Pre-onset subthreshold psychotic symptoms are associated with differential treatment delays before a first episode of psychosis: Initial evidence and implications

BACKGROUND

Help-seeking and treatment delays are increasingly critical areas of study in mental health services. The duration of untreated psychosis (DUP), or the time between illness onset and initiation of treatment, is a predictor of symptom remission and functioning for a first episode of psychosis (FEP). The World Health Organization recommends that specialized treatment for psychosis be initiated within the first three months of FEP onset. As a result, research has focused on factors that are associated with threshold-level DUP, while the experience of subthreshold psychotic symptoms (STPS) prior to a FEP may also complicate and present barriers to accessing care for young people. We therefore examine the possibility that STPS can impact DUP and its components.

METHOD

Using a follow-back cross-sectional design, we sought to describe duration of untreated illness, length of prodrome, DUP, help-seeking delay, referral delay, and number of help-seeking contacts among FEP patients who did and did not have STPS prior to psychosis onset.

RESULTS

We found that patients who experienced STPS had a longer median duration of untreated illness, prodrome length, DUP, and help-seeking delay compared to patients who did not have such symptoms. Referral delay did not differ substantially between the two groups. Importantly, treatment delays were extremely lengthy for many participants.

CONCLUSIONS

Pre-onset STPS are associated with help-seeking delays along the pathway to care even during a FEP. Examining early signs and symptoms may help to improve and tailor interventions aimed at reducing treatment delays and ultimately providing timely care when the need arises.

Cancer-associated mesothelial cells are regulated by the anti-Müllerian hormone axis

Cancer-associated mesothelial cells (CAMCs) in the tumor microenvironment are thought to promote growth and immune evasion. We find that, in mouse and human ovarian tumors, cancer cells express anti-Müllerian hormone (AMH) while CAMCs express its receptor AMHR2, suggesting a paracrine axis. Factors secreted by cancer cells induce AMHR2 expression during their reprogramming into CAMCs in mouse and human in vitro models. Overexpression of AMHR2 in the Met5a mesothelial cell line is sufficient to induce expression of immunosuppressive cytokines and growth factors that stimulate ovarian cancer cell growth in an AMH-dependent way. Finally, syngeneic cancer cells implanted in transgenic mice with Amhr2-/- CAMCs grow significantly slower than in wild-type hosts. The cytokine profile of Amhr2-/- tumor-bearing mice is altered and their tumors express less immune checkpoint markers programmed-cell-death 1 (PD1) and cytotoxic T lymphocyte-associated protein 4 (CTLA4). Taken together, these data suggest that the AMH/AMHR2 axis plays a critical role in regulating the pro-tumoral function of CAMCs in ovarian cancer.

Ensemble GaAsSb/GaAs axial configured nanowire-based separate absorption, charge, and multiplication avalanche near-infrared photodetectors

In this study, molecular beam epitaxially grown axially configured ensemble GaAsSb/GaAs separate absorption, charge, and multiplication (SACM) region-based nanowire avalanche photodetector device on non-patterned Si substrate is presented. Our device exhibits a low breakdown voltage (V _BR) of ∼ -10 ± 2.5 V under dark, photocurrent gain (M) varying from 20 in linear mode to avalanche gain of 700 at V _BR at a 1.064 μm wavelength. Positive temperature dependence of breakdown voltage ∼ 12.6 mV K^-1 further affirms avalanche breakdown as the gain mechanism in our SACM NW APDs. Capacitance-voltage (C-V) and temperature-dependent noise characteristics also validated punch-through voltage ascertained from I-V measurements, and avalanche being the dominant gain mechanism in the APDs. The ensemble SACM NW APD device demonstrated a broad spectral room temperature response with a cut-off wavelength of ∼1.2 μm with a responsivity of ∼0.17-0.38 A W^-1 at -3 V. This work offers a potential pathway toward realizing tunable nanowire-based avalanche photodetectors compatible with traditional Si technology.

Are we overtreating patients with malignant colorectal polyps? A 5-year review of the ACPGBI position statement

INTRODUCTION

In 2013, The Association of Coloproctology of Great Britain and Ireland (ACPGBI) issued a position statement regarding management of malignant polyps. We reviewed the management of endoscopically resected malignant colorectal polyps in a district general hospital to evaluate whether patients were being overtreated as per these guidelines.

METHODS

All patients who underwent a complete, non-piecemeal endoscopic removal of a malignant polyp between October 2013 and September 2018 were studied. Polyps were risk stratified for residual disease and followed up as per the ACPGBI. Patients were divided into two groups based on management after polypectomy. Primary outcome measured was the presence of residual tumour or involved lymph nodes in the resection specimen. Secondary outcomes included complications and recurrence.

RESULTS

Thirty-three patients were included: 21 in the non-operative group (NOG) and 12 in the operative group (OG). The ACPGBI risk score in the NOG varied between 1 and over 4 compared with the OG who all scored over 4. Two patients in the OG (16%) demonstrated residual disease. Five patients suffered a postoperative complication. No recurrences were noted in the OG and one in the NOG.

