Ten-year clinical outcome, toxicity and compliance of dose-dense sequential adjuvant administration of cyclophosphamide & epirubicin followed by docetaxel in patients with early breast cancer: A hellenic cooperative oncology group observational study (HE 10/10) with concurrent investigation of significance of tumor infiltrating lymphocytes

BACKGROUND

Dose-dense sequential (dds) chemotherapy has changed the clinical outcome of patients with early breast cancer (BC). To investigate the impact of dose intensity (DI) in the adjuvant setting of BC, this observational trial (HE 10/10) was conducted assessing the long-term survival outcome, safety and toxicity of a currently widely used chemotherapeutic regimen. In addition, the prognostic significance of tumor infiltrating lymphocytes (TILs) and infiltrating CD8+ lymphocytes were also evaluated in the same cohort.

PATIENTS AND METHODS

Totally, 1054 patients were prospectively enrolled in the current study with 1024 patients being eligible, while adequate tissue was available for 596 of them. TILs, CD8+ lymphocytes in intratumoral areas in contact with malignant cells (iCD8), CD8+ lymphocytes in tumor stroma (sCD8) as well as the total number of CD8+ lymphocytes within the tumor area (total CD8) were assessed by immunohistochemistry.

RESULTS

Within a median follow-up of 125.18 months, a total of 200 disease-free survival (DFS) events (19.5%) were reported. Importantly, the 10-year DFS and OS rates were 78.4% (95% CI 75.0-81.5) and 81.7% (95% CI 79.0-84.1), respectively. Interestingly, higher CD8+ T cells as well as TILs in the tumor microenvironment were associated with an improved long-term survival outcome.

CONCLUSIONS

In conclusion, this study confirms the significance of dds adjuvant chemotherapeutic regimen in terms of long-term survival outcome, safety and toxicity as well as the prognostic significance of TILs and infiltrating CD8+ lymphocytes in BC patients with early-stage disease.

Real-world Data and Economic Evaluation of Nivolumab in Previously Treated Non-small Cell Lung Cancer Greek Patients

BACKGROUND/AIM

Nivolumab is an FDA-approved immune checkpoint inhibitor (ICI) for patients with advanced, pre-treated non-small cell lung cancer (NSCLC). However, treatment profiles and patient outcomes often differ in routine clinical practice while the financial impact of approved therapies is largely unknown. In this study, we investigated the efficacy, tolerability, and economic impact of nivolumab in real-world settings (RWS) in Greece.

PATIENTS AND METHODS

Patients diagnosed with advanced pre-treated NSCLC, receiving nivolumab were recruited from October 2015 until November 2019 across 18 different clinical centers in Greece. Endpoints included progression-free survival (PFS), overall survival (OS), objective response rate (ORR), and safety. Cost analysis was conducted using a third-party public-payer perspective (National Organization for Healthcare Services Provision; EOPYY).

RESULTS

A total of 346 patients, median age 66.5 years, were included. With 43.4 months median follow-up, median PFS was 7.8 months and median OS 15.8 months. The 1-year OS rate was 56.5%, 2-year OS 38.8%, and 3-year OS 27.3%. The ORR was 29.5% and DCR 58.7%, with a median response duration of 26.8 months. Patients with objective response were more likely to experience long-term survival (HR=0.14, p<0.001). Only 8.4% of patients experienced grade 3-4 adverse events. The presence of immune-related adverse events was associated with improved OS (HR=0.77, p=0.043). Nivolumab-associated economic burden accounted for €2,214.10 per cycle for each patient, mainly attributed to drug-acquisition costs.

CONCLUSION

This is the first report of real-world efficacy, safety, and economic burden of nivolumab in pre-treated patients with NSCLC in Greece. Indirectly compared to clinical trials, nivolumab was associated with improved efficacy in RWS, further supporting its use in clinical practice and providing insights on clinical prognosticators. The main cost component affecting the nivolumab economic burden was drug-acquisition costs, while toxicity-associated cost was negligible.

