Direct-to-participant recruitment of mothers and infants: A strategic approach during challenging pandemic times

Under traditional circumstances, most clinical trials rely on in-person operations to identify, recruit, and enroll study participants and to complete study-related visits. During unusual circumstances, such as the COVID-19 pandemic, the typical clinical trial model is challenged and forced to explore alternative approaches to implementing study recruitment, participant enrollment, and data collection strategies. One such alternative is a direct-to-participant approach which leverages electronic resources and relevant technological devices (e.g., smart phones) available to researchers and patients. This approach functions under the assumption that a participant has access to a device that connects to the internet such as a smart phone, tablet, or computer. Researchers are then able to transition a typical paper-based, in-person model to an electronic-based, siteless, remote study. This article describes the challenges clinicians and researchers faced when implementing a direct-to-participant study approach during the COVID-19 pandemic. The lessons learned during this study of infant populations could help increase efficiency of future trials, specifically, by lessening the burden on participants and clinicians as well as streamlining the process for enrollment and data collection. While direct-to-adult participant recruitment is not a novel approach, our findings suggest that studies attempting to recruit the infant population may benefit from such a direct-to-participant approach.

Parental occupations at birth and risk of adult testicular germ cell tumors in offspring: a French nationwide case-control study

Background

Testicular germ cell tumors (TGCT) are the most frequent cancer in young men in developed countries. Parental occupational exposures during early-life periods are suspected to increase TGCT risk. The objective was to estimate the association between parental occupations at birth and adult TGCT.

Methods

A case-control study was conducted, including 454 TGCT cases aged 18-45 from 20 French university hospitals, matched to 670 controls based on region and year of birth. Data collected from participants included parental jobs at birth coded according to the International Standard Classification of Occupation-1968 and the French nomenclature of activities-1999. Odds ratios (OR) for TGCT and 95% confidence intervals (CI) were estimated using conditional logistic regression, adjusting for TGCT risk factors.

Results

Paternal jobs at birth as service workers (OR = 1.98, CI 1.18-3.30), protective service workers (OR = 2.40, CI 1.20-4.81), transport equipment operators (OR = 1.96, CI 1.14-3.37), specialized farmers (OR = 2.66, CI 1.03-6.90), and maternal jobs as secondary education teachers (OR = 2.27, CI 1.09-4.76) or in secondary education (OR = 2.35, CI 1.13-4.88) were significantly associated with adult TGCT. The risk of seminoma was increased for the above-mentioned paternal jobs and that of non-seminomas for public administration and defence; compulsory social security (OR = 1.99, CI 1.09-3.65); general, economic, and social administration (OR = 3.21, CI 1.23-8.39) for fathers; and secondary education teacher (OR = 4.67, CI 1.87-11.67) and secondary education (OR = 3.50, CI 1.36-9.01) for mothers.

Conclusion

Some paternal jobs, such as service workers, transport equipment operators, or specialized farmers, and maternal jobs in secondary education seem to be associated with an increased risk of TGCT with specific features depending on the histological type. These data allow hypotheses to be put forward for further studies as to the involvement of occupational exposures in the risk of developing TGCT, such as exposure to pesticides, solvents, or heavy metals.

Rationale for Prostate-Specific-Membrane-Antigen-Targeted Radionuclide Theranostic Applied to Metastatic Clear Cell Renal Carcinoma

Prostate-specific membrane antigen (PSMA), whose high expression has been demonstrated in metastatic aggressive prostate adenocarcinoma, is also highly expressed in the neovessels of various solid tumors, including clear cell renal cell carcinoma (ccRCC). In the VISION phase III clinical trial, PSMA-targeted radioligand therapy (PRLT) with lutetium 177 demonstrated a 4-month overall survival OS benefit compared to the best standard of care in heavily pretreated metastatic prostate cancer. Despite the improvement in the management of metastatic clear cell renal cell carcinoma (mccRCC) with antiangiogenic tyrosine kinase inhibitor (TKI) and immunotherapy, there is still a need for new treatments for patients who progress despite these drugs. In this study, we discuss the rationale of PRLT applied to the treavtment of mccRCC.

Testicular germ cell tumour risk by occupation and industry: a French case-control study - TESTIS

OBJECTIVE

Testicular germ cell tumours (TGCT) are the most common cancer in men of working age and its incidence has increased notably over the past 40 years. Several occupations have been identified as potentially associated with TGCT risk. The aim of this study was to further explore the relationship between occupations, industries and TGCT risk in men aged 18-45 years.

METHODS

The TESTIS study is a multicenter case-control study conducted between January 2015 and April 2018 in 20 of 23 university hospital centers in metropolitan France. A total of 454 TGCT cases and 670 controls were included. Full job histories were collected. Occupations were coded according to the International Standard Classification of Occupation 1968 version (ISCO-1968) and industry according to the 1999 version of Nomenclature d'Activités Française (NAF-1999). For each job held, ORs and 95% CIs were estimated using conditional logistic regression.

