self-reported responses to demographic, quality-of-life, functional status, pain, recovery expectations, and workplace response to injury questions were used to determine selection factors for community clinic attendance. Economic and non-economic outcomes were compared for clinic attenders and non-attenders.

RESULTS

For the 885 male and female new back problem cases in the study, overall clinic attenders were not systematically different from non-attenders at baseline. Analysis of duration of benefits showed no significant difference between attenders and non-attenders, although health care costs for clinic attenders were significantly higher. Functional status, health-related quality-of-life, and pain measures all improved significantly throughout time for both groups, bit there were no statistically significant differences in rate of improvement.

CONCLUSION

There was no advantage from the program compared with usual care on the outcomes measured-a finding consistent with recent studies that examined the longer-term effectiveness of other interventions in the first few weeks of back pain symptoms.