External control cohorts for the single-arm LIBRETTO-001 trial of selpercatinib in RET+ non-small-cell lung cancer

Background

Data for selpercatinib [a selective REarranged during Transfection (RET) inhibitor] from a single-arm trial (LIBRETTO-001, NCT03157128) in RET-fusion-positive advanced/metastatic non-small-cell lung cancer (NSCLC) were used in combination with external data sources to estimate comparative efficacy [objective response rate (ORR), progression-free survival, and overall survival (OS)] in first- and second-line treatment settings.

Methods

Patient-level data were obtained from a de-identified real-world database. Patients diagnosed with advanced/metastatic NSCLC with no prior exposure to a RET inhibitor and one or more prior line of therapy were eligible. Additionally, individual patient-level data (IPD) were obtained from the pemetrexed + platinum arm of KEYNOTE-189 (NCT03950674, first line) and the docetaxel arm of REVEL (NCT01168973, post-progression). Patients were matched using entropy balancing, doubly robust method, and propensity score approaches. For patients with unknown/negative RET status, adjustment was made using a model fitted to IPD from a real-world database.

Results

In first-line unadjusted analyses of the real-world control, ORR was 87.2% for LIBRETTO-001 versus 66.7% for those with RET-positive NSCLC (P = 0.06). After adjustment for unknown RET status and other patient characteristics, selpercatinib remained significantly superior versus the real-world control for all outcomes (all P < 0.001 except unadjusted RET-fusion-positive cohort). Similarly, outcomes were significantly improved versus clinical trial controls (all P < 0.05).

Conclusions

Findings suggest improvement in outcomes associated with selpercatinib treatment versus the multiple external control cohorts, but should be interpreted with caution. Data were limited by the rarity of RET, lack of mature OS data, and uncertainty from assumptions to create control arms from external data.

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Single-arm trials are limited by the lack of a comparison arm, and external controls are needed.

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Multiple methodological approaches with various external control arms evaluated the comparative efficacy of selpercatinib.

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Findings suggest that selpercatinib is associated with significantly improved clinical outcomes versus standard therapies.

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Results should be considered exploratory and hypothesis generating due to the limitations of this study.

Abstract P5-19-02: Withdrawn

This abstract was withdrawn by the authors.

Importance of inhaler-device satisfaction in asthma treatment: real-world observations of physician-observed compliance and clinical/patient-reported outcomes

INTRODUCTION

It is hypothesized that health and patient-reported outcomes in asthma are positively influenced by the level of patient satisfaction with their inhaler device. This paper uses data from a real-world observational study to investigate the extent of the relationship between inhaler satisfaction and patient compliance, and the influence this has on health and patient-reported outcomes.

METHODS

Data were drawn from the Adelphi Respiratory Disease Specific Programme® (Adelphi, Macclesfield, UK), a cross-sectional study of consulting patients in five European countries undertaken between June and September 2009. A range of clinical and patient-reported outcomes were observed allowing analysis of these and their relationship with patient-reported inhaler satisfaction and patient compliance.

RESULTS

The analysis demonstrates that for the majority of patients the higher the level of satisfaction that the patient reports for their device the more likely the patient is observed to be compliant and to experience better outcomes including quality of life (as measured by EuroQol 5 Dimensions [EQ-5D] utility score, P<0.001), fewer exacerbations (P<0.001), fewer hospital visits (P=0.011), fewer healthcare visits (P=0.001), fewer primary care physician visits (P=0.001), and fewer sleep disturbances (P<0.001).

CONCLUSION

The level of patient satisfaction with their inhaler device is observed to have a positive influence on the treatment goals for asthma through its association with improved compliance.

The patient-physician partnership in asthma: real-world observations associated with clinical and patient-reported outcomes

INTRODUCTION

It is hypothesized that a good partnership between asthma patients and their physicians has a direct and positive influence on the patients' clinical and patient-reported outcomes. Conversely, poor partnership has a detrimental effect on clinical and patient-reported outcomes. This paper uses data from a real-world observational study to define partnership through matched physician and patient data and correlate the quality of partnership with observed clinical and patient-reported outcomes.

