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Duvivier HL, Rothe M, Mangat PK, Garrett-Mayer E, Ahn ER, Al Baghdadi T, Alva AS, Dublis SA, Cannon TL, Calfa CJ, Li R, Behl D, Chiu VK, Gold PJ, Marr AS, Mileham KF, Powell SF, Rodon J, Thota R, Grantham GN, Gregory A, Hinshaw DC, Halabi S, Schilsky RL. Pembrolizumab in Patients With Tumors With High Tumor Mutational Burden: Results From the Targeted Agent and Profiling Utilization Registry Study. J Clin Oncol 2023; 41:5140-5150. [PMID: 37561967 DOI: 10.1200/jco.23.00702] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Revised: 04/25/2023] [Accepted: 07/01/2023] [Indexed: 08/12/2023] Open
Abstract
PURPOSE The Targeted Agent and Profiling Utilization Registry (TAPUR) Study is a pragmatic basket trial evaluating antitumor activity of approved targeted agents in patients with advanced cancers harboring potentially actionable genomic alterations. Data from cohorts of patients with high tumor mutational burden (HTMB, defined as ≥9 mutations per megabase) with advanced colorectal cancer (CRC) and other advanced cancers treated with pembrolizumab are reported. METHODS Eligible patients were 18 years and older with measurable tumors and a lack of standard treatment options, an Eastern Cooperative Oncology Group performance status of 0-1, and adequate organ function. The primary end point was disease control (DC), defined as complete or partial response or stable disease (SD) of at least 16-weeks duration. For the CRC cohort, Simon's two-stage design with a null DC rate of 15% versus 35% (power = 0.85; α = .10) was used. Low accruing histology-specific cohorts were collapsed into one histology-pooled (HP) cohort. For the HP cohort, the null hypothesis of a DC rate of 15% was rejected if the lower limit of a one-sided 90% CI was >15%. Secondary end points included objective response (OR), safety, progression-free survival, overall survival, duration of response, and duration of SD. RESULTS Seventy-seven patients with HTMB with CRC (n = 28) or advanced cancers (n = 49) were treated with pembrolizumab. For the CRC cohort, the DC rate was 31% (P = .04) and the OR rate was 11%. For the HP cohort, the DC rate was 45% (one-sided 90% CI, 35 to 100) and the OR rate was 26%. The null hypothesis of a 15% DC rate was rejected for both cohorts. Twelve of 77 patients experienced treatment-related grade 3 adverse events (AEs) or serious AEs, including two deaths. CONCLUSION Pembrolizumab demonstrated antitumor activity in pretreated patients with advanced cancers and HTMB.
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Affiliation(s)
- Herbert L Duvivier
- Cancer Treatment Centers of America-Atlanta, Part of City of Hope, Newnan, GA
| | - Michael Rothe
- American Society of Clinical Oncology, Alexandria, VA
| | - Pam K Mangat
- American Society of Clinical Oncology, Alexandria, VA
| | | | - Eugene R Ahn
- Cancer Treatment Centers of America-Chicago, Part of City of Hope, Zion, IL
| | - Tareq Al Baghdadi
- Michigan Cancer Research Consortium, IHA Hematology Oncology, Ypsilanti, MI
| | - Ajjai S Alva
- University of Michigan Rogel Comprehensive Cancer Center, Ann Arbor, MI
| | | | | | - Carmen J Calfa
- Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, FL
| | - Rui Li
- Providence Cancer Institute, Providence Portland Medical Center, Portland, OR
| | - Deepti Behl
- Sutter Sacramento Medical Center, Sacramento, CA
| | - Vi K Chiu
- The Angeles Clinic and Research Institute, A Cedars-Sinai Affiliate, Los Angeles, CA
| | | | | | | | | | - Jordi Rodon
- Department of Investigational Cancer Therapeutics, University of Texas MD Anderson Cancer Center, Houston, TX
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Heinzerling JH, Pen OV, Robinson M, Foster R, Kelly B, Mileham KF, Moeller B, Prabhu RS, Corso C, Ward MW, Sullivan CM, Burri S, Simone CB. Full Dose SBRT in Combination With Mediastinal Chemoradiation for Locally Advanced, Non-Small Cell Lung Cancer: A Practical Guide for Planning, Dosimetric Results From a Phase 2 Study, and a Treatment Planning Guide for the Phase 3 NRG Oncology LU-008 Trial. Pract Radiat Oncol 2023; 13:531-539. [PMID: 37406774 DOI: 10.1016/j.prro.2023.04.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Revised: 04/21/2023] [Accepted: 04/25/2023] [Indexed: 07/07/2023]
Abstract
PURPOSE Stereotactic body radiation therapy (SBRT) has been used with high effectiveness in early-stage non-small cell lung cancer (NSCLC) but has not been studied extensively in locally advanced NSCLC. We conducted a phase 2 study delivering SBRT to the primary tumor followed by conventionally fractionated chemoradiation to the involved lymph nodes for patients with node-positive locally advanced NSCLC. This manuscript serves as both a guide to planning techniques used on this trial and the subsequent phase 3 study, NRG Oncology LU-008, and to report patient dosimetry and toxicity results. METHODS AND MATERIALS We initiated a phase 2 multicenter single arm study evaluating SBRT to the primary tumor (50-54 Gy in 3-5 fractions) followed by conventionally fractionated chemoradiation to 60 Gy in 2 Gy fractions with doublet chemotherapy to the involved lymph nodes for patients with stage III or unresectable stage II NSCLC. Patients eligible for adjuvant immunotherapy received up to 12 months of durvalumab. We report a detailed guide for the entire treatment process from computed tomography simulation through treatment planning and delivery. The dosimetric outcomes from the 60 patients who completed therapy on study are reported both for target coverage and normal structure doses. We also report correlation between radiation-related toxicities and dosimetric parameters. RESULTS Sixty patients were enrolled between 2017 and 2022. Planning techniques used were primarily volumetric modulated arc therapy for SBRT to the primary tumor and conventionally fractionated radiation to the involved nodes, with a minority of cases using dynamic conformal arc technique or static dynamic multileaf collimator intensity modulated radiation therapy. Grade 2 or higher pneumonitis was associated with lung dose V5 Gy > 70% and grade 2 or higher pulmonary toxicity was associated with lung dose V10 Gy > 50%. Only 3 patients (5%) experienced grade 3 or higher pneumonitis. Grade 2 or higher esophagitis was associated with esophageal doses, including mean dose > 20 Gy, V60 Gy > 7%, and D1cc > 55 Gy. Only 1 patient (1.7%) experienced grade 3 esophagitis. CONCLUSIONS SBRT to the primary tumor followed by conventionally fractionated chemoradiation to the involved lymph nodes is feasible with planning techniques as described. Radiation-related toxicity on this phase 2 study was low. This manuscript serves as a guideline for the recently activated NRG Oncology LU-008 phase 3 trial evaluating this experimental regimen.
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Affiliation(s)
- John H Heinzerling
- Levine Cancer Institute, Atrium Health, Southeast Radiation Oncology, Charlotte, North Carolina.
