Initial versus early switch to targeted therapy during first-line treatment among patients with biomarker-positive advanced or metastatic non-small cell lung cancer in the United States

OBJECTIVES

This study compared outcomes between patients with biomarker-positive advanced/metastatic non-small cell lung cancer (a/mNSCLC) who initiated treatment with targeted therapy versus those who initiated chemotherapy-based treatment and switched to targeted therapy during the first ∼3 cycles (defined as the first 56 days) of first-line treatment.

MATERIALS AND METHODS

This was an observational study of patients with a/mNSCLC who received targeted therapy from a nationwide electronic health record (EHR)-derived de-identified database. Outcomes were compared between those who initiated targeted therapy versus those who switched from chemotherapy to a targeted agent. Time-to-event outcomes were evaluated using Kaplan-Meier method; Cox proportional hazards models (adjusted for baseline covariates) were used to compare outcomes between groups.

RESULTS

Of the 4,244 patients in this study, 3,107 (73.2%) initiated the first line with targeted therapy and 346 (8.2%) switched to targeted therapy. Patients who received initial targeted therapy were significantly more likely to be non-smokers, treated in an academic practice setting, and of slightly older age (all p < 0.05). Patients who received initial targeted therapy also had a significantly longer time to start of first-line treatment (35.8 vs 25.3 days, p < 0.001). No significant differences were observed for clinical outcomes between groups.

CONCLUSION

In both unadjusted and adjusted analyses, there were no differences in the clinical outcomes observed among patients with a/mNSCLC in this study. This study found that initiating chemotherapy with an early switch to targeted therapy (within 56 days) of receiving biomarker positive results may be an acceptable strategy for a patient for whom immediate care is needed.

Challenges in the care of patients with RET-altered thyroid cancer: a multicountry mixed-methods study

BACKGROUND

The discovery of driver oncogenes for thyroid carcinomas and the identification of genomically targeted therapies to inhibit those oncogenes have altered the treatment algorithm in thyroid cancer (TC), while germline testing for RET mutations has become indicated for patients with a family history of RET gene mutations or hereditary medullary TC (MTC). In the context of an increasing number of selective RET inhibitors approved for use, this paper aims to describe challenges and barriers affecting providers' ability to deliver optimal care for patients with RET-altered TC across the patient healthcare journey.

METHODS

A mixed-method educational and behavioral needs assessment was conducted in Germany (GER), Japan (JPN), the United Kingdom (UK), and the United States (US) prior to RET-selective inhibitor approval. Participants included medical oncologists (MO), endocrinologists (EN) and clinical pathologists (CP) caring for patients affected with TC. Data collection tools were implemented in three languages (English, German, Japanese). Qualitative data were coded and thematically analyzed in NVivo. Quantitative data were analyzed via frequency and crosstabulations in SPSS. The findings presented here were part of a broader study that also investigated lung cancer challenges and included pulmonologists.

RESULTS

A total of 44 interviews and 378 surveys were completed. Suboptimal knowledge and skills were self-identified among providers, affecting (1) assessment of genetic risk factors (56%, 159/285 of MOs and ENs), (2) selection of appropriate genetic biomarkers (59%, 53/90 of CPs), (3) treatment plan initiation (65%, 173/275 of MOs and ENs), (4) management of side effects associated with multitargeted tyrosine kinase inhibitors (78%, 116/149 of MOs and ENs), and (5) transfer of patients into palliative care services (58%, 160/274 of MOs and ENs). Interviews underscored the presence of systemic barriers affecting the use of RET molecular tests and selective inhibitors, in addition to suboptimal knowledge and skills necessary to manage the safety and efficacy of targeted therapies.

CONCLUSION

This study describes concrete educational needs for providers involved in the care of patients with RET-altered thyroid carcinomas. Findings can be used to inform the design of evidence-based education and performance improvement interventions in the field and support integration into practice of newly approved RET-selective inhibitors.

Challenges in diagnosis and biomarker testing for RET-altered lung and thyroid cancer care: an international mixed-method study

BACKGROUND

The introduction of new targeted therapies for RET-altered lung and thyroid cancers (LC/TC) has impacted pathologists' practice by making genomic testing more relevant. Variations in health systems and treatment access result in distinct clinical challenges and barriers. This study aimed to assess practice gaps and challenges experienced by pathologists involved in the diagnosis of RET-altered LC/TC, including biomarker testing, to inform educational solutions.

