Body composition measures as a determinant of Alpelisib related toxicity

BACKGROUND

Body composition has emerged as an important prognostic factor in patients treated with cancer. Severe depletion of skeletal muscle, sarcopenia, has been associated with poor performance status and worse oncological outcomes. We studied patients with metastatic breast cancer receiving alpelisib, to determine if sarcopenia and additional body composition measures accounting for muscle and adiposity are associated with toxicity.

METHODS

A retrospective observational analysis was conducted, including 38 women with metastatic breast cancer and a PIK3CA mutation, treated with alpelisib as advanced line of therapy. Sarcopenia was determined by measuring skeletal muscle cross-sectional area at the third lumbar vertebra using computerized tomography. Various body composition metrics were assessed along with drug toxicity, dose reductions, treatment discontinuation, hospitalizations, time to treatment failure and overall survival.

RESULTS

Sarcopenia was observed in half of the patients (n = 19, 50%), spanning normal weight, overweight, and obese individuals. Among the body composition measures, lower skeletal muscle density (SMD) was associated with an increased risk of treatment-related hyperglycaemia (P = 0.03). Additionally, lower visceral adipose tissue (VAT) was associated with alpelisib-induced rash (P = 0.04) and hospitalizations (P = 0.04). Notably, alpelisib treatment discontinuation was not impacted by alpelisib toxicity.

CONCLUSION

Body composition measures, specifically SMD and VAT may provide an opportunity to identify patients at higher risk for severe alpelisib related hyperglycemia, and cutaneous toxicity. These findings suggest the potential use of body composition assessment to caution toxicity risk, allowing for personalized therapeutic observation and intervention.

Medical cannabis and its effect on oncological outcomes in patients with ovarian cancer treated with PARP inhibitors

BACKGROUND

Poly (ADP-ribose) polymerase inhibitors (PARPi) play a pivotal role in ovarian cancer management. With medical cannabis emerging as a novel component of supportive care, this study investigated the impact of medical cannabis use on oncological outcomes in patients with ovarian cancer undergoing PARPi therapy.

METHODS

The study included patients from a single institution database treated for ovarian cancer between January 2014 and January 2020 who received PARPi maintenance therapy in a first-line or recurrent disease setting after a confirmed response to platinum-based treatment. The study categorized patients as cannabis users and cannabis-naïve. Univariate and multivariate Cox regression analysis and the Kaplan-Meier method were used to assess the effects of medical cannabis use on the duration of PARPi therapy, progression-free survival, and overall survival.

RESULTS

Among the eligible patients (n=93), most were cannabis-naïve (69%, n=64) while the rest used medical cannabis (31%, n=29). Medical cannabis use rates were comparable for patients receiving PARPi therapy post-primary treatment or for recurrence (42%, n=9, vs 27%, n=20; p=0.1). Both groups exhibited similar median duration for PARPi therapy (12.1 vs 9.5 months; p=0.89) and progression-free survival (20 vs 21 months; p=0.83). Kaplan-Meier analysis detected no differences in progression-free survival associated with cannabis use. Although cannabis users had an extended overall survival compared with the cannabis-naïve group (129.3 vs 99 months; p=0.03), cannabis use was insignificant for overall survival on multivariate analysis (p=0.10). Multivariate analysis showed stage IV at diagnosis (p=0.02) to be the sole factor associated with progression-free survival (p=0.02).

CONCLUSION

Medical cannabis usage in patients receiving PARPi treatment showed no association with duration of PARPi therapy, progression-free survival, or overall survival.

Effectiveness and safety of standard chemotherapy in older patients with ovarian cancer: a retrospective analysis by age group and treatment regimen

Objective

To evaluate the effectiveness and safety of standard chemotherapy administered to patients >70 years with advanced ovarian cancer (OC).

Methods

Medical records of 956 advanced-stage patients with OC treated between 2002-2020 with standard surgery and paclitaxel-carboplatin chemotherapy in a three-weekly (PC-3W) or weekly (PC-1W) regimen were reviewed. Treatment response and tolerability were compared between patients ≤70 years (N=723) and >70 years (N=233) with stratification to septuagenarians (>70-80 years) and octogenarians (>80 years).

