Patient interest in and clinician reservations on polygenic embryo screening: a qualitative study of stakeholder perspectives

PURPOSE

We explored and compared perspectives of reproductive endocrinology and infertility specialists (REIs) and in vitro fertilization (IVF) patients regarding polygenic embryo screening (PES), a new type of preimplantation screening that estimates the genetic chances of developing polygenic conditions and traits in the future.

METHODS

Qualitative thematic analysis of semi-structured interviews with US-based REIs and IVF patients.

RESULTS

Clinicians and patients often held favorable views of screening embryos for physical or psychiatric conditions, though clinicians tended to temper their positive attitudes with specific caveats. Clinicians also expressed negative views about screening embryos for traits more frequently than patients, who generally held more positive views. Most clinicians were either unwilling to discuss or offer PES to patients or were willing to do so only under certain circumstances, while many patients expressed interest in PES. Both stakeholder groups envisioned multiple potential benefits or uses of PES and raised multiple potential, interrelated concerns about PES.

CONCLUSION

A gap exists between clinician and patient attitudes toward PES; clinicians generally maintained reservations about such screening and patients indicated interest in it. Clinicians and patients sometimes imagined using PES to prepare for the birth of a predisposed or "affected" individual-a rationale that is often associated with prenatal testing. Many clinicians and patients held different attitudes depending on what is specifically screened, despite the sometimes blurry distinction between conditions and traits. Considerations raised by clinicians and patients may help guide professional societies in developing guidelines to navigate the uncertain terrain of PES.

Treatment Efficacy Outcomes Combining Dual Checkpoint Immunotherapy with Ablative Radiation to All Sites of Oligometastatic Non-Small Cell Lung Cancer: Survival Analysis of a Phase IB trial

PURPOSE/OBJECTIVE(S)

Aggressivelocal treatment to a limited number of metastatic sites in patients with oligometastatic NSCLC increases progression free survival (PFS) and overall survival (OS). Prior studies have shown the safety of combining high dose stereotactic body radiation therapy (SBRT) with single agent anti-PD1/PD-L1 therapy. Here, we report secondary survival endpoint outcomes from a phase Ib clinical trial investigating the safety of combining ablative, high dose radiation with dual checkpoint, anti-CTLA-4 and anti-PD-L1 immunotherapy for patients with oligometastatic NSCLC.

MATERIALS/METHODS

Patients with up to 6 sites of extracranial metastatic disease were eligible for trial enrollment. All sites of disease were treated with stereotactic body radiation therapy to a dose of 30 - 50 Gy in 5 fractions. Dual checkpoint immunotherapy was started 7 days following completion of radiation utilizing anti-CTLA-4 (Tremelimumab) and anti-PD-L1 (Durvalumab) immunotherapy for a total of four cycles followed by durvalumab alone until dose limiting toxicity or progression was observed. Primary toxicity outcomes were previously reported. Progression free and overall survival was analyzed using Kaplan Meier statistical methods.

RESULTS

Fifteen patients were treated with SBRT and received at least one dose of dual agent immunotherapy per protocol. The median follow up was 43 months. The median number of extracranial metastatic sites was 2. Seven patients had 3 or more sites of extracranial disease. The most commonly treated sites were separate metastatic pulmonary lesions or osseous metastatic lesions. Median progression free survival (PFS) was 42 months and median overall survival (OS) was 48 months. Seven patients remain alive without evidence of progressive disease. Prior history of brain metastases was associated with significantly worse PFS (Median PFS 4 months vs 42 months, HR 6.1 (95% CI 1.6 - 37.0) p = 0.0248), but no difference in OS (Median OS 24 vs 42 months, HR 1.9 (95% CI 0.3 - 10.4).

CONCLUSION

Ablative SBRT radiation to up to 6 sites of disease followed by dual checkpoint immunotherapy in oligometastatic NSCLC resulted in a favorable progression free survival (42 months) and overall survival (48 months) compared to historical controls. These findings suggest potential benefit to patient outcomes compared to immunotherapy or radiation alone in this patient population and warrant further investigation.

