A phase 2 study of neoadjuvant chemotherapy plus durvalumab in resectable locally advanced head and neck squamous cell carcinoma

BACKGROUND

Patients with locally advanced head and neck squamous cell cancer (HNSCC) are treated with surgery followed by adjuvant (chemo) radiotherapy or definitive chemoradiation, but recurrence rates are high. Immune checkpoint blockade improves survival in patients with recurrent/metastatic HNSCC; however, the role of chemo-immunotherapy in the curative setting is not established.

METHODS

This phase 2, single-arm, multicenter study evaluated neoadjuvant chemo-immunotherapy with carboplatin, nab-paclitaxel, and durvalumab in patients with resectable locally advanced HNSCC. The primary end point was a hypothesized pathologic complete response rate of 50%. After chemo-immunotherapy and surgical resection, patients received study-defined, pathologic risk adapted adjuvant therapy consisting of either durvalumab alone (low risk), involved field radiation plus weekly cisplatin and durvalumab (intermediate risk), or standard chemoradiation plus durvalumab (high risk).

RESULTS

Between December 2017 and November 2021, 39 subjects were enrolled at three centers. Oral cavity was the most common primary site (69%). A total of 35 of 39 subjects underwent planned surgical resection; one subject had a delay in surgery due to treatment-related toxicity. The most common treatment-related adverse events were cytopenias, fatigue, and nausea. Post treatment imaging demonstrated an objective response rate of 57%. Pathologic complete response and major pathologic response were achieved in 29% and 49% of subjects who underwent planned surgery, respectively. The 1-year progression-free survival was 83.8% (95% confidence interval, 67.4%-92.4%).

CONCLUSIONS

Neoadjuvant carboplatin, nab-paclitaxel, and durvalumab before surgical resection of HNSCC were safe and feasible. Although the primary end point was not met, encouraging rates of pathologic complete response and clinical to pathologic downstaging were observed.

Results of a Multi-institutional Randomized Phase 3 Trial of Parotid-Sparing Whole Brain Radiotherapy

PURPOSE/OBJECTIVE(S)

Observational studies have reported that xerostomia is common after conventional whole brain radiotherapy (WBRT) and associated with parotid dose. In this multi-institutional, single-blind randomized controlled trial, we hypothesized that patient-reported xerostomia is reduced in patients randomized to parotid-sparing vs. standard WBRT fields.

MATERIALS/METHODS

Between 2018 and 2021, patients receiving conventional WBRT (30-35 Gy in 10-15 fractions) for any diagnosis were enrolled at 3 academic institutions. Patients were randomized between standard WBRT fields covering the C1 vertebra with no prospective parotid delineation (control) vs. parotid-sparing fields without C1 coverage (experimental). Patients completed the University of Michigan Xerostomia Questionnaire (Scored 0-100, higher is worse) at baseline, EndRT, 2 weeks, 1 month, 3 months, and 6 months. Patients were excluded from toxicity analyses if baseline xerostomia score was >50 or if they did not complete any post-baseline questionnaires. The primary endpoint was proportion of patients with ≥15 point absolute increase in xerostomia score from baseline to 1 month; 108 patients were needed for an 80% power to detect a 22% absolute difference (1-sided significance of 0.05). The secondary endpoint was the rate of marginal failures.

RESULTS

The study closed early after 56 patients were randomized. Median survival was 4.6 months. 46 patients (23 in each arm) were eligible for analysis. Mean parotid dose was 17 vs. 10 Gy in the standard vs. parotid-sparing arms, respectively. The table below shows mean xerostomia score and proportion of patients with ≥15 increase in xerostomia score at each time point. There was no difference in the proportion of patients experiencing ≥15 increase in xerostomia score at 1 month, though there was a trend toward lower xerostomia score at 1 month in patients randomized to parotid-sparing fields (p = 0.07, Table). Xerostomia rates were also significantly improved in the parotid-sparing arm at EndRT (p = 0.03), but no longer-term difference was observed with greater attrition at 3 and 6 months. On linear regression, there was a trend toward association between mean parotid dose and xerostomia score at 1 month (p = 0.06). There were no reported marginal failures in either arm.

CONCLUSION

Parotid-sparing without coverage of the C1 vertebra appears safe and may meaningfully reduce acute xerostomia in patients with limited life expectancy who are candidates for conventional WBRT, although the study was underpowered to detect a significant difference at 1 month.

Knowledge, Attitudes, and Resources of Frontline Oncology Support Personnel Regarding Financial Burden in Patients With Cancer

PURPOSE

Financial navigation services support patients with cancer and address the direct and indirect financial burden of cancer diagnosis and treatment. These services are commonly delivered through a variety of frontline oncology support personnel (FOSP) including navigators, social workers, supportive care providers, and other clinic staff, but the perspective of FOSPs is largely absent from current literature on financial burden in oncology. We surveyed a national sample of FOSPs to understand their perspectives on patient financial burden, resource availability, and barriers and facilitators to assisting patients with cancer-related financial burden.

METHODS

We used Qualtrics online survey software and recruited participants using multiple professional society and interest group mailing lists. Categorical responses were described using frequencies, distributions of numeric survey responses were described using the median and IQR, and two open-ended survey questions were categorized thematically using a priori themes, allowing additional emergent themes.

RESULTS

Two hundred fourteen FOSPs completed this national survey. Respondents reported a high awareness of patient financial burden and felt comfortable speaking to patients about financial concerns. Patient assistance resources were commonly available, but only 15% described resources as sufficient for the observed needs. A substantial portion of respondents reported moral distress related to this lack of resources.

CONCLUSION

FOSPs, who already have requisite knowledge and comfort in discussing patient financial needs, are a critical resource for mitigating cancer-related financial burden. Interventions should leverage this resource but prioritize transparency and efficiency to reduce the administrative and emotional toll on the FOSP workforce and reduce the risk of burnout.

Accelerated epigenetic aging and myopenia in young adult cancer survivors

BACKGROUND

Young adult cancer survivors experience early aging-related morbidities and mortality. Biological aging biomarkers may identify at-risk survivors and increase our understanding of mechanisms underlying this accelerated aging.