| | - Olga V Pen
- Levine Cancer Institute, Atrium Health, Charlotte, North Carolina
| | - Myra Robinson
- Levine Cancer Institute, Atrium Health, Charlotte, North Carolina
| | - Ryan Foster
- Levine Cancer Institute, Atrium Health, Charlotte, North Carolina
| | - Brian Kelly
- Levine Cancer Institute, Atrium Health, Charlotte, North Carolina
| | | | - Benjamin Moeller
- Levine Cancer Institute, Atrium Health, Southeast Radiation Oncology, Charlotte, North Carolina
| | - Roshan S Prabhu
- Levine Cancer Institute, Atrium Health, Southeast Radiation Oncology, Charlotte, North Carolina
| | - Christopher Corso
- Levine Cancer Institute, Atrium Health, Southeast Radiation Oncology, Charlotte, North Carolina
| | - Matt W Ward
- Levine Cancer Institute, Atrium Health, Southeast Radiation Oncology, Charlotte, North Carolina
| | - Cara M Sullivan
- Levine Cancer Institute, Atrium Health, Charlotte, North Carolina
| | - Stuart Burri
- Levine Cancer Institute, Atrium Health, Southeast Radiation Oncology, Charlotte, North Carolina
| | - Charles B Simone
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York; New York Proton Center, New York, New York
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Mileham KF, Farhangfar CJ. Expanding the Multidisciplinary Team in Prediagnostic Care of Lung Cancer: How Else Can We Improve Time to Targeted Treatment in Metastatic Non-Small-Cell Lung Cancer? JCO Oncol Pract 2023; 19:694-696. [PMID: 37607326 DOI: 10.1200/op.23.00416] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Accepted: 07/25/2023] [Indexed: 08/24/2023] Open
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Eisner JR, Mayhew GM, Davison JM, Beebe KD, Shibata Y, Guo Y, Farhangfar C, Farhangfar F, Uronis JM, Conroy JM, Milburn MV, Hayes DN, Mileham KF. Association of Antifolate Response Signature Status and Clinical Activity of Pemetrexed-Platinum Chemotherapy in Non-Small Cell Lung Cancer: The Piedmont Study. Clin Cancer Res 2023; 29:3203-3213. [PMID: 37233991 PMCID: PMC10425722 DOI: 10.1158/1078-0432.ccr-22-2558] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Revised: 12/13/2022] [Accepted: 05/24/2023] [Indexed: 05/27/2023]
Abstract
PURPOSE The Piedmont study is a prospectively designed retrospective evaluation of a new 48-gene antifolate response signature (AF-PRS) in patients with locally advanced/metastatic nonsquamous (NS) non-small cell lung cancer (NSCLC) treated with pemetrexed-containing platinum doublet chemotherapy (PMX-PDC). The study tested the hypothesis that AF-PRS identifies patients with NS-NSCLC who have a higher likelihood of responding positively to PMX-PDC. The goal was to gather clinical evidence supporting AF-PRS as a potential diagnostic test. EXPERIMENTAL DESIGN Residual pretreatment FFPE tumor samples and clinical data were analyzed from 105 patients treated with first-line (1L) PMX-PDC. Ninety-five patients had sufficient RNA sequencing (RNA-seq) data quality and clinical annotation for inclusion in the analysis. Associations between AF-PRS status and associate genes and outcome measures including progression-free survival (PFS) and clinical response were evaluated. RESULTS Overall, 53% of patients were AF-PRS(+), which was associated with extended PFS, but not overall survival, versus AF-PRS(-) (16.6 months vs. 6.6 months; P = 0.025). In patients who were stage I to III patients at the time of treatment, PFS was further extended in AF-PRS(+) versus AF-PRS(-) (36.2 months vs. 9.3 months; P = 0.03). Complete response (CR) to therapy was noted in 14 of 95 patients. AF-PRS(+) preferentially selected a majority (79%) of CRs, which were evenly split between patients stage I to III (six of seven) and stage IV (five of seven) at the time of treatment. CONCLUSIONS AF-PRS identified a significant population of patients with extended PFS and/or clinical response following PMX-PDC treatment. AF-PRS may be a useful diagnostic test for patients indicated for systemic chemotherapy, especially when determining the optimal PDC regimen for locally advanced disease.
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Affiliation(s)
| | | | | | - Kirk D. Beebe
- GeneCentric Therapeutics, Inc., Durham, North Carolina
| | | | - Yuelong Guo
- GeneCentric Therapeutics, Inc., Durham, North Carolina
| | - Carol Farhangfar
- Levine Cancer Institute, Atrium Health, Charlotte, North Carolina
| | | | | | | | | | - David Neil Hayes
- University of Tennessee Health Science Center, Center for Cancer Research, Memphis, Tennessee
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Thummalapalli R, Choudhury NJ, Ehrich F, Beardslee T, Brazel D, Zhang SS, Merchant S, Chen MF, Heller G, Ramalingam SS, Ou SHI, Mileham KF, Riely GJ. Lorlatinib Tolerability and Association With Clinical Outcomes in Patients With Advanced ALK- or ROS1-Rearranged NSCLC: A Brief Report. JTO Clin Res Rep 2023; 4:100546. [PMID: 37644967 PMCID: PMC10460990 DOI: 10.1016/j.jtocrr.2023.100546] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Revised: 06/12/2023] [Accepted: 06/24/2023] [Indexed: 08/31/2023] Open
Abstract
Introduction Treatment with lorlatinib for patients with advanced ALK- and ROS1-rearranged NSCLC (ALK+ and ROS1+ NSCLC) is associated with a unique set of adverse events (AEs) often requiring dose reduction. However, the impact of dose reductions on outcomes remains unclear and is mainly limited to analyses from prospective studies of lorlatinib in the first-line setting. Methods We reviewed the course of 144 patients with advanced ALK- or ROS1-rearranged NSCLC treated with lorlatinib in the second-line or later setting to assess the frequency of dose reductions resulting from treatment-related AEs (TRAEs) and the association between dose reductions and progression-free survival (PFS) and overall survival (OS). Results A total of 58 patients (40%) had TRAE-related dose reductions, most (59%) owing to neurocognitive AEs or neuropathy. Among all patients, the median PFS was 8.1 months (95% confidence interval [CI]: 6.4-11.8); the median OS was 20.7 months (95% CI: 16.3-30.5). Among patients who were started on lorlatinib 100 mg/d (n = 122), a Cox regression model with the occurrence of a dose reduction as a time-dependent covariate indicated no association between dose reduction and PFS (hazard ratio = 0.86, 95% CI: 0.54-1.39) or OS (hazard ratio = 0.78, 95% CI: 0.47-1.30). Conclusions Lorlatinib dose reductions were not associated with inferior clinical outcomes in this multicenter analysis. Prompt identification of lorlatinib TRAEs and implementation of dose reductions may help maximize tolerability without compromising outcomes.
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Affiliation(s)
- Rohit Thummalapalli
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Noura J. Choudhury
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Fiona Ehrich
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Tyler Beardslee
- Department of Hematology and Medical Oncology, Winship Cancer Institute, Emory University School of Medicine, Atlanta, Georgia
| | - Danielle Brazel
- Chao Family Comprehensive Cancer Center, University of California Irvine School of Medicine, Orange, California
| | - Shannon S. Zhang
- Chao Family Comprehensive Cancer Center, University of California Irvine School of Medicine, Orange, California
| | - Shelby Merchant
- Department of Pharmacy, Levine Cancer Institute, Atrium Health, Charlotte, North Carolina
| | - Monica F. Chen
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Glenn Heller
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Suresh S. Ramalingam
- Department of Hematology and Medical Oncology, Winship Cancer Institute, Emory University School of Medicine, Atlanta, Georgia
| | - Sai-Hong Ignatius Ou
- Chao Family Comprehensive Cancer Center, University of California Irvine School of Medicine, Orange, California
| | - Kathryn F. Mileham
- Thoracic Medical Oncology, Levine Cancer Institute, Atrium Health, Charlotte, North Carolina
| | - Gregory J. Riely
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
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Foureau AVI, Foureau DM, Farhangfar CJ, Mileham KF. Abstract 281: Phosphodiesterase 8/9 inhibition to sensitize squamous non-small cell lung cancer (NSCLC) to pemetrexed (PMX): A double-edge strategy. Cancer Res 2023. [DOI: 10.1158/1538-7445.am2023-281] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/07/2023]
Abstract
Abstract
Introduction. Phosphosidesterases (PDE) are key regulators of cyclic nucleotide (cAMP/cGMP) signaling regulating many cellular processes including cell proliferation, growth arrest and apoptosis. In squamous NSCLC (SCC), PDE inhibitors (PDEi) have shown anti-tumor activity both as single agent and in combination with chemotherapy. A strong putative synergistic mechanistic activity exists between pemetrexed (PMX) and PDEi through cAMP/Protein kinase A (PKA) and cGMP/Protein Kinase G signaling. We therefore thought to investigate whether SCC, classically resistance to PMX can be sensitized to the drug through PDE inhibition.
Methods. Whole exome sequencing and survival data from TCGA was surveyed to identify PDEs most closely associated with clinical outcome in NSCLC. Whole exome sequencing data from GEmiCCL database were used to select SCC cell lines with unaltered PDE genes. Two SCC cell lines (H226, H1703) were evaluated for viability (WST8 assay), proliferation and apoptosis (Apo-Tox-Glo assay) after treatment with PMX with or without sildenafil citrate, PF-04671536 or PF-04447943 (PDE5i, PDE8i and PDE9i respectively). PDE expression was quantified by qPCR and Western Blot (WB). PDE activity and downstream signaling was quantified by measuring PKA/PKG target activation (PKA/pVASP157, PKG/pVAP239).
Results. Presence of function altering mutations in PDE8 (cAMP/PKA signaling) and PDE9 (cGMP/PKG signaling) improved NSCLC overall survival (P<0.1). PDE5 (cGMP/PKG signaling) mutations had no significant clinical impact. Both SCC cell lines investigated expressed high level of PDE8-9, but H1703 had only trace levels of PDE5. Endogenous PKA activity and PKG activity was significantly lower in H1703 cells compared with H226. PDEi stimulated SCC cell growth (30-60% increase). PDE8i and PDE9i (EC50<40nM, significant PKA/PKG activation) were more potent than PDE5i (>1.5µM, no PKA/PKG activation). PMX also displayed a pro-mitotic activity toward SCC (40% increase at 250µM) coupled with significant PKA activation in H226 and PKG activation in H1703 cells. Combination of PDE5i, 8i or 9i (2X EC50 concentrations) with low dose PMX (0.025µM) inhibited SCC cell growth, H1703 showing greater response than H226 (30-37% vs 8-11% growth reduction). No cell death, necrosis or apoptosis, was detected. This cytostatic activity of PDEi combination treatment was not observed at high dose PMX (250µM).
