The positive effect of a dedicated adolescent and young adult fertility program on the rates of documentation of therapy-associated infertility risk and fertility preservation options

PURPOSE

Minimal data exist regarding documentation of therapy-associated infertility risk (IR) and fertility preservation (FP) options during the initial oncology consultation prior to systemic therapy. This study investigated factors affecting IR/FP documentation and assessed the effect of implementation of an Adolescent and Young Adult (AYA) program on documentation rates.

METHODS

A retrospective review of charts of patients receiving gonadotoxic therapy was undertaken for documentation of IR/FP pre- and post-implementation of an AYA program. Change in documentation rates was assessed using univariate and multiple logistic regression.

RESULTS

A total of 173 charts were reviewed. On univariate analysis, IR/FP documentation was less likely if patients had metastatic disease (P < 0.01, P < 0.01), by tumor type (P < 0.01, P < 0.01), received less intensive chemotherapy (P = 0.03, P = 0.06), were older (P = 0.14, P < 0.01), had more children (P < 0.01, P < 0.01), or lacked AYA program involvement (P < 0.01, P < 0.01). FP discussion was more common in males (P = 0.02). On multivariable analysis, more children (P = 0.01, P = 0.03), older age (P < 0.01, P < 0.01), tumor type (P < 0.01, P = 0.01), stage (P = 0.02, NS), relationship (P = 0.03, NS), and lack of AYA involvement (P < 0.01, P < 0.01) were associated with lower rates of IR/FP documentation. Following AYA program implementation, IR/FP rates increased from 56% (CI 46-65%) to 85% (CI 74-92%, P < 0.01) and 54% (CI 45-64%) to 86% (CI 75-93%, P < 0.01), respectively. The effect of AYA program implementation on IR/FP documentation was most noticeable in leukemia, lymphoma, and breast groups (P < 0.01).

CONCLUSIONS

Implementing an AYA consultation service at an adult cancer institution had a positive effect on the rates of IR/FP documentation. Specific programming can improve service delivery to AYA cancer patients, and fertility counseling should be integrated for patients undergoing gonadotoxic therapy.

Second-line Chemotherapy in Older Patients With Metastatic Urothelial Carcinoma: Pooled Analysis of 10 Second-line Studies

BACKGROUND

Older patients with metastatic urothelial carcinoma (UC) are under-represented in clinical trials, and data regarding outcomes for second-line therapy is limited.

MATERIALS AND METHODS

Individual data for patients with metastatic UC, aged ≥ 70 years, were pooled from 10 second-line studies. The influence of potential prognostic factors on overall survival (OS) was assessed via univariate and multivariate Cox regression analysis.

RESULTS

In total, 102 patients were included; the median age was 74.0 years (range, 70-88 years). Second-line chemotherapy was single-agent in 42 (41%) patients and combination regimens in 60 (59%) patients. Median progression-free and OS were 4.3 and 9.7 months, respectively. In multivariate analysis, age > 75 years, Eastern Cooperative Oncology Group performance status ≥ 1, serum hemoglobin < 10 g/dL, and non-lymph node only metastasis predicted inferior OS. Median OS for patients with 0, 1, 2, and ≥ 3 adverse factors was unreached, 15.5, 9.8, and 4.8 months, respectively (P < .001). There was no difference in OS between patients treated with single-agent or combination chemotherapy. Combination regimens were associated with higher occurrences of any ≥ grade 2 toxicity (80% vs. 38%; P < .001), ≥ grade 2 hematologic (78% vs. 12%; P < .001), and ≥ grade 2 gastrointestinal toxicity (36% vs. 7%; P < .001).

CONCLUSION

In this pooled analysis of older patients with metastatic UC, combination chemotherapy for second-line treatment was associated with greater toxicity without improvement in OS. Eastern Cooperative Oncology Group performance status ≥1, serum hemoglobin < 10 g/dL, and age > 75 years predicted worse survival, whereas isolated lymph node metastasis predicted a favorable outcome.

Abstract 5287: Heterogeneity of mutation calling and annotation: a survey of cancer next-generation sequencing initiatives by the Global Alliance for Genomics and Health (GA4GH)

Although genomic data sharing is widely endorsed, practical barriers exist. For example, annotation and calling of mutations vary significantly with the method used. This poses clear challenges in data harmonization and sharing. In this setting, GA4GH conducted a survey of Cancer Next Generation Sequencing (NGS) initiatives globally to chart the technical implementation of genomic programs.