METHODS

Using an observational study design, we cross-sectionally measured DNA methylation-based epigenetic age in young adult cancer survivors at a tertiary, academic state cancer hospital. Participants were a convenience sample of consecutively enrolled survivors of childhood, adolescent, and young adult cancers treated with either an anthracycline or alkylating agent, and who were at least 3 months post-treatment. Similarly aged healthy comparators were consecutively enrolled. Cancer treatment and treatment intensity were compared to DNA methylation-based epigenetic age and pace of aging.

RESULTS

Sixty survivors (58 completing assessments, mean age 20.5 years, range 18-29) and 27 comparators (mean age 20 years, range 17-29) underwent DNA methylation measurement. Survivors were predominantly female (62%) and white (60%) and averaged nearly 6 years post-treatment (range 0.2-25 years). Both epigenetic age (AgeAccelGrim: 1.5 vs. -2.4, p < 0.0001; AgeAccelPheno 2.3 vs. -3.8, p = 0.0013) and pace of aging (DunedinPACE 0.99 vs. 0.83, p < 0.0001) were greater in survivors versus comparators. In case-case adjusted analysis, compared to survivors with normal muscle mass, myopenic survivors had higher AgeAccelGrim (2.2 years, 95% CI 0.02-4.33, p = 0.02), AgeAccelPheno (6.2 years, 2.36-10.09, p < 0.001), and DunedinPACE (0.11, 0.05-0.17, p < 0.001).

CONCLUSIONS

Epigenetic age is older and pace of aging is faster in young adult cancer survivors compared to noncancer peers, which is evident in the early post-therapy period. Survivors with physiological impairment demonstrate greater epigenetic age advancement. Measures of epigenetic age may identify young adult survivors at higher risk for poor functional and health outcomes.

Pregnancy attempts among adolescent and young adult cancer survivors

OBJECTIVE

To examine whether demographic and cancer-related characteristics and factors such as fertility discussion with a medical provider and fertility preservation use are associated with attempting pregnancy after adolescent and young adult cancer.

DESIGN

Cross-sectional online survey.

SETTING

Not applicable.

PATIENT(S)

Women with lymphoma, breast cancer, thyroid cancer, or gynecologic cancer diagnosed at 15-39 years from 2004 to 2016 were identified from the North Carolina Cancer Registry and the Kaiser Permanente Northern and Southern California health care systems and responded to an online survey addressing survivorship concerns, including fertility and reproductive outcomes.

EXPOSURES

Demographic characteristics, cancer characteristics, fertility discussion with a medical provider or fertility specialist between cancer diagnosis and starting cancer treatment, use of fertility preservation strategies (freezing embryos or oocytes) after cancer diagnosis.

MAIN OUTCOME MEASURE(S)

Pregnancy attempt after cancer diagnosis, defined by either a pregnancy or 12 months of trying to become pregnant without pregnancy.

RESULT(S)

Among 801 participants who had not reached their desired family size at diagnosis, 77% had a fertility discussion with any medical provider between cancer diagnosis and treatment initiation, and 8% used fertility preservation after cancer diagnosis. At survey (median =7 years after diagnosis; interquartile range, 4-10), 32% had attempted pregnancy. Neither fertility discussion with any medical provider nor fertility counseling with a fertility specialist was significantly associated with pregnancy attempts. However, the use of fertility preservation was significantly associated with attempting pregnancy (prevalence ratios = 1.74; 95% confidence interval: 1.31-2.32). Other characteristics positively associated with pregnancy attempts included younger age at diagnosis, longer time since diagnosis, having a partner (at diagnosis or at survey), and having a history of infertility before cancer diagnosis.

CONCLUSION(S)

Use of fertility preservation strategies was uncommon in our cohort but was associated with attempting pregnancy after cancer. Ensuring access to fertility preservation methods may help adolescent and young adult cancer survivors to plan and initiate future fertility.

Tolerability of palbociclib in younger and older patients with advanced breast cancer

INTRODUCTION

Palbociclib is a small-molecule cyclin-dependent kinase 4/6 inhibitor used to treat hormone receptor-positive, human epidermal growth factor receptor-2 negative advanced breast cancer. Patient-specific factors impacting dose reductions or discontinuations are unknown.

METHODS

The primary objective was to evaluate the association of age (<60 vs. ≥60 years) with palbociclib dose reductions or discontinuations secondary to neutropenia. This single-center, retrospective chart review included hormone receptor-positive, human epidermal growth factor receptor-2 negative advanced breast cancer patients ≥18 years treated with palbociclib between April 2015 and May 2020. Patients <60 years at the time of palbociclib initiation were in the younger group and patients ≥60 years were in the older group.

RESULTS

Among the 107 patients included, younger patients were less likely than older patients to have a palbociclib starting dose <125 mg (0% vs. 11.9%, p = 0.02). Differences in palbociclib dose reductions or treatment discontinuations secondary to neutropenia were not detected (35.4% vs. 42.4%, p = 0.55). Neither the total number of palbociclib dose reductions (none: 54.2% vs. 49.1%, one: 33.3% vs. 42.4%, two: 12.5% vs. 8.5%, p = 0.61), nor the final dose of palbociclib (125 mg: 54.2% vs. 40.7%, 100 mg: 29.2% vs. 27.1%, 75 mg: 16.7% vs. 32.2%, p = 0.17) differed between younger and older patients.

CONCLUSIONS

Age (<60 vs. ≥60 years) was not associated with the rate of palbociclib dose reductions or discontinuations secondary to neutropenia. Older (≥60 years) patients were more likely to start palbociclib at lower doses which may impact neutropenia and non-neutropenic intolerance.

Exploring barriers to vaccine delivery in adult migrants: a qualitative study in primary care

Background

The COVID-19 pandemic has highlighted shortfalls in the delivery of vaccine programmes to older migrant groups. Guidelines exist, however, little is known around care pathways and engagement of these older cohorts in routine vaccinations in primary care, including catch-up programmes. We explored the views of primary care professionals around barriers and facilitators to catch-up vaccination in adult migrants (defined as foreign born; 18+ years) with incomplete or uncertain vaccination status.

Methods

We did a qualitative interview study with purposive sampling and thematic analysis in UK primary care (50 practices included nationally; 1 hour qualitative interviews) with 64 primary care professionals (PCPs): 48 clinical staff including GPs, Practice Nurses and healthcare assistants (HCAs); 16 administrative staff including practice managers and receptionists (mean age 45 years; 84.4% female; a range of ethnicities).

