Impact of the coronavirus disease 2019 pandemic on cancer treatment: the patients' perspective

Background

The coronavirus disease 2019 (COVID-19) pandemic, caused by severe acute respiratory syndrome coronavirus 2, has inevitable consequences for medical care of patients without COVID-19. To assess the impact of this pandemic on oncological care, a nationwide survey was conducted among patients with cancer in the Netherlands.

Methods

The patients' perspective on oncological care was investigated using an online survey between March 29th 2020 and April 18th 2020. The survey consisted of 20 questions on four topics: patients’ characteristics, contact with the hospital, consequences of the COVID-19 pandemic and concerns about COVID-19.

Results

Five thousand three hundred two patients with cancer completed this nationwide survey. Overall, 30% of patients reported consequences for their oncological treatment or follow-up. In the majority of cases, this resulted in conversion from hospital visit to consultation by phone or video. The most frequently adjusted treatments were chemotherapy (30%) and immunotherapy (32%). Among patients with delay and discontinuation of treatment, 55% and 63% of patients, respectively, were (very) concerned about these consequences of the COVID-19 pandemic. Consequences were independent of regional differences in COVID-19 incidence. However, patients in regions with high COVID-19 incidence were significantly more concerned.

Conclusion

This is the first study investigating perspectives of patients with cancer during the COVID-19 pandemic. The study demonstrates the significant impact of the COVID-19 crisis on oncological care, indicating the need for psycho-oncological support during this pandemic.

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Impact of COVID-19 on oncological care from cancer patients’ perspective.

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5302 patients with cancer completed a nationwide online survey.

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30% of the patients reported consequences for oncological treatment or follow-up.

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The consequences were independent of regional differences in COVID-19 incidence.

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This study indicates the need for psycho-oncological support during this pandemic.

Nationwide comprehensive gastro-intestinal cancer cohorts: the 3P initiative

BACKGROUND

The increasing sub-classification of cancer patients due to more detailed molecular classification of tumors, and limitations of current trial designs, require innovative research designs. We present the design, governance and current standing of three comprehensive nationwide cohorts including pancreatic, esophageal/gastric, and colorectal cancer patients (NCT02070146). Multidisciplinary collection of clinical data, tumor tissue, blood samples, and patient-reported outcome (PRO) measures with a nationwide coverage, provides the infrastructure for future and novel trial designs and facilitates research to improve outcomes of gastrointestinal cancer patients.

MATERIAL AND METHODS

All patients aged ≥18 years with pancreatic, esophageal/gastric or colorectal cancer are eligible. Patients provide informed consent for: (1) reuse of clinical data; (2) biobanking of primary tumor tissue; (3) collection of blood samples; (4) to be informed about relevant newly identified genomic aberrations; (5) collection of longitudinal PROs; and (6) to receive information on new interventional studies and possible participation in cohort multiple randomized controlled trials (cmRCT) in the future.

RESULTS

In 2015, clinical data of 21,758 newly diagnosed patients were collected in the Netherlands Cancer Registry. Additional clinical data on the surgical procedures were registered in surgical audits for 13,845 patients. Within the first two years, tumor tissue and blood samples were obtained from 1507 patients; during this period, 1180 patients were included in the PRO registry. Response rate for PROs was 90%. The consent rate to receive information on new interventional studies and possible participation in cmRCTs in the future was >85%. The number of hospitals participating in the cohorts is steadily increasing.

CONCLUSION

A comprehensive nationwide multidisciplinary gastrointestinal cancer cohort is feasible and surpasses the limitations of classical study designs. With this initiative, novel and innovative studies can be performed in an efficient, safe, and comprehensive setting.

Towards better dose individualisation: metabolic phenotyping to predict cabazitaxel pharmacokinetics in men with prostate cancer

BACKGROUND

Cabazitaxel is approved for treatment of castration-resistant metastatic prostate cancer. The current dosing strategy of cabazitaxel is based on body surface area (BSA). Body surface area is known as a poor predictor for total systemic exposure to drugs, since it does not take into account variability in activity of metabolising enzymes, necessary for clearance of drugs. As exposure to cabazitaxel is related to treatment response, it is essential to develop a better individualised dosing strategy.

METHODS

Ten patients with metastatic castration-resistant prostate cancer, who received cabazitaxel dosed on BSA as a part of routine palliative care, were enrolled in this study. Midazolam was administered as phenotyping probe for cytochrome P450 isoenzyme 3A (CYP3A). The relationship between midazolam and cabazitaxel clearance was investigated using non-linear mixed effects modelling.

