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Evans D, Rothschild S, Tordella C, Chacón M. Leveraging Patient Engagement Through Collaboration for Improved Global Health Outcomes in Sarcoma. Am Soc Clin Oncol Educ Book 2024; 44:e438934. [PMID: 38862132 DOI: 10.1200/edbk_438934] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/13/2024]
Abstract
In the dynamic landscape of oncology, collaborative efforts between the medical community and patient advocacy groups are pivotal in shaping standards of care and advancing research. Nowhere is this collaboration more evident than in sarcoma, a group of rare cancers posing unique challenges to diagnosis, management, and treatment, which profoundly affect patient outcomes. Here, we explore the vital role of patient-centric collaboration in improving global health outcomes in sarcoma, emphasizing the transformative power of collective action and shared expertise. Challenges in sarcoma care, including diagnostic complexities, disparities in access to care, and genomic tumor heterogeneity, underscore the urgent need for collaborative solutions. Initiatives like the Sarcoma European and Latin American Network (SELNET) and The Life Raft Group (LRG) exemplify successful models of collaborative research and patient advocacy, driving advancements in diagnosis, treatment, and disease understanding. Stakeholders across disciplines are uniting to improve sarcoma care and outcomes through the development of clinical practice guidelines, continuous medical education, patient registries, virtual tumor boards, and consortium-driven research endeavors, all of which foster the growth of global collaborative groups. The success of these collaborative efforts serves as a model for other rare diseases, highlighting the potential of collective action to drive progress and innovation in health care.
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Affiliation(s)
| | | | | | - Matías Chacón
- Instituto Alexander Fleming, Buenos Aires, Argentina
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2
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Roets E, Ijzerman NS, Ho VKY, Desar IME, Reyners AKL, Gelderblom H, Grünhagen DJ, Van Etten B, Van Houdt WJ, Van der Graaf WTA, Steeghs N. Referral patterns of GIST patients: data from a nationwide study. Acta Oncol 2024; 63:28-34. [PMID: 38353407 PMCID: PMC11332507 DOI: 10.2340/1651-226x.2024.23722] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2023] [Accepted: 12/25/2023] [Indexed: 02/16/2024]
Abstract
BACKGROUND This study compares the characteristics, referral and treatment patterns and overall survival (OS) of gastrointestinal stromal tumor (GIST) patients treated in reference and non-reference centers in the Netherlands. PATIENTS AND METHODS This retrospective cohort study on patients diagnosed between 2016 and 2019, utilises data from the Netherlands Cancer Registry and the Dutch Nationwide Pathology Database. Patients were categorized into two groups: patients diagnosed in or referred to reference centers and patients diagnosed in non-reference centers without referral. RESULTS This study included 1,550 GIST patients with a median age of 67.0 in reference and 68.0 years in non-reference centers. Eighty-seven per cent of patients were diagnosed in non-reference centers, of which 36.5% (493/1,352) were referred to a reference center. Referral rates were higher for high-risk (62.2% [74/119]) and metastatic patients (67.2% [90/134]). Mutation analysis was performed in 96.9% and 87.6% of these cases in reference and in non-reference centers (p < 0.01), respectively. Systemic therapy was given in reference centers versus non-reference in 89.5% versus 82.0% (p < 0.01) of high-risk and in 94.1% versus 65.9% (p < 0.01) of metastatic patients, respectively. The proportion of positive resection margins and tumor rupture did not differ between reference and non-reference centers. Median OS was not reached. CONCLUSION A substantial amount of metastatic GIST patients in non-reference centers did not receive systemic treatment. This might be due to valid reasons. However, optimisation of the referral strategy of GIST patients in the Netherlands could benefit patients. Further research is needed to explore reasons for not starting systemic treatment in metastatic GIST patients.
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Affiliation(s)
- Evelyne Roets
- Department of Medical Oncology, The Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - Nikki S Ijzerman
- Department of Medical Oncology, The Netherlands Cancer Institute, Amsterdam, the Netherlands; Department of Medical Oncology, Erasmus MC Cancer Institute, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Vincent K Y Ho
- Department of Research and Development, Netherlands Comprehensive Cancer Organisation (IKNL), Utrecht, the Netherlands
| | - Ingrid M E Desar
- Department of Medical Oncology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Anna K L Reyners
- Department of Medical Oncology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Hans Gelderblom
- Department of Medical Oncology, Leiden University Medical Center, Leiden, the Netherlands
| | - Dirk J Grünhagen
- Department of Surgical Oncology, Erasmus MC Cancer Institute, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Boudewijn Van Etten
- University of Groningen, University Medical Center Groningen, Department of Surgical Oncology and gastrointestinal surgery, Groningen, the Netherlands
| | - Winan J Van Houdt
- Department of Surgical Oncology, The Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - Winette T A Van der Graaf
- Department of Medical Oncology, The Netherlands Cancer Institute, Amsterdam, the Netherlands; Department of Medical Oncology, Erasmus MC Cancer Institute, Erasmus University Medical Center, Rotterdam, the Netherlands.
