Modeling health outcomes associated with BRCA testing and treatment strategies for patients with metastatic pancreatic cancer

BACKGROUND

Germline BRCA mutations (gBRCAm) occur in 4%-8% patients with metastatic pancreatic cancer (mPC); guidelines recommend platinum-based chemotherapies and olaparib maintenance in this population. We evaluated, through modeling, the role of treatments and gBRCA testing on health outcomes of mPC patients.

METHODS

A decision tree/partitioned survival model was developed to assess lifetime health outcomes for four strategies: 1) no testing; 2) early testing/no olaparib maintenance; 3) early testing (i.e., before 1L treatment)/olaparib maintenance; and 4) late testing/olaparib maintenance. Treatment patterns were assumed to follow current practice in the United States. Overall survival and progression-free survival curves were extrapolated from pivotal trials, including POLO trial for outcomes from olaparib maintenance after at least 16 weeks of platinum-based chemotherapy.

RESULTS

Among patients with gBRCAm, almost twice as many patients received platinum-based regimens in strategies involving early testing compared to when early testing was not employed (78.7 % vs 40.2 %). Health outcomes were highest in the strategy with early testing and available olaparib treatment whether considering progression-free life years (PF LYs, 1.27 vs 0.55-0.87), LYs (1.82 vs 0.95-1.27) or quality adjusted life years (QALYs, 1.15 vs 0.73-0.92 for others). Consistent patterns of results were observed in the overall cohort of mPC patients (i.e., irrespective of gBRCAm).

CONCLUSION

Patients with mPC achieved longest health outcomes (as measured by mean PF LYs, LYs and QALYs) with a scenario of early gBRCA testing and availability of olaparib maintenance. The results were primarily driven by improved health outcomes associated with higher efficacy of platinum-based chemotherapies and olaparib used in gBRCAm patients.

Patient-centered outcomes in the POLO study of active maintenance olaparib for germline BRCA-mutated metastatic pancreatic cancer

BACKGROUND

The phase 3 POLO study demonstrated a significant progression-free survival (PFS) benefit and preserved health-related quality of life (HRQOL) for active maintenance treatment with olaparib vs placebo in patients with metastatic pancreatic cancer and a germline BRCA mutation. Here, we present a post hoc analysis of the patient-centered outcomes: time without significant symptoms of disease progression or toxicity (TWiST) and quality-adjusted TWiST (Q-TWiST).

METHODS

Patients were randomized 3:2 to maintenance olaparib (300 mg tablets twice daily) or placebo. Overall survival time was divided into TWiST, toxicity (TOX; time before disease progression with significant symptoms of toxicity), and relapse (REL; time after disease progression until death or censoring). Q-TWiST was the sum of TWiST, TOX, and REL, each weighted by HRQOL utility scores during the relevant health-state period. A base-case and three sensitivity analyses were performed using differing definitions of TOX.

RESULTS

In total, 154 patients were randomized (olaparib, n = 92; placebo, n = 62). TWiST was significantly longer for olaparib than placebo in the base-case analysis (14.6 vs 7.1 months; 95% CI, 2.9-12.0; p = .001) and all sensitivity analyses. No statistically significant benefit for Q-TWiST was observed in the base-case analysis (18.4 vs 15.9 months; 95% CI, -1.1 to 6.1; p = .171) or the sensitivity analyses.

CONCLUSION

These results support the previous findings that maintenance olaparib significantly improves PFS relative to placebo without compromising HRQOL and demonstrate that the clinically meaningful benefits of olaparib persist even when symptoms of toxicity are considered.

Health-Related Quality of Life of Patients with Metastatic Pancreatic Cancer: A Systematic Literature Review

Background

Metastatic pancreatic cancer (mPaC) has a poor prognosis and available treatments provide only moderate improvements in survival. Preserving or improving health-related quality of life (HRQoL) is therefore an important treatment outcome for patients with mPaC. This systematic review identified HRQoL data in patients with mPaC before and after treatment, compared these with data from the general population, and reported the effects of different mPaC treatments on HRQoL.

Methods

Searches were performed in Embase, PubMed, and the Cochrane Library from January 2008 to May 2021, and the articles identified were screened for HRQoL data in patients with mPaC. Abstracts from relevant congresses were also manually searched. Publications included were randomized controlled trials and observational studies written in English that reported HRQoL data for adult patients with non-resectable mPaC who were on or off treatment.

Results

Thirty relevant publications were identified and HRQoL scores were collected. Overall, baseline mean scores from the European Organization for the Research and Treatment of Cancer Quality of Life Questionnaire-Core 30 (EORTC QLQ-C30), 5-dimension EuroQol questionnaire (EQ-5D), and Functional Assessment of Cancer Therapy-General (FACT-G) for newly diagnosed and previously treated patients with mPaC were worse than those of the general population. Baseline scores were generally better for previously treated patients than for newly diagnosed patients, indicating that mPaC treatments preserve or improve HRQoL. Identified publications also reported changes in HRQoL following first- or subsequent-line chemotherapy. When reported, 10 studies found improvements in overall HRQoL compared with baseline scores, four reported no changes in overall HRQoL after treatment, and six found deteriorations in overall HRQoL.

Conclusion

Patients with mPaC had worse HRQoL than the general population. Available anti-cancer therapies can improve or preserve HRQoL.

Cost Effectiveness of Adding Pembrolizumab to Platinum and Fluoropyrimidine-Based Chemotherapy as First-Line Treatment for Advanced Esophageal Cancer: A US Healthcare Payer's Perspective

BACKGROUND AND OBJECTIVE

Pembrolizumab plus cisplatin and fluorouracil demonstrated superior efficacy and comparable safety compared with fluorouracil and cisplatin (FP) as first-line treatment for locally advanced unresectable or metastatic carcinoma of the esophagus and gastroesophageal junction adenocarcinoma in a phase III trial (KEYNOTE-590). This study evaluated the cost effectiveness of pembrolizumab plus FP versus FP and versus a blended chemotherapy comparator including FP, carboplatin plus paclitaxel, FOLFOX, FOLFIRI, docetaxel plus FP, trastuzumab plus FP, and trastuzumab plus FOLFOX from a US healthcare payer's perspective.

