Strain measurement for 2D echo with ultrasound enhancing agents can be performed with software available for non-enhanced recordings

Funding Acknowledgements

Type of funding sources: Public Institution(s). Main funding source(s): ABACUS Cardiovascular Research Centre, Mazankowski Alberta Heart Institute

Background

Global longitudinal strain (GLS) measurement are less reliable when 2D image quality is reduced. While ultrasound enhancing agents (UEA; also known as "echo contrast") have been shown to enhance the reliability of EF measurements, there has been sparse evidence on performing GLS measurements after UEA injection. The aim of this study was to assess the feasibility of GLS analysis using the same software validated for non-enhanced 2D recordings.

Methods

GLS measurements were performed before and after injection of an approved UEA in 131 patients with acceptable image quality for GLS measurements. These patients were referred prior to chemotherapy initiation or were being monitored for potential cardiotoxic effects. As all these patients undergo echocardiography with UEA in order to achieve the best reproducibility of EF measurements, comparison of GLS measurements with and without UEA was possible. A commercially available ultrasound system was used and the same analysis software was applied. On end-diastolic and end-systolic frames, the inner border of the region of interest was manually adjusted to align with interface between the compact and trabeculated myocardium on non-enhanced images and the LV blood pool on the recordings with UEA.

Results

GLS measurements on recordings with UEA were performed in 131 patients. A strong positive correlation (r 0.67, p < 0.001) was found between measurements on non-enhanced recordings with mean bias 0.58% (see figure). Mean GLS was 19.5 +/- 2.1% from non-enhanced recordings and 20.1 +/- 2.2% from UEA recordings. Differences in GLS > 2% between methods were related to foreshortening or suboptimal delineation of segments on non-contrast recordings.

Conclusion

On a commercially available echocardiography scanner, software developed for GLS measurements on non-enhanced 2D recordings can be also applied to recordings that use UEA. Comparable results are obtained, provided the LV cavity is well delineated and not foreshortened. Abstract Figure 1

Comparison of two ultrasound contrast agents for left ventricular opacification

Funding Acknowledgements

Type of funding sources: None.

Background

Several ultrasound contrast agents have been approved and used for measurement of LV volumes and ejection fraction (EF). However, there has been no direct comparison between these agents.

Purpose

To compare different imaging parameters between two widely used ultrasound contrast agents for LV opacification when imaged with a low power contrast specific imaging modality

Methods

A retrospective study was performed using recordings of the local echocardiography registry for patients undergoing chemotherapy for cancer treatment.  Patients were included who underwent follow-up echocardiograms (3 months) with 2 different ultrasound contrast agents and had only minor changes in the LV ejection fraction (EF) between the studies (<5%). Qualitative and quantitative analysis of the contrast effect was performed in apical four- and two chamber views (4CV,2CV). For quantitative analysis of the LV opacification square regions of interest (ROI) were placed in the apical and basal regions of the ventricle in each echocardiographic recording and the arithmetic mean and standard deviation of pixel intensity within each ROI was recorded throughout the entire loop. Qualitative visual assessment was performed using a three step visual score in order to assess the endocardial border delineation, basal attenuation and apical swirling. Wilcoxon signed-rank test was used to compare the measurements obtained with different contrast agents.

Results

41 patients fulfilled the inclusion criteria. In all patients suitable recordings for measurement of LV volumes and EF were obtained. The mean + standard deviation of the EF was 61 + 9%. Both contrast agents provided intensive LV opacification in the basal and apical cavities. The video intensities (mean + standard deviation) in the apical and basal cavities were comparable across both contrast agents in the 2CV apical ROI (219.96 + 21.42 vs 224.69 + 20.23, p = 0.32), the 2CV basal ROI (114.55, 42.02 vs 112.79, 42.57, p = 0.81), the 4CV apical ROI (228.02, 17.80 vs 225.51, 20.37, p = 0.30), and the 4CV basal ROI (100.05, 41.11 vs 92.84, 42.54, p = 0.37). Visual assessment of endocardial delineation on end-diastolic and end-systolic frames revealed no statistical difference between the contrast agents.

Conclusion

In patients with normal LV function no clinically relevant differences were found between the two contrast agents regarding LV opacification and endocardial border delineation.

Prevalence and predictors of right ventricular dysfunction in cancer patients treated with cardiotoxic chemotherapy – a prospective cardiovascular magnetic resonance study

Background

Right ventricular (RV) function has an established incremental prognostic value in cardiomyopathy. Studies on cancer therapeutics-related cardiac dysfunction (CTRCD) primarily focused on the left ventricle (LV), with conflicting results from small studies dedicated to RV dysfunction.

