ADT-1004: A First-in-Class, Orally Bioavailable Selective pan-RAS Inhibitor for Pancreatic Ductal Adenocarcinoma

Here, we evaluated in vivo antitumor activity, target engagement, selectivity, and tumor specificity of ADT-1004, an orally bioavailable prodrug of ADT-007 having highly potent and selective pan-RAS inhibitory activity. ADT-1004 strongly blocked tumor growth and RAS activation in mouse PDAC models without discernable toxicity. As evidence of target engagement and tumor specificity, ADT-1004 inhibited activated RAS and ERK phosphorylation in PDAC tumors at dosages approximately 10-fold below the maximum tolerated dose and without discernable toxicity. ADT-1004 inhibited ERK phosphorylation in PDAC tumors. In addition, ADT-1004 blocked tumor growth and ERK phosphorylation in PDX PDAC models with KRAS G12D , KRAS G12V , KRAS G12C , or KRAS G13Q mutations. ADT-1004 treatment increased CD4 + and CD8 + T cells in the TME consistent with exhaustion and increased MHCII + M1 macrophage and dendritic cells. ADT-1004 demonstrated superior efficacy over sotorasib and adagrasib in tumor models involving human PDAC cells resistant to these KRAS G12C inhibitors. As evidence of selectivity for tumors from PDAC cells with mutant KRAS, ADT-1004 did not impact the growth of tumors from RAS WT PDAC cells. Displaying broad antitumor activity in multiple mouse models of PDAC, along with target engagement and selectivity at dosages that were well tolerated, ADT-1004 warrants further development.

Significance

ADT-1004 displayed robust antitumor activity in aggressive and clinically relevant PDAC models with unique tumor specificity to block RAS activation and MAPK signaling in RAS mutant cells. As a pan-RAS inhibitor, ADT-1004 has broad activity and potential efficacy advantages over allele-specific KRAS inhibitors by averting resistance. These findings support clinical trials of ADT-1004 for KRAS mutant PDAC.

Association between frailty and overall survival among older adults with hepatocellular carcinoma

INTRODUCTION

Older adults undergoing cancer treatment often experience more treatment-related toxicities and increased risk of mortality compared to younger patients. The role of frailty among older individuals as a predictor of outcomes has gained growing significance. We evaluated the association between frailty and overall survival (OS) in patients with hepatocellular carcinoma (HCC) ≥60 years.

MATERIALS AND METHODS

Older adults ≥60 years with HCC enrolled in a prospective single-institution registry underwent a patient-reported geriatric assessment (GA) covering multiple health domains related to prior to their initial medical oncology appointment. Frailty was measured using a 44-item deficit accumulation frailty index. We categorized patients as robust, pre-frail, and frail using standard cutpoints. The primary outcome was overall survival (OS). Univariable and multivariable models were built to evaluate the association between frailty and OS after adjusting for potential confounders.

RESULTS

Total of 116 older adults with HCC with a median age of 67 years were enrolled; 82% male, 27% Black, and 78% with stage III/IV disease. Overall, 19 (16.3%) were robust, 39 (33.6%) pre-frail, and 58 (50.1%) frail. There were 76 patients receiving liver directed therapy. Of these, 13 (17%) were robust, 26 (34%) were pre-frail, and 37 (49%) were frail. Over a median follow up of 0.9 years, 53 patients died. After adjusting for age, stage, etiology, and Child-Pugh class, being frail (vs. robust) was associated with worse OS (hazard ratio (HR) 2.6 [95% CI 1.03-6.56]; p = 0.04).

DISCUSSION

Half of the participants in this study were frail, which was independently associated with worse survival in adults ≥60 years of age with HCC. Identification of pre-treatment frailty may allow opportunities to guide treatment decisions and prognostication.

Impact of pre-transplant immune checkpoint inhibitor use on post-transplant outcomes in HCC: A systematic review and individual patient data meta-analysis

BACKGROUND & AIMS

Treatment with immune checkpoint inhibitors (ICIs) for hepatocellular carcinoma (HCC) prior to liver transplantation (LT) has been reported; however, ICIs may elevate the risk of allograft rejection and impact other clinical outcomes. This study aims to summarize the impact of ICI use on post-LT outcomes.

METHODS

In this individual patient data meta-analysis, we searched databases to identify HCC cases treated with ICIs before LT, detailing allograft rejection, HCC recurrence, and overall survival. We performed Cox regression analysis to identify risk factors for allograft rejection.

RESULTS

Among 91 eligible patients, with a median (IQR) follow-up of 690.0 (654.5) days, there were 24 (26.4%) allograft rejections, 9 (9.9%) HCC recurrences, and 9 (9.9%) deaths. Age (adjusted hazard ratio [aHR] per 10 years 0.72, 95% CI 0.53-0.99, p = 0.044) and ICI washout time (aHR per 1 week 0.92, 95% CI 0.86-0.99, p = 0.022) were associated with allograft rejection. The median (IQR) washout period for patients with ≤20% probability of allograft rejection was 94 (196) days. Overall survival did not differ between cases with and without allograft rejection (log-rank test, p = 0.2). Individuals with HCC recurrence had fewer median (IQR) ICI cycles than those without recurrence (4.0 [1.8] vs. 8.0 [9.0]; p = 0.025). The proportion of patients within Milan post-ICI was lower for those with recurrence vs. without (16.7% vs. 65.3%, p = 0.032).

CONCLUSION

Patients have acceptable post-LT outcomes after ICI therapy. Age and ICI washout length relate to the allograft rejection risk, and a 3-month washout may reduce it to that of patients without ICI exposure. Number of ICI cycles and tumor burden may affect recurrence risk. Large prospective studies are necessary to confirm these associations.

