A phase I trial of cabozantinib (XL184) and gemcitabine in advanced pancreatic cancer

334

Background: Hepatocyte growth factor (HGF) and its receptor (c-Met) are activated in pancreatic ductal adenocarcinoma (PDAC). Preclinical data showed a combination of cabozantinib (cabo) and gemcitabine (gem) improved tumor control through inhibition of c-Met. We sought to determine the maximum tolerated dose (MTD) of cabo and gem in patients with advanced PDAC. Methods: Patients with unresectable or metastatic PDAC with ≤1 prior treatment and adequate organ function/performance status were eligible. Cabo was given orally once daily for 7 days and continued with gem infused IV over 30 min on days 1, 8, and 15 of a 28 day schedule. Doses were assigned in accordance with a Time to Event Continual Reassessment Method (TITE-CRM) per table below. Primary endpoint was MTD, defined as the highest dose level at which ≤25% of patients incurred a dose-limiting toxicity (DLT) in the first 35 days of therapy. Secondary endpoints included response rate, progression-free survival (PFS), and overall survival (OS). Results: Twelve patients were treated from July 2012 – May 2015. Median number of cycles given was 3 (range: 1-6). MTD was not determined. The probability of DLT was >25% for all dose levels attempted. Four of 10 evaluable patients experienced DLT (shown in table below), including grade 3 ALT/AST elevations (n=3) and thrombocytopenia (n=2). Five of 6 patients who continued therapy beyond cycle 2 incurred at least one grade 3 adverse event. Three patients had a partial response, but each discontinued therapy due to toxicity. Median PFS and OS were 4.7 (95% CI: 1.4 – 9.7) and 10.1 months (95% CI: 3.6 – 20.6), respectively, in treated patients. Conclusions: While the combination of cabo and gem demonstrated activity in PDAC, this regimen is impractical due to DLT at low doses and continuing toxicities despite dose reductions and schedule changes. Clinical trial information: NCT01663272. [Table: see text]

Development of a new photonumeric scale for acute radiation dermatitis in patients with breast cancer

86

Background: The Common Terminology Criteria for Adverse Events (CTCAE) is frequently used to grade the severity of acute radiation dermatitis (ARD), but has not been validated despite decades of clinical use. We sought to develop a photonumeric scale to consistently describe ARD in breast cancer patients undergoing radiation (RT). Methods: Patients enrolled on a prospective study that included photographs and quantitative measurements of erythema and hyperpigmentation using colorimetry. 209 photographs from 35 patients with white skin and 369 photographs from 50 patients with skin of color were used to develop two photonumeric scales. Predominant erythema (in white skin) OR hyperpigmentation (in skin of color) were rated on a 4 point scale, with grading of desquamation on a separate 3 point scale. Four raters used both CTCAE and photonumeric scales to independently score all photographs. Intra- and inter-rater agreements were assessed using weighted kappa scores. Results: Using the CTCAE, 95% of photos were rated as grade 1 or 2. There was a trend toward higher grade in patients with skin of color, with grade 2 toxicity in 43% vs. 24%. Intra-rater agreement for CTCAE ratings was 65—87% (kappa 0.34—0.67), with a wide range of inter-rater agreement (56—81% agreement fraction, kappa 0.04—0.58). Using the photonumeric scale, intra-rater agreement was high for erythema/hyperpigmentation in patients with white skin (74—82%, kappa 0.49—0.70) and skin of color (69—86%, kappa 0.55—0.79), along with desquamation (78—87%, kappa 0.52—0.66). There was moderate inter-rater agreement for erythema/hyperpigmentation (51—82%, kappa 0.15—0.71) and desquamation (63—88%, kappa 0.36—0.58). Colorimetric measurements correlated strongly with photonumeric grade. Conclusions: We report a new photonumeric scale for ARD in breast cancer patients with satisfactory reliability across the spectrum of skin pigmentation. Intra-physician ratings were consistent, with moderate inter-physician agreement. The CTCAE functions as a binary scale, with 95% of ARD rated as grade 1 or 2 toxicity. Future work includes correlation with patient-reported outcomes and physician ratings at the point-of-care. Funded by a Munn Idea Grant (G011480).

Oncologists' Experiences and Attitudes About Their Role in Philanthropy and Soliciting Donations From Grateful Patients

PURPOSE

Physician participation in philanthropy is important to marshal resources that allow hospitals to pursue their missions, but little is known about how physicians participate and their attitudes toward participation.

METHODS

To characterize philanthropic roles physicians play and their attitudes about participation and its ethical acceptability, medical oncologists affiliated with the 40 National Cancer Institute-designated comprehensive cancer centers were randomly sampled and surveyed to evaluate experiences and attitudes regarding participation in philanthropy at their institutions. Responses were tabulated; significant associations by physicians' characteristics were explored.

RESULTS

A total of 405 (52%) physicians responded; 62% were men, and 72% were white. Most (71%) had been exposed to their institution's fundraising/development staff; 48% of those were taught how to identify patients who would be good donors; 26% received information about ethical guidelines for soliciting donations from their patients; 21% were taught how their institution ensures Health Insurance Portability and Accountability Act compliance. A third (32%) of respondents had been asked to directly solicit a donation from their patients for their institution, of whom half declined to do so. Those who had solicited from their patients had been in practice significantly longer (mean, 19 v 13 years; P < .001). A substantial minority (37%) felt comfortable talking to their patients about donation (men more than women, 43% v 26%; P = .008); however, 74% agreed it could interfere with the physician-patient relationship, and 52% believe conflict of interest exists.

CONCLUSION

Institutions are asking physicians to directly solicit their patients for donations with variability in physicians' perceptions of the impact on relationships with patients and responses toward those requests.

Glycogen Synthase Kinase 3 Beta Predicts Survival in Resected Adenocarcinoma of the Pancreas

PURPOSE

GSK3β is a protein kinase that can suppress a number of key oncoproteins. We have previously shown in preclinical models of pancreatic ductal adenocarcinoma (PDAC) that inhibition of GSK3β causes stabilization and nuclear translocation of β-catenin, poor differentiation, proliferation, and resistance to radiation. The objective of this study was to determine its utility as a biomarker of clinical outcomes.

EXPERIMENTAL DESIGN

Automated Quantitative Immunofluorescence Analysis (AQUA) of GSK3β was performed on a tissue microarray with samples from 163 patients treated on RTOG 9704. On the basis of findings in an exploratory cohort, GSK3β was analyzed as a categorical variable using its upper quartile (>Q3) as a cut point. Overall survival (OS) and disease-free survival (DFS) were estimated with the Kaplan-Meier method, and GSK3β groupings were compared using the log-rank test. Univariable and multivariable Cox proportional hazards models were used to determine associations between GSK3β and OS/DFS.

RESULTS

The 3-year OS rates for GSK3β≤Q3 versus GSK3β >Q3 were 16% (95% confidence intervals; CI, 10%-23%) and 30% (95% CI, 17%-44%), respectively, P = 0.0082. The 3-year DFS rates were 9% (95% CI, 5%-15%) and 20% (95% CI, 9%-33%) respectively, P value = 0.0081. On multivariable analysis, GSK3β was a significant predictor of OS. Patients with GSK3β >Q3 had a 46% reduced risk of dying of pancreatic cancer (HR, 0.54; 95% CI, 0.31-0.96, P value = 0.034). The HR for DFS was 0.65 (95% CI, 0.39-1.07; P value = 0.092).

CONCLUSIONS

GSK3β expression is a strong prognosticator in PDAC, independent of other known factors such as tumor (T) stage, nodal status, surgical margins and CA19-9. Clin Cancer Res; 21(24); 5612-8. ©2015 AACR.

Caveolin-1 is Associated with Tumor Progression and Confers a Multi-Modality Resistance Phenotype in Pancreatic Cancer

Caveolin-1 (Cav-1) is a 21 kDa protein enriched in caveolae, and has been implicated in oncogenic cell transformation, tumorigenesis, and metastasis. We explored roles for Cav-1 in pancreatic cancer (PC) prognostication, tumor progression, resistance to therapy, and whether targeted downregulation could lead to therapeutic sensitization. Cav-1 expression was assessed in cell lines, mouse models, and patient samples, and knocked down in order to compare changes in proliferation, invasion, migration, response to chemotherapy and radiation, and tumor growth. We found Cav-1 is overexpressed in human PC cell lines, mouse models, and human pancreatic tumors, and is associated with worse tumor grade and clinical outcomes. In PC cell lines, disruption/depletion of caveolae/Cav-1 reduces proliferation, colony formation, and invasion. Radiation and chemotherapy up-regulate Cav-1 expression, while Cav-1 depletion induces both chemosensitization and radiosensitization through altered apoptotic and DNA repair signaling. In vivo, Cav-1 depletion significantly attenuates tumor initiation and growth. Finally, Cav-1 depletion leads to altered JAK/STAT, JNK, and Src signaling in PC cells. Together, higher Cav-1 expression is correlated with worse outcomes, is essential for tumor growth and invasion (both in vitro and in vivo), is responsible for promoting resistance to therapies, and may serve as a prognostic/predictive biomarker and target in PC.