METHODS

Data were drawn from Adelphi's Respiratory Disease Specific Programme, a cross-sectional study of consulting patients in five European countries undertaken between June and September 2009. A range of clinical and patient-reported outcomes were observed allowing analysis of the partnership between 2251 asthma patients and their physicians.

RESULTS

Analysis demonstrates that the better the partnership between patient and physician, the more likely the patient is to have their asthma condition controlled (P<0.001), to experience fewer exacerbations (P<0.001), to have better quality of life (P<0.001), to have fewer sleep disturbances (P<0.001), and to have fewer patient-reported symptoms (P<0.001). Partnership is also associated with lower impact on lifestyle (P<0.01) and reduced days lost at work/school (P<0.05), and with patient satisfaction with their inhaler device (P<0.05).

CONCLUSION

The patient-physician partnership is a contributory factor in the improvement of asthma treatment, and patient education may lead to improvement in a patient's ability to contribute to this. Device satisfaction is one of the markers of good partnership.

Consensus statement on the anticipation and prevention of acute postoperative pain: multidisciplinary RADAR approach

BACKGROUND

There has been considerable investment in efforts to improve postoperative pain management, including the introduction of acute pain teams. There have also been a number of guidelines published on postoperative pain management and there is widespread agreement on how pain should be practically managed. Despite these advances, there is no apparent improvement in the number of patients experiencing moderately severe or extreme pain after surgery. This highlights significant scope for improvement in acute postoperative pain management.

SCOPE

In January 2009, a multidisciplinary UK expert panel met to define and agree a practical framework to encourage implementation of the numerous guidelines and fundamentals of pain management at a local level. The panel recognised that to do this, there was a need to organise the information and guidelines into a simplified, accessible and easy-to-implement system based on their practical clinical experience. Given the volume of literature in this area, the Chair recommended that key international guidelines from professional bodies should be distributed and then reviewed during the meeting to form the basis of the framework. Consensus was reached by unanimous agreement of all ten participants.

FINDINGS

This report provides a framework for the key themes, including consensus recommendations based upon practical experience agreed during the meeting, with the aim of consolidating the key guidelines to provide a fundamental framework which is simple to teach and implement in all areas. Key priorities that emerged were: Responsibility, Anticipation, Discussion, Assessment and Response. This formed the basis of RADAR, a novel framework to help pain specialists educate the wider care team on understanding and prioritising the management of acute pain.

CONCLUSION

Acute postoperative pain can be more effectively managed if it is prioritised and anticipated by a well-informed care team who are educated with regard to appropriate analgesic options and understand what the long-term benefits of pain relief are. The principles of RADAR provide structure to help with training and implementation of good practice, to achieve effective postoperative pain management.

Phase I study of the combination of anti-GD2 antibody 3F8 and barley-derived (1→3,1→4)-β-D-glucan for patients with resistant neuroblastoma

