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Hesko C, Mittal N, Avutu V, Thomas SM, Heath JL, Roth ME. Creation of a quality improvement collaborative to address adolescent and young adult cancer clinical trial enrollment: ATAQI (AYA trial access quality initiative). Curr Probl Cancer 2023; 47:100898. [PMID: 36207194 DOI: 10.1016/j.currproblcancer.2022.100898] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Accepted: 09/08/2022] [Indexed: 02/04/2023]
Abstract
Adolescent and young adult (AYA) participation in cancer clinical trials (CCTs) is suboptimal, hindering further improvements in survival, quality of life, and basic understanding of cancer pathophysiology in this population. Prior studies have identified barriers and facilitators to AYA CCT enrollment; however, few interventional studies have attempted to address these barriers and measure tangible changes. In September 2020, a task force was established to address CCT enrollment barriers at a multi-institutional level utilizing a quality improvement collaborative model for improvement. The AYA Trial Access Quality Initiative was developed with the goal of bring multidisciplinary teams together across multiple sites to learn, apply and share their methods of improvement. It uses a structured process of learning sessions lead by quality improvement and clinical experts who help facilitate learning and problem solving which are followed by action phases. During the pilot phase of the collaboration, one key driver of CCT enrollment in AYA's will be addressed: communication between adult and pediatric oncology by implementation of various interventions at sites. The number of AYAs screened for and enrolled on CCTs will be tracked over the course of the collaborative along with the process measures. It is expected that the interventions will promote engagement of stakeholders in the process of screening AYA oncology patients for eligibility on CCTs. This will hopefully create a favorable environment conducive for increasing enrollment on CCTs and lead to the development of a system-wide quality improvement framework to improve AYA CCT enrollment.
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Affiliation(s)
- Caroline Hesko
- Department of Pediatrics, University of Vermont Children's Hospital, Burlington, VT.
| | - Nupur Mittal
- Department of Pediatrics, Rush University Medical Center, Chicago, IL
| | - Viswatej Avutu
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Stefanie-M Thomas
- Department of Pediatric Hematology/Oncology and Bone Marrow Transplant, Cleveland Clinic Children's, Cleveland, OH
| | - Jessica-L Heath
- Departments of Pediatrics, Biochemistry, University of Vermont Cancer Center, University of Vermont, Burlington, VT
| | - Michael-E Roth
- Division of Pediatrics, The University of Texas MD Anderson Cancer Center, Houston, TX
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Rosenbaum E, Seier K, Bradic M, Kelly C, Movva S, Nacev BA, Gounder MM, Keohan ML, Avutu V, Chi P, Thornton KA, Chan JE, Dickson MA, Donoghue MT, Tap WD, Qin LX, D'Angelo SP. Immune-related Adverse Events after Immune Checkpoint Blockade-based Therapy Are Associated with Improved Survival in Advanced Sarcomas. Cancer Res Commun 2023; 3:2118-2125. [PMID: 37787759 PMCID: PMC10583739 DOI: 10.1158/2767-9764.crc-22-0140] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Revised: 05/31/2022] [Accepted: 09/26/2023] [Indexed: 10/04/2023]
Abstract
The association between immune-related AEs (irAE) and outcome in patients with sarcoma is not known. We retrospectively reviewed a cohort of patients with advanced sarcoma treated with immune checkpoint blockade (ICB)-based therapy. Association of irAEs with survival was assessed using a Cox regression model that incorporated irAE occurrence as a time-dependent covariate. Tumor samples with available RNA sequencing data were stratified by presence of an irAE to identify patterns of differential gene expression. A total of 131 patients were included. Forty-two (32%) had at least one irAE of any grade and 16 (12%) had at least one grade ≥ 3 irAE. The most common irAEs were hypothyroidism (8.3%), arthralgias (5.3%), pneumonitis (4.6%), allergic reaction (3.8%), and elevated transaminases (3.8%). Median progression-free survival (PFS) and overall survival (OS) from the time of study entry were 11.4 [95% confidence interval (CI), 10.7-15.0) and 74.6 weeks (CI, 44.9-89.7), respectively. On Cox analysis adjusting for clinical covariates that were significant in the univariate setting, the HR for an irAE (HR, 0.662; CI, 0.421-1.041) approached, but did not reach statistical significance for PFS (P = 0.074). Patients had a significantly lower HR for OS (HR, 0.443; CI, 0.246-0.798; P = 0.007) compared with those without or before an irAE. Gene expression profiling on baseline tumor samples found that patients who had an irAE had higher numbers of tumor-infiltrating dendritic cells, CD8+ T cells, and regulatory T cells as well as upregulation of immune and inflammatory pathways. SIGNIFICANCE irAE after ICB therapy was associated with an improved OS; it also approached statistical significance for improved PFS. Patients who had an irAE were more likely to have an inflamed tumor microenvironment at baseline.
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Affiliation(s)
- Evan Rosenbaum
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
- Department of Medicine, Weill Cornell Medical College, New York, New York
| | - Kenneth Seier
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Martina Bradic
- Marie-Josée and Henry R. Kravis Center for Molecular Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Ciara Kelly
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
- Department of Medicine, Weill Cornell Medical College, New York, New York
| | - Sujana Movva
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
- Department of Medicine, Weill Cornell Medical College, New York, New York
| | - Benjamin A. Nacev
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
- Department of Medicine, Weill Cornell Medical College, New York, New York
| | - Mrinal M. Gounder
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
- Department of Medicine, Weill Cornell Medical College, New York, New York
| | - Mary L. Keohan
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
- Department of Medicine, Weill Cornell Medical College, New York, New York
| | - Viswatej Avutu
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
- Department of Medicine, Weill Cornell Medical College, New York, New York
| | - Ping Chi
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
- Department of Medicine, Weill Cornell Medical College, New York, New York
- Human Oncology and Pathogenesis Program, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Katherine A. Thornton
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
- Department of Medicine, Weill Cornell Medical College, New York, New York
| | - Jason E. Chan
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
- Department of Medicine, Weill Cornell Medical College, New York, New York
| | - Mark A. Dickson
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
- Department of Medicine, Weill Cornell Medical College, New York, New York
| | - Mark T.A. Donoghue
- Marie-Josée and Henry R. Kravis Center for Molecular Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - William D. Tap
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
- Department of Medicine, Weill Cornell Medical College, New York, New York
| | - Li-Xuan Qin
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Sandra P. D'Angelo
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
- Department of Medicine, Weill Cornell Medical College, New York, New York
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Whiteway SL, Weiss AR, Ahmed SK, Allen-Rhoades WA, Avutu V, Cardona K, Davis LE, Davis EJ, Indelicato DJ, Isakoff MS, Janeway KA, Livingston JA, Patel SR, Reed DR, Riedel RF, Thornton KA, Kopp LM. Joint Adult and Pediatric Working Group as a Successful Platform to Strengthen Adolescent and Young Adult (AYA) Clinical Trial Collaboration: A Report from the NCTN/SARC AYA Clinical Trials Sarcoma Working Group. J Adolesc Young Adult Oncol 2023; 12:792-793. [PMID: 36724495 DOI: 10.1089/jayao.2022.0179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Affiliation(s)
- Susan L Whiteway
- Division of Hematology/Oncology, Department of Pediatrics, Walter Reed National Military Medical Center, Bethesda, Maryland, USA
- Department of Pediatrics, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
| | - Aaron R Weiss
- Division of Pediatric Hematology-Oncology, Department of Pediatrics, Maine Medical Center, Portland, Maine, USA
| | - Safia K Ahmed
- Department of Radiation Oncology Mayo Clinic Arizona, Phoenix, Arizona, USA
| | - Wendy A Allen-Rhoades
- Department of Pediatric and Adolescent Medicine, Division of Pediatric Oncology, Mayo Clinic, Rochester, Minnesota, USA
| | - Viswatej Avutu
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Kenneth Cardona
- Division of Surgical Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia, USA
| | - Lara E Davis
- Knight Cancer Institute, Department of Medicine and Department of Pediatrics, Oregon Health & Science University, Portland, Oregon, USA
| | - Elizabeth J Davis
- Division of Hematology-Oncology, Department of Internal Medicine, Vanderbilt-Ingram Cancer Center, Nashville, Tennessee, USA
| | - Daniel J Indelicato
- Department of Radiation Oncology, University of Florida, Jacksonville, Florida, USA
| | - Michael S Isakoff
- Division of Hematology and Oncology, Center for Cancer and Blood Disorders, Connecticut Children's Medical Center, Hartford, Connecticut, USA
| | - Katherine A Janeway
- Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Harvard Medical School, Boston, Massachusetts, USA
| | - J Andrew Livingston
- Department of Sarcoma Medical Oncology, UT MD Anderson Cancer Center, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Shreyaskumar R Patel
- Department of Sarcoma Medical Oncology, UT MD Anderson Cancer Center, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Damon R Reed
- Department of Individualized Cancer Management, Moffitt Cancer Center, Tampa, Florida, USA
| | - Richard F Riedel
- Division of Medical Oncology, Duke Cancer Institute, Durham, North Carolina, USA
| | - Katherine A Thornton
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Lisa M Kopp
- Department of Epidemiology and Biostatistics, University of Arizona, Tucson, Arizona, USA
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4
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Kelly CM, Qin LX, Whiting KA, Richards AL, Avutu V, Chan JE, Chi P, Dickson MA, Gounder MM, Keohan ML, Movva S, Nacev BA, Rosenbaum E, Adamson T, Singer S, Bartlett EK, Crago AM, Yoon SS, Hwang S, Erinjeri JP, Antonescu CR, Tap WD, D’Angelo SP. A Phase II Study of Epacadostat and Pembrolizumab in Patients with Advanced Sarcoma. Clin Cancer Res 2023; 29:2043-2051. [PMID: 36971773 PMCID: PMC10752758 DOI: 10.1158/1078-0432.ccr-22-3911] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Revised: 02/15/2023] [Accepted: 03/22/2023] [Indexed: 03/29/2023]
Abstract
PURPOSE Epacadostat, an indole 2,3 dioxygenase 1 (IDO1) inhibitor, proposed to shift the tumor microenvironment toward an immune-stimulated state, showed early promise in melanoma but has not been studied in sarcoma. This study combined epacadostat with pembrolizumab, which has modest activity in select sarcoma subtypes. PATIENTS AND METHODS This phase II study enrolled patients with advanced sarcoma into five cohorts including (i) undifferentiated pleomorphic sarcoma (UPS)/myxofibrosarcoma, (ii) liposarcoma (LPS), (iii) leiomyosarcoma (LMS), (iv) vascular sarcoma, including angiosarcoma and epithelioid hemangioendothelioma (EHE), and (v) other subtypes. Patients received epacadostat 100 mg twice daily plus pembrolizumab at 200 mg/dose every 3 weeks. The primary endpoint was best objective response rate (ORR), defined as complete response (CR) and partial response (PR), at 24 weeks by RECIST v.1.1. RESULTS Thirty patients were enrolled [60% male; median age 54 years (range, 24-78)]. The best ORR at 24 weeks was 3.3% [PR, n = 1 (leiomyosarcoma); two-sided 95% CI, 0.1%-17.2%]. The median PFS was 7.6 weeks (two-sided 95% CI, 6.9-26.7). Treatment was well tolerated. Grade 3 treatment-related adverse events occurred in 23% (n = 7) of patients. In paired pre- and post-treatment tumor samples, no association was found between treatment and PD-L1 or IDO1 tumor expression or IDO-pathway-related gene expression by RNA sequencing. No significant changes in serum tryptophan or kynurenine levels were observed after baseline. CONCLUSIONS Combination epacadostat and pembrolizumab was well tolerated and showed limited antitumor activity in sarcoma. Correlative analyses suggested that inadequate IDO1 inhibition was achieved.