Wide Variation in the Diffusion of a New Technology: Practice-Based Trends in Intensity-Modulated Radiation Therapy (IMRT) Use in the State of Michigan, With Implications for IMRT Use Nationally

IMRT use grew significantly across the state of Michigan over time, with four-fold variability among centers, which was related to facility characteristics.

Abstract P1-15-01: Association between ischemic cardiac events and targeting of the internal mammary nodal region with adjuvant radiation for breast cancer

Background: Cardiac toxicity has been well documented following adjuvant breast cancer radiation therapy (RT) using outdated treatment methods. Limited information exists, however, regarding cardiac outcomes following contemporary RT fields and techniques. Inclusion of the internal mammary nodal (IMN) field for appropriately selected patients with breast cancer coincided with our department’s transition to computed-tomography (CT) based planning. The objectives of this study, therefore, were to assess the risk of ischemic cardiac events following IMN irradiation and to assess the risks following CT-based versus two-dimensional (2D) planning.

Methods: All patients treated with adjuvant RT for breast cancer and without history of additional chest RT from January 1, 1984 – December 31, 2007 in our department were assessed. CT planning for breast cancer began for select patients in 1997 and was used for all patients as of 2001. The inclusion of the IMN region was determined by review of our clinical database. Ischemic cardiac endpoints were defined as myocardial infarction, coronary artery bypass grafting procedure, angioplasty/stent placement, and/or diagnosis of coronary artery disease. A text-based and diagnosis code-based search was used to flag possible endpoints which were then confirmed by manual chart review. Hypertension (HTN), diabetes (DM), hyperlipidemia (HLD), and anthracycline use were identified by a diagnosis code-based search.

Results: We identified 2,126 patients who received adjuvant RT. Median follow-up was 9.6 years. 311 (14.6%) patients had IMNs targeted and 1,813 (85.3%) did not (data not available for 2 patients). RT to the IMNs was not associated with a higher risk of ischemic cardiac events (HR: 0.88, P = 0.731). 1,072 (50.4%) patients had CT planning, 1,003 (47.2%) had 2D planning, and no information was available for 51 (2.4%) patients. Overall, there were 56 (5.6%) ischemic events in the 2D cohort and 27 (2.5%) in the CT cohort. After truncating follow-up to 10 years to account for differential potential follow-up, there were 28 (2.8%) and 23 (2.2%) ischemic cardiac events, respectively. The table lists the association of patient and treatment characteristics and risk of ischemic cardiac events. HTN, HLD, and DM were each associated with a significantly increased risk of ischemic cardiac events.

Conclusions: After reviewing all patients treated in our department for breast cancer from 1984 – 2007, we were unable to find an association between IMN irradiation and ischemic cardiac events. CT-based planning has been shown to allow accurate targeting of the IMNs. These data suggest that even with inclusion of the IMNs, CT-based planning minimizes dose to the heart and coronary arteries thereby decreasing the risk of ischemic cardiac toxicity. These results will be followed with time.

Association between characteristics and ischemic cardiac eventsCharacteristicHazard Ratio95% Confidence IntervalP-valueRT to the IMNs0.880.42-1.830.7312D vs. CT planning1.140.68-1.910.613Left vs. right1.210.79-1.850.372Anthracycline use0.750.44-1.260.270HTN5.612.06-15.300.001HLD1.901.25-2.900.003DM3.111.99-4.86&lt;0.001

Citation Format: Adam L Liss, Kent A Griffith, Reshma Jagsi, Jean M Moran, Robin B Marsh, Todd M Koelling, Lori J Pierce. Association between ischemic cardiac events and targeting of the internal mammary nodal region with adjuvant radiation for breast cancer [abstract]. In: Proceedings of the Thirty-Seventh Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2014 Dec 9-13; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2015;75(9 Suppl):Abstract nr P1-15-01.

Doxorubicin plus the IGF-1R antibody cixutumumab in soft tissue sarcoma: a phase I study using the TITE-CRM model

BACKGROUND

Insulin-like growth factor receptor (IGF-1R) has been studied as an oncologic target in soft tissue sarcoma (STS), but its role in sarcoma biology is unclear. Anti-IGF-1R antibody cixutumumab demonstrated acceptable toxicity but limited activity as a single agent in STS. We carried out a dose-escalation study of cixutumumab with doxorubicin to evaluate safety and dosing of the combination.

PATIENTS AND METHODS

Eligible patients with advanced STS were treated with cixutumumab intravenously on days 1/8/15 at one of three dose levels (A: 1 mg/kg, B: 3 mg/kg, C: 6 mg/kg) with doxorubicin at 75 mg/m(2) as a 48 h infusion on day 1 of a 21 day cycle. After six cycles of the combination, patients could receive cixutumumab alone. The Time-to-Event Continual Reassessment Method was used to estimate the probability of dose-limiting toxicity (DLT) and to assign patients to the dose with an estimated probability of DLT≤20%.

RESULTS

Between September 2008 and January 2012, 30 patients with advanced STS received a median of six cycles of therapy (range <1-22). Two DLTs were observed, grade 3 mucositis (dose level B) and grade 4 hyperglycemia (dose level C). Grade 2 and 3 reduced left ventricular ejection fraction was seen in three and two patients, respectively. Five partial responses were observed, and estimated progression-free survival was 5.3 months (95% confidence interval 3.0-6.3) in 26 response-assessable patients. Immunohistochemical staining of 11 available tumor samples for IGF-1R and phospho-IGF-1R was not significantly different among responders and non-responders, and serum analysis of select single-nucleotide polymorphisms did not predict for cardiotoxicity.

CONCLUSION

The maximum tolerated dose was doxorubicin 75 mg/m(2) on day 1 and cixitumumab 6 mg/kg on days 1/8/15 of a 21 day cycle. Cardiac toxicity was observed and should be monitored in subsequent studies, which should be considered in STS only if a predictive biomarker of benefit to anti-IGF-1R therapy is identified.

TRIAL REGISTRATION

ClinicalTrials.gov:NCT00720174.

Concerns about cancer risk and experiences with genetic testing in a diverse population of patients with breast cancer

PURPOSE

To evaluate preferences for and experiences with genetic testing in a diverse cohort of patients with breast cancer identified through population-based registries, with attention to differences by race/ethnicity.

METHODS

We surveyed women diagnosed with nonmetastatic breast cancer from 2005 to 2007, as reported to the SEER registries of metropolitan Los Angeles and Detroit, about experiences with hereditary risk evaluation. Multivariable models evaluated correlates of a strong desire for genetic testing, unmet need for discussion with a health care professional, and receipt of testing.

RESULTS

Among 1,536 patients who completed the survey, 35% expressed strong desire for genetic testing, 28% reported discussing testing with a health care professional, and 19% reported test receipt. Strong desire for testing was more common in younger women, Latinas, and those with family history. Minority patients were significantly more likely to have unmet need for discussion (failure to discuss genetic testing with a health professional when they had a strong desire for testing): odds ratios of 1.68, 2.44, and 7.39 for blacks, English-speaking Latinas, and Spanish-speaking Latinas compared with whites, respectively. Worry in the long-term survivorship period was higher among those with unmet need for discussion (48.7% v 24.9%; P <.001). Patients who received genetic testing were younger, less likely to be black, and more likely to have a family cancer history.

CONCLUSION

Many patients, especially minorities, express a strong desire for genetic testing and may benefit from discussion to clarify risks. Clinicians should discuss genetic risk even with patients they perceive to be at low risk, as this may reduce worry.

A statistical evaluation of dose expansion cohorts in phase I clinical trials

BACKGROUND

Phase I trials often include a dose expansion cohort (DEC), in which additional patients are treated at the estimated maximum tolerated dose (MTD) after dose escalation, with the goal of ensuring that data are available from more than six patients at a single dose level. However, protocols do not always detail how, or even if, the additional toxicity data will be used to reanalyze the MTD or whether observed toxicity in the DEC will warrant changing the assigned dose. A DEC strategy has not been statistically justified.

METHODS

We conducted a simulation study of two phase I designs: the "3+3" and the Continual Reassessment Method (CRM). We quantified how many patients are assigned the true MTD using a 10 to 20 patient DEC and how a sensible reanalysis using the DEC changes the probability of selecting the true MTD. We compared these results with those from an equivalently sized larger CRM that does not include a DEC.

RESULTS

With either the 3+3 or CRM, reanalysis with the DEC increased the probability of identifying the true MTD. However, a large CRM without a DEC was more likely to identify the true MTD while still treating 10 or 15 patients at this dose level.

CONCLUSIONS

Where feasible, a CRM design with no explicit DEC is preferred to designs that fix a dose for all patients in a DEC.