RESULTS

The clearance of Midazolam highly correlated with cabazitaxel clearance (R=0.74). Midazolam clearance significantly (P<0.004) explained the majority (∼60%) of the inter-individual variability in cabazitaxel clearance in the studied population.

CONCLUSIONS

Metabolic phenotyping of CYP3A using midazolam is a promising strategy to individualise cabazitaxel dosing. Before clinical application, a randomised study is warranted.

Abstract P1-10-09: Are patients with breast cancer undergoing adjuvant treatment able to follow an exercise program with a moderate to high intensity?

PURPOSE: We recently showed in a randomized trial, the Physical Activity during Cancer Treatment (PACT) study, that an 18-week exercise program reduced complaints of fatigue and improved physical fitness in newly diagnosed breast cancer patients undergoing adjuvant treatment. The beneficial effects were probably underestimated due to high levels of physical activity in the control group that received usual care only. Another possibility for dilution of the effect might be limited participation of the intervention group in the supervised exercise program or low compliance, i.e., an adjustment of the prescribed exercise protocol. We set out to study participation and compliance and to find determinants of reduced compliance.

METHODS: 102 patients in the PACT study were randomized into the intervention group that received a supervised exercise program 2 times a week for 18 weeks (36 sessions in total). Each session had a duration of 60 minutes and included a pre-specified period of aerobic interval exercises of specific intensities as well as muscle strength exercises. Sessions were supervised by physiotherapists, intensity was based on individual fitness characteristics and results were kept in a log.

We computed attendance (percentage of total sessions attended) and compliance (adherence to the prescribed duration and intensity of the aerobic part and to the muscle strength part of each attended session). We computed for each woman the percentage of sessions the women complied with the protocol, and report median percentages for compliance with the aerobic exercises, duration and intensity, and with the muscle strength exercises separately. Determinants of low compliance that were included in linear regression models were: age, behavioral, physical and psychosocial factors.

RESULTS: For 92 patients exercise logs were available. Patients were, on average, 50.2±7.8 years of age, all patients received chemotherapy and 70% received radiotherapy. Participation was high: patients participated in 83% (interquartile range 69-91%) of the sessions offered. Overall, also compliance was high: in 88% (63-97%) and 84% (65-94%) of all attended sessions patients were able to complete the aerobic (duration) and muscle strength program, respectively, as prescribed in the protocol. Compliance to the high-intensity part of the aerobic program was lower: in 50% (22-82%) of the sessions the intensity of the aerobic exercises was adjusted. Especially patients who received radiotherapy in addition to chemotherapy and patients who were more physically fatigued at baseline had a lower compliance to the high-intensity part of the aerobic exercises (β=-5.3 (confidence interval -9.4;-1.2) and β=-0.6 (-1.0;-0.1), respectively).

CONLUSIONS: Participation in and compliance to an 18-week aerobic and muscle strength exercise program was high. Thus, patients are well capable to exercise during adjuvant treatment for breast cancer. This study shows that preferably high intensity aerobic exercises were adjusted in a significant number of participants rather than the duration or the strength exercises. This has to be taken into account when developing training programs, especially in those patients who receive both, radiotherapy and chemotherapy.

Citation Format: May AM, Boer JH, Velthuis M, Steins Bisschop CN, Los M, Erdkamp F, ten Bokkel Huinink D, Bloemendal HJ, Rodenhuis C, de Roos MAJ, Verhaar M, van der Wall E, Peeters PHM. Are patients with breast cancer undergoing adjuvant treatment able to follow an exercise program with a moderate to high intensity?. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P1-10-09.

Drug composition matters: the influence of carrier concentration on the radiochemical purity, hydroxyapatite affinity and in-vivo bone accumulation of the therapeutic radiopharmaceutical 188Rhenium-HEDP

INTRODUCTION

(188)Rhenium-HEDP is an effective bone-targeting therapeutic radiopharmaceutical, for treatment of osteoblastic bone metastases. It is known that the presence of carrier (non-radioactive rhenium as ammonium perrhenate) in the reaction mixture during labeling is a prerequisite for adequate bone affinity, but little is known about the optimal carrier concentration.

METHODS

We investigated the influence of carrier concentration in the formulation on the radiochemical purity, in-vitro hydroxyapatite affinity and the in-vivo bone accumulation of (188)Rhenium-HEDP in mice.

RESULTS

The carrier concentration influenced hydroxyapatite binding in-vitro as well as bone accumulation in-vivo. Variation in hydroxyapatite binding with various carrier concentrations seemed to be mainly driven by variation in radiochemical purity. The in-vivo bone accumulation appeared to be more complex: satisfactory radiochemical purity and hydroxyapatite affinity did not necessarily predict acceptable bio-distribution of (188)Rhenium-HEDP.