METHODS

A partitioned survival model was developed with three health states (progression-free, progressive disease, and death). Overall survival, progression-free survival, time on treatment, and adverse events were informed by patient-level data from KEYNOTE-590. The blended chemotherapy comparator reflected the current US treatment landscape and was assumed to have similar efficacy and safety as FP. Health utilities were estimated using linear mixed-effects models based on EQ-5D-5L data from the trial. Resource use and cost inputs (2020 US dollars) were based on US standard sources and literature. Costs, life-years, and quality-adjusted life-years (QALYs) discounted at 3.0% per year and incremental cost-effectiveness ratio were outcomes in the model. Sensitivity and scenario analyses were conducted to assess the robustness of base-case results.

RESULTS

Compared with FP, pembrolizumab plus FP produced a mean gain of 0.86 life-year and 0.77 QALY with additional costs of $112,630 over 37.6 years, yielding an incremental cost-effectiveness ratio of $147,097 per QALY. Results were similar when the intervention was pembrolizumab plus alternative chemotherapies or when blended chemotherapy became the comparator. Results were most sensitive to different overall survival extrapolation approaches.

CONCLUSIONS

Our analysis suggests that pembrolizumab plus chemotherapy extended life-years and QALYs and is cost effective compared with chemotherapy alone as a first-line treatment for advanced esophageal cancer in the USA given a willingness-to-pay threshold of $150,000 per QALY.

Adjuvant and neoadjuvant treatment patterns among resectable pancreatic cancer patients in the USA

Aim: Chemotherapy is standard before and/or after pancreatic cancer resection, yet benefits of pre-resection chemotherapy are unclear. Real-world pre- and post-resection treatment patterns were evaluated retrospectively. Methods: Neoadjuvant (3-months pre-surgery) and adjuvant (6-months post-surgery) treatment claims from 1 January 2016 to 31 December 2019 in US adults with resectable pancreatic cancer were analyzed. Results: Of the 737 patients, 29% received no chemotherapy in either setting; 22% received chemotherapy in both settings. In the neoadjuvant and adjuvant settings, 69 and 33% of patients, respectively, received no treatment at all. FOLFIRINOX and gemcitabine monotherapy were the most common chemotherapies in the neoadjuvant and adjuvant settings, respectively. Adjuvant FOLFIRINOX increased post-2018, whereas gemcitabine-based regimens decreased. Conclusion: Several chemotherapy regimens were used in both settings. Treatment patterns differed between the two settings.

Health-related quality of life scores of metastatic pancreatic cancer patients responsive to first line chemotherapy compared to newly derived EORTC QLQ-C30 reference values

Background

Metastatic pancreatic cancer (mPC) and its treatments significantly impact health-related quality of life (HRQoL). POLO, a randomized, double-blind, placebo-controlled phase 3 trial evaluated the efficacy of olaparib as maintenance therapy in germline BRCA mutated mPC patients who had not progressed during ≥16 weeks of first-line platinum-based chemotherapy. HRQoL was assessed using the EORTC QLQ-C30. To enhance score interpretation, we derived reference values for treatment-naïve mPC patients from the literature.

Methods

A targeted literature review identified EORTC QLQ-C30 baseline values in treatment-naïve mPC patients. Reference values were calculated by deriving means from studies meeting inclusion criteria, with scores from 0 to 100 (higher scores indicate better QoL/functioning but worse symptoms). For POLO patients, means were calculated using pooled baseline data across study arms.

Results

Four studies met inclusion criteria. Depending on the specific scale, sample sizes ranged from n = 466 to n = 639. Compared to newly derived reference values, POLO patients reported markedly better HRQoL scores at baseline across most scales, with eight scales showing differences of ≥10 points. POLO patients’ HRQoL scores were often close to or better than general population norm data.

Conclusions

This is the first study to systematically derive EORTC QLQ-C30 reference values for mPC. POLO patients had better HRQoL scores than those in the literature and similar to general population data. Comparatively high HRQoL of POLO patients are likely due to effects of prior first-line treatment and resolution of chemotherapy-related symptoms, response shift, or a combination. Newly derived reference values can enhance interpretation of mPC patients’ HRQoL.

Trial registration

The POLO trial was registered on 9 July 2014 with ClinicalTrials.gov as NCT 02184195.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12885-022-09661-7.

Abstract P5-13-11: Patient characteristics and treatment patterns by BRCA/ATM mutation status in patients with metastatic triple-negative breast cancer in the US: An electronic health records (EHR) based study