IMPACT AND IMPLICATIONS

This systematic review and individual patient data meta-analysis of 91 patients with hepatocellular carcinoma and immune checkpoint inhibitor use prior to liver transplantation suggest acceptable overall post-transplant outcomes. Older age and longer immune checkpoint inhibitor washout period have a significant inverse association with the risk of allograft rejection. A 3-month washout may reduce it to that of patients without immune checkpoint inhibitor exposure. Additionally, a higher number of immune checkpoint inhibitor cycles and tumor burden within Milan criteria at the completion of immunotherapy may predict a decreased risk of hepatocellular carcinoma recurrence, but this observation requires further validation in larger prospective studies.

Management of Older Adults With Colorectal Cancer: The Role of Geriatric Assessment

Older adults share a growing burden of cancer morbidity and mortality. This is present across the spectrum of oncologic diagnoses and is particularly true with colorectal cancer (CRC), where older adults continue to share the burden of diagnoses. However, optimal cancer treatment decision making in older adults remains a significant challenge, as the majority of previous clinical trials shaping the current treatment landscape have focused on younger patients, often with more robust performance status and fewer medical comorbid conditions. The heterogeneous aging process of older adults with CRC necessitates a personalized treatment approach, as approximately three-quarters of older adults with CRC also have a concominant geriatric syndrome and more than half of older adults with CRC are pre-frail or frail. Treatment decisions shoud be multifaceted, including consultation with the patient and their familes regarding their wishes, with consideration of the patient's quality of life, functional status, medical comorbid conditions, social support, and treatment toxicity risk. Geriatric assessment is a systematic and validated approach to assess an older adults's potential strengths and vulnerabilities, which can in turn be used to assist with comprehensive cancer care planning and support. In this review, we will summarize current treatment approaches for older adults with CRC, with a particular focus on the incorporation of the geriatric assessment.

Safety and Efficacy of Concurrent Atezolizumab/Bevacizumab or Nivolumab Combination Therapy with Yttrium-90 Radioembolization of Advanced Unresectable Hepatocellular Carcinoma

To evaluate the safety and efficacy of combining yttrium-90 radioembolization (Y90-RE) with immune checkpoint inhibitor therapy, consecutive advanced unresectable hepatocellular carcinoma (HCC) patients treated between 2016 and 2022 with atezolizumab/bevacizumab or nivolumab within three-months pre- and post-Y90-RE were retrospectively evaluated. Tumor response and treatment-related clinical/laboratory adverse events (AE) were assessed at 1 and 6 months, as well as differences in clinical and laboratory variables and median overall survival (OS) from initial treatment (whether it was Y90-RE or systemic therapy) between the two cohorts. A total of 19 patients (10 atezolizumab/bevacizumab; 9 nivolumab), comprising 84% males with median age 69 years, met the inclusion criteria. Compared to the atezolizumab/bevacizumab group, there were less males (100% vs. 67%; p = 0.02) and more ECOG ≥ 2 patients in the nivolumab group (0% vs. 33%; p = 0.02). Baseline characteristics or incidence of 6-month post-treatment any-grade AE (60% vs. 56%; p = 0.7), grade ≥ 3 AE (0% vs. 11%; p = 0.3), objective response (58% total, 60% vs. 56%; p = 0.7), and complete response (16% total; 10% vs. 22%; p = 0.8) were similar between the atezolizumab/bevacizumab and the nivolumab cohorts. Median OS was 12.9 months for the whole cohort, 16.4 months for nivolumab, and 10.7 months for atezolizumab/bevacizumab. Among patients with advanced unresectable HCC, the utilization of Y90-RE concurrently or within 90 days of nivolumab or atezolizumab/bevacizumab immunotherapy, appears to be well-tolerated and with a low incidence of severe AE.

Advances in Immunotherapy for Hepatocellular Carcinoma (HCC)

Hepatocellular carcinoma (HCC) is the second most common cause of cancer-related deaths in the world. More than half of patients with HCC present with advanced stage, and highly active systemic therapies are crucial for improving outcomes. Immune checkpoint inhibitor (ICI)-based therapies have emerged as novel therapy options for advanced HCC. Only one third of patients achieve an objective response with ICI-based therapies due to primary resistance or acquired resistance. The liver tumor microenvironment is naturally immunosuppressive, and specific mutations in cell signaling pathways allow the tumor to evade the immune response. Next, gene sequencing of the tumor tissue or circulating tumor DNA may delineate resistance mechanisms to ICI-based therapy and provide a rationale for novel combination therapies. In this review, we discuss the results of key clinical trials that have led to approval of ICI-based therapy options in advanced HCC and summarize the ongoing clinical trials. We review resistance mechanisms to ICIs and discuss how immunotherapies may be optimized based on the emerging research of tumor biomarkers and genomic alterations.

Implementation of the Web-Enabled Cancer & Aging Resilience Evaluation (WeCARE) in an outpatient oncology setting

INTRODUCTION

Although geriatric assessments (GAs) are recommended for use in older adults with cancer, their integration into oncology practice remain suboptimal. Here, we report our experience integrating web-enabled GA (WeCARE) into oncology practice as an augmented delivery method and provider interface format to overcome implementation barriers.

MATERIALS AND METHODS

Older patients (≥60 years) with a gastro-intestinal (GI) malignancy presenting for an initial visit to medical oncology clinic at a single institution between December 7, 2021 and October 10, 2022 were contacted by staff two days in advance of their visits and sent a link to the WeCARE GA, rather than the paper version used previously. Results were directly embedded into the medical record. We describe our initial implementation outcomes and the results of a provider usability survey.

