Abstract P6-18-38: Treatment patterns and sequences among pre-menopausal women with HR+/HER2- metastatic breast cancer: A chart review study

Background: Recently, a novel class of treatments, CDK4/6 inhibitors, has been approved, and is now recommended for pre-menopausal women with HR+/HER2- metastatic breast cancer (mBC). This study examined prevailing treatment patterns and sequencing among premenopausal women with mBC treated in clinical practice.

Methods: Patient-level data were collected from patient charts in May 2018 from 30 oncologists, mostly from community practice, in the US. Treatment sequences and patterns were assessed for pre-menopausal women diagnosed with HR+/HER2- mBC between January 2015 and January 2017 (with a minimum of 1 year of follow-up).

Results: Data were collected on 201 pre-menopausal women with HR+/HER2- mBC. In first-line therapy for mBC, 52.7% of the patients received a CDK4/6 inhibitor-based regimen, 23.4% received endocrine monotherapy, 20.9% received a chemotherapy-based regimen, and the remaining 3.0% received an everolimus-based regimen. The majority of patients who received a CDK4/6 inhibitor received it in combination with an AI (73.6%), fulvestrant (11.3%), or tamoxifen (6.6%). Approximately half of all patients (51.2%) received an ovarian suppression agent during first-line therapy. Overall, median time on treatment from Kaplan Meier (KM) analysis for first-line therapy was 16.1 months. Most common reason for discontinuing first line was disease progression or suboptimal response (79.0% of patients who discontinued); another common reason was the completion of the planned duration of therapy (12.6%).

Among the 106 patients who received a CDK4/6 inhibitor in the first line, median time on treatment from KM analysis was 26.8 months. Main reason for CDK4/6 inhibitor discontinuation was disease progression or suboptimal response (90.2% of patients who discontinued).

For the 109 patients for whom we observed a second-line therapy, treatment sequences are presented in Table 1. Median time on treatment for second and third line therapy was 9.6 and 7.8 months, respectively.

Conclusion: Following the introduction of novel CDK4/6 inhibitor treatments in the mBC setting, we observed that approximately half of pre-menopausal patients received a CDK4/6-based regimen in the first line of therapy.

Top 5 treatment sequences in pre-menopausal HR+/HER2- mBC patients (n=109)Treatment SequenceN(%)CDK4/6 - ET -> Everolimus - ET21(19.3%)Chemo -> Chemo16(14.7%)CDK4/6 - ET -> Chemo13(11.9%)ET -> CDK4/6 - ET13(11.9%)Chemo -> CDK4/6 - ET10(9.2%)ET: endocrine therapy; Chemo: chemotherapy; -> indicates a change to the next line of therapy. Percentages calculated among patients with at least 2 lines of therapy

Citation Format: Dalal AA, Goldschmidt D, Romdhani H, Kelkar S, Guerin A, Wang H, Caria N, Sawhney A, O'Shaughnessy J. Treatment patterns and sequences among pre-menopausal women with HR+/HER2- metastatic breast cancer: A chart review study [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P6-18-38.

The utility of the Sports Concussion Assessment Tool in hospitalized traumatic brain injury patients

The Sports Concussion Assessment Tool 3rd version is a sports screening tool that is often used to support return to play decisions following a head injury. The Sports Concussion Assessment Tool 3rd version is presumed to identify brain dysfunction (implying a degree of brain injury); however, the Sports Concussion Assessment Tool has never been validated with patients with definite acute brain injury. In this study, we found that all three Sports Concussion Assessment Tool 3rd version domains – symptoms, cognitive and balance assessments – were sensitive in discriminating traumatic brain injury patients (all with abnormal acute neuroimaging) from healthy controls. Through a correlation matrix (Bonferroni corrected), we found no correlation between the subjective (symptoms) and objective (examination) Sports Concussion Assessment Tool 3rd version assessments, e.g. complaints of imbalance and memory dysfunction were not correlated, respectively, with performance on testing balance and memory function. When relaxing the correction for multiple comparisons we found that of all Sports Concussion Assessment Tool 3rd version symptoms, a feeling of ‘pressure in the head’ had the largest number of co-correlations (including affective symptoms) and overwhelmingly in a pattern indicative of migraine. Taken together, that objective and subjective assessments in the Sports Concussion Assessment Tool 3rd version are poorly correlated, could suggest that symptoms in the Sports Concussion Assessment Tool 3rd version poorly reflect brain injury but rather indicate non-brain injury processes such as migraine. It follows that the current prominent orthodoxy of resting athletes following a head injury until their symptoms settle for fear of exacerbating brain injury may be unfavourable for their recovery – at least in some cases. Prospective clinical studies would be required to assess patient recovery from concussion with early active investigation and treatment versus rest – a notion supported by recent international consensus.

