Early onset pancreatic cancer-exploring contemporary treatment and outcomes using real-world data

BACKGROUND

Pancreatic cancer incidence is increasing in younger populations. Differences between early onset pancreatic cancer (EOPC) and later onset pancreatic cancer (LOPC), and how these should inform management warrant exploration in the contemporary setting.

METHODS

A prospectively collected multi-site dataset on consecutive pancreatic adenocarcinoma patients was interrogated. Patient, tumour, treatment, and outcome data were extracted for EOPC (≤50 years old) vs LOPC (>50 years old).

RESULTS

Of 1683 patients diagnosed between 2016 and 2022, 112 (6.7%) were EOPC. EOPC more frequently had the tail of pancreas tumours, earlier stage disease, surgical resection, and trended towards increased receipt of chemotherapy in the curative setting compared to LOPC. EOPC more frequently received 1st line chemotherapy, 2nd line chemotherapy, and chemoradiotherapy than LOPC in the palliative setting. Recurrence-free survival was improved for the tail of pancreas EOPC vs LOPC in the resected setting; overall survival was superior for EOPC compared to LOPC across the resected, locally advanced unresectable and metastatic settings.

CONCLUSIONS

EOPC remains a small proportion of pancreatic cancer diagnoses. The more favourable outcomes in EOPC suggest these younger patients are overall deriving benefits from increased treatment in the curative setting and increased therapy in the palliative setting.

Adjuvant Chemotherapy for Older Patients With Stage III Colorectal Cancer: A Real-World Analysis of Treatment Recommendations, Treatment Administered and Impact on Cancer Recurrence

BACKGROUND

A substantial proportion of patients with stage III colorectal cancer (CRC) are older than 70 years. Optimal adjuvant chemotherapy (AC) for older patients (OP) continues to be debated, with subgroup analyses of randomized trials not demonstrating a survival benefit from the addition of oxaliplatin to a fluoropyrimidine backbone.

PATIENTS AND METHODS

We analyzed the multisite Australian ACCORD registry, which prospectively collects patient, tumor and treatment data along with long term clinical follow-up. We compared OP (≥70) with stage III CRC to younger patients ([YP] <70), including the proportion recommended AC and any reasons for not prescribing AC. AC administration, regimen choice, completion rates, and survival outcomes were also examined.

RESULTS

One thousand five hundred twelve patients enrolled in the ACCORD registry from 2005 to 2018 were included. Median follow-up was 57.0 months. Compared to the 827 YP, the 685 OP were less likely to be offered AC (71.5% vs. 96.5%, P < .0001) and when offered, were more likely to decline treatment (15.1% vs. 2.8%, P < .0001). Ultimately, 60.0% of OP and 93.7% of YP received AC (P < .0001). OP were less likely to receive oxaliplatin (27.5% vs. 84.7%, P < .0001) and to complete AC (75.9% vs. 85.7%, P < .0001). The probability of remaining recurrence-free was significantly higher in OP who received AC compared to those not treated (HR 0.73, P = .04) but not significantly improved with the addition of oxaliplatin (HR 0.75, P = .18).

CONCLUSION

OP were less likely than YP to receive AC. Receipt of AC reduced recurrences in OP, supporting its use, although no significant benefit was observed from the addition of oxaliplatin.

Disparities in neighbourhood characteristics and 10-year dementia risk by nativity status

AIMS

Prior research indicates that neighbourhood disadvantage increases dementia risk. There is, however, inconclusive evidence on the relationship between nativity and cognitive impairment. To our knowledge, our study is the first to analyse how nativity and neighbourhood interact to influence dementia risk.

METHODS

Ten years of prospective cohort data (2011-2020) were retrieved from the National Health and Aging Trends Study, a nationally representative sample of 5,362 U.S. older adults aged 65+. Cox regression analysed time to dementia diagnosis using nativity status (foreign- or native-born) and composite scores for neighbourhood physical disorder (litter, graffiti and vacancies) and social cohesion (know, help and trust each other), after applying sampling weights and imputing missing data.

RESULTS

In a weighted sample representing 26.9 million older adults, about 9.5% (n = 2.5 million) identified as foreign-born and 24.4% (n = 6.5 million) had an incident dementia diagnosis. Average baseline neighbourhood physical disorder was 0.19 (range 0-9), and baseline social cohesion was 4.28 (range 0-6). Baseline neighbourhood physical disorder was significantly higher among foreign-born (mean = 0.28) compared to native-born (mean = 0.18) older adults (t = -2.4, p = .02). Baseline neighbourhood social cohesion was significantly lower for foreign-born (mean = 3.57) compared to native-born (mean = 4.33) older adults (t = 5.5, p < .001). After adjusting for sociodemographic, health and neighbourhood variables, foreign-born older adults had a 51% significantly higher dementia risk (adjusted hazard ratio = 1.51, 95% CI = 1.19-1.90, p < .01). There were no significant interactions for nativity with neighbourhood physical disorder or social cohesion.

CONCLUSIONS

Our findings suggest that foreign-born older adults have higher neighbourhood physical disorder and lower social cohesion compared to native-born older adults. Despite the higher dementia risk, we observed for foreign-born older adults, and this relationship was not moderated by either neighbourhood physical disorder or social cohesion. Further research is needed to understand what factors are contributing to elevated dementia risk among foreign-born older adults.

Sleep-related painful erections: a survey-based analysis of patient-reported experiences with diagnosis and management

Sleep-related painful erection (SRPE) is a condition characterized by painful nocturnal erections and frequent nighttime awakenings; however, the pathophysiology is not well understood and existing literature consists mainly of case reports. We aimed to investigate the causes, treatments, and impact on quality of life among individuals affected by SRPE. An e-questionnaire comprising of 30 items was administered to a group of men with SRPE identified through social media in October of 2021. The survey collected information on demographics, clinical and social history, symptomatology, interventions and quality of life. 44 patients with SRPE completed surveys (70.9% response rate), with a mean age ± SD of 43.3 ± 12.8 years. Most respondents had no relevant medical history related to erectile function disorders. 43.2% of subjects reported sleep apnea, and 27.1% reported a mental health disorder or psychiatric medication use. Baclofen was the most common medication, but only 25% of patients found it beneficial. Sleep repositioning, oxygen device use and pelvic floor therapy were interventions that provided the most relief. Most patients did not require emergency department visits (93.2%); only a small number needed penile aspiration (n = 2). As reported by most respondents, SRPE significantly impacted patients' quality of life.

Unified framework for patient-derived, tumor-organoid-based predictive testing of standard-of-care therapies in metastatic colorectal cancer

Predictive drug testing of patient-derived tumor organoids (PDTOs) holds promise for personalizing treatment of metastatic colorectal cancer (mCRC), but prospective data are limited to chemotherapy regimens with conflicting results. We describe a unified framework for PDTO-based predictive testing across standard-of-care chemotherapy and biologic and targeted therapy options. In an Australian community cohort, PDTO predictions based on treatment-naive patients (n = 56) and response rates from first-line mCRC clinical trials achieve 83% accuracy for forecasting responses in patients receiving palliative treatments (18 patients, 29 treatments). Similar assay accuracy is achieved in a prospective study of third-line or later mCRC treatment, AGITG FORECAST-1 (n = 30 patients). "Resistant" predictions are associated with inferior progression-free survival; misclassification rates are similar by regimen. Liver metastases are the optimal site for sampling, with testing achievable within 7 weeks for 68.8% cases. Our findings indicate that PDTO drug panel testing can provide predictive information for multifarious standard-of-care therapies for mCRC.

Boynton Lecture: Wiring specificity and plasticity of the vertebrate retina

Vision relies on the output of the many functionally distinct and precisely wired circuits of the retina. Using transgenic techniques, imaging methods and electrophysiology, we seek to uncover the developmental mechanisms that help establish the wiring specificity of retinal circuits in vertebrates. Moreover, because injury or disease can cause rewiring after maturation, we are also reconstructing primate retinal circuits impacted by the loss of input, in order to identify the challenges to circuit repair.

Interventions to reduce falls in community-dwelling adults with intellectual disability: a systematic review

BACKGROUND

People with intellectual disability have a high risk of falls and falls-related injuries. Although people with intellectual disability are at increased risk of falls, there is a need to better understand the efficacy of interventions that can help reduce falls and address risk factors in this population. This systematic review aimed to evaluate the type, nature and effectiveness of interventions undertaken to reduce falls with community-dwelling adults with intellectual disability and the quality of this evidence.

METHOD

Four electronic databases were searched: Ovid MEDLINE, PsycINFO, CINAHL Plus and the Cochrane Library. Studies were included if they involved people aged 18 years or over, at least 50% of study participants had intellectual disability, participants were community-dwelling, and the study evaluated any interventions aiming to reduce falls. Study quality was assessed using the National Institutes of Health study quality assessment tools. Reporting of the review followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.

RESULTS

Seven studies were eligible for review, with a total of 286 participants and mean age of 50.4 years. As only one randomised trial was identified, a narrative synthesis of results was undertaken. Five studies evaluated exercise interventions, one evaluated a falls clinic programme, and one evaluated stretch fabric splinting garments. Methodological quality varied (two studies rated as good, four as fair, and one as poor). Exercise interventions varied in terms of exercise type and dosage, frequency and intensity, and most did not align with recommendations for successful falls prevention exercise interventions reported for older people. While the majority of studies reported reduced falls, they differed in methods of reporting falls, and most did not utilise statistical analyses to evaluate outcomes.

CONCLUSION

This review identified a small number of falls prevention intervention studies for people with intellectual disability. Although several studies reported improvements in fall outcomes, ability to draw conclusions about intervention effectiveness is limited by small sample sizes and few studies. Further large-scale research is required to implement and evaluate falls prevention interventions specifically for adults with intellectual disability.

A Qualitative Exploration of Ontario Caregivers' Perspectives of Their Role in Navigating Mental Health and/or Addiction Services for Their Youth

Many youth experiencing mental health and/or addiction (MHA) concerns rely on their caregivers to find and access services. Considering that caregivers often play a significant role in their youth's treatment trajectory, a descriptive qualitative study was used to explore how caregivers (n = 26) in the Greater Toronto Area perceive their role in navigating MHA care for their youth (ages 13 to 26). The Person-Environment-Occupation model was used to guide the thematic analysis. The findings reveal three main themes (1) the internal experience of caregiving, which describes caregivers' emotions and thought processes; (2) the external factors impacting the caregiver's ability to find and access youth MHA services, which explores systemic and social factors that impact navigation; and (3) the demands of the caregiving role. The discussion highlights the importance of supporting the wellbeing of caregivers as they navigate youth MHA services and can provide useful information for healthcare professionals and policy-makers to increase equitable access to youth MHA services.