RESULTS

Of 266 eligible patients, 221 (83.1%) were successfully contacted by telephone and 200 (75.2%) completed the WeCARE prior to their appointment. More than one phone call was required to make contact for 35.7% of patients, with a mean duration of phone conversation of 2.8 min. Most patients preferred email delivery to text (63% vs 31%); 4.5% were unable to access surveys due to inadequate technology, and 25.7% brought up additional logistical concerns. Among GI oncology providers surveyed, all six found the WeCARE tool and dashboard acceptable, appropriate, and feasible. However, only a third of providers often or always used the dashboard to inform treatment decisions and guide interventions.

DISCUSSION

With nearly three-quarters of patients completing the WeCARE prior to their visits with minimal staff support and time required, this method of administration may be a viable format to overcome barriers to GA implementation. Additional work is needed to integrate the results meaningfully into clinical practice.

Short Course Radiotherapy (SCRT) with Simultaneous Integrated Boost (SIB) in the Treatment of Rectal Cancer: Feasibility and Early Toxicities

PURPOSE/OBJECTIVE(S)

To report the feasibility and early toxicities of dose-escalated SCRT in rectal cancer patients receiving total neoadjuvant therapy (TNT).

MATERIALS/METHODS

This retrospective cohort study included 13 patients treated via a TNT approach (guided by RAPIDO trial) for locally advanced rectal cancer. The planned radiation was a standard dose of 25 Gy in 5 fractions to the primary tumor and at-risk lymphatics (PTV_Low). The dose-escalation was achieved via SIB delivering 30 Gy to the primary tumor (PTV_Mid) and 40 Gy (PTV_High) to inoperable lateral pelvic lymph nodes (LN), when present, over 5 fractions. A 5 mm margin was added to the rectal tumor and lateral pelvic LN to create the SIB targets. All patients were planned for intensity modulated radiation therapy via Varian EclipseTM (Palo Alto, CA) treatment planning system. Prior to treatment patients underwent kV and cone beam CT (CBCT) imaging for image guidance. Shifts were not performed solely to accommodate the boost target volume if it was felt to compromise the coverage of at-risk lymphatics. Normal tissue constraints were prioritized over boost coverage. Early toxicities were assessed for 30 days following treatment and graded using the Common Terminology Criteria for Adverse Events version 5.0. Offline image review was performed to determine the frequency at which the gross tumor volume (GTV) was captured within the 5 mm planning target volume (PTV_Mid) margin on daily CBCT scans. If a misalignment (tumor crossing outside of PTV_High) was discovered, the direction of misalignment (lateral/anterior/posterior) and location (superior/inferior) in relation to the superior border of the pubic symphysis was documented. An additional 5 mm margin from the PTV_Mid was created to determine if this would have captured the target.

RESULTS

Twelve of the 13 patients were ≥ 30 days from treatment completion and were included in the toxicity analysis. The most common grade 1-2 toxicities were proctitis and diarrhea, which occurred in 42% and 25% of patients, respectively. Other toxicities were new onset rectal bleeding (17%), rectal pain (17%) and radiation dermatitis (8%). No grade 3+ toxicities were observed. Given five fractions for each of the 13 patients, a total of 65 CBCTs were reviewed and compared to the planning CT obtained at simulation. A total of 14/65 (22%) misalignments were discovered across six patients. All occurred above the superior edge of the pubic symphysis. Four misalignments were multi-directional. Nine were anterior, 6 were lateral, and 1 was posterior. Twelve of the 14 (86%) would have been covered within the additional 5 mm expansion volume.

CONCLUSION

In this cohort of patients who received dose-escalated SCRT, the composite rate of acute toxicity was expectedly low. Feasibility of treatment delivery was established but could be improved upon with an addition 5 mm expansion, specifically in locations cranial to the superior edge of the pubic symphysis.

Phase II trial of nivolumab and metformin in patients with treatment-refractory microsatellite stable metastatic colorectal cancer

BACKGROUND

Preclinical studies showed metformin reduces exhaustion of tumor-infiltrating lymphocytes and potentiates programmed cell death protein-1 (PD-1) blockade. We hypothesized that metformin with nivolumab would elicit potent antitumor and immune modulatory activity in metastatic microsatellite stable (MSS) colorectal cancer (CRC). We evaluated this hypothesis in a phase II study.

METHODS

Nivolumab (480 mg) was administered intravenously every 4 weeks while metformin (1000 mg) was given orally, two times per day following a 14-day metformin only lead-in phase. Patients ≥18 years of age, with previously treated, stage IV MSS CRC, and Eastern Cooperative Oncology Group 0-1, having received no prior anti-PD-1 agent were eligible. The primary endpoint was overall response rate with secondary endpoints of overall survival (OS) and progression-free survival (PFS). Correlative studies using paired pretreatment/on-treatment biopsies and peripheral blood evaluated a series of immune biomarkers in the tumor microenvironment and systemic circulation using ChipCytometry and flow cytometry.

RESULTS

A total of 24 patients were enrolled, 6 patients were replaced per protocol, 18 patients had evaluable disease. Of the 18 evaluable patients, 11/18 (61%) were women and the median age was 58 (IQR 50-67). Two patients had stable disease, but no patients had objective response, hence the study was stopped for futility. Median OS and PFS was 5.2 months (95% CI (3.2 to 11.7)) and 2.3 months (95% CI (1.7 to 2.3)). Most common grade 3/4 toxicities: Anemia (n=2), diarrhea (n=2), and fever (n=2). Metformin alone failed to increase the infiltration of T-cell subsets in the tumor, but combined metformin and nivolumab increased percentages of tumor-infiltrating leukocytes (p=0.031). Dual treatment also increased Tim3+ levels in patient tissues and decreased naïve CD8+T cells (p=0.0475).

