Targeting BRAF V600E in metastatic colorectal cancer: where are we today?

Colorectal cancer (CRC) is the second most frequent cause of direct cancer death worldwide. The study of the molecular state of oncogenes has predictive and prognostic value in metastatic CRC (mCRC). The B-raf proto-oncogene (BRAF) gene mutation represents the 8%-12% of all mutations in mCRC. The BRAF V600E mutation, considered the most common alteration of BRAF, corresponds to a constitutive kinase with a high activating capacity of the RAS/RAF/MEK/ERK pathway after a cascade of successive phosphorylations in the transcription of genes. BRAF V600E mutation is more prevalent in women, elderly, right-sided colon cancer and Caucasian population. Unfortunately, it is considered a poor predictive and prognosis biomarker. Patients with mCRC BRAF V600E mutated (BRAFm) are generally associated with poor response to chemotherapy and short progression-free survival and overall survival. Recently, randomised clinical trials have studied the combination of different chemotherapy regimens with angiogenic inhibitors in mCRC BRAFm. In addition, new anti-BRAF and immunotherapy agents have also been studied in this population, with positive results. The objective of this review is to acknowledge the biology and molecular pathway of BRAF, critically analyse the clinical trials and the therapy options published until today and evaluate the options of treatment according to the patient's clinical presentation.

A high number of co-occurring genomic alterations detected by NGS is associated with worse clinical outcomes in advanced EGFR-mutant lung adenocarcinoma: Data from LATAM population

BACKGROUND

Co-occurring genomic alterations identified downstream main oncogenic drivers have become more evident since the introduction of next-generation sequencing (NGS) analyses at diagnosis and progression. Emerging evidence has stated that co-occurring genomic alterations at diagnosis might represent de novo and primary resistance mechanisms to tyrosine kinase inhibitors (TKIs) in advanced EGFR-mutant (EGFRm) non-small lung cancer (NSCLC). In this study, we assessed the prognostic role of co-occurring genomic alterations in advanced EGFRm NSCLC.

METHODS

A cohort of 111 patients with advanced NSCLC harboring EGFR-sensitive mutations detected by PCR was analyzed in 5 Latin American oncological centers from January 2019 to December 2020. All eligible patients received upfront therapy with EGFR-TKI. Co-occurring genomic alterations were determined at diagnosis in every patient by the NGS (FoundationOneCDx) comprehensive platform, which evaluates 324 known cancer-related genes.

RESULTS

EGFR exon19 deletion was the most frequent oncogenic driver mutation (60.4 %) detected by NGS. According to the NGS assay, 31 % and 68.3 % of patients had 1-2 and ≥ 3 co-occurring genomic alterations, respectively. The most frequent co-occurring genomic alterations were TP53 mutations (64.9 %) followed by CDKN2AB alterations (13.6 %), BRCA2 (13.6 %), and PTEN (12.7 %) mutations. Baseline central nervous system disease was present in 42.7 % of patients. First- or second-generation EGFR TKIs (gefitinib, afatinib, or erlotinib) were the most common treatment in 67.5 % of patients, while osimertinib was administered in 27.9 % of cases. The median PFS in all evaluated patients was 13.63 months (95 %CI: 11.79-15.52). Using ≥ 3 co-occurring alterations as the cut-off point, patients with ≥ 3 co-occurring genomic alterations showed a median PFS, of 12.7 months (95 %CI: 9.92-15.5) vs 21.3 months (95 %CI: 13.93-NR) in patients with 2 or less co-occurring genomic alterations [HR 3.06, (95 %CI: 1.55-5.48) p = 0.0001]. Also, patients with a TP53 mutation had a shorter PFS, 13.6 (95 %CI: 10.7-15.5) vs 19.2 months (95 %CI: 12.8-NR); in wild type TP53 [HR 2.01 (95 %CI: 1.18-3.74) p = 0.12]. In the multivariate analysis, the number (≥3) of concurrent genomic alterations and ECOG PS of 2 or more were related to a significant risk factor for progression [HR 2.79 (95 %CI: 1.49-5.23) p = 0.001 and HR 2.42 (95 %CI: 1.22-4.80) p = 0.011 respectively].