RESULTS

A positive association was observed between TGCT and occupation as agricultural, animal husbandry worker (ISCO: 6-2; OR 1.71; 95% CI (1.02 to 2.82)), as well as salesman (ISCO: 4-51; OR 1.84; 95% CI (1.20 to 2.82)). An increased risk was further observed among electrical fitters and related, electrical and electronics workers employed for 2 years or more (ISCO: 8-5; OR≥2 years 1.83; 95% CI (1.01 to 3.32)). Analyses by industry supported these findings.

CONCLUSIONS

Our findings suggest that agricultural, electrical and electronics workers, and salesmen workers experience an increased risk of TGCT. Further research is needed to identify the agents or chemicals in these high-risk occupations which are relevant in the TGCT development.

TRIAL REGISTRATION NUMBER

NCT02109926.

Approaches for enhancing the informativeness and quality of clinical trials: Innovations and principles for implementing multicenter trials from the Trial Innovation Network

One challenge for multisite clinical trials is ensuring that the conditions of an informative trial are incorporated into all aspects of trial planning and execution. The multicenter model can provide the potential for a more informative environment, but it can also place a trial at risk of becoming uninformative due to lack of rigor, quality control, or effective recruitment, resulting in premature discontinuation and/or non-publication. Key factors that support informativeness are having the right team and resources during study planning and implementation and adequate funding to support performance activities. This communication draws on the experience of the National Center for Advancing Translational Science (NCATS) Trial Innovation Network (TIN) to develop approaches for enhancing the informativeness of clinical trials. We distilled this information into three principles: (1) assemble a diverse team, (2) leverage existing processes and systems, and (3) carefully consider budgets and contracts. The TIN, comprised of NCATS, three Trial Innovation Centers, a Recruitment Innovation Center, and 60+ CTSA Program hubs, provides resources to investigators who are proposing multicenter collaborations. In addition to sharing principles that support the informativeness of clinical trials, we highlight TIN-developed resources relevant for multicenter trial initiation and conduct.

Real world data of diagnosis, survival, and treatment outcomes in patients with metastatic non clear cell renal cell carcinoma

INTRODUCTION

Metastatic non clear cell renal cell carcinoma (nccRCC) is an heterogenous group, usually excluded from phase 3 trials. We report real life data of prognosis and systemic management of those patients.

METHODS

We retrospectively included 102 metastatic nccRCC patients (unspecified papillary, n = 10; type 1 and 2 papillary n = 10 and n = 32; translocation RCC, n = 9; chromophobe, n = 14; collecting duct, n = 14) treated between 2006 and 2020. Objective response rate (ORR), progression-free survival (PFS) and overall survival (OS) were evaluated.

RESULTS

Among patients who underwent pathological review, 40.8% presented a complete histological discordance. First line treatments were mainly tyrosine kinase inhibitor (60.8%), combination including immunotherapy (7.8%) or combination of chemotherapy (13.7%). Median ORR ranged from 0% in unspecified papillary RCC to 42.9% in type 1 papillary RCC. Median PFS ranged from 2.9 months in collecting duct carcinoma to 10.9 months in type 1 papillary RCC. Median OS ranged from 6.8 months in collecting duct carcinoma to 29.1 months in MiT family translocation RCC. Thirty (29.4%) patients were included in a treatment trial during their treatment course.

CONCLUSION

Metastatic nccRCC patients have variable prognosis due to heterogeneity of histological subtypes. Their diagnosis and access to therapeutic innovation remain suboptimal. Dedicated prospective trials are needed.

P02-16 Implementation of a program based on adapted physical activity and recommendations for second cancers prevention for adolescents and young adults with cancer: PREVAPAJA study

Background/Objectives

About 1,000,000 new cases of cancer in Adolescent and Young Adults (AYAs) are diagnosed annually worldwide. . While their long term survival is about 80%, they are six times more likely to develop a second primary cancer (SPC) compared to their peers. This risk is multifactorial and depends on the type of first cancer, treatment received and prevalence of risk factors. PREVAPAJA aimed to implement a clinical program based on physical activity (PA) and cancer prevention recommendations for AYAs with cancer at Centre Léon Bérard-AYAs Department.

Methods

The study was conducted at Leon Berard Comprehensive Cancer Centre among patients aged 15-25 years. AYAs attended PA sessions during the active treatment period and were individually informed on SPC risk prevention. PA, sedentary, anthropometrics, quality of life and fatigue were assessed at baseline (T1) and at the end of treatment (T2). PA level and intention of changes in health behaviors were assessed by phone 1 year after T1.

Results

68 AYAs (median age=19 years) were enrolled in 2016-2017). The results showed an improvement in PA level during and at distance of the intervention, with also a reduction of sitting time. Fatigue decreased between T1 and T2 (p>0.003) and overall quality of life improved significantly between T1 and T2 (p>0.001).

Conclusions

This study showed the feasibility of implementing a clinical program based on PA intervention and cancer prevention recommendations for AYAs with cancer. It responded to AYAs' needs for support and discussions regarding PA recommendations and ways to prevent SPC. Beneficial outcomes of this program should encourage to systematically proposing PA intervention in combination with information exchanges with AYAs with cancer.