Health care provider preferences for, and barriers to, cannabis use in cancer care

Background

Limited research has been conducted about the perspectives of oncology health care providers (hcps) concerning the use of cannabis in cancer care and their potential role in advising patients. We sought to determine the barriers encountered by hcps with respect to medical cannabis and their preferred practices in this area.

Methods

An anonymous survey about cannabis was distributed to oncology hcps at the Tom Baker Cancer Centre in Calgary, Alberta. The 45-question survey measured the opinions of hcps about cannabis use and authorization in oncology.

Results

Of 103 oncology hcps who participated in the study, 75% were women. By hcp type, the most commonly reported professional groups were oncology nurse (40%), radiation therapist (9%), and pharmacist (6%). Of respondents, 75% reported providing direct care to cancer patients. More than half (69%) had spoken to a patient about cannabis in the preceding month, and 84% believed that they lacked sufficient knowledge about cannabis to make recommendations. Barriers such as monitoring the patient's use of cannabis (54%), prescribing an accurate dose (61%) or strain (53%), and having insufficient research (50%) were most commonly reported. More than half of hcps (53%) would be interested in receiving more information or training about the use of cannabis in oncology.

Conclusions

The survey indicated that this group of oncology hcps believed that they lacked sufficient knowledge about cannabis to make recommendations to patients. In addition to that lack of knowledge, a number of notable barriers were reported, and more than half the hcps indicated interest in learning more about cannabis in the future.

Search for Electron Antineutrino Appearance in a Long-Baseline Muon Antineutrino Beam

Electron antineutrino appearance is measured by the T2K experiment in an accelerator-produced antineutrino beam, using additional neutrino beam operation to constrain parameters of the Pontecorvo-Maki-Nakagawa-Sakata (PMNS) mixing matrix. T2K observes 15 candidate electron antineutrino events with a background expectation of 9.3 events. Including information from the kinematic distribution of observed events, the hypothesis of no electron antineutrino appearance is disfavored with a significance of 2.40σ and no discrepancy between data and PMNS predictions is found. A complementary analysis that introduces an additional free parameter which allows non-PMNS values of electron neutrino and antineutrino appearance also finds no discrepancy between data and PMNS predictions.

Search for CP Violation in Neutrino and Antineutrino Oscillations by the T2K Experiment with 2.2×10^{21} Protons on Target

The T2K experiment measures muon neutrino disappearance and electron neutrino appearance in accelerator-produced neutrino and antineutrino beams. With an exposure of 14.7(7.6)×10^{20} protons on target in the neutrino (antineutrino) mode, 89 ν_{e} candidates and seven anti-ν_{e} candidates are observed, while 67.5 and 9.0 are expected for δ_{CP}=0 and normal mass ordering. The obtained 2σ confidence interval for the CP-violating phase, δ_{CP}, does not include the CP-conserving cases (δ_{CP}=0, π). The best-fit values of other parameters are sin^{2}θ_{23}=0.526_{-0.036}^{+0.032} and Δm_{32}^{2}=2.463_{-0.070}^{+0.071}×10^{-3}  eV^{2}/c^{4}.

Combined Analysis of Neutrino and Antineutrino Oscillations at T2K

T2K reports its first results in the search for CP violation in neutrino oscillations using appearance and disappearance channels for neutrino- and antineutrino-mode beams. The data include all runs from January 2010 to May 2016 and comprise 7.482×10^{20} protons on target in neutrino mode, which yielded in the far detector 32 e-like and 135  μ-like events, and 7.471×10^{20} protons on target in antineutrino mode, which yielded 4 e-like and 66  μ-like events. Reactor measurements of sin^{2}2θ_{13} have been used as an additional constraint. The one-dimensional confidence interval at 90% for the phase δ_{CP} spans the range (-3.13, -0.39) for normal mass ordering. The CP conservation hypothesis (δ_{CP}=0, π) is excluded at 90% C.L.

