The proportion and characterization of patients with metastatic renal cell carcinoma who are never treated or have delayed treatment with targeted therapy: Results from a large prospective cohort

424

Background: The proportion and characterization of patients (pts) with metastatic renal cell carcinoma (mRCC) who never start or delay starting targeted therapy (TT) is unknown. It is important to understand and characterize these pts. Methods: Data from the Canadian Kidney Cancer information system (CKCis) database were utilized. CKCis data were collected prospectively from 14 REB-approved academic centers in Canada. The study population included pts with mRCC managed from 2006 (when VEGFR TT became available) to 2014. Results: 920 pts met the inclusion criteria, but 67 pts had <6 months (mo) follow up and were excluded. Thus, 853 pts make up the study cohort with a median follow up of 21 mo. The cohort was divided into 3 groups: early (started TT within 6 mo), delayed (started TT after 6 mo), and never (never started TT). The groups consisted of 406 pts (47.6%), 182 pts (21.3%), and 265 pts (31.1%), respectively. In those that started TT, median time to initiation was 3.2 mo; 69% by 6 mo, 82% by 12 mo, 92% by 24 mo, and 99.7% by 5 yrs. Multiple baseline characteristics were determined, compared, and will be presented. On univariable analysis, pts never treated were older, had a longer interval from original diagnosis to metastases (mets), fewer metastatic sites, fewer liver mets, more lung-only mets, more metastectomies, and less radiation (RT). On Cox regression analysis, pts were less likely to initiate TT if they were older, had earlier year of diagnosis of mets, had metastectomy, never had RT, fewer sites of mets, and brain mets. Median survival from time of metastatic diagnosis was 1.53 yrs, 3.54 yrs, and 1.41 yrs in the early, delayed, and never treated groups, respectively. Conclusions: 31% of pts with mRCC never received TT in this cohort of pts treated in academic centers, which may underrepresent the reality in the community. Baseline characteristics in the delayed treatment group were better and likely represent a more indolent biology. More data on the untreated group will be presented as it comprises a heterogenous group of pts: potentially those lost to follow up, those treated with metastectomy, pts too ill with limited survival, and pts felt to have excellent outcomes without treatment.

Impact of statins and survival outcomes in patients with metastatic renal cell carcinoma

435

Background: A growing body of evidence has demonstrated the antineoplastic activity of statins. The objective of this study was to investigate the impact of statin use on survival in patients with metastatic renal cell carcinoma (mRCC) treated in the modern therapy era. Methods: We conducted a pooled analysis of mRCC patients treated on phase II and III clinical trials. Statistical analyses were performed using Cox regression adjusted for age, sex, race, histology, prior therapy, body-mass index, and other known prognostic factors and the Kaplan-Meier method. Results: We identified 4,736 patients treated with sunitinib (n=1,059), sorafenib (n=772), axitinib (n=896), temsirolimus (n=457), temsirolimus + interferon-alpha (n=208), bevacizumab + temsirolimus (n=393), bevacizumab + interferon-alpha (n=391), or interferon-alpha (n=560), of whom 511 were statin users. Overall, statin users demonstrated a statistically significant improvement in overall survival (OS) but not progression-free survival (PFS) compared to non-users (OS: 25.6 versus 18.9 months; p=0.015; adjusted hazard ratio [aHR] 0.787; 95% CI, 0.648-0.955; PFS: 7.9 versus 6.9 months; p=0.823, aHR 1.018; 95% CI, 0.867-1.196). When stratified by therapy type, a benefit in OS was demonstrated in statin users compared to non-users in individuals receiving therapy targeting vascular endothelial growth factor (28.4 versus 22.2 months, p=0.023; aHR 0.749; 95% CI, 0.584-0.961) or mammalian target of rapamycin (18.6 versus 14.0; p=0.035; aHR 0.657; 95% CI, 0.445-0.972), but not in those receiving interferon-alpha (15.6 versus 14.8 months; p=0.410; aHR 1.292; 95% CI 0.703-2.275). Adverse events were similar between statin users and non-users. Conclusions: In the largest RCC analysis to date, we demonstrate that statin use improved survival outcomes in patients with mRCC treated in the targeted therapy era. Statins could represents a potential adjunct therapeutic option for patients with metastatic RCC; however, this hypothesis needs to be corroborated with preclinical work exploring the mechanisms underlying their anti-cancer effects and well-designed clinical trials investigating the clinical benefits of adding statins to modern therapies.

