Real-World Evidence of EGFR Targeted Therapy in NSCLC- A Brief Report of Decade Long Single Center Experience

The significance of EGFR targeted therapy in the lung adenocarcinoma is paramount. Several controlled clinical trials have reported considerable survival of EGFR mutation positive patients on receiving the EGFR tyrosine kinase inhibitor (TKI). However, the real-world evidence of benefits of EGFR TKI would be further useful to understand how the designated therapeutic regimen benefits the patients. In this study, we report a decade long real-world evidence of EGFR molecular testing in lung cancer at Tata Memorial Hospital (Mumbai, India). Laboratory and hospital records containing basic demographic details, clinical characteristics, treatment regimen, survival outcome were collected retrospectively. Statistical association and survival analysis were performed using the R programming. The cohort includes 9,053 lung cancer patients tested for EGFR mutations during 2011 to 2019. Baseline T790M and compound mutations were the only mutations observed co-occurring while all other EGFR mutations were mutually exclusive. Furthermore, the baseline T790M were also observed to be associated with TTF1 positivity, smoking and local metastasis. Overall survival of the patients harboring co-occurring compound mutations was significantly lesser than the other EGFR positive patients. Overall, our study suggests that EGFR TKI may provide real-world benefit to the lung cancer patients harboring mutually exclusive EGFR mutations. On the other hand, further systematic study is essential to develop better therapeutic regimen for co-occurring baseline EGFR T790M and other compound mutations.

Pediatric cancer-associated thrombosis: Analysis from a tertiary care cancer center in India

BACKGROUND AND AIMS

Thrombotic events (TEs) have been extensively studied in adult cancer patients, but data in children are limited. We prospectively analyzed pediatric cancer-associated thrombosis (PCAT) in children with malignancies.

METHODS

Children below 15 years of age with confirmed malignancies, treated at a large tertiary cancer center in India from July 2015 to March 2020 developing any TE were eligible. A standardized approach for detection and management was followed. Data were collected after informed consent.

RESULTS

Of 6132 eligible children, 150 (2.44%) had 152 TEs, with median age 8.5 years and male:female of 1.83:1. Most TEs occurred on chemotherapy: 111 (74.0%). The most common site was central nervous system (CNS) 59 (39.3%), followed by upper-limb venous system 37 (24.7%). Hemato-lymphoid (HL) malignancies were more prone to PCAT than solid tumors (ST) (incidence 3.23% vs. 1.58%; odds ratio [OR] = 2.06, 95% confidence interval [CI] [1.36-2.88]; p < .001). Malignancies associated with PCAT were acute lymphoblastic leukemia (ALL) 2.94%, acute myeloid leukemia (AML) 6.66%, and non-Hodgkin lymphomas 5.35%. Response imaging done in 106 (70.7%) children showed complete to partial resolution in almost 90% children. Death was attributable to TE in seven (4.66%) children. Age above 10 years (OR 2.33, 95% CI [1.59-3.41]; p < .001), AML (OR 4.62, 95% CI [1.98-10.74]; p = .0062), and non-Hodgkin lymphoma (OR 4.01, 95% CI [1.15-14.04]; p = .029) were significantly associated with TEs. In ALL, age more than 10 years (OR 1.86, 95% CI [1.06-3.24]; p < .03), T-ALL (OR 3.32, 95% CI [1.69-6.54]; p = .001), and intermediate-risk group (OR 4.97, 95% CI [1.12-22.02]; p = .035) were significantly associated with thrombosis. The 2-year event-free survival (EFS) for HL malignancies with PCAT was 55.3% versus 72.1% in those without PCAT (p = .05), overall survival (OS) being 84.6% versus 80.0% (p = .32).

CONCLUSION

Incidence of PCAT was 2.4%, and occurred predominantly in older children with hematolymphoid malignancies early in treatment. Most resolved completely with low molecular weight heparin (LMWH) and mortality was low. In hematolymphoid malignancies, PCAT reduce EFS, highlighting the need for prevention.

Phase 3 randomised study evaluating the addition of low-dose nivolumab to palliative chemotherapy in head and neck cancer