CONCLUSIONS

Nivolumab and metformin were well tolerated in patients with MSS CRC but had no evidence of efficacy. Correlative studies did not reveal an appreciable degree of immune modulation from metformin alone, but showed trends in tumorous T-cell infiltration as a result of dual metformin and PD-1 blockade despite progression in a majority of patients.

NEO-GAP: A Single-Arm, Phase II Feasibility Trial of Neoadjuvant Gemcitabine, Cisplatin, and Nab-Paclitaxel for Resectable, High-Risk Intrahepatic Cholangiocarcinoma

PURPOSE

Most patients with intrahepatic cholangiocarcinoma (IHCC) develop recurrence after resection. Adjuvant capecitabine remains the standard of care for resected IHCC. A combination of gemcitabine, cisplatin, and nab-paclitaxel (GAP) was associated with a 45% response rate and 20% conversion rate among patients with unresectable biliary tract cancers. The aim of this study was to evaluate the feasibility of delivering GAP in the neoadjuvant setting for resectable, high-risk IHCC.

METHODS

A multi-institutional, single-arm, phase II trial was conducted for patients with resectable, high-risk IHCC, defined as tumor size > 5 cm, multiple tumors, presence of radiographic major vascular invasion, or lymph node involvement. Patients received preoperative GAP (gemcitabine 800 mg/m2, cisplatin 25 mg/m2, and nab-paclitaxel 100 mg/m2 on days 1 and 8 of a 21-day cycle) for a total of 4 cycles prior to an attempt at curative-intent surgical resection. The primary endpoint was completion of both preoperative chemotherapy and surgical resection. Secondary endpoints were adverse events, radiologic response, recurrence-free survival (RFS), and overall survival (OS).

RESULTS

Thirty evaluable patients were enrolled. Median age was 60.5 years. Median follow-up for all patients was 17 months. Ten patients (33%) experienced grade ≥ 3 treatment-related adverse events, the most common being neutropenia and diarrhea; 50% required ≥ 1 dose reduction. The disease control rate was 90% (progressive disease: 10%, partial response: 23%, stable disease: 67%). There was zero treatment-related mortality. Twenty-two patients (73%, 90% CI 57-86; p = 0.008) completed all chemotherapy and surgery. Two patients (9%) who successfully underwent resection had minor postoperative complications. Median length of hospital stay was 4 days. Median RFS was 7.1 months. Median OS for the entire cohort was 24 months and was not reached in patients who underwent surgical resection.

CONCLUSION

Neoadjuvant treatment with gemcitabine, cisplatin, and nab-paclitaxel is feasible and safe prior to resection of intrahepatic cholangiocarcinoma and does not adversely impact perioperative outcomes.

Association of emotional support with quality of life, mental health, and survival in older adults with gastrointestinal malignancies-Results from the CARE registry

BACKGROUND

Emotional support (ES) is the most frequently reported support need among older adults with cancer. Yet, the association of ES with cancer outcomes is largely unknown. This study examined the association of ES with health-related quality of life (HRQoL), mental health, and survival among older adults with gastrointestinal (GI) malignancies.

METHODS

We included newly diagnosed older adults (≥60 years) with GI cancer undergoing self-reported geriatric assessment at their first clinic visit. ES was measured using an adaptation of the Medical Outcomes Study (dichotomized adequate ES vs. inadequate ES). Outcomes included physical and mental HRQoL, anxiety, depression, and survival. Multivariable linear regression evaluated the association between ES and HRQoL scores. Multivariable logistic regression evaluated the association of ES with anxiety and depression. All models were adjusted for age at geriatric assessments, race, sex, and cancer type/stage.

RESULTS

795 participants were included. Median patient age was 68 years (IQR: 64-74), 58% were male, and most cancers were either colorectal (37.9%) or pancreatic (30.8%). Most (77.6%) had adequate ES. Patients with inadequate ES were more likely to be Black (31.5 vs. 20.8%, p = 0.005), disabled (24.1 vs. 10.4%, p < 0.001), widowed/divorced (54.2 vs. 24.8%, p < 0.001) and had lower physical and mental HRQoL t-scores (Physical β: -3.35, 95% CI: -5.25, -1.46; Mental β: -2.46, 95% CI: -4.11, -0.81) and higher odds of depression (aOR: 2.22, CI: 1.34-3.69). This study found no difference between those with adequate ES versus inadequate ES in the proportion of deaths within 1 year of diagnosis (24.3% vs. 24.2%, p = 0.966), or within 2 years of diagnosis (32.4% vs. 33.2%, p = 0.126).

CONCLUSIONS

Older adults with inadequate ES have worse physical and mental HRQoL and higher odds of depression compared to those with adequate ES.

Use of Metformin and Survival in Patients with Hepatocellular Carcinoma (HCC) Undergoing Liver Directed Therapy: Analysis of a Nationwide Cancer Registry

BACKGROUND

Examine the association of metformin use and overall survival (OS) in patients with HCC undergoing image-guided liver-directed therapy (LDT): ablation, transarterial chemoembolization (TACE), or Yttrium-90 radioembolization (Y90 RE).