Development of circulating tumor cell-endocrine therapy index in patients with hormone receptor-positive breast cancer

BACKGROUND

Endocrine therapy (ET) fails to induce a response in one half of patients with hormone receptor (HR)-positive metastatic breast cancer (MBC), and almost all will eventually become refractory to ET. Circulating tumor cells (CTC) are associated with worse prognosis in patients with MBC, but enumeration alone is insufficient to predict the absolute odds of benefit from any therapy, including ET. We developed a multiparameter CTC-Endocrine Therapy Index (CTC-ETI), which we hypothesize may predict resistance to ET in patients with HR-positive MBC.

METHODS

The CTC-ETI combines enumeration and CTC expression of four markers: estrogen receptor (ER), B-cell lymphoma 2 (BCL-2), Human Epidermal Growth Factor Receptor 2 (HER2), and Ki67. The CellSearch System and reagents were used to capture CTC and measure protein expression by immunofluorescent staining on CTC.

RESULTS

The feasibility of determining CTC-ETI was initially established in vitro and then in a prospective single-institution pilot study in patients with MBC. CTC-ETI was successfully determined in 44 of 50 (88%) patients. Eighteen (41%), 9 (20%), and 17 (39%) patients had low, intermediate, and high CTC-ETI scores, respectively. Interobserver concordance of CTC-ETI determination was from 94% to 95% (Kappa statistic, 0.90-0.91). Inter- and cell-to-cell intrapatient heterogeneity of expression of each of the CTC markers was observed. CTC biomarker expression was discordant from both primary and metastatic tissues.

CONCLUSIONS

CTC expression of ER, BCL-2, HER2, and Ki67 can be reproducibly measured with high analytical validity using the CellSearch System. The clinical implications of CTC-ETI, and of the heterogeneity of CTC biomarker expression, are being evaluated in an ongoing prospective trial.

Pilot clinical trial of hedgehog pathway inhibitor GDC-0449 (vismodegib) in combination with gemcitabine in patients with metastatic pancreatic adenocarcinoma

PURPOSE

The hedgehog (HH) signaling pathway is a key regulator in tumorigenesis of pancreatic adenocarcinoma and is upregulated in pancreatic adenocarcinoma cancer stem cells (CSCs). GDC-0449 is an oral small-molecule inhibitor of the HH pathway. This study assessed the effect of GDC-0449-mediated HH inhibition in paired biopsies, followed by combined treatment with gemcitabine, in patients with metastatic pancreatic adenocarcinoma.

EXPERIMENTAL DESIGN

Twenty-five patients were enrolled of which 23 underwent core biopsies at baseline and following 3 weeks of GDC-0449. On day 29, 23 patients started weekly gemcitabine while continuing GDC-0449. We evaluated GLI1 and PTCH1 inhibition, change in CSCs, Ki-67, fibrosis, and assessed tumor response, survival and toxicity.

RESULTS

On pretreatment biopsy, 75% of patients had elevated sonic hedgehog (SHH) expression. On posttreatment biopsy, GLI1 and PTCH1 decreased in 95.6% and 82.6% of 23 patients, fibrosis decreased in 45.4% of 22, and Ki-67 in 52.9% of 17 evaluable patients. No significant changes were detected in CSCs pre- and postbiopsy. The median progression-free and overall survival for all treated patients were 2.8 and 5.3 months. The response and disease control rate was 21.7% and 65.2%. No significant correlation was noted between CSCs, fibrosis, SHH, Ki-67, GLI1, PTCH1 (baseline values or relative change on posttreatment biopsy), and survival. Grade ≥ 3 adverse events were noted in 56% of patients.

CONCLUSION

We show that GDC-0449 for 3 weeks leads to downmodulation of GLI1 and PTCH1, without significant changes in CSCs compared with baseline. GDC-0449 and gemcitabine were not superior to gemcitabine alone in the treatment of metastatic pancreatic cancer.

Quality of life in a prospective, multicenter phase 2 trial of neoadjuvant full-dose gemcitabine, oxaliplatin, and radiation in patients with resectable or borderline resectable pancreatic adenocarcinoma

PURPOSE

To determine the health-related quality of life (QOL) during and after neoadjuvant chemoradiation therapy and surgery for patients with pancreatic adenocarcinoma.

METHODS AND MATERIALS

Participants of a prospective, phase 2 multi-institutional trial treated with neoadjuvant chemoradiation followed by surgery completed QOL questionnaires (European Organization for Research and Treatment in Cancer Quality of Life Questionnaire version 3.0 [EORTC-QLQ C30], EORTC-Pancreatic Cancer module [EORTC-PAN 26], and Functional Assessment of Cancer Therapy Hepatobiliary and Pancreatic subscale [FACT-Hep]) at baseline, after 2 cycles of neoadjuvant therapy, after surgery, at 6 months from initiation of therapy, and at 6-month intervals for 2 years. Mean scores were compared with baseline. A change >10% was considered a minimal clinically important difference.

RESULTS

Of 71 participants in the trial, 55 were eligible for QOL analysis. Compliance ranged from 32% to 74%. The EORTC-QLQ C30 global QOL did not significantly decline after neoadjuvant therapy, whereas the Functional Assessment of Cancer Therapy global health measure showed a statistically, but not clinically significant decline (-8, P=.02). This was in parallel with deterioration in physical functioning (-14.1, P=.001), increase in diarrhea (+16.7, P=.044), and an improvement in pancreatic pain (-13, P=.01) as per EORTC-PAN 26. Because of poor patient compliance in the nonsurgical group, long-term analysis was performed only from surgically resected participants (n=36). Among those, global QOL returned to baseline levels after 6 months, remaining near baseline through the 24-month visit.

CONCLUSIONS

The study regimen consisting of 2 cycles of neoadjuvant therapy was completed without a clinically significant QOL deterioration. A transient increase in gastrointestinal symptoms and a decrease in physical functioning were seen after neoadjuvant chemoradiation. In those patients who underwent surgical resection, most domains returned back to baseline levels by 6 months.

Attitudes toward blinding of peer review and perceptions of efficacy within a small biomedical specialty

PURPOSE

Peer reviewers' knowledge of author identity may influence review content, quality, and recommendations. Therefore, the International Journal of Radiation Oncology, Biology, Physics ("Red Journal") implemented double-blinded peer review in 2011. Given the relatively small size of the specialty and the high frequency of preliminary abstract presentations, we sought to evaluate attitudes, the efficacy of blinding, and the potential impact on the disposition of submissions.

METHODS AND MATERIALS

In May through August 2012, all Red Journal reviewers and 1 author per manuscript completed questionnaires regarding demographics, attitudes, and perceptions of success of blinding. We also evaluated correlates of the outcomes of peer review.

RESULTS

Questionnaires were received from 408 authors and 519 reviewers (100%). The majority of respondents favored double blinding; 6% of authors and 13% of reviewers disagreed that double blinding should continue in the Red Journal. In all, 50% of the reviewers did not suspect the identity of the author of the paper that they reviewed; 19% of reviewers believed that they could identify the author(s), and 31% suspected that they could. Similarly, 23% believed that they knew the institution(s) from which the paper originated, and 34% suspected that they did. Among those who at least suspected author identity, 42% indicated that prior presentations served as a clue, and 57% indicated that literature referenced did so. Of those who at least suspected origin and provided details (n=133), 13% were entirely incorrect. Rejection was more common in 2012 than 2011, and submissions from last authors with higher H-indices (>21) were more likely to survive initial review, without evidence of interactions between submission year and author gender or H-index.

CONCLUSIONS

In a relatively small specialty in which preliminary research presentations are common and occur in a limited number of venues, reviewers are often familiar with research findings and suspect author identity even when manuscript review is blinded. Nevertheless, blinding appears to be effective in many cases, and support for continuing blinding was strong.

Patient-reported voice and speech outcomes after whole-neck intensity modulated radiation therapy and chemotherapy for oropharyngeal cancer: prospective longitudinal study

PURPOSE

To describe voice and speech quality changes and their predictors in patients with locally advanced oropharyngeal cancer treated on prospective clinical studies of organ-preserving chemotherapy-intensity modulated radiation therapy (chemo-IMRT).

METHODS AND MATERIALS

Ninety-one patients with stage III/IV oropharyngeal cancer were treated on 2 consecutive prospective studies of definitive chemoradiation using whole-field IMRT from 2003 to 2011. Patient-reported voice and speech quality were longitudinally assessed from before treatment through 24 months using the Communication Domain of the Head and Neck Quality of Life (HNQOL-C) instrument and the Speech question of the University of Washington Quality of Life (UWQOL-S) instrument, respectively. Factors associated with patient-reported voice quality worsening from baseline and speech impairment were assessed.