Abstract P4-22-21: NCI9782: A phase 1 study of talazoparib in combination with carboplatin and paclitaxel in patients with advanced solid tumors

Background: Poly(ADP-ribose) polymerase (PARP) enzymes are involved in DNA repair and activated by DNA strand breaks. DNA damage from carboplatin is associated with activation of PARP. Preclinical data indicate that PARP inhibition potentiates the anti-tumor effect of platinum chemotherapy. Talazoparib (T) is an oral, selective PARP inhibitor with a single agent maximum tolerated dose (MTD) of 1mg orally qd. Primary dose-limiting toxicity (DLT) was thrombocytopenia. This phase I study combines T with the commonly used chemotherapy regimen of carboplatin (C) and paclitaxel (P).

Methods: Two dosing schedules are being investigated. In both schedules, C is administered on day 1 and P on days 1, 8, and 15 of a 21-day cycle. T (100-1000mcg) is dosed once daily for days 1-7 (schedule A) or days 1-3 (schedule B) starting on day 1. A 3+3 design is used for dose escalation. Key eligibility criteria include age 318 with a measurable or evaluable solid incurable malignancy. Patients (pts) must have tumor type that is expected to respond to C + P or have BRCA germline or somatic mutation. Stable, treated brain metastases are allowed. No prior C for metastatic disease is allowed. Pts must have platelets>150 and no need for anticoagulation. After 4-6 cycles of combination therapy, pts may continue the combination, change to C and intermittent T without P or change to T alone with continuous daily dosing. Each schedule will have a 6 subject dose expansion at the MTD. The starting dose level for schedule B will be the MTD from schedule A.

Results: Schedule A cohort results are reported: 11 pts (median age 59 [range 39-68]; 8 female; 3 male) have been enrolled. Pts had breast (6), ovarian (2), pancreatic (1), and SCC of oropharynx (1) and concurrent ovarian and pancreatic (1). Five pts are BRCA2+ and 3 pts are BRCA1+. Dose level 3 on schedule A (T 350mcg with C AUC 6 and P 80mg/m2) exceeded the MTD with 2 of 3 pts experiencing hematologic dose limiting toxicities (DLTs) including 1 pt with grade (gr) 3 neutropenic fever and gr 4 thrombocytopenia and another pt with grade 3/4 neutropenia lasting > 7 days. Most common AEs include neutropenia (grade 3-4: 7), anemia (grade 3-4: 3), and thrombocytopenia (grade 3-4: 4). Results from expansion of dose level 2 (T 250mcg with C AUC 6 and T 80mg/m2) will be presented. The 11 pts were on study a median of 9 weeks (range 9-36+). Four pts have discontinued study therapy: 1 due to need for anticoagulation for PE, 1 for prolonged cytopenias, and 2 for disease progression. Of the 8 pts with measurable disease evaluated for response to date, 4 had SD, 1 had a cPR, 1 had radiographic CR, and 2 with PD. A pt with BRCA 1+ triple negative breast cancer has maintained a prolonged PR (36+ weeks) even after dose reductions to T 100mcg with C AUC 3. One pt with ovarian cancer (BRCA WT) has radiographic CR (CA 125 remains mildly elevated) after 15+ weeks of therapy.

Conclusion: PARP inhibition with talazoparib days 1-7 in combination with carboplatin and paclitaxel leads to DLT of myelosuppression. However, clinical responses are seen even with lower dose combinations.

Citation Format: Turk A, Chan N, Leal T, O'Regan R, Tevaarwerk A, Rice L, Campbell T, Barroilhet L, Mehnert J, Eickhoff J, Kolesar J, Liu G, Wisinski K. NCI9782: A phase 1 study of talazoparib in combination with carboplatin and paclitaxel in patients with advanced solid tumors [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P4-22-21.