METHODS

Using National Cancer Institute Surveillance, Epidemiology, and End Results registry and Medicare claims databases between 2007 and 2016, we identified patients ≥ 66 years who underwent LDT within 30 days of HCC diagnosis. Patients with liver transplant, surgical resection, and other malignancies were excluded. Metformin use was identified by at least two prescription claims within 6 months before LDT. OS was measured by time between first LDT and death or last Medicare observation. Comparisons were performed between both all and diabetic patients on and not on metformin.

RESULTS

Of 2746 Medicare beneficiaries with HCC undergoing LDT, 1315 (47.9%) had diabetes or diabetes-related complications. Among all and diabetic patients, 433(15.8%) and 402 (30.6%) were on metformin respectively. Median OS was greater for patients on metformin (19.6 months, 95% CI 17.1-23.0) vs those not (16.0 months, 15.0-16.9; p = 0.0238). Patients on metformin had lower risk of death undergoing ablation (HR 0.70; 0.51-0.95; p = 0.0239) and TACE (HR 0.76, 0.66-0.87; p = 0.0001), but not Y90 RE (HR1.22, 0.89-1.69; p = 0.2231). Among diabetics, OS was greater for those on metformin vs those not (HR 0.77, 0.68-0.88; p < 0.0001). Diabetic patients on metformin had longer OS undergoing TACE (HR 0.71, 0.61-0.83; p < 0.0001), but not ablation (HR 0.74, 0.52-1.04; p = 0.0886) or Y90 RE (HR 1.26, 0.87-1.85; p = 0.2217).

CONCLUSION

Metformin use is associated with improved survival in HCC patients undergoing TACE and ablation.

Combinatorial targeting of immune checkpoints and epigenetic regulators for hepatocellular carcinoma therapy

Hepatocellular carcinoma (HCC) is the second leading cause of cancer-related mortality worldwide. The five-year survival rate of patients with unresectable HCC is about 12%. The liver tumor microenvironment (TME) is immune tolerant and heavily infiltrated with immunosuppressive cells. Immune checkpoint inhibitors (ICIs), in some cases, can reverse tumor cell immune evasion and enhance antitumor immunity. Rapidly evolving ICIs have expanded systemic treatment options in advanced HCC; however, single-agent ICIs achieve a limited 15-20% objective response rate in advanced HCC. Therefore, other combinatorial approaches that amplify the efficacy of ICIs or suppress other tumor-promoting pathways may enhance clinical outcomes. Epigenetic alterations (e.g., changes in chromatin states and non-genetic DNA modifications) have been shown to drive HCC tumor growth and progression as well as their response to ICIs. Recent studies have combined ICIs and epigenetic inhibitors in preclinical and clinical settings to contain several cancers, including HCC. In this review, we outline current ICI treatments for HCC, the mechanism behind their successes and failures, and how ICIs can be combined with distinct epigenetic inhibitors to increase the durability of ICIs and potentially treat "immune-cold" HCC.

The association of the CARE Frailty Index with survival among older adults with pancreatic cancer

699

Background: Outcomes of older adults with pancreatic cancer are highly variable with increased susceptibility to chemotherapy toxicities and inferior survival compared to younger patients. Determining which older adults are at higher risk for adverse outcomes remains a clinical challenge. We evaluated the association of a novel patient-reported geriatric assessment (GA)-based frailty index with survival among older adults with pancreatic cancer. Methods: Older adults (≥60y) referred for initial consultation at the UAB GI oncology clinic were prospectively enrolled in the Cancer and Aging Resilience Evaluation (CARE) registry. All patients underwent a patient-reported GA capturing multiple aging-related domains of health. The 44-item CARE frailty index (CARE-FI) based on the principles of deficit accumulation was utilized to determine frailty. The primary outcome was overall survival (OS) from the time of GA. Kaplan Meier method was used to estimate OS and comparisons between groups were by log-rank. A multivariate Cox regression model adjusted for age, sex, race, and cancer stage. Results: A total 254 older adults with pancreatic cancer were included; median age 70y, 52.4% male, 77% non-Hispanic white and 43.4% with stage IV disease. Overall, 40.1% (n=102) were frail, 26.0% (n=66) pre-frail and 33.9% (n=86) robust. No significant clinico-demographic differences across the 3 frailty groups were found. Differences in OS over two-year period was observed across the three frailty groups by the KM method ( p=0.008). In multivariate cox regression, frail status was associated with an increased risk of mortality (HR 1.9 [95% CI 1.19 – 2.98]; p=0.01) compared to robust status after adjustment for aforementioned confounders. Conclusions: The CARE-FI is a novel frailty index built on the principles of deficit accumulation using a patient-reported GA and is independently associated with survival among older adults with pancreatic cancer.[Table: see text]

Targeted therapy for intractable cancer on the basis of molecular profiles: An open-label, phase II basket trial (Long March Pathway)

Purpose

We evaluated he effects of molecular guided-targeted therapy for intractable cancer. Also, the epidemiology of druggable gene alterations in Chinese population was investigated.

Materials and methods

The Long March Pathway (ClinicalTrials.gov identifier: NCT03239015) is a non-randomized, open-label, phase II trial consisting of several basket studies examining the molecular profiles of intractable cancers in the Chinese population. The trial aimed to 1) evaluate the efficacy of targeted therapy for intractable cancer and 2) identify the molecular epidemiology of the tier II gene alterations among Chinese pan-cancer patients.

