Risk thresholds for patients to switch between daily tablets and biweekly infusions in second-line treatment for advanced hepatocellular carcinoma: a patient preference study

BACKGROUND

Historically, high hepatocellular carcinoma (HCC)-related mortality has been, in part, due to lack of effective therapies; however, several systemic therapies have been recently approved for HCC treatment, including regorafenib and ramucirumab. These two treatments utilize different routes of administration (four daily tablets and biweekly intravenous infusions, respectively) and have different risks of adverse events (AEs). However, we lack data on patient preferences in balancing the route of administration and risk of AEs in patients with HCC. We aimed to determine patient preferences and trade-offs for second-line treatment in patients with HCC.  METHODS: Patients with advanced or metastatic HCC were recruited through their physicians for this study. Patient preferences were assessed by using a modified threshold technique (TT) design in which respondents were asked two direct-elicitation questions before (assuming same safety and efficacy and only varying mode of administration) and after (incorporating the safety profiles of ramucirumab and regorafenib) the TT series on seven risks of clinically relevant AEs.

RESULTS

In total, of the 157 patients recruited by their physicians, 150 were eligible and consented to participate. In the first elicitation question (assuming risk and efficacy were equivalent), 61.3% of patients preferred daily tablets. However, 76.7% of patients preferred the biweekly infusion when the safety profiles of the two available second-line therapies were included. The TT analysis confirmed that preferences for oral administration were not strong enough to balance out the risk of AEs that differentiate the two therapies.

DISCUSSION

We found that when patients were asked to choose between a daily, oral medication and a biweekly IV medication for HCC, they were more likely to choose a daily, oral medication if efficacy and safety profiles were the same. However, when risks of AEs representing the safety profiles of two currently available second-line treatments were introduced in a second direct-elicitation question, respondents often selected an IV administration with a safety profile similar to ramucirumab, rather than oral tablets with a safety profile similar to regorafenib. Our findings indicate that the risk profile of a second-line treatment for HCC may be more important than the mode of administration to patients.

Ramucirumab in the second-line for patients with hepatocellular carcinoma and elevated alpha-fetoprotein: patient-reported outcomes across two randomised clinical trials

BACKGROUND

Symptoms of advanced hepatocellular carcinoma (HCC) represent a substantial burden for the patient and are important endpoints to assess when evaluating treatment. Patient-reported outcomes were evaluated in subjects with advanced HCC and baseline alpha-fetoprotein (AFP) ≥400 ng/mL treated with second-line ramucirumab.

PATIENTS AND METHODS

Patients with AFP≥400 ng/mL enrolled in the REACH or REACH-2 phase 3 studies were used in this analysis. Eligible patients had advanced HCC, Child-Pugh A, Eastern Cooperative Oncology Group performance status 0/1 and prior sorafenib. Patients received ramucirumab 8 mg/kg or placebo once every 2 weeks. Disease-related symptoms and health-related quality of life (HRQoL) were assessed with the Functional Assessment of Cancer Therapy Hepatobiliary Symptom Index (FHSI)-8 and EuroQoL-5-Dimensions (EQ-5D) instruments, respectively. Time to deterioration (TTD) (≥3-point decrease in FHSI-8 total score;≥0.06-point decrease in EQ-5D score, from randomisation to first date of deterioration) was determined using Kaplan-Meier estimation and the Cox proportional hazards model. Both separate and pooled analyses for REACH AFP≥400 ng/mL and REACH-2 patients were conducted.

RESULTS

In the pooled population with AFP ≥400 ng/mL (n=542; ramucirumab, n=316; placebo, n=226), median TTD in FHSI-8 total score was prolonged with ramucirumab relative to placebo (3.3 vs 1.9 months; HR 0.725; (95% CI 0.559 to 0.941); p=0.0152), including significant differences in back pain (0.668; (0.497 to 0.899); p=0.0044), weight loss (0.699; (0.505 to 0.969); p=0.0231) and pain (0.769; (0.588 to 1.005); p=0.0248) symptoms. TTD in EQ-5D score was not significantly different between ramucirumab and placebo groups (median 2.9 vs 1.9 months). Results in the individual trials were consistent with these findings.

CONCLUSIONS

Ramucirumab in second-line treatment of advanced HCC demonstrates consistent benefit in the delay of deterioration in disease-related symptoms with no worsening of HRQoL. Taken with previously demonstrated ramucirumab-driven survival benefits in this setting, these data may inform patient-clinician discussions about the benefit-risk profile of this therapy.