Conclusions. In the absence of PDE mutations, single agent PDE5i, 8i and 9i promote SCC growth with PDE8,9i displaying a far greater potency than PDE5i. PMX is also pro-mitotic toward SCC cells but PDE5i, 8i, and PDE9i can sensitize SCC cells to the drug. SCC cells with lower endogenous PKA/PKG activity are more sensitive to PDEi+PMX treatment. This combination is not cytotoxic though, rather is cytostatic, and displays a very narrow window of therapeutic activity.
Citation Format: Anna V. Ivanina Foureau, David M. Foureau, Carol J. Farhangfar, Kathryn F. Mileham. Phosphodiesterase 8/9 inhibition to sensitize squamous non-small cell lung cancer (NSCLC) to pemetrexed (PMX): A double-edge strategy [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2023; Part 1 (Regular and Invited Abstracts); 2023 Apr 14-19; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2023;83(7_Suppl):Abstract nr 281.
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Smith MR, Wang Y, D'Agostino R, Liu Y, Ruiz J, Lycan T, Oliver G, Miller LD, Topaloglu U, Pinkney J, Abdulhaleem MN, Chan MD, Farris M, Su J, Mileham KF, Xing F. Prognostic Mutational Signatures of NSCLC Patients treated with chemotherapy, immunotherapy and chemoimmunotherapy. NPJ Precis Oncol 2023; 7:34. [PMID: 36973365 PMCID: PMC10042886 DOI: 10.1038/s41698-023-00373-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Accepted: 03/13/2023] [Indexed: 03/29/2023] Open
Abstract
Different types of therapy are currently being used to treat non-small cell lung cancer (NSCLC) depending on the stage of tumor and the presence of potentially druggable mutations. However, few biomarkers are available to guide clinicians in selecting the most effective therapy for all patients with various genetic backgrounds. To examine whether patients' mutation profiles are associated with the response to a specific treatment, we collected comprehensive clinical characteristics and sequencing data from 524 patients with stage III and IV NSCLC treated at Atrium Health Wake Forest Baptist. Overall survival based Cox-proportional hazard regression models were applied to identify mutations that were "beneficial" (HR < 1) or "detrimental" (HR > 1) for patients treated with chemotherapy (chemo), immune checkpoint inhibitor (ICI) and chemo+ICI combination therapy (Chemo+ICI) followed by the generation of mutation composite scores (MCS) for each treatment. We also found that MCS is highly treatment specific that MCS derived from one treatment group failed to predict the response in others. Receiver operating characteristics (ROC) analyses showed a superior predictive power of MCS compared to TMB and PD-L1 status for immune therapy-treated patients. Mutation interaction analysis also identified novel co-occurring and mutually exclusive mutations in each treatment group. Our work highlights how patients' sequencing data facilitates the clinical selection of optimized treatment strategies.
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Affiliation(s)
- Margaret R Smith
- Department of Cancer Biology, Wake Forest University School of Medicine, Winston-Salem, NC, 27157, USA
| | - Yuezhu Wang
- Department of Cancer Biology, Wake Forest University School of Medicine, Winston-Salem, NC, 27157, USA
| | - Ralph D'Agostino
- Department of Biostatistics and Data Science, Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | - Yin Liu
- Department of Cancer Biology, Wake Forest University School of Medicine, Winston-Salem, NC, 27157, USA
| | - Jimmy Ruiz
- Department of Hematology and Oncology, Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | - Thomas Lycan
- Department of Hematology and Oncology, Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | - George Oliver
- Department of Pharmacy, Atrium Health Wake Forest Baptist Medical Center, Winston-Salem, NC, USA
| | - Lance D Miller
- Department of Cancer Biology, Wake Forest University School of Medicine, Winston-Salem, NC, 27157, USA
| | - Umit Topaloglu
- Department of Cancer Biology, Wake Forest University School of Medicine, Winston-Salem, NC, 27157, USA
| | - Jireh Pinkney
- Department of Biology, Winston Salem State University, Winston-Salem, NC, USA
| | - Mohammed N Abdulhaleem
- Department of Hematology and Oncology, Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | - Michael D Chan
- Department of Radiation Oncology, Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | - Michael Farris
- Department of Radiation Oncology, Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | - Jing Su
- Department of Biostatistics, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Kathryn F Mileham
- Department of Solid Tumor Oncology, Levine Cancer Institute, Atrium Health, Charlotte, NC, USA
| | - Fei Xing
- Department of Cancer Biology, Wake Forest University School of Medicine, Winston-Salem, NC, 27157, USA.
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Kurbegov D, Bruinooge SS, Lei XJ, Kirkwood MK, Dickson N, Hattiangadi T, Mileham KF, Patrick A, Williams JH, Kaltenbaugh M, Gralow JR, Garrett-Mayer E. Rate of COVID-19 vaccination among patients with cancer who tested positive for severe acute respiratory syndrome-coronavirus 2: Analysis of the American Society of Clinical Oncology Registry. Cancer 2023; 129:1752-1762. [PMID: 36920457 DOI: 10.1002/cncr.34726] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Revised: 02/03/2023] [Accepted: 02/06/2023] [Indexed: 03/16/2023]
Abstract
BACKGROUND The availability of safe and effective COVID-19 vaccines has enabled protections against serious COVID-19 outcomes, which are particularly important for patients with cancer. The American Society of Clinical Oncology Registry enabled the study of COVID-19 vaccine uptake in patients with cancer who were positive for severe acute respiratory syndrome-coronavirus 2. METHODS Medical oncology practices entered data on patients who were in cancer treatment. The cohort included patients who had severe acute respiratory syndrome-coronavirus 2 infection in 2020 and had visits and vaccine data after December 31, 2020. The primary end point was the time to first vaccination from January 1, 2021. Cumulative incidence estimates and Cox regression with death as a competing risk were used to describe the time to vaccine uptake and factors associated with vaccine receipt. RESULTS The cohort included 1155 patients from 56 practices. Among 690 patients who received the first vaccine dose, 92% received the second dose. The median time to vaccine was 99 days. After adjustment, older patients were associated with a higher likelihood of vaccination compared with patients younger than 50 years in January through March 2021, and age exhibited a linear effect, with older patients showing higher rates of vaccination. Metastatic solid tumors (hazard ratio [HR], 0.85; 95% confidence interval [CI], 0.73-0.98) or non-B-cell hematologic malignancies (HR, 0.71; 95% CI, 0.54-0.93) compared with nonmetastatic solid tumors, and any comorbidity (HR, 0.83; 95% CI, 0.73-0.95) compared with no comorbidity, were associated with lower vaccination rates. Area-level social determinants of health (lower education attainment and higher unemployment rates) were associated with lower vaccination rates. CONCLUSIONS Patient age, cancer type, comorbidity, area-level education attainment, and unemployment rates were associated with differential vaccine uptake rates. These findings should inform strategies to communicate about vaccine safety and efficacy to patients with cancer.
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Affiliation(s)
- Dax Kurbegov
- Sarah Cannon Research Institute, Nashville, Tennessee, USA
| | | | | | | | | | | | - Kathryn F Mileham
- Atrium Health-Levine Cancer Institute, Charlotte, North Carolina, USA
| | - Alicia Patrick
- Atrium Health-Levine Cancer Institute, Charlotte, North Carolina, USA
| | | | | | - Julie R Gralow
- American Society of Clinical Oncology, Alexandria, Virginia, USA
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Ivanina Foureau AV, Sha W, Foureau DM, Symanowski JT, Farhangfar CJ, Mileham KF. Landscape and clinical impact of metabolic alterations in non-squamous non-small cell lung cancer. Transl Lung Cancer Res 2022; 11:2464-2476. [PMID: 36636422 PMCID: PMC9830272 DOI: 10.21037/tlcr-22-377] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Accepted: 11/06/2022] [Indexed: 12/24/2022]
Abstract
Background Metabolomics studies to date have described widespread metabolic reprogramming events during the development of non-squamous non-small cell lung cancer (NSCLC). Extending far beyond the Warburg effect, not only is carbohydrate metabolism affected, but also metabolism of amino acids, cofactors, lipids, and nucleotides. Methods We evaluated the clinical impact of metabolic reprogramming. We performed comparative analysis of publicly available data on non-squamous NSCLC, to identify concensus altered metabolic pathways. We investigated whether alterations of metabolic genes controlling those consensus metabolic pathways impacted clinical outcome. Using the clinically annotated lung adenocarcinoma (LUAD) cohort from The Cancer Genome Atlas, we surveyed the distribution and frequency of function-altering mutations in metabolic genes and their impact on overall survival (OS). Results We identified 42 metabolic genes of clinical significance, the majority of which (37 of 42) clustered across three metabolic superpathways (carbohydrates, amino acids, and nucleotides) and most functions (40 of 42) were associated with shorter OS. Multivariate analyses showed that dysfunction of carbohydrate metabolism had the most profound impact on OS [hazard ratio (HR) =5.208; 95% confidence interval (CI): 3.272 to 8.291], false discovery rate (FDR)-P≤0.0001, followed by amino acid metabolism (HR =3.346; 95% CI: 2.129 to 5.258), FDR-P≤0.0001 and nucleotide metabolism (HR =2.578; 95% CI: 1.598 to 4.159), FDR-P=0.0001. The deleterious effect of metabolic reprogramming on non-squamous NSCLC was observed independently of disease stage and across treatments groups. Conclusions By providing a detailed landscape of metabolic alterations in non-squamous NSCLC, our findings offer new insights in the biology of the disease and metabolic adaptation mechanisms of clinical significance.
