Perinatal optimisation for periviable birth and outcomes: a 4-year network analysis (2018-2021) across a change in national guidance

Introduction

The British Association of Perinatal Medicine (BAPM) released their revised framework for extremely preterm infant management in 2019. This revised framework promotes consideration of perinatal optimisation and survival-focused care from 22 weeks gestation onwards. This was a departure from the previous BAPM framework which recommended comfort care as the only recommended management for infants <23 + 0 weeks.

Methods

Our study evaluates the clinical impact that this updated framework has had across the Northwest of England. We utilised anonymised network data from periviable infants delivered across the region to examine changes in perinatal optimisation practices and survival outcomes following the release of the latest BAPM framework.

Results

Our data show that after the introduction of the updated framework there has been an increase in perinatal optimisation practices for periviable infants and an 80% increase in the number of infants born at 22 weeks receiving survival-focused care and admission to a neonatal unit.

Discussion

There remain significant discrepancies in optimisation practices by gestational age, which may be contributing to the static survival rates that were observed in the lowest gestational ages.

Observation of Seven Astrophysical Tau Neutrino Candidates with IceCube

We report on a measurement of astrophysical tau neutrinos with 9.7 yr of IceCube data. Using convolutional neural networks trained on images derived from simulated events, seven candidate ν_{τ} events were found with visible energies ranging from roughly 20 TeV to 1 PeV and a median expected parent ν_{τ} energy of about 200 TeV. Considering backgrounds from astrophysical and atmospheric neutrinos, and muons from π^{±}/K^{±} decays in atmospheric air showers, we obtain a total estimated background of about 0.5 events, dominated by non-ν_{τ} astrophysical neutrinos. Thus, we rule out the absence of astrophysical ν_{τ} at the 5σ level. The measured astrophysical ν_{τ} flux is consistent with expectations based on previously published IceCube astrophysical neutrino flux measurements and neutrino oscillations.

Observation of high-energy neutrinos from the Galactic plane

The origin of high-energy cosmic rays, atomic nuclei that continuously impact Earth's atmosphere, is unknown. Because of deflection by interstellar magnetic fields, cosmic rays produced within the Milky Way arrive at Earth from random directions. However, cosmic rays interact with matter near their sources and during propagation, which produces high-energy neutrinos. We searched for neutrino emission using machine learning techniques applied to 10 years of data from the IceCube Neutrino Observatory. By comparing diffuse emission models to a background-only hypothesis, we identified neutrino emission from the Galactic plane at the 4.5σ level of significance. The signal is consistent with diffuse emission of neutrinos from the Milky Way but could also arise from a population of unresolved point sources.

