Real-world evaluation of access-driven Canadian treatment sequences in progressive prostate cancer (REACTIVATE)

INTRODUCTION

The results of the phase 3 ALSYMPCA trial showed that Radium-223 (Ra-223) improves overall survival (OS) and delays onset of first symptomatic skeletal event vs. placebo in patients with metastatic castration-resistant prostate cancer (mCRPC). The purpose of the REACTIVATE study was to inform the optimal placement of Ra-233 in the treatment sequence by evaluating clinical outcomes and healthcare resource utilization using real-world data from multiple Canadian provinces.

METHODS

This retrospective cohort study analyzed patient outcomes according to Ra-223 placement using administrative databases of four Canadian provinces, encompassing 4301 patients with mCRPC who received at least two lines of life-prolonging therapy (LPT) for mCRPC. Outcomes included OS, event-free survival (EFS), and healthcare resource utilization. Each province was analyzed separately.

RESULTS

OS, measured from the start of second-line LPT, differed between provinces: those in Ontario receiving second-line Ra-223 had a longer OS vs. those receiving it in third-line or later (hazard ratio [HR] 0.79, 95% confidence interval [CI] 0.66-0.95). There was no difference between lines of therapy in patients in British Columbia (HR 1.165, 95% CI, 0.894-1.518, p=0.2576), and OS was numerically worse but not statistically significant in patients receiving Ra-223 in second-line in Quebec (HR 1.44, 95% CI, 0.93-2.24). Other outcomes also varied across provinces, with second-line use of Ra-223 being associated with longer EFS and reduced healthcare utilization vs. third-line use in Ontario but not in Quebec.

CONCLUSIONS

Significant heterogeneity exists in the management and outcomes of mCRPC between provinces, particularly regarding the placement of Ra-223 in the treatment sequence.

Impact of Oncology Drug Review Times on Public Funding Recommendations

New oncology drugs undergo detailed review prior to public funding in a single-payer healthcare system. The aim of this study was to assess how cancer drug review times impact funding recommendations. Drugs reviewed by the pan-Canadian Oncology Drug Review (pCODR) between the years 2012 and 2020 were included. Data were collected including Health Canada approval dates, initial and final funding recommendations, treatment intent, drug class, clinical indications, and incremental cost-effectiveness ratios (ICER). Univariable and multivariable analyses were used to determine the association between funding recommendations and review times. Of the 164 applications submitted, 130 received a positive final recommendation. Median time from Health Canada (HC) approval to final recommendation was longer for drugs indicated for the treatment of gastrointestinal (GI) and lung cancer compared to breast, genitourinary (GU), and other tumours (205 vs. 198 vs. 111 vs. 129 vs. 181 days, respectively; Kruskal-Wallis p = 0.0312). Drugs with longer review times were more likely to receive a negative pCODR recommendation, even when adjusting for tumour type, drug class, and intent of therapy (157 vs. 298 days; Wilcoxon p = 0.0003, OR 1.002 95% CI [1.000-1.004].). There was no association between funding recommendation and tumour type or class of drug. The exploration of factors associated with variance in review times will be important in ensuring timely patient access to cancer drugs.

Cost-Effectiveness of Surveillance after Metastasectomy of Stage IV Colorectal Cancer

Surveillance of stage IV colorectal cancer (CRC) after curative-intent metastasectomy can be effective for detecting asymptomatic recurrence. Guidelines for various forms of surveillance exist but are supported by limited evidence. We aimed to determine the most cost-effective strategy for surveillance following curative-intent metastasectomy of stage IV CRC. We performed a decision analysis to compare four active surveillance strategies involving clinic visits and investigations elicited from National Comprehensive Cancer Network (NCCN) recommendations. Markov model inputs included data from a population-based cohort and literature-derived costs, utilities, and probabilities. The primary outcomes were costs (2021 Canadian dollars) and quality-adjusted life years (QALYs) gained. Over a 10-year base-case time horizon, surveillance with follow-ups every 12 months for 5 years was most economically favourable at a willingness-to-pay threshold of CAD 50,000 per QALY. These patterns were generally robust in the sensitivity analysis. A more intensive surveillance strategy was only favourable with a much higher willingness-to-pay threshold of approximately CAD 425,000 per QALY, with follow-ups every 3 months for 2 years then every 12 months for 3 additional years. Our findings are consistent with NCCN guidelines and justify the need for additional research to determine the impact of surveillance on CRC outcomes.

Stage migration of testicular germ cell tumours in Alberta, Canada, during the COVID-19 pandemic: a retrospective cohort study

BACKGROUND

An absence of screening recommendations and the rapid progression of testicular germ cell tumours (TGCTs) offer a perspective on the potential impact of the COVID-19 pandemic on cancer presentations. We evaluated the presenting cancer stages of TGCTs in a real-world population before and during the pandemic to assess stage migration.

METHODS

We performed a retrospective review of all new patients with TGCT diagnoses in Alberta, Canada, from Dec. 31, 2018, to Apr. 30, 2021, using the Alberta Cancer Registry. Because potential changes in staging should not occur instantaneously, we used a 6-month lag time from Apr. 1, 2020, for seminomas, and a 3-month lag time for nonseminomas, to compare initial cancer stages at presentation before and during the pandemic. We evaluated monthly rates of presentation by stage and histology. Exploratory outcomes included the largest tumour dimension, tumour markers and, for advanced disease, risk category and treatment setting.