Compliance with Therapeutic Goods Association prescribing information: weekly or second weekly cetuximab for the treatment of metastatic colorectal cancer

BACKGROUND

Treatment with cetuximab provides a survival benefit for patients with RAS wild-type metastatic colorectal cancer (mCRC). Practice-defining cetuximab studies utilised weekly (q1w) administration. More convenient second weekly (q2w) administration is supported by pharmacokinetic data and a recent meta-analysis, but large head-to-head studies have not been conducted. Therapeutic Goods Association (TGA) prescribing information states cetuximab be administered q1w for all indications.

AIM

To assess the real-world use of q1w versus q2w cetuximab schedule and any difference in outcomes.

METHODS

We analysed data from a prospective mCRC database at seven Melbourne hospitals from January 2010 to August 2019. Characteristics and outcomes for cetuximab-treated patients were examined, comparing q1w versus q2w schedules. Progression-free survival (PFS) and overall survival (OS) were the primary endpoints.

RESULTS

Of 214 eligible patients, 103 (48%) received q1w and 111 (52%) received q2w cetuximab. Q2w cetuximab has been used in >70% of patients from 2015. Q2w was more commonly used in public patients (70% vs 13% in private, P < 0.001), in left-sided primary tumours (83% vs 68%, P = 0.025) and in combination with chemotherapy (73% q2w vs 40% q1w, P < 0.001). Q2w treatment was less common in BRAFV600E mutated tumours (4% vs 13%, P = 0.001). PFS was similar across all lines of therapy, including when analyses were limited to a left-sided primary and there was no difference in OS in multivariate analysis.

CONCLUSION

This real-world analysis shows q2w cetuximab has become the dominant method of administration, despite TGA guidance. Our outcome data adds to other data supporting the use of q2w cetuximab as the standard option. Consideration could be given to modifying current TGA advice.

Does COVID-19 Infection Increase the Risk of Diabetes? Current Evidence

PURPOSE OF REVIEW

Multiple studies report an increased incidence of diabetes following SARS-CoV-2 infection. Given the potential increased global burden of diabetes, understanding the effect of SARS-CoV-2 in the epidemiology of diabetes is important. Our aim was to review the evidence pertaining to the risk of incident diabetes after COVID-19 infection.

RECENT FINDINGS

Incident diabetes risk increased by approximately 60% compared to patients without SARS-CoV-2 infection. Risk also increased compared to non-COVID-19 respiratory infections, suggesting SARS-CoV-2-mediated mechanisms rather than general morbidity after respiratory illness. Evidence is mixed regarding the association between SARS-CoV-2 infection and T1D. SARS-CoV-2 infection is associated with an elevated risk of T2D, but it is unclear whether the incident diabetes is persistent over time or differs in severity over time. SARS-CoV-2 infection is associated with an increased risk of incident diabetes. Future studies should evaluate vaccination, viral variant, and patient- and treatment-related factors that influence risk.

Implementing real-time prescription benefit tools: Early experiences from 5 academic medical centers

BACKGROUND

Medication price transparency tools are increasingly available, but data on their use, and their potential effects on prescribing behavior, patient out of pocket (OOP) costs, and clinician workflow integration, is limited.

OBJECTIVE

To describe the implementation experiences with real-time prescription benefit (RTPB) tools at 5 large academic medical centers and their early impact on prescription ordering.

DESIGN

and Participants: In this cross-sectional study, we systematically collected information on the characteristics of RTPB tools through discussions with key stakeholders at each of the five organizations. Quantitative encounter data, prescriptions written, and RTPB alerts/estimates and prescription adjustment rates were obtained at each organization in the first three months after "go-live" of the RTPB system(s) between 2019 and 2020.

MAIN MEASURES

Implementation characteristics, prescription orders, cost estimate retrieval rates, and prescription adjustment rates.

KEY RESULTS

Differences were noted with respect to implementation characteristics related to RTPB tools. All of the organizations with the exception of one chose to display OOP cost estimates and suggested alternative prescriptions automatically. Differences were also noted with respect to a patient cost threshold for automatic display. In the first three months after "go-live," RTPB estimate retrieval rates varied greatly across the five organizations, ranging from 8% to 60% of outpatient prescriptions. The prescription adjustment rate was lower, ranging from 0.1% to 4.9% of all prescriptions ordered.

CONCLUSIONS

In this study reporting on the early experiences with RTPB tools across five academic medical centers, we found variability in implementation characteristics and population coverage. In addition RTPB estimate retrieval rates were highly variable across the five organizations, while rates of prescription adjustment ranged from low to modest.

Clinical encounter heterogeneity and methods for resolving in networked EHR data: a study from N3C and RECOVER programs

OBJECTIVE

Clinical encounter data are heterogeneous and vary greatly from institution to institution. These problems of variance affect interpretability and usability of clinical encounter data for analysis. These problems are magnified when multisite electronic health record (EHR) data are networked together. This article presents a novel, generalizable method for resolving encounter heterogeneity for analysis by combining related atomic encounters into composite "macrovisits."

MATERIALS AND METHODS

Encounters were composed of data from 75 partner sites harmonized to a common data model as part of the NIH Researching COVID to Enhance Recovery Initiative, a project of the National Covid Cohort Collaborative. Summary statistics were computed for overall and site-level data to assess issues and identify modifications. Two algorithms were developed to refine atomic encounters into cleaner, analyzable longitudinal clinical visits.

RESULTS

Atomic inpatient encounters data were found to be widely disparate between sites in terms of length-of-stay (LOS) and numbers of OMOP CDM measurements per encounter. After aggregating encounters to macrovisits, LOS and measurement variance decreased. A subsequent algorithm to identify hospitalized macrovisits further reduced data variability.

DISCUSSION

Encounters are a complex and heterogeneous component of EHR data and native data issues are not addressed by existing methods. These types of complex and poorly studied issues contribute to the difficulty of deriving value from EHR data, and these types of foundational, large-scale explorations, and developments are necessary to realize the full potential of modern real-world data.

CONCLUSION

This article presents method developments to manipulate and resolve EHR encounter data issues in a generalizable way as a foundation for future research and analysis.

Characterizing terminology applied by authors and database producers to informatics literature on consumer engagement with wearable devices

OBJECTIVE

Identifying consumer health informatics (CHI) literature is challenging. To recommend strategies to improve discoverability, we aimed to characterize controlled vocabulary and author terminology applied to a subset of CHI literature on wearable technologies.

MATERIALS AND METHODS

To retrieve articles from PubMed that addressed patient/consumer engagement with wearables, we developed a search strategy of textwords and Medical Subject Headings (MeSH). To refine our methodology, we used a random sample of 200 articles from 2016 to 2018. A descriptive analysis of articles (N = 2522) from 2019 identified 308 (12.2%) CHI-related articles, for which we characterized their assigned terminology. We visualized the 100 most frequent terms assigned to the articles from MeSH, author keywords, CINAHL, and Engineering Databases (Compendex and Inspec together). We assessed the overlap of CHI terms among sources and evaluated terms related to consumer engagement.

RESULTS

The 308 articles were published in 181 journals, more in health journals (82%) than informatics (11%). Only 44% were indexed with the MeSH term "wearable electronic devices." Author keywords were common (91%) but rarely represented consumer engagement with device data, eg, self-monitoring (n = 12, 0.7%) or self-management (n = 9, 0.5%). Only 10 articles (3%) had terminology from all sources (authors, PubMed, CINAHL, Compendex, and Inspec).

DISCUSSION

Our main finding was that consumer engagement was not well represented in health and engineering database thesauri.

CONCLUSIONS

Authors of CHI studies should indicate consumer/patient engagement and the specific technology investigated in titles, abstracts, and author keywords to facilitate discovery by readers and expand vocabularies and indexing.

Are fewer cases of diabetes mellitus diagnosed in the months after SARS-CoV-2 infection? A population-level view in the EHR-based RECOVER program

Long-term sequelae of severe acute respiratory coronavirus-2 (SARS-CoV-2) infection may include increased incidence of diabetes. Here we describe the temporal relationship between new type 2 diabetes and SARS-CoV-2 infection in a nationwide database. We found that while the proportion of newly diagnosed type 2 diabetes increased during the acute period of SARS-CoV-2 infection, the mean proportion of new diabetes cases in the 6 months post-infection was about 83% lower than the 6 months preinfection. These results underscore the need for further investigation to understand the timing of new diabetes after COVID-19, etiology, screening, and treatment strategies.

A method for comparing multiple imputation techniques: A case study on the U.S. national COVID cohort collaborative

Healthcare datasets obtained from Electronic Health Records have proven to be extremely useful for assessing associations between patients' predictors and outcomes of interest. However, these datasets often suffer from missing values in a high proportion of cases, whose removal may introduce severe bias. Several multiple imputation algorithms have been proposed to attempt to recover the missing information under an assumed missingness mechanism. Each algorithm presents strengths and weaknesses, and there is currently no consensus on which multiple imputation algorithm works best in a given scenario. Furthermore, the selection of each algorithm's parameters and data-related modeling choices are also both crucial and challenging. In this paper we propose a novel framework to numerically evaluate strategies for handling missing data in the context of statistical analysis, with a particular focus on multiple imputation techniques. We demonstrate the feasibility of our approach on a large cohort of type-2 diabetes patients provided by the National COVID Cohort Collaborative (N3C) Enclave, where we explored the influence of various patient characteristics on outcomes related to COVID-19. Our analysis included classic multiple imputation techniques as well as simple complete-case Inverse Probability Weighted models. Extensive experiments show that our approach can effectively highlight the most promising and performant missing-data handling strategy for our case study. Moreover, our methodology allowed a better understanding of the behavior of the different models and of how it changed as we modified their parameters. Our method is general and can be applied to different research fields and on datasets containing heterogeneous types.