TRIAL REGISTRATION NUMBER

NCT01140347; NCT02435433, NCT02435433.

Evaluation of meaningful change in bowel movement frequency for patients with carcinoid syndrome

Background

Carcinoid syndrome is associated with a reduced quality of life that can be attributed to symptoms such as diarrhea and fatigue as well as social and financial issues. This study was conducted to psychometrically assess meaningful change in bowel movement frequency among carcinoid syndrome patients using data from the TELESTAR clinical study.

Methods

An anchor-based approach for deriving meaningful change thresholds consisted of mapping change from baseline bowel movement frequency to other patient-reported assessments of change. These included the European Organization for Research and Treatment of Cancer (EORTC) Quality of Life Questionnaire - Core Questionnaire (QLQ-C30) Diarrhea Symptom responders, the EORTC Gastrointestinal NET questionnaire (GI.NET21) GI Symptom responders, and reported adequate relief at Week 12 (≥ 10-point score decrease from Day 1 to Week 12). Parameters included within-group mean change from baseline to Week 12, t-tests of the change (Wilcoxon rank sum for adequate relief), and effect size.

Results

There were 135 carcinoid syndrome patients with a mean baseline frequency of 5.7 bowel movements a day. A distribution-based method yielded meaningful change estimates of 0.62 bowel movements a day for overall frequency and 0.83 bowel movements a day at Week 12. Anchor-based analysis indicated a large effect size among patients who reported adequate relief at Week 12 (− 1.58; n = 18; P = 0.014), the QLQ-C30 Diarrhea domain responders (− 1.24; n = 40; P < 0.001), and the GI.NET21 GI Symptoms Domain responders (− 1.49; n = 25; P = 0.005). Exit interview data for meaningful change yielded effect size estimates of − 1.57 for overall change during the Double-blind Treatment Period and − 1.97 for change between Baseline and Week 12.

Conclusions

Meaningful change derivation is critical to interpret patient outcomes for evaluating treatment efficacy. In this study, carcinoid syndrome patients experienced clinically meaningful reductions in bowel movement frequency of ≥30% over 12 weeks with telotristat ethyl treatment.

Trial registration

NCT01677910.

Abstract P6-16-01: Health-related quality of life in MONARCH 3: Abemaciclib plus an aromatase inhibitor as initial therapy in women with HR+, HER2- advanced breast cancer

Background: In the MONARCH 3 trial, abemaciclib plus an aromatase inhibitor (AI) significantly improved progression free survival and overall response rate with a generally tolerable safety profile compared to placebo plus AI. Here we report patient-reported outcomes (PRO) including health-related quality of life (Qol), functioning, and symptoms.

Methods: MONARCH 3 was a double-blind, randomized phase III study of abemaciclib or placebo plus an AI in 493 post-menopausal women with hormone receptor-positive (HR+), human epidermal growth factor receptor 2-negative (HER2-) advanced breast cancer with no prior systemic therapy in the advanced setting. Two European Organization for Research and Treatment of Cancer (EORTC) questionnaires were included: Quality of Life Questionnaire (QLQ)-Core 30 (C30) and the EORTC QLQ-Breast 23 (BR23) that were assessed at baseline, every 2 cycles through cycle 19, then every 3 cycles until treatment discontinuation, and at short-term follow up. Higher scores on functional and health status/QoL outcomes indicate higher/better levels of functioning or health; conversely higher scores on symptom outcomes indicate higher/worse levels of symptom burden. Between-arm comparisons of change from baseline were conducted using mixed model methods. Statistical significance was set at 0.05 and clinical meaningfulness was set at ≥10 points on a 0-100 scale1.

Results: PRO completion rates were &gt;91% through cycle 19; duration of treatment was longer for abemaciclib plus AI patients (median number of cycles 19 vs.15). Compared to the placebo arm, diarrhea PRO scores in the abemaciclib arm showed a clinically (18.68 points) and statistically significant (p&lt;0.001) increase/worsening. By-cycle analysis showed group mean diarrhea scores returned to near-baseline levels post-therapy. Other symptom PROs showed statistically significant (&lt;0.05) but not clinically meaningful differences; fatigue (4.96; p=0.004), systemic therapy side effects (4.48, p&lt;0.001), appetite loss (4.03; p=0.034), and nausea/vomiting (2.77; p=0.013). These results were consistent with the investigator-reported treatment emergent adverse events (TEAEs). Several non-symptom results were also statistically significant but not clinically meaningful including global health/health status (-4.36; p=0.003), role function (-4.25; p=0.025), social function (-3.41, p=0.047), and body image (-5.11, p=0.009). No statistically significant between-treatment differences were observed for physical, emotional, and cognitive functioning or for symptoms of pain, dyspnea, insomnia, constipation, or financial difficulties.