LBA6016

Background: The regimens approved for the treatment of advanced head and neck squamous cell carcinoma (HNSCC) are accessible to only 1-3% of patients in low and middle-income countries due to cost. In our previous study, metronomic chemotherapy (MC) improved survival in this setting. Retrospective data suggest that a low dose of nivolumab may be efficacious. Hence, we aimed to assess whether the addition of low dose nivolumab to MC improved the overall survival. Methods: This was a randomised phase 3 superiority open-label study. Adult patients with relapsed -recurrent or newly diagnosed advanced HNSCC being treated with palliative intent with ECOG PS 0-1 were eligible. Patients were randomised 1:1 to MC consisting of methotrexate 15 mg/m2 PO weekly, celecoxib 200 mg PO daily and erlotinib 150 mg PO daily, or MC with intravenous nivolumab 20 mg flat dose once-every-3-weeks. Therapy was continued until disease progression or intolerable adverse events. Response assessment (RECIST version 1.1) was performed every 2 months. The primary endpoint was 1-year overall survival (OS) and this was a pre-specified interim analysis with the nominal p-value for efficacy being 0.006. Results: 151 patients were randomised, 75 in MC and 76 in the MC-I arm respectively. The addition of low dose nivolumab led to an improvement in the 1-year overall survival from 16.3% (95%CI 7.95-27.4) to 43.4% (95% CI 30.8-52.3) [Hazard ratio-0.545; 95%CI 0.362-0.82; P=0.00358]. The median overall survival in MC and MC-I arms was 6.7 months (95%CI 5.83 -8.07) and 10.1 months (95%CI 7.37-12.63) respectively (P=0.0052). The median progression-free survival in MC and MC-I arms was 4.57 months (95%CI 4.2 -5.3) and 6.57 months (95%CI 4.43-8.9) respectively (P=0.0021). Response rate in MC and MC-I arm were 49.3% (95% CI 37.8-60.8) and 65.2% (95%CI 53.4-75.4) respectively (P=0.085). The rate of grade 3 and above adverse events was 50% and 46.1% in MC and MC-I arm respectively (P=0.744). Conclusions: In this first-ever randomised study, the addition of low dose nivolumab led to improved overall survival and is an alternative standard of care for those who cannot access full dose nivolumab. Clinical trial information: CTRI/2020/11/028953.

Geriatric assessment as a predictor of survival among older Indian patients with cancer

e24012

Background: ASCO guidelines recommend that geriatric assessment (GA) should be performed in all older adults with cancer. However, GA is labor- and time-intensive, hence the uptake is poor, especially in crowded resource poor-settings. There are no data correlating GA with overall survival (OS) outcomes from the Indian subcontinent. Methods: A prospective observational study in the geriatric oncology clinic of the Tata Memorial Hospital in Mumbai, India. Patients aged 60 years and above, with cancer who underwent a GA were enrolled. The domains assessed included: function (basic and instrumental activities of daily living, timed-up-and-go), nutrition (body mass index, unintentional weight loss, mini-nutritional assessment), comorbidities, cognition, psychological (depression, anxiety), social support, and medication (polypharmacy and potentially inappropriate medications). Patients with > 2 deranged GA domains were considered frail. Results: Between June 2018 and January 2022, 909 patients were enrolled. The median age was 69 (IQR, 60-88) years. Common malignancies included lung (40%), esophagus (21%) and head and neck (11%); 53% had metastatic disease. 80% had > 2 impaired domains in GA patients had vulnerabilities in a median of 3 (IQR, 0-5) domains. Median OS in fit patients based on the GA was 17.5 (95% CI, 13.9-21.0) months vs 12.1 (95% CI, 10.1-14.0) months in frail patients, (HR 0.66; 95% CI, 0.49-0.88, p = 0.005), which remained significant after adjusting for age, sex, and stage (HR, 0.71; 95% CI: 0.53-0.94, p = 0.021). In the multivariate analysis (Table), the domains that were predictive of survival were nutrition (HR: 0.65, 95% CI: 0.47-0.92, p = 0.014), cognition (HR: 0.65; 95% CI: 0.46-0.91, p = 0.012) and fatigue (HR: 0.74, 95% CI: 0.56-0.98, p = 0.038). Conclusions: In older Indian patients with cancer, GA is a powerful prognosticator of survival. In settings where a complete GA is not possible, nutrition, cognition, and fatigue should be the minimum domains assessed. Clinical trial information: CTRI/2020/04/024675. [Table: see text]

Phase III randomized control study evaluating adjuvant metronomic chemotherapy in locally advanced head and neck cancers post-radical chemoradiation (MACE-CTRT)

6073

Background: Locally advanced head and neck cancer treated with radical chemoradiation have unsatisfactory outcomes. Oral metronomic chemotherapy improves outcomes in comparison to maximum tolerated dose chemotherapy in the palliative setting. There is also limited evidence that it may do so in an adjuvant setting. Hence this randomised study was conducted. Methods: Patients of HN cancer with primary in oropharynx, larynx or hypopharynx, with PS 0-2 post radical chemoradiation with documented complete response were 1:1 randomised to either observation or oral metronomic adjuvant chemotherapy (MAC) for 18 months. MAC consisted of weekly oral methotrexate (15 mg/m2) and celecoxib (200 mg PO BD). The primary endpoint was OS and the overall sample size was 1038. The study had 3 planned interim analyses for efficacy and futility. Results: 137 patients were recruited and an interim analysis was done. The 3 year PFS in the observation arm was 67.1% (95% CI 53.8-77.3) and the same in the MAC arm was 62.5%(95%CI 49.4-73.1). The corresponding hazard ratio was 1.402 (95% CI 0.7393-2.66, P-value = 0.3). The 3 year OS in the observation arm was 77.3% (95% CI 64.4-86) and the same in the MAC arm was 64.1% (95%CI 51-74.5). The corresponding hazard ratio was 1.588 (95% CI 0.8734-2.886, P-value = 0.1). Any grade mucositis was seen in 30 patients (45.5%) in the MAC arm and 20 patients (28.2%) in the observation arm (P-value = 0.05). The rate of grade 3 or above mucositis was 7.6%(n = 5) in the MAC arm and 1.4%(n = 1) in the observation arm (P-value = 0.106). Conclusions: Both arms had similar OS. Hence observation post complete response post radical chemoradiation remains the standard of care. Clinical trial information: CTRI/2016/09/007315.

