POS0140 PREDICTING OUTCOMES IN SYSTEMIC SCLEROSIS: STRATIFICATION BY AUTO-ANTIBODIES OUTPERFORMS CUTANEOUS SUBSETTING IN THE EUSTAR COHORT

Background

Risk-stratification is key in a heterogeneous disease like systemic sclerosis (SSc). Until now, SSc patients are stratified according to the extent of skin involvement into limited cutaneous, diffuse cutaneous and sine scleroderma subtypes. However, this classification remains inaccurate to capture disease heterogeneity. Autoantibodies are found in more than 90% of the patients and can be detected before onset of the disease. Among them, three predominant and specific antibodies are used: anti-centromere, anti-Scl70 and RNA polymerase III antibodies.

Objectives

To compare the performances of stratification into LeRoy’s cutaneous subtypes versus autoantibody status in SSc versus combination of cutaneous subtypes and autoantibodies status.

Methods

Patients from the EUSTAR database were classified either as (i) limited cutaneous, diffuse cutaneous or sine scleroderma (based on the recording made by the treating physician) or (ii) according to autoantibodies with the following subclassifications: (1) no specific autoantibodies, (2) isolated ANA, (3) anti-centromere antibodies, (4) anti-Scl70 antibodies and (5) anti-RNA polymerase III antibodies or (iii) according to combination of cutaneous subset and auto-antibodies. The respective performance of each model to predict overall survival (OS), progression-free survival (PFS), disease progression and different organ involvements was assessed and the three models were compared by the area under the receiver operating characteristic curve (AUC 95%CI) and the net reclassification improvement (NRI). Missing data were imputed through multiple imputation using chain equations.

Results

In all, 10’711 patients were included: 84.6% females, mean age: 54.4±13.8 years, mean disease duration: 7.9±8.2 years. In the prospective analysis (n= 6’467 to 7’829 according to the outcome), after a mean follow-up of 56 months and a mean of three visits per patient, we did not identify any difference in AUC between the cutaneous-based model and the antibody-based model for prediction of OS and disease progression. However, the NRI showed a significant improvement in prediction of OS (0.57 [0.46-0.71] vs. 0.29 [0.19-0.39]) and disease progression (0.36 [0.29-0.46] vs. 0.21 [0.14-0.28]) at 4 years using the antibody-based model. Regarding prediction of each organ involvement in longitudinal analyses, the antibody-based model showed better performance than the cutaneous-one for renal crisis (AUC: 0.719 [0.696-0.742] vs. 0.664 [0.643-0.685]), with the highest association observed with anti-RNA polymerase III (OR: 7.47 [1.63-34.24], p= 0.010). Similarly, the antibody-based model was better than the cutaneous model in predicting lung fibrosis (AUC 0.719 [0.715-724] vs. 0.653 [0.647-0.659]) and restrictive lung fibrosis (AUC 0.759 [0.749-0.766] vs. 0.711 [0.701-0.721]) which were both associated with anti-Scl70 antibodies (OR: 9.29 [8.17-10.55] and 7.92 [5.37-11.69], respectively, p<0.0001 for both). Although there was no difference in the AUC to predict digital ulcers, NRI showed an improvement using the antibody-based model (0.31 [0.29-0.33] vs. 0.24 [0.22-0.26]) with the highest association with anti-Scl70 antibodies (OR: 3.57 [2.68-4.75], p<0.0001). The two models had similar performances in assessing occurrence of intestinal involvement, heart dysfunction or elevated sPAP. Combining both antibody status and cutaneous subtype did not improve the performance of our models. In the exploratory analysis, there was no change using modified Rodnan skin score to define cutaneous form.

Conclusion

Auto-antibody status outperforms the common cutaneous subsetting to risk-stratify SSc patients in the EUSTAR cohort. This easily performed subclassification using autoantibodies specific status can be used by the clinicians to risk-stratify their patients and to adapt disease monitoring in routine practice.