Change in neutrophil to lymphocyte ratio as a prognostic and predictive marker in response to targeted therapy for metastatic renal cell carcinoma

404

Background: The neutrophil to lymphocyte ratio (NLR) is a marker of inflammation. We evaluated whether NLR is independently prognostic when adjusted for the International mRCC Database Consortium (IMDC) model and evaluated change in NLR ("NLR conversion") as a predictive marker of response to targeted therapy. Methods: A total of 5,227 metastatic renal cell carcinoma (mRCC) patients treated with targeted therapy were included; 1,199 patients in the training cohort from the IMDC and 4028 patients as the validation cohort from pooled prospective randomized controlled trials involving targeted therapy. NLR was examined at initiation of first-line targeted therapy and at 6 weeks after. The prognostic role of NLR and NLR conversion on overall survival (OS) and progression free survival (PFS) was assessed using Cox regression models adjusting for IMDC prognostic score. Results: Median baseline NLR was 3.4 and 2.9 in the training and validation cohorts, respectively. NLR >3.0 at baseline was independently associated with OS and PFS in both the training and validation cohorts (Table). A decrease in NLR by week 6 was associated with longer OS (21.1 vs. 9.7 months; HR 0.57, p<0.001), PFS (8.8 vs. 4.6 months; HR 0.54, p<0.001), and higher objective response rates (35% vs. 13%, p<0.001) compared to patients without a decrease. A rise in NLR showed opposite effects for all three endpoints. These findings were also confirmed in the validation set. Conclusions: NLR is an independent prognostic factor after controlling for IMDC criteria. NLR conversion can be an early biomarker of benefit to targeted therapy. [Table: see text]

The impact of BMI on outcomes of patients with metastatic renal cell carcinoma treated with targeted therapy: An external validation data set and analysis of underlying biology from The Cancer Genome Atlas

405

Background: Obesity is a risk factor for renal cell carcinoma (RCC) and a poor prognostic factor across many tumor types. However, reports have suggested that RCC developing in an obesogenic environment may be more indolent. We recently reported on the favorable impact of body mass index (BMI) on survival in the International mRCC Database Consortium (IMDC). The current work aims to externally validate this finding and characterize the underlying biology. Methods: We conducted an analysis of 4,657 metastatic RCC (mRCC) patients (pts) treated on phase II-III clinical trials sponsored by Pfizer from 2003-2013. We assessed the impact of BMI on overall survival (OS), progression-free survival (PFS) and overall response rate (ORR). Additionally, we analysed metastatic pts from the clear cell RCC (ccRCC) cohort of TCGA dataset to correlate the expression of Fatty Acid Synthase (FASN) with BMI and OS. Results: At targeted therapy (TT) initiation, 1,829 (39%) pts were normal or underweight (BMI <25 kg/m2) and 2,828 (61%) were overweight or obese (BMI ≥25 kg/m2). Overall, the high BMI group had a longer median OS (23.4 months) than the low BMI group (14.5 months) (hazard ratio (HR) = 0.830, p= 0.0008, 95% CI 0.743-0.925) after adjusting for the IMDC prognostic risk group and other risks factors. In addition, pts with high BMI had improved PFS (HR=0.821, 95% CI 0.746-0.903, p<0.0001) and ORR (odds ratio =1.527, 95% CI 1.258-1.855, p<0.001). These results remain valid when stratified by line of therapy. When stratified by histological subtype, the favorable outcome associated with high BMI was only observed in ccRCC. Toxicity patterns did not differ between BMI groups. In the the Cancer Genome Atlas (TCGA) dataset (n=61), there was a trend towards improved OS in the high BMI group (p=0.07). FASN gene expression inversely correlated with both OS (p=0.002) and BMI (p=0.034). Conclusions: In an external cohort,we validate BMI as an independent prognostic factor for improved survival in mRCC. Given that this finding was observed in ccRCC only, we hypothesize that lipid metabolism may be modulated by the fat laden tumors cells. FASN staining in the IMDC cohort is ongoing to better investigate the obesity paradox in mRCC.