9566

Background: Beta glucans are complex, naturally occurring polysaccharides that prime leucocyte dectin and CR3 receptors. Based on our preclinical observations that oral barley-derived (1→3,1→4)-β-D-Glucan (BG) synergizes with the murine anti-GD2 antibody 3F8 against neuroblastoma (NB) (Clin Cancer Res 8:1217), we conducted a phase I study to determine the safety of the combination of BG and 3F8 in patients with resistant NB. Methods: Heavily pre-treated patients with recurrent or refractory advanced stage NB were treated with 3F8/BG. Each cycle consisted of intravenous (IV) 3F8 at a fixed dose of 10 mg/m2/day ×10 days, plus oral BG dose escalated from 10 to 80 mg/kg/day ×10 days in 4 cohorts of 6 patients each. Patients without human anti-mouse antibody (HAMA) could be re-treated up to a total of 4 cycles. Results: Twenty-three patients with stage 4 and one with stage 3 NB (M:F = 11:13; median age 8 (range 2–19) years completed 47 cycles of therapy with 3F8/BG. 8 patients had progressive disease (PD) while 16 had stable refractory NB (SD) at enrollment. All patients completed at least one cycle of therapy and were evaluated for toxicity and response. Maximum tolerated dose for BG was not reached. Two patients developed dose-limiting toxicities (DLT). Both had grade 4 thrombocytopenia after completing one cycle of treatment: one at BG dose of 20mg/kg/day and the other at 40 mg/kg/day. Both cases responded to therapy with a short course of ITP (idiopathic thrombocytopenic purpura) therapy; one subsequently developed chronic ITP. There were no other >grade 2 toxicities related to 3F8/BG therapy. 14, 4, 2 and 6 patients completed 1, 2, 3 and 4 cycles respectively. Reasons for withdrawal in patients who did not complete 4 cycles were PD in 10, persistently elevated HAMA in 6 and DLT in 2. Overall 11 patients had SD and 13 PD. 14/23 patients with positive MIBG scans prior to therapy demonstrated improvement after one cycle. Responses did not correlate with BG dose received. 7 patients, all with residual disease survive at a median of 40 (range 24–45) months post-treatment. Conclusions: 3F8/BG is well tolerated and shows activity against resistant NB. Further clinical investigation of this novel combination is warranted.

No significant financial relationships to disclose.

Value of PSA measured in middle age in predicting diagnosis of advanced prostate cancer in an unscreened population

5006

Background: The association between PSA-levels in blood and prostate cancer (PCa) is currently under intense debate as many benign conditions also affect blood levels. We recently reported that PSA-levels in blood predicted very strongly later PC-diagnosis at any stage in a large representative population-based cohort in Malmö, Sweden (MPM) where the rate of PSA-testing is very low. Now, we studied predictors of stages =T3 or metastatic (M+) PCa at the time of cancer diagnosis. Material: Among archived bloods from 22,439 men (aged =50 or 60) during 1974–86, 192/549 men diagnosed with PCa until Dec 31, 1999, were eligible cases with =T3 or M+ at time of diagnosis. Median delay from baseline to diagnosis was 17 years among cases aged =50 (n=161) and 10 years among men aged 60 (n=31). Conditional logistic regression between cases and controls nested within our study cohort determined association and interaction between analyte levels, time to diagnosis, and age. Results: There was strong evidence that plasma levels of all PSA-forms and kallikrein 2 (hK2) associate with case status (p<0.01), and even a small elevation in total PSA (tPSA) markedly increased the risk of subsequent event. A tPSA of 2.1 - 3.0 ng/ml raised the odds of subsequent event 22-fold compared to a tPSA =0.5 ng/ml and men with tPSA =2 ng/ml had a predicted probability of advanced prostate cancer of 12% - three times the population mean. AUC for a model with tPSA alone, compared to tPSA+cPSA+%fPSA+hK2 were higher in men aged 60 (AUC increase of 0.054) compared to men aged =50 (AUC increase of 0.030). This is consistent with the results of interaction analysis showing that the association between hK2-level and cases status grows stronger as the interval between date of venipuncture and diagnosis decreases. Similarly, the effect of %fPSA on case status was dependent on age suggesting that the association between %fPSA and case status is stronger in older compared to younger men. Conclusion: Very strong associations exist between levels of all PSA-forms and hK2 measured at middle age and decade(s) before diagnosis of advanced stages of prostate cancer. There is an urgent need to validate these data in independent study cohorts as they could contribute important arguments in the revision of current PC- screening guidelines.

No significant financial relationships to disclose.

Quality of life and relative importance: a comparison of time trade-off and conjoint analysis methods in patients with age-related macular degeneration

AIM

To investigate the relative priorities in quality of life (QoL) in patients with age-related macular degeneration (AMD).