A, Barbano A, Barwick SW, Bastian B, Basu V, Baur S, Bay R, Beatty JJ, Becker KH, Becker Tjus J, Bellenghi C, BenZvi S, Berley D, Bernardini E, Besson DZ, Binder G, Bindig D, Blaufuss E, Blot S, Boddenberg M, Bontempo F, Borowka J, Böser S, Botner O, Böttcher J, Bourbeau E, Bradascio F, Braun J, Brinson B, Bron S, Brostean-Kaiser J, Browne S, Burgman A, Burley RT, Busse RS, Campana MA, Carnie-Bronca EG, Chen C, Chen Z, Chirkin D, Choi K, Clark BA, Clark K, Classen L, Coleman A, Collin GH, Conrad JM, Coppin P, Correa P, Cowen DF, Cross R, Dappen C, Dave P, De Clercq C, DeLaunay JJ, Delgado López D, Dembinski H, Deoskar K, Desai A, Desiati P, de Vries KD, de Wasseige G, de With M, DeYoung T, Diaz A, Díaz-Vélez JC, Dittmer M, Dujmovic H, Dunkman M, DuVernois MA, Dvorak E, Ehrhardt T, Eller P, Engel R, Erpenbeck H, Evans J, Evenson PA, Fan KL, Fazely AR, Fedynitch A, Feigl N, Fiedlschuster S, Fienberg AT, Filimonov K, Finley C, Fischer L, Fox D, Franckowiak A, Friedman E, Fritz A, Fürst P, Gaisser TK, Gallagher J, Ganster E, Garcia A, Garrappa S, Gerhardt L, Ghadimi A, Glaser C, Glauch T, Glüsenkamp T, Goldschmidt A, Gonzalez JG, Goswami S, Grant D, Grégoire T, Griswold S, Günther C, Gutjahr P, Haack C, Hallgren A, Halliday R, Halve L, Halzen F, Ha Minh M, Hanson K, Hardin J, Harnisch AA, Haungs A, Hebecker D, Helbing K, Henningsen F, Hettinger EC, Hickford S, Hignight J, Hill C, Hill GC, Hoffman KD, Hoffmann R, Hokanson-Fasig B, Hoshina K, Huang F, Huber M, Huber T, Hultqvist K, Hünnefeld M, Hussain R, Hymon K, In S, Iovine N, Ishihara A, Jansson M, Japaridze GS, Jeong M, Jin M, Jones BJP, Kang D, Kang W, Kang X, Kappes A, Kappesser D, Kardum L, Karg T, Karl M, Karle A, Katz U, Kauer M, Kellermann M, Kelley JL, Kheirandish A, Kin K, Kintscher T, Kiryluk J, Klein SR, Koirala R, Kolanoski H, Kontrimas T, Köpke L, Kopper C, Kopper S, Koskinen DJ, Koundal P, Kovacevich M, Kowalski M, Kozynets T, Kun E, Kurahashi N, Lad N, Lagunas Gualda C, Lanfranchi JL, Larson MJ, Lauber F, Lazar JP, Lee JW, Leonard K, Leszczyńska A, Li Y, Lincetto M, Liu QR, Liubarska M, Lohfink E, Lozano Mariscal CJ, Lu L, Lucarelli F, Ludwig A, Luszczak W, Lyu Y, Ma WY, Madsen J, Mahn KBM, Makino Y, Mancina S, Mariş IC, Martinez-Soler I, Maruyama R, Mase K, McElroy T, McNally F, Mead JV, Meagher K, Mechbal S, Medina A, Meier M, Meighen-Berger S, Micallef J, Mockler D, Montaruli T, Moore RW, Morse R, Moulai M, Naab R, Nagai R, Nahnhauer R, Naumann U, Necker J, Nguyen LV, Niederhausen H, Nisa MU, Nowicki SC, Nygren D, Obertacke Pollmann A, Oehler M, Oeyen B, Olivas A, O’Sullivan E, Pandya H, Pankova DV, Park N, Parker GK, Paudel EN, Paul L, Pérez de los Heros C, Peters L, Peterson J, Philippen S, Pieper S, Pittermann M, Pizzuto A, Plum M, Popovych Y, Porcelli A, Prado Rodriguez M, Price PB, Pries B, Przybylski GT, Raab C, Rack-Helleis J, Raissi A, Rameez M, Rawlins K, Rea IC, Rehman A, Reichherzer P, Reimann R, Renzi G, Resconi E, Reusch S, Rhode W, Richman M, Riedel B, Roberts EJ, Robertson S, Roellinghoff G, Rongen M, Rott C, Ruhe T, Ryckbosch D, Rysewyk Cantu D, Safa I, Saffer J, Sanchez Herrera SE, Sandrock A, Sandroos J, Santander M, Sarkar S, Sarkar S, Satalecka K, Schaufel M, Schieler H, Schindler S, Schmidt T, Schneider A, Schneider J, Schröder FG, Schumacher L, Schwefer G, Sclafani S, Seckel D, Seunarine S, Sharma A, Shefali S, Silva M, Skrzypek B, Smithers B, Snihur R, Soedingrekso J, Soldin D, Spannfellner C, Spiczak GM, Spiering C, Stachurska J, Stamatikos M, Stanev T, Stein R, Stettner J, Steuer A, Stezelberger T, Stokstad R, Stürwald T, Stuttard T, Sullivan GW, Taboada I, Ter-Antonyan S, Tilav S, Tischbein F, Tollefson K, Tönnis C, Toscano S, Tosi D, Trettin A, Tselengidou M, Tung CF, Turcati A, Turcotte R, Turley CF, Twagirayezu JP, Ty B, Unland Elorrieta MA, Valtonen-Mattila N, Vandenbroucke J, van Eijndhoven N, Vannerom D, van Santen J, Verpoest S, Walck C, Watson TB, Weaver C, Weigel P, Weindl A, Weiss MJ, Weldert J, Wendt C, Werthebach J, Weyrauch M, Whitehorn N, Wiebusch CH, Williams DR, Wolf M, Woschnagg K, Wrede G, Wulff J, Xu XW, Yanez JP, Yoshida S, Yu S, Yuan T, Zhang Z, Zhelnin P. Evidence for neutrino emission from the nearby active galaxy NGC 1068