A total of 59 of 108 invited initiatives responded (response rate = 55%) via a web-based survey. In total, 63% of programs share their data, and 10% are partially sharing or planning to share. Most initiatives were North American (33%) or European (28%) based. Of the 59 respondents, 51 responded to queries on technical aspects of their NGS program (Table 1). For diagnostic application, 67% employ a small panel (&lt;50 genes), 55% a medium panel (50-250 genes), 45% a large panel (251-1000 genes); only 22% indicated they (also) use whole exome sequencing (WES). Diagnostic programs tend to favor panels and deep sequencing, while research programs favor WES/WGS. Overall, mutation and copy number calls were stored centrally in a single project database (96% and 92% respectively), with lower rates for raw data (BAM files, 86%) and histological data (75%). Somatic mutations were identified primarily via GATK (57%), Samtools (49%), Varscan (47%), MuTect (40%); all but 7 initiatives used combinations of these tools. Mutational variants were annotated by Cosmic (73%), PolyPhen (66%), and dbSnp (64%). Germline samples were used as control in only 62% of initiatives.

In conclusion, the majority of initiatives use an ensemble of tools for calling and annotating mutational variants. Harmonization efforts on gene panel composition and the standardization of tools (eg, methods, application program interfaces (APIs)) are urgently needed to prevent continued generation of isolated data silos that hamper NGS-enabled advances in precision medicine. Primary purpose of test% Diagnostic (n = 9)% Research (n = 22)% Diagnostic & Research (n = 20)OrganizationCentralized testing22%64%30%Unique sample identifiers89%77%70%Certification ISO/CLIA/NE88%45%65%Initiative &gt; 1000 Patients33%36%35%SequencingSequencing depth 50-250x0%55%80%Sequencing depth &gt;250x100%45%20%Panel sequencing89%68%60%Whole Exome/Genome Sequencing22%77%65%SamplesFresh frozen (FF)11%23%15%Formalin Fixed Paraffin Embedded (FFPE)44%27%20%FFPE or FF44%50%65%Germline as control22%68%65%

Citation Format: Daniel J. Vis, Jeremy Lewin, Lillian Siu, Rachel Liao, Jean Claude Zenklusen, Fabien Calvo, Edit Szepessy, Ana Vivancos, Valtteri Wirta, Subha Madhavan, Keunchil Park, Daniel Tan, Janessa Laskin, Melissa Brammer, Emmanuel Dias-Neto, Anthony Tolcher, Thomas J. Hudson, Charles Sawyers, Mark Lawler, Emile E. Voest. Heterogeneity of mutation calling and annotation: a survey of cancer next-generation sequencing initiatives by the Global Alliance for Genomics and Health (GA4GH). [abstract]. In: Proceedings of the 107th Annual Meeting of the American Association for Cancer Research; 2016 Apr 16-20; New Orleans, LA. Philadelphia (PA): AACR; Cancer Res 2016;76(14 Suppl):Abstract nr 5287.

Abstract 1832: Large variations in clinical and ethical aspects of genomic sequencing initiatives: A Global Alliance for Genomics and Health (GA4GH) survey

Although next generation sequencing (NGS) has expanded our understanding of disease prognostication and cancer treatment, there is heterogeneity regarding its implementation. GA4GH is a not-for-profit organization that promotes and harmonizes responsible and effective data sharing, as unconnected data silos unacceptably stall the advancement of precision medicine. The GA4GH Cancer Task Team conducted a survey of international cancer sequencing activities to evaluate variability in these initiatives and report our findings on clinical/ethical aspects.

A total of 108 sequencing initiatives were approached via a web-based survey, of which 59 responded (55%) (Characteristics: Table 1). Most initiatives (61%) were North American or European based. Genomic-based drug matching occurred in 39 initiatives (66%): unplanned opportunistic matching to existent trials e.g. phase I (n = 29), specifically designed genomics driven trials (n = 10). In matching initiatives, outcome data was collected via RECIST in 24 (62%), time on treatment in 23 (59%), and clinical assessment in 10 (26%). Toxicity data was collected in all clinical trials but in few genomic sequencing programs.

Specific or implied informed consent was identified in 34 (58%) and 7 (14%) initiatives respectively and 36 (61%) allowed re-contacting of patients. However, only 31 (53%) had a protocol for communicating genetic results and 23 (39%) had a policy to handle incidental germline mutations. In total, 63% of initiatives are currently sharing data with an additional 10% partially sharing or planning to share.