CONCLUSIONS

For development of new bisphosphonate-based radiopharmaceuticals for clinical use, human administration should not be performed without previous animal bio-distribution experiments. Furthermore, our clinical formulation of (188)Rhenium-HEDP, containing 10 μmol carrier, showed excellent bone accumulation that was comparable to other bisphosphonate-based radiopharmaceuticals, with no apparent uptake in other organs.

ADVANCES IN KNOWLEDGE

Radiochemical purity and in-vitro hydroxyapatite binding are not necessarily predictive of bone accumulation of (188)Rhenium-HEDP in-vivo.

IMPLICATIONS FOR PATIENT CARE

The formulation for (188)Rhenium-HEDP as developed by us for clinical use exhibits excellent bone uptake and variation in carrier concentration during preparation of this radiopharmaceutical should be avoided.

Lapatinib: clinical benefit in patients with HER 2-positive advanced breast cancer

BACKGROUND

Lapatinib, a tyrosine kinase inhibitor of human epidermal growth factor receptor 2 (HER2), has shown activity in combination with capecitabine in patients with HER2-positive advanced breast cancer progressive on standard treatment regimens. We present results on preapproval drug access for this combination in such patients occurring in the general oncology practice in the Netherlands.

METHODS

Patients with HER2-positive advanced breast cancer progressive on schedules containing anthracyclines, taxanes, and trastuzumab were eligible. Brain metastases were allowed if stable. Lapatinib 1250 mg÷day was given continuously in combination with capecitabine 1000 mg÷m2 twice daily for two weeks in a three-week cycle. Efficacy was assessed by use of response evaluation criteria in solid tumours version 1.0. Progression-free survival (PFS) and overall survival (OS) were calculated.

RESULTS

Eighty-three patients were enrolled from January 2007 until July 2008. The combination was generally well tolerated and the most common drug-related serious adverse events were nausea and÷or vomiting (5%) and diarrhoea (2%). Seventy-eight patients were evaluable for response. Clinical benefit (response or stable disease for at least 12 weeks) was observed in 50 patients (64%) of whom 15 had a partial response and 35 stable disease. The median PFS and OS were 17 weeks (95% CI: 13 to 21) and 39 weeks (95% CI: 24 to 54), respectively. For OS, higher Eastern Cooperative Oncology Group (ECOG) status (p=0.016), brain metastases at study entry (p=0.010) and higher number of metastatic sites (p=0.012) were significantly negative predictive factors.

CONCLUSION

In a patient population with heavily pretreated HER2-positive advanced breast cancer lapatinib plus capecitabine was well tolerated and offered clinical benefit.

[Cerebral infarction and myocardial infarction due to cisplatin-containing chemotherapy]

A 33-year-old man was treated for a testicular non-seminoma carcinoma with three different chemotherapeutic agents: bleomycin, etoposide en cisplatin (BEP). During the second course of BEP he experienced two cerebral infarctions and a myocardial infarction at almost the same time. A CT-scan of the brain revealed a subcortical infarction in the left hemisphere. Angiography of the head and neck arteries revealed an almost completely thrombotic left carotid artery. ECG recordings showed signs of transmural ischaemia of the heart and an echocardiogram demonstrated irreversible myocardial damage. The time interval between the chemotherapy and the complications suggests a cisplatin-related cause (such adverse effects are unknown with bleomycin or etoposide). Cisplatin toxicity can give rise to serious vascular complications for which several factors appear to be responsible, such as an increased thrombogenicity and vascular spasm due to hypomagnesaemia.

New strategies in anti-vascular cancer therapy

Angiogenesis is a critical step in the progression of tumours from dormancy to a clinical relevant cancer. Inhibition of this process is one of the most promising new anti-cancer strategies. To develop new drugs that interfere with the cascade of events required for the formation of new blood vessels, insight into this process is essential. Here, we discuss the molecular basis of angiogenesis and the concepts of vascular targeting. Furthermore new strategies will be discussed to discover surface markers on endothelial cells that confer sufficient specificity for targeted intervention in the tumour vasculature.

Hyperamylasaemia in multiple myeloma

A 71-year-old woman, known to have multiple myeloma, was admitted because of fever, abdominal pain and hyperamylasaemia and hyperamylasuria. She was diagnosed as having acute pancreatitis. Because the diagnosis could not be confirmed, and serum lipase was normal, it appeared that this patient had developed an amylase-producing myeloma lesion in the pelvis.