Disclosure of Interests

Muriel Elhai Speakers bureau: BMS outside of the submitted work, Marouane Boubaya: None declared, Nanthara Sritharan: None declared, Alexandra Balbir-Gurman: None declared, Elise Siegert: None declared, Eric Hachulla: None declared, Jeska de Vries-Bouwstra: None declared, Gabriela Riemekasten: None declared, Jörg H.W. Distler: None declared, Douglas Veale: None declared, Edoardo Rosato: None declared, Francesco Del Galdo: None declared, Fabian A Mendoza: None declared, Daniel Furst Consultant of: Abbvie, Novartis, Pfizer, R-Pharm, Grant/research support from: Emerald, Kadmon, PICORI, Pfizer,Prometheus, Talaris, Mitsubishi, Carlos De la Puente Bujidos: None declared, Anna-Maria Hoffmann-Vold Speakers bureau: Actelion, Boehringer Ingelheim, Jansen, Lilly, Medscape, Merck Sharp & Dohme, Roche, Consultant of: Actelion, ARXX, Bayer, Boehringer Ingelheim, Jansen, Lilly, Medscape, Merck Sharp & Dohme, Roche, Grant/research support from: Boehringer Ingelheim, Armando Gabrielli: None declared, Oliver Distler Speakers bureau: Bayer, Boehringer Ingelheim, Janssen, Medscape, Consultant of: Abbvie, Acceleron, Alcimed, Amgen, AnaMar, Arxx, AstraZeneca, Baecon, Blade, Bayer, Boehringer Ingelheim, Corbus, CSL Behring, 4P Science, Galapagos, Glenmark, Horizon, Inventiva, Kymera, Lupin, Miltenyi Biotec, Mitsubishi Tanabe, MSD, Novartis, Prometheus, Roivant, Sanofi and Topadur, Grant/research support from: Kymera, Mitsubishi Tanabe, Boehringer Ingelheim, Coralie Bloch-Queyrat: None declared, Yannick Allanore Consultant of: Actelion, Bayer, BMS, Boehringer-Ingelheim, Inventiva, Roche, Sanofi-Aventis, Grant/research support from: Actelion, Bayer, BMS, Boehringer-Ingelheim, Inventiva, Roche, Sanofi-Aventis

Two-year follow-up of 196 interstitial lung disease patients after ICU stay

OBJECTIVE: Interstitial lung diseases (ILDs) are associated with poor prognosis in the intensive care unit (ICU). We aimed to assess factors associated with hospital mortality in ILD patients admitted to the ICU and to investigate long-term outcome.MATERIAL AND METHODS: This was a retrospective study in a teaching hospital specialised in ILD management. Patients with ILD who were hospitalised in the ICU between 2000 and 2014 were included. Independent predictors of hospital mortality were identified using logistic regression.RESULTS: A total of 196 ILD patients were admitted to the ICU during the study period. Overall hospital mortality was 55%. Two years after ICU admission, 70 (36%) patients were still alive. Of the 196 patients, 108 (55%) required invasive mechanical ventilation, of whom 21 (20%) were discharged alive from hospital. Acute exacerbation of ILD and multi-organ failure were highly associated with hospital mortality (OR 5.4, 95% CI 1.9-15.5 and OR 12.6, 95% CI 4.9-32.5, respectively).CONCLUSION: Hospital mortality among ILD patients hospitalised in the ICU was high, but even where invasive mechanical ventilation was required, a substantial number of patients were discharged alive from hospital. Multi-organ failure could lead to major ethical concerns.

Intérêt de la corticothérapie dans la prise en charge des patients atteints de pneumopathie grave à SARS-CoV-2

Introduction

Au cours des pneumopathies à SARS-CoV-2, plusieurs stratégies thérapeutiques ont été proposées. La description d’une aggravation secondaire liée à un orage cytokinique a justifié l’utilisation de molécules anti-inflammatoires.

Du fait de la disponibilité, du faible coût, de son utilisation dans d’autres pathologies infectieuses, les corticoïdes ont été proposés pour la prise en charge des patients à ce stade de l’infection.

