Docetaxel, Oxaliplatin, and 5-Fluorouracil (DOF) in Metastatic and Unresectable Gastric/Gastroesophageal Junction Adenocarcinoma: A Phase II Study with Long-Term Follow-Up

Lessons Learned.

Adding docetaxel to the modified FOLFOX7 backbone (DOF) is a feasible three‐drug combination therapy for advanced gastric cancer with high activity, providing evidence that leucovorin is not necessary in this setting.

The DOF regimen represents an alternative to the FLOT (5‐FU 2,600 mg/m² as 24‐hour infusion with leucovorin 200 mg/m², oxaliplatin 85 mg/m², and docetaxel 50 mg/m²) regimen that can be considered in select patients with advanced gastric cancer and is a potential choice in the curative setting.

Background.

The combination of docetaxel, cisplatin, and 5‐fluorouracil (5‐FU) demonstrates high response rates in advanced gastric cancer, albeit with increased toxicity. Given the efficacy of platinum‐taxane‐fluoropyrimidine regimens, this phase II study evaluated the efficacy and toxicity of docetaxel, oxaliplatin, and 5‐FU (DOF) for the treatment of metastatic or unresectable gastric or gastroesophageal junction (GEJ) adenocarcinoma.

Methods.

Patients with metastatic or unresectable gastric or GEJ adenocarcinoma with no prior therapy for metastatic disease received docetaxel 50 mg/m² on day 1, oxaliplatin 85 mg/m² on day 1, and 5‐FU 2,400 mg/m² continuous intravenous infusion over 46 hours; cycles were repeated every 2 weeks. The primary endpoint was overall response rate (ORR).

Results.

Forty‐four patients were enrolled. Assessment of treatment response and toxicity was feasible in 41 and 43 patients, respectively. ORR was 73.2% (68.3% partial response; 4.9% complete response). Therapy was discontinued for progressive disease in 53%, toxicity in 26%, and death on treatment in 16%. Two patients underwent surgical resection. Thirty‐three patients (76.7%) received at least seven cycles (7–34). Grade 3–4 toxicities occurred in 31 patients (72.1%), including neutropenia (23.3%), neurologic (20.9%), and diarrhea (14.0%). Median overall survival was 10.3 months.

Conclusion.

DOF demonstrates a high response rate, expected safety profile, and prolonged survival and remains an option for select patients with unresectable or metastatic gastric or GEJ adenocarcinoma.

HSR19-094: A Comparison of Cancer Burden and Funding From the National Cancer Institute and Nonprofit Organizations Reveals Disparities in the Distribution of Funding Across Cancer Types

Background: National Cancer Institute (NCI) and nonprofit organization (NPO) funding have driven recent advancements in oncology through research and advocacy. However, some cancers may be underfunded relative to their burden. This study examined the alignment of cancer burden by histology with NCI and NPO funding for each histology. Methods: The GuideStar database was used to find all cancer NPOs with >$5 million (M) in annual revenue (AR) using NTEE codes and 165 cancer-related search terms. Care delivery NPOs were excluded. NPOs were classified by the histology they support. AR was obtained from IRS Form 990s for each NPO. NCI funding allocation across histologies was obtained from the NCI Funded Research Portfolio data. Total funding for each histology was calculated by adding the NCI funding and the ARs for all NPOs in that histology. Cancer burden based on annual incidence, deaths, and person-years of life lost (PYLL) was obtained from SEER data. Comparison of total NCI and NPO funding with incidence, deaths, and PYLL of each histology was done using descriptive statistics and Pearson correlation coefficients. Results: 119 NPOs with total AR of $6 billion were included. 59 (50%) were histology agnostic and accounted for $4.6 billion (76.8%) of total AR. Cancers with the most NPOs were breast (13, 11%), pediatric (13, 11%), leukemia (4, 3.4%) and lung (4, 3.4%). There were no NPOs with AR >$5 M for esophageal, gastric, kidney, or bladder cancers. Cancers with the most combined NCI and NPO funding were breast ($1 billion), leukemia ($448 M), lung ($348 M), and prostate ($303 M). The ratios of combined NCI and NPO funding vs incidence, mortality, and PYLL are shown in Table 1. Cancers with the best funding vs incidence were leukemia, ovarian, and breast. Cancers with the best funding vs deaths were breast, leukemia, and melanoma. Cancers with the best funding vs PYLL were breast, leukemia, and prostate. Colon, liver, lung, and bladder cancers were poorly funded in all 3 metrics. The correlation coefficients between funding and incidence, deaths, and PYLL were 0.74, 0.34, and 0.36, respectively. Conclusions: There is substantial support for cancer research and advocacy in both the government and nonprofit sectors. While funding by cancer type was moderately proportional to incidence, it was poorly correlated with deaths and PYLL. There is significant need to increase awareness and support for many under-supported, but common and highly lethal cancers.

