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Ebrahimi H, Megally S, Plotkin E, Shivakumar L, Salgia NJ, Zengin ZB, Meza L, Chawla N, Castro DV, Dizman N, Bhagat R, Liv S, Li X, Rock A, Liu S, Tripathi A, Dorff T, Oyer RA, Boehmer L, Pal S, Chehrazi-Raffle A. Barriers to Clinical Trial Implementation Among Community Care Centers. JAMA Netw Open 2024; 7:e248739. [PMID: 38683608 PMCID: PMC11059033 DOI: 10.1001/jamanetworkopen.2024.8739] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2023] [Accepted: 02/28/2024] [Indexed: 05/01/2024] Open
Abstract
Importance While an overwhelming majority of patients diagnosed with cancer express willingness to participate in clinical trials, only a fraction will enroll onto a research protocol. Objective To identify critical barriers to trial enrollment to translate findings into actionable practice changes that increase cancer clinical trial enrollment. Design, Setting, and Participants This survey study included designated site contacts at oncology practices with teams who were highly involved with the Association of Community Cancer Centers (ACCC) Community Oncology Research Institute (ACORI) clinical trials activities, all American Society of Clinical Oncology (ASCO)-ACCC collaboration pilot sites, and/or sites providing care to at least 25% African American and Hispanic residents. To determine participation trends among health care practices in oncology-focused research, identify barriers to clinical trial implementation and operation, and establish unmet needs for cancer clinics interested in trial participation, a 34-question survey was designed. Survey questions were defined within 3 categories: cancer center demographic characteristics, clinical trial characteristics, and referral practices. The survey was distributed through email and was open from June 20 through October 5, 2022. Main Outcomes and Measures Participation in and barriers to conducting oncology trials in different community oncology settings. Results The survey was distributed to 100 cancer centers, with completion by 58 centers (58%) across 25 states. Fifty-two centers (88%) reported that they conduct therapeutic clinical trials, of which 33 (63%) were from urban settings, 11 (21%) were from suburban settings, and 8 (15%) were from rural settings. Only 25% of rural practices (2 of 8) offered phase 1 trials, compared with 67% of urban practices (22 of 33) (P = .01). Respondents noted challenges in conducting research, including patient recruitment (27 respondents [52%]), limited staffing (27 [52%]), and nonrelevant trials for their patient population (25 [48%]). Among sites not offering therapeutic trials, barriers to research conduct included limited infrastructure, funding, and staffing. Most centers (46 of 58 [79%]) referred patients to outside centers for clinical trial enrollment, particularly in the context of late-stage disease and/or disease progression. Only 17 of these sites (37%) had established protocols for patient follow-up subsequent to outside referral. Conclusions and Relevance In this national survey study of barriers to clinical trial implementation, most sites offered therapeutic trials, but there were significant disparities in trial availability across care settings. Furthermore, fundamental deficiencies in trial support infrastructure limited research activity, including within programs currently conducting research as well as at sites interested in future clinical research opportunities. These results identify crucial unmet needs for oncology clinics to effectively offer clinical trials to patients seeking care.
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Affiliation(s)
- Hedyeh Ebrahimi
- City of Hope Comprehensive Cancer Center, Duarte, California
| | - Sandra Megally
- Association of Community Cancer Centers, Rockville, Maryland
| | - Elana Plotkin
- Association of Community Cancer Centers, Rockville, Maryland
| | | | | | - Zeynep B. Zengin
- Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Luis Meza
- Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Neal Chawla
- City of Hope Comprehensive Cancer Center, Duarte, California
| | | | - Nazli Dizman
- Department of Internal Medicine, MD Anderson Cancer Center, Houston, Texas
| | - Ruma Bhagat
- Genentech, Inc, South San Francisco, California
| | - Seila Liv
- Genentech, Inc, South San Francisco, California
| | - Xiaochen Li
- City of Hope Comprehensive Cancer Center, Duarte, California
| | - Adam Rock
- City of Hope Comprehensive Cancer Center, Duarte, California
| | - Sandy Liu
- City of Hope Orange County Lennar Foundation Cancer Center, Irvine, California
| | | | - Tanya Dorff
- City of Hope Comprehensive Cancer Center, Duarte, California
| | - Randall A. Oyer
- Penn Medicine Ann B. Barshinger Cancer Institute, Lancaster, Pennsylvania
| | - Leigh Boehmer
- Association of Community Cancer Centers, Rockville, Maryland
| | - Sumanta Pal
- City of Hope Comprehensive Cancer Center, Duarte, California
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Govindarajan A, Salgia NJ, Li H, Castro DV, Mirzapoiazova T, Armstrong B, Zhao D, Mercier BD, Dizman N, Chawla N, Zengin Z, Meza L, Tripathi N, Sayegh N, Chehrazi-Raffle A, Tripathi A, Pal SK. Characterization of papillary and clear cell renal cell carcinoma through imaging mass cytometry reveals distinct immunologic profiles. Front Immunol 2023; 14:1182581. [PMID: 37638025 PMCID: PMC10457014 DOI: 10.3389/fimmu.2023.1182581] [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] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Accepted: 07/20/2023] [Indexed: 08/29/2023] Open