Nous avons analysé l’ensemble des données d’une cohorte de patients hospitalisés pour une infection grave à SARS-CoV-2.

L’objectif principal était d’étudier l’effet des corticoïdes sur l’incidence de ces évènements graves : intubation orotrachéale (IOT) ou décès (DC).

Matériels et méthodes

Les données ont été recueillies de manière rétrospective chez les patients hospitalisés pour une infection grave documentée par PCR (81 %) ou scanner thoracique (93 %) entre le 15/03/2020 et le 15/04/2020. Nous avons inclus les patients avec un score OMS = 5 et nécessitant un débit d’O₂ supérieur à 3 L/min pour maintenir une saturation > 94 %. Les patients décédés ou transférés en réanimation dans les 48 heures suivant l’admission ont été exclus, ainsi que ceux inclus dans des protocoles thérapeutiques.

La corticothérapie était administrée, après discussion pluridisciplinaire, à la posologie de 2 mg/kg équivalent prednisone de j1 à j3 puis 1 mg/kg les 3 jours suivants.

Les malades traités par corticoïdes (groupe CT) ont été comparés aux malades de même niveau de gravité pris en charge avant la mise en place de la RCP le 2 avril, et traités selon le même standard de soin (groupe sans CT).

Le critère d’évaluation principal était la survenue d’une IOT ou le DC.

Résultats

Un total de 120 patients a été analysé : 39 dans le groupe CT, 81 dans le groupe sans CT.

Les 2 groupes avaient la même moyenne d’âge (66,4 ± 14 ans groupe CT, 66,1 ± 15 ans groupe sans CT ; p = −0,9), même sexe ratio (p = 0,4), même niveau d’atteinte sur le TDM, même paramètres d’inflammation à l’entrée (CRP 135 ± 86 mg/L groupe CT et 118 ± 90 mg/L groupe sans CT).

Le nombre de patient en limitation de soin était le même dans chaque groupe, n = 14 (35 %) groupe CT, n = 27 (33 %) groupe sans CT (p = 0,9).

Le nombre de malades IOT ou DC était significativement différent dans le groupe CT n = 9 (23 %), comparativement au groupe sans CT n = 42 (53 %) avec p < 0,01.

Cette différence était plus importante chez les patients sans limitation de soins : groupe CT aucun IOT ou DC, groupe sans CT n = 20 (37 %).

La différence d’incidence d’IOT ou DC n’était pas significative dans le sous-groupe des patients limités, groupe CT n = 9 (64 %) et groupe sans CT n = 22 (81 %) IOT/DC (p = 0,27).

Conclusion

Même si le nombre limité de patients, le caractère rétrospectif et monocentrique de l’étude ne permettent pas d’extrapoler les données, nous confirmons l’intérêt de la corticothérapie pour la prise en charge des patients atteints de pneumopathie à SARS-CoV-2 aigu, à la phase inflammatoire. Les bénéfices à long terme restent à être évalués.

Slow Gait Speed Is an Independent Predictor of Early Death in Older Cancer Outpatients: Results from a Prospective Cohort Study

OBJECTIVE

To assess the predictive value of gait speed for early death in older outpatients with cancer.

DESIGN

Prospective bicentric observational cohort study.

SETTING

The Physical Frailty in Elder Cancer patients (PF-EC) study (France).

PARTICIPANTS

One hundred and ninety outpatients with cancer during the first 6 months of follow up in the PF-EC study.

MEASUREMENTS

The association between usual gait speed over 4 m alone (GS) or included in the short physical performance battery (SPPB) and overall survival within 6 months following a comprehensive geriatric assessment (CGA). A Cox proportional-hazard regression model was performed in non-survivors for clinical factors from the CGA, along with c reactive protein (CRP). Two models were created to assess GS alone and from inclusion in the SPPB.