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Affiliation(s)
| | - Wei Sha
- Cancer Biostatistics, Levine Cancer Institute, Atrium Health, Charlotte, NC, USA
| | - David M. Foureau
- Translational Research, Levine Cancer Institute, Atrium Health, Charlotte, NC, USA
| | - James T. Symanowski
- Cancer Biostatistics, Levine Cancer Institute, Atrium Health, Charlotte, NC, USA
| | - Carol J. Farhangfar
- Translational Research, Levine Cancer Institute, Atrium Health, Charlotte, NC, USA
| | - Kathryn F. Mileham
- Thoracic Medical Oncology, Levine Cancer Institute, Atrium Health, Charlotte, NC, USA
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Farhangfar CJ, Scarola GT, Morris VA, Farhangfar F, Dumas K, Symanowski J, Hwang JJ, Mileham KF, Carrizosa DR, Naumann RW, Livasy C, Kim ES, Raghavan D. Impact of a Clinical Genomics Program on Trial Accrual for Targeted Treatments: Practical Approach Overcoming Barriers to Accrual for Underserved Patients. JCO Clin Cancer Inform 2022; 6:e2200011. [PMID: 35839431 DOI: 10.1200/cci.22.00011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Clinical trials of novel and targeted agents increasingly require biomarkers for eligibility. Precision oncology continues to evolve, but challenges hamper broad use of molecular profiling (MP) that could increase the number of patients benefiting from targeted therapy. We implemented an integrated clinical genomics program (CGP), including a virtual Molecular Tumor Board (MTB), and examined its impact on MP use and impact on clinical trial accrual in a multisite regional-based cancer system with an emphasis on effects for isolated clinicians. METHODS We assessed MP and MTB use from 2010 to 2020 by practice location, physician experience, and patient characteristics. Use of MTB-recommended treatments was assessed. Clinical trial enrollment was evaluated for patients with MP versus MP and MTB review. RESULTS After CGP implementation, the number of physicians using MP and the number of MP tests increased ≥ 10-fold. The proportion of Hispanic patients with MP was the same as that in the system (both 2%) with marginal differences observed in the proportion of African Americans tested compared with the system population (16% v 19%). Physicians followed MTB treatment recommendations in 74% of cases. Rapid clinical decline was the most common reason why physicians did not follow MTB recommendations. Clinical trial accrual was 15% (669 of 4,459) for patients with MP alone and 28% (94 of 334) with both MP and MTB review. Clinical trial availability and patient out-of-pocket costs affected MP use. CONCLUSION Integrating CGP into clinical workflow with decision support tools, trial matching, and management of patient costs led to increased use of MP by physicians with all levels of experience, enhanced clinical trial accrual, and has the potential to reduce disparities in MP.
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Affiliation(s)
- Carol J Farhangfar
- Department of Translational Research, Levine Cancer Institute, Atrium Health, Charlotte, NC
| | - Gregory T Scarola
- Department of Translational Research, Levine Cancer Institute, Atrium Health, Charlotte, NC.,Department of Surgery, Atrium Health, Charlotte, NC
| | - Victoria A Morris
- Department of Information and Analytics Services, Levine Cancer Institute, Atrium Health, Charlotte, NC
| | - Farhang Farhangfar
- Department of Biospecimen Repository, Levine Cancer Institute, Atrium Health, Charlotte, NC
| | - Kathryn Dumas
- Department of Solid Tumor Oncology, Levine Cancer Institute, Atrium Health, Charlotte, NC.,Johns Hopkins Medical Institution, Baltimore, MD
| | - James Symanowski
- Department of Biostatistics, Levine Cancer Institute, Atrium Health, Charlotte, NC
| | - Jimmy J Hwang
- Department of Solid Tumor Oncology, Levine Cancer Institute, Atrium Health, Charlotte, NC
| | - Kathryn F Mileham
- Department of Solid Tumor Oncology, Levine Cancer Institute, Atrium Health, Charlotte, NC
| | - Daniel R Carrizosa
- Department of Solid Tumor Oncology, Levine Cancer Institute, Atrium Health, Charlotte, NC
| | - R Wendel Naumann
- Division of Gynecologic Oncology, Levine Cancer Institute, Atrium Health, Charlotte, NC
| | - Chad Livasy
- Department of Pathology, Levine Cancer Institute, Atrium Health, Charlotte, NC
| | - Edward S Kim
- Department of Solid Tumor Oncology, Levine Cancer Institute, Atrium Health, Charlotte, NC.,City of Hope, National Medical Center, Los Angeles, CA
| | - Derek Raghavan
- Department of Solid Tumor Oncology, Levine Cancer Institute, Atrium Health, Charlotte, NC
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11
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Mileham KF, Rothe M, Mangat PK, Garrett-Mayer E, Yang ES, Alese OB, Jain A, Duvivier HL, Palmbos P, Ahn ER, Aragon-Ching JB, Beekman KW, Behl D, Meric-Bernstam F, Gutierrez R, Sanford A, Thota R, Zakem M, Zhao S, O'Lone R, Grantham GN, Halabi S, Schilsky RL. Abstract CT110: Olaparib (O) in patients (pts) with solid tumors with ATM mutation or deletion: Results from the Targeted Agent and Profiling Utilization Registry (TAPUR) Study. Cancer Res 2022. [DOI: 10.1158/1538-7445.am2022-ct110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
Background: TAPUR is a phase II basket study evaluating anti-tumor activity of commercially available targeted agents in pts with advanced cancers with specific genomic alterations. Results in a cohort of pts with solid tumors with ATM mutation (mut) or deletion (del) treated with O are reported.
Methods: Eligible pts had solid tumors, no standard treatment (tx) options, measurable disease, ECOG Performance Status (PS) 0-2, and adequate organ function. Genomic testing was performed in CLIA-certified, CAP-accredited site selected labs. Pts received O tablets (300mg) or capsules (400mg) orally twice daily until disease progression. Low accruing histology-specific cohorts with the same genomic alteration were collapsed into one histology-pooled cohort for this analysis. Primary endpoint was disease control (DC) (complete (CR) or partial (PR) response or stable disease at 16+ wks (SD16+)) (RECIST v1.1). For histology-specific cohorts a Simon 2-stage design with a null DC rate of 15% vs. 35% (power = 0.85; α = 0.10) requires 28 pts with futility stopping after 10 pts. For histology-pooled cohorts with sample size > 28, if the lower limit of a one-sided 90% CI is >15%, the null hypothesis of a DC rate of 15% is rejected. 2-sided 95% CIs were used for other efficacy endpoint estimates. Secondary endpoints were progression-free survival (PFS), overall survival (OS) and safety.
Results: 39 pts with solid tumors (17 histologies) with ATM mut (n=36) or del (n=3) were enrolled from 6/2016 to 1/2019. 3 pts were unevaluable for efficacy. Table 1 shows demographics and outcomes. 1 CR (prostate), 2 PR (unknown primary) and 6 SD16+ were observed in pts with ATM mut for a DC rate of 25% (90% CI: 16%, 100%) and an OR rate of 8% (95% CI: 2%, 23%). The null DC rate was rejected. 9 pts had ≥1 Grade 3 tx-related adverse or serious adverse event related to O.
Conclusions: Monotherapy O showed evidence of anti-tumor activity in pts with various solid tumors with ATM mut.
Table 1. Demographics and Baseline Characteristics (N=39); Efficacy Outcomes (N=36); Toxicity Outcomes (N=39) Median (Med) age, years (range) 65 (35, 77) Female, % 46 ECOG PS, % 0 33 1 59 2 8 Prior systemic regimens, % 0 3 1 8 2 15 ≥3 74 DC rate, % (OR or SD 16+) (1-sided 90% CI) 25 (16, 100) OR rate, % (95% CI) 8 (2, 23) Med PFS, wks (95% CI) 8.4 (8.0, 15.9) Med OS, wks (95% CI) 40.4 (30.3, 50.7) Med duration OR (range), wks 18.9 (4.3, 24.4) Med duration SD16+ (range), wks 27.3 (19.4, 31.0) Number of pts1 with treatment-related adverse or serious adverse events (all Grade 3) AE2 9 SAE3 4 1Patients may have experienced one or more events2anemia, anorexia, dehydration, fatigue, hypokalemia, nausea 3colitis, dizziness, lung infection, proteinuria, urinary tract infection/obstruction
Citation Format: Kathryn F. Mileham, Michael Rothe, Pam K. Mangat, Elizabeth Garrett-Mayer, Eddy S. Yang, Olatunji B. Alese, Angela Jain, Herbert L. Duvivier, Phillip Palmbos, Eugene R. Ahn, Jeanny B. Aragon-Ching, Kathleen W. Beekman, Deepti Behl, Funda Meric-Bernstam, Rodolfo Gutierrez, Amy Sanford, Ramya Thota, Michael Zakem, Song Zhao, Raegan O'Lone, Gina N. Grantham, Susan Halabi, Richard L. Schilsky. Olaparib (O) in patients (pts) with solid tumors with ATM mutation or deletion: Results from the Targeted Agent and Profiling Utilization Registry (TAPUR) Study [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2022; 2022 Apr 8-13. Philadelphia (PA): AACR; Cancer Res 2022;82(12_Suppl):Abstract nr CT110.