Magnetic resonance imaging monitoring therapeutic response to dendritic cell vaccine in murine orthotopic pancreatic cancer models

Pancreatic ductal adenocarcinoma (PDAC) carries the worst prognosis and caused one of the highest cancer-related mortalities. Dendritic cell (DC) vaccination is a promising cancer immunotherapy; however, the clinical outcomes are often poor. The administration route of DC vaccine can significantly alter the anti-tumor immune response. Here we report on the cytotoxic T lymphocyte (CTL) responses induced by DC vaccination administered via intraperitoneal (IP) for murine PDAC, and the longitudinal assessment of tumor growth and therapeutic responses using magnetic resonance imaging (MRI). In this study, we established murine orthotopic Panc02 models of PDAC and delivered apoptotic Panc02 cell-pulsed DCs via IP injection. The migration of Panc02-pulsed DCs into spleens significantly increased from 6 h to 12 h after initiation of treatment (P = 0.002), and Panc02-pulsed DCs injected via IP induced a significantly higher level of CTL responses against Panc02 cells compared to unpulsed DCs. Tumor size and tumor apparent diffusion coefficient (ADC) were measured on MR images. Tumor sizes were significantly smaller in the treated mice than in the untreated mice (P < 0.05). The reduction of tumor ADC was less in the treated mice than in the untreated mice (P < 0.05), and the changes in tumor ADC showed significant negative correlation with the changes in tumor volume (r = -0.882, 95% confidence interval, -0.967 to -0.701, P < 0.0001). These results demonstrated the efficacy of DC vaccination administered via IP injection in murine PDAC, and the feasibility of ADC measurement as an imaging biomarker for assessment of therapeutic responses in immunotherapy.

Financial toxicity in cancer care: Prevalence, causes, consequences, and reduction strategies

Financial toxicity is the adverse impact of a cancer diagnosis on a patient's financial well-being resulting from direct or indirect costs. Potential consequences of financial toxicity include material loss, psychological distress, and/or maladaptive coping strategies. This review will summarize the prevalence, causes, and consequences of financial toxicity, with an emphasis on strategies to anticipate and reduce its burden. Improvement will require multilevel, coordinated efforts between stakeholders including patients, providers, health systems, payers, manufacturers, and policymakers.

Piloting a Financial Counseling Intervention for Patients With Cancer Receiving Chemotherapy

PURPOSE

National organizations encourage communication about costs of cancer care; however, few data are available on health system models for identifying and assisting patients with financial distress (FD). We report the feasibility and acceptability of a financial counseling (FC) intervention for patients who receive chemotherapy at a comprehensive cancer center.

MATERIALS AND METHODS

Patients were randomly assigned 1:1 to FC or standard care. The FC arm received education, financial assistance screening, and an estimation tool with total billed charges and out-of-pocket (OOP) cost of one cycle of chemotherapy from a financial counselor through phone call and in-person visit. Participants completed measures of FD, health-related quality of life, and acceptability.

RESULTS

Ninety-five participants enrolled (mean age, 61 years; 72% white; 50% commercially insured), with a 32% attrition rate between assessments. Rates of completion for the phone call, in-person, and entire intervention were 98%, 47%, and 30%, respectively. The OOP estimation tool was considered understandable and acceptable to the majority of participants. No significant changes in FD were found between arms. Emotional functioning was negatively associated with having high FD (95% CI, -0.13379 to -0.013; P = .0189). Being married was associated with a decrease in log-odds of having high FD (β = -1.916; 95% CI, -3.358 to -0.475; P = .0092).

CONCLUSION

Implementation of an FC program that provides transparent cost data is feasible and acceptable. Incorporation of FC into clinical workflow, including phone counseling, is important to improve feasibility. Additional work is needed to develop tailored educational materials that are patient specific.