Background: Mutational testing of genes involved in DNA damage repair can help identify patients with metastatic triple-negative breast cancer (mTNBC) who might derive clinical benefit from poly (ADP-ribose) polymerase (PARP) inhibitors. We examined clinical characteristics and treatment patterns by BRCA1/2/ATM mutation status in patients with mTNBC receiving routine care in the United States.Methods: Included patients were aged ≥18 years with metastatic BC (≥2 BC diagnoses within 90 days and ≥1 diagnosis or ≥2 note mentions of metastatic disease) in Optum’s de-identified electronic health record (EHR) database (1/1/2013 - 6/30/2020; N=22.5M total lives). Index date was the first diagnosis/note mention of metastatic disease; TN status was based on ER, PR and HER2 negative test results in the 1-year baseline through 90 days post-index. We assessed baseline demographic, clinical and prognostic factors in the 12 months preceding the index date and followed for up to 36 months or until death.Results: A total of 3,017 patients with mTNBC were identified. Among 1,234 (40.9%) patients tested for BRCA/ATM mutation, 394 (31.9%) had a BRCA/ATM mutation (BRCA/ATMmut), 487 (39.5%) were negative for BRCA/ATMmut, and 353 (28.6%) had unknown BRCA/ATMmut status. BRCA/ATMmut patients had a mean age (SD) of 49.5 (12.9) years compared with 51.2 (12.1) years in patient with no BRCA/ATMmut. Racial distribution among patients with vs without BRCA/ATMmut was 73.1% vs 71.5% Caucasian, 15.5% vs 19.3% African American, 3.8% vs 1.2% Asian, and 7.6% vs 8.0% unknown, respectively. Among patients with BRCA/ATMmut, 22.1% had 2+ metastases, 11.4% had bone metastases, 5.6% had brain metastasis, 5.1% had liver metastasis, and 9.1% had lung metastasis. Among patients without BRCA/ATMmut, 18.5% had 2+ metastases, 9.4% had bone metastases, 5.7% had brain metastasis, 5.3% had liver metastasis, and 8.4% had lung metastasis. At 36-months post-index, the majority of patients had received an anthracycline (BRCA/ATMmut: 50.8%, no BRCA/ATMmut: 55.7%). The use of platinum-based therapies and PARP inhibitors was 23.2% and 9.7%, respectively in patients with BRCA/ATMmut; and 16.7% and 0.4%, respectively in patients without BRCA/ATMmut (table). Among Caucasian patients with BRCA/ATMmut, 12% had PARP inhibitor use compared to 0.0% of African American or Asian patients with BRCA/ATMmut.

Conclusions: A 32% BRCA/ATM mutation rate in mTNBC was observed and access to PARP inhibitor use appeared to differ by race. The suboptimal BRCA testing rates observed among patients with mTNBC represent an important unmet need. Further research is needed to understand the barriers to optimal access to mutational testing and impacts on treatment choice and outcomes.

Table. First-Line Regimens & Targeted Therapies by BRCA/ATM Status and RaceTreated PatientsAll (n=1,178)Caucasian (n=855)African American (n=240)Asian (n=21)BRCA/ATM TestingYesNoYesNoYesNoYesNo582(49.4%)596(50.6%)425(49.7%)430(50.3%)110(45.8%)130(54.2%)13(61.9%)8(38.1%)BRCA/ATMmut 185(31.8%)246(42.3%)142(33.4%)174(40.9%)29(26.4%)49(44.5%)5(38.5%)5(38.5%)Anthracycline-based therapy in 1st line50.8%55.7%49.3%54.6%58.6%63.3%40.0%20.0%Taxane therapy in 1st line9.2%7.3%8.5%6.3%13.8%8.2%0.0%0.0%Platinum-based therapy in any line/setting23.2%16.7%23.2%20.1%17.2%10.2%40.0%20.0%Immune Checkpoint Inhibitor in any line/setting7.0%7.3%7.7%8.6%6.9%4.1%0.0%20.0%PARP Inhibitor in any line/setting9.7%0.4%12.0%0.6%0.0%0.0%0.0%0.0%

Citation Format: Gboyega Adeboyeje, Maria Sierra, Amy Bartels, Michelle Field, Sumit Jhamb, Ami Buikema, Seongjung Joo. Patient characteristics and treatment patterns by BRCA/ATM mutation status in patients with metastatic triple-negative breast cancer in the US: An electronic health records (EHR) based study [abstract]. In: Proceedings of the 2021 San Antonio Breast Cancer Symposium; 2021 Dec 7-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2022;82(4 Suppl):Abstract nr P5-13-11.

Abstract P2-08-21: Overall survival associated with BRCA or ATM mutation status in patients with metastatic triple-negative breast cancer: Findings from the PRIOR-2 study

Background: Many clinical guidelines recommend patients with metastatic triple-negative breast cancer (mTNBC) undergo mutational testing of genes involved in DNA damage repair response as a predictive marker of clinical benefit from recently approved targeted therapies. However, there is little known regarding the prognostic impact of BRCA1/2 or ATM mutation on the survival experience of mTNBC patients receiving contemporary routine care in the United States.Methods: In this retrospective cohort study, we identified patients aged ≥18 years with metastatic BC (≥2 BC diagnoses within 90 days and ≥1 diagnosis or ≥2 note mentions of metastatic disease) in Optum’s de-identified electronic health record (EHR) database (1/1/2013 - 6/30/2020; N=22.5M total lives). Index date was first diagnosis/note mention of metastatic disease; TN status was based on ER, PR and HER2 negative test results in the 1-year baseline through 90 days post-index. Patients were stratified by BRCA/ATM status and followed for up to 24 months from the start of treatment to assess overall survival (OS) using death information captured from the EHR and linked social security and obituary data. Differences in 2-year OS by BRCA/ATM status were evaluated using a Cox Proportional-Hazards model, adjusting for baseline demographics, comorbidities, clinical and prognostic factors.Results: Among 3,017 patients with mTNBC, 1,234 (40.9%) had evidence of being tested for BRCA/ATM: 394 (31.9%) had a BRCA/ATM mutation (POS), 487 (39.5%) were negative for a BRCA/ATM mutation (NEG), and 353 (28.6%) had unknown BRCA/ATM mutation status. Patients with a BRCA/ATM mutation had a mean age (SD) of 49.5 (12.9) years, while NEG patients had a mean age (SD) of 51.2 (12.1) years. Among POS patients, 22.1% had 2+ metastases at diagnosis, 11.4% had bone metastases, 5.6% had brain metastasis, 5.1% had liver metastasis, and 9.1% had lung metastasis. Among NEG patients, 18.5% had 2+ metastases at diagnosis, 9.4% had bone metastases, 5.7% had brain metastasis, 5.3% had liver metastasis, and 8.4% had lung metastasis. Of the 762 patients (338 POS; 424 NEG) with known stage at diagnosis, 40% of both POS and NEG patients presented at stage 3/4. Two-year OS rates were not significantly different by BRCA/ATM mutation status from start of treatment in the metastatic setting (POS: 79.3% vs NEG: 74.6%, p=0.30); unadjusted hazard ratio (HR) 1.28 (95% CI =0.81-2.03); adjusted HR 1.22 (95% CI 0.75-2.00). Conclusion: In this observational study of US patients with mTNBC, there was no statistically significant difference in 2-year OS rates between patients with or without BRCA/ATM mutation. OS at 2-years may have been overestimated in our sample due to the potential for unobserved death. Additional research is needed to evaluate the association between BRCA/ATM status and overall survival in different patient populations.