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Affiliation(s)
- Ciara M. Kelly
- Department of Medicine, Memorial Sloan Kettering Cancer Center
- Department of Medicine, Weill Cornell Medical College
| | - Li-Xuan Qin
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center
| | - Karissa A. Whiting
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center
| | - Allison L. Richards
- Marie-Josée and Henry R. Kravis Center for Molecular Oncology, Memorial Sloan Kettering Cancer Center
| | - Viswatej Avutu
- Department of Medicine, Memorial Sloan Kettering Cancer Center
- Department of Medicine, Weill Cornell Medical College
| | - Jason E. Chan
- Department of Medicine, Memorial Sloan Kettering Cancer Center
- Department of Medicine, Weill Cornell Medical College
| | - Ping Chi
- Department of Medicine, Memorial Sloan Kettering Cancer Center
- Department of Medicine, Weill Cornell Medical College
| | - Mark A. Dickson
- Department of Medicine, Memorial Sloan Kettering Cancer Center
- Department of Medicine, Weill Cornell Medical College
| | - Mrinal M. Gounder
- Department of Medicine, Memorial Sloan Kettering Cancer Center
- Department of Medicine, Weill Cornell Medical College
| | - Mary Louise Keohan
- Department of Medicine, Memorial Sloan Kettering Cancer Center
- Department of Medicine, Weill Cornell Medical College
| | - Sujana Movva
- Department of Medicine, Memorial Sloan Kettering Cancer Center
- Department of Medicine, Weill Cornell Medical College
| | - Benjamin A. Nacev
- Department of Medicine, Memorial Sloan Kettering Cancer Center
- Department of Medicine, Weill Cornell Medical College
| | - Evan Rosenbaum
- Department of Medicine, Memorial Sloan Kettering Cancer Center
- Department of Medicine, Weill Cornell Medical College
| | - Travis Adamson
- Department of Medicine, Memorial Sloan Kettering Cancer Center
| | - Sam Singer
- Department of Surgery, Memorial Sloan Kettering Cancer Center
| | | | - Aimee M. Crago
- Department of Surgery, Memorial Sloan Kettering Cancer Center
| | - Sam S. Yoon
- Department of Surgery, Memorial Sloan Kettering Cancer Center
| | - Sinchun Hwang
- Department of Radiology, Memorial Sloan Kettering Cancer Center
| | | | | | - William D. Tap
- Department of Medicine, Memorial Sloan Kettering Cancer Center
- Department of Medicine, Weill Cornell Medical College
| | - Sandra P. D’Angelo
- Department of Medicine, Memorial Sloan Kettering Cancer Center
- Department of Medicine, Weill Cornell Medical College
- Parker Institute for Cancer Immunotherapy, Memorial Sloan Kettering Cancer Center
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5
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Kinnaman M, Goodboy C, Avutu V, Glade Bender J, Dickson M, Dela Cruz F, O'Donohue T, Tap W, Wexler L, Slotkin E, Kolb E, Kushner B, Meyers P. 52P Long-term outcomes in children, adolescents, and young adults with localized Ewing sarcoma treated with standard vs dose-intensified ifosfamide. ESMO Open 2023. [DOI: 10.1016/j.esmoop.2023.101089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/05/2023] Open
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Avutu V, Slotkin EK, Livingston JAA, Chawla SP, Pressey JG, Nandkumar P, Zheng C, Misir S, Pultar P, Voliotis D, Thornton KA, Federman N. A phase 1/2 dose-escalation and dose-expansion study of ZN-c3 in combination with gemcitabine in adult and pediatric subjects with relapsed or refractory osteosarcoma. J Clin Oncol 2022. [DOI: 10.1200/jco.2022.40.16_suppl.tps11584] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
TPS11584 Background: Osteosarcoma (OS) is the most common primary bone malignancy of childhood and adolescence with 5-year survival rates of 65-70% for localized disease and < 30% for de novo metastatic disease or recurrent disease. Pooled analysis of previous phase 2 trials by the Children’s Oncology Group has determined a 4-month event-free survival (EFS) of 12%. The Wee1 kinase helps regulate DNA damage repair at the G2-M checkpoint. In the presence of DNA damage, the Wee1 kinase is activated, arresting cells in the G2 phase and preventing entry into the M phase. Inhibition of the Wee1 kinase abrogates the G2-M checkpoint, forcing cancer cells to undergo unscheduled mitosis even in the presence of DNA damage, leading to mitotic catastrophe. However, the Wee1 kinase is often upregulated in OS, preserving the G2-M checkpoint and allowing tumor growth and metastases. Additionally, up to 90% of OS tumors have alterations in p53, a critical protein in the regulation of the G1-S checkpoint, especially in relapsed or refractory cases. With a dysfunctional G1-S checkpoint, cancer cells further rely on G2-M checkpoint to repair DNA damage and preserve genomic integrity. Prior studies have demonstrated that pharmacologic inhibition of the Wee1 kinase produced cell death in OS cell lines and patient-derived xenografts. While p53 mutational status appeared to modulate efficacy of the Wee1 kinase inhibitor, activity was observed in p53 wild type, mutant and null cell lines. Combination therapy studies have also been performed, demonstrating potential synergism with gemcitabine. As expected, by precipitating DNA damage, susceptibility to inhibition of the G2-M checkpoint is further increased. Methods: NCT04833582 is an ongoing, open label, multicenter, phase 1/2 clinical trial to evaluate the activity of ZN-c3, an oral Wee1 inhibitor, in combination with gemcitabine in subjects ≥12 years and ≥40 kg, with relapsed, refractory OS. Subjects are dosed once daily, continuously with ZN-c3 and receive gemcitabine 1000 mg/m2 on days 1 and 8 of 21-day cycles. Up to 18 subjects are expected to enroll in the phase 1 portion based on a typical 3 + 3 escalation design; ̃60 subjects will be enrolled in the phase 2 portion, consisting of three stages: futility, promising clinical activity, and improved precision for clinical activity. The first two stages follow a Simon two-stage optimal design with 30 subjects, to differentiate an EFS rate at 18 weeks between 12% and 36% (which may be considered a more suitable endpoint for OS, compared with radiographic response). Tumor and skin punch biopsies are incorporated into the trial to identify potential biomarkers of treatment response. Subjects must be able to swallow oral tablets and have measurable disease by RECIST v1.1; prior exposure to gemcitabine is allowed. Global enrollment began August 1, 2021, and is ongoing. Clinical trial information: NCT04833582.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | - Noah Federman
- David Geffen School of Medicine UCLA Jonsson Comprehensive Cancer Center, Los Angeles, CA
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Movva S, Avutu V, Chi P, Dickson MA, Gounder MM, Kelly CM, Keohan ML, Nacev BA, Rosenbaum E, Thornton KA, Cohen SM, Hensley ML, Konner JA, Schram AM, Qin LX, Lefkowitz RA, Erinjeri JP, D'Angelo SP. A pilot study of lenvatinib plus pembrolizumab in patients with advanced sarcoma. J Clin Oncol 2022. [DOI: 10.1200/jco.2022.40.16_suppl.tps11588] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
TPS11588 Background: New treatment options are needed for sarcomas. Pazopanib is the only targeted agent approved for multiple soft tissue sarcoma (STS) subtypes with a response rate of 6% and a PFS of 4.6 months. Immunotherapy has a limited role in STS, as the SARC028 study of pembrolizumab demonstrated an overall response rate of 18%, with the highest response rate seen in the undifferentiated pleomorphic sarcoma (UPS) cohort at 23%. Lenvatinib is an oral, multi-tyrosine kinase inhibitor approved for the treatment of multiple cancer types including progressive, radioiodine-refractory thyroid cancer and unresectable hepatocellular carcinoma with inhibitory activity against the receptor tyrosine kinases VEGFR 1-3, FGFR 1-3, KIT, PDGFR alpha/beta, and RET. Early outcomes with the combination of lenvatinib and pembrolizumab suggest that this regimen could be broadly superior to PD-1 targeting alone for several tumor types as high rates of objective response have been noted. The rationale for this study is based on preclinical work demonstrating the immunosuppressive effects of VEGF in the tumor immune microenvironment including inhibition of dendritic cell maturation, recruitment of immunosuppressive Tregs, MDSCs and TAMs and up-regulation of PD-1 on CD8+ cells. Methods: This is a pilot study evaluating the efficacy of lenvatinib and pembrolizumab in the treatment of select metastatic and/or unresectable sarcomas. Patients will be enrolled in one of five cohorts: Cohort A: leiomyosarcoma; Cohort B: UPS; Cohort C: vascular sarcomas (including angiosarcoma and epithelioid hemangioendothelioma); Cohort D: synovial sarcoma and malignant peripheral nerve sheath tumor; and Cohort E: bone sarcomas (limited to osteosarcoma and chondrosarcoma). Eligible patients should have had at least one prior therapy for unresectable and/or metastatic disease, but no more than three prior lines of therapy. Prior treatment with angiogenesis inhibitors or immunotherapy is excluded. Archival tissue is required for eligibility. Patients enrolled in the study will be treated initially with a 2 week run-in of lenvatinib 20 mg orally daily which will be continued daily thereafter. Subsequently, they will start pembrolizumab 200 mg intravenously every 21 days. The primary endpoint for each cohort is best overall response rate documented by RECIST v1.1 Criteria at 27 weeks. A sample size of 10 patients is planned for each of the five histological cohorts. If 2 or more confirmed responses are observed among the 10 patients in an arm, the drug combination will be considered positive and worthy of further investigation for that arm. Secondary endpoints are PFS, OS, duration of response and safety/tolerability of the combination. On-treatment biopsy and blood samples will be required for correlative assessments. Accrual in all cohorts is ongoing. Clinical trial information: NCT04784247.
