A randomised phase II study of osimertinib and bevacizumab versus osimertinib alone as second-line targeted treatment in advanced NSCLC with confirmed EGFR and acquired T790M mutations: the European Thoracic Oncology Platform (ETOP 10-16) BOOSTER trial

BACKGROUND

While osimertinib, a third-generation epidermal growth factor receptor (EGFR) tyrosine kinase inhibitor (TKI) is the standard treatment in patients with advanced non-small-cell lung cancer (NSCLC) with sensitising EGFR and acquired T790M mutations, progression inevitably occurs. The angiogenic pathway is implicated in EGFR TKI resistance.

PATIENTS AND METHODS

BOOSTER is an open-label randomised phase II trial investigating the efficacy and safety of combined osimertinib 80 mg daily and bevacizumab 15 mg/kg every 3 weeks, versus osimertinib alone, in patients with EGFR-mutant advanced NSCLC and acquired T790M mutations after failure on previous EGFR TKI therapy. Primary endpoint was investigator-assessed progression-free survival (PFS). Secondary endpoints were overall survival (OS), objective response rate (ORR) and adverse events (AEs).

RESULTS

Between May 2017 and February 2019, 155 patients were randomised (combination: 78; osimertinib: 77). At data cut-off of 22 February 2021, median follow-up was 33.8 months [interquartile range (IQR): 26.5-37.6 months] and 129 (83.2%) PFS events were reported in the intention-to-treat population. There was no difference in median PFS between the combination [15.4 months; 95% confidence interval (CI) 9.2-18.0 months] and osimertinib arm (12.3 months; 95% CI 6.2-17.2 months; stratified log-rank P = 0.83), [hazard ratio (HR) = 0.96; 95% CI 0.68-1.37]. Median OS was 24.0 months (95% CI 17.8-32.1 months) in the combination arm and 24.3 months (95% CI 16.9-37.0 months) in the osimertinib arm (stratified log-rank P = 0.91), (HR = 1.03; 95% CI 0.67-1.56). Exploratory analysis revealed a significant interaction of smoking history with treatment for PFS (adjusted P = 0.0052) with a HR of 0.52 (95% CI 0.30-0.90) for smokers, and 1.47 (95% CI 0.92-2.33) for never smokers. ORR was 55% in both arms and the median time to treatment failure was significantly shorter in the combination than in the osimertinib arm, 8.2 months versus 10.8 months, respectively (P = 0.0074). Safety of osimertinib and bevacizumab was consistent with previous reports with grade ≥3 treatment-related AEs (TRAEs) reported in 47% and 18% of patients on combination and osimertinib alone, respectively.

CONCLUSIONS

No difference in PFS was observed between osimertinib plus bevacizumab and osimertinib alone. Grade ≥3 TRAEs were more common in patients on combination.

The impact of COVID-19 on cancer care and oncology clinical research: an experts' perspective

The coronavirus disease-19 (COVID-19) pandemic promises to have lasting impacts on cancer clinical trials that could lead to faster patient access to new treatments. In this article, an international panel of oncology experts discusses the lasting impacts of the pandemic on oncology clinical trials and proposes solutions for clinical trial stakeholders, with the support of recent data on worldwide clinical trials collected by IQVIA. These lasting impacts and proposed solutions encompass three topic areas. Firstly, acceleration and implementation of new operational approaches to oncology trials with patient-centric, fully decentralized virtual approaches that include remote assessments via telemedicine and remote devices. Geographical differences in the uptake of remote technology, including telemedicine, are discussed in the article, focusing on the impact of the local adoption of new operational approaches. Secondly, innovative clinical trials. The pandemic has highlighted the need for new trial designs that accelerate research and limit risks and burden for patients while driving optimization of clinical trial objectives and endpoints, while testing is being minimized. Areas of considerations for clinical trial stakeholders are discussed in detail. In addition, the COVID-19 pandemic has exposed the underrepresentation of minority groups in clinical trials; the approach for oncology clinical trials to improve generalizability of efficacy and outcomes data is discussed. Thirdly, a new problem-focused collaborative framework between oncology trial stakeholders, including decision makers, to leverage and further accelerate the innovative approaches in clinical research developed during the COVID-19 pandemic. This could shorten timelines for patient access to new treatments by addressing the cultural and technological barriers to adopting new operational approaches and innovative clinical trials. The role of the different stakeholders is described, with the aim of making COVID-19 a catalyst for positive change in oncology clinical research and eventually in cancer care.

