Adoption of single agent anticancer therapy for advanced hepatocellular carcinoma and impact of facility type, insurance status, and income on survival: Analysis of the national cancer database 2004-2014

Background

This study analyzes the pattern of use of single agent anticancer therapy (SAACT) in the treatment and survival of advanced hepatocellular carcinoma (aHCC) before and after sorafenib was FDA approved in 2007.

Methods

Adult patients diagnosed with HCC and treated with only ACT from 2004 – 2014 were identified in NCDB database. Patients were analyzed during three time frames: 2004–2006 (pre‐sorafenib (PS)), 2007–2010 (early sorafenib (ES)) and 2011–2014 (late sorafenib (LS)). Cox proportional hazards models and Kaplan‐Meier method were used for analyses.

Results

The NCDB contained 31,107 patients with HCC diagnosed from 2004–2014 and treated with ACT alone. Patients were generally men (78.0%), >50 years of age (92.5%). A significant increase in the rate of adaption of SAACT was observed over time: 6.2% PS, 15.2% ES, and 22.2% LS (p < 0.0001). During this later period, the highest proportion of SAACT is among academic and integrated network facilities (23.3%) as compared to community facilities (17.0%, p < 0.0001). The median overall survival of patients with aHCC treated only with SAACT improved significantly over time from 8.0 months (m) (95% CI: 7.4–8.8) to 10.7 m (10.4–11.2) to 15.6 m (15.2–16.0, p < 0.001). Multivariate analysis indicates worse outcomes for patients treated at community cancer programs (HR 1.28, (5% CI: 1.23–1.32), patients without insurance (HR 1.11, 1.06–1.16) and estimated household income of <$63,000 (HR 1.09, 1.05–1.13).

Conclusion

aHCC patients treated only with ACT have experienced an overall improvement in survival, but significant differences exist between facility type, insurance status, and income.

Monitoring DOACs with a Novel Dielectric Microsensor: A Clinical Study

BACKGROUND

 There are acute settings where assessing the anticoagulant effect of direct oral anticoagulants (DOACs) can be useful. Due to variability among routine coagulation tests, there is an unmet need for an assay that detects DOAC effects within minutes in the laboratory or at the point of care.

METHODS

 We developed a novel dielectric microsensor, termed ClotChip, and previously showed that the time to reach peak permittivity (T _peak) is a sensitive parameter of coagulation function. We conducted a prospective, single-center, pilot study to determine its clinical utility at detecting DOAC anticoagulant effects in whole blood.

RESULTS

 We accrued 154 individuals: 50 healthy volunteers, 49 rivaroxaban patients, 47 apixaban, and 8 dabigatran patients. Blood samples underwent ClotChip measurements and plasma coagulation tests. Control mean T _peak was 428 seconds (95% confidence interval [CI]: 401-455 seconds). For rivaroxaban, mean T _peak was 592 seconds (95% CI: 550-634 seconds). A receiver operating characteristic curve showed that the area under the curve (AUC) predicting rivaroxaban using T _peak was 0.83 (95% CI: 0.75-0.91, p < 0.01). For apixaban, mean T _peak was 594 seconds (95% CI: 548-639 seconds); AUC was 0.82 (95% CI: 0.73-0.91, p < 0.01). For dabigatran, mean T _peak was 894 seconds (95% CI: 701-1,086 seconds); AUC was 1 (p < 0.01). Specificity for all DOACs was 88%; sensitivity ranged from 72 to 100%.

CONCLUSION

 This diagnostic study using samples from "real-world" DOAC patients supports that ClotChip exhibits high sensitivity at detecting DOAC anticoagulant effects in a disposable portable platform, using a miniscule amount of whole blood (<10 µL).

Impact of facility type, insurance status, and income on use of single agent chemotherapy (SACT) for advanced hepatocellular carcinoma (AHCC): Analysis of National Cancer Database (NCDB)