| | - Neeltje Steeghs
- Department of Medical Oncology, The Netherlands Cancer Institute, Amsterdam, the Netherlands
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3
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Heinrich MC, Jones RL, George S, Gelderblom H, Schöffski P, von Mehren M, Zalcberg JR, Kang YK, Razak AA, Trent J, Attia S, Le Cesne A, Siontis BL, Goldstein D, Boye K, Sanchez C, Steeghs N, Rutkowski P, Druta M, Serrano C, Somaiah N, Chi P, Reichmann W, Sprott K, Achour H, Sherman ML, Ruiz-Soto R, Blay JY, Bauer S. Ripretinib versus sunitinib in gastrointestinal stromal tumor: ctDNA biomarker analysis of the phase 3 INTRIGUE trial. Nat Med 2024; 30:498-506. [PMID: 38182785 PMCID: PMC10878977 DOI: 10.1038/s41591-023-02734-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Accepted: 11/22/2023] [Indexed: 01/07/2024]
Abstract
INTRIGUE was an open-label, phase 3 study in adult patients with advanced gastrointestinal stromal tumor who had disease progression on or intolerance to imatinib and who were randomized to once-daily ripretinib 150 mg or sunitinib 50 mg. In the primary analysis, progression-free survival (PFS) with ripretinib was not superior to sunitinib. In clinical and nonclinical studies, ripretinib and sunitinib have demonstrated differential activity based on the exon location of KIT mutations. Therefore, we hypothesized that mutational analysis using circulating tumor DNA (ctDNA) might provide further insight. In this exploratory analysis (N = 362), baseline peripheral whole blood was analyzed by a 74-gene ctDNA next-generation sequencing-based assay. ctDNA was detected in 280/362 (77%) samples with KIT mutations in 213/362 patients (59%). Imatinib-resistant mutations were found in the KIT ATP-binding pocket (exons 13/14) and activation loop (exons 17/18). Mutational subgroup assessment showed 2 mutually exclusive populations with differential treatment effects. Patients with only KIT exon 11 + 13/14 mutations (ripretinib, n = 21; sunitinib, n = 20) had better PFS with sunitinib versus ripretinib (median, 15.0 versus 4.0 months). Patients with only KIT exon 11 + 17/18 mutations (ripretinib, n = 27; sunitinib, n = 25) had better PFS with ripretinib versus sunitinib (median, 14.2 versus 1.5 months). The results of this exploratory analysis suggest ctDNA sequencing may improve the prediction of the efficacy of single-drug therapies and support further evaluation of ripretinib in patients with KIT exon 11 + 17/18 mutations. ClinicalTrials.gov identifier: NCT03673501.
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Affiliation(s)
- Michael C Heinrich
- Division of Hematology/Oncology, Portland VA Health Care System, Portland, OR, USA
- Department of Medicine, OHSU Knight Cancer Institute, Portland, OR, USA
| | - Robin L Jones
- Sarcoma Unit, The Royal Marsden NHS Foundation Trust and Institute of Cancer Research, London, UK
| | - Suzanne George
- Center for Sarcoma and Bone Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Hans Gelderblom
- Department of Medical Oncology, Leiden University Medical Center, Leiden, Netherlands
| | - Patrick Schöffski
- Department of General Medical Oncology, University Hospitals Leuven, Leuven Cancer Institute, KU Leuven, Leuven, Belgium
| | - Margaret von Mehren
- Department of Hematology/Oncology, Fox Chase Cancer Center, Temple University Health System, Philadelphia, PA, USA
| | - John R Zalcberg
- Department of Medical Oncology, Monash University School of Public Health and Preventive Medicine, Alfred Health, Melbourne, Victoria, Australia
| | - Yoon-Koo Kang
- Department of Oncology, Asan Medical Center, University of Ulsan, Seoul, Korea
| | - Albiruni Abdul Razak
- Division of Medical Oncology, Toronto Sarcoma Program, Princess Margaret Cancer Center, Toronto, ON, Canada
| | - Jonathan Trent
- Department of Medical Oncology, Sylvester Comprehensive Cancer Center, University of Miami Health System, Miami, FL, USA
| | - Steven Attia
- Department of Medical Oncology, Mayo Clinic, Jacksonville, FL, USA
| | - Axel Le Cesne
- Medical Oncology Department, Gustave Roussy, Villejuif, France
| | | | - David Goldstein
- Department of Medical Oncology, Prince of Wales Hospital, Randwick, New South Wales, Australia
| | - Kjetil Boye
- Department of Tumor Biology, Oslo University Hospital, Oslo, Norway
| | - Cesar Sanchez
- Department of Hematology-Oncology, Centro de Cáncer, Hospital Clínico Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Neeltje Steeghs
- Department of Medical Oncology, The Netherlands Cancer Institute, Antoni van Leeuwenhoek Hospital, Amsterdam, Netherlands
| | - Piotr Rutkowski
- Department of Soft Tissue/Bone Sarcoma and Melanoma, Maria Sklodowska-Curie National Research Institute of Oncology, Warszawa, Poland
| | - Mihaela Druta
- Sarcoma Program, Moffitt Cancer Center, Tampa, FL, USA
| | - César Serrano
- Sarcoma Translational Research Group, Vall d'Hebron Institute of Oncology, Barcelona, Spain
| | - Neeta Somaiah
- Department of Sarcoma Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Ping Chi
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Department of Medicine, Weill Cornell Medicine, New York, NY, USA
| | | | - Kam Sprott
- Biometrics, Deciphera Pharmaceuticals, LLC, Waltham, MA, USA
- Translational Medicine, Deciphera Pharmaceuticals, LLC, Waltham, MA, USA
| | - Haroun Achour
- Biometrics, Deciphera Pharmaceuticals, LLC, Waltham, MA, USA
- Clinical Development, Deciphera Pharmaceuticals, LLC, Waltham, MA, USA
| | - Matthew L Sherman
- Clinical Development, Deciphera Pharmaceuticals, LLC, Waltham, MA, USA
| | - Rodrigo Ruiz-Soto
- Clinical Development, Deciphera Pharmaceuticals, LLC, Waltham, MA, USA
| | - Jean-Yves Blay
- Department of Medical Oncology, Centre Léon Bérard, Lyon, France
| | - Sebastian Bauer
- Department of Medical Oncology and Sarcoma Center, West German Cancer Center, University Hospital Essen, University Duisburg-Essen, Essen, Germany.
