Palliative care delivery according to age among metastatic breast cancer patients. ESME-MBC cohort

Background

Metastatic breast cancer (MBC) may require inpatient palliative care (IPC) but literature suggests age-related disparities in palliative care delivery. This study, based on real-world data, aimed to assess the cumulative incidence function (CIF) of IPC delivery and if age is an independent factor, taking into account the competing risk of death.

Methods

The national multicenter ESME (Epidemio-Strategy-Medical-Economical)-MBC cohort includes consecutive MBC patients treated in the 18 French Comprehensive Cancer Centers. IPC identification used ICD-10 palliative care coding. Main analysis first estimated pseudo values of 2-year and 8-year CIF of IPC. Linear regression models estimated the mean changes of pseudo-values (2 models: 2-year and 8-year CIF of IPC).

Results

Our analysis included 12375 patients, 5093 (41.2%) of whom were aged 65 or over. The median follow-up was 41.5 months (95% CI, 40.5-42.5). The CIF of IPC was 10.3% (95% CI, 10.2-10.4) and 24.8% (95% CI, 24.7-24.8) at two and eight years, respectively. At two years, among triple-negative patients, young patients (<65 yo) had a higher CIF of IPC than older patients after adjusting for cancer characteristics, centre, and period (65+/<65: β=-0.05; 95% CI, -0.08 to -0.01). Among other tumour subtypes, older patients received short-term IPC more frequently than young patients (65+/<65: β = 0.02; 95% CI, 0.01 to 0.03). At eight years, outside large centres, IPC was delivered less frequently to older patients adjusted to cancer characteristics and period (65+/<65: β=-0.03; 95% CI, -0.06 to -0.01).

Conclusions

We found a relatively low CIF of IPC and that age influenced IPC delivery. Young triple negative and older non-triple negative patients needed more short-term IPC. Older patients diagnosed outside large centres received less long-term IPC. These findings highlight the need for a wider implementation of IPC facilities and for more age-specific interventions.

Key messages

Our study highlighted particular challenge for older MBC patients diagnosed outside large French Comprehensive Cancer Centers. By identifying age at MBC diagnosis as a factor of IPC delivery, this report supports a wider implementation of IPC facilities and more age-specific interventions.

Abstract P5-09-07: Risk reducing strategy in germline BRCA mutated patients with locally advanced breast cancer. Establishing mastectomy as a preventing procedure of local recurrence

Introduction

Neoadjuvant chemotherapy (NAC) is proposed for locally advanced breast cancer (LABC) to increase the breast conservative treatment (BCT). In France, mastectomy is the risk-reducing prophylactic surgical strategy only for pre-symptomatic germline BRCA-mutated (gBRCAm) patients. On the other hand, BCT is proposed to all patients following NAC based on clinical response, regardless the gBRCAm status. The aim of this retrospective study is to evaluate the risk of local recurrence (LR) according to BRCA status.

Patients and methods

Inclusion criteria were: (i) patients treated for unilateral LABC, T2-3, N≥0, M0 by NAC, and (ii) patients who underwent germline BRCA screening. , using targeted next-generation screening, was carried out either during NAC (rapid process) or after surgery. Deleterious mutations were confirmed using Sanger sequencing before passing on the results to the clinical geneticist. Some gBRCAm patients from Olympia study were also included. Patients were followed-up over a long term for overall survival, LR and disease-free survival. Chi-square and Fischer test were used to generate statistical comparison.

Results

Between 2007 and 2015, 988 women were treated for LABC at our institution. Among them, 151 patients underwent clinical genetic testing for gBRCAm based on these criteria: young age at diagnosis or familial history of breast or ovarian cancer or histological characteristics as grade 2/3, Her2-3+ or basal like. A total of 122 patients were included in the study; 28 patients had gBRCAm status and no mutations were detected in 94 patients (wtBRCA). Significant differences between the two groups (gBRCAm vs wtBRCA) were observed for

Mean age, (36.7 vs 40.1y (p=0.0032) ,

Intrinsic tumor subtypes basal like (64.3% vs 42.5%, p=0.0432)

ER are more often negative (21.4% vs 46.8%, p=0.0165).