Measurement of Coherent π^{+} Production in Low Energy Neutrino-Carbon Scattering

We report the first measurement of the flux-averaged cross section for charged current coherent π^{+} production on carbon for neutrino energies less than 1.5 GeV, and with a restriction on the final state phase space volume in the T2K near detector, ND280. Comparisons are made with predictions from the Rein-Sehgal coherent production model and the model by Alvarez-Ruso et al., the latter representing the first implementation of an instance of the new class of microscopic coherent models in a neutrino interaction Monte Carlo event generator. We observe a clear event excess above background, disagreeing with the null results reported by K2K and SciBooNE in a similar neutrino energy region. The measured flux-averaged cross sections are below those predicted by both the Rein-Sehgal and Alvarez-Ruso et al.

THE EARTH SYSTEM PREDICTION SUITE: Toward a Coordinated U.S. Modeling Capability

The Earth System Prediction Suite (ESPS) is a collection of flagship U.S. weather and climate models and model components that are being instrumented to conform to interoperability conventions, documented to follow metadata standards, and made available either under open source terms or to credentialed users. The ESPS represents a culmination of efforts to create a common Earth system model architecture, and the advent of increasingly coordinated model development activities in the U.S. ESPS component interfaces are based on the Earth System Modeling Framework (ESMF), community-developed software for building and coupling models, and the National Unified Operational Prediction Capability (NUOPC) Layer, a set of ESMF-based component templates and interoperability conventions. This shared infrastructure simplifies the process of model coupling by guaranteeing that components conform to a set of technical and semantic behaviors. The ESPS encourages distributed, multi-agency development of coupled modeling systems, controlled experimentation and testing, and exploration of novel model configurations, such as those motivated by research involving managed and interactive ensembles. ESPS codes include the Navy Global Environmental Model (NavGEM), HYbrid Coordinate Ocean Model (HYCOM), and Coupled Ocean Atmosphere Mesoscale Prediction System (COAMPS®); the NOAA Environmental Modeling System (NEMS) and the Modular Ocean Model (MOM); the Community Earth System Model (CESM); and the NASA ModelE climate model and GEOS-5 atmospheric general circulation model.

A prospective cohort study of risk prediction in simultaneous pancreas and kidney transplantation

INTRODUCTION

Current risk prediction scoring systems in pancreas transplantation are limited to organ factors and are specific to predicting graft outcome. They do not consider recipient factors or inform regarding recipient morbidity. The aim of this study was to assess the utility of commonly used general surgical risk prediction models (P-POSSUM [Portsmouth Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity], MODS [multiple organ dysfunction score], Charlson co-morbidity index, revised cardiac risk index, ASA [American Society of Anesthesiologists] grade and Waterlow score), and to correlate them with total length of hospital stay (LOS) and critical care unit (CCU) LOS, important surrogate markers of patient outcome.

METHODS

All risk prediction scores were calculated prospectively for all simultaneous pancreas and kidney (SPK) transplant recipients from November 2011 to October 2013, and correlated with outcome measures.

RESULTS

Overall, 57 SPK transplant recipients were analysed. The mean age was 42.0 years (standard deviation [SD]: 7.60 years), 27 (52%) were male and the mean body mass index was 25.43kg/m(2) (SD: 3.11kg/m(2)). The mean pancreas and kidney cold ischaemic times were 703 minutes (SD: 182 minutes) and 850 minutes (SD: 192 minutes) respectively. The median total LOS and mean CCU LOS was 17 days (range: 8-79 days) and 7 days (SD: 4.04 days) respectively. When correlated with risk prediction scores, Waterlow score was the only significant predictor of total LOS and CCU LOS (p<0.001 [Spearman's correlation] and p=0.001 [Pearson's correlation] respectively).

CONCLUSIONS

Preoperative risk prediction plays an important part in planning perioperative care. To date, no validated risk prediction scoring system exists for SPK transplantation. This prospective study indicates that Waterlow score identifies high risk individuals and has value in the prediction of outcome following SPK transplantation.

Three-dimensional visualization of stranded source migration following prostate brachytherapy

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Background: The use of radioactive seeds embedded in absorbable vicryl suture material has emerged as one preferred method for prostate cancer brachytherapy. However, it is unclear how strand displacement affects post-implant dosimetry. Our objective was to use CT imaging and 3D reconstruction to determine strand displacement between day zero and day 30 and to assess the dosimetric consequences of strand displacement.