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Affiliation(s)
- Sujana Movva
- Memorial Sloan Kettering Cancer Center, NewYork, NY
| | | | - Ping Chi
- Memorial Sloan Kettering Cancer Center, New York, NY
| | | | - Mrinal M. Gounder
- Memorial Sloan Kettering Cancer Center and Weill Cornell Medical College, New York, NY
| | | | - Mary Louise Keohan
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
| | | | | | | | - Seth M. Cohen
- Continuum Cancer Ctr of New York St Lukes Roosevelt Hosp, New York, NY
| | - Martee Leigh Hensley
- Memorial Sloan Kettering Cancer Center and Weil Cornell Medical College, New York, NY
| | | | | | - Li-Xuan Qin
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY
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Slotkin EK, Mauguen A, Ortiz MV, Dela Cruz FS, O'Donohue T, Kinnaman MD, Meyers PA, Wexler LH, Rodriguez S, Avutu V, Kelly CM, D'Angelo SP, Keohan ML, Gounder MM, Nacev BA, Rosenbaum E, Dickson MA, Thornton KA, Glade Bender JL, Tap WD. A phase I/II study of prexasertib in combination with irinotecan in patients with relapsed/refractory desmoplastic small round cell tumor and rhabdomyosarcoma. J Clin Oncol 2022. [DOI: 10.1200/jco.2022.40.16_suppl.11503] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
11503 Background: Prexasertib (PRX) is an inhibitor of CHK1, prevents DNA repair leading to mitotic catastrophe, and can enhance the activity of DNA-damaging chemotherapy. Translocation driven sarcomas exhibit high levels of replication stress and have demonstrated susceptibility to CHK1 inhibition in preclinical models. Desmoplastic small round cell tumor (DSRCT) and rhabdomyosarcoma (RMS) are aggressive sarcomas of children, adolescents and young adults for which novel therapies are urgently required. Methods: We conducted a phase I/II trial of PRX with irinotecan (irino) in patients ≥ 12 months of age with relapsed or refractory DSRCT or RMS. Eligible patients could have any number of prior therapies, including irino. Dose level 1 was PRX 80 mg/m2 on day 1 + irino 20 mg/m2 for 10 days. Dose levels 2 and 2A were PRX 105 or 150 mg/m2 (>21 years or ≤ 21 years) on day 1 and irino 20 mg/m2 for 10 (level 2) or 5 (level 2A) days. All cycles were 21 days. The primary objectives were to determine the RP2D of PRX with irino, and to determine the best overall response rate (ORR) in 6 months at the RP2D (RECIST v1.1) in DSRCT, with 3 or more responses out of 16 considered promising. Results: 21 patients were enrolled (DSRCT: 19; 2 RMS:2). The RP2D was dose level 2A. Treatment was well tolerated with the most common adverse events being neutropenia (48%), nausea (48%), and fatigue (52%). Cytopenias were managed with the aid of growth factor support in all patients once the RP2D was established. The DSRCT expansion enrolled 13 of 16 planned patients due to discontinuation of PRX supply prior to study completion. Four patients remain on therapy at the time of this submission. Responses in DSRCT patients at all dose levels are shown in Table. Sixteen of 21 enrolled patients, and 5 of 6 patients achieving PR had previously received irino. The median (range) number of cycles was 7 (2-26). Both RMS patients treated at the RP2D experienced SD as best response. The estimated ORR at the RP2D was 23%, and lower boundary of the one-sided 90% confidence interval was 9%, exceeding the unpromising rate of 5%. The two-sided 90% confidence interval was 7 to 49%. In addition, 3 patients had a PR at doses lower than the RP2D, bringing the ORR for all dose levels (n = 19) to 32% (90%CI: 15 to 53%). Conclusions: The RP2D of PRX in combination with irino is PRX 105 or 150 mg/m2 (>21 years or ≤ 21 years) on day 1 and irino 20 mg/m2 for 5 days in 21 day cycles with myelosuppression successfully managed with growth factor support. The study met its primary objective to consider PRX + irino promising in DSRCT and should be further investigated. Clinical trial information: NCT04095221. [Table: see text]
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | - Mary Louise Keohan
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Mrinal M. Gounder
- Memorial Sloan Kettering Cancer Center and Weill Cornell Medical College, New York, NY
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9
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Nacev BA, Bradic M, Richards AL, Kelly CM, Dickson MA, Gounder MM, Keohan ML, Chi P, Movva S, Thornton KA, Slotkin EK, Rosenbaum E, Avutu V, Chan JE, Banks LB, Adamson T, Singer S, Donoghue M, Tap WD, D'Angelo SP. Presence of immune infiltrates, increased expression of transposable elements, and viral response pathways in sarcoma associate with response to checkpoint inhibition. J Clin Oncol 2022. [DOI: 10.1200/jco.2022.40.16_suppl.11510] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
11510 Background: Response to checkpoint inhibition (CPI) in sarcoma is overall low and varies between and within subtypes. Understanding tumor intrinsic determinants of this response may improve efficacy and patient selection. The de-repression of transposable elements (TEs), which are epigenetically silenced repetitive DNA elements of viral origin, is linked to anti-tumor immunity through an antiviral inflammatory response. We hypothesize that baseline expression of TEs and epigenetic regulators correlates with overall response rate (ORR) in sarcoma CPI clinical trials. Methods: This is a retrospective analysis of bulk RNA-sequencing data from pre-treatment biopsies of patients on CPI trials in sarcoma (pembrolizumab plus talimogene laherparepvec, nivolumab plus bempegaldesleukin, and pembrolizumab plus epacadostat). Sixty-seven samples from unique patients representing 12 subtypes were analyzed. The MCP counter deconvolution method and unsupervised clustering were used to group samples by immune phenotypes resulting in immune ‘hot’ and ‘cold’ clusters. ORR was defined by RECIST. To determine if baseline expression of TEs and epigenetic regulators significantly predicted immune types, we implemented a lasso penalized logistic regression. Results: Immune ‘hot’ tumors were characterized by increased immune infiltrates including CD8+ T-cells, B-cells, and NK cells vs ‘cold’ tumors. Patients with ‘hot’ vs ‘cold’ tumors had an ORR of 30.5% (11/36) vs. 3.2% (1/31) (p = 0.003; chi-squared). The best predictors of ‘hot vs ‘cold’ was the increased expression of multiple TE families including MER45A, MER57F, and LTR21B (respective lasso coefficients, 0.27, 0.07, and 0.07). Expression of IKZF1, a chromatin-interacting transcription factor, was also predictive (lasso coefficient, 0.35) and increased expression correlated with improved ORR (p = 0.003; unpaired t-test). TE and IKFZ1 expression was significantly correlated with CD8+ T-cell signaling and antiviral response pathways such as cGAS-STING (MER57F, r2= 0.43, padj = 1.75E-4; IKZF1, r2= 0.63, padj = 6.28E-9) and type II interferon (MER57F, r2= 0.67, padj = 2.51E-10; IKZF1, r2= 0.60, padj = 7.19E-8). Increased expression of cGAS-STING (p = 3.9E-4; unpaired t-test) and type II interferon pathways (p = 1.89E-10; unpaired t-test) was significant in ‘hot’ tumors. Conclusions: Immune ‘hot’ baseline immune profiles of sarcoma are associated with improved ORR to CPI and with increased expression of TEs and IKZF1. These differences in gene expression correlate with increased inflammatory signaling, which suggests a response to TE-encoded viral-like sequences that are typically epigenetically silenced. Induction of TE de-repression and IKZF1 expression through epigenetic targeting warrants pre-clinical investigation as a strategy to promote CPI response in sarcomas.