CONCLUSION

Our findings against a backdrop of the available literature suggest that the risk of residual disease after malignant polypectomy may not be as high as stated by the ACPGBI. As a result, there is a risk of overtreating patients and exposing them to the significant complications of surgery if careful consideration is not exercised.

The ECHELON-2 Trial: 5-year results of a randomized, phase 3 study of brentuximab vedotin with chemotherapy for CD30-positive peripheral T-cell lymphoma

Background:

For patients with peripheral T-cell lymphoma (PTCL), outcomes using frontline treatment with cyclophosphamide, doxorubicin, vincristine, and prednisone (CHOP) or CHOP-like therapy are typically poor. The ECHELON-2 study demonstrated that brentuximab vedotin plus cyclophosphamide, doxorubicin, and prednisone (A+CHP) exhibited statistically superior progression-free survival (PFS) per independent central review and improvements in overall survival versus CHOP for the frontline treatment of patients with systemic anaplastic large cell lymphoma or other CD30-positive PTCL.

Patients and methods:

ECHELON-2 is a double-blind, double-dummy, randomized, placebo-controlled, active-comparator phase III study. We present an exploratory update of the ECHELON-2 study, including an analysis of 5-year PFS per investigator in the intent-to-treat analysis group.

Results:

A total of 452 patients were randomized (1 : 1) to six or eight cycles of A+CHP (N = 226) or CHOP (N = 226). At median follow-up of 47.6 months, 5-year PFS rates were 51.4% [95% confidence interval (CI): 42.8% to 59.4%] with A+CHP versus 43.0% (95% CI: 35.8% to 50.0%) with CHOP (hazard ratio = 0.70; 95% CI: 0.53–0.91), and 5-year overall survival (OS) rates were 70.1% (95% CI: 63.3% to 75.9%) with A+CHP versus 61.0% (95% CI: 54.0% to 67.3%) with CHOP (hazard ratio = 0.72; 95% CI: 0.53–0.99). Both PFS and OS were generally consistent across key subgroups. Peripheral neuropathy was resolved or improved in 72% (84/117) of patients in the A+CHP arm and 78% (97/124) in the CHOP arm. Among patients who relapsed and subsequently received brentuximab vedotin, the objective response rate was 59% with brentuximab vedotin retreatment after A+CHP and 50% with subsequent brentuximab vedotin after CHOP.

Conclusions:

In this 5-year update of ECHELON-2, frontline treatment of patients with PTCL with A+CHP continues to provide clinically meaningful improvement in PFS and OS versus CHOP, with a manageable safety profile, including continued resolution or improvement of peripheral neuropathy.

Emergency hip disarticulations for severe necrotising fasciitis of the lower limb: a series of rare cases from a rural district general hospital

Hip disarticulation is the removal of the entire lower limb through the hip joint by detaching the femur from the acetabulum. This major ablative procedure is rarely performed for infection but may be required in severe necrotising fasciitis. We present a single centre retrospective review of all cases of emergency hip disarticulations in patients with necrotising fasciitis between 2010 and 2020. All five patients included in the review presented with acute lower limb pain and sepsis. Three patients had comorbidities predisposing them to necrotising fasciitis. Three were deemed to be high risk and two were at intermediate risk of developing necrotising fasciitis. There were two deaths in the postoperative period. Of the three survivors, two required revision surgery for a completion hindquarter amputation and one for flap closure. All three survivors had good functional outcomes after discharge from hospital. Despite its associated morbidity, emergency amputation of the entire lower limb is a life-saving treatment in cases of rapidly progressing necrotising fasciitis and should be considered as a first-line option in managing this condition.

Neck failure following pathologically node-negative neck dissection (pN0) in oral squamous cell carcinoma: a systematic review and meta-analysis

Due to the risk of occult cervical metastasis, elective neck dissection (END) is recommended in the management of patients with early oral cavity squamous cell carcinoma (OSCC) and a clinically node-negative (cN0) neck. This paper presents a systematic review and meta-analysis of studies that recorded isolated regional recurrence (RR) in the pathologically node-negative neck dissection (pN0) neck following END in order to quantify the failure rate. Pubmed and Ovid databases were systematically searched for relevant articles published between January 2009 and January 2019. Studies reporting RR following END in patients with OSCC who had no pathological evidence of lymph node metastasis were eligible for inclusion in this meta-analysis. In addition, a selection of large head and neck units were invited to submit unpublished data. Search criteria produced a list of 5448 papers, of which 18 studies met the inclusion criteria. Three institutions contributed unpublished data. This included a total of 4824 patients with median follow-up of 34 months (2.8 years). Eight datasets included patients staged T1-T4 with RR 17.3% (469/2711), 13 datasets included patients staged T1-T2 with RR 7.5% (158/2113). Overall across all 21 studies, isolated neck recurrence was identified in 627 cases giving a RR of 13.0% (627/4824) on meta-analysis. Understanding the therapeutic effectiveness of END provides context for evaluation of clinical management of the cN0 in these patients. A pathologically negative neck does not guarantee against future recurrence.