Molecular profile and clinical features of patients with gliomas using a broad targeted next generation-sequencing panel

Gliomas are the most common malignant primary brain tumors characterized by poor prognosis. The genotyping of tumors using next generation sequencing (NGS) platforms enables the identification of genetic alterations that constitute diagnostic, prognostic and predictive biomarkers. The present study investigated the molecular profile of 32 tumor samples from 32 patients with high-grade gliomas by implementing a broad 80-gene targeted NGS panel while reporting their clinicopathological characteristics and outcomes. Subsequently, 14 of 32 tumor specimens were also genotyped using a 55-gene NGS panel to validate the diagnostic accuracy and clinical utility of the extended panel. The median follow-up was 19.2 months. In total, 129 genetic alterations including 33 structural variants were identified in 38 distinct genes. Among 96 variants (single nucleotide variants and insertions and deletions), 38 were pathogenic and 58 variants of unknown clinical significance. TP53 was the most frequently mutated gene, followed by PTEN and IDH1 genes. Glioma patients with IDH1 mutant tumors were younger and had significantly longer overall survival compared to patients with wild-type IDH1 tumors. Similarly, tumors with TP53 mutations were more likely observed in younger patients with glioma. Subsequently, a comparison of mutational profiles of samples analyzed by both panels was also performed. Implementation of the comprehensive pan-cancer and the MOL panels resulted in the identification of 37 and 15 variants, respectively. Of those, 13 were common. Comprehensive pan-cancer panel identified 24 additional variants, 22 of which were located in regions that were not targeted by the MOL panel. By contrast, the MOL panel identified two additional variants. Overall, the present study demonstrated that using an extended tumor profile assay instead of a glioma-specific tumor profile panel identified additional genetic changes that may be taken into consideration as potential therapeutic targets for glioma diagnosis and molecular classification.

BIOM-16. NTRK (NEUROTROPHIC TYROSINE RECEPTOR KINASE) FUSIONS IN GLIOMA PATIENTS: A PROMISING MOLECULAR TARGET?

BACKGROUND

NTRK gene fusions are rare in gliomas (less than 2%). The use of TRK inhibitors in NTRK-fused solid tumors has generated significant clinical interest. It is likely that the unmet need for effective therapies in glioma will lead to routine testing for NTRK fusions.

METHODS

We performed a retrospective review of 22 patients with malignant gliomas accrued between 2007 and 2021. We collected tumor samples from those patients and NTRK fusions were tested using either immunohistochemistry or FISH or NGS. We then evaluated their association with clinical characteristics, histology and other markers (IDH1/2 mutation, MGMT methylation, BRAF mutation, EGFR expression, ATRX expression, TERT mutation).

RESULTS

Median age at diagnosis was 50 years. NTRK1 translocation was detected in 3 out of 22 patient tumors, while NTRK1 duplication was present in 1 patient (probably related to a translocation, but not proven). All NTRK1 translocations were not found in glioblastomas and their median survival was 15.8 months. On the other hand, median survival of gliomas without NTRK translocations was 11 months. In one NTRK1-translocated patient a TRK inhibitor (entrectinib) was used (for a few days), but we cannot evaluate its efficacy as the patient deteriorated and died. As far as the other biomarkers are concerned, 2 out of 3 NTRK1-translocated gliomas were MGMT methylated.

CONCLUSION

NTRK fusions are rare in gliomas, as confirmed in our small sample analysis. Although adult NTRK-fused gliomas are considered to predominantly involve high-grade histology, in our study all patients had initially lower grade gliomas. NTRK alterations can be detected by different laboratory assays, but each of these approaches has specific advantages and limitations and more data are needed in order to identify the best method. For glioblastomas, NTRK fusions and TRK inhibitors are potentially a new targeted therapeutic strategy but more data are needed.

An Observational Study to Assess the Molecular Epidemiology and Direct Medical Costs of Epidermal Growth Factor Receptor (EGFR) Mutations in Patients with Advanced EGFR Mutation-Positive Non-Small Cell Lung Cancer Treated with Afatinib in Real-World Clinical Settings in Greece

Purpose

Epidermal growth factor receptor (EGFR) tyrosine kinase inhibitors (TKIs) are the preferred first-line option for patients with advanced, EGFR-mutant non-small cell lung cancer (NSCLC). Afatinib, a second-generation irreversible EGFR-TKI, has been extensively used in Greece in this setting; however, real-world data regarding molecular epidemiology and financial implications of afatinib use are lacking.