RESULTS

Of 335 patients with TGCTs, 231 were diagnosed before the pandemic and 104 during the pandemic (using a lag time). In total, 18 (7.8%) patients diagnosed before the pandemic presented with stage III disease, compared to 16 (15.4%) diagnosed during the pandemic (relative risk 1.97, 95% confidence interval [CI] 1.05-3.72). We observed no significant differences for secondary outcomes. Without a lag time, the rate ratio for a stage II presentation decreased significantly during the pandemic (0.40, 95% CI 0.21-0.72).

INTERPRETATION

We observed signs of TGCT stage migration during the COVID-19 pandemic, driven by a decline in stage II disease and a potential rise in stage III disease. Management of TGCTs should remain a priority, even during a global pandemic.

Systemic Therapy and Its Surgical Implications in Patients with Resectable Liver Colorectal Cancer Metastases. A Report from the Western Canadian Gastrointestinal Cancer Consensus Conference

The Western Canadian Gastrointestinal Cancer Consensus Conference (WCGCCC) convened virtually on 4 November 2021. The WCGCCC is an interactive multi-disciplinary conference attended by health care professionals, including surgical, medical, and radiation oncologists; pathologists; radiologists; and allied health care professionals from across four Western Canadian provinces, British Columbia, Alberta, Saskatchewan, and Manitoba, who are involved in the care of patients with gastrointestinal cancer. They participated in presentation and discussion sessions for the purpose of developing recommendations on the role of systemic therapy and its optimal sequence in patients with resectable metastatic colorectal cancer.

Report from the Western Canadian Gastrointestinal Consensus Cancer Conference—Management of Total Neoadjuvant Therapy in Rectal Cancer

An educational session related to the Western Canadian Gastrointestinal Cancer Consensus Conference (WCGCCC) was held virtually on 14 October 2020. The WCGCCC is an interactive multidisciplinary conference attended by health care professionals from across Western Canada (British Columbia, Alberta, Saskatchewan, and Manitoba), who are involved in the care of patients with gastrointestinal cancer. Surgical, medical, and radiation oncologists; pathologists, radiologists, and allied health care professionals participated in presentation and discussion sessions for the purpose of developing the recommendations presented here. This consensus statement addresses current issues in the management of total neoadjuvant therapy in rectal cancer.

Report from the 21st Annual Western Canadian Gastrointestinal Cancer Consensus Conference; Calgary, Alberta; 20-21 September 2019

The 21st annual Western Canadian Gastrointestinal Cancer Consensus Conference (WCGCCC) was held in Calgary, Alberta, 20-21 September 2019. The WCGCCC is an interactive multi-disciplinary conference attended by health care professionals from across Western Canada (British Columbia, Alberta, Saskatchewan, and Manitoba) involved in the care of patients with gastrointestinal cancer. Surgical, medical, and radiation oncologists, pathologists, radiologists, and allied health care professionals such as dietitians and nurses participated in presentation and discussion sessions to develop the recommendations presented here. This consensus statement addresses current issues in the management of hepato-pancreato-biliary (HPB) cancers.

Efficacy of perioperative chemotherapy in resected colorectal liver metastasis: A systematic review and meta-analysis

BACKGROUND

Nearly half of patients with colorectal cancer develop liver metastases. Radical resection of colorectal liver metastases (CRLM) offers the best chance of cure, significantly improving 5-year survival. Recurrence of metastatic disease is common, occurring in 60 % or more of patients. Clinical equipoise exists regarding the role of perioperative chemotherapy in patients with resected CRLM. This investigation sought to clarify the efficacy of perioperative chemotherapy in patients that have undergone curative-intent resection of CRLM.

METHODS

A systematic review and meta-analysis was completed of randomized controlled trials (RCTs) comparing perioperative chemotherapy to surgery alone in patients with resected CRLM. MEDLINE (Ovid), EMBASE and Cochrane Central Register of Controlled Trials (CENTRAL) databases were searched, as well as abstracts from recent oncology conferences. A meta-analysis was performed pooling the hazard ratios for disease-free survival (DFS) and overall survival (OS), using a random-effects model.

RESULTS

A total of five, phase 3, open-label, RCTs were included resulting in a pooled analysis of 1119 of the total 1146 enrolled patients. 559 patients were randomized to perioperative chemotherapy and 560 to surgery alone. Pooled estimates demonstrated a statistically significant improvement in DFS (HR 0.71, 95 % CI: 0.61-0.82; p < 0.001) but not OS (HR 0.87, 95 % CI: 0.73-1.04; p = 0.136).

CONCLUSION

Perioperative chemotherapy in the setting of resected CRLM resulted in an improvement in DFS, however this did not translate into an OS benefit. Poor compliance to post-hepatectomy oxaliplatin-based chemotherapy regimens was identified. Further investigation into the optimal regimen and sequencing of perioperative chemotherapy is justified.