Volume and location of the defect as predictors of speech outcome after glossectomy: correlation with a classification

The evaluation of speech outcomes after resection and reconstruction of the oral tongue remains largely unsystematic. A cross-sectional study was performed to analyse the speech outcomes of patients who underwent curative treatment with appropriate reconstruction. Sixty-nine patients were assessed for speech intelligibility and phonetics using a validated speech intelligibility assessment tool in the local language. Volume defects were classified as class I (less than one third), II (one third to half), III (half to two-thirds), or IV (two-thirds to total glossectomy). Defect location was defined as lateral, tip, or sulcus. The χ² test and Kruskal-Wallis test were used to test volume and location as predictors. Twenty-six patients had class I defects, 29 had class II defects, seven had class III defects, and seven had class IV defects. Twenty-two patients (31.9%) received adjuvant radiotherapy. Mean vowel, consonant, word, and paragraph intelligibility were 99.27%, 86.86%, 85.52%, and 88.72%, respectively. The incremental volume of the glossectomy defect was significantly correlated with speech intelligibility scores and phonatory alterations. In classes II and III, tip resection significantly affected interdental sounds. All patients in class III had affected alveolar and alveo-palatal sounds. The results positively corroborated the volume and location of the glossectomy defect to a classification system.

Association between school racial/ethnic composition during adolescence and adult health

OBJECTIVES

School racial/ethnic segregation in U.S. schoolsDifferences in school racial/ethnic composition may increase health disparities by concentrating educational opportunities that confer long-term health benefits in schools serving predominantly wwhite students. For racial minority students, high concentrations of white students may increase exposure to racismis also associated with psychologicstress, which may ultimately reduceing the long-term health benefits from educational opportunities. Meanwhile associations of racial/ethnic academic tacking within schools and health have been mixed. We sought to test whether: 1) differences in racial/ethnic composition between schools and, 2) racial/ethnic distribution of students in academic tracks within schools are associated with long-term health benefits or risks for white, Black and Latinx students.

METHODS

We analyzed the National Longitudinal Study of Adolescent to Adult Health (12,438 participants, collected 1994-2008), to test whether the school-level segregation (percent of non-Latinx white students at participants' school during adolescence) was associated with adult health outcomes at ages 18-26 & 24-32, controlling for contextual factorscomparing Black, Latinx, and white students, and controlling for contextualf factors. A secondary analysis explored whether racial/ethnic cohorting across levels of English courses was associated with each health outcome.

RESULTS

Attending a school with a higher percent of white students was associated with higher adult depression scores, substance abuse, and worse self-rated health for black Black students; lower depression scores, better self-rated health, and alcohol abuse for white students; and no health differences for Latinx students. Greater within school racial/ethnic cohorting across English courses was associated with increased odds of alcohol abuse for white students; decreased odds of alcohol abuse for Black and Latinx students; and decreased odds of drug abuse for Black students.

CONCLUSION

Among Bblack youth, attending a school with a higher percentage of white students is associated with worse behavioral health in adulthood. Understanding the potential impacts of school racial/ethnic composition on health is critical to designing policies that maximize access to opportunity and health.Education policies should comprehensively address school quality and racism to maximize adult health.

Pirfenidone Alleviates Features of Well-Established Chronic Pancreatitis in Mouse Models

Introduction/Objective

Chronic pancreatitis (CP) is a fibro-inflammatory disease of pancreas with no targeted therapy and is considered irreversible. Antifibrotic agent pirfenidone is FDA approved for idiopathic pulmonary fibrosis.

However, exact molecular mechanism of its action is not clear. The aim of this study was to evaluate pirfenidone as a therapeutic agent for CP.

Methods

Caerulein-CP was induced in C57BL/6 mice by caerulein injections (50ug/kgx7, i.p., hourly x twice weekly x10 weeks). At 11 weeks, animals were randomized and assigned to either saline or pirfenidone group (400 mg/kg/d by oral gavage for 5 weeks). Mice were euthanized at 17 weeks. L-arginine induced CP was induced by i.p. injections of L-arginine (4.5g/kg x2 hourly, once a week x 4) and treatment was started after 5 weeks of start. Mice were sacrificed at early time-points after starting treatment. Single-cell suspension of pancreata were used for flow- cytometry. Pancreatic atrophy, histology, fibrosis and cytokine mRNA profile were evaluated. In vitro studies were done on stellate cells.