Mebendazole in recurrent glioblastoma: Results of a phase 2 randomized study

2029

Background: Recurrent glioblastoma (GBM) has dismal outcomes and limited treatment options. Mebendazole (MBZ) is an anti-helminthic drug with in-vivo and in-vitro activity against glioma cell lines and has been demonstrated to be well tolerated in combination with lomustine (CCNU) and temozolomide (TMZ). In this phase 2 study, we sought to determine whether the addition of MBZ to CCNU or TMZ would improve overall survival (OS) in recurrent GBM. Methods: Adult patients with ECOG PS 0-3, with recurrent glioblastoma who were not eligible for re-radiation, were randomized 1:1 between CCNU-MBZ (n = 44) and TMZ-MBZ (n = 44). The primary endpoint was OS at 9 months, selected to reflect the BELOB trial. A 9-month OS of 55% or more in any arm was hypothesized to warrant further evaluation and a value below 35% was too low to warrant further investigation. Results: At 17.4 months, 68 events for OS analysis had occurred. The 9-month overall survival was 36.6% (95%CI 22.3-51) and 45% (95%CI 29.6-59.2) in the TMZ-MBZ and CCNU-MBZ arms respectively. ECOG PS was the only independent prognostic factor impacting OS (HR-0.478 95%CI 0.268-0.851; P = 0.012). Twenty-three patients (28.6%) enrolled had an ECOG PS 2-3 with inferior outcomes (median OS-5.67, HR-2.092 95%CI 1.175-3.731). Analysis restricted to ECOG PS 0-1 (n = 65) patients revealed a 9-month OS of 39.6% (95% CI 22.4-56.3) and 57.9% (95% CI 38.7-73) in TMZ-MBZ and CCNU-MBZ arms respectively. Grade 3-5 adverse events were seen in 8 (18.6%; n = 43) and 4 (9.5%; n = 42) patients in the TMZ-MBZ and CCNU-MBZ arms respectively. Conclusions: The addition of MBZ to TMZ or CCNU failed to achieve the pre-set benchmark of 55% 9-month OS. This was probably due to 28.6% of patients with poor PS of 2-3. In patients with ECOG PS 0-1, CCNU-MBZ had a 9 month OS of 57.9% and needs to be evaluated further. Clinical trial information: CTRI/2018/01/011542.

Prevalence and outcomes of frailty in older patients with cancer: A prospective study from geriatric oncology clinic

e24011

Background: Frail older patients present with increased symptom burden, medical complexity and reduced tolerance to medical and surgical interventions. Data regarding the prevalence of frailty and its association with outcomes, such as overall survival, is limited from India. This study aimed to establish the prevalence of frailty and its association with overall survival (OS) in older patients with cancer. Methods: This was a prospective study conducted in geriatric oncology clinic of Tata memorial hospital (Mumbai India). Patients aged 60 years and above referred to the clinic were included. Frailty was identified using the Rockwoods Clinical frailty scale, and patients with a score of five or more were diagnosed as frail. Demographic details, type of cancer, stage and multi-domains geriatric assessment was done. Cancer and Ageing Research group online toxicity tool was used to assess the chemotherapy toxicity risk. A t-test or two-sample Wilcoxon rank-sum test was used to study the association between frailty status and non-categorical variables and the Pearson chi-squared test was used to measure the association between categorical variables. The Kaplan Meier survival estimation and the Cox proportional hazard model were used to perform the survival analysis. Results: Between June 2018 to January 2022, 909 patients were evaluated and 662 patients with clinical frailty score were included. The median age was 68 (60-86) years and 107 (16%) were above the age of 75 years. The most common malignancies were lung (39%), esophagus (21%) and head and neck (10%); 53% had metastatic disease. 192 (29%) were frail, and it prevalence increased with age. Frailty status was associated with poor OS (unadjusted HR: 2.512; 95% CI: 1.931-3.268). This association was significant even after adjusting for age, gender, BMI and stage of cancer (adjusted HR: 2.104; 95% CI: 1.598-2.770). Frailty was associated with comorbidities such as diabetes (32% vs 23%, p = 0.014), chronic obstructive pulmonary disease (13% vs 7%, p = 0.045) and cardiovascular disease (19% vs 12%, p = 0.017). Among the geriatric domains, frail patients had greater incidence of polypharmacy (52% vs 33%, p < 0.01), slower gait speed (53% vs 12%, p < 0.01), impaired cognition (25% vs 7%, p < 0.01), poor nutritional status (51% vs 17%, p < 0.001), depression (29% vs 8%, p < 0.01) and anxiety (14% vs 5%, p < 0.01). Conclusions: The prevalence of frailty among older cancer patients is high. It is associated with poor physical, cognitive and psychological resilience and is associated with poor overall survival. Our study supports the routine assessment of frailty in older patients with cancer to guide treatment decisions. Clinical trial information: CTRI/2020/04/024675.