RESULTS

Voice quality decreased maximally at 1 month, with 68% and 41% of patients reporting worse HNQOL-C and UWQOL-S scores compared with before treatment, and improved thereafter, recovering to baseline by 12-18 months on average. In contrast, observer-rated larynx toxicity was rare (7% at 3 months; 5% at 6 months). Among patients with mean glottic larynx (GL) dose ≤20 Gy, >20-30 Gy, >30-40 Gy, >40-50 Gy, and >50 Gy, 10%, 32%, 25%, 30%, and 63%, respectively, reported worse voice quality at 12 months compared with before treatment (P=.011). Results for speech impairment were similar. Glottic larynx dose, N stage, neck dissection, oral cavity dose, and time since chemo-IMRT were univariately associated with either voice worsening or speech impairment. On multivariate analysis, mean GL dose remained independently predictive for both voice quality worsening (8.1%/Gy) and speech impairment (4.3%/Gy).

CONCLUSIONS

Voice quality worsening and speech impairment after chemo-IMRT for locally advanced oropharyngeal cancer were frequently reported by patients, underrecognized by clinicians, and independently associated with GL dose. These findings support reducing mean GL dose to as low as reasonably achievable, aiming at ≤20 Gy when the larynx is not a target.

Long-term financial burden of breast cancer: experiences of a diverse cohort of survivors identified through population-based registries

PURPOSE

To evaluate the financial experiences of a racially and ethnically diverse cohort of long-term breast cancer survivors (17% African American, 40% Latina) identified through population-based registries.

METHODS

Longitudinal study of women diagnosed with nonmetastatic breast cancer in 2005 to 2007 and reported to the SEER registries of metropolitan Los Angeles and Detroit. We surveyed 3,133 women approximately 9 months after diagnosis and 4 years later. Multivariable models evaluated correlates of self-reported decline in financial status attributed to breast cancer and of experiencing at least one type of privation (economically motivated treatment nonadherence and broader hardships related to medical expenses).

RESULTS

Among 1,502 patients responding to both surveys, median out-of-pocket expenses were ≤ $2,000; 17% of respondents reported spending > $5,000; 12% reported having medical debt 4 years postdiagnosis. Debt varied significantly by race: 9% of whites, 15% of blacks, 17% of English-speaking Latinas, and 10% of Spanish-speaking Latinas reported debt (P = .03). Overall, 25% of women experienced financial decline at least partly attributed to breast cancer; Spanish-speaking Latinas had significantly increased odds of this decline relative to whites (odds ratio [OR], 2.76; P = .006). At least one privation was experienced by 18% of the sample; blacks (OR, 2.6; P < .001) and English-speaking Latinas (OR, 2.2; P = .02) were significantly more likely to have experienced privation than whites.

CONCLUSION

Racial and ethnic minority patients appear most vulnerable to privations and financial decline attributable to breast cancer, even after adjustment for income, education, and employment. These findings should motivate efforts to control costs and ensure communication between patients and providers regarding financial distress, particularly for vulnerable subgroups.

Decline of cosmetic outcomes following accelerated partial breast irradiation using intensity modulated radiation therapy: results of a single-institution prospective clinical trial

PURPOSE

To report the final cosmetic results from a single-arm prospective clinical trial evaluating accelerated partial breast irradiation (APBI) using intensity modulated radiation therapy (IMRT) with active-breathing control (ABC).

METHODS AND MATERIALS

Women older than 40 with breast cancer stages 0-I who received breast-conserving surgery were enrolled in an institutional review board-approved prospective study evaluating APBI using IMRT administered with deep inspiration breath-hold. Patients received 38.5 Gy in 3.85-Gy fractions given twice daily over 5 consecutive days. The planning target volume was defined as the lumpectomy cavity with a 1.5-cm margin. Cosmesis was scored on a 4-category scale by the treating physician. Toxicity was scored according to National Cancer Institute Common Terminology Criteria for Adverse Events (CTCAE version 3.0). We report the cosmetic and toxicity results at a median follow-up of 5 years.

RESULTS

A total of 34 patients were enrolled. Two patients were excluded because of fair baseline cosmesis. The trial was terminated early because fair/poor cosmesis developed in 7 of 32 women at a median follow-up of 2.5 years. At a median follow-up of 5 years, further decline in the cosmetic outcome was observed in 5 women. Cosmesis at the time of last assessment was 43.3% excellent, 30% good, 20% fair, and 6.7% poor. Fibrosis according to CTCAE at last assessment was 3.3% grade 2 toxicity and 0% grade 3 toxicity. There was no correlation of CTCAE grade 2 or greater fibrosis with cosmesis. The 5-year rate of local control was 97% for all 34 patients initially enrolled.

CONCLUSIONS

In this prospective trial with 5-year median follow-up, we observed an excellent rate of tumor control using IMRT-planned APBI. Cosmetic outcomes, however, continued to decline, with 26.7% of women having a fair to poor cosmetic result. These results underscore the need for continued cosmetic assessment for patients treated with APBI by technique.

Gender differences in time spent on parenting and domestic responsibilities by high-achieving young physician-researchers

BACKGROUND

Female physician-researchers do not achieve career success at the same rate as men. Differences in nonprofessional responsibilities may partially explain this gap.

OBJECTIVE

To investigate the division of domestic labor by gender in a motivated group of early-career physician-researchers.

DESIGN

Nationwide postal survey between 2010 and 2011.

SETTING

United States.

PARTICIPANTS

Physician recipients of National Institutes of Health K08 or K23 awards between 2006 and 2009 with active academic affiliation at the time of the survey.

MEASUREMENTS

Time spent on parenting and domestic tasks was determined through self-report. Among married or partnered respondents with children, a linear regression model of time spent on domestic activities was constructed considering age, gender, race, specialty, MD or MD/PhD status, age of youngest child, number of children, work hours, K award type, and spousal employment.

RESULTS

A 74% response rate was achieved, and 1049 respondents were academic physicians. Women were more likely than men to have spouses or domestic partners who were employed full-time (85.6% [95% CI, 82.7% to 89.2%] vs. 44.9% [CI, 40.8% to 49.8%]). Among married or partnered respondents with children, after adjustment for work hours, spousal employment, and other factors, women spent 8.5 more hours per week on domestic activities. In the subgroup with spouses or domestic partners who were employed full-time, women were more likely to take time off during disruptions of usual child care arrangements than men (42.6% [CI, 36.6% to 49.0%] vs. 12.4% [CI, 5.4% to 19.5%]).

LIMITATIONS

Analyses relied on self-reported data. The study design did not enable investigation of the relationship between domestic activities and professional success.

CONCLUSION

In this sample of career-oriented professionals, gender differences in domestic activities existed among those with children. Most men's spouses or domestic partners were not employed full-time, which contrasted sharply with the experiences of women.

PRIMARY FUNDING SOURCE

National Institutes of Health.

Mentoring and the career satisfaction of male and female academic medical faculty

PURPOSE

To explore aspects of mentoring that might influence medical faculty career satisfaction and to discover whether there are gender differences.

METHOD

In 2010-2011, the authors surveyed 1,708 clinician-researchers who received (in 2006-2009) National Institutes of Health K08 and K23 awards, which provided mentoring for career development. The authors compared, by gender, the development and nature of mentoring relationships, mentor characteristics, extent of mentoring in various mentor roles, and satisfaction with mentoring. They evaluated associations between mentoring and career satisfaction using multivariable linear regression analysis.

RESULTS

The authors received 1,275 responses (75% response rate). Of these respondents, 1,227 (96%) were receiving K award support at the time and constituted the analytic sample. Many respondents had > 1 designated mentor (440/558 women, 79%; 410/668 men, 61%; P < .001). Few were dissatisfied with mentoring (122/1,220, 10.0%; no significant gender difference). Career dissatisfaction was generally low, but 289/553 women (52%) and 268/663 men (40%) were dissatisfied with work-life balance (P < .001). Time spent meeting or communicating with the mentor, mentor behaviors, mentor prestige, extent of mentoring in various roles, and collegiality of the mentoring relationship were significantly associated with career satisfaction. Mentor gender, gender concordance of the mentoring pair, and number of mentors were not significantly associated with satisfaction.

CONCLUSIONS

This study of junior faculty holding mentored career development awards showed strong associations between several aspects of mentoring and career satisfaction, indicating that those concerned about faculty attrition from academic medicine should consider mentor training and development.

Sex, role models, and specialty choices among graduates of US medical schools in 2006-2008

BACKGROUND

Undergraduate education studies have suggested instructor sex can influence female students to pursue a discipline. We sought to evaluate a similar hypothesis in medical students.

STUDY DESIGN

We obtained Association of American Medical Colleges (AAMC) data about the specialization of 2006-2008 graduates of US medical schools, the sex of their faculty and department chairs, and sex of residents in the residency programs in which they enrolled. We used logistic regression to examine associations between faculty and leadership sex and female students' pursuit of 5 surgical specialties along with 3 nonsurgical specialties for context. We used Wilcoxon rank-sum tests to evaluate whether women entered residency programs with a higher proportion of female residents.