Results

The treated caerulein-CP mice had improvement in pancreas/mouse weight ratio, (7.03±0.41 vs. 4.75±0.28; p<0.0001). Histology scores and fibrosis markers were reduced. Pancreatic atrophy and histology scores showed significant improvement by day 14 of treatment in L-arginine CP. Flow cytometry showed that by day 7 of treatment there was significant reduction in macrophage infiltration (1.09 ± 0.18 % vs 3.26 ± 0.4 %; p<0.001) and pro-fibrotic M2 macrophage markers [IL-4 (1.5 ± 0.1 % vs 2.8 ± 0.2%; p=0.007)], while M1 marker (MHC II) did not change. mRNA levels of pro-inflammatory and pro-fibrotic cytokines decreased, and of anti-inflammatory cytokines increased. In vitro study on stellate cells showed reduction in mRNA levels of pro-fibrotic and pro-inflammatory cytokines as well as fibrosis markers in treatment group.

Conclusion

Pirfenidone ameliorates well-established CP in mouse models by altering immune cells.

Unusual presentation of intussusception: Gallstone ileus

Gallstone ileus is a rare pathology, occurring in an estimated 0.5% of cases, which preferentially affect females and the elderly population. This rare pathology is the result of a fistulous connection between the bowel and gallbladder. This connection allows gallstones to pass into the bowel leading to mechanical obstruction. On rare occasions the enteric gallstone can act as a lead point causing intussusception. We present a rare case of intussusception secondary to gallstone ileus in a young, relatively asymptomatic patient. CT played a critical role in diagnosis and appropriate management of our patient.

PRL3 enhances T-cell acute lymphoblastic leukemia growth through suppressing T-cell signaling pathways and apoptosis

T cell acute lymphoblastic leukemia (T-ALL) is an aggressive malignancy of thymocytes and is largely driven by the NOTCH/MYC pathway. Yet, additional oncogenic drivers are required for transformation. Here, we identify protein tyrosine phosphatase type 4 A3 (PRL3) as a collaborating oncogenic driver in T-ALL. PRL3 is expressed in a large fraction of primary human T-ALLs and is commonly co-amplified with MYC. PRL3 also synergized with MYC to initiate early-onset ALL in transgenic zebrafish and was required for human T-ALL growth and maintenance. Mass spectrometry phosphoproteomic analysis and mechanistic studies uncovered that PRL3 suppresses downstream T cell phosphorylation signaling pathways, including those modulated by VAV1, and subsequently suppresses apoptosis in leukemia cells. Taken together, our studies have identified new roles for PRL3 as a collaborating oncogenic driver in human T-ALL and suggest that therapeutic targeting of the PRL3 phosphatase will likely be a useful treatment strategy for T-ALL.

Effect of Neprilysin Inhibition on Various Natriuretic Peptide Assays

BACKGROUND

With sacubitril/valsartan treatment, B-type natriuretic peptide (BNP) concentrations increase; it remains unclear whether change in BNP concentrations is similar across all assays for its measurement. Effects of sacubitril/valsartan on atrial natriuretic peptide (ANP) concentrations in patients are unknown. Lastly, the impact of neprilysin inhibition on mid-regional pro-ANP (MR-proANP), N-terminal pro-BNP (NT-proBNP), proBNP_1-108, or C-type natriuretic peptide (CNP) is not well understood.

OBJECTIVES

This study sought to examine the effects of sacubitril/valsartan on results from different natriuretic peptide assays.

METHODS

Twenty-three consecutive stable patients with heart failure and reduced ejection fraction were initiated and titrated on sacubitril/valsartan. Change in ANP, MR-proANP, BNP (using 5 assays), NT-proBNP (3 assays), proBNP_1-108, and CNP were measured over 3 visits.

RESULTS

Average time to 3 follow-up visits was 22, 46, and 84 days. ANP rapidly and substantially increased with initiation and titration of sacubitril/valsartan, more than doubling by the first follow-up visit (+105.8%). Magnitude of ANP increase was greatest in those with concentrations above the median at baseline (+188%) compared with those with lower baseline concentrations (+44%); ANP increases were sustained. Treatment with sacubitril/valsartan led to inconsistent changes in BNP, which varied across methods assessed. Concentrations of MR-proANP, NT-proBNP, and proBNP_1-108 variably declined after treatment; whereas CNP concentrations showed no consistent change.

CONCLUSIONS

Initiation and titration of sacubitril/valsartan led to variable changes in concentrations of multiple natriuretic peptides. These results provide important insights into the effects of sacubitril/valsartan treatment on individual patient results, and further suggest the benefit of neprilysin inhibition may be partially mediated by increased ANP concentrations.

Impact of palbociclib plus letrozole on patient-reported health-related quality of life: results from the PALOMA-2 trial

Background

Patient-reported outcomes are integral in benefit-risk assessments of new treatment regimens. The PALOMA-2 study provides the largest body of evidence for patient-reported health-related quality of life (QOL) for patients with metastatic breast cancer (MBC) receiving first-line endocrine-based therapy (palbociclib plus letrozole and letrozole alone).