Citation Format: Gboyega Adeboyeje, Maria Sierra, Amy Bartels, Michelle Field, Sumit Jhamb, Ami Buikema, Seongjung Joo. Overall survival associated with BRCA or ATM mutation status in patients with metastatic triple-negative breast cancer: Findings from the PRIOR-2 study [abstract]. In: Proceedings of the 2021 San Antonio Breast Cancer Symposium; 2021 Dec 7-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2022;82(4 Suppl):Abstract nr P2-08-21.

Health outcomes of gBRCA testing strategies for metastatic pancreatic cancer patients

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Background: About 4-8% metastatic pancreatic cancer (mPC) patients have germline BRCA mutation (gBRCAm). Identifying gBRCAm through early testing benefits mPC patients through: 1. better health outcomes when gBRCAm patients receive platinum (plat) based 1st line (1L) chemotherapy compared to non-plat 1L regimen; 2. additional benefit, if eligible, from olaparib (O) maintenance treatment (mTx), which was approved by the FDA for the gBRCAm mPC patients who have not progressed on at least 16 weeks of a 1L plat regimen. Objective: To evaluate the health outcomes of gBRCA testing and treatment strategies among mPC patients using simulation model. Methods: A 3-state partitioned survival model was developed to assess the lifetime (20 year) health outcomes among treatment naïve mPC patients for the following strategies: 1. No gBRCA testing, no O mTx; 2. gBRCA testing before 1L, no O mTx; 3. gBRCA testing before 1L, O mTx; 4. gBRCA testing after 1L, O mTx. Without gBRCAm information before 1L (i.e., strategy 1&4) or if gBRCA negative, 45% mPC patients with good performance status (PS) and 27% with poor PS received 1L plat. We assumed that for gBRCAm patients, if known, 90% with good PS and 50% with poor PS received 1st line plat (i.e., strategy 2&3) in the base case. We assumed gBRCA testing had 100% of sensitivity and specificity. OS and PFS survival curves were extrapolated from pivotal trials. The additional health outcome benefit from O mTx after 16 weeks were modeled using efficacy from POLO trial. Health outcomes were measured by life years (LY) and, after applying health utilities by health state, quality adjusted life years (QALY). Results: The proportion of gBRCAm mPC patients receiving O mTx were 58.7% (4.4% of mPC patients) for strategy 3 vs 30.0% (2.2% of mPC patients) for strategy 4. For gBRCAm mPC patients, no testing generated the least LY and QALY, while testing before 1st line with O mTx resulted in the most. This trend was also observed in the overall cohort of mPC patients with the best outcomes from testing before 1st line with O mTx and worse outcomes from no testing or testing after 1st line with O Mtx. These survival gains are primarily derived by higher proportion of patients on platinum with better survival along with O Mtx gains. Conclusions: mPC patients achieve the highest health benefits by gBRCA testing before 1L treatment followed by O mTx, even with less than 5% mPC patients becoming eligible for O mTx (strategy 3).[Table: see text]

Real-world timelines of BRCA1/2-related molecular testing in pancreatic cancer

601

Background: BRCA1/2 mutations are present in ̃6-8% of patients with pancreatic adenocarcinoma. Olaparib is a recently approved PARP inhibitor (PARPi) in the US and Europe for germline BRCA1/2-mutated metastatic PaC in the 1st line maintenance setting following response to at least 16 weeks of a platinum-containing regimen. However, the availability of BRCA1/2 testing results at the time of 1st line and subsequent treatment decisions in the advanced stage has not been established in real-world settings. Methods: Longitudinal clinical/molecular data collected between 1/2012-12/2020 were retrospectively analyzed in 75 PaC pts with germline or somatic BRCA1/2 mutations (BRCA1/2m) who enrolled in Perthera’s US real-world observational registry. Tumor NGS testing results were generated by commercial labs for all patients. Germline status was assessed by a molecular tumor board when testing results are available. BRCA1/2m discovery timing (days since advanced presentation), molecular testing turnaround time (days from physician order to result), and platinum utilization were abstracted from physician records. Associations between BRCA1/2m discovery timing and platinum utilization were evaluated using Fisher’s exact test. Results: At the time of advanced PaC diagnosis, BRCA1/2m status was known in a minority of patients (29% (22 of 75). In the remaining 71% (53 of 75) patients, the median time to report BRCA1/2m status was 76 days (IQR=56-558) following advanced diagnosis. The median tumor NGS testing turnaround time was 35 days after physician order (IQR=24-54). Platinum use in any setting was documented in 85% (64 of 75) of patients and the majority of these patients (62%, 40 of 64) initiated a platinum-based regimen before BRCA1/2m status was first reported. Platinum agents were initiated before 2nd line in 75% (48 of 64) patients, and this was associated with BRCA1/2m identification before advanced diagnosis (p=0.03). Conclusions: BRCA1/2 testing results may not always be available when 1st line regimens are chosen which can impact ideal treatment sequencing in PaC patients. These real-world analyses underscore the importance of upfront BRCA1/2 testing in PaC patients.