Materials and Methods

This was an observational, non-interventional, multicenter, retrospective cohort study, based on real-world data collected from the medical charts/records of patients treated with afatinib between 15/03/2015 and 25/06/2020 and were recorded on a web-based data capture system. Cox models were used to assess the prognostic significance of clinicopathological parameters with respect to clinical outcomes of interest. Cost analysis was conducted from a public third-payer perspective, and only direct medical costs reimbursed by the payer were considered.

Results

A total of 59 patients were treated with afatinib for their EGFR mutation-positive advanced NSCLC; the median age was 61 years (range: 37-91). Performance status was zero in 61%, and brain metastases were present in 13.6%. Forty-four patients (74.6%) had a deletion in exon 19 only, while nine (15.3%) had a mutation in exon 21, 8 of them in L858R and one in L861Q. At a median follow-up of 41.8 months (95% CI 35.9-51.4), the median PFS was 14.3 months (95% CI 12.2-16.4), and the median OS was 29 months (95% CI 25.6-33.4). Corresponding values for patients with deletion 19 only were 14.3 months (95% CI 11.5-18.5) and 28.1 months (95% CI 21.1-32.6), respectively. The mean expenditure for the treatment of each patient equals €25,333.68; with €21,865.06 being attributed to drug acquisition costs, €3325.35 to monitoring costs and €143.27 to adverse event treatment-related costs.

Conclusion

Long-term data in the real-world setting in Greece confirm activity, tolerability and cost-effectiveness of afatinib as first-line treatment of patients with advanced EGFR-mutant NSCLC.

Clinical Trial Registration

Clinicaltrials.gov NCT04640870.

The Value of New Fields in the Medical Record for Quality Improvement

Introduction

Quality in healthcare delivery is important for the safety and experience of patients with cancer. Effective documentation is an integral component of quality improvment, and accurate documentation can be affected by prompts in the medical record, potentially improving quality of services.

Methods

The Contemporary Oncology Team (COT) is a Greek private oncology practice that participated in the American Society of Clinical Oncology's (ASCO's) Quality in Oncology Practice Initiative (QOPI). Between 2014 and 2019, COT implemented changes in its paper patient medical record, in order to improve quality of care and documentation. Fields regarding pain, emotional well-being and psychosocial assessment, discussions with the patient and consent about treatment and disease, medication details and cumulative dose, treatment goals, side-effect grading, pregnancy screening, treatment adherence and anticipated duration were added. In this report, we present the association of these improvements with COT performance in QOPI.

Results

Pain and emotional well-being assessment and documentation were significantly improved by the development of a structured patient follow-up form. In contrast, the assessment of fertility issues, tobacco use, and the documentation of treatment plan and intent did not present a drastic change, because COT performance was already above QOPI average.

Conclusion

A thorough reform of COT paper medical record according to QOPI standards improved QOPI scores, but more importantly effected a shift in the team's culture to safer and more standardized quality based care.

Evaluation of the Role of p95 HER2 Isoform in Trastuzumab Efficacy in Metastatic Breast Cancer

BACKGROUND/AIM

Human epidermal growth factor receptor 2 (HER2) P95-isoform could be involved in trastuzumab resistance in HER2 metastatic breast cancer.

MATERIALS AND METHODS

A total of 114 metastatic breast cancer patients treated with trastuzumab were evaluated retrospectively. HER2 was centrally reviewed. P95 was evaluated along with other markers possibly affecting trastuzumab efficacy in regards to progression-free survival and overall survival.

RESULTS

HER2 was centrally negative in 54 cases. P95 expression was significantly higher in HER2-positive tumors. High p95 was associated with gain of HER2 copy number variations (CNVs), high pHER2Tyr877, Ki67 and HER2 mRNA. P95 as a continuous variable was positively correlated with mRNA expression of HER2 and negatively correlated with HER4 and IGF1. HER2-negative p95-high patients had a marginally higher risk for death (HR=2.15, p=0.055).

CONCLUSION

p95 was associated with higher HER2 CNVs and mRNA expression, pHER2Tyr877 expression and high Ki67, indicating a more aggressive phenotype.