Association of Concomitant Bone Resorption Inhibitors With Overall Survival Among Patients With Metastatic Castration-Resistant Prostate Cancer and Bone Metastases Receiving Abiraterone Acetate With Prednisone as First-Line Therapy

IMPORTANCE

Bone resorption inhibitors (BRIs) are recommended by international guidelines to prevent skeletal-related events (SREs) among patients with metastatic castration-resistant prostate cancer (mCRPC) and bone metastases. Abiraterone acetate with prednisone is currently the most common first-line therapy for the treatment of patients with mCRPC; however, the clinical impact of the addition of BRIs to abiraterone acetate with prednisone in this disease setting is unknown.

OBJECTIVE

To evaluate the association of the use of concomitant BRIs with overall survival (OS) and time to first SRE among patients with mCRPC and bone metastases receiving abiraterone acetate with prednisone as first-line therapy.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective cohort study collected data from 745 consecutive patients who began receiving abiraterone acetate with prednisone as first-line therapy for mCRPC with bone metastases between January 1, 2013, and December 31, 2016. Data were collected from 8 hospitals in Canada, Europe, and the US from June 15 to September 15, 2019.

EXPOSURES

Patients were classified by receipt vs nonreceipt of concomitant BRIs and subclassified by volume of disease (high volume or low volume, using definitions from the Chemohormonal Therapy Vs Androgen Ablation Randomized Trial for Extensive Disease in Prostate Cancer [CHAARTED] E3805 study) at the initiation of abiraterone acetate with prednisone therapy.

MAIN OUTCOMES AND MEASURES

The primary end point was OS. The secondary end point was time to first SRE. The Kaplan-Meier method and Cox proportional hazards models were used.

RESULTS

Of the 745 men (median age, 77.6 years [interquartile range, 68.1-83.6 years]; 699 White individuals [93.8%]) included in the analysis, 529 men (71.0%) received abiraterone acetate with prednisone alone (abiraterone acetate cohort), and 216 men (29.0%) received abiraterone acetate with prednisone plus BRIs (BRI cohort). A total of 420 men (56.4%) had high-volume disease, and 276 men (37.0%) had low-volume disease. The median follow-up was 23.5 months (95% CI, 19.8-24.9 months). Patients in the BRI cohort experienced significantly longer OS compared with those in the abiraterone acetate cohort (31.8 vs 23.0 months; hazard ratio [HR], 0.65; 95% CI, 0.54-0.79; P < .001). The OS benefit in the BRI cohort was greater for patients with high-volume vs low-volume disease (33.6 vs 19.7 months; HR, 0.51; 95% CI, 0.38-0.68; P < .001). The BRI cohort also had a significantly shorter time to first SRE compared with the abiraterone acetate cohort (32.4 vs 42.7 months; HR, 1.27; 95% CI, 1.00-1.60; P = .04), and the risk of a first SRE was more than double in the subgroup with low-volume disease (HR, 2.29; 95% CI, 1.57-3.35; P < .001). In the multivariable analysis, concomitant BRIs use was independently associated with longer OS (HR, 0.64; 95% CI, 0.52-0.79; P < .001).

CONCLUSIONS AND RELEVANCE

In this study, the addition of BRIs to abiraterone acetate with prednisone as first-line therapy for the treatment of patients with mCRPC and bone metastases was associated with longer OS, particularly in patients with high-volume disease. These results suggest that the use of BRIs in combination with abiraterone acetate with prednisone as first-line therapy for the treatment of mCRPC with bone metastases could be beneficial.

Effect of sorafenib starting dose and dose intensity on survival in patients with hepatocellular carcinoma: Results from a Canadian Multicenter Database

Background

Sorafenib has been shown to improve survival in patients with advanced hepatocellular carcinoma (HCC), however, full dose can be difficult to tolerate. The aim of this study was to determine whether sorafenib starting dose and mean dose intensity affect survival.

Methods

Patients treated with sorafenib for HCC from January 2008 to July 2016 in several Canadian provinces were included and retrospectively analyzed. The primary end point was overall survival (OS) of patients starting on sorafenib full dose compared to reduced dose. Secondary analysis compared OS with different mean dose‐intensity groups. Survival outcomes were assessed with Kaplan‐Meier curves and Cox proportional hazards models. A propensity score analysis was performed to account for treatment bias and confounding.

Results

Of 681 patients included, sorafenib was started at full dose in 289 patients (42%). Median survival for starting full and reduced dose was 9.4 months and 8.9 months (P = .15) respectively. After propensity score matching and adjusting for potential confounders there was still no difference in survival (HR 0.8, 95% CI, 0.61‐1.06, P = .12). Almost half of the patients (45%) received a dose intensity < 50%. Median survival for mean dose intensity > 75%, 50%‐75%, and < 50% were 9.5 months, 12.9 months, and 7.1 months (P = .005) respectively. In multivariable models, starting dose(HR 1.16, 95% CI 0.93‐1.44, P = .180) and mean dose intensity were not associated with survival.

Conclusions

Starting HCC patients on a reduced dose of sorafenib compared to full dose may not compromise survival. Mean dose‐intensity of sorafenib may also not affect survival.

