Pharmacist management of atrial fibrillation: a pilot educational intervention study

Introduction

AF increases the risk of stroke by a factor of five [1], oral anticoagulants (OACs) can reduce stroke by ∼60% and death by ∼25% [2]. Pharmacists, especially those based in primary care are well placed to support patients in this therapeutic area. However, research indicates that pharmacists do not always feel confident in supporting patients on OACs, which are the mainstay of AF management [3].

Purpose

The aim of this pilot study is to assess pharmacists' knowledge prior to an educational session on AF and its management. Training was provided on AF, its management and the use of an associated app, AF Manager (Figure) with the intention to re-assess pharmacists' knowledge and use of the app 3, 6 and 12-months post-training. Here, we report the assessment of pharmacist baseline knowledge.

Methods

Various social media platforms were used to invite UK-based, practicing primary care pharmacists to an educational session. Training was developed in collaboration with consultant pharmacists from an Academic Health Science Network, AF Programme. Participant knowledge was assessed immediately before the educational session by use of the Jessa Atrial Fibrillation Knowledge Questionnaire (JAKQ), adapted for use with pharmacists. Quantitative data were analysed using SPSS version 27.

Results

Twenty UK-based practicing pharmacists attended the educational session. Four pharmacists were excluded from analysis as they were not based in primary care. The mean practice experience of participants was 14.6±10.5 years; 62.5% were female and 50% had undertaken postgraduate qualifications. For this group of pharmacists, out of a maximum of 19 points, the mean score for the adapted JAKQ was 13.7±2.5. General knowledge about OACs (i.e. that which might be used to counsel patients taking OACs, such as time of day to take the medicines, side effects, drug interactions/contraindications) was high with knowledge about the different types of OACs similar (vitamin K antagonists (VKAs) 66.7±25.3% versus non-vitamin K antagonist oral anticoagulants (NOACs) 66.7±41.6%). However, several important knowledge gaps about AF and its management were identified. Only half of the participants knew that patients taking OACs for AF would continue to experience AF and only five participants (31.3%) knew that AF symptoms could be self-managed. Knowledge of INR monitoring frequency for VKAs and the use of NOAC patient alert cards was also lacking, with nine (56.2%) and thirteen (81.2%) of participants unable to answer these questions, respectively.

Conclusions

Primary care pharmacists are knowledgeable about the medicines used in AF management. However, there are specific knowledge gaps around AF management that need to be addressed via educational interventions to enable pharmacists to support patients effectively. Our follow-up research will investigate knowledge retention post-training and assess app usability for pharmacists in the management of patients with AF.

Funding Acknowledgement

Type of funding sources: None. Figure 1. Screenshots of the AF Manager app

Cross-sectional and longitudinal characterisation of cognitive function and outcomes in patients presenting to hospital with cardiovascular risk factors

Background/Introduction

Cardiovascular (CV) diseases including atrial fibrillation and arteriosclerosis are associated with impaired cognitive function. Cognitive dysfunction can impact the process of shared clinical decision making, reduce adherence to polypharmacy, and decrease quality of life. The prevalence of cognitive dysfunction in contemporary patients with CV diseases and its implication on future CV events is not well known.

Purpose

We 1) quantified cognitive function in patients presenting to hospital with CV diseases, 2) identified clinical variables and blood biomarkers associated with cognitive dysfunction, and 3) quantified the hazard of abnormal cognitive function for predicting MACCE (major adverse CV and cerebrovascular events).

Methods and results

Of 1625 consecutive patients presenting acutely to a large teaching hospital with CV diseases, 614 patients (median age [Q1, Q3] 68 [58, 76] years; 66% male) who completed the Montreal Cognitive Assessment (MoCA) were analysed. The median [Q1, Q3] MoCA score was 25 points [21, 27]. 360 patients (59%) had an abnormal score (<26). At baseline, patients with abnormal scores were more likely to be female (odds ratio, OR [95% confidence intervals], 1.874 [1.287, 2.728]), have BMI<30 (OR 0.584 [0.410, 0.831]), heart failure (OR 1.492 [1.043, 2.135]), diabetes (OR 2.212 [1.529, 3.199]), chronic kidney disease (CKD-EPI<60 ml/min, OR 1.553 [1.021, 2.361]), and have more CV co-morbidities (OR per additional co-morbidity 1.415 [1.246, 1.605]). Amongst 12 CV biomarkers tested, elevated Bone Morphogenetic Protein 10 (OR 1.325 [1.022, 1.719]) and Growth Differentiation Factor 15 (OR 1.419 [1.054, 1.912]) increased odds of abnormal scores.

Cox proportional hazards model adjusted for competing risk of non-CV death assessed the relationship between abnormal cognitive function and MACCE (stroke, TIA, myocardial infarction, hospitalisation for heart failure, CV death). Follow-up time ranged from 2.7 to 6.1 years. Patients were censored at 2.5 years for this analysis. 130 out of 614 patients experienced a MACCE (21%) and 71 had a non-CV death (12%). Patients with abnormal MoCA scores were at higher risk for MACCE (subhazard ratio, sHR [95% CI] 1.827 [1.253, 2.664]). The hazard remained significant after adjustment for age, sex, obesity, atrial fibrillation, stroke, heart failure, hypertension, coronary artery disease, diabetes, peripheral artery disease and renal dysfunction (sHR 1.367 [1.056, 2.326]; Figure). All-cause mortality was 1.785 times higher for those with abnormal MoCA scores [1.061, 3.002].