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Affiliation(s)
| | | | | | | | | | - Mrinal M. Gounder
- Memorial Sloan Kettering Cancer Center and Weill Cornell Medical College, New York, NY
| | - Mary Louise Keohan
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Ping Chi
- Memorial Sloan Kettering Cancer Center, New York, NY
| | - Sujana Movva
- Memorial Sloan Kettering Cancer Center, New York, NY
| | | | | | | | | | | | - Lauren Baker Banks
- Memorial Sloan-Kettering Cancer Center-Fellowship (GME Office), New York, NY
| | | | - Samuel Singer
- Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY
| | - Mark Donoghue
- Memorial Sloan Kettering Cancer Center, New York, NY
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10
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Rosenbaum E, Qin LX, Thornton KA, Movva S, Nacev BA, Dickson MA, Gounder MM, Keohan ML, Avutu V, Chi P, Kelly CM, Chan JE, Martindale M, Adamson T, McKennan OR, Erinjeri JP, Lefkowitz RA, Tap WD, D'Angelo SP. A phase I/II trial of the PD-1 inhibitor retifanlimab (R) in combination with gemcitabine and docetaxel (GD) as first-line therapy in patients (Pts) with advanced soft-tissue sarcoma (STS). J Clin Oncol 2022. [DOI: 10.1200/jco.2022.40.16_suppl.11516] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
11516 Background: In a phase III trial, GD had similar response and survival rates to doxorubicin when administered as first-line therapy to advanced STS pts. G and D have each demonstrated synergy with PD-1 blockade in pre-clinical or clinical studies. We hypothesized that GD plus R would be safe, tolerable, and have synergistic activity in STS. Methods: This is an ongoing open-label, single-center, phase I/II trial of R (INCMGA00012) combined with GD in pts with treatment-naïve unresectable or metastatic high-grade STS. Herein, we report the phase I results, which included a safety run-in followed by a 3+3 dose de-escalation design. G (900 mg/m2) was administered on days 1 and 8 and D (75 mg/m2) on day 8, in 21-day cycles. R (210 mg IV flat dose on the run-in portion and 375 mg on the dose de-escalation portion) was administered on day 1 of each cycle starting in cycle 2 and continued as monotherapy after completion of 6 cycles of GD. The primary endpoint of the phase I was to determine the recommended phase 2 dose (RP2D) of R plus GD. Secondary endpoints included describing the safety, assessing best overall response rate (ORR) by RECIST 1.1, disease control rate (DCR), and progression-free survival (PFS). Results: Thirteen pts were treated, 7on the run-in and 6 on the de-escalation portion. One pt progressed prior to starting R and was replaced. Median pt age was 53 (range 28 – 74) and 7 were female. Histologies included leiomyosarcoma (n = 6), undifferentiated pleomorphic sarcoma (2), dedifferentiated liposarcoma (2), pleomorphic liposarcoma (1), angiosarcoma (1), and myxofibrosarcoma (1). The Table lists treatment-related adverse events (TRAEs) that occurred in ≥ 20% pts in descending order of frequency. Additional Grade (Gr) 3 TRAEs occurring in 1 pt each, included: infusion reaction, leukopenia, anorectal infection, neutropenia, and pyelonephritis. Gr 3 pyelonephritis was the only dose-limiting toxicity. There were no Gr ≥ 4 TRAEs. One pt (Gr 3 elevated AST/ALT) required corticosteroids and cessation of study therapy. The RP2D was determined to be 375 mg of R plus GD. Twelve pts were evaluable for response. ORR was 17% (1 of 6; 95% CI 1 - 64%) and 50% (3 of 6; 95% CI 19% - 81%) in the run-in and de-escalation cohorts, respectively. DCR was 100% (6 of 6; 95% CI 52 - 100%) and 83% (5 of 6; 95% CI: 36 - 99%). PFS rates at 24 weeks were 60% (95% CI: 29 - 100%) and 44% (95% CI: 17 - 100%). Conclusions: R plus GD was generally safe and well tolerated with no unexpected safety signals to date. The phase II portion evaluating efficacy of R plus GD at the RP2D is ongoing. Clinical trial information: NCT04577014. [Table: see text]
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Affiliation(s)
| | - Li-Xuan Qin
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY
| | | | - Sujana Movva
- Memorial Sloan Kettering Cancer Center, New York, NY
| | | | | | - Mrinal M. Gounder
- Memorial Sloan Kettering Cancer Center and Weill Cornell Medical College, New York, NY
| | - Mary Louise Keohan
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
| | | | - Ping Chi
- Memorial Sloan Kettering Cancer Center, New York, NY
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11
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Rosenbaum E, Antonescu CR, Smith S, Bradic M, Kashani D, Richards AL, Donoghue M, Kelly CM, Nacev B, Chan JE, Chi P, Dickson MA, Keohan ML, Gounder MM, Movva S, Avutu V, Thornton K, Zehir A, Bowman AS, Singer S, Tap W, D'Angelo S. Clinical, genomic, and transcriptomic correlates of response to immune checkpoint blockade-based therapy in a cohort of patients with angiosarcoma treated at a single center. J Immunother Cancer 2022; 10:jitc-2021-004149. [PMID: 35365586 PMCID: PMC8977792 DOI: 10.1136/jitc-2021-004149] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/12/2022] [Indexed: 12/15/2022] Open
Abstract
Background Angiosarcoma is a histologically and molecularly heterogeneous vascular neoplasm with aggressive clinical behavior. Emerging data suggests that immune checkpoint blockade (ICB) is efficacious against some angiosarcomas, particularly cutaneous angiosarcoma of the head and neck (CHN). Methods Patients with histologically confirmed angiosarcoma treated with ICB-based therapy at a comprehensive cancer center were retrospectively identified. Clinical characteristics and the results of targeted exome sequencing, transcriptome sequencing, and immunohistochemistry analyses were examined for correlation with clinical benefit. Durable clinical benefit was defined as a progression-free survival (PFS) of ≥16 weeks. Results For the 35 patients included in the analyses, median PFS and median overall survival (OS) from the time of first ICB-based treatment were 11.9 (95% CI 7.4 to 31.9) and 42.5 (95% CI 19.6 to 114.2) weeks, respectively. Thirteen patients (37%) had PFS ≥16 weeks. Clinical factors associated with longer PFS and longer OS in multivariate analyses were ICB plus other therapy regimens, CHN disease, and white race. Three of 10 patients with CHN angiosarcoma evaluable for tumor mutational burden (TMB) had a TMB ≥10. Five of six patients with CHN angiosarcoma evaluable for mutational signature analysis had a dominant mutational signature associated with ultraviolet (UV) light. No individual gene or genomic pathway was significantly associated with PFS or OS; neither were TMB or UV signature status. Analyses of whole transcriptomes from nine patient tumor samples found upregulation of angiogenesis, inflammatory response, and KRAS signaling pathways, among others, in patients with PFS ≥16 weeks, as well as higher levels of cytotoxic T cells, dendritic cells, and natural killer cells. Patients with PFS <16 weeks had higher numbers of cancer-associated fibroblasts. Immunohistochemistry findings for 12 patients with baseline samples available suggest that neither PD-L1 expression nor presence of tumor-infiltrating lymphocytes at baseline appears necessary for a response to ICB-based therapy. Conclusions ICB-based therapy benefits only a subset of angiosarcoma patients. Patients with CHN angiosarcoma are more likely to have PFS ≥16 weeks, a dominant UV mutational signature, and higher TMB than angiosarcomas arising from other primary sites. However, clinical benefit was seen in other angiosarcomas also and was not restricted to tumors with a high TMB, a dominant UV signature, PD-L1 expression, or presence of tumor infiltrating lymphocytes at baseline.