Clinical outcomes of abiraterone acetate + prednisone (AA) + bone resorption inhibitors (BRI) versus AA alone as first-line therapy for castration-resistant prostate cancer (CRPC) with bone metastases (BM) in an international multicenter database

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Background: BM in patients (pts) with CRPC are associated with shorter overall survival (OS) and higher costs. BRI zoledronic acid and denosumab are frequently used to prevent skeletal-related events (SRE) in pts with CRPC and BM. AA is the most common 1st line therapy for men with metastatic CRPC. We aimed to assess the impact of BRI on OS and time to first SRE (ttSRE) of pts receiving 1st line treatment AA for CRPC with BM. Methods: A retrospective cohort of pts starting AA as 1st line therapy for CRPC with BM between 2013-2016 was identified through 8 hospitals’ IRB approved registries. Pts were classified by use of concomitant BRI and subgrouped by volume of disease (per E3805 definition) at AA start. Kaplan-Meier method and Cox models were used to assess OS and ttSRE with hazard ratio (HR) estimates (95% CI). Results: Of the 745 pts included (543 deaths), 529 (71.0%) had AA alone and 216 (29.0%) AA+BRI. Median follow-up was 23.5 months. Pts receiving concomitant BRI showed a significantly longer OS and a 35% reduced risk of death compared to AA alone (HR=0.65; 95% CI, 0.54-0.79; P<.0001). The OS benefit with BRI was greater for the subgroup with high volume disease (HV) (HR=0.51; 95% CI, 0.38-0.68; P<.0001). The cohort with AA+BRI had a significantly shorter ttSRE (HR=1.27; 95% CI; 1.0-1.60; P=.0439) and, notably, the risk of first SRE was more than doubled for the subgroup with LV (HR=2.29; 95% CI, 1.57-3.35; P<.0001). On MVA, BRI vs. no BRI, prior local therapy (PLT) vs. no PLT, LV vs. HV, baseline VAS pain ≤3 vs. >5, PS 0 vs. ≥1, and PSA are independently associated with longer OS. Conclusions: The addition of BRI to 1st line AA for CRPC men with BM was associated with improved OS, particularly in HV, and worsened ttSRE, more evident in LV. These data suggest a potentially different impact of concomitant BRI on HV vs. LV, which could affect clinical decision making.[Table: see text]

Report from the 20th annual Western Canadian Gastrointestinal Cancer Consensus Conference; Saskatoon, Saskatchewan; 28-29 September 2018

The 20th annual Western Canadian Gastrointestinal Cancer Consensus Conference was held in Saskatoon, Saskatchewan, 28-29 September 2018. This interactive multidisciplinary conference is attended by health care professionals from across Western Canada (British Columbia, Alberta, Saskatchewan, and Manitoba) who are involved in the care of patients with gastrointestinal cancers. In addition, invited speakers from other provinces participate. Surgical, medical, and radiation oncologists, and allied health care professionals participated in presentations and discussion sessions for the purpose of developing the recommendations presented here. This consensus statement addresses current issues in the management of colorectal cancers.

Active treatment in low-risk prostate cancer: a population-based study

Background

Active surveillance instead of active treatment (at) is preferred for patients with low-risk prostate cancer (lr-pca), but practice varies widely. We conducted a population-based study to assess the proportion of patients who underwent at between January 2011 and December 2014, and to evaluate factors associated with at.

Methods

The provincial cancer registry was linked to administrative health datasets to identify patients with lr-pca and to acquire demographic, tumour, and treatment data. The primary outcome was receipt of at during the first 12 months after diagnosis, defined as any receipt of external-beam radiotherapy, brachytherapy, radical prostatectomy, cryotherapy, or androgen deprivation. Univariate and multivariate logistic regression were used to analyze the correlation between patient and tumour factors and at.

Results

Of 1565 patients with lr-pca, 554 (35.4%) underwent at within 12 months of diagnosis. Radical prostatectomy was the most common treatment (58%), followed by brachytherapy (29.6%). Younger age [odds ratio (or) 0.92; 95% confidence interval (ci): 0.91 to 0.94], lower score (≥3) on the Charlson comorbidity index (OR: 0.36; 95% ci: 0.19 to 0.68), T2 stage (or: 3.05; 95% ci: 2.03 to 4.58), higher prostate-specific antigen (psa) at diagnosis (or: 1.13; 95% ci: 1.06 to 1.21), radiation oncologist consultation (or: 3.35; 95% ci: 2.55 to 4.39), and earlier diagnosis year (2012 or: 0.46; 95% ci: 0.34 to 0.63; 2013 or: 0.45; 95% ci: 0.32 to 0.63; 2014 or: 0.33; 95% ci: 0.23 to 0.47) were associated with a higher probability of at.

Conclusions

This contemporary population-based study demonstrates that approximately one third of patients with lr-pca undergo at. Patients of younger age, with less comorbidity, a higher tumour stage, higher psa, earlier year of diagnosis, and radiation oncologist consultation were more likely to undergo at. Further investigation is needed to identify strategies that could minimize overtreatment.