Results

In the first stage, molecular profiles of 520 intractable pan-cancer patients were identified, and 115 patients were identified to have tier II gene alterations. Then, 27 of these 115 patients received targeted therapy based on molecular profiles. The overall response rate (ORR) was 29.6% (8/27), and the disease control rate (DCR) was 44.4% (12/27). The median duration of response (DOR) was 4.80 months (95% CI, 3.33-27.2), and median progression-free survival (PFS) was 4.67 months (95% CI, 2.33-9.50). In the second stage, molecular epidemiology of 17,841 Chinese pan-cancer patients demonstrated that the frequency of tier II gene alterations across cancer types is 17.7%. Bladder cancer had the most tier-II alterations (26.1%), followed by breast cancer (22.4%), and non-small cell lung cancer (NSCLC; 20.2%).

Conclusion

The Long March Pathway trial demonstrated a significant clinical benefit for intractable cancer from molecular-guided targeted therapy in the Chinese population. The frequency of tier II gene alterations across cancer types supports the feasibility of molecular-guided targeted therapy under basket trials.

Survival and Prognostic Factors in Patients With Pancreatic Colloid Carcinoma Compared With Pancreatic Ductal Adenocarcinoma

OBJECTIVES

Colloid carcinoma (CC) is a rare subtype of pancreatic carcinoma. The aims of the study are to characterize the clinicopathological features and to evaluate the overall survival (OS) of patients with CC.

METHODS

Patients diagnosed with pancreatic CC and pancreatic ductal adenocarcinoma (PDAC) between 2004 and 2016 were identified from the National Cancer Database using International Classification of Disease-O-3 morphology (8480/3 and 8140/3) and topography (C25) codes. Kaplan-Meier analysis and Cox proportional hazards models were used to analyze OS.

RESULTS

Fifty-six thousand eight hundred forty-six patients were identified. A total of 2430 patients (4.3%) were diagnosed with pancreatic CC. Males constituted 52.8% of CC and 52.2% of PDAC. Colloid carcinoma presented with pathological stage I disease more often (16.7% vs 5.9%) and stage IV disease less often (42.1% vs 52.4%) than PDAC (P < 0.001). Stage I CC received chemotherapy (36.0% vs 59.4%) and neoadjuvant chemotherapy (4.4% vs 14.2%) less often compared with PDAC (P < 0.001). Statistically significant improved OS was seen among stage I, II, and IV CC compared with PDAC.

CONCLUSIONS

Pancreatic CC presented as stage I disease more often compared with PDAC. Neoadjuvant chemotherapy was administered more often in stage I PDAC compared with CC. Colloid carcinoma had improved OS compared with PDAC among all stages except stage III.

Role of local therapy in the management of patients with metastatic anal squamous cell carcinoma: a National Cancer Database study

BACKGROUND

About 10-20% of patients with anal squamous cell carcinoma (SCCa) present with metastatic disease and are usually treated with systemic chemotherapy. However, primary tumor control is crucial as local failure is associated with significant morbidity. Using the largest cohort to date, we report the impact of local therapy on survival among patients with metastatic anal SCCa.

METHODS

Data were collected from US hospitals that contributed to the National Cancer Database (NCDB) between 2004 and 2015. Patients who did not receive palliative systemic chemotherapy were excluded from analysis. Univariate (UVA) and multivariable analyses (MVA) were performed to identify factors associated with patient outcome. Kaplan-Meier analysis and Cox proportional hazards models were used to evaluate the association between tumor/patient characteristics and overall survival (OS).

RESULTS

A total of 1,160 patients were identified over the 12 years of study. Median age was 57 years. Majority were female (64.9%), non-Hispanic Whites (79.1%) and had Charlson-Deyo Score of 0 (83.6%). Most common metastatic sites were liver (25.9%), lung (11.6%) and bone (8.5%). More than 79% of the patients had received radiation to the primary site, and 10.4% underwent surgical resection for local control. Use of local therapy correlated closely with OS on MVA (HR 0.66; 0.55-0.79; P<0.001), with a 12-month and 5-year OS rates of 72.8% and 25.7% respectively, compared with 61.1% and 14.6% for patients treated with chemotherapy only. Poor prognostic factors included male gender (HR 1.44; 1.24-1.67; P<0.001), age >70 years (HR 1.28; 1.02-1.62; P=0.034), lack of health insurance (HR 1.32; 1.02-1.71; P=0.034), and cloacogenic zone location (HR 4.02; 1.43-11.30; P=0.008). There was no benefit from abdominoperineal resection (mOS =19.7 months; HR 1.05; 0.48-2.29; P=0.909), but both local resection of the primary (mOS =24.8 months, HR 0.48; 0.29-0.80; P=0.005) and palliative radiation (mOS =22.6 months; HR 0.66; 0.55-0.79; P<0.001) were associated with improved OS.

CONCLUSIONS

In addition to systemic therapy, resection of the primary tumor or palliative radiation improved OS in patients with anal SCCa. Patients unlikely to benefit from local control were those >70 years of age, male, lack of health insurance and cloacogenic carcinoma.

Abstract 3482: Correlative analysis of metformin and nivolumab combination in treatment-refractory microsatellite stable (MSS) metastatic colorectal cancer (mCRC)

Background: Preclinical results indicate that metformin can modulate immune cell populations in the tumor microenvironment of solid tumors by diminishing exhaustion of CD8+ tumor infiltrating cells and improving T cell responses. Studies also suggest that metformin could complement PD-1 blockade and potentiate its antitumor activity. Previously we reported the results of a phase II trial with metformin and nivolumab and here we report the findings of correlative analysis of the prospectively collected research samples of 18 patients.