METHODS

Pathologists in Germany, Japan, the UK, and US participated in this ethics-approved mixed-methods study, which included interviews and surveys (data collected January-March 2020). Qualitative data was thematically analysed, quantitative data was analysed with chi-square and Kruskal-Wallis H-tests, and both were triangulated.

RESULTS

A total of 107 pathologists took part in this study. Knowledge gaps were reported regarding genomic testing for LC/TC in Japan (79/60%), the UK (73/66%), and the US (53/30%). Skill gaps were reported when selecting genomic biomarker tests to diagnose TC in Japan (79%), the UK (73%) and US (57%) and when performing specific biomarker tests, especially in Japan (82% for RET) and in the UK (75% for RET). Japanese participants (80%) reported uncertainty about what information to share with the multidisciplinary team to ensure optimal patient-centered care. At the time of data collection, pathologists in Japan faced access barriers to using RET biomarker tests: only 28% agreed that there are relevant RET genomic biomarker tests available in Japan, versus 67% to 90% in other countries.

CONCLUSIONS

This study identified areas where pathologists need additional continuing professional development opportunities to enhance their competencies and better support delivery of care to patients with RET-altered lung or thyroid tumours. Addressing identified gaps and improving competencies of pathologists in this field should be emphasised in continuing medical education curricula and through quality improvement initiatives. Strategies deployed on an institutional and health system level should aim to improve interprofessional communication and genetic biomarker testing expertise.

Biomarker testing patterns in patients with stage IV non-small cell lung cancer (NSCLC) in U.S. community-based oncology practice setting

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Background: This study evaluated rates of biomarker testing for patients with stage IV non-squamous NSCLC, which is known to have a ̃40% biomarker-positive rate (AMP, 2020), in a community-based oncology practice setting in the United States (US). Methods: A retrospective study was performed using data from a US electronic medical record database of patients aged ≥18 years with an initial diagnosis (index dx) of stage IV non-squamous NSCLC between Jan 1, 2015 and Dec 31, 2019. Unstructured data on molecular biomarker testing (single-gene and next-generation sequencing [NGS]-based) were abstracted from patient charts utilizing Natural Language Processing for EGFR mutation, ALK rearrangement, BRAF mutation, ROS1 rearrangement, MET exon14 mutation, RET fusion, NTRK fusion, and PD-L1 expression. Systemic therapy was obtained from structured data. Data were summarized using descriptive statistics. This study received a waiver of consent from Advarra IRB. Results: Of 646 patients identified in the database, 500 met all inclusion criteria and are included in this analysis. The majority (73.8%) were diagnosed in 2018 (n = 162; 32.4%) and 2019 (n = 207; 41.4%). Mean age (SD) was 70.0 (10.1) years, with 53.2% female. A total of 447 (89.4%) were tested for at least one biomarker after index diagnosis of which 81.2% (n = 406) had at least one single-gene test; 54.8% (n = 274) had an NGS test and 66.8% were tested for PD-L1. Single-gene or NGS-based testing was > 85% of patients across all index years. The use of NGS-based tests ranged from 35.0% among patients whose first diagnosis was in 2015 to 59.4% in 2019. Overall, 85.4% (n = 427) of the cohort received first-line treatment with chemotherapy (53.6%), immunotherapy (48.2%), or targeted therapy (14.2%). Among patients who received biomarker tests, 15.4% received targeted treatment and 49.7% received immunotherapy treatment, including checkpoint inhibitors, during first-line treatment. Conclusions: NGS testing utilization increased during the study period and by 2019, 59% of patients received NGS-based testing. Opportunities persist for practices to improve testing and achieve guideline recommendations. PD-L1 biomarker testing was performed amongst the highest proportion of patients in this study and nearly 50% of all patients received immunotherapy, including checkpoint inhibitors. Targeted therapy was used in 14.2% of this population, suggesting that patients with actionable biomarkers may not be receiving targeted treatment for their disease, potentially due to gaps in testing among patients in this dataset.