Results

Participants highlighted direct and indirect barriers to catch-up vaccines in adult migrants who may have missed vaccines as children, missed boosters, and not be aligned with the UK's vaccine schedule, from both a personal and service-delivery level, with themes including: lack of training and knowledge of guidance around catch-up vaccination among staff; unclear or incomplete vaccine records; and lack of incentivization (including financial reimbursement) and dedicated time and care pathways. Adult migrants were reported as being excluded from many vaccination initiatives, most of which focus exclusively on children. PCPs noted that migrants expressed to them a range of views around vaccines, from positivity to uncertainty, to refusal.

Conclusions

Vaccine uptake in adult migrants could be improved through implementing new financial incentives, strengthening care pathways and training, and working directly with local community groups to improve understanding around the benefits of vaccination at all ages.

Key messages

The use of social media platforms by migrant populations during the COVID-19 pandemic

Background

The rapid expansion of internet and social media use has meant that both useful and potentially harmful health information can spread rapidly. Groups experiencing barriers to health systems may be more reliant on social media as a source of health information. We did a systematic review to determine the extent and nature of social media use in migrant and ethnic minority communities for COVID-19 information, and implications for preventative health measures including vaccination intent and uptake.

Methods

We reviewed published and grey literature following PRISMA guidelines (PROSPERO registered CRD42021259190). Global research was included that reported on the use of social media by migrants and/or ethnic minority groups in relation to COVID-19.

Results

1849 unique records were screened, and 21 data sources included in our analysis involving studies from the UK, US, China, Jordan, Qatar, and Turkey. We found evidence of consistent use of a range of social media platforms for COVID-19 information in some migrant and ethnic minority populations (including WeChat, Facebook, WhatsApp, Instagram, Twitter, YouTube), which may stem from difficulty in accessing COVID-19 information in their native languages or from trusted sources. There were positive and negative associations with social media use reported, with some evidence suggesting circulating misinformation and social media use may be associated with lower participation in preventative health measures, including vaccine intent and uptake, findings of which are likely relevant to multiple population groups.

Conclusions

Urgent actions and further research are now needed to better understand the use of social media platforms for accessing health information by groups who may be marginalised from health systems, effective approaches to tackling circulating misinformation, and to seize on opportunities to make better use of social media platforms to support public health communication.

Key messages

Strategies to increase catch-up vaccination among migrants: a qualitative study and rapid review

Background

WHO’s Immunization Agenda 2030 has placed renewed focus on catch-up vaccination across the life course to meet global targets for reduction in vaccine-preventable diseases through increased vaccine coverage, including among migrant groups who may require catch-up vaccination to align them with host country vaccination schedules.

Methods

We did a global rapid review (01/2010 to 04/2022) to explore drivers of vaccine hesitancy among migrants followed by an in-depth qualitative study (semi-structured, telephone interviews) among recently arrived adult migrants (foreign-born, &gt;18 years old, residing in the UK &lt; 10 years). Interviews explored views on routine vaccination including accessibility, confidence and awareness. Data were analysed iteratively using thematic analysis.

Results

63 papers were included in the rapid review, including data from 22 countries/regions. Multiple factors driving under-immunisation and hesitancy in migrants were reported, including language barriers, low health literacy, social exclusion, low cultural competency and accessibility in healthcare systems. Our qualitative study recruited 40 migrants (mean age: 36.7 years; 62.5% female) resident in the UK (6 refugees, 19 asylum-seekers, 8 undocumented, 7 labour migrants). Major barriers to catch-up vaccination included a lack of provider recommendation and low awareness, with vaccination viewed as only relevant to children. Hesitancy around specific vaccines, such as MMR, was often influenced by misinformation. Participants suggested that novel strategies such as walk-in or mobile access points, consistent provider recommendations, and translation of information into relevant languages, may enhance accessibility and uptake of routine vaccinations.

Conclusions

Targeted and tailored information campaigns, versatile and proactive access pathways and education for healthcare staff on cultural competency will be needed to ensure uptake of catch-up vaccination among marginalised migrant groups.

Key messages

• Newly arrived adult migrants face barriers to catch-up vaccination in host countries, which may hinder immunisation coverage and increase the risk of vaccine-preventable disease outbreaks.

• Health systems must develop novel mechanisms to proactively offer culturally competent and accessible catch-up vaccination services to adult migrants on and after arrival.

Effect of an Antiracism Intervention on Racial Disparities in Time to Lung Cancer Surgery

PURPOSE

Timely lung cancer surgery is a metric of high-quality cancer care and improves survival for early-stage non-small-cell lung cancer. Historically, Black patients experience longer delays to surgery than White patients and have lower survival rates. Antiracism interventions have shown benefits in reducing racial disparities in lung cancer treatment.

METHODS

We conducted a secondary analysis of Accountability for Cancer Care through Undoing Racism and Equity, an antiracism prospective pragmatic trial, at five cancer centers to assess the impact on overall timeliness of lung cancer surgery and racial disparities in timely surgery. The intervention consisted of (1) a real-time warning system to identify unmet care milestones, (2) race-specific feedback on lung cancer treatment rates, and (3) patient navigation. The primary outcome was surgery within 8 weeks of diagnosis. Risk ratios (RRs) and 95% CIs were estimated using log-binomial regression and adjusted for clinical and demographic factors.

RESULTS

A total of 2,363 patients with stage I and II non-small-cell lung cancer were included in the analyses: intervention (n = 263), retrospective control (n = 1,798), and concurrent control (n = 302). 87.1% of Black patients and 85.4% of White patients in the intervention group (P = .13) received surgery within 8 weeks of diagnosis compared with 58.7% of Black patients and 75.0% of White patients in the retrospective group (P < .01) and 64.9% of Black patients and 73.2% of White patients (P = .29) in the concurrent group. Black patients in the intervention group were more likely to receive timely surgery than Black patients in the retrospective group (RR 1.43; 95% CI, 1.26 to 1.64). White patients in the intervention group also had timelier surgery than White patients in the retrospective group (RR 1.10; 95% CI, 1.02 to 1.18).

CONCLUSION

Accountability for Cancer Care through Undoing Racism and Equity is associated with timelier lung cancer surgery and reduction of the racial gap in timely surgery.

Social support and outcomes in older adults with lung cancer

BACKGROUND

Insufficient social support is associated with increased mortality among older adults. Lung cancer is primarily a disease of older adults and is the leading cause of all cancer deaths. We assessed the association of social support with outcomes among older adults with lung cancer.