Reporting on quality indicators in renal cell carcinoma: Proportion of metastatic patients who initially commence on full-dose targeted therapy

265

Background: Measuring quality of care is required to improve patient outcomes. There are 23 established Quality Indicators in Renal Cell Carcinoma (RCC) (Wood LA et al, JOP 2013) including initiating targeted therapy (TT) at full dose. It is recognized that the dose of TT is important to optimize clinical outcomes. Methods: The Canadian Kidney Cancer Information System (CKCis) is a prospectively maintained database of RCC pts from 14 Canadian academic centers. CKCis data was used to determine the use of TT in metastatic pts, the initial dose in the first line setting, and factors influencing whether pts initiated full dose TT. Descriptive statistics were performed to characterize current practices and a multivariate logistic regression was performed to assess predictors of initiating full dose TT. Results: Between 2006 and 2014, 560 pts received first-line TT and make up the study cohort. 92% received VEGF TT (81% sunitinib; 9% pazopanib; 2% sorafenib) and 8% received mTOR TT (5% everolimus; 3% temsirolimus). All pts receiving mTOR inhibitors received full dose and are excluded from further analysis. Full dose VEGF TT was initiated in 87% on sunitinib, 78% on pazopanib, and 92% on sorafenib. The sunitinib schedule was 4/2 in 81%, 2/1 in 12%, and other in 7%. Pts were less likely to initiate full dose TT if they were older (OR: 1.10, 95% CI 1.06-1.15), female (OR: 2.23, 95% CI 1.09-4.55) or had a worse ECOG PS (2,3,4 vs 0,1) (OR: 2.30, 95% CI 0.95-5.59). Data on initial versus final dose of TT will also be presented. Conclusions: Maximizing exposure to TT is important in metastatic RCC which is why initiating full dose TT was prioritized as a key QI in RCC. In this study, 87% of pts were initiated on full dose VEGF TT in the first line setting, and 100% of pts on mTOR TT which is higher than predicted. Those less likely to start on full dose VEGF TT were older, female and had a lower ECOG PS. The gender discrepancy will be explored in future studies.

Outcomes of patients with metastatic renal cell carcinoma that do not meet eligibility criteria for clinical trials

BACKGROUND

Targeted therapies in metastatic renal cell carcinoma (mRCC) have been approved based on registration clinical trials that have strict eligibility criteria. The clinical outcomes of patients treated with targeted agents but are ineligible for trials are unknown.

PATIENTS AND METHODS

mRCC patients treated with vascular endothelial growth factor-targeted therapy were retrospectively deemed ineligible for clinical trials (according to commonly used inclusion/exclusion criteria) if they had a Karnofsky performance status (KPS) <70%, nonclear-cell histology, brain metastases, hemoglobin ≤9 g/dl, creatinine >2× the upper limit of normal, corrected calcium ≥12 mg/dl, platelet count of <100 × 10(3)/uL, or neutrophil count <1500/mm(3).

RESULTS

Overall, 768 of 2210 (35%) patients in the International Metastatic RCC Database Consortium (IMDC) were deemed ineligible for clinical trials by the above criteria. Between ineligible versus eligible patients, the response rate, median progression-free survival (PFS) and median overall survival of first-line targeted therapy were 22% versus 29% (P = 0.0005), 5.2 versus 8.6 months, and 12.5 versus 28.4 months (both P < 0.0001), respectively. Second-line PFS (if applicable) was 2.8 months in the trial ineligible versus 4.3 months in the trial eligible patients (P = 0.0039). When adjusted by the IMDC prognostic categories, the HR for death between trial ineligible and trial eligible patients was 1.55 (95% confidence interval 1.378-1.751, P < 0.0001).

CONCLUSIONS

The number of patients that are ineligible for clinical trials is substantial and their outcomes are inferior. Specific trials addressing the unmet needs of protocol ineligible patients are warranted.

First-, second-, third-line therapy for mRCC: benchmarks for trial design from the IMDC

BACKGROUND

Limited data exist on outcomes for metastatic renal cell carcinoma (mRCC) patients treated with multiple lines of therapy. Benchmarks for survival are required for patient counselling and clinical trial design.

METHODS

Outcomes of mRCC patients from the International mRCC Database Consortium database treated with 1, 2, or 3+ lines of targeted therapy (TT) were compared by proportional hazards regression. Overall survival (OS) and progression-free survival (PFS) were calculated using different population inclusion criteria.