Purpose

We sought to investigate the influence of chemotherapy on RV function relative to LV function using serial cardiac magnetic resonance (CMR).

Methods

Patients were enrolled as part of Cardiotoxicity Prevention Research Initiative (CAPRI) Registry aimed at evaluating CMR-based markers for surveillance of CTRCD. Patients underwent non-contrast CMR imaging prior to initiation of anthracyclines and/or trastuzumab and serially every 3 months during the first year, then annually thereafter. We included patients who had a baseline and ≥1 follow-up scan and excluded those with baseline LV ejection fraction (EF)<50%, providing 320 patients completing 1,453 CMR studies. Cine images were analysed to calculate chamber volumes indexed to body surface area and EF. We defined LV CTRCD using CMR modality specific criteria of a drop in LV EF ≥5% from baseline to <57%; RV CTRCD as a drop ≥5% to <49% in females and <47% in males. We used linear mixed models to study the changes in ventricular volumes and EF with time.

Results

The majority of patients were females (80%), had breast cancer (68%) or lymphoma (32%), with a mean age of 52.7±13 years. Figure 1 shows temporal changes in mean ventricular volumes and function over the first year. Mean changes in RV function followed those of the LV, with the nadir of EF and maximum of volumes occurring at 6 months. Respective values for mean decrease in LV and RV EF at this time point versus baseline were 4.1 and 2.9% (p<0.001). Concomitant mean increase in indexed RV end-diastolic (ED) and end-systolic (ES) volumes were 1.6 and 2.7 ml/m2 (p=0.2 and <0.001). There was significant interaction of chemotherapy regimen with time for RV volumes (p=0.001 and 0.003), but not RV EF (p=0.7), with worst changes occurring with combined anthracyclines and trastuzumab. In all, 70 (22%) and 28 (9%) patients met criteria for LV and RV CTRCD, respectively. Among those who developed RV CTRCD, 10 had persistently normal LV function. Figure 2 shows the results of logistic regression to predict RV CTRCD. Significant univariable predictors included combined chemotherapy regimen and baseline LV and RV volumes and LV EF. Adjusting for age, sex, and chemotherapy regimen, baseline RV ED volume remained associated with RV CTRCD (odds ratio 1.6; p=0.005).

Conclusion

In this large study, RV volumes and function were similarly influenced by chemotherapy versus comparable LV-based measures. Using similar threshold criteria, the incidence of RV CTRCD was lower than for LV CTRCD; however, one third of those who develop RV CTRCD showed normal LV function. Future studies are warranted to study the prognostic influence of RV injury in cancer patients.

Funding Acknowledgement

Type of funding sources: Other. Main funding source(s): Alberta InnovatesGenome Alberta Figure 1. Temporal changes in LV & RV functionFigure 2. Predictors of RV CTRCD

Age-dependent increased odds of cardiovascular risk factors in cancer survivors: Canadian Longitudinal Study on Aging cohort

Background

This study compared the odds of self-reported and objectively measured cardiovascular (cv) risk factors in a sample of Canadian cancer survivors and individuals without cancer.

Methods

A nationally representative sample of 45- to 85-year-old cancer survivors (n = 6288) in the Canadian Longitudinal Study on Aging were compared with individuals without cancer (n = 44,051).

Results

The most prevalent risk factors in cancer survivors were all self-reported or easily measured in clinic: overweight or obesity (68.0%), former smoking (62.9%), fewer than 5 daily servings of fruits and vegetables (59.8%), hypertension (43.7%), and high waist circumference (47.0%). After adjustment for sex and education, the odds ratios of several cv risk factors varied by age in cancer survivors and the non-cancer controls. At ages 50 and 60, cancer survivors have increased odds of overweight or obesity, former smoking, hypertension, high waist circumference and truncal fat, diabetes, lung disease, and heart rate greater than 80 bpm compared with non-cancer controls. At age 70, odds did not differ for many risk factors; at age 80, no differences were evident. Without modification by age, low physical activity was more prevalent in cancer survivors (odds ratio: 1.27; 95% confidence interval: 1.17 to 1.39). There were no differences in the odds of cv risk factors measured by specialized equipment, including electrocardiography, carotid ultrasonography, spirometry, and dual-energy X-ray absorptiometry.

Conclusions

The odds of several easy-to-assess cv disease risk factors are higher among middle-aged, but not older, cancer survivors relative to the general Canadian population. Initial assessment of cv risk for middle-aged adults in the survivorship setting could be quickly and inexpensively performed using self-reported and easily measured metrics.