MATERIALS AND METHODS

Adults age 65 and older with lung cancer with a completed geriatric assessment (GA) were assessed. Emotional social support (ES) and tangible (material, instrumental) support (TS) measures and patient characteristics were obtained from the GA. The electronic health record was used to extract clinical variables. Simple linear regression models evaluated the association between social support scales with patient and clinical factors.

RESULTS

79 adults were assessed. White race was positively associated with ES score (p=.04), while higher BMI (p=.03), depression (p=.03) and anxiety (p=.02) were associated with worse ES. Higher BMI was associated with higher/better TS score (p=.02) while living alone was associated with lower/worse TS score (p=.03). Completion of platinum-based doublet chemotherapy with immunotherapy as planned was associated with higher ES scores (p=.02) and higher TS scores (p=.02). Disease progression was associated with lower ES scores (p=.03).

CONCLUSION

Social support may influence clinical outcomes in older adults with lung cancer. As lung cancer often portends to poor prognosis, social support may be an important prognostic indicator.

Analysing drivers of routine and COVID-19 vaccination in migrants to develop tailored interventions

Background

Migrants in Europe are at risk of under-immunisation and may also have lower COVID-19 vaccination intent and uptake. There is an urgent need to better understand the drivers of uptake in these groups to inform the development of migrant-sensitive interventions for COVID-19 vaccination and routine vaccination beyond the pandemic.

Methods

We did a systematic review (PROSPERO: CRD42020219214) following PRISMA guidelines to explore factors influencing vaccine uptake in migrants in the EU/EEA and identify determinants of under-immunisation. We also held 3 participatory workshops with multinational migrant community leaders (n = 23) in London, to explore solutions and approaches to strengthen COVID-19 vaccine roll-out.

Results

We included 66 papers reporting data on 262,761 migrants in the review. Numerous access-related factors (e.g. government policy, communication barriers) influenced uptake. Vaccine hesitancy was attributed to lack of information, concerns about side-effects, and cultural beliefs/stigma around specific vaccinations. Migrants who had recently arrived, were older, female or of African and Eastern Mediterranean origin were at risk for under-immunisation for key vaccine-preventable diseases. Migrant community leaders reported considerable hesitancy towards COVID-19 vaccination in their communities and misinformation circulating via social media. Leaders requested support in producing simple COVID-19 guidance that could be translated and adapted locally, alongside more meaningful engagement and partnership-working.

Conclusions

Access barriers and vaccine hesitancy may affect vaccine uptake in some migrant populations in Europe, which needs to be urgently addressed for COVID-19 vaccine roll-out but also beyond the pandemic to strengthen uptake of routine vaccinations. Actively involving migrant communities in the planning, co-production and implementation of tailored and targeted approaches will be essential.

On behalf of ESGITM.

Key messages

Access barriers and vaccine hesitancy (from information gaps, cultural factors) contribute to low vaccine uptake in some migrant populations in the EU/EEA, with implications for COVID-19 vaccination. Meaningful engagement and co-production of tailored approaches with under-immunised migrants are urgently needed to ensure their inclusion in COVID-19 and routine vaccination programmes.

Impact of COVID-19 on migrant populations in high-income countries: a systematic review

Background

Migrants in high-income countries (HICs) may have been disproportionately affected by the COVID-19 pandemic, yet the extent to which they are impacted, and their predisposing risk factors, are not clearly understood. We did a systematic review to assess clinical outcomes, indirect health and social impacts, and key risk factors in migrants.

Methods

Our systematic review following PRISMA guidelines (PROSPERO CRD42020222135) identified peer-reviewed and grey literature relating to migrants (foreign-born) and COVID-19 in 82 HICs. Primary outcomes were cases, hospitalisations and deaths from COVID-19 involving migrants; secondary outcomes were indirect health and social impacts and risk factors.

Results

3016 data sources were screened with 158 from 15 countries included in the analysis. We found migrants are at increased risk of SARS-CoV-2 infection and are over-represented among cases (e.g. constituting 42% of cases in Norway [to 27/4/2020], 26% in Denmark [to 7/9/2020], and 32% in Sweden [to 7/5/2020]); some datasets from Europe show migrants may be over-represented in deaths with increased all-cause mortality in migrants in some countries in 2020. Undocumented migrants, migrant health and care workers, and migrants housed in camps have been especially affected, with certain nationality groups disproportionately impacted. Migrants experience a range of risk factors for COVID-19, including high-risk occupations, overcrowded accommodation, and barriers to healthcare including inadequate information, language barriers, and reduced entitlement.

Conclusions

Migrants in HICs are at high risk of COVID-19, with a range of specific risk factors that have not been well-considered in the public health response to date. These data are of immediate relevance to the policy response to the pandemic, with strategies urgently needed to reduce transmission. Migrant populations must also be better considered in national plans for COVID-19 vaccination roll-out.

On behalf of ESGITM

Key messages

Migrants in high-income countries may be disproportionately represented in COVID-19 infections and deaths, with higher levels of many vulnerabilities and risk factors.

Migrants must be better included in all aspects of the pandemic response, including vaccination roll-out.

Digital screening tool (Health Catch-UP!) to promote multi-disease screening in migrants

Background

The ECDC has called for innovative strategies to deliver multi-disease screening (TB, LTBI, HIV, hepatitis B/C, Chagas, Strongyloidiasis and schistosomiasis) and catch-up vaccination (MMR, DTP) to adult migrants within the primary care context. We did a UK i qualitative study to explore current practice and seek views on a novel integrated digital tool to support delivery of screening recommendations for migrants https://emishealth.vids.io/videos/a49ad1bb1a18e4c72c/health-catch-up-with-requested-edits-mp4).

Methods

Phase 1 was conducted via telephone with clinical primary care practitioners (PCPs) (phase 1) and informed data collection and analysis for phase 2 with administrative staff. Data were analysed iteratively, informed by thematic analysis (Ethics no.20/HRA/1674).

