Brief report: High incidence of peridiagnosis thromboembolic events in patients with BRAF-mutant lung cancer

INTRODUCTION

We aimed to determine if advanced BRAF-mutant NSCLC has a higher thromboembolic events (TEE) rate than the expected.

METHODS

Between 2008 and 2021, 182 patients with BRAF-mutant advanced NSCLC (BRAF V600E, n = 70; BRAF non-V600E, n = 112) were retrospectively identified from 18 centers in Spain. Patients received chemotherapy (n = 147), immunotherapy (n = 69), targeted therapy (n = 42), and immunotherapy + chemotherapy (n = 26).

RESULTS

Incidence rate of TEE was 26.4 % (95%CI: 19.9 %-32.9 %). A total of 72 TEE were documented among 48 patients, as 18 patients (37.5 %) developed more than one event. Median time to TEE onset was 2 months, 69 % of TEE occurred in the peridiagnostic period (+/- 90 days from cancer diagnosis), and in 16 pts. (33 %) TEE was the form of lung cancer presentation. Although most TEE were only venous (82 %; PE, n = 33; DVT, n = 16), arterial events were reported in 31 % and occurred earlier, or TEE presented in atypical locations (13.9 %). TEE were related to high hospitalization rate (59 %), recurrence (23 %), and mortality (10.4 %) despite appropriate anticoagulant/antiaggregant treatment. Median OS in patients without-TEE was 19.4 months (95%CI: 4.6-34.1), and significantly shorter in patients with arterial-TEE vs venous-TEE vs both of them: 9.9 months (95%CI: 0-23.5) vs 41.7 months (95%CI: 11.3-72.2 m) vs 2.7 months (95%CI: 2.1-3.3), p = 0.001. Neither clinical or molecular features (BRAF V600E/non-V600E), nor cancer treatment was associated to TEE occurrence. Khorana score underperformed to predict thrombosis at cancer diagnosis, as only 19.2 % of patients were classified as high-risk.

CONCLUSIONS

Thrombotic events represent a new clinical feature of BRAF-mutant lung cancer. Patients with almost a 30 % incidence of TEE should be offered systematic anticoagulation.

Clinical and survival characteristics of patients with BRAF-mutated metastatic colorectal cancer (mCRC) who receive metastases surgery in a Spanish cohort

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Background: Patients with mCRC harboring BRAF mutation have worse prognosis and poor outcomes. However, those who have resectable metastatic disease and undergo surgery may have better outcomes compared to those who do not. Differences in clinical characteristics are not well known and may be critical to identify patients with better prognosis. Methods: We performed a retrospective analysis of 299 patients with mCRC in a tumor registry from 2015 to 2021. We compared the clinical characteristics and survival trends of both cohorts (BRAF mutated and BRAF wild type). Furthermore, we analyzed clinical and survival features of 23 patients with BRAF mutated mCRC who received metastases resection. Results: We identified 34 patients with BRAF mutation (11.37%). Several characteristics were significantly more frequent in this group: age <65 years (n = 24, OR 1.38, p = 0.03), female sex (n = 24, OR 1.74, p = 0.008), primary tumor in the right colon (n = 15, OR 1.93, p = 0.003), peritoneal carcinomatosis (n = 18, OR 2.29, p = 0.007) and increased CA19.9 levels at diagnosis (n = 18, OR 1.79, p = 0.003). They received more peritoneal surgery (n = 12, OR 4.27, p = 0.000) and less liver metastases resection (n = 7, OR 0.51, p = 0.011). Median PFS in the first line of treatment was shorter in patients with BRAF mutation (9.5 vs 12.6 months; HR 1.69; IC 95%: 1.16 – 2.45; p = 0.006); however, we did not found differences in OS. Within the 23 patients with BRAF mutated mCRC who underwent surgery (67,64%), we found significant differences compared with those without metastases surgery: primary tumor resection (n = 21, OR 2.51, p = 0.0017) and having a single metastatic location (n = 18, OR 2.04, p = 0.01). Other features were more frequent in patients who underwent surgery but did not reach statistical significance: right colon location (63.6% vs 37.5%), metachronic disease (47.8% vs 18.2%), normal CEA (50% vs 25%) and CA19.9 (45% vs 12%) at diagnosis, and receiving 3 or more lines of systemic treatment (57% vs 22%). Median PFS after metastasectomy was 14.9 months, but we found no differences between both groups. Conclusions: In our cohort, BRAF mutated mCRC patients were more frequently younger, women, had right-sided primary tumors, higher rates of peritoneal metastases and abnormal CA19.9 levels at diagnosis, including worse outcomes in terms of PFS. On the other hand, resection of the primary tumor and single metastatic location were associated with higher probability of having metastases surgery, although in this study no subsequent survival benefit was found, probably due to the small number of BRAF mutated patients analyzed.