Efficacy of bone resorption inhibitors (BRI) + abiraterone acetate + prednisone (AA) vs. AA alone as first-line therapy for men with castration-resistant prostate cancer (CRPC) and bone metastases (BM) in an international multicenter hospital-based registry

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Background: BM in patients (pts) with CRPC correlate with higher mortality and costs. BRI zoledronic acid and denosumab are frequently used for the prevention of skeletal-related events (SRE) in pts with CRPC and BM. AA is the most common 1st line treatment for men with metastatic CRPC. We sought to evaluate the impact of BRI on time to first SRE (ttSRE) and OS of pts receiving 1st line therapy AA for CRPC with BM. Methods: We identified a cohort of men starting AA as 1st line therapy for CRPC with BM between 2013-2015 from 7 hospitals’ IRB approved registries. Pts were grouped by use of concomitant BRI and subgrouped by volume of disease (per E3805 definition) at AA start. The endpoints were OS, defined as time from AA start to death or last follow-up visit, and ttSRE. Results: Of the 338 pts included, 256 (76%) received AA alone and 82 (24%) AA+BRI. ECOG PS (PS) was ≥1 for 178 pts (52.7%). No statistically significant difference in ttSRE was found between the 2 cohorts [see Table]. Median follow-up for OS was 25.6 months. Pts receiving concomitant BRI showed a significantly longer OS and a 36% decreased risk of death compared to AA alone (HR = 0.64; 95% CI, 0.64 0.46-0.91; p = 0.012). Notably, OS in the AA alone group was shorter than commonly described. The OS benefit with BRI was greater for men with high volume disease (HV) (HR = 0.42; 95% CI, 0.25-0.71; p = 0.001). On MVA, BRI vs. no BRI, low volume of disease vs. HV, PS 0 vs. ≥1, baseline VAS pain ≤3 vs. > 5, and baseline PSA are independently associated with longer OS. Conclusions: Using a multicenter database, the addition of BRI to 1st line AA for CRPC men with BM and poor prognostic factors did not improve prevention of SRE. However, concomitant use of BRI and AA was associated with a significantly improved OS, particularly in HV. Further research to determine the driving factors is needed. [Table: see text]

Oncology education for Canadian internal medicine residents: the value of participating in a medical oncology elective rotation

Background

Despite the high incidence and burden of cancer in Canadians, medical oncology (mo) rotations are not mandatory in most Canadian internal medicine (im) residency training programs.

Methods

All im residents scheduled for a mo rotation at 4 Canadian teaching cancer centres between 1 January 2013 and 31 December 2015 were invited to complete an online survey before and after their rotation. The survey was designed to evaluate perceptions of oncology, comfort in managing cancer patients, and basic oncology knowledge.

Results

The survey was completed by 68 im residents pre-rotation and by 48 (71%) post-rotation. Cancer-related learning was acquired mostly from mo physicians in clinic (35%). Self-directed learning, didactic teaching, and resident or fellow teaching accounted for 31%, 26%, and 10% respectively of learning acquisition. Comfort level in dealing with cancer patients and patients at end of life improved to 4.0/5 from 3.2/5 (p < 0.001) and to 4.0/5 from 3.6/5 (p = 0.003) respectively. Mean knowledge assessment score improved to 83% post-rotation from 76% pre-rotation (p = 0.003), with the greatest increase observed in general knowledge of common malignancies. The 3 topics ranked as most important to learn during a mo rotation were oncologic emergencies, common complications of treatment, and approach to diagnosis of cancer.

Conclusions

A rotation in mo improves the perceptions of im residents about oncology and their comfort level in dealing with cancer patients and patients at end of life. Overall cancer knowledge is also improved. Given those benefits, im residency programs should encourage most of their residents to complete a mo rotation.

The Prognostic Role of the Change in Neutrophil-to-Lymphocyte Ratio During Neoadjuvant Chemotherapy in Patients with Muscle-Invasive Bladder Cancer: A Retrospective, Multi-Institutional Study

Background:

The impact of the change in the neutrophil-to-lymphocyte ratio (NLR) during neoadjuvant chemotherapy (NAC) on outcomes in patients with muscle-invasive bladder cancer (MIBC) is poorly understood.

Objective:

To evaluate the prognostic impact of the change in NLR during NAC for patients with MIBC.

Methods:

Patients referred to academic, community, and quaternary referral centres in Alberta, Canada from 2005 to 2015, Ontario, Canada from 2005 to 2013, and Southampton, UK from 2004 to 2010 were evaluated. 376 eligible patients were treated with NAC for clinical T2-4aN0M0 disease, and 296 were evaluable for the change in NLR. A high NLR was defined as being an NLR > 3. Relationships between the change in NLR from baseline to mid-NAC (pre-cycle 3) and outcomes were analyzed using multivariable Cox regression. Kaplan-Meier analysis was used with the log-rank test for group comparisons.

Results:

Median follow-up was 22.0 months (95% confidence interval [CI]: 14.9–30.0). Patients with a sustained high NLR had a median disease-free survival (DFS) of 12.6 months, compared to 34.8 months for those with a sustained low NLR (log-rank test p = 0.0025; hazard ratio [HR] 0.61 [95% CI: 0.44–0.84]). Median overall survival (OS) was 19.4 months for patients with a sustained high NLR, compared to 44.0 months for patients with a sustained low NLR (log-rank test p = 0.0011; HR 0.54 [95% CI: 0.38–0.77]).

Conclusions:

A sustained high NLR from baseline to mid-NAC is an independent prognostic factor for patients with MIBC.