Phase III randomized controlled trial comparing chemotherapy to best supportive care in advanced esophageal and gastroesophageal junction cancer

4065

Background: Patients with advanced esophageal/gastroesophageal junction (GEJ) cancer have a dismal outcome. No study has unequivocally proven that systemic chemotherapy prolongs survival. Current NCCN guidelines recommend palliative/best supportive care as a first-line option for patients with unresectable locally advanced, recurrent, or metastatic esophageal/GEJ cancers. Methods: Phase III randomized controlled study conducted in the Department of Medical Oncology at the Tata Memorial Hospital (Mumbai, India) in patients with advanced unresectable or metastatic esophageal or GEJ cancer, planned for palliative intent therapy. Patients aged 18 to 70 years, with a performance status < 2, were stratified based on histopathology, presence of metastatic disease and receipt of prior curative therapy, and randomized 1:1 to best supportive care alone, or best supportive care with chemotherapy consisting of intravenous paclitaxel 80 mg/m2 once-a-week, continued until disease progression or intolerable toxicity. Best supportive care consisted of patient education and counselling, non-chemotherapeutic palliative measures like radiation, or stenting, placement of feeding tube, analgesia, antiemesis and other supportive medications, nutritional support, and referral to a patient support group. Primary endpoint was overall survival (OS); secondary endpoints included progression free survival (PFS), response rate, adverse events, and quality of life. Results: Between May 2016 and Dec 2020, we recruited 281 patients; 143 to chemotherapy and 138 to best supportive care. Histopathology was squamous in 269 (95.7%) patients. In the 143 patients in the chemotherapy arm, median number of paclitaxel cycles was 12 (IQR, 7-23). The response rate was 32%. Grade > 3 toxicities occurred in 82 (57%) patients who received paclitaxel; commonly hyponatremia (18%), anemia (11%), fatigue (10%), peripheral neuropathy (10%), infection (9%), and neutropenia (7%). Median PFS was 2.1 months (95% CI, 1.98-2.23) in the best supportive care arm, and 4.1 months in the chemotherapy arm (95% CI, 3.54-4.74); HR, 0.51 (95% CI, 0.39-0.64); P < 0.001. The 1-year OS was 11.6% in the best supportive care arm, versus 30.8% in the chemotherapy arm. Median OS was 4.2 months (95% CI, 2.93-5.42) in the best supportive care arm, and 8.6 months in the chemotherapy arm (95% CI, 7.56-9.66); HR, 0.52 (95% CI, 0.40-0.66); P < 0.001. Conclusions: Systemic chemotherapy significantly prolongs survival and should be considered the standard of care in patients with advanced esophageal and GEJ squamous cell carcinoma. Metronomic weekly paclitaxel is an attractive option, especially in LMICs with limited access to newer immunotherapy-based combination regimens. Clinical trial information: CTRI/2016/01/006474.

Impact of the geriatric assessment on clinical treatment decision in older Indian persons with cancer

e24015

Background: The geriatric assessment (GA) is a multidimensional evaluation of an older person. Identification of the non-oncologic vulnerabilities, estimation of life expectancy and chemotherapy risk prediction aid the clinicians in the therapeutic risk-benefit ratio analysis. Globally, GA leads to changes in oncologic decisions in 28% of patients. Methods: An observational study with a retrospective and prospective cohort of patients who underwent a GA in the geriatric oncology clinic at the Tata Memorial Hospital in Mumbai, India. The study was approved by the institutional ethics committee (IEC) and registered with Clinical Trials Registry of India-CTRI/2020/04/024675. Written informed consent was obtained from the patients enrolled in the prospective part of the study; the IEC granted a consent waiver for the retrospective portion of the study. Patients aged 60 years and older with a diagnosis of malignancy were evaluated in the geriatric oncology clinic. The results of the GA were entered in the electronic medical records (EMR). The systemic therapy plan prior to the GA and the actual therapy plan made were retrospectively captured from the EMR. The primary objective was to determine the proportion of patients in whom the systemic therapy plan was changed following the GA. Results: Between June 2018 and Feb 2021, 340 patients were evaluated in the geriatric oncology clinic for whom the pre-GA and post-GA systemic therapy plans were available. The median age was 70 years (range, 60-100); 264 (78%) were men. The common malignancies were lung cancer in 134 (39.4%) and gastrointestinal in 119 (35%). The intent of therapy was palliative in 190 (56%) patients. Following the GA, the systemic therapy plan was changed in 125 (36.8%) patients. The most common change was deintensification of therapy in 106 patients (31.2%), including dose reduction in 41 (12%), decrease in the number of chemotherapy medicines in 8 (2.4%), substitution of chemotherapy by targeted therapy (4, 1.2%)/oral hormonal therapy (4, 1.2%)/oral TKI (11, 3.2%)/immunotherapy (2, 0.6%) and withholding systemic therapy in 36 (10.6%) patients. Withholding systemic therapy consisted of a change from chemoradiotherapy to radical radiation alone in 17 (5%), withholding neoadjuvant or adjuvant chemotherapy in 5 (1.5%) and a change to best supportive care in 14 (4.1%). Conclusions: The results of the GA led to a change in the management plan in over one-third of older Indian patients with cancer. GA is an important tool in the oncologic decision-making process for older persons with cancer. Clinical trial information: CTRI/2020/04/024675.

