Consensus statement: the 16th Annual Western Canadian Gastrointestinal Cancer Consensus Conference; Saskatoon, Saskatchewan; September 5-6, 2014

The 16th annual Western Canadian Gastrointestinal Cancer Consensus Conference was held in Saskatoon, Saskatchewan, September 4-5, 2014. The Consensus Conference is an interactive, multidisciplinary event attended by health care professionals from across western Canada (British Columbia, Alberta, Saskatchewan, and Manitoba) involved in the care of gastrointestinal cancer. Surgical, medical, and radiation oncologists; pathologists; radiologists; and allied health care professionals participated in presentation and discussion sessions for the purposes of developing the recommendations presented here. This consensus statement addresses current issues in the management of colorectal cancer.

Potential-based methodology for active sound control in three dimensional settings

This paper extends a potential-based approach to active noise shielding with preservation of wanted sound in three-dimensional settings. The approach, which was described in a previous publication [Lim et al., J. Acoust. Soc. Am. 129(2), 717-725 (2011)], provides several significant advantages over conventional noise control methods. Most significantly, the methodology does not require any information including the characterization of sources, impedance boundary conditions and surrounding medium, and that the methodology automatically differentiates between the wanted and unwanted sound components. The previous publication proved the concept in one-dimensional conditions. In this paper, the approach for more realistic conditions is studied by numerical simulation and experimental validation in three-dimensional cases. The results provide a guideline to the implementation of the active shielding method with practical three-dimensional conditions. Through numerical simulation it is demonstrated that while leaving the wanted sound unchanged, the developed approach offers selective volumetric noise cancellation within a targeted domain. In addition, the method is implemented in a three-dimensional experiment with a white noise source in a semi-anechoic chamber. The experimental study identifies practical difficulties and limitations in the use of the approach for real applications.

A prospective clinical utility and pharmacoeconomic study of the impact of the 21-gene Recurrence Score® assay in oestrogen receptor positive node negative breast cancer

PURPOSE

The primary purpose of this study was to measure the impact of the 21-gene Recurrence Score® result on systemic treatment recommendations and to perform a prospective health economic analysis in stage I-II, node-negative, oestrogen receptor positive (ER+) breast cancer.

METHODS

Consenting patients with ER+ node negative invasive breast cancer and their treating medial oncologists were asked to complete questionnaires about treatment preferences, level of confidence in those preferences and a decisional conflict scale (patients only) after a discussion of their diagnosis and risk without knowledge of the Recurrence Score. At a subsequent visit, the assay result and final treatment recommendations were discussed prior to both parties completing a second set of questionnaires. A Markov health state transition model was constructed, simulating the costs and outcomes experienced by a hypothetical 'assay naïve' population and an 'assay informed' population.

RESULTS

One hundred and fifty-six patients across two cancer centres were enrolled. Of the 150 for whom successful assay results were obtained, physicians changed their chemotherapy recommendations in 45 cases (30%; 95% confidence interval (CI) 22.8-38.0%); either to add (10%; 95% CI 5.7-16.0%) or omit (20%; 95% CI 13.9-27.3%) adjuvant chemotherapy. There was an overall significant improvement in physician confidence post-assay (p<0.001). Patient decisional conflict also significantly decreased following the assay (p<0.001). The simulation model found an incremental cost-effectiveness ratio of Canadian Dollars (CAD) $6630/quality-adjusted life years (QALY).

CONCLUSION

Within the context of a publicly funded health care system, the Recurrence Score assay significantly affects adjuvant treatment recommendations and is cost effective in ER+ node negative breast cancer.

Impact of nutritional status and dietary quality on stroke: do we need specific recommendations?

Stroke, one of the most prevalent geriatric diseases, is a leading cause of death worldwide that often results in permanent physical disability and decreased quality of life, and can have a negative impact on families both financially and emotionally. Although many previous studies have shown relationships between the risk of stroke and nutritional factors, clear dietary recommendations for the prevention and reduction of stroke recurrence have not been established. Several factors should be considered to control and manage stroke. For example, a considerable number of patients with stroke are poorly nourished, have several comorbidities and undesirable health-related behaviors may be present. Stroke patients are less likely to consume beneficial foods, have poorer eating habits and have impoverished dietary quality. In addition, psychological factors such as depression must also be considered in stroke management. Given these factors, dietary recommendations for stroke patients should be established. In this article, we summarized the nutritional status and dietary quality of stroke patients. We also suggested some nutritional guidelines for stroke patients and for those who are at risk for stroke.

