HLA-haploidentical donor lymphocyte infusions for patients with relapsed hematologic malignancies after related HLA-haploidentical bone marrow transplantation

Treatment of relapse after related HLA-haploidentical T cell-replete bone marrow transplantation (haploBMT) with post-transplantation cyclophosphamide (PTCy) using haploidentical donor lymphocyte infusion (haploDLI) is not documented. All patients who received haploDLI after haploBMT with PTCy between June 2003 and October 2012 were identified and assessed for graft-versus-host disease (GVHD) and outcomes. Forty patients received 52 haploDLI doses. Sixteen patients had acute myeloid leukemia, 11 had lymphomas, and 34 had nonmyeloablative conditioning before haploBMT. The median time from haploBMT to relapse was 183 (range, 0 to 1399) days. The median age at haploDLI was 48 (range, 3 to 70) years. The first haploDLI doses were 1 × 10(5) CD3(+) cells/kg with subsequent escalation. The most commonly used first haploDLI dose was 1 × 10(6) CD3(+) cells/kg. The median follow-up after haploDLI was 7 (mean, 15.4; range, .5 to 96) months for the entire cohort, and 17.5 (mean, 28; range, 2.4 to 96) months for the responders. Acute GVHD developed in 10 patients (25%), 6 patients had grade 3 to 4, and 3 developed chronic GVHD. Twelve (30%) patients achieved a complete response (CR) with a median duration of 11.8 (mean, 22.5; range, .4 to 94) months. At last follow-up, 8 responders were alive in CR; 6 for over a year. HaploDLI for relapse after haploBMT is associated with acceptable toxicities and can result in durable responses.

Structured approach to improving wait times and overall customer service in an oncology outpatient phlebotomy department

77

Background: Demands on the Johns Hopkins phlebotomy service have increased exponentially over the past several years leading to increased patient (pt) waiting times and reduced patient and staff satisfaction. Methods: The goal of our project was to reduce waiting times for outpatient phlebotomy to <30 mins for 90% of pts by May 2013 using a multi-disciplinary lean sigma approach. The following interventions were implemented - Two weekly multidisciplinary lean sigma meetings; Move to set appointment times; Twice daily staff "huddles" to plan the work schedule; Ensure a minimum of 8 phlebotomists on duty daily; Expand training for clinical assistants (CAs) to access VADs; Introduce pager system for pts to reduce needless waiting; Introduce leadership positions among phlebotomy and CA staff to manage change. Results: Within 6 months of these concerted efforts wait times have reduced to <30 mins and patient satisfaction scores for >90% of pts are very good or excellent. Conclusions: Difficult problems such as increasing patient demand with constrained resources can be ameliorated with a multidisciplinary structured approach. The project as outlined may serve as a template for other oncology services dealing with the increasing demands of an aging population in a time of increasingly limited resources.

Measuring the impact of chemotherapy cost discussions between patients and providers at the time of prescribing

257

Background: In 2007, the ASCO Cost of Care Task Force was established to deal with the soaring costs of cancer treatment in the United States. One of the key recommendations was that the cost of chemotherapy should be introduced into the patient-physician discussion from the outset. It is unknown if these discussions are occurring in academic Institutions and what if any is the impact on the doctor/patient relationship. Methods: The National Comprehensive Cancer Network (NCCN) Guidelines and the Eviti advisor platform were jointly used in an academic oncology center during the patient/doctor consultation to demonstrate treatment options to patients and display the costs at the time of prescribing to providers and patients alike. Questionnaires measured oncology providers attitudes to cost discussions and assessed physician satisfaction with the shared decision making process when costs are introduced into the patient/doctor relationship. Patients were interviewed before and after their doctor consultation to measure their satisfaction with the process using modifications of the shared decision making scale, satisfaction with decision scale and decisional conflict scale. Basic descriptive statistics were applied. Results: Only 5/18 oncologists (28%) reported feeling comfortable discussing costs with patients and just one (6%) admitted to regularly asking patients about financial difficulties. The majority (83%) of doctors reported that the NCCN guidelines should contain cost information. Seventy-one patients (42 females, 29 males) with metastatic breast (27%), lung (49%), and colorectal cancer (24%) have been interviewed. Interestingly, 70% of patients responded that no health care professional has ever discussed costs with them despite 57/71 (80%) rating this as very important information. The majority of patients (75%) had no negative feelings to hearing cost information. Only 4% admitted to developing significant negative feelings. Conclusions: In an era of rising co-pays, patients want cost of treatment discussions and these do not lead to negative feelings in the majority of patients. Additional training to prepare clinicians for how to discuss costs with their patients is needed.

What lies within: novel strategies in immunotherapy for non-small cell lung cancer

Immunotherapy has become an increasingly important therapeutic strategy for those with cancer, with phase III studies demonstrating survival advantages in melanoma and castration-resistant prostate cancer. Non-small cell lung cancer (NSCLC) is a promising target for the next generation of immune-based strategies. In this article, we examine the current state of the art in lung cancer immunotherapy, including vaccines that specifically target lung tumor antigens and immune checkpoint antibodies such as antiprogrammed death 1 (anti-PD-1). Both approaches harness innate immunity against tumors by suppressing tumor-induced immune paresis. Methods. To identify relevant clinical trials of immunotherapy in NSCLC, PubMed and Medline databases were searched using the terms "immunotherapy" and "NSCLC," and several other therapy-specific search terms (e.g., PD-1, NSCLC). Additionally, abstracts presented at international lung cancer symposia, the American Society of Clinical Oncology annual meeting, and the European Society of Medical Oncology annual meeting between 2005 and 2013 were evaluated. Results. Large international phase III trials of NSCLC vaccines have completed accrual in both the adjuvant and metastatic disease settings. Results of the START study were disappointing, but results from other studies are still awaited. Immune checkpoint modulation has shown promise, with separate phase I studies of the anti-PD-1 antibody, nivolumab, and anti-PD-L1 antibody, MPDL3280A, demonstrating good tolerance and durable responses for certain patients with NSCLC who were heavily pretreated. Conclusions. Immune-based strategies have shown initial promise for early- and advanced-stage NSCLC. Validating these findings in randomized studies and discovering durable biomarkers of response represent the next challenges for investigation.