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Affiliation(s)
| | - Michael Rothe
- 2American Society of Clinical Oncology, Alexandria, VA
| | - Pam K. Mangat
- 2American Society of Clinical Oncology, Alexandria, VA
| | | | - Eddy S. Yang
- 3University of Alabama Comprehensive Cancer Center, Birmingham, AL
| | | | | | | | | | - Eugene R. Ahn
- 8Cancer Treatment Centers of America Chicago, Zion, IL
| | | | | | - Deepti Behl
- 11Sutter Sacramento Medical Center, Sacramento, CA
| | | | - Rodolfo Gutierrez
- 13The Angeles Clinic and Research Institute, Cedars Sinai Affiliate, Santa Monica, CA
| | | | | | | | - Song Zhao
- 17Swedish Cancer Institute, Seattle, WA
| | - Raegan O'Lone
- 2American Society of Clinical Oncology, Alexandria, VA
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12
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Mileham KF, Schenkel C, Bruinooge SS, Freeman‐Daily J, Basu Roy U, Moore A, Smith RA, Garrett‐Mayer E, Rosenthal L, Garon EB, Johnson BE, Osarogiagbon RU, Jalal S, Virani S, Weber Redman M, Silvestri GA. Defining comprehensive biomarker-related testing and treatment practices for advanced non-small-cell lung cancer: Results of a survey of U.S. oncologists. Cancer Med 2022; 11:530-538. [PMID: 34921524 PMCID: PMC8729042 DOI: 10.1002/cam4.4459] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2021] [Revised: 11/10/2021] [Accepted: 11/18/2021] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND An ASCO taskforce comprised of representatives of oncology clinicians, the American Cancer Society National Lung Cancer Roundtable (NLCRT), LUNGevity, the GO2 Foundation for Lung Cancer, and the ROS1ders sought to: characterize U.S. oncologists' biomarker ordering and treatment practices for advanced non-small-cell lung cancer (NSCLC); ascertain barriers to biomarker testing; and understand the impact of delays on treatment decisions. METHODS We deployed a survey to 2374 ASCO members, targeting U.S. thoracic and general oncologists. RESULTS We analyzed 170 eligible responses. For non-squamous NSCLC, 97% of respondents reported ordering tests for EGFR, ALK, ROS1, and BRAF. Testing for MET, RET, and NTRK was reported to be higher among academic versus community providers and higher among thoracic oncologists than generalists. Most respondents considered 1 (46%) or 2 weeks (52%) an acceptable turnaround time, yet 37% usually waited three or more weeks to receive results. Respondents who waited ≥3 weeks were more likely to defer treatment until results were reviewed (63%). Community and generalist respondents who waited ≥3 weeks were more likely to initiate non-targeted treatment while awaiting results. Respondents <5 years out of training were more likely to cite their concerns about waiting for results as a reason for not ordering biomarker testing (42%, vs. 19% with ≥6 years of experience). CONCLUSIONS Respondents reported high biomarker testing rates in patients with NSCLC. Treatment decisions were impacted by test turnaround time and associated with practice setting and physician specialization and experience.
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Affiliation(s)
| | | | | | | | | | - Amy Moore
- LUNGevity FoundationChicagoIllinoisUSA
| | - Robert A. Smith
- American Cancer Society National Lung Cancer RoundtableAtlantaGeorgiaUSA
| | | | - Lauren Rosenthal
- American Cancer Society National Lung Cancer RoundtableAtlantaGeorgiaUSA
| | - Edward B. Garon
- University of California Los Angeles David Geffen School of MedicineLos AngelesCaliforniaUSA
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13
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Mileham KF, Bruinooge SS, Aggarwal C, Patrick AL, Davis C, Mesenhowski DJ, Spira A, Clayton EJ, Waterhouse D, Moore S, Jazieh AR, Chen RC, Kaltenbaugh M, Williams JH, Gralow JR, Schilsky RL, Garrett-Mayer E. Changes Over Time in COVID-19 Severity and Mortality in Patients Undergoing Cancer Treatment in the United States: Initial Report From the ASCO Registry. JCO Oncol Pract 2021; 18:e426-e441. [PMID: 34694907 PMCID: PMC9014452 DOI: 10.1200/op.21.00394] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
PURPOSE People with cancer are at increased risk for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. ASCO's COVID-19 registry promotes systematic data collection across US oncology practices. METHODS Participating practices enter data on patients with SARS-CoV-2 infection in cancer treatment. In this analysis, we focus on all patients with hematologic or regional or metastatic solid tumor malignancies. Primary outcomes are 30- and 90-day mortality rates and change over time. RESULTS Thirty-eight practices provided data for 453 patients from April to October 2020. Sixty-two percent had regional or metastatic solid tumors. Median age was 64 years. Forty-three percent were current or previous cigarette users. Patients with B-cell malignancies age 61-70 years had twice mortality risk (hazard ratio = 2.1 [95% CI, 1.3 to 3.3]) and those age > 70 years had 4.5 times mortality risk (95% CI, 1.8 to 11.1) compared with patients age ≤ 60 years. Association between survival and age was not significant in patients with metastatic solid tumors (P = .12). Tobacco users had 30-day mortality estimate of 21% compared with 11% for never users (log-rank P = .005). Patients diagnosed with SARS-CoV-2 before June 2020 had 30-day mortality rate of 20% (95% CI, 14% to 25%) compared with 13% (8% to 18%) for those diagnosed in or after June 2020 (P = .08). The 90-day mortality rate for pre-June patients was 28% (21% to 34%) compared with 21% (13% to 28%; P = .20). CONCLUSION Older patients with B-cell malignancies were at increased risk for death (unlike older patients with metastatic solid tumors), as were all patients with cancer who smoke tobacco. Diagnosis of SARS-CoV-2 later in 2020 was associated with more favorable 30- and 90-day mortality, likely related to more asymptomatic cases and improved clinical management.
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Affiliation(s)
| | | | - Charu Aggarwal
- University of Pennsylvania School of Medicine, Abramson Cancer Center, Philadelphia, PA
| | | | - Christiana Davis
- University of Pennsylvania School of Medicine, Abramson Cancer Center, Philadelphia, PA
| | | | - Alexander Spira
- Virginia Cancer Specialists, US Oncology Research, Johns Hopkins Oncology, Fairfax, VA
| | - Eric J Clayton
- OHC, Cincinnati OH/an Affiliate of US Oncology, Cincinnati, OH
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14
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Heinzerling JH, Mileham KF, Simone CB. The utilization of immunotherapy with radiation therapy in lung cancer: a narrative review. Transl Cancer Res 2021; 10:2596-2608. [PMID: 35116573 PMCID: PMC8797746 DOI: 10.21037/tcr-20-2241] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2020] [Accepted: 09/20/2020] [Indexed: 12/13/2022]
Abstract
Despite decreasing smoking rates, lung cancer remains the leading cause of death from cancer in the United States. Radiation therapy has been established as an effective locoregional therapy for both early stage and locally advanced disease and is known to stimulate local immune response. Past treatment paradigms have established the role of combining cytotoxic chemotherapy regimens and radiation therapy to help address the local and systemic nature of lung cancer. However, these regimens have limitations in their tolerability due to toxicity. Additionally, cytotoxic chemotherapy has limited efficacy in preventing systemic spread of lung cancer. Newer systemic agents such as immune checkpoint inhibitors have shown improved survival in metastatic and locally advanced lung cancer and have the advantage of more limited toxicity profiles compared to cytotoxic chemotherapy. Furthermore, improved overall response rates and systemic tumor responses have been observed with the combination of radiation therapy and immunotherapy, leading to numerous active clinical trials evaluating the combination of immune checkpoint inhibition with radiotherapy. This comprehensive review discusses the current clinical data and ongoing studies evaluating the combination of radiation therapy and immunotherapy in both non-small cell lung cancer (NSCLC) and small cell lung cancer (SCLC).