Clinical characteristics and survival trends of patients with metastatic colorectal cancer (mCRC) and peritoneal carcinomatosis who receive metastases surgery in a Spanish cohort

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Background: Peritoneal metastases in patients with mCRC are commonly associated with poor outcomes. Some of these patients are candidates to undergo metastases surgery, which may result in better prognosis; however, clinical and molecular characteristics of these patients remain uncertain. Methods: We conducted a retrospective analysis of 166 patients with mCRC and peritoneal metastases in a tumor registry from 2015 to 2021, analyzing the clinical and molecular characteristics, as well as progression-free survival (PFS) and overall survival (OS) of patients who received peritoneal surgery versus those who did not. Results: From the whole population, 65 patients (39%) underwent peritoneal metastases surgery, and several characteristics were more frequent in this subgroup: ECOG 0 (n = 26, OR 2.75, p = 0,0069), age &lt;65 years (n = 43, OR 2.29, p = 0,0162), absence of hepatic metastases (n = 56, OR 3.31, p = 0,0037), single metastatic location (n = 43, OR 3.48, p = 0,0002), normal CEA levels at diagnosis (n = 33, OR 2.02, p = 0,0455) and BRAF mutation (n = 12, OR 3.32, p = 0,0345). Moreover, these patients received more lines of systemic treatment (2.8 vs 2, p = 0,006) and more metastases surgeries (1.7 vs 0.9, p = 0,000). Significant differences in tumor mutational status regardless of BRAF (KRAS, NRAS, MSI, PI3K and HER2), sex and primary tumor location between groups were not found. PFS was longer in patients receiving metastases surgery (median, 13.68 vs 7.76 months; HR for progression 0.64; 95 % confidence interval (CI) 0.46 to 0.89; p = 0,009), as well as overall survival (median NR vs 29.53; HR for death 0.39; 95 % CI, 0.25 to 0.60; p = 0,000). Conclusions: In our cohort, patients with mCRC and peritoneal carcinomatosis who underwent metastases surgery had more frequently less than 65 years, ECOG 0, absence of liver metastases, single metastatic location, normal CEA levels at diagnosis and BRAF mutation. Moreover, this subgroup showed better outcomes with a statistically significant increase in PFS and OS.

Outcomes of COVID-19 in Patients With Lung Cancer Treated in a Tertiary Hospital in Madrid

Background: Cancer patients represent a vulnerable population for COVID-19 illness. We aimed to analyze outcomes of lung cancer patients affected by COVID-19 in a tertiary hospital of a high-incidence region during the pandemic. Methods: We annotated 23 lung cancer patients consecutively diagnosed with COVID-19 at our institution (HGUGM; Madrid, Spain) between March 4th, 2020 and May 12th, 2020. Only patients with a confirmatory SARS-CoV-2 RT-PCR were included in the study. Results: All patients had at least 1 COVID-19 related symptom; cough (48%), shortness of breath (48%), fever (39%), and low-grade fever (30%) were the most common. Time from symptoms onset to first positive SARS-CoV-2 PCR was 5.5 days (range 1-17), with 13% of cases needed from a 2nd PCR to confirm diagnosis. There was a high variability on thoracic imaging findings, with multilobar pneumonia as the most commonly found pattern (74%). Main lab test abnormalities were low lymphocytes count (87%), high neutrophil to lymphocyte ratio -NLR- (78%), and elevated inflammatory markers: fibrinogen (91%), c-reactive protein -CRP- (87%), and D-dimer (70%). In our series, hospitalization rate was 74%, 39% of patients developed acute respiratory distress syndrome (ARDS), and the case-fatality rate was 35% (8/23). 87% of patients received anti-viral treatment (87% hydroxychloroquine, 74% lopinavir/ritonavir, 13% azithromycin), 43% corticosteroids, 26% interferon-β, 4% tocilizumab, and 82% of hospitalized patients received anticoagulation. High-oxygen requirements were needed in 39% of patients, but only 1 pt was admitted for invasive MV and was discharged 42 days after admission. Multiple variables related to tumor status, clinical baseline conditions, and inflammation markers were associated with mortality but did not remain statistically significant in a multivariate model. In patients with lung cancer receiving systemic therapy (n = 242) incidence and mortality from COVID-19 were 4.5, and 2.1%, respectively, with no differences found by type of treatment. Conclusions: Lung cancer patients represent a vulnerable population for COVID-19, according to the high rate of hospitalization, onset of ARDS, and high mortality rate. Although larger series are needed, no differences in mortality were found by type of cancer treatment. Measures to minimize the risk of SARS-CoV-2 infection remain key to protect lung cancer patients.