Conclusion

In this study, 3 out of 5 patients with CV diseases had abnormal MoCA scores at baseline. Abnormal cognitive scores significantly predicted patients who went on to experience a MACCE within 2.5 years of follow-up. These observations call for further research and action to provide additional diagnostics, support and early intervention to address cognitive dysfunction in CV patients.

Funding Acknowledgement

Type of funding sources: Public grant(s) – EU funding. Main funding source(s): EU H2020 CATCH ME Cumulative incidence function

Identification of novel biomarkers for predicting atrial fibrillation outcomes in patients with cardiovascular risk factors

Funding Acknowledgements

Type of funding sources: Public grant(s) – EU funding. Main funding source(s): CATCH ME European Commission H2020 grant (no. 633196)

Background

Several novel blood biomarkers were recently found to reflect underlying pathophysiology implicated in atrial fibrillation (AF). These biomarkers could be used for stratifying patients at risk of developing AF or AF-related adverse events.

Purpose

We combined 9 clinical risk factors and 12 biomarkers to model composite outcomes of 1) incident AF, hospitalisation for arrhythmias, and cardiovascular death in sinus rhythm patients at risk of AF, and 2) recurrent AF, hospitalisation for arrhythmias, and cardiovascular death in patients with AF.

Methods

1455 patients presenting acutely to hospital with either diagnosed AF (n = 648) or sinus rhythm and ≥2 CHA2DS2-VASc risk factors (n = 807, silent AF ruled out by 7-day ECG monitoring) were followed up for two years. Outcomes were collected from linked hospital episode statistics (HES) and Office of National Statistics (ONS) data from NHS Digital. We univariately evaluated 12 cardiovascular biomarkers quantified from EDTA plasma collected at baseline (ANG2, BMP10, CA125, CRP, ESM1, FABP3, FGF23, GDF15, IGFBP7, IL6, NTproBNP, Troponin T). Two predictive models combining clinical characteristics and biomarkers were developed for each patient group, using Cox regression with backward elimination and considering non-cardiovascular death as a competing risk.

Results

In sinus rhythm patients (n = 117/807 with outcome), elevated BMP10, ANG2, CA125, IGFBP7, NTproBNP univariately predicted the composite outcome (adjusted for age, sex, body mass index (BMI), eGFR, heart failure, stroke/TIA, hypertension, diabetes, coronary artery disease – see Figure part A). In the combined model, age, prior stroke/TIA, coronary artery disease, ANG2, IGFBP7 and NTproBNP predicted the outcome (C-statistic [95% confidence interval (CI)] 0.733 [0.683, 0.784]).

In patients with AF (n = 193/648 with outcome), elevated BMP10, ANG2, CA125, troponin T, GDF15, IGFBP7, NTproBNP univariately predicted the composite outcome (adjusted for same variables as above – see Figure part B). In the combined model, high BMI, low eGFR, hypertension, IGFBP7, NTproBNP and troponin T were predictive of the composite outcome (C-statistic [95% CI]: 0.643 [0.596, 0.689]).

Conclusion

Combinations of clinical risk factors and biomarkers were predictive of two-year AF-related adverse events in sinus rhythm patients at risk of AF and in patients with AF. These markers could be used to identify patients for more intensive follow-up or therapy. IGFBP7 and NTproBNP were present in both models, implicating pathways involved with cardiac overload, inflammation, and oxidative stress. These findings call for external validation of these markers and prospective evaluation in at-risk populations. Abstract Figure. Biomarkers predicting 2-year AF outcomes

Plasma pre-treatment T790M relative allelic frequency in patients with advanced EGFR-mutated non-small cell lung cancer predicts treatment response to subsequent-line osimertinib

Background

Approximately half of all patients with advanced EGFR-mutant NSCLC will develop acquired resistance to first or second-generation EGFR tyrosine kinase inhibitors (EGFR-TKIs) with a T790M mutation. In the AURA3 trial, patients with a T790M mutation had a response rate of 71% to osimertinib, a third-generation EGFR-TKI. The response to osimertinib may vary according to plasma T790M mutation frequency. Our aim was to determine the effect of plasma T790M mutation load on treatment response to osimertinib in an Australian multi-institutional cohort.

Methods

We performed a retrospective study on patients treated with osimertinib in the second-line setting and beyond between 2016-2018 from ten centres in Australia, who had T790M mutations detected in tumour or plasma. The primary objective was to investigate if there was a difference in disease control rate (DCR) between patients with high vs. low T790M relative allelic frequency (RAF) as detected in plasma, using a 0.3 RAF cut-off, as determined by ddPCR or BEAMing PCR. Secondary objective was to determine the survival outcomes according to high versus low plasma T790M RAF. Additional analyses were performed to investigate the survival outcome for patients with plasma versus tissue T790M positivity.