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Affiliation(s)
- Evan Rosenbaum
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York City, New York, USA .,Department of Medicine, Weill Cornell Medical College, New York City, New York, USA
| | - Cristina R Antonescu
- Department of Pathology, Memorial Sloan Kettering Cancer Center, New York City, New York, USA
| | - Shaleigh Smith
- Marie-Josée and Henry R. Kravis Center for Molecular Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Martina Bradic
- Marie-Josée and Henry R. Kravis Center for Molecular Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Daniel Kashani
- Department of Medicine, SUNY Downstate Medical Center, New York City, New York, USA
| | - Allison L Richards
- Marie-Josée and Henry R. Kravis Center for Molecular Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Mark Donoghue
- Marie-Josée and Henry R. Kravis Center for Molecular Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Ciara M Kelly
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York City, New York, USA.,Department of Medicine, Weill Cornell Medical College, New York City, New York, USA
| | - Benjamin Nacev
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York City, New York, USA.,Department of Medicine, Weill Cornell Medical College, New York City, New York, USA
| | - Jason E Chan
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York City, New York, USA.,Department of Medicine, Weill Cornell Medical College, New York City, New York, USA
| | - Ping Chi
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York City, New York, USA.,Department of Medicine, Weill Cornell Medical College, New York City, New York, USA.,Human Oncology and Pathogenesis Program, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Mark A Dickson
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York City, New York, USA.,Department of Medicine, Weill Cornell Medical College, New York City, New York, USA
| | - Mary L Keohan
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York City, New York, USA.,Department of Medicine, Weill Cornell Medical College, New York City, New York, USA
| | - Mrinal M Gounder
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York City, New York, USA.,Department of Medicine, Weill Cornell Medical College, New York City, New York, USA
| | - Sujana Movva
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York City, New York, USA.,Department of Medicine, Weill Cornell Medical College, New York City, New York, USA
| | - Viswatej Avutu
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York City, New York, USA.,Department of Medicine, Weill Cornell Medical College, New York City, New York, USA
| | - Katherine Thornton
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York City, New York, USA.,Department of Medicine, Weill Cornell Medical College, New York City, New York, USA
| | - Ahmet Zehir
- Department of Pathology, Memorial Sloan Kettering Cancer Center, New York City, New York, USA
| | - Anita S Bowman
- Department of Pathology, Memorial Sloan Kettering Cancer Center, New York City, New York, USA
| | - Samuel Singer
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York City, New York, USA
| | - William Tap
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York City, New York, USA.,Department of Medicine, Weill Cornell Medical College, New York City, New York, USA
| | - Sandra D'Angelo
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York City, New York, USA.,Department of Medicine, Weill Cornell Medical College, New York City, New York, USA
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12
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Mittal N, Saha A, Avutu V, Monga V, Freyer DR, Roth M. Shared barriers and facilitators to enrollment of adolescents and young adults on cancer clinical trials. Sci Rep 2022; 12:3875. [PMID: 35264642 PMCID: PMC8907177 DOI: 10.1038/s41598-022-07703-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Accepted: 02/14/2022] [Indexed: 12/12/2022] Open
Abstract
Adolescent and young adult (AYA) enrollment in cancer clinical trials (CCT) is suboptimal. Few studies have explored site level barriers and facilitators to AYA enrollment on CCTs and the efficacy of interventions to enhance enrollment. A cross sectional survey was developed by the COG AYA Oncology Discipline Committee Responsible Investigator (RI) Network to identify perceived barriers and facilitators to enrollment, as well as opportunities to improve enrollment. Associations of barriers and facilitators to enrollment with program demographics were assessed. The survey was sent to all AYA RI Network members (n = 143) and quantitative and thematic analyses were conducted. The overall response rate was 42% (n = 60/143). Participants represented diverse institutions based on size, presence or absence of dedicated AYA programs, and proximity and relationship between pediatric and medical oncology practices within the institution. The most frequently cited barriers to enrolling AYAs in CCTs were administrative logistical issues (45%), disparate enrollment practices (42%) and communication issues (27%) between pediatric and medical oncology and perceived limited trial availability (27%). The most frequently reported facilitators to enrollment included having strong communication between pediatric and medical oncology (48%), having a supportive research infrastructure (35%) and the presence of AYA champions (33%). Many barriers and facilitators were similar across institutions and AYA program types. Shared barriers and facilitators to AYA CCT enrollment exist across the landscape of cancer care settings. Interventions aimed at increasing coordination between pediatric and medical oncology clinical trials offices and providers have high potential to improve site-level AYA enrollment.
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Affiliation(s)
- Nupur Mittal
- Department of Pediatrics, Rush University Medical Center, Chicago, IL, USA
| | - Aniket Saha
- Department of Pediatrics, Prisma Health Children's Hospital, Greenville, SC, USA
| | - Viswatej Avutu
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Varun Monga
- Division of Medical Oncology, Department of Internal Medicine, University of Iowa, Iowa City, IA, USA
| | - David R Freyer
- Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Michael Roth
- Division of Pediatrics, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd., Houston, TX, 77030, USA.
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13
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Avutu V, Monga V, Mittal N, Saha A, Andolina JR, Bell DE, Fair DB, Flerlage JE, Frediani JN, Heath JL, Kahn JM, Reichek JL, Super L, Terao MA, Freyer DR, Roth ME. Use of Communication Technology to Improve Clinical Trial Participation in Adolescents and Young Adults With Cancer: Consensus Statement From the Children's Oncology Group Adolescent and Young Adult Responsible Investigator Network. JCO Oncol Pract 2022; 18:224-231. [PMID: 34905405 PMCID: PMC8932547 DOI: 10.1200/op.21.00554] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Adolescents and young adults (AYAs; age 15-39 years) with cancer are under-represented in cancer clinical trials because of patient, provider, and institutional barriers. Health care technology is increasingly available to and highly used among AYAs and has the potential to improve cancer care delivery. The COVID-19 pandemic forced institutions to rapidly adopt novel approaches for enrollment and monitoring of patients on cancer clinical trials, many of which have the potential for improving AYA trial participation overall. This consensus statement from the Children's Oncology Group AYA Oncology Discipline Committee reviews opportunities to use technology to optimize AYA trial enrollment and study conduct, as well as considerations for widespread implementation of these practices. The use of remote patient eligibility screening, electronic informed consent, virtual tumor boards, remote study visits, and remote patient monitoring are recommended to increase AYA access to trials and decrease the burden of participation. Widespread adoption of these strategies will require new policies focusing on reimbursement for telehealth, license portability, facile communication between electronic health record systems and advanced safeguards to maintain patient privacy and security. Studies are needed to determine optimal approaches to further incorporate technology at every stage of the clinical trial process, from enrollment through study completion.
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Affiliation(s)
- Viswatej Avutu
- Department of Medicine, Memorial Sloan Kettering Cancer Center; New York, NY,Viswatej Avutu, MD, Department of Medicine, Memorial Sloan Kettering Cancer Center, 300 E 66th Floor 14, New York, NY 10065; e-mail:
| | - Varun Monga
- Division of Medical Oncology, Department of Internal Medicine, University of Iowa, Iowa City, IA
| | - Nupur Mittal
- Division of Pediatric Hematology Oncology, Department of Pediatrics, Rush University Medical Center, Chicago, IL
| | - Aniket Saha
- Division of Pediatric Hematology-Oncology, University of South Carolina School of Medicine, Greenville, SC
| | - Jeffrey R. Andolina
- Department of Pediatrics, Golisano Children's Hospital, University of Rochester Medical Center, Rochester, NY
| | - Danielle E. Bell
- Department of Pediatrics, Ascension St John Hospital, Detroit, MI
| | - Douglas B. Fair
- Division of Hematology/Oncology, Department of Pediatrics, University of Utah, Primary Children's Hospital, Huntsman Cancer Institute, Salt Lake City, UT
| | - Jamie E. Flerlage
- Department of Oncology, St Jude Children's Research Hospital, Memphis, TN
| | | | - Jessica L. Heath
- Departments of Pediatrics and Biochemistry, University of Vermont, Burlington, VT
| | - Justine M. Kahn
- Division of Pediatric Hematology/Oncology/Stem Cell Transplantation, Columbia University Irving Medical Center, New York, NY
| | - Jennifer L. Reichek
- Division of Hematology/Oncology/Stem Cell Transplantation, Department of Pediatrics, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL
| | - Leanne Super
- Department of Paediatrics, School of Medicine, Monash University, Melbourne, Australia
| | - Michael A. Terao
- Division of Pediatric Adolescent and Young Adult Hematology and Oncology, Department of Pediatrics, Medstar Georgetown University Hospital, Washington, DC
| | - David R. Freyer
- Departments of Pediatrics, Medicine, and Preventive Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Michael E. Roth
- Division of Pediatrics, University of Texas MD Anderson Cancer Center, Houston, TX
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14
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Avutu V, Weiss AR, Reed DR, Ahmed SK, Allen-Rhoades WA, Chen YLE, Davis LE, Eaton BR, Hawkins DS, Indelicato DJ, Patel SR, Randall RL, Reinke DK, Riedel RF, Scharschmidt TJ, Thornton KA, Wang D, Janeway KA, Kopp LM. Identified Enrollment Challenges of Adolescent and Young Adult Patients on the Nonchemotherapy Arm of Children's Oncology Group Study ARST1321. J Adolesc Young Adult Oncol 2021; 11:328-332. [PMID: 34515544 DOI: 10.1089/jayao.2021.0103] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
ARST1321, a trial of patients with advanced soft tissue sarcoma, was the first National Clinical Trials Network study codeveloped by pediatric and adult consortia with two treatment cohorts. We report on the findings of a survey to identify barriers to enrolling adolescent and young adult patients (15-39 years) onto the nonchemotherapy arm. The survey response rate was 31% with a 70% completion rate. Common identified reasons for low accrual in order of decreasing frequency included insufficient funding, lack of study awareness or interest, competing trials, toxicity concerns, philosophical differences in the therapy backbone, and regulatory and infrastructure barriers. Clinical Trials.gov ID: NCT02180867.