Effect of sorafenib (S) starting dose and dose intensity on survival in patients with hepatocellular carcinoma (HCC): Results from a Canadian multicenter HCC database

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Background: The SHARP trial showed that S improves survival in advanced HCC. Full dose (FD) S at 400mg bid can be difficult to tolerate, so some clinicians begin with a reduced dose (RD) & escalate as tolerated to maximum dose. The purpose of this study was to determine whether starting dose or dose intensity of S affects survival. Methods: All patients treated with S for HCC from 01/2008 to 06/2016 in British Columbia, Alberta, Ontario (Princess Margaret Cancer Centre & Sunnybrook Odette Cancer Centre), were included. Patient demographics, clinical, tumor characteristics, S starting dose & mean dose intensity were collected & analyzed. Patients were dichotomized into starting FD or RD of S. Mean dose intensity was categorized into > 75%, 50-75% & < 50%. Survival outcomes were assessed with Kaplan-Meier curves & compared with the log-rank test. A Cox-proportional hazard model was constructed with starting dose, dose intensity & relevant clinical & pathologic factors to assess their impact on survival. Results: We included 681 patients. Median age 64 years, 80% men, 37% East Asian, & most frequent causes of liver disease were hepatitis B (33%) & C (29%). ECOG performance status prior to starting S was 0 in 30% & 1 in 60%. Most patients were Childs-Pugh A (86%) at start of S. Overall median survival was 9.1 months (m). S was started at FD in 42% of patients & 31% had a dose intensity > 75%. The median survival for starting FD & RD was 9.4 m & 8.9 m, respectively (p = 0.15). The median survival for a dose intensity > 75% was 9.5 m, 50-75% was 12.9 m & < 50% was 7.1 m (p = 0.005). In multivariate models that adjusted for demographic, stage, performance status, AFP, prior treatment, toxicity & liver function, starting dose (HR 1.1, 95%CI 0.86-1.3, p = 0.51) & dose intensity (50-75% HR 0.93, 95% CI 0.73-1.2; < 50% HR 0.89, 95% CI 0.69-1.1, p = 0.65) were not predictors of survival. Conclusions: Based on our multi-center database, starting HCC patients on a RD of S may be a reasonable since it does not appear to compromise survival. Patients receiving a dose intensity of S at 50-75% appear to have a superior median survival, though this is not significant after controlling for baseline characteristics.

The effect of sorafenib (S) starting dose and dose intensity on survival in patients with advanced hepatocellular carcinoma (HCC)

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Background: The SHARP trial showed that S improves survival in advanced HCC. In clinical practice full dose (FD) of S at 400mg bid can be difficult to tolerate and so a reduced dose (RD) is often required. The purpose of this study was to determine whether starting dose or dose intensity of S affects survival in patients with HCC. Methods: All patients treated with S for HCC in Alberta, Canada from January 2008 to July 2016 were included in this study. Patient demographics, clinical, tumor characteristics, S starting dose and dose intensity were collected and analyzed. Patients were dichotomized into starting FD or RD of S. A mean dose intensity of > 75% and < / = 75% were considered normal and reduced, respectively. Survival outcomes were assessed with Kaplan-Meier curves and compared with the log-rank test. A Cox-proportional hazard model was constructed with starting dose, dose intensity and relevant clinical and pathologic factors to assess their impact on survival. Results: A total of 156 patients were included. Median age was 63, 78% were men, 34% were East Asian, 77% were Childs-Pugh A, and the most common causes of liver disease were hepatitis B (30%) and C (30%). Most patients had EGOG performance status of 0 and 1 prior to starting S (29% and 62%, respectively). S was started at FD in 58% of patients and 50% had a dose intensity > 75%. The median survival for both starting FD and RD was 10.3 months, and not significantly different (p = 0.14).The median survival for a dose intensity > 75% vs < / = 75% was 10.7 vs 9.5 months, respectively (p = 0.76). In multivariable models that adjusted for demographic, stage, performance status and liver function, starting dose (HR 0.8 95%CI 0.5-1.2) and dose intensity (HR0.9 95% CI 0.6-1.4) were not associated with survival. Conclusions: Starting S with a RD may be a reasonable strategy for HCC, since it does not appear to impact survival. Also, dose intensity did not impact survival, suggesting that additional dose modifications may not compromise effectiveness. Though limited by small numbers, we are planning to confirm these findings in a larger, pan-Canadian dataset.

A Comparison of Survival by Site of Metastatic Resection in Metastatic Colorectal Cancer

BACKGROUND

Metastatic resection (MR) of liver-limited disease is an effective therapy for selected patients with metastatic colorectal cancer (mCRC). Despite limited data, this approach has been expanded to include MR of other sites, such as the lung, locoregional, and other distant disease (ODD). We performed a population-based study of patients with mCRC who had undergone MR and compared survival between MR of the liver and MR of other sites.

METHODS

Patients with mCRC who were referred to the British Columbia Cancer Agency between 1995 and 2010 were reviewed. Patients were included if they had an R0 MR with a negative margin and no residual disease. The site of MR was classified according to collaborative staging criteria as liver, lung, locoregional, or ODD. Median overall survival (mOS) was assessed with Kaplan-Meier methods and compared using the log-rank test. A Cox proportional-hazards model was used to compare mOS, while adjusting for known prognostic factors.

RESULTS

A total of 2082 patients with mCRC were identified, of whom 257 underwent R0 MR. Sites of MR included liver (65%), lung (16%), locoregional (5%), and ODD (14%). The mOS of liver, lung, locoregional, and ODD were 48.0, 42.8, 37.2, and 26.2 months, respectively (P = .087). On multivariate analysis, only MR of ODD had a significantly different survival estimate than MR of the liver (hazard ratio, 1.78; 95% confidence interval, 1.13-2.80; P = .012).