Challenges in lung cancer multidisciplinary collaboration experienced by specialists in four countries

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Background: The importance and challenges of Multidisciplinary Team (MDT) collaboration in managing lung cancer have been increasingly recognized in an ever more complex therapeutic environment. Data on physicians’ viewpoints regarding MDT collaboration in lung cancer care, collected in a broader study assessing challenges related to lung/thyroid cancer patient management, are presented. Methods: A mixed-methods approach was used to analyze this data, combining qualitative interviews and a quantitative survey. Pulmonologists (PLM), oncologists (ONC) and pathologists (PTH) from Germany (GE), Japan (JP), the United Kingdom (UK) and the United States (US) were recruited. Results: A total of 44 specialists participated in interviews and 377 in a survey. Quantitative data reveal that 53% of pulmonologists in JP and 39% in GE have suboptimal knowledge of the timing of patient referral to an oncologist. Fewer PLM/PTH from JP (43%/47%) report a fully integrated MDT team approach in their clinical setting, compared to those from GE (80%/95%), the UK (96%/82%) and the US (82%/97%). Qualitative data indicate that current MDT team practices are perceived as delaying patient care due to significant inefficiencies (sometimes due to lack of knowledge/skills) and unclear responsibilities within the team. Around half of ONC in each country and 78% of PLM from the UK report a gap in knowledge and relevance of each genetic biomarker test according to clinical presentation. PTH in the UK (70%), the US (50%), and JP (72%) report sub-optimal skills identifying biomarker tests to inform the progression of lung cancer (also a challenge for PLM/ONC). Conclusions: This study indicates a need for multi-level interventions addressing systemic and attitudinal barriers as well as knowledge gaps which affect physicians’ ability to collaborate in lung cancer care.

Characteristics and outcomes of patients with RET-fusion positive non-small lung cancer in real-world practice in the United States

BACKGROUND

Contradictory and limited data are available about the presentation and outcomes of patients with RET-fusion positive metastatic NSCLC as compared to patients without RET fusions. This observational study utilizing a linked electronic health records (EHR) database to genomics testing results was designed to compare characteristics, tumor response, progression-free (PFS) and overall survival (OS) outcomes by RET fusion status among patients with metastatic NSCLC treated with standard therapies.

METHODS

Adult patients with metastatic NSCLC with linked EHR and genomics data were eligible who received systemic anti-cancer therapy on or after January 1, 2011. Adjusted, using all available baseline covariates, and unadjusted analyses were conducted to compare tumor response, PFS and OS between patients with RET-fusion positive and RET-fusion negative disease as detected by next-generation sequencing. Tumor response outcomes were analysed using Fisher's exact test, and time-to-event analyses were conducted using Cox proportional hazards model.

RESULTS

There were 5807 eligible patients identified (RET+ cohort, N = 46; RET- cohort, N = 5761). Patients with RET fusions were younger, more likely to have non-squamous disease and be non-smokers and had better performance status (all p < 0.01). In unadjusted analyses, there were no significant differences in tumor response (p = 0.17) or PFS (p = 0.06) but OS was significantly different by RET status (hazard ratio, HR = 1.91, 95% CI:1.22-3.0, p = 0.005). There were no statistically significant differences by RET fusion status in adjusted analyses of either PFS or OS (PFS HR = 1.24, 95% CI:0.86-1.78, p = 0.25; OS HR = 1.52, 95% CI: 0.95-2.43, p = 0.08).

CONCLUSIONS

Patients with RET fusions have different baseline characteristics that contribute to favorable OS in unadjusted analysis. However, after adjusting for baseline covariates, there were no significant differences in either OS or PFS by RET status among patients treated with standard therapy prior to the availability of selective RET inhibitors.