Results

A total of 139 patients were included in this study. Patients with higher RAF demonstrated higher DCR (74% vs. 36%, P=0.02), however there was no statistically significant difference in survival outcomes in the two groups. Exploratory analysis showed that patients with tissue T790M+ had improved DCR compared with those with plasma T790M+ (89% vs. 68%, P=0.01) and longer progression free survival (median 15.4 vs. 9.7 months; HR 0.51, 95% CI: 0.34 to 0.77, P=0.003) and overall survival (median not reached, HR 0.51, 95% CI: 0.30 to 0.86, P=0.02). Patients who were tissue T790M+ demonstrated superior survival compared to plasma T790M+ after correcting for confounding variables in a multivariate model.

Conclusions

DCR was superior in patients with higher plasma T790M mutation load versus lower plasma T790M mutational load, without significant survival benefit. Plasma T790M RAF is a potential predictive biomarker which should be investigated and validated in larger prospective studies.

Tumour immune microenvironment biomarkers predicting cytotoxic chemotherapy efficacy in colorectal cancer

The role of the local tumour and stromal immune landscape is increasingly recognised to be important in cancer development, progression and response to therapy. The composition, function, spatial orientation and gene expression profile of the infiltrate of the innate and adaptive immune system at the tumour and surrounding tissue has an established prognostic role in colorectal cancer (CRC). Multiple studies have confirmed that a tumour immune microenvironment (TIME) reflective of a type 1 adaptive immune response is associated with improved prognosis. There have been significant efforts to evolve these observations into validated, histopathology-based prognostic biomarkers, such as the Immunoscore. However, the clinical need lies much more in the development of predictive, not prognostic, biomarkers which have the potential to improve patient outcomes. This is particularly pertinent to help guide cytotoxic chemotherapy use in CRC, which remains the standard of care. Cytotoxic chemotherapy has recognised immunomodulatory activity distinct from its antimitotic effects, including mechanisms such as immunogenic cell death (ICD) and induction/inhibition of key immune players. Response to chemotherapy may differ with regard to molecular subtype of CRC, which are strongly associated with immune phenotypes. Thus, immune markers are potentially useful, though under-reported, predictive biomarkers. In this review, we discuss the impact of the TIME on response to cytotoxic chemotherapy in CRC, with a focus on baseline immune markers, and associated genomic and transcriptomic signatures.

[177Lu]Lu-PSMA-617 versus cabazitaxel in patients with metastatic castration-resistant prostate cancer (TheraP): a randomised, open-label, phase 2 trial

BACKGROUND

Lutetium-177 [¹⁷⁷Lu]Lu-PSMA-617 is a radiolabelled small molecule that delivers β radiation to cells expressing prostate-specific membrane antigen (PSMA), with activity and safety in patients with metastatic castration-resistant prostate cancer. We aimed to compare [¹⁷⁷Lu]Lu-PSMA-617 with cabazitaxel in patients with metastatic castration-resistant prostate cancer.

METHODS

We did this multicentre, unblinded, randomised phase 2 trial at 11 centres in Australia. We recruited men with metastatic castration-resistant prostate cancer for whom cabazitaxel was considered the next appropriate standard treatment. Participants were required to have adequate renal, haematological, and liver function, and an Eastern Cooperative Oncology Group performance status of 0-2. Previous treatment with androgen receptor-directed therapy was allowed. Men underwent gallium-68 [⁶⁸Ga]Ga-PSMA-11 and 2-flourine-18[¹⁸F]fluoro-2-deoxy-D-glucose (FDG) PET-CT scans. PET eligibility criteria for the trial were PSMA-positive disease, and no sites of metastatic disease with discordant FDG-positive and PSMA-negative findings. Men were randomly assigned (1:1) to [¹⁷⁷Lu]Lu-PSMA-617 (6·0-8·5 GBq intravenously every 6 weeks for up to six cycles) or cabazitaxel (20 mg/m² intravenously every 3 weeks for up to ten cycles). The primary endpoint was prostate-specific antigen (PSA) response defined by a reduction of at least 50% from baseline. This trial is registered with ClinicalTrials.gov, NCT03392428.

FINDINGS

Between Feb 6, 2018, and Sept 3, 2019, we screened 291 men, of whom 200 were eligible on PET imaging. Study treatment was received by 98 (99%) of 99 men randomly assigned to [¹⁷⁷Lu]Lu-PSMA-617 versus 85 (84%) of 101 randomly assigned to cabazitaxel. PSA responses were more frequent among men in the [¹⁷⁷Lu]Lu-PSMA-617 group than in the cabazitaxel group (65 vs 37 PSA responses; 66% vs 37% by intention to treat; difference 29% (95% CI 16-42; p<0·0001; and 66% vs 44% by treatment received; difference 23% [9-37]; p=0·0016). Grade 3-4 adverse events occurred in 32 (33%) of 98 men in the [¹⁷⁷Lu]Lu-PSMA-617 group versus 45 (53%) of 85 men in the cabazitaxel group. No deaths were attributed to [¹⁷⁷Lu]Lu-PSMA-617.