Delineation atlas of the Circle of Willis and the large intracranial arteries for evaluation of doses to neurovascular structures in pediatric brain tumor patients treated with radiation therapy

BACKGROUND

Survivors of pediatric brain tumors are susceptible to neurovascular disease after radiotherapy, with dose to the chiasm or Circle of Willis (CW) as risk factors. The aims of this study were to develop a delineation atlas of neurovascular structures, to investigate the doses to these structures in relation to tumor location and to investigate potential dose surrogates for the CW dose.

MATERIAL AND METHODS

An atlas of the CW, the large intracranial arteries and the suprasellar cistern (SC) was developed and validated. Thirty proton plans from previously treated pediatric brain tumor patients were retrieved and grouped according to tumor site: 10 central, 10 lateralized, and 10 posterior fossa tumors. Based on the atlas, neurovascular structures were delineated and dose metrics (mean dose (D_mean) and maximal dose (D_max)) to these structures and the already delineated chiasm were evaluated. The agreement between dose metrics to the CW vs. chiasm/SC was investigated. The minimal Hausdorff distance (HD_min) between the target and SC was correlated with the SC D_mean.

RESULTS

The median D_mean/D_max to the CW were 53 Gy(RBE)/55 Gy(RBE) in the central tumors, 18 Gy(RBE)/25 Gy(RBE) in the lateralized tumors and 30 Gy(RBE)/49 Gy(RBE) in the posterior fossa tumors. There was a good agreement between the D_max/D_mean to the CW and the SC for all cases (R²=0.99), while in the posterior fossa group, the CW D_max was underestimated when using the chiasm as surrogate (R²=0.76). Across all patients, cases with HD_min < 10 mm between the target and the SC received the highest SC D_mean.

CONCLUSION

The pattern of dose to neurovascular structures varied with the tumor location. For all locations, SC doses could be used as a surrogate for CW doses. A minimal distance larger than 10 mm between the target and the SC indicated a potential for neurovascular dose sparing.

Low glycaemic state increases risk of frailty and functional decline in older people with type 2 diabetes mellitus - Evidence from a systematic review

AIMS

To explore risk of frailty and functional decline associated with low glycaemia in older people with type 2 diabetes.

METHODS

Systematic review.

RESULTS

11 studies included. Six studies investigated risk of frailty or physical decline with hypoglycaemia. Hypoglycaemia increased risk of incident frailty (HR 1.60, 95% CI 1.14 to 2.42) in one study and risk of fractures in four studies (2.24, 1.56 to 3.21, 1.24, 1.13 to 1.37, 1.94, 1.67 to 2.24 and 1.71, 1.35 to 2.16 respectively). In sixth study, hypoglycaemia associated with dependency (P < 0.001). Five studies explored association of low blood glucose/HbA1c with frailty. One study showed that mean blood glucose decreased with increasing frailty (p = 0.003). Two studies reported that HbA1c inversely correlated with clinical frailty scale (r = -0.31, p < 0.01) and HbA1c < 6.9% increased risk of frailty (HR, 1.41 95% CI 1.12 to 1.78) respectively. Last two studies showed that HbA1c < 6.5% associated with risk of any fracture (HR 1.08, 95% CI 1.06 to 1.11) and HbA1c < 6.0% associated with increased risk of care need (3.45, 1.02 to 11.6) respectively.

CONCLUSIONS

Low glycaemia increases risk of frailty and functional decline in older people with type 2 diabetes. Management should minimise incidence of low glycaemia in these patients.

Low voltage in limb leads in arrhythmogenic cardiomyopathy

 

Low voltage in limb leads characterizes left ventricular involvement in arrhythmogenic cardiomyopathy. A large collective of patients with arrhythmogenic cardiomyopathy including 438 patients (268 males, mean age 46.8±11.6 years) were analyzed.

Method

Low voltage in limb leads were analyzed in typical patients with arrhythmogenic cardiomyopathy. Several other ECG features such a slow voltage in precordial leads, epsilon waves, right precordial T wave inversions, QRS fragmentation, typical appearance in lead aVR, amplitude of T wave inversion in special right ventricular leads, and developing complete right bundle branch block.