RESULTS

In total, 2705 patients were treated with TT of which 57% received only first-line TT, 27% received two lines of TT, and 16% received 3+ lines of TT. Overall survival of patients who received 1, 2, or 3+ lines of TT were 14.9, 21.0, and 39.2 months, respectively, from first-line TT (P<0.0001). On multivariable analysis, 2 lines and 3+ lines of therapy were each associated with better OS (HR=0.738 and 0.626, P<0.0001). Survival outcomes for the subgroups were as follows: for all patients, OS 20.9 months and PFS 7.2 months; for those similar to eligible patients in the first-line ADAPT trial, OS 14.7 months and PFS 5.6 months; for those similar to patients in first-line TIVO-1 trial, OS 24.8 months and PFS 8.2 months; for those similar to patients in second-line INTORSECT trial, OS 13.0 months and PFS 3.9 months; and for those similar to patients in the third-line GOLD trial, OS 18.0 months and PFS 4.4 months.

CONCLUSIONS

Patients who are able to receive more lines of TT live longer. Survival benchmarks provide context and perspective when interpreting and designing clinical trials.

Anti-VEGF therapy in mRCC: differences between Asian and non-Asian patients

Background:

Several reports suggest that vascular endothelial growth factor (VEGF)-targeted therapy in metastatic renal cell carcinoma (mRCC) may be more toxic in Asian vs non-Asian populations. Comparative efficacy of these agents with respect to ethnicity is not well characterised.

Methods:

A multicentre, retrospective, cohort study using Asian and non-Asian centres which collected data on ethnicity, dose reductions and outcomes using the International mRCC Database Consortium.

Results:

This study included 1024 (464 Asian, 560 non-Asian) patients with a 29.4 months median follow-up. The percentage of dose modifications/reductions between non-Asians and Asians was similar (55% vs 61% P=0.1197). When adjusted for risk groups, there was no difference in overall or progression-free survival between non-Asians and Asians. Patients with dose reductions due to toxicity had longer treatment durations and overall survival than those who did not in both non-Asian (10.6 vs 5.0 months, P<0.0001; 22.6 vs 16.1 months, P=0.0016, respectively) and Asian populations (8.9 vs 5.4 months, P=0.0028; 28.0 vs 18.7 months, P=0.0069, respectively).

Conclusions:

Adjusting for risk groups, there appears to be no difference in outcome between Asian vs non-Asian patients with mRCC treated with VEGF-targeted therapy. Judicious dose reductions may allow for better outcomes in both populations due to longer treatment durations, but direct comparisons are needed.

Neutrophil to lymphocyte ratio (NLR) and its effect on the prognostic value of the International Metastatic Renal Cell Carcinoma Database Consortium (IMDC) model for patients treated with targeted therapy (TT)

470

Background: The neutrophil to lymphocyte ratio (NLR) is a marker of host inflammation and appears to have prognostic value in many solid tumors. We have found in a pilot RCC study that a NLR > 2.5 was predictive of a lower likelihood of response to TT on a multivariable analysis. Here we aim to explore the added value of the NLR to improve the prognostic value of the established IMDC criteria (Heng et al JCO 2009). Methods: We included patients from 7 consortium sites where NLR data was available for patients treated with TT and compared NLR cutoff <= 2.5 vs. >2.5 (i.e. low vs. high NLR) and adjusted using proportional hazards regression for the known poor prognostic criteria (listed in Table). Results: Data from 859 patients were included. NLR values were: Mean 4.98, Median 3.51, Mode 2.5, 95%CI 1.42 – 14.0. Using Cutoff <=2.5 vs. >2.5 Median overall survival (OS) is 30.4 months (95%CI 24.9-37.0, n= 237) vs. 15.7 months (95%CI 13.0-17.2, n=622); log-rank p value <0.0001. If we adjust for all six IMDC poor prognosis criteria in a proportional hazards regression model: HR of death for high NLR is 1.506 (1.177-1.928) p=0.0011, demonstrating NLR is still an independent predictor of poor OS even after using IMDC criteria. Conclusions: The NLR is a simple clinical value and is independently associated with poor overall survival even after adjustment for IMDC factors, including neutrophilia. The updated data set will be presented. [Table: see text]