Results

64 participants were recruited in Phase 1 (25 general practitioners [GPs], 15 nurses, 7 healthcare assistants, 1 pharmacist); Phase 2 comprised administrative staff (11 Practice-Managers, 5 receptionists). There was lack of consistency in delivery of screening and vaccination. Most GP practices adopted a practice-specific approach, or had no system in place; screening only for HIV and hepatitis B/C. Barriers to screening were perceived lack of knowledge/training and limited financial resources. Facilitators included having an infectious disease/migrant-health champion, incentivisation, and clear protocols. Participants responded positively to the integrated Health Catch-UP! tool, confirming that it would increase screening and vaccination, reduce missed opportunities for preventative healthcare, and raise awareness of migrant health.

Conclusions

Infectious disease screening and catch-up vaccination is not currently delivered well in primary care in high-migrant receiving European countries. Innovative digital tools like Health Catch-UP! could aid clinical decision-making and facilitating improved health outcomes for migrants. Further work is needed to evaluate this intervention.

Key messages

Infectious disease screening and catch-up vaccination is not currently delivered well in primary care in high-migrant receiving European countries. Innovative digital tools could aid clinical decision-making and facilitating improved health outcomes for migrants.

A systematic review of the association between mental health and tuberculosis disease risk

Background

Tuberculosis (TB) and mental illnesses are highly prevalent globally and often co-exist. Whilst poor mental health is known to modulate immune function, whether mental disorders causally increase TB incidence is unknown. This systematic review examines the association between mental health and TB disease risk to inform clinical and public health measures.

Methods

We carried out a systematic review following PRISMA guidelines (PROSPERO CRD42019158071). We searched MEDLINE, PsycINFO and PsycEXTRA databases alongside reference list and citation searching. Inclusion criteria were original research studies published 01/01/1970-11/05/2020 reporting data on the relationship between mental health and risk of TB disease. CASP and AXIS checklists were used to critically appraise included studies.

Results

We screened 1546 records published over 50 years, resulting in data synthesised from 607,184 individuals. Settings include Asia, South America, and Africa, and both mood (e.g. depression) and psychotic (e.g. schizophrenia) disorders are investigated. Robust evidence from cohort studies in Asia shows that depression and schizophrenia can increase risk of TB disease, with effect estimates ranging from HR = 1.15 [95% CI 1.03-1.28] to HR = 2.63 [95% CI 1.74-3.96] for depression and HR = 1.52 [95% CI 1.29-1.79] to RR = 3.04 for schizophrenia, and a dose-response relationship reported in one study. These data are consistent with data from cross-sectional studies, such as a large survey across low- and middle-income countries (n = 242,952) reporting OR = 3.36 [95% CI 3.01-4.50] for a depressive episode in those with TB versus those without.

Conclusions

Individuals with mental illnesses including depression and schizophrenia experience increased TB incidence and represent a high-risk population to target for screening and treatment. Integrated care for mental health and TB is needed, and interventions tackling mental illnesses and underlying drivers may help reduce TB incidence globally.

Key messages

This systematic review examines data from 607,184 individuals and finds evidence that mental health is a risk factor for TB disease. Those suffering from depression and schizophrenia are an at-risk population that could be identified and targeted for TB screening and treatment.

Response to Tyrosine Kinase Inhibitors in Real-World Patients With Chronic Myeloid Leukemia

BACKGROUND

Tyrosine kinase inhibitors (TKIs) are the front-line therapy for chronic myeloid leukemia (CML), where phase 3 clinical trials have demonstrated their safety and efficacy. However, trial patients may not be representative of real-world patients (RWPs).

OBJECTIVE

To evaluate RWP clinical factors associated with effectiveness and safety in CML patients treated with TKIs.

METHODS

Patients with CML treated with at least 30 days of imatinib, dasatinib, nilotinib, or bosutinib between 2014 and 2018 were included. Patients were stratified into categories based on the number of factors that would have precluded enrollment into pivotal TKI phase 3 trials (0, 1, ≥2). End points included complete hematologic response (CHR), early molecular response (EMR), major molecular response (MMR), adverse event (AE)-induced dose decreases, treatment interruptions, and treatment discontinuations.

RESULTS

Final analyses included 174 patients. Patients with ≥2 factors had a higher risk of dose decreases (relative risk = 1.54; 95% CI = 1.02-2.34; P = 0.02) and a shorter time to dose decrease (hazard ratio = 2.43; 95% CI = 1.23-4.97; P = 0.006) compared with patients with 0 factors. Significant differences were observed in CHR at 1 month and MMR at 3 months between patients with 0 and ≥2 factors (P = 0.03 and P = 0.04, respectively).

CONCLUSION AND RELEVANCE

Approximately 60% of our RWPs would have been excluded from the pivotal phase 3 TKI trials. These data suggest that RWPs require more precise dosing to achieve CML clinical milestones and to mitigate AEs, but findings should be validated prospectively.

Clinical Utility and User Perceptions of a Digital System for Electronic Patient-Reported Symptom Monitoring During Routine Cancer Care: Findings From the PRO-TECT Trial

PURPOSE

There is increasing interest in implementing digital systems for remote monitoring of patients' symptoms during routine oncology practice. Information is limited about the clinical utility and user perceptions of these systems.

METHODS

PRO-TECT is a multicenter trial evaluating implementation of electronic patient-reported outcomes (ePROs) among adults with advanced and metastatic cancers receiving treatment at US community oncology practices (ClinicalTrials.gov identifier: NCT03249090). Questions derived from the Patient-Reported Outcomes version of the Common Terminology Criteria for Adverse Events (PRO-CTCAE) are administered weekly by web or automated telephone system, with alerts to nurses for severe or worsening symptoms. To elicit user feedback, surveys were administered to participating patients and clinicians.

RESULTS

Among 496 patients across 26 practices, the majority found the system and questions easy to understand (95%), easy to use (93%), and relevant to their care (91%). Most patients reported that PRO information was used by their clinicians for care (70%), improved discussions with clinicians (73%), made them feel more in control of their own care (77%), and would recommend the system to other patients (89%). Scores for most patient feedback questions were significantly positively correlated with weekly PRO completion rates in both univariate and multivariable analyses. Among 57 nurses, most reported that PRO information was helpful for clinical documentation (79%), increased efficiency of patient discussions (84%), and was useful for patient care (75%). Among 39 oncologists, most found PRO information useful (91%), with 65% using PROs to guide patient discussions sometimes or often and 65% using PROs to make treatment decisions sometimes or often.

CONCLUSION

These findings support the clinical utility and value of implementing digital systems for monitoring PROs, including the PRO-CTCAE, in routine cancer care.