Domestic use of pesticides during early periods of development and risk of testicular germ cell tumors in adulthood: a French nationwide case-control study

BACKGROUND

Testicular germ cell tumours (TGCT) are the most frequent cancers in young men in developed countries and their incidence rate has doubled worldwide over the past 40 years. Early life exposures to pesticides are suspected to increase TGCT risk. Our research aimed at estimating adult TGCT risk associated with parental domestic use of pesticides during early periods of child development.

METHODS

We conducted a case-control study of 304 TGCT cases, aged 18-45 years old, recruited in 20 French university hospitals, and 274 controls frequency-matched on hospital and birth year. Participants' mothers provided information on their domestic use of pesticides from 1 year before start of pregnancy to 1 year after their son's birth, for gardening activities, treatment of indoor plants, pets, wood and mold, and pest control. Odds ratios (OR) for TGCT (overall and by histological subtype) and 95% confidence intervals (CI) were estimated using conditional logistic regression.

RESULTS

Prevalence of reported domestic use of pesticides was 77.3% for insecticides, 15.9% for fungicides and 12.1% for herbicides. While no association was found for any use of insecticides (OR = 1.27, CI = 0.80-2.01) or herbicides (OR = 1.15, CI = 0.67-2.00), elevated risks of TGCT overall (OR = 1.73, CI = 1.04-2.87) and non-seminoma subtype (OR = 2.44, CI = 1.26-4.74) were observed for any use of fungicides. When specific purposes were examined, using fungicides and/or insecticides for woodwork (OR = 2.35, CI = 1.06-5.20) and using insecticides on cats and dogs (OR = 1.95, CI = 1.12-3.40) were associated with increased risk of non-seminoma subtype. We found no association for seminoma subtype.

CONCLUSIONS

Although recall bias may partially explain the elevated ORs, our study provides some evidence of a positive association between domestic use of pesticides during early periods of development, particularly fungicides and risk of adult TGCT and non-seminoma. Given the common domestic use of pesticides in France, further research on TGCT risk is warranted.

Implementation of a Prevention Program Based on Adapted Physical Activity and Recommendations for Adolescents and Young Adults with Cancer: PREVAPAJA Study

Purpose: In Europe, 20,000 Adolescent and Young Adults (AYAs) aged 15-25 years are diagnosed with cancer annually. Although prognosis is good, AYA cancer survivors are at greater risk of second primary cancers, cardiovascular disease, and various long-term effects. Benefits of physical activity (PA) in AYAs reported in current studies remain difficult to generalize; none has been performed in France. This single-arm intervention study tested the feasibility of combining hospital-based supervised and home-based unsupervised physical activity sessions (PAS) and providing cancer prevention recommendations for AYAs. Methods: The AYAs attended PAS concomitant to treatment and participated in one face-to-face prevention interview. PA (international physical activity questionnaire), 6-min walk distance (6MWD), sedentarity, anthropometrics, quality of life (QoL), and fatigue were assessed at baseline (T1) and end of intervention (T2). PA, satisfaction and cancer prevention behaviors were assessed 1 year after baseline (T3). Results: Fifty-nine AYAs (mean 19 years) participated in the study. Acceptability and attrition were 80% and 12%, respectively. Between T1 and T2, 6MWD and global QoL improved (p < 0.001), and fatigue decreased (p = 0.003). Total PA improved and sitting time decreased (p < 0.001) overall (T1-T3). Assessment at T3 showed interindividual differences in how participants considered risk factors (e.g., more attention to PA, UV exposures, nutrition). Conclusion: Combined supervised and unsupervised home-based PAS in AYAs undergoing cancer treatment is acceptable and feasible. The program contributes to maintaining and improving physical fitness and QoL, while reducing fatigue and other cancer and treatment symptoms. Larger randomized controlled trials are needed to confirm these results.

Immune checkpoint inhibitor treatment of a first cancer is associated with a decreased incidence of second primary cancer

Background

Second primary cancers (SPCs) are diagnosed in over 5% of patients after a first primary cancer (FPC). We explore here the impact of immune checkpoint inhibitors (ICIs) given for an FPC on the risk of SPC in different age groups, cancer types and treatments.

Patients and methods

The files of the 46 829 patients diagnosed with an FPC in the Centre Léon Bérard from 2013 to 2018 were analyzed. Structured data were extracted and electronic patient records were screened using a natural language processing tool, with validation using manual screening of 2818 files of patients. Univariate and multivariate analyses of the incidence of SPC according to patient characteristics and treatment were conducted.

Results

Among the 46 829 patients, 1830 (3.9%) had a diagnosis of SPC with a median interval of 11.1 months (range 0-78 months); 18 128 (38.7%) received cytotoxic chemotherapy (CC) and 1163 (2.5%) received ICIs for the treatment of the FPC in this period. SPCs were observed in 7/1163 (0.6%) patients who had received ICIs for their FPC versus 437/16 997 (2.6%) patients receiving CC and no ICIs for the FPC versus 1386/28 669 (4.8%) for patients receiving neither CC nor ICIs for the FPC. This reduction was observed at all ages and for all histotypes analyzed. Treatment with ICIs and/or CC for the FPC are associated with a reduced risk of SPC in multivariate analysis.