Results

Median overall survival (mOS) in patients >70 was 41.26 months (95% confidence interval [Cl], 37.22-45.14) and median progression-free survival (mPFS) was 11.04 months (95% Cl, 8.97-15.74). No statistically significant differences in mPFS and mOS were observed between septuagenarians and octogenarians. Patients >70 treated with PC-1W versus PC-3W had significantly longer mOS (57.17 versus 30.00 months) and mPFS (19.09 versus 8.15 months). Toxicity rates were mostly similar between younger and older patients. Among patients >70 treated with PC-1W, the rate of neutropenia (75.7% versus 51.8%, p=0.0005), thrombocytopenia (41.0% versus 22.2%, p=0.0042) and anemia (78.1% versus 51.9%, p<0.0001) were significantly higher and the rate of grade 2 alopecia was statistically significantly lower compared with those >70 treated with PC-3W. Significantly more patients treated with PC-1W completed ≥6 chemotherapy cycles, suggesting better tolerability of this regimen.

Conclusions

Older patients with OC may benefit from improved OS with reasonable toxicity if treated with standard chemotherapy. Older patients treated with PC-1W are more likely to complete the full chemotherapy course and survive longer compared with those treated with conventional PC-3W.

Real-life daily activity: the impact of misbeliefs on quality of life among cancer patients

Background

While side-effects and health-related quality of life (QoL) are routinely assessed in clinical trials, commonly used tools do not measure patients’ ability to maintain normal daily activities. QoL can be severely affected directly by the disease, the treatment side-effects and by personal and societal misconceptions promoting avoidance from activities perceived as dangerous for cancer patients. We examined practices of actively treated patients with cancer.

Methods

A questionnaire was designed, assessing daily activities (11 items) and dietary limitations (7 items) distributed between October and December 2019 (before the coronavirus pandemic) among patients treated at the Oncology Division of Tel Aviv Sourasky Medical Center.

Results

The study population comprised 208 patients who participated in the survey. The majority reported at least one social-environmental avoidance or dietary limitation (136, 65% and 120, 57.7%, respectively), including abstaining from social contact, avoiding pets, public domains, traveling and maintaining dietary constraints. Adoption of these measures was not associated with clinical, demographic factors and treatment type. The major sources guiding restrictions came from advice of non-medical personnel (55.7%), the Internet (7.2%) and personal choice by the patients themselves (24%).

Conclusions

Most cancer patients reported compromised daily activities, which are likely attributed to misbeliefs about disease and treatment, and have a deleterious impact on QoL, in its wider sense, namely, the ability to conduct a full and meaningful life. These findings call for the development and implementation of tools examining patients’ real-life activity, beyond side-effects or health-related QoL (HRQoL). We propose this assessment as an integral part in the evaluation of new drugs and technologies and as an additional endpoint in pivotal clinical trials.

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Side-effects and HRQoL routinely assessed in clinical trials do not fully measure patients’ maintenance of daily activities.

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We developed a questionnaire examining daily practices and implications of misbeliefs among actively treated cancer patients.

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Most patients reported compromised daily activities, affecting QoL in its wider sense: conducting a full and meaningful life.

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These findings call for the development and implementation of tools examining patients’ real-life activity, beyond HRQoL.

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We propose accounting for a more comprehensive assessment of QoL, and patient health care education dispelling misbeliefs.

Brain metastases in patients with ovarian cancer

BACKGROUND

Brain metastasis (BM) are uncommon among women with epithelial ovarian cancer (EOC). The frequency, risk factors and clinical repercussions of BM in these patients are not well described.

METHODS

We retrospectively evaluated EOC patients treated at our center from 2002 to 2020 and assessed their clinical parameters, risk for BM development and association with overall survival (OS). This cohort has a known high frequency of BRCA mutation carriers (BRCAm) due to women of Ashkenazi Jewish descent.

RESULTS

Among 1035 EOC patients, 29 (2.8%) were diagnosed with BM. The prevalence of BRCA mutations was more common among women with BM (56.5% vs. 34.3%, p = 0.033). The BM rate in patients with BRCAm was higher than the BM rate in those with wildtype BRCA (BRCAw; 5.1% vs. 2.1%, OR = 2.6; 95% CI: 1.2-5.4, p = 0.013). Median time from diagnosis to BM and from disease recurrence to BM was longer among patients with BRCAm. Median OS was not significantly different among patients with BM versus those without BM (59.4 vs. 73.4 months, p = 0.243). After BM diagnosis, median OS was not statistically significantly different between patients with BRCAm and those with BRCAw (20.6 vs. 12.3 months, p = 0.441). Treatment with poly (ADP-ribose) polymerase inhibitors and bevacizumab had no impact on subsequent development of BM.