Where Do Real-Time Prescription Benefit Tools Fit in the Landscape of High US Prescription Medication Costs? A Narrative Review

The problem of unaffordable prescription medications in the United States is complex and can result in poor patient adherence to therapy, worse clinical outcomes, and high costs to the healthcare system. While providers are aware of the financial burden of healthcare for patients, there is a lack of actionable price transparency at the point of prescribing. Real-time prescription benefit (RTPB) tools are new electronic clinical decision support tools that retrieve patient- and medication-specific out-of-pocket cost information and display it to clinicians at the point of prescribing. The rise in US healthcare costs has been a major driver for efforts to increase medication price transparency, and mandates from the Centers for Medicare & Medicaid Services for Medicare Part D sponsors to adopt RTPB tools may spur integration of such tools into electronic health records. Although multiple factors affect the implementation of RTPB tools, there is limited evidence on outcomes. Further research will be needed to understand the impact of RTPB tools on end results such as prescribing behavior, out-of-pocket medication costs for patients, and adherence to pharmacologic treatment. We review the terminology and concepts essential in understanding the landscape of RTPB tools, implementation considerations, barriers to adoption, and directions for future research that will be important to patients, prescribers, health systems, and insurers.

Coding long COVID: characterizing a new disease through an ICD-10 lens

BACKGROUND

Naming a newly discovered disease is a difficult process; in the context of the COVID-19 pandemic and the existence of post-acute sequelae of SARS-CoV-2 infection (PASC), which includes long COVID, it has proven especially challenging. Disease definitions and assignment of a diagnosis code are often asynchronous and iterative. The clinical definition and our understanding of the underlying mechanisms of long COVID are still in flux, and the deployment of an ICD-10-CM code for long COVID in the USA took nearly 2 years after patients had begun to describe their condition. Here, we leverage the largest publicly available HIPAA-limited dataset about patients with COVID-19 in the US to examine the heterogeneity of adoption and use of U09.9, the ICD-10-CM code for "Post COVID-19 condition, unspecified."

METHODS

We undertook a number of analyses to characterize the N3C population with a U09.9 diagnosis code (n = 33,782), including assessing person-level demographics and a number of area-level social determinants of health; diagnoses commonly co-occurring with U09.9, clustered using the Louvain algorithm; and quantifying medications and procedures recorded within 60 days of U09.9 diagnosis. We stratified all analyses by age group in order to discern differing patterns of care across the lifespan.

RESULTS

We established the diagnoses most commonly co-occurring with U09.9 and algorithmically clustered them into four major categories: cardiopulmonary, neurological, gastrointestinal, and comorbid conditions. Importantly, we discovered that the population of patients diagnosed with U09.9 is demographically skewed toward female, White, non-Hispanic individuals, as well as individuals living in areas with low poverty and low unemployment. Our results also include a characterization of common procedures and medications associated with U09.9-coded patients.

CONCLUSIONS

This work offers insight into potential subtypes and current practice patterns around long COVID and speaks to the existence of disparities in the diagnosis of patients with long COVID. This latter finding in particular requires further research and urgent remediation.

Use and outcomes from neoadjuvant chemotherapy in borderline resectable pancreatic ductal adenocarcinoma in an Australasian population

BACKGROUND

Use of neoadjuvant (NA) chemotherapy is recommended when pancreatic ductal adenocarcinoma (PDAC) is borderline resectable METHOD: A retrospective analysis of consecutive patients with localized PDAC between January 2016 and March 2019 within the Australasian Pancreatic Cancer Registry (PURPLE, Pancreatic cancer: Understanding Routine Practice and Lifting End results) was performed. Clinicopathological characteristics, treatment, and outcome were analyzed. Overall survival (OS) comparison was performed using log-rank model and Kaplan-Meier analysis.

RESULTS

The PURPLE database included 754 cases with localised PDAC, including 148 (20%) cases with borderline resectable pancreatic cancer (BRPC). Of the 148 BRPC patients, 44 (30%) underwent immediate surgery, 80 (54%) received NA chemotherapy, and 24 (16%) were inoperable. The median age of NA therapy patients was 63 years and FOLFIRINOX (53%) was more often used as NA therapy than gemcitabine/nab-paclitaxel (31%). Patients who received FOLFIRINOX were younger than those who received gemcitabine/nab-paclitaxel (60 years vs. 67 years, p = .01). Surgery was performed in 54% (43 of 80) of BRPC patients receiving NA chemotherapy, with 53% (16 of 30) achieving R0 resections. BRPC patients undergoing surgery had a median OS of 30 months, and 38% (9 of 24) achieved R0 resection. NA chemotherapy patients had a median OS of 20 months, improving to 24 months versus 10 months for patients receiving FOLFIRINOX compared to gemcitabine/nab-paclitaxel (Hazard Ratio (HR) .3, p < .0001).

CONCLUSIONS

NA chemotherapy use in BRPC is increasing in Australia. One half of patients receiving NA chemotherapy proceed to curative resection, with 53% achieving R0 resections. Patients receiving Infusional 5-flurouracil, Irinotecan and Oxaliplatin (FOLIRINOX) had increased survival than gemcitabine/nab-paclitaxel. Treatment strategies are being explored in the MASTERPLAN and DYNAMIC-Pancreas trials.

T-cell cellular stress and reticulocyte signatures, but not loss of naïve T lymphocytes, characterize severe COVID-19 in older adults

In children and younger adults up to 39 years of age, SARS-CoV-2 usually elicits mild symptoms that resemble the common cold. Disease severity increases with age starting at 30 and reaches astounding mortality rates that are ~330 fold higher in persons above 85 years of age compared to those 18-39 years old. To understand age-specific immune pathobiology of COVID-19, we have analyzed soluble mediators, cellular phenotypes, and transcriptome from over 80 COVID-19 patients of varying ages and disease severity, carefully controlling for age as a variable. We found that reticulocyte numbers and peripheral blood transcriptional signatures robustly correlated with disease severity. By contrast, decreased numbers and proportion of naïve T-cells, reported previously as a COVID-19 severity risk factor, were found to be general features of aging and not of COVID-19 severity, as they readily occurred in older participants experiencing only mild or no disease at all. Single-cell transcriptional signatures across age and severity groups showed that severe but not moderate/mild COVID-19 causes cell stress response in different T-cell populations, and some of that stress was unique to old severe participants, suggesting that in severe disease of older adults, these defenders of the organism may be disabled from performing immune protection. These findings shed new light on interactions between age and disease severity in COVID-19.

SARS-CoV-2 Reinfection is Preceded by Unique Biomarkers and Related to Initial Infection Timing and Severity: an N3C RECOVER EHR-Based Cohort Study

Although the COVID-19 pandemic has persisted for over 2 years, reinfections with SARS-CoV-2 are not well understood. We use the electronic health record (EHR)-based study cohort from the National COVID Cohort Collaborative (N3C) as part of the NIH Researching COVID to Enhance Recovery (RECOVER) Initiative to characterize reinfection, understand development of Long COVID after reinfection, and compare severity of reinfection with initial infection. We validate previous findings of reinfection incidence (5.9%), the occurrence of most reinfections during the Omicron epoch, and evidence of multiple reinfections. We present novel findings that Long COVID diagnoses occur closer to the index date for infection or reinfection in the Omicron BA epoch. We report lower albumin levels leading up to reinfection and a statistically significant association of severity between first infection and reinfection (chi-squared value: 9446.2, p-value: 0) with a medium effect size (Cramer's V: 0.18, DoF = 4).

An integrated LSTM-HeteroRGNN model for interpretable opioid overdose risk prediction

Opioid overdose (OD) has become a leading cause of accidental death in the United States, and overdose deaths reached a record high during the COVID-19 pandemic. Combating the opioid crisis requires targeting high-need populations by identifying individuals at risk of OD. While deep learning emerges as a powerful method for building predictive models using large scale electronic health records (EHR), it is challenged by the complex intrinsic relationships among EHR data. Further, its utility is limited by the lack of clinically meaningful explainability, which is necessary for making informed clinical or policy decisions using such models. In this paper, we present LIGHTED, an integrated deep learning model combining long short term memory (LSTM) and graph neural networks (GNN) to predict patients' OD risk. The LIGHTED model can incorporate the temporal effects of disease progression and the knowledge learned from interactions among clinical features. We evaluated the model using Cerner's Health Facts database with over 5 million patients. Our experiments demonstrated that the model outperforms traditional machine learning methods and other deep learning models. We also proposed a novel interpretability method by exploiting embeddings provided by GNNs to cluster patients and EHR features respectively, and conducted qualitative feature cluster analysis for clinical interpretations. Our study shows that LIGHTED can take advantage of longitudinal EHR data and the intrinsic graph structure of EHRs among patients to provide effective and interpretable OD risk predictions that may potentially improve clinical decision support.

The World Organization of Family Doctors Air Health Train the Trainer Program: lessons learned and implications for planetary health education

The World Organization of Family Doctors (WONCA) Air Health Train the Trainer Program was a pilot educational programme that focused on a key aspect of planetary health: the intersection of air pollution, human health, and climate change. In this Viewpoint, we-the coordinators of the training programme and some of the most active trainers-briefly describe the programme and discuss implementation successes, challenges, and lessons learned, which relate to the creation and use of training materials appropriate for health professionals in low-income and middle-income countries, strategies to improve the retention of trainers to deliver activities in their communities, and the development of stronger networks and further tools to support trainers. These findings could be applied to future education and training programmes.

T-cell cellular stress and reticulocyte signatures, but not loss of naïve T lymphocytes, characterize severe COVID-19 in older adults

In children and younger adults up to 39 years of age, SARS-CoV-2 usually elicits mild symptoms that resemble the common cold. Disease severity increases with age starting at 30 and reaches astounding mortality rates that are ~330 fold higher in persons above 85 years of age compared to those 18-39 years old. To understand age-specific immune pathobiology of COVID-19 we have analyzed soluble mediators, cellular phenotypes, and transcriptome from over 80 COVID-19 patients of varying ages and disease severity, carefully controlling for age as a variable. We found that reticulocyte numbers and peripheral blood transcriptional signatures robustly correlated with disease severity. By contrast, decreased numbers and proportion of naïve T-cells, reported previously as a COVID-19 severity risk factor, were found to be general features of aging and not of COVID-19 severity, as they readily occurred in older participants experiencing only mild or no disease at all. Single-cell transcriptional signatures across age and severity groups showed that severe but not moderate/mild COVID-19 causes cell stress response in different T-cell populations, and some of that stress was unique to old severe participants, suggesting that in severe disease of older adults, these defenders of the organism may be disabled from performing immune protection. These findings shed new light on interactions between age and disease severity in COVID-19.