Conclusions: The addition of abemaciclib to an AI resulted in clinically and statistically significant changes in diarrhea without clinically meaningful differences in other symptom scores. Increased GI-related symptoms were consistent with the manageable, reversible AE profile; the highest symptom burden was reported during early visits. No clinically meaningful differences in global health status or functional scores were observed.

ClinicalTrials.gov: NCT02246621

Reference:

1. Osoba D et al. J Clin Oncol 2002;20(14):3106-13.

Citation Format: Goetz MP, Johnston S, Martin M, Tokunaga E, Park IH, Huober J, Toi M, Price GL, Boye M, Li L, Forrester T, Gainford C, Gable J, Carter GC, Sood A, DiLeo A. Health-related quality of life in MONARCH 3: Abemaciclib plus an aromatase inhibitor as initial therapy in women with HR+, HER2- advanced 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 P6-16-01.

Abstract P2-08-66: Outcomes among metastatic breast cancer patients with characteristics that confer a less favorable prognosis

Background: Recent advances in the treatment of hormone receptor positive (HR+), human epidermal growth factor receptor 2-negative (HER2-) metastatic breast cancer (MBC) have contributed to increased overall survival (OS). Despite advances, MBC remains incurable and there is a subset of patients with clinical features that are associated with poorer prognosis. This study described the patient characteristics, treatment patterns, and outcomes of a cohort of US patients with HR+, HER2- MBC as a function of various factors associated with poor prognosis, including presence (vs. absence) of liver metastases (LM).

Methods: This retrospective study used US community oncology electronic health record data from the Vector Oncology Data Warehouse. Eligible women who received systemic treatment for MBC, had a diagnosis of MBC in 2008 or later, and had completed at least three Patient Care Monitor (PCM) surveys, (a patient-reported outcomes survey collected as a part of clinical care), were included. OS was measured from the start of the first three regimen-based lines (1L, 2L and 3L) of treatment; patients without evidence of death were censored at the last observed visit. The statistical significance of differences in categorical and continuous variables between LM positive (LM+) and LM negative (LM-) were evaluated with chi-square (X2) tests, and t-tests, respectively. Kaplan-Meier and Cox analyses were applied to evaluate differences in OS by LM status and by line of therapy at the start of MBC treatment (unadjusted for treatment).

Results: A total of 378 women, 98.4% residing in the South and 40.5% African-American, were included; 295 (78.0%) were LM- at the time of diagnosis. Following 1L, approximately 82.8% and 60.8% of patients received 2L and 3L, respectively. Patients with a LM+ status had a lower mean age (mean: 57.2, SD: 13.8 vs. 61.2, 13.1; p=0.016) and a higher percentage had a grade 3 tumor (36.1 vs. 24.7%; p=0.039) compared to patients with LM-status. Table 1 shows the OS results for 1L-3L. For all 3 lines, median OS for LM+ was shorter than the LM- median OS. LM+ patients had a poorer prognosis as they were more likely to have an OS event across 1L-3L compared to LM- patients.

Conclusions: Among this community oncology cohort, median OS in 1L was 14 months shorter in LM+ patients compared to LM- patients. It is important to note that the sample size and selection criteria may limit generalizability of these results. Despite progress in treating women with MBC, treatment options are lacking for patients with less favorable prognosis, including those with LM. Other potential indicators of poor prognosis, such as high tumor grade, are being explored.

Table 1.OS (months) by regimen-based line of therapy Measure Liver Mets (LM+) No Liver Mets (LM-) HR p-value 1L, # of Events/ # of Patients55/83168/295  Median (95% CI)23.9 (15.5-28.6)35.2 (30.1-42.3) &lt;0.0001* Cox Hazard Ratio  1.93&lt;0.0001 2L, # of Events/ # of Patients48/72149/241  Median (95% CI)16.6 (12.0-22.6)24.2 (21.3-29.0) 0.002* Cox Hazard Ratio  1.490.040 3L, # of Events/ # of Patients35/52118/178  Median (95% CI)11.5 (7.0-21.0)17.4 (14.7-20.0) 0.038* Cox Hazard Ratio  1.540.060CI=Confidence Interval; *p-value was derived using log rank test.