Population-based analysis of a novel prognostic model for metastatic castration-resistant prostate cancer (mCRPC) patients (pts) treated with abiraterone acetate (AA)

29

Background: Using data from the COU-AA-301 trial, a novel prognostic model was recently developed for predicting overall survival (OS) in post-chemotherapy mCRPC pts treated with AA (J Clin Oncol 31, 2013 (suppl; abstr 5013)). The model is comprised of six pre-treatment risk-factors (RF) associated with poor outcome: ECOG performance status (PS) ≥ 2, presence of visceral metastases, time from start of LHRH agonists to start of AA ≤ 36 months, low albumin, high ALP and high LDH. The aim of this study was to evaluate this model in an unselected population-based cohort. Methods: Cancer registries at three Canadian centers were used to identify mCRPC pts treated with AA. OS was estimated using the Kaplan-Meier method. Multivariate Cox proportional hazard regression was used to determine independent prognostic factors for OS. Results: A total of 415 pts received AA – 286 were post-docetaxel and 129 were chemotherapy-naïve. In post-docetaxel pts, 21%, 50% and 28% were classified into good (0-1 RF), intermediate (2-3 RF) and poor (4-6 RF) prognosis (prog) groups respectively based on the COU-AA-301 model. Median OS in the post-docetaxel cohort was significantly longer for pts with good prog disease (23.9 months) compared to intermediate (17.6 months) and poor prog pts (8.4 months) (Table). ECOG PS (p<0.001), LDH (p=0.025), albumin (p=0.007) and visceral metastases (p<0.001) were confirmed as independent prognostic factors. Although the number of events in chemotherapy-naïve pts was low, median OS was significantly longer in good prog pts (not reached) compared to both intermediate (22.9 months; p=0.011, log-rank) and poor prog pts (10.3 months; p<0.001, log-rank). Conclusions: In a population-based setting, our data validate the COU-AA-301 model as a tool for prognostic stratification of mCRPC pts treated with AA after docetaxel. Prospective evaluation of this prognostic model in post-docetaxel and docetaxel-naive pts commencing AA is warranted. [Table: see text]

Impact of prior response to abiraterone acetate (AA) on subsequent activity of docetaxel (D) in metastatic castration-resistant prostate cancer (mCRPC) patients (pts)

97

Background: Questions about optimal sequencing of systemic agents in mCRPC and whether cross-resistance occurs between agents remain largely unanswered. Recently, it was reported that D is inactive in mCRPC pts who did not have a ≥ 50% PSA decline on prior AA (Ann Oncol 2012; 23(11):2943-7). To investigate this further, we evaluated the activity of D in mCRPC pts who had previously received AA. Methods: Cancer registries at two Canadian centers were used to identify mCRPC pts treated with D after AA. Outcomes from D treatment were compared between AA responders (≥ 50% PSA decrease with prior AA) and AA non-responders (< 50% PSA decrease with prior AA). Progression-free survival (PFS) (Prostate Cancer Working Group 2 criteria) and overall survival (OS) were estimated using the Kaplan-Meier method. Results: Of 40 eligible pts, 14 (35%) were classified as AA responders and 26 (65%) as AA non-responders (including 16 pts who had no PSA decline on AA). The median number of cycles of D administered to AA responders and non-responders was 6 (range: 1-10) and 4 (range: 1-13) respectively. Thirty (75%) pts had also received D prior to AA. Notably, among 39 pts evaluable for PSA response, no difference was seen in the proportion of AA responders and non-responders who had PSA falls ≥ 50% (p=0.72; Fisher’s exact test) or ≥ 30% (p=0.75; Fisher’s exact test) on D (Table). Analysis of survival outcomes from date of initiation of D also revealed similar median PFS (p=0.54; log-rank) and median OS (p=0.93; log-rank) in both groups (Table). Conclusions: PSA response rates to D did not differ between AA responders and non-responders. These data suggest that the anti-tumor activity of D in mCRPC may be independent of prior response to AA and that chemotherapy is still a therapeutic option in patients who do not respond to AA. Prospective studies evaluating optimal sequencing of AA and D in mCRPC are warranted. [Table: see text]