CONCLUSIONS

Patients with limited lung and locoregional disease seem to have a comparable survival advantage from MR as patients with liver-limited metastases.

PROSPECT Eligibility and Clinical Outcomes: Results From the Pan-Canadian Rectal Cancer Consortium

BACKGROUND

The PROSPECT trial (N1048) is evaluating the selective use of chemoradiation in patients with cT2N1 and cT3N0-1 rectal cancer undergoing sphincter-sparing low anterior resection. We evaluated outcomes of PROSPECT-eligible and -ineligible patients from a multi-institutional database.

PATIENTS AND METHODS

Data from patients with locally advanced rectal cancer who received chemoradiation and low anterior resection from 2005 to 2014 were retrospectively collected from 5 Canadian centers. Overall survival, disease-free survival (DFS), recurrence-free survival (RFS), and time to local recurrence (LR) were estimated using the Kaplan-Meier method, and a multivariate analysis was performed adjusting for prognostic factors.

RESULTS

A total of 566 (37%) of 1531 patients met the PROSPECT eligibility criteria. Eligible patients were more likely to have better PS (P = .0003) and negative circumferential resection margin (P < .0001). PROSPECT eligibility was associated with improved DFS (hazard ratio [HR], 0.75; 95% confidence interval [CI], 0.61-0.91), overall survival (HR, 0.73; 95% CI, 0.57-0.95), and RFS (HR, 0.68; 95% CI, 0.54-0.86) in univariate analyses. In multivariate analysis, only RFS remained significantly improved for PROSPECT-eligible patients (HR, 0.75; 95% CI, 0.57-1.00, P = .0499). The 3-year DFS and freedom from LR for PROSPECT-eligible patients were 79.1% and 97.4%, respectively, compared to 71.1% and 96.8% for PROSPECT-ineligible patients.

CONCLUSION

Real-world data corroborate the eligibility criteria used in the PROSPECT study; the criteria identify a subgroup of patients in whom risk of recurrence is lower and in whom selective use of chemoradiation should be actively examined.

Current management and future perspectives of metastatic renal cell carcinoma

Over the last number of years, the treatment of metastatic renal cell cancer has evolved tremendously with the advent of targeted therapy. Previously, immunotherapies, such as interferon alpha and interleukin-2, were the only treatment options available for this chemoresistant malignancy. Currently, seven additional agents, including sunitinib, sorafenib, axitinib, pazopanib, bevacizumab, everolimus and temsirolimus, have been approved for use in metastatic renal cell cancer, with several more in development. The efficacy of these agents depends primarily on inhibition of the vascular endothelial growth factor and mammalian target of rapamycin pathways, and have drastically improved the outcomes of patients diagnosed with metastatic renal cell cancer. This article reviews the major treatment advances that have occurred for metastatic renal cell cancer with the advent of targeted treatments, summarizes the evidence to support their use and addresses clinical issues that have arisen with them. To help guide clinicians in their decision-making with these emerging therapeutic choices, the evidence for sequencing and combining these agents, and the need for biomarkers will be addressed. The role of surgical management options, such as cytoreductive nephrectomy and metastectomy, in the era of targeted treatment is also reviewed. Several novel treatments are also on the horizon, which might serve as future avenues for treatment advancement in metastatic renal cell cancer.

Abstract 156: Prognostic significance of distance travelled to the cancer center in women treated with adjuvant trastuzumab

Background: Adjuvant trastuzumab therapy (ATT) in women with HER2 positive breast cancer has significantly improved survival. The current standard duration of ATT is one year. In order to prevent symptomatic cardiac dysfunction, periodic cardiac monitoring is recommended during ATT. Rural residents have to travel in excess of several hundred kilometers both for cardiac monitoring and treatment. The study aims to determine relationship between distance travelled to the cancer center and disease free survival (DFS) and overall survival (OS) in women with HER2 positive breast cancer.

Methods: Retrospective cohort study of women with early stage HER2 positive breast cancer treated in the province of Saskatchewan from 2005 to 2009. The study cohort was divided into two groups: group I (distance travelled &lt;100 km) and group II (distance travelled 100 km). Kaplan-Meier methods were used for survival estimation and Log Rank testing was done for survival comparison. Cox proportional hazard models were performed and various clinico-pathological variables were examined for their prognostic significance.

Results: A total of 211 eligible women with median age of 54 yrs (range: 27-80) were identified. 70% were postmenopausal, 52% had node positive disease and 60% had ER or PR positive disease. 57% women were rural residents. A statistically significant difference was noted between the 2 groups with respect to age, rural residence, comorbid illness and delay in start of therapy. All women received adjuvant chemotherapy and ATT. 97% women completed adjuvant chemotherapy and 83% completed planned ATT. During the median follow-up period of 37.1 months, 30 women developed recurrent disease and 26 died. Median DFS of Group II was 63.09 months and has not reached in Group I (p=0.5). Median OS of both groups has not reached. 5 years estimated DFS of group I was 77% compared with 57% in Group II (p=0.5). ER/PR negative disease, hazard ratio (HR) 2.53 (95% CI: 1.14-5.64) and discontinuation of ATT, HR 2.3 (95% CI: 1.06-5.00) were significantly correlated with an increased risk of recurrence. With respect to survival younger age, HR 5.33 (95% CI: 1.72-16.52); ER/PR negative tumors, HR 6.6 (95% CI: 2.23-19.37); and premenopausal status, HR 8.18 (95% CI: 2.27-29.51) were correlated with an increased mortality.