RESULTS

In 2006-2008, US medical school graduates included 23,642 women. Women were substantially under-represented among residents in neurosurgery, orthopaedics, urology, otolaryngology, general surgery, and radiology; women constituted 47.4% of US graduates specializing in internal medicine and 74.9% in pediatrics. We found no significant associations between exposure to a female department chair and selection of that specialty and no consistent associations with the proportion of female full-time faculty. Compared with male students, female students entered residency programs in their chosen specialty that had significantly higher proportions of women residents in the year before their graduation.

CONCLUSIONS

Although we did not detect consistent significant associations between exposure to potential female faculty role models and specialty choice, we observed that female students were more likely than males to enter programs with higher proportions of female residents. Sex differences in students' specialization decisions merit additional investigation.

Work-life balance in academic medicine: narratives of physician-researchers and their mentors

BACKGROUND

Leaders in academic medicine are often selected from the ranks of physician-researchers, whose demanding careers involve multiple professional commitments that must also be balanced with demands at home.

OBJECTIVE

To gain a more nuanced understanding of work-life balance issues from the perspective of a large and diverse group of faculty clinician-researchers and their mentors.

DESIGN

A qualitative study with semi-structured, in-depth interviews conducted from 2010 to 2011, using inductive analysis and purposive sampling.

PARTICIPANTS

One hundred former recipients of U.S. National Institutes of Health (NIH) K08 or K23 career development awards and 28 of their mentors.

APPROACH

Three researchers with graduate training in qualitative methods conducted the interviews and thematically coded verbatim transcripts.

KEY RESULTS

Five themes emerged related to work-life balance: (1) the challenge and importance of work-life balance for contemporary physician-researchers, (2) how gender roles and spousal dynamics make these issues more challenging for women, (3) the role of mentoring in this area, (4) the impact of institutional policies and practices intended to improve work-life balance, and (5) perceptions of stereotype and stigma associated with utilization of these programs.

CONCLUSIONS

In academic medicine, in contrast to other fields in which a lack of affordable childcare may be the principal challenge, barriers to work-life balance appear to be deeply rooted within professional culture. A combination of mentorship, interventions that target institutional and professional culture, and efforts to destigmatize reliance on flexibility (with regard to timing and location of work) are most likely to promote the satisfaction and success of the new generation of clinician-researchers who desire work-life balance.

Management of worry about recurrence in breast cancer survivors

21

Background: Worry about recurrence is a significant concern for breast cancer survivors. We explored physicians‘ confidence and practices in identifying and managing worry. Methods: We surveyed a random sample of 1,500 surgeons and medical oncologists drawn from the AMA Masterfile in 2012. Physician responses to questions regarding their confidence were stratified by practice specialty and compared using the Wilcoxon rank-sum test. Correlates of use of each strategy for managing worry were modeled using multiple variable logistic regression. Results: 896 physicians (59.7%) responded: 498 surgeons and 398 medical oncologists, of whom 85.5% saw breast cancer patients. 62% reported initiating discussions regarding worry about recurrence. Overall, medical oncologists reported more confidence than surgeons in their ability to present risk information to patients, identify survivors with high levels of worry, and help patients manage their worry (p<0.001). Of note, 40.2% of physicians reported low levels of confidence managing worries surrounding recurrence. Confidence presenting risk information was significantly associated with treatment volume, which was highest with >50 cases/year. Surgeons who routinely followed breast cancer survivors for >3 years reported higher confidence; no such correlation existed among medical oncologists, but >90% of this group routinely followed patients for >3 yrs. Female physicians were significantly more likely to report being able to identify survivors with high levels of worry. Practice in an academic setting demonstrated associations with increased confidence. Use of worry management strategies varied by specialty. Medical oncologists were more likely to prescribe medication, address concerns in detail themselves, or refer to a psychologist or social worker. Longer follow-up was associated with increased likelihood of physicians addressing concerns themselves. Conclusions: A sizeable minority of physicians lack confidence in their ability to identify and manage worry in cancer survivors. Medical oncologists and surgeons differ significantly in their approach to worry management, suggesting that greater attention toward this issue in training and continuing education may be warranted.

Gender differences in salary in a recent cohort of early-career physician-researchers

PURPOSE

Studies have suggested that male physicians earn more than their female counterparts. The authors examined whether this disparity exists in a recently hired cohort.

METHOD

In 2010-2011, the authors surveyed recent recipients of National Institutes of Health (NIH) mentored career development (i.e., K08 or K23) awards, receiving responses from 1,275 (75% response rate). For the 1,012 physicians with academic positions in clinical specialties who reported salary, they constructed linear regression models of salary considering gender, age, race, marital status, parental status, additional doctoral degree, academic rank, years on faculty, specialty, institution type, region, institution NIH funding rank, K award type, K award funding institute, K award year, work hours, and research time. They evaluated the explanatory value of spousal employment status using Peters-Belson regression.

RESULTS

Mean salary was $141,325 (95% confidence interval [CI] 135,607-147,043) for women and $172,164 (95% CI 167,357-176,971) for men. Male gender remained an independent, significant predictor of salary (+$10,921, P < .001) even after adjusting for specialty, academic rank, work hours, research time, and other factors. Peters-Belson analysis indicated that 17% of the overall disparity in the full sample was unexplained by the measured covariates. In the married subset, after accounting for spousal employment status, 10% remained unexplained.

CONCLUSIONS

The authors observed, in this recent cohort of elite, early-career physician-researchers, a gender difference in salary that was not fully explained by specialty, academic rank, work hours, or even spousal employment. Creating more equitable procedures for establishing salary is important.

Surgeons' knowledge and practices regarding the role of radiation therapy in breast cancer management

PURPOSE

Population-based studies suggest underuse of radiation therapy, especially after mastectomy. Because radiation oncology is a referral-based specialty, knowledge and attitudes of upstream providers, specifically surgeons, may influence patients' decisions regarding radiation, including whether it is even considered. Therefore, we sought to evaluate surgeons' knowledge of pertinent risk information, their patterns of referral, and the correlates of surgeon knowledge and referral in specific breast cancer scenarios.

METHODS AND MATERIALS

We surveyed a national sample of 750 surgeons, with a 67% response rate. We analyzed responses from those who had seen at least 1 breast cancer patient in the past year (n=403), using logistic regression models to identify correlates of knowledge and appropriate referral.

RESULTS

Overall, 87% of respondents were general surgeons, and 64% saw >10 breast cancer patients in the previous year. In a scenario involving a 45-year-old undergoing lumpectomy, only 45% correctly estimated the risk of locoregional recurrence without radiation therapy, but 97% would refer to radiation oncology. In a patient with 2 of 20 nodes involved after mastectomy, 30% would neither refer to radiation oncology nor provide accurate information to make radiation decisions. In a patient with 4 of 20 nodes involved after mastectomy, 9% would not refer to radiation oncology. Fewer than half knew that the Oxford meta-analysis revealed a survival benefit from radiation therapy after lumpectomy (45%) or mastectomy (32%). Only 16% passed a 7-item knowledge test; female and more-experienced surgeons were more likely to pass. Factors significantly associated with appropriate referral to radiation oncology included breast cancer volume, tumor board participation, and knowledge.

CONCLUSIONS

Many surgeons have inadequate knowledge regarding the role of radiation in breast cancer management, especially after mastectomy. Targeted educational interventions may improve the quality of care.

Analytic morphometric assessment of patients undergoing colectomy for colon cancer

BACKGROUND

Analytic morphometrics provides objective data that may better stratify risk. We investigated morphometrics and outcome among colon cancer patients.

METHODS

An IRB-approved review identified 302 patients undergoing colectomy who had CT scans. These were processed to measure psoas area (PA), density (PD), subcutaneous fat (SFD), visceral fat (VF), and total body fat (TBF). Correlation with complications, recurrence, and survival were obtained by t-tests and linear regression models after adjusting for age and Charlson index.

RESULTS

The best predictor of surgical complications was PD. PMH, Charlson, BMI, and age were not significant when PD was considered. SF area was the single best predictor of a wound infection. While all measures of obesity correlated with outcome, TBF was most predictive. Final multivariate Cox models for survival included age, Charlson score, nodal positivity, and TBF.

CONCLUSIONS

Analytic morphometric analysis provided objective data that stratified complications and outcome better than age, BMI, or co-morbidities.

A multi-institutional phase 2 study of neoadjuvant gemcitabine and oxaliplatin with radiation therapy in patients with pancreatic cancer

BACKGROUND

The purpose of this study was to evaluate preoperative treatment with full-dose gemcitabine, oxaliplatin, and radiation therapy (RT) in patients with localized pancreatic cancer.