INTERPRETATION

[¹⁷⁷Lu]Lu-PSMA-617 compared with cabazitaxel in men with metastatic castration-resistant prostate cancer led to a higher PSA response and fewer grade 3 or 4 adverse events. [¹⁷⁷Lu]Lu-PSMA-617 is a new effective class of therapy and a potential alternative to cabazitaxel.

FUNDING

Prostate Cancer Foundation of Australia, Endocyte (a Novartis company), Australian Nuclear Science and Technology Organization, Movember, The Distinguished Gentleman's Ride, It's a Bloke Thing, and CAN4CANCER.

Effect of Virtual Reality Therapy in Reducing Pain and Anxiety for Cancer-Related Medical Procedures: A Systematic Narrative Review

CONTEXT

Virtual reality (VR) has emerged as a novel form of nonpharmacological analgesia therapy. We wished to review the use of VR to treat pain and anxiety in cancer-related medical procedures and chemotherapy.

OBJECTIVES

To determine if immersive VR influences pain and/or anxiety outcomes in patients with cancer undergoing medical interventions. To discuss critical limitations in the current evidence base and provide suggestions for future areas of research.

METHODS

A systematic review was performed on Ovid MEDLINE, PubMed, and Google Scholar from 1999 to December 2019. The following search terms were run in each of the databases: Virtual Reality and pain or anxiety. Articles were assessed by two independent authors for inclusion.

RESULTS

From 999 retrieved citations, nine studies met inclusion criteria for review. Methodological limitations and small sample sizes preclude strong guidance for clinical applications. Although studies demonstrated a trend toward improvement in pain and anxiety, only two studies reached statistical significance.

CONCLUSION

There is inconclusive evidence on the significance of immersive VR in reducing pain (five studies) or anxiety (six studies) for patients with cancer undergoing medical interventions or receiving chemotherapy. Further research on the effect of immersive VR as a tool for medical procedures and/or patients with cancer undergoing treatment is required.

The Multiple Potential Biomarkers for Predicting Immunotherapy Response-Finding the Needle in the Haystack

Immune checkpoint inhibitors (ICIs) are being increasingly utilised in a variety of advanced malignancies. Despite promising outcomes in certain patients, the majority will not derive benefit and are at risk of potentially serious immune-related adverse events (irAEs). The development of predictive biomarkers is therefore critical to personalise treatments and improve outcomes. A number of biomarkers have shown promising results, including from tumour (programmed cell death ligand 1 (PD-L1), tumour mutational burden (TMB), stimulator of interferon genes (STING) and apoptosis-associated speck-like protein containing a CARD (ASC)), from blood (peripheral blood mononuclear cells (PBMCs), circulating tumour DNA (ctDNA), exosomes, cytokines and metal chelators) and finally the microbiome.

Polypharmacy and the use of low or limited value medications in advanced cancer

BACKGROUND

Patients with advanced malignancy are often on medications for co-morbidities, including those for primary or secondary prevention. The benefit from these medications can be limited and may result in adverse effects, interact with medications used for the malignancy or associated symptoms, increase pill burden and reduce quality of life.

AIMS

To evaluate the proportion of patients with advanced malignancy that were continued on low or limited value medications and identify the factors associated with this. We also sought to determine how prevalent polypharmacy was within this group of patients and the factors associated with this.

METHODS

A retrospective chart review was conducted of patients with incurable malignancy admitted under medical oncology at Liverpool Hospital over a 90-day period. Demographic variables, co-morbidities, disease related parameters and medications were reviewed. Criteria were established to identify low or limited value medications.

RESULTS

Seventy-eight patients were identified between September and December 2018. Thirty-day mortality was 33%. Sixty-five percent of the cohort was on five or more medications and 24% on 10 or more. One low or limited value medication was reported in 36% and 20% were on two or more. Age ≤60 years was associated with a risk of being on at least one unnecessary medication. Patients with fewer co-morbidities and those in their last 3 months of life were significantly less likely to have polypharmacy. Nine percent of the cohort was on three or more antihypertensives and 6% of patients were on three or more oral hypoglycaemics.

CONCLUSION

Polypharmacy and continued prescribing of low or limited value medications was identified in a high proportion of patients. Further studies are needed to assess the impact of continuing these medications, as well as investigation of patient and physician attitudes towards de-escalation.

Aberrant Expression of RAD52, Its Prognostic Impact in Rectal Cancer and Association with Poor Survival of Patients

The DNA damage response enables cells to survive and maintain genome integrity. RAD52 is a DNA-binding protein involved in the homologous recombination in DNA repair, and is important for the maintenance of tumour genome integrity. We investigated possible correlations between RAD52 expression and cancer survival and response to preoperative radiotherapy. RAD52 expression was examined in tumour samples from 179 patients who underwent surgery for rectal cancer, including a sub-cohort of 40 patients who were treated with neoadjuvant therapy. A high score for RAD52 expression in the tumour centre was significantly associated with worse disease-free survival (DFS; p = 0.045). In contrast, reduced RAD52 expression in tumour centre samples from patients treated with neoadjuvant therapy (n = 40) significantly correlated with poor DFS (p = 0.025) and overall survival (OS; p = 0.048). Our results suggested that RAD52 may have clinical value as a prognostic marker of tumour response to neoadjuvant radiation and both disease-free status and overall survival in patients with rectal cancer.