A supermassive black hole, obscured by cosmic dust, powers the nearby active galaxy NGC 1068. Neutrinos, which rarely interact with matter, could provide information on the galaxy’s active core. We searched for neutrino emission from astrophysical objects using data recorded with the IceCube neutrino detector between 2011 and 2020. The positions of 110 known gamma-ray sources were individually searched for neutrino detections above atmospheric and cosmic backgrounds. We found that NGC 1068 has an excess of 79 − 20 + 22 neutrinos at tera–electron volt energies, with a global significance of 4.2σ, which we interpret as associated with the active galaxy. The flux of high-energy neutrinos that we measured from NGC 1068 is more than an order of magnitude higher than the upper limit on emissions of tera–electron volt gamma rays from this source.

Search for Unstable Sterile Neutrinos with the IceCube Neutrino Observatory

We present a search for an unstable sterile neutrino by looking for a resonant signal in eight years of atmospheric ν_{μ} data collected from 2011 to 2019 at the IceCube Neutrino Observatory. Both the (stable) three-neutrino and the 3+1 sterile neutrino models are disfavored relative to the unstable sterile neutrino model, though with p values of 2.8% and 0.81%, respectively, we do not observe evidence for 3+1 neutrinos with neutrino decay. The best-fit parameters for the sterile neutrino with decay model from this study are Δm_{41}^{2}=6.7_{-2.5}^{+3.9}  eV^{2}, sin^{2}2θ_{24}=0.33_{-0.17}^{+0.20}, and g^{2}=2.5π±1.5π, where g is the decay-mediating coupling. The preferred regions of the 3+1+decay model from short-baseline oscillation searches are excluded at 90% C.L.

Strong Constraints on Neutrino Nonstandard Interactions from TeV-Scale ν_{μ} Disappearance at IceCube

We report a search for nonstandard neutrino interactions (NSI) using eight years of TeV-scale atmospheric muon neutrino data from the IceCube Neutrino Observatory. By reconstructing incident energies and zenith angles for atmospheric neutrino events, this analysis presents unified confidence intervals for the NSI parameter ε_{μτ}. The best-fit value is consistent with no NSI at a p value of 25.2%. With a 90% confidence interval of -0.0041≤ε_{μτ}≤0.0031 along the real axis and similar strength in the complex plane, this result is the strongest constraint on any NSI parameter from any oscillation channel to date.

Search for Relativistic Magnetic Monopoles with Eight Years of IceCube Data

We present an all-sky 90% confidence level upper limit on the cosmic flux of relativistic magnetic monopoles using 2886 days of IceCube data. The analysis was optimized for monopole speeds between 0.750c and 0.995c, without any explicit restriction on the monopole mass. We constrain the flux of relativistic cosmic magnetic monopoles to a level below 2.0×10^{-19}  cm^{-2} s^{-1} sr^{-1} over the majority of the targeted speed range. This result constitutes the most strict upper limit to date for magnetic monopoles with β≳0.8 and up to β∼0.995 and fills the gap between existing limits on the cosmic flux of nonrelativistic and ultrarelativistic magnetic monopoles.

Propylene glycol toxicity from compulsive corn starch ingestion: A case report and review

INTRODUCTION

Propylene glycol (PG) is usually considered safe, however, toxicity can develop with high doses or when used for prolonged periods of time. PG can be found in some medications as well as some food products. We report a case of likely PG toxicity that occurred after compulsive daily ingestion of large amounts of corn starch.

CASE REPORT

Our patient initially presented to an outside hospital (OSH) via ambulance for altered mental status. Her mental status improved after her blood sugar of 25 was corrected. On admission to OSH Emergency Department her initial vital signs included a heart rate of 115 bpm, blood pressure 113/59 mm/hg, temperature 35.8C. Pertinent labs included: sodium 119 mEq/L, bicarbonate 9 mEq/L, anion gap 29 mEq/L, creatinine 2.5 mg/dL and lactic acid 20 mEq/L. On transfer to our hospital her repeat lactic acid was 20 mEq/L, osmolar gap was 20. Her PG level, which was drawn several hours after her initial presentation, was 11 mg/dL. Our patient noted that she ingested a 16 oz. package of corn starch mixed with baking soda approximately every 2 days. Given the concerns for PG she was underwent intermittent hemodialysis. PG and lactic acid levels improved, however, she ultimately died due to complications from her hospitalization.