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Background: This study analyzes the pattern of use of SACT in the treatment and survival of AHCC before and after sorafenib was FDA approved in late 2007. Methods: Adult patients diagnosed with HCC and treated with only chemotherapy (CT) from 2004 – 2014 were identified in NCDB database. Patients were analyzed during 3 time frames: 2004–2006 (pre-sorafenib (PS), 2007–2011 (early sorafenib (ES) and 2012–2014 (late sorafenib (LS)). Cox proportional hazards models and Kaplan-Meier method were used for analyses. Results: The NCDB contained 31,107 patients with HCC diagnosed from 2004–2014 and treated with CT alone. Patients were generally men (77.3%), >50 years of age (92.5%), and with a variety of T-stages - T1 (31.0%), T2 (23.9%), T3 (28.3%), and T4 (16.9%). The use of SACT was only 6.2% in the PS period, increased to 15.5% in the ES period, and to 22.3% in the LS period (p<0.0001). During this later period, the highest proportion of SACT is among academic and integrated network facilities (23.4%) as compared to community facilities (16.4%, p<0.0001). The MS of patients with AHCC treated only with CT has improved significantly over the study periods from 10 months (m) (95% CI: 9.5-10.6) to 12.5m (12.0-12.9) to 16m (15.6-16.4, p< 0.001). Significant differences in MS were found between facility types in all time frames (Table). Multivariate analysis indicates worse outcomes for patients treated at community cancer programs (HR 1.66, 1.53-1.79) as compared to academic programs as well as for no insurance (HR 1.13, 1.05-1.22) and estimated household income of <$63,000 (HR 1.09, 1.05-1.13). Conclusions: Despite an overall improvement in survival for AHCC patients treated with only CT, significant differences in the utilization of SACT and survival exist by facility type, insurance status, and income.

[Table: see text]

Primary liver angiosarcoma and factors associated with improved outcomes: An analysis of the National Cancer Database

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Background: Primary liver angiosarcoma (LAS) is a rare and aggressive tumor of the liver. In this analysis of the national cancer database (NCDB) we sought the risk of mortality and factors associated with survival amongst patient diagnosed with LAS. Methods: Patients diagnosed with hepatocellular carcinoma (HCC) or LAS from 2004 – 2014 were identified in the NCDB. The Kaplan-Meier method with the log-rank test was used to calculate survival for HCC and LAS patients. Additional analyses were performed on the cohort with LAS to assess the impact of surgery, chemotherapy, radiation therapy (RT) and facility type on overall survival (OS). Multivariable analyses using cox proportional methods, adjusted for age, sex, Charlson/Deyo score, race, ethnicity, insurance status, facility location and type, surgery status, and chemotherapy status were performed to obtain adjusted hazard ratio (aHR). Results: Total of 118,066 patients with HCC and 346 patients with LAS were identified in the database. Median survival for HCC patients was 11.9 months (95% CI: 11.7-12.2) and 2.0 months for LAS patients (95% CI: 1.8 – 2.4). Risk of mortality was higher for patients with LAS compared to those with HCC (aHR (95% CI): 2.23 (1.97 - 2.53), p < .0001). Among the LAS patients, those who received surgery had a median survival of 8.6 months (95% CI: 5.6 - 17.3), and 1.8 months for those who did not (95% CI: 1.48 - 1.94). Risk of mortality was lower in patients who received surgery compared to those who did not (aHR (95% CI): 0.23 (0.15 - 0.37), p < .0001). Patients treated at and academic center had a higher median survival (3.3 months, 95% CI: 2.2 - 4.1) then those treated at a non-academic center (1.5 months, 95% CI: 1.2 - 1.8). Though, there was no significant difference in OS (aHR (95% CI): 0.48 (0.21 - 1.10), p = 0.082). A very small number of patients received chemotherapy or RT to conduct a meaningful analysis. Conclusions: Patients diagnosed with primary LAS have a worse OS compared to those with HCC. Amongst patients with primary LAS, surgical resection is associated with best survival outcomes. Treatment at an academic center is associated with better median survival, although OS did not reach statistical significance in our analysis.

The impact of sorafenib on the treatment and survival of advanced hepatocellular carcinoma (HCC): Analysis of the National Cancer Database (NCDB) from 2004 to 2014