Are fewer cases of diabetes mellitus diagnosed in the months after SARS-CoV-2 infection?

Long-term sequelae of severe acute respiratory coronavirus-2 (SARS-CoV-2) infection may include an increased incidence of diabetes. Our objective was to describe the temporal relationship between new diagnoses of diabetes mellitus and SARS-CoV-2 infection in a nationally representative database. There appears to be a sharp increase in diabetes diagnoses in the 30 days surrounding SARS-CoV-2 infection, followed by a decrease in new diagnoses in the post-acute period, up to 360 days after infection. These results underscore the need for further investigation, as understanding the timing of new diabetes onset after COVID-19 has implications regarding potential etiology and screening and treatment strategies.

Effect of SARS-CoV-2 Infection and Infection Severity on Longer-Term Glycemic Control and Weight in People With Type 2 Diabetes

OBJECTIVE

To evaluate the association of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and severity of infection with longer-term glycemic control and weight in people with type 2 diabetes (T2D) in the U.S.

RESEARCH DESIGN AND METHODS

We conducted a retrospective cohort study using longitudinal electronic health record data of patients with SARS-CoV-2 infection from the National COVID Cohort Collaborative (N3C). Patients were ≥18 years old with an ICD-10 diagnosis of T2D and at least one HbA1c and weight measurement prior to and after an index date of their first coronavirus disease 2019 (COVID-19) diagnosis or negative SARS-CoV-2 test. We used propensity scores to identify a matched cohort balanced on demographic characteristics, comorbidities, and medications used to treat diabetes. The primary outcome was the postindex average HbA1c and postindex average weight over a 1 year time period beginning 90 days after the index date among patients who did and did not have SARS-CoV-2 infection. Secondary outcomes were postindex average HbA1c and weight in patients who required hospitalization or mechanical ventilation.

RESULTS

There was no significant difference in the postindex average HbA1c or weight in patients who had SARS-CoV-2 infection compared with control subjects. Mechanical ventilation was associated with a decrease in average HbA1c after COVID-19.

CONCLUSIONS

In a multicenter cohort of patients in the U.S. with preexisting T2D, there was no significant change in longer-term average HbA1c or weight among patients who had COVID-19. Mechanical ventilation was associated with a decrease in HbA1c after COVID-19.

Prognostically distinct phenotypes of metabolic health beyond obesity in aortic stenosis

Background

Whilst current evidence are in favour of metabolic health and non-obesity in the reduction of incident cardiovascular disease, little is known regarding the prognosis across the metabolic phenotypes once cardiovascular disease occurs. This study examined the prognosis of patients with significant aortic stenosis (AS) based on the presence of metabolic health and obesity.

Methods

This retrospective cohort on consecutive patients presenting with moderate-to-severe AS to a tertiary hospital between 2010 and 2015. Patients were allocated into 4 groups based on obesity and metabolic health: metabolically healthy obese (MHO), metabolically healthy non-obese (MHNO), metabolically unhealthy obese (MUO) and metabolically unhealthy non-obese (MUNO). Metabolic health was defined in accordance to Program Adult Treatment Panel III criteria. The primary outcome was all-cause mortality. Cox regression examined independent associations between mortality and metabolic phenotypes, adjusting for aortic valve area, ejection fraction, age, sex, chronic kidney disease and AVR as a time-dependent covariate.

Results

Of 727 patients, the majority (51.6%) were MUNO, followed by MUO (32.7%), MHNO (11.4%), and MHO (4.3%). MHNO had the highest mortality (43.0%), followed by the MUNO (37.5%), MUO (30.0%) and MHO (6.9%) groups (p=0.001). Compared to MHNO, MHO (HR 0.159, 95% CI 0.038–0.668, p=0.012) and MUO (HR 0.614, 95% CI 0.403–0.937, p=0.024) were independently associated with lower all-cause mortality rates, after adjusting for confounders. In obese patients, metabolic health had favourable survival compared to metabolically unhealthy (p=0.015), but this protective impact of metabolic health was not observed in overweight or normal weight individuals. Obesity had favourable survival compared to overweight and normal weight, in both metabolically health (p=0.002) and unhealthy (p=0.007) patients,

Conclusion

MHO patients with AS have the most favourable prognosis whilst the seemingly healthy MHNO group had the worst survival. There should be a paradigm shift towards prioritising metabolic health rather than weight reduction in patients with significant AS.

Funding Acknowledgement

Type of funding sources: None.

Impact of first-line FOLFIRINOX versus Gemcitabine/Nab-Paclitaxel chemotherapy on survival in advanced pancreatic cancer: Evidence from the prospective international multicentre PURPLE pancreatic cancer registry

BACKGROUND

First-line palliative chemotherapy regimens in advanced pancreatic ductal adenocarcinoma (PDAC) have not been compared in head-to-head phase III randomised controlled trials (RCT). Data on optimum first-line treatment and subsequent sequencing is lacking.

OBJECTIVE

To compare overall survival (OS) between first-line treatment regimens in a real-world population to determine if an optimal therapeutic sequence is associated with survival benefit.

METHODS

A retrospective analysis of prospectively collated data from the Australasian PURPLE pancreatic cancer registry was undertaken.

FINDINGS

From 2016 to 2020, of 1551 pancreatic cancer patients, 615 received palliative-intent chemotherapy. Patients with early-stage resected disease without recurrence (n = 369), radiotherapy alone (n = 43), received supportive care alone (n = 458) or had less than 3 months follow-up (n = 66) were excluded. Median OS was comparable between patients receiving first-line Gemcitabine/Nab-Paclitaxel (n = 376) and those receiving FOLFIRINOX (n = 73) (11.3 versus 12.3 months, P = 0.37), with 38% proceeding to second-line chemotherapy which was associated with longer mOS compared to first-line treatment alone (17.4 versus 8.2 months, P &lt; 0.001). With second-line treatment following prior FOLFIRINOX (n = 29) or Gemcitabine/Nab-Paclitaxel (n = 101), mOS did not differ significantly (17.3 versus 15.9 months, P = 0.92), respectively, whilst median progression-free survival was longer with prior FOLFIRINOX (5.2 versus 2.9 months, P = 0.03).

CONCLUSION

There was no significant difference in overall survival between either first-line chemotherapy choice, despite patients receiving FOLFIRINOX being younger, fitter, and more likely to have localised disease. However, FOLFIRINOX was associated with delayed progression. In the absence of phase III RCT data, clinicians should be comfortable using either Gemcitabine/Nab-Paclitaxel or FOLFIRINOX as first-line therapy in advanced PDAC.

Coding Long COVID: Characterizing a new disease through an ICD-10 lens

Background

Naming a newly discovered disease is a difficult process; in the context of the COVID-19 pandemic and the existence of post-acute sequelae of SARS-CoV-2 infection (PASC), which includes Long COVID, it has proven especially challenging. Disease definitions and assignment of a diagnosis code are often asynchronous and iterative. The clinical definition and our understanding of the underlying mechanisms of Long COVID are still in flux, and the deployment of an ICD-10-CM code for Long COVID in the US took nearly two years after patients had begun to describe their condition. Here we leverage the largest publicly available HIPAA-limited dataset about patients with COVID-19 in the US to examine the heterogeneity of adoption and use of U09.9, the ICD-10-CM code for "Post COVID-19 condition, unspecified."

Methods

We undertook a number of analyses to characterize the N3C population with a U09.9 diagnosis code ( n = 21,072), including assessing person-level demographics and a number of area-level social determinants of health; diagnoses commonly co-occurring with U09.9, clustered using the Louvain algorithm; and quantifying medications and procedures recorded within 60 days of U09.9 diagnosis. We stratified all analyses by age group in order to discern differing patterns of care across the lifespan.

Results

We established the diagnoses most commonly co-occurring with U09.9, and algorithmically clustered them into four major categories: cardiopulmonary, neurological, gastrointestinal, and comorbid conditions. Importantly, we discovered that the population of patients diagnosed with U09.9 is demographically skewed toward female, White, non-Hispanic individuals, as well as individuals living in areas with low poverty, high education, and high access to medical care. Our results also include a characterization of common procedures and medications associated with U09.9-coded patients.

Conclusions

This work offers insight into potential subtypes and current practice patterns around Long COVID, and speaks to the existence of disparities in the diagnosis of patients with Long COVID. This latter finding in particular requires further research and urgent remediation.

Leveraging Comprehensive Cancer Registry Data to Enable a Broad Range of Research, Audit and Patient Support Activities

Simple Summary

Registry data has the potential to support a broad range of research, audit and education initiatives. Here, we describe the experience and learnings of a series of large multi-institutional cancer registries that leverage real-world clinical data for a range of purposes, that informs the conduct and output of each registry in a virtuous cycle. Lessons learnt include the need for careful and continuous curation of information being collected, regular database updates, and the need for a continued focus on data quality. As a standalone resource, each registry has supported numerous projects, but linkage with external datasets with patients in common has enhanced the research potential. Multiple projects have linked registry data with matched tissue specimens to support the discovery and valiation of prognostic and predictive markers in the tumour and blood specimens. Registry-based biomarker trials have been successfully supported, generating novel and practice-changing data. Registry-based clinical trials, particularly studies exploring the best use of drug options are now complementing the research conducted in traditional clinical trials. More recent projects supported by the registries include health economic studies, personalised patient education material, and increased consumer engagement, including consumer entered data.

Abstract

Traditional cancer registries have often been siloed efforts, established by single groups with limited objectives. There is the potential for registry data to support a broad range of research, audit and education initiatives. Here, we describe the establishment of a series of comprehensive cancer registries across the spectrum of common solid cancers. The experience and learnings of each registry team as they develop, implement and then use collected data for a range of purposes, that informs the conduct and output of other registries in a virtuous cycle. Each registry is multi-site, multi-disciplinary and aims to collect data of maximal interest and value to a broad range of enquiry, which would be accessible to any researcher with a high-quality proposal. Lessons learnt include the need for careful and continuous curation of data fields, with regular database updates, and the need for a continued focus on data quality. The registry data as a standalone resource has supported numerous projects, but linkage with external datasets with patients in common has enhanced the audit and research potential. Multiple projects have linked registry data with matched tissue specimens to support prognostic and predictive biomarker studies, both validation and discovery. Registry-based biomarker trials have been successfully supported, generating novel and practice-changing data. Registry-based clinical trials, particularly randomised studies exploring the optimal use of available therapy options are now complementing the research conducted in traditional clinical trials. More recent projects supported by the registries include health economic studies, personalised patient education material, and increased consumer engagement, including consumer entered data.