Prognostic utility of serial 18F-FDG-PET/CT in patients with locally advanced rectal cancer who underwent tri-modality treatment

OBJECTIVE

This study explored the value of serial 18-fludeoxyglucose-positron emission tomography (¹⁸F-FDG-PET/CT) in predicting disease-free survival (DFS) in locally advanced rectal cancer (LARC) treated with neoadjuvant chemoradiation (NCRT) and surgery.

METHODS

We prospectively studied 46 patients with LARC who underwent NCRT and surgery. ¹⁸F-FDG-PET/CT scans were performed at three time-points before surgery (pre-NCRT-PET1, during NCRT-PET2 and following completion of NCRT-PET3). The following semi-quantitative PET parameters were analysed at each time point: maximum standardized uptake value (SUVmax), SUVmean, metabolic tumour volume (MTV) and tumour lesion glycolysis (TLG). Absolute and percentage changes in these parameters were analysed between time points. Statistical analysis consisted of median tests, Cox regression and Kaplan-Meier analysis for DFS.

RESULTS

The median follow-up time was 24 months. A reduction in PET parameters showed statistically significant differences for patients with recurrence compared to those without; percentage changes in MTV between PET1 and PET3 (cut-off: 87%, p = 0.023), percentage changes in TLG between PET1 and PET3 (cut-off: 94%, p = 0.02) and absolute change in MTV PET1 and PET2 (cut-off: 10.25, p = 0.001).An absolute reduction in MTV between PET1 and PET3 (p=0.013), a percentage reduction in TLG between PET1 and PET2 (p=0.021), SUVmax and SUVmean at PET2 (p = 0.01, p = 0.027 respectively)were also prognostic indicators of recurrence.MTV percentage change between PET1 and PET2 and SUVmean percentage change between PET1 and PET3 were also trending towards significance (p = 0.052, p = 0.053 respectively).

CONCLUSION

Serial ¹⁸F-FDG-PET/CT is a potentially reliable non-invasive method to predict recurrence in patients with LARC. Volumetric parameters were the best predictors. This could allow risk-stratification in patients who may benefit from conservative management.

ADVANCES IN KNOWLEDGE

This paper will add to the literature in risk-stratifying patients with LARC based on prognosis, using ¹⁸F-FDG-PET/CT. This may improve patient outcomes by selecting suitable candidates for conservative management.

P5662Development of a prognostic model for prevalent atrial fibrillation using individual patient data: Results of CATCH ME

Background/Introduction

Atrial fibrillation (AF) can be challenging to diagnose due to asymptomatic and paroxysmal presentation. Identifying prognostic factors of AF would elucidate potential mechanisms causing AF and refine screening for at risk patients.

Purpose

To identify the main predictors of AF and to develop a prognostic model for prevalent AF.

Methods

Data of 120 potential predictors were harmonised in individual patient data from 4 independent European studies. A three stage Delphi expert consensus process identified predictors based on clinical knowledge. The predictors were further reduced using statistical selection (backward elimination), and a logistic regression model was fitted. We calculated odds ratios (OR) for each of the selected predictors and evaluated model performance using the C-statistic.

Results

Overall, 2420 patients (mean [standard deviation] age = 62.7 [14.5] years, 35.6% female, 43.1% with AF) were included in the analysis. Thirty-one potential predictors identified from the Delphi process which had sufficient data across all datasets were modelled. Of these 14 were deemed prognostic in predicting AF (age, sex, BMI, height, hypertension, diabetes, history of coronary artery disease, left atrial volume, left ventricular end systolic diameter, abnormality on echo, tricuspid valve disease of at least moderate intensity, aldosterone-antagonists, beta-blockers and P2Y12 blockers; see Figure 1). There was a clear interaction between age and sex indicating that males are at higher risk than females early in life, while females are at increased risk of AF at older age (Figure 1). The risk prediction model combining these prognostic factors performed well (C-statistic 0.79; 95% CI 0.77–0.81).

Figure 1. (a) Forest plot; (b) Interaction

Conclusion(s)

Our preliminary analysis identified important prognostic factors and a complex relationship between age and sex, which predicts prevalent AF, highlighting the different potential causes of AF in different patients. There is a clear need to validate these factors in external datasets and for further investigation into the molecular mechanism underlying these factors.

Acknowledgement/Funding

European Commission H2020 framework

Plasma next generation sequencing and droplet digital PCR-based detection of epidermal growth factor receptor (EGFR) mutations in patients with advanced lung cancer treated with subsequent-line osimertinib

BACKGROUND

Gene mutation analysis from plasma circulating tumor DNA (ctDNA) can provide timely information regarding the mechanism of resistance that could translate to personalised treatment. We compared concordance rate of next generation sequencing (NGS) and droplet digital polymerase chain reaction (ddPCR) in the detection of the EGFR activating and T790M mutation from plasma ctDNA with diagnostic tissue biopsy-based assays. The second objective was to test whether putative osimertinib resistance associated mutations were detectable from plasma using NGS.