Conclusion

Immunotherapy with ICIs alone and in combination with CC was found to be associated with a reduced incidence of SPC for all ages and cancer types.

•

From 2013 to 2018, 3.9% of the 46 829 patients diagnosed with a first cancer presented with an SPC.

•

Treatment of the first cancer with ICIs was associated with a major reduction of SPC.

•

CC given for an FPC was also associated with a lower magnitude of reduction of SPC.

•

There were no SPC in cancer patients treated with ICIs in the localized phase of their first cancer.

ECCO Essential Requirements for Quality Cancer Care: Prostate cancer

BACKGROUND

ECCO Essential Requirements for Quality Cancer Care (ERQCC) are written by experts representing all disciplines involved in cancer care in Europe. They give oncology teams, patients, policymakers and managers an overview of essential care throughout the patient journey.

PROSTATE CANCER

Prostate cancer is the second most common male cancer and has a wide variation in outcomes in Europe. It has complex diagnosis and treatment challenges, and is a major healthcare burden. Care must only be a carried out in prostate/urology cancer units or centres that have a core multidisciplinary team (MDT) and an extended team of health professionals. Such units are far from universal in European countries. To meet European aspirations for comprehensive cancer control, healthcare organisations must consider the requirements in this paper, paying particular attention to multidisciplinarity and patient-centred pathways from diagnosis, to treatment, to survivorship.

Phase I dose-escalation study of pazopanib combined with bevacizumab in patients with metastatic renal cell carcinoma or other advanced tumors

BACKGROUND

Vascular endothelial growth factor (VEGF) directed therapies are being used in a large number of advanced tumors. Metastatic renal cell carcinoma (mRCC) is highly dependent on the VEGF pathway; VEGF receptor (VEGFR) tyrosine kinase inhibitors (TKI) and humanized VEGF monoclonal antibody have been registered for clinical use in advanced renal cell carcinoma. The VEGFR TKI, pazopanib, with a rather manageable toxicity profile, was preferred to sunitinib by mRCC patients. We investigate the combination of pazopanib and bevacizumab to determine the maximum tolerated dose (MTD) in mRCC and other advanced solid tumors.

METHODS

In this bicentric phase I trial with a 3 + 3 + 3 dose-escalation design, patients received oral pazopanib once daily plus intravenous infusion of bevacizumab every 2 weeks from D15, at one of the four dose levels (DL) planned according to the occurrence of dose limiting toxicities (DLT). 400 and 600 mg pazopanib were respectively combined with 7.5 mg/kg bevacizumab in DL1 and DL2, and 600 and 800 mg pazopanib with 10 mg/kg bevacizumab in DL3 and DL4. Tumor response was evaluated every 8 weeks. Blood samples were assayed to investigate pazopanib pharmacokinetics.

RESULTS

Twenty five patients including seven mRCC were enrolled. Nine patients received the DL1, ten received the DL2. No DLT were observed at DL1, five DLT at DL2, and 3 DLT in the six additional patients who received the DL1. A grade 3 microangiopathic hemolytic anemia syndrome was observed in four (16%) patients. Five (22%) patients achieved a partial response. The mean (range) plasmatic concentrations of 400 and 600 pazopanib were respectively 283 (139-427) and 494 (227-761) μg.h/mL at Day 1, and 738 (487-989) and 1071 (678-1464) μg.h/mL at Day 15 i.e. higher than those previously reported with pazopanib, and were not directly influenced by bevacizumab infusion.

CONCLUSIONS

The combination of pazopanib and bevacizumab induces angiogenic toxicity in patients without any pre-existing renal or vascular damage. Even if a marginal efficacy was reported with five (22%) patients in partial response in different tumor types, the toxicity profile compromises the development of this combination.

TRIAL REGISTRATION

The study was retrospectively registered on ClinicalTrials.gov (number NCT01202032 ) on 2010, Sept 14th.

Management of Febrile Neutropenias in Adolescents and Young Adults: A Cost-Minimization Analysis Between Adult Versus Pediatric Units

PURPOSE

Management of adolescents and young adults (AYAs) differs between adult and pediatric units, especially regarding febrile neutropenia (FN). In our previous study, we found that AYAs treated in adult units were significantly less hospitalized for FN than in pediatric units, without difference in morbimortality. The objective of this work was to assess the economic impact of these practices.

METHODS

This study retrospectively collected data from the medical records of AYAs treated at the Comprehensive Cancer Center Léon Bérard, Lyon, France, in the Euro-E-W-I-N-G99 protocol between September 1, 2000 and May 31, 2013. We focused on FN occurring after VIDE (vincristine, ifosfamide, doxorubicin, etoposide) courses. Costs were calculated using a micro-costing technique from the hospital's perspective (in 2014-Euro); the time horizon was the induction period. Multivariate analyses were performed on the total cost and cost of FN. Uncertainty was captured by sensitivity analyses.