Abstract P1-03-07: Breast cancer diagnosis is associated with relative left ventricular hypertrophy

Background: Cardiac dysfunction is a major concern for patients with breast cancer (BC) receiving adjuvant therapy. Retrospective, cross-sectional echocardiographic data suggests that patients with cancer have reduced myocardial strain prior to cancer therapy exposure. Cardiac magnetic resonance (CMR) is the gold standard imaging modality for cardiac structure and function and can also evaluate myocardial micro-architecture with T1 mapping. We hypothesized that treatment naïve patients with early-stage BC (ESBC) have abnormal myocardial tissue characteristics on CMR.

Methods: Women with newly diagnosed ESBC were prospectively recruited for CMR prior to cancer drug treatment. Those with hypertension, diabetes mellitus or prior cancer treatments were excluded. Age and sex matched healthy controls were identified from a prior prospective study. All participants underwent a non-contrast CMR scan on a 1.5T magnet. Image acquisition included cines for cardiac structure and function as well as T1 mapping using saturation recovery single-shot acquisitions. Global longitudinal strain (GLS) was derived from cine images. Demographics and imaging metrics for healthy controls and patients were compared using two-sample t-test.

Results: 106 patients with ESBC, mean age 51±9, were included along with 55 matched healthy controls. Body mass index and systolic blood pressure were similar between groups, however resting heart rate was elevated in patients compared to controls, 77±11 vs 67±11 /min respectively, p<0.001 (Table 1). On CMR there was no difference in left ventricular volume or ejection fraction however global longitudinal strain was higher in patients compared to controls, -20.9±2.3 vs -19.9±3.7%, p=0.04 (Table 2). Left ventricular mass was higher compared to controls, 52±6 and 47±6 g/m2 respectively, p<0.001. However myocardial T1 was similar between groups, T1=1198±27ms for controls vs 1206±46ms for patients, p=0.42.

Conclusions: The cardiac phenotype of patients with ESBC is characterized by relative left ventricular hypertrophy with normal myocardial tissue. Further understanding of the mechanisms involved may provide insight into the cardiovascular risk associated with BC diagnosis.

Table 1.Demographics Healthy Controls (n=55)Breast Cancer (n=106)P valueAge, years (SD)52(14)51(9)0.49Body mass index, kg/m2 (SD)26(5)27(6)0.38Hypertension, number00NADiabetes Mellitus, number00NAReceptor status, number (%)  NAER/PRNA92(87%) HER2NA74(70%) Triple negativeNA2(2%) Stage, number (%)  NA1NA43(42%) 2NA41(38%) 3NA23(20%) Systolic blood pressure, mmHg (SD)127(15)124(13)0.19Heart rate, /min (SD)67(11)77(11)<0.001SD=standard deviation, NA=not applicable

Table 2.Cardiac Magnetic Resonance Healthy Controls (n=55)Breast Cancer (n=106)P valueLVEF, % (SD)62(4)62(5)0.91Indexed LVEDV, ml/m2 (SD)69(9)72(14)0.18Indexed LV mass, g/m2 (SD)47(6)52(6)<0.001LV mass/LVEDV (SD)0.69(0.08)0.74(0.13)0.002Indexed left atrial volume, ml/m2 (SD)40(9)37(10)0.21Global longitudinal strain, % (SD)-19.9(3.7)-20.9(2.3)0.04Myocardial T1, ms (SD)1198(27)1206(46)0.42SD=standard deviation, LVEF=left ventricular ejection fraction, LVEDV=left ventricular end-diastolic volume, LV=left ventricular

Citation Format: Kirkham A, Xu L, Wang H, Chow K, Pagano JJ, White J, Haykowsky MJ, Dyck JR, Ezekowitz JA, Oudit GY, Mackey JR, Thompson RB, Pituskin E, Paterson I. Breast cancer diagnosis is associated with relative left ventricular hypertrophy [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 P1-03-07.

Abstract P4-16-12: Does initial cardiac imaging impact clinical outcomes in patients with breast cancer?

Background: Echocardiography (echo) and multigated acquisition (MUGA) scans are the most commonly used modalities to assess cardiac function during breast cancer (BC) treatment. However, a case series of 176 patients with cancer suggests enhanced cardiac care with echo surveillance. We hypothesized that patients with early BC imaged by echo have improved cardiac outcomes compared to those imaged by MUGA.