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Affiliation(s)
- Viswatej Avutu
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Aaron R Weiss
- Department of Pediatrics, Maine Medical Center, Portland, Maine, USA
| | - Damon R Reed
- Department of Individualized Cancer Management, Moffitt Cancer Center, Tampa, Florida, USA
| | - Safia K Ahmed
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota, USA
| | - Wendy A Allen-Rhoades
- Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Yen-Lin E Chen
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Lara E Davis
- Department of Medicine, Oregon Health & Science University, Portland, Oregon, USA
| | - Bree R Eaton
- Department of Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, Georgia, USA
| | - Douglas S Hawkins
- Department of Pediatrics, Seattle Children's Hospital, Seattle, Washington, USA
| | - Danny J Indelicato
- Department of Radiation Oncology, University of Florida, Jacksonville, Florida, USA
| | - Shreyaskumar R Patel
- Department of Medicine, University of Texas M.D. Anderson Cancer Center, Houston, Texas, USA
| | - R Lor Randall
- Department of Orthopaedic Surgery, UC Davis Health, Sacramento, California, USA
| | - Denise K Reinke
- Sarcoma Alliance for Research through Collaboration, Ann Arbor, Michigan, USA
| | - Richard F Riedel
- Department of Medicine, Duke Cancer Institute, Durham, North Carolina, USA
| | - Thomas J Scharschmidt
- Department of Orthopaedic Surgery, Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Katherine A Thornton
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Dian Wang
- Department of Radiation Oncology, Rush University Medical Center, Chicago, Illinois, USA
| | - Katherine A Janeway
- Department of Pediatrics, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Lisa M Kopp
- Department of Epidemiology and Biostatistics, University of Arizona, Tucson, Arizona, USA
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15
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Rosenbaum E, Movva S, Kelly CM, Dickson MA, Keohan ML, Gounder MM, Thornton KA, Chi P, Chan JE, Nacev B, Avutu V, Biniakewitz M, McKennan OR, Phelan H, Perez S, Hwang S, Singer S, Qin LX, Tap WD, D'Angelo SP. A phase 1b study of avelumab plus DCC-3014, a potent and selective inhibitor of colony stimulating factor 1 receptor (CSF1R), in patients with advanced high-grade sarcoma. J Clin Oncol 2021. [DOI: 10.1200/jco.2021.39.15_suppl.11549] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
11549 Background: Select sarcomas are infiltrated with immunosuppressive myeloid cells. DCC-3014 is an inhibitor of the CSF1R kinase that decreases tumor infiltrating myeloid cells in preclinical models. We hypothesized that DCC-3014 combined with the anti-PDL1 inhibitor avelumab would be safe and tolerable, decrease immunosuppressive myeloid cells, and increase cytotoxic T cells. Methods: This investigator initiated, open label, single center, phase I study of DCC-3014 plus avelumab in patients (pts) with unresectable or metastatic sarcoma utilized a standard 3+3 dose escalation design. DCC-3014 was administered on days 1-3 (loading dose of 20, 30, or 50 mg) followed by oral daily maintenance (10, 14, or 20 mg) in 28-day cycles; 800 mg of IV avelumab was administered q2weeks. The primary endpoint was to determine the recommended phase 2 dose (RP2D). Secondary endpoints defined the adverse event (AE) profile and assessed clinical efficacy. Peripheral blood CD14+Lin-HLA-DRlo myeloid-derived suppressor cells (MDSCs) were measured by flow cytometry. Results: 13 pts were treated; median age was 61 (range 32 – 71), 8 were female, and median prior lines of therapy was 5 (range 2 – 10). Histologic subtypes included leiomyosarcoma (LMS, n = 7), undifferentiated pleomorphic sarcoma (2), dedifferentiated liposarcoma (LPS, 2), synovial sarcoma (1), and pleomorphic LPS (1). The Table lists treatment-related AEs (TRAEs) of any grade (G) occurring in ≥ 10% of pts and all G ≥ 3 TRAEs, sorted by frequency. All pts had at least 1 TRAE. Seven pts (54%) had a G ≥ 3 TRAE. Most TRAEs were either G ≤ 2 or expected on-target effects of CSF1R inhibition. 1 of 6 pts on the highest dose level had a dose limiting toxicity (G4 elevated AST with abdominal pain) that resolved with treatment cessation. The highest dose level was declared the RP2D. Best objective response by RECIST 1.1 was stable disease in 3 pts; 2 had LMS and were treated at the highest dose level. At baseline, the mean proportion of monocytes in peripheral blood samples with an MDSC phenotype was 12.2% (range 7.1 – 19.9). 5 of 7 pts with serial blood samples had decreased circulating MDSCs (mean decrease of 26.9% from baseline to last time point). Conclusions: DCC-3014 combined with avelumab was safe and tolerable. Study therapy decreased circulating MDSCs in select patients; T cell analyses will be reported. Study expansion at the RP2D is ongoing. Clinical trial information: NCT04242238. [Table: see text]
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Affiliation(s)
| | | | - Ciara Marie Kelly
- Memorial Sloan Kettering Cancer Center and Weill Cornell Medical College, New York, NY
| | | | - Mary Louise Keohan
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
| | | | | | - Ping Chi
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
| | | | | | | | | | | | - Haley Phelan
- Memorial Sloan Kettering Cancer Center, New York, NY
| | - Silvia Perez
- Memorial Sloan Kettering Cancer Center, New York, NY
| | - Sinchun Hwang
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Samuel Singer
- Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY
| | - Li-Xuan Qin
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY
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Jee J, Foote MB, Lumish M, Stonestrom AJ, Wills B, Narendra V, Avutu V, Murciano-Goroff YR, Chan JE, Derkach A, Philip J, Belenkaya R, Kerpelev M, Maloy M, Watson A, Fong C, Janjigian Y, Diaz LA, Bolton KL, Pessin MS. Chemotherapy and COVID-19 Outcomes in Patients With Cancer. J Clin Oncol 2020; 38:3538-3546. [PMID: 32795225 PMCID: PMC7571792 DOI: 10.1200/jco.20.01307] [Citation(s) in RCA: 170] [Impact Index Per Article: 42.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/17/2020] [Indexed: 12/13/2022] Open
Abstract
PURPOSE Coronavirus-2019 (COVID-19) mortality is higher in patients with cancer than in the general population, yet the cancer-associated risk factors for COVID-19 adverse outcomes are not fully characterized. PATIENTS AND METHODS We reviewed clinical characteristics and outcomes from patients with cancer and concurrent COVID-19 at Memorial Sloan Kettering Cancer Center until March 31, 2020 (n = 309), and observed clinical end points until April 13, 2020. We hypothesized that cytotoxic chemotherapy administered within 35 days of a COVID-19 diagnosis is associated with an increased hazard ratio (HR) of severe or critical COVID-19. In secondary analyses, we estimated associations between specific clinical and laboratory variables and the incidence of a severe or critical COVID-19 event. RESULTS Cytotoxic chemotherapy administration was not significantly associated with a severe or critical COVID-19 event (HR, 1.10; 95% CI, 0.73 to 1.60). Hematologic malignancy was associated with increased COVID-19 severity (HR, 1.90; 95% CI, 1.30 to 2.80). Patients with lung cancer also demonstrated higher rates of severe or critical COVID-19 events (HR, 2.0; 95% CI, 1.20 to 3.30). Lymphopenia at COVID-19 diagnosis was associated with higher rates of severe or critical illness (HR, 2.10; 95% CI, 1.50 to 3.10). Patients with baseline neutropenia 14-90 days before COVID-19 diagnosis had worse outcomes (HR, 4.20; 95% CI, 1.70 to 11.00). Findings from these analyses remained consistent in a multivariable model and in multiple sensitivity analyses. The rate of adverse events was lower in a time-matched population of patients with cancer without COVID-19. CONCLUSION Recent cytotoxic chemotherapy treatment was not associated with adverse COVID-19 outcomes. Patients with active hematologic or lung malignancies, peri-COVID-19 lymphopenia, or baseline neutropenia had worse COVID-19 outcomes. Interactions among antineoplastic therapy, cancer type, and COVID-19 are complex and warrant further investigation.