RESULTS

Forty-four AYAs (18 in the adult sector, 26 in the pediatric sector) received 260 courses of VIDE. Mean cost of care was €37,544 in the pediatric sector, including €11,948 (32%) for FN (€11,851 in hospitalization), versus €34,677 in the adult sector, including €6,143 (18%) for FN (€5,789 in hospitalization). Cost for FN was significantly higher in pediatric units (difference in mean cost of €5,830 per patient, 95% bootstrapped confidence interval [1,939.1; 10,028.9]). In multivariate analysis, the only factor significantly influencing this cost difference was the sector of care. The most sensitive parameter was the unit cost of conventional hospitalization.

CONCLUSION

These results support the adult sector strategy, in agreement with the results of our first work showing comparable effectiveness.

Haemoglobin level increase as an efficacy biomarker during axitinib treatment for metastatic renal cell carcinoma: a retrospective study

Background

Axitinib is used after failure of first line treatment for metastatic renal cell carcinoma (mRCC). A known side effect is the increase of haemoglobin level (HbL) during treatment with a suspected correlation with better outcome. Our objective was to examine whether HbL increase during the first three months of axitinib treatment is associated with better prognosis.

Methods

Retrospective multicentre analysis including patients with mRCC treated with axitinib for at least three months from 2012 to 2014. Progression-free survival (PFS) was analysed by a Cox model according to gender, International Metastatic Renal Cell Carcinoma Database Consortium (IMDC) prognostic score, high blood pressure (hBP), and maximum increase in HbL within the first three months of treatment.

Results

Ninety-eight patients were analysed (71% men; median age at treatment initiation: 62 years; IMDC: 24%, 50%, and 26% in the favourable, intermediate, and poor-risk group, respectively). Patients received axitinib for a median of 8 months. During the first three months, the median increase of HbL was +2.3 g/dL (−1.1; 7.2). Fifty-six (57%) patients developed hBP.

In multivariate analysis, after adjustment for performance status (P < 0.0001) and gender (P = 0.0041), the combination of HbL increase ≥2.3 g/dL and any grade hBP was significantly associated with longer PFS (HR = 0.40, 95%CI [0.24; 0.68]).

Conclusions

Early HbL increase during axitinib treatment combined with hBP is an independent predictive factor of PFS. These results require validation in a prospective setting.

Urachal Carcinoma with Choroidal, Lung, Lymph Node, Adrenal, Mammary, and Bone Metastases and Peritoneal Carcinomatosis Showing Partial Response after Chemotherapy Treatment with a Modified Docetaxel, Cisplatin and 5-Fluorouracil Regimen

Urachal carcinoma (UC) is a rare tumor mainly affecting middle-aged males. Metastases occur most frequently in lymph nodes and the lungs. There are no standard adjuvant and metastatic treatments. We report the case of a 36-year-old female with UC treated with partial cystectomy who relapsed 3 years after surgery with left choroidal, lung, mediastinal lymph node, right adrenal, mammary, and bone metastases as well as peritoneal carcinomatosis. She obtained a partial response after 10 cycles of chemotherapy with a modified docetaxel, cisplatin and 5-fluorouracil (mTPF) regimen. This is the first report on the use of the mTPF regimen in UC and on the existence of choroidal, adrenal, and mammary metastases.

Tivozanib: a novel VGFR inhibitor for kidney cancer

Treatment of kidney cancer has changed over the past 10 years with the approval of several targeted agents. These drugs are given on a long term base and toxicity is an issue for most patients. Despite improvement compared to immunotherapy, most patients will progress on these drugs. There is a need for more portent and better tolerated drugs. Tivozanib is a potent pan VEGR specific inhibitor. In this phase II trial it gave interesting results with an overall median PFS throughout the study of 11.7 months (95% CI: 8.3-14.3 months) and an overall objective response rate of 24% (95% CI: 19-30%). “Off”-target toxicity was mild.

Brain Metastases in Patients With Germ Cell Tumors: Prognostic Factors and Treatment Options--An Analysis From the Global Germ Cell Cancer Group

PURPOSE

To define characteristics, treatment response, and outcomes of men with brain metastases (BM) from germ cell tumors (GCT).

PATIENTS AND METHODS

Data from 523 men with BM from GCT were collected retrospectively from 46 centers in 13 countries by using standardized questionnaires. Clinical features were correlated with overall survival (OS) as the primary end point.

