Thrombopoietin Receptor Agonists for Thrombocytopenia Secondary to HER2-Targeted Antibody Drug Conjugates

Trastuzumab emtansine and trastuzumab deruxtecan are widely used in breast cancer and other solid tumor malignancies. Thrombocytopenia is a common adverse event associated with the use of these agents that can lead to a treatment delay, reduction in dose intensity, and discontinuation. The role of thrombopoietin receptor agonists (TPO-RA) remains unknown in this setting. We report a case series of 6 individuals with breast cancer that experienced dose-reductions and therapy delays due to thrombocytopenia secondary to trastuzumab emtansine or trastuzumab deruxtecan therapy and received intervention with TPO-RA. All 6 were able to resume therapy with TPO-RA support.

HER2-targeted antibody-drug conjugates for breast cancer: ancestry and dose adjustment for thrombocytopenia

BACKGROUND

Thrombocytopenia is a common adverse event on HER2-targeted therapies, fam-trastuzumab deruxtecan (T-DXd) and ado-trastuzumab emtansine (T-DM1). A reported association of Asian ancestry with this event merits investigation to rule out potential confounding.

METHODS

Subjects in this retrospective cohort were female patients with HER2 positive breast cancer, of Asian or non-Hispanic White ancestry, who initiated T-DM1 or T-DXd from January 2017 through October 2021. Follow-up closed in January 2022. Primary endpoint was dose adjustment for thrombocytopenia. Competing endpoints were discontinuation of drug for other toxicity, disease progression, or for completion of prescribed cycles. The association between Asian ancestry and thrombocytopenia-related dose adjustment was tested at p < 0.01 in a proportional hazards model for the sub-distributions of 4 (primary and competing) endpoints. Covariates examined as potential confounders were age, metastatic disease, specific HER2-targeted drug, and prior drug switching for toxicity.

RESULTS

Among 181 subjects, 48 reported Asian ancestry. Incidence of dose adjustment for thrombocytopenia was higher in patients with Asian ancestry and among patients switched to T-DXd after experiencing thrombocytopenia on T-DM1. Independent of specific drug and prior drug switching, Asian ancestry was associated with dose adjustment for thrombocytopenia (hazards ratio 2.95, 95% confidence interval 1.41-6.18) but not with competing endpoints. Among participants of Asian ancestry, the ancestral origin was usually China or the Philippines (where Chinese ancestry is common).

CONCLUSIONS

The association between Asian ancestry and thrombocytopenia on HER2-targeted therapy is independent of age, metastatic disease, drug, and history of similar toxicity. This association may have a genetic basis linked to Chinese ancestry.

Phenotypes of disease severity in a cohort of hospitalized COVID-19 patients: Results from the IMPACC study

BACKGROUND

Better understanding of the association between characteristics of patients hospitalized with coronavirus disease 2019 (COVID-19) and outcome is needed to further improve upon patient management.

METHODS

Immunophenotyping Assessment in a COVID-19 Cohort (IMPACC) is a prospective, observational study of 1164 patients from 20 hospitals across the United States. Disease severity was assessed using a 7-point ordinal scale based on degree of respiratory illness. Patients were prospectively surveyed for 1 year after discharge for post-acute sequalae of COVID-19 (PASC) through quarterly surveys. Demographics, comorbidities, radiographic findings, clinical laboratory values, SARS-CoV-2 PCR and serology were captured over a 28-day period. Multivariable logistic regression was performed.

FINDINGS

The median age was 59 years (interquartile range [IQR] 20); 711 (61%) were men; overall mortality was 14%, and 228 (20%) required invasive mechanical ventilation. Unsupervised clustering of ordinal score over time revealed distinct disease course trajectories. Risk factors associated with prolonged hospitalization or death by day 28 included age ≥ 65 years (odds ratio [OR], 2.01; 95% CI 1.28-3.17), Hispanic ethnicity (OR, 1.71; 95% CI 1.13-2.57), elevated baseline creatinine (OR 2.80; 95% CI 1.63- 4.80) or troponin (OR 1.89; 95% 1.03-3.47), baseline lymphopenia (OR 2.19; 95% CI 1.61-2.97), presence of infiltrate by chest imaging (OR 3.16; 95% CI 1.96-5.10), and high SARS-CoV2 viral load (OR 1.53; 95% CI 1.17-2.00). Fatal cases had the lowest ratio of SARS-CoV-2 antibody to viral load levels compared to other trajectories over time (p=0.001). 589 survivors (51%) completed at least one survey at follow-up with 305 (52%) having at least one symptom consistent with PASC, most commonly dyspnea (56% among symptomatic patients). Female sex was the only associated risk factor for PASC.