The use of G8 and VES13 as screening and prognostic tools in older Indian patients with cancer

e24024

Background: The ‘G8’ and ‘VES13’ are quick and easy-to-use screening tools, developed and validated in Western patients for predicting abnormalities in the subsequent geriatric assessment (GA). These tools predict functional decline and survival in older patients with cancer, but their applicability in our older Indian patients with cancer is not known. We performed this study in an attempt to validate the use of these screening tools in our patient population. Methods: An observational study with a retrospective and prospective cohort of 308 patients, aged 60 years and above, presenting to the Geriatric Oncology clinic at Tata Memorial Hospital, Mumbai, between June 2018 - November 2020. Patients either planned for or recently started on systemic therapy were enrolled and underwent the G8 & VES13 screening tools followed by a GA. The primary objective was to determine the appropriateness of the use of G8/VES13 screening tools to detect an abnormal GA. Our secondary objectives were to determine the optimal G8 cut-off value (using the AU-ROC curves) in our patient population, correlation between abnormal G8/VES13 scores and OS and to assess the utility of combining the G8 and VES13 scores (i.e. abnormal score on either of the two screening tools) to predict for an abnormal GA and poorer OS. Results: The abnormal G8 cut-off score appropriate for our population was 12. This revised cut-off score was compared with the international standard (Abnormal G8 < / = 14). With abnormal G8 cut-offs at < / = 14 the sensitivity, specificity & overall accuracy was 84%, 18% & 80% respectively; the corresponding values were 57%, 88% & 58% with cut-off < 12. An abnormal G8 ( < / = 14) and VES13 score correlated with poor ECOG PS (PS 2/3, p = 0.0001 [G8], p = 0.00001 [VES13]) and CARG high risk scores (p = 0.006 [G8], p = 0.005 [VES13]) however it did not correlate with an abnormal GA (p = 0.736 [G8], p = 0.195 [VES13). The median OS in patients with abnormal ( < / = 14) vs normal G8 scores was 13m vs 18m respectively (HR 0.777). Abnormal G8 cut-off scores < 12 correlated with a poor ECOG PS (p < 0.00001), CARG high risk scores (p = 0.006) and also with an abnormal GA (p < 0.001). The median OS in patients with abnormal ( < 12) vs normal G8 scores was 11m vs 17m (HR 1.658). Abnormal G8 ( < 12) + VES13 scores also correlated with abnormal GA (p 0.0001) and predicted for worse survival outcomes (Median OS 13m vs 17mHR 1.641). Abnormal VES13 scores also predicted for shorter survival (Median OS 10m vs 17m, HR 1.097). Conclusions: An abnormal G8 cut-off score < 12 is appropriate in our older Indian patients with cancer as compared to the internationally validated cut-off of < / = 14. This revised G8 cut-off score ( < 12) predicts for the presence of non-oncological vulnerability, poorer OS and translated to a 35% reduction in the number of patients undergoing a full GA. Combined with VES13, the G8 can be used as a screening tool which may help in optimal resource utilization especially in busy Indian centers.

Pulmonary sarcomatoid carcinoma: Retrospective analysis from a single center

e21188

Background: Pulmonary sarcomatoid carcinoma (PSC) constitutes a heterogeneous group of poorly differentiated non-small cell lung cancer (NSCLC). Since these are rare tumors, no definitive randomized trials or clinical guidelines are available for management. This is the largest single centre study of patients with pulmonary sarcomatoid carcinoma. Methods: We retrospectively evaluated all patients with pulmonary sarcomatoid carcinoma between January 2013 to September 2020 at the Tata Memorial Hospital, Mumbai, India. Cases were identified from the pathology database. Baseline demographic, treatment data and outcomes were obtained from a prospectively maintained database in the Department of Medical Oncology. Results: A total of 151 patients with PSC were diagnosed during this period. Among these, 129 patients were included for survival analysis. The median age at diagnosis was 61 years (range, 18-87) with a majority of them being males (81.5%) and smokers (73%). A significant percentage of patients presented with poor performance status (PS was 2-4 in 48%). A majority of patients had T4 (73%) or N3 nodal status (44%). The clinical stage was stage I in 2%, stage II in 2.7%, stage III in 25.9%, and stage IV in 69.4%. The initial treatment modalities include surgery (10.9%), radical chemoradiotherapy (CRT, 3.9%), palliative chemotherapy (46.5%), palliative radiotherapy (7%), and best supportive care (31.8%). The median follow-up duration for the entire cohort was 32 months (95% CI 15.0 to 48.9). The median OS for the entire patient cohort was 5 months (95% CI 3.4 to 6.5). The median OS of patients who received curative surgery was 18 months (95% CI: 2.59 to 33.4) and the corresponding 1- and 5-year survival rates for patients who underwent surgery were 64% and 33% respectively. The median OS for patients who received CRT was 11 months (95% CI: 2.99 to 19). The median OS for the patients who received palliative radiotherapy alone was 4 months (95% CI: 1.91 to 6.08), for palliative chemotherapy was 8 months (95% CI: 5.24 to 10.75) and for patients who received only best supportive care was 1 month (95% CI: 0.43 to 1.57, p = 0.001). The median PFS and ORR for first, second- and third-line palliative chemotherapies were 4 months (95% CI: 2.95 to 5.04) and 15.1%, 4 months (95% CI: 0.33 to 7.67) and 13.3%, and 1 month (95% CI 0.21 to 1.78) and 0%. In a multivariate analysis, independent prognostic factors included the presence of brain metastasis (p 0.018, HR, 2.47, 95% CI 1.34-4.49) and administration of palliative chemotherapy (p = 0.037, HR2.2, 95% CI 1.04-4.94). Conclusions: PSC usually presents in advanced stages and carries a poor prognosis. Effective therapeutic options are required to improve the outcomes.