Citation Format: Saverno K, Cuyun Carter G, Dufour R, Price G, Li L, DeLuca A, Nash Smyth E, Battiato L, Gable J, Walker MS, Huang Y-J, Hannas S, Schwartzberg LS. Outcomes among metastatic breast cancer patients with characteristics that confer a less favorable prognosis [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 P2-08-66.

Evaluation of meaningful change in bowel movement frequency for patients with carcinoid syndrome

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Background: Telotristat ethyl is a tryptophan hydroxylase inhibitor in development for the treatment of carcinoid syndrome (CS) in patients who receive somatostatin analog (SSA) therapy. In TELESTAR, a pivotal Phase 3 study, telotristat ethyl significantly reduced bowel movement (BM) frequency compared to placebo. The objective of this study was to psychometrically assess meaningful change in BM frequency using data collected within the TELESTAR study. Methods: An anchor-based approach consisted of mapping change from baseline in BM frequency to other patient reported assessments of change. These included the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire - Core Questionnaire (EORTC QLQ-C30) Diarrhea Symptom responders, the EORTC GI.NET21 GI Symptom responders, and patient reported adequate relief at Week 12 (responders had a ≥ 10-point decrease in scores from Day 1 to Week 12). Parameters included within group mean change from baseline to Week 12, t-tests of the change (Wilcoxon Rank Sum for adequate relief), effect size (ES: calculated as the difference between mean on-treatment and baseline BM frequency, divided by the standard deviation of the baseline), and related confidence intervals. Results: There were 135 patients with CS, with a mean age of 63.6 years and mean baseline BM frequency of 5.7 BM/day. Anchor-based analyses indicated significant differences in BM frequency between adequate relief groups at Week 12 (ES: −1.58 vs. −0.79; p = 0.014), responders and non-responders on the EORTC QLQ-C30 Diarrhea Symptoms domain (ES: −1.24 vs. −0.59; p < 0.0001), and responders and non-responders on the EORTC GI.NET21 GI Symptoms Domain (ES: −1.49 vs. −0.75; p = 0.0053). These corresponded to BM frequency reductions of 1.7–1.9 BM/day, or ≥ 30%. Conclusions: Results of this study indicated that patients with CS experienced clinically meaningful reductions in BM frequency of ≥ 30% over the course of 12 weeks. Clinical trial information: NCT01677910.

Evaluation of meaningful change in bowel move frequency for patients with carcinoid syndrome

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Background: Telotristat ethyl is a tryptophan hydroxylase inhibitor in development for the treatment of carcinoid syndrome (CS) in patients who receive somatostatin analog (SSA) therapy. In TELESTAR, a pivotal Phase 3 study, telotristat ethyl significantly reduced bowel movement (BM) frequency compared to placebo. Objective: The objective of this study was to psychometrically assess meaningful change in BM frequency using data collected within the TELESTAR study. Methods: An anchor-based approach consisted of mapping change from baseline in BM frequency to other patient reported assessments of change. These included the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire - Core Questionnaire (EORTC QLQ-C30) Diarrhea Symptom responders, the EORTC GI.NET21 GI Symptom responders, and patient reported adequate relief at Week 12 (responders had a ≥ 10-point decrease in scores from Day 1 to Week 12). Parameters included within group mean change from baseline to Week 12, t-tests of the change (Wilcoxon Rank Sum for adequate relief), effect size (ES: calculated as the difference between mean on-treatment and baseline BM frequency, divided by the standard deviation of the baseline), and related confidence intervals. Results: There were 135 patients with CS, with a mean age of 63.6 years and mean baseline BM frequency of 5.7 BM/day. Anchor-based analyses indicated significant differences in BM frequency between adequate relief groups at Week 12 (ES: -1.58 vs. -0.79; p = 0.014), responders and non-responders on the EORTC QLQ-C30 Diarrhea Symptoms domain (ES: -1.24 vs. -0.59; p < 0.0001), and responders and non-responders on the EORTC GI.NET21 GI Symptoms Domain (ES: -1.49 vs. -0.75; p = 0.0053). These corresponded to BM frequency reductions of 1.7-1.9 BM/day, or ≥ 30%. Conclusions: Results of this study indicated that patients with CS experienced clinically meaningful reductions in BM frequency of ≥ 30% over the course of 12 weeks.

