Abstract P5-19-07: Defining priorities for research: Interim results of the Canadian metastatic breast cancer priority setting partnership

Background: Research priorities are generally determined by funders and researchers without direct involvement and input from patients and caregivers. Certain disease areas have incorporated the patient voice to determine patient driven priorities. In this study, this approach was employed to better understand the needs and priorities of metastatic breast cancer patients and their caregivers.

Methods: This study was conducted using methodology outlined by the James Lind Alliance. A steering committee of patients, physicians, patient advocates, and allied health care professionals was assembled to oversee the research study. The initial survey collected unanswered research questions from patients, caregivers, and clinicians. Responses were collected and categorized by consensus of the steering committee. Here we present the results from the national survey.

Results: Between November 2016 and April 2017, 733 responses from 311 individuals were collected (62% patients, 11% physicians, 9% caregivers or relatives, 5% nurses/allied health professionals, 2% patient organization representatives, and 10% other). The main themes for key patient priorities are: 136 (19%) related to treatment and monitoring, 78 (11%) linked lifestyle and alternative therapy, 58 (8%) regarded tumour biology, 53 (7%) regarded psychosocial aspects, 46 (6%) to diagnosis, 35 (5%) to toxicity, 24 (3%) to prevention, and 17 (2%) to young or pre-menopausal population. Two hundred and eighty-six (39%) were considered out of scope. The most frequently identified priorities included the role of alternative therapies for improving survival, the role of immune therapy for treating metastatic breast cancer, and the potential for improving outcomes with early detection/surveillance with modern treatment and diagnostic modalities.

Conclusion: Patient derived research priorities in advanced breast cancer point to an improved understanding of alternative therapies, integration of immune therapy and a focus on early detection of relapse. These priorities should be addressed by the research community to meet the needs of our patients with advanced breast cancer.

Citation Format: Nixon N, Simmons C, Lemieux J, Verma S. Defining priorities for research: Interim results of the Canadian metastatic breast cancer priority setting partnership [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P5-19-07.

Transformational change: nurses substituting for ophthalmologists for intravitreal injections - a quality-improvement report

BACKGROUND

The dramatic increase in need for anti-vascular endothelial growth factor (anti-VEGF) intravitreal therapy in the treatment of retinal disease and the absence of an equivalent increase in ophthalmologists to undertake such intravitreal injections created a patient-safety risk. Timing of intravitreal therapy (IVT) is critical to prevent vision loss and local clinics lacked capacity to treat patients appropriately. We aimed to improve capacity for IVT by nurse injections.

MATERIALS AND METHODS

A multidisciplinary prospective service-improvement process was undertaken at two adjacent general hospitals in the northwest of England. IVT injections by nurses were a principal component of solution development. After we had obtained appropriate institutional approval, experienced ophthalmic nurses were trained, supervised, and assessed to undertake IVT. Ophthalmologists directly supervised the first 200 injections, and a retina specialist was always on site.

RESULTS

Nurses undertook 3,355 intravitreal injections between June 2012 and November 2013, with minor adverse events (0.3% subconjunctival hemorrhage and corneal abrasion). There were no patient complaints at either hospital.

CONCLUSION

Experienced ophthalmic nurses quickly learned how to perform such injections safely. IVT by nurses was well accepted by patients and staff. Hospital A trained three nurses sequentially for improved flexibility in scheduling. Novel use of appropriately trained non-medical staff can improve efficiency and access in an overburdened service with time-sensitive disease. Retinal assessment was undertaken by ophthalmologists only. Improved access to IVT is important, as treatment with anti-VEGF therapy reduces blindness at population levels.

Abstract P2-12-03: I-SPY 2 Clinical Trial: Telephone Support Provided by Peer Counselors

Background: I-SPY 2 is an innovative collaboration to assess 8-12 investigational agents and numerous biomarkers in an adaptive, neoadjuvant clinical trial for patients with locally advanced breast cancer and a high likelihood of recurrence. The first site opened in March 2010, and the trial will eventually open in up to 20 sites and enroll 800 patients. It is well known that patients who have recently been diagnosed with breast cancer are often overwhelmed, frightened and cognitively impaired. Making treatment decisions and dealing with the strain of treatment are among the most traumatic events patients are likely to experience. Nevertheless, they are often significantly helped by peer support. Methods: The Breast Cancer Network of Strength (formerly Y-ME) provides 24x7 peer support for callers seeking information and/or support related to breast cancer. All peer counselors are trained and certified breast cancer survivors. I-SPY 2 partnered with this organization to leverage their services in the I-SPY 2 trial. In particular, ten experienced peer counselors received a day of training to prepare them to counsel I-SPY 2 patients. They learned about the details of the trial, support materials available to patients (i.e., I-SPY 2 brochure, DVD and website), and specific challenges patients going through the trial are likely to face. Training included extensive role play exercises. When patients agree to treatment within the I-SPY 2 trial, they are offered the option of peer counseling. If they so choose, a counselor will call five times during their six months of treatment. Calls will be scheduled to meet the needs of individual patients, but are expected to take place: 1) shortly after enrollment; 2) a week after the first chemotherapy treatment; 3) shortly after completion of pacitaxel and any investigational agent; 4) shortly before surgery; and 5) shortly after surgery. The goals of providing peer support to I-SPY2 participants are to: 1) provide participants with an opportunity to discuss their diagnosis,treatment, and trial issues to validate emotions and provide support for dealing with the rigors of receiving breast cancer treatment; 2) help patients understand and anticipate upcoming aspects of their treatment; and 3) encourage patients to comply with trial requirements and raise concerns with their health care providers. Discussion: The I-SPY 2 trial initially planned to offer patients who were deciding whether to participate in the trial the option of speaking to a peer counselor. However, one IRB objected to this use of peer counselors despite demonstration of peer counselors being helpful and not coercive. For example, when this service was provided in CALGB 49907, a majority of patients who used the service expressed appreciation of counseling, but only about 50% who spoke to counselors enrolled in the trial. In the current study, use of peer counselors will initially be restricted to enrolled patients. However, it is likely that it be expanded to patients contemplating participation at sites where IRBs agree. Future research will clarify which patients request counselors and why, how they view their experience, and to what extent peer counseling influences patient enrollment, compliance and trial completion.