Abstract
Objective To characterize and further compare the immune cell populations of the tumor microenvironment (TME) in both clear cell and papillary renal cell carcinoma (RCC) using heavy metal-labeled antibodies in a multiplexed imaging approach (imaging mass cytometry). Materials and methods Formalin-fixed paraffin-embedded (FFPE) baseline tumor tissues from metastatic patients with clear cell renal cell carcinoma (ccRCC) and papillary renal cell carcinoma (pRCC) were retrospectively requisitioned from an institutional biorepository. Pretreated FFPE samples from 33 RCC patients (10 ccRCC, 23 pRCC) were accessioned and stained for imaging mass cytometry (IMC) analysis. Clinical characteristics were curated from an institutional RCC database. FFPE samples were prepared and stained with heavy metal-conjugated antibodies for IMC. An 11-marker panel of tumor stromal and immune markers was used to assess and quantify cellular relationships in TME compartments. To validate our time-of-flight (CyTOF) analysis, we cross-validated findings with The Cancer Genome Atlas Program (TCGA) analysis and utilized the CIBERSORTx tool to examine the abundance of main immune cell types in pRCC and ccRCC patients. Results Patients with ccRCC had a longer median overall survival than did those with pRCC (67.7 vs 26.8 mo, respectively). Significant differences were identified in the proportion of CD4+ T cells between disease subtypes (ccRCC 14.1%, pRCC 7.0%, p<0.01). Further, the pRCC cohort had significantly more PanCK+ tumor cells than did the ccRCC cohort (24.3% vs 9.5%, respectively, p<0.01). There were no significant differences in macrophage composition (CD68+) between cohorts. Our results demonstrated a significant correlation between the CyTOF and TCGA analyses, specifically validating that ccRCC patients exhibit higher levels of CD4+ T cells (ccRCC 17.60%, pRCC 15.7%, p<0.01) and CD8+ T cells (ccRCC 17.83%, pRCC 11.15%, p<0.01). The limitation of our CyTOF analysis was the large proportion of cells that were deemed non-characterizable. Conclusions Our findings emphasize the need to investigate the TME in distinct RCC histological subtypes. We observed a more immune infiltrative phenotype in the TME of the ccRCC cohort than in the pRCC cohort, where a tumor-rich phenotype was noted. As practical predictive biomarkers remain elusive across all subtypes of RCC, further studies are warranted to analyze the biomarker potential of such TME classifications.
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Affiliation(s)
- Ameish Govindarajan
- Department of Medical Oncology and Therapeutics Research, City of Hope Comprehensive Cancer Center, Duarte, CA, United States
| | - Nicholas J. Salgia
- Department of Medical Oncology and Therapeutics Research, City of Hope Comprehensive Cancer Center, Duarte, CA, United States
- Jacobs School of Medicine and Biomedical Sciences, Buffalo, NY, United States
- Department of Immunology, Roswell Park Comprehensive Cancer Center, Buffalo, NY, United States
| | - Haiqing Li
- Integrative Genome Core, Beckman Research Institute, City of Hope National Medical Center, Duarte, CA, United States
| | - Daniela V. Castro
- Department of Medical Oncology and Therapeutics Research, City of Hope Comprehensive Cancer Center, Duarte, CA, United States
| | - Tamara Mirzapoiazova
- Integrative Genome Core, Beckman Research Institute, City of Hope National Medical Center, Duarte, CA, United States
| | - Brian Armstrong
- Light Microscopy/Digital Imaging Core, Beckman Research Institute, City of Hope National Medical Center, Duarte, CA, United States
| | - Dan Zhao
- Department of Medical Oncology and Therapeutics Research, City of Hope Comprehensive Cancer Center, Duarte, CA, United States
- Department of Gastrointestinal Medical Oncology, Division of Cancer Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Benjamin D. Mercier
- Department of Medical Oncology and Therapeutics Research, City of Hope Comprehensive Cancer Center, Duarte, CA, United States
| | - Nazli Dizman
- Department of Medical Oncology and Therapeutics Research, City of Hope Comprehensive Cancer Center, Duarte, CA, United States
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT, United States
| | - Neal Chawla
- Department of Medical Oncology and Therapeutics Research, City of Hope Comprehensive Cancer Center, Duarte, CA, United States
| | - Zeynep Zengin
- Department of Medical Oncology and Therapeutics Research, City of Hope Comprehensive Cancer Center, Duarte, CA, United States
| | - Luis Meza
- Department of Medical Oncology and Therapeutics Research, City of Hope Comprehensive Cancer Center, Duarte, CA, United States
| | - Nishita Tripathi
- Huntsman Cancer Institute-University of Utah Health Care, Salt Lake City, UT, United States
| | - Nicolas Sayegh
- Huntsman Cancer Institute-University of Utah Health Care, Salt Lake City, UT, United States
| | - Alex Chehrazi-Raffle
- Department of Medical Oncology and Therapeutics Research, City of Hope Comprehensive Cancer Center, Duarte, CA, United States
| | - Abhishek Tripathi
- Department of Medical Oncology and Therapeutics Research, City of Hope Comprehensive Cancer Center, Duarte, CA, United States
| | - Sumanta K. Pal