The epidemiological trend of esophageal cancer in Mumbai, India over the past two decades

e16095

Background: There has been a definite histopathological shift in esophageal cancer in the West over the past few decades, with adenocarcinoma overtaking squamous cell carcinoma as the commonest type. Asian countries with a high human development index like China have also reported an increased incidence of esophageal adenocarcinoma. Data on the epidemiology of esophageal cancer in India are limited. Methods: We retrospectively evaluated the data of all patients with histologically proven esophageal cancer at Tata Memorial Hospital, from 2003 to 2018. We excluded non-squamous and non-adenocarcinoma histologies. Results: Of a total of 7,874 patients with esophageal cancer, 5,092 (64.7%) were men, for a male to female ratio of 2.5:1. The median age was 57 years (IQR, 50-65); 4,465 (56.7%) were below 60 years old. Of the 4912 patients in whom a history of tobacco or alcohol use had been elicited, there were 1,360 (27.7%) patients with no history of substance use. The site of the primary was the upper third in 906 (12.8%), middle third esophagus in 2,942 (41.5%), lower third in 2,331 (32.8%) and gastroesophageal junction in 917 (12.9%) patients. The predominant histology was squamous cell carcinoma in 6,413 (81.4%) patients and adenocarcinoma in 1461 (18.6%). There was no change in the histologic pattern over the period of the study; squamous cell carcinoma constituted 78.5% of the cases in 2003, and 85.5% in 2018; Chi square test for the year wise trend in histologic patterns was not significant, p=0.143. Evaluation of the histologic subtype according to sex revealed that in the male patients, there were 3890 (76.4%) squamous and 1202 (23.6%) adenocarcinoma cases, while in female patients, there were 2523 (90.7%) squamous and 259 (9.3%) adenocarcinoma cases. On a uni variate analysis, male sex (p<0.001), a history of tobacco or alcohol use (p<0.001), and the presence of comorbidity (p<0.007) were associated with an increased risk of squamous cell carcinoma. Multivariate analysis by logistic regression model revealed that female sex and use of tobacco or alcohol were positively associated with squamous cell carcinoma, while the presence of comorbities and primary in lower esophagus/GEJ were positively associated with adenocarcinoma. Conclusions: Squamous cell carcinoma continues to be the commonest esophageal cancer histologic subtype in over 80% Indian patients. The mid esophagus is the most common site (42%). There is no evidence of an epidemiological shift or an increase in the occurrence of adenocarcinoma or of lower esophageal/GEJ malignancy over the past two decades.

Caregiver burden in older Indian patients with cancer: Experience from a tertiary care center

e24022

Background: Most of the care for adults with chronic/debilitating illnesses is provided by unpaid family members. There is little information on caregiver burden in older patients with cancer in India. Methods: This was an observational study conducted in the geriatric oncology clinic at the Tata Memorial Centre, a tertiary care oncology center in Mumbai, India. The Fronto Temporal Lobe Disorders (FTLDA) caregiver burden scale was administered to the caregiver who accompanied the patient to the geriatric clinic. The scale has 22 questions, each scored from 0 to 4. The points were added to give the total caregiver burden score. The severity of the caregiver burden was scored based on the standard key: 0-20 little or no burden, 21-40 mild to moderate burden, 41-60 moderate to severe burden, 61-88 severe burden. Descriptive statistics were used for demographic & clinical variables. The factors impacting the caregiver burden were analyzed using multiple linear regression analysis. The caregiver burden score was the dependent variable in this analysis. The independent variables evaluated were patient-related factors (sex, education, primary tumor type), vulnerabilities noted on the geriatric assessment (function & falls, psychological status -depression & anxiety, cognition, nutrition, comorbidity) and caregiver-related, i.e., the relationship of the caregiver with the patient. Results: The caregiver burden scores were obtained from the caregivers of 127 older Indian patients with cancer between June 2020 & January 2021. The median age of patients in this study was 69 years (range, 60-90). There were 96 (75.6%) males; the two commonest malignancies were lung carcinoma (47 patients, 37%) & gastrointestinal cancers (46 patients, 36.2%). The relationship of the caregiver to the patient was child (94, 74%), in-law (12, 9.4%), spouse (7, 5.5%), grandchild (6, 4.7%) and other relative (8, 6.3%). The median caregiver burden score was 12 (IQR, 6-20). The caregiver burden was -little/no in 97 (76.4%), mild-moderate in 25 (19.7%), moderate-severe in 4 (3.1%) & severe in 1 (0.8%) of the caregivers assessed. On multivariate analysis, the factors that significantly impacted the caregiver burden score included the sex of the patient ( P= .0445) & the presence of psychological problems ( P= .0164). In the univariate analysis, the caregiver burden was higher in caregivers of female patients (median score, 16 [IQR 9-25] versus 10 [IQR 5-19], P= .02036). Caregivers of patients with psychological issues also had higher caregiver burden (median score, 19 [IQR 10-28] versus 10 [IQR 5.25-17], P= .00224). Conclusions: The caregiver burden was low in older Indian patients with cancer. Higher caregiver burden was experienced by the caregivers of female patients & patients with psychological disorders. Clinical trial information: CTRI/2020/04/024675.