CONCLUSION

EGFR-mutant NSCLC is not a single oncogene-driven disease in the majority of cases, harboring a higher number of co-occurring genomic alterations. This study finds the number of co-occurring genomic alterations and the presence of TP53 mutations as negative prognostic biomarkers, which confers potentially earlier resistance mechanisms to target therapy.

STK11 and KEAP1 mutations in non-small cell lung cancer patients: Descriptive analysis and prognostic value among Hispanics (STRIKE registry-CLICaP)

BACKGROUND

Mutations in STK11 (STK11^Mut) and, frequently co-occurring, KEAP1 mutations (KEAP1^Mut) are associated with poor survival in metastatic Non-small Cell Lung Cancer (mNSCLC) patients treated with immunotherapy. However, there are limited data regarding the prognostic or predictive significance of these genomic alterations among Hispanics.

METHODS

This retrospective study analyzed a cohort of Hispanic patients (N = 103) diagnosed with mNSCLC from the US and seven Latin American countries (LATAM) treated with immune checkpoint inhibitors (ICI) alone or in combination as first-line (Cohort A). All cases were treated in routine care between January 2016 and December 2021. The main objectives were to determine the association of mutations in STK11 or KEAP1 in these patients' tumors with overall (OS) and progression-free survival (PFS), presence of KRAS mutations, tumor mutational burden (TMB), and other relevant clinical variables. To compare outcomes with a STK11^Wt/KEAP1^Wt population, historical data from a cohort of Hispanic patients (N = 101) treated with first-line ICI was used, matching both groups by country of origin, gender, and Programed Death-ligand 1 (PD-L1) expression level (Cohort B).

RESULTS

Most tumors had mutations only in STK11 or KEAP1 (45.6%) without KRAS co-mutation or any other genomic alteration. Besides, 35%, 8.7%, 6.8%, and 3.9% were KRAS^Mut + STK11^Mut, KRAS^Mut + STK11^Mut + KEAP1^Mut, STK11^Mut + KEAP1^Mut, and KRAS^Mut + KEAP1^Mut, respectively. Based on KRAS status, STK11 alterations were associated with significantly lower PD-L1 expression among those with KRAS^Wt (p = 0.023), whereas KEAP1 mutations were predominantly associated with lower PD-L1 expression among KRAS^Mut cases (p = 0.047). Tumors with KRAS^Mut + KEAP1^Mut had significantly higher median TMB when compared to other tumors (p = 0.040). For Cohort A, median PFS was 4.9 months (95%CI 4.3-5.4), slightly longer in those with KEAP1^mut 6.1 months versus STK11^Mut 4.7 months (p = 0.38). In the same cohort, PD-L1 expression and TMB did not influence PFS. OS was significantly longer among patients with tumors with PD-L1 ≥ 50% (30.9 months), and different from those with PD-L1 1-49% (22.0 months), and PD-L1 < 1% (12.0 months) (p = 0.0001). When we compared the cohorts A and B, OS was significantly shorter for patients carrying STK1 [STK11^Mut 14.2 months versus STK11^Wt 27.0 months (p = 0.0001)] or KEAP1 [KEAP1^Mut 12.0 months versus KEAP1^Wt 24.4 months (p = 0.005)] mutations. PD-L1 expression significantly affected OS independently of the presence of mutations in STK11, KEAP1, or KRAS. TMB-H favored better OS.

CONCLUSIONS

This is the first large Hispanic cohort to study the impact of STK11 and KEAP1 mutations in NSCLC patient treated with ICI. Our data suggest that mutations in the above-mentioned genes are associated with PD-L1 expression levels and poor OS.

Associated factors for poor response in advanced EGFR-mutated NSCLC patients under tirosine kinasa inhibitors: Peruvian real-world data