In conclusion, there is currently no uniform approach for collecting data for precision medicine application. GA4GH is actively leading harmonization efforts (e.g. standardized outcome data, toxicity data collection, policies for returning genetic results and strategies for data sharing) to maximize the value of the increasingly complex datasets generated from NGS. Table 1N (%)Number of initiatives59Regional LocationNorth America20 (34)Europe16 (27)Asia7 (12)Australia3 (5)South America3 (5)Intercontinental10 (17)Regional ScopeInstitutional (local)15 (25)Multi-institutional (regional) / National28 (48)European Union4 (7)International10 (17)Unknown2 (3)Patient Samples per Year1-50022 (37)501-500022 (37)&gt;50007 (12)Unknown8 (14)Purpose of testDiagnostic9 (15)Research22 (37)Diagnostic /Research20 (34)Unknown8 (14)

Citation Format: Jeremy Lewin, Daniel J. Vis, Mark Lawler, Rachel Liao, Mao Mao, Bin Tean Teh, William Sellers, Robyn Ward, Anamaria Aranha Camargo, Fabrice Andre, Richard Schilsky, Denis Lacombe, Tatsuhiro Shibata, Stephen Fox, Christophe Le Tourneau, William S. Dalton, Bartha Maria Knoppers, Charles Sawyers, Emile E. Voest, Lillian L. Siu. Large variations in clinical and ethical aspects of genomic sequencing initiatives: A Global Alliance for Genomics and Health (GA4GH) survey. [abstract]. In: Proceedings of the 107th Annual Meeting of the American Association for Cancer Research; 2016 Apr 16-20; New Orleans, LA. Philadelphia (PA): AACR; Cancer Res 2016;76(14 Suppl):Abstract nr 1832.

Facilitating a culture of responsible and effective sharing of cancer genome data

Rapid and affordable tumor molecular profiling has led to an explosion of clinical and genomic data poised to enhance the diagnosis, prognostication and treatment of cancer. A critical point has now been reached at which the analysis and storage of annotated clinical and genomic information in unconnected silos will stall the advancement of precision cancer care. Information systems must be harmonized to overcome the multiple technical and logistical barriers to data sharing. Against this backdrop, the Global Alliance for Genomic Health (GA4GH) was established in 2013 to create a common framework that enables responsible, voluntary and secure sharing of clinical and genomic data. This Perspective from the GA4GH Clinical Working Group Cancer Task Team highlights the data-aggregation challenges faced by the field, suggests potential collaborative solutions and describes how GA4GH can catalyze a harmonized data-sharing culture.

High-dose chemotherapy with autologous stem cell transplantation in relapsed or refractory germ cell tumours: outcomes and prognostic variables in a case series of 17 patients

BACKGROUND

Optimal therapy for men relapsing after initial chemotherapy for germ cell tumours (GCT) is poorly defined. Both conventional dose salvage regimens and high-dose chemotherapy with autologous stem cell transplantation (HDCT-ASCT) have been utilised.

AIMS

To examine patients who received HDCT-ASCT for relapsed GCT within a single Australian centre.

METHODS

Records between 2000 and 2012 were analysed for baseline characteristics, treatment-related toxicity and survival. Prognosis at the time of HDCT-ASCT was classified according to the International Prognostic Factors Study Group (IPFSG).

RESULTS

Seventeen patients received HDCT-ASCT, median age 34 (21-46), with 41% having primary refractory disease and 53% with high/very high risk disease by IPFSG. The most common regimen utilised was paclitaxel/ifosfamide followed by high-dose carboplatin/etoposide (TI-CE; n = 12). The median duration of grade 4 (G4) neutropenia was 11 days (range 9-17) with febrile neutropenia in 90% resulting in four intensive care unit admissions (8%). Median duration of G4 thrombocytopenia was 10 days (range 8-19) requiring a median of two pooled platelets bags (range 0-33) per episode. Transplant-related mortality occurred in one patient (veno-occlusive disease). Twenty-seven per cent of HDCT-ASCT cycles were associated with grade 3 mucositis (median total parenteral nutrition days = 5 (0-23)). Two-year progression-free survival (PFS) and overall survival (OS) rates were 59% and 71%. Patients who received HDCT-ASCT as second or subsequent relapse fared worse than those treated with HDCT-ASCT at first relapse (hazard ratio 0.23 (95% confidence interval: 0.04, 1.37; P-value 0.09). Three-year OS for those who received TI-CE at first relapse was 90%.