Electrochemical Heterogeneity at the Nanoscale: Diffusion to Partially Active Nanocubes

How does heterogeneity in activity affect the response of nanoparticles? This problem is key to studying the structure-activity relationship of new electrocatalytic materials. However, addressing this problem theoretically and to a high degree of accuracy requires the use of three-dimensional electrochemical simulations that have, until recently, been challenging to undertake. To start to probe this question, we investigate how the diffusion-limited flux to a cube changes as a function of the number of active faces. Importantly, it is clearly demonstrated how the flux is not linearly proportional to the active surface area of the material due to the faces of the cube not having diffusional independence, meaning that the flux to each face reflects the activity or not of nearby faces. These results have clear and important implications for experimental work that uses a correlation-based approach to evidence changes in activity at the nanoscale.

Mesothelium-Derived Factors Shape GATA6-Positive Large Cavity Macrophages

The local microenvironment shapes macrophage differentiation in each tissue. We hypothesized that in the peritoneum, local factors in addition to retinoic acid can support GATA6-driven differentiation and function of peritoneal large cavity macrophages (LCMs). We found that soluble proteins produced by mesothelial cells lining the peritoneal cavity maintained GATA6 expression in cultured LCMs. Analysis of global gene expression of isolated mesothelial cells highlighted mesothelin (Msln) and its binding partner mucin 16 (Muc16) as candidate secreted ligands that potentially regulate GATA6 expression in peritoneal LCMs. Mice deficient for either of these molecules showed diminished GATA6 expression in peritoneal and pleural LCMs that was most prominent in aged mice. The more robust phenotype in older mice suggested that monocyte-derived macrophages were the target of Msln and Muc16. Cell transfer and bone marrow chimera experiments supported this hypothesis. We found that lethally irradiated Msln−/− and Muc16−/− mice reconstituted with wild-type bone marrow had lower levels of GATA6 expression in peritoneal and pleural LCMs. Similarly, during the resolution of zymosan-induced inflammation, repopulated peritoneal LCMs lacking expression of Msln or Muc16 expressed diminished GATA6. These data support a role for mesothelial cell–produced Msln and Muc16 in local macrophage differentiation within large cavity spaces such as the peritoneum. The effect appears to be most prominent on monocyte-derived macrophages that enter into this location as the host ages and also in response to infection.

Hierarchical partner selection shapes rod-cone pathway specificity in the inner retina

Neurons form stereotyped microcircuits that underlie specific functions. In the vertebrate retina, the primary rod and cone pathways that convey dim and bright light signals, respectively, exhibit distinct wiring patterns. Rod and cone pathways are thought to be assembled separately during development. However, using correlative fluorescence imaging and serial electron microscopy, we show here that cross-pathway interactions are involved to achieve pathway-specific connectivity within the inner retina. We found that A17 amacrine cells, a rod pathway-specific cellular component, heavily bias their synaptogenesis with rod bipolar cells (RBCs) but increase their connectivity with cone bipolar cells (CBCs) when RBCs are largely ablated. This cross-pathway synaptic plasticity occurs during synaptogenesis and is triggered even on partial loss of RBCs. Thus, A17 cells adopt a hierarchical approach in selecting postsynaptic partners from functionally distinct pathways (RBC>CBC), in which contact and/or synaptogenesis with preferred partners (RBCs) influences connectivity with less-preferred partners (CBCs).

•

A17s establish rod pathway-specific connectivity early during synaptogenesis

•

A17s engage both selective wiring and remodeling to shape their wiring pattern

•

A17s demonstrate a hierarchical choice of postsynaptic partners

•

A17s increase wiring with the cone pathway when rod bipolar targets are scarce

Circulating Tumor DNA Analysis Guiding Adjuvant Therapy in Stage II Colon Cancer

BACKGROUND

The role of adjuvant chemotherapy in stage II colon cancer continues to be debated. The presence of circulating tumor DNA (ctDNA) after surgery predicts very poor recurrence-free survival, whereas its absence predicts a low risk of recurrence. The benefit of adjuvant chemotherapy for ctDNA-positive patients is not well understood.

METHODS

We conducted a trial to assess whether a ctDNA-guided approach could reduce the use of adjuvant chemotherapy without compromising recurrence risk. Patients with stage II colon cancer were randomly assigned in a 2:1 ratio to have treatment decisions guided by either ctDNA results or standard clinicopathological features. For ctDNA-guided management, a ctDNA-positive result at 4 or 7 weeks after surgery prompted oxaliplatin-based or fluoropyrimidine chemotherapy. Patients who were ctDNA-negative were not treated. The primary efficacy end point was recurrence-free survival at 2 years. A key secondary end point was adjuvant chemotherapy use.

RESULTS

Of the 455 patients who underwent randomization, 302 were assigned to ctDNA-guided management and 153 to standard management. The median follow-up was 37 months. A lower percentage of patients in the ctDNA-guided group than in the standard-management group received adjuvant chemotherapy (15% vs. 28%; relative risk, 1.82; 95% confidence interval [CI], 1.25 to 2.65). In the evaluation of 2-year recurrence-free survival, ctDNA-guided management was noninferior to standard management (93.5% and 92.4%, respectively; absolute difference, 1.1 percentage points; 95% CI, -4.1 to 6.2 [noninferiority margin, -8.5 percentage points]). Three-year recurrence-free survival was 86.4% among ctDNA-positive patients who received adjuvant chemotherapy and 92.5% among ctDNA-negative patients who did not.

CONCLUSIONS

A ctDNA-guided approach to the treatment of stage II colon cancer reduced adjuvant chemotherapy use without compromising recurrence-free survival. (Supported by the Australian National Health and Medical Research Council and others; DYNAMIC Australian New Zealand Clinical Trials Registry number, ACTRN12615000381583.).

Adjuvant chemotherapy guided by circulating tumor DNA analysis in stage II colon cancer: The randomized DYNAMIC trial

LBA100

Background: The role of adjuvant chemotherapy (CT) in stage II colon cancer continues to be debated. The presence of circulating tumor DNA (ctDNA) after surgery predicts very poor recurrence-free survival (RFS), while its absence predicts a low recurrence risk. For ctDNA-positive cases the benefit of adjuvant CT is unknown. DYNAMIC was designed to assess if a ctDNA-guided approach could reduce the use of adjuvant CT without compromising recurrence risk. Methods: DYNAMIC is a multi-center randomized controlled phase II trial. Eligible patients had resected stage II colon cancer and were suitable for adjuvant CT. Patients were randomly assigned 2:1 to ctDNA-guided management or standard management (clinician-guided based on conventional criteria), after stratification for T stage and participating center location. Criteria for clinical low versus high risk were predefined. The Safe-SeqS tumor-informed personalized ctDNA assay was used. For ctDNA-guided management, a ctDNA-positive result at 4 or 7 weeks after surgery prompted oxaliplatin-based or fluoropyrimidine CT; ctDNA-negative patients were not treated. The primary efficacy endpoint was non-inferiority in RFS rate at 2 years. A key secondary endpoint was adjuvant CT use. The target sample size of 450 provided 80% power with 95% confidence to confirm non-inferiority between the two arms with a margin of 8.5%. Results: Of 455 patients randomized between Aug 2015 and Aug 2019, 302 were assigned to ctDNA-guided and 153 to standard management. Median follow-up was 37 months. In the ctDNA-guided arm, ctDNA analysis was successful in all but three patients; only two patients did not receive ctDNA-guided management. In the intention to treat population, fewer patients overall in the ctDNA-guided arm received adjuvant CT compared to standard management (15.3% vs 27.9%, odds ratio 2.14; P = 0.002), with the largest difference seen in patients with T4 or poorly differentiated tumors (odds ratios 6.22 and 6.31, respectively). Of those who received treatment, oxaliplatin-based doublet was more frequently administered than fluoropyrimidine alone for ctDNA-guided compared to standard management patients (62.2% vs. 9.8%; P < 0.001). ctDNA-guided management was non-inferior to standard management for 2-year RFS (93.5% vs 92.4%, difference 1.1%, 95% confidence interval, -4.1% to 6.2%). Following adjuvant CT, 3-year RFS for ctDNA-positive patients was 86.4%. Without adjuvant CT, 3-year RFS for ctDNA-negative patients was 92.5%, with a 3-year RFS of 96.7% in the clinical low risk subgroup. Conclusions: A ctDNA-guided approach to stage II colon cancer reduced adjuvant chemotherapy use without compromising recurrence-free survival. The low recurrence rate in ctDNA-positive patients who received chemotherapy suggests a survival benefit from adjuvant therapy. ctDNA-negative patients are unlikely to benefit from chemotherapy. Clinical trial information: ACTRN12615000381583.

POS0343 TREATMENT PERSISTENCE AND ADHERENCE AMONG PATIENTS WITH JUVENILE IDIOPATHIC ARTHRITIS RECEIVING ABATACEPT OR TNF INHIBITORS USING US CLAIMS DATA

Background

Juvenile idiopathic arthritis (JIA) is the most common rheumatic condition among children and teens1 and contributes to a diminished quality of life.2 Previous data underscore the potential for abatacept to improve health-related outcomes in patients with JIA after demonstrating poor responses to other DMARDs.3 Patients with RA show greater persistence on abatacept vs TNF inhibitors (TNFi), and this should also be confirmed in patients with JIA.4

Objectives

To evaluate treatment persistence and adherence at 12- and 18-month follow-up in patients with JIA newly initiating either abatacept or a TNFi.