- German Cancer Consortium (DKTK), Partner Site University Hospital Essen, Essen, Germany.
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Lopes David BB, Nazareth Aguiar Junior P, Costa e Silva M, Dienstmann R, Gil Ferreira C, Serrano C. Cost Evaluation Analysis of Genetic Testing and Tailored Adjuvant Imatinib in Patients With Resected High-Risk GI Stromal Tumors: The Brazilian Perspective. JCO Glob Oncol 2023; 9:e2300070. [PMID: 37856732 PMCID: PMC10664859 DOI: 10.1200/go.23.00070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Revised: 07/31/2023] [Accepted: 08/25/2023] [Indexed: 10/21/2023] Open
Abstract
PURPOSE Mutations of the KIT gene are the molecular hallmark of most GI stromal tumors (GISTs). Imatinib has revolutionized GIST treatment. Adjuvant imatinib for 3 years is the standard of care for high-risk resected GIST. However, the GIST molecular biologic profile has found different responses to this approach. Despite this, genetic testing at diagnosis is not a routine and empirical adjuvant imatinib remains the rule. Barriers to genetic profiling include concerns about the cost and utility of testing. This analysis aims to determine whether targeted genetic testing reduces costs as an ancillary tool for a limited-resource scenario instead of adjuvant empirical imatinib in patients with resected high-risk GIST. METHODS The cost evaluation analysis of molecular testing for GIST was based on the Cost of Preventing an Event (COPE), considering the Number Needed to Treat and the costs of each test compared with the cost of 3-year empirical adjuvant imatinib and real treatment costs (median number of cycles) from the public and private Brazilian Healthcare System's perspective. The analysis compared the costs of the molecular tests (broad next-generation sequencing [NGS], GS Infinity DNA/RNA assay, and targeted NGS: GS Focus GIST and the Fleury GIST Tumor DNA sequencing panel), costs of drug acquisition, considering discounts (imatinib mesylate and Glivec), and the costs of supportive care. RESULTS In both scenarios, public and private, regardless of the use of imatinib or Glivec, tailoring adjuvant treatment reduced costs, irrespective of the number of cycles. The only exception was the combination of the broad NGS test and imatinib in the Public Healthcare System. CONCLUSION The molecularly tailored adjuvant imatinib reduced costs considering the COPE of available NGS tests for both the public and private Brazilian health care systems.
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Affiliation(s)
- Bruna Bianca Lopes David
- Grupo Oncoclinicas, São Paulo, Brazil
- Division of Clinical Research and Technological Development, Brazilian National Cancer Institute, Rio de Janeiro, Brazil
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Khosroyani HM, Klug LR, Heinrich MC. TKI Treatment Sequencing in Advanced Gastrointestinal Stromal Tumors. Drugs 2023; 83:55-73. [PMID: 36607590 PMCID: PMC10029090 DOI: 10.1007/s40265-022-01820-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/23/2022] [Indexed: 01/07/2023]
Abstract
Prior to the early 2000s, patients with advanced gastrointestinal stromal tumors (GIST) had very poor prognoses owing to a lack of effective therapies. The development of tyrosine kinase inhibitors at the turn of the century significantly improved the overall survival for patients with GIST. The resounding success of imatinib in the first clinical trial of a tyrosine kinase inhibitor to treat GIST led to its approval for first-line therapy for advanced GIST; this study was open to all comers and not restricted to any GIST subtype(s). The trials that led to the approvals of second-, third-, and fourth-line therapy for advanced GIST were also open to all patients with advanced/metastatic GIST. Only in retrospect do we realize the role that the molecular subtypes played in the results observed in these studies. In this review, we discuss the studies that led to the US Food and Drug Administration approval of imatinib (first line), sunitinib (second line), regorafenib (third line), and ripretinib (fourth line) for advanced KIT-mutant GIST. In addition, we review how information about GIST molecular subtypes has been used to accelerate the approval of other targeted therapies for non-KIT mutant GIST, leading to the approval of five additional drugs indicated for the treatment of specific GIST molecular subtypes. We also discuss how our understanding of the molecular subtypes will play a role in the next generation of therapeutic approaches for treating advanced GIST.
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Affiliation(s)
- Homma M Khosroyani
- Portland VA Health Care System and Knight Cancer Institute, Oregon Health & Science University, R&D-19, 3710 SW US Veterans Hospital Road, Portland, OR, 97239, USA
| | - Lillian R Klug
- Portland VA Health Care System and Knight Cancer Institute, Oregon Health & Science University, R&D-19, 3710 SW US Veterans Hospital Road, Portland, OR, 97239, USA
| | - Michael C Heinrich
- Portland VA Health Care System and Knight Cancer Institute, Oregon Health & Science University, R&D-19, 3710 SW US Veterans Hospital Road, Portland, OR, 97239, USA.
