Results of the c-TRAK TN trial: a clinical trial utilising ctDNA mutation tracking to detect molecular residual disease and trigger intervention in patients with moderate- and high-risk early-stage triple-negative breast cancer

BACKGROUND

Post-treatment detection of circulating tumour DNA (ctDNA) in early-stage triple-negative breast cancer (TNBC) patients predicts high risk of relapse. c-TRAK TN assessed the utility of prospective ctDNA surveillance in TNBC and the activity of pembrolizumab in patients with ctDNA detected [ctDNA positive (ctDNA+)].

PATIENTS AND METHODS

c-TRAK TN, a multicentre phase II trial, with integrated prospective ctDNA surveillance by digital PCR, enrolled patients with early-stage TNBC and residual disease following neoadjuvant chemotherapy, or stage II/III with adjuvant chemotherapy. ctDNA surveillance comprised three-monthly blood sampling to 12 months (18 months if samples were missed due to coronavirus disease), and ctDNA+ patients were randomised 2 : 1 to intervention : observation. ctDNA results were blinded unless patients were allocated to intervention, when staging scans were done and those free of recurrence were offered pembrolizumab. A protocol amendment (16 September 2020) closed the observation group; all subsequent ctDNA+ patients were allocated to intervention. Co-primary endpoints were (i) ctDNA detection rate and (ii) sustained ctDNA clearance rate on pembrolizumab (NCT03145961).

RESULTS

Two hundred and eight patients registered between 30 January 2018 and 06 December 2019, 185 had tumour sequenced, 171 (92.4%) had trackable mutations, and 161 entered ctDNA surveillance. Rate of ctDNA detection by 12 months was 27.3% (44/161, 95% confidence interval 20.6% to 34.9%). Seven patients relapsed without prior ctDNA detection. Forty-five patients entered the therapeutic component (intervention n = 31; observation n = 14; one observation patient was re-allocated to intervention following protocol amendment). Of patients allocated to intervention, 72% (23/32) had metastases on staging at the time of ctDNA+, and 4 patients declined pembrolizumab. Of the five patients who commenced pembrolizumab, none achieved sustained ctDNA clearance.

CONCLUSIONS

c-TRAK TN is the first prospective study to assess whether ctDNA assays have clinical utility in guiding therapy in TNBC. Patients had a high rate of metastatic disease on ctDNA detection. Findings have implications for future trial design, emphasising the importance of commencing ctDNA testing early, with more sensitive and/or frequent ctDNA testing regimes.

Quality-improvement program for ultrasound-based fetal anatomy screening using large-scale clinical audit

OBJECTIVE

A large-scale audit and peer review of ultrasound images may improve sonographer performance, but is rarely performed consistently as it is time-consuming and expensive. The aim of this study was to perform a large-scale audit of routine fetal anatomy scans to assess if a full clinical audit cycle can improve clinical image-acquisition standards.

METHODS

A large-scale, clinical, retrospective audit was conducted of ultrasound images obtained during all routine anomaly scans performed from 18 + 0 to 22 + 6 weeks' gestation at a UK hospital during 2013 (Cycle 1), to build a baseline understanding of the performance of sonographers. Targeted actions were undertaken in response to the findings with the aim of improving departmental performance. A second full-year audit was then performed of fetal anatomy ultrasound images obtained during the following year (Cycle 2). An independent pool of experienced sonographers used an online tool to assess all scans in terms of two parameters: scan completeness (i.e. were all images archived?) and image quality using objective scoring (i.e. were images of high quality?). Both were assessed in each audit at the departmental level and at the individual sonographer level. A random sample of 10% of scans was used to assess interobserver reproducibility.

RESULTS

In Cycle 1 of the audit, 103 501 ultrasound images from 6257 anomaly examinations performed by 22 sonographers were assessed; in Cycle 2, 153 557 images from 6406 scans performed by 25 sonographers were evaluated. The analysis was performed including the images obtained by the 20 sonographers who participated in both cycles. Departmental median scan completeness improved from 72% in the first year to 78% at the second assessment (P < 0.001); median image-quality score for all fetal views improved from 0.83 to 0.86 (P < 0.001). The improvement was greatest for those sonographers who performed poorest in the first audit; with regards to scan completeness, the poorest performing 15% of sonographers in Cycle 1 improved by more than 30 percentage points, and with regards to image quality, the poorest performing 11% in Cycle 1 showed a more than 10% improvement. Interobserver repeatability of scan completeness and image-quality scores across different fetal views were similar to those in the published literature.

CONCLUSIONS

A clinical audit and a set of targeted actions helped improve sonographer scan-acquisition completeness and scan quality. Such adherence to recommended clinical acquisition standards may increase the likelihood of correct measurement and thereby fetal growth assessment, and should allow better detection of abnormalities. As such a large-scale audit is time consuming, further advantages would be achieved if this process could be automated. © 2018 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of the International Society of Ultrasound in Obstetrics and Gynecology.