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Background: Although tirosine kinasa inhibitors (TKI) are the first line of therapy in patients with non-small cell lung cancer (NSCLC) harboring EGFR mutations, some patients do not have benefit with TKI. The aim of this study is to determinate if there are associated factors with poor response with TKI. Methods: This is an observational study of a single institution patient cohort. Clinical records of advanced NSCLC patients harboring EGFR mutations that have received TKI as first line therapy in ALIADA cancer center since january 2015 until december 2019 were evaluated. Clinical records with incomplete data were excluded. Type of EGFR mutation, type of TKI agent, BMI, neutrophil, lymphocyte, platelets, neutrophil/lymphocyte ratio (NLR) and platelet/lymphocyte ratio (PLR) were evaluated in all cases. Poor responders where defined as NSCLC patients who progressed within 3 months with erlotinib or afatinib and 6 months within osimertinib. The statistical analysis was performed with SPSS version 20 and MINITAB 14. Results: 46 patients were finally included. Mean age was 63.6 ± 11.7 years, 54.4% of patients were female and 93% had adenocarcinoma histology. Mean neutrophil, lymphocyte and platelet counts were 4.82, 1.96 and 396.07 respectively; meanwhile mean NLR was 4.85 and mean PLR 282.36. 45% of patients were overweight or obese. 65.2% of all mutations were EGFR exon 19 deletions, 19.6% were exon21 L858R substitution and 10% EGFR uncommon mutations (de novo exon20 T790 mutations and exon18 G719X substitution). 45.7% of patients received erlotinib, 37% received afatinib and 17.3% osimertinib. 61.5% of patients achieved partial response, 17.3% achieved complete response, 9.6% stable disease and 28.3% of patients were poor responders to TKI treatment. In bivariate analysis, odds ratio for poor response was more associated with uncommon mutations (OR = 8.21, IC95% = 1.94-97.18; p = 0.025) and patients with neutrophil > 4.82 (OR = 1.65, IC 95% = 1.08-2.52; p = 0.020). Odds ratio for poor response decreases 95% with erlotinib (OR = 0.05, IC95% = 0.00-0.58; p = 0.016). There was no statistical association with the rest factors. In the logistic regression model, poor response to TKI are related to uncommon EGFR mutations (OR = 8.21, 95% CI = 1.3-51.99; p = 0.009) and neutrophils > 4.82 (OR: 1.85, 1.13 -3.05). Conclusions: Disease progression is a phenomenon present in patients with EGFR-mutated NSCLC. According to our data, poor response is associated with uncommon EGFR mutations, TKI agent (erlotinib) and neutrophil count level. We need larger studies to validate our results.

Evaluation of TKI toxicity according to inflammatory markers and body mass index in patients with non-small cell lung cancer (NSCLC) harboring an EGFR mutation: A retrospective observational study

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Background: The standard treatment for patients with advance EGFR mutated NSCLC are Tirosine Kinasa inhibitors (TKI), we face in our clinical practice a different profile of toxicity; there is limited data of Inflammatory markers in this especial population. The aim of our study is to determine whether neutrophil lymphocyte ratio (NLR), lymphocyte platelet ratio(PLR), RDW-CV and body mass index (BMI) are related to the develop of this toxicity. Methods: We retrospectively analyzed data of patients with EGFRm NSCLC at Aliada Clinic between January 2016 to December 2019. Inflammatory markers were obtained from laboratory tests performed during the first visit as outpatient. The BMI kg/m2 at the start of the treatment was defined as the weight (kg) divided by the height (m) squared. Adverse event (AE) were graded according CTCAE v5.0. Results: A total of 164 patients were diagnosed with advanced NSCLC, of these 50 patients were assessed, 29 women and 21 men. The average age was 58.9 years, median of 59.5 ( 38 to 83; SD: 11.7). The most frequent EGFR mutation was deletion 19 (59.6%) followed by L858R mutation ( 23.1%) . The median BMI was 25.18 (16.2 to 41.3 kg/m2) 46.2% were normal, 36.5% were overweight, and 11.5 % were obese. 80% present any grade of AE. The most frequent AE was skin related: 75% (90 % grade I or II) follow by gastrointestinal: 57.6% (74 % grade I or II). There were no significant differences between NLR according to toxicity grade I-II vs III-IV (media: 3.44 and 4.32; P = 0.46); PLR according toxicity grade I-II vs III-IV (media: 229.41 and 251-50; P = 0.78); and RDW-CV according to toxicity grade I-II vs III-IV (media: 14.17 and 14.4; P = 0.74). Similarly, no significant differences were observed among toxicity profiles in relation to BMI (p = 0.2). Finally, there was no impact of severity of toxicity on progression-free survival (p = 0.64) or overall survival 24,33 months (IC 95% 16,05 – 32,6; p = 0.9). Conclusions: There was no relation between inflammatory markers and the grade of toxicity in patients with EGFRm advance NSCLC receiving TKIs. We suggest increase the population to validate our results.