CONCLUSIONS

HDCT-ASCT for relapsed GCT is effective with acceptable toxicity. There was encouraging PFS/OS, particularly in a poor-prognosis cohort.

A phase Ib/II translational study of sunitinib with neoadjuvant radiotherapy in soft-tissue sarcoma

Background:

Preoperative radiotherapy (RT) is commonly used to treat localised soft-tissue sarcomas (STS). Hypoxia is an important determinant of radioresistance. Whether antiangiogenic therapy can ‘normalise' tumour vasculature, thereby improving oxygenation, remains unknown.

Methods:

Two cohorts were prospectively enrolled. Cohort A evaluated the implications of hypoxia in STS, using the hypoxic tracer ¹⁸F-azomycin arabinoside (FAZA-PET). In cohort B, sunitinib was added to preoperative RT in a dose-finding phase 1b/2 design.

Results:

In cohort A, 13 out of 23 tumours were hypoxic (FAZA-PET), correlating with metabolic activity (r²=0.85; P<0.001). Two-year progression-free (PFS) and overall (OS) survival were 61% (95% CI: 0.44–0.84) and 87% (95% CI: 0.74–1.00), respectively. Hypoxia was associated with radioresistance (P=0.012), higher local recurrence (Hazard ratio (HR): 10.2; P=0.02), PFS (HR: 8.4; P=0.02), and OS (HR: 41.4; P<0.04). In Cohort B, seven patients received sunitinib at dose level (DL): 0 (50 mg per day for 2 weeks before RT; 25 mg per day during RT) and two patients received DL: −1 (37.5 mg per day for entire period). Dose-limiting toxicities were observed in 4 out of 7 patients at DL 0 and 2 out of 2 patients at DL −1, resulting in premature study closure. Although there was no difference in PFS or OS, patients receiving sunitinib had higher local failure (HR: 8.1; P=0.004).

Conclusion:

In STS, hypoxia is associated with adverse outcomes. The combination of sunitinib with preoperative RT resulted in unacceptable toxicities, and higher local relapse rates.

Denosumab: a new treatment option for giant cell tumor of bone

Giant cell tumor of bone (GCTB) is an osteolytic, usually benign neoplasm characterized by infiltration with osteoclast-like giant cells, and the osteoclast differentiation factor receptor activator of nuclear factor kappa-B ligand (RANKL) is heavily involved in its pathogenesis. Denosumab belongs to a new class of drugs that inhibit RANKL. Prior to denosumab, multimodality treatment in refractory, recurrent and metastatic GCTB has shown variable results. Recent phase II data have demonstrated denosumab's activity with regard to disease and symptom control, without significant adverse effects. On the basis of this data, the FDA approved denosumab for the treatment of patients whose GCTB is unresectable, or when surgery is likely to result in severe morbidity. Ongoing questions remain, including the optimal scheduling, patient selection, use in the adjuvant setting and long-term toxicity concerns.

Intra-patient dose escalation in Ewing's sarcoma treated with vincristine, doxorubicin, cyclophosphamide alternating with ifosfamide and etoposide: a retrospective review

Background

Data suggests that males experience less toxicity and poorer survival than females treated for Ewing’s sarcoma. We instituted an intra-patient dose escalation (DE) policy with Vincristine/Doxorubicin/Cyclophosphamide (VDC) alternating with Ifosfamide/Etoposide (IE) based on hematological nadirs and report its feasibility and safety.

Methods

A retrospective review of adherence to DE guidelines and toxicities was conducted for patients who received DE with VDC/IE over 3 years at a single cancer center. Absolute neutrophil counts (ANC) was collected on days 8, 12 and 15 for cycles 1–6. DE of 10%/cycle was applied if ANC > 1.5×10⁹/L and platelet > 100×10⁹/L on all blood results. The primary endpoint was the proportion of patients who received appropriate DE. The secondary endpoint was to assess morbidity, changes in hematologic nadirs between gender and age and a comparison with a prior cohort of ESFT patients who did not receive DE. Gender comparisons were assessed via independent 2-sample t-tests assuming unequal variances. Within cycle changes in hematologic nadirs were assessed using repeated measures ANOVA. Relapse free survival and overall survival (OS) curves were estimated using the Kaplan-Meier method.

