The impact of the COVID-19 pandemic on oncology clinical trial recruitment in an Irish cancer center

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Background: The COVID-19 pandemic has created unprecedented disruptions to cancer clinical trial research across the world due to a temporary global suspension of patients’ recruitment to cancer clinical trials. Access to clinical trials permits better treatment options and best clinical practice standards for patients with cancer. We present the impact of the COVID-19 pandemic on cancer clinical trial activity at the Cancer Clinical Trials Unit (CCTU) at the Mid-Western Cancer Centre, University Hospital Limerick (UHL). Over the last 4 years 28 clinical trials, both interventional and translational, have opened here, across a variety of primary disease sites, with 5 trials opened in 2017, 11 in 2018, 7 in 2019 but only 2 in the first 10 months of 2020 until 3 further trials were opened in December. Methods: CCTU records were reviewed to identify the number of patients screened and consented to participate in cancer clinical trials at UHL in 2020, which were compared directly with corresponding numbers for 2019. Results: In 2019, 17 clinical trials were open and recruiting at the CCTU, UHL. During 2020, 19 trials were recruiting although during the 1st surge of the COVID-19 pandemic recruitment was essentially suspended and CCTU staff were redeployed throughout the hospital. 1st Six months 2020 vs 2019 In the six months from January 2020 until the end of June 2020, 99 patients were screened and only 15 (15.2%) signed informed consent to participate in a cancer clinical trial. When these figures are directly compared with the first six months of 2019, there is a 33% reduction in patients screened for participation (147 vs 99) and a 60% reduction in patients consented (37 vs 15) to clinical trials. 12 Months 2020 vs 2019 In total during 2019, 376 patients were screened for inclusion to participate and 49 (13%) patients signed informed consent to participate in a clinical trial within CCTU at UHL. In 2020, 914 patients were screened for participation with 51 patients consented to participate (5.6%). The majority (45/51 (88%)) of patients consented to cancer clinical trials in 2020 at the CCTU, UHL were recruited to translational based studies and only 6 (12%) consented to interventional studies compared with 2019 when 30/49 (61%) consented to translational and 30/49 (39%) to interventional studies. Conclusions: During the COVID-19 pandemic, the percentage of patients consented to participation in a clinical trial reduced significantly, as compared to the previous year (5.6% vs 13%). Fewer interventional studies have recruited patients during 2020. As we enter the third surge of COVID-19 infections in Ireland, we must continue to monitor and identify effective strategies to navigate the ever-changing situation for cancer clinical trials, in an attempt to maintain access to high quality cancer clinical trial opportunities for our patients.

Cancer antigen 125 (CA125) and the law of unintended consequences

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Background: CA125 is a serum tumour marker used to monitor patients with ovarian cancer (OvCa). Its usefulness as a screening tool remains unproven. There is no restriction in its use at our institution, a university teaching hospital. We sought to establish patterns of testing during one calendar year (2013), focussing on the economic costs of such unrestricted testing. Methods: A lookback of the CA125 reports issued by the Biochemistry Laboratory was undertaken. The CA125 requests were from physicians within the hospital & from the community. Individual requests for CA125 & those part of tumour marker panel were included & correlated with radiology & histopathology records to identify subsequent investigations (invxs) & diagnoses (dxs). Economic costings were provided by hospital finance department. For the purpose of this study we only included the costs of invxs triggered by out of range CA 125 test results. Results: In 2013, 7,132 CA125 measurements were performed. 871 repeat tests, 40 tests performed on men & 16 tests with inadequate patient identifiers were excluded. Of the remaining 6,205 patient tests; median age was 53yrs (range 13 – 96yrs); median CA125 was 5.5 IU/L (range 0.1 – 22452 IU/L). Out of range tests (>35 IU/L) led to 619 ultrasound scans, 339 CT scans. In total, 20 new cases of OvCa were dx. The crude cost per new dx was €11,459.80. Median time to diagnosis was 4 days (range -2 – 251), median CA125 at dx was 271 (range 8.1 - 9444). Median age at dx was 62 (range 40 – 87). 65% of dx were made during inpatient stays;10% by family physicians;25% by gynaecologists. There was a statistically significant difference in median CA125 in patients diagnosed with OvCa, compared to those who were not dx with a malignant condition (p<0.0001); this was not true of age at dx (p=0.27). Conclusions: This study underlines the lack of efficacy in unrestricted serum CA125 testing & that such testing creates a significant economic burden on hospitals, far in excess of the cost of the CA125 test alone. We plan to implement guidelines in our institution & will reassess this issue following an education programme with local clinicians. [Table: see text]

Mucoepidermoid carcinoma of lung masquerading as urothelial carcinoma of bladder

BACKGROUND

Mucoepidermoid carcinoma (MEC) of the lung is a rare subtype of non-small cell lung cancer. There is no consensus regarding optimal management for this disease.