Methods: Consecutive patients with stage I to III breast cancer undergoing pre-treatment echo or MUGA were retrospectively screened from January 2010 to December 2014. Patients participating in clinical trials with mandated imaging and/or cardiac reviews were excluded. Demographics, medical history and clinical events were collected via chart review and electronic health records. All patients had a minimum 1 year of follow-up. The primary outcome was a composite of death, cardiac hospitalization or cardiac emergency room visit.

Results: 598 patients were identified as having a baseline echo and 636 had had baseline MUGA. Mean follow-up was 4.5±1.4 years. Patients undergoing MUGA were younger, had more advanced stage of disease and received more anthracycline and trastuzumab (table1). Patients imaged by MUGA had lower cardiac function at baseline compared to echo, LVEF 64% vs. LVEF 65% respectively, P <0.001. Cancer therapy related cardiac dysfunction was similar between groups, 10% vs. 11%, p=0.81. Patients in the echo group were more likely to be seen by cardiology, 7% vs. 3%, p<0.0001, and to be initiated on beta blocker, 4% vs. 1%, p=0.006, or angiotensin converting enzyme inhibitor, 3% vs. 1%, p=0.002.However, there was no difference between groups for the primary outcome, 10% event rate in each group, even after adjustment for age, BC stage, chemotherapy and cardiac medications, hazard ratio 1.04 (CI 0.72-1.49), p=0.842.

Conclusion: For patients with early stage BC, the choice of cardiac imaging modality at baseline does not impact adverse cardiac events. However, patients undergoing echo were more likely to be evaluated and managed by cardiology.

Table 1.Baseline Characteristics Echo (N=598)MUGA (N=636)Age mean54±1053±10*BMI mean29±629±7Cardiovascular HistoryDiabetes66(11%)56(9%)Hypertension154(26%)155(24%)Dyslipidemia83(14%)75(12%)CAD9(2%)6(1%)CHF7(1%)4(1%)Beta Blocker22(4%)28(4%)ACE-Inhibitor51(9%)64(10%)Angiotensin Receptor Blocker69(12%)44(7%)*Cancer HistoryStage*Stage I65(11%)56(9%)Stage II377(63%)361(57%)Stage III155(26%)219(34%)Receptor StatusTriple negative64(11%)76(12%)HER2 negative, hormone positive342(58%)387(61%)HER2 positive192(32%)173(27%)Cancer TherapyChemotherapy (any)528(88%)594(93%)*Anthracycline310(52%)394(62%)*Trastuzumab170(28%)148(23%)*Anthracycline & trastuzumab6(1%)19(3%)*Hormone therapy459(77%)487(77%)Radiation (any)487(81%)527(83%)Radiation left side237(49%)259(49%)Surgery597(100%)633(100%)* p<0.05 for comparison between echo and MUGA groups

Citation Format: Parent S, Xu L, Becher H, Mackey J, King K, Pituskin E, Paterson I. Does initial cardiac imaging impact clinical outcomes in patients with breast cancer? [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 P4-16-12.

Abstract P6-13-08: A novel comparative analysis approach to personalize chemotherapy dose in early breast cancer

Background: Worldwide, body surface area [BSA] is used to calculate chemotherapy dose. The BSA formula was originally developed in 1916, derived from height and weight, with no consideration of other patient characteristics. Most chemotherapy agents have a narrow therapeutic index and are distributed in lean body mass [LBM], leading to under- or over-dosing and deleterious effects to major organs when body composition is not considered. To date, while experts worldwide acknowledge the limitations and risks of BSA dosing, no practical approach to personalizing chemotherapy dose has been developed. Ideally, body composition would be assessed by tests already routinely performed, avoiding unnecessary radiation exposure, clinic visits, discomfort to the patient, and cost. The majority of patients undergo cardiac imaging prior to chemotherapy. We hypothesized that clinical parameters routinely performed prior to chemotherapy could predict LBM in early breast cancer patients.

Method: Early stage breast cancer patients (n = 45) enrolled in the Multidisciplinary Team Intervention in Cardio-Oncology (TITAN) study underwent pre-treatment cardiac MRI, body composition (iDEXA) and laboratory (complete blood cell count and chemistry). Cardiac MRI and iDEXA are considered 'gold standard' imaging modalities, the accuracy of which allow for significantly reduced sample size.

Our modeling approach, which is novel in this area, aimed to select the best combination of parameters with the most predictive ability of total lean mass (iDEXA). The parameters included in study are: cardiac MRI metrics (LV mass, cardiac output), and laboratory parameters associated with major organ function (albumin, creatinine, bilirubin). All parameters were tested using univariate, multivariate and subset selection approach. Akaike's Information Criterion (AIC) was used to measure model quality, with lower AIC values indicating closer prediction.