Slewing Mirror Telescope optics for the early observation of UV/optical photons from Gamma-Ray Bursts

We report on design, manufacture, and testing of a Slewing Mirror Telescope (SMT), the first of its kind and a part of Ultra-Fast Flash Observatory-pathfinder (UFFO-p) for space-based prompt measurement of early UV/optical light curves from Gamma-Ray Bursts (GRBs). Using a fast slewing mirror of 150 mm diameter mounted on a 2 axis gimbal stage, SMT can deliver the images of GRB optical counterparts to the intensified CCD detector within 1.5~1.8 s over ± 35 degrees in the slewing field of view. Its Ritchey-Chrétien telescope of 100 mm diameter provides a 17 × 17 arcmin² instantaneous field of view. Technical details of design, construction, the laboratory performance tests in space environments for this unique SMT are described in conjunction with the plan for in-orbit operation onboard the Lomonosov satellite in 2013.

Measurement of direct photons in Au+Au collisions at √(s(NN))=200 GeV

We report the measurement of direct photons at midrapidity in Au+Au collisions at √(s(NN))=200 GeV. The direct photon signal was extracted for the transverse momentum range of 4 GeV/c<p(T)<22 GeV/c, using a statistical method to subtract decay photons from the inclusive photon sample. The direct photon nuclear modification factor R(AA) was calculated as a function of p(T) for different Au+Au collision centralities using the measured p+p direct photon spectrum and compared to theoretical predictions. R(AA) was found to be consistent with unity for all centralities over the entire measured p(T) range. Theoretical models that account for modifications of initial direct photon production due to modified parton distribution functions in Au and the different isospin composition of the nuclei predict a modest change of R(AA) from unity. They are consistent with the data. Models with compensating effects of the quark-gluon plasma on high-energy photons, such as suppression of jet-fragmentation photons and induced-photon bremsstrahlung from partons traversing the medium, are also consistent with this measurement.

Hepatic embolotherapy in interventional oncology: technology, techniques, and applications

Embolotherapy continues to play a growing role in the management of primary and secondary hepatic malignancies. In this review article, we examine the basis of therapy with a focus on neovascularization, which makes treatments via the hepatic artery possible. An overview of the three generations of embolic and therapeutic agents follows. The techniques, technologies, and complications of bland embolization, transarterial chemoembolization, drug-eluting beads, and selective internal radiotherapy are covered to give the reader an overview of this exciting field in interventional radiology.

Lenalidomide enhancement of human T cell functions in human immunodeficiency virus (HIV)-infected and HIV-negative CD4 T lymphocytopenic patients

Suppressed T cell functions in human immunodeficiency virus (HIV) infection were identified and corrected by lenalidomide in middle-aged HIV-infected patients. Chemotaxis of T cells from HIV-infected men (n = 6, mean 43 years) to sphingosine 1-phosphate (S1P) and CCL21 was significantly lower than that of HIV-negative men (n = 6, mean 41 years), and was enhanced significantly up to control levels by 100 and 1000 nM lenalidomide. Generation of interleukin (IL)-2, but not interferon (IFN)-γ, by T cells of middle-aged HIV-infected men was significantly lower than that for controls and was increased significantly by 10-1000 nM lenalidomide up to a maximum of more than 300%. CD4 and CD8 T cells isolated from healthy middle-aged men and reconstituted in vitro at a low CD4 : CD8 ratio typical of HIV infection had depressed chemotaxis to S1P, but not CCL21, and generation of IL-2, but not IFN-γ. Significant enhancement of chemotaxis to S1P and CCL21 was induced by 100-1000 nM lenalidomide only for normal T cells at a low CD4 : CD8 ratio. T cells from HIV-negative middle-aged CD4 T lymphocytopenic patients (n = 3), with a CD4 : CD8 ratio as low as that of HIV-infected patients, had similarly diminished chemotaxis to S1P and CCL21, and depressed generation of IL-2, but not IFN-γ. Lenalidomide at 30-1000 nM significantly enhanced chemotaxis to S1P and IL-2 generation for T cells from HIV-negative CD4 T lymphocytopenic patients as from HIV-infected patients, with less effect on CCL21-elicited chemotaxis and none for IFN-γ generation. Defects in functions of T cells from middle-aged HIV-infected men are partially attributable to CD4 T lymphocytopenia and are corrected by lenalidomide.

P1-08-15: Pattern of Cardiac Monitoring and Risk of Trastuzumab Associated-Cardiac Dysfunction in a Clinical Practice: A Population Based Study

Background: Adjuvant trastuzumab therapy (ATT) in women with early-stage HER2+ breast cancer has been associated with significant reduction in the disease recurrence and mortality. Cardiac dysfunction (CD) is a known serious adverse effect of ATT. Although periodic cardiac monitoring is recommended during ATT, little is known about pattern of cardiac monitoring and incidence of CD in a clinical setting. The study aimed to determine extent of cardiac monitoring and rate of CD during ATT and to identify factors correlated with CD.