Clinical Significance of Germline Cancer Predisposing Variants in Unselected Patients with Pancreatic Adenocarcinoma

Our aim was to determine the prevalence, prognostic and predictive role of germline pathogenic/likely pathogenic variants (P/LPVs) in cancer predisposing genes in patients with pancreatic ductal adenocarcinoma (PDAC). Germline testing of 62 cancer susceptibility genes was performed on unselected patients diagnosed from 02/2003 to 01/2020 with PDAC, treated at Hellenic Cooperative Oncology Group (HeCOG)-affiliated Centers. The main endpoints were prevalence of P/LPVs and overall survival (OS). P/LPVs in PDAC-associated and homologous recombination repair (HRR) genes were identified in 22 (4.0%) and 42 (7.7%) of 549 patients, respectively. P/LPVs were identified in 16 genes, including ATM (11, 2.0%) and BRCA2 (6, 1.1%), while 19 patients (3.5%) were heterozygotes for MUTYH P/LPVs and 9 (1.6%) carried the low-risk allele, CHEK2 p.(Ile157Thr). Patients carrying P/LPVs had improved OS compared to non-carriers (22.6 vs. 13.9 months, p = 0.006). In multivariate analysis, there was a trend for improved OS in P/LPV carriers (p = 0.063). The interaction term between platinum exposure and mutational status of HRR genes was not significant (p-value = 0.35). A significant proportion of patients with PDAC carries clinically relevant germline P/LPVs, irrespectively of age, family history or disease stage. The predictive role of these P/LPVs has yet to be defined. ClinicalTrials.gov Identifier: NCT03982446.

Cancer of unknown primary ultimately diagnosed as male breast cancer: A rare case report

Cancers of unknown primary (CUP) constitute a significant diagnostic and therapeutic challenge for clinicians and a frequent cause of cancer-related mortality in Western countries. Immunohistochemistry assays are commonly used to identify the primary cancer, but fail in approximately one-third of cases. The identification of the possible origin of CUP is crucial, as it may help select the appropriate treatment options. We herein present the case of a 54-year-old male patient, who presented with lower back pain in June, 2013. Following a thorough investigation, the clinical and pathological findings could not identify the primary cancer, leading towards a misdiagnosis. Ultimately, microRNA testing of the resected spine lesion was able to identify the primary tumor as male breast cancer and allow for optimal treatment of the patient.

New fields in the patient record: A tool or a nuisance?

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Background: The Contemporary Oncology Team was the first practice in Greece to participate in the Quality in Oncology Practice Initiative (QOPI). As a result, several corrective measures were designed and implemented to improve the quality of the services provided to patients. Methods: The plan-do-check-act approach was used to implement changes, primarily in the follow up form, over a period of 18 months. Several improvement opportunities were identified. 1.) A numerical scale for pain intensity quantification became a required field. 2.) Emotional well-being fields were added so the patient’s state could be documented by providers. 3.) Fertility assessment and counseling was added as a required field in the patient record. For this report we evaluated retrospectively the effect of these changes on our QOPI scores. Results: Contemporary Oncology Team QOPI scores after the implementation of the new forms have shown increased compliance, compared to QOPI aggregate scores for all participating US practices, in the areas related to the changes made. Specifically, pain assessment documentation improved from -54.56% to +9.96%. The use of a numerical tool proved invaluable to comparing pain intensity between different visits. Emotional well-being documentation improved from -42.55% to +18.26%. Fertility assessment documentation has not improved but this finding could be due to a decrease in patient chart sample size. Providers seemed to adapt quickly and without difficulty. Conclusions: Developing new fields in the patient record is an evolving process because it requires provider education and acquaintance with the new method of documentation. However, in this retrospective analysis it proved to be an effective method to improve provider compliance with assessment of pain and emotional well-being, and it is likely to be useful in other areas in need of improved documentation.