DISCUSSION

PG causes toxicity through metabolism to lactic acid. While there are small amounts in food products and medications, under the right circumstances, PG can accumulate and lead to significant toxicity.

AB0630 PEGLOTICASE/METHOTREXATE CO-THERAPY IMPROVED JOINT AND PATIENT-REPORTED HEALTH ASSESSMENTS IN PATIENTS WITH UNCONTROLLED GOUT: 12-MONTH EXPLORATORY OUTCOMES OF THE MIRROR OPEN-LABEL TRIAL

Background:

Gout development follows persistent serum uric acid (sUA) elevation. Patients who are refractory to or cannot tolerate oral urate lowering therapies (ULTs) have limited treatment options. Pegloticase is effective in treating refractory gout, but many patients develop anti-drug antibodies (ADAs), which are associated with loss of urate-lowering efficacy1-3 and infusion reactions (IRs).1,2 In phase 3 trials, the pooled pegloticase responder rate during Months 3 and 6 combined was 42% (8 mg infusion every 2 weeks), with high-titer ADA positive patients losing efficacy prior to 6 months.1 The 6-month results from the MIRROR open-label trial (79% response rate [11/14], 95%CI 49-95%)4 suggest that methotrexate (MTX) administered in conjunction with pegloticase increases treatment responder rate.

Objectives:

To examine longer-term (12-month) exploratory endpoints from the MIRROR open-label trial, including joint, overall health, and gout global assessments. Serial dual-energy computed tomography (DECT) images were also examined when available.

Methods:

Adult patients with uncontrolled gout (sUA ≥6 mg/dL with ≥1 of the following: sUA ≥6 mg/dL despite ULT use, intolerance to ULT, or functionally limiting tophaceous deposits) were included. Patients with immunocompromised status, G6PD deficiency, severe renal impairment, or MTX contraindication were excluded. Patients were administered oral MTX (15 mg/week) and folic acid (1 mg/day) 4 weeks prior to and throughout pegloticase therapy (8 mg biweekly infusion for up to 52 weeks). Exploratory outcomes included mean change from baseline (CFB) in number of affected joints (tophi, swollen, tender), Health Assessment Questionnaire (HAQ) scores (Disability Index [DI; score 0−3], Pain [score 0−100], Health [score 0−100]), and Gout Global Assessments (Patient, Physician; score 0−10). A decrease in these measures reflects clinical/patient-reported health improvement. Change in urate deposition volume, as measured on DECT imaging, was also examined as available. Analyses were performed on the modified intent-to-treat (mITT) population (≥1 pegloticase infusion received).

Results:

14 patients (all male, mean±SD age: 49.3±8.7 years) made up the mITT population. Mean±SD sUA prior to pegloticase treatment was 9.2±2.5 mg/dL and 13 patients had visible tophi. 3 patients discontinued due to 2 consecutive sUA levels >6 mg/dL and 1 patient completed the study at week 24 (pre-protocol amendment extending treatment from 24 to 52 weeks). 10 patients completed the 52-week study. Of these, 8 patients received 26 infusions and 2 patients received 12 infusions, discontinued pegloticase after meeting their treatment goal at 24 weeks, and started allopurinol while remaining in study under observation. At week 52 (n=10, sUA=1.1±2.5 mg/dL), the number of affected joints improved, along with HAQ measures (Figure 1). Global Assessments of Gout also improved (Physician: CFB=-5.7±2.6, Patient CFB=-4.6±2.1) and majority of subjects had a score of 0 or 1 (0=“excellent health”) at week 52 (Physician: 0.3±0.5, Patient: 1.1±1.3). Two patients had available DECT imaging. One received pegloticase/methotrexate co-therapy thru week 52 and had a marked reduction in total urate volume (baseline: 128.76 cm3, week 52: 1.33 cm3). The other received only 5 pegloticase infusions, but also showed total urate volume reduction (baseline: 59.20 cm3, week 10: 25.07 cm3). Both patients displayed improvement in bone erosion healing.

Conclusion:

These 12-month exploratory endpoints of the MIRROR open-label trial suggest that MTX/pegloticase co-therapy results in meaningful changes in clinical evaluations (tophaceous, tender, and swollen joint counts), and patient-reported outcomes (pain, disability) in patients with uncontrolled gout.