Methods

This analysis used data from the IQVIA PharMetrics Plus claims database from Jan 2008–Apr 2021. We identified patients with ≥ 1 claim of JIA diagnosis after Jan 2008, who were < 18 years old at initial diagnosis, had ≥ 1 claim of abatacept or TNFi treatment (adalimumab, etanercept, golimumab) following diagnosis, had continuous enrollment in medical and pharmacy benefits for ≥ 12 months before index date (first prescription of abatacept or TNFi), and had 12 or 18 months’ continuous medical and pharmacy enrollment after index date. Patients receiving abatacept or TNFi treatment ≤ 12 months prior to index date and patients initiating combined abatacept + TNFi treatment on the index date were excluded. Specific outcomes included: discontinuation (absence of a new prescription for index treatment within the gap of 5× treatment half-life), persistence rate (proportion of patients continuing index medication without any gaps exceeding 5× treatment half-life), and treatment adherence (defined as medication possession ratio [MPR, proportion of follow-up period where medication supply is available] and proportion of days covered [PDC, proportion of follow-up period where a patient is covered by a given drug]). All outcomes were reported at 12 and 18 months. All statistical analyses are descriptive with the intent for hypothesis generation.

Results

There were 2847 patients (abatacept, n = 111; TNFi, n = 2736) at 12-month follow-up; fewer completed the 18-month follow-up (2403 patients: abatacept, n = 94; TNFi, n = 2309). At index date, treatment groups were similar for sex, geographic location, and comorbidities (Table 1). Numerically higher persistence was observed in patients prescribed abatacept compared with TNFi overall at both time points. Abatacept persistence was higher than etanercept but similar to adalimumab (Figure 1). At 12 months, the percent of patients with PDC ≥ 0.8 was 57% for abatacept, 51% for adalimumab, and 38% for etanercept, while MPR ≥ 0.8 was 63% for abatacept, 55% for adalimumab, and 42% for etanercept. Patients prescribed abatacept had numerically greater proportions of PDC ≥ 0.8 (abatacept, 48%; adalimumab, 40%; etanercept, 29%) and MPR ≥ 0.8 (abatacept, 53%; adalimumab, 44%; etanercept, 33%) at 18 months.

Table 1.

Baseline characteristics of patients with 12-month follow-up data

CharacteristicAbatacept (n = 111)TNFi (n = 2736)Age, years, mean (SD)14.4 (3.8)12.6 (4.6)Female sex89 (80.2)1930 (70.5)Geographic region South43 (38.7)865 (31.6) Midwest40 (36.0)818 (29.9) West9 (8.1)408 (14.9) East19 (17.1)540 (19.7) Unknown0 (0)105 (3.8)Comorbidities Asthma9 (8.1)275 (10.1) COPD11 (9.9)323 (11.8) Cardiovascular disease14 (12.6)222 (8.1) Uveitis14 (12.6)321 (11.7) Iridocyclitisa12 (10.8)216 (7.9)CCI score, mean (SD)0.58 (0.73)0.46 (0.68)

Data are shown as n (%) unless otherwise specified.

aSubgroup disease under uveitis.

CCI, Charlson Comorbidity Index; COPD, chronic obstructive pulmonary disease.

Conclusion

The present findings suggest that patients with JIA initiating abatacept treatment display numerically higher persistence and adherence compared with patients treated with TNFis at both 12- and 18-months’ follow-up.

References

[1]Prakken B, et al. Lancet 2011;377:2138–49.

[2]Lovell DJ, et al. Arthritis Rheumatol 2015;67:2759–70.

[3]Ruperto N, et al. Lancet 2008;372:383–91.

[4]Han X, et al. J Health Econ Outcomes Res 2021;8:71–8.

Acknowledgements

This study was sponsored by Bristol Myers Squibb. Medical writing and editorial assistance were provided by Ryan Miller, of Caudex, and were funded by Bristol Myers Squibb. Project analysis was provided by Akshay Vinod (Mu Sigma).

Disclosure of Interests

Ching-An Wang Consultant of: Novartis (used to work there as an external contractor from Jan 2016 to Apr 2021), Employee of: Bristol Myers Squibb, Robert Wong Shareholder of: Bristol Myers Squibb, Employee of: Bristol Myers Squibb, Tzuyung Douglas Kou Shareholder of: Bristol Myers Squibb, Employee of: Bristol Myers Squibb, Hanke Zheng Employee of: Bristol Myers Squibb, Keith Wittstock Shareholder of: Bristol Myers Squibb, Employee of: Bristol Myers Squibb, Vadim Khaychuk Shareholder of: Bristol Myers Squibb, Employee of: Bristol Myers Squibb, Vardhaman PATEL Shareholder of: Bristol Myers Squibb, Employee of: Bristol Myers Squibb

The association between quality care and outcomes for a real-world population of Australian patients diagnosed with pancreatic cancer

BACKGROUND

This study: (i) assessed compliance with a consensus set of quality indicators (QIs) in pancreatic cancer (PC); and (ii) evaluated the association between compliance with these QIs and survival.

METHODS

Four years of data were collected for patients diagnosed with PC. Cox proportional hazards models were used to estimate hazard ratios (HRs) and 95% confidence intervals (CIs). A multivariable analysis tested the relationship between significant patient and hospital characteristics, patient cluster effects within hospitals and survival.

RESULTS

1061 patients were eligible for this study. Significant association with improved survival were: (i) in the potentially resectable group having adjuvant chemotherapy administered following surgery or a reason documented (HR, 0.29; 95 CI, 0.19-0.46); (ii) in the locally advanced group included having chemotherapy ± chemoradiation, or a reason documented for not undergoing treatment (HR, 0.38; 95 CI, 0.25-0.58); and (iii) in the metastatic disease group included having documented performance status at presentation (HR, 0.65; 95 CI, 0.47-0.89), being seen by an oncologist in the absence of treatment (HR, 0.48; 95 CI, 0.31-0.77), and disease management discussed at a multidisciplinary team meeting (HR, 0.79; 95 CI, 0.64-0.96).

CONCLUSION

Capture of a concise data set has enabled quality of care to be assessed.

POS0579 ABSENCE OF ASSOCIATION BETWEEN ABATACEPT EXPOSURE LEVELS AND INITIAL INFECTION IN PATIENTS WITH RA: A POST HOC ANALYSIS OF THE RANDOMIZED, PLACEBO-CONTROLLED AVERT-2 STUDY

Background

Infections are the most commonly reported AE observed in patients with RA treated with immunosuppressive therapies and can be clinically significant. A recent review reported differences in the risk of infection for some biologics such as tocilizumab and TNF inhibitors.1 Abatacept selectively modulates T-cell co-stimulation and is approved for the treatment of RA. In patients with polyarticular-course juvenile idiopathic arthritis, no association was found between higher serum abatacept exposure and the incidence of infection.2 This has not been evaluated for adult patients with RA.

Objectives

To determine if higher serum abatacept exposure during treatment with SC abatacept was associated with increased risk of infection in adult patients with RA.

Methods

AVERT-2 (Assessing Very Early Rheumatoid arthritis Treatment-2) was a randomized, placebo-controlled study of SC abatacept + MTX vs abatacept placebo + MTX in MTX-naive, anti-citrullinated protein antibody–positive patients with early, active RA.3 A post hoc population pharmacokinetic (PK) analysis was performed using PK-evaluable patient data from the induction period (year 1) of AVERT-2. Association between steady-state abatacept exposure (min plasma concentration [Cmin], max plasma concentration [Cmax], and average plasma concentration [Cavg]) and first infection was evaluated using Kaplan–Meier plots of probability vs time on treatment by abatacept exposure quartiles and Cox proportional-hazards models.

Results

PK of SC abatacept was defined as a linear 2-compartment model with first-order absorption and first-order elimination. The findings of the updated PK analysis were consistent with those reported in prior population analyses of abatacept PK in adults with RA. The final model included effects of baseline body weight, estimated glomerular filtration rate, sex, age, albumin, MTX use, NSAID use, SJC, and race on abatacept clearance. The only covariate with a clinically relevant effect was higher body weight, which caused an increase in clearance and volume. Infections occurred in a total of 330/693 (47.6%; serious, 1.6%) patients treated with abatacept, and 134/301 (44.5%; serious, 1.3%) with placebo during the first year of AVERT-2. In patients taking abatacept, the mean (SD) study exposure to abatacept was 376 (60) days, while mean (SD) prednisone equivalent dose was 6.7 (3.8) mg/day and mean (SD) MTX dose was 9.6 (3.0) mg/week. No exposure–response relationship was observed between the probability of first infection and steady-state abatacept exposure quartiles (Cavg, Cmin, and Cmax), or compared with placebo (Figure 1A–C). Kaplan–Meier assessment also showed no increase in risk of infection with concomitant use of MTX and glucocorticoids.

Conclusion

No association was found between initial infection and steady-state abatacept exposure (Cavg, Cmin, Cmax) or MTX and glucocorticoid use in patients with RA treated with SC abatacept.

References

[1]Jani M, et al. Curr Opin Rheumatol 2019;31:285–92.

[2]Ruperto N, et al. J Rheumatol 2021;48:1073–81.

[3]Emery P, et al. Arthritis Rheumatol 2019;71(suppl 10):L11.

Acknowledgements

This study was sponsored by Bristol Myers Squibb. Writing and editorial assistance were provided by Fiona Boswell, PhD, of Caudex, and was funded by Bristol Myers Squibb. Support was provided by Sandra Overfield as Protocol Manager, and Prema Sukumar and Renfang Hwang as Data Science Leads.