Methods: Medical records of women with localized HER+ breast cancer diagnosed between the years 2005–2007 in the province of Saskatchewan was reviewed. Women with advanced or recurrent disease or if they were treated in the setting of an adjuvant trastuzumab trial were excluded. A logistic regression analysis was performed to determine various clinical variables correlated with CD.

Results: A total 116 eligible women with median age of 54 yrs (range: 27–74) and median BMI of 27 (range: 44–17) were indentified. 40% had a cardiac risk factor & 30% were premenopausal. 51% had node positive & 53% had ER or PR+ breast cancer. 92% received anthracycline-based chemotherapy and 23% received sequential ATT. Of 62 patients with ER/PR+ breast cancer, 61% received adjuvant aromatase inhibitors. Baseline cardiac assessment was performed in 93% women. 98% women underwent periodic cardiac monitoring during ATT, 55% had monitoring performed at the interval of 3–4 months & 82% women had monitoring performed at the interval of 3–6 months. Mean baseline cardiac ejection fraction (EF%) prior to the commencement of chemotherapy and ATT were 65% & 63.9% respectively (p=NS). CD was observed in 32 (28%) women and only 4% were symptomatic. Trastuzumab was interrupted in 34%, and was discontinued in 20% women. Of 32 women with CD, 59% were referred to a cardiologist and 53% were treated with medication. CD was reversible in 84% cases. On multivariate analysis adjuvant aromatase inhibitor therapy was significantly correlated with cardiac dysfunction (Odd ratio 6.9 [95% CI: 1.4−33.0]). During the follow up period 18% women developed recurrent disease and 16% were died.

Conclusions: Our results confirm high compliance with cardiac monitoring, though not as frequently as recommended in the clinical trial setting. Overall the rate of symptomatic decline in cardiac function was similar to the rate reported in the clinical trials, however, a relatively higher incidence of asymptomatic decline in the left ventricle EF% was noted. Among various variables examined, adjuvant aromatase inhibitor therapy was associated with an increased risk of CD.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P1-08-15.

P1-17-05: Preliminary Results of a Randomized Phase 2 Study of PD 0332991, a Cyclin-Dependent Kinase (CDK) 4/6 Inhibitor, in Combination with Letrozole for First-Line Treatment of Patients (pts) with Post-Menopausal, ER+, HER2−Negative (HER2–) Advanced Breast Cancer

Background: PD 0332991 is an orally bioavailable selective inhibitor of CDK 4/6 and prevents cellular DNA synthesis by prohibiting progression of the cell cycle from G1 into the S phase. Preclinical evaluations suggest that reduction in CDKN2A (p16) expression and cyclin D1 (CCND1) overexpression confer susceptibility to PD 0332991 (Finn 2009). In addition, PD 0332991 was synergistic in combination with tamoxifen in vitro in ER+ human breast cancer cell lines. Based on these observations, a phase 1/2 study in combination with letrozole as first-line therapy for advanced ER+ post-menopausal breast cancer was initiated. The phase 1 part of the study (completed) determined the recommended phase 2 dose to be PD 0332991 125 mg QD on Schedule 3/1 (3 weeks on treatment followed by 1-week off treatment) in combination with letrozole 2.5 mg QD. The combination was generally well tolerated and encouraging antitumor activity was observed. We present preliminary data from the randomized Phase 2 portion comparing letrozole alone to letrozole plus PD 0332991.

Methods: The Phase 2 portion of the study is designed as a two-part study; we present data from Part 1. In both parts, eligible patients are randomized 1:1 to letrozole 2.5 mg QD alone (control) or PD 0332991 125 mg QD on schedule 3/1 and letrozole 2.5 mg QD (treatment, tx). Part 1enrolled post-menopausal women with ER+, HER2− cancer using only ER+, HER2−as a selection criteria. Part 2 is now enrolling post-menopausal women with ER+, HER2− breast cancer with CCND1 amplification and/or loss of p16 by FISH (target N=150). The primary endpoint is progression-free survival (PFS); secondary endpoints include overall survival, response rate, safety, and correlative studies. Pts are stratified for disease site and length from prior adjuvant therapy. Pts continue assigned study treatment until disease progression, unacceptable toxicity, or consent withdrawal and are followed every 2 months to assess disease status. Tumor tissue was required for participation.

