Biosimilar Use Among 38 ASCO PracticeNET Practices, 2019-2021

PURPOSE

Biosimilars offer increased patient choice and potential cost-savings, compared with originator biologics. We studied 3 years of prescribed biologics among US physician practices to determine the relationship of practice type and payment source to oncology biosimilar use.

METHODS

We acquired biologic utilization data from 38 practices participating in PracticeNET. We focused on six biologics (bevacizumab, epoetin alfa, filgrastim, pegfilgrastim, rituximab, and trastuzumab) for the period from 2019 to 2021. We complemented our quantitative analysis with a survey of PracticeNET participants (prescribers and practice leaders) to reveal potential motivators and barriers to biosimilar use. We implemented logistic regression to evaluate the biosimilar use for each biologic, with covariates including time, practice type, and payment source, and accounted for clusters of practices.

RESULTS

Use of biosimilars increased over the 3-year period, reaching between 51% and 80% of administered doses by the fourth quarter of 2021, depending on the biologic. Biosimilar use varied by practice, with independent physician practices having higher use of biosimilars for epoetin alfa, filgrastim, rituximab, and trastuzumab. Compared with commercial health plans, Medicaid plans had lower biosimilar use for four biologics; traditional Medicare had lower use for five biologics. The average cost per dose decreased between 24% and 41%, dependent on the biologic.

CONCLUSION

Biosimilars have, through increased use, lowered the average cost per dose of the studied biologics. Biosimilar use differed by originator biologic, practice type, and payment source. There remains further opportunity for increases in biosimilar use among certain practices and payers.

Outcomes of a quality improvement project integrating an EHR (electronic health record) for improved adverse drug reaction (ADR) communication at an adult outpatient cancer infusion center

372

Background: An adult oncology practice achieved 41% compliance with communication of ADRs involving infusion drugs to ordering provider during the year 2020. We aim at achieving communication of ADRs to ordering provider with a goal compliance rate of 75% over a period of 8 months. Methods: We assembled an interdisciplinary team comprising of medical oncologists, fellows, clinical nurse managers, infusion & clinic nurses, information technology (IT))providers and a clinical pharmacist. We reviewed ADRs occurring between April-December of 2021 in adult patients receiving outpatient infusion therapy at our institution. We created a current-state process map of ADRs in our infusion center. We identified issues that needed to be addressed including no clear standard for documenting or reporting an infusion reaction, no standard process was in place for proper notification to all parties involved nor was there a consistent location in the EHR regarding the description of events that took place. Acknowledgment by ordering provider to an ADR was used as a primary outcome measure. The RL6 (internal tracking system) patient safety events reported was used as a process measure. PDSA cycle 1 January 2021:We implemented a new flowsheet section in the EHR titled “Adverse Drug Reaction”. We created a smart phrase for clarification of documentation, when used will pull information from the flowsheet section into the note. Education was provided to nursing on this new standardized process. Clinicians were educated where to find this information as a standardized location within the EHR. The ordering provider was notified when an ADR occurred by having the infusion nurse document a clinical support note that is routed to the provider’s EHR in-basket. PDSA cycle 2 June 2021: Once nursing documented an ADR, an automated message was sent to all the care-team members via the ADR event folder within the EHR in-basket. The nursing staff then would add the ADR orders group to the treatment plan for clinician review. An alert was generated which prompted the clinician to acknowledge the ADR within the Beacon plan thereby alerting the nursing team if any changes were made. Results: In 2021 there were 73 ADR events that have occurred in Infusion Services. Our interventions were associated with an 80% improvement in communication of ADRs to ordering providers and 35% increase in reporting ADR within our internal tracking system. Conclusions: Developing a standardized ADR process enhanced communication of ADRs to the ordering providers as our intervention was associated with an 80% improvement in communication of ADRs over a 8-month period. Involving all major stakeholders, especially the staff working in information technology services, resulted in exponential results demonstrating the potential future solutions within the EHR.