METHODS

From January 2016 to December 2017, we prospectively collected plasma samples from patients prior to commencement of second- or third-line osimertinib therapy and upon disease progression, in a single tertiary hospital in South Western Sydney, Australia. Amplicon-based NGS and ddPCR assays were used to detect activating epidermal growth factor receptor (EGFR) and T790M mutations in 18 plasma samples from nine patients; all patients were required to have tissue biopsies with known EGFR status.

RESULTS

High concordance of allelic fractions were seen in matched plasma NGS and ddPCR for activating EGFR mutations and T790M mutations (R² = 0.92, P < 0.0001). Using tissue biopsies as reference standard, sensitivity was 100% for NGS and 94% for ddPCR. Several possible osimertinib resistance associated mutations, including PIK3CA, BRAF and TP53 mutations, were detected by NGS in samples upon progression on osimertinib therapy.

CONCLUSION

ddPCR assays for EGFR mutations appear to be as sensitive and highly concordant as amplicon-based NGS. NGS has the ability to detect novel resistance mutations.

Detection of AR-V7 in Liquid Biopsies of Castrate Resistant Prostate Cancer Patients: A Comparison of AR-V7 Analysis in Circulating Tumor Cells, Circulating Tumor RNA and Exosomes

Detection of androgen receptor (AR) variant 7 (AR-V7) is emerging as a clinically important biomarker in castrate resistant prostate cancer (CRPC). Detection is possible from tumor tissue, which is often inaccessible in the advanced disease setting. With recent progress in detecting AR-V7 in circulating tumor cells (CTCs), circulating tumor RNA (ctRNA) and exosomes from prostate cancer patients, liquid biopsies have emerged as an alternative to tumor biopsy. Therefore, it is important to clarify whether these approaches differ in sensitivity in order to achieve the best possible biomarker characterization for the patient. In this study, blood samples from 44 prostate cancer patients were processed for CTCs and ctRNA with subsequent AR-V7 testing, while exosomal RNA was isolated from 16 samples and tested. Detection of AR and AR-V7 was performed using a highly sensitive droplet digital PCR-based assay. AR and AR-V7 RNA were detectable in CTCs, ctRNA and exosome samples. AR-V7 detection from CTCs showed higher sensitivity and has proven specificity compared to detection from ctRNA and exosomes. Considering that CTCs are almost always present in the advanced prostate cancer setting, CTC samples should be considered the liquid biopsy of choice for the detection of this clinically important biomarker.

Patterns of Presentation and Treatment Outcomes of Non-clear-cell Renal Cell Carcinoma and Sarcomatoid Renal Cell Carcinoma Patients in 2 Tertiary Referral Centers in Sydney, Australia

BACKGROUND

Non-clear-cell renal cell carcinoma (nccRCC) and renal cell carcinoma with sarcomatoid features (scRCC) are rare, and represent subtypes with less defined treatment strategies. The aim of this study is to describe the patterns of care and outcomes of these patients in 2 tertiary referral centers in South Western Sydney Local Health District over a 10-year period.

PATIENTS AND METHODS

Patients with RCC seen at South Western Sydney Local Health District from January 1, 2005 to December 31, 2015 were identified from electronic medical records. For each patient, we extracted details regarding demographics, tumor characteristics, treatment, recurrences, and survival, which was analyzed using the Kaplan-Meier method.

RESULTS

Of 178 patients with RCC identified between 2005 and 2015, 23% (n = 41) had nccRCC and 8% (n = 15) had scRCC. Twenty-five patients in total had de novo metastatic disease or disease recurrence. The median follow-up was 46 and 16 months for nccRCC and scRCC, respectively. The median overall survival for nccRCC with metastatic disease was 34 months (range, 14 months to not reached). Seventy percent of these patients received systemic therapy. By contrast, the median overall survival for scRCC with metastatic disease was 10 months (range, 1.6-89 months). Less than one-half of the patients with scRCC received systemic therapy in our cohort, with only 34% receiving no more than 1 line of treatment.

CONCLUSIONS

Our data confirm the rapid and aggressive course of scRCC, highlighting the need for more effective therapeutic strategies in this rare patient population.

Patterns of adjuvant therapy use and survival outcomes in patients with rectal cancer not receiving neoadjuvant therapy in an Australian cohort