Pembrolizumab for the treatment of gastric cancer

INTRODUCTION

Gastric cancer is one of a few gastrointestinal malignancies in which immunotherapy has shown meaningful activity. Pembrolizumab is the first and only immune checkpoint inhibitor to be FDA-approved in gastric cancer. Areas Covered: This review summarizes the current and emerging clinical evidence for immune checkpoint inhibitors in advanced and metastatic gastric cancer, with a focus on pembrolizumab. Expert Commentary: Pembrolizumab has shown impressive activity in the third-line treatment of locally advanced and metastatic gastric cancer. It is currently being studied as upfront therapy in combination with chemotherapy. The emerging understanding of the molecular alterations and tumor immune microenvironment as predictors of immunotherapy response in gastric cancer are discussed. The impact of gastric mucosal dysbiosis on gastric carcinogenesis and the modulation of immunotherapy response by the gut microbiome are also reviewed.

Institutional decision to adopt Y90 as primary treatment for hepatocellular carcinoma informed by a 1,000-patient 15-year experience

Yttrium-90 transarterial radioembolization (TARE) is a locoregional therapy (LRT) for hepatocellular carcinoma (HCC). In this study, we present overall survival (OS) outcomes in a 1,000-patient cohort acquired over a 15-year period. Between December 1, 2003 and March 31, 2017, 1,000 patients with HCC were treated with TARE as part of a prospective cohort study. A comprehensive review of toxicity and survival outcomes was performed. Outcomes were stratified by baseline Child-Pugh (CP) class, United Network for Organ Sharing (UNOS), and Barcelona Clinic Liver Cancer (BCLC) staging systems. Albumin and bilirubin laboratory toxicities were compared to baseline. OS outcomes were reported using censoring and intention-to-treat methodologies. All treatments were outpatient, with a median one treatment per patient. Five hundred six (51%) were CP A, 450 (45%) CP B, and 44 (4%) CP C. Two hundred sixty-three (26%) patients were BCLC A, 152 (15%) B, 541 (54%) C, and 44 (4%) D. Three hundred sixty-eight (37%) were UNOS T1/T2, 169 (17%) T3, 147 (15%) T4a, 223 (22%) T4b, and 93 (9%) N/M. In CP A patients, censored OS for BCLC A was 47.3 (confidence interval [CI], 39.5-80.3) months, BCLC B 25.0 (CI, 17.3-30.5) months, and BCLC C 15.0 (CI, 13.8-17.7) months. In CP B patients, censored OS for BCLC A was 27 (CI, 21-30.2) months, BCLC B 15.0 (CI, 12.3-19.0) months, and BCLC C 8.0 (CI, 6.8-9.5) months. Forty-nine (5%) and 110 (11%) patients developed grade 3/4 albumin and bilirubin toxicities, respectively.

CONCLUSION

Based on our experience with 1,000 patients over 15 years, we have made a decision to adopt TARE as the first-line transarterial LRT for patients with HCC. Our decision was informed by prospective data and incrementally reported demonstrating outcomes stratified by BCLC, applied as either neoadjuvant or definitive treatment. (Hepatology 2017).

From the Past to the Present: Insurer Coverage Frameworks for Next-Generation Tumor Sequencing

Next-generation sequencing promises major advancements in precision medicine but faces considerable challenges with insurance coverage. These challenges are especially important to address in oncology in which next-generation tumor sequencing (NGTS) holds a particular promise, guiding the use of life-saving or life-prolonging therapies. Payers' coverage decision making on NGTS is challenging because this revolutionary technology pushes the very boundaries of the underlying framework used in coverage decisions. Some experts have called for the adaptation of the coverage framework to make it better equipped for assessing NGTS. Medicare's recent decision to cover NGTS makes this topic particularly urgent to examine. In this article, we discussed the previously proposed approaches for adaptation of the NGTS coverage framework, highlighted their innovations, and outlined remaining gaps in their ability to assess the features of NGTS. We then compared the three approaches with Medicare's national coverage determination for NGTS and discussed its implications for US private payers as well as for other technologies and clinical areas. We focused on US payers because analyses of coverage approaches and policies in the large and complex US health care system may inform similar efforts in other countries. We concluded that further adaptation of the coverage framework will facilitate a better suited assessment of NGTS and future genomics innovations.

First-line systemic treatment adherence, healthcare resource utilization, and costs in patients with gastrointestinal neuroendocrine tumors (GI NETs) in the USA

AIMS

To assess treatment adherence, healthcare resource utilization, and costs in gastrointestinal neuroendocrine tumor (GI NET) patients initiating pharmacologic treatments in the US.