Methods: Between March 2006 and December 2009 there were 86 prostate brachytherapy patients with day zero and day 30 post-plan imaging. There was a mean of 18.24 strands per implant, 9.81 loose seeds per implant, and 69.08 total seeds per implant. Substantial strand displacement was identified by inspection. Migrated strands were identified on day zero and day 30 scans and the distance of displacement was measured using 3D fusion software.

Results: Of 1550 strands placed, 23 were found to show substantial migration revealed by 3D imaging. These displacements occurred in 21 of the 86 cases. The estimated distance of strand displacement ranged from 0.5 cm to 2.5 cm with an average movement of 1.5 cm. The exact distance of strand displacement ranged from 0.31 m to 3.44 cm, with mean movement of 2.75 cm.

Conclusions: 3D imaging reveals unexpected spatial instability in stranded brachytherapy sources. Significant movement may be expected to occur in approximately 1.48% of stranded sources and 24.42% of cases. Factors which predict for the migration of sources remain relatively undefined. Minimal dosimetric effects from strand displacement appear to be offset by resolution of prostate edema.

[Table: see text]

No significant financial relationships to disclose.

Phenotypic heterogeneity and genetic modification of P102L inherited prion disease in an international series

The largest kindred with inherited prion disease P102L, historically Gerstmann-Sträussler-Scheinker syndrome, originates from central England, with émigrés now resident in various parts of the English-speaking world. We have collected data from 84 patients in the large UK kindred and numerous small unrelated pedigrees to investigate phenotypic heterogeneity and modifying factors. This collection represents by far the largest series of P102L patients so far reported. Microsatellite and genealogical analyses of eight separate European kindreds support multiple distinct mutational events at a cytosine-phosphate diester-guanidine dinucleotide mutation hot spot. All of the smaller P102L kindreds were linked to polymorphic human prion protein gene codon 129M and were not connected by genealogy or microsatellite haplotype background to the large kindred or each other. While many present with classical Gerstmann-Sträussler-Scheinker syndrome, a slowly progressive cerebellar ataxia with later onset cognitive impairment, there is remarkable heterogeneity. A subset of patients present with prominent cognitive and psychiatric features and some have met diagnostic criteria for sporadic Creutzfeldt-Jakob disease. We show that polymorphic human prion protein gene codon 129 modifies age at onset: the earliest eight clinical onsets were all MM homozygotes and overall age at onset was 7 years earlier for MM compared with MV heterozygotes (P = 0.02). Unexpectedly, apolipoprotein E4 carriers have a delayed age of onset by 10 years (P = 0.02). We found a preponderance of female patients compared with males (54 females versus 30 males, P = 0.01), which probably relates to ascertainment bias. However, these modifiers had no impact on a semi-quantitative pathological phenotype in 10 autopsied patients. These data allow an appreciation of the range of clinical phenotype, modern imaging and molecular investigation and should inform genetic counselling of at-risk individuals, with the identification of two genetic modifiers.

Expression of the inhibitor of apoptosis protein family in multiple sclerosis reveals a potential immunomodulatory role during autoimmune mediated demyelination

A failure of autoreactive T cells to undergo apoptosis may contribute to the pathogenesis of multiple sclerosis (MS). The role of the inhibitor of apoptosis (IAP) family of anti-apoptotic proteins such as X-linked IAP (XIAP), human inhibitor of apoptosis-1 (HIAP-1), human inhibitor of apoptosis-2 (HIAP-2), neuronal apoptosis inhibitory protein (NAIP) and Survivin in relapsing–remitting, secondary-progressive, primary-progressive or benign forms of MS is unclear. We report here that expression of the IAP family of genes in peripheral blood samples and brain tissues from MS cases support a role for differential regulation of these potent anti-apoptotic proteins in the pathology of MS. XIAP mRNA and protein levels were elevated in peripheral blood mononuclear cells from patients with active disease relative to normal subjects. In patients with active MS, HIAP-1 and HIAP-2 mRNA levels were elevated in resting T cells while NAIP mRNA was increased in whole blood. In post-mortem MS brain tissue, XIAP and HIAP-1 in myelin lesions were co-localized with microglia and T cells, respectively. Only in primary-progressive patients was Survivin expression elevated suggestive of a distinct pathological basis for this subtype of MS. Taken together, these results suggest that patterns of inhibitor of apoptosis expression in immune cells may have value in distinguishing between MS subtypes and offer insight into the mechanisms responsible for their distinct clinical courses.