Patients and methods

Treatment-naïve postmenopausal women with estrogen receptor-positive (ER+)/human epidermal growth factor receptor 2-negative (HER2-) MBC were randomized 2 : 1 to palbociclib plus letrozole (n = 444) or placebo plus letrozole (n = 222). Patient-reported outcomes were assessed at baseline, day 1 of cycles 2 and 3, and day 1 of every other cycle from cycle 5 using the Functional Assessment of Cancer Therapy (FACT)-Breast and EuroQOL 5 dimensions (EQ-5D) questionnaires.

Results

As of 26 February 2016, the median duration of follow-up was 23 months. Baseline scores were comparable between the two treatment arms. No significant between-arm differences were observed in change from baseline in FACT-Breast Total, FACT-General Total, or EQ-5D scores. Significantly greater improvement in pain scores was observed in the palbociclib plus letrozole arm (-0.256 versus -0.098; P = 0.0183). In both arms, deterioration of FACT-Breast Total score was significantly delayed in patients without progression versus those with progression and patients with partial or complete response versus those without. No significant difference was observed in FACT-Breast and EQ-5D index scores in patients with and without neutropenia.

Conclusions

Overall, women with MBC receiving first-line endocrine therapy have a good QOL. The addition of palbociclib to letrozole maintains health-related QOL and improves pain scores in treatment-naïve postmenopausal patients with ER+/HER2- MBC compared with letrozole alone. Significantly greater delay in deterioration of health-related QOL was observed in patients without progression versus those who progressed and in patients with an objective response versus non-responders. ClinicalTrials.gov: NCT01740427 (https://clinicaltrials.gov/ct2/show/NCT01740427).

Short duration of untreated psychosis enhances negative symptom remission in extended early intervention service for psychosis

OBJECTIVE

To test whether duration of untreated psychosis (DUP) < 3 months, recommended by the World Health Organization/International Early Psychosis Association, enhances the effects of an extended early intervention service (EEIS) on symptom remission.

METHOD

We examined data from a randomized controlled trial in which patients who received 2 years of treatment in EIS for psychosis were subsequently randomized to either 3 years of EEIS or 3 years of regular care (RC). Using a DUP cut-off ≤ 12 weeks (approximately < 3 months), patients were split into two groups. Length of positive, negative and total symptom remission were the outcomes.

RESULTS

Patients (N = 217) were mostly male (68%) with schizophrenia spectrum disorder (65%); 108 (50%) received EEIS (58 had DUP ≤12 weeks; 50 had DUP >12 weeks). Interaction between treatment condition (EEIS vs. RC) and DUP cut-off ≤ 12 weeks was only significant in multiple linear regression model examining length of negative symptom remission as the outcome (adjusted β = 36.88 [SE = 15.88], t = 2.32, P = 0.02). EEIS patients with DUP ≤12 weeks achieved 25 more weeks of negative symptom remission than EEIS patients with DUP >12 weeks.

CONCLUSION

Having a short DUP may be critical in deriving long-term benefits from EIS for psychosis, including EEIS settings. This work empirically supports policy recommendations of reducing DUP <3 months.

Clinical considerations of the role of palbociclib in the management of advanced breast cancer patients with and without visceral metastases

Background

This report assesses the efficacy and safety of palbociclib plus endocrine therapy (ET) in women with hormone receptor-positive, human epidermal growth factor receptor 2-negative advanced breast cancer (ABC) with or without visceral metastases.

Patients and methods

Pre- and postmenopausal women with disease progression following prior ET (PALOMA-3; N = 521) and postmenopausal women untreated for ABC (PALOMA-2; N = 666) were randomized 2 : 1 to ET (fulvestrant or letrozole, respectively) plus palbociclib or placebo. Progression-free survival (PFS), safety, and patient-reported quality of life (QoL) were evaluated by prior treatment and visceral involvement.

Results

Visceral metastases incidence was higher in patients with prior resistance to ET (58.3%, PALOMA-3) than in patients naive to ET in the ABC setting (48.6%, PALOMA-2). In patients with prior resistance to ET and visceral metastases, median PFS (mPFS) was 9.2 months with palbociclib plus fulvestrant versus 3.4 months with placebo plus fulvestrant [hazard ratio (HR), 0.47; 95% confidence interval (CI), 0.35–0.61], and objective response rate (ORR) was 28.0% versus 6.7%, respectively. In patients with nonvisceral metastases, mPFS was 16.6 versus 7.3 months, HR 0.53; 95% CI 0.36–0.77. In patients with visceral disease and naive to ET in the advanced disease setting, mPFS was 19.3 months with palbociclib plus letrozole versus 12.9 months with placebo plus letrozole (HR 0.63; 95% CI 0.47–0.85); ORR was 55.1% versus 40.0%; in patients with nonvisceral disease, mPFS was not reached with palbociclib plus letrozole versus 16.8 months with placebo plus letrozole (HR 0.50; 95% CI 0.36–0.70). In patients with prior resistance to ET with visceral metastases, palbociclib plus fulvestrant significantly delayed deterioration of QoL versus placebo plus fulvestrant, whereas patient-reported QoL was maintained with palbociclib plus letrozole in patients naive to endocrine-based therapy for ABC.