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Affiliation(s)
- John H. Heinzerling
- Levine Cancer Institute, Atrium Health, Southeast Radiation Oncology, Charlotte, NC, USA
| | | | - Charles B. Simone
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- New York Proton Center, New York, NY, USA
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15
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Smith SM, Wachter K, Burris HA, Schilsky RL, George DJ, Peterson DE, Johnson ML, Markham MJ, Mileham KF, Beg MS, Bendell JC, Dreicer R, Keedy VL, Kimple RJ, Knoll MA, LoConte N, MacKay H, Meisel JL, Moynihan TJ, Mulrooney DA, Mulvey TM, Odenike O, Pennell NA, Reeder-Hayes K, Smith C, Sullivan RJ, Uzzo R. Clinical Cancer Advances 2021: ASCO's Report on Progress Against Cancer. J Clin Oncol 2021; 39:1165-1184. [DOI: 10.1200/jco.20.03420] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Affiliation(s)
| | - Kerri Wachter
- American Society of Clinical Oncology, Alexandria, VA
| | | | | | | | | | | | | | | | | | | | - Robert Dreicer
- University of Virginia Cancer Center, Charlottesville, VA
| | | | | | | | - Noelle LoConte
- University of Wisconsin Carbone Cancer Center, Madison, WI
| | - Helen MacKay
- Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | | | | | | | | | | | | | - Katherine Reeder-Hayes
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC
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16
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Harvey RD, Mileham KF, Bhatnagar V, Brewer JR, Rahman A, Moravek C, Kennedy AS, Ness EA, Dees EC, Ivy SP, Ebbinghaus SW, Schenkel C, Uldrick TS. Modernizing Clinical Trial Eligibility Criteria: Recommendations of the ASCO-Friends of Cancer Research Washout Period and Concomitant Medication Work Group. Clin Cancer Res 2021; 27:2400-2407. [PMID: 33563635 DOI: 10.1158/1078-0432.ccr-20-3855] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Revised: 11/25/2020] [Accepted: 12/14/2020] [Indexed: 11/16/2022]
Abstract
PURPOSE Washout periods and concomitant medication exclusions are common in cancer clinical trial protocols. These exclusion criteria are often applied inconsistently and without evidence to justify their use. The authors sought to determine how washout period and concomitant medication allowances can be broadened to speed trial enrollment and improve the generalizability of trial data to a larger oncology practice population without compromising the safety of trial participants. EXPERIMENTAL DESIGN A multistakeholder working group was convened to define problems associated with excessively long washout periods and exclusion of patients due to concomitant medications. The group performed a literature search and evaluated study data from the Pancreatic Cancer Action Network (PanCAN), Emory University School of Medicine (Atlanta, GA), and the FDA to understand recent approaches to these eligibility criteria. The group convened to develop consensus recommendations for broadened eligibility criteria. RESULTS The data analysis found that exclusion criteria based on washout periods and concomitant medications are frequently inconsistent and lack scientific rationale. Scientific rationale for appropriate eligibility criteria are presented in the article; for washout periods, rationale is presented by treatment type. CONCLUSIONS Arbitrary or blanket washout and concomitant medication exclusions should be eliminated. Where there is evidence to support them, clinically relevant washout periods and concomitant medication-related eligibility criteria may be included.See related commentary by Giantonio, p. 2369.
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Affiliation(s)
| | | | | | | | | | | | | | | | - E Claire Dees
- UNC Lineberger Comprehensive Cancer Center, Chapel Hill, North Carolina
| | - S Percy Ivy
- NCI Cancer Therapy Evaluation Program, Bethesda, Maryland
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17
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Mileham KF, Schenkel C, Chuk MK, Buchmeier A, Perez RP, Hurley P, Levit LA, Garrett-Mayer E, Davis C, Bruinooge SS, Vose J. Assessing an ASCO Decision Aid for Improving the Accuracy and Attribution of Serious Adverse Event Reporting From Investigators to Sponsors. J Oncol Pract 2019; 15:e1050-e1065. [DOI: 10.1200/jop.19.00366] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE: Investigators often send reports to sponsors that incorrectly categorize adverse event (AE)s as serious or attribute AEs to investigational drugs. Such errors can contribute to high volumes of uninformative investigational new drug safety reports that sponsors submit to the US Food and Drug Administration and participating investigators, which strain resources and impede the detection of valid safety signals. To improve the quality of serious AE (SAE) reporting by physician-investigators and research staff, ASCO developed and tested a Decision Aid. METHODS: A preliminary study with crossover design was conducted in a convenience sample. Physician-investigators and research staff were randomly assigned to receive case studies. Case studies were assessed for seriousness and attribution, first unassisted and then with the Decision Aid. Participants completed a feedback survey about the Decision Aid. Effectiveness of reporting and attribution are reported as odds ratios (ORs) with 95% CI. Power to detect associations was limited because of a small sample size. RESULTS: The Decision Aid did not significantly affect accuracy of determining seriousness (OR, 0.87; 95% CI, 0.31 to 2.46), but it did significantly increase accuracy of attributing an SAE to a drug (OR, 3.60; 95% CI, 1.15 to 11.4). Most of the 29 participants reported that the Decision Aid was helpful (93%) and improved decision-making time (69%) and confidence in reporting (83%), and that they would use the Decision Aid in practice (83%). CONCLUSION: The Decision Aid shows promise as a method to improve the quality of SAE attribution, which may improve the detection of valid safety signals and reduce the administrative burden of uninformative investigational new drug safety reports. Study of the Decision Aid in a larger sample with analysis stratified by participant role and SAE reporting experience would further assess the tool’s impact.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | - Julie Vose
- University of Nebraska Medical Center, Omaha, NE
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18
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Raghavan D, Wheeler M, Doege D, Doty JD, Levy H, Dungan KA, Davis LM, Robinson JM, Kim ES, Mileham KF, Oliver J, Carrizosa D. Initial Results from Mobile Low-Dose Computerized Tomographic Lung Cancer Screening Unit: Improved Outcomes for Underserved Populations. Oncologist 2019; 25:e777-e781. [PMID: 31771991 PMCID: PMC7216453 DOI: 10.1634/theoncologist.2019-0802] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2019] [Accepted: 10/23/2019] [Indexed: 12/26/2022] Open
Abstract
Introduction The National Lung Screening Trial (NLST) demonstrated that screening high‐risk patients with low‐dose computed tomography (CT) of the chest reduces lung cancer mortality compared with screening with chest x‐ray. Uninsured and Medicaid patients usually lack access to this hospital‐based screening test because of geographic and socioeconomic factors. We hypothesized that a mobile screening unit would improve access and confer the benefits demonstrated by the NLST to this underserved group, which is most at risk of lung cancer deaths. Patients and Methods We created a mobile unit by building a Samsung BodyTom portable 32‐slice low‐dose CT scanner into a 35‐foot coach; it delivers high‐quality images for both soft tissue and bone and includes a waiting area and high‐speed wireless internet connection for fast image transfer. The unit was extensively tested to show robustness and stability of mobile equipment. This project was designed to screen uninsured and underinsured patients, otherwise with eligibility criteria identical to that of the National Lung Screening Trial, with the only difference being exclusion of patients eligible for Medicare (which provides financial coverage for CT‐based lung cancer screening). Results We screened 550 patients (20% black, 3% Hispanic, 70% rural) with a male‐to‐female ratio of 1.1:1, median age 61 years (range, 55–64), and found 12 lung cancers at initial screen (2.2%), including 6 at stage I–II (58% of total lung cancers early stage) and 38 Lung‐RADS 4 (highly suspicious) lesions that are being followed closely. Incidental findings included nonlung cancers and coronary artery disease. Discussion In this initial pilot study, using the first mobile low‐dose whole body CT screening unit in the U.S., the initial cancer detection rate is comparable to that reported in the NLST, despite excluding patients over the age of 64 years who have Medicare coverage, but with marked improvement of screening rates specifically in underserved sociodemographic, racial, and ethnic groups and with better outcomes than conventionally found in the underserved and at lower cost per case. Implications for Practice This study shows clearly that a mobile low‐dose CT scanning unit allows effective lung cancer screening for underserved populations, such as impoverished African Americans, Hispanics, Native Americans, or isolated rural groups, and has a pick‐up rate of 1% for early stage disease. If confirmed in a planned randomized trial, this will be policy changing, as these groups usually present with advanced disease; this approach will produce better survival data at lower cost per case. The BodyTom CT is the first mobile screening unit in the U.S., designed to improve access to lung cancer screening for underserved patient groups. This article reports results of the initial pilot study using this first‐of‐its‐kind mobile low‐dose whole body CT screening unit. Twelve cases of lung cancer were found in 550 smokers (including 6 early stage).