METHODS

In two US commercial claims databases, patients ≥18 years with ≥1 inpatient or ≥2 outpatient GI NET claims within 12 months were identified. The first claim for pharmacologic treatments (e.g. somatostatin analogs [SSAs], cytotoxic chemotherapy [CC], targeted therapy [TT]) following diagnosis, between July 1, 2009 - December 31, 2014, was defined as the index date. A 6-month pre-index NET treatment-free period, and ≥1-year post-index enrollment were required. Proportion of days covered (PDC) was calculated during the follow-up period. Outcomes were reported separately for patients with 1- and 2-years post-index enrollment. Descriptive statistics, including means, standard deviations, and frequencies and percentages for continuous and categorical data, respectively, were reported.

RESULTS

Of 1,322 patients with 1-year follow-up, 847 initiated SSA, 397 CC, 35 TT, two interferon, and 41 various combinations. Mean (SD) PDC was 0.669 (0.331) for SSA, 0.466 (0.236) for CC, and 0.505 (0.328) for TT. Mean (SD) office visits and hospitalizations, respectively, were 20.5 (13.5) and 0.59 (1.03) for SSA, 30.5 (19.8) and 0.89 (1.45) for CC, and 17.7 (12.5) and 1.23 (1.93) for TT. Total annual cost for patients during year 1 was $99,691 (82,423) for SSA, $134,912 (116,078) for CC, and $158,397 (82,878) for TT. Among 685 patients with 2-years follow-up, annual mean costs in year 2 were $8,071, $58,944, and $36,248 lower than year 1 for SSA, CC, and TT, respectively.

LIMITATIONS

Findings may not be generalizable to the US population. Claims are designed for reimbursement, not research. The study may under-estimate costs not covered by insurance.

CONCLUSION

This study reports utilization and costs associated with different treatment therapies. Costs were higher in year 1 than year 2. This two-database study offers new information on the magnitude and trends in the cost of pharmacologically-treated GI NETs.

Abstract CT062: A phase I dose escalation study of trifluridine and tipiracil (FTD/TPI) in combination with irinotecan (IRI) in patients with advanced gastrointestinal (GI) tumors

Background: FTD/TPI combines a thymidine-based nucleoside analog, FTD, and a thymidine phosphorylase inhibitor, TPI, and is approved for previously treated patients with metastatic colorectal cancer (mCRC). Preclinical results with FTD/TPI indicated additive antitumor activity with IRI. The primary objectives of this Phase I study were to determine the safety, maximum tolerated dose (MTD), and dose-limiting toxicity (DLT) of combined FTD/TPI and IRI treatment in patients with advanced GI tumors.

Methods: Patients aged ≥18 years with advanced GI tumors who were refractory to ≥1 line of chemotherapy were included. Patients were excluded if they had received any prior IRI dose reductions, dose delay, or growth factor support in the first 8 weeks of treatment with IRI. Escalating doses of FTD/TPI (20, 25, 30, or 35 mg/m2/dose BID p.o.) and IRI (30-minute i.v. infusion of 120, 150, or 180 mg/m2/dose) were administered using a standard 3+3 design. FTD/TPI was given on days 1-5 of 14-day cycles; IRI on day 1 of each cycle. DLT was assessed during the first 28 days.

Results: 26 patients were enrolled and assigned to 6 treatment cohorts consisting of 3-6 patients per cohort. The most common cancer types were colon (54%) and rectal (27%). All patients initiated treatment but 3 patients were not evaluable for DLT (2 patients had disease-related complications and 1 was ineligible). The majority (65%) of patients had received ≥4 lines of prior systemic therapies and 25/26 patients initiated cycle 3. Two patients in the dose-escalation phase were IRI-naïve. Mean relative dose intensities (ratio to planned) for FTD/TPI and IRI during the first 2 cycles were 92% and 93%, respectively. Two DLTs (grade 3 fatigue and grade 2 neutropenia resulting in a &gt;2-week delay to cycle 3) were observed in the FTD/TPI 30 mg/m2 and IRI 180 mg/m2 cohort. Thus, the MTD was FTD/TPI 25 mg/m2 and IRI 180 mg/m2. Based on a data cut-off point for the dose-escalation phase (March 22, 2016), grade ≥3 adverse events were reported in 15 patients (58%); the most common were fatigue (15%), nausea (11%), and vomiting (11%). Of 25 patients (data missing for 1 patient due to early discontinuation), the most common laboratory abnormalities that worsened from baseline were leukocytes (28%), neutrophils (24%), lymphocytes (20%), hemoglobin (16%), and hypokalemia (12%).