Clinical outcomes between patients with and without RET fusions in advanced/metastatic non-small cell lung cancer in the United States

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Background: Fusions involving the REarranged during Transfection ( RET) gene are known oncogenic drivers in non-small cell lung cancer (NSCLC). The patient profile is distinct from a genomically-unselected population of NSCLC patients and may lead to the potentially confounded conclusion that RET fusion-positive patients have a better prognosis. This study characterized clinical outcomes in patients with RET fusion-positive NSCLC versus those without when correcting for known demographic differences. Methods: The Flatiron ClinicoGenomics Database, electronic medical record data linked to Foundation Medicine, Inc genomic test results, was used to identify individuals diagnosed with advanced or metastatic NSCLC who initiated anti-cancer systemic therapy between JAN2011 and JUN2019 in the US. Follow up data were available through JUN2019. Patients were considered RET+ if a fusion was reported and RET- if no fusion was reported. Baseline characteristics and tumor response were compared using Fisher’s exact, chi-squared or t-tests; unadjusted and adjusted COX models were used to compare progression-free survival (PFS) and overall survival (OS). Results: There were 5,807 eligible patients with NSCLC; 46 (0.8%) and 5,761 (99.2%) were RET+ and RET-, respectively. Patients with RET+ tumors were significantly younger (63 vs 67 yrs), better performance status, less likely to have smoking history (37% vs 82%), more likely to have non-squamous tumors (98% vs 76%) (all p < 0.05), and less likely to have ALK, ROS1, KRAS or BRAF alterations, which were each 0% in the RET+ group. There were no differences in total lines of therapy received; treatment regimens were comparable. In unadjusted analyses, patients with RET+ tumors had no significant differences in tumor response (p = 0.17) or PFS (p = 0.06) but significantly better OS outcomes (p = 0.005) from the start of first-line therapy. After adjusting for all available baseline covariates, survival outcomes were not significantly different between RET- and RET+ groups (PFS hazard ratio [HR] = 1.24, 95% confidence interval [CI] = 0.86, 1.78, p = 0.26; OS HR = 1.53, 95% CI = 0.95, 2.44, p = 0.08). Conclusions: Patients with RET fusion-positive NSCLC have different baseline characteristics than patients without these fusions. The unadjusted differences in OS between groups appear to be driven by baseline demographic features and not the presence of the RET fusion, however further research is needed. Conclusions are limited by the rarity of RET fusions in NSCLC and subsequent small sample size.

Clinical utility and reimbursement for expanded genomic panel testing in adult oncology

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Background: The routine use of large next generation sequencing (NGS) cancer panels is required to identify the increasing number of, but often uncommon actionable alterations present across multiple tumor histologies to guide therapy. Inconsistent coverage and variable payment is hindering adoption of these tests into clinical practice. A review of clinical utility, coverage and reimbursement was conducted in a cohort of adult oncology patients who received expanded genomic panel testing as part of their clinical care. Methods: The Columbia Combined Cancer Panel (CCCP), a 467 gene panel designed to detect single nucleotide variants, indels, and copy number variations in solid and liquid tumors was performed in a CLIA-certified laboratory at Columbia University Irving Medical Center. Clinical utility categories included: immediate change in management; informed future treatment options; provided diagnostic/prognostic information; and other impact. Claims were submitted between 1/1/17 and 4/30/18. Carriers were categorized into commercial, managed-government, and government plans. Results: 300 tumors underwent NGS. Reimbursement data were available for 258 cases. 57% of testing was performed for a treatment-resistant, recurrent, or high stage cancer, or for a cancer of rare/mixed histology (21%). Findings were clinically actionable in 183 cases (61%). Results led to an immediate change in management (n = 6, 2%), informed future treatment options (n = 140, 47%), and provided diagnostic/prognostic information (n = 29, 10%). Only 57 tests (22%) received coverage. In 59% of denials (118/201), a clinically-actionable result was found. Commercial plans reimbursed 29/119 tests (24%) and managed-government plans reimbursed 28/54 tests (52%). Government plans provided no coverage for 85 tests. On average, insurers reimbursed 10% of the total CCCP service charges: 12.5% for commercial and 22% for managed-government plans. Conclusions: Expanded genomic testing identified clinically-impactful alterations in 61% of cases. Limited coverage and low reimbursement remain a barrier and broader reimbursement policies are needed to adopt expanded genomic testing that benefits patients into clinical practice.

Identification of a secondary RET mutation in a pediatric patient with relapsed acute myeloid leukemia leads to the diagnosis and treatment of asymptomatic metastatic medullary thyroid cancer in a parent: a case for sequencing the germline

The incorporation of tumor-normal genomic testing into oncology can identify somatic mutations that inform therapeutic measures but also germline variants associated with unsuspected cancer predisposition. We describe a case in which a RET variant was identified in a 3-yr-old male with relapsed leukemia. Sanger sequencing revealed the patient's father and three siblings carried the same variant, associated with multiple endocrine neoplasia 2A (MEN2A). Evaluation of the father led to the diagnosis and treatment of metastatic medullary thyroid carcinoma. Detection of RET mutations in families with hereditary MTC allows for genetic risk stratification and disease surveillance to reduce morbidity and mortality.