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Affiliation(s)
- Derek Raghavan
- Levine Cancer Institute/Atrium Health SystemCharlotteNorth CarolinaUSA
| | - Mellisa Wheeler
- Levine Cancer Institute/Atrium Health SystemCharlotteNorth CarolinaUSA
| | - Darcy Doege
- Levine Cancer Institute/Atrium Health SystemCharlotteNorth CarolinaUSA
| | - John D. Doty
- Levine Cancer Institute/Atrium Health SystemCharlotteNorth CarolinaUSA
| | - Henri Levy
- Levine Cancer Institute/Atrium Health SystemCharlotteNorth CarolinaUSA
| | - Kia A. Dungan
- Levine Cancer Institute/Atrium Health SystemCharlotteNorth CarolinaUSA
| | - Lauren M. Davis
- Levine Cancer Institute/Atrium Health SystemCharlotteNorth CarolinaUSA
| | - James M. Robinson
- Levine Cancer Institute/Atrium Health SystemCharlotteNorth CarolinaUSA
| | - Edward S. Kim
- Levine Cancer Institute/Atrium Health SystemCharlotteNorth CarolinaUSA
| | | | - James Oliver
- Levine Cancer Institute/Atrium Health SystemCharlotteNorth CarolinaUSA
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Oxnard GR, Hu Y, Mileham KF, Husain H, Costa DB, Tracy P, Feeney N, Sholl LM, Dahlberg SE, Redig AJ, Kwiatkowski DJ, Rabin MS, Paweletz CP, Thress KS, Jänne PA. Assessment of Resistance Mechanisms and Clinical Implications in Patients With EGFR T790M-Positive Lung Cancer and Acquired Resistance to Osimertinib. JAMA Oncol 2019; 4:1527-1534. [PMID: 30073261 DOI: 10.1001/jamaoncol.2018.2969] [Citation(s) in RCA: 473] [Impact Index Per Article: 94.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
Importance Osimertinib mesylate is used globally to treat EGFR-mutant non-small cell lung cancer (NSCLC) with tyrosine kinase inhibitor resistance mediated by the EGFR T790M mutation. Acquired resistance to osimertinib is a growing clinical challenge that is poorly understood. Objective To understand the molecular mechanisms of acquired resistance to osimertinib and their clinical behavior. Design, Setting, and Participants Patients with advanced NSCLC who received osimertinib for T790M-positive acquired resistance to prior EGFR tyrosine kinase inhibitor were identified from a multi-institutional cohort (n = 143) and a confirmatory trial cohort (NCT01802632) (n = 110). Next-generation sequencing of tumor biopsies after osimertinib resistance was performed. Genotyping of plasma cell-free DNA was studied as an orthogonal approach, including serial plasma samples when available. The study and analysis were finalized on November 9, 2017. Main Outcomes and Measures Mechanisms of resistance and their association with time to treatment discontinuation on osimertinib. Results Of the 143 patients evaluated, 41 (28 [68%] women) had tumor next-generation sequencing after acquired resistance to osimertinib. Among 13 patients (32%) with maintained T790M at the time of resistance, EGFR C797S was seen in 9 patients (22%). Among 28 individuals (68%) with loss of T790M, a range of competing resistance mechanisms was detected, including novel mechanisms such as acquired KRAS mutations and targetable gene fusions. Time to treatment discontinuation was shorter in patients with T790M loss (6.1 vs 15.2 months), suggesting emergence of pre-existing resistant clones; this finding was confirmed in a validation cohort of 110 patients with plasma cell-free DNA genotyping performed after osimertinib resistance. In studies of serial plasma levels of mutant EGFR, loss of T790M at resistance was associated with a smaller decrease in levels of the EGFR driver mutation after 1 to 3 weeks of therapy (100% vs 83% decrease; P = .01). Conclusions and Relevance Acquired resistance to osimertinib mediated by loss of the T790M mutation is associated with early resistance and a range of competing resistance mechanisms. These data provide clinical evidence of the heterogeneity of resistance in advanced NSCLC and a need for clinical trial strategies that can overcome multiple concomitant resistance mechanisms or strategies for preventing such resistance.
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Affiliation(s)
- Geoffrey R Oxnard
- Lowe Center for Thoracic Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts.,Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Yuebi Hu
- Lowe Center for Thoracic Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Kathryn F Mileham
- Levine Cancer Institute, Carolinas HealthCare System, Charlotte, North Carolina
| | - Hatim Husain
- Moores Cancer Center, University of California San Diego, La Jolla
| | - Daniel B Costa
- Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Philip Tracy
- Lowe Center for Thoracic Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts.,Medical student, Tufts University School of Medicine, Boston, Massachusetts
| | - Nora Feeney
- Belfer Center for Applied Cancer Science, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Lynette M Sholl
- Department of Pathology, Brigham and Women's Hospital, Boston, Massachusetts
| | - Suzanne E Dahlberg
- Lowe Center for Thoracic Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Amanda J Redig
- Lowe Center for Thoracic Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts.,Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - David J Kwiatkowski
- Lowe Center for Thoracic Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts.,Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Michael S Rabin
- Lowe Center for Thoracic Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts.,Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Cloud P Paweletz
- Belfer Center for Applied Cancer Science, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Kenneth S Thress
- Translational Sciences, Oncology IMED Biotech Unit, AstraZeneca, Boston, Massachusetts
| | - Pasi A Jänne
- Lowe Center for Thoracic Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts.,Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts.,Belfer Center for Applied Cancer Science, Dana-Farber Cancer Institute, Boston, Massachusetts
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Mileham KF, Ahmad MN, Kim ES. Targeted Therapy for Mutation-Driven Metastatic Non-Small-Cell Lung Cancer: Considerations for ALK-Rearranged Tumors. Oncology (Williston Park) 2019; 33:152-155. [PMID: 30990569] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
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Affiliation(s)
- Sheenu Sheela
- Department of Solid Tumor Oncology, Levine Cancer Institute, Atrium Health, Charlotte, NC, USA
| | - Edward S Kim
- Department of Solid Tumor Oncology, Levine Cancer Institute, Atrium Health, Charlotte, NC, USA
| | - Kathryn F Mileham
- Department of Solid Tumor Oncology, Levine Cancer Institute, Atrium Health, Charlotte, NC, USA
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Tsimberidou AM, Levit LA, Schilsky RL, Averbuch SD, Chen D, Kirkwood JM, McShane LM, Sharon E, Mileham KF, Postow MA. Trial Reporting in Immuno-Oncology (TRIO): An American Society of Clinical Oncology-Society for Immunotherapy of Cancer Statement. J Clin Oncol 2018; 37:72-80. [PMID: 30339040 DOI: 10.1200/jco.18.00145] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
PURPOSE To develop recommendations for clinical trial reporting that address the unique efficacy, toxicity, and combination and sequencing aspects of immuno-oncology (IO) treatments. METHODS ASCO and the Society for Immunotherapy of Cancer (SITC) convened a working group that consisted of practicing medical oncologists, immunologists, clinical researchers, biostatisticians, and representatives from industry and government to develop Trial Reporting in Immuno-Oncology (TRIO) recommendations. These recommendations are based on expert consensus, given that existing data to support evidence-based recommendations are limited. CONCLUSION The TRIO recommendations are intended to improve the reporting of IO clinical trials and thus provide more complete evidence on the relative benefits and risks of an IO therapeutic approach. Given the rapid expansion of the number of IO clinical trials and ongoing improvements to the evidence base supporting the use of IO treatments in clinical care, these recommendations will likely need regular revision as the IO field develops.
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Affiliation(s)
| | - Laura A Levit
- 2 American Society of Clinical Oncology, Alexandria, VA
| | | | | | | | | | | | | | | | - Michael A Postow
- 8 Memorial Sloan Kettering Cancer Center and Weill Cornell Medical College, New York, NY
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Tsimberidou AM, Levit LA, Schilsky RL, Averbuch SD, Chen D, Kirkwood JM, McShane LM, Sharon E, Mileham KF, Postow MA. Trial Reporting in Immuno-Oncology (TRIO): an American society of clinical oncology-society for immunotherapy of cancer statement. J Immunother Cancer 2018; 6:108. [PMID: 30340549 PMCID: PMC6195705 DOI: 10.1186/s40425-018-0426-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2018] [Accepted: 10/09/2018] [Indexed: 01/08/2023] Open
Abstract
Purpose To develop recommendations for clinical trial reporting that address the unique efficacy, toxicity, and combination and sequencing aspects of immuno-oncology (IO) treatments. Methods ASCO and the Society for Immunotherapy of Cancer (SITC) convened a working group that consisted of practicing medical oncologists, immunologists, clinical researchers, biostatisticians, and representatives from industry and government to develop Trial Reporting in Immuno-Oncology (TRIO) recommendations. These recommendations are based on expert consensus, given that existing data to support evidence-based recommendations are limited. Conclusion The TRIO recommendations are intended to improve the reporting of IO clinical trials and thus provide more complete evidence on the relative benefits and risks of an IO therapeutic approach. Given the rapid expansion of the number of IO clinical trials and ongoing improvements to the evidence base supporting the use of IO treatments in clinical care, these recommendations will likely need regular revision as the IO field develops.