RESULTS

BM were present at initial diagnosis in 228 men (group A) and at relapse in 295 men (group B). OS at 3 years (3-year OS) was superior in group A versus group B (48% v 27%; P < .001). Multiple BM and the presence of liver or bone metastasis were independent adverse prognostic factors in both groups; primary mediastinal nonseminoma (group A) and elevations of α-fetoprotein of 100 ng/mL or greater or of human chorionic gonadotropin of 5,000 U/L or greater (group B) were additional independent adverse prognostic factors. Depending on these factors, the 3-year OS ranged from 0% to 70% in group A and from 6% to 52% in group B. In group A, 99% of patients received chemotherapy; multimodality treatment or high-dose chemotherapy was not associated with statistically improved survival in multivariable analysis. In group B, only 54% of patients received chemotherapy; multimodality treatment was associated with improved survival compared with single-modality therapy (hazard ratio, 0.51; 95% CI, 0.36 to 0.73; P < .001), as was high-dose compared with conventional-dose chemotherapy (hazard ratio, 0.41; 95% CI, 0.24 to 0.70; P = .001).

CONCLUSION

Men with BM from GCT have poor OS, particularly if additional risk factors are present. High-dose chemotherapy and multimodality treatment seemed to improve survival probabilities in men with BM at relapse.

[Management of febrile neutropenias in adolescents and young adults: Differences of practice between adult and pediatric units]

INTRODUCTION

Adolescents and young adults (AYA, 15-25years old) with cancer are treated either in adult or pediatric units. Management of febrile neutropenia (FN) is different between these units. Monitoring rules and indications of hospitalization are often stricter in pediatrics. This study evaluates if these differences influence the occurrence of complications.

METHODS

The medical records of AYA patients treated in our institution in the Euro-E-W-I-N-G99 protocol between 01/09/2000 and 31/05/2013 were retrospectively analyzed. We studied febrile neutropenias occurring after VIDE courses, during the induction period.

RESULTS

Forty-four patients were included (18 from adult units, 26 from pediatrics). Median age at inclusion was 19.6. After 260 courses of VIDE, we observed a median of 2 FN per adult and 3 per pediatric patient (P=0.2). Hospitalization occurred in median 1.5 time per adult and 3 per pediatric patient (P=0.008). Median cumulated length of stay was 4.5days for adults versus 16 days for pediatric patients (P=0.008). There was no significant difference for survival, number of documented infections, transfusions, dose modifications, chemotherapy delay, need for intensive care, infection after post-induction surgery.

CONCLUSION

AYA treated in adult services are less frequently hospitalized for FN with no difference in morbi-mortality. Homogeneous recommendations could be made for these patients, whatever the units they are treated in.

[Life style and occupational factors and prevention of second primary cancers after childhood and adolescent cancer: Current state of knowledge]

CONTEXT

Survival of children, adolescents and young adults treated for cancer increased with improved treatments. But there is still an increased risk of second primary cancer (SPC) in the long term compared to the population of the same age, especially related to treatments. A reflection on the follow-up of this population and the prevention of SPC is an important issue.

OBJECTIVES

To perform a synthesis of the available literature on SCP risk factors, related risk behaviors, occupational exposures and prevention strategies.

METHODS

Literature search on PubMed from the following equation: "cancer [Tiab] AND young adult [Tiab] or teen [Tiab] or childhood [Tiab] AND prevention [Tiab] AND survivors [Mesh term]".

RESULTS

Twenty-seven articles were included in this synthesis. Children, adolescents and young adults have similar risk behaviors than those of their peers regarding tobacco, diet and sun exposure; however, they have lower physical activity. There are few studies on prevention strategies focused on this population. Results of available studies remain inconclusive. No publication was found in relation to occupational exposure and risk of second cancer.

CONCLUSIONS

Children, adolescents and young adults treated for cancer are a population at risk and require long-term follow-up and the implementation of effective prevention strategies tailored to this population.

Management of prostate cancer in older patients: updated recommendations of a working group of the International Society of Geriatric Oncology

In 2010, the International Society of Geriatric Oncology (SIOG) developed treatment guidelines for men with prostate cancer who are older than 70 years old. In 2013, a new multidisciplinary SIOG working group was formed to update these recommendations. The consensus of the task force is that older men with prostate cancer should be managed according to their individual health status, not according to age. On the basis of a validated rapid health status screening instrument and simple assessment, the task force recommends that patients are classed into three groups for treatment: healthy or fit patients who should have the same treatment options as younger patients; vulnerable patients with reversible impairment who should receive standard treatment after medical intervention; and frail patients with non-reversible impairment who should receive adapted treatment.

[Testicular germ cell tumours and early exposures to pesticides: The TESTEPERA pilot study]

Testicular germ cell tumors (TGCT) represent the most frequent cancer in men aged between 15 and 45 years. Current hypotheses are focusing on environmental exposures occurring during prenatal periods. However, very few studies have explored intra-uterine environmental exposure related to TGCT. TESTEPERA is a pilot case-control study aiming to determine the effectiveness of different recruitment approaches in the French context and to verify our ability to collect relevant data on their prenatal periods. Between 2011 and 2012, 150 male subjects were contacted in the Rhône-Alpes region (58 cases from a cancer center and 92 controls from a regional maternity). Participation rate varied from 33% for cases diagnosed in 2008 vs 68% for cases diagnosed in 2010. Participation rate of controls varied depending on modalities of contact (13% for face-to-face recruitment; 0% for contact by phone only; 50% for face-to-face contact with phone reminder). Data collection allowed precise job identification and geolocation of subjects' addresses. Precision of geolocation was dependent upon the level of urbanization (p < 0.001) but not on the time period (p = 0.52). Our results support the feasibility of a case-control study focusing on the relation between TGCT and environmental pesticide exposures during early and later life.