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6
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Montoya D, Call JW, Eshak J, Knox P, Luedke M, Kaur S, Rothschild S, Garland M, Scherzer NJ. Barriers to mutational testing in patients with gastrointestinal stromal tumors (GIST) – a survey of life raft group members. BMC Gastroenterol 2022; 22:455. [DOI: 10.1186/s12876-022-02548-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Accepted: 10/20/2022] [Indexed: 11/16/2022] Open
Abstract
Abstract
Background
Due to the low mutational testing rate in patients with Gastrointestinal Stromal Tumors (GIST), The Life Raft Group (LRG), a non-profit organization that provides support, advocacy and conducts research for patients with GIST, analyzed various factors that may have an impact on patients’ ability to receive mutational testing.
Methods
A survey about mutational testing for patients with GIST or their caregivers, was conducted in June 2020. The survey, sent to 1004 GIST patients and caregivers through email, was promoted through social media with instructions to contact the LRG to participate. The survey was designed by the LRG Patient Registry Department. Members of the LRG, regardless of Patient Registry status, were eligible to participate.
Results
A total of 295 patients/caregivers participated in this study (response rate: 29.4%). The percentage of patients who indicated they had received mutational testing was much higher in this survey (80%) than in the general GIST community (26.7%).
Several reasons were cited for having a test, including: “My doctor ordered/suggested that I have it done” (54%); “The Life Raft Group advised/suggested I have it done” (25%); “I asked my doctor to have it done” (22%); “I had it done as part of a clinical trial” (5%); “I am not sure” (3%) and “Other” (14%). Mutational testing resulted in a treatment change in 25% of cases. Patients were able to select more than one option when completing this question resulting in a percentage greater than 100.
Conclusions
The LRG membership is voluntary and proactive; patients who join are more likely to participate in surveys and mutational testing, as well as more likely to have a GIST specialist. Mutational testing can influence understanding of a patient’s GIST and the treatment best suited to each case. These are extremely important findings, as it helps ensure that patients are on the proper treatment, which should lead to better outcomes.
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Qian H, Yan N, Hu X, Jiang J, Cao Z, Shen D. Molecular Portrait of GISTs Associated With Clinicopathological Features: A Retrospective Study With Molecular Analysis by a Custom 9-Gene Targeted Next-Generation Sequencing Panel. Front Genet 2022; 13:864499. [PMID: 35547262 PMCID: PMC9081536 DOI: 10.3389/fgene.2022.864499] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Accepted: 03/03/2022] [Indexed: 01/04/2023] Open
Abstract
Objectives: The study aims to investigate genetic characterization of molecular targets and clinicopathological features with gastrointestinal stromal tumors based on targeted next-generation sequencing. Materials and Methods: We selected 106 patients with GISTs from Sir Run Run Shaw Hospital between July 2019 and March 2021. FFPE samples and paired blood samples were obtained from these patients who underwent excision of the tumor. A customized targeted-NGS panel of nine GIST-associated genes was designed to detect variants in the coding regions and the splicing sites of these genes. Results: In total, 106 patients with a GIST were included in the study which presented with various molecular driver alterations in this study. KIT mutations occurred most often in GISTs (94/106, 95.92%), followed by point mutations in PDGFRA. KIT or PDGFRA mutations were detected to be mutually exclusive in the GIST. A total of eight patients with wide-type KIT/PDGFRA were characterized as WT-GISTs, according to clinical diagnosis which included six quadruple-WT GISTs, 1 BRAF-mutant, and 1 NF1-mutant GIST. In KIT exon 11, the most common mutation type was the codon Mutation (in-frame deletion or indels), whereas the missense mutation was the dominant type in KIT exon 13 and KIT exon 17. All variations in KIT exon 11 observed in this study were concentrated at a certain position of codon 550 to codon 576. Mutation in KIT exon 9 was mostly located at codon 502–503. Two germline pathogenic mutations were detected: NF1-R681* and KRAS-T58I. NF1-L591P was a germline mutation to be identified for the first time and is not recorded in the database. The frequency of driving mutations differed between the primary anatomical site in the GIST (p = 0.0206). KIT exon 11 mutants had a lower proliferation index of Ki67 (68.66%,≤5%), while 50.00% of KIT exon 9 mutants had the Ki67 status greater than 10%. Conclusion: The occurrence and development of a GIST is driven by different molecular variations. Resistance to TKIs arises mainly with resistance mutations in KIT or PDGFRA when they are the primary drivers. Targeted NGS can simultaneously and efficiently detect nine GIST-related gene mutations and provide reference for clinicians’ individualized diagnosis and treatment. Our results have important implications for clinical management.