The International Metastatic Renal Cell Carcinoma Database Consortium (IMDC) model as a prognostic tool in metastatic renal cell carcinoma (mRCC) patients previously treated with first-line targeted therapy (TT)

398

Background: Prior prognostic models for 2nd-line systemic therapy have not been studied in the setting of contemporary sequential targeted therapy (TT). We sought to validate the IMDC prognostic model in patients with mRCC receiving next-line TT after progression on 1st-line TT. Methods: Patients who received 2nd-line TT after progressing on 1st-line TT for mRCC at 19 centres were analyzed. For the patients who had immunotherapy (22%) prior to their 1st TT, we examined their second TT (ie 3rd-line therapy). The endpoint was median overall survival (OS) since the initiation of 2nd-line therapy. Additionally, we compared the IMDC model with the 3-factor-MSKCC model (Motzer et al JCO 2004) used for previously-treated patients. Results: 1,021 patients treated with a second TT were included. Median time on 2nd-line TT was 3.9 months (range 0-76+). 871 (85%) of patients had stopped 2nd-line TT by the time of analysis. Median OS since 2nd-line TT was 12.5 months (95% CI: 11.3-14.3 months), with 369 (36.1%) of patients remaining alive. 5 out of 6 pre-defined factors in IMDC model (anemia, thrombocytosis, neutrophilia, KPS <80%, and <1 year from diagnosis to treatment) measured at the time of 2nd-line TT were independent predictors of poorer OS (HR between 1.39 and 1.58, p<0.05). Hypercalcemia was not statistically significant in multivariable analysis (p=0.3008) likely due to the low incidence of hypercalcemia (9%). The concordance index using all 6 prognostic factors was 0.70, and was 0.66 with the 3-factor-MSKCC model. When patients were divided into 3 risk categories using IMDC criteria, median OS was 35.8 months (95% CI 28.3-47.8) in the favorable risk group (n=76), 16.6 months (95% CI 14.9-17.9) in the intermediate risk group (n=529), and 5.4 months (95% CI 4.7-6.8) in the poor risk group (n=261). Conclusions: The IMDC prognostic model has been validated in and can be applied to patients previously treated with TT, in addition to previously validated populations in 1st-line TT and non-clear cell setting.

Neutrophil to lymphocyte ratio and response to tyrosine kinase inhibitor therapy in metastatic renal cell carcinoma

477

Background: Neutrophil to lymphocyte ratio (NLR) and platelet to lymphocyte ratio (PLR) are markers of host inflammation and have prognostic value in many solid tumors. Here we aimed to explore the association of NLR and PLR with response to tyrosine kinase inhibitor (TKI) treatment in metastatic renal cell carcinoma (mRCC). Methods: Data from patients with mRCC treated at the Princess Margaret Cancer Centrein Toronto with a TKI as first-line treatment were retrospectively collected. The association of several variables with response to treatment (complete response [CR] or partial response [PR] vs. stable disease > 3 months [SD] or progressive disease [PD]) was assessed by binary logistic regression. Significant variables were dichotomized and cut-offs selected by the area under the receiver operating characteristic (AUC) curve. Results: Data from 157 patients treated between 11/2004 and 09/2012 were analyzed. Median age at start of TKI treatment was 61 years and first-line treatment was sunitinib, sorafenib, and other in 49%, 43%, and 8% of patients, respectively. Best response was CR/PR, SD, and PD in 27%, 55%, and 18% patients. On multivariable analysis NLR > 2.5 and Karnofsky Performance Status (KPS) < 90% were associated with a lower likelihood of response and each allocated a score of 1 unit. Response rates for a score of 0, 1, or 2 were 45% (29-61%), 28% (17-38%), 10% (1-19%), respectively. PLR did not retain association with response in multivariable analysis. Conclusions: NLR and KPS are associated with response to TKI treatment in mRCC. Data from an external validation set will also be presented.