RESULTS

The mean age was 80.6 years, and 50.5% of the participants were men. Death occurred in 11% (n=22) of the participants within the 6 month follow up period. Of these participants, 98% had solid cancers, and 33% had a metastatic disease. A GS < 0.8 m/s (HR=5.6, 95%CI=1.6-19.7, p=0.007), a SPPB < 9 (HR=5.8, 95%CI=1.6-20.9, p=0.007) and a CRP of 50 mg/l or greater (p<0.0001) were significantly associated with early death in the two multivariate analyses. Cancer site and extension were not significantly associated with early death.

CONCLUSION

Walking tests are associated with early death within the 6 month follow up period after a CGA independent of cancer site and cancer extension. GS alone < 0.8 m/s is at least as efficacious as the SPPB in predicting this outcome. GS alone could be used routinely as a marker of early death to adapt oncologic therapeutics. Further studies are needed to validate these preliminary data.

Increased mean corpuscular haemoglobin concentration: artefact or pathological condition?

INTRODUCTION

In daily practice in haematology laboratories, spurious increased MCHC induces an analytical alarm and needs prompt corrective action to ensure delivery of the right results to the clinicians. The aim of this study was to establish a 'decision tree' using the new parameters red blood cells (RBC-O) and haemoglobin (HGB-O) from the Sysmex XN-10 RET obtained by flow cytometry to deliver appropriate results.

METHODS

From 128 unknown patients with MCHC > 365 g/L, all erythrocyte parameters including reticulocyte parameters were measured and analysed in parallel with blood smears, chemistry index and osmolarity. Differences between optical parameters (RBC-O, HGB-O) and usual parameters (RBC, HGB) obtained by impedance and photometry were reported also.

RESULTS

Four groups were defined from observations: -RBC agglutination (n = 22); -optical interference (n = 17); -RBC disease (n = 18); and -others (n = 71). The use of RBC-O and HGB-O permitted efficient correction of the abnormalities when RBC agglutination and/or optical interference were present in 36 of 39 patients. Reticulocyte parameters permitted to elaborate an RBC score that allowed a highly sensitive detection of RBC disease patients (17/18).

CONCLUSION

Based on new parameters, we propose a 'decision tree' that delivers time savings and supports biological interpretation in case of elevated MCHC.

What threshold values of antral follicle count and serum AMH levels should be considered for oocyte cryopreservation after in vitro maturation?

STUDY QUESTION

What threshold values of ultrasonographic antral follicle count (AFC) and serum anti-Müllerian hormone (AMH) levels should be considered for ensuring the cryopreservation of sufficient number of in vitro matured (IVM) oocytes, in cancer patients seeking fertility preservation (FP)?

SUMMARY ANSWER

AFC and serum AMH values >20 follicles and 3.7 ng/ml, respectively, are required for obtaining at least 10 IVM oocytes for cryopreservation.

WHAT IS KNOWN ALREADY

IVM of cumulus oocyte complexes (COCs) followed by oocyte cryopreservation has emerged recently as an option for urgent FP. Recent data have reported that, in healthy patients, 8-20 cryopreserved oocytes after ovarian stimulation would maximize the chance of obtaining a live birth. Although both AFC and AMH have been reported as predictive factors of IVM success in infertile patients with polycystic ovary syndrome (PCOS), there is a dramatic lack of data regarding the values of these parameters in oncological patients as candidates for FP.

STUDY DESIGN, SIZE, DURATION

From January 2009 to April 2015, we prospectively studied 340 cancer patients, aged 18-41 years, as candidates for oocyte cryopreservation following IVM.

PARTICIPANTS/MATERIALS, SETTING, METHODS

All patients had AFC and AMH measurements, 48-72 h before oocyte retrieval, regardless of the phase of the cycle. COCs were recovered under ultrasound guidance 36 h after hCG priming. Logistic regression allowed the determination of threshold values of AFC and AMH, for obtaining at least 8, 10 or 15 matures oocytes frozen after the IVM procedure. Similar analyses were performed for a final number of mature oocytes ≤2.