Randomized phase III Trial of MEDI4736 (durvalumab) as concurrent and consolidative therapy or consolidative therapy alone for unresectable stage 3 NSCLC: A trial of the ECOG-ACRIN Cancer Research Group (EA5181)

TPS8584

Background: Platinum-based concurrent chemoradiation(CRT) followed by one year of the human immunoglobulin G1 kappa (IgG1κ) monoclonal antibody, durvalumab, which blocks the interaction of PD-L1 with its receptors PD-1 and CD80, is the standard of care for locally advanced, unresectable non-small cell lung cancer (NSCLC). Early studies have noted the feasibility of concomitant administration of radiotherapy and immune checkpoint inhibition in NSCLC. EA5181 will evaluate the use of concomitant durvalumab with chemo-radiotherapy for locally advanced NSCLC. Methods: EA5181 is a randomized, multi-center, phase III study for patients with unresectable Stage III NSCLC comparing the efficacy of CRT with concomitant durvalumab to CRT, followed by one year of durvalumab. Eligibility criteria include: an ECOG PS of 0-1, adequate pulmonary function (FEV1 and DLCO both > 40%), no history of auto-immune disease and no past chemotherapy or RT for this lung cancer. Stratification factors include age, sex, stage, and planned concurrent chemotherapy type. Eligible patients with be randomized 1:1 to receive 60Gy RT (2Gy fractions) CRT and durvalumab (Arm A) or 60Gy CRT (Arm B). Investigators will be allowed to choose from three different chemotherapy options: cisplatin/etoposide q 28 days, Pemetrexed/cisplatin q 21 days, and weekly paclitaxel/Carboplatin. Arm A will use 750mg fixed of durvalumab (considered equivalent to 10mg/kg) on days 1, 11, and 21 of RT. Assuming no disease progression, patients in both arms will be followed by monthly (q28 days) fixed dose of 1500mg durvalumab for one year which will be given optimally within 14 days of radiation or when (non)hematologic toxicity is < Grade 2. The primary endpoint is overall survival. Secondary endpoints include progression-free survival, incidence of local/distant progression and toxicity. The target sample size is 660 patients, anticipated to recruit over 55 months, with follow up for an additional 42 months. This provides approximately 82% power if the true hazard ratio for overall survival was 0.75 or less, with 2-sided alpha of 0.05, and assuming a median survival of 42.5 months in the control arm. The study was activated on 04/09/20 and has currently accrued 90 patients on 02/03/21. Clinical trial information: NCT04092283.

American Society of Clinical Oncology Road to Recovery Report: Learning From the COVID-19 Experience to Improve Clinical Research and Cancer Care

This report presents the American Society of Clinical Oncology's (ASCO's) evaluation of the adaptations in care delivery, research operations, and regulatory oversight made in response to the coronavirus pandemic and presents recommendations for moving forward as the pandemic recedes. ASCO organized its recommendations for clinical research around five goals to ensure lessons learned from the COVID-19 experience are used to craft a more equitable, accessible, and efficient clinical research system that protects patient safety, ensures scientific integrity, and maintains data quality. The specific goals are: (1) ensure that clinical research is accessible, affordable, and equitable; (2) design more pragmatic and efficient clinical trials; (3) minimize administrative and regulatory burdens on research sites; (4) recruit, retain, and support a well-trained clinical research workforce; and (5) promote appropriate oversight and review of clinical trial conduct and results. Similarly, ASCO also organized its recommendations regarding cancer care delivery around five goals: (1) promote and protect equitable access to high-quality cancer care; (2) support safe delivery of high-quality cancer care; (3) advance policies to ensure oncology providers have sufficient resources to provide high-quality patient care; (4) recognize and address threats to clinician, provider, and patient well-being; and (5) improve patient access to high-quality cancer care via telemedicine. ASCO will work at all levels to advance the recommendations made in this report.

Patient and provider perceptions about exercise in cancer care, excluding breast: Are we on the same page?