Results: The univariate analysis of each parameter independently showed LV mass is most predictive with AIC 857.8, while combination of all parameter in multivariate fashion show improvement in prediction with AIC 851. The subset selection approach shows, Adjusted R2 with 4 parameters had AIC 849.14, Schwartz's information criterion (BIC) with 2 parameters had AIC 849.66 and Mallows' C Selection (Cp) model with 3 parameters had the least AIC 848.71 value (P < 0.001).

Conclusion: Our comparative analysis showed that the Cp model with 3 parameters (LV mass, cardiac output and bilirubin) has high prediction ability of LBM. This model will form the basis of a personalized formula for chemotherapy dose calculation. We expect this work to result in optimal cancer-specific outcomes while reducing short and long-term toxicities associated with necessary chemotherapy.

Citation Format: Perri MD, Singhal S, Hegadoren K, Norris C, Mackey J, Paterson I, Pituskin E. A novel comparative analysis approach to personalize chemotherapy dose in early breast cancer [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P6-13-08.

Beta blockers and improved progression-free survival in patients with advanced HER2 negative breast cancer: a retrospective analysis of the ROSE/TRIO-012 study

BACKGROUND

Recent retrospective studies suggest that beta-adrenergic blocking drugs (BB) are associated with improved outcomes in patients with a range of cancers. Although limited and discordant data suggest that BB may increase overall survival (OS) in localized breast cancer (BC), there is no information on the effects of BB in women with advanced BC.

PATIENTS AND METHODS

To explore the association between BB use and BC outcomes, we retrospectively reviewed ROSE/TRIO-012, a double-blinded, multinational phase III trial that randomized 1144 patients with HER2-negative advanced BC to first-line docetaxel in combination with ramucirumab or placebo. We compared progression-free survival (PFS), OS, overall response rate, and clinical benefit rate in patients who received BB to those who did not.

RESULTS

153/1144 (13%) patients received BB; 62% prior to enrolment and 38% began after enrolment. Median PFS in BB treated patients was longer than in patients who did not receive them (10.3 versus 8.3 months; HR 0.81; 95% CI 0.66-0.99; P = 0.038). Patients treated with BB only after enrolment had even higher median PFS (15.5 versus 8.3 months, P < 0.001). In the TNBC subset, median PFS was 13.0 months with BB, compared to 5.2 months without BB (HR 0.52; 95% CI 0.34-0.79; P = 0.002). The benefit of BB intake in PFS was independent of treatment-emergent hypertension (P = 0.476) but associated with treatment arm (P = 0.037). The test for interactions between BB and treatment arm was not significant (P = 0.276). No differences were seen in OS, overall response rate, or clinical benefit rate. A validation dataset analysis had consistent but less substantial improved outcomes for women with node positive operable breast cancer receiving BB in the BCIRG-005 trial.

CONCLUSIONS

In this exploratory analysis, BB intake was associated with significant improvement in PFS, particularly in patients with TNBC and patients not previously exposed to BB.

CLINICAL TRIAL NUMBER

NCT00703326.

Abstract P4-10-16: Long term effects of trastuzumab on cardiopulmonary and left ventricular function in women with HER2 overexpressing breast cancer

Background: Adjuvant trastuzumab (TRZ) is the standard of care for HER2-overexpressing (HER2+) early stage breast cancer (EBC) patients (PTS), with five-year survival rates exceeding 90%. However, significant cardiac toxicities are observed, with a fivefold increase in clinical heart failure (HF). Left ventricular (LV) remodeling (increased heart size and mass) is an early indicator of cardiac injury, progressing to further LV dysfunction, reduced exercise tolerance and overt HF. Therefore, effective prevention of such negative sequelae is of enormous clinical interest. As the pivotal TRZ trials assessed cardiac function with MUGA or echocardiography, insensitive modalities to evaluate LV remodeling, the long-term sequelae of TRZ remain unknown.

Objective: to determine the long term effects of trastuzumab on cardiopulmonary and left ventricular function in women with HER2 overexpressing breast cancer. Additionally as aerobic training is an effective intervention in HF PTS who adhere to prescribed exercise, a sub-analysis compared those who adhered during a 4 month exercise intervention (AEX) vs those who did not adhere (NEX).