CONCLUSIONS

BM are rare among EOC patients. However, the risk is three-fold higher among patients with BRCAm. BM do not significantly alter OS among EOC patients. The higher rate of BM in patients with BRCAm may be related to longer OS in this subpopulation.

Sexual dysfunction among adolescent and young adult cancer patients: diagnostic and therapeutic approach

PURPOSE OF REVIEW

We present a review for healthcare professionals, formulated by a multidisciplinary team, for screening and interventions, describing common sexual impairments encountered by adolescent and young adult cancer patients (AYACP), and suggest a comprehensive evidence-based assessment approach and interventions for treatment of sexual dysfunction (SD).

RECENT FINDINGS

We discuss the various aspects of SD in AYACP, including causes, challenges and etiologies, and then go on to recommend increased awareness and guidance in healthcare workers, in order to optimize diagnosis and treatment of SD.

SUMMARY

Although the extent of SD among AYACP is widely recognized, oncological clinicians rarely address SD in their routine practice, lacking a clear approach of interdisciplinary diagnostic and therapeutic interventions. Here, we suggest guiding clinical management to optimize treatment quality.

The impact of tumor detection method on genomic and clinical risk and chemotherapy recommendation in early hormone receptor positive breast cancer

BACKGROUND

Symptomatic breast cancers share aggressive clinico-pathological characteristics compared to screen-detected breast cancers. We assessed the association between the method of cancer detection and genomic and clinical risk, and its effect on adjuvant chemotherapy recommendations.

PATIENTS AND METHODS

Patients with early hormone receptor positive (HR+) HER2neu-negative (HER2-) breast cancer, and known OncotypeDX Breast Recurrence Score test were included. A natural language processing (NLP) algorithm was used to identify the method of cancer detection. The clinical and genomic risks of symptomatic and screen-detected tumors were compared.

RESULTS

The NLP algorithm identified the method of detection of 401 patients, with 216 (54%) diagnosed by routine screening, and the remainder secondary to symptoms. The distribution of OncotypeDX recurrence score (RS) varied between the groups. In the symptomatic group there were lower proportions of low RS (13% vs 23%) and higher proportions of high RS (24% vs. 13%) compared to the screen-detected group. Symptomatic tumors were significantly more likely to have a high clinical risk (59% vs 40%). Based on genomic and clinical risk and current guidelines, we found that women aged 50 and under, with a symptomatic cancer, had an increased probability of receiving adjuvant chemotherapy recommendation compared to women with screen-detected cancers (60% vs. 37%).

CONCLUSIONS

We demonstrated an association between the method of cancer detection and both genomic and clinical risk. Symptomatic breast cancer, especially in young women, remains a poor prognostic factor that should be taken into account when evaluating patient prognosis and determining adjuvant treatment plans.

OTHR-03. Brain Metastasis Among Ovarian Cancer Patients

Background

Brain metastasis (BM) are uncommon among ovarian cancer (OC) patients. Their frequency, risk factors and clinical repercussions are not well described. We assessed OC patients who developed BM, the role of BRCA status and survival implications.

Methods

Study cohort included OC patients treated at our center, from 2002–2020. We retrospectively evaluated clinical parameters, risk for BM development and association with survival data.

Results

Among 972 OC patients, 28 (2.9%) were diagnosed with BM. Comparing the BM to non-BM group, median age of 60 across both groups, stage III-IV at diagnosis was more common among BM group (96.4% vs. 84.8%, p=0.0065) while platinum sensitivity was similar (92.3% in BM vs. 80.8% in non-BM, p=0.2193). Out of 658 patients tested for BRCA, 33.6% (n=221) were BRCA mutation carriers (BRCA+). Of the patients with BM, 22 tested for BRCA, 13 were carriers. BRCA+ was significantly higher in the BM group compared to the non-BM group (59.1% vs. 32.9%, p=0.0123). Among BRCA+ the rate of BM was higher than among BRCA- (5.8% vs. 2.1%, p=0.0123, HR=3.029; 95%CI: 1.4–6.5). Median time from OC diagnosis to BM and from disease recurrence to BM, was longer for BRCA+ compared to BRCA- (44.3mo vs. 32.3mo and 11.8mo vs. 0.7mo, respectively). Median survival (mOS) was not significantly different among patients with BM compared to those without BM (59.4mo vs. 71.2mo, p=0.36). Following diagnosis of BM, mOS was 20.6mo among BRCA+ and 12.3mo among BRCA- (p=0.4266). No correlation was demonstrated with PARP inhibitors or bevacizumab treatment and subsequent development of BM.