References:

[1]Sundy JS et al. JAMA 2011;306:711-20

[2]Baraf HS et al. J Clin Rheumatol 2014;20:427-32

[3]Lipsky PE et al. Arthritis Res Ther 2014, 16:R60

[4]Botson JK et al. J Rheum 2020 [Epub ahead of print]

Disclosure of Interests:

John Botson Speakers bureau: Horizon Therapeutics, Celgene, Novartis, and AbbVie, Consultant of: Horizon Therapeutics, Celgene, Novartis, and AbbVie, Grant/research support from: Horizon Therapeutics and Radius Health, Paul M. Peloso Shareholder of: Horizon Therapeutics plc, Employee of: Horizon Therapeutics plc, Katie Obermeyer Shareholder of: Horizon Therapeutics plc, Employee of: Horizon Therapeutics plc, Brian LaMoreaux Shareholder of: Horizon Therapeutics plc, Employee of: Horizon Therapeutics plc, Lin Zhao Shareholder of: Horizon Therapeutics plc, Employee of: Horizon Therapeutics plc, Michael E. Weinblatt Shareholder of: Lycera, Can-Fite BioPharma, Scipher Medicine, Inmedix, and Vorso, Consultant of: Bristol Myers Squibb, Corona, Lilly, AbbVie, Amgen, Arena, GlaxoSmithKline, Gilead Sciences, Horizon Therapeutics, Lycera, Novartis, Pfizer, Roche, Samsung, Scipher Medicine, and Set Point, Grant/research support from: Amgen, Bristol-Myers Squibb, Crescendo Bioscience, Lilly and Sanofi, Jeff Peterson Speakers bureau: Horizon Therapeutics plc, Grant/research support from: Horizon Therapeutics plc.

Transcriptomic Response in the Spleen after Whole-Body Low-Dose X-Ray Irradiation

As the use of medical radiation procedures continues to rise, it is imperative to further our understanding of the effects of this exposure. The spleen is not known as a particularly radiosensitive organ, although its tolerance to radiation is not well understood. Low-dose radiation exposure has been implicated in beneficial responses, particularly in cell death and DNA damage repair. In this study, adult male rats received 2, 20, 200 mGy or 4 Gy whole-body X-ray irradiation and the transcriptional response in the spleen was analyzed at 0.5, 4 and 24 h postirradiation. We analyzed expression of genes involved in apoptosis, cell cycle progression and DNA damage repair. As expected, 4 Gy irradiated animals demonstrated elevated expression of genes related to apoptosis at 0.5, 4 and 24 h postirradiation in the spleen. These animals also showed upregulation of DNA damage repair genes at 24 h postirradiation. Interestingly, the spleens of 20 mGy irradiated animals showed reduced apoptosis and cell cycle arrest compared to the spleens of sham-irradiated animals. These results further reveal that the cellular response in the spleen to whole-body irradiation differs between low- and high-dose irradiation.

Postnatally acquired CMV meningitis diagnosed via BioFire FilmArray: A case report

Postnatally acquired cytomegalovirus (CMV) is commonly acquired via breast milk, with premature infants more frequently developing symptoms of CMV infection in comparison to term infants. Meningitis is a rare clinical manifestation of CMV infection. The diagnosis of meningitis is difficult to make in infants, particularly those who are preterm. Consequentially, broad-spectrum empiric antimicrobial coverage is often administered for several days while waiting for current gold standard CSF testing to result. The BioFire FilmArray (BFA) simultaneously tests for 14 different pathogens, including CMV, allowing for quicker diagnosis and shorter time to definitive treatment. Here, we report a very low birth weight infant with postnatally acquired CMV meningitis, the first to our knowledge to be diagnosed using the BioFire FilmArray.

