Molecular profiling of advanced biliary cancer: Lost in translation from bench to bedside

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Background: Advanced Biliary Cancer (ABC) is a collection of diseases which carry poor prognosis, and many patients derive limited benefit from chemotherapy. Identification of molecular drivers of ABC may help to predict treatment response and direct development of targeted therapy. Methods: Formalin fixed paraffin embedded (FFPE) tissue form patients with ABC treated at Princess Margaret Cancer Centre was analysed by MassARRAY Sequenom panel (23 genes, 279 mutations), or by next general sequencing (NGS) using Proton or Illumina MiSeq TruSeq Amplicon Cancer Panel (48 genes, 212 amplicons, ≥500x coverage). Clinicopathologic and treatment data were collected from electronic health records. Results: Of 112 tested patients, 16 had insufficient DNA, and 96 had data for analysis: 13 with ampullary cancer (AC), 19 with hilar/distal bile duct (DBD), 43 with gallbladder (GBC), and 21 with intrahepatic (IHC). 13 patients had Sequenom testing, 85 had NGS with Miseq or Proton. 127 mutations were identified in 60 patients, 36 had no mutations detected: 23 in AC, 54 in GBC, 24 in IHC, 26 in DBD. The most frequent mutations were in TP53 (34%) and KRAS (20%). TP53 and SMAD4 mutations appeared most common in GBC, BRAF and KRAS mutations were most common in AC, and IDH1 and FGFR2mutations were seen only in IHC. 14 patients (15%) had a mutation for which targeted treatment could be applied. Conclusions: Profiling of patients with ABC is feasible and can identify some molecular drivers, with different tumour sites demonstrating distinct biological patterns. Only a limited number of patients are shown to have clinically relevant mutations with current NGS techniques, suggesting additional techniques (whole genome/RNA sequencing) may be required to fully characterise these diseases and identify new therapeutic targets. [Table: see text]

Long-term responders to palliative chemotherapy for advanced biliary tract cancer

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Background: Standard palliative chemotherapy (PC) in patients (pts) with Advanced Biliary Tract Cancer (ABTC) since publication of ABC-02 study in 2010 is cisplatin/gemcitabine (cis/gem), with median overall survival (OS) of 11.7 months. Prior to this, institutional standard was gemcitabine/fluoropyrimidine combination. From the ABC-02 study, 8 cycles of PC is standard. Some pts benefit from continuing PC longer than 8 cycles. Methods: Pts treated for ABTC in Princess Margaret Cancer Centre between 06/1987 and 09/2015, receiving > 8 cycles of PC were included for analysis. Data was collected on demographics, clinicopathologic features, PC regimen, toxicities, and survival. Results: Of 553 pts who received PC, 119 pts met inclusion criteria of PC > 8 cycles. Median age was 60 (range 27-80). Site of tumour was ampullary in 11, distal bile duct in 14, gallbladder in 28, intrahepatic in 37, perihilar in 26, and unspecified in 3 pts. 61 (51%) required biliary stenting. 30 (25%) had definitive surgical resection at diagnosis, while 89 (75%) presented with ABTC. First-line PC regimens were cis/gem in 44 and gemcitabine/capecitabine in 62. Other regimens included gemcitabine and 5-fluorouracil alone or combined. Median time on first line PC was 10 months, with median of 12 cycles (range 9-47). 22 pts (19%) had treatment breaks > 8 weeks then restarted same PC. Any tumour shrinkage was seen in 73 pts (61%). The majority of pts discontinued PC due to disease progression (69), however 16 stopped due to toxicity such as thrombocytopenia, neutropenia, fatigue and neuropathy. At time of analysis, 103 pts had progressive disease, with median progression free survival of 11.8 months. 51 and 21 pts received second and third line chemotherapy, respectively. 27 pts are alive; median OS for the whole group was 22 months (95%CI 18.7-27.3 months). Conclusions: A cohort of ABTC pts continued to derive benefit from chemotherapy beyond 8 cycles, with median OS considerably greater than that seen in clinical trials. Toxicities were mostly manageable, with treatment breaks from PC for relief of side-effects observed. Further exploration of factors prognostic and predictive for continued benefit from PC will be explored and updated at presentation.

What is the role of comorbidity, frailty, and functional status in the decision-making process for older adults with cancer and their family members, oncologists, and family physician?