- Department of Medical Oncology and Therapeutics Research, City of Hope Comprehensive Cancer Center, Duarte, CA, United States
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Zengin ZB, Chehrazi-Raffle A, Salgia NJ, Muddasani R, Ali S, Meza L, Pal SK. Targeted therapies: Expanding the role of FGFR3 inhibition in urothelial carcinoma. Urol Oncol 2021; 40:25-36. [PMID: 34840077 DOI: 10.1016/j.urolonc.2021.10.003] [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] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Revised: 09/13/2021] [Accepted: 10/12/2021] [Indexed: 12/24/2022]
Abstract
The management of urothelial carcinoma (UC) has rapidly advanced in recent years with new approvals for immune checkpoint inhibitors and antibody-drug conjugates. However, while many UC tumors contain potentially actionable mutations, the role for targeted small molecule inhibitors has been limited. One such target is the fibroblast growth factor receptor (FGFR) family of proteins. Activating mutations and amplifications of FGFR3 are common in UC with higher incidences seen in upper tract as compared to lower tract disease. Consequently, multiple FGFR-directed targeted therapies have been developed and trialed in both UC and other solid tumors harboring FGFR mutations. At current, erdafitinib, an inhibitor of FGFR1-4, is the only approved targeted therapy in metastatic UC following the BLC2001 study, which demonstrated a 49% overall response rate in patients with UC harboring an FGFR3 mutation. Additional FGFR-directed agents also continue to be investigated across multiple disease stages in FGFR-mutated UC including infigratinib, rogaratinib, and AZD4547, among others. Ongoing trials are combining these agents with immune checkpoint inhibitors and chemotherapy regimens. The precision medicine revolution has begun in UC, and FGFR3 inhibitors are leading the charge toward a more personalized, biomarker-driven treatment paradigm.
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Affiliation(s)
- Zeynep B Zengin
- Department of Medical Oncology & Experimental Therapeutics, City of Hope Comprehensive Cancer Center, Duarte, CA
| | - Alex Chehrazi-Raffle
- Department of Medical Oncology & Experimental Therapeutics, City of Hope Comprehensive Cancer Center, Duarte, CA
| | - Nicholas J Salgia
- Department of Medical Oncology & Experimental Therapeutics, City of Hope Comprehensive Cancer Center, Duarte, CA
| | - Ramya Muddasani
- Department of Medical Oncology & Experimental Therapeutics, City of Hope Comprehensive Cancer Center, Duarte, CA
| | - Sana Ali
- Department of Internal Medicine, Harbor-UCLA Medical Center, Torrance, CA
| | - Luis Meza
- Department of Medical Oncology & Experimental Therapeutics, City of Hope Comprehensive Cancer Center, Duarte, CA
| | - Sumanta K Pal
- Department of Medical Oncology & Experimental Therapeutics, City of Hope Comprehensive Cancer Center, Duarte, CA.
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Salgia NJ, Chehrazi-Raffle A, Hsu J, Zengin Z, Salgia S, Chawla NS, Meza L, Malhotra J, Dizman N, Muddasani R, Ruel N, Cianfrocca M, Gong J, Anand S, Chiu V, Yeh J, Pal SK. Characterizing the relationships between tertiary and community cancer providers: Results from a survey of medical oncologists in Southern California. Cancer Med 2021; 10:5671-5680. [PMID: 34331372 PMCID: PMC8366095 DOI: 10.1002/cam4.4119] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [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: 04/12/2021] [Revised: 05/12/2021] [Accepted: 06/14/2021] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Tertiary cancer centers offer clinical expertise and multi-modal approaches to treatment alongside the integration of research protocols. Nevertheless, most patients receive their cancer care at community practices. A better understanding of the relationships between tertiary and community practice environments may enhance collaborations and advance patient care. METHODS A 31-item survey was distributed to community and tertiary oncologists in Southern California using REDCap. Survey questions assessed the following attributes: demographics and features of clinical practice, referral patterns, availability and knowledge of clinical trials and precision medicine, strategies for knowledge acquisition, and integration of community and tertiary practices. RESULTS The survey was distributed to 98 oncologists, 85 (87%) of whom completed it. In total, 52 (61%) respondents were community practitioners and 33 (38%) were tertiary oncologists. A majority (56%) of community oncologists defined themselves as general oncologists, whereas almost all (97%) tertiary oncologists reported a subspecialty. Clinical trial availability was the most common reason for patient referrals to tertiary centers (73%). The most frequent barrier to tertiary referral was financial considerations (59%). Clinical trials were offered by 97% of tertiary practitioners compared to 67% of community oncologists (p = 0.001). Most oncologists (82%) reported only a minimal-to-moderate understanding of clinical trials available at regional tertiary centers. CONCLUSIONS Community oncologists refer patients to tertiary centers primarily with the intent of clinical trial enrollment; however, significant gaps exist in their knowledge of trial availability. Our results identify the need for enhanced communication and collaboration between community and tertiary providers to expand patients' access to clinical trials.