Results: 66 patients have been randomized in Part 1. At the time of data cut-off (April 2011) median duration of treatment is 20 (range 4–64) wks for control and 27 (2-59) wks for tx. Dose reductions occurred in 9 pts on the tx arm and none on the control arm. There are no complete responses. The number of partial responses for pts with measurable disease are similar between arms (4/22 control vs 5/24 in tx). The number of pts with stable disease&gt; 24 weeks was higher in the tx arm (5 vs 8). The number of pts with best response of progressive disease is lower in the treatment arm (2 vs 6). PFS data are immature. Twelve pts remain on control vs. 21 on tx. As in the Phase I portion of the study, the most common treatment-related AEs were neutropenia and leucopenia without febrile neutropenia. Biomarker studies for CCND1 amplification, p16 loss, RB status, and Ki67 are ongoing.

Conclusion: The combination of PD 0332991 and letrozole is well tolerated as first-line treatment of ER+, HER2− post-menopausal breast cancer. Updated efficacy data and biomarker data will be presented.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P1-17-05.

Phase II study of a polyethoxylated castor oil–free, polymeric micelle formulation of paclitaxel for patients with advanced urothelial cancer previously treated with gemcitabine and platinum

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Background: Paclitaxel-loaded polymeric micelle (Genexol-PM; G-PM) is a novel polyethoxylated castor oil (Cremophor EL [CrEL])-free formulation of paclitaxel. This multicenter phase II study was designed to evaluate the efficacy and safety of the G-PM monotherapy for the treatment of gemcitabine- and cisplatin-refractory advanced urothelial cancer.

Methods: Patients with advanced urothelial cancer received G-PM 240 mg/m2 intravenously over 3 hours every 3 weeks without premedication as salvage chemotherapy after failure to gemcitabine and cisplatin combination chemotherapy. Intrapatient dose escalation of G-PM to 300 mg/m2 was carried out from the second cycle if the prespecified toxicities were not observed after the first cycle.

Results: Thirty-seven patients were enrolled in this study. Platinum-free interval was less than 6 months in 72% of patients and 64% of patients were categorized into intermediate or poor prognostic group. Overall response rate was 19% including one complete response. When response occurs it is long lasting with a median response duration of 7.8 months (range 1.5∼19.3+). The median progression-free survival was 2.7 months (95% CI, 09-4.6) with a median overall survival of 5.7 months (95% CI, 3.1-8.3). The most common major grade 3-4 non-hematologic toxicity was peripheral neuropathy (sensory type 5.6% and motor type 8.3%) followed by infection (5.6%). Grade 3 or worse hematologic toxicities were observed in only one patient.

Conclusions: G-PM showed modest activity with favorable toxicity profiles when used as salvage therapy after gemcitabine-cisplatin failure in advanced urothelial cancer.

No significant financial relationships to disclose.

Multicenter prospective phase II study of sunitinib in non-clear cell type renal cell carcinoma

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Background: Sunitinib has been shown to produce a high response rate (RR), and improved progression-free survival (PFS) in patients (pts) with clear cell RCC. Retrospective data suggest sunitinib may be effective in papillary and chromophobe RCC. We conducted a multicenter phase II trial of sunitinib in non-clear cell RCC (nccRCC).

Methods: Eligibility criteria included PS 0-1, measurable disease, and adequate organ function. Pts with brain metastases were not excluded if controlled without steroid dependence. Response assessment was performed every 6 weeks. Primary endpoint was RR. Secondary endpoints were TTP, safety and OS.

Results: Between 6/2008 and 7/2010, 29 pts with nccRCC were enrolled (total accrual 35: P0=5%, P1=20%, alpha=0.05, beta=0.2, drop-out rate 15%). Median age was 52 (18–76). Twenty-four pts (84%) had prior nephrectomy. Seven pts (24%) had poor risk and 13 (45%) had intermediate risk disease by MSKCC criteria. Twenty-one pts had papillary RCC (type II in 11 and type not- specified in 10), and 4 patients had chromophobe RCC. Two pts discontinued protocol treatment due to toxicity prior to completion of cycle 1 (one pt had cardiogenic shock 27 days after start of therapy and the other refused further treatment 5 days after therapy). Eleven pts out of 29 had partial response with a RR of 38% (95% CI, 20.2%–55.6%) and additional 15 patients (52%) had SD with a disease control rate of 90%. Response rates were not significantly different according to the histologic type (43% in papillary type and 25% in chromophobe type). Median duration of response was 12.7 months (95% CI, 2.3∼23.1) and median TTP was 6.4 months (95% CI, 4.5∼8.3). With a median FU duration of 16 months (95% CI, 8.6∼23.4), 10 pts have been dead resulting in an estimated median OS of 17.9 months. Toxicity profiles were commensurate with prior reports on Korean patients (Yoo, et al. Jpn J Clin Oncol 2010). However, there was one treatment-related death caused by acute heart failure in patient without relevant risk factors for heart disease.

Conclusions: Although our study is ongoing, the primary endpoint has been met and these data suggest that suntinib has promising activity in patients with nccRCC.

No significant financial relationships to disclose.