CASE REPORT

We present a case of MEC of the lung in a 75 year-old female with a history of superficial urothelial carcinoma of the bladder. The patient was found to have an asymptomatic lung mass. Initial biopsy suggested metastatic recurrence of urothelial carcinoma and therefore, cisplatin and gemcitabine chemotherapy was administered prior to surgical resection. Pathological analysis of the resected specimen confirmed a diagnosis of stage IIIA MEC with focal high-grade features including transitional cell-like areas. Adjuvant radiotherapy was administered due to a positive microscopic resection margin. No chemotherapy was given due to lack of supporting data. The patient developed widespread metastatic disease 3 months following completion of radiotherapy and died 1 month later.

CONCLUSION

This case demonstrates the possibility of dual pathology in cases where metastatic disease is suspected. The use of small tissue samples may complicate diagnosis due to the heterogeneity of malignant tumours.

Early adulthood body mass index, cumulative smoking, and esophageal adenocarcinoma survival

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Background: Little is known about the individual and combined effect of early-adulthood obesity and cumulative smoking on the survival of esophageal adenocarcinoma (EAC) patients. Methods: We analyzed two independent cohorts of EAC patients: 235 patients from Toronto, Canada (TO, 2006-2011) and 329 patients from Boston, USA (BO,1999-2004). Associations between early adulthood body mass index (EA-BMI) and smoking with overall survival (OS) were assessed using Cox proportional hazard models, adjusted for stage, treatment, and other relevant covariates. Results: Median age (range) for TO dataset was 64(29-88)yrs; for BO dataset, 64(21-91)yrs. Males comprised 86% of TO and 89% of BO datasets. 90% of TO and 98% of BO patients were Caucasians. The Median (range) for packyears was 34 (0.2-118; TO) and 34 (0.2-212; BO). The Median (range) for EA-BMI was 24(15-44; TO) and 24(15-47; BO). Median BMI 1 yr prior to diagnosis was 25(16-43; TO) and 25(20-49; BO). 92% of TO and 88% of BO patients had ECOG 0 or 1. Disease stage distribution (early/locally-advanced/metastatic) was 11%/64%/25% (TO) and 30%/52%/18% (BO). For TO, the aHR for smoking was 1.03 (95%CI: 1.02-1.04; p=8E-08) per packyear, while for BO, smoking also independently conferred worse OS, with aHR of 1.007 (95%CI: 1.002-1.01; p=0.003) for each packyear increase. The aHRs for being underweight (EA-BMI<18.5), overweight (EA-BMI 25-30), and obese (EA-BMI>30) in early adulthood were 2.19 (95%CI: 1.0-4.6), 1.89 (95%CI:1.2-3.0), and 2.49 (95%CI:1.5-4.2), respectively for the TO dataset (global p=0.003 for EA-BMI). In BO, the corresponding values were 1.30 (95%CI: 0.8-2.2), 1.45 (95%CI: 1.0-2.5), and 2.39 (95%CI:1.5-3.8), respectively (global p=0.002). In contrast, BMI at one year prior to diagnosis had no association with OS in either study. Conclusions: Elevated BMI in early adulthood and heavy cumulative smoking history are independently associated with increased mortality risk in two North American EAC populations. These survival differences may reflect comorbidity differences, biological differences or both, and offer insight into how key modifiable behaviors in prevention can also affect cancer prognoses. AS, LC, DCC and GL contributed equally.