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Affiliation(s)
- Nicholas J Salgia
- Department of Medical Oncology & Experimental Therapeutics, City of Hope Comprehensive Cancer Center, Duarte, CA, USA
| | - Alexander Chehrazi-Raffle
- Department of Medical Oncology & Experimental Therapeutics, City of Hope Comprehensive Cancer Center, Duarte, CA, USA
| | - JoAnn Hsu
- Department of Medical Oncology & Experimental Therapeutics, City of Hope Comprehensive Cancer Center, Duarte, CA, USA
| | - Zeynep Zengin
- Department of Medical Oncology & Experimental Therapeutics, City of Hope Comprehensive Cancer Center, Duarte, CA, USA
| | - Sabrina Salgia
- Department of Medical Oncology & Experimental Therapeutics, City of Hope Comprehensive Cancer Center, Duarte, CA, USA
| | - Neal S Chawla
- Department of Medical Oncology & Experimental Therapeutics, City of Hope Comprehensive Cancer Center, Duarte, CA, USA
| | - Luis Meza
- Department of Medical Oncology & Experimental Therapeutics, City of Hope Comprehensive Cancer Center, Duarte, CA, USA
| | - Jasnoor Malhotra
- Department of Medical Oncology & Experimental Therapeutics, City of Hope Comprehensive Cancer Center, Duarte, CA, USA
| | - Nazli Dizman
- Department of Medical Oncology & Experimental Therapeutics, City of Hope Comprehensive Cancer Center, Duarte, CA, USA
| | - Ramya Muddasani
- Department of Medicine, City of Hope Comprehensive Cancer Center, Duarte, CA, USA
| | - Nora Ruel
- Biostatistics and Mathematical Modeling Core, City of Hope Comprehensive Cancer Center, Duarte, CA, USA
| | - Mary Cianfrocca
- Department of Medical Oncology & Experimental Therapeutics, City of Hope Comprehensive Cancer Center, Duarte, CA, USA
| | - Jun Gong
- Division of Hematology/Oncology, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Sidharth Anand
- Division of Hematology/Oncology, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Victor Chiu
- Division of Hematology/Oncology, UCLA-Olive View Medical Center, Los Angeles, CA, USA
| | - James Yeh
- Division of Hematology and Medical Oncology, Department of Medicine, Harbor-UCLA Medical Center, Torrance, CA, USA
| | - Sumanta K Pal
- Department of Medical Oncology & Experimental Therapeutics, City of Hope Comprehensive Cancer Center, Duarte, CA, USA
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Abstract
A recent article in Nature Medicine explored the combination of immunotherapy with multiple distinct targeted therapies in patients with metastatic urothelial cancer, employing a biomarker-driven approach. Herein, we discuss the merits of this ambitious study and highlight the need for larger biomarker-based randomized trials to arrive at definitive clinical conclusions.
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Affiliation(s)
- Luis Meza
- Department of Medical Oncology and Therapeutics Research, City of Hope Comprehensive Cancer Center, Duarte, CA, USA
| | - Nicholas J Salgia
- Department of Medical Oncology and Therapeutics Research, City of Hope Comprehensive Cancer Center, Duarte, CA, USA; Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY, USA
| | - Kalen C Patel
- Department of Medical Oncology and Therapeutics Research, City of Hope Comprehensive Cancer Center, Duarte, CA, USA
| | - Sumanta K Pal
- Department of Medical Oncology and Therapeutics Research, City of Hope Comprehensive Cancer Center, Duarte, CA, USA.