INTERPRETATION

Integration of PCR cycle threshold, and antibody values with demographics, comorbidities, and laboratory/radiographic findings identified risk factors for 28-day outcome severity, though only female sex was associated with PASC. Longitudinal clinical phenotyping offers important insights, and provides a framework for immunophenotyping for acute and long COVID-19.

FUNDING

NIH.

HER2-targeted immunoconjugates for breast cancer: Ancestry and dose adjustment for thrombocytopenia

1048

Background: Thrombocytopenia (TCP) is a common toxicity of HER2-targeted agents, trastuzumab emtansine (TDM1) and trastuzumab deruxtecan (TDXd). A high incidence of this toxicity was observed in pivotal trials that led to approval of these agents. We investigated whether Asian ancestry increases risk of dose adjustment for TCP on TDM1/TDXd and its impact on dosing in the real-world setting. Methods: Females with HER2+ breast cancer who initiated TDM1/TDXd between 1/16/17-10/26/21 were identified by retrospective review. Primary endpoint was number of chemotherapy cycles until adjustment of TDM1/TDXd dose for TCP; competing endpoints included discontinuation for other toxicity, disease progression, and completion of treatment. Individuals who were switched from TDM1 to TDXd contributed an additional observation post-switch. Recurrent events analysis evaluated Asian ancestry (p<0.05) using a proportional means model, with robust sandwich estimate recognizing correlation between repeated observations per individual. Covariates (age, metastatic disease, drug, prior adjustment) were retained if they improved the model. Results: The study excluded individuals who declined to self-identify (n=23), self-identified as other than Asian or White (n=28), and/or dissented to research (n=24). The study included n=181 individuals (mean age 55.1+12.8 years), of whom n=48 (26.5%) identified as Asian and n=124 (68.5%) had metastatic disease. Overall, 33 individuals received TDXd exclusively, leaving 148 (81.8%) individuals who received TDM1, including 45 individuals who later switched to TDXd after development of TCP while on TDM1 (n=9) or other toxicity (n=36) on TDM1. For n=226 observations (total 2551 cycles), the endpoint was dose adjustment for TCP (n=32), discontinuation for other toxicity or disease progression (n=112), completion of treatment (n=27), or censoring (n=55). Taking into account history of switching drug for TCP, Asian ancestry was associated with increased risk of dose adjustment for TCP (Table). Neither age, metastatic disease, nor specific drug improved the model (data not shown). Conclusions: Among individuals taking TDM1 and/or TDXd for HER2+ breast cancer, we observed that those with Asian ancestry are at greater risk of dose reduction for TCP than their non-Asian counterparts. Upon confirmation in additional individuals with HER2+ cancers of the breast and other sites, this heightened susceptibility to TCP among Asian individuals should be further investigated to elucidate the underlying mechanism and optimize clinical guidelines for prevention and management. [Table: see text]

Management of Relapsed/Refractory Chronic Lymphocytic Leukemia/Small Lymphocytic Lymphoma in the Era of Targeted Therapies

PURPOSE OF REVIEW

The treatment landscape for relapsed chronic lymphocytic leukemia (CLL) and small lymphocytic lymphoma (SLL) has changed substantially over the past decade and continues to evolve. Despite the emergence of targeted therapies that are well tolerated and prolong survival, the disease remains incurable and relapse is common particularly in individuals with high-risk features. Herein, we review the key literature about the current options for relapsed disease and explore the emerging role of cellular therapies.

RECENT FINDINGS

Clinical trials have established the role of Bruton tyrosine kinase inhibitors, selective BCL-2 inhibition, and anti-CD20 monoclonal antibodies as treatment options for CLL/SLL. The role of chimeric antigen receptor T cells has shown promise in individuals with CLL/SLL in early phase clinical trials. Novel therapeutic approaches with targeted therapies have redefined the management of CLL/SLL in both the front-line and relapsed/refractory settings. Optimal management in terms of sequencing or combining therapies, especially in individuals with high-risk features, remains a challenge. The emerging role of cellular therapies has the potential to build upon and further improve the current treatment paradigm.