238

Background: Cancer organizations recommend physical activity as part of therapy to aid in symptom management, reduce recurrence and improve overall quality of life. What the optimal exercise program should look like and what stakeholder barriers exist are unclear. Methods: We convened three focus groups, one with metastatic patients, one with non-metastatic patients, one with the providers in the Cancer Center and conducted individual interviews at Gundersen Health System in La Crosse, Wisconsin. The constant comparative method was used to identify themes about exercise as part of cancer treatment. Results: No statistical differences in demographic characteristics exist between metastatic (N = 9) and non-metastatic (N = 11) patients. Impacts of exercise on cancer, who should instruct patients about exercise and how/where the exercise should take place emerged as the main themes. Discordance between patients and providers (N = 10) was identified in these areas. Patients felt that exercise during treatment provided intrinsic value (“Exercise mentally is important”) whereas providers connect exercise to positive disease outcome (“There are decreased recurrence rates for multiple different malignancies that have been proven in large studies”). Patients resoundingly expressed a desire to receive instructions for exercise from their oncologist (“I rely a lot on my oncologist...they are tuned into you”). Providers expressed a desire for a referral process to a cancer trained physical therapist or trainer who would guide patients through an exercise program (“to have assistance from someone who is trained… would be really beneficial”). Conclusions: Providers recognize the importance of exercise as part of a cancer treatment plan, yet they agree that time constraints associated with a busy practice impacts the priority of exercise instructions. Bridging the gap we identified between patient and providers’ perceptions has potential for cancer care across the nation. We plan to further study the discord after designing standard exercise recommendations at varied levels of intensity through collaboration with oncology providers, physical therapy and Livestrong personnel utilizing venues in our region.

Vorinostat and bortezomib as third-line therapy in patients with advanced non-small cell lung cancer: a Wisconsin Oncology Network Phase II study

INTRODUCTION

The primary objective of this phase II trial was to evaluate the efficacy and tolerability of vorinostat and bortezomib as third-line therapy in advanced non-small cell lung cancer (NSCLC) patients.

METHODS

Eligibility criteria included recurrent/metastatic NSCLC, having received 2 prior systemic regimens, and performance status 0-2. Patients took vorinostat 400 mg PO daily days 1-14 and bortezomib 1.3 mg/m2 IV day 1, 4, 8 and 11 in a 21-day cycle. Primary endpoint was 3-month progression free survival (3m-PFS), with a goal of at least 40 % of patients being free of progression at that time point. This study followed a two-stage minimax design.

RESULTS

Eighteen patients were enrolled in the first stage. All patients had two prior lines of treatment. Patients received a median of two treatment cycles (range: 1-6) on study. There were no anti-tumor responses; stable disease was observed in 5 patients (27.8 %). Median PFS was 1.5 months, 3m-PFS rate 11.1 %, and median overall survival 4.7 months. The most common grade 3/4 toxicities were thrombocytopenia and fatigue. Two patients who had baseline taxane-related grade 1 peripheral neuropathy developed grade 3 neuropathy. The study was closed at its first interim analysis for lack of efficacy.

CONCLUSIONS

Bortezomib and vorinostat displayed minimal anti-tumor activity as third-line therapy in NSCLC. We do not recommend this regimen for further investigation in unselected patients.

Preclinical and clinical impact of the GLI2 transcription factor in non-small cell lung cancer (NSCLC)