Consolidation With Pembrolizumab and Nab-Paclitaxel After Induction Platinum-Based Chemotherapy for Advanced Non-Small Cell Lung Cancer

Background

Induction with four cycles of platinum-based chemotherapy was the standard of care for metastatic non-small cell lung cancer (NSCLC) until the approval of immune checkpoint blockade (ICB) in the first-line setting. Switch maintenance therapy has shown promise in improving survival by exposing patients to novel, non-cross–resistant agents earlier in their treatment course.

Methods

We performed this open-label, three-arm, randomized phase II study (NCT02684461) to evaluate three sequences of consolidation with pembrolizumab and nab-paclitaxel in patients without progressive disease post induction chemotherapy. Consolidation was either sequential with pembrolizumab for four cycles followed by nab-paclitaxel for four cycles (P→A), nab-paclitaxel followed by pembrolizumab (A→P), or concurrent nab-paclitaxel and pembrolizumab for four cycles (AP).

Results

Twenty patients were randomized before the study was closed early due to the approval of first-line checkpoint inhibitors. We found that consolidation is feasible and well tolerated, with 30% of patients experiencing grade 3 toxicity. The median progression-free survival and OS in months (95% CI) in P→A were 10.1 (1.5–NR), 27.6 (1.7–NR); 8.4 (1.2–9.0), 12.7 (4.4–NR) in A→P; and 10.2 (5.1–NR), NR. Quality of life as measured by FACT-L improved in the majority of patients during the course of the study.

Conclusion

Sequential and concurrent consolidation regimens are well tolerated and have encouraging overall survival in patients with metastatic NSCLC.

Impact of Adherence to Ibrutinib on Clinical Outcomes in Real-World Patients With Chronic Lymphocytic Leukemia

Background

Chronic lymphocytic leukemia (CLL) is a B-cell neoplasm with clonal expansion of small lymphocytes. Ibrutinib, an irreversible inhibitor of Bruton tyrosine kinase (BTK), is a first-line treatment option, and recent data suggest that strict adherence is directly related to clinical outcomes.

Objectives

The primary objective of this study was to quantify ibrutinib adherence rates in real-world patients with CLL on ibrutinib; secondary outcomes included progression-free survival and overall survival.

Methods

This retrospective study included subjects who were treated at a large academic medical center over approximately 5 years. Subjects were at least 18 years, diagnosed with CLL or small lymphocytic lymphoma, and treated with ibrutinib monotherapy for at least 6 months. Adherence was quantified using the medication possession ratio (MPR), which is the ratio of the sum of days' supply of medication in a period over the number of days in that period, and was based on fill history from the medical center's specialty pharmacy.

Results

For the 32 subjects in this study, the mean ibrutinib adherence rate was 91.7% (range, 84.4%-100%). Only 3 subjects had disease progression, and 1 death was recorded while on therapy (all with MPR < 95%); therefore, analyses of clinical outcomes were unable to be assessed due to a low number of events. There were no statistically significant differences in rates of adherence based on baseline characteristics and adverse drug events.

Conclusion

In patients with CLL treated with ibrutinib, mean adherence was 91.7%, which is lower than rates seen in clinical trials.

Gender-Based Differences in Urology Residency Applicant Personal Statements

OBJECTIVE

To gain insight into the perceptions of urology held by medical students as they enter the field, we analyzed the linguistic characteristics and gender differences in personal statements written by urology residency program applicants.

METHODS

Personal statements were abstracted from residency applications to a urology residency program. Linguistic Inquiry and Word Count, a validated text analysis software, characterized the linguistic content of the statements. Analyzed statements were compared according to gender of the applicant using multivariate analysis, examining the association of applicant gender and statement characteristics. Multivariate analysis was also performed to determine the association of personal statement characteristics with matching into urology residency.

RESULTS

Of 342 analyzed personal statements, no significant difference was found in statement characteristics between matched and unmatched applicants. Male and female applicants wrote with the same degree of overall analytical thinking, authenticity, and emotional tone. Clout, a measure of portrayed confidence, was low for both genders. Female applicants used more social and affective process words. Male applicants used more words indicating a sense of community and acceptance. Female applicants had more references to women within their statements.

CONCLUSION

Significant linguistic differences exist among personal statements written by men and women applying to urology residency. Word usage differences follow societal gender norms. Statement content demonstrates a difference between genders in perceived sense of belonging, highlighting the importance of gender concordant mentorship within the field.

Migration and outbreaks of vaccine-preventable disease in Europe: a systematic analysis (1990-2019)

Background

Migrant populations (defined as foreign-born) in the EU/EEA may be one of several under-immunised populations yet their role in outbreaks of vaccine-preventable diseases (VPDs) has been poorly defined to date.

Methods

We did both a temporal analysis to map published reports of migrant-related outbreaks against data from the ECDC's Surveillance Atlas of Infectious Disease, and a systematic review (PROSPERO CRD42019157473; 1990-2019) adhering to PRISMA guidelines, to explore whether migrants are involved in outbreaks in Europe and which particular subpopulations may be at increased risk. Studies on VPD outbreaks (measles, mumps, rubella, diphtheria, pertussis, polio, hepatitis A, N meningitidis, and H influenzae) in migrants residing in the EU/EEA were included.

Results

46 studies were included, reporting on 50 VPD outbreaks across 13 EU/EEA countries, of which 98% (n = 49) occured since January 2000. Measles had the highest number of reports of outbreaks involving migrants (n = 21; 5043 cases), followed by varicella (n = 10; 595 cases) and hepatitis A (n = 10; 1226 cases). 21 (40%) of outbreaks were reported from shelters for asylum seekers and refugees (mainly varicella or measles). Of 27 outbreaks where the index case was defined, 20 (74.1%) were migrants, including 9 (33.3%) from Eastern Europe and 6 (22.2%) from Africa. When mapped against the ECDC timeline of measles outbreaks, migrant-related outbreaks coincide with Europe-wide peaks in measles incidence (in 2006, 2010, and 2018).

Conclusions

Migrants represent one key group involved in VPD outbreaks, with refugees/asylum seekers residing in shelters or camps particularly at risk. Measles accounted for 38% of all reported outbreaks. Improved data collection on migrant status across Europe is crucial to understanding the complex relationship between migration and occurrence of VPD outbreaks to inform policy decisions on the most effective strategies to prevent future outbreaks.