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Affiliation(s)
- Haoran Qian
- Department of General Surgery, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Na Yan
- Dian Diagnostics Group Co., Ltd., Hangzhou, China.,Key Laboratory of Clinical in Vitro Diagnostic Techniques of Zhejiang Province, Hangzhou, China
| | - Xiaotong Hu
- Department of Pathology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Junchang Jiang
- Department of Pathology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Zhengzheng Cao
- Dian Diagnostics Group Co., Ltd., Hangzhou, China.,Key Laboratory of Clinical in Vitro Diagnostic Techniques of Zhejiang Province, Hangzhou, China
| | - Dan Shen
- Dian Diagnostics Group Co., Ltd., Hangzhou, China.,Key Laboratory of Clinical in Vitro Diagnostic Techniques of Zhejiang Province, Hangzhou, China
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Abstract
Over the past 20 years, gastrointestinal stromal tumor (GIST) has evolved into an increasingly complex clinical entity with ever more challenges. While surgical resection is the gold standard, advancements in genetic testing, therapeutic options, immunotherapy, and management of metastatic disease necessitate a comprehensive, multimodal approach for these tumors. This chapter highlights the importance of genomic testing of GIST, the use of neoadjuvant and adjuvant therapy for localized disease, surgical principles for GIST, as well as current and new approaches for addressing metastatic disease.
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9
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Martin NA, Tepper JE, Giri VN, Stinchcombe TE, Cheng HH, Javle MM, Konnick EQ. Adopting Consensus Terms for Testing in Precision Medicine. JCO Precis Oncol 2021; 5:PO.21.00027. [PMID: 34651094 PMCID: PMC8509918 DOI: 10.1200/po.21.00027] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Revised: 06/28/2021] [Accepted: 07/19/2021] [Indexed: 12/28/2022] Open
Abstract
Despite the well-understood benefits of biomarker and genetic testing in precision medicine, uptake remains low, particularly for patients with low socioeconomic status and minority ethnic backgrounds. Patients report having limited familiarity with testing terminology and may not be able to accurately explain testing's role in treatment decisions. Patient confusion and lack of understanding is exacerbated by a multiplicity of overlapping terms used in communicating about testing. A LUNGevity Foundation–led working group composed of five professional societies, 23 patient advocacy groups, and 19 industry members assessed and recommended specific terms for communicating with patients on testing for tumor characteristics and germline mutations.
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Affiliation(s)
| | - Joel E Tepper
- Department of Radiation Oncology, UNC/Lineberger Comprehensive Cancer Center, UNC School of Medicine, Chapel Hill, NC
| | - Veda N Giri
- Cancer Risk Assessment and Clinical Cancer Genetics, Departments of Medical Oncology, Cancer Biology, and Urology, Sidney Kimmel Cancer Center, Thomas Jefferson University, Philadelphia, PA
| | | | - Heather H Cheng
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA.,Department of Medicine, Division of Oncology, University of Washington, Seattle, WA.,Seattle Cancer Care Alliance, Seattle, WA
| | - Milind M Javle
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Eric Q Konnick
- Seattle Cancer Care Alliance, Seattle, WA.,Department of Laboratory Medicine and Pathology, University of Washington, Seattle, WA
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Utilization of Mutational Analysis (MA) in Gastrointestinal Stromal Tumor (GIST) Management in British Columbia (BC) Between January 2008 to December 2017: a Retrospective Population-Based Study. J Gastrointest Cancer 2021; 53:709-717. [PMID: 34486087 DOI: 10.1007/s12029-021-00682-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/30/2021] [Indexed: 01/22/2023]
Abstract
PURPOSE To examine oncologists' practice pattern of ordering MA in localized and metastatic GISTs in British Columbia (BC). METHODS Patients diagnosed with GIST from January 2008 to December 2017 in BC were identified. Chart review was performed to determine clinical characteristics and the use of MA as part of their oncologic care. RESULTS The cohort included 411 patients: median age 64 (18-94 years), 49.1% male, primary site included stomach (53%), small intestine (32%), and others (15%). Sixty-nine percent had localized disease, while 13% presented with de novo metastatic disease and 18% had recurrent metastatic disease. MA was ordered in 41% of the patients overall, 28% in localized, and 70% in metastatic settings (63% in de novo metastasis and 78% in recurrent metastasis). Among patients with localized disease, higher MA use rates were observed among those undergoing neoadjuvant/adjuvant treatment (45%) compared to those not receiving systemic therapy (18%). While MA use rates in localized GIST did not change over time (28.5% before 2015 and 28% after 2015), MA use in metastatic disease increased from 54% before 2015 to 79% after 2015. Among all MA ordered for metastatic disease, 82.4% were ordered at the time of de novo metastatic diagnosis, and 77.4% were ordered either at the time of recurrent metastatic diagnosis or earlier when the disease was localized. CONCLUSION MA use has remained stable for localized disease but has increased after 2015 in the metastatic setting which may be due to evolving sequencing technology, expansion of metastatic treatment options, and enhanced awareness of MA.
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Henriques-Abreu M, Serrano C. Avapritinib in unresectable or metastatic gastrointestinal stromal tumor with PDGFRA exon 18 mutation: safety and efficacy. Expert Rev Anticancer Ther 2021; 21:1081-1088. [PMID: 34404327 DOI: 10.1080/14737140.2021.1963235] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
INTRODUCTION Avapritinib (formerly known as BLU-285) is an orally available type I tyrosine kinase inhibitor that, in 2020, obtained regulatory approval for the treatment of patients with gastrointestinal stromal tumors (GISTs) harboring a primary mutation in PDGFRA exon 18, including the PDGFRA D842V mutation. AREAS COVERED Herein, we comprehensively review the available efficacy and safety data on avapritinib, with the final goal of providing practical knowledge to both sarcoma and community-based oncologists for the correct management of this rare GIST subpopulation with this novel therapy. EXPERT OPINION The approval of avapritinib in GIST is a milestone in precision oncology, as this is the first agent ever demonstrating unequivocal antitumoral activity in GIST driven by the multi-resistant PDGFRA D842V mutation. The safety profile is manageable and tolerability-guided dose adjustment is recommended to manage treatment-related adverse events without compromising efficacy. Based on its unprecedented activity, avapritinib should be considered as first-line therapy for GIST patients harboring this mutation. We strongly recommend to determine KIT/PDGFRA genotype in order to identify the different GIST molecular subtypes and guide treatment decision.