Abstract P5-17-02: Patient advocates are partners in global breast research: Value is recognised by early advocate involvement in the PREvent ductal carcinoma in situ invasive overtreatment now (PRECISION) study and related trials

Background

Early introduction and international collaboration of patient advocates is essential in the investigation of safe treatment of DCIS. This diagnosis has increased since the introduction of screening. The treatment of low risk DCIS has been the subject of debate, controversy, anxiety and cost to women and health services globally. There has been much "public" as well as "professional" discussion leading to considerable distress. Some surgeons have concerns about carrying out unnecessary surgery on patients with low risk DCIS, but this is current best practice due to lack of credible evidence that monitoring can be safe. Some women feel their "lives were saved" whilst others feel "mutilated" by "unnecessary” surgery. These women cannot know the true harm or benefit of the treatment which they receive without evidence from clinical trials and biological/molecular research.

Aims

· To provide evidence of the value of patient involvement.

· To encourage recruitment in "difficult to recruit studies" by educating the public, patients and clinicians.

· To assist in the design of effective information tools.

· To increase liaison between advocates internationally to understand differences in culture, health services, and patient expectation.

Methods

The PRECISION team includes 2 patient advocates from each of the DCIS randomized trials (LORIS in the UK, LORD in the Netherlands and COMET in the US).

Our group will liaise with other groups involved in the wider efforts around DCIS. We will take part in media interviews and public debates to raise awareness and the need for evidence to change practice to reduce overtreatment of low riskDCIS. We will work with our researcher colleagues in each PRECISION work project, join the PRECISION steering group, and liaise together via regular calls. Importantly, we will encourage awareness amongst clinicians to emphasize that patients wish to be informed about available trials, and that not to do so is denying patient choice.

Results

An increase in interest and recruitment can be measured and the influence of early involvement of patient advocates can be demonstrated so that the model can be used in other trials. The biology is intricate, scientific and exciting but it is crucial that the outcome is available and understood by all women and their physicians worldwide. The results will be promoted by patient advocates through publications, social media and patient groups. Advocates will appear as co-authors on scientific publications.

CONCLUSIONS With the increase in international clinical trials, there is a need for further understanding of the differences in practice and patient need in different hospitals - as well as in different countries. We will show the value of our collaboration by demonstrating the results of patient advocate involvement in the PRECISION program.

* The PRECISION Team is a Cancer Research UK Grand Challenge Award 2017 winning team and will be jointly funded by Cancer Research UK and the Dutch Cancer Society.

Citation Format: Verschuur E, Collyar D, Oirsouw Mv, Pinto D, Stobart H, Wilcox M, On Behalf of the PRECISION Project. Patient advocates are partners in global breast research: Value is recognised by early advocate involvement in the PREvent ductal carcinoma in situ invasive overtreatment now (PRECISION) study and related trials [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P5-17-02.

Abstract P1-10-01: Patient advocate involvement shapes UK’s first national breast cancer tissue bank - The breast cancer campaign tissue bank

The Breast Cancer Campaign Tissue Bank (BCCTB) was initiated in 2010 after the charity Breast Cancer Campaign heard from breast cancer experts that insufficient high quality breast cancer tissue was preventing research which would impact people with breast cancer1. The charity decided to involve patient advocates in the development of the BCCTB from the beginning.

Two advocates reviewed the initial applications to form the BCCTB. These included both single and multi-centre applications so they suggested that, rather than choosing one centre to form the Bank, the charity consider a collaboration of centres. Throughout the development of the BCCTB, the patient advocates asked the ‘elephant in the room’ questions and brought a different perspective. They also helped to design the Bank's processes, including the consent process and asking that all tissue applicants produce a lay summary of their research.

There are now two advocates on the Board which provides strategic direction to the BCCTB. The advocates have equal status to other Board members. There are also three advocates on the Tissue Access Committee which controls the use of tissue in the Bank. Lay summaries of projects have to be approved by all advocates before an application can proceed. This means that no precious tissue is released without the approval of a lay person, who can ensure maximum patient benefit will be achieved from any research. The Bank's data return policy was also driven by the patient advocates who were keen that the tissues donated were used to their maximum benefit. This has resulted in the first publication from BCCTB2

Patient advocates have been involved in promoting the use of tissue from the bank presenting at conferences and at BCCTB road shows. Patient advocates have also been involved in asking potential donors to consent to donate to the tissue bank.

The involvement of patient advocates in the development and oversight of the BCCTB has shown researchers that patient and public involvement works. The advocates can also help promote the Bank and the benefits of tissue donation to both professionals and lay groups.

The patient advocates involved in the Breast Cancer Campaign Tissue Bank are members of the charity Independent Cancer Patients’ Voice

1. Thompson P, Brennan K, Cox A, Gee J, Harcourt D, Harris A, Harvie M, Holen I, Howell A, Nicholson R, Steel M, Streuli C. Evaluation of the current knowledge limitations in breast cancer research: a gap analysis. Breast Cancer Res 2008: 10(2); R26.

2. Speirs V, Morgan A. Investment biobanking – increased returns on tissue samples. Nat Rev Clin Onc 2013; 10:128-129.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P1-10-01.