METHODS

Eligibility included confirmation of adenocarcinoma, resectable or borderline resectable disease, a performance status ≤2, and adequate organ function. Treatment consisted of two 28-day cycles of gemcitabine (1 g/m(2) over 30 minutes on days 1, 8, and 15) and oxaliplatin (85 mg/m(2) on days 1 and 15) with RT during cycle 1 (30 Gray [Gy] in 2-Gy fractions). Patients were evaluated for surgery after cycle 2. Patients who underwent resection received 2 cycles of adjuvant chemotherapy.

RESULTS

Sixty-eight evaluable patients received treatment at 4 centers. By central radiology review, 23 patients had resectable disease, 39 patients had borderline resectable disease, and 6 patients had unresectable disease. Sixty-six patients (97%) completed cycle 1 with RT, and 61 patients (90%) completed cycle 2. Grade ≥3 adverse events during preoperative therapy included neutropenia (32%), thrombocytopenia (25%), and biliary obstruction/cholangitis (14%). Forty-three patients underwent resection (63%), and complete (R0) resection was achieved in 36 of those 43 patients (84%). The median overall survival was 18.2 months (95% confidence interval, 13-26.9 months) for all patients, 27.1 months (95% confidence interval, 21.2-47.1 months) for those who underwent resection, and 10.9 months (95% confidence interval, 6.1-12.6 months) for those who did not undergo resection. A decrease in CA 19-9 level after neoadjuvant therapy was associated with R0 resection (P = .02), which resulted in a median survival of 34.6 months (95% confidence interval, 20.3-47.1 months). Fourteen patients (21%) are alive and disease free at a median follow-up of 31.4 months (range, 24-47.6 months).

CONCLUSIONS

Preoperative therapy with full-dose gemcitabine, oxaliplatin, and RT was feasible and resulted in a high percentage of R0 resections. The current results are particularly encouraging, because the majority of patients had borderline resectable disease.

Pain sensitivity and aromatase inhibitor (AI)-associated arthralgias (AIAA)

9615

Background: AIAA affect up to half of AI-treated women with early stage breast cancer, and can lead to treatment discontinuation in 20-30%. The etiology is thought to be related to estrogen deprivation although the mechanism is unknown. In premenopausal women, lower estrogen levels have been associated with increased pain. Impaired descending pain inhibitory pathways, which may be a risk factor for developing chronic pain, have also been associated with lower estrogen levels. We prospectively tested whether AI-induced estrogen deprivation alters pain sensitivity, thereby increasing the risk of developing AIAA. Methods: Fifty postmenopausal women with early stage breast cancer initiating AI therapy were enrolled to the study. Subjects underwent experimental pressure pain testing and conditioned pain modulation (CPM) assessment and completed symptom questionnaires prior to AI initiation and after 3 months. Positive CPM values (>0) signify impaired descending pain inhibition. Serum estradiol concentrations were determined using an ultrasensitive assay. T-tests, Fisher’s exact test, and linear regression models were used to assess associations among baseline (BL) experimental pain measures, patient-reported pain, and clinical factors. P values <0.05 were considered statistically significant. Results: All subjects had decreased serum estradiol concentrations with AI therapy. No statistically significant change in pressure pain threshold or CPM with AI therapy was detected. In addition, no association between change in patient-reported pain with AI therapy and change in pain threshold or CPM was identified. Patients demonstrated impaired CPM at baseline (mean 8.0, SD 14.9), and this impairment was greater in patients previously treated with chemotherapy 14.4 vs 2.0, p=0.006), with non-significant trends towards this being more pronounced in those with more severe pain. Conclusions: AI therapy did not impact pressure pain threshold or CPM, suggesting that AIAA is not likely due to pain amplification from estrogen depletion. Studies examining chemotherapy-induced changes in pain processing are needed to better understand how these alterations might contribute to the pain that these patients often develop.

Treatment outcome with the combination of carfilzomib, lenalidomide, and low-dose dexamethasone (CRd) for newly diagnosed multiple myeloma (NDMM) after extended follow-up

8543

Background: We previously reported results from a phase 1/2 trial of CRd in NDMM (NCT01029054), demonstrating a high rate (42%) of stringent complete response (sCR) and overall favorable efficacy /safety after a median of 12 cycles of treatment (tx) and a median follow-up of 13 mo (Jakubowiak et al Blood, 2012). Here we report updated results after extended tx and additional 12 mo of follow-up. Methods: Patients (pts) received 28-day (d) cycles of carfilzomib (CFZ) 20–36 mg/m2 IV (d1, 2, 8, 9, 15, 16), lenalidomide (LEN) 25 mg PO (d1–21), and dexamethasone 40/20 mg PO wkly (cycles 1–4/5–8). For cycles 8–24, CRd was given with a modified CFZ schedule (d1, 2, 15, 16) and then LEN alone after cycle 24. Stem cell transplant was an option after cycle 4. Response was assessed by IMWG plus nCR. Results: As of Nov 2012, 53 pts had received a median of 22 CRd cycles (range 2–24); 7 pts opted for transplant; 24 continued LEN maintenance for median 8 mo (range 1–10). Median follow-up was 25 mo (range 5–37). With extended tx, the CR rate was 64%; sCR improved from 42% to 53%, ≥nCR from 62% to 72%, and ≥VGPR from 81% to 87% (follow-up 13 vs 25 mo); ≥PR remained at 98%. Immunophenotypic CR (IMWG) was achieved in 22/26 evaluated pts. Of pts in sCR, 25% had high-risk cytogenetics per IMWG. In pts who did not proceed to transplant (n=46), the sCR was 59%, CR 70%, ≥nCR 78%, ≥VGPR 91%, and ≥PR 100%. Over the course of tx, depth of response improved. Median time to ≥VGPR was 4 cycles (range 2–17), ≥nCR 4.5 cycles (range 2–15), and sCR 10 cycles (range 4–30); 2 pts converted to sCR during LEN maintenance. At 2 years, the estimated PFS rate was 94% and OS was 98%; for pts with sCR, rates were 96% and 100%, respectively. Adverse event types, rates, and dose modifications during extended tx were comparable with those previously reported. There was 1 death off study due to disease progression. Conclusions: Extended follow-up showed that depth of response continued to improve over the course of prolonged CRd tx, resulting in exceptional CR, sCR, and PFS. Extended tx continued to be well tolerated. The results compare favorably with historical studies in both transplant and non-transplant NDMM. Clinical trial information: NCT01029054.

Racial and ethnic variation in employment and financial experiences of breast cancer survivors

9601

Background: Concerns exist regarding the employment and financial experiences of cancer survivors and whether they differ by race/ethnicity. Methods: In a longitudinal survey of women reported to the Los Angeles and Detroit SEER registries for nonmetastatic breast cancer, we compared experiences of 4-year survivors by race/ethnicity. Results: Overall, 31% of 1,536 respondents (68% response rate) felt their financial status was worse since diagnosis (63% attributed this to breast cancer). This varied by race/ethnicity: 41% of Spanish-speaking Latinas (SSL), 33% English-speaking Latinas (ESL), 23% blacks (B), and 29% whites (W), p<0.001. The median respondent had spent ≤$2000 on breast cancer medical expenses; 16% had spent >$5000. 12% had medical debt 4 yrs post-diagnosis: 17% of ESL, 14% B, 10% SSL, and 9% W (p=0.01). Minority respondents were more likely to report foregoing medical care due to cost and other privations due to their medical expenses (Table). Overall, 14% felt their employment status was worse since diagnosis, and 61% of these attributed this to breast cancer. 755 worked for pay some time after diagnosis, of whom 56% said it was at least somewhat important to work to keep health insurance (55% of SSL, 65% ESL, 65% B, 50% W, p=0.03); 24% would look for a new job if assured of comparable benefits (45% of SSL, 29% ESL, 22% B, 17% W, p<0.001); 7% had increased work hours to cover cancer-related expenses; 27% had decreased work hours due to cancer-related health issues; and 7% believed they had been denied job opportunities because of cancer. Conclusions: In this population-based sample of breast cancer survivors, job lock was common, and many women perceived being worse off with respect to finances and employment as a result of their breast cancer. Medical debt and privation varied significantly by race/ethnicity. [Table: see text]