METHODS

Measures of visual function, QoL and utility associated with visual loss were obtained from 122 patients with AMD classified according to macular morphology. The two methods of utility assessment were time trade-off (TTO) and conjoint analysis (CA), which have been recommended by the UK's National Institute of Clinical Excellence as techniques for the assessment of healthcare priorities.

RESULTS

Results show that the two methods for assessing utility are poorly related: TTO relates moderately to visual function and disease severity but CA does not. CA identified two different subgroups of patients: one with outdoor mobility and the other with reading as their main priority.

CONCLUSION

Further work is needed and caution required in interpreting data obtained using these methodologies for determining their relative importance in vision-related QoL studies.

International multi-centre study of incidence and risk factors of symptomatic deep venous thrombosis (DVT) and or pulmonary embolism (PE) in prostate cancer patients undergoing laparoscopic radical prostatectomy (LRP)

8555

Background: There is no data regarding the incidence and variables associated with symptomatic DVT and or PE in patients undergoing LRP. Our aim was to evaluate the multi-centric incidence and risk factors for perioperative symptomatic DVT and PE after LRP. Methods: Patients with symptomatic DVT and or PE occurring within 2 months of surgery since start of the respective institutional LRP experience were included. Eight academic centers from both the United States and Europe participated. Diagnoses were made by Doppler ultrasound for DVT; and lung ventilation/perfusion scan and or chest computed tomography for PE. Associations between variables and DVT and/or PE were evaluated using Fisher’s exact test for categorical predictors and logistic regression for continuous predictors. Results: Patient reoperation (p value) (<0.001), tobacco exposure (0.02), prior DVT (0.007), larger prostate size (0.02) and length of hospital stay (0.009) were significantly associated with higher risk of symptomatic DVT/PE. The nonuse of perioperative heparin was not a risk factor (1), as well as neoadjuvant therapy (1), perioperative transfusion (0.1), body mass index (0.9), surgical technique (0.3), operating time (0.2) and pathologic stage (0.5). There were no related deaths. Patients receiving preoperative heparin had significantly higher mean operative blood loss, 480cc vs 332cc (<0.001) However, this did not translate into longer hospital stay (0.07); higher transfusion rates (0.09) or reoperation rates (0.3). The estimated cost of heparin prophylaxis in these patients exceeded $2.5 million. Conclusion: The incidence of symptomatic DVT or PE was similar despite different prophylactic regimens. Our data does not support the administration of prophylactic heparin in LRP to low risk patients (no prior DVT, no tobacco exposure, no prostate enlargement and or no anticipation of prolonged hospital stay).

[Table: see text]

No significant financial relationships to disclose.

Acupuncture-point stimulation for chemotherapy-induced nausea or vomiting

BACKGROUND

There have been recent advances in chemotherapy-induced nausea and vomiting using 5-HT(3) inhibitors and dexamethasone. However, many still experience these symptoms, and expert panels encourage additional methods to reduce these symptoms.

OBJECTIVES

The objective was to assess the effectiveness of acupuncture-point stimulation on acute and delayed chemotherapy-induced nausea and vomiting in cancer patients.

SEARCH STRATEGY

We searched MEDLINE, EMBASE, PsycLIT, MANTIS, Science Citation Index, CCTR (Cochrane Controlled Trials Registry), Cochrane Complementary Medicine Field Trials Register, Cochrane Pain, Palliative Care and Supportive Care Specialized Register, Cochrane Cancer Specialized Register, and conference abstracts.

SELECTION CRITERIA

Randomized trials of acupuncture-point stimulation by any method (needles, electrical stimulation, magnets, or acupressure) and assessing chemotherapy-induced nausea or vomiting, or both.

DATA COLLECTION AND ANALYSIS

Data were provided by investigators of the original trials and pooled using a fixed effect model. Relative risks were calculated on dichotomous data. Standardized mean differences were calculated for nausea severity. Weighted mean differences were calculated for number of emetic episodes.