Results

Low voltage in limb leads was found in 60 patients (15%). Two patients represented with low voltage in limb leads and T wave inversions in inferolateral leads charactizing arrhythmogenic left ventricular leads with moderate reduction of left ventricular function with a large aneurysm of the apex. The other patients presented with sustained RBBB-VT. In 38 patients low voltage in limb leads and typical ECG findings of arrhythmogenic cardiomyopathy were found. These patients had arrhythmogenic biventricular cardiomyopathy of moderate reduction of left ventricular function and typical arrhythmias. Low voltage in limb and precordial leads was found in 14 patients with two cardiac deaths due to therapy-resistant heart failure. In 6 cases low voltage in limb and precordial leads and developing complete right bundle branch block were found. Four patients were tranplanted, two cases died due to heart failure. These 20 patients characterize advances, end-stage disease arrhythmogenic cardiomyopathy.

Conclusion

Standard ECG can differentiate between arrhythogenic left ventricular, arrhythmogenic biventricular, and arrhythmogenic advanced end-stage cardiomyopathy

Funding Acknowledgement

Type of funding sources: None.

Consolidation nivolumab and ipilimumab versus observation in limited-disease small-cell lung cancer after chemo-radiotherapy - results from the randomised phase II ETOP/IFCT 4-12 STIMULI trial

BACKGROUND

Concurrent chemotherapy and thoracic radiotherapy followed by prophylactic cranial irradiation (PCI) is the standard treatment in limited-disease small-cell lung cancer (LD-SCLC), with 5-year overall survival (OS) of only 25% to 33%.

PATIENTS AND METHODS

STIMULI is a 1:1 randomised phase II trial aiming to demonstrate superiority of consolidation combination immunotherapy versus observation after chemo-radiotherapy plus PCI (protocol amendment-1). Consolidation immunotherapy consisted of four cycles of nivolumab [1 mg/kg, every three weeks (Q3W)] plus ipilimumab (3 mg/kg, Q3W), followed by nivolumab monotherapy (240 mg, Q2W) for up to 12 months. Patient recruitment closed prematurely due to slow accrual and the statistical analyses plan was updated to address progression-free survival (PFS) as the only primary endpoint.

RESULTS

Of the 222 patients enrolled, 153 were randomised (78: experimental; 75: observation). Among the randomised patients, median age was 62 years, 60% males, 34%/65% current/former smokers, 31%/66% performance status (PS) 0/1. Up to 25 May 2020 (median follow-up 22.4 months), 40 PFS events were observed in the experimental arm, with median PFS 10.7 months [95% confidence interval (CI) 7.0-not estimable (NE)] versus 42 events and median 14.5 months (8.2-NE) in the observation, hazard ratio (HR) = 1.02 (0.66-1.58), two-sided P = 0.93. With updated follow-up (03 June 2021; median: 35 months), median OS was not reached in the experimental arm, while it was 32.1 months (26.1-NE) in observation, with HR = 0.95 (0.59-1.52), P = 0.82. In the experimental arm, median time-to-treatment-discontinuation was only 1.7 months. CTCAE v4 grade ≥3 adverse events were experienced by 62% of patients in the experimental and 25% in the observation arm, with 4 and 1 fatal, respectively.

CONCLUSIONS

The STIMULI trial did not meet its primary endpoint of improving PFS with nivolumab-ipilimumab consolidation after chemo-radiotherapy in LD-SCLC. A short period on active treatment related to toxicity and treatment discontinuation likely affected the efficacy results.

Trends in guideline implementation: an updated scoping review protocol

OBJECTIVE

The objective of the review is to assess trends in guideline implementation, including the interventions used, rationale provided, and the impact on patient or health care professional knowledge, behavior or outcomes.

INTRODUCTION

Guidelines must be actively implemented to promote use and achieve beneficial outcomes. A review published in 2015 found that studies of guideline implementation did not employ a range of implementation planning approaches to select and tailor interventions, resulting in inconsistent impact. This study will update the 2015 review and elaborate beyond the four diseases originally covered to assess if more recent efforts to implement guidelines were informed by best implementation practices.

INCLUSION CRITERIA

We will include published studies that describe the implementation of guidelines on any clinical topic relevant to primary, secondary, or tertiary care using interventions targeted to patients, families/caregivers, or health care professionals.

METHODS

We will search MEDLINE, Embase, AMED, CINAHL, Scopus, and the Cochrane Library from 2014 (search date in 2015 review) to the present. Two or more persons will screen titles and full-text articles, and extract data from included studies. We will use summary statistics, tables, and a narrative summary to describe study characteristics, guideline implementation interventions, the rationale for intervention selection and tailoring (pre-identified barriers, patient or stakeholder preferences, theory), and intervention impact.