Association between inflammatory markers and progression-free survival in patients with advanced EGFR-mutated non-small cell lung cancer under treatment with tirosin kinasa inhibitors: Real-world data from Peru

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Background: Tirosine Kinasa Inhibitors (TKI) are the standard treatment in patients with non-small cell lung cancer (NSCLC) harboring EGFR mutation. However, eventually patients will progress to TKI. The aim of this study is to determinate if neutrophil-lymphocyte ratio (NLR), RDW-CV and platelet-lymphocyte ratio (PLR) are associated with progression free survival (PFS). Methods: This is a retrospective observational study of a single patient cohort. Clinical records of advanced NSCLC patients that received TKI as first line therapy in ALIADA cancer center since January 2015 and December 2019 were evaluated. NLR, RDW-CV and PLR were calculated from blood counts before beginning of TKI. The statistical analysis was performed with SPSS version 20 and MINITAB 14. Results: 182 patients were diagnosed with advanced NSCLC and 30% of them harbor a EGFR mutation. 43 patients were finally included, 55.8% were women and mean age was 58 years. The 65% of patients had exon19 deletion, 25% exon21 L858R substitution, 7% exon20 T790 mutations and 3% exon18 G719X substitution. 44% of patients received erlotinib, 38% afatinib and 18% osimertinib. The 61.5% of patients achieved partial response; they had a mean NLR, PRL and RDW-CV of 2.98 (0.93–7.41), 238.59 (101.63–863.01) and 13.8 (12.6–15.5) respectively. 17.3% achieved complete response, with a mean NLR, PRL and RDW-CV of 2.93 (1.22–4.64), 204.37 (109.21–417.46) and 13.7 (12.8–15.4). Finally, 9.6% maintain stable disease; with a mean NLR, PRL and RDW-CV of 4.25 (3.6-4.91), 200.7 (196.4-205) and 14.35 (14.3-14.4). 74% of patients progressed. The mean PFS was 24.33 months (95% CI 16.05 - 32.6). Patients that developed progressive disease and those who did not, had no significant difference in the mean NLR (3.98 vs 3.68, p = 0.706) and mean RDW-CV (14.12 vs 14.3, p = 0.655). However, patients with clinical benefit during TKI had a mean PLR of 163.68, meanwhile patients with progressive disease had a mean PLR of 276.54 (T of Student, p = 0.03). Conclusions: In patients with advanced EGFR mutated NSCLC, a high level of PLR is associated with a lower PFS. It is necessary to carry out studies with a bigger amount of population to validate the PLR as a predictive biomarker. To our knowledge this is the first study that analyzes these characteristics in Latin American population.

Thrombolytic therapy for acute myocardial infarction

Numerous factors must be considered when determining the formulary status of thrombolytic agents for the treatment of acute myocardial infarction. Defined treatment options, predicted outcomes, and the economic consequences of this disorder continue to evolve from clinical trials. Pharmacists have a major role in delivering patient care, with responsibility for evaluating, procuring, and monitoring thrombolytic agents and drug therapy in general. By participating in the development and implementation of treatment guidelines, evaluating economic and therapeutic outcomes, providing timely optimal drug therapy, and educating health care providers and the public, they contribute significantly to the health care team.

Work activities before and after implementation of an automated dispensing system