Disclosure of Interests

Paul Emery Consultant of: AbbVie, AstraZeneca, Boehringer Ingelheim, Bristol Myers Squibb, Eli Lilly, Galapagos, Gilead, Janssen, Merck Sharp & Dohme, Novartis, Pfizer, Roche, Samsung, Grant/research support from: AbbVie, Bristol Myers Squibb, Eli Lilly, Novartis, Pfizer, Roche, Samsung, Roy Fleischmann Consultant of: Amgen, AbbVie, Bristol Myers Squibb, Gilead, GlaxoSmithKline, Novartis, Pfizer, Grant/research support from: Amgen, AbbVie, Arthrosi, Biosplice, Bristol Myers Squibb, Gilead, GlaxoSmithKline, Horizon, Novartis, Pfizer, Regeneron, TEVA, UCB, Robert Wong Shareholder of: Bristol Myers Squibb, Employee of: Bristol Myers Squibb, Karissa Lozenski Shareholder of: Bristol Myers Squibb, Employee of: Bristol Myers Squibb, Yoshiya Tanaka Speakers bureau: AbbVie, Amgen, Astellas, AstraZeneca, Boehringer Ingelheim, Bristol Myers Squibb, Chugai, Eisai, Eli Lilly, Gilead, Mitsubishi Tanabe, YL Biologics, Consultant of: AbbVie, Ayumi, Daiichi Sankyo, Eli Lilly, GlaxoSmithKline, Taisho, Sanofi, Grant/research support from: AbbVie, Asahi Kasei, Boehringer Ingelheim, Chugai, Corrona, Daiichi Sankyo, Eisai, Kowa, Mitsubishi Tanabe, Takeda, Vivian Bykerk Consultant of: Amgen, Bristol Myers Squibb, Genzyme Corporation, Gilead, Regeneron, UCB, Grant/research support from: Amgen, Bristol Myers Squibb, Genzyme Corporation, Pfizer, Regeneron, Sanofi Aventis, UCB, Clifton Bingham Consultant of: AbbVie, Bristol Myers Squibb, Eli Lilly, Janssen, Pfizer, Sanofi, Grant/research support from: Bristol Myers Squibb, Thomas Huizinga Speakers bureau: Abblynx, Abbott, Biotest AG, Bristol Myers Squibb, Crescendo Bioscience, Eli Lilly, Epirus, Galapagos, Janssen, Merck, Novartis, Pfizer, Roche, Sanofi- Aventis, UCB, Consultant of: Abblynx, Abbott, Biotest AG, Bristol Myers Squibb, Crescendo Bioscience, Eli Lilly, Epirus, Galapagos, Janssen, Merck, Novartis, Pfizer, Roche, Sanofi- Aventis, UCB, Grant/research support from: Abblynx, Abbott, Biotest AG, Bristol Myers Squibb, Crescendo Bioscience, Eli Lilly, Epirus, Galapagos, Janssen, Merck, Novartis, Pfizer, Roche, Sanofi- Aventis, UCB, Gustavo Citera Speakers bureau: AbbVie, Amgen, Bristol Myers Squibb, Eli Lilly, Janssen, Pfizer, Sandoz, Consultant of: AbbVie, Amgen, Bristol Myers Squibb, Pfizer, Grant/research support from: Pfizer, Yedid Elbez Consultant of: Bristol Myers Squibb, Employee of: Signifience, Vidya Perera Shareholder of: Bristol Myers Squibb, Employee of: Bristol Myers Squibb, Bindu Murthy Shareholder of: Bristol Myers Squibb, Employee of: Bristol Myers Squibb, Kelly Maxwell Consultant of: Bristol Myers Squibb, Employee of: Cognigen Corporation, Julie Passarell Consultant of: Bristol Myers Squibb, Employee of: Cognigen Corporation, William Hedrich: None declared, Daphne Williams Consultant of: Black Diamond Network, Joule, Syneos, Employee of: Bristol Myers Squibb.

POS0340 PREDICTORS OF CLINICAL RESPONSE TO ABATACEPT IN CHILDREN WITH POLYARTICULAR JUVENILE IDIOPATHIC ARTHRITIS

Background

For children with polyarticular juvenile idiopathic arthritis (pJIA) and inadequate response or intolerance to initial treatment with MTX, treatment options include abatacept.1 Abatacept, a selective T-cell co-stimulation modulator, has a distinct mechanism of action from other current treatments for rheumatic diseases,2 and factors predicting clinical response can help determine optimal treatment strategy. Two phase 3 studies demonstrated the efficacy and safety of IV and SC abatacept in patients with pJIA and an inadequate response to other DMARDs.2,3

Objectives

To determine baseline and post-baseline factors that may predict a clinical response in children and adolescents with pJIA treated with abatacept for 2 years.

Methods

Baseline demographic and disease characteristics and post-baseline factors (50% and 70% improvement in ACR criteria [ACR50, ACR70] at days 57 and 85) were analyzed using data from 2 phase 3 studies of abatacept in patients with JIA aged 2–17 years (SC administration) and 6–17 years (IV administration). Efficacy endpoints were Juvenile Arthritis Disease Activity Score in 10 joints based on CRP (JADAS10-CRP) inactive disease (ID; score of ≤ 2.7),4 and remission, defined as 6 consecutive months of post-baseline JADAS10-CRP ID. Data were analyzed over the entire 2-year study period. The earliest time point at which patients achieved these outcomes was reported. The aforementioned study factors were subjected to a time-to-event analysis, including Cox proportional hazards univariate regression analysis and Cox proportional hazards multivariate regression analysis using stepwise regression; results of the multivariate analysis are reported. Kaplan–Meier analysis was used to estimate time to achieve clinical response. Receiver operating characteristic curves were used to determine threshold values for continuous variables.

Results

Overall, 347 patients were included in the analysis (SC, n = 219; IV, n = 128; 73.8% female; mean [SD] age, 11.3 [4.0] years). Following abatacept treatment, both time to JADAS10-CRP ID and time to JADAS10-CRP remission were predicted (nominal P ≤ 0.05) by age (≤ 11 years: hazard ratio [HR], 1.52 [95% CI, 1.14–2.02] and ≤ 10 years: HR, 1.73 [95% CI, 1.20–2.48], respectively), high-sensitivity CRP (hsCRP; ≤ 0.6 mg/dL: HR, 1.67 [95% CI, 1.22–2.28] and ≤ 0.21 mg/dL: HR, 1.67 [95% CI, 1.15–2.42], respectively), Parent/Patient Global Assessment of well-being (≤ 35.86: HR, 1.88 [95% CI, 1.41–2.51] and ≤ 43.16: HR, 2.05 [95% CI, 1.35–3.10], respectively), and Childhood HAQ-DI (CHAQ-DI; ≤ 1.63: HR, 2.23 [95% CI, 1.47–3.39] and ≤ 0.75: HR, 1.84 [95% CI, 1.24–2.73], respectively) (remission data shown in Figure 1). Disease duration ≤ 2 years from baseline (HR, 1.66 [95% CI, 1.25–2.21]) and SC route of administration (HR, 2.05 [95% CI, 1.45–2.91]) also predicted ID. Among the post-baseline factors, ACR50 at days 57 and 85 predicted both ID (HR, 1.57 [95% CI, 1.04–2.36] and HR, 1.88 [95% CI, 1.41–2.51], respectively) and remission (HR, 1.96 [95% CI, 1.11–3.45] and HR, 3.05 [95% CI, 1.47–6.34], respectively); ACR70 at day 57 also predicted ID (data not shown). Patients with predictive factors for age, hsCRP, Parent/Patient Global Assessment of well-being, and CHAQ-DI, and with lower disease activity achieved ID and/or remission earlier than patients with high disease activity.

Conclusion

We identified baseline and post-baseline factors that predicted JADAS10-CRP ID and remission in patients with pJIA treated with abatacept for 2 years. Screening of abatacept-treated patients with pJIA for such factors may help predict earlier achievement of ID and/or remission.

References

[1]Ringold S, et al. Arthritis Rheumatol 2019;71:846–63.

[2]Brunner HI, et al. Arthritis Rheumatol 2018;70:1144–54.

[3]Ruperto N, et al. Lancet 2008;372:383–91.

[4]Trincianti C, et al. Arthritis Rheumatol 2021;73:1966–75.

Acknowledgements

This study was sponsored by Bristol Myers Squibb. Writing and editorial assistance were provided by Candice Judith Dcosta, MSc, of Caudex, funded by Bristol Myers Squibb. We would like to acknowledge Mara Becker, Duke Clinical Research Institute, Durham, NC, USA, for her contribution to the study analysis.

Disclosure of Interests

Nicolino Ruperto Speakers bureau: Honoraria for consultancies or speaker bureaus from the following pharmaceutical companies in the past 3 years: 2 Bridge, Amgen, AstraZeneca, Aurinia, Bayer, Brystol Myers Squibb, Cambridge Healthcare Research, Celgene, Domain Therapeutic, Eli Lilly, EMD Serono, GlaxoSmithKline, Idorsia, inMed, Janssen, Novartis, Pfizer, Sobi, UCB, Consultant of: Honoraria for consultancies or speaker bureaus from the following pharmaceutical companies in the past 3 years: 2 Bridge, Amgen, AstraZeneca, Aurinia, Bayer, Brystol Myers Squibb, Cambridge Healthcare Research, Celgene, Domain Therapeutic, Eli Lilly, EMD Serono, GlaxoSmithKline, Idorsia, inMed, Janssen, Novartis, Pfizer, Sobi, UCB, Hermine Brunner Speakers bureau: GlaxoSmithKline, Novartis, Pfizer, Consultant of: AbbVie, AstraZeneca-Medimmune, Biogen, Boehringer, Bristol Myers Squibb, Celgene, Cerocor, Eli Lilly, EMD Serono, F. Hoffmann-La Roche, GlaxoSmithKline, Idorsia, Janssen, Merck, Novartis, R-Pharm, Sanofi, Grant/research support from: The Cincinnati Children’s Hospital, where HIB works as a full-time public employee, has received contributions from the following industries in the past 3 years: Bristol Myers Squibb, F. Hoffmann-La Roche, Janssen, Novartis, and Pfizer. This funding has been reinvested for the research activities of the hospital in a fully independent manner, without any commitment to third parties, Alberto Berman Grant/research support from: AbbVie, Amgen, Bristol Myers Squibb, Lilly, Novartis, Pfizer, Roche, Francisco Avila Zapata: None declared, Gerd Horneff Speakers bureau: AbbVie, Chugai, Janssen, Novartis, Pfizer, Grant/research support from: AbbVie, Chugai, MSD, Novartis, Pfizer, Roche, Linda Wagner-Weiner Grant/research support from: Abbott, Bristol Myers Squibb, Merck, Pfizer, UCB, Alexander Belot Speakers bureau: Chugai, GlaxoSmithKline, Novartis, Roche (punctual scientific intervention), Grant/research support from: Boehringer Ingelheim, Merck (joint research project), Ruben Burgos-Vargas: None declared, Maria Luz Gámir Gámir: None declared, Claudia Goldenstein-Schainberg Speakers bureau: AbbVie, Janssen, Novartis, Consultant of: AbbVie, Janssen, Novartis, Maria T. Terreri: None declared, Margarita Askelson Consultant of: Acerta Pharma, Bristol Myers Squibb, Employee of: Bristol Myers Squibb, Robert Wong Shareholder of: Bristol Myers Squibb, Employee of: Bristol Myers Squibb, Alberto Martini Consultant of: AbbVie, Eli Lilly, EMD Serono, Idorsia, Janssen, Novartis, Pfizer, Daniel J Lovell Consultant of: AstraZeneca, Boehringer Ingelheim, GlaxoSmithKline, Hoffman LaRoche, Novartis, UBC (all contracts with employer, CCHMC), Grant/research support from: Bristol Myers Squibb, Janssen, Pfizer, Roche (all contracts with employer, CCHMC); NIH grants: NIAMS, NICHD

Understanding Is a Process

How do we gauge understanding? Tests of understanding, such as Turing's imitation game, are numerous; yet, attempts to achieve a state of understanding are not satisfactory assessments. Intelligent agents designed to pass one test of understanding often fall short of others. Rather than approaching understanding as a system state, in this paper, we argue that understanding is a process that changes over time and experience. The only window into the process is through the lens of natural language. Usefully, failures of understanding reveal breakdowns in the process. We propose a set of natural language-based probes that can be used to map the degree of understanding a human or intelligent system has achieved through combinations of successes and failures.