THU0416 PEGLOTICASE RESPONSE IMPROVEMENT BY CO-TREATMENT WITH METHOTREXATE: RESULTS FROM THE MIRROR OPEN-LABEL CLINICAL TRIAL IN PATIENTS WITH UNCONTROLLED GOUT

Background:

Gout is a painful inflammatory arthritis caused by persistently elevated serum uric acid (sUA) levels. Pegloticase, an infused recombinant PEGylated uricase, rapidly lowers sUA levels by converting uric acid to allantoin, a water-soluble molecule that is readily excreted by the kidneys. In the phase 3 clinical trials, 42% of patients1dosed with pegloticase every two weeks maintained sUA levels below 6.0 mg/dL during months 3 and 6 of pegloticase treatment. The loss of pegloticase efficacy has been attributed to the development of anti-drug antibodies (ADAs)1-3and these ADAs have been associated with infusion reactions (IRs).1,2Case reports4and prospective case series5, 6indicate that methotrexate (MTX) may allow patients to attain more complete therapeutic benefits, presumably through attenuation of pegloticase immunogenicity. The current study prospectively examines the efficacy and safety of MTX-pegloticase co-therapy in patients with uncontrolled gout.

Objectives:

To assess efficacy and safety of concomitant pegloticase and MTX therapy in patients with uncontrolled gout.

Methods:

Adult patients with uncontrolled gout who were beginning pegloticase therapy were considered for enrollment in this ongoing multicenter, open-label, efficacy and safety study of pegloticase with MTX co-treatment (NCT03635957). Patients were administered oral MTX (15 mg/week) and folate (1 mg/day) 4 weeks prior to the first pegloticase infusion (Day 1) and throughout the pegloticase treatment period. Blood was drawn prior to each infusion to measure sUA level, monitor clinical parameters, and examine for ADA development. All patients followed typical IR prophylaxis protocols (fexofenadine one day before and the morning of each infusion and acetaminophen and IV corticosteroid the morning of each infusion). Patients also received gout flare prophylaxis with either NSAIDs, colchicine or prednisone initiated at least 1 week prior to Day 1. The primary study outcome was the proportion of responders, defined as sUA <6 mg/dL for at least 80% of the time during month 6 (weeks 20, 22, and 24). All analyses were performed on a modified intent-to-treat population, defined as patients who received ≥1 pegloticase infusion.

Results:

A total of 17 patients were screened and 14 patients (all men, average age: 49.3 ± 8.7 years) were enrolled. On Day 1, mean sUA was 9.2 ± 2.5 mg/dL and 12 of the 14 patients had visible tophi. At the 6 months timepoint, 11/14 (78.6%, 95%CI 49.2-95.3%) met the responder definition, with 3 patients discontinuing after meeting stopping rules (pre-infusion sUA values greater than 6 mg/dL at 2 consecutive scheduled visits). All patients tolerated MTX. One serious AE of bacterial sepsis occurred (resolved). AEs that occurred in >1 patient during the co-treatment period were: diarrhea and upper respiratory tract infection in 3 patients each, sinusitis, muscle strain, and hypertension in 2 patients each. Gout flares occurred in 12/14 (85.7%) patients. No new safety concerns were identified.

Conclusion:

An increased proportion of patients maintained therapeutic response at 6 months when treated concomitantly with MTX and pegloticase (78.6%) when compared to the previously reported 42% using pegloticase alone.1These results support and reflect the improved response rates demonstrated in two prior case series.5,6A definitive randomized double-blinded trial evaluating pegloticase with MTX vs. pegloticase with placebo is ongoing.

References:

[1]Sundy JS et al.JAMA2011;306:711-20.

[2]Baraf HS et al.J Clin Rheumatol2014;20:427-32.

[3]Lipsky PE et al.Arthritis Res Ther2014;16:R60.

[4]Bessen SY et al.Semin Arthritis Rheum2019;49:56-61.

[5]Botson J, Peterson J.Ann Rheum Dis2019;78:A1289.

[6]Albert JA et al.Arthritis & Rheumatology2019;71(S10):A1236.

Disclosure of Interests: :

John Botson Grant/research support from: Horizon Therapeutics (PI and study site), Radius Health (study site), Consultant of: Horizon Therapeutics, Speakers bureau: Celgene, Eli Lilly, Horizon Therapeutics, Mallinckrodt, Novartis, Pfizer, Paul M. Peloso Shareholder of: Horizon Therapeutics, Employee of: Horizon Therapeutics, Katie Obermeyer Shareholder of: Horizon Therapeutics, Employee of: Horizon Therapeutics, Brian LaMoreaux Shareholder of: Horizon Therapeutics, Employee of: Horizon Therapeutics, Michael E. Weinblatt Grant/research support from: BMS, Amgen, Lilly, Crescendo and Sonofi-Regeneron, Consultant of: Horizon Therapeutics, Bristol-Myers Squibb, Amgen, Abbvie, Crescendo, Lilly, Pfizer, Roche, Gilead, Jeff Peterson Grant/research support from: Abbvie, UCB, Smith Klein, Horizon Therapeutics, Consultant of: Lilly, Norvartis, Horizon Therapeutics, Speakers bureau: Lilly, Novartis, Horizon Therapeutics, Abbvie, Genentech