Methods: We conducted a phase II trial with nivolumab and metformin in treatment-refractory microsatellite stable (MSS) metastatic colorectal cancer (mCRC). Nivolumab 480 mg IV every 4 weeks and metformin 1000 mg orally twice daily was administered in 28-day cycles following a 14-day metformin only lead-in phase. The primary endpoint was overall response rate (ORR). Secondary endpoints were overall survival (OS) and progression free survival (PFS). Pre-treatment and on-treatment research biopsies and correlative peripheral blood specimens were collected. Paired biopsies obtained at baseline and following treatment with metformin only (n=9) or metformin and nivolumab (n=9) and were stained with a panel of 13 markers using ChipCytometry technology by Canopy Biosciences. Sample was assessed prior to establishing the multiplex assay. 30 out of 36 samples were imaged and analyzed up to 30 Fields of View. Single cell recognition and quantitative biomarker analysis were performed to compare immune cell numbers and population distribution in pre- versus post-treatment samples.

Results: As previously reported, no patients had objective response based on RECIST version 1.1 and the study was stopped after the first stage for futility. Median OS and PFS was 5.1 months [95% CI (2-11.7)] and 2.3 months [95% CI (1.7-2.4)], respectively. Multiplex analysis of tissues from patients receiving lead in with metformin alone revealed fewer effector CD4 T cells and effector and effector memory CD8 T cells after treatment vs. baseline biopsy. Biopsy tissue from patients treated with metformin and nivolumab had lower pAMPK and decreased PDL-1 expression vs. baseline. The combination also increased percentages of leukocytes, effector CD4 T cells, effector and effector memory CD8 T cells as well as levels of PDL1-Tim3+ cells.

Conclusion: In the setting of MSS mCRC, metformin as a single agent did not enhance effector CD4 and CD8 T cell percentages in clinical samples in our patient cohort. Metformin in combination with nivolumab was associated with increased percentages of effector CD4 and CD8 T cells in biopsy specimens, although these improvements did not translate into enhanced clinical endpoints. Analysis of peripheral blood samples are currently underway to corroborate the findings in the tissue samples.

Citation Format: Batoul Farran, Jeffrey M. Switchenko, Lana Khalil, Walid L. Shaib, Brian Olson, Amanda Ruggieri, Christina Wu, Olatunji B. Alese, Maria Diab, Gregory B. Lesinski, Bassel El-Rayes, Mehmet Akce. Correlative analysis of metformin and nivolumab combination in treatment-refractory microsatellite stable (MSS) metastatic colorectal cancer (mCRC) [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2022; 2022 Apr 8-13. Philadelphia (PA): AACR; Cancer Res 2022;82(12_Suppl):Abstract nr 3482.

Abstract 6274: Prognostic impact of Sarcopenia on clinical outcomes in advanced hepatocellular carcinoma (HCC) treated with systemic therapy

Background: Sarcopenia is one of the early pathological features of cancer cachexia, yet the effect of sarcopenia on clinical outcomes in patients with advanced HCC is unclear. Our objective was to determine the effect of Sarcopenia on response to systemic therapy with advanced HCC.

Methods: Patients with unresectable and advanced liver cancer were retrospectively evaluated between 2010 to 2019. Skeletal muscle area (SMA) was computed with a previously validated computed tomography (CT) body composition AI algorithm. The skeletal muscle index (SMI) was derived from the skeletal muscle area (SMA) (cm2) divided by patient height (m2) calculated from images at the level of L3 on pretreatment CT. Sarcopenia cutoffs for females was less than 39 cm2/m2 SMI or less than 50 cm2/m2 SMI for males. Patients’ demographics, systemic treatment response, toxicity, progression-free survival (PFS) and overall survival (OS) were compared between first-line therapy groups. Kaplan-Meier and Cox proportional hazards regression were used for survival analysis comparisons.

Results: A total of 146 patients with advanced HCC were assessed from Mayo Clinic Arizona and Emory University. Seventy-six patients received immunotherapy as first-line treatment and seventy patients received TKI as first-line therapy. Sarcopenia at baseline was assessed in a total of 91 patients at first-line systemic treatment: n=48 with immunotherapy (IO) and n=43 with tyrosine kinase inhibitor (TKI). Sarcopenia was more prevalent in male patients (p=0.009), and in patients with low BMI (p=0.02). When comparing those with sarcopenia at baseline, higher response rate was observed in patients treated with IO without sarcopenia (47% versus 15%, p=0.019), this was not observed in TKI group. Interestingly, median PFS and OS was not significantly changed in patients with or without sarcopenia treated with IO or TKI on first-line therapy.

Conclusions: Sarcopenia was associated with reduced response rate (RR) in patients treated with IO, but not in TKI groups. Both didn’t translate into deleterious effect in PFS and or OS. Further research with sufficient adjustments for confounding factors is warranted to better elucidate the prognostic value of sarcopenia in these patients.

Citation Format: Gehan Botrus, Pedro Luiz Serrano Uson Junior, Heidi Kosiorek, Mehmet Akce, Isabela Chang, Zhubene Mesbah, Eric Yancey, Daniel Blezek, Jason Klug, Lana Khalil, Puneet Raman, Mohamad Sonbol, Mitesh Borad, Daniel Ahn, Tanios Bekaii-Saab. Prognostic impact of Sarcopenia on clinical outcomes in advanced hepatocellular carcinoma (HCC) treated with systemic therapy [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2022; 2022 Apr 8-13. Philadelphia (PA): AACR; Cancer Res 2022;82(12_Suppl):Abstract nr 6274.