Among the 30 patients who underwent BRCA screening during NAC and eligible for BCT, 8 of the 9 patients with gBRCAm choose mastectomy (88%). Among the 92 patients with screening mutation after breast cancer treatment, 5 of the 19 patients with gBRCAm had a mastectomy (28%). In the 28 gBRCAm patients, 15 had a BCT and 13 a mastectomy. In the 94 wtBRCA patients, 67 had a BCT and 27 a mastectomy. After a follow-up of 4.32 years, we observed 8 relapses, 5 LRs after BCT and 3 contro-lateral relapses. Of the 5 LRs, 3 came from 15 gBRCAm with BCT and 2 of the 67 wtBRCA (p=0.0403).

Discussion

In this selected subgroup of patients, gBRCAm rate is higher (23%) than the rate based on familial criteria for BRCA testing (12%). Regarding the rationale for BCT or mastectomy procedure in LABC and pre-symptomatic gBRCAm patients, this study led us to establish mastectomy as risk-reducing strategy in a sole surgery procedure for gBRCAm patients. Moreover, 88% gBRCAm patients chose mastectomy; the mastectomy rate was lower when the patient was unaware of their BRCA status (26%). The LR rate was higher in the gBRCAm vs wtBRCA with a statistical difference. In LABC patients with high genetic risk, the knowledge of mutation status could influence patients' and surgeons' choice of surgery. In case of gBRCAm status, mastectomy is recommended to decrease LR risk.

Citation Format: Tunon de Lara C, Leroux J, Bonnet F, Debled M, Barrouk-Simonet E, Quenel-Tueux N, Lagarde P, Chassaigne F, Esnaud T, Fournier M, Bubien V, Breton-Callu C, Charitansky H, Petit A, Mathoulin-Pelissier S, Macgrogan G, Longy M, Sevenet N. Risk reducing strategy in germline BRCA mutated patients with locally advanced breast cancer. Establishing mastectomy as a preventing procedure of local recurrence [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P5-09-07.

Radiofrequency ablation of stage IA non-small cell lung cancer in patients ineligible for surgery: results of a prospective multicenter phase II trial

Background

A prospective multicenter phase II trial to evaluate the survival outcomes of percutaneous radiofrequency ablation (RFA) for patients with stage IA non-small cell lung cancer (NSCLC), ineligible for surgery.

Methods

Patients with a biopsy-proven stage IA NSCLC, staging established by a positron emission tomography-computed tomography (PET-CT), were eligible. The primary objective was to evaluate the local control of RFA at 1-year. Secondary objectives were 1- and 3-year overall survival (OS), 3-year local control, lung function (prior to and 3 months after RFA) and quality of life (prior to and 1 month after RFA).

Results

Of the 42 patients (mean age 71.7 y) that were enrolled at six French cancer centers, 32 were eligible and assessable. Twenty-seven patients did not recur at 1 year corresponding to a local control rate of 84.38% (95% CI, [67.21–95.72]). The local control rate at 3 years was 81.25% (95% CI, [54.35–95.95]). The OS rate was 91.67% (95% CI, [77.53–98.25]) at 1 year and 58.33% (95% CI, [40.76–74.49]) at 3 years. The forced expiratory volume was stable in most patients apart from two, in whom we observed a 10% decrease. There was no significant change in the global health status or in the quality of life following RFA.

Conclusion

RFA is an efficient treatment for medically inoperable stage IA NSCLC patients. RFA is well tolerated, does not adversely affect pulmonary function and the 3-year OS rate is comparable to that of stereotactic body radiotherapy, in similar patients.

Trial registration

ClinicalTrials.gov Identifier NCT01841060 registered in November 2008.