Abstract PO-036: Safety outcomes of resuming anticancer treatment in patients with lung cancer affected by COVID-19 illness

Background: We aimed to describe how patients with lung cancer affected by COVID-19 recovered and were subsequently treated.

Methods: From March 4th to May 12th, 2020, we have previously identified 23 COVID-19 lung cancer patients confirmed by SARS-CoV-2 RT-PCR in our institution (HGUGM; Madrid, Spain). After symptom recovery patients were tested weekly with nasopharyngeal swabs for SARS-CoV2. We did not start any anticancer treatment until at least 1 PCR confirmed a negative SARS-CoV-2 result. We reviewed treatment records, hospitalization, and outcomes of patients who recovered from COVID-19.

Results: With a median follow-up of 9.7 weeks after COVID-19 diagnosis (range 3.7-13 weeks), 15 patients are clinically recovered (65%) and 8 patients died (35%) from COVID-19. In COVID-19 survivors, time to SARS-CoV-2 PCR negativization from symptoms onset was 31 days (range 13-54 days). Three patients remain SARS-CoV-2 RT-PCR positive to date. Of the 12 patients who negativized for SARS-CoV-2, 8 pts have started systemic anticancer treatment as follows: immune checkpoint inhibitors (n=3), chemotherapy (n=3), and initiation of definitive thoracic chemoradiation (n=2). All 3 pts on immunotherapy resumed the same treatment that they were receiving before COVID-19 (pembrolizumab, atezolizumab), as 2 out of 3 pts did with chemotherapy (pemetrexed; carboplatin + paclitaxel). With a median time on treatment of 40 days (range 22-48 days), only 1 patient has developed treatment-related adverse events so far (grade 1 thrombocytopenia after cycle 1, and grade 2 neutropenia after cycle 2 of carboplatin plus etoposide in a patient with relapsed SCLC previously treated with chemoradiation). The 4 patients with negative SARS-CoV-2 PCR who did not start any further treatment had either already completed planned treatment just before COVID-19 or were under surveillance without evidence of disease. Readmission was required in 4/15 patients: 1 pt due to tumor progression and pulmonary embolism, 1 pt due to brain edema from known brain metastasis, 1 pt due to Salmonella gastroenteritis, and 1 pt with hematuria due to prostate cancer. Of note, 1 patient who previously tested negative for SARS-CoV-2 -and who already resumed chemotherapy tested positive again upon admission without COVID-19-related symptoms.

Conclusions: Lung cancer patients who survived COVID-19 can be considered for cancer treatment without preliminary early safety concerns. Long-term efficacy and safety evaluation by treatment modality is needed.

Citation Format: Antonio Calles, Mar Galera, Inmaculada Aparicio, Manuel Alva, Marianela Bringas, Natalia Gutierrez, Javier Soto, Victoria Tirado, Rosa Alvarez. Safety outcomes of resuming anticancer treatment in patients with lung cancer affected by COVID-19 illness [abstract]. In: Proceedings of the AACR Virtual Meeting: COVID-19 and Cancer; 2020 Jul 20-22. Philadelphia (PA): AACR; Clin Cancer Res 2020;26(18_Suppl):Abstract nr PO-036.