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Affiliation(s)
- Justin Jee
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Michael B. Foote
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Melissa Lumish
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Aaron J. Stonestrom
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Beatriz Wills
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Varun Narendra
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Viswatej Avutu
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
| | | | - Jason E. Chan
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Andriy Derkach
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY
| | - John Philip
- Department of Health Informatics, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Rimma Belenkaya
- Department of Health Informatics, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Marina Kerpelev
- Department of Information Systems, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Molly Maloy
- Department of Health Informatics, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Adam Watson
- Department of Health Informatics, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Chris Fong
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Yelena Janjigian
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Luis A. Diaz
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Kelly L. Bolton
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Melissa S. Pessin
- Department of Laboratory Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
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Kopp LM, Reed DR, Ahmed SK, Allen-Rhoades W, Avutu V, Chen YL, Davis LE, Eaton BR, Hawkins DS, Indelicato DJ, Patel S, Randall RL, Reinke DK, Riedel RF, Scharschmidt T, Thornton KA, Wang D, Janeway KA, Weiss AR. Enrollment barriers of adolescents and young adults (AYA) on the non-chemotherapy arm of ARST1321. J Clin Oncol 2020. [DOI: 10.1200/jco.2020.38.15_suppl.e19214] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
e19214 Background: ARST1321(PAZNTIS): A Phase II/III Randomized Trial of Preoperative Chemoradiation or Preoperative Radiation Plus or Minus Pazopanib (NCT02180867) was the first National Clinical Trials Network (NCTN) study co-developed by pediatric (COG) and adult (NRG Oncology) consortia anticipating enrollment of adolescent and young adult (AYA) cancer patients. ARST1321 had two treatment cohorts, enrolling patients ≥ 2 years of age to either chemotherapy (C) (chemoradiation ± pazopanib) or non-chemotherapy (NC) (radiation ± pazopanib) arms. It was anticipated adults would contribute the majority of enrollments on the NC arm based on prior enrollment patterns. While the C arm accrued as anticipated (with high enrollment of adults and children), the NC arm had low enrollment leading to premature closure. We report on AYA accrual (defined as 15-39 years) to the NC arm and a survey aiming to identify barriers to enrolling AYA patients onto ARST1321. Methods: Our survey was emailed to 161 adult, surgical, and radiation oncologists at large sarcoma centers. A link was sent to an online questionnaire via SurveyMonkey Inc. and responses were reviewed on their platform. Results: 33 patients enrolled on the ARST1321 NC arm, of which 24% were AYA. 25% of AYA enrollments were from non-COG adult cooperative groups. This trial arm was closed in October 2017 after 3.25 years of accrual below anticipated rates. The survey response rate was 31% with a 70% completion rate. Almost half of respondents were medical oncologists with most seeing 50-200 new sarcoma cases/year at an academic institution and 30% in a pediatric environment (divided equally between radiation and surgical oncologists). 70% of respondents have a joint collaboration with their pediatric oncology team with 23% having a joint clinic. 70% of respondents’ sites opened ARST1321 and anticipated 1-5 patients would be eligible for the NC cohort. However, 42% of respondents’ sites had zero patients enrolled on that arm. The most common reasons for not opening the study and/or not enrolling patients on the NC arm included: lack of interest, disagreement with the therapy, lack of a site investigator, premature study closure, patient/family decision, competing trials, insufficient reimbursement, and regulatory delays. Conclusions: Our survey highlights multiple barriers to enrollment of AYA onto cross-NCTN consortia clinical trials spanning the age spectrum. The information obtained will help inform investigators aiming to effectively design, enroll, and conduct similar trial efforts for AYA in the future.
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Affiliation(s)
| | - Damon R. Reed
- H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL
| | | | | | | | | | | | - Bree Ruppert Eaton
- Department of Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, GA
| | - Douglas S. Hawkins
- Seattle Children’s Hospital, University of Washington, Fred Hutchinson Cancer Research Center, Seattle, WA
| | | | | | - R. Lor Randall
- Huntsman Cancer Institute at the University of Utah, Salt Lake City, UT
| | | | | | | | | | - Dian Wang
- Rush University Medical Center, Chicago, IL
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18
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Avutu V, Lynch K, Barnett M, Vera J, Glade Bender JL, Tap WD, Atkinson TM. Defining patient-elicited concepts unique to adolescents and young adults with cancer. J Clin Oncol 2020. [DOI: 10.1200/jco.2020.38.15_suppl.12118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
12118 Background: Adolescents and young adults (AYAs) require a multidisciplinary approach to cancer care due to complex biopsychosocial variables and varied developmental maturity. Currently, age and diagnosis determine referral to pediatric or adult oncology with differing care paradigms and service utilization. These issues, in conjunction with differences in tumor biology and lower accrual to clinical trials, have contributed to marginal improvements in outcomes for AYAs. Compounding this dilemma is a lack of validated patient-reported outcome measures (PROs) for AYAs. Tracking standardized PROs longitudinally is a crucial step in understanding psychosocial variables, identifying tailored needs, improving outcomes and standardizing care. However, developing a PRO tool for AYAs first requires identifying AYA-unique domains. Methods: Three, 90-minute focus groups were conducted with AYAs treated at Memorial Sloan Kettering in the context of 1) pediatric oncology, 2) medical oncology, and 3) either service. Topics explored included: experiences of cancer care as an AYA; physical, social and emotional concerns; and information needs, including appropriateness, timing, and depth of information. Thematic content analysis of transcripts was performed by four interdisciplinary coders in weekly iterative consensus rounds. Phase one consisted of identification of key domains to guide line-by-line coding with NVivo software. Phase two consisted of independent review and categorization of codes, followed by three successive consensus meetings to identify distinct themes. Results: A mean of 6 patients (range 5-7) participated in each of the 3 groups; the total sample (n = 17) included 9 males and 8 females, ages 19-35 years (median 26). Four AYA-unique themes were identified: 1. AYAs have an uncertain sense of the future and desire more engagement in conversations pertaining to survivorship, long-term effects and transition to outpatient life. 2. Cancer as an AYA is a socially-isolating experience, prompting a strong desire to connect with peers during and post-treatment. 3. AYAs want control over who can be present during discussions with their care team as the presence of loved ones can impede or facilitate communication. 4. AYAs may be living far away from loved ones during treatment and lack supports needed to help them navigate treatment and daily life. Conclusions: Concept elicitation via focus groups identified novel themes related to survivorship, isolation, communication and social support, which can inform development of AYA-specific PROs.
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Affiliation(s)
| | | | - Marie Barnett
- Memorial Sloan Kettering Cancer Center, New York, NY
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19
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Eberly LA, Richterman A, Beckett AG, Wispelwey B, Marsh RH, Cleveland Manchanda EC, Chang CY, Glynn RJ, Brooks KC, Boxer R, Kakoza R, Goldsmith J, Loscalzo J, Morse M, Lewis EF, Abel S, Adams A, Anaya J, Andrews EH, Atkinson B, Avutu V, Bachorik A, Badri O, Bailey M, Baird K, Bakshi S, Balaban D, Barshop K, Baumrin E, Bayomy O, Beamesderfer J, Becker N, Berg DD, Berman AN, Blum SM, Boardman AP, Boden K, Bonacci RA, Brown S, Campbell K, Case S, Cetrone E, Charrow A, Chiang D, Clark D, Cohen AJ, Cooper A, Cordova T, Cuneo CN, de Feria AA, Deffenbacher K, DeFilippis EM, DeGregorio G, Deutsch AJ, Diephuis B, Divakaran S, Dorschner P, Downing N, Drescher C, D'Silva KM, Dunbar P, Duong D, Earp S, Eckhardt C, Elman SA, England R, Everett K, Fedotova N, Feingold-Link T, Ferreira M, Fisher H, Foo P, Foote M, Franco I, Gilliland T, Greb J, Greco K, Grewal S, Grin B, Growdon ME, Guercio B, Hahn CK, Hasselfeld B, Haydu EJ, Hermes Z, Hildick-Smith G, Holcomb Z, Holroyd K, Horton L, Huang G, Jablonski S, Jacobs D, Jain N, Japa S, Joseph R, Kalashnikova M, Kalwani N, Kang D, Karan A, Katz JT, Kellner D, Kidia K, Kim JH, Knowles SM, Kolbe L, Kore I, Koullias Y, Kuye I, Lang J, Lawlor M, Lechner MG, Lee K, Lee S, Lee Z, Limaye N, Lin-Beckford S, Lipsyc M, Little J, Loewenthal J, Logaraj R, Lopez DM, Loriaux D, Lu Y, Ma K, Marukian N, Matias W, Mayers JR, McConnell I, McLaughlin M, Meade C, Meador C, Mehta A, Messenger E, Michaelidis C, Mirsky J, Mitten E, Mueller A, Mullur J, Munir A, Murphy E, Nagami E, Natarajan A, Nsahlai M, Nze C, Okwara N, Olds P, Paez R, Pardo M, Patel S, Petersen A, Phelan L, Pimenta E, Pipilas D, Plovanich M, Pong D, Powers BW, Rao A, Ramirez Batlle H, Ramsis M, Reichardt A, Reiger S, Rengarajan M, Rico S, Rome BN, Rosales R, Rotenstein L, Roy A, Royston S, Rozansky H, Rudder M, Ryan CE, Salgado S, Sanchez P, Schulte J, Sekar A, Semenkovich N, Shannon E, Shaw N, Shorten AB, Shrauner W, Sinnenberg L, Smithy JW, Snyder G, Sreekrishnan A, Stabenau H, Stavrou E, Stergachis A, Stern R, Stone A, Tabrizi S, Tanyos S, Thomas C, Thun H, Torres-Lockhart K, Tran A, Treasure C, Tsai FD, Tsaur S, Tschirhart E, Tuwatananurak J, Venkateswaran RV, Vishnevetsky A, Wahl L, Wall A, Wallace F, Walsh E, Wang P, Ward HB, Warner LN, Weeks LD, Weiskopf K, Wengrod J, Williams JN, Winkler M, Wong JL, Worster D, Wright A, Wunsch C, Wynter JS, Yarbrough C, Yau WY, Yazdi D, Yeh J, Yialamas MA, Yozamp N, Zambrotta M, Zon R. Identification of Racial Inequities in Access to Specialized Inpatient Heart Failure Care at an Academic Medical Center. Circ Heart Fail 2019; 12:e006214. [PMID: 31658831 DOI: 10.1161/circheartfailure.119.006214] [Citation(s) in RCA: 91] [Impact Index Per Article: 18.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Racial inequities for patients with heart failure (HF) have been widely documented. HF patients who receive cardiology care during a hospital admission have better outcomes. It is unknown whether there are differences in admission to a cardiology or general medicine service by race. This study examined the relationship between race and admission service, and its effect on 30-day readmission and mortality Methods: We performed a retrospective cohort study from September 2008 to November 2017 at a single large urban academic referral center of all patients self-referred to the emergency department and admitted to either the cardiology or general medicine service with a principal diagnosis of HF, who self-identified as white, black, or Latinx. We used multivariable generalized estimating equation models to assess the relationship between race and admission to the cardiology service. We used Cox regression to assess the association between race, admission service, and 30-day readmission and mortality. RESULTS Among 1967 unique patients (66.7% white, 23.6% black, and 9.7% Latinx), black and Latinx patients had lower rates of admission to the cardiology service than white patients (adjusted rate ratio, 0.91; 95% CI, 0.84-0.98, for black; adjusted rate ratio, 0.83; 95% CI, 0.72-0.97 for Latinx). Female sex and age >75 years were also independently associated with lower rates of admission to the cardiology service. Admission to the cardiology service was independently associated with decreased readmission within 30 days, independent of race. CONCLUSIONS Black and Latinx patients were less likely to be admitted to cardiology for HF care. This inequity may, in part, drive racial inequities in HF outcomes.