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Affiliation(s)
| | - Laura A Levit
- American Society of Clinical Oncology, 2318 Mill Rd, Alexandria, VA, 22314, USA.
| | - Richard L Schilsky
- American Society of Clinical Oncology, 2318 Mill Rd, Alexandria, VA, 22314, USA
| | | | | | - John M Kirkwood
- University of Pittsburgh Cancer Institute, Pittsburgh, PA, USA
| | | | - Elad Sharon
- National Cancer Institute, Bethesda, MD, USA
| | | | - Michael A Postow
- Memorial Sloan Kettering Cancer Center and Weill Cornell Medical College, New York, NY, USA
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Abstract
Accrual continues to be a challenge for oncology clinical trials. Interventions to enhance accrual after study activation exist, including corrective action plans for NCI-sponsored trials. Clinical trials would benefit from a proactive approach rather than a reactive approach. Accrual strategy planning early in trial development is suggested. Clin Cancer Res; 22(22); 5397-9. ©2016 AACRSee related article by Massett et al., p. 5408.
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Affiliation(s)
- Kathryn F Mileham
- Department of Solid Tumor Oncology and Investigational Therapeutics, Levine Cancer Institute, Carolinas HealthCare System, Charlotte, North Carolina
| | - Edward S Kim
- Department of Solid Tumor Oncology and Investigational Therapeutics, Levine Cancer Institute, Carolinas HealthCare System, Charlotte, North Carolina.
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Abstract
Lung cancer remains the single deadliest cancer both in the US and worldwide. The great majority of squamous cell carcinoma (SCC) is attributed to cigarette smoking, which fortunately is declining alongside cancer incidence. While we have been at a therapeutic plateau for advanced squamous cell lung cancer patients for several decades, recent observations suggest that we are on the verge of seeing incremental survival improvements for this relatively large group of patients. Current studies have confirmed an expanding role for immunotherapy [including programmed cell death-1 (PD-1)/programmed cell death ligand 1 (PD-L1) and cytotoxic T-lymphocyte-associated protein 4 (CTLA-4) inhibition], a potential opportunity for VEGFR inhibition, and even future targets in fibroblast growth factor receptor (FGFR) and PI3K-AKT that collectively should improve survival as well as quality of life for those affected by squamous cell lung cancer over the next decade.
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Affiliation(s)
- Benjamin A Derman
- 1 Department of Internal Medicine, Rush University Medical Center, Chicago, IL, USA ; 2 Levine Cancer Institute, Carolinas HealthCare System, Charlotte, NC, USA ; 3 Section of Medical Oncology, Rush University Medical Center, Chicago, IL, USA
| | - Kathryn F Mileham
- 1 Department of Internal Medicine, Rush University Medical Center, Chicago, IL, USA ; 2 Levine Cancer Institute, Carolinas HealthCare System, Charlotte, NC, USA ; 3 Section of Medical Oncology, Rush University Medical Center, Chicago, IL, USA
| | - Philip D Bonomi
- 1 Department of Internal Medicine, Rush University Medical Center, Chicago, IL, USA ; 2 Levine Cancer Institute, Carolinas HealthCare System, Charlotte, NC, USA ; 3 Section of Medical Oncology, Rush University Medical Center, Chicago, IL, USA
| | - Marta Batus
- 1 Department of Internal Medicine, Rush University Medical Center, Chicago, IL, USA ; 2 Levine Cancer Institute, Carolinas HealthCare System, Charlotte, NC, USA ; 3 Section of Medical Oncology, Rush University Medical Center, Chicago, IL, USA
| | - Mary J Fidler
- 1 Department of Internal Medicine, Rush University Medical Center, Chicago, IL, USA ; 2 Levine Cancer Institute, Carolinas HealthCare System, Charlotte, NC, USA ; 3 Section of Medical Oncology, Rush University Medical Center, Chicago, IL, USA
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Mileham KF, Zhang Q, Farhangfar CJ, Haggstrom DE, Fairclough S, Zill OA, Carrizosa DR, Lanman RB, Kim ES. Abstract C80: Development of EGFR C797S mutation in serial liquid biopsy assessments in the clinical practice setting. Mol Cancer Ther 2015. [DOI: 10.1158/1535-7163.targ-15-c80] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
Introduction: EGFR T790M has emerged as an important biomarker to predict response to 3rd-generation tyrosine kinase inhibitors (TKI). Therapies such as AZD 9291 and Rociletinib demonstrated impressive results in the clinical setting in patients with non-small cell lung cancer (NSCLC). However just as this resistance biomarker (T790M) has developed as a result of treatment with prior EGFR TKIs, EGFR C797S mutation is an acquired resistance mechanism to EGFR T790M inhibitors. This mutation was recently reported for the first time in clinical practice utilizing tissue-biopsy based next generation sequencing (NGS) and in the clinical trial setting in cell-free circulating DNA (cfDNA). Here we report the first case of a patient with NSCLC and emergence of C797S mutation utilizing a cfDNA biopsy-free NGS panel in serial assessments in the clinical setting.
Methods: Patients with NSCLC were seen at Levine Cancer Institute and had serial blood draws to assess molecular aberrations in cfDNA over time for comparison with radiographic reviews. Blood samples were sent to Guardant360 for assessment by NGS with a targeted cfDNA NGS panel for 68 genes with complete exon sequencing for all 28 exons in EGFR, and other genes in the panel. Mutant allele fractions (MAF) are reported as% of mutant DNA molecules divided by total molecules (mostly leukocyte DNA-derived) overlapping the same mutated nucleotide base position.
Results: A 50 year old African-American female never-smoker with lung adenocarcinoma developed a tissue-biopsy confirmed EGFR T790M mutation after 12 months on erlotinib for EGFR exon 19 deletion. She had significant clinical and radiographic responses to a 3rd generation TKI started May 2014. cfDNA NGS tests in March and April 2015 showed no genomic alterations detectable. In late May 2015, she developed clinical symptoms of cough, dyspnea and fatigue but no definitive radiographic evidence of progression on scans June 2015. She received steroids and antibiotics and continued treatment with the 3rd generation TKI. However, corresponding cfDNA NGS testing revealed emergence of multiple low level mutations and the original deletion in EGFR (EGFR L747_P753 DelInsS, T790M, C797S, and A755G variant of uncertain significance) and TP53 (all <1.1%). Repeat scans in July 2015 demonstrated clear progression of disease and a fourth cfDNA NGS test showed a rise in all low level aberrations previously detected in cfDNA: EGFR A755G 4.2%, TP53 P278R 3.6%, EGFR T790M 3.1%, EGFR L747_P753 DelInsS 2.9%, EGFR C797S 1.4%. NGS indicated that there may be 2 clones present for EGFR C797S but confirmation is required as disease progresses.
Discussion: Complete exon sequencing of cfDNA upon clinical progression uncovered the simultaneous re-emergence of the original driver EGFR exon 19 del and resistance driver mutation EGFR T790M as well as the emergence of the next resistance driver mutation EGFR C797S. The latter mutation interferes with covalent binding of a 3rd generation TKI and under treatment pressure, the tumor appears to have simultaneously evolved two different EGFR C797S clones at low MAFs. cfDNA can be a dynamic measure of tumor response, easily obtained from a patient on any visit with potential for detection before macroscopic/radiographic evidence of progression, as demonstrated in this case with tumor evolution of the EGFR T790M and C797S alterations.
Citation Format: Kathryn F. Mileham, Qing Zhang, Carol J. Farhangfar, Daniel E. Haggstrom, Stephen Fairclough, Oliver A. Zill, Daniel R. Carrizosa, Richard B. Lanman, Edward S. Kim. Development of EGFR C797S mutation in serial liquid biopsy assessments in the clinical practice setting. [abstract]. In: Proceedings of the AACR-NCI-EORTC International Conference: Molecular Targets and Cancer Therapeutics; 2015 Nov 5-9; Boston, MA. Philadelphia (PA): AACR; Mol Cancer Ther 2015;14(12 Suppl 2):Abstract nr C80.
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Mileham KF, Kim ES, William WN. EGFR Tyrosine Kinase Inhibitors and Monoclonal Antibodies: Clinical Trial Review. Lung Cancer 2014. [DOI: 10.1002/9781118468791.ch26] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
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Carrizosa DR, Mileham KF, Haggstrom DE. New targets and new mechanisms in lung cancer. Oncology (Williston Park) 2013; 27:396-404. [PMID: 25184262] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
With the advent of the importance of histology in non-small-cell lung cancer (NSCLC) and the development of targeted agents that work on newly found mutations, the field of lung cancer therapy has greatly changed. In addition to new uses of chemotherapeutics and targeted agents, the possibilities of immunotherapy are also being explored. This review will describe the well-known use of vascular endothelial growth factor (VEGF) antibodies; the current uses of epidermal growth factor receptor (EGFR) and anaplastic lymphoma kinase (ALK) tyrosine kinase inhibitors; newer agents being used against MET, fibroblast growth factor receptor (FGFR), and other intracellular targets; insights regarding the field of immunotherapy in lung cancer; and finally, newer developments in chemotherapy.
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Affiliation(s)
- Daniel R Carrizosa
- Levine Cancer Institute, Carolinas HealthCare System, Charlotte, North Carolina, USA
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