Cancer in the elderly in an equatorial area: French Guiana

Little information is available on the management of cancer in equatorial areas, and specifically the management of elderly cancer patients. We have retrospectively reviewed the clinical files of 71 patients older than 70 years with cancer who were treated in the Cayenne Hospital in French Guiana. The population is that of an equatorial country with the health organization of a European country. We found that oncogeriatric evaluation was feasible but is far from being routinely used. The selection of screening tools of frailty is likely to be useful in making decisions for these patients. However, specific problems are emerging: cultural mediation; low income; illegal immigrants; comorbidities; specific tropical diseases; and the incidence of HIV, human T-lymphotropic virus Type 1 and hepatitis infections. This led us to expand the study to the whole cancer patient population and to implement specific information in the database used for follow-up. These preliminary observations should be relevant for other countries.

Addition of Bevacizumab to Temsirolimus in Kidney Cancer Patients

Treatment of metastatic kidney cancer has changed dramatically in the past years with the use of VEGF-targeted therapies and mTOR inhibitors. However, resistance occurs. We report here two cases of patients who benefited, both on disease control and side effects, from the addition of bevacizumab to temsirolimus, after progression on the mTOR inhibitor alone.

Intra- and interobserver reproducibility of interpretation of immunohistochemical stains of prostate cancer

The evaluation of immunohistochemistry (IHC) is usually semiquantitative, and thus subject to observer variability. We analyzed the reproducibility of different IHC measures. Fifty TMA cores of prostate cancer were stained for PDX-1, a transcription factor overexpressed in the cytoplasm of prostate cancer cells. The strongest intensity was scored 0-3 and 1-3 was used for extent (1-33%, 34-66%, and 67-100%). The stains were evaluated twice by four observers: two genitourinary pathologists, and two medical doctors with no formal pathology training. Staining intensity was also measured with automated image analysis. The pathologists read the slides faster than nonpathologists (total time 88 and 178 min, respectively, p = 0.03). Mean weighted kappa for intraobserver agreement was 0.85 (range 0.81-0.89) for intensity and 0.43 (range 0.38-0.51) for extent with similar results among pathologists and nonpathologists. Mean weighted kappa for interobserver agreement was 0.80 (range 0.77-0.84) for intensity and 0.21 (range 0.11-0.26) for extent. The subjective estimations of intensity correlated with results of image analysis (r = 0.61-0.66, p < 0.001), but the correlation between observers was stronger (r = 0.75-0.81) and correlated better with Gleason grade. Thus, subjective assessment of intensity can be done with a high level of reproducibility while estimation of staining extent is less reliable. Although educated pathologists were faster, the level of pathology training is not crucial for obtaining reproducible results in the analysis of TMA-based studies.

Major prognostic value of modeled AUChCG-AFP, a dynamic kinetic marker characterizing tumor marker decline of nonseminomatous germ cell tumors (NSGCT) intermediate-poor-risk patients according to the IGCCCG

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Background: The level of human chorionic gonadotrophin (hCG) and alpha-foetoprotein (AFP) serum tumor marker is well established in NSGCT as prognostic factor, the relevance of marker kinetic analysis under treatment is still unclear. This may be due to the inaccuracy of methods employed so far, simplifying complex exponential decrease curves by a median half-life (HL). We propose to model patient's AFP and hCG decline profiles in order to calculate area under the curve of marker concentrations versus time (AUChCG-AFP) and to test its prognostic value. Methods: Our retrospective study involved 65 pts treated by 4 cycles of bleomycin-etoposide-cisplatin (BEP) regimen for an intermediate-poor-risk group NSGCT in the same center between 1997 and 2008. A kinetic population approach with NONMEM software was used to model equations of hCG and AFP individual decrease profiles between day 7 (D7) and D42 after the first BEP cycle. AUChCG and AUCAFP were calculated between day D0 and D42 as: AUC0–42=AUC0–7+AUC7–42 where AUC0–7 = trapezium area between D0 and D7 while AUC7–42=integral of modeled equation. Survival univariate and multivariate analyses tested the prognostic value of AUChCG-AFP regarding PFS. Results: Mono-exponential models best fitted AFP and hCG decreases: CAFP (t) = 381*e - 0.14 *t +3.27 and ChCG (t) = 1230*e - 0.25 *t +1.22. Three prognostic groups (AUChCG-AFP) were determined according to AUCAFP median and AUChCG terciles: good if AUCAFP<=11729.4 and AUChCG0–42<=6670; intermediate if AUCAFP>11729 and/or if 6670<=AUChCG<18178 and poor risk if AUChCG>18178 whatever AUCAFP. AUChCG-AFP was a significant prognostic factor in the univariate analysis on the 2 year PFS (100% vs 73.8% vs 67.7%, p = 0.035) as well as IGCCCG score (poor/intermediate risk groups), primary site (mediastinal/other) and HLhCG-AFP. Yet AUChCG-AFP was the only significant independent factor in the multivariate Cox model (HR = 3.3, 95%CI = [1.2–9.2], p = 0.032). Conclusions: Modeled AUChCG-AFP is a dynamic kinetic marker characterizing NSGCT patient marker decline during BEP treatment. These results must be validated in a prospective cohort. It may be a major prognostic factor.