Low accuracy of manual white blood cell count in amniotic fluid

Intra-amniotic infection (IAI) is a common cause of pre-term labour. Manual WBC count on amniotic fluid (AF) has been suggested as a diagnostic test for IAI using a threshold of 50 cells/mm(3). However, no validation studies assessing the accuracy of this method have been performed. AF samples were selected for cell count analysis. WBCs were introduced to 47 AF samples. The results from two technologists' counts were compared with the calculated expected value for WBCs in these samples. Results showed that a comparison between the technologists' WBC count to the expected WBC count yielded R(2) coefficients of 0.62 and 0.78, indicating moderate accuracy. Percentage agreement between the technologists was 67%, indicating low reproducibility. It was concluded that there was moderate correlation between the manual and the expected WBC in the spiked AF samples. Clinicians should be aware of the inaccuracy and imprecision associated with this test when evaluating a patient for IAI.

Abstract 2735: Inactivation of activin signaling pathway accelerates the development of pancreatic intraductal papillary mucinous neoplasms in vivo

The association of TGF-β pathway with human tumorigenesis has been rigorously demonstrated. However, little is known about activin signaling, part of the TGF-β family, in pancreatic tumorigenesis. We have previously reported sporadic mutations of the Activin receptor type 1B (ACVR1B) in human pancreatic ductal adenocarcinoma (PDAC). To investigate the significance of ACVR1B in pancreatic tumorigenesis, Acvr1bflox/flox; Pdx1-Cre mice were generated and examined. Chronic pancreatitis-like histological changes such as inflammatory cell infiltration, acinar to ductal metaplasia, and fibrosis were observed in Acvr1b mutant alone mice older than 8 months of age. In combination with mutant KrasG12D in the pancreas, Acvr1b deletion accelerated the development of pancreatic intraductal papillary mucious neoplasms (IPMN), but not the pancreatic intraepithelial neoplasias (PanINs). The IPMN progressed to invasive and metastatic cancer was observed in this model. The expressions of Cox-2 and phospho-PDK1 are dramatically increased in preneoplastic and neoplastic lesions, but activated Notch4 expression is exclusively observed in the IPMN lesions by immunohistochemistry, suggesting that Notch4 signaling may play a role in the formation or maintenance of the mucin-rich ductal phenotype in this model. Interestingly, the progression of IPMN to invasive cancer appears to require additional p16 loss in this double mutant mouse model. In human IPMN, loss of p16 expression is associated with increasing grade. Our data provide the first evidence that Acvr1b acts as a tumor-suppressor in vivo and that activin signaling plays a predominant role in the development of pancreatic IPMNs.

Significance: PDAC can arise from PanINs or IPMN. It has been reported previously that disruption of TGF-β signaling promotes the progression of PanIN to

PDAC in the TGFβRII knockout background. In contrast, here we present that activin signaling deficiency favors the development of IPMNs and enhances their progression to PDAC. This phenotype overlaps with those observed in the Smad4 knockout background, suggesting that the involvement of activin signaling in the IPMN to PDAC sequence is Smad4-dependent. Together these data demonstrate that TGF-β superfamily ligands play critical roles in regulating the IPMN-derived versus PanIN-derived carcinogenesis.

Citation Format: Wanglong Qiu, Sophia Tang, Sohyae Lee, Andrew T. Turk, Anthony Sireci, Anne Qiu, Ralph H. Hruban, Helen E. Remotti, Gloria H. Su. Inactivation of activin signaling pathway accelerates the development of pancreatic intraductal papillary mucinous neoplasms in vivo. [abstract]. In: Proceedings of the 104th Annual Meeting of the American Association for Cancer Research; 2013 Apr 6-10; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2013;73(8 Suppl):Abstract nr 2735. doi:10.1158/1538-7445.AM2013-2735

A Method for Optimizing and Validating Institution-Specific Flagging Criteria for Automated Cell Counters

Context.—Automated cell counters use alerts (flags) to indicate which differential white blood cell counts can be released directly from the instrument and which samples require labor-intensive slide reviews. The thresholds at which many of these flags are triggered can be adjusted by individual laboratories. Many users, however, use factory-default settings or adjust the thresholds through a process of trial and error.