Documenting the impact of alopecia in breast cancer: Assessing the performance of the alopecia patient assessment (APA) questionnaire

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Background: The APA questionnaire was developed to document the emotional and social burden of alopecia experienced by breast cancer patients undergoing therapy. Content, clarity, and relevance of the measure were assessed by patients undergoing chemotherapy; the instructions, recall and APA items were found to be clear and relevant (Mathias et al., 2013). The next phase consists of documenting the performance of the APA measure as an evaluative tool for use in clinical research. Methods: The APA was implemented in a US observational multicentre, prospective, longitudinal cohort of 497 patients with HER2+ metastatic breast cancer (SystHERs) with a mixed modality for data collection (first paper and then transition to ePRO). The APA was collected at baseline and every 90 (± 15) days. The psychometric analysis was adapted based on the study design and on the manifestation of alopecia (onset, duration) in this population. The select set of psychometric tests included quality and pattern of completion, construct validity and reliability. Results: Quality of completion as measured by correct scale use was 85.2% (compliance was 95.6%). Discrimination indices were above the 0.3 threshold for each item on the APA and ranged from 0.59 to 0.82 at baseline. The scale demonstrated good internal consistency as assessed by 0.88 Cronbach alpha. Weighted kappa agreement of 0.49 was observed between the APA and the ‘I am bothered by hair loss’ item (B5) of the Functional Assessment of Cancer Therapy-Breast (FACT-B) measure. Conclusions: The APA is a valid and reliable measure able to discriminate change in patients’ daily functioning resulting from an alopecia event related to treatment for breast cancer. Results support the use of the APA in clinical research to better characterize the impact of alopecia on patients’ lives.

Hoarding and treatment response in 38 nondepressed subjects with obsessive-compulsive disorder

OBJECTIVE

The authors studied factors associated with short-term treatment response in 38 nondepressed subjects with DSM-III-R obsessive-compulsive disorder (OCD).

METHOD

The subjects completed 12 weeks of treatment with paroxetine (N = 20), placebo (N = 8), or cognitive-behavioral therapy (N = 10). Clinician and self-rated measures were gathered at baseline, during treatment, and after treatment.

RESULTS

Seventeen (45%) subjects had "much" or "very much" improvement and achieved at least a 40% decrease in their total Yale-Brown Obsessive Compulsive Scale (Y-BOCS) score. Responders had lower obsessive-compulsive scores on the Symptom Checklist 90-Revised, had a lower checking score on the Maudsley Obsessive-Compulsive Inventory, were less likely to have had prior drug therapy, and in general suffered more obsessive-compulsive symptoms. They were significantly less likely to have hoarding obsessions and corresponding compulsions. The latter finding was confirmed using multiple regression analysis.

CONCLUSION

Hoarding is an important symptom that predicts poor treatment response in patients with OCD.

Protein synthesis, cellular amino acids, and energy levels in CAPD patients

Cellular energy-related bioactivities [energy charge = ATP + 0.5 ADP/(ATP + ADP + AMP)], enzyme activities adenylate kinase, pyruvate kinase, phosphofructokinase, glucose-6-phosphate dehydrogenase, free amino acids in plasma and cells, and protein synthesis (3H-leucine incorporation) were measured in granulocytes isolated from peripheral blood of 13 CAPD-treated adult patients. The values were compared with 37 normal adult controls, 29 of whom had complete data for all biochemical parameters. Eleven of the CAPD patients were studied a second time, 3 to 8 months after the first study. Initially, after 20 +/- 8 months of CAPD compared (P less than 0.05, only) to controls, the patients had normal or increased activities of the enzymes pyruvate kinase, phosphofructokinase, glucose-6-phosphate dehydrogenase, in contrast to previous results from hemodialyzed patients; but adenylate kinase, ATP, and protein synthesis were reduced. Concentrations of many amino acids in plasma were abnormal, including reduced valine, leucine, threonine, tryptophan, and tyrosine, as noted by others. Histidine, glutamic acid, and citrulline especially were increased. The intracellular concentrations of the essential amino acids were within normal limits, but citrulline, glycine, and taurine levels were markedly increased while glutamic acid and SAGN (serine + asparagine + glutamine) were decreased. With the second study, intracellular energy-related bioactivities and the abnormal concentrations of the amino acids in plasma were essentially unchanged. However, virtually all the intracellular amino acid concentrations were higher. These results also were in striking contrast to previously reported hemodialysis patients in whom the intracellular concentrations of the branched-chain amino acids and methionine as well as protein synthesis were strikingly decreased.(ABSTRACT TRUNCATED AT 250 WORDS)