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Zengin ZB, Weipert C, Salgia NJ, Dizman N, Hsu J, Meza L, Chehrazi-Raffle A, Muddasani R, Salgia S, Malhotra J, Chawla N, Philip EJ, Kiedrowski L, Maughan BL, Rathi N, Goel D, Choueiri TK, Agarwal N, Pal SK. Complementary Role of Circulating Tumor DNA Assessment and Tissue Genomic Profiling in Metastatic Renal Cell Carcinoma. Clin Cancer Res 2021; 27:4807-4813. [PMID: 34130999 DOI: 10.1158/1078-0432.ccr-21-0572] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [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: 02/14/2021] [Revised: 04/30/2021] [Accepted: 06/11/2021] [Indexed: 11/16/2022]
Abstract
PURPOSE The role of circulating cell-free tumor DNA (ctDNA) as an adjunct to tissue genomic profiling is poorly defined in metastatic renal cell carcinoma (mRCC). In this study, we aim to validate previous findings related to genomic alteration (GA) frequency in ctDNA and determine the concordance between ctDNA and tissue-based profiling in patients with mRCC. EXPERIMENTAL DESIGN Results of 839 patients with mRCC who had ctDNA assessment with a Clinical Laboratory Improvement Amendments (CLIA)-certified ctDNA assay between November 2016 and December 2019 were collected. Tissue-based genomic profiling was collected when available and concordance analysis between blood- and tissue-based testing was performed. RESULTS ctDNA was assessed in 839 patients (comprising 920 samples) with mRCC. GAs were detected in 661 samples (71.8%). Tissue-based GAs were assessed in 112 patients. Limiting our analyses to a common 73-/74-gene set and excluding samples with no ctDNA detected, a total of 228 mutations were found in tissue and blood. Mutations identified in tissue (34.7%; 42/121) were also identified via ctDNA, whereas 28.2% (42/149) of the mutations identified in liquid were also identified via tissue. Concordance between ctDNA and tissue-based profiling was inversely related to the time elapsed between these assays. CONCLUSIONS This study confirms the feasibility of ctDNA profiling in the largest mRCC cohort to date, with ctDNA identifying multiple actionable alterations. It also demonstrates that ctDNA and tissue-based genomic profiling are complementary, with both platforms identifying unique alterations, and confirms that the frequency of unique alterations increases with greater temporal separation between tests.
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Affiliation(s)
- Zeynep B Zengin
- Department of Medical Oncology and Experimental Therapeutics, City of Hope Comprehensive Cancer Center, Duarte, California
| | | | - Nicholas J Salgia
- Department of Medical Oncology and Experimental Therapeutics, City of Hope Comprehensive Cancer Center, Duarte, California
| | - Nazli Dizman
- Department of Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Joann Hsu
- Department of Medical Oncology and Experimental Therapeutics, City of Hope Comprehensive Cancer Center, Duarte, California
| | - Luis Meza
- Department of Medical Oncology and Experimental Therapeutics, City of Hope Comprehensive Cancer Center, Duarte, California
| | - Alexander Chehrazi-Raffle
- Department of Medical Oncology and Experimental Therapeutics, City of Hope Comprehensive Cancer Center, Duarte, California
| | - Ramya Muddasani
- Department of Medical Oncology and Experimental Therapeutics, City of Hope Comprehensive Cancer Center, Duarte, California
| | - Sabrina Salgia
- Department of Medical Oncology and Experimental Therapeutics, City of Hope Comprehensive Cancer Center, Duarte, California
| | - Jasnoor Malhotra
- Department of Medical Oncology and Experimental Therapeutics, City of Hope Comprehensive Cancer Center, Duarte, California
| | - Neal Chawla
- Department of Medical Oncology and Experimental Therapeutics, City of Hope Comprehensive Cancer Center, Duarte, California
| | - Errol J Philip
- University of California San Francisco (UCSF) School of Medicine, San Francisco, California
| | | | - Benjamin L Maughan
- Department of Medical Oncology, Huntsman Cancer Center, University of Utah, Salt Lake City, Utah
| | - Nityam Rathi
- Department of Medical Oncology, Huntsman Cancer Center, University of Utah, Salt Lake City, Utah
| | - Divyam Goel
- Department of Medical Oncology, Huntsman Cancer Center, University of Utah, Salt Lake City, Utah
| | - Toni K Choueiri
- Lank Center for Genitourinary Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Neeraj Agarwal
- Department of Medical Oncology, Huntsman Cancer Center, University of Utah, Salt Lake City, Utah.
| | - Sumanta K Pal
- Department of Medical Oncology and Experimental Therapeutics, City of Hope Comprehensive Cancer Center, Duarte, California.