Real-world use of PARP inhibitors in BRCA1/2-mutated pancreatic cancer: A retrospective analysis

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Background: BRCA1 or BRCA2 mutations can be found in approximately 6 to 8 percent of patients patients with metastatic pancreatic adenocarcinoma (mPaC). Olaparib is the only PARP inhibitor (PARPi) approved in the EU and the US as maintenance treatment for biomarker-selected patients with mPaC in the 1st line platinum-sensitive setting. However, treatment sequencing can be heterogeneous, and there is a lack of real-world data on patterns of PARPi use in relation to platinum use in BRCA1/2-mutated mPaC. Methods: Longitudinal records collected between 1/2012-12/2020 were analyzed for a cohort of 55 mPaC patients with BRCA1 or BRCA2 mutations identified by commercial NGS testing who enrolled in Perthera’s US real-world observational registry study. Treatment patterns including PARPi utilization and platinum-sensitivity (16 weeks without progression at any point within known history) were abstracted via physician notes across all lines of therapy. Results: PARPi use was documented in 60% (N=33) of 55 patients with BRCA1/2-mutated mPaC in any treatment setting. Within this cohort, 21 patients received a single agent PARPi outside of clinical trials. Among these patients, only 38% (8 of 21) transitioned to a PARPi in a platinum-sensitive context, and only 14% (3 of 21) of these transitions occurred before 2nd line. Notably, 6 patients received a PARPi in the platinum-resistant setting. Within the broader cohort, platinum-sensitive criteria was fully met for 73% (40 of 55); however, only 49% (27 of 55) reached this milestone of platinum-sensitivity prior to initiating a 2nd line therapy. Conclusions: The majority of these BRCA1/2-mutated patients received a PARPi-based therapy in a variety of contexts with respect to line of therapy and prior platinum history. These findings highlight the value of upfront genetic and molecular testing and the need for further exploration to identify factors associated with treatment response as well as optimized treatment sequencing.

Association of beta-blockers or inhibitors of renin-angiotensin system with clinical outcomes in patients with mid-range left ventricular ejection fraction after acute myocardial infarction

Background

In the era of the initial optimal interventional and medical therapy for acute myocardial infarction (AMI), a number of patients with mid-range left ventricular ejection fraction (EF) (>40%, <50%) becomes increasing.

Purpose

This observational study aimed to investigate the association between oral beta-blockers or inhibitors of renin-angiotensin system (RAS) and 2-year clinical outcomes in patients with mid-range EF after AMI.

Methods

Among 13,624 patients enrolled in the Korea Acute Myocardial Infarction Registry-National Institute of Health (KAMIR-NIH), propensity-score matched patients who survived the initial attack and had mid-range EF were selected according to beta-blocker or RAS inhibitor therapy at discharge.

Results

Beta-blocker therapy at discharge was associated with lower 2-year major adverse cardiac events (MACE) of cardiac death, MI, revascularization or re-hospitalization due to heart failure (8.7 vs. 12.8/100 person-year; hazard ratio [HR] 0.68; 95% confidence interval [CI] 0.50–0.93; P=0.015), and no significant interaction between EF ≤45% and >45% was observed (P for interaction=0.354). This association was mainly driven by lower MI in patients with beta-blockers (1.6 vs. 3.1/100 person-year; HR 0.50; 95% CI 0.26–0.95; P=0.035). Inhibitors of RAS at discharge were not associated with lower 2-year MACE, but with lower re-hospitalization due to heart failure (1.8 vs. 3.5/100 person-year; HR 0.53; 95% CI 0.33–0.86; P=0.010) without significant interaction between EF ≤45% and >45% (P for interaction=0.333).

Conclusions

Beta-blockers or RAS inhibitors at discharge were associated with better 2-year clinical outcomes without significant interaction between ≤45% and >45% in patients with mid-range EF after AMI.</ef<50%)>

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Korea Centers for Disease Control and Prevention. 2-year clinical outcomes

Real-world neo-adjuvant with or without adjuvant treatment patterns among pancreatic ductal adenocarcinoma patients in the U.S

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Background: The vast majority of pancreatic ductal adenocarcinoma (PDAC) patients have unresectable disease at diagnosis, with only about 20% presenting with either resectable or borderline resectable tumors and who may receive adjuvant with or without neo-adjuvant treatment with surgery. This study seeks to characterize these treatment patterns in the real-world setting. Methods: This was a retrospective observational study to evaluate adjuvant treatment of PDAC patients, with or without neo-adjuvant treatment in the U.S. Patients with at least two medical claims with a primary diagnosis for PDAC between 2016 to 2019 were identified in the Truven MarketScan administrative claims database. A surgical resection within 3 months of any primary PDAC coded medical encounter was the index event, with patients required to be continuously enrolled for at least 3 months before and 6 months after the surgery. Patient demographics and treatment patterns (chemotherapy, radiotherapy, and chemoradiation) were evaluated over the pre-index (3 months) and post-index (3 and 6 months) observation windows. Neo-adjuvant and adjuvant treatment patterns were reported for the overall population and also stratified by age and sex. Results: 737 patients met the selection criteria with a majority (n=520, 71%) being <65 years old and 53% females (n=387). 65% (n=478) of patients received adjuvant chemotherapy during the 6-month post-index compared with 28% (n=207) receiving neo-adjuvant treatment. In the neo-adjuvant setting, patients were likely to receive leucovorin+fluorouracil+irinotecan+oxaliplatin (FOLFIRINOX; 43%, n=88) followed by gemcitabine+pacitaxel (18%, n=37), across all patients, as well as stratified by age or sex. Among patients that received adjuvant but did not receive neo-adjuvant treatment, patients were likely to receive gemcitabine monotherapy (35%, n=112) followed by gemcitabine+capecitabine (GEMCAP; 23%, n=72). Among adjuvant patients that had received neo-adjuvant treatment, the most common chemotherapy regimens were gemcitabine monotherapy (22%, n=35), GEMCAP (18%, n=29) and FOLFIRINOX (16%, n=26). For patients ≥ 65 years old, the most common adjuvant regimen was gemcitabine monotherapy (n=62, 29%) whereas for patients <65, the most common regimens were GEMCAP (25%, n=90) and gemcitabine monotherapy (16%, n=85). Gemcitabine monotherapy (41%; n=118 of 453) was the main adjuvant regimen for patients with index dates of 2016-2017 but for those with index dates of 2018-2019 the most common was FOLFIRINOX (34%; n=64 of 284) followed by GEMCAP (18%; n=35 of 284). Conclusions: The majority (70%) of patients that underwent PDAC resection surgery did not receive neo-adjuvant treatment and about a third of patients did not receive any adjuvant treatment. These results suggest an unmet need in the management of PDAC.