Key messages

Migrants represent one key group involved in vaccine-preventable diseases outbreaks in Europe. Refugees and asylum seekers may be particularly at risk.

Feasibility and delivery of patient-reported outcomes in clinical practice among racially diverse bladder and prostate cancer patients

OBJECTIVE

To assess the feasibility of enrollment and collecting patient-reported outcome (PRO) data as part of routine clinical urologic care for bladder and prostate cancer patients and examine overall patterns and racial variations in PRO use and symptom reports over time.

SUBJECTS/PATIENTS AND METHODS

We recruited 76 patients (n = 29 Black and n = 47 White) with prostate or bladder cancer at a single, comprehensive cancer center. The majority of prostate cancer patients had intermediate risk (57%) disease and underwent either radiation or prostatectomy. Over half (58%) of bladder cancer patients had muscle invasive disease and underwent cystectomy. Patients were asked to complete PRO symptom surveys using their preferred mode [web- or phone-based interactive voice response (IVR)]. Symptom summary reports were shared with providers during visits. Surveys were completed at 3 time points and assessed urinary, sexual, gastrointestinal, anxiety/depression, and sleep symptoms. Feasibility of enrollment and survey completion were calculated, and linear mixed effects models estimated differences in outcomes by race and time.

RESULTS

Sixty three percent of study participants completed all PRO measures at all 3 time points. Black patients were more likely to select IVR as their survey mode (40% vs. 13%, P < 0.05), and less likely to complete all surveys (55% vs. 74%, P = 0.13). Patients using IVR were also less likely to complete all surveys (41% vs. 69%, P = 0.046).

CONCLUSIONS

Reported preferences for survey mode and completion rates differ by race, which may influence survey completion rates and highlight potential obstacles for equitable implementation of PROs into clinical care.

Reducing Cancer-related Financial Toxicity through Financial Navigation: Results from a Pilot Intervention

Our purpose was to pilot a novel patient-centered financial navigation (FN) intervention to decrease the burden of financial toxicity (FT) among uninsured and underinsured patients with cancer treated at the North Carolina Cancer Hospital (NCCH). Methods: Participants were recruited by cancer clinic nurses and social workers at the NCCH. Eligible patients scored less than 22 points (indicating significant FT) on the COmprehensive Score for financial Toxicity (COST) instrument. Fifty patients were enrolled in the intervention, which included an intake assessment of financial needs and vulnerability, initial one-on-one consultation with a trained financial navigator (i.e., financial counselor or social worker), triage to financial support services matching patients' needs, and multiple follow-up appointments. Navigator recommendations were based upon a detailed review of patients' financial status, billing information, insurance, and other indicators used to refer patients to appropriate financial and social services resources offered by the hospital, government, nonprofits and private corporations. Following the initial appointment, patients were given a checklist of resources they were eligible for and the required paperwork to complete applications. During follow-up appointments, application status was reviewed, and practical assistance was provided. Patients were re-contacted at 2-week intervals to assess progress toward financial assistance goals. Outcome data collection included pre/post-intervention COST scores, patient satisfaction with the intervention, and intervention fidelity and retention. Results: The first fifty patients approached all screened positive for FT (COST &lt; 22). Baseline COST scores ranged from 0–19. Results indicated a significant improvement in COST scores following the FN intervention (average increase = 6.86, 95% CI = 4.30–9.42), P &lt; 0.0001). Post-intervention questionnaires indicated excellent patient satisfaction and retention with the FN intervention, and navigator logs indicated high fidelity to the intervention protocol. Conclusions: A novel FN intervention was feasible, acceptable, and effective in reducing FT among uninsured and underinsured oncology patients.

Phase II study of stereotactic radiosurgery for the treatment of patients with oligoprogression on erlotinib

INTRODUCTION

Retrospective studies have evaluated the approach of stereotactic radiotherapy (SRT) to address oligoprogression in patients with EGFR mutant NSCLC on TKI therapy, it has never been prospectively studied.

MATERIALS AND METHODS

We treated 25 patients with EGFR mutant NSCLC on erlotinib who had 3 or fewer sites of extra-cranial progression with SRT to progressing sites, followed by re-initiation of erlotinib.

RESULTS

Median PFS from the initiation of SRT was 6 months (95% CI 2.5 to 11.6) and median OS was 29 months (95% CI 21.7 to 36.3). Neither baseline nor changes in the Veristrat proteomic predicted PFS.

CONCLUSIONS

SRT and TKI continuation may be considered for select patients with EGFR mutant NSCLC and oligo-progression on EGFR TKI therapy.

Combined kinase inhibitors of MEK1/2 and either PI3K or PDGFR are efficacious in intracranial triple-negative breast cancer

Background

Triple-negative breast cancer (TNBC), lacking expression of hormone and human epidermal growth factor receptor 2 receptors, is an aggressive subtype that frequently metastasizes to the brain and has no FDA-approved systemic therapies. Previous literature demonstrates mitogen-activated protein kinase kinase (MEK) pathway activation in TNBC brain metastases. Thus, we aimed to discover rational combinatorial therapies with MEK inhibition, hypothesizing that co-inhibition using clinically available brain-penetrant inhibitors would improve survival in preclinical models of TNBC brain metastases.

Methods

Using human-derived TNBC cell lines, synthetic lethal small interfering RNA kinase screens were evaluated with brain-penetrant inhibitors against MEK1/2 (selumetinib, AZD6244) or phosphatidylinositol-3 kinase (PI3K; buparlisib, BKM120). Mice bearing intracranial TNBC tumors (SUM149, MDA-MB-231Br, MDA-MB-468, or MDA-MB-436) were treated with MEK, PI3K, or platelet derived growth factor receptor (PDGFR; pazopanib) inhibitors alone or in combination. Tumors were analyzed by western blot and multiplexed kinase inhibitor beads/mass spectrometry to assess treatment effects.

Results

Screens identified MEK+PI3K and MEK+PDGFR inhibitors as tractable, rational combinations. Dual treatment of selumetinib with buparlisib or pazopanib was synergistic in TNBC cells in vitro. Both combinations improved survival in intracranial SUM149 and MDA-MB-231Br, but not MDA-MB-468 or MDA-MB-436. Treatments decreased mitogen-activated protein kinase (MAPK) and PI3K (Akt) signaling in sensitive (SUM149 and 231Br) but not resistant models (MDA-MB-468). Exploratory analysis of kinome reprogramming in SUM149 intracranial tumors after MEK ± PI3K inhibition demonstrates extensive kinome changes with treatment, especially in MAPK pathway members.