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Dizman N, Salgia NJ, Bergerot PG, Hsu J, Ruel N, Pal SK. Race/Ethnicity and Survival in Metastatic Renal Cell Carcinoma: Outcomes for Patients Receiving First Line Targeted Therapies. KCA 2020. [DOI: 10.3233/kca-200092] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
BACKGROUND: No study to date has assessed the relationship between treatment-specific therapeutic outcomes and race/ethnicity in metastatic renal cell carcinoma (mRCC). As targeted therapies have formed the backbone of first-line treatment options for mRCC until very recently, we assessed the relationship between race/ethnicity and targeted therapy-related outcomes in mRCC. OBJECTIVE: To retrospectively compare response rates and survival outcomes across ethnicities in patients who received first-line targeted therapies for mRCC. METHODS: Patients with mRCC receiving a first-line targeted therapy were identified from an institutional database encompassing consecutive patients treated between 2009 and 2019. Patient demographics, clinical characteristics and survival outcomes were recorded. The racial/ethnic groups included for analysis were Caucasian American, Hispanic American, and Asian American. Survival and response outcomes including progression-free survival (PFS), overall survival (OS), objective response rate (ORR) and disease control rate (DCR) were calculated and compared across ethnic groups using Kaplan-Meier method and Chi-square test, respectively. RESULTS: In total, 295 patients were included for analysis. There were 184 (62.4%) Caucasian American patients, 82 (27.8%) Hispanic American patients, and 29 (9.8%) Asian American patients. No statistically significant differences in PFS nor OS were found between groups (PFS: 5.6 vs. 4.7 vs. 4.7 months, respectively) (OS: 32 vs. 31.7 vs. 51.7 months, respectively). No significant difference was found in ORR nor DCR across groups. Univariate cox regression analyses demonstrated no independent effect of race/ethnicity on PFS or OS. CONCLUSIONS: The apparent lack of differences in treatment-related outcomes across racial/ethnic groups is encouraging. However, further validation is required in larger series.
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Affiliation(s)
- Nazli Dizman
- Department of Medical Oncology & Experimental Therapeutics, City of Hope Comprehensive Cancer Center, Duarte, CA, USA
| | - Nicholas J. Salgia
- Department of Medical Oncology & Experimental Therapeutics, City of Hope Comprehensive Cancer Center, Duarte, CA, USA
| | - Paulo G. Bergerot
- Department of Medical Oncology & Experimental Therapeutics, City of Hope Comprehensive Cancer Center, Duarte, CA, USA
| | - JoAnn Hsu
- Department of Medical Oncology & Experimental Therapeutics, City of Hope Comprehensive Cancer Center, Duarte, CA, USA
| | - Nora Ruel
- Beckman Research Institute, City of Hope National Medical Center, Duarte, CA, USA
| | - Sumanta K. Pal
- Department of Medical Oncology & Experimental Therapeutics, City of Hope Comprehensive Cancer Center, Duarte, CA, USA
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Salgia NJ, Bergerot PG, Maia MC, Dizman N, Hsu J, Gillece JD, Folkerts M, Reining L, Trent J, Highlander SK, Pal SK. Stool Microbiome Profiling of Patients with Metastatic Renal Cell Carcinoma Receiving Anti-PD-1 Immune Checkpoint Inhibitors. Eur Urol 2020; 78:498-502. [PMID: 32828600 DOI: 10.1016/j.eururo.2020.07.011] [Citation(s) in RCA: 107] [Impact Index Per Article: 26.8] [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: 03/30/2020] [Accepted: 07/11/2020] [Indexed: 12/16/2022]
Abstract
Preclinical models and early clinical data suggest an interplay between the gut microbiome and response to immunotherapy in solid tumors including metastatic renal cell carcinoma (mRCC). We sought to characterize the stool microbiome of mRCC patients receiving a checkpoint inhibitor (CPI) and to assess treatment-related changes in microbiome composition over the course of CPI therapy. Stool was collected from 31 patients before initiation of nivolumab (77%) or nivolumab plus ipilimumab (23%) therapy, of whom 58% experienced clinical benefit. Greater microbial diversity was associated with clinical benefit from CPI therapy (p = 0.001), and multiple species were associated with clinical benefit or lack thereof. Temporal profiling of the microbiome indicated that the relative abundance of Akkermansia muciniphila increased in patients deriving clinical benefit from CPIs. This study substantiates results from previous CPI-related microbiome profiling studies in mRCC. Temporal changes in microbiome composition suggest potential utility in modulating the microbiome for more successful CPI outcomes. PATIENT SUMMARY: We compared the composition and diversity of the gut microbiome in patients receiving immunotherapy for renal cell carcinoma. We found that higher microbial diversity is associated with better treatment outcomes. Treatment response is characterized by changes in microbial species over the course of treatment.
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Affiliation(s)
- Nicholas J Salgia
- Department of Medical Oncology and Therapeutics Research, City of Hope Comprehensive Cancer Center, Duarte, CA, USA
| | - Paulo G Bergerot
- Department of Medical Oncology and Therapeutics Research, City of Hope Comprehensive Cancer Center, Duarte, CA, USA
| | | | - Nazli Dizman
- Department of Medical Oncology and Therapeutics Research, City of Hope Comprehensive Cancer Center, Duarte, CA, USA
| | - JoAnn Hsu
- Department of Medical Oncology and Therapeutics Research, City of Hope Comprehensive Cancer Center, Duarte, CA, USA
| | - John D Gillece
- Pathogen and Microbiome Division, Translational Genomics Research Institute North, Flagstaff, AZ, USA
| | - Megan Folkerts
- Pathogen and Microbiome Division, Translational Genomics Research Institute North, Flagstaff, AZ, USA
| | - Lauren Reining
- Pathogen and Microbiome Division, Translational Genomics Research Institute North, Flagstaff, AZ, USA
| | - Jeffrey Trent
- Translational Genomics Research Institute, Phoenix, AZ, USA
| | - Sarah K Highlander
- Pathogen and Microbiome Division, Translational Genomics Research Institute North, Flagstaff, AZ, USA.
| | - Sumanta K Pal
- Department of Medical Oncology and Therapeutics Research, City of Hope Comprehensive Cancer Center, Duarte, CA, USA.