Conclusions: Although there was a trend toward increased risk of recurrence in women travelled longer distance, it was not statistically significant. Younger age, premenopausal status, ER/PR - tumors and discontinuation of ATT were correlated with inferior outcomes.

Citation Format: Sarah Roberts, Sabuj Sarker, Richard Lee-Ying, Charanpreeti Ubhi, Shahid Ahmed. Prognostic significance of distance travelled to the cancer center in women treated with adjuvant trastuzumab. [abstract]. In: Proceedings of the 104th Annual Meeting of the American Association for Cancer Research; 2013 Apr 6-10; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2013;73(8 Suppl):Abstract nr 156. doi:10.1158/1538-7445.AM2013-156

Chemotherapy-related thrombocytosis: does it increase the risk of thromboembolism?

OBJECTIVES

Chemotherapy increases the risk of thromboembolism in patients with cancer. Although thrombocytopenia is a known side effect of chemotherapy, reactive thrombocytosis related to chemotherapy is uncommonly reported. The present study aimed to determine the incidence of gemcitabine-related thrombocytosis and the associated risk of thromboembolism.

METHODS

Medical records of 250 consecutive patients with a malignant disease who received gemcitabine-based therapy were reviewed. A multivariate analysis was done to determine factors associated with thromboembolism.

RESULTS

A total of 220 eligible patients with a median age of 63 years (range 26-83) were identified. Of these 220 patients, 95% had advanced malignancy and 59% had received prior chemotherapy. A total of 69% of patients received a platinum combination. In all, 46% patients experienced thrombocytosis following chemotherapy, with a median platelet count of 632 × 10(9)/l (range 457-1,385). Twenty-three of the 220 patients experienced a vascular event within 6 weeks of treatment. Eleven patients with thrombocytosis experienced a vascular event compared with 10 patients without thrombocytosis (not significant). On multivariate analysis, leukocytosis (odds ratio 5.8, 95% confidence interval 2.1-15.8) and comorbid illnesses (odds ratio 4.1, 95% confidence interval 1.4-12.6) were correlated with thromboembolism.

CONCLUSIONS

Although gemcitabine-based therapy has been associated with an increased incidence of thrombocytosis, it does not increase the risk of thromboembolism in cancer patients. Leukocytosis and comorbid illnesses do increase the risk of thromboembolism.

P1-08-15: Pattern of Cardiac Monitoring and Risk of Trastuzumab Associated-Cardiac Dysfunction in a Clinical Practice: A Population Based Study

Background: Adjuvant trastuzumab therapy (ATT) in women with early-stage HER2+ breast cancer has been associated with significant reduction in the disease recurrence and mortality. Cardiac dysfunction (CD) is a known serious adverse effect of ATT. Although periodic cardiac monitoring is recommended during ATT, little is known about pattern of cardiac monitoring and incidence of CD in a clinical setting. The study aimed to determine extent of cardiac monitoring and rate of CD during ATT and to identify factors correlated with CD.

Methods: Medical records of women with localized HER+ breast cancer diagnosed between the years 2005–2007 in the province of Saskatchewan was reviewed. Women with advanced or recurrent disease or if they were treated in the setting of an adjuvant trastuzumab trial were excluded. A logistic regression analysis was performed to determine various clinical variables correlated with CD.

Results: A total 116 eligible women with median age of 54 yrs (range: 27–74) and median BMI of 27 (range: 44–17) were indentified. 40% had a cardiac risk factor & 30% were premenopausal. 51% had node positive & 53% had ER or PR+ breast cancer. 92% received anthracycline-based chemotherapy and 23% received sequential ATT. Of 62 patients with ER/PR+ breast cancer, 61% received adjuvant aromatase inhibitors. Baseline cardiac assessment was performed in 93% women. 98% women underwent periodic cardiac monitoring during ATT, 55% had monitoring performed at the interval of 3–4 months & 82% women had monitoring performed at the interval of 3–6 months. Mean baseline cardiac ejection fraction (EF%) prior to the commencement of chemotherapy and ATT were 65% & 63.9% respectively (p=NS). CD was observed in 32 (28%) women and only 4% were symptomatic. Trastuzumab was interrupted in 34%, and was discontinued in 20% women. Of 32 women with CD, 59% were referred to a cardiologist and 53% were treated with medication. CD was reversible in 84% cases. On multivariate analysis adjuvant aromatase inhibitor therapy was significantly correlated with cardiac dysfunction (Odd ratio 6.9 [95% CI: 1.4−33.0]). During the follow up period 18% women developed recurrent disease and 16% were died.

Conclusions: Our results confirm high compliance with cardiac monitoring, though not as frequently as recommended in the clinical trial setting. Overall the rate of symptomatic decline in cardiac function was similar to the rate reported in the clinical trials, however, a relatively higher incidence of asymptomatic decline in the left ventricle EF% was noted. Among various variables examined, adjuvant aromatase inhibitor therapy was associated with an increased risk of CD.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P1-08-15.