Money Talks: Pilot Financial Wellness Programs to Promote Positive Financial Planning Behaviors Among Residents

PROBLEM

Graduate medical education programs and national organizations are becoming more involved in promoting trainee financial wellness. Current literature reports residents have poor financial knowledge, high debt levels, low concern about their finances, and deficits in financial preparedness, but there has been little published on best practices for implementing financial wellness programs for residents or measuring meaningful outcomes of such programs.

APPROACH

From June 2017 to 2019, the authors invited 277 internal medicine residents from the Stony Brook University Hospital, Montefiore Medical Center, and Johns Hopkins Bayview Medical Center residency programs to participate in financial wellness programs. Each institution held at least one 90-minute financial planning session; Stony Brook also had biannual financial wellness check-ins. Participants were invited to complete a presession, an immediate postsession, and a year-end survey to assess changes in financial planning behaviors.

OUTCOMES

Survey response rates were 49% (135/277) for the presession survey, 47% (130/277) for the immediate postsession survey, and 22% (61/277) for the year-end survey. Ninety-six percent (125/130) found the sessions helpful and 98% (120/123) recommended continuing the program in the future. At year-end, the most frequent completed financial planning actions prompted by the session included saving emergency funds, creating a monthly budget, consolidating loans via the Public Service Loan Forgiveness program, contributing to retirement savings, and participating in an employer's retirement plan. Residents liked that some sessions were during intern orientation before the selection of retirement plans. Postgraduate year (PGY) 1 residents were more likely to complete positive financial planning actions and to agree or strongly agree that the session prompted them to take financial planning actions than PGY-2 and PGY-3 residents.

NEXT STEPS

While financial wellness programs are well received by internal medicine residents, more robust evidence is needed on curricular delivery methods and program features that promote positive financial planning behaviors.

Glycemic Control and Clinical Outcomes in U.S. Patients With COVID-19: Data From the National COVID Cohort Collaborative (N3C) Database

OBJECTIVE

The purpose of the study is to evaluate the relationship between HbA1c and severity of coronavirus disease 2019 (COVID-19) outcomes in patients with type 2 diabetes (T2D) with acute COVID-19 infection.

RESEARCH DESIGN AND METHODS

We conducted a retrospective study using observational data from the National COVID Cohort Collaborative (N3C), a longitudinal, multicenter U.S. cohort of patients with COVID-19 infection. Patients were ≥18 years old with T2D and confirmed COVID-19 infection by laboratory testing or diagnosis code. The primary outcome was 30-day mortality following the date of COVID-19 diagnosis. Secondary outcomes included need for invasive ventilation or extracorporeal membrane oxygenation (ECMO), hospitalization within 7 days before or 30 days after COVID-19 diagnosis, and length of stay (LOS) for patients who were hospitalized.

RESULTS

The study included 39,616 patients (50.9% female, 55.4% White, 26.4% Black or African American, and 16.1% Hispanic or Latino, with mean ± SD age 62.1 ± 13.9 years and mean ± SD HbA1c 7.6% ± 2.0). There was an increasing risk of hospitalization with incrementally higher HbA1c levels, but risk of death plateaued at HbA1c >8%, and risk of invasive ventilation or ECMO plateaued >9%. There was no significant difference in LOS across HbA1c levels.

CONCLUSIONS

In a large, multicenter cohort of patients in the U.S. with T2D and COVID-19 infection, risk of hospitalization increased with incrementally higher HbA1c levels. Risk of death and invasive ventilation also increased but plateaued at different levels of glycemic control.

Early-onset pancreatic cancer: Defining contemporary presentation, treatment, and outcomes in the under 50 age group using real-world data

533

Background: The incidence of pancreatic cancer is increasing in younger patients (pts). Early onset pancreatic cancer (EOPC) is reportedly diagnosed at a later stage, potentially compromising outcomes compared to later onset pts (LOPC). With recent gains in staging and neo/adjuvant regimens, we sought to elaborate on the characteristics of EOPC and LOPC in a contemporary real-world cohort. Methods: The PURPLE registry, a prospectively collected multi-site data set on consecutive pancreatic cancer pts was interrogated. Patient, tumor, treatment and outcome data were extracted for EOPC vs LOPC. EOPC were those diagnosed prior to age 50 and LOPC after age 50. Resectability status was per MDT consensus. Results: Of 1534 pts, 93 (6%) were EOPC (51% male) and 1442 (94%) LOPC (51% male). EOPC had better ECOG performance status (0-1: 95% vs 81%, Relative Risk [RR] 1.2, p < 0.001) and Charlson Comorbidity Index Score (0-2: 98% vs 28%, RR 3.5, p < 0.001). Primary tumor site (head/body/tail: 66%/11%/20% for EOPC and 68%/17%/14% for LOPC), and staging (resectable/borderline resectable/locally advanced/metastatic: 29%/16%/14%/41% for EOPC vs 28%/9%/21%/41% for LOPC) did not differ. 25 (93%) of EOPC and 320 (79%) LOPC resectable pts underwent resection (p = 0.13). 12 (80%) EOPC and 36 (26%) LOPC borderline resectable pts underwent resection (RR 3.0, p < 0.001). Resection margin status (R0 vs R1 vs R2) did not differ. Resected EOPC more frequently received neoadjuvant therapy (30% vs 9%, RR 3.2, p = 0.001). EOPC were more likely to receive palliative chemotherapy in the advanced/metastatic setting (77% vs 49%, RR 1.6, p < 0.001), and were more likely to receive first line (1L) FOLFIRINOX than gemcitabine-nab-paclitaxel (36% vs 18%, RR 2, p = 0.019). Median overall survival (OS) was superior for EOPC (24 vs 12 months, Hazard Ratio [HR] 0.55, p < 0.001). For resectable pts, relapse free survival (RFS) did not differ but OS was superior for EOPC (undefined vs 27.7 months, HR 0.26, p = 0.004). In borderline resectable pts, RFS was similar and OS only numerically superior for EOPC (31.2 vs 17.7 months, p = 0.20). For locally advanced disease, 1L progression free survival (PFS1) was similar and OS was superior for EOPC (27.8 vs 11 months, HR 0.40, p = 0.008). There was no difference in PFS1/OS for metastatic pts. Conclusions: EOPC are fitter, with similar stage at diagnosis as LOPC. EOPC are more likely to receive neoadjuvant chemotherapy and undergo resection when presenting with borderline resectable disease. EOPC receive more treatment and have superior OS, with RFS/PFS1 not statistically different to LOPC.

Options beyond BRAF targeted therapy in second-line treatment of patients with BRAFV600E mutant (BRAFmt) metastatic colorectal cancer (mCRC)

47

Background: BRAFmt is a negative prognostic factor in mCRC but also identifies a patient population that may benefit from BRAF targeted therapy. Results from recent trials (BEACON and SWOG1406) demonstrate improved survival outcomes in second- and third-line settings when combining a BRAF inhibitor, an EGFR inhibitor (EGFRi) +/- a MEK inhibitor. In both trials, irinotecan and cetuximab was the control arm with a dismal response rate of 2-4% and progression free survival (PFS) of only 2 months. This suggests chemotherapy plus an EGFRi may not be the optimal approach where BRAF-targeted therapies are not available or have failed. Methods: Data from July 2009 to September 2021 was analysed from TRACC, a multi-site Australian mCRC comprehensive prospective registry enrolling consecutive patients. Patient characteristics, treatment and survival outcomes were examined for patients treated with chemotherapy (CT) alone, with bevacizumab (BEV) or with an EGFRi. Results: Of 2046 registry patients, 256 (13%) harboured a BRAFmt. 72 BRAFmt patients had received second-line (28%) treatment, including CT alone (n = 28), CT plus BEV (n = 26), and CT plus EGFRi (n = 18). Baseline characteristics are shown in the table. Median second-line PFS was 3.3, 4.7 and 1.8 months, for CT alone, CT plus BEV and CT plus EGFRi respectively. Median overall survival (OS) was 8.7, 7.9 and 2.5 months respectively. In multivariate analysis, PFS when treated with CT plus EGFRi trended inferior to CT alone (p = 0.054) and CT plus BEV (p = 0.061), whereas for OS, treatment with CT plus EGFRi was inferior to CT alone (p = 0.038) and CT plus BEV (p = 0.015). Poor PFS was associated with age ≥ 65 years (HR 3.03, p < 0.001) and ECOG ≥ 2 (HR 2.62, p = 0.004), but not associated with a right side primary (p = 0.17), mismatch repair (MMR) status (p = 0.86), or ≥ 3 organs with metastases (p = 0.32). Poor OS was associated with age ≥ 65 years (HR 3.11, p < 0.001), ECOG ≥ 2 (HR 7.32, p < 0.001), right side primary (HR 3.03, p = 0.002) and proficient MMR status (HR 3.57, p = 0.018), but not associated with ≥ 3 organs with metastases (p = 0.17). Conclusions: Less than one-third of BRAFmt mCRC patients received second-line therapy in a real-world setting, indicating an urgency to explore activity of BRAF targeted therapy in the first line setting. Treated patients received limited benefit, with CT plus EGFRi PFS outcomes comparable to BEACON control arm (1.8 vs 2.0 months) and trending inferior to other options. The best OS outcomes were achieved with CT alone or CT plus BEV.[Table: see text]