MAIN RESULTS

Eleven trials (N = 1247) were pooled. Overall, acupuncture-point stimulation of all methods combined reduced the incidence of acute vomiting (RR = 0.82; 95% confidence interval 0.69 to 0.99; P = 0.04), but not acute or delayed nausea severity compared to control. By modality, stimulation with needles reduced proportion of acute vomiting (RR = 0.74; 95% confidence interval 0.58 to 0.94; P = 0.01), but not acute nausea severity. Electroacupuncture reduced the proportion of acute vomiting (RR = 0.76; 95% confidence interval 0.60 to 0.97; P = 0.02), but manual acupuncture did not; delayed symptoms for acupuncture were not reported. Acupressure reduced mean acute nausea severity (SMD = -0.19; 95% confidence interval -0.37 to -0.01; P = 0.04) but not acute vomiting or delayed symptoms. Noninvasive electrostimulation showed no benefit for any outcome. All trials used concomitant pharmacologic antiemetics, and all, except electroacupuncture trials, used state-of-the-art antiemetics.

AUTHORS' CONCLUSIONS

This review complements data on post-operative nausea and vomiting suggesting a biologic effect of acupuncture-point stimulation. Electroacupuncture has demonstrated benefit for chemotherapy-induced acute vomiting, but studies combining electroacupuncture with state-of-the-art antiemetics and in patients with refractory symptoms are needed to determine clinical relevance. Self-administered acupressure appears to have a protective effect for acute nausea and can readily be taught to patients though studies did not involve placebo control. Noninvasive electrostimulation appears unlikely to have a clinically relevant impact when patients are given state-of-the-art pharmacologic antiemetic therapy.

Significance of non-calcified pulmonary nodules in patients with extrapulmonary cancers

BACKGROUND

This study sought to determine the rate and patterns of malignancy in patients with extrapulmonary cancers and non-calcified pulmonary nodules, and to develop a statistical model to guide clinicians regarding choice of patients for diagnostic biopsy.

METHOD

The medical records of 151 patients evaluated at the Memorial Sloan-Kettering Cancer Center between January 1999 and December 2001 for non-calcified pulmonary nodules were reviewed. Nodules were considered malignant based on the results of a diagnostic biopsy, and were considered benign if their appearance remained stable 2 years after the initial study, if they resolved, or if a biopsy showed a non-malignant condition.

RESULTS

Sixty four of 151 patients (42%) were diagnosed with malignant nodules; 32 had newly diagnosed lung cancers, 28 had metastatic spread of their primary cancers, and four had lesions that were either new cancers or of undetermined aetiology. On univariate analysis the likelihood of malignancy increased with nodule size, tobacco exposure, and the finding of a solitary nodule. On multivariable analysis only nodule size and tobacco exposure were predictive of malignancy. The model had good predictive accuracy (area under the curve 0.751) but had insufficient discrimination for use as a clinical tool to determine which patients should undergo diagnostic biopsy.

CONCLUSION

Nearly half the non-calcified pulmonary nodules identified in this series were malignant. Lung cancer was more common than metastatic disease. These findings support the need for close interval follow up and a low threshold for diagnostic biopsy in patients with extrapulmonary cancers and non-calcified pulmonary nodules. In smokers, such lesions should raise concern for lung cancer.