Phase II study of low-dose methotrexate to reduce the incidence of human anti-mouse antibodies in patients receiving I-131 tositumomab as first-line treatment for follicular lymphoma

e19519

Background: I-131 tositumomab is a radiolabeled murine anti-CD20 antibody. In a frontline phase II follicular lymphoma (FL) trial, treatment with I-131 tositumomab produced a 95% ORR with 75% CR (NEJM 352:441, 2005). Median PFS was 6.1 yrs. However, 30% of patients (pts) developed high levels of human anti-mouse antibodies (HAMA) and a serum sickness syndrome within 7 weeks of treatment (early onset HAMA). The 5-yr PFS for this group was 35% compared to 70% for the others (p = 0.003). Low-dose oral methotrexate (mtx) reduces the incidence of human anti-chimeric antibody (HACA) formation in rheumatoid arthritis pts receiving infliximab. We hypothesized that low-dose mtx would likewise reduce the incidence of early onset HAMA when given in combination with I-131 tositumomab. Methods: This is a single arm, phase II study in pts with FL, grade 1-2, stage III or IV disease without limits on marrow involvement, and ≥ 1 of the GELF criteria. Prior therapy, other than focal radiotherapy, is not allowed. Pts must have adequate hematologic, hepatic and renal function, and serum HAMA levels ≤ ULN. I-131 tositumomab is given as a dosimetric dose followed within 1-2 weeks by a therapeutic dose of 75cGy of total body radiation. Pts take mtx 7.5 mg orally once weekly for 3 weeks prior to their dosimetric dose, followed by 7 additional weekly doses. The primary endpoint is the rate of HAMA formation within 7 wks of I-131 tositumomab treatment. Secondary endpoints are overall HAMA incidence, ORR, CR, PFS OS, and safety. Results: Between 8/2011 and 10/2012, 15 pts were enrolled. Median age was 56 (39-83); 11 were male. Three pts had serum HAMA levels >ULN at baseline. One pt had a spontaneous remission prior to starting treatment, leaving 11 evaluable pts. One pt developed early onset HAMA (9%). ORR = 82%, CR = 64%. Two pts progressed with DLBCL. Grade 3 or 4 toxicities included thrombocytopenia n = 3, neutropenia n = 2 and pain n = 3. Conclusions: These preliminary results show that concurrent low-dose oral mtx appears to reduce the incidence of early onset HAMA in FL patients receiving first- line I-131 tositumomab (9% vs. 30% in historical controls) while preserving efficacy. Clinical trial information: NCT01389076.

Clinicopathologic features of primary Merkel cell carcinoma: a detailed descriptive analysis of a large contemporary cohort

BACKGROUND

Little uniformity exists in the clinical and histologic variables reported with primary Merkel cell carcinoma (MCC).

OBJECTIVE

To provide a rigorous descriptive analysis of a contemporary cohort and promote the prospective collection of detailed data on MCC for future outcome studies.

METHODS AND MATERIALS

A detailed descriptive analysis was performed for clinical and histologic features of 147 patients with 150 primary MCC tumors in a prospectively collected database from 2006 to 2010.

RESULTS

The majority (73.5%) of patients were at American Joint Committee on Cancer clinical stage I or II at presentation, 20.4% at stage III, and 6.1% at stage IV. Detailed descriptive clinical and histologic findings are presented.

CONCLUSION

Clinical and histologic profiling of primary MCC in the literature is variable and limited. Systematic prospective collection of MCC data is needed for future outcome studies and the ability to compare and share data from multiple sources for this relatively rare tumor.

Preclinical and clinical studies of gamma secretase inhibitors with docetaxel on human breast tumors

PURPOSE

Accumulating evidence supports the existence of breast cancer stem cells (BCSC), which are characterized by their capacity to self-renew and divide indefinitely and resistance to conventional therapies. The Notch pathway is important for stem cell renewal and is a potential target for BCSC-directed therapy.

EXPERIMENTAL DESIGN

Using human breast tumorgraft studies, we evaluated the impact of gamma secretase inhibitors (GSI) on the BCSC population and the efficacy of combining GSI with docetaxel treatment. The mouse experimental therapy paralleled a concurrent clinical trial in patients with advanced breast cancer, designed to determine the maximum-tolerated dose of the GSI, MK-0752, administered sequentially with docetaxel, and to evaluate BCSC markers in serial tumor biopsies.

RESULTS

Treatment with GSI reduced BCSCs in MC1 and BCM-2147 tumorgrafts by inhibition of the Notch pathway. GSI enhanced the efficacy of docetaxel in preclinical studies. In the clinical trial, 30 patients with advanced breast cancer were treated with escalating doses of MK-0752 plus docetaxel. Clinically, meaningful doses of both drugs were possible with manageable toxicity and preliminary evidence of efficacy. A decrease in CD44(+)/CD24(-), ALDH(+), and mammosphere-forming efficiency were observed in tumors of patients undergoing serial biopsies.

CONCLUSIONS

These preclinical data show that pharmacologic inhibition of the Notch pathway can reduce BCSCs in breast tumorgraft models. The clinical trial shows feasibility of combination GSI and chemotherapy, and together these results encourage further study of Notch pathway inhibitors in combination with chemotherapy in breast cancer.

Variation in the use of intensity-modulated radiation therapy (IMRT) in the state of Michigan: 2005-2010

219

Background: Interest is growing in value in health care, defined as better outcomes at lower costs. A primary driver of cost in radiation oncology is the use of IMRT. We examined the patterns and correlates of use of IMRT across Michigan using publicly available data. Methods: As a certificate of need state, Michigan requires every radiation oncology facility to report yearly the number of external beam and IMRT treatments delivered. Data for 2005-2008 were obtained through a Freedom of Information Act request of the Michigan Department of Community Health, while 2009-2010 data were available at its website. Percentage of external beam treatments delivered using IMRT (IMRT%) was examined across centers over time and repeated-measures longitudinal linear regression was used to identify factors associated with use. Results: During 2005-2010, 48 to 65 centers reported data. Median IMRT% (range) rose steadily during the study period: 2005 16% (0-64); 2006 21% (0-57); 2007 27% (0-79); 2008 37% (7-85); 2009 41% (0-87) 2010 45% (7-100). There was also significant between-center variation (see table). Regression modeling demonstrated that IMRT% was associated with year (+6.7% per year, p<0.0001), facility type (+7.1% freestanding versus hospital, p<0.11), facility annual volume (+5.0% high volume: 7,000+ versus low: <7,000, p=0.01) and the interaction between year and volume (low volume +2.4% per year versus high volume p<0.02). The significant interaction between year and volume suggests that the greatest IMRT% growth was in low volume centers (6.7% per year versus 4.3% per year for high volume). Conclusions: IMRT utilization has grown steadily across Michigan between 2005 and 2010. There is significant variation in its use that appears to be related in part to facility characteristics. The newly established Michigan Radiation Oncology Quality Collaborative (MROQC) is beginning to explore the use of IMRT in patients with breast and lung cancer statewide to identify those groups of patients where improved outcomes may justify its higher cost. [Table: see text]

Frequency of physician misconceptions that may drive underuse of radiotherapy (RT) in patients with breast cancer

237

Background: Registry studies suggest underuse of RT for breast cancer, especially after mastectomy. Because radiation oncology is referral-based, knowledge and attitudes of upstream providers may influence patients’ RT decisions, including whether they even consider it. Methods: We surveyed a random sample of 750 medical oncologists (MO) and 750 surgeons (S) drawn from the AMA Masterfile in 2012; 895 responded. We analyzed responses to scenarios in which RT should be considered from the 766 (403 S, 363 MO) who had seen breast cancer patients in the past year. Results: Mean age was 52; 36% worked in a practice with an academic affiliation. 84% of MO and 64% of S saw more than 10 breast cancer patients in the previous year (p<0.001). 44% participated in multidisciplinary breast clinics. In a 45 yo T1cN0 ER+/PR+/HER2- patient receiving lumpectomy and tamoxifen, half of respondents substantially underestimated the 10-year risk of locoregional recurrence without RT. 19% of MO and 38% of S did not know that guidelines recommend RT in that case, but reassuringly, almost all would refer the patient to radiation oncology (97%). Referral to radiation oncology was less common for node-positive patients after mastectomy; however, in a T1cN1 patient with 2/20 nodes s/p mastectomy (in whom guidelines state that RT should be strongly considered), only 53% of MO and 34% of S recommend RT; 29% of MO and 43% of S would not refer to radiation oncology. If 4/20 nodes were involved (where RT is clearly guideline-recommended), 94% of MO but only 79% of S would recommend RT, and 9% of S would not refer to radiation oncology. The majority (53% of MO, 68% of S) substantially underestimated the risk of LRR in a patient with pN2 disease after mastectomy without RT. Fewer than half knew that the EBCTCG meta-analysis revealed a survival benefit from RT after lumpectomy (45%) or mastectomy (47% of MO, 32% of S, p<0.001). Only 66% of MO and 54% of S recognized the 10-year risk of RT-induced second malignancy to be <1%. Conclusions: Many MO and S who treat breast cancer patients have misconceptions relevant to RT decision-making. Educational interventions targeted towards referring providers may improve the quality of care received by breast cancer patients.