Abstract PD6-12: Evaluating racial disparities in breast cancer referrals for hereditary risk assessment

Background: There is a pronounced onco-racial disparity in Washington, D.C., which had the highest national incidence of breast cancer in African Americans (AA) patients in between 2010-2015 and the worst outcomes (American Cancer Society). Recent data indicates a higher incidence of deleterious BRCA1 [and BRCA2] mutations and variants of uncertain significance (VUS) in AA patients compared to Caucasian (C) patients when controlled for patients of Ashkenazi Jewish (AJ) populations (Hall 2009). Despite this, AA women meeting National Comprehensive Cancer Network (NCCN) criteria for genetic testing are less likely to complete such testing compared to C women nationally. Studies have investigated psycho-social drivers of minority patient aversion to genetic testing. We hypothesize that lack of physician referral for cancer genetic counseling and testing for AA women contributes to this disparity.

Methods: The George Washington Cancer Center (GWCC) Registry was used to identify non-Hispanic African Americans (BNH) and non-Hispanic whites (WNH) treated for breast cancer between 2014-2018. Of those individuals selected for inclusion were those who met select NCCN criteria for referral for genetic evaluation including breast cancer diagnosis under age 50, triple negative breast cancer (TNBC) under age 60, and two primary breast cancers. Only BNH and WNH individuals were included. Excluded patients were those who were not BNH or WNH or who did not meet the NCCN criteria listed above. Patients were then stratified by race according to who underwent genetic evaluation, whether at our Ruth Paul Cancer Genetics and Prevention Service (RPCGPS) or elsewhere, by reviewing GWCC, RPCGPS, and patient clinic records for genetic testing results from outside institutions. Patient charts were used to identify individuals who received a physician referral over the course of their cancer care.

Results: 1180 patients were treated at the GWCC for breast cancer (both in situ and invasive carcinoma) between 2014–2018. Of those, BNH n=502; WNH n=435. Twenty-seven percent of BNH and WNH patients met the study criteria for referral for genetic evaluation (n=252; BNH n=115, WNH n=137), including breast cancer diagnosis under age 50 (BNH n=76; WNH n=108), TNBC under age 60 (BNH n=14; WNH n=5), and two primary breast cancers (BNH n=18, WNH n=16). Several patients identified met two or more criteria for referral (BNH n=7, WNH n=8). Physician referral rates differed significantly by race (BNH 76%, n=87 and WNH 91%; n=125; χ2=11.4, p-value&lt;0.001). Of referred patients, there was no significant difference in those who followed-up at RPCGPS by race (BNH 93%, n=81; WNH= 93%, n=116, χ2 =0.0072, p-value=0.93).

Conclusions: Low genetic testing rates for AA breast cancer patients are an impediment to resolving the prominent onco-racial breast cancer disparities. This study identified physician referral as a potential contributor to racial disparity in the utilization of cancer genetics services. Potential reasons for the discrepancy in referral may include lag in physician education on the topic of hereditary risk and barriers in physician-patient communication. These findings need to be confirmed and explored at other sites to help improve the identification of at-risk women in the AA community.

Citation Format: Pepin A, Peterson J, Thomas R, Johnson K, Stark E, Biagi T, Kaltman R. Evaluating racial disparities in breast cancer referrals for hereditary risk assessment [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 PD6-12.

Characterization of immune responses to anti-PD-1 mono and combination immunotherapy in hematopoietic humanized mice implanted with tumor xenografts

Background

The success of agents that reverse T-cell inhibitory signals, such as anti-PD-1/PD-L1 therapies, has reinvigorated cancer immunotherapy research. However, since only a minority of patients respond to single-agent therapies, methods to test the potential anti-tumor activity of rational combination therapies are still needed. Conventional murine xenograft models have been hampered by their immune-compromised status; thus, we developed a hematopoietic humanized mouse model, hu-CB-BRGS, and used it to study anti-tumor human immune responses to triple-negative breast cancer (TNBC) cell line and patient-derived colorectal cancer (CRC) xenografts (PDX).