Global longitudinal assessment of treatment outcomes in recurrent/metastatic nasopharyngeal carcinoma: GLANCE-NPC study

Aim: Given a lack of standard of care treatment for recurrent/metastatic nasopharyngeal carcinoma (R/M NPC), we assessed treatment patterns and overall survival in the real-world setting. Materials & methods: A retrospective chart review was conducted in patients who initiated first-line systemic therapy in Taiwan and South Korea between January 2012 and June 2013 with follow-up through December 2015. Results: Among 154 R/M NPC patients, all patients in Taiwan (n = 104) had distant metastases, whereas in South Korea (n = 50) 42% had distant metastases. Patients with distant metastases generally received systemic therapy only (71%) for whom median overall survival was 23 months (95% CI: 18-32). Conclusion: Prognosis in R/M NPC with distant metastases remains poor, underscoring the need for more efficacious treatments.

Reference values for EORTC QLQ-C30, for metastatic pancreatic cancer (mPC): Enhancing the interpretation of HRQoL scores in the POLO trial

393

Background: Metastatic pancreatic cancer (mPC) and its treatments significantly impact patients’ (pts) health-related quality of life (HRQoL). POLO, a randomized, double-blind, placebo-controlled phase 3 trial evaluated the efficacy of olaparib as maintenance therapy in mPC pts who had not progressed during ≥16 weeks of first-line platinum-based chemo. HRQoL was assessed in POLO using EORTC QLQ-C30. To enhance the interpretation of HRQoL scores in POLO, we derived EORTC QLQ-C30 reference (ref) values for mPC from the literature, as these had not been previously established. Methods: A systematic literature review was conducted to identify existing baseline values in published data. EORTC QLQ-C30 ref values were calculated by deriving mean scores based on studies meeting all inclusion criteria. EORTC QLQ-C30 mean values were calculated for POLO using pooled baseline data from both study arms (olaparib; placebo). Results: Out of 186 studies identified, 4 met all inclusion criteria. Depending on respective EORTC QLQ-C30 subscale, the final sample sizes ranged from n=466 to n=639. Compared to the newly derived EORTC QLQ-C30 ref values based on the literature, POLO pts reported markedly better HRQoL scores at baseline across most subscales, with eight subscales showing differences of >15 points (table). Conclusions: This is the first study to systematically derive EORTC QLQ-C30 ref values for mPC. We found that mPC pts enrolled in POLO had better HRQoL scores compared with those reported in the literature and often close to or better than general population norm data, possibly due to positive effects of prior platinum-based first-line treatment, resolution of chemotherapy-related symptoms, response shift, or a combination. These newly derived ref values enhance the interpretation of patients’ HRQoL trajectory within a maintenance treatment setting. [Table: see text]

POLO: Quality-adjusted (QA) progression-free survival (PFS) and patient (pt)-centered outcomes with maintenance olaparib in pts with metastatic pancreatic cancer (mPaC)

4626

Background: In the Phase III POLO trial (NCT02184195), maintenance olaparib significantly prolonged PFS vs placebo in pts with a germline BRCA1 and/or BRCA2 mutation (gBRCAm) and mPaC (median 7.4 vs. 3.8 months). The aim of maintenance treatment is to extend PFS and survival without compromising health-related quality of life due to adverse events. The duration of time spent without symptoms or toxicities (TWiST) and the QA-PFS were assessed in a post hoc analysis of the POLO trial. Methods: Patients were randomized 3:2 to receive maintenance olaparib (tablets; 300 mg bid) or placebo. Restricted mean (RM)-PFS was calculated by estimating the area under the Kaplan–Meier PFS curve between randomization and 29.8 months after randomization (maximum follow-up for the placebo arm in POLO). Patient-centered outcomes were assessed by QA-PFS (derived from the product of the EQ-5D-5L single-index utility score from randomization to disease progression and RM-PFS) and TWiST (RM-PFS minus time with toxicity after randomization). Results: RM-PFS was significantly longer with olaparib, with a between-treatment difference of 4.8 months ( P=0.009; Table). Over this period, no significant or meaningful differences in mean EQ-5D-5L index were observed between treatment groups. The corresponding mean QA-PFS was significantly longer with olaparib vs placebo. TWiST analysis demonstrated a benefit with olaparib over placebo (Table): between-arm difference, 3.8 months ( P=0.039) for the primary analysis (criteria 1: grade ≥2 nausea, vomiting or fatigue). Sensitivity analysis (criteria 1 plus abdominal pain, diarrhea, decreased appetite or constipation) also revealed a trend toward benefit with olaparib (difference: 3.4 months, P=0.062). Conclusions: Consistent with the primary PFS analysis of the POLO trial, RM-PFS and QA-PFS were significantly longer with maintenance olaparib than with placebo. As demonstrated by the findings of the TWiST analyses, the PFS benefit observed with olaparib in pts with a gBRCAm and mPaC persists even when symptoms of toxicity are considered. Clinical trial information: NCT02184195 . [Table: see text]

Pancreatic cancer (PaC)-specific health-related quality of life (HRQoL) with maintenance olaparib (O) in patients (pts) with metastatic (m) PaC and a germline BRCA mutation (gBRCAm): Phase III POLO trial