Methylation Analyses Reveal Promoter Hypermethylation as a Rare Cause of "Second Hit" in Germline BRCA1-Associated Pancreatic Ductal Adenocarcinoma

BACKGROUND AND OBJECTIVE

Pancreatic ductal adenocarcinoma (PDAC) is characterized by the occurrence of pathogenic variants in BRCA1/2 in 5-6% of patients. Biallelic loss of BRCA1/2 enriches for response to platinum agents and poly (ADP-ribose) polymerase 1 inhibitors. There is a dearth of evidence on the mechanism of inactivation of the wild-type BRCA1 allele in PDAC tumors with a germline BRCA1 (gBRCA1) pathogenic or likely pathogenic variant (P/LPV). Herein, we examine promotor hypermethylation as a "second hit" mechanism in patients with gBRCA1-PDAC.

METHODS

We evaluated patients with PDAC who underwent Memorial Sloan Kettering-Integrated Mutation Profiling of Actionable Cancer Targets (MSK-IMPACT) somatic and germline testing from an institutional database. DNA isolated from tumor tissue and matched normal peripheral blood were sequenced by MSK-IMPACT. In patients with gBRCA1-PDAC, we examined the somatic BRCA1 mutation status and promotor methylation status of the tumor BRCA1 allele via a methylation array analysis. In patients with sufficient remaining DNA, a second methylation analysis by pyrosequencing was performed.

RESULTS

Of 1012 patients with PDAC, 19 (1.9%) were identified to harbor a gBRCA1 P/LPV. Fifteen patients underwent a methylation array and the mean percentage of BRCA1 promotor methylation was 3.62%. In seven patients in whom sufficient DNA was available, subsequent pyrosequencing confirmed an unmethylated BRCA1 promotor. Loss of heterozygosity was detected in 12 of 19 (63%, 95% confidence interval 38-84) patients, demonstrating loss of heterozygosity is the major molecular mechanism of BRCA1 inactivation in PDAC. Two (10.5%) cases had a somatic BRCA1 mutation.

CONCLUSIONS

In patients with gBRCA1-P/LPV-PDAC, loss of heterozygosity is the main inactivating mechanism of the wild-type BRCA1 allele in the tumor, and methylation of the BRCA1 promoter is a distinctly uncommon occurrence.

Is COVID 19 introducing a new model of internal medicine ward?

Background

Covid 19 has recently been defined as a syndemia, because it combines the epidemic emergency of Sars Cov 2 with that of non-communicable diseases. This aspect is particularly known in internal medicine wards (IM), which have had to split up to support these new criticalities.

Methods

Delphi method has been used to make the Ishikawa's diagram to analyze the reasons of the death in COVID ward. Each item was attributed a score according to a pros/cons and opportunities/threats system, derived from evidence in the literature. Scores were presented in a Cartesian graph showing the positioning according to the potential value and the perceived risk associated with the items. In the end, the performances of MC (Covid ward, split in I wave, II wave and overall) and MCF (internal medicine Covid-free ward) have been compared through the Barber's nomogram.

Results

MCF hospitalized 790 patients (-23,90% compared to 2019), Overall-MC patients: 50% of the 2019 MCF. Main cause of mortality-risk: patients originating from local facilities (+7%) and comorbidities (58% Chronic renal failure, 41% cancer, 90% age, 70% COVID 19 WHO stage 3. >3 comorbidities: 100%, ≥5: 24,7%). Length of stay: 8-60 days (mean value, MV: 17) for MC, 2-12 (MV 8) for MCF. Turnover Index: 10 day for MC II, 8 MC I, 1 for MCF. 25% of patients in MC have been treated with Non Invasive Ventilation (NIV), with high cost hospitalization-related.

Conclusions

Internal-Medicine ward model is a ward strictly tied to the community both before and after hospitalization. COVID 19 proposes a new model of IM, nearly subintensive ward, with NIV and continuous monitoring of vital signs, long length of stay and low turnover index. Is this the internal medicine ward for the future?

Key messages

COVID 19 proposes a new model of Internal Medicine ward, nearly subintensive ward, with Non Invasive Ventilation and continuous monitoring of vital signs, long length of stay and low turnover index.

Covid 19 mortality is strictly connected with the origin from territorial health-assisted residences.