No significant financial relationships to disclose.

ET 743 is an effective agent against sarcoma

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Background: ET-743 has shown clinical activity in soft tissue sarcoma after failure of anthracyclines and ifosfamide. We propose to assess these results in our institution. Methods: We reviewed the patients treated (in phase II studies or on a compassionate basis) until June 2006 Results: Median age of the 99 patients was 53 years (18–82, with 20% leiomyosarcomas, 18% other spindle cell sarcomas, 12% liposarcomas, 9% osteosarcomas and 4% Ewing's sarcomas. The initial tumor was in the lower limbs in 31% of cases, and 70% had lung metastases. Patients had received anthracyclines (72%) or ifosfamide (61%), but 12% received ET-743 as their 1st chemotherapy. Most patients received ET-743 as a single agent, but 7 received it in combination with doxorubicin. After a median of 4 cycles (1–25), 50% of patients responded: 0 CR, 12 patients with PR, 4 MR (minor response), 34 SD and 49 progressed. Median time to progression for patients with a clinical benefit (PR+MR+SD) was 7 months (1.5 to 66 months). Among the 29 patients who didn't progress in the first six months, 10 had leiomyosarcomas and 8 spindle cell sarcomas. Grade3/4 toxicity, mainly hematological (42% neutropenia, 16% anemia, 11% thrombocytopenia) and hepatic (33%), was noted in 69 patients (28 needed a dose reduction). Main cause of treatment discontinuation was progression (70%) but 7 patients had to stop treatment because of toxicity. Conclusions: ET- 743 can benefit some patients with sarcomas, especially leiomyosarcomas, even pretreated. Some patients have long lasting responses. Grade ¾ toxicity is frequent but rarely leads to treatment discontinuation

No significant financial relationships to disclose.

ET-743: a novel agent with activity in soft-tissue sarcomas

PURPOSE OF REVIEW

ET-743 (ecteinascidin-743, trabectedin, Yondelis) is a natural marine product that has shown clinical activity in sarcoma. This paper reviews the current knowledge on this compound.

RECENT FINDINGS

ET-743 interferes with several transcription factors, traps protein from the nucleotide-excision repair system, thus resulting in DNA damage, modulates gene expression, and blocks cells in the G2-M phase. In the clinical setting, after failure of standard treatment, ET-743 at 1.5 mg/m2 in 24 h continuous infusion every 21 days yielded an overall response rate close to 8% and stabilization rates of 30-40%, some lasting beyond 3 years. Leiomyosarcomas, liposarcomas, and synovial sarcomas may be the more sensitive histotypes. The major toxicities of ET-743 are hepatic--through biliary duct destruction--and hematologic. They are not cumulative and a significant number of patients may receive 12 courses or more. In a randomized Phase II study testing weekly ET-743 with treatment every 3 weeks, an improved progression-free survival rate was observed in the 3-weekly arm; the results of the follow-up Phase III trial should be available at the American Society of Clinical Oncology meeting of 2006. Phase I combination studies are in currently progress.

SUMMARY

ET-743 is a novel active drug for sarcoma which yields prolonged disease-free survival in subsets of patients.

ET‐743: A Novel Agent with Activity in Soft Tissue Sarcomas

Ecteinascidin-743 (ET-743) is a natural product derived from the marine tunicate Ectenascidia turbinate. ET-743 binds in the minor groove of DNA, blocks transcription factors activity, and traps protein from the nucleotide excision repair system, thus blocking cells in G2-M phase. ET-743 demonstrated cytotoxic activity at very low concentrations against sarcoma cell lines in pre-clinical studies. In several phase II clinical studies in patients with advanced sarcoma failing conventional doxorubicin- and ifosfamide-based chemotherapy, ET-743 delivered by continuous intravenous 24-hour infusion at a dose of 1,500 microg/m2 every 21 days yielded 8% overall response and 30%-40% stabilization rates for a clinical benefit rate close to 40%. Interestingly, long-term stabilizations over more than 3 years have been described. In vivo, ET-743 has a specific toxicity profile, the major toxicity of this product being hepatic, through biliary duct destruction, and hematologic. ET-743 has also been evaluated in first-line treatment for these patients. Finally, due to its original mode of action and the lack of cross-resistance with other chemotherapy agents, ET-743 was tested in a preclinical model in combination with other drugs. Synergy was reported in vitro with doxorubicin and cisplatin; phase I combination studies are in progress.