Conclusions: In patients with advanced GI tumors, the safety findings of FTD/TPI in combination with IRI were consistent with the existing safety profiles of these drugs. The MTD was declared as FTD/TPI 25 mg/m2 and IRI 180 mg/m2. Further safety, pharmacokinetic, and efficacy (with bevacizumab) analyses in patients with mCRC are complete and will be presented at a later date.

Citation Format: Anna M. Varghese, Dana B. Cardin, Jon Hersch, Al B. Benson, Howard S. Hochster, Robert Winkler, Fabio Benedetti, Kensuke Hamada, Jordan D. Berlin, Leonard Saltz. A phase I dose escalation study of trifluridine and tipiracil (FTD/TPI) in combination with irinotecan (IRI) in patients with advanced gastrointestinal (GI) tumors [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2018; 2018 Apr 14-18; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2018;78(13 Suppl):Abstract nr CT062.

Pancreatic Adenocarcinoma, Version 2.2017, NCCN Clinical Practice Guidelines in Oncology

Ductal adenocarcinoma and its variants account for most pancreatic malignancies. High-quality multiphase imaging can help to preoperatively distinguish between patients eligible for resection with curative intent and those with unresectable disease. Systemic therapy is used in the neoadjuvant or adjuvant pancreatic cancer setting, as well as in the management of locally advanced unresectable and metastatic disease. Clinical trials are critical for making progress in treatment of pancreatic cancer. The NCCN Guidelines for Pancreatic Adenocarcinoma focus on diagnosis and treatment with systemic therapy, radiation therapy, and surgical resection.

Epidemiology of Anal Canal Cancer

Anal cancer is a rare malignancy, although its incidence has been increasingly in recent decades. This article discusses risk factors for anal cancer and how these risk factors affect the changing demographics of this disease.

NCCN Guidelines Insights: Colon Cancer, Version 2.2018

The NCCN Guidelines for Colon Cancer provide recommendations regarding diagnosis, pathologic staging, surgical management, perioperative treatment, surveillance, management of recurrent and metastatic disease, and survivorship. These NCCN Guidelines Insights summarize the NCCN Colon Cancer Panel discussions for the 2018 update of the guidelines regarding risk stratification and adjuvant treatment for patients with stage III colon cancer, and treatment of BRAF V600E mutation-positive metastatic colorectal cancer with regimens containing vemurafenib.

Real-World Treatment Patterns for Lung Neuroendocrine Tumors: A Claims Database Analysis

OBJECTIVE

The aim of this study was to describe real-world lung neuroendocrine tumor (NET) treatment patterns.

METHODS

This study examined cytotoxic chemotherapy (CC), somatostatin analogues (SSA), targeted therapy (TT), interferon, and liver-directed therapies in 2 US claims databases. Patients ≥18 years with ≥1 inpatient or ≥2 outpatient claims for lung NET, initiating pharmacologic treatment between July 1, 2009, and June 30, 2014, were identified and followed until the end of enrollment or study end, whichever occurred first.

RESULTS

A total of 785 newly pharmacologically treated lung NET patients were identified: mean (SD) age was 58.6 (9.1) years; 54.0% were female; 78.2% started first-line therapy with CC, 18.1% with SSA, and 1.1% with TT. Mean duration of first-line treatment was 397 days for SSA, 142 days for CC, and 135 days for TT. 74.1% of patients received no pharmacological treatment beyond first-line. The most common second-line treatment was SSA.

CONCLUSIONS

Most patients received CC as first-line treatment, with SSA being less common. SSA-treated patients remained on therapy for > 1 year, compared to < 5 months for CC. The high proportion of patients using chemotherapy and the low proportion receiving second-line treatment seems consistent with treatment guidelines for small cell lung cancer rather than for NET. Future studies are warranted to describe reasons for treatment choice, discontinuation, and switching.

Nut Consumption and Survival in Patients With Stage III Colon Cancer: Results From CALGB 89803 (Alliance)

Purpose

Observational studies have reported increased colon cancer recurrence and mortality in patients with states of hyperinsulinemia, including type 2 diabetes, obesity, sedentary lifestyle, and high glycemic load diet. Nut intake has been associated with a lower risk of type 2 diabetes, metabolic syndrome, and insulin resistance. However, the effect of nut intake on colon cancer recurrence and survival is not known.