Estimating attributable fraction of lung cancer linked to smoking in Morocco

The objective of this research was to estimate the attributable fraction (AF) of lung cancer linked to smoking in Morocco. The estimation was based on the SAMMEC (Adult Smoking-Attributable Mortality, Morbidity and Economic Costs) method based on the Levin formula to calculate AF linked to tobacco. Data about frequencies, association measures and relative risks were taken from available sources. The AF of lung cancer linked to smoking was about 87%, and around 3049 cases of this cancer in men could be avoided if tobacco use could be prevented. About a 10% reduction in smoking prevalence would result in a reduction of 346 lung cancer cases. Our study provides additional important elements for further advocacy to policy-makers to implement a tobacco control strategy based on a prevention policy in line with the epidemiological situation which could avoid a huge burden on the country.

Quality of reporting of phase II trials: a focus on highly ranked oncology journals

BACKGROUND

Phase II trials represent an essential step in the development of anticancer drugs. This study assesses the quality of their reporting in highly ranked oncology journals, investigates predictive factors of quality, and proposes reporting guidelines.

PATIENTS AND METHODS

We reviewed the table of contents of all volumes of eight peer-reviewed oncology journals published in English between January and December 2011 with a 2011 impact factor (IF)>4. Two reviewers assessed the quality of each report by using a 44-point overall quality score (OQS). Primary end point definition, justification of sample size, and definition of the evaluable population, were assessed separately to establish a 3-point key methodological score (KMS). Exploratory analyses identified predictive factors associated with scores.

RESULTS

One hundred fifty-six articles were included. The median OQS was 28 (range: 9-35). OQS subsection analysis showed that reporting of statistical methods was low with a median OQS of 3. Median KMS was 2 (range 0-3). Primary end point definition, justification of sample size and definition of the evaluable population were reported in only 107 (68.6%), 121 (77.6%), and 52 (33.3%) cases, respectively. At multivariate analysis, registration on clinicaltrials.gov and IF>10 were associated with improved OQS. No associations for KMS were observed.

CONCLUSION

Phase II trial reporting is still poor even in journals with strict editorial policies. This may lead to biased interpretation of phase II trial results. Besides using a checklist during the preparation of their manuscript, authors should also provide reviewers and readers with the last version of the study's protocol.

Radiological features of triple-negative breast cancers (73 cases)

OBJECTIVES

Triple-negative breast cancers generally occur in young women and they have the potential to be aggressive. It is important for this subtype of tumour to be detected early. We studied the appearance of 73 tumours on mammography, sonography and MRI in order to determine what specific features they showed on imaging.

PATIENTS AND METHODS

From July 2009 to December 2010, we retrospectively reviewed mammogram and sonogram images of 73 triple-negative cancers. Colour Doppler had been used to depict vascularisation in 34 cases and elastography score calculated in 17 cases. Sixteen patients had undergone MRI. The radiological description of these different modalities draws on the BI-RADS lexicon and categorisation.

RESULTS

On mammography, triple-negative cancers often presented as a round mass (59.3%) or an oval or lobulated mass (65%), with circumscribed (15%), microlobulated (12.5%), indistinct (55%) or occasionally spiculated margins (15%). On sonography, the vast majority of these cancers appeared as masses (92.8%) with occasional posterior acoustic attenuation (22.6%). MRI showed more suspicious images than the standard examinations, notably rim-enhancement (eight out of 12 masses).

CONCLUSION

. Radiological images appear as lobulated masses more readily, while on sonography posterior enhancement is shown more often than attenuation, and MRI finds rim-enhancement.

Unresectable colorectal cancer liver metastases treated by intraoperative radiofrequency ablation with or without resection19

Background

Despite neoadjuvant chemotherapy, few patients with colorectal cancer liver metastases (CRLM) are eligible for liver resection. The aim of the present study was to investigate the efficacy of intraoperative radiofrequency ablation (IRFA) in the treatment of unresectable CRLM.