648

Background: In POLO (NCT02184195), maintenance O significantly improved progression-free survival vs placebo (P) in pts with a gBRCAm and mPaC without compromising HRQoL (Hammel Ann Oncol 2019). We report additional predefined exploratory HRQoL data from the PaC-specific EORTC QLQ-PAN26 questionnaire. Methods: Pts were randomized to O (300 mg bid; tablets) or P. QLQ-PAN26 was completed at baseline (BL), after 1, 2, 3 + 4 weeks (wk) of treatment, every 4 wks until progression, at discontinuation, and 30 days after last dose. Scale range = 1–100 (higher score = greater symptoms); a 10-point change was predefined as clinically meaningful. Adjusted mean change from BL (CFBL) was analyzed by mixed model for repeated measures; time to sustained clinically meaningful deterioration (TSCMD) by log-rank test. Results: Analyses included the 89/92 O- and 58/62 P-arm pts with BL data (overall compliance: 97.8% vs 98.3%). Symptom scores were well balanced in both groups at BL and remained low and stable over time (Table). There were no clinically meaningful between-group differences in adjusted mean CFBL symptom scores. TSCMD in symptoms were not significantly different with O vs P. Conclusions: HRQoL was preserved with maintenance O, as shown by a low and stable PaC symptom burden over time, with no difference vs P. These data support the clinical benefit of O in pts with a gBRCAm and mPaC. Clinical trial information: NCT02184195 . [Table: see text]

Global treatment patterns and outcomes among patients with recurrent and/or metastatic head and neck squamous cell carcinoma: Results of the GLANCE H&N study

OBJECTIVES

Given a lack of universally-accepted standard-of-care treatment for patients with recurrent/metastatic head and neck squamous cell carcinoma (R/M HNSCC), study objectives were to assess treatment utilization and survival outcomes for R/M HNSCC in the real-world setting.

MATERIALS AND METHODS

A multi-site retrospective chart review was conducted in Europe (Germany, United Kingdom, Italy, Spain), Asia Pacific (Australia, South Korea, Taiwan), and Latin/North America (Brazil and Canada) to identify patients who initiated first-line systemic therapy for R/M HNSCC between January 2011 and December 2013. Patients were followed through December 2015 to collect clinical characteristics, treatment and survival data.

RESULTS

Among 733 R/M HNSCC patients across 71 sites, median age was 60 years (inter-quartile range 54-67), 84% male, and 70% Eastern Cooperative Oncology Group performance status 0-1; 32% had oral cavity and 30% oropharyngeal cancers. The most common first-line regimen across all countries consisted of platinum-based combinations (73%), including platinum + 5-fluorouracil (5-FU) (26%), cetuximab + platinum ± 5-FU (22%), or taxane + platinum ± 5-FU (16%). However, use of different platinum-based combinations varied substantially; administration of cetuximab + platinum ± 5-FU was frequent in Italy (81%), Germany (46%) and Spain (38%), whereas use in other countries was limited. Median follow-up was 22.6 months (95% confidence interval [CI]: 21.5-24.6 months). Median real-world overall survival was only 8.0 months (95% CI: 7.0-8.0), with one-year survival reaching only 30.9% (95% CI: 27.5-34.3).

CONCLUSION

Systemic therapies used in clinical practice for patients with R/M HNSCC vary substantially across countries. Prognosis remains poor in this patient population, highlighting the need for newer, more efficacious treatments.

Health-related quality of life in patients with a germline BRCA mutation and metastatic pancreatic cancer receiving maintenance olaparib

BACKGROUND

Patients with metastatic pancreatic cancer often have a detriment in health-related quality of life (HRQoL). In the randomized, double-blind, phase III POLO trial progression-free survival was significantly longer with maintenance olaparib, a poly(ADP-ribose) polymerase inhibitor, than placebo in patients with a germline BRCA1 and/or BRCA2 mutation (gBRCAm) and metastatic pancreatic cancer whose disease had not progressed during first-line platinum-based chemotherapy. The prespecified HRQoL evaluation is reported here.

PATIENTS AND METHODS

Patients were randomized to receive maintenance olaparib (300 mg b.i.d.; tablets) or placebo. HRQoL was assessed using the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire Core 30-item module at baseline, every 4 weeks until disease progression, at discontinuation, and 30 days after last dose. Scores ranged from 0 to 100; a ≥10-point change or difference between arms was considered clinically meaningful. Adjusted mean change from baseline was analysed using a mixed model for repeated measures. Time to sustained clinically meaningful deterioration (TSCMD) was analysed using a log-rank test.

RESULTS

Of 154 randomized patients, 89 of 92 olaparib-arm and 58 of 62 placebo-arm patients were included in HRQoL analyses. The adjusted mean change in Global Health Status (GHS) score from baseline was <10 points in both arms and there was no significant between-group difference [-2.47; 95% confidence interval (CI) -7.27, 2.33; P = 0.31]. Analysis of physical functioning scores showed a significant between-group difference (-4.45 points; 95% CI -8.75, -0.16; P = 0.04). There was no difference in TSCMD for olaparib versus placebo for GHS [P = 0.25; hazard ratio (HR) 0.72; 95% CI 0.41, 1.27] or physical functioning (P = 0.32; HR 1.38; 95% CI 0.73, 2.63).

CONCLUSIONS

HRQoL was preserved with maintenance olaparib treatment with no clinically meaningful difference compared with placebo. These results support the observed efficacy benefit of maintenance olaparib in patients with a gBRCAm and metastatic pancreatic cancer.

CLINCALTRIALS.GOV NUMBER

NCT02184195.

Treatment patterns and outcomes among patients with recurrent/metastatic squamous cell carcinoma of the head and neck

Aim: Cetuximab was approved in 2008 for treating recurrent/metastatic (R/M) head-and-neck squamous-cell carcinoma (HNSCC), and this study assessed the utilization of cetuximab for R/M-HNSCC in a real-world setting. Materials & methods: Adult patients with R/M-HNSCC, who initiated systemic therapy between 1 September 2011 and 31 December 2014 and followed through 31 December 2015, were identified from iKnowMed electronic-health-records database (McKesson Specialty Health) supplemented with manual chart-abstraction. Results: For 325 R/M-HNSCC patients; median age 62 years; 82% males, 67% had oropharyngeal cancer, most common first-line (1L) regimen was platinum-based combinations (76%), of whom only 8% received platinum + cetuximab +/− 5-fluorouracil. Conclusion: Despite US FDA approval and National Comprehensive Cancer Network guidelines recommending use of cetuximab for palliative treatment of R/M-HNSCC, our study demonstrates low utilization in 1L and 2L settings, underscoring the need to understand reasons for low utilization.