675

Background: Consensus international guidelines recommend the use of neoadjuvant chemo-radiotherapy in patients with stage II-III rectal cancer. Despite this, due to factors including inaccurate/under-staging, patient co-morbidities and acute presentations, a proportion will undergo up-front surgical resection. The survival benefit of adjuvant therapy is unclear in this real world, non-trial population. Methods: A retrospective analysis of patients presenting with stage II-III rectal adenocarcinoma in South Western Sydney and Illawarra Shoalhaven Health Districts, Australia, between 2006 to 2015 was performed. Data was extracted from electronic health records, with institutional ethics approval. Treatment modalities, clinicopathological, recurrence and survival data were analyzed. The primary endpoint was overall survival (OS) by treatment modality. Results: 549 patients were identified, of which 295 (54%) underwent up-front surgical resection without neoadjuvant therapy. Of this cohort, 137 (46%) had no adjuvant therapy (Group A), 103 (35%) had adjuvant chemotherapy alone (Group B), and 55 (19%) had adjuvant radiotherapy +/- chemotherapy (Group C). Receipt of any adjuvant treatment was significantly associated with improved OS (5 year OS 56 vs. 79%, HR 0.44, 95% CI 0.3 – 0.6, p < 0.0001) and recurrence free survival (5 yr RFS 25% vs. 47%, HR 0.66, 95% CI 0.5 – 0.9, p=0.01), but not cancer specific survival (5yr CSS 75 vs. 80%, HR 0.78, 95% CI 0.5 – 1.3, p = 0.30). Group B had improved OS compared to Group A (5 yr OS 56% vs. 80%, HR 0.35, 95% CI 0.22 – 0.55, p < 0.0001). There was a trend to improved OS in Group C vs. Group A (5yr OS 56.0% vs. 69.2%, HR 0.79 95% CI 0.6 – 1.01, p = 0.052). The improved OS in Group B versus Group A remained significant in multivariate analysis (HR 0.41, 95% CI 0.22 – 0.77, p = 0.005). Conclusions: Adjuvant chemotherapy improved OS in this real world cohort, and there was a trend to a benefit with adjuvant chemo-radiotherapy. However, the lack of difference in cancer specific survival suggests that this benefit may be partly driven by patient selection bias. Further exploratory analyses to identify sub-groups deriving a cancer specific survival benefit are required.

Rectal cancer treatment and outcomes in elderly patients treated with curative intent

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Background: There is limited information on outcomes in elderly patients with rectal cancer as they are often excluded from clinical trials. This study aimed to assess treatment patterns and outcomes in these patients. Methods: We utilised data from electronic records to identify patients aged ≥ 70 years with a histological diagnosis of rectal cancer from 2006-2015, treated in the South Western Sydney and Illawarra Shoalhaven Local Health Districts, Australia. Treatment modalities, recurrence and survival data were analysed. Results: We identified 942 patients with rectal cancer, with median follow-up of 3.4 years. 393 patients (42%) were aged ≥ 70 years. Median age of this cohort was 77 years (range 70–96 years). Elderly patients were more likely to present with locoregional disease (stage I-III, 83% vs. 75%) and more likely to receive palliative treatment only (21% vs. 16%, p = 0.0005). Of 704 patients who received treatment with curative intent, 300 (43%) were ≥ 70 years. Although clinicopathological features were similar between elderly and young patients, patients ≥ 70 years were more likely to be treated with surgery alone (56% vs. 28%, p < 0.0001), less likely to receive neoadjuvant (25% vs. 44%, p < 0.0001) or adjuvant treatments (29% vs. 55%, p < 0.0001), or be discussed in a multidisciplinary meeting (51% vs. 61%, p = 0.001). Compared to younger patients, elderly patients had a significantly poorer overall survival (HR 2.9, 95% CI 2.2 – 3.7, p < 0.0001). There were no significant differences in cancer specific survival (HR 1.4, 95% CI 0.98 – 2.0, p = 0.06) or relapse free survival (HR 0.92, 95% CI 0.7 – 1.2, p = 0.60). Conclusions: Although more elderly patients were treated with palliative intent compared to younger patients, the majority of elderly rectal cancer patients were still treated with curative intent. Most had surgery alone. Uptake of neoadjuvant and adjuvant therapy, as well as multidisciplinary involvement, was lower. Elderly patients had similar cancer-specific outcomes compared to younger patients, supporting curative intent treatment in these patients. Further analyses are underway to identify subgroups in the elderly population who benefit from trimodality therapy, and potential differences in their disease biology.

A Study of a Caucasian Family with Variant von Willebrand’s Disease in Association with Vascular Telangiectasia and Haemoglobinopathy

A family was identified which carries multi-haematological disorders including Type IIA von Willebrand’s disease, vascular telangiectasia, and a haemoglobinopathy (haemoglobin S trait). In the affected individuals, the von Willebrand’s disease varies in its expression from an asymptomatic form to a severe form especially in those patients with telangiectasia. Some patients have vascular telangiectasia in the mucous membranes of the mouth and lips. In two patients endoscopy disclosed telangiectasia in the mucous membranes of the gastrointestinal tract. All of the patients who had telangiectasia also had von Willebrand’s disease. An incidental finding was the presence of an abnormal haemoglobin (haemoglobin S) in some family members. The pattern of inheritance of the haemoglobinopathy was unrelated to the inheritance pattern of von Willebrand’s disease. The presence of haemoglobin S did not interfere with the aggregation of platelets in response to ristocetin.

Clinical outcomes in patients with advanced epidermal growth factor receptor-mutated non-small-cell lung cancer in South Western Sydney Local Health District

BACKGROUND

Epidermal growth factor receptor (EGFR)-mutated non-small-cell lung cancer (NSCLC) is a subgroup of oncogene addicted lung cancer that predicts response to tyrosine kinase inhibitors (TKI). However, there is variability in response and survival outcomes in patients with EGFR mutation treated with TKI.

AIM

To describe clinical characteristics, treatment patterns and factors influencing outcomes in patients with EGFR-mutated NSCLC in South Western Sydney Local Health District.