Objective.—To develop a systematic method, combining statistical analysis and clinical judgment, to optimize the flagging thresholds on automated cell counters.

Design.—Data from 502 samples flagged by Sysmex XE-2100/5000 (Sysmex, Kobe, Japan) instruments, with at least 1 of 5 user-adjustable, white blood cell count flags, were used to change the flagging thresholds for maximal diagnostic effectiveness by optimizing the Youden index for each flag (the optimization set). The optimized thresholds were then validated with a second set of 378 samples (the validation set).

Results.—Use of the new thresholds reduced the review rate caused by the 5 flags from 6.5% to 2.9% and improved the positive predictive value of the flagging system for any abnormality from 27% to 37%.

Conclusions.—This method can be used to optimize thresholds for flag alerts on automated cell counters of any type and to improve the overall positive predictive value of the flagging system at the expense of a reduction in the negative predictive value. A reduced manual review rate helps to focus resources on differential white blood cell counts that are of clinical significance and may improve turnaround time.

Therapeutic effects of coenzyme Q10 (CoQ10) and reduced CoQ10 in the MPTP model of Parkinsonism

Coenzyme Q10 (CoQ10) is a promising agent for neuroprotection in neurodegenerative diseases. We tested the effects of various doses of two formulations of CoQ10 in food and found that administration in the diet resulted in significant protection against loss of dopamine (DA), which was accompanied by a marked increase in plasma concentrations of CoQ10. We further investigated the neuroprotective effects of CoQ10, reduced CoQ10 (ubiquinol), and CoQ10 emulsions in the (MPTP) model of Parkinson's disease (PD). We found neuroprotection against MPTP induced loss of DA using both CoQ10, and reduced CoQ10, which produced the largest increases in plasma concentrations. Lastly, we administered CoQ10 in the diet to test its effects in a chronic MPTP model induced by administration of MPTP by Alzet pump for 1 month. We found neuroprotective effects against DA depletion, loss of tyrosine hydroxylase neurons and induction of alpha-synuclein inclusions in the substantia nigra pars compacta. The finding that CoQ10 is effective in a chronic dosing model of MPTP toxicity, is of particular interest, as this may be more relevant to PD. These results provide further evidence that administration of CoQ10 is a promising therapeutic strategy for the treatment of PD.

Pulsed radiofrequency of the dorsal root ganglia is superior to pharmacotherapy or pulsed radiofrequency of the intercostal nerves in the treatment of chronic postsurgical thoracic pain

BACKGROUND

Chronic postsurgical thoracic pain (CPTP) represents a major therapeutic challenge characterized by an absence of clinical studies to guide treatment. Recently, the implementation of pulsed radiofrequency (RF) has generated intense interest in the medical community as a safe and potentially effective treatment for neuropathic pain. To date, there are no studies comparing pulsed RF to more conventional therapeutic modalities for any pain condition.

OBJECTIVES

To compare treatment outcomes between pharmacotherapy, pulsed RF of the intercostal nerves (ICN) and pulsed RF of the dorsal root ganglia (DRG) in CPTP.

METHODS

Retrospective data analysis involving 49 patients.

RESULTS

At 6-week follow-up, 61.5% of the pulsed RF DRG group reported > or =50% pain relief vs. 27.3% in the medical management (MM) group and 21.4% in the IC group (P = 0.12). At 3-month follow-up, 53.8% in the DRG group continued to report > or = 50% pain relief vs. 19.9% in the MM and 6.7% in the ICN groups, respectively (P = 0.02). Among the pulsed RF patients who did report a successful outcome, the mean duration of pain relief was 2.87 months in the ICN group and 4.74 months in the DRG group (P = 0.01).

CONCLUSIONS

Pulsed RF of the DRG was a superior treatment to pharmacotherapy and pulsed RF of the ICN in patients with CPTP. Prospective studies are needed to confirm these results and identify the best candidates for this treatment.