The impact of an automated dispensing system (ADS) on medication-related work activities by nurses and pharmacists was studied. A point-of-care ADS (Baxter Sure-Med) was installed on two nursing units (the surgical intensive care unit [SICU] and a medicine unit [4NMU]) of a 400-bed university hospital as part of a pilot project. A self-reported work-sampling study was used to collect observations of medication-related work activities by nurses, health unit coordinators (nursing support staff), and pharmacists for a seven-day period before ADS implementation and a seven-day period after implementation. There were 7797 observations of nurse work activities, 1408 observations of health unit coordinator work activities, and 4236 observations of pharmacist work activities. The percentage of nurse work activities that were medication related decreased from 20.7% before ADS implementation to 18.4% afterward on 4NMU and increased slightly from 10.8% to 11.0% on the SICU. Medication-related health unit coordinator work activities increased from 17.5% to 25.3% of total activities on 4NMU and decreased from 16.6% to 10.7% on the SICU. None of these changes was significant. For decentralized pharmacists supporting 4NMU, the percentage of work activities classified as clinical increased significantly from 36.5% to 49.1%. For decentralized pharmacists supporting the SICU, clinical activities increased from 27.9% to 35.1%. There were no significant changes on either unit in pharmacist activities classified as technical. An overall measure of the efficiency with which pharmacists used their time for patient care-related activities increased. A point-of-care ADS did not affect the proportion of time spent by nurses on medication-related activities and seemed to give pharmacists more time for clinical work.

Work activities of pharmacy teams with drug distribution and clinical responsibilities

The time spent by satellite pharmacists and technicians on various activities was measured by using work sampling to evaluate the pharmacists' use of time for patient care. Between December 1992 and April 1993, pharmacists and technicians on satellite pharmacy teams at a tertiary care teaching hospital reported their work activities on forms. A total of 11,485 observations of pharmacist work activities and 7,626 observations of technician work activities were made. Pharmacists on teams with fewer support staff members spent less time on patient care-related work activities, and vice versa. As measured by an institution-specific index, the efficiency with which pharmacists used the available work time for patient care ranged from 60% to 83% for the various teams (100% would mean that pharmacists spent all their work time on patient care tasks). Changes were made in technician staffing that enabled the pharmacists to devote more time to patient care. Measuring the time pharmacists and technicians spent on various work activities provided a means of identifying and correcting organizational inefficiencies in order to give the pharmacists more time for patient care.

Documenting the provision of pharmaceutical care

There is a growing importance and need for the documentation of the clinical work done by the pharmacist in providing pharmaceutical care. The data provided by documentation of care are critical to the effective and efficient transition from a product-based profession to a patient-care, service-based profession, especially during a period of great scrutiny of resource utilization in the hospital industry. Intervention documentation can serve both to document the provision of pharmaceutical care to individual patients and to provide critical information to managers to justify and expand the level of service provided.

Pharmacist salaries and hiring practices in teaching hospitals

A survey of selected teaching hospitals was conducted in early 1990 to determine salary ranges for pharmacist positions, salaries at which pharmacists were typically hired for these positions, differences in salary between clinical practitioner and managerial positions, and geographic differences in these salaries. Surveys were mailed to 50 members of the University Hospital Consortium (UHC) and 50 other university-affiliated and non-university-affiliated hospitals believed to be comparable to the investigators' hospital. Hospital capacity and census data, numbers of pharmacist and support staff positions, qualifications preferred and required for those positions, and salary information were requested. Data from 22 UHC hospitals and 23 non-UHC hospitals were evaluated. Relative to average daily census, UHC hospitals indicated higher pharmacist staffing levels and non-UHC hospitals reported higher support staff levels. More non-UHC hospitals than UHC hospitals (69.2% versus 43.5%) used an integrated model for delivery of clinical and distributive services. Nationally, the reported annual salaries were as follows: staff pharmacist, $34,881 to $47,906; clinical pharmacist, $37,768 to $51,564; clinical specialist, $38,905 to $55,282; supervisor, $39,905 to $54,416; assistant director, $43,554 to $58,758. Overall, typical hire rates (THRs) exceeded mean minimum salaries by about 10%. The percentages by which THRs exceeded mean minimum salaries were greatest in the West for staff pharmacist, clinical pharmacist, and clinical specialist positions and greatest in the Midwest for supervisor and assistant director positions. THRs for supervisors and assistant directors exceeded those for clinical specialists. Respondents' preferences varied regarding advanced education and training, and their actual requirements did not match their stated preferences.(ABSTRACT TRUNCATED AT 250 WORDS)