MAIN RESULTS AND THE ROLE OF CHANCE

Among the 340 cancer patients included, 300 were diagnosed with breast cancers, 14 had hematological malignancies and 26 underwent the procedure for others indications. Overall, the mean age of the population was 31.8 ± 4.5 years. Mean AFC and serum AMH levels were 21.7 ± 13.3 follicles and 4.4 ± 3.8 ng/ml, respectively. IVM was performed in equal proportions during the follicular or luteal phase of the cycle (49 and 51%, respectively). Statistical analysis showed that AFC and AMH values above 28 follicles and 3.9 ng/ml, 20 follicles and 3.7 ng/ml and 19 follicles and 3.5 ng/ml are required, respectively, for obtaining at least 15, 10 or 8 frozen IVM oocytes with a sensitivity ranging from 0.82 to 0.90. On the contrary, ≤2 IVM oocytes were cryopreserved when AFC and AMH were <19 follicles and 3.0 ng/ml, respectively.

LIMITATIONS, REASONS FOR CAUTION

Although the potential of cryopreserved IVM oocytes from cancer patients remains unknown, data obtained from infertile PCOS women have shown a dramatically reduced competence of these oocytes when compared with that of oocytes recovered after ovarian stimulation. As a consequence, the optimal number of IVM oocytes frozen in candidates for FP is currently unpredictable.

WIDER IMPLICATIONS OF THE FINDINGS

Cryopreservation of oocytes after IVM should be considered in the FP strategy when ovarian stimulation is unfeasible, in particular when markers of the follicular ovarian status are at a relatively high range. Further investigation is needed to objectively assess the real potential of these IVM oocytes after cryopreservation. Therefore, even when a good COCs yield is expected, we should systematically encourage IVM in combination with ovarian tissue cryopreservation.

STUDY FUNDING/COMPETING INTERESTS

No external funding was obtained for the present study. The authors have no conflict of interest to declare.

TRIAL REGISTRATION NUMBER

Not applicable.

Abstract P6-12-12: How can we improve vulnerability score in breast cancer survivors? A pilot experience in an underprivileged community

BACKGROUND: We decided to evaluate the evolution of vulnerability in breast cancer survivors receiving an individualized survivorship care plan and living in an area (Seine-Saint-Denis, SSD), which is among the poorest in France with a median household income is 68% lower than in Paris. In SSD, cancer is the leading cause of premature mortality. Whereas it is widely admitted in France that 25% of patients are faced with financial difficulties after breast cancer, this proportion reaches 40% in SSD.

PATIENTS AND METHODS: Ac'Santé93 is a non-profit organization whose aim is to provide supportive care, health education and individualized assistance to patients and families, and to facilitate timely access to quality medical and psychosocial care. Vulnerability was evaluated using a 11-item standardized score (EPICES) previously investigated by French Health Examination Centers. Strictly speaking this score was aimed at measuring precarity, a concept referring to a social condition assumed to face worsening. This score is more strongly related to health status than the administrative classification of poverty (Sass, Sante Publique 2006). Vulnerability was defined by a score ≥30 and considered as severe when ≥40. In SSD two thirds of the population are affected by vulnerability. Patients included in the study were scored after cancer diagnosis (E1) and 6 mos. after the first evaluation (E2). Patients were divided into tertiles according to E1: 30-40, 40-67 and 67-100. Psychosocial comorbidities, demographic data, and supportive care received were also recorded. Actions undertaken were divided in three categories: social/advocacy (e.g. help with filling out administrative forms), individual (e.g. dietician consultation) and group (e.g. group sessions led by a sport instructor).

RESULTS: Over the year 2014, 120 breast cancer survivors were included and had E1 and E2 scores. Median E1 and E2 were 52.1 and 47.3 and the mean difference was 7.2 (p&lt;0.0001). The score improved for 72% of pts but worsened in 16% and remained stable in 12%. Whereas a significant improvement of E2 was observed whatever E1 in patients included in a support group, it was not the case in the other patients (social/advocacy and/or individual). Surprisingly, the effect of support groups on vulnerability score was significantly greater in the highest tertile of pts (E1 from 67 to 100). Being in the highest tertile at inclusion was also the strongest predictor for improvement in all patients (RR=7.7, p=0.007). Younger patients were at significantly higher risk of worsening: median age was 49.2 in case of worsening v 54.3 in case of improvement (p=0.047).