Methods

Patients with unresectable metastases confined to the liver were eligible for this prospective, multicentre phase II study conducted between 2003 and 2008. They received IRFA treatment either with or without parenchymal resection, and underwent clinical and pathological examinations. The primary endpoint was complete hepatic response at 3 months. Overall, event-free and local progression-free survival, morbidity and quality of life were also examined.

Results

Fifty-two patients were included, all of whom received neoadjuvant chemotherapy. They had a median of 5 (range 1–13) metastases, mostly bilateral or recurrent. A complete hepatic response was observed in 39 patients (75 (95 per cent confidence interval (c.i.) 61 to 86) per cent). Of ten patients with hepatic recurrence at 3 months, two relapses were at the site of ablation. Median follow-up was 2·9 (95 per cent c.i. 2·5 to 3·6) years. The 1-year local progression-free survival rate was 46 (95 per cent c.i. 32 to 59) per cent, the 3-year event-free survival rate was 10 (95 per cent c.i. 4 to 21) per cent and the 5-year overall survival rate was 43 (95 per cent c.i. 21 to 64) per cent. Twenty patients had postoperative complications, including one death. Quality of life increased over time for patients without disease progression.

Conclusion

IRFA, either with or without resection, is a promising treatment option for patients with unresectable CRLM. Registration number: NTC00210106 (http://www.clinicaltrials.gov).

Consolidation with high-dose chemotherapy for responding patients to standard chemotherapy in advanced, metastatic soft tissue sarcoma (STS): A randomized trial from FNCLCC-French Sarcoma Group

10505

Background: Whether high dose (HD) chemotherapy improves disease-free (DFS) or overall (OS) survival has been suggested in phase II trial, but never explored in a randomized setting. This randomized, open, phase III study was designed to assess whether or not an HD chemotherapy with peripheral blood stem cells (PBSC) would improve OS in patients with advanced or metastatic STS responding to MAID chemotherapy. Methods: Pts aged 18 to 65 and with advanced STS were enrolled. After 4 courses of MAID, patients in PR or CR, or in whom complete surgical removal of all lesions was performed, were proposed for randomisation between 2 more cycles of MAID (control arm) vs 1 MAID followed by an intensification with MICE, ie: mesna (3.6g/m2, d1–5), ifosfamide (4g/m2, d1–4), carboplatin (UCA5, d2–4) and etoposide (300mg/m2, d1–4), followed by PBSC (HD arm). The primary endpoint was OS and the study was designed to detect by logrank test a 25% difference between the arms. Results: From 03/00 to 06/08, 266 patients were included and 87 were randomised (15 centres); low accrual and new treatment concepts lead to an IDMC in 11/08 who analysed 45 treated in the control arm (41 with full treatment) and 40 in the HD arm [only 21 received MICE, because consent withdrawal (6), insufficient PBSC harvest (5), tumor reprogression (4)]. Baseline characteristics (pts and tumors) were similar between treatment arms. With a 39 months follow-up, 25 pts were alive in the control arm, and 19 in the HD arm. The 3 years OS was 45.5% for control arm versus 35.8 for HD arm (HR = 1.12; 95% CI 0.58, 2.14; p = 0.72 Intention to treat analysis); PFS was 29.9% and 12.1 respectively (HR = 1.48; 95% CI 0.87, 2.53; p = 0.14). Higher rate of grade 3 - 4 hematologic (87% vs 46%), and digestive toxicity (33% vs 0%) were observed in the HD arm. Two treatment-related deaths occurred, both in the HD arm. Conclusions: In this study, HD chemotherapy for STS patients didn't improve OS and DFS. Consolidations with new concepts have to be explored.