Methods: 16 PTS (mean age 58 ± 7) who participated in an exercise intervention study during the first 4 months of TRZ therapy were recruited, with an average of 4 years elapsing since TRZ completion. Cardiopulmonary exercise (VO2peak) testing and resting cardiac MRI (CMR) were performed and compared with baseline and 4 month assessments. Adherence to exercise intevention was defined as attendance ≥80% prescribed sessions.

Results: All 16 PTS reported independent living with no limitations to ADLs. At 4 years, mean VO2peak for all PTS was 22.4 ml/kg/min (20.0 at baseline and 22.0 at 4 months). In AEX PTS, higher VO2peak persisted 4 years after cessation of therapy, 4.1 mL/kg/min higher than NEX PTS (24.9 and 20.8 mL/kg/min, respectively ). Mean LVEF for all PTS was 60 ± 6%, not significantly different from baseline or 4 months (61 ± 5 and 55 ± 4%, respectively) . Statistically significant interactions of exercise adherence to other CMR metrics were not observed.

Conclusions: Clinically significant impairment of cardiopulmonary function (equal to 14 years of aging) are present before therapy and persist in PTS four years following exposure to TRZ-based chemotherapy. This observation is consistent with our other work, and occurs on a background of normal LVEF, implying additional negative effects to other components of the oxygen cascade. As mortality risk has been shown to decrease by 17% for every 3.5 mL/kg/min difference in aerobic capacity in healthy females, these findings indicate adherence to exercise interventions during TRZ-based therapy has potentially important long-term implications.

Citation Format: Pituskin E, Paterson I, Ghosh S, Mackey JR, Haykowsky MJ. Long term effects of trastuzumab on cardiopulmonary and left ventricular function in women with HER2 overexpressing breast cancer. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P4-10-16.

Optimizing pain relief in a specialized outpatient palliative radiotherapy clinic: contributions of a clinical pharmacist

PURPOSE

Bone metastases are the most common cause of cancer pain, with palliative radiotherapy (RT) the mainstay of treatment. However, relief from RT may be delayed, incomplete, or short-lived and therefore optimized pharmacologic therapy is essential. Our objective was to describe the contribution of the clinical pharmacist (CP) to an outpatient palliative RT clinic.

METHODS

The Edmonton Symptom Assessment System, an 11-point scale for measuring nine symptoms, and other validated screening tools were administered, and a medication history performed by the CP. Baseline CP assessment also included opioid toxicity, need for supportive medications, and drug interactions. Anonymized clinical information was collected prospectively and descriptive statistics were compiled including themes of counselling performed by the CP.

RESULTS

The CP reviewed 114 patients over 140 clinic visits (01/2007-12/2008). Median age was 68.3 years, 68.4% were male and 36.8% had prostate cancer. All symptoms improved or stabilized in ≥ 80% by 4 weeks. Median pain score was 6/10 (SD 2.6) at baseline, and 2.1/10 (SD 2.4) by week 4. Average morphine equivalent daily dose was 76.8 mg at baseline and 44.5 mg at week 4. CP assessment included screening for opioid toxicity (87.9%), recommending a change in analgesic (28.9%), and liaison with the community pharmacy (17.1%). Medication counselling took place in 84.3% of visits, on bowel routine (85.6% of the time), opioids (82.2%), and hydration (40.7%).

CONCLUSIONS

The CP plays a key role in holistic patient assessment and optimization of pharmacologic therapy, contributing to improved symptom control of patients receiving palliative RT.

Abstract P3-08-04: Germline Copy Number Polymorphisms Associated with Toxicity from Adjuvant Docetaxel

Background: Chemotherapy-induced toxicities frequently limit the ability to administer full doses of cytotoxic drugs on schedule, and adversely affected quality of life. Although single nucleotide polymorphisms (SNPs) in cytochrome p-450 (CYP) and multi-drug resistance genes (MDR1) explain a proportion of interpatient variability in drug metabolism, there remains significant unexplained variability that may arise from genetic/heritable contributions; understanding these might enable more appropriate patient selection and individualized drug dosing. Copy number variations (CNVs) are structural variants (amplifications, deletions and insertions, etc.) in the genome and increasingly provide mechanistic explanations of gene dosage/disruption events and their clinical consequences. Materials and methods: We studied women (n=149) from Edmonton, Alberta, Canada who received docetaxel (Taxotere), doxorubicin (Adriamycin) and cyclophosphamide in the adjuvant setting. All subjects provided informed consent and the study was approved by the institutional research ethics board. Detailed toxicity profiles (grades 0-5) on these patients were documented and the population was genetically homogeneous (analysed by Helix Tree software using SNP markers). Our objective was to identify and analyse overall and docetaxel specific toxicities (characterized by hypersensitivity, fatigue, myalgia and neurotoxicity). We stratified patients as experiencing low toxicity (treated as controls) where the toxicity grade was between 0-2 (group 0; n=58) whereas patients experiencing grade ≥3 (cases) were classified as overall high-toxicity group (group 1; n=91). We further stratified group 1 into those experiencing docetaxel specific (group 2; n=36) and non-docetaxel related toxicities (group 3; n=54). We used Affymetrix SNP 6.0 high-throughput platform for copy number detection using germline DNA. Association analysis for CNV was carried out using Partek™ software and Fisher's exact test statistic. We compared groups 1, 2 and 3 with group 0 to detect associations with the chemotoxicity phenotype.