The impact of body mass index on survival in stage 3 and 4 lung cancer

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Background: Obesity is an adverse prognostic factor in several cancers, including colorectal, breast, endometrial and prostate. Studies on body mass index (BMI) and lung cancer outcomes are lacking. Understanding the clinical impact of body weight is important given the high prevalence of obesity globally. We retrospectively evaluated the BMI at diagnosis and its effects on survival in stage 3/4 lung cancer patients. Methods: 1,121 patients with stage 3/4 lung cancer were analyzed. Clinicopathologic data were collected retrospectively. Adjusted hazard ratios (aHR) for overall survival (OS) were generated by Cox regression for each BMI (kg/m2) category (underweight: <18.5, normal: 18.5-24.9, overweight: 25.0-29.9, obese: ≥30), after adjusting for age, gender, Charlson Comorbidity Index, performance status (PS), clinical stage and treatment regimen. Results: In this cohort (n=1,121), the frequencies of stage 3A, 3B and 4 lung cancers were 35%, 32% and 33%, respectively. There were 633 (57%) adenocarcinomas, 238 (21%) squamous cell carcinomas, 38 (3%) small cell lung cancers, and 210 (19%) other histologies. Patients had variable BMI: 82 (7%) underweight, 550 (49%) normal weight, 333 (30%) overweight, 156 (14%) obese. Being overweight/obese was associated with older age (p=0.002) and stage 3A disease (p=0.001); underweight patients were more likely current smokers (p<0.001). OS was significantly decreased with age ≥65, males, PS 2-3, stage 4, and lack of systemic therapy (p<0.001). Median OS in underweight, normal weight, overweight and obese patients were 14, 23, 24 and 26 months, respectively. Compared with BMI≥18.5, being underweight was associated with poorer OS (aHR 1.33, 95% CI 1.01-1.77, p=0.045), but not progression-free survival (aHR 1.12, 95% CI 0.86-1.46, p=0.414). The magnitude of this association was greatest in those aged <65 (aHR 1.57, 95% CI 1.11-2.22, p=0.011). Conclusions: Underweight patients with stage 3/4 lung cancer, especially if aged <65, have significantly poorer OS. Lower BMI was mostly observed in current smokers, while above normal BMI was seen in stage 3A. Unlike other cancers, obesity does not increase mortality in this population. The inverse BMI-survival relationship in lung cancer requires further study.

Illness intrusiveness and subjective well-being in patients with glioblastoma multiforme

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Background: Glioblastoma multiforme (GBM) is the most common adult CNS malignancy. The quality-of-life (QOL) impact of its neurological sequelae and poor prognosis is poorly understood. In this study we examined relations between disease severity and mood in GBM patients. Methods: GBM patients (n=73) completed validated questionnaires examining depression (CESD), positive affect (ABS), illness intrusiveness (II), and health-related QOL (EORTC-QLQ30, BN-20). Median age was 53 years (range 26-75), median time since diagnosis was 1.1 years (range 0.1-12.4). 88% were on temozolomide. Questionnaire scores were compared to normative data from GI, GU, Breast, Head and Neck, Lymphoma, and Lung cancer groups using t-tests. Hierarchical multiple regression analyses tested the impact of disease severity indicators (ECOG; Symptoms, derived from QLQ30, BN20) and potential moderators on mood and whether II mediates those effects. Results: GBM patients reported less positive affect, more depression and greater II than other cancer patients (p<.05). Increase in symptoms correlated with greater II (β=.59; 95% CI [.31, .87], p<.0001) and depression (β=.37; 95% CI [.20, .55], p<.0001) and less positive affect (β=-.04; 95% CI [-.08, -.01], p=.02). Surprisingly, higher ECOG (i.e., poorer performance status) was associated with less II (β=-3.58; 95%CI [-7.06, -.10], p=.04) and depression (β=-2.20; 95%CI [-4.21, -.19], p=.03). II partially mediated the relations between disease severity and mood, evidenced by the change in the disease severity coefficient when II was added to the models (mean change measured by bootstrap sampling: CESD=.23, 95% CI [.06, .43]; ABS=.21, 95%CI [.02, .44]). The occurrence of other stressful life events was associated with II (β=2.73; 95% CI [.43, 5.02], p=.02), but there was no evidence of a moderating effect on this or any other relationship (p>.05). Conclusions: GBM patients are more distressed than other cancer patients. GBM-induced lifestyle disruptions partially mediate the association between disease severity and subjective well-being. Efforts to engage patients in valued activities and interests, despite the constraints, can help to preserve QOL.

How affordable are targeted therapies in non-small cell lung cancer?