Device therapy for the major complications detection and early treatment of patients with natural and iatrogenic comorbidities admitted to internal medicine wards

Background

Whith advances in devices miniaturization and wireless technologies, wereable “on body” ECG patch devices are unobtrusive and easy to use. Continuous ECG monitoring in the short term is indicated in patients who, due to age, comorbidities and polytherapy, are at greater risk of arrhythmias. Since 2017, a randomized-open label study is being conducted at the admission of acute patients in Internal Medicine Unit for 72 hours with continuous monitoring of vital parameters and the 5 leads-ECG (VP-ECG CM) trace by the mean of a tele-cardiology program.

Purpose

Objective of this study is to perform a cost-effectiveness evaluation of the VP-ECG CM program in inpatient settings.

Methods

Data were used in order to evaluate costs, the program effectiveness and the QALY gains using wireless monitoring compared to nurses traditional one. Costs were estimated by mean of the identification, measuring and valorization of the resources uptake. Cost drivers included: time spent by personnel, cost of the device, consumables, medical treatments, diagnostic exams and complications. The perspective of the Italian National Health Service was adopted. The incremental analysis was performed in order to present the cost per complication avoided and the cost per QALY gained. Net monetary benefit was also calculated. Either a deterministic and probabilistic analysis were performed by means of a bootstrap simulation allowing for re-sampling. A cost-effectiveness-acceptability curve was estimated, considering a cost-effectiveness threshold of €35,000/QALY.

Results

On 143 patients, arrhythmias and acute coronary syndrome were detected 4.3% in the experimental arm and 1.9% in the control arm, whilst 29,5% major complications were detected in the experimental arm vs 43.5% in the control and reduction in the number of sudden deaths (16% control and 9.3% experimental). Time spent by nurses in the control arm (58 minutes/day/patient) was the most relevant cost driver and allowed a saving ranging €54–90/patient. This saving overwhelmed the costs for the equipment whilst the other costs remained unchanged, thus allowing for the VP-ECG CM to be dominant versus the standard of care. One way and multiway sensitivity analyses confirmed the robustness of our results with p-value 0,05 involved in the bootstrap presenting dominance of the VP-ECG CM.

Conclusions

Notwithstanding the concerns of a loss of control in patient management, telemedicine (digital health infrastructure and driver) could perform healthcare transformation enabling physicians to increase the volume of patients seen, reduce the time to diagnosis, improve efficiency and efficacy of disease management, and reduce unnecessary clinic visits and hospital admissions. The miniaturized technologies can improve patient adherence, and the detection, characterization and monitoring of cardiac arrhythmias – readily digitalized markers and phenotypes of cardiovascular disease.

Funding Acknowledgement

Type of funding sources: None. Wireless Monitoring Study flowchart

An Emerging Paradigm for Germline Testing in Pancreatic Ductal Adenocarcinoma and Immediate Implications for Clinical Practice: A Review

Importance

Pancreatic ductal adenocarcinoma (PDAC) is a malignant neoplasm with a rising incidence and is a leading public health challenge. Pancreatic ductal adenocarcinoma has been well characterized genomically, with findings of therapeutic actionability that have substantive implications for clinical practice based on recent high-level evidence.

Observations

Pathogenic germline alterations (PGAs) are relatively common in individuals with PDAC, as evidenced in multiple recent data sets, with a frequency of approximately 10%. The most common PGAs are in BRCA1, BRCA2, and ATM and more rarely in PALB2, MLH1, MSH2, MSH6, PMS2, CDKN2A, and TP53, among others, with an aggregate frequency of 3.8% to 9.7%. These PGAs are of key interest owing to therapeutic actionability and the downstream identification of at-risk family members and possible hereditary cancer syndromes. Approximately 3% to 7% of individuals with PDAC harbor a BRCA1 or BRCA2 mutation, which are among the most frequently mutated genes in PDAC. Recent updates to the American Society of Clinical Oncology and the National Comprehensive Cancer Network guidelines recommend risk assessment for all individuals with PDAC irrespective of personal or family history or ethnicity. Treatment implications include the use of checkpoint inhibitor therapy for mismatch repair-deficient PDAC and the validation of poly-ADP (adenosine diphosphate)-ribose polymerase inhibitor (PARPi) therapy as a maintenance strategy in platinum-sensitive PDAC.

Conclusions and Relevance

With increasing evidence and slow improvement of outcomes, PDAC has entered the era of precision medicine. Germline mutations have been identified in key genes with an aggregate frequency of 3.8% to 9.7%, several of which are therapeutically actionable with platinum, PARPi, and checkpoint inhibitor therapy. Potential therapeutic targets need to be actively sought and identified.