A high-resolution anorectal manometry parameter based on integrated pressurized volume: A study based on 204 male patients with constipation and 26 controls

BACKGROUND

Conventional anorectal manometric parameters based on linear waves cannot properly predict balloon expulsion (BE) time. We aimed to determine the correlation between integrated pressurized volume (IPV) parameters during simulated evacuation (SE) and BE time in healthy individuals and constipated patients and to assess the correlation between each parameter and symptoms.

METHODS

A total of 230 male participants (including 26 healthy volunteers and 204 chronically constipated patients) underwent high-resolution anorectal manometry (HRAM) and BE tests. The IPV was calculated by multiplying the amplitude, distance, and time from the HRAM profile. Receiver operating characteristic curve (ROC) analysis and partial least square regression (PLSR) were performed.

KEY RESULTS

ROC analysis indicated that the IPV ratio between the upper 1 cm and lower 4 cm of the anal canal was more effective for predicting BE time (area under the curve [AUC]: 0.74, 95% confidence interval [CI]: 0.67-0.80, P < .01) than the conventional anorectal parameters, including defecation index and rectoanal gradient (AUC: 0.60, 95% CI: 0.52-0.67, P = .01). PLSR analysis of a linear combination of IPV parameters yielded an AUC of 0.79. Moreover, the IPV ratio showed a greater clinical correlation with patient symptoms than conventional parameters.

CONCLUSIONS AND INFERENCES

The IPV parameters and the combination of IPV parameters via PLSR were more significantly correlated with BE time than the conventional parameters. Thus, this study presents a useful diagnostic tool for the evaluation of pathophysiologic abnormalities in dyssynergic defecation using IPV and BE time.

Treatment patterns in recurrent/metastatic head and neck squamous cell carcinoma in the US

6033

Background: Given the most recent FDA approval of cetuximab in 2008 for treatment of recurrent/metastatic (R/M) head and neck squamous cell carcinoma (HNSCC), the objective was to assess utilization of cetuximab and other treatments for R/M HNSCC in real world setting. Methods: Adult patients (pts) with R/M HNSCC who initiated systemic therapy between 9/1/2011-12/31/2014 were identified from iKnowMedelectronic health records database (McKesson Specialty Health) supplemented with chart abstraction. Pts were followed through 12/31/2015 to collect data on clinical characteristics, treatments and survival outcomes. Results: Among 325 pts with R/M HNSCC, median age was 62 yrs; 82% were male, and 67% had oropharyngeal cancer. The most common first line (1L) regimen consisted of platinum-based combinations (76%; Table 1); 63% received platinum+taxane +/-5FU and only 8% received platinum+cetuximab +/- 5FU. Median overall survival was 13.6 months (range 11.7-16.6). Following 1L therapy, 171 pts (53%) received a 2L regimen; 57 pts (18%) received platinum monotherapy and 8% received 2L platinum+taxane +/- 5FU, while only 12% received cetuximab mono- or platinum+cetuximab + /- 5FU. Among pts receiving 1L platinum combination, 32% were re-treated with platinum based therapy of which platinum monotherapy (23%) and platinum+taxane +/- 5FU (7%) were most common. Conclusions: Despite FDA approval and NCCN guidelines recommending use of cetuximab for palliative treatment of R/M HNSCC, our study demonstrates underutilization in both 1L and 2L settings, underscoring the need to understand reasons for underutilization and the need for newer efficacious treatments. [Table: see text]

Effects of Achieving Target Measures in Rheumatoid Arthritis on Functional Status, Quality of Life, and Resource Utilization: Analysis of Clinical Practice Data

Objective

To evaluate associations between achieving guideline‐recommended targets of disease activity, defined by the Disease Activity Score in 28 joints using C‐reactive protein level (DAS28‐CRP) <2.6, the Simplified Disease Activity Index (SDAI) ≤3.3, or the Clinical Disease Activity Index (CDAI) ≤2.8, and other health outcomes in a longitudinal observational study.

Methods

Other defined thresholds included low disease activity (LDA), moderate (MDA), or severe disease activity (SDA). To control for intraclass correlation and estimate effects of independent variables on outcomes of the modified Health Assessment Questionnaire (M‐HAQ), the EuroQol 5‐domain (EQ‐5D; a quality‐of‐life measure), hospitalization, and durable medical equipment (DME) use, we employed mixed models for continuous outcomes and generalized estimating equations for binary outcomes.

Results

Among 1,297 subjects, achievement (versus nonachievement) of recommended disease targets was associated with enhanced physical functioning and lower health resource utilization. After controlling for baseline covariates, achievement of disease targets (versus LDA) was associated with significantly enhanced physical functioning based on SDAI ≤3.3 (ΔM‐HAQ −0.047; P = 0.0100) and CDAI ≤2.8 (−0.073; P = 0.0003) but not DAS28‐CRP <2.6 (−0.022; P = 0.1735). Target attainment was associated with significantly improved EQ‐5D (0.022–0.096; P < 0.0030 versus LDA, MDA, or SDA). Patients achieving guideline‐recommended disease targets were 36–45% less likely to be hospitalized (P < 0.0500) and 23–45% less likely to utilize DME (P < 0.0100).

Conclusion

Attaining recommended target disease‐activity measures was associated with enhanced physical functioning and health‐related quality of life. Some health outcomes were similar in subjects attaining guideline targets versus LDA. Achieving LDA is a worthy clinical objective in some patients.