Conclusions

Palbociclib plus ET prolonged mPFS in patients with visceral metastases, increased ORRs, and in patients previously treated for ABC, delayed QoL deterioration, presenting a standard treatment option among patients with visceral metastases amenable to endocrine-based therapy.

Clinical trial registration

NCT01942135, NCT01740427

Palbociclib plus letrozole as first-line therapy in estrogen receptor-positive/human epidermal growth factor receptor 2-negative advanced breast cancer with extended follow-up

PURPOSE

In the initial PALOMA-2 (NCT01740427) analysis with median follow-up of 23 months, palbociclib plus letrozole significantly prolonged progression-free survival (PFS) in women with estrogen receptor-positive (ER+)/human epidermal growth factor receptor 2-negative (HER2-) advanced breast cancer (ABC) [hazard ratio (HR) 0.58; P < 0.001]. Herein, we report results overall and by subgroups with extended follow-up.

METHODS

In this double-blind, phase 3 study, post-menopausal women with ER+/HER2- ABC who had not received prior systemic therapy for their advanced disease were randomized 2:1 to palbociclib-letrozole or placebo-letrozole. Endpoints include investigator-assessed PFS (primary), safety, and patient-reported outcomes (PROs).

RESULTS

After a median follow-up of approximately 38 months, median PFS was 27.6 months for palbociclib-letrozole (n = 444) and 14.5 months for placebo-letrozole (n = 222) (HR 0.563; 1-sided P < 0.0001). All subgroups benefited from palbociclib treatment. The improvement of PFS with palbociclib-letrozole was maintained in the next 2 subsequent lines of therapy and delayed the use of chemotherapy (40.4 vs. 29.9 months for palbociclib-letrozole vs. placebo-letrozole). Safety data were consistent with the known profile. Patients' quality of life was maintained.

CONCLUSIONS

With approximately 15 months of additional follow-up, palbociclib plus letrozole continued to demonstrate improved PFS compared with placebo plus letrozole in the overall population and across all patient subgroups, while the safety profile remained favorable and quality of life was maintained. These data confirm that palbociclib-letrozole should be considered the standard of care for first-line therapy in patients with ER+/HER2- ABC, including those with low disease burden or long disease-free interval. Sponsored by Pfizer; ClinicalTrials.gov: NCT01740427.

Abstract P6-18-36: Real world treatment patterns and outcomes of patients receiving palbociclib plus aromatase inhibitor in the United States: Sub-groups analysis based on age, performance status and sites of metastases from the IRIS study

Background: Ibrance Real World Insights (IRIS) is a multi-country study aimed to describe clinical characteristics, treatment patterns and clinical outcomes of patients receiving palbociclib plus aromatase inhibitor. Previously the results on the overall population within the US have been communicated. The current analysis focuses on subgroups stratified by age, performance status and visceral status.

Materials and methods: A retrospective chart review of HR+/HER2- ABC/MBC patients who received palbociclib plus aromatase inhibitor as initial endocrine based therapy for their advanced disease was conducted between June and October 2017. Physicians completed electronic case report forms, extracting data on patient demographics, clinical characteristics, treatment history/patterns and clinical outcomes.Progression free and survival rates at 12 and 24 months were estimated via Kaplan-Meier analysis.

Results: Data for the US are reported here. In total 63 physicians completed 360 eCRFs with a mean follow up time since palbociclib initiation of 12 months. Majority of the patients were &gt;65 years (53%), and had ECOG status of 0 (30%) or 1 (56%). Overall 293 (81%) patients had metastatic disease, of which 50% had visceral metastases. Across all sub-groups, majority of patients prescribed an initial palbociclib dose of 125mg did not require a change of dose while on treatment. The 12-month and 24-month progression free and overall survival rates across subgroups are presented in Table 1. Patients with a performance status of ECOG=1 had a slightly lower progression and survival rates at 12 and 24 months compared to those with a score =0. Likewise, patients with visceral disease were observed to have slightly lower progression free and survival rates than others.

Table 1:Clinical Outcomes for the different sub-groups.Patient Sub-groups AgeECOG statusVisceral Status Up to 65 n=169Over 65 n=1910 n=1071 n=200Visceral metastases n=147Non-visceral metastases n=146Progression free survival rate at 12 months, %86.382.194.386.580.285.8Progression free survival rate at 24 months, %59.769.071.267.450.780.6Overall survival rate At 12 months, %97.992.8100.099.590.599.3Overall survival rate at 24 months, %95.185.695.796.487.290.7

Conclusions: The analysis indicates consistent trends in different clinical outcomes were observed with palbociclib plus aromatase inhibitor across patients sub-groups based on age, performance status and visceral metastases.