Conclusion

BM are an infrequent event among OC patients. However, the risk is three-folds higher among BRCA+. Interestingly, BM do not significantly alter survival among OC patients. Our work suggests that the higher rate of BM in BRCA+ may be related to longer survival. Another hypothesis requiring further evaluation, is possible higher brain tropism among this population.

First-Line Efficacy of Anti-HER2 Treatments in Previously Treated HER2-Positive Metastatic Breast Cancer Patients: A Retrospective Observational Study Investigating the Efficacy of Re-Exposure to Anti-HER2 Therapy for HER2-Positive Metastatic Breast Cancer Patients in Comparison with Naïve Patients

<b><i>Background:</i></b> Most patients with HER2-positive metastatic breast cancer (MBC) receive first-line treatment with anti-HER2 agents and have already received anti-HER2 therapy as adjuvant or neoadjuvant therapy in the local setting of their disease presentation. Despite that, they constitute only a minority among clinical trials, and their response to reintroduction to anti-HER2 treatments is inconclusive based upon conflicting studies. We aimed to examine if previous exposure influences the clinical outcome of patients treated with anti-HER2 treatments compared to patients who were naïve to anti-HER2 agents. <b><i>Methods:</i></b> We conducted a retrospective observational study of HER2-positive MBC patients who were treated with trastuzumab and pertuzumab from 2014 to 2018. We collected and analyzed data including patients’ demographic characteristic as well as extracted data of previous treatment regimens and the efficiency of the anti-HER2 therapy measured by response rate (RR), time to tumor progression (TTP), and overall survival (OS). <b><i>Results:</i></b> Eighty patients met the inclusion criteria, 26 (32.5%) of them were previously exposed to anti-HER2 treatments and 54 (67.5%) were not previously exposed to anti-HER2 therapy. No significant differences were detected in RR after 3 months of treatment (<i>p</i> = 0.684). TTP was significantly better among patients with no previous exposure in comparison with patients with previous exposure to anti-HER2 therapy (21 vs. 14 months, <i>p</i> = 0.044) and we noted a trend in better OS (<i>p</i> = 0.056). <b><i>Conclusion:</i></b> Our analysis suggests that previous exposure to anti-HER2 agents might influence the clinical outcome of first-line treatment in metastatic HER2 patients. These findings justify further exploration of the benefit of reintroduction of anti-HER2 treatment enabling the optimal treatment for patients with previous anti-HER2 therapy exposure.

Next generation sequencing in ovarian cancer patients: Does personalized medicine improve oncological outcomes?

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Background: Ovarian cancer (OC) is the second most common gynecologic malignancy and the most common cause of gynecologic cancer mortality in the United States. Homologous recombination deficiency (HRD), including the BRCA mutations, are found in 50% of OC tumors. Next generation sequencing (NGS) provides understanding the underlying molecular and genetic patterns to improve OC treatment. This study examines the prognostic and predictive biomarkers identified with NGS in hopes to improve OC patients outcomes. Methods: The patient cohort included 890 consecutive OC patients treated between 2002 and 2020,at the Tel-Aviv Medical Center. We retrospectively evaluated patients with histopathologically confirmed OC. Cox models were used to analyze the clinical impact of various mutations and biomarkers among OC patients with and without FoundationOne CDx NGS testing, by assessing overall survival (OS), progression free survival (PFS), and physicians' timing preferences for referral to NGS testing. Results: Among the 890 OC patients, 103 (11.57%) completed NGS molecular testing. The median OS among patients with and without NGS testing, adjusted for age, stage and recurrence status, was 73.36 and 68.50 months, respectively (P =.02). The median PFS was 17.23 and 17.43 months, respectively (P =.77). We also evaluated physicians' preferences regarding timing of molecular profiling, upon diagnosis, after first recurrence and at advanced line of treatment in 31.95%, 36.08% and 26.8% of practitioners, respectively. Of the patients who completed NGS, 48 (52.75%) harbored actionable mutations, and 21 patients (43.75%) received matched targeted therapy. Forty-five patients were microsatellite stable (MSS) (45%), 55 with undetermined status (55%) and 0 patients with MSI-H. Forty-one (71.93%) patients had low ( < 5) tumor mutation burden status (TMB), 16 (28.07%) intermediate (5-15) and none with high ( > 15) TMB. There was no noticeable survival difference when comparing low with intermediate TMB (P = 0.3). Loss of heterozygosity (LOH) was a significant prognostic biomarker. Patients with high LOH (hLOH > = 16%) had longer OS compared to low LOH (lLOH < 16%), 99.02 vs. 50.23 months, respectively (P <.005). Patients with hLOH and BRCA mutations (BRCA+) had longer OS compared to hLOH/BRCA WT (BRCA-), lLOH/BRCA+, and lLOH/BRCA-, with an unreached median OS of 91.5 vs. 60.48 vs. 45.21 months, respectively (P =.005). Conclusions: Our work demonstrates the clinical benefit of NGS personalized medicine as a cornerstone of future treatment strategies in OC. Our study suggests an OS benefit among the NGS tested cohort. We identified LOH as a prognostic biomarker. Prospective studies evaluating larger cohorts are necessary to generate a more extensive evaluation of additional prognostic and predictive biomarkers among OC patients.