Abstract PO-031: Outcomes of COVID-19 in patients with lung cancer treated in a tertiary hospital in Madrid

Background: Cancer patients represent a vulnerable population for COVID-19 illness. We aimed to analyze outcomes of lung cancer patients affected by COVID-19 in a tertiary hospital of a high-incidence region during the pandemic.

Methods: We retrospectively collected all lung cancer patients diagnosed with COVID-19 at our institution (HGUGM; Madrid, Spain) between February 24th, 2020 to May 12th, 2020. Patients must have a confirmatory SARS-CoV-2 RT-PCR to be included in the study. Clinically suspected cases and cases with close contact to COVID-19 confirmed cases were not included if either not tested or tested negative by RT-PCR.

Results: On March 4th, 2020, we confirmed our first lung cancer patient with COVID-19 in our institution. Since then, 23 lung cancer pts developed COVID-19 confirmed by SARS-CoV-2 PCR. Median age was 69 years-old (range 49-86), predominantly male (78%), with smoking history (former, 52%; current, 35%), and 87% presented comorbidities. Histology was 61% adenocarcinoma, 26% squamous cell carcinoma (SqCC), and 9% small-cell lung cancer (SCLC). Stage IV was the most commonly found (IVa 22%, IVb 39%), followed by stage III (35%) and stage I-II (4%). 70% of pts were receiving active treatment at the time of COVID-19 diagnosis (30-day window for systemic treatment, 15 days for radiation therapy): chemotherapy (n=4), immune checkpoint inhibitors (n=5), targeted therapy (n=1), thoracic chemo-radiation (n=1), and nonradical nonthoracic radiation therapy (n=6). All lung cancer patients had at least 1 COVID-19 related symptom; cough (48%), shortness of breath (48%), fever (39%), and low-grade fever (30%) were the most common COVID-19 symptoms. Time from symptoms onset to first positive SARS-CoV-2 PCR was 5.5 days (range 1-17), with 13% of cases needing a 2nd PCR to confirm diagnosis. High variability on thoracic imaging findings were found (no pneumonia, n=4; unilobar, n=1; multilobar, n=17). 87% of pts received treatment for COVID-19: hydroxychloroquine (n=20), lopinavir/ritonavir (n=17), azithromycin (n=3), interferon (n=3), and tocilizumab (n=1). In our series, hospitalization rate was 74%, and 39% of pts developed ARDS within 6 days after symptoms initiation (range 2-22 days). Only 1 patient was admitted in the ICU for VM and received tocilizumab and was discharged 42 days after admission. Case fatality rate was 35% (8/23), with 3 pts still on 30-day follow-up period. Considering only those patients with lung cancer who were actively receiving systemic therapy during the pandemic in our institution, we estimated a 4.5% incidence and a 2.1% mortality from COVID-19. Analysis of prognostic factors of mortality is under way.

Conclusions: Lung cancer patients represent a vulnerable population for COVID-19, according to the high rate of hospitalization, onset of ARDS, and high mortality rate. Although larger series are needed, no differences in mortality were found by type of cancer treatment. Measures to minimize the risk of SARS-CoV-2 infection remain key to protect lung cancer patients.

Citation Format: Antonio Calles, Inmaculada Aparicio, Manuel Alva, Marianela Bringas, Natalia Gutierrez, Javier Soto, Mar Galera, Rosa Alvarez. Outcomes of COVID-19 in patients with lung cancer treated in a tertiary hospital in Madrid [abstract]. In: Proceedings of the AACR Virtual Meeting: COVID-19 and Cancer; 2020 Jul 20-22. Philadelphia (PA): AACR; Clin Cancer Res 2020;26(18_Suppl):Abstract nr PO-031.

Abstract PO-021: Impact of COVID-19 in continuity of cancer treatment for lung cancer patients

Background: We aimed to analyze the impact on treatment delivery in patients with lung cancer during the COVID-19 pandemic and to describe the patterns of treatment change.

Methods: We accessed treatment records of all lung cancer patients treated from 02/20 to 06/20 at the oncology day hospital in our institution (HGUGM; Madrid, Spain). We have prospectively identified all COVID-19 lung cancer patients confirmed by SARS-CoV-2 RT-PCR and included all those on active treatment (&lt;30 days from last dose of any systemic therapy).