Attitudes toward and use of cancer management guidelines in a national sample of medical oncologists and surgeons

163

Background: Previous studies have assessed physician perceptions of practice guidelines and identified barriers to adherence, including lack of knowledge, attitudes, and other factors. Little is known about attitudes toward and use of cancer management guidelines specifically. Methods: We surveyed a random sample of 750 medical oncologists and 750 surgeons drawn from the AMA Masterfile between January and June 2012. 896 responded; 130 of these reported that they had not seen breast cancer patients in the previous year and were asked not to complete the remainder of the survey. We analyzed responses from the remaining 766 (403 surgeons and 363 medical oncologists). Results: Mean participant age was 52; 36% worked in a practice with an academic affiliation. Attitudes towards clinical practice guidelines were generally favorable. Few (<3%) disagreed that guidelines were good educational tools or convenient, and only 12% felt that they were biased, although 24% felt they were oversimplified, 20% found them too rigid, and 20% perceived them as a challenge to physician autonomy. Most agreed that guidelines were intended to improve the quality of care (98%) but opinion split about whether they were intended to decrease costs (51% felt they were). NCCN guidelines were reported to influence the cancer management decisions of 96% of medical oncologists and 70% of surgeons (p<0.001), and ASCO guidelines influenced 65% of medical oncologists and 45% of surgeons (p<0.001). Many respondents looked at the NCCN guidelines at least every few months (93% of medical oncologists, 48% of surgeons, p<0.001). Most respondents reported they made guideline-concordant decisions in the majority of their cancer cases. Yet most respondents reported that they rarely refer patients to the patient versions of the NCCN guidelines (76% refer ¼ or fewer of their patients). When making a guideline-inconsistent recommendation, 17% do not routinely discuss the inconsistency with patients. Conclusions: Attitudes toward physician-directed cancer management guidelines are generally positive, and they are frequently used. However, physicians infrequently advise use of patient versions.

Is there a dose-response relationship for heart disease with low-dose radiation therapy?

PURPOSE

To quantify cardiac radiation therapy (RT) exposure using sensitive measures of cardiac dysfunction; and to correlate dysfunction with heart doses, in the setting of adjuvant RT for left-sided breast cancer.

METHODS AND MATERIALS

On a randomized trial, 32 women with node-positive left-sided breast cancer underwent pre-RT stress single photon emission computed tomography (SPECT-CT) myocardial perfusion scans. Patients received RT to the breast/chest wall and regional lymph nodes to doses of 50 to 52.2 Gy. Repeat SPECT-CT scans were performed 1 year after RT. Perfusion defects (PD), summed stress defects scores (SSS), and ejection fractions (EF) were evaluated. Doses to the heart and coronary arteries were quantified.

RESULTS

The mean difference in pre- and post-RT PD was -0.38% ± 3.20% (P=.68), with no clinically significant defects. To assess for subclinical effects, PD were also examined using a 1.5-SD below the normal mean threshold, with a mean difference of 2.53% ± 12.57% (P=.38). The mean differences in SSS and EF before and after RT were 0.78% ± 2.50% (P=.08) and 1.75% ± 7.29% (P=.39), respectively. The average heart Dmean and D95 were 2.82 Gy (range, 1.11-6.06 Gy) and 0.90 Gy (range, 0.13-2.17 Gy), respectively. The average Dmean and D95 to the left anterior descending artery were 7.22 Gy (range, 2.58-18.05 Gy) and 3.22 Gy (range, 1.23-6.86 Gy), respectively. No correlations were found between cardiac doses and changes in PD, SSS, and EF.

CONCLUSIONS

Using sensitive measures of cardiac function, no clinically significant defects were found after RT, with the average heart Dmean <5 Gy. Although a dose response may exist for measures of cardiac dysfunction at higher doses, no correlation was found in the present study for low doses delivered to cardiac structures and perfusion, SSS, or EF.

Sarcopenia to predict tolerance of adjuvant breast cancer chemotherapy

138

Background: Despite improved survival with adjuvant chemotherapy among older women, it is less often recommended for fear they cannot complete therapy or will have excessive toxicity. Analytic morphometrics uses objective imaging measurements such as muscle size, bone mineral density (BMD) and body composition to improve risk stratification. We examined whether morphometrics might help predict toxicity of chemotherapy in breast cancer patients. Methods: Our prospective IRB-approved breast cancer database was queried for all patients who underwent adjuvant or neoadjuvant chemotherapy and had CT scans of the chest, abdomen and pelvis prior to chemo. Complications of chemotherapy were graded according to the NCI-CTC. CT scans were processed using semi-automated algorithms (MATLAB v13.0) to measure psoas area (PA) and density (PD), BMD and subcutaneous fat (SF), visceral fat (VF), and total body area (TBA. Outcome (DFS and OS) was assessed by K-M, and logistic regression models and ANOVA were used for toxicity events. Results: We identified 129 patients, ranging in age from 24 to 83 (median 52). 105 (81%) received AC/T while 19% received alternate regimens, all full weight based. T-stage, nodal status and HER2 expression were significantly associated with measures of obesity, except BMI, but not sarcopenia. After adjusting for stage and Her-2, BMI remained a significant predictor of DFS (OR 1.07 (95%CI 1.01, 1.13)) and OS (OR 1.06 (95% CI 1.00, 1.12)).After controlling for age, PD and VF were predictors of chemotherapy completion. The OR for completing chemotherapy decreased 0.95 (95% CI: 0.90, 1.01, p=0.08) for every increase of 1000 in VF and increased 1.08 (95% CI: 1.01, 1.15, p=0.03) for every unit increase in PD. Sarcopenia was associated with an increased risk of pulmonary complications (p=0.01) and anemia (p=0.06). Conclusions: Although age is a significant predictor of increased toxicity and inability to complete chemotherapy, sarcopenia is an objective, independent predictor of chemotherapy completion. Psoas density, easily obtainable from a pre-treatment CT scan, can help the clinician older breast cancer patients for adjuvant chemotherapy.

The elderly breast cancer patient: Association of age, tumor size, and grade with sentinel lymph node status

15

Background: Nodal evaluation of the elderly breast cancer patient remains controversial, and some have suggested that selected older women with breast cancer may not require sentinel lymph node biopsy (SLNB). Methods: An IRB-approved database was queried for patients undergoing SLNB for invasive breast cancer from 2000-2006. We compared 8 cohorts: age <40 years, 40-44, 45-49, 50-54, 55-59, 60-64, 65-69, and >70 years. Logistic regression and chi-square test were used. Results: Procedure success rate was above 95% for all groups in a total sample size of 1268 patients. Patients >70 years had lower grade tumors than patients <40 years (Grade 1: 25% vs. 7%; Grade 2: 53% vs. 47%; Grade 3: 17% vs. 40%, p<0.0001) and higher ER expression (ER+: 83% vs. 59%, p<0.0005). Patients <40 years also had a higher proportion of multifocal disease (21% vs. 9%, p<0.002), lymphovascular invasion (20% vs. 10%, p<0.007), and number of positive sentinel lymph nodes (PSLN) removed (mean: 3.7 vs. 2.7, p<0.028). Upon multivariate analysis, the odds of a PSLN decrease 9% for every 5-year increase in age (OR 0.91, p<0.003), but increase significantly with certain tumor characteristics (ER+ vs. ER-: OR 1.7, p=0.002), larger size (0.5 cm increase: OR 1.26, p<0.0001), and higher grade (Grades 2-3: OR 1.99, p<0.0007). The predicted probability of a PSLN for patients age 35, 55, and 70 years is 27%, 22%, and 16%, assuming each had a ER+, low grade, 2 cm tumor. Conclusions: Older breast cancer patients have more favorable pathology, and the chance of a PSLN decreases as age increases. However, the odds of a PSLN are significantly higher in patients with certain tumor characteristics, which are known prior to definitive surgery. Given recent reports that older patients are less likely to receive standard treatment for breast cancer and prognosis may worsen as a result, tumor size and characteristics rather than age should dictate the decision to perform SLNB, and we should continue appropriate, aggressive staging of the older breast cancer patient.

Quantifying dose to the reconstructed breast: can we adequately treat?

To evaluate how immediate reconstruction (IR) impacts postmastectomy radiotherapy (PMRT) dose distributions to the reconstructed breast (RB), internal mammary nodes (IMN), heart, and lungs using quantifiable dosimetric end points. 3D conformal plans were developed for 20 IR patients, 10 autologous reconstruction (AR), and 10 expander-implant (EI) reconstruction. For each reconstruction type, 5 right- and 5 left-sided reconstructions were selected. Two plans were created for each patient, 1 with RB coverage alone and 1 with RB + IMN coverage. Left-sided EI plans without IMN coverage had higher heart Dmean than left-sided AR plans (2.97 and 0.84 Gy, p = 0.03). Otherwise, results did not vary by reconstruction type and all remaining metrics were evaluated using a combined AR and EI dataset. RB coverage was adequate regardless of laterality or IMN coverage (Dmean 50.61 Gy, D95 45.76 Gy). When included, IMN Dmean and D95 were 49.57 and 40.96 Gy, respectively. Mean heart doses increased with left-sided treatment plans and IMN inclusion. Right-sided treatment plans and IMN inclusion increased mean lung V(20). Using standard field arrangements and 3D planning, we observed excellent coverage of the RB and IMN, regardless of laterality or reconstruction type. Our results demonstrate that adequate doses can be delivered to the RB with or without IMN coverage.