Palliative radiotherapy referrals in the last days of cancer patients' life: Could we do better?

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Background: The role of active cancer therapy towards the end of life (EOL) is debatable and may even be considered harmful. While palliative radiotherapy may be highly effective in reducing cancer-related symptoms of advanced disease, the beneficial effects are usually at least 2-4 weeks from completion of treatment. Thus, radiotherapy administered at the end of life is often ineffective, and may actually impair quality of life and be associated with an unnecessary burden to the health care system. The universal Israeli health care system enables the administration of radiotherapy without financial or regulatory barriers, even at EOL. We aimed to assess the use radiotherapy towards EOL in a tertiary care Israeli cancer center. Methods: We retrospectively analyzed data of patients receiving palliative radiation and died within 30 days of their simulation from March 2019 until September 2020. Results: Out of approximately 2,000 patients treated with radiotherapy during the study period, 148 (8%) patients were referred for palliative radiation and died within 30 days of their simulation. The majority (88, 59.5%) were male, the median age was 67.3 years and the most common malignancies patients suffered from were lung cancer (49, 33.1%), gastrointestinal tumors (28, 18.9%), genito-urinary malignancies (23, 15.5%) or breast cancer (15, 10.1%). The median ECOG PS was 3. Nineteen patients (12.8%) did not initiate radiation treatment plan, 24 patients (16.2%) completed less than half of the planned treatment and 89 patients (60.1%) completed the entire duration of treatment. Of the patients who completed the planned therapy, 34 patients (38.2%) received a single fraction protocol. The majority of patients (89, 60.1%) were referred to the radiation unit by their treating medical oncologists or hemato-oncologist. None of the patients were referred by palliative care team members at our center. Most (105, 70.9%) received previous systemic therapies; but less than half (48, 45.7%) were under active treatments within a month prior to the radiation simulation. Conclusions: Relatively large number of patients with advanced malignancies are referred for futile palliative radiotherapy during the last 30 days of their life, thus impairing their quality of life and creating an unnecessary burden on public health services. These patients are often being referred by their treating oncologists who are familiar with their oncological history. These findings call for the implementation of collaborative multi-disciplinary teams, primarily directed at optimizing care at the end of life, setting achievable treatment goals, and improving quality of life.

Pathology Consultation Clinic for Patients With Cancer: Meeting the Clinician Behind the Microscope

PURPOSE

Traditionally, pathologists have been branded the doctor's doctor, with a position behind the microscope and limited interaction among patients, despite their rich understanding of disease development and ability to navigate personalized medicine in an era of dynamic molecular testing.

METHODS

We piloted a unique patient-pathology consultation service, whereby pathologists review tissue specimens with oncology patients, facilitating a platform for heightening patient understanding of their disease and guiding additional genetic and molecular evaluation. We conducted a retrospective survey assessing patient experience.

RESULTS

Fifty-nine patients participated in the patient-pathology clinic consultation, with a median age of 64 years and a female predominance (33, 55.9%). The majority of patients were treated for sarcomas (11, 18.6%), breast cancer (10, 17%), and GI tumors (10, 17%). Half of the participants consulted regarding a metastatic disease (28, 47.5%). Thirty patients (50.8%) were referred to additional workup, 11 patients (18.6%) to a second opinion, and 25 participants (42.4%) were counseled to complete genetic sequencing or additional molecular profiles on their pathologic samples. Twelve patients (20.3%) were referred for pathology revision within our institution. Three patients (5.1%) had a change in treatment plan resulting from the clinic visit. The majority (90%) would recommend the patient-pathology clinic to other oncology patients.