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Affiliation(s)
| | - César Serrano
- Department of Medical Oncology, Vall d'Hebron University Hospital, Barcelona, Spain.,Sarcoma Translational Research Laboratory, Vall d'Hebron Institute of Oncology (VHIO), Vall d'Hebron Hospital Campus, Barcelona, Spain
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12
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Sharma AK, de la Torre J, IJzerman NS, Sutton TL, Zhao B, Khan TM, Banerjee S, Cui C, Nguyen V, Alkhuziem M, Snaebjornsson P, van Boven H, Bruining A, Tang CM, Yoon H, De la Fuente A, Kato S, Patel H, Heinrich MC, Corless CL, Horgan S, Burgoyne AM, Fanta P, Mesirov JP, Blakely AM, Davis JL, Mayo SC, van Houdt WJ, Steeghs N, Sicklick JK. Location of Gastrointestinal Stromal Tumor (GIST) in the Stomach Predicts Tumor Mutation Profile and Drug Sensitivity. Clin Cancer Res 2021; 27:5334-5342. [PMID: 34326133 DOI: 10.1158/1078-0432.ccr-21-1221] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Revised: 06/11/2021] [Accepted: 07/26/2021] [Indexed: 11/16/2022]
Abstract
PURPOSE Gastrointestinal stromal tumors (GIST) commonly arise in different regions of the stomach and are driven by various mutations (most often in KIT, PDGFRA, and SDHx). We hypothesized that the anatomic location of gastric GIST is associated with unique genomic profiles and distinct driver mutations. EXPERIMENTAL DESIGN We compared KIT versus non-KIT status with tumor location within the National Cancer Database (NCDB) for 2,418 patients with primary gastric GIST. Additionally, we compiled an international cohort (TransAtlantic GIST Collaborative, TAGC) of 236 patients and reviewed sequencing results, cross-sectional imaging, and operative reports. Subgroup analyses were performed for tumors located proximally versus distally. Risk factors for KIT versus non-KIT tumors were identified using multivariate regression analysis. A random forest machine learning model was then developed to determine feature importance. RESULTS Within the NCDB cohort, non-KIT mutants dominated distal tumor locations (P < 0.03). Proximal GIST were almost exclusively KIT mutant (96%) in the TAGC cohort, whereas 100% of PDGFRA and SDH-mutant GIST occurred in the distal stomach. On multivariate regression analysis, tumor location was associated with KIT versus non-KIT mutations. Using random forest machine learning analysis, stomach location was the most important feature for predicting mutation status. CONCLUSIONS We provide the first evidence that the mutational landscape of gastric GIST is related to tumor location. Proximal gastric GIST are overwhelmingly KIT mutant, irrespective of morphology or age, whereas distal tumors display non-KIT genomic diversity. Anatomic location of gastric GIST may therefore provide immediate guidance for clinical treatment decisions and selective confirmatory genomic testing when resources are limited.
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Affiliation(s)
- Ashwyn K Sharma
- Department of Surgery, Division of Surgical Oncology, University of California San Diego, San Diego, California.,Moores Cancer Center, University of California San Diego, La Jolla, California
| | - Jorge de la Torre
- Department of Surgery, Division of Surgical Oncology, University of California San Diego, San Diego, California.,Moores Cancer Center, University of California San Diego, La Jolla, California
| | - Nikki S IJzerman
- Department of Medical Oncology, Netherlands Cancer Institute, Amsterdam, the Netherlands.,Department of Medical Oncology, Erasmus MC Cancer Institute, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Thomas L Sutton
- Department of Surgery, Division of Surgical Oncology, Oregon Health and Science University, Knight Cancer Institute, Portland, Oregon
| | - Beiqun Zhao
- Department of Surgery, Division of Surgical Oncology, University of California San Diego, San Diego, California.,Moores Cancer Center, University of California San Diego, La Jolla, California
| | - Tahsin M Khan
- Surgical Oncology Program, Center for Cancer Research, NCI, NIH, Bethesda, Maryland
| | - Sudeep Banerjee
- Department of Surgery, Division of Surgical Oncology, University of California San Diego, San Diego, California.,Moores Cancer Center, University of California San Diego, La Jolla, California.,Department of Surgery, University of California, Los Angeles, Los Angeles, California
| | - Christina Cui
- Department of Surgery, Division of Surgical Oncology, University of California San Diego, San Diego, California
| | - Vi Nguyen
- Department of Surgery, Division of Surgical Oncology, University of California San Diego, San Diego, California
| | - Maha Alkhuziem
- Department of Surgery, Division of Surgical Oncology, University of California San Diego, San Diego, California.,Moores Cancer Center, University of California San Diego, La Jolla, California
| | - Petur Snaebjornsson
- Department of Pathology, Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - Hester van Boven
- Department of Pathology, Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - Annemarie Bruining
- Department of Radiology, Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - Chih-Min Tang
- Department of Surgery, Division of Surgical Oncology, University of California San Diego, San Diego, California.,Moores Cancer Center, University of California San Diego, La Jolla, California
| | - Hyunho Yoon