Abstract OT1-04-04: A phase 2 randomized, double-blind, placebo-controlled trial of endocrine therapy ± radium-223 dichloride in HER2-negative, hormone receptor–positive breast cancer patients with bone metastases

Background: Bone-metastatic breast cancer (MBC) treatment is limited. In a phase 2a study of bone-dominant MBC patients, radium-223, a first-in-class α emitter with targeted cytotoxic effect on bone metastases (mets), reduced bone biomarker levels with favorable safety (Coleman et al. Breast Cancer Res Treat. 2014).

Trial design: This study evaluates efficacy and safety of radium-223 versus placebo (pbo), each + endocrine treatment (ET), in patients with HER2- estrogen receptor+ (ER+)bone-dominant MBC (NCT02258464). Patients receive (1:1) radium-223 50 kBq/kg IV or pbo q 4 wk (6 cycles) + ET + denosumab or bisphosphonates + best supportive care. Stratification is by geographic region (EU/N America vs Asia), number of prior ET lines (1 vs ≥ 2) for MBC, and number of prior skeletal-related events (SREs) (1 vs 2).

Eligibility criteria: Eligible patients are pre- or postmenopausal with HER2- ER+ bone-dominant MBC and ≥ 2 bone mets or with soft tissue and/or visceral mets, and 1-2 prior SREs (external beam radiotherapy, pathologic bone fracture, spinal cord compression, orthopedic surgery); they have received ≥ 1 line of ET for MBC and are considered appropriate for further ET. Patients must have evaluable disease (RECIST 1.1), be taking bisphosphonates or denosumab for ≥ 1 month before study treatment, have an ECOG score 0-1, and have adequate hematologic, renal, and liver function. Patients must not have had visceral or brain mets or leptomeningeal disease, or need chemotherapy for MBC, and must not be suitable for everolimus for MBC. Patients are not eligible if they had prior radium-223 treatment or have untreated spinal cord compression.

Specific aims: The primary end point is SSE-free survival (SSE-FS). Secondary end points are radiologic progression-free survival; overall survival; times to opioid use, pain progression, and cytotoxic chemotherapy; pain improvement rate; and safety. Patients are assessed for efficacy and safety and are followed to SSE, radiologic progression, death, or withdrawal.

Statistical methods: Assuming 1-sided α 0.1, power 90%, ∼ 119 SSE-FS events are needed for analysis. Time-to-event analysis will use a log-rank test, accounting for stratification. Kaplan-Meier estimates and survival curves will be given for each treatment group. Safety analyses will be descriptive.

Present and target accrual: Target accrual is ∼ 227. Currently, 40 patients are randomized.

Contact Oana Petrenciuc, Bayer HealthCare Pharmaceuticals, oana.petrenciuc@bayer.com, for more information.

Citation Format: Coleman RE, Fried G, Petrenciuc O, Sawhney A, Li R, Rugo HS. A phase 2 randomized, double-blind, placebo-controlled trial of endocrine therapy ± radium-223 dichloride in HER2-negative, hormone receptor–positive breast cancer patients with bone metastases [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr OT1-04-04.

Cost-effectiveness of combining systematic identification and treatment of co-morbid major depression for people with chronic diseases: the example of cancer

BACKGROUND

Co-morbid major depression occurs in approximately 10% of people suffering from a chronic medical condition such as cancer. Systematic integrated management that includes both identification and treatment has been advocated. However, we lack information on the cost-effectiveness of this combined approach, as published evaluations have focused solely on the systematic (collaborative care) treatment stage. We therefore aimed to use the best available evidence to estimate the cost-effectiveness of systematic integrated management (both identification and treatment) compared with usual practice, for patients attending specialist cancer clinics.

METHOD

We conducted a cost-effectiveness analysis using a decision analytic model structured to reflect both the identification and treatment processes. Evidence was taken from reviews of relevant clinical trials and from observational studies, together with data from a large depression screening service. Sensitivity and scenario analyses were undertaken to determine the effects of variations in depression incidence rates, time horizons and patient characteristics.

RESULTS

Systematic integrated depression management generated more costs than usual practice, but also more quality-adjusted life years (QALYs). The incremental cost-effectiveness ratio (ICER) was £11,765 per QALY. This finding was robust to tests of uncertainty and variation in key model parameters.

CONCLUSIONS

Systematic integrated management of co-morbid major depression in cancer patients is likely to be cost-effective at widely accepted threshold values and may be a better way of generating QALYs for cancer patients than some existing medical and surgical treatments. It could usefully be applied to other chronic medical conditions.

Treatment of depression in adults with cancer: a systematic review of randomized controlled trials

BACKGROUND

Depression is a leading cause of disease burden worldwide and is especially problematic in people with chronic diseases, including cancer. Although depression can be effectively treated in the general population using antidepressant medication and psychological treatments, these treatments may have different benefits and harms in cancer patients. Previous reviews have not adequately addressed this topic. We therefore aimed to determine which, if any, treatments are effective for patients with diagnoses of both cancer and depression.