Methods

BALB/c-Rag2^nullIl2rγ^nullSIRPα^NOD (BRGS) pups were humanized through transplantation of cord blood (CB)-derived CD34+ cells. Mice were evaluated for human chimerism in the blood and assigned into experimental untreated or nivolumab groups based on chimerism. TNBC cell lines or tumor tissue from established CRC PDX models were implanted into both flanks of humanized mice and treatments ensued once tumors reached a volume of ~150mm³. Tumors were measured twice weekly. At end of study, immune organs and tumors were collected for immunological assessment.

Results

Humanized PDX models were successfully established with a high frequency of tumor engraftment. Humanized mice treated with anti-PD-1 exhibited increased anti-tumor human T-cell responses coupled with decreased Treg and myeloid populations that correlated with tumor growth inhibition. Combination therapies with anti-PD-1 treatment in TNBC-bearing mice reduced tumor growth in multi-drug cohorts. Finally, as observed in human colorectal patients, anti-PD-1 therapy had a strong response to a microsatellite-high CRC PDX that correlated with a higher number of human CD8+ IFNγ+ T cells in the tumor.

Conclusion

Hu-CB-BRGS mice represent an in vivo model to study immune checkpoint blockade to human tumors. The human immune system in the mice is inherently suppressed, similar to a tumor microenvironment, and thus allows growth of human tumors. However, the suppression can be released by anti-PD-1 therapies and inhibit tumor growth of some tumors. The model offers ample access to lymph and tumor cells for in-depth immunological analysis. The tumor growth inhibition correlates with increased CD8 IFNγ+ tumor infiltrating T cells. These hu-CB-BRGS mice provide a relevant preclinical animal model to facilitate prioritization of hypothesis-driven combination immunotherapies.

Electronic supplementary material

The online version of this article (10.1186/s40425-019-0518-z) contains supplementary material, which is available to authorized users.

Advancing Cancer Health Equity in Pacific Islanders: A 15-Year Investment in Cancer Research, Training and Outreach in Guam, Hawaii and the U.S. Associated Pacific Islands

Background: Pacific Islanders (PI) in Guam (GU), Hawaii (HI), and the U.S. associated Pacific Islands (USAPI) experience greater cancer health disparities compared with majority populations in GU, HI, and the U.S. continent. Social determinants including geographic, socio-cultural, and economic factors are barriers to health and health care, leading to late stage diagnosis and poor survival outcomes. PIs are also highly underrepresented among cancer researchers. Aim: The University of Guam (UOG)/University of Hawaii Cancer Center (UHCC) partnership aims to grow cancer research capacity at UOG, develop cancer health disparities research at UHCC focusing on Pacific Islanders (PI), raise awareness of cancer and cancer prevention in GU, HI and the USAPI, and increase the number of cancer and biomedical scientists of PI ancestry in the U.S. Methods: An infrastructure comprised of five principal investigators and approximately 30 participating faculty, administrative staff, and community and scientific advisory members, supported by funds from the National Cancer Institute and the partnering institutions, has provided 15 years of support for cancer research, training, and outreach designed to reduce cancer health disparities and advance health equity among Pacific Islanders in GU, HI and the USAPI. Results: Fifteen collaborative research projects have been funded through the partnership. Many of these projects have focused on the prevention of unhealthy lifestyle behaviors that lead to increased cancer risk. Prepilot, pilot and full research projects address cancer health disparities of regional relevance and global importance, notably breast, cervical and oral cancers as well as tobacco and betel nut use. A betel nut cessation intervention, the first of its kind, shows promising quit rates. This research has resulted in over 80 publications, 100+ abstracts, and 9 grant awards. The partnership has recruited and trained 26 underrepresented graduate scholars in cancer health disparities, including two scholars who have since joined UOG's faculty and are now independently conducting research, participating in the partnership as investigators, and mentoring tomorrow's scientists. UOG faculty and early stage investigators continue to receive mentorship and career development support. Outreach activities have contributed to the introduction and passage of significant cancer prevention and control legislation in Guam and Saipan. Outcomes are communicated through the partnership's Website, social media, and community reports and seminars. Conclusion: The partnership has significantly increased research capacity at UOG and cultivated interest in cancer research among underrepresented minority students at the partnering institutions. A regional research infrastructure has been established, and research findings are informing public health policy and planning. Resources have been leveraged to address PI cancer health disparities in GU, HI, and the USAPI.