Citation Information: Cancer Res 2010;70(24 Suppl):Abstract nr P2-12-03.

Association of polymorphism in the transforming growth factor {beta}1 gene with disease outcome and mortality in rheumatoid arthritis

OBJECTIVE

To investigate whether polymorphism in the transforming growth factor beta1 (TGFbeta1) gene is associated with disease outcome in rheumatoid arthritis.

METHODS

208 patients with established rheumatoid arthritis were genotyped for the TGFbeta1 T869C polymorphism using an amplification refractory mutation system-polymerase chain reaction (ARMS-PCR) method. Disease severity was assessed by measuring radiographic damage by Larsen score and functional outcome by the health assessment questionnaire (HAQ). Patients were tracked on the NHS central register for notification of death, and the relation between TGFbeta1 polymorphism and mortality was analysed using Cox proportional hazards regression.

RESULTS

Patients carrying a TGFbeta1 T allele had a higher mean HAQ score than those without this allele (1.60 v 1.22, p = 0.04). The T allele was also associated with higher five year mean area under the curve (MAUC) erythrocyte sedimentation rate (ESR), and nodular disease. Larsen score was higher in patients with the TT genotype compared with CC + CT genotypes, although this was not significant after correction for disease duration. There was a trend of increasing mortality risk with T allele dose after adjustment for age, sex, and disease duration (hazard ratio = 1.6 (95% confidence interval, 1.1 to 2.4), p = 0.01).

CONCLUSIONS

TGFbeta1 T869C gene polymorphism is associated with disease outcome in rheumatoid arthritis. Carriage of the T allele (putatively associated with decreased TGFbeta1 production) was associated with increased inflammatory activity and poor functional outcome, while increasing T allele dose was associated with worse survival.

Demonstration of cytokeratin in endothelial cells of the synovial microvasculature in situ and in vitro

We have used a panel of anti-cytokeratin antibodies and immunofluorescence microscopy to examine synovial tissue from a variety of large and small joints in patients with various rheumatic conditions, including RA, OA, AS, pigmented villonodular synovitis (PVNS) and tenosynovitis (TS). In every case we regularly found blood vessels with endothelia which express cytokeratin. Positive staining was obtained with a guinea pig anti-keratin antibody, with monoclonal antibody 8.13 and with a monoclonal antibody specific for keratin 18. Staining of endothelial cells was confirmed by double labelling with antibodies to cytokeratin and factor VIII/von Willebrand factor. We also detected a polypeptide corresponding to cytokeratin 18 (MW 45,000) by Western blotting of synovial tissue. In addition we have isolated pure populations of synovial endothelial cells in culture and demonstrate an extensive cytokeratin intermediate filament network which co-localizes with vimentin filaments. An understanding of the role of the cytokeratin 18 network in synovial endothelium may be important for our understanding of endothelial changes in synovial disease.

Alpha, mu and pi class glutathione S-transferases in human synovium and cultured synovial fibroblasts: effects of interleukin-1 alpha, hydrogen peroxide and inhibition of eicosanoid synthesis

We describe expression of alpha, mu and pi class glutathione S-transferase (GST) and, CuZn- and Mn superoxide dismutase (SOD) in human synovium and cultured synovial fibroblasts. Immunohistochemical and immunoblotting studies showed synovium and cultured cells expressed pi GST and both isoforms of SOD. Cellular localisation was largely perinuclear. No expression of alpha or mu GST was detected even though polymerase chain reaction analysis showed 4/6 subjects had positive genotypes at the polymorphic, mu class GSTM1 locus. Incubation of cultured synovial fibroblasts with H2O2, IL-1 alpha and the cyclooxygenase and lipoxygenase inhibitor, Tenidap, did not induce expression of alpha, mu or pi GST though treatment with IL-1 alpha caused a marked increase in the expression of Mn SOD.

Rheumatoid arthritis and chronic lymphatic leukaemia

There is evidence for an increased incidence of lymphoproliferative disorders in patients with rheumatoid arthritis (RA). We present the clinical features of 4 patients with RA and chronic lymphatic leukaemia (CLL) which, occurring in a population of 1505 RA patients, represents a significantly increased prevalence of CLL (p less than 0.05) compared to the general population. These patients had significantly lower natural killer cell activity than matched rheumatoid controls (p less than 0.05) or normal controls (p less than 0.01) and we discuss this as a possible mechanism of association.