Accuracy of the CARG chemotherapy toxicity risk prediction tool in older Indian patients with cancer

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Background: Clinical judgement alone is inadequate in accurately predicting chemotherapy toxicity in older adult cancer patients. Hurria and colleagues developed and validated, the CARG score (range, 0–17) as a convenient and reliable tool for predicting chemotherapy toxicity in older cancer patients in America, however, its applicability in Indian patients is unknown. Methods: An observational retrospective and prospective study between 2018 and 2020 was conducted in the Department of Medical Oncology at Tata Memorial Hospital, Mumbai, India. The study was approved by the institutional ethics committee (IEC-III; Project No. 900596) and registered in the Clinical Trials Registry of India (CTRI/2020/04/024675). Written informed consent was obtained in the prospective part of the study. Patients aged ≥ 60 years and planned for systemic therapy were evaluated in the geriatric oncology clinic and their CARG score was calculated. Patients were stratified into low (0-4), intermediate (5-9) and high risk (10-17) based on the CARG scores. The CARG score was provided to the treating physicians, along with the results of the geriatric assessment. Chemotherapy-related toxicities were captured from the electronic medical record and graded as per the NCI CTCAE, version 4.0. Results: We assessed 130 patients, with a median age 69 years (IQR, 60 to 84); 72% patients were males. The common malignancies included gastrointestinal (52%) and lung (30%). Approximately 78% patients received polychemotherapy and 53% received full dose chemotherapy. Based on the CARG score, 28 (22%) patients belonged to low risk, 80 (61%) to intermediate risk and 22 (17%) to the high risk category. The AU-ROC of the CARG score in predicting grade 3-5 toxicities was 0.61 (95% CI, 0.51-0.71). The sensitivity and specificity of the CARG score in predicting grade 3-5 toxicities were 60.8% and 78.6%. Grade 3-5 toxicities occurred in 6/28 patients (21%) in the low risk group, compared to 62/102 patients (61%) in the intermediate /high risk group, p = 0.0002. There was also a significant difference in the time to development of grade 3-5 toxicities, which occurred at a median of 2.5 cycles (IQR, 1-3.8) in the intermediate /high risk group and at a median of 6 cycles (IQR, 3.5-8) in the low risk group, p = 0.0011. Conclusions: In older Indian patients with cancer, the CARG score reliably stratifies patients into low risk and intermediate/high risk categories, predicting both the occurrence and the time to occurrence of grade 3-5 toxicities from chemotherapy. The CARG score may aid the oncologist in estimating the risk-benefit ratio of chemotherapy. An important limitation was that we provided the CARG score to the treating oncologists prior to the start of chemotherapy, which may have resulted in alterations in the chemotherapy regimen and dose and may have impacted the CARG risk prediction model. Clinical trial information: CTRI/2020/04/024675.

Comparison of validated screening tools for the assessment of potentially inappropriate medications in older Indian patients with cancer

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Background: The use of potentially inappropriate medication (PIM) and polypharmacy are highly prevalent in older cancer patients and are recognized as potential risk factors for adverse outcomes during cancer treatment. With geriatric cases increasing steadily in India, there is a need for comprehensive studies to identify a reliable screening tool for the assessment of PIMs. Methods: Retrospective analysis of patients ≥ 60 years who visited the Geriatric Oncology Clinic of the Tata Memorial Hospital, Mumbai, India between 2018-2021. Five tools (Beers-2015, STOPP and START-2014, PRISCUS-2010, FORTA-2018, and the EU (7)-PIM list-2015) were used to assess PIM. A standardized PIM value (SPV) was assigned for each patient for each scale which represented the ratio of the number of PIMs identified by a given scale to the total number of medications taken. The median SPV of all 5 scales for each patient was considered the reference standard. Agreement between each scale and the reference was carried out using Bland-Altman plots. The agreement was determined based on bias and the width of the limit of agreement. Association between categorical variables such as sex, comorbidities, and number of medications (above and below the median) and PIM use was determined using the chi-squared test. Results: 352 patients were included; median age - 70(range: 60-100) years, 287 (81.6%) were males. The bias and limit of agreement given by the Bland-Altman plot for each scale is shown in Table 1. The EU(7)-PIM list was found to have the least bias of 0.7% and the narrowest limits of agreement of 0.43 (-0.21 to 0.22). PIM use was observed to be significantly higher in patients with diabetes than without (83/281 versus 13/82, respectively, p = 0.013) and, patients prescribed with > 7 medications compared with ≤7 (137/281 versus 06/70, respectively, p < 0.001). Conclusions: The EU(7)-PIM list was found to have the least bias and thus considered the most reliable among all other scales in our study population. A high degree of discordance was observed between the tools, thus, we emphasize the need for future studies to identify the most reliable tool for the prediction of PIMs to aid clinical decision-making in geriatric practice.[Table: see text]

Pregnancy associated breast cancer (PABC): Report from a gestational cancer registry from a tertiary cancer care centre, India

Background

Pregnancy associated breast cancer (PABC) is a rare entity and defined as breast cancer diagnosed during pregnancy or one-year post-partum. There is sparse data especially from low and middle-income countries (LMIC) and merits exploration.