Cytoreductive nephrectomy (CN) in patients with synchronous metastases from renal cell carcinoma: Results from the International Metastatic Renal Cell Carcinoma Database Consortium (IMDC)

396

Background: The role of cytoreductive nephrectomy is unclear in patients with synchronous metastases from renal cell carcinoma (RCC) in the age of targeted therapy. Methods: Comparisons were made between patients treated with targeted therapy who had a CN versus not and adjusted using proportional hazards regression for known poor prognostic criteria (IMDC criteria Heng et al JCO 2009). Results: 2569/3245 (79%) mRCC patients received a nephrectomy. Patients who had nephrectomy before the diagnosis of metastatic disease were excluded (n=1634). Among the remaining patients, 935 patients had a CN and 676 patients did not have nephrectomy. All patients received targeted therapy with the majority receiving first-line sunitinib 72%, sorafenib 15%, temsirolimus 5%, bevacizumab 3%, pazopanib 3%. Patients who had CN had better IMDC prognostic profiles versus those without (favorable/intermediate/poor in 9%/63%/28% vs 1%/45%/54% p<0.0001). The median overall survival of patients with CN vs without was 20.6 vs 9.5 months (p<0.0001). When adjusted for IMDC criteria to correct for imbalances, the HR of death was 0.60 (95%CI 0.52-0.69, p<0.0001). The Table demonstrates the increasing benefit of CN if a given patient has a longer survival time. Conclusions: CN can be beneficial in patients with synchronous metastatic RCC even after adjustment for prognostic factors. Patients who are estimated to survive less than 9-12 months may have a marginal benefit compared to those with longer estimated survival. This may aid in patient selection as we await results from randomized controlled trials. [Table: see text]

Predictors of pathologic complete response after neoadjuvant treatment for rectal cancer: A multicenter study

397

Background: Pathologic complete response (pCR) to neoadjuvant chemoradiation (CRT) for rectal cancer is associated with better long-term outcomes, and is used as an early indicator of response to novel agents. To assess the rate and predictors of pCR, we performed a retrospective population based study in four Canadian provinces. Methods: Cancer Registries identified consecutive patients with clinical stage I-III rectal cancer from the Tom Baker Cancer Center, Cross Cancer Institute, BC Cancer Agency, Ottawa Hospital Cancer Centre and the Dr. H. Bliss Murphy Cancer Centre who received fluoropyrimidine-based CRT and had curative intent surgery (Sx) from 2005 to 2012. Patient, tumor, and therapy characteristics were correlated with response. Results: Of the 891 patients included, 885 patients had pCR data available. 161 (18.2%) had a pCR to CRT, while 724 (81.8%) did not. Patients with a pCR had a lower pre-treatment (tx) CEA, and higher hemoglobin on univariate analysis (see table). On multivariable analysis, statin use at baseline (OR 1.7, 95% CI 1.04-2.89, p=0.044), lower pre-tx CEA (OR 1.03, 95% CI 1.003-1.05 p=0.028) and distance closer to anal verge (OR 1.07, 95% CI 1.004-1.15, p=0.039) were significant predictors of pCR. The 3yr DFS was 86% in those with pCR vs 62.5% in those without a pCR (P<0.0001). Conclusions: Lower pre-tx CEA, distance closer to anal verge and statin use are predictors of pCR. Clinical trials investigating statins combined with neoadjuvant CRT may be warranted. [Table: see text]

Predictors of treatment interruption/dose reduction of neoadjuvant chemotherapy for rectal cancer: A multicenter study

580

Background: Neoadjuvant chemoradiation (CRT) is the standard of care for patients with locally advanced rectal cancer. Many patients require dose reduction or chemotherapy interruption due to significant toxicities. To assess the predictors of neoadjuvant chemotherapy treatment (tx) adjustments, we performed a retrospective study in four Canadian provinces. Methods: Cancer Registries identified consecutive patients with clinical stage I-III rectal cancer from the Tom Baker Cancer Center, Cross Cancer Institute, BC Cancer Agency, Ottawa Hospital Cancer Centre and the Dr. H. Bliss Murphy Cancer Centre who received CRT and had curative intent surgery (Sx) from 2005 to 2012. Patient, tumor and tx characteristics were correlated with treatment completion. Results: Of the 891 patients included, 886 patients had tx dose adjustments data available. 738 (83.2%) completed the planned neoadjuvant chemotherapy, while 148 (16.7%) failed to complete planned chemotherapy. Patients who required tx interruption/cessation or dose reduction were more likely to be female, elderly, had higher ECOG PS and were treated with fluorouracil (FU) chemotherapy in univariate analysis (see Table). On multivariable analysis, female gender (OR 1.807, 95% CI 1.02-3.2, p=0.042) and tx with FU (vs capecitabine) (OR 2.7, 95% CI 1.52-4.77, p=0.0007) were associated with dose reduction and tx interruption/cessation. Conclusions: Gender and type of chemotherapy are predictors of neoadjuvant chemotherapy interruption or dose reduction in rectal cancer. Careful monitoring of these patients is warranted during neoadjuvant CRT. [Table: see text]