Conclusions

Results demonstrate that rational combinations of the clinically available inhibitors selumetinib with buparlisib or pazopanib may prove to be promising therapeutic strategies for the treatment of some TNBC brain metastases. Additionally, effective combination treatments cause widespread alterations in kinase pathways, including targetable potential resistance drivers.

Patient-centered prioritization of bladder cancer research

BACKGROUND

Patient-centered research requires the meaningful involvement of patients and caregivers throughout the research process. The objective of this study was to create a process for sustainable engagement for research prioritization within oncology.

METHODS

From December 2014 to 2016, a network of engaged patients for research prioritization was created in partnership with the Bladder Cancer Advocacy Network (BCAN): the BCAN Patient Survey Network (PSN). The PSN leveraged an online bladder cancer community with additional recruitment through print advertisements and social media campaigns. Prioritized research questions were developed through a modified Delphi process and were iterated through multidisciplinary working groups and a repeat survey.

RESULTS

In year 1 of the PSN, 354 patients and caregivers responded to the research prioritization survey; the number of responses increased to 1034 in year 2. The majority of respondents had non-muscle-invasive bladder cancer (NMIBC), and the mean time since diagnosis was 5 years. Stakeholder-identified questions for noninvasive, invasive, and metastatic disease were prioritized by the PSN. Free-text questions were sorted with thematic mapping. Several questions submitted by respondents were among the prioritized research questions. A final prioritized list of research questions was disseminated to various funding agencies, and a highly ranked NMIBC research question was included as a priority area in the 2017 Patient-Centered Outcomes Research Institute announcement of pragmatic trial funding.

CONCLUSIONS

Patient engagement is needed to identify high-priority research questions in oncology. The BCAN PSN provides a successful example of an engagement infrastructure for annual research prioritization in bladder cancer. The creation of an engagement network sets the groundwork for additional phases of engagement, including design, conduct, and dissemination. Cancer 2018. © 2018 American Cancer Society.

Implementation of medical scribes in an academic urology practice: an analysis of productivity, revenue, and satisfaction

PURPOSE

Pressure on physicians to increase productivity is rising in parallel with administrative tasks, regulations, and the use of electronic health records (EHRs). Physician extenders and clinical pathways are already in use to increase productivity and reduce costs and burnout, but other strategies are required. We evaluated whether implementation of medical scribes in an academic urology clinic would affect productivity, revenue, and patient/provider satisfaction.

METHODS

Six academic urologists were assigned scribes for 1 clinic day per week for 3 months. Likert-type patient and provider surveys were developed to evaluate satisfaction with and without scribes. Matched clinic days in the year prior were used to evaluate changes in productivity and physician/hospital charges and revenue.

RESULTS

After using scribes for 3 months, providers reported increased efficiency (p value = 0.03) and work satisfaction (p value = 0.03), while seeing a mean 2.15 more patients per session (+ 0.96 return visits, + 0.99 new patients, and + 0.22 procedures), contributing to an additional 2.6 wRVUs, $542 in physician charges, and $861 in hospital charges per clinic session. At a gross collection rate of 36%, actual combined revenue was + $506/session, representing a 26% increase in overall revenue. At a cost of $77/session, the net financial impact was + $429 per clinic session, resulting in a return-to-investment ratio greater than 6:1, while having no effect on patient satisfaction scores. Additionally, with scribes, clinic encounters were closed a mean 8.9 days earlier.

CONCLUSIONS

Implementing medical scribes in academic urology practices may be useful in increasing productivity, revenue, and provider satisfaction, while maintaining high patient satisfaction.

Widowed parenting self-efficacy scale: A new measure

The authors developed and tested a novel measure of parenting self-efficacy specifically for recently widowed parents of dependent-age children. They tested the scale among 244 recently widowed fathers via an open-access web survey. Exploratory factor analysis identified 3 factors: perception of meeting parenting expectations (α = .88), provision of effective discipline (α = .69), and sense of parental burden (α = .69). Scores on the new scale correlated positively with Kansas Parenting Satisfaction and Psychological Adaptation Scale scores, and negatively with CES-D (depression) and TRIG (grief) scale scores. The resulting 9-item Widowed Parenting Self Efficacy Scale is a promising measure for use in research and clinical settings.

Vincristine toxicity with co-administration of fluconazole during induction therapy for pediatric acute lymphoblastic leukemia

BACKGROUND

Antifungal prophylaxis is recommended for patients with acute lymphoblastic leukemia (ALL) during high-risk periods such as induction; however, increased vincristine toxicities have been reported with the co-administration of triazole antifungals. We sought to determine whether vincristine-associated toxicities are higher among children with ALL concurrently given fluconazole prophylaxis compared to no prophylaxis.

PROCEDURE

Using a retrospective cohort design, we reviewed records of pediatric patients treated for newly diagnosed ALL from 2003 to 2013. Patients were classified by fluconazole exposure during induction. The development of vincristine-associated toxicity and vincristine dose adjustment were the primary outcomes evaluated. The adjusted risk difference (RD) for vincristine-related toxicity associated with triazole exposure was determined.

RESULTS

We identified 197 patients meeting inclusion criteria for evaluation, 160 (81%) of whom received fluconazole prophylaxis. Among patients receiving fluconazole, 36/160 (22%) developed vincristine toxicity compared to 7/37 (19%) among those not receiving prophylaxis (RD: 3%, 95% confidence interval [CI] -11 to 18%). Adjusting for patient age and race, no statistically significant increased risk for vincristine-associated toxicity with fluconazole exposure was observed (RD 5%, 95% CI -8 to 17%). An increased risk for vincristine-associated toxicity was independently associated with age 10 years or older (RD 19%, 95% CI 4-34%).

CONCLUSION

Co-administration of fluconazole during induction therapy for pediatric ALL does not significantly increase the risk for vincristine-associated toxicities; however, patients 10 years or older are at an increased risk for toxicity independent of fluconazole exposure. Prophylaxis with fluconazole during induction therapy for pediatric ALL, if warranted, appears to be a safe clinical practice.