e18537

Background: Components of the Hedgehog (Hh) signaling pathway are over-expressed in NSCLC. Hh signaling contributes to tumorigenesis in lung cancer and is under investigation as a therapeutic target. We assessed in vitro characteristics of the GLI2 transcription factor, a primary mediator of Hh signaling, in NSCLC tumorigenesis, and its prognostic impact in early stage NSCLC. Methods: Colony formation, growth in soft agar, and measurement of GLI2 RNA were assayed in A549 NSCLC cells. Changes in tumor growth and proliferation were evaluated using a two-sample t-test. The automated quantitative analysis system (AQUA) was used to assess protein expression of GLI2 in NSCLC specimens from 88 deceased patients (pts) with resected stages I and II NSCLC. Pts did not receive additional pre- or post-operative anti-cancer therapies. Pt age, sex, smoking history, histology, TNM stage, and type of resection were also collected. Progression-free survival (PFS) and overall survival (OS) were estimated per Kaplan-Meier; multivariate Cox proportional hazard analyses were used to determine if the GLI2 AQUA score was an independent prognostic factor. Results: GLI2 knockdown in A549 NSCLC cells using GLI2 shRNA resulted in inhibition of colony formation and in the anchorage-independent growth, compared to A549 cells with intact GLI2 function. Characteristics of our population included median age 73 (43-96), males 62.5%, smokers 96%, adenocarcinoma 46.6%, squamous cell histology 40.9%, and stage I 62.5%. GLI2 AQUA score was not associated with any clinical variable per Wilcoxon analyses. High GLI2 AQUA score was associated with shorter PFS (median PFS 8.6 mo [95% CI 7.0-10.7 mo]) compared to low GLI2 AQUA score (median PFS 17.2 mo [95% CI 15.8-22.6 mo], p=0.001), and with shorter OS (median OS 14.8 mo [95% CI 10.5-23.0 mo]), compared to low GLI2 score (median 25.9 mo [95% CI 20.2-35.7 mo], p<0.001), independent of clinical variables. Conclusions: The GLI2 transcription factor of Hh signaling impacts in vitro models of NSCLC tumorigenicity and is an independent negative prognostic factor in early stage disease. Hh signaling remains a worthwhile investigational therapeutic target in NSCLC.

Nuclear EGFR protein expression predicts poor survival in early stage non-small cell lung cancer

INTRODUCTION

Nuclear EGFR (nEGFR) has been identified in various human tumor tissues, including cancers of the breast, ovary, oropharynx, and esophagus, and has predicted poor patient outcomes. We sought to determine if protein expression of nEGFR is prognostic in early stage non-small cell lung cancer (NSCLC).

METHODS

Resected stages I and II NSCLC specimens were evaluated for nEGFR protein expression using immunohistochemistry (IHC). Cases with at least one replicate core containing ≥5% of tumor cells demonstrating strong dot-like nucleolar EGFR expression were scored as nEGFR positive.

RESULTS

Twenty-three (26.1% of the population) of 88 resected specimens stained positively for nEGFR. Nuclear EGFR protein expression was associated with higher disease stage (45.5% of stage II vs. 14.5% of stage I; p = 0.023), histology (41.7% in squamous cell carcinoma vs. 17.1% in adenocarcinoma; p = 0.028), shorter progression-free survival (PFS) (median PFS 8.7 months [95% CI 5.1-10.7 mo] for nEGFR positive vs. 14.5 months [95% CI 9.5-17.4 mo] for nEGFR negative; hazard ratio (HR) of 1.89 [95% CI 1.15-3.10]; p = 0.011), and shorter overall survival (OS) (median OS 14.1 months [95% CI 10.3-22.7 mo] for nEGFR positive vs. 23.4 months [95% CI 20.1-29.4 mo] for nEGFR negative; HR of 1.83 [95% CI 1.12-2.99]; p = 0.014).

CONCLUSIONS

Expression of nEGFR protein was associated with higher stage and squamous cell histology, and predicted shorter PFS and OS, in this patient cohort. Nuclear EGFR serves as a useful independent prognostic variable and as a potential therapeutic target in NSCLC.

Phase I/II study of gemcitabine and exisulind as second-line therapy in patients with advanced non-small cell lung cancer

BACKGROUND

The study was designed to evaluate the safety and efficacy of exisulind, a selective apoptotic antineoplastic drug, in combination with gemcitabine as second-line therapy in patients with progressing advanced non-small cell lung cancer.