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Background: HCC is a common cause of mortality in the U.S. among men and women (5thand 7th, respectively) with overall five-year survival of ~18%. Sorafenib was the only FDA approved therapy for advanced HCC from 2007 until 2018. This study analyzes trends in the treatment and survival of advanced HCC before and after sorafenib approval. Methods: Adult patients ( > 18 years) with diagnosis of HCC treated with only chemotherapy from 2004 – 2014 were identified in NCDB database. Comparisons were made between 3 time frames: 2004 – 2007 (pre-sorafenib), 2008 – 2011 (early sorafenib) and 2012 – 2014 (late sorafenib). Patients treated with single or multi-agent chemotherapy were analyzed. Cox proportional hazards models were used for univariate and multivariable analyses. Kaplan-Meier method was used for survival analysis. Results: The NCDB contained 33,136 patients with HCC diagnosed between 2004 – 2014 and treated with chemotherapy alone. Patients were generally men (77.4%), over the age of 50 years (92.4%), with an elevated AFP at diagnosis (64.4%), and had limited co-morbidities (76.0%, Charlson/Deyo score of 0-1). The T-stages were T1 (26.3%), T2 (20.5%), T3 (25.6%), and T4 (16.2%). The number and proportion of patients treated with single agent chemotherapy increased significantly during the study period: 2,733 (45.3%) pre-sorafenib, 9,723 (72.7%) early sorafenib, and 13,502 (86.1%) late sorafenib. The proportion of all HCC patients in the NCDB receiving only chemotherapy increased from 17.2% to 26.4% to 28.3% across the 3 time frames. The survival of patients with advanced HCC treated only with chemotherapy improved significantly in the early and late sorafenib cohorts compared to the pre-sorafenib cohort (10.3 months (95% CI: 9.8-10.6) vs. 12.3 months (12.0-12.7) vs. 15.5 months (15.1-15.9), p-value < 0.001). Age > 70 years, male sex, higher Charlson/Deyo score ( > 1), elevated AFP at diagnosis, and higher T-stage were associated with worse survival (p value < 0.001). Conclusions: The approval of sorafenib has dramatically increased the use of chemotherapy for the treatment of advanced HCC and has resulted in a significant survival advantage.

The effect of race on adherence to NCCN Guidelines for patients with biliary tract cancers (BTC) after surgery

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Background: BTC has a limited prognosis even for localized cancers (15-30% 5-year survival) emphasizing the importance of multidisciplinary management. NCCN guidelines recommend adjuvant chemotherapy (CT) +/- radiotherapy (RT) for high risk disease. We analyzed adherence to NCCN guidelines among patients following surgery for BTC and the influence of race. Methods: Subjects were identified from the National Cancer Database (NCDB) for BTC patients who underwent surgery and found to have metastatic lymph nodes (LN+) or positive surgical margins (M+) from 2004 to 2015. We defined adherence to NCCN guidelines as receiving surgery+ CT +/- RT and non-adherence to the guidelines as surgery +/- RT. Descriptive studies and multivariate logistic regression analysis was performed. Results: A total of 3,792 patients were identified with approximately half being female (55.4%) and between the ages of 50-69 (52.8%). Most were White (76.3%) followed by Black (10.6%), Hispanic (8.5%), and Asian (5.3%). The BTC included extrahepatic cholangiocarcinoma (CCA) (48.6%), gallbladder cancer (43.5%), and intrahepatic CCA (7.9%). Most patients had an R0 resection (71.9%) but also had LN+ disease (88.0%). There were no significant differences between racial groups in disease presentation (histological grade, tumor stage) and surgical outcomes (LN+, M+, hospital readmission, and 90 day post-surgery mortality). Hispanic patients as compared to White patients were less likely to be insured (85.7% vs 96.3%, p < 0.001) and less likely to be treated at an academic facility (42.1% vs 52.1%, p = 0.008). Overall 29.7% of patient did not adhere to NCCN guidelines with Hispanics having the highest proportion of non-adherence as compared to Whites, (36.1% vs 28.7%, p = 0.029). On multivariate analysis, Hispanic race (HR = 1.51, 95% CI: 1.15-1.99) remained significant for receiving treatment non-adherent to NCCN guidelines. Conclusions: This study indicates that Hispanics are significantly more likely to receive non-adherent care in comparison to White patients in accordance with NCCN guidelines. More research is needed to confirm and understand the observed disparities and guide targeted interventions.

Contribution of platelets, the coagulation and fibrinolytic systems to cutaneous wound healing

Wound healing is a complex process that consists of multiple phases, each of which are indispensable for adequate repair. Timely initiation and resolution of each of these phases namely, hemostasis, inflammation, proliferation and tissue remodeling, is critical for promoting healing and avoiding excess scar formation. While platelets have long been known to influence the healing process, other components of blood particularly coagulation factors and the fibrinolytic system also contribute to efficient wound repair. This review aims to summarize our current understanding of the role of platelets, the coagulation and fibrinolytic systems in cutaneous wound healing, with a focus on how these components communicate with immune and non-immune cells in the wound microenvironment. We also outline current and potential therapeutic strategies to improve the management of chronic, non-healing wounds.