- Department of Surgery, Division of Surgical Oncology, University of California San Diego, San Diego, California.,Moores Cancer Center, University of California San Diego, La Jolla, California
| | - Alexa De la Fuente
- Department of Surgery, Division of Surgical Oncology, University of California San Diego, San Diego, California
| | - Shumei Kato
- Moores Cancer Center, University of California San Diego, La Jolla, California.,Department of Medicine, Division of Medical Oncology, University of California San Diego, San Diego, California
| | - Hitendra Patel
- Moores Cancer Center, University of California San Diego, La Jolla, California.,Department of Medicine, Division of Medical Oncology, University of California San Diego, San Diego, California
| | - Michael C Heinrich
- Department of Medical Oncology, Portland VA Health Care System and Oregon Health and Science University, Knight Cancer Institute, Portland, Oregon
| | - Christopher L Corless
- Department of Pathology, Oregon Health and Science University, Knight Cancer Institute, Portland, Oregon
| | - Santiago Horgan
- Department of Surgery, Division of Minimally Invasive Surgery, University of California San Diego, San Diego, California
| | - Adam M Burgoyne
- Moores Cancer Center, University of California San Diego, La Jolla, California.,Department of Medicine, Division of Medical Oncology, University of California San Diego, San Diego, California
| | - Paul Fanta
- Moores Cancer Center, University of California San Diego, La Jolla, California.,Department of Medicine, Division of Medical Oncology, University of California San Diego, San Diego, California
| | - Jill P Mesirov
- Moores Cancer Center, University of California San Diego, La Jolla, California.,Department of Medicine, University of California San Diego, San Diego, California
| | - Andrew M Blakely
- Surgical Oncology Program, Center for Cancer Research, NCI, NIH, Bethesda, Maryland
| | - Jeremy L Davis
- Surgical Oncology Program, Center for Cancer Research, NCI, NIH, Bethesda, Maryland
| | - Skye C Mayo
- Department of Surgery, Division of Surgical Oncology, Oregon Health and Science University, Knight Cancer Institute, Portland, Oregon
| | - Winan J van Houdt
- Department of Surgical Oncology, Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - Neeltje Steeghs
- Department of Medical Oncology, Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - Jason K Sicklick
- Department of Surgery, Division of Surgical Oncology, University of California San Diego, San Diego, California. .,Moores Cancer Center, University of California San Diego, La Jolla, California
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13
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Joseph CP, Abaricia SN, Angelis MA, Polson K, Jones RL, Kang Y, Riedel RF, Schöffski P, Serrano C, Trent J, Tetzlaff ED, Si TD, Zhou T, Doyle A, Bauer S, Roche M, Havnaer T. Optimal Avapritinib Treatment Strategies for Patients with Metastatic or Unresectable Gastrointestinal Stromal Tumors. Oncologist 2021; 26:e622-e631. [PMID: 33301227 PMCID: PMC8018323 DOI: 10.1002/onco.13632] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2020] [Accepted: 11/25/2020] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Avapritinib, a novel inhibitor of KIT/PDGFRA, is approved in the U.S. for the treatment of adults with PDGFRA exon 18-mutant unresectable or metastatic gastrointestinal stromal tumors (U/M GISTs). We assessed the safety of avapritinib and provide evidence-based guidance on management of avapritinib-associated adverse events (AEs), including cognitive effects and intracranial bleeding. MATERIALS AND METHODS We performed a post hoc analysis of data from a two-part, single-arm dose escalation/expansion phase I study (NAVIGATOR; NCT02508532) in patients with U/M GISTs treated with oral avapritinib 30-600 mg once daily. The primary endpoints were safety and tolerability; the impact of dose modification (interruption and/or reduction) on progression-free survival (PFS) was a secondary endpoint. Efficacy analyses were limited to patients who started avapritinib at 300 mg (approved dose). RESULTS Of 250 patients enrolled in the study, 74.0% presented with KIT mutation and 24.8% presented with PDGFRA exon 18-mutation; 66.8% started avapritinib at 300 mg. The most common treatment-related AEs (any grade) were nausea (59.2%), fatigue (50.0%), periorbital edema (42.0%), anemia (39.2%), diarrhea (36.0%), vomiting (36.0%), and increased lacrimation (30.8%). No treatment-related deaths occurred. Among 167 patients starting on 300 mg avapritinib, all-cause cognitive effects rate (grade 1-2) was 37.0% in all patients and 52.0% in patients ≥65 years. Cognitive effects improved to a lower grade more quickly with dose modification (1.3-3.1 weeks) than without (4.9-7.6 weeks). Median PFS was 11.4 months with dose modification and 7.2 months without. CONCLUSION Tolerability-guided dose modification of avapritinib is an effective strategy for managing AEs in patients with GISTs. IMPLICATIONS FOR PRACTICE Early recognition of adverse events and tailored dose modification appear to be effective approaches for managing treatment-related adverse events and maintaining patients on avapritinib. Dose reduction does not appear to result in reduced efficacy. Patients' cognitive function should be assessed at baseline and monitored carefully throughout treatment with avapritinib for the onset of cognitive adverse events. Dose interruption is recommended at the first sign of any cognitive effect, including grade 1 events.