METHODS

Patients whose disease progressed more than 3 months from completion of first-line chemotherapy were eligible for this phase I/II trial. Primary end points were maximally tolerated dose and time to progression. Patients in the phase I portion of the study were treated with gemcitabine (1250 mg/m) in combination with three escalated dose levels of exisulind. Treatment involved six cycles of gemcitabine and exisulind followed by exisulind maintenance. The study was subsequently expanded to phase II.

RESULTS

Thirty-nine patients (15 in phase I and 24 in phase II) were treated. The regimen was well tolerated with grade 3 fatigue and grade 3 constipation being dose-limiting toxicities. The maximally tolerated dose was not reached. Dose level 3 of exisulind (250 mg twice daily) in combination with gemcitabine was used for phase II. The overall response rates were 7% (phase I), 17% (phase II), and 13% (all). Median time to progression and median and 1-year survival, respectively, were 3.7 and 9.7 months and 33% (phase I); 4.3 and 9.4 months and 41% (phase II); and 4.1 and 9.4 months and 39% (all).

CONCLUSION

Although the study met its primary end point of improving time to progression (more than 4.1 months in phase II), we did not observe a clear survival advantage and thus do not plan to further investigate this schedule of gemcitabine and exisulind.

Allogeneic T-cell clones able to selectively destroy Philadelphia chromosome-bearing (Ph1+) human leukemia lines can also recognize Ph1- cells from the same patient

Immunocompetent cells in bone marrow allografts have been associated with a graft-versus-leukemia (GVL) effect. To further characterize effector mechanisms that may be involved in this GVL phenomenon, we have previously established an in vitro model to identify allogeneic T-cell clones that selectively mediate cytotoxicity against a patient's leukemic cells, but not against nonleukemic lymphocytes from the same patient. We have modified this in vitro model to test whether the Ph1 chromosome and the P210 fusion protein it controls have a detectable role in leukemia-specific recognition by allogeneic T-cell clones. In this report, T-cell lines reactive with allogeneic Ph1 chromosome-bearing (Ph1+) chronic myeloid leukemia (CML) cell lines were derived and selected to be minimally reactive with Ph1 negative (Ph1-) lymphoid lines from the same patient. However, after prolonged culture, these same T-cell lines also mediated significant destruction of the Ph1- target cells from the same patients. These T-cell lines specifically recognized cells from the allogeneic CML patient to which they were sensitized, and were not contaminated by an outgrowth of natural killer cells. Furthermore, subclones could be derived from these T-cell lines, and some of these subclones again showed selective killing of the allogeneic Ph1+ leukemia cell lines, and not of the Ph1- cell line from the same patient. Analyses of T-cell receptor (TCR) genes showed the alloreactive T-cell lines and the Ph1+ selective subclones derived from them to be of the same clonal origin. This suggests that the same T cells reacting with antigens expressed on the nonleukemic Ph1- targets can at times selectively and preferentially kill the allogeneic Ph1+ cells. As the same TCR that recognizes Ph1+ cells also can recognize the Ph1- targets, it appears that the Ph1+ chromosome does not play a detectable role in recognition by these allogeneic T-cell clones. This in vitro observation may provide a model for evaluating the relationship between GVL and graft-versus-host disease effects.

Limiting dilution analysis of lymphokine-activated killer cell precursor frequencies in peripheral blood lymphocytes of cancer patients receiving interleukin-2 therapy

Eleven patients receiving weekly cycles of therapy with recombinant interleukin-2 (IL-2) were evaluated with a sensitive limiting dilution analysis to determine lymphokine-activated killer (LAK) cell precursor frequencies in peripheral blood lymphocytes. An increase in LAK precursor frequency above baseline was suggested by day 6 of this protocol and was clearly significant by day 20, indicating an expansion of the circulating precursor pool results from in vivo IL-2 administration. Correlations were not significant between LAK precursor frequency during IL-2 therapy and the total number of circulating lymphocytes, the percentage of CD56+ lymphocytes, IL-2 proliferative responses, or LAK activity of peripheral blood lymphocytes, indicating that the precursor frequency identification based on functional testing of individual cells is not accurately reflected by these analyses of heterogeneous bulk populations. Selective cell depletion analyses revealed that the majority of LAK precursors after in vivo IL-2 therapy were cells with the natural killer phenotype. Analysis of LAK precursors may help define the in vivo IL-2 administration, alone or in combination with other hematopoietic or immunodifferentiative cytokines, necessary to further augment in vivo effector cell numbers and activity for patients with cancer.