The role of neutrophils in thrombosis

Despite significant evidence implicating an important role for neutrophils in thrombosis, their impact on the thrombotic process has remained a matter of controversy. Until 2010, platelets, coagulation factors, fibrinogen and monocytes were implicated in the thrombotic process. Several studies conducted over the last decade now support the growing notion that neutrophils indeed do contribute significantly to this process. Neutrophils can contribute to pathologic venous and arterial thrombosis or 'immunothrombosis' by the release of neutrophil extracellular traps (NETs) and NET release is emerging as a major contributor to thrombogenesis in pathologic situations such as sepsis and malignancy. Further, blood-cell derived microparticles, including those from neutrophils, have been implicated in thrombus formation. Finally, inflammasome activation in the neutrophil identifies another important mechanism that may be operative in neutrophil-driven risk for thrombosis. The knowledge of these roles of neutrophils in thrombosis may pave the road for novel anti-thrombotic agents in the future that do not affect hemostasis.

Outcomes in bone predominant (BP) urothelial carcinoma (UC)

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Background: The clinical phenotype of BP UC includes those patients (pts) with at least as many or more bone lesions than non-bone lesions. UC molecular subtypes that may correlate with prognosis have been defined. Better understanding of the clinical BP phenotype, which might correspond to the p53-like molecular subtype, is needed. Methods: We searched our biorepository to identify pts with metastatic UC. Electronic records of identified pts were reviewed and those with accessible records who received treatment at our institution were selected. Demographic, pathologic, treatment, response, progression-free and overall survival (PFS, OS) data were recorded. Imaging was reviewed to identify non-bone predominant (NBP) or BP disease based on imaging criteria. Results: 23 NBP and 9 BP pts, (59% men) were identified. Of BP pts, 44% had bone metastatic disease present at diagnosis (dx) vs. none of the NBP. Only 8% of NBP pts developed bone metastases during their course. The median number of lines of therapy in the metastatic setting was 2 for each cohort. All BP pts received platinum therapy vs. 74% of NBP. 11% of BP pts were treated with checkpoint immunotherapy (CPI) vs. 34% of NBP. 70% of BP pts received palliative radiation (all to bone) vs. 4% of the NBP cohort. The median OS from date of UC dx was 27.5 months. There was a significant difference in OS between BP and NBP cohorts from UC dx date (16.9 vs. 30.6 months, p < 0.0001) as well as from muscle invasive bladder cancer (MIBC) dx date (15.2 vs. 22.8 months, p = 0.019), respectively. OS from initiation of 1st line treatment in the metastatic setting for the entire cohort was 12.5 months and was not significantly different between the cohorts (p = 0.633). PFS from dx of MIBC to date of 1st progression or death was not significant (p = 0.08) with median PFS of 8.4 vs. 13.6 months for BP vs. NBP cohorts, respectively. Conclusions: BP pts require more frequent palliative radiation and have shorter OS measured from time of dx, but not significantly different when measured from the initiation of 1st line treatment, compared to NBP pts. Further analysis with a larger cohort is ongoing for validation. Molecular analysis on pathological specimens is planned.

Implantable intravenous devices (“ports”) as a survivorship issue

9

Background: Women with early stage breast cancer often receive chemotherapy through implantable intravenous access devices (ports). There is little information on the duration of port use for breast cancer patients who have completed treatment. Methods: The EMR was searched for women who received adjuvant chemotherapy using a port for Stage I-III breast cancer between 2007- 2012. Data abstracted from the EMR included demographics, duration and type of chemotherapy, duration of port use and complications. Results: During the years 2007-2012, a total of 167 patients qualified for the study. 28 (16.8%) patients were excluded as complete data was not available. The Mean age of the remaining 127 women was 60 (SD: 1) years. The distribution of cancer stage was 18.1%, 59.1%, 22.8% of stage I, II, and III respectively. The median total length of duration of indwelling port was 506 days and median duration from chemotherapy completion to port removal was 299 days. The duration of time after completing treatment that the port remained in place was 0-6 months (31.5%), 6-12 months (25.2%), 12-24 months (24.4%), and > 24 months (18.9%). Patients with stage III cancer had significantly longer time to port removal relative to patients with stage I and stage II cancer (p < 0.005). Complications of ports (n = 4), all occurred during active treatment and included non-functioning/mispositioning (n = 2), and thrombosis (n = 2). Assuming the cost of port maintenance was $225 per visit and port maintenance was required every four weeks, the estimated average cost of maintaining the port after the completion of chemotherapy was $3,494 for this group of patients. Conclusions: Oncologists typically do not use the word “cure”; maintaining a port in place after chemotherapy may reinforce concerns about the risk of recurrence. This is highlighted by the fact that treatment type and hormone receptor status were not significantly associated with time of port removal. We found that 43% of patients still have their port in place one year after completing treatment and almost 19% of patients have their port in place greater than two years after completing treatment. The high cost and the possible psychological impact of leaving a port in place for long periods of time needs further study.