CONCLUSION

To our knowledge, this is the largest study of patient-pathologist consultation services implemented at a single institution. Our work suggests that the program may provide effective patient understanding and reinforce the role of the pathologist as the patient's doctor. This work surfaced the concerns of patients, regarding their pathology reports, and demonstrated that the patient-pathology clinics are a valuable platform to address patients' distress regarding uncertainty of their diagnosis and an integral resource engaging directly with patients, driving additional evaluation and patient-targeted treatment.

Kambô-Induced Systemic Inflammatory Response: A Case Report of Acute Disease Progression of Cholangiocarcinoma

Kambô is a cleansing ritual involving the application of a toxin produced by the giant leaf frog (Phyllomedusa bicolor). The Kambô ritual has increasingly been adopted among cancer patients in Europe. Accumulating data indicate various adverse effects. We report another severe adverse reaction to Kambô, a systemic inflammatory response syndrome mimicking disease progression in a patient with cholangiocarcinoma. We describe a systemic reaction to Kambô, manifested as tachycardia, tachypnea, impaired liver cholestatic enzymes, and enlargement of lymphadenopathy mimicking disease progression. The clinical features and onset of symptoms, the rapid reaction, and the lack of other identified causes make the diagnosis of Kambô-induced SIRS highly probable. This case report calls for future studies examining standard oncological care such as chemotherapy, radiotherapy, and immunotherapy in conjunction with alternative therapy. Additionally, greater awareness and physician education should be promoted, encouraging inquiry of oncology patients’ administration of alternative, complementary, and integrative medicine.

Rapid Implementation of Telemedicine During the COVID-19 Pandemic: Perspectives and Preferences of Patients with Cancer

Introduction

The use of telemedicine in oncology practice is rapidly expanding and is considered safe and cost effective. However, the implications of telemedicine on patient‐physician interaction, patient satisfaction, and absence of the personal touch have not been studied to date. Following the spread of COVID‐19, telemedicine services were rapidly incorporated at the Oncology Division of Tel Aviv Medical Center. We aimed to evaluate patients' perspectives and preferences regarding telemedicine and to assess whether this virtual communication platform affects the patient‐physician relationship.

Methods

Between March 2020 and May 2020, adult cancer patients who conducted at least one successful telemedicine meeting were interviewed by trained medical personnel. The interview was based on validated patient satisfaction questionnaires and focused on patient‐physician interaction in relation to the last in‐patient visit.

Results

Of 236 patients, 172 (74%) patients agreed to participate. The study population comprised mainly patients with gastrointestinal malignancies (n = 79, 46%) with a median age of 63 years (range 21–88). The majority of patients were male (n = 93, 54%). Eighty‐nine (51.7%) patients were receiving active oncologic treatment, and 58 (33.7%) were under routine surveillance following completion of active therapy. Almost all had a sense of secured privacy (n = 171, 96%), the majority of patients affirmed that their concerns were met (n = 166, 93%) and perceived that eye contact with the treating physician was perceived (n = 156, 87%). Only a minority felt that the absence of physical clinic visits harmed their treatment (n = 36, 20%). Most patients (n = 146, 84.9%) wished to continue telemedicine services. A multivariate analysis revealed that higher satisfaction and visits for routine surveillance were both predictors of willingness to continue future telemedicine meetings over physical encounters (odds ratio [OR] = 2.41, p = .01; OR = 3.34, p = .03, respectively).

Conclusion

Telemedicine is perceived as safe and effective, and patients did not feel that it compromised medical care or the patient‐physician relationship. Integration of telemedicine is ideal for patients under surveillance after completion of active oncologic treatment. Physician communication skills workshops are warranted with implementing this platform.

Implications for Practice

During the COVID‐19 pandemic, telemedicine was rapidly implemented worldwide to facilitate continuity of quality care and treatment. Despite many potential setbacks, telemedicine has become a useful and safe tool for oncology practitioners to care for their patients. The use of telemedicine regarding patients' perspectives, emotions, and patient‐physician communication in daily oncology practice has not been studied to date. This study demonstrated telemedicine is perceived as safe and effective and does not compromise medical care or the patient‐physician relationship. Its use is ideal for surveillance after completion of active oncologic treatment. Physician communication skills workshops are warranted with implementing this platform.