[Table: see text]

Epoetin beta treatment of chemotherapy induced anemia in cancer patients: Results of a large prospective cohort study

19582

Background: The efficacy of epoetin beta (E) is well documented in clinical trials in anemic cancer patients (pts). This study was conducted to assess E use, efficacy, safety and effect on quality of life in cancer pts, in usual practice. Methods: This prospective, multicenter, longitudinal, observational French study assessed a 4-month follow-up of informed consent cancer pts (including both solid tumors (ST) and hematological malignancies (H)) treated with E for chemotherapy-related anemia. Data were collected between January 2005 and March 2006. Results: Among 3100 pts enrolled by 423 specialists, 2810 were analysed. Pts’ characteristics were: mean age 63±13 yrs, male 50%, performance status 0 (13%), 1 (46%), =2 (41%). 74% of pts suffered from a ST and 26% from a H. The most frequent cancer types were lung (22%), breast (15%), non-Hodgkin lymphoma (12%), colon (9%), multiple myeloma (7%), ovary (7%), prostate (3%), head and neck (3%) and chronic lymphocytic leukemia (3%). The mean time from diagnosis to inclusion was 2 yrs. 52% of pts received their first line of chemotherapy, 25% their second one. 55% and 10% of ST and H pts received platinum based regimen, respectively. At inclusion, hemoglobin levels were distributed as follows: < 9 g/dl (ST 14%, H 32%), [9–11 [g/dl (ST 70%, H 56%), [11–13 [g/dl (ST 16%, H 11%). Regarding pre-treatment biological tests, endogenous erythropoietin rate was controlled for only 3% of pts (ST 1% and H 7%, median 37 IU/ml [0; 388]), ferritin was available for 15% of pts (ST 11% and H 28%), transferrin saturation for 12% of pts (ST 10% and H 17%) and reticulocytes for 11% of pts (ST 7% and H 24%). At initiation, pts received a median dose of 30000 U/week of E on a once weekly regimen schedule for 98% of pts. E was associated with iron supplementation in 49% and 13% of ST and H pts, and with blood transfusion in 5% and 15% of ST and H pts. Conclusion: These preliminary results describe baseline characteristics of cancer patients treated with epoetin beta. The study suggests very few biological controls before initiation of E in routine practice. Final analyses of hemoglobin evolution and quality of life will be presented.

[Table: see text]

Quality of reports related to survival events in randomized clinical trials: A review of recent cancer trials published in eight major journals

6611

Background: About ten years ago, Altman pointed the low quality of survival analyses published in cancer journals. Despite the development of Consort statement, the lack of quality standards remained in the reports of randomized clinical trials (RCT).The aim of this study was to evaluate quality of definitions and reports of survival endpoints in recent cancer RCTs. Methods: A computerized search in Medline databases identified 274 cancer RCTs published from January 2004 to December 2004 in 4 general medical journals (BMJ, JAMA, Lancet, NEJM) and 4 clinical oncology journals (BJC, Cancer, JCO, JNCI). Eligible papers were these that reported primary analyses of RCT with survival endpoints. Three methodologists have reviewed and scored 1/3 of papers according to 7 key points: prevalence of adequate definition of survival end-points (time to origin, survival events, censures) and relevant information about their analyses (Kaplan-meier method, confidence interval, number of events, patients at risk). Reliability of scoring was checked among a random subsample of 30 papers with an independent biostatistician (kappa coefficient). Results: Following eligibility screening, 149 papers were not included. Among the 125 selected papers, 104 trials were of phase III (83%) and 98 publications (78%) were obtained from the 4 oncology journals. Among these RCTs, a total of 268 survivals endpoints were recorded and overall survival (OS) was the most frequent outcome (118 terms, 44%). Survival terms were adequately defined in 116 endpoints (43%) and OS was most frequent adequately defined (49%). Accurate information about analysis was found in 51 endpoints (19%). The less adequate information was patient's number at risk (55%). Finally, according to the 7 key methodological points, optimal quality of report was found in 19 of the endpoints (7 %) i.e.6 articles (kappa value: 0.65). Conclusions: Majority of published papers failed to provide an adequate definition and analysis reports of survival endpoints. Finally survival definitions add another source of variability actually not controlled. Readers should critically pay attention to the reported definitions since the lack of these elements may lead to misinterpretation of the RCT results.

No significant financial relationships to disclose.