Results: A total of 242 patients with lung cancer were receiving active treatment as follows: chemotherapy (117 pts, 48%), immunotherapy (56 pts, 23%), targeted therapy (52 pts, 21%), chemo-immunotherapy (13 pts, 5%), radio-immuno-chemotherapy (4 pts, 2%). Intention of treatment was palliative in 84% vs. curative in 16% (28 pts on chemoradiation; 11 pts on adjuvant/neoadjuvant therapy). Median number of treatment lines was 1 (range 1-6). 11 patients had confirmed COVID-19 illness during active cancer treatment, and 5 patients died due to COVID-19. On average, 61 patients with lung cancer were treated per week before the pandemic. After an initial peak during the first week of pandemic, treatment delivery dropped by -62.2% four weeks after the first case confirmed in our institution (chemotherapy, -58.2%; immunotherapy, -72.6%; chemo-immunotherapy, -100.0%; targeted therapy, -59.0%) and came back to normal at week +7. Treatment interruption or dose delay was observed in 125 pts (28% temporal, 24% definitive). Overall, 23 patients refused to continue treatment due to fear or mobility restrictions due to the pandemic. Additionally, we identified doses skipped in 51 pts (21%), increase on dose intervals in 42 pts (17%), and dose reductions in 16 pts (7%). Route of administration remained the same for all pts but 1 (i.v. to oral). Although absolute use of G-CSF fell by -57.9% during the pandemic, tied to less administration of chemotherapy, the relative use of G-CSF increased in patients receiving chemotherapy-based treatments: G-CSF was initiated in 31 pts who were not previously receiving G-CSF, and expanded in days of use in 7 pts already on treatment. Telemedicine was used in 106/242 patients (44%) to minimize physical presence in the hospital. Drug home delivery system was initiated in 22 patients (9% of total), all of them on targeted therapy (representing 42% of all active patients on targeted therapy). Of the 32 patients who were receiving treatment in clinical trials (10 pts immunotherapy; 8 pts targeted therapy; 8 pts chemo-immunotherapy; 2 chemotherapy, 4 radio-chemo-immunotherapy), neither treatment delays nor COVID-19 illness was documented in any patient.

Conclusions: COVID-19 pandemic significantly modified treatment patterns in patients with lung cancer who were receiving active treatment. Measures were taken to reduce the number of visits to outpatient facilities, and treatment home delivery was facilitated when feasible.

Citation Format: Antonio Calles, Manuel Alva, Inmaculada Aparicio, Javier Soto, Natalia Gutierrez, Marianela Bringas, Vicente Escudero, Roberto Collado, Mar Galera, Rosa Alvarez. Impact of COVID-19 in continuity of cancer treatment for lung cancer patients [abstract]. In: Proceedings of the AACR Virtual Meeting: COVID-19 and Cancer; 2020 Jul 20-22. Philadelphia (PA): AACR; Clin Cancer Res 2020;26(18_Suppl):Abstract nr PO-021.

Hopkins Verbal Learning Test- Revised: Normative data for the Latin American Spanish speaking adult population

OBJECTIVE

To generate normative data on the Hopkins Verbal Learning Test- Revised (HVLT-R) across 11 countries in Latin America, with country-specific adjustments for gender, age, and education, where appropriate.

METHOD

The sample consisted of 3,977 healthy adults who were recruited from Argentina, Bolivia, Chile, Cuba, El Salvador, Guatemala, Honduras, Mexico, Paraguay, Peru, and, Puerto Rico. Each subject was administered the HVLT-R as part of a larger neuropsychological battery. A standardized five-step statistical procedure was used to generate the norms.

RESULTS

The final multiple linear regression models explained 17- 45% of the variance in HVLT-R scores. Although t-tests showed significant differences between men and women in Guatemala on the HVLT-R, it was a small effect size. As a result, gender-adjusted norms were not generated.

CONCLUSIONS

The results from this study will have a substantial impact on the practice of neuropsychology in Latin America, as this is the first normative multicenter study to develop norms for the HVLT-R in this region.