The use of telemedicine in oncology practice is rapidly expanding; however, the implications for patient‐physician interaction and patient satisfaction have not been well studied. This article evaluates patients' perspectives and preferences regarding telemedicine and whether a virtual communication platform affects the patient‐physician relationship.

Perception of patients regarding telemedicine at times of COVID-19: Did they miss the personal touch?

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Background: The patient-oncologist relationship is cultivated from the first clinic visit, trust and assurance established throughout the follow up period until the end of life. In March 2020, with the break of the COVID-19 pandemic, social distancing restrictions were implement throughout Israel. The adoptions of telemedicine services were incorporate as a response at our institution. Almost all ambulatory activity in the oncology division in Tel Aviv Medical Center was converted to telemedicine services. Several studies report favorable results regarding patient preference and cost effectiveness of telemedicine. Methods: We conducted a telephone interview questionnaire assessing patient satisfaction. Inclusion criteria included solid tumor patients over 18 years who utilized the telemedicine platform at Tel Aviv Sourasky Medical Center between March 2020 - May 2020. We aimed to evaluate patient's perspectives and preferences regarding telemedicine and assess whether this virtual communication affects the patient-doctor relationship. Results: Following the COVID-19 outbreak, 400 telephone calls were made to patients, 100 patients agreed to participate and surveyed. Fifty-two percent were female. The majority of patients independently downloaded the telemedicine application and did not encounter technical constraints (67%). Family members and friend attended 45% of telemedicine visits. Patients cancer diagnosis included colorectal cancer (47%), breast cancer (18%), genitourinary cancer (18%), sarcoma (9%) lung malignancies (6%), gynecological cancer (1%) and CNS tumors (2%). Visit intent included post-treatment follow up (40%), active treatment follow (53%), and first visit intake (7%). The majority of patients felt their emotional needs were met (88%) and felt that their treatment was not harmed due to absence of a physical visit (84%). Almost all patients (99%) felt their privacy was maintained. Ninety-five percent of patients affirmed that the virtual visit relieved their worries regarding treatment interruption. Importantly, 75% of patients affirmed their interest to continue telemedicine regardless of COVID-19 pandemic. Conclusions: Telemedicine is an acceptable platform that may replace follow up visits without comprising patients’ experience. Our data call for research and development of tools enabling long-term implementation of remote telemedicine and assess the patient-physician relationship and quality of care among oncology patients.

Adoption of behavioral restrictions as anti-infective measures: A survey among solid tumor patients

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Background: Despite lack of evidence, a wide range of rigorous behavioral and social restrictions are recommended in various guidelines and websites in an attempt to mitigate infections. These include patient guided sites. We aimed to study the practices of patients with solid tumors treated with active therapy. Methods: We conducted an anonymous survey among cancer patients treated at a tertiary care center, addressing behavioral approach to infection prevention, by assessing adopted social (seven items), environmental (five items), and dietary (eight items) limitations, as well as compliance to influenza vaccinations. Clinical data included neutropenic fever (NF), and therapy myelosuppressive potential. Multivariable Poisson regression adjusted for sex, age, disease status, therapy to estimate the impact of these restrictions. Results: 214 patients with solid tumors responded to the survey, the majority female (59%), with a median age of 63. The most common tumor types included breast (28%), lung (14%), and colon (9.3%). Most (68%) were treated with chemotherapy, 17% with immunotherapy, 11% with biologicals and 3% with chemo-immunotherapy. Only 6% were admitted for NF. Sources of information regarding restrictions included physicians (4%), nurses (32.9%), and internet (9.8%); the majority were self-imposed. 53% maintained environmental limitations (traveling, sun exposure, hair dying), 37% adopted social restrictions (abstained from children, public places), and 21% affirmed dietary constraints (raw vegetables, tap water consumption). Females practiced stricter environmental and dietary restraint (p < 0.05), with a numerical trend reflecting stricter female social measures (p < 0.4). With no difference in practices among patients treated for a malignant disease and curative intent, and no difference in practice across therapies, in those treated with chemotherapy and immuno-therapy. 37% affirmed difficulty in adherence to these limitations. Conclusions: Our findings indicate that despite lack of evidence, cancer patients adopt anti-infective behavioral measures, which have a deleterious impact on quality of life. These practices are being used even among patients at low or no risk of NF. These findings call for implementation of an education program and development of practical instructions enabling patients to resume their normal life

Safety, tolerability and efficacy of a novel self-use biodegradable device for management of obesity

OBJECTIVE

Obesity is a major public health issue with significant impact on quality of life, morbidity and mortality rates. It is estimated that if the current trends continue, 18% of men and 21% of women worldwide will be obese by 2025. All the current therapies are not optimal due to limited efficacy or safety; thus, there is a need for additional devices for the treatment of obesity. This study aimed to examine the safety, tolerability, and efficacy of a biodegradable encapsulated Epitomee device for weight loss. The technology is based on absorbent pharmaceuticals polymers and bonding materials that self-expand in the stomach to create a pH-sensitive super absorbent gel structure for weight loss.