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Affiliation(s)
| | | | - Michelle A. Angelis
- James Cancer Hospital and Solove Research Institute and The Ohio State University Wexner Medical CenterColumbusOhioUSA
| | | | - Robin L. Jones
- Royal Marsden Hospital and Institute of Cancer ResearchLondonEngland
| | - Yoon‐Koo Kang
- Asan Medical Center, University of UlsanSeoulSouth Korea
| | - Richard F. Riedel
- Duke Cancer Institute, Duke University Medical CenterDurhamNorth CarolinaUSA
| | | | | | - Jonathan Trent
- Sylvester Comprehensive Cancer Center, University of MiamiMiamiFloridaUSA
| | | | - Tuan Dong Si
- Blueprint Medicines CorporationCambridgeMassachusettsUSA
| | - Teresa Zhou
- Blueprint Medicines CorporationCambridgeMassachusettsUSA
| | - Ashley Doyle
- Blueprint Medicines CorporationCambridgeMassachusettsUSA
| | | | - Maria Roche
- Blueprint Medicines CorporationCambridgeMassachusettsUSA
| | - Tracy Havnaer
- Oregon Health & Science UniversityPortland, OregonUSA
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14
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Hølmebakk T, Wiedswang AM, Meza-Zepeda LA, Hompland I, Lobmaier IVK, Berner JM, Stoldt S, Boye K. Integrating Anatomical, Molecular and Clinical Risk Factors in Gastrointestinal Stromal Tumor of the Stomach. Ann Surg Oncol 2021; 28:6837-6845. [PMID: 33651216 PMCID: PMC8460510 DOI: 10.1245/s10434-021-09605-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Accepted: 11/07/2020] [Indexed: 12/31/2022]
Abstract
BACKGROUND Adjuvant imatinib for 3 years is recommended to patients with high-risk gastrointestinal stromal tumor (GIST). Risk stratification is inaccurate, and risk assessments are further complicated by the increased use of neoadjuvant treatment. Anatomical criteria for prognostication have not been investigated. METHODS Clinical, molecular, and anatomical variables were retrospectively studied in a population-based cohort of 295 patients with gastric GIST resected between 2000 and 2018. Gastric subsite was divided into the upper, middle, and lower thirds. Growth pattern was classified as luminal, exophytic, or transmural based on imaging and surgical reports. RESULTS Of 113 tumors in the upper third of the stomach, 103 (91.2%) were KIT mutated, 7 (6.2%) were PDGFRA mutated, and 104 (92.0%) harbored genotypes sensitive to imatinib. Transmural tumors were strongly associated with a high mitotic index. Five-year recurrence-free survival (RFS) was 71% for patients with transmural tumors versus 96% with luminal or exophytic tumors (hazard ratio [HR] 8.45, 95% confidence interval [CI] 3.69-19.36; p < 0.001), and, in high-risk patients, 5-year RFS was 46% for patients with transmural tumors versus 83% with luminal or exophytic tumors (HR 4.47, 95% CI 1.71-11.66; p = 0.001). Among 134 patients with tumors > 5 cm, there were 29 recurrences. Only five patients with exophytic or luminal tumors had recurrent disease, of whom four had tumor rupture. Five-year RFS for patients with exophytic/luminal tumors >5 cm without rupture was 98%. CONCLUSIONS In the upper third, over 90% of tumors were sensitive to imatinib. Patients with exophytic or luminal tumors without rupture, irrespective of size, had an excellent prognosis and may not benefit from adjuvant therapy.
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Affiliation(s)
- Toto Hølmebakk
- Department of Abdominal and Pediatric Surgery, Oslo University Hospital, The Norwegian Radium Hospital, Nydalen, Oslo, Norway.
| | - Anne Marit Wiedswang
- Department of Radiology, Oslo University Hospital, The Norwegian Radium Hospital, Oslo, Norway
| | - Leonardo A Meza-Zepeda
- Department of Tumor Biology, Institute for Cancer Research, Oslo University Hospital, The Norwegian Radium Hospital, Oslo, Norway.,Genomics Core Facility, Department of Core Facilities, Institute for Cancer Research, Oslo University Hospital, The Norwegian Radium Hospital, Oslo, Norway
| | - Ivar Hompland
- Department of Oncology, Oslo University Hospital, The Norwegian Radium Hospital, Oslo, Norway
| | - Ingvild V K Lobmaier
- Department of Pathology, Oslo University Hospital, The Norwegian Radium Hospital, Oslo, Norway
| | - Jeanne-Marie Berner
- Department of Pathology, Oslo University Hospital, The Norwegian Radium Hospital, Oslo, Norway
| | - Stephan Stoldt
- Department of Abdominal and Pediatric Surgery, Oslo University Hospital, The Norwegian Radium Hospital, Nydalen, Oslo, Norway
| | - Kjetil Boye
- Department of Tumor Biology, Institute for Cancer Research, Oslo University Hospital, The Norwegian Radium Hospital, Oslo, Norway.,Department of Oncology, Oslo University Hospital, The Norwegian Radium Hospital, Oslo, Norway
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15
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Properties of FDA-approved small molecule protein kinase inhibitors: A 2021 update. Pharmacol Res 2021; 165:105463. [DOI: 10.1016/j.phrs.2021.105463] [Citation(s) in RCA: 165] [Impact Index Per Article: 55.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Accepted: 01/22/2021] [Indexed: 02/06/2023]
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