Results: We identified an average of 110 CNVs per sample and a majority of these identified CNVs have been mapped to the database of genomic variants. We identified 350, 195 and 184 CNVs (group 1, 2 and 3 respectively) showing significant associations with the chemotoxicity in our study population and these CNVs harbor 67, 37 and 47 annotated genes, respectively. A number of genes from signal transduction pathways as well as oncogenes and transcription factors were found associated with chemotoxicity phenotypes. Analysis of CNV signatures for Gene Ontology term enrichment identified metallochaperone activity and biological adhesion pathways as dominant ones in molecular function and biological process categories, respectively.

Conclusions: CNVs are increasingly associated with regulation of gene expression and the identified variants in this study require functional validation and independent replication as genetic determinants of docetaxel toxicity. To our knowledge, this is the first genome-wide CNV association study for chemotoxicity phenotypes.

Citation Information: Cancer Res 2010;70(24 Suppl):Abstract nr P3-08-04.

Uridine glucuronosyltransferase 2B7 pharmacogenetics predicts epirubicin clearance and myelosuppression

2504

Background: Epirubicin (EPI) is widely used to treat breast cancer. EPI is predominantly metabolized by uridine glucuronosyltransferase (UGT) 2B7 to inactive glucuronides. We previously showed that a UGT enhancer single nucleotide polymorphism (SNP) at position -161 T to C correlated with rates of morphine glucuronidation. Methods: We performed a prospective pharmacogenetic study of effects of this SNP on EPI metabolism in M0 breast cancer patients (PTS) receiving adjuvant or neoadjuvant FEC100 (5-fluorouracil 500 mg/m2, EPI 100 mg/m2 and cyclophosphamide 500 mg/m2) given every 3 wks. PTS with ALT and AST ≤ upper limit of normal (ULN), a total bilirubin ≤ ULN, and normal renal and cardiac function were eligible. EPI levels were drawn at approximately 1 and 24 hrs. Cycle 1 toxicities were assessed using NCIC CTG toxicity criteria. Results: 123 PTS entered this study, mean (range): age 51 (28 - 74), sex 122 F/ 1 M, baseline AST 24 U/L (13–66), ALT 22 U/L (5–90), bilirubin 8 μmol/L (2–26), creatinine 74 μmol/L (50 - 126). PTS were genotyped using Pyrosequencing; 26 PTS were TT homozygotes, 59 were CT heterozygotes, and 33 were CC homozygotes. 5 PTS could not be genotyped. A three compartment population pharmacokinetic model in NONMEM V 1.1 for EPI was used incorporating all PTS. The baseline objective function was 1817, and inclusion of genotype significantly improved the objective function to 1764; CC genotype PTS had decreased EPI clearance 88.9 L/hr compared to CT/TT genotype PTS 129 L/hr, p<0.001. Rates of first cycle grade 3/4 leucopenia were 78% in CC PTS and 48% in CT/TT PTS; consistent with the pharmacokinetic analysis. Conclusions: A SNP in UGT 2B7 is common and appears to predicts EPI clearance and myelosuppresion in non-metastatic breast cancer PTS and may form the basis for a method to individualize EPI treatment.

No significant financial relationships to disclose.

The addition of an audiocassette recording of a consultation to written recommendations for patients with advanced cancer: A randomized, controlled trial

BACKGROUND

Communication between physicians and advanced cancer patients is frequently difficult. Patients often report poor levels of satisfaction with communication. The purpose of this study was to assess the impact on patients' recall of and overall satisfaction with their consultation by the addition of an audiocassette recording of a consultation to written recommendations.

METHODS

Sixty patients with advanced cancer were randomized to either receive a tape recording of their consultation or receive no tape in addition to written recommendations in this randomized, double-blind trial. Patients gave their global ratings of the clinic, were tested for their recall of information given, and responded to questions about the utilization and role of the cassette in influencing family communication.