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Salgia NJ, Dizman N, Mambetsariev I, Mirzapoiazova T, Zhao D, Kulkarni P, Salgia R, Pal SK. Abstract 5426: Genomic and immunohistochemical characterization of patients with advanced papillary renal cell carcinoma: Focus on exceptional responders. Cancer Res 2020. [DOI: 10.1158/1538-7445.am2020-5426] [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: Approximately 10-15% of patients with renal cell carcinoma (RCC) demonstrate papillary histology. Unfortunately for patients with advanced disease, there is no standard therapy for papillary RCC (pRCC). Herein, we provide detailed biologic characterization of patients with pRCC who have achieved exceptional responses to either targeted therapy or checkpoint inhibition.
Methods: Patients with pRCC were identified from an institutional database. Demographic and treatment-related data were compiled. Genomic characterization using CLIA-certified next-generation sequencing (NGS) platforms (FoundationOne; Foundation Medicine, Cambridge, MA or GEM ExTra: Ashion/TGen, Phoenix, AZ) was performed when deemed clinically relevant; this data was used to characterize the frequency of relevant genomic alterations (GAs) in this subset. Archived tissue was obtained when available and immunohistochemical staining was performed for CD4, CD8, CD11b and other markers to characterize T-cell subtype. Staining for MET, ALK and other protooncogenes was also performed and the spatial relationship between these proteins and immune cells was characterized.
Results: 64 pts with pRCC were identified (50:14 M:F). By International Metastatic RCC Database Consortium (IMDC) criteria, 3 were good risk, 42 were intermediate/poor risk, and 19 were considered unevaluable. Patients received a median of two lines of therapy (range, 1-7). The most common genomic alterations encountered among fifteen patients with available NGS profiling were BAP1 (20%) and TERT (20%). Three patients with ALK mutations were identified – each was treated with FDA approved ALK-inhibitors and all had a response to therapy, with a median progression-free survival (PFS) of 9.65 months (range, 1.25–23.47). Two patients with MET mutations were identified. Fifteen patients received an immune-checkpoint inhibitor as part of their care – eight (53%) experienced a PFS of greater than three months (median PFS, 3.1 months; range, 0.25–43.4). 30 patients received a MET-directed therapy (median PFS, 2.8 months; range, 0.4–29.9), including both patients with recorded MET GAs (PFS of 5.3 and 7.87 months, respectively), and 41 patients received a Vascular Endothelial Growth Factor Tyrosine Kinase Inhibitor (VEGF-TKI) (median PFS, 4.2 months; range, 0.33–134.47). In total, fifteen patients achieved an exceptional response (>10 months) to therapy. Six such patients also had NGS data and tissue available for immunohistochemical characterization. Immunohistochemical characterization will be reported at the meeting.
Conclusions: Our results indicate that genomic profiling can yield actionable targets in pRCC. Matching these targets to relevant targeted therapies produces clinically meaningful responses.
Citation Format: Nicholas J. Salgia, Nazli Dizman, Isa Mambetsariev, Tamara Mirzapoiazova, Dan Zhao, Prakash Kulkarni, Ravi Salgia, Sumanta K. Pal. Genomic and immunohistochemical characterization of patients with advanced papillary renal cell carcinoma: Focus on exceptional responders [abstract]. In: Proceedings of the Annual Meeting of the American Association for Cancer Research 2020; 2020 Apr 27-28 and Jun 22-24. Philadelphia (PA): AACR; Cancer Res 2020;80(16 Suppl):Abstract nr 5426.