Genomic alterations in advanced esophageal cancer may lead to subtype-specific therapies

The development of targeted agents for metastatic esophageal or gastroesophageal junction (GEJ) tumors has been limited when compared with that for other common tumors. To date, the anti-human epidermal growth factor receptor-2 (HER-2) antibody, trastuzumab, in combination with chemotherapy, is the only approved novel agent for these cancers, and its use is limited to the small population of patients whose tumors overexpress HER-2. Despite recent progress in the field, median overall survival remains only 8-12 months for patients with stage IV esophageal or GEJ cancer. In this article, we examine the molecular aberrations thought to drive the development and spread of esophageal cancer and identify promising targets for specific tumor inhibition. Data from clinical studies of targeted agents are reviewed, including epidermal growth factor receptor antibodies, tyrosine kinase inhibitors, HER-2, and vascular endothelial growth factor-directed therapy. Current and future targets include MET, fibroblast growth factor receptor, and immune-based therapies. Evidence from trials to date suggests that molecularly unselected patient cohorts derive minimal benefit from most target-specific agents, suggesting that future collaborative investigation should focus on preselected molecular subgroups of patients with this challenging heterogeneous disease.

Advanced pulmonary carcinoid (APC): 20-year experience at Johns Hopkins (JH)

7598

Background: APC is a rare thoracic malignancy with limited prognostic data and a perceived lack of treatment options other than surgical resection. This is the largest series of APC patients (pts) ever reported and contains data on locally advanced and metastatic disease. Here we compare clinical outcomes and treatment responses for typical carcinoid (TC) and atypical carcinoid (AC). Methods: This retrospective cohort includes pts referred to JH from 1992 to 2012. Pts were identified using pathology and medical record databases. Information extracted included, pathology, demographics, stage, prior curative resection, time to relapse, chemotherapy/targeted agents and response rate (RR), date of death/last follow-up. Primary outcome was overall survival (OS), defined as time from diagnosis of advanced disease to death from any cause. Secondary endpoint was recurrence-free survival (RFS), defined as time from curative resection to tumor recurrence. OS and RFS were estimated by using the Kaplan-Meier method and log-rank test comparing TC and AC. Results: 49 APC pts (30 female/19 male; 32 AC/17 TC) were identified. 25 pts had relapsed after previous curative resection. Median RFS (n=25), was significantly longer for TC vs. AC (119 months (m) vs. 66 m, p=0.008). Median OS was 85m and significantly longer for TC vs. AC (122m vs. 48m, p=0.009). 39 (80%) pts received systemic therapy for APC. RR to first-line chemotherapy was 22% (5/23) with all 5 (3 AC, 2 TC) responses occurring in pts receiving cisplatin/etoposide. First-line somatostatin therapy was given to 11 pts with 1 partial response (PR) (9%) and 10 pts with stable disease (5 AC, 5 TC) for a median 15m. 5 pts received first-line targeted agents including sunitinib and gefitinib however no responses were seen. 50% (2/4 pts) RR occurred to second-line temozolomide/capecitabine An ongoing PR > 6m to everolimus occurred in a heavily pretreated AC pt. Conclusions: Both AC and TC may recur many years after resection. This study demonstrates significantly poorer survival for AC in advanced disease. Thoracic oncologists perceive APC as resistant to systemic therapy however here we report that both AC and TC may respond to cisplatin/etoposide, temozolomide/capecitabine and mTOR targeted therapy.

Ipilimumab-induced immune-related renal failure--a case report

Ipilimumab is a fully human monoclonal antibody targeting cytotoxic T-lymphocyte antigen-4 and has become the first immune checkpoint inhibitor to enter clinical practice, being recently approved for the treatment of metastatic melanoma. Immune toxicity due to ipilimumab causing colitis, hepatitis, dermatitis and hypophysitis is well-described. We report on a case of acute renal failure resolving rapidly with high-dose corticosteroid treatment highlighting the importance of vigilance for rarer immune-related toxicities as clinical experience with ipilimumab grows.

Abiraterone for the Treatment of Advanced Prostate Cancer

Until recently, treatment options for castration-resistant prostate cancer (CRPC) were limited to only the chemotherapeutic agent docetaxel which demonstrated a survival advantage over palliative chemotherapy. Abiraterone acetate (AA) is an orally available, potent irreversible inhibitor of the adrenal microsomal enzyme cytochrome P450-17 (CYP17). In a large phase III study of AA in docetaxel-pretreated patients, AA demonstrated excellent tolerance and a 4-month survival advantage over placebo, leading to the approval of AA for docetaxel-pretreated patients by the FDA in 2011. More recently, phase III data in docetaxel-naïve patients have become available, showing clear clinical benefits in this population as well, and it is likely that the label for AA will soon be expanded to include men with CRPC who have not yet received chemotherapy. This article summarizes clinical studies of AA in CRPC patients and discusses the emerging treatment paradigm in this rapidly evolving area.