Using the Delphi technique to improve clinical outcomes through the development of quality indicators in renal cell carcinoma

PURPOSE

Optimal quality of care is needed for ideal outcomes. In renal cell carcinoma (RCC), there is a lack of information defining optimal care. This is particularly important in RCC, with increased complexity of care and a need for coordination among providers. The goal of this study was to identify quality indicators (QIs) and measures of quality care across the RCC disease spectrum.

MATERIALS AND METHODS

A modified Delphi technique was used to select QIs that are relevant and practical to RCC care. This technique involved an expert panel of 13 urologic and medical oncologists who participated in two e-mail questionnaires and an in-person meeting to review and prioritize potential QIs. These potential QIs were identified from a systematic literature review or were suggested by panel members.

RESULTS

From 233 literature citations, 34 possible QIs were identified; 24 additional potential QIs were suggested. A final set of 23 QIs was established. These are distributed across the RCC disease spectrum as follows (number of QIs in parentheses): screening (n=1), diagnosis/prognosis (n=3), surgical for localized disease (n=6), surgery for advanced disease (n=3), systemic therapy (n=6), and follow-up (n=2). In addition, two QIs related to survival outcomes (overall and progression-free survival) were selected.

CONCLUSION

A systematic, consensus-based approach was used to determine relevant QIs in RCC care. These 23 QIs will provide a means of evaluating the quality of RCC care in an effort to improve outcomes in patients. The next step will be to establish a means of measuring each QI based on defined or yet-to-be-defined benchmarks.

A phase II multicenter study of the efficacy and safety of sunitinib given on an individualized schedule as first-line therapy for metastatic renal cell cancer

TPS4594

Background: Retrospective reviews have shown poorer than expected response rate (RR), progression free survival (PFS) and overall survival (OS) in Sunitinib treated (Rx) Renal Cell Cancer (RCC) patients (pts) who experience minimal toxicity. This study is based on an individualized (individ) Rx strategy where dose/schedule modifications (DSM) were done to maximize dose and minimize time off Rx in 172 pts (Bjarnason ASCO-GU 2011). Pts started on 50mg 28 days (d) on/14d off. DSM were done to keep toxicity (fatigue, skin, GI, hematology) at ≤ grade-2. DSM-1 was 50mg 14d/7d with individ increases in d on Rx based on toxicity. DSM-2 was 50mg 7d/7d with individ increases in d on Rx. DSM-3 was 37.5mg continuously with individ 7d breaks. DSM-4 was 25mg continuously with individ 7d breaks.In pts with clear cell histology PFS was inferior (5.8 mo) on the standard 50mg 28d/14d schedule vs. DSM schedules (>14 months, p=0.0002) These data, confirmed in 185 pts at MD Anderson (Jonasch KCA 2012), suggest that pts with minimal toxicity after 28d on Rx may benefit from dose escalation. Methods: A prospective phase II study has opened in 11 centers in Canada. DSM are done as described above. Pts with minimal toxicity after 28d are escalated to 62.5 mg and then 75 mg on a 14d /7d schedule. We expect to dose escalate 25% of pts and maintain another 40% of pts on a 50 mg dose that would otherwise have been dose reduced. The primary objective is the PFS associated with this strategy. Secondary objectives include dose intensity, RR, OS, toxicity, and quality of life. Samples for Sunitinib pharmacokinetics are obtained during the first course and again when the ideal sunitinib schedule has been established. Samples for biomarker and DNA correlative studies are collected. Based on the standard arm of the EFFECT trial (identical eligibility criteria), we assume a median PFS of 8.5 months in pts Rx using standard dosing. We expect pts treated with the indiv dosing will have a median PFS of 14 months. With alpha=0.05, a two-sided, single-arm non-parametric survival test would have over 90% power to detect this difference with a total of 110 pts on study. Study enrollment began in July 2012 with 25 pts currently on study. Clinical trial information: NCT01499121.