As the treatment of non-small cell lung cancer (NSCLC) evolves to include more targeted therapies, costs of treatment have increased significantly. Advances in NSCLC treatment include longer survival duration, and in some cases, better progression-free survival and quality of life, and the potential for decreased toxicity. Through pharmacoeconomic analyses, payors seek to value the improvements in outcomes from novel therapies, and relate these improvements to their costs. In NSCLC, three categories of novel agents have been introduced into clinical practice: (1) agents targeting the epidermal growth factor receptor (EGFR); (2) agents targeting the vascular endothelial growth factor (VEGF) and (3) novel chemotherapy agents, specifically pemetrexed. Here we review published economic analyses for these agents in lung cancer, and their potential impact on treatment decisions.

Maintenance therapy in advanced non-small cell lung cancer: evolution, tolerability and outcomes

Non-small cell lung cancer (NSCLC) is the leading cause of cancer death in the industrialized world. Despite significant progress in early stage disease, survival rates for advanced disease remain low. Maintenance therapy is a treatment strategy that has been investigated extensively in NSCLC and has been the subject of considerable recent debate. Options for maintenance include continuing the initial combination chemotherapy regimen, continuing only single agent chemotherapy ('continuation maintenance') or introducing a new agent ('switch' maintenance therapy). Therapies that have been studied in this setting in randomized trials to date include chemotherapy, molecularly targeted agents and immunotherapy approaches. Following the development of multiple new agents that show activity in NSCLC, and have a tolerable side-effect profile, there has been increasing interest in utilizing them to maintain response to initial therapy after treatment with platinum-based doublets. Despite considerable controversy, it has become an acceptable treatment paradigm. Here, we briefly outline the evolution of this treatment paradigm and examine which subgroups of patients are most likely to benefit.

Molecular predictive and prognostic markers in non-small-cell lung cancer

Non-small-cell lung cancer (NSCLC) remains the leading cause of cancer death in the developed world. Platinum-based chemotherapy is the therapeutic foundation of treatment both in the metastatic and adjuvant setting and targeted therapies are entering standard treatment paradigms. However, many patients do not obtain benefit from cytotoxic agents or newer targeted therapies, but are still exposed to their toxic effects. Reliable biomarkers to select treatments for patients most likely to obtain benefit have, therefore, been an important focus for many research groups. In this paper, we review current predictive and prognostic biomarkers in NSCLC. We assess their potential clinical use and explore recent data pertaining to genome-wide approaches for treatment selection in NSCLC.

Molecular predictive and prognostic markers in non-small-cell lung cancer

Non-small-cell lung cancer (NSCLC) remains the leading cause of cancer death in the developed world. Platinum-based chemotherapy is the therapeutic foundation of treatment both in the metastatic and adjuvant setting and targeted therapies are entering standard treatment paradigms. However, many patients do not obtain benefit from cytotoxic agents or newer targeted therapies, but are still exposed to their toxic effects. Reliable biomarkers to select treatments for patients most likely to obtain benefit have, therefore, been an important focus for many research groups. In this paper, we review current predictive and prognostic biomarkers in NSCLC. We assess their potential clinical use and explore recent data pertaining to genome-wide approaches for treatment selection in NSCLC.

Molecular predictive and prognostic markers in non-small-cell lung cancer

Non-small-cell lung cancer (NSCLC) remains the leading cause of cancer death in the developed world. Platinum-based chemotherapy is the therapeutic foundation of treatment both in the metastatic and adjuvant setting and targeted therapies are entering standard treatment paradigms. However, many patients do not obtain benefit from cytotoxic agents or newer targeted therapies, but are still exposed to their toxic effects. Reliable biomarkers to select treatments for patients most likely to obtain benefit have, therefore, been an important focus for many research groups. In this paper, we review current predictive and prognostic biomarkers in NSCLC. We assess their potential clinical use and explore recent data pertaining to genome-wide approaches for treatment selection in NSCLC.

A Comparison of Whole-Body MRI and CT for the Staging of Lymphoma

OBJECTIVE

Our objective was to compare whole-body MRI and CT for the staging of lymphoma.

CONCLUSION

Whole-body MRI represents an alternative to CT in the staging of lymphoma, with an ability to stage disease, identify lymph nodes greater than 1.2 cm, and the additional ability to evaluate for the presence or absence of disease spread to bone marrow. CT allows detection of more nodes (< 1.2 cm) than MRI but this does not alter tumor stage.