Patients and Methods

We conducted a prospective, observational study of 826 eligible patients with stage III colon cancer who reported dietary intake on food frequency questionnaires while enrolled onto a randomized adjuvant chemotherapy trial. Using Cox proportional hazards regression, we assessed associations of nut intake with cancer recurrence and mortality.

Results

After a median follow-up of 6.5 years, compared with patients who abstained from nuts, individuals who consumed two or more servings of nuts per week experienced an adjusted hazard ratio (HR) for disease-free survival of 0.58 (95% CI, 0.37 to 0.92; P_trend = .03) and an HR for overall survival of 0.43 (95% CI, 0.25 to 0.74; P_trend = .01). In subgroup analysis, the apparent benefit was confined to tree nut intake (HR for disease-free survival, 0.54; 95% CI, 0.34 to 0.85; P_trend = .04; and HR for overall survival, 0.47; 95% CI, 0.27 to 0.82; P_trend = .04). The association of total nut intake with improved outcomes was maintained across other known or suspected risk factors for cancer recurrence and mortality.

Conclusion

Diets with a higher consumption of nuts may be associated with a significantly reduced incidence of cancer recurrence and death in patients with stage III colon cancer.

Phase 2 study of treatment selection based on tumor thymidylate synthase expression in previously untreated patients with metastatic colorectal cancer: A trial of the ECOG-ACRIN Cancer Research Group (E4203)

BACKGROUND

The authors hypothesized that patients with metastatic colorectal cancer (mCRC) who had tumors with low thymidylate synthase (TS-L) expression would have a higher response rate to combined 5-fluorouracil, leucovorin, and oxaliplatin (FOLFOX) plus bevacizumab (FOLFOX/Bev) than those with high TS (TS-H) expression and that combined irinotecan and oxaliplatin (IROX) plus bevacizumab (IROX/Bev) would be more effective than FOLFOX/Bev in those with TS-H tumors.

METHODS

TS protein expression was determined in mCRC tissue. Patients who had TS-L tumors received FOLFOX/Bev, and those who had TS-H tumors were randomly assigned to receive either FOLFOX/Bev or IROX/Bev. The primary endpoint was the response rate (complete plus partial responses).

RESULTS

In total, 211 of 247 patients (70% TS-H) were registered to the treatment phase. Efficacy analyses included eligible patients who had started treatment (N = 186). The response rates for patients who received IROX/Bev (TS-H), FOLFOX/Bev (TS-H), and FOLFOX/Bev (TS-L) were 33%, 38%, and 49%, respectively (P = nonsignificant). The median progression-free survival (PFS) was 10 months (95% confidence interval [CI], 9-12 months; 10 months in the IROX/Bev TS-H group, 9 months in the FOLFOX/Bev TS-H group, and 13 months in the FOLFOX/Bev TS-L group). The TS-L group had improved PFS compared with the TS-H group that received FOLFOX/Bev (hazard ratio, 1.6; 95% CI, 1.0%-2.4%; P = .04; Cox regression). The median overall survival (OS) was 22 months (95% CI, 20 29 months; 18 months in the IROX/Bev TS-H group, 21 months in the FOLFOX/Bev TS-H group, and 32 months in the TS-L group). OS comparisons for the 2 TS-H arms and for the FOLFOX/Bev TS-H versus TS-L arms were not significantly different.

CONCLUSIONS

TS expression was prognostic: Patients with TS-L tumors who received FOLFOX/Bev had a longer PFS than those with TS-H tumors, along with a trend toward longer OS. Patients with TS-H tumors did not benefit more from IROX/Bev than from FOLFOX/Bev. Cancer 2018;124:688-97. © 2017 American Cancer Society.

NCCN Guidelines Insights: Hepatobiliary Cancers, Version 1.2017

The NCCN Guidelines for Hepatobiliary Cancers provide treatment recommendations for cancers of the liver, gallbladder, and bile ducts. The NCCN Hepatobiliary Cancers Panel meets at least annually to review comments from reviewers within their institutions, examine relevant new data from publications and abstracts, and reevaluate and update their recommendations. These NCCN Guidelines Insights summarize the panel's discussion and most recent recommendations regarding locoregional therapy for treatment of patients with hepatocellular carcinoma.