Self-reported work-sampling methods for evaluating pharmaceutical services

The steps involved in designing a self-reported work-sampling study of pharmacy department operations are described. Traditional methods of work measurement include subjective evaluation, time-and-motion studies, and analysis of departmental statistics and are appropriate when the research question concerns repetitive work and when data about single activities at single points in time are sought. When institution-wide changes are being considered, a more global measurement approach is needed. Work sampling allows a manager to measure indirectly the amount of time spent by employees on work activities during a specified period. Many instantaneous observations are taken randomly or systematically to estimate the proportion of time spent on any activity. Data may be collected by trained observers or may be self-reported; self-reporting facilitates a large number of short-interval observations and allows for the reporting of cognitive activities. In designing a self-reported work-sampling study, the manager must (1) identify the study objective, (2) define the service area and staff to be studied, (3) inform all staff members to be involved, (4) define temporally relevant workload measures, (5) decide how many observations are needed, (6) decide for how long data will be collected, (7) choose between randomized and systematic sampling times, (8) define categories of work representative of staff activities, (9) design data collection forms and communicate procedures, and (10) conduct a pilot study. To interpret the results, an analysis of simple summary statistics may be more appropriate than a sophisticated statistical analysis.(ABSTRACT TRUNCATED AT 250 WORDS)

Integrated patient-specific model of pharmacy practice

The deficiencies of traditional models for the provision of clinical pharmacy services are discussed, and a patient-specific model that integrates drug distribution and clinical pharmacy functions is proposed. Traditional models have either designated specific individuals as providers of clinical pharmacy services or have combined distributive and supportive services with clinical services. In both cases, clinical services have been of secondary importance. Such models have resulted in inconsistent clinical services for which the patient is not necessarily the primary focus and have made it difficult for pharmacists to understand their mission. The lack of a well-defined primary clinical role for pharmacists has confused health-care providers and created problems for managers attempting to evaluate pharmacists and justify clinical services. The integrated patient-specific model is based on the ethical imperative that the patient must be central to any health-care endeavor. Under this model, clinical pharmacy services are of central importance and distributive services are integrated as a secondary but still very important aspect of comprehensive institutional pharmacy services. Critical elements of the integrated model include a patient-centered philosophy of practice, a definition of clinical pharmacy work, and a managerial framework. The integrated patient-specific model of pharmacy practice puts pharmacists in a professional relationship with patients and explicitly defines clinical services and priorities.

Strategic planning for patient-specific clinical pharmacy services

Planning for the development, implementation, or redirection of new or existing clinical pharmacy services necessitates that several key issues be addressed. Managers must submit to critical subjective and objective evaluation of their departmental practices as a first step to the development of a strategic plan to meet goals for pharmacy practice. Strategic plans must address the mission of the department and clearly define the management systems and practice model that will achieve that mission. The strategic plan must be structured for the purpose of obtaining organizational commitment to the strategic goals and to the programs and resources that will allow those goals to be realized.

Diagnosis and treatment of neuroleptic malignant syndrome

A patient who developed neuroleptic malignant syndrome (NMS) from the use of several neuroleptic agents and the therapeutic interventions used to reverse the syndrome are described, and the clinical presentation and treatment of NMS are reviewed. Fever, leukocytosis, seizures, delirium, and elevated serum creatine phosphokinase levels developed in a 17-year-old girl who was receiving perphenazine and haloperidol. The patient was admitted to a hospital for treatment of atypical psychosis and received haloperidol and, later, thioridazine. Autonomic disturbances, altered consciousness, and muscular rigidity developed. Thioridazine was discontinued in favor of perphenazine because of anticholinergic adverse effects. Symptoms persisted despite treatment with benztropine and diphenhydramine. After the diagnosis of NMS was made, all neuroleptics were discontinued, and the patient began therapy with dantrolene sodium and bromocriptine. Dramatic improvement in the patient's condition followed. NMS has four characteristic signs: hyperthermia, muscular rigidity, altered consciousness, and autonomic dysfunction. Mechanisms believed to cause NMS include alteration of central neuoregulatory mechanisms and neuroleptic-induced imbalance between central dopaminergic and gamma-aminobutyric acid neurotransmitter systems. Bromocriptine, amantadine, dantrolene sodium, and electroconvulsive therapy have been used effectively in the treatment of NMS. NMS is a rare but potentially fatal adverse drug reaction that occurs in situations that make diagnosis difficult. Dramatic, favorable responses can be achieved with early diagnosis and appropriate treatment.