CONCLUSION: Survivorship care plans can improve vulnerability in most pts. Paradoxically, it seems easier to improve vulnerability in pts with highest initial scores. Furthermore these patients are those who benefit the most from support groups. We hypothesize that desocialization is frequently underestimated in this population, and that support groups, besides their primary goal, act through developing social links. Finally, the finding that younger patients are at higher risk for worsening vulnerability underscores the burden of unmet needs in youngest breast cancer survivors.

Citation Format: Jaouen A, Festa A, Boubaya M, Levy V, Zelek L. How can we improve vulnerability score in breast cancer survivors? A pilot experience in an underprivileged community. [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 P6-12-12.

Abstract P1-09-20: Patient navigation significantly improves vulnerability score after breast cancer. A pilot experience in an underprivileged community

BACKGROUND: We decided to evaluate the effect of patient navigation in an area (Seine-Saint-Denis, SSD) with an estimated population of 1.4 billion, which is among the poorest in France. Median household income is 68% lower than in Paris (+68%), a gap growing with time. In SSD, cancer is the leading cause of premature mortality. Whereas it is widely admitted in France that 25% of patients are faced with financial difficulties after breast cancer, this proportion reaches 40% in SSD.

PATIENTS AND METHODS: Oncologie 93 is a non-profit organization whose aim is to provide supportive care, health education and individualized assistance to patients and families, and to facilitate timely access to quality medical and psychosocial care. Vulnerability was evaluated using a 11-item standardized score (EPICES) previously investigated by French Health Examination Centers. Strictly speaking this score was aimed at measuring precarity, a concept referring to a social condition assumed to face worsening. This score is more strongly related to health status than the administrative classification of poverty (Sass, Sante Publique 2006). Vulnerability was defined by a score &gt;30 and considered as severe when &gt;40. In SSD two thirds of the population are affected by vulnerability. Patients included in the navigation program were scored after cancer diagnosis (E1) and 1 year after the beginning of cancer therapy (E2). Psychosocial comorbidities, demographic data, and treatments received were also recorded.

RESULTS: Over a 1-year period 74 breast cancer patients were included and had E1 and E2 scores, detail of therapy was available for 64 pts. The score significantly improved for the whole population (p = 0.04) but worsened in 23 pts (31%). Among all the variables studied, undergoing surgery was the only one to be significantly correlated with outcome. However, surprisingly, patients who did not undergo surgery had a significantly better evolution of the score than those who did (p = 0.04). E1 score was lower in patients eligible for surgery.

Evolution of median vulnerability score before (E1) and after (E2) breast cancer therapy, first and third quartiles (Q1-Q3) and minimal-maximal values. n =E1Q1-Q3min-maxE2Q1-Q3min-maxwhole population7439.615.8-63.53.17-92.232.87.1-45.81.6-92.1no surgery2447.925.8-57.83.17-75.115.13.6-40.22.7-78.7surgery403714.5-63.93.17-92.233.48-47.31.6-92.9

CONCLUSION: We showed that patient navigation significantly improves vulnerability score during cancer therapy. It emphasizes the importance of evaluating deprivation with standardized tools in cancer patients in order to propose appropriate interventions. The only factor correlated with the evolution of the score is surgery. Patients that were not eligible for surgery had higher E1 score but significantly better evolution during the following year. We hypothesize that deprivation leads to more advanced tumors or is associated with comorbidities contraindicating breast surgery. For unclear reasons, the magnitude of the benefit seems greater in this population. About one third of patients experience worsening of the vulnerability after breast cancer therapy and the underlying mechanisms remain to be determined.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P1-09-20.