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Background: Little is known about the treatment decision making process (TDMP) in older adults (OA) with cancer. The objective of this study is to develop a theoretical framework with the aim to improve the TDMP for this population. Methods: This is a mixed methods multi-perspective longitudinal study. OAs aged > 70 years with advanced prostate, breast, colorectal, or lung cancer, their family members, oncologists and family physicians are invited to participate in individual, semi-structured interviews. Each OA also completes a short survey to characterize their health, functional status, frailty level, decision-making preferences, and satisfaction with the TDMP. The sample is stratified on age (70-79 and 80+) to obtain data saturation for the oldest old. All interviews will be analyzed using the grounded-theory approach. Results: To date, 32 first interviews and 15 second interviews have been completed with 32 older adults, 21 family members and 12 family physicians and 7 cancer specialists. Interviews lasted between 10-60 minutes. Most older adults felt that they should have the final say in the treatment decision, but strongly valued their physician’s opinion. Most participants felt they received enough information, time and support from the oncologist to make their decision. About half the participants went to see their family physician to talk about the diagnosis and plan. Comorbidity and potential side-effects did not play a major role in the decision-making processes for patients and families but it did for oncologists. Family physicians reported they were not involved in treatment decisions, and they preferred more timely information about the patient. Conclusions: This study-in-progress is examining the TDMP from four different perspectives and examining changes over time in the TDMP. Patients and family members were generally satisfied with the treatment decision making process. Final results will be presented at the conference.

Intensity of palliative care and its impact on the aggressiveness of end-of-life care in patients with advanced pancreatic cancer

9518

Background: Quality indicators have been developed to avoid overly aggressive care in patients with advanced cancer. Specialized palliative care (PC) may reduce overly aggressive care in patients with advanced pancreatic cancer. Our objective was to examine the impact of the intensity of specialized PC (defined as a physician consultation focusing on PC needs, lasting at least 40 minutes) on (a) use of chemotherapy within 14 days of death; (b) more than one emergency department (ED) visit; (c) more than one hospitalization; and (d) at least one intensive care unit (ICU) admission, all within 30 days of death. Methods: A retrospective population-based cohort study using linked administrative databases in Ontario, Canada was conducted with patients diagnosed with advanced pancreatic cancer from Jan 1 2005 to Dec 31 2010. Multivariable logistic regression analyses were performed with the above quality indicators as the outcomes of interest and the intensity of PC visits as the exposure, adjusting for other variables (age, sex, comorbidity, rurality, and health region). Intensity of PC was defined in both absolute numbers (ie 0, 1, 2, 3+ visits) and rate of visits per month. Results: Of 6076 patients with advanced pancreatic cancer, 5381 had died at last followup. 2816 (52%) received a PC consultation, 218 (4%) received chemotherapy near death, 234 (4%) patients went to the ICU near death, 993 (18%) had multiple ED visits near death, and 447 (8%) had multiple hospitalizations near death. 2565 (48%) had 0 PC visits, 513 (10%) had 1, 555 (10%) had 2, and 1748 (32%) had 3 or more. In multivariable analyses, having had one PC consultation was associated with a lower odds of ICU admission near death (odds ratio (OR) 0.25; 95% CI 0.13-0.46), multiple ED visits near death (OR 0.44; 95% CI 0.33-0.58), and multiple hospitalizations near death (OR 0.47; 95% CI 0.33-0.69). Two PC visits were associated with a lower OR for chemotherapy near death (OR 0.26; 95% CI 0.14-0.51). Using the monthly PC visit rate, a higher rate was associated with less aggressive care for each outcome. Conclusions: In patients with advanced pancreatic cancer, more intensive PC involvement is associated with less frequent overly aggressive care.

Serious adverse events among a population-based cohort of patients receiving first-line chemotherapy for metastatic colorectal cancer (mCRC)

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Background: Little is known about the toxicity of first line chemotherapy for mCRC in the general population. We sought to determine the proportion of patients who experienced at least one of the following: a serious toxicity (defined as an emergency department visit or hospitalization) or death within 30 days of receiving chemotherapy. Methods: All patients, age 18 or older, diagnosed with CRC from January 1 2007 to December 31 2009 in Ontario, Canada were identified using the Ontario Cancer Registry. Patient records were linked deterministically to multiple provincial healthcare databases to identify receipt of first-line chemotherapy for metastatic disease and to evaluate Emergency Department (ED) visits, hospitalizations, and deaths. An event was determined to be potentially treatment related if it occurred within 30 days of any cycle of chemotherapy. Results: The cohort contained 2359 patients. Mean age was 62 (range 19-89) and 59% were men. See table below. Conclusions: A significant proportion of patients visit the ED at some point during first line chemotherapy and many are hospitalized. A quarter of all patients had a hospital admission whereby an infectious complication was at least a contributing diagnosis. A significant minority of patients died within 30 days of receiving chemotherapy, raising concerns of either poor patient selection or severe treatment toxicity. [Table: see text]