RESULTS

The addition of the audiocassette to written communications significantly increased patient satisfaction with the clinic (8.7 +/- 1.7 vs. 7.7 +/- 2.0 on a scale of 0-10; P = 0.04) and significantly improved recall of the information given during the consultation (88% +/- 8.7% vs. 80% +/- 15.5%; P = 0.02). Patients expressed a high level of satisfaction with the audiocassette. Patients listened to the tape a median of 2 (range 1-4) times, whereas family members and friends listened to the cassette a median of 2 (range 1-3) times.

CONCLUSIONS

The addition of an audiocassette recording of an outpatient consultation to written recommendations for patients with advanced cancer is capable of increasing both the overall patient recall of the visit and satisfaction with the outpatient clinical setting. Patients expressed a high level of satisfaction with the audiocassette.

A randomized controlled trial of local injections of hyaluronidase versus placebo in cancer patients receiving subcutaneous hydration

BACKGROUND

Most cancer patients develop reduced oral intake or dehydration before death. Subcutaneous hydration (SCH) can be safe and effective. SCH is frequently administered using hyaluronidase to improve fluid absorption. The objective of this study was to determine the effects of hyaluronidase on patient comfort during bolus SCH.

PATIENTS AND METHODS

Twenty-one cancer patients requiring parenteral hydration were administered a 500 cc bolus of two-thirds dextrose (5%) and one-third normal saline solution subcutaneously at 08:00 and 16:00 hours during day 1 and day 2. On day 1 patients were randomized on a double-blind basis to receive 150 units of hyaluronidase versus placebo as a bolus into the site of infusion immediately before starting each one-hour infusion. During day 2 patients were crossed over to receive the alternate treatment at a new infusion site. Visual analogue scales (0 = best, 100 = worst) for pain and swelling at the infusion site were completed by each patient. In addition, investigators blindly assessed the site of infusion for the presence of edema, rash, and leakage.

RESULTS

No significant differences were observed for pain, swelling, edema, rash or leakage between the placebo and the hyaluronidase scores. After completion of the two days of the study, patients blindly chose hyaluronidase in 1 (5%) case, placebo in 5 (24%) cases, and no preference in 15 (71%) cases (P < 0.01). There was no treatment or interaction effect for pain, except for a period effect (P = 0.045) for the morning bolus administration. There were no treatment, period, or interaction effects for any of the other variables.

CONCLUSIONS

Our results suggest that hyaluronidase is not necessary for routine bolus SCH. It may still be useful for a minority of patients who are not able to tolerate infusion well due to swelling or pain.

Telephone triage in acute oncology

Cancer patients experience a variety of complex problems over the course of their illness. Shorter hospital stays and fewer inpatient beds have created additional challenges for patients diagnosed with cancer, as they often continue complicated treatment protocols as outpatients. As one result, patients and their families often telephone their physician or cancer clinic to seek advice.

Randomized, double-blind, cross-over trial comparing safety and efficacy of oral controlled-release oxycodone with controlled-release morphine in patients with cancer pain

PURPOSE

Use of oxycodone for chronic cancer pain has been hampered by its short elimination half-life. This study was designed to compare the efficacy and safety of controlled-release formulations of oxycodone and morphine for cancer pain.

PATIENTS AND METHODS

Thirty-two adult patients with cancer pain and a > or = 3-day history of stable analgesia with oral opioids provided written informed consent and were randomized to controlled-release oxycodone or controlled-release morphine for 7 days. To blind the study using available tablet strengths, the dose ratio of oxycodone to morphine was set at 1:1.5. On day 8, patients were crossed over to the alternate drug for 7 days. Pain intensity was assessed using a visual analog scale (VAS 0 to 100 mm) and a categorical scale (CAT 0 to 4). Side effects were assessed using a checklist (four-point categorical severity) and a nondirected questionnaire. Patients and investigators made blinded global ratings of efficacy and treatment preference.

RESULTS

Twenty-three patients completed the study (10 men, 13 women). The VAS and CAT scores were (mean+/-SD) 23+/-21 and 1.2+/-0.8 on controlled-release oxycodone, and 24+/-20 (P=.43) and 1.3+/-0.7 (P=.36) on controlled-release morphine. No period or carryover effect was detected. There were no significant differences in adverse effects (P=.40) or ratings of efficacy and preference. The median oxycodone/morphine dose ratio was 1.5 and the maximum was 2.3.

CONCLUSION

Controlled-release oxycodone is as safe and effective as controlled-release morphine in the treatment of cancer pain.