METHODS

A prospective, 12-week twice daily use of the encapsulated device in patients with body mass index of 27-40 kg m-2. Efficacy endpoints were the percent total body weight loss (%TBWL), proportion of participants with 5% TBWL and changes in cardio-metabolic markers. Safety analysis included evaluation of adverse events, laboratory and endoscopic findings.

RESULTS

Overall, 52 patients completed the study. TBWL per intension-to-treat analysis was 3.68 ± 3.07% (3.23 ± 2.69 kg) and 4.52 ± 2.97% (3.95 ± 2.57 kg) per protocol. No device serious adverse effects reported. The most common adverse events were headache (18.1%), viral infection (11.5%), abdominal discomfort (10.1%), bloating (7.9%), nausea and constipation (5% each) and flatulence (4.3%). Endoscopy in 26 patients revealed mild, asymptomatic gastric/duodenal erythema without erosions in five patients.

CONCLUSIONS

Twelve weeks of Epitomee capsules treatment combined with lifestyle counselling resulted in 3.68-4.52% of TBWL. With continued research, the Epitomee capsules have considerable potential to become a non-invasive, safe and effective treatment option for weight loss.

Unusually long-term responses to vemurafenib in BRAF V600E mutated colon and thyroid cancers followed by the development of rare RAS activating mutations

INTRODUCTION

V600E BRAF mutation is an established driver mutation in a variety of tumors. Vemurafenib is a selective inhibitor of the BRAF V600E kinase, known to be highly effective in BRAF V600E-positive metastatic melanoma. As a single agent, vemurafenib is relatively ineffective in other V600E-positive malignancies. Case 1: A 72 year old man with metastatic CRC who failed several previous lines of chemotherapy. Genetic analysis of 315 cancer-related genes (Foundation Medicine, FMI) revealed a BRAF V600E mutation. The patient was treated with vemurafenib resulting in a partial response of 18 months. Genetic analysis following development of resistance revealed a new mutation in KRAS-G12R. Case 2: V600E mutation was identified in a 59 year old woman with metastatic PTC refractory to radioiodine therapy. The patient was treated with vemurafenib resulting in a partial response lasting 43 months. Genetic analysis following development of resistance revealed a new mutation in NRAS-Q61K. The presented cases demonstrated the development of rare RAS mutations as a genetic mechanism of acquired BRAF inhibitor resistance. This observation is strongly supported by the analysis of a large database consisting of 712 BRAF V600E-positive melanoma samples showing higher rates of BRAF V600E and RAS mutations co-occurrence in metastatic lesions compared to local tumors (OR = 3.8, p = 0.035). This enrichment is likely a result of the development of RAS mutations following treatment with BRAF inhibitors.

DISCUSSION

We report two cases showing extreme response to vemurafenib, which could not be predicted prior to treatment commencement. Genetic testing demonstrated a resistant mechanism not previously reported in CRC or PTC patients, namely an acquired mutation of RAS. This is supported by an analysis of a large cohort of BRAF V600E-positive melanomas. Further studies are needed in order to identify predictive markers for response to vemurafenib and to explore novel strategies to overcome RAS-mediated resistance.

Suspected induction of a pyoderma gangrenosum-like eruption due to sulpiride treatment

A case of a pyoderma gangrenosum (PG)-like eruption due to the antipsychotic drug sulpiride, a form of risperidone, is described. The contribution of sulpiride to the etiology of the PG-like lesion is based on the reduction and healing of the ulcer upon cessation of the drug and the formation of a bulla following the drug's re-administration. The literature on drug-induced PG or PG-like eruptions is discussed. The selectivity of sulpiride for dopamine receptors and its limited effect on other neuronal pathways differentiates sulpiride from other types of antispychotic drugs commonly used in Israel, including phenothiazine, butyrophenone, and thioxanthene. Adverse systemic and cutaneous reactions to sulpiride and to risperidone are described. To our knowledge, this is the first report of a PG-like eruption due to the former.