METHOD

We conducted a systematic review of relevant randomized controlled trials identified through searches of Medline, EMBASE, PsycINFO and The Cochrane Central Register of Controlled Trials (CENTRAL).

RESULTS

Seven relatively small trials met the selection criteria. These provided some evidence that antidepressant medication, given alone or in combination with a psychological treatment, may be effective. We found no good evidence for psychological treatments given alone or for any other forms of treatment.

CONCLUSIONS

There is very limited evidence from clinical trials to guide the treatment of cancer patients with a diagnosis of depression, especially for psychological treatments. High quality trials of treatments for depression in patients with cancer are urgently needed.

Screening medical patients for distress and depression: does measurement in the clinic prior to the consultation overestimate distress measured at home?

BACKGROUND

Medical patients are often screened for distress in the clinic using a questionnaire such as the Hospital Anxiety and Depression Scale (HADS) while awaiting their consultation. However, might the context of the clinic artificially inflate the distress score ? To address this question we aimed to determine whether those who scored high on the HADS in the clinic remained high scorers when reassessed later at home.

METHOD

We analysed data collected by a distress and depression screening service for cancer out-patients. All patients had completed the HADS in the clinic (on computer or on paper) prior to their consultation. For a period, patients with a high score (total of > or = 15) also completed the HADS again at home (over the telephone) 1 week later. We used these data to determine what proportion remained high scorers and the mean change in their scores. We estimated the effect of ‘ regression to the mean’ on the observed change.

RESULTS

Of the 218 high scorers in the clinic, most [158 (72.5 %), 95% confidence interval (CI) 66.6–78.4] scored high at reassessment. The mean fall in the HADS total score was 1.74 (95% CI 1.09–2.39), much of which could be attributed to the estimated change over time (regression to the mean) rather than the context.

CONCLUSIONS

Pre-consultation distress screening in clinic is widely used. Reassuringly, it only modestly overestimates distress measured later at home and consequently would result in a small proportion of unnecessary further assessments. We conclude it is a reasonable and convenient strategy.

Prone versus supine position in mechanically ventilated children: a pilot study

BACKGROUND

It is known that mechanically ventilated patients in the prone position have improved oxygenation compared with those supine. We did a prospective, randomized, controlled trial to evaluate the effect of prone position during mechanical ventilation, on survival in critically ill children.

MATERIAL/METHODS

Forty-two children needing mechanical ventilation for various illnesses were randomized to receive initial ventilation for four hours prone or supine by drawing lots. Initial severity of illness and blood gases in all children were noted. In a crossover design, after the initial four hours the children were turned over and ventilated in the alternate posture for an hour. Oxygenation parameters and mean airway pressures were noted at one hour, four hours, and five hours. Mortality, duration of ventilation, and the above parameters were compared in the two groups.

RESULTS

Initial PRISM scores were similar in the two groups. Mortality in the prone group was less than in the supine group. The odds ratio of mortality was 0.20 (95% CI 0.05-0.75). Duration of ventilation was similar in the two groups. The oxygenation index was significantly lower in the prone group at one, four, and five hours after onset of ventilation.

CONCLUSIONS

Prone position in the first few hours of ventilation significantly improves gas exchange and oxygenation, reduces the mean airway pressures required to ventilate children, and may cause significant improvement in survival. Our study protocol allowed ventilator settings to be changed as needed during ventilation.

Cytokine therapy for arterial restenosis: inhibition of neointimal hyperplasia by gamma-interferon

Inhibition of neointimal hyperplasia by gamma-interferon (gIFN) treatment was evaluated. Four groups of Sprague-Dawley rats (n = 72) weighing 500 g underwent endothelial injury of the carotid artery using the previously described Fogarty catheter technique. Group I (controls, n = 8) received one phosphate-buffered saline (PBS) injection 24h before injury and every 24h thereafter for a total of eight injections. Groups II (n = 8) and III (n = 8) received daily injections of 200,000 units of gIFN according to the same schedule except that group III did not receive the preoperative dose. Animals were killed on postoperative day 14. Histologic sections were analyzed morphometrically and immunohistochemically. Both gIFN groups had a statistically significant 50% reduction of the cross-sectional area of the neointimal hyperplasia compared with that of the controls (P < 0.01). Cell replication analysis of smooth muscle cells in the media and neointima revealed no statistically significant difference between controls and gIFN-treated groups. Group IV consisted of 48 rats that were treated with either PBS or gIFN on a schedule similar to that of groups I and II. Animals were killed at frequent time intervals during the first 7 days after injury. Their arteries were analyzed histologically and immunohistochemically. The results confirm previous findings that gIFN reduces the development of neointimal hyperplasia following arterial injury. The results also indicate that smooth muscle cells restore their proliferative activity by 7 days after discontinuation of gIFN treatment. It is proposed that efficacy of gIFN can be enhanced by lengthening the period of treatment.