Personalizing Adjuvant Therapy for Stage II/III Colorectal Cancer

This review focuses on three areas of interest with respect to the treatment of stage II and III colon and rectal cancer, including (1) tailoring adjuvant therapy for the geriatric population, (2) the controversy as to the optimal adjuvant therapy strategy for patients with locoregional rectal cancer and for patients with colorectal resectable metastatic disease, and (3) discussion of the microenvironment, molecular profiling, and the future of adjuvant therapy. It has become evident that age is the strongest predictive factor for receipt of adjuvant chemotherapy, duration of treatment, and risk of treatment-related toxicity. Although incorporating adjuvant chemotherapy for patients who have received neoadjuvant chemoradiation and surgery would appear to be a reasonable strategy to improve survivorship as an extrapolation from stage III colon cancer adjuvant trials, attempts at defining the optimal rectal cancer population that would benefit from adjuvant therapy remain elusive. Similarly, the role of adjuvant chemotherapy for patients after resection of metastatic colorectal cancer has not been clearly defined because of very limited data to provide guidance. An understanding of the biologic hallmarks and drivers of metastatic spread as well as the micrometastatic environment is expected to translate into therapeutic strategies tailored to select patients. The identification of actionable targets in mesenchymal tumors is of major interest.

Comparing the Cost of Treatment with Octreotide Long-Acting Release versus Lanreotide in Patients with Metastatic Gastrointestinal Neuroendocrine Tumors

BACKGROUND

The 2 somatostatin analogs currently recommended by the National Comprehensive Cancer Network for the treatment of gastrointestinal (GI) neuroendocrine tumors (NETs) include octreotide long-acting release (Sandostatin LAR) for injectable suspension and lanreotide (Somatuline Depot) injection for subcutaneous use.

OBJECTIVE

To estimate the costs to payers associated with 30-mg octreotide LAR and 120-mg lanreotide treatment among patients with metastatic GI-NETs.

METHODS

The costs to payers associated with the 2 drugs were estimated by including the costs of each drug, drug administration, and adverse events. The unit drug costs for octreotide LAR and for lanreotide were obtained from ReadyPrice Wholesale Acquisition Cost; the doses were obtained from published studies. The adverse event rates were obtained from 2 phase 3 clinical trials, PROMID and CLARINET. Deterministic one-way sensitivity analyses were used to assess the impact of modifying assumptions and inputs on the results, including the 2017 Average Sales Price (ASP). All costs were estimated in 2016 US dollars, with a constant discount of 3%.

RESULTS

The costs to payers associated with the treatment of GI-NETs during 1-, 3-, and 5-year horizons were $74,566, $180,082, and $262,344, respectively, for octreotide LAR and $84,856, $205,562, and $299,667, respectively, for lanreotide. Thus, octreotide LAR was associated with lower costs by $10,290 (1 year), $25,480 (3 years), and $37,323 (5 years) compared with lanreotide. Over a 5-year horizon, the costs of adverse events and administration accounted for 0.72% of the total cost for octreotide LAR and 0.51% of the total cost for lanreotide. Sensitivity analyses confirmed that the main factor affecting the cost difference was the price of the drugs; analyses using the ASP yielded similar results.

CONCLUSION

For the management of metastatic GI-NETs, the cost to payers of treatment with 30-mg octreotide LAR is considerably lower than with 120-mg lanreotide over 1-, 3-, and 5-year horizons. In the presence of healthcare resource constraints, these findings may support decision-making when considering the care of patients with metastatic GI-NETs.

Colon Cancer, Version 1.2017, NCCN Clinical Practice Guidelines in Oncology

This portion of the NCCN Guidelines for Colon Cancer focuses on the use of systemic therapy in metastatic disease. Considerations for treatment selection among 32 different monotherapies and combination regimens in up to 7 lines of therapy have included treatment history, extent of disease, goals of treatment, the efficacy and toxicity profiles of the regimens, KRAS/NRAS mutational status, and patient comorbidities and preferences. Location of the primary tumor, the BRAF mutation status, and tumor microsatellite stability should also be considered in treatment decisions.

An Intergroup Randomized Phase II Study of Bevacizumab or Cetuximab in Combination with Gemcitabine and in Combination with Chemoradiation in Patients with Resected Pancreatic Carcinoma: A Trial of the ECOG-ACRIN Cancer Research Group (E2204)

OBJECTIVES

Evaluate toxicity of two treatment arms, A (cetuximab) and B (bevacizumab), when combined with gemcitabine, and chemoradiation in patients with completely resected pancreatic carcinoma. Secondary objectives included overall survival (OS) and disease-free survival (DFS).