Results

23 patients were identified (mean age: 27; range 17–54). 91 decisions for DE were made (1 decision excluded because of progressive disease) with 90% concordance with guidelines. No adverse outcomes occurred as a result of the inappropriate escalation. Grade 3/4 febrile neutropenia (FN) during VDC and IE was 26.1% (6/23 patients) and 17.4% respectively with no difference for those who were DE. Males were less neutropenic after C1 and C3 of VDC compared to females (P-value C1 = 0.003; C3 = 0.005). VDC was associated with greater neutropenia on day 8 whereas IE had greater neutropenia on day 12 (P-value <0.001). During VDC, a non statistical difference in neutropenia was seen for individuals aged 15–25 (n = 13) compared with older individuals (P-value = 0.09). OS comparison for those with localized disease with a prior cohort who were not DE showed similar outcomes (P-value = 0.37).

Conclusions

DE is deliverable without increased adverse outcomes. Males have less myelosuppression during VDC, and should be especially considered for DE.

Hypoxia, angiogenic markers, and response to neoadjuvant radiotherapy in soft-tissue sarcomas

10567

Background: Hypoxia is common in soft-tissue sarcomas (STS) and may correlate with radiotherapy (RT) resistance and worse outcomes. We aimed to quantify intratumoral hypoxia with 18-fluoroazamycin arabinoside (FAZA)-PET in resectable STS and correlate this to 18-fluorodeoxyglucose (FDG)-PET, tumour response, angiogenesis biomarkers and patient (pt) outcomes. Methods: This phase II prospective study enrolled pts with resectable STS prior to neoadjuvant RT. Pts underwent FDG-PET and FAZA-PET prior to RT. Circulating and immunohistochemical (IHC) markers of hypoxia and vessel architecture were measured weekly. Response to RT was measured by surgically resected pathologic necrosis (PN), radiological response and relapse-free survival. Results: 23 pts were recruited. 47% (8/17) demonstrated hypoxia on FAZA-PET with a possible association between hypoxia and enhanced metabolic activity on FDG-PET (FDG SUVmax=15.33 with hypoxia; SUVmax=5.86 without hypoxia p=.08). FDG-PET response to RT correlated with PN (good/equivocal FDG-PET response: 59% PN; poor FDG-PET response: 19%PN p=.008). All relapses were distant (n=10) at average follow up of 5 years. Relapse was associated with higher FAZA-PET SUV (1.94 vs 1.28 p=0.02), FDG-PET SUVmax (14.4 vs 6.2 p=0.05), and poorer response to RT (PN 36% vs 66%, p=0.04). Baseline VEGF-C (531±82pg/ml, mean±SEM) were higher than VEGF-A (35±8pg/ml) and VEGF-D (131±17pg/ml), and correlated with protein expression on IHC staining. Hypoxia on FAZA-PET correlated with lower baseline VEGF-A/C (VEGF-C: (292pg/ml vs 688pg/ml p=0.16) and VEGF–A (14pg/ml vs 46pg/ml p=0.13). Low VEGF-C correlated with resistance to RT assessed by FDG-PET. In hypoxic tumors after 1 week of RT, VEGF-A and C levels were significantly increased (VEGF-A 80pg/ml vs 14pg/ml; VEGF-C 541ng/ml vs 292ng/ml). Response to RT correlated with less induction of VEGF-A/C. Relapse was associated with lower baseline VEGF and higher IHC levels of other hypoxic markers (GLUT-1, CA 9). Conclusions: In STS, hypoxia is common, measurable, predicts poorer response to RT and is associated with adverse outcomes. Circulating levels of VEGF-C, the dominant isoform, inversely correlated with hypoxia and is induced by RT.

The fluvial record of climate change

Fluvial landforms and sediments can be used to reconstruct past hydrological conditions over different time scales once allowance has been made for tectonic, base-level and human complications. Field stratigraphic evidence is explored here at three time scales: the later Pleistocene, the Holocene, and the historical and instrumental period. New data from a range of field studies demonstrate that Croll-Milankovitch forcing, Dansgaard-Oeschger and Heinrich events, enhanced monsoon circulation, millennial- to centennial-scale climate variability within the Holocene (probably associated with solar forcing and deep ocean circulation) and flood-event variability in recent centuries can all be discerned in the fluvial record. Although very significant advances have been made in river system and climate change research in recent years, the potential of fluvial palaeohydrology has yet to be fully realized, to the detriment of climatology, public health, resource management and river engineering.