Two cycles of carboplatin as adjuvant therapy in stage I seminoma: 8-year experience by the Hellenic Co-operative Oncology Group (HECOG)

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Background: Adjuvant chemotherapy is used in stage I testicular seminoma. We have reported a risk-adapted strategy of 2 cycles of cisplatin/etoposide (EP) in 64 patients with age < 34 and/or tumor diameter > 4cm) (Bamias et al, Urology 2007), resulting in no relapses over a median follow up of 5 years. Following the establishment of adjuvant carboplatin as a standard, we adopted this treatment for all patients with stage I seminoma. We report our 8-year experience and compare these results with our previous EP strategy. Methods: Patients with stage I seminoma, treated with 2 cycles of carboplatin AUC 6 and a minimum follow up of 1 year after chemotherapy were selected. All patients consented for the use of their medical information and the analysis was approved by the centers involved. Survival functions were presented using Kaplan-Meier curves. The log-rank test was used to test for survival differences across different categories. Results: 137 patients (Median age: 34; Age<34: 49%, tumor diameter>4cm: 42%; rete testis invasion: 24%), treated between 11/2003-12/2011 were selected. During a median follow up of 4 years, there were 5 relapses (5-y relapse rate [RR]: 97% [SE: 2%]): retroperitoneal lymph nodes (n=4) and isolated brain (n=1). All patients with relapse had tumor diameter > 4cm and/or age < 34. No relapse was associated with rete testis invasion. Patients with at least 1 of the above risk factors (n=94) had a significantly higher relapse rate compared with a similar population (n=64) treated with 2 cycles of adjuvant EP: 5-y RR was 95% (SE: 2%) vs.100% (SE 0%), (p=0.033). All relapsed patients were treated with BEP chemotherapy and are currently alive with no evidence of relapse. Neutropenia and nausea/vomiting were less frequent with carboplatin than with EP (11% vs. 36% and 15% vs. 65%). Conclusions: Our analysis confirms the association of age and tumor diameter with relapse in stage I seminoma treated with adjuvant carboplatin. Although adjuvant carboplatin in patients with age<34 and/or tumor diameter> 4 cm is associated with higher RR than EP, the prognosis of these patients is excellent with salvage chemotherapy and, therefore, the use of less toxic treatment is justified.

Re-emergence of animal rabies in northern Greece and subsequent human exposure, October 2012 – March 2013

Greece has been rabies-free since 1987 with no human cases since 1970. During 2012 to 2013, rabies has re-emerged in wild and domestic animals in northern Greece. By end March 2013, rabies was diagnosed in 17 animals including 14 red foxes, two shepherd dogs and one cat; 104 subsequent human exposures required post-exposure prophylaxis according to the World Health Organization criteria. Human exposures occurred within 50 km radius of a confirmed rabies case in a wild or domestic animal, and most frequently stray dogs were involved.

Re-emergence of animal rabies in northern Greece and subsequent human exposure, October 2012 - March 2013

Greece has been rabies-free since 1987 with no human cases since 1970. During 2012 to 2013, rabies has re-emerged in wild and domestic animals in northern Greece. By end March 2013, rabies was diagnosed in 17 animals including 14 red foxes, two shepherd dogs and one cat; 104 subsequent human exposures required post-exposure prophylaxis according to the World Health Organization criteria. Human exposures occurred within 50 km radius of a confirmed rabies case in a wild or domestic animal, and most frequently stray dogs were involved.

BRCAness: finding the Achilles heel in ovarian cancer

Ovarian cancer is the leading cause of death among gynecological cancers. It exhibits great heterogeneity in tumor biology and treatment response. Germline mutations of DNA repair genes BRCA1/2 are the fundamental defects in hereditary ovarian cancer that expresses a distinct phenotype of high response rates to platinum agents, improved disease-free intervals and survival rates, and high-grade serous histology. The term "BRCAness" describes the phenotypic traits that some sporadic ovarian tumors share with tumors in BRCA1/2 germline mutation carriers and reflects similar causative molecular abnormalities. BRCA pathway studies and molecular profiling reveal BRCA-related defects in almost half of the cases of ovarian cancer. BRCA-like tumors are particularly sensitive to DNA-damaging agents (e.g., platinum agents) because of inadequate BRCA-mediated DNA repair mechanisms, such as nucleotide-excision repair and homologous recombination (HR). Additional inhibition of other DNA repair pathways leads to synthetic lethality in HR-deficient cells; this has been employed in the treatment of BRCA-like ovarian tumors with poly(ADP-ribose) polymerase inhibitors with promising results. This article presents a comprehensive review of the relevant literature on the role of BRCAness in ovarian cancer with respect to BRCA function, methods of BRCA epigenetic defect detection and molecular profiling, and the implications of BRCA dysfunction in the treatment of ovarian cancer.