Citation Format: Taylor-Stokes G, Mitra D, Waller J, Gibson K, Milligan G, Zhan L, Iyer S. Real world treatment patterns and outcomes of patients receiving palbociclib plus aromatase inhibitor in the United States: Sub-groups analysis based on age, performance status and sites of metastases from the IRIS study [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P6-18-36.

Abstract P6-18-29: Real-world treatment patterns and clinical outcomes with palbociclib combination therapy received in US community oncology practices

Background:

The treatment landscape for women with HR+/HER2- advanced and metastatic breast cancer (A/MBC) is changing as new agents are being combined with more established treatments to achieve greater efficacy in combating resistant and unresponsive disease. The present study is designed to describe patient characteristics, treatment patterns, and clinical outcomes in a cohort of women with HR+/HER2- A/MBC treated with palbociclib plus aromatase inhibitor (P+AI) or palbociclib plus fulvestrant (P+FV) in the US community oncology setting.

Methods:

Retrospective medical record data from adult women diagnosed with HR+/HER2- A/MBC who initiated P+AI or P+FV for treatment of A/MBC on or after February 3, 2015 were collected from the Vector Oncology Data Warehouse, a network comprised of 10 community oncology practices across the US. Descriptive analyses were performed on patient characteristics, treatment patterns, and clinical outcomes. Time to event outcomes (progression-free rate (PFR) and survival rate (SR)) at 12 (PFR-12, SR-12) and 24 (PFR-24, SR-24) months for the P+AI combination as first line endocrine therapy and 12 and 18 months for the P+FV combination as treatment following prior endocrine based therapy in either the adjuvant or metastatic setting.

Results:

Among 304 patients who received palbociclib combination therapy, 281 (92.4%) received it per labeled indication. Of the 281 on-label users, the focus of reporting here, 233 (82.9%) received P+AI as their initial endocrine therapy after A/MBC diagnosis; 48 (17.1%) received P+FV after prior endocrine therapy for breast cancer. Patient mean age (SD) was 63.1 (11.4) and 68.2 (10.2) years for patients receiving P+AI and P+FV, respectively. Patients were predominantly white (74.2% for P+AI and 77.1% for P+FV patients).The initial dosing for palbociclib was 125mg/day in 85.4% (n=199) of P+AI and 79.2% (n=38) of P+FV patients. Among patients who received P+AI, PFR-12 was 69.8% and PFR-24 was 46.8% with median follow up time of 10.8 months and 36.8% of progression events. The SR-12 was 89.8% and SR-24 was 71.4%. For patients who received P+FV, PFR-12 was 43.5% and PFR-18 was 39.9% with a median follow up time of 7.6 months and 50.0% of progression events. The SR-12 was 76.3% and SR-18 was 65.0%.

Conclusions:

This study provides real-world assessment of treatment patterns and clinical outcomes of patients with HR+/ HER2- A/MBC who received palbociclib in combination with an AI or a FV in US community oncology settings. These findings demonstrate the benefit of palbociclib combination therapy in a diverse real world population.

Sponsor: Pfizer, Inc.

Citation Format: Trocio J, Lin J, Fisher MD, Hu N, Davis C, McRoy L, Walker MS, Iyer S. Real-world treatment patterns and clinical outcomes with palbociclib combination therapy received in US community oncology practices [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P6-18-29.

Abstract P6-18-33: GI toxicities in metastatic breast cancer: A comprehensive literature review

Background

Treatments for advanced or metastatic breast cancer (aBC/mBC) are associated with gastrointestinal (GI) toxicities. The objective of this study was to assess the association between GI toxicities in mBC/aBC and health-related quality of life (HRQoL) and economic burden.

Methods

We conducted a comprehensive literature search of the Cochrane Central Register of Controlled Trials (2017), NHS Economic Evaluation Database (2016), Embase (1988 – 2017 week 34), and Ovid MEDLINE (1946 to August 2017). Eligible studies evaluated an intervention/comparator treatment in adult patients (age ≥18 years) with aBC/mBC and reported a direct connection between GI toxicities (ie, diarrhea, constipation, nausea, vomiting) and HRQoL and economic evidence. All studies published from January 2000 to August 2017 were assessed for eligibility. Editorials, case reports, conference abstracts, and studies of early, locally advanced, or inflammatory BC were excluded. Abstract and title screening, and full-text screening were conducted by single reviewers. Data were extracted by a single reviewer and verified by a second. Results were synthesized narratively.

Results

Database searches identified 3,428 articles; an additional 16 articles were identified through other sources. Ninety-four studies underwent full-text review, of which 27 reported a direct connection between GI toxicities and HRQoL (n = 11) and economic burden (n = 19). Some studies reported both HRQoL and economic data.

Patients identified treatment-related adverse events (AEs), such as GI events, as an important aspect of treatment that can affect therapy choice, discontinuation, and switching. Generally, patients with mBC had lower HRQoL than other BC groups, and increasing toxicity was associated with a greater degree of HRQoL impairment. When patients were asked to rank which AEs they most wanted to avoid, only pain ranked higher than nausea and vomiting. In a willingness to pay study, women with mBC were willing to pay $3,894 (2014 USD) per year to avoid severe diarrhea and $3,211 to avoid severe nausea.