Enhancing partner support to improve smoking cessation

BACKGROUND

While many cessation programs are available to assist smokers in quitting, research suggests that partner involvement may encourage long-term abstinence.

OBJECTIVES

The purpose of this review was to determine if an intervention to enhance partner support helps smoking cessation when added as an adjunct to a smoking cessation program.

SEARCH STRATEGY

The search was performed in: Cochrane Tobacco Addiction Group specialized register (Apr 2004), Cochrane controlled trials register (Apr 2004), CDC and Prevention-Tobacco Information and Prevention Database (Jul 2000), MEDLINE (1966-Apr 2004), Cancer Lit (1966-Apr 2004), EMBASE (1974-Apr 2004), CINAHL (1966-Jul 2000), PsycInfo (1861-Apr 2004), ERIC, PsycLit, & Dissertation Abstracts (1861-Dec 1999), SSCI (1972-Apr 2004) and HealthStar (1975-Jul 2000). The search terms used were smoking (prevention, control, therapy), smoking cessation, and support (family, marriage, spouse, partner, sexual partner, buddy, friend, co-habitees, and co-worker). The search was also limited to English language.

SELECTION CRITERIA

Randomized controlled trials of smoking cessation interventions that compared an intervention that included a partner support component with an otherwise identical intervention and reported follow-up of 6 months or greater.

DATA COLLECTION AND ANALYSIS

Two reviewers independently identified the included studies and extracted data using a structured form. A third reviewer was consulted to aid in the resolution of discrepancies. Abstinence and biochemical assessment were the primary outcome measures and were analyzed at two post-treatment intervals: 6-9 months and >12 months. The scores of PIQ (partner interaction questionnaire) were also analyzed to assess partner support. A fixed-effects model was used to assess the summary effect of the studies.

MAIN RESULTS

A total of 40 articles were identified for this review. Only eight articles (nine studies) met the inclusion criteria. The definition of partner varied among the studies. All studies included data on self reported smoking cessation rates, but there was limited biochemical validation of abstinence rates. The odds ratio for self-reported abstinence at 6-9 months was 1.08 (CI 95%, 0.81 -1.44); and at 12 months post-treatment was 1.0 (CI 95%, 0.75 - 1.34). Of the six studies that measured partner support at follow-up, only two studies reported significant increase in partner support in the intervention groups.

REVIEWERS' CONCLUSIONS

In this review of the randomized controlled trials of interventions designed to enhance partner support for smokers in cessation programs, we failed to detect an increase in quit rates. Limited data from several of the trials suggest that these interventions did not increase partner support either. No conclusions can be made about the impact of partner support on smoking cessation. More systematic intervention to affect partnership significantly should be delivered if partner support were part of an existing cessation program.

Prevalence, disclosure and interpretations of sexual activities in a sample of Canadian college-aged blood donors

This study assessed the prevalence, level of disclosure, and interpretations of sexual activities in a sample of 123 college-aged blood donors in Montreal, Quebec. Within six months of their donation, participants completed an anonymous questionnaire designed to assess sexual definitions, levels of disclosure to sexual partners, as well as prevalence of various blood safety behavioural risks. Responses indicated that (1) there was a lack of consensus regarding what constitutes 'sex', (2) levels of sexual disclosure varied widely, and (3) participants engaged in numerous blood safety behavioural risk activities. These results are discussed with respect to their implications for how people think about sex, particularly in the blood donation context. Suggestions to improve specific blood donor screening questions are also presented.