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Affiliation(s)
- Lauren A Eberly
- University of Pennsylvania, Department of Medicine, Division of Cardiovascular Medicine, Philadelphia, PA (L.A.E.)
| | - Aaron Richterman
- Department of Medicine (A.R., A.G.B., B.W., K.C.B., R.K., J.L., M.M.), Brigham and Women's Hospital, Boston, MA
| | - Anne G Beckett
- Department of Medicine (A.R., A.G.B., B.W., K.C.B., R.K., J.L., M.M.), Brigham and Women's Hospital, Boston, MA
| | - Bram Wispelwey
- Department of Medicine (A.R., A.G.B., B.W., K.C.B., R.K., J.L., M.M.), Brigham and Women's Hospital, Boston, MA
| | - Regan H Marsh
- Department of Emergency Medicine (R.H.M., E.C.C.M., C.Y.C), Brigham and Women's Hospital, Boston, MA
| | | | - Cindy Y Chang
- Department of Emergency Medicine (R.H.M., E.C.C.M., C.Y.C), Brigham and Women's Hospital, Boston, MA.,Harvard Medical School, Boston, MA (C.Y.C)
| | - Robert J Glynn
- Division of Preventive Medicine, Department of Medicine (R.J.G.), Brigham and Women's Hospital, Boston, MA.,Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA (R.J.G)
| | - Katherine C Brooks
- Department of Medicine (A.R., A.G.B., B.W., K.C.B., R.K., J.L., M.M.), Brigham and Women's Hospital, Boston, MA
| | - Robert Boxer
- Division of General Internal Medicine, Department of Medicine (R.B.), Brigham and Women's Hospital, Boston, MA
| | - Rose Kakoza
- Department of Medicine (A.R., A.G.B., B.W., K.C.B., R.K., J.L., M.M.), Brigham and Women's Hospital, Boston, MA
| | - Jennifer Goldsmith
- Division of Global Health Equity, Department of Medicine (J.G., M.M.), Brigham and Women's Hospital, Boston, MA
| | - Joseph Loscalzo
- Department of Medicine (A.R., A.G.B., B.W., K.C.B., R.K., J.L., M.M.), Brigham and Women's Hospital, Boston, MA
| | - Michelle Morse
- Department of Medicine (A.R., A.G.B., B.W., K.C.B., R.K., J.L., M.M.), Brigham and Women's Hospital, Boston, MA.,Division of Global Health Equity, Department of Medicine (J.G., M.M.), Brigham and Women's Hospital, Boston, MA
| | - Eldrin F Lewis
- Division of Cardiovascular Medicine, and Department of Medicine (E.F..L.), Brigham and Women's Hospital, Boston, MA
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Inaba H, Gaur AH, Cao X, Flynn PM, Pounds SB, Avutu V, Marszal LN, Howard SC, Pui CH, Ribeiro RC, Hayden RT, Rubnitz JE. Feasibility, efficacy, and adverse effects of outpatient antibacterial prophylaxis in children with acute myeloid leukemia. Cancer 2014; 120:1985-92. [PMID: 24677028 PMCID: PMC4063871 DOI: 10.1002/cncr.28688] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2013] [Revised: 02/10/2014] [Accepted: 02/24/2014] [Indexed: 12/12/2022]
Abstract
BACKGROUND Intensive chemotherapy for pediatric acute myeloid leukemia incurs the risk of infectious complications, but the benefits of antibiotic prophylaxis remain unclear. METHODS In the current study, among 103 children treated on the AML02 protocol between October 2002 and October 2008 at St. Jude Children's Research Hospital, the authors retrospectively assessed the effect of antibiotic prophylaxis on the frequency of febrile neutropenia, clinically or microbiologically confirmed infections (including bacteremia), and antibiotic resistance, as well as on the results of nasal and rectal surveillance cultures. Initially, patients received no prophylaxis or oral cephalosporin (group A). The protocol was then amended to administer intravenous cefepime alone or intravenous vancomycin plus either oral cephalosporin, oral ciprofloxacin, or intravenous cefepime (group B). RESULTS There were 334 infectious episodes. Patients in group A had a significantly greater frequency of documented infections and bacteremia (both P < .0001) (including gram-positive and gram-negative bacteremia; P = .0003 and .001, respectively) compared with patients in group B, especially viridans streptococcal bacteremia (P = .001). The incidence of febrile neutropenia without documented infection was not found to be different between the 2 groups. Five cases of bacteremia with vancomycin-resistant enterococci (VRE) occurred in group B (vs none in group A), without related mortality. Two of these cases were preceded by positive VRE rectal surveillance cultures. CONCLUSIONS Outpatient intravenous antibiotic prophylaxis is feasible in children with acute myeloid leukemia and reduces the frequency of documented infection but not of febrile neutropenia. Despite the emergence of VRE bacteremia, the benefits favor antibiotic prophylaxis. Creative approaches to shorten the duration of prophylaxis and thereby minimize resistance should be explored.
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Affiliation(s)
- Hiroto Inaba
- Department of Oncology, St. Jude Children’s Research Hospital, Memphis, Tennessee
- Department of Pediatrics, College of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Aditya H Gaur
- Department of Pediatrics, College of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee
- Department of Infectious Diseases, St. Jude Children’s Research Hospital, Memphis, Tennessee
| | - Xueyuan Cao
- Department of Biostatistics, St. Jude Children’s Research Hospital, Memphis, Tennessee
| | - Patricia M Flynn
- Department of Pediatrics, College of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee
- Department of Infectious Diseases, St. Jude Children’s Research Hospital, Memphis, Tennessee
| | - Stanley B Pounds
- Department of Biostatistics, St. Jude Children’s Research Hospital, Memphis, Tennessee
| | - Viswatej Avutu
- Department of Oncology, St. Jude Children’s Research Hospital, Memphis, Tennessee
| | - Lindsay N Marszal
- Department of Oncology, St. Jude Children’s Research Hospital, Memphis, Tennessee
| | - Scott C Howard
- Department of Oncology, St. Jude Children’s Research Hospital, Memphis, Tennessee
- Department of Pediatrics, College of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Ching-Hon Pui
- Department of Oncology, St. Jude Children’s Research Hospital, Memphis, Tennessee
- Department of Pediatrics, College of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Raul C Ribeiro
- Department of Oncology, St. Jude Children’s Research Hospital, Memphis, Tennessee
- Department of Pediatrics, College of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Randall T Hayden
- Department of Pathology, St. Jude Children’s Research Hospital, Memphis, Tennessee
| | - Jeffrey E Rubnitz
- Department of Oncology, St. Jude Children’s Research Hospital, Memphis, Tennessee
- Department of Pediatrics, College of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee
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