A phase 1 multiple-ascending dose study to evaluate the safety and tolerability of XmAb23104 (PD-1 x ICOS) in subjects with selected advanced solid tumors (DUET-3)

2604

Background: XmAb23104 is a bispecific antibody targeting T cells that simultaneously express PD-1, an immune checkpoint, and ICOS, a costimulatory molecule expressed after T cell activation. DUET-3 is a Phase 1, first-in-human, dose-escalation and expansion study in subjects with advanced solid tumors, designed to assess safety, tolerability and to identify the maximum tolerated dose (MTD) of XmAb23104. Secondary objectives are to assess pharmacokinetics (PK), immunogenicity, and preliminary anti-tumor activity. We report preliminary data from the completed dose-escalation phase. Methods: A 3+3 monotherapy dose escalation with 9 dose levels from 0.002 to 15 mg/kg has been completed. Subjects with measurable disease who progressed on prior standard therapy were eligible. A minimum 6-week washout from prior pembrolizumab was required. XmAb23104 was administered biweekly and RECIST 1.1 assessment was performed every 8 weeks. Results: Sixty-two subjects were treated in escalation at doses up to 15 mg/kg; no dose-limiting toxicities were observed and an MTD was not reached. These subjects had advanced disease, 92% were Stage IV at screening, the median number of prior therapies was 3, and 37% had previous checkpoint therapy. Thirty-seven subjects (59.7%) experienced a treatment-related adverse event (TRAE); the most common were diarrhea (9.7%), decreased appetite (9.7%), and fatigue (9.7%). The majority of TRAEs were Grades 1 or 2, with 6 subjects (9.7%) having a Grade 3 or higher TRAE. Thirteen immunotherapy-related adverse events (irAEs) occurred in 8 subjects; no individual irAE occurred in more than 1 subject. Most irAEs were mild (Grades 1 and 2) with 1 Grade 3 pruritus and 1 asymptomatic Grade 4 lipase elevation. Partial responses were observed in 3 subjects (sarcoma; prior PD-1 head and neck squamous cell carcinoma [HNSCC] and renal cell carcinoma [RCC]), and stable disease > 12 months was observed in 2 subjects with colorectal cancer (CRC; 1 MSS and 1 MSI-H). A dose of 10 mg/kg was selected after consideration of PK, safety, and clinical activity data in consultation with the investigators and continues to be evaluated in the expansion part of the study. Conclusions: The dose escalation part of this study indicates XmAb23104 was generally well tolerated at doses up to 15 mg/kg and has shown clinical activity in subjects with advanced solid tumors. CTLA4 blockade has been found to increase the frequency of ICOS-expressing T cells in prostate cancer, bladder cancer, melanoma, and hepatocellular cancer (Chen, 2009; Liakou, 2008; Wei, 2017) and may be applicable to other immunogenic tumor types. XmAb23104 is currently being studied alone or in combination with ipilimumab in expansion in non-squamous non-small cell lung carcinoma, melanoma, CRC, undifferentiated pleomorphic sarcoma, HNSCC, and RCC. Clinical trial information: NCT03752398.

NEO-GAP: A phase II single-arm prospective feasibility study of neoadjuvant gemcitabine/cisplatin/nab-paclitaxel for resectable high-risk intrahepatic cholangiocarcinoma

4097

Background: Given a high recurrence rate, surgical resection for localized intrahepatic cholangiocarcinoma (IHCC) is curative in only 30-35% of patients. BILCAP has established a standard of care for adjuvant therapy with monotherapy capecitabine. Gemcitabine, cisplatin and nab-paclitaxel combination chemotherapy (GAP) was associated with a response rate of 45% in biliary cancer and 20% of patients who were previously inoperable underwent margin negative resection. Based on these data, we conducted a neoadjuvant study of GAP for resectable but high-risk IHCC. Methods: A multi-institutional prospective single-arm phase II trial was conducted for patients with resectable high-risk disease, as defined by tumor size > 5cm, multiple tumors, presence of radiographic major vascular invasion, and lymph node involvement. Patients were administered 4 cycles (3 months) of preoperative GAP (gemcitabine 800 mg/m2, cisplatin 25 mg/m2 and nab-paclitaxel 100 mg/m2 on days 1 and 8 of a 21-day cycle) prior to an attempt at curative-intent surgical resection. The primary endpoint was completion of all therapy, including both preoperative chemotherapy and resection. Secondary endpoints were toxicity, radiologic response according to Response Evaluation Criteria in Solid Tumor (RECIST) criteria, RFS, and OS. Thirty evaluable patients provided 73% power to reject a null therapy completion rate of 50%, with a target completion rate of 70% using a one-sided exact test with a Type I error of 0.05. Results: Thirty-seven patients were screened and 30 evaluable patients were enrolled. The trial was sequentially activated at each of the 4 sites from 09/18-02/21 and the final patient was enrolled in 09/21. Median age was 60.5 years and 40% were female. Twenty-three patients (77%, 90% CI: 60.6-88.5%; p = 0.0026) completed all preoperative chemotherapy and underwent surgical resection. Ten patients (33%) experienced grade 3-4 treatment-related adverse events, the most common being neutropenia and diarrhea; 47% required at least one dose reduction. Partial response rate was 23% and disease control rate was 90% (PD: 10%, PR: 23%, SD: 67%). Of the 23 patients who successfully underwent surgical resection, 2 (9%) had minor postoperative complications. Median size of largest tumor was 5.5cm, median number of tumors was 3, and 39% were lymph node positive. Median length of hospital stay was 4 days. There was zero treatment related mortality. Conclusions: This study met its primary endpoint and demonstrated that neoadjuvant gemcitabine/cisplatin/nab-paclitaxel is feasible and safe prior to resection of intrahepatic cholangiocarcinoma and does not adversely impact perioperative outcomes. Continued follow-up for RFS and OS with this treatment strategy is underway and larger validation studies are planned. Clinical trial information: NCT03579771.