Adhesion enhancement of steel fibers to acrylic bone cement through a silane coupling agent

The use of a silane coupling agent (methacryloxypropyl-trichlorosilane) to improve the mechanical properties of steel fiber-reinforced acrylic bone cements was assessed. Changes to the tensile and fracture properties of bone cements reinforced with silane-coated or uncoated 316L stainless steel fibers of different aspect ratios were studied. Contact-angle measurements indicated that the coupling agent coats the metal surface through room temperature treatments in a short time (within 2 h). Push-out tests indicated that the interfacial shear strength of silane-coated 316L stainless steel rods is 141% higher than the uncoated rods. The elastic moduli, ultimate stresses, and fracture toughness of the silane-coated, steel fiber-reinforced bone cements are significantly higher than the bone cements reinforced with uncoated steel fibers. There were no differences in the tensile mechanical properties of the silane-coated or uncoated, steel fiber-reinforced cements after aging in a physiological saline solution, indicating that the bonding effectiveness is decreased by the intrusion of water at the metal-polymer interface. Because of possible biocompatibility issues with leaching of the silane coupling agent and no long-term mechanical benefit in simulated aging experiments, the use of these agents is not recommended for in vivo use.

Systematic reviews of herbal medicines--an annotated bibliography

OBJECTIVE

To provide a comprehensive collection and a summary of systematic reviews of clinical trials on herbal medicines.

METHODS

Potentially relevant reviews were searched through the register of the Cochrane Complementary Medicine Field, the Cochrane Library, Medline, and bibliographies of articles and books. To be included articles had to review prospective clinical trials of herbal medicines; had to describe review methods explicitly; had to be published; and had to focus on treatment effects. Information on conditions, interventions, methods, results and conclusions was extracted using a pretested form and summarized descriptively.

RESULTS

From a total of 79 potentially relevant reviews preselected in the screening process 58 met the inclusion criteria. 30 of the reports reviewed ginkgo (for dementia, intermittent claudication, tinnitus, and macular degeneration), hypericum (for depression) or garlic preparations (for cardiovascular risk factors and lower limb atherosclerosis). The quality of primary studies was criticized in the majority of the reviews. Most reviews judged the available evidence as promising but definitive conclusions were rarely possible.

CONCLUSIONS

Systematic reviews are available on a broad range of herbal preparations prescribed for defined conditions. There is very little evidence on the effectiveness of herbalism as practiced by specialist herbalists who combine herbs and use unconventional diagnosis.

Does use of alternative medicine predict survival from cancer?

This study examines the association between alternative medicines (AM) and cancer survival. A national multicentre study was carried out in Norway in December 1992 to assess the prevalence of AM use among cancer patients. One of the aims of this study was to assess the association between AM and long-time survival. In January 2001, survival data were obtained with a follow-up of 8 years for 515 cancer patients. A total of 112 (22%) assessable patients used AM. During the follow-up period, 350 patients died. Death rates were higher in AM users (79%) than in those who did not use AM (65%). In a Cox regression model adjusted for demographic, disease and treatment factors, the hazard ratio of death for any use of AM compared with no use was 1.30, (95% Confidence Interval (CI) 0.99, 1.70; P=0.056), suggesting that AM use may predict a shorter survival. Sensitivity analyses strengthened the negative association between AM use and survival. AM use had the most detrimental effect in patients with an ECOG (Eastern Cooperative Oncology Group) performance status (PS) of 0 (hazard ratio for use=2.32, 95% CI, 1.44, 3.74, P=0.001), when compared with an ECOG PS of 1 or higher. The use of AM seems to predict a shorter survival from cancer. The effect appears predominantly in patients with a good PS.

How to reduce the number of patients needed for randomized trials: a basic introduction

Complementary therapies are often used to treat patients with persisting conditions. In a typical randomized trial, patients are assessed for symptom severity at baseline, randomized to treatment or control and then reassessed after a suitable follow-up period. It can be shown that the number of patients required for such trials can be reduced by the use of two methods: repeat measurement and analysis of co-variance (ANCOVA). An example is given of a trial of acupuncture for back pain. Administering the pain questionnaire twice at baseline and four times at follow-up reduces the number of patients by approximately 20% compared to single questionnaire administration. Use of ANCOVA decreases the number of patients by approximately a further 10%. There are considerable economic and ethical advantages to reducing sample size by a third; however, ANCOVA is statistically complex and expert statistical help is required.