Gastrointestinal events were among the costliest class of AEs, with mean costs as high as $4,809 (2016 USD) per episode; costs increased by 24% if events were persistent or recurrent.

Conclusions

Gastrointestinal toxicities are common in patients with aBC/mBC and have significant consequences for HRQoL and system-level economic outcomes. Frequency and implications of GI effects of treatment regimens should be considered carefully during patient counseling,, prescribing and coverage decisions in metastatic breast cancer.

Citation Format: Disher T, Siddiqui M, Mitra D, Cameron C, Zhan L, Iyer S. GI toxicities in metastatic breast cancer: A comprehensive literature review [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P6-18-33.

Abstract P6-18-21: Real world treatment patterns and outcomes of patients receiving palbociclib plus fulvestrant in the United States: Sub-groups analysis based on age, performance status and sites of metastases

Background: Ibrance Real World Insights (IRIS) is a multi-country study aimed to describe the clinical characteristics and understand treatment patterns and clinical outcomes of patients receiving palbociclib plus fulvestrant in real world clinical practice. Previously the results on the overall population within the US have been communicated. The current analyses focus on subgroups stratified by age, performance status and visceral status.

Materials and methods: A retrospective chart review of HR+/HER2- ABC/MBC patients was conducted between June and October 2017. Physicians extracted data from patient medical records for HR+/HER2- ABC patients who received palbociclib plus fulvestrant following disease progression with endocrine based therapy for their advanced disease. Electronic case report forms collected data covering patient demographics, clinical characteristics, treatment history/patterns and clinical outcomes.Progression free rates and survival rates at 6 and 12 months were estimated via Kaplan-Meier analysis.

Results: Data for the US are reported here. In total, 65 physicians extracted data for 292 patients who had a mean follow up time of 7.4 months. Majority of the patients were &gt;65 years (54%), and had ECOG status of 0 (32%) or 1 (48%). Overall 224 (77%) patients had metastatic disease, of which 93 (42%) had visceral metastases. Across all sub-groups, majority of patients prescribed an initial palbociclib dose of 125mg did not require a change of dose while on treatment. The 6-month and 12-month progression free and survival rates across subgroups are presented in Table 1. Patients with a performance status of ECOG ≥ 2 had a slightly lower progression and survival rates at 6 and 12 months compared to those with a score &lt;1. Likewise, patients with visceral disease were observed to have slightly lower progression free and survival rates than others.

Table 1:Clinical Outcomes by Patient Sub-groups.Patient Sub-groups AgeECOGstatusVisceral Status Up to 65 n=158Over 65 n=1340 n=931 n=1392+ n=60Visceral Metastases n=93Non-visceral Metastases n=131Progression free survival rate at 6 months, %95.293.297.893.490.689.694.8Progression free survival rate at 12 months, %81.277.884.683.0-73.276.5Survival rate at 6 months, %98.096.3100.098.290.692.298.9Survival rate at 12 months, %90.085.197.695.1-80.892.7

Conclusions: The analysis indicates consistent trends in different clinical outcomes were observed with palbociclib plus fulvestrant across patients sub-groups based on age, performance status and visceral metastases.

Citation Format: Waller J, Mitra D, Taylor-Stokes G, Gibson K, Milligan G, Zhan L, Iyer S. Real world treatment patterns and outcomes of patients receiving palbociclib plus fulvestrant in the United States: Sub-groups analysis based on age, performance status and sites of metastases [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P6-18-21.

Impact of postoperative radiotherapy on survival and loco-regional control in node-negative oral cavity tumours classified as T3 using the AJCC Cancer Staging Manual eighth edition

According to the eighth edition of the AJCC Cancer Staging Manual (AJCC8), a depth of invasion (DOI) >10mm is classified as pT3, representing a locally advanced tumour requiring postoperative radiotherapy (PORT). When node-negative, however, evidence regarding whether PORT improves loco-regional control or survival is unclear. To clarify this, two cohorts of patients were studied: (1) patients classified as pT3N0 by the seventh edition of the AJCC manual (AJCC7), with DOI >10mm and a tumour diameter >4cm (17 patients who received PORT), and (2) patients classified as pT1N0 and pT2N0 by AJCC7, with DOI >10mm and a tumour diameter <4cm (55 patients who did not receive PORT). Loco-regional control and survival were analysed. PORT was found not to impact overall survival or disease-free survival. It was also found not to impact local, regional, or distant recurrence. Although the two subsets of patients considered here (DOI >10mm with tumour diameter below or above 4cm) were previously distinct, they are both considered pT3 in AJCC8. Data from this study indicate that the routine administration of PORT to patients with a DOI >10mm may not be warranted in the absence of other risk features such as nodal disease or close margins.