METHODS

Patients with R0/R1 resection were randomized 1:1 to cetuximab or bevacizumab administered in combination with gemcitabine for two treatment cycles. Next three cycles included concurrent cetuximab/bevacizumab plus chemoradiation, followed by one cycle of cetuximab/bevacizumab. Cycles 7-12 included cetuximab/bevacizumab with gemcitabine. Cycles were 2 weeks. Frequency of specific toxicities was summarized for each treatment arm at two times during the study, after chemotherapy but prior to chemoradiation and after all therapy.

RESULTS

A total of 127 patients were randomized (A, n = 65; B, n = 62). Prior to chemoradiation, the overall rate for toxicities of interest was 10% for arm A and 2% for arm B. After all therapy, the overall rates for toxicities of interest were 30 and 25% for arms A and B, respectively. Overall median OS and DFS were 17 and 11 months, respectively, which is not a significant improvement over expected survival rates for historical controls.

CONCLUSIONS

Both treatments were tolerable with manageable toxicities, and were safe enough for a phase III trial had this been indicated.

Neoadjuvant Therapy for Rectal Cancer Affects Lymph Node Yield and Status Without Clear Implications on Outcome: The Case for Eliminating a Metric and Using Preoperative Staging to Guide Therapy

BACKGROUND

Nodal status has long been considered pivotal to oncologic care, staging, and management. This has resulted in the establishment of rudimentary metrics regarding adequate lymph node yield in colon and rectal cancers for accurate cancer staging. In the era of neoadjuvant treatment, the implications of lymph node yield and status on patient outcomes remains unclear.

PATIENT AND METHODS

This study included 1,680 patients with locally advanced rectal cancer from the NCCN prospective oncology database stratified into 3 groups based on preoperative therapy received: no neoadjuvant therapy, neoadjuvant chemoradiation, and neoadjuvant chemotherapy. Clinicopathologic characteristics and survival were compared between the groups, with univariate and multivariate analyses undertaken.

RESULTS

The clinicopathologic characteristics demonstrated statistically significant differences and heterogeneity among the 3 groups. The neoadjuvant chemoradiation group demonstrated the statistically lowest median lymph node yield (n=15) compared with 17 and 18 for no-neoadjuvant and neoadjuvant chemotherapy, respectively (P<.0001). Neoadjuvant treatment did impact survival, with chemoradiation demonstrating increased median overall survival of 42.7 compared with 37.3 and 26.6 months for neoadjuvant chemotherapy and no-neoadjuvant therapy, respectively (P<.0001). Patients with a yield of fewer than 12 lymph nodes had improved median overall survival of 43.3 months compared with 36.6 months in patients with 12 or more lymph nodes (P=.009). Multivariate analysis demonstrated that neither node yield nor status were predictors for overall survival.

DISCUSSION

This analysis reiterates that nodal yield in rectal cancer is multifactorial, with neoadjuvant therapy being a significant factor. Node yield and status were not significant predictors of overall survival. A nodal metric may not be clinically relevant in the era of neoadjuvant therapy, and guidelines for perioperative therapy may need reconsideration.

A Blueprint to Advance Colorectal Cancer Immunotherapies

Immunotherapy is rapidly becoming a standard of care for many cancers. However, colorectal cancer had been generally resistant to immunotherapy, despite features in common with sensitive tumors. Observations of substantial clinical activity for checkpoint blockade in colorectal cancers with defective mismatch repair (microsatellite instability-high tumors) have reignited interest in the search for immunotherapies that could be extended to the larger microsatellite stable (MSS) population. The Cancer Research Institute and Fight Colorectal Cancer convened a group of scientists, clinicians, advocates, and industry experts in colorectal cancer and immunotherapy to compile ongoing research efforts, identify gaps in translational and clinical research, and provide a blueprint to advance immunotherapy. We identified lack of a T-cell inflamed phenotype (due to inadequate T-cell infiltration, inadequate T-cell activation, or T-cell suppression) as a broad potential explanation for failure of checkpoint blockade in MSS. The specific cellular and molecular underpinnings for these various mechanisms are unclear. Whether biomarkers with prognostic value, such as the immunoscores and IFN signatures, would also predict benefit for immunotherapies in MSS colon cancer is unknown, but if so, these and other biomarkers for measuring the potential for an immune response in patients with colorectal cancer will need to be incorporated into clinical guidelines. We have proposed a framework for research to identify immunologic factors that may be modulated to improve immunotherapy for colorectal cancer patients, with the goal that the biomarkers and treatment strategies identified will become part of the routine management of colorectal cancer. Cancer Immunol Res; 5(11); 942-9. ©2017 AACR.