METHODS

Retrospective review of patients with EGFR-mutated NSCLC diagnosed between January 2010 and June 2016.

RESULTS

A total of 85 EGFR-mutated NSCLC patients was identified; 80 (94%) received first-line treatment with EGFR-TKI. The median follow-up was 10.7 months with a median duration of treatment of 9 months. On disease progression (n = 44), 37% had best supportive care only, 30% received chemotherapy, 23% participated in clinical trials, 7% continued on a first generation EGFR-TKI and 3% received afatinib. Overall response rate to first-line EGFR-TKI was 66%. Median progression-free survival (PFS) was 10.7 months (range 2.7-55.9 months) and median overall survival (OS) was 23 months (range 0.4-35.8 months). Multivariate Cox regression analysis showed that patients with lower disease burden (<4 sites) had longer PFS (hazard ratio (HR) 0.36, 95% confidence interval (CI) 0.18-0.72, P = 0.004) but not OS. Good performance status predicts longer OS (HR 0.33, CI 0.14-0.77, P = 0.01). Lower (<5) pre-treatment neutrophil-to-lymphocyte ratio (NLR) was associated with better PFS (HR 0.40, 95% CI 0.18-0.87, P = 0.02) and OS (HR 0.43, 95% CI 0.19-0.94, P = 0.04). There were no survival differences when patients were stratified by age, baseline albumin level and types of EGFR mutation.

CONCLUSION

Results from this community-based cohort confirm known prognostic factors in patients with EGFR-mutated NSCLC receiving TKI and suggest the negative influence of a heightened host systemic inflammatory response on patient outcomes.

Serum microRNA expression during neoadjuvant chemoradiation for rectal cancer

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Background: Changes in microRNA (miRNA) expression during treatment for locally advanced rectal cancer (LARC) may provide insight into disease biology and potentially act as predictive biomarkers. We investigated 112 miRNAs in serum during neoadjuvant chemoradiation for LARC. Methods: Serum was collected at baseline, week 3 and at completion of chemoradiation from 40 prospectively recruited patients with LARC. Responders were classed as tumour regression grade (AJCC classification) 0 or 1 and non-responders as 2 or 3. Serum was also collected from 20 healthy controls. RNA extraction was performed using the Norgen total RNA purification kit. Reverse transcription and pre-amplification were performed according to Taqman OpenArray MicroRNA Panels manufacturer's instructions. QuantStudio12K platform was used for miRNA array qPCR. The delta-delta-Ct method was used to identifiy differentially expressed miRNAs, normalised against U6 snRNA. Analysis was performed in R using paired t-statistics and the Benjamini-Hochberg False Discovery Rate for multiple hypothesis testing adjustment, with q < 0.05 for significance. Enriched KEGG pathways were identified using DIANA, based on verified gene targets of each miRNA from Tarbase. Results: Four miRNAs (miR-125b-1, miR-1183, miR-130a, miR-375) were differentially expressed in baseline patient samples compared to controls. From baseline to completion of treatment, three of these - miR-125b-1, miR-1183, miR-130a were downregulated by more than 2-fold. Comparing responders and non-responders, miR-130a was significantly downregulated in the non-responders only. Conclusions: miR-125b-1, miR-1183 and miR-130a are significantly downregulated in patients with LARC during chemoradiation. These miRNAs are known to target key colorectal cancer genes such as ATM and CHEK1, which have been implicated in chemoradiation resistance. miR-130a warrants further investigation as a predictive biomarker, being downregulated in patients with a poor response to therapy. Work is ongoing, investigating these miRNA targets in the solid tissue in these patients. To our knowledge, this is the first study to profile potentially predictive miRNA changes during chemoradiation in LARC.

CTC-mRNA (AR-V7) Analysis from Blood Samples-Impact of Blood Collection Tube and Storage Time

Circulating tumour cells (CTCs) are an emerging resource for monitoring cancer biomarkers. New technologies for CTC isolation and biomarker detection are increasingly sensitive, however, the ideal blood storage conditions to preserve CTC-specific mRNA biomarkers remains undetermined. Here we tested the preservation of tumour cells and CTC-mRNA over time in common anticoagulant ethylene-diamine-tetra-acetic acid (EDTA) and acid citrate dextrose solution B (Citrate) blood tubes compared to preservative-containing blood tubes. Blood samples spiked with prostate cancer cells were processed after 0, 24, 30, and 48 h storage at room temperature. The tumour cell isolation efficiency and the mRNA levels of the prostate cancer biomarkers androgen receptor variant 7 (AR-V7) and total AR, as well as epithelial cell adhesion molecule (EpCAM) were measured. Spiked cells were recovered across all storage tube types and times. Surprisingly, tumour mRNA biomarkers were readily detectable after 48 h storage in EDTA and Citrate tubes, but not in preservative-containing tubes. Notably, AR-V7 expression was detected in prostate cancer patient blood samples after 48 h storage in EDTA tubes at room temperature. This important finding presents opportunities for measuring AR-V7 expression from clinical trial patient samples processed within 48 h-a much more feasible timeframe compared to previous recommendations.