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Affiliation(s)
| | - Nazli Dizman
- City of Hope Comprehensive Cancer Center, Duarte, CA
| | | | | | - Dan Zhao
- City of Hope Comprehensive Cancer Center, Duarte, CA
| | | | - Ravi Salgia
- City of Hope Comprehensive Cancer Center, Duarte, CA
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10
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Salgia NJ, Feng M, Prajapati D, Harwood R, Nissanoff M, Dara Y, Ruel N, Salgia MM, Pal SK. Examining the Association of Academic Rank and Productivity with Metrics of Twitter Utilization Amongst Kidney Cancer Specialists. KCA 2020. [DOI: 10.3233/kca-200083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Nicholas J. Salgia
- Department of Medical Oncology & Experimental Therapeutics, City of Hope Comprehensive Cancer Center, Duarte, CA, USA
| | - Matthew Feng
- Department of Medical Oncology & Experimental Therapeutics, City of Hope Comprehensive Cancer Center, Duarte, CA, USA
| | - Dhruv Prajapati
- Department of Medical Oncology & Experimental Therapeutics, City of Hope Comprehensive Cancer Center, Duarte, CA, USA
| | - Richard Harwood
- Department of Medical Oncology & Experimental Therapeutics, City of Hope Comprehensive Cancer Center, Duarte, CA, USA
| | - Michael Nissanoff
- Department of Medical Oncology & Experimental Therapeutics, City of Hope Comprehensive Cancer Center, Duarte, CA, USA
| | - Yash Dara
- Department of Medical Oncology & Experimental Therapeutics, City of Hope Comprehensive Cancer Center, Duarte, CA, USA
| | - Nora Ruel
- Biostatistics and Mathematical Modeling Core, City of Hope Comprehensive Cancer Center, Duarte, CA, USA
| | - Meghan M. Salgia
- Department of Medical Oncology & Experimental Therapeutics, City of Hope Comprehensive Cancer Center, Duarte, CA, USA
| | - Sumanta K. Pal
- Department of Medical Oncology & Experimental Therapeutics, City of Hope Comprehensive Cancer Center, Duarte, CA, USA
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11
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Salgia NJ, Zengin ZB, Pal SK. Tivozanib in renal cell carcinoma: a new approach to previously treated disease. Ther Adv Med Oncol 2020; 12:1758835920923818. [PMID: 32547647 PMCID: PMC7249546 DOI: 10.1177/1758835920923818] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [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: 01/30/2020] [Accepted: 04/09/2020] [Indexed: 01/05/2023] Open
Abstract
Targeted therapies have been a mainstay of the renal cell carcinoma (RCC)
treatment paradigm for the better part of two decades. Multikinase inhibitors of
the vascular endothelial growth factor receptor tyrosine kinases (VEGF-TKIs)
comprise nearly all targeted therapies in RCC, having been prospectively tested
through large, multi-institutional phase III trials. Tivozanib is a VEGF-TKI
with high selectivity for VEGF receptors 1–3. Tivozanib has been under
investigation for nearly 15 years, with a robust portfolio of preclinical and
clinical data. This review seeks to characterize tivozanib within the context of
RCC by highlighting preclinical and early clinical trials alongside the phase
III trials in RCC, TIVO-1, and TIVO-3. We also aim to explore further trials of
tivozanib, whether in combination with other agents and/or in differing disease
settings, while providing insight into the utility of tivozanib as a clinical
tool for the management of RCC.
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Affiliation(s)
- Nicholas J Salgia
- Department of Medical Oncology & Experimental Therapeutics, City of Hope Comprehensive Cancer Center, Duarte, CA, USA
| | - Zeynep B Zengin
- Department of Medical Oncology & Experimental Therapeutics, City of Hope Comprehensive Cancer Center, Duarte, CA, USA
| | - Sumanta K Pal
- Department of Medical Oncology & Experimental Therapeutics, City of Hope Comprehensive Cancer Center, 1500 East Duarte Road, Duarte, CA 91010, USA
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Meng WS, Salgia NJ, Pham NB, Velankar KY, Pal SK. A drug delivery perspective on intratumoral-immunotherapy in renal cell carcinoma. Urol Oncol 2020; 39:338-345. [PMID: 32402767 DOI: 10.1016/j.urolonc.2020.03.018] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2020] [Revised: 03/02/2020] [Accepted: 03/20/2020] [Indexed: 10/24/2022]
Abstract
In less than 5years immune checkpoint inhibitors (ICI) went from first FDA approval to become first-line options in advanced renal cell carcinoma. Despite that many patients have benefited from ICI, a significant fraction of individuals are refractory to these new immunological treatments. In this review, we discussed using intratumoral (i.t.) route of drug administration as an alternative to systemic therapy to increase the response rates and to circumvent potential drug-induced systemic adverse events. We provided a historic account of i.t. drug treatments in cancer and reviewed the contemporary experience in local drug delivery. We discussed the potential for enhancing the therapeutic impact of ICI by leveraging hydrogels as drug delivery vehicles and presented an outlook for implementing i.t. in renal cell carcinoma.
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Affiliation(s)
- Wilson S Meng
- Graduate School of Pharmaceutical Sciences, Duquesne University, Pittsburgh, PA; McGowan Institute for Regenerative Medicine, University of Pittsburgh, Pittsburgh, PA.
| | - Nicholas J Salgia
- Department of Medical Oncology and Experimental Therapeutics, City of Hope Comprehensive Cancer Center, Duarte, CA
| | - Ngoc B Pham
- Graduate School of Pharmaceutical Sciences, Duquesne University, Pittsburgh, PA
| | - Ketki Y Velankar
- Graduate School of Pharmaceutical Sciences, Duquesne University, Pittsburgh, PA
| | - Sumanta K Pal
- Department of Medical Oncology and Experimental Therapeutics, City of Hope Comprehensive Cancer Center, Duarte, CA.
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