Specific recognition of human leukemic cells by allogeneic T cells: II. Evidence for HLA-D restricted determinants on leukemic cells that are crossreactive with determinants present on unrelated nonleukemic cells

Transplantation of immunocompetent cells present within allogeneic bone marrow has been associated with the elimination of residual host leukemia, both in animal tumor models and in patients receiving marrow transplants for leukemia. This observation has been called the "graft-versus-leukemia effect." We have attempted to study this phenomenon in vitro by characterizing the cytolytic response of T cells from normal donors after in vitro activation with allogeneic leukemic cells. As expected, most T cells that react against an allogeneic patient's leukemic cells recognize their foreign HLA antigens and lyse the patient's nonleukemic remission lymphoid cells. In addition, we have shown that a small fraction of the T cells recognize and lyse foreign leukemic targets without lysis of nonmalignant remission targets from the same leukemic patient. These T cells have been isolated and characterized as CD3+, CD4+ cells expressing the alpha/beta T cell receptor (TCR). Their lysis appears to reflect specific antigen recognition mediated via the CD3-TCR complex and interactions involving the CD4 receptor. Some of these "leukemic specific" T cell lines, which are restricted by HLA class II molecules, can also lyse occasional nonleukemic cells from certain unrelated donors. This recognition appears to involve crossreactive determinants shared by the leukemic cells and the unrelated allogeneic nonleukemic cells. These specific interactions may represent an in vitro model of the graft-versus-leukemia effect.

Specific recognition of human leukemic cells by allogeneic T cell lines

Clinical and experimental data suggest a role for the immune response in preventing leukemic relapses following allogeneic bone marrow transplantation the graft-versus-leukemia (GVL) effect. In the context of an allogeneic BMT, a number of different immune mechanisms mediated by donor cells may be responsible for the GVL effect. We have approached this question by using limiting dilution cultures of alloactivated human lymphocytes to analyze the in vitro allogeneic cytolytic response against fresh allogeneic leukemia. Initial results in the limiting dilution assays with split culture analyses demonstrated frequent alloreactive cytolytic T lymphocyte precursors that destroyed remission peripheral blood lymphocytes and leukemic cells from the allogeneic leukemic patient. These assays also demonstrated frequent lymphokine-activated killer (LAK) cell precursors that lysed both the LAK sensitive Daudi line and the allogeneic leukemia. In these experiments, isolated cultures also showed cytolytic activity directed against the allogeneic leukemic blasts without activity against remission PBL, or the LAK-sensitive Daudi cell line. Two T cell lines (ABL1 and ABL2) isolated from an LDA, demonstrated this form of specificity, mediating destruction specifically against the allogeneic acute lymphoblastic leukemic cells. Both cell lines ABL1 and ABL2 were CD3+, TCR alpha beta +, and CD4+. These 2 cell lines mediated little or no cytotoxicity against a large panel of other targets tested (natural killer sensitive and resistant cell lines, allogeneic PBL, and allogeneic fresh leukemic blasts). Antibody-blocking experiments revealed a role for the CD3-TCR receptor of both cell lines in lysis of leukemic cells; the CD4 and MHC class II molecules were clearly involved in the lysis by the ABL1 cell line. Specificity of recognition for the allogeneic leukemic blasts was further confirmed by unlabeled target competitive inhibition studies. The mechanism of the preferential lysis of leukemia by the alloactivated T cell lines described in this paper remains uncertain. Nevertheless, these leukemic-specific populations provide a means by which the human GVL effect may be further studied in vitro.