Methods

The study (2013–2020) evaluated demographics, treatment patterns and outcomes of PABC.

Results

There were 104 patients, median age of 31 years; 43 (41%) had triple-negative disease, 31(29.8%) had hormone-receptor (HR) positive and HER2 negative, 14 (13.5%) had HER2-positive and HR negative and 16(15.4%) had triple positive disease. 101(97%) had IDC grade III tumors and 74% had delayed diagnosis. 72% presented with early stage (24, EBC) or locally advanced breast cancer (53, LABC) and received either neoadjuvant (n = 49) or adjuvant (n = 26) chemotherapy and surgery. Trastuzumab, tamoxifen, and radiotherapy were administered post-delivery. At a median follow up of 27 (IQR:19–35) months, the estimated 3-year event-free survival (EFS) for EBC and LABC was 82% (95% CI: 65.2–100) and 56% (95% CI: 42–75.6%) and for metastatic 24% (95% CI: 10.1%–58.5%) respectively.

Of the 104 patients, 34 were diagnosed antepartum (AP) and 15 had termination, 2 had preterm and 16 had full-term deliveries(FTDs). Among postpartum cohort (n = 70), 2 had termination, 1 had preterm, 67 had FTDs. 83(including 17 from AP) children from both cohorts were experiencing normal milestones.

Conclusion

Data from the first Indian PABC registry showed that the majority had delayed diagnosis and aggressive features(TNBC, higher grade). Treatment was feasible in majority and stage matched outcomes were comparable to non-PABCs.

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Pregnancy associated breast cancer (PABC) is a rare and Challenging entity with lack of data from low-middle income countries.

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First Indian data showed that stage matched oncologic outcomes were comparable to non-PABC.

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Obstetric outcomes were similar to non-cancer associated pregnancies with normal cognitive development.

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Creating awareness and early diagnosis is of utmost importance to improve prognosis in this unique entity

A randomized clinical trial evaluating the efficacy and safety of the addition of oral metronomic chemotherapy after completion of standard chemoradiation versus observation in patients with locally advanced esophageal and gastroesophageal junction squamous cell carcinoma

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Background: In RTOG 85-01, patients with locally advanced esophageal and gastroesophageal junction (GEJ) cancer treated with concurrent chemoradiotherapy (CRT) had a median overall survival (OS) of 14 months and 5-year OS of 27%. Improving outcomes in these patients is an unmet need. We investigated the addition of oral metronomic chemotherapy (OMC) following definitive CRT. Methods: A randomized integrated phase II/III clinical trial (CTRI/2015/09/006204) in patients with squamous cell carcinoma of the esophagus or the GEJ who had completed definitive radical CRT within the past 12 weeks, had an ECOG PS 0-2 and no clinical or radiologic evidence of progressive disease. Patients were stratified based on whether or not they had received induction chemotherapy followed by CRT, and then randomized 1:1 to receive OMC (celecoxib 200 mg twice daily and methotrexate 15 mg/m2 weekly) for 12 months or observation. The primary efficacy endpoint for the phase II portion was progression free survival (PFS). The secondary endpoints were OS and toxicity. With a power of 70% and an alpha of 10%, we hypothesized a hazard ratio of 1.5, with a median follow-up of 6 months. The planned sample size for the phase II portion was 151 patients. The p-value for stopping the trial after the phase II part of the study was set at 0.2 for the PFS. Results: Between Jan 2016 and Dec 2019, we enrolled 151 patients, 75 to the OMC arm and 76 to observation. The median age was 57 years, 59% were male. The tumor originated in the upper thoracic esophagus in 79% patients, with median tumor length 6 cm. Induction chemotherapy was received by 14% of the patients. Concurrent CRT consisted of median 63 Gy in median 35 fractions; 91% patients received concurrent weekly paclitaxel and carboplatin with radiation. OMC was started at a median of 11 weeks (IQR, 9 to 12) from the start of CRT. Grade 3 or higher toxicities (regardless of relatedness to study intervention) were noted in 27 patients (17.9%), 18 in the OMC arm and 9 in the observation arm; P=0.071. The median time to disease progression or death was 23 months (95% CI, 7.9-38.1) in the OMC arm and not reached in the observation arm; HR, 1.33, 95% CI, 0.83-2.14; P=0.23. The 1-year PFS was 67% in both the arms; the 2-year PFS were 48% and 61% in the OMC and observation arms respectively. The median OS was 36 months (95% CI, 17.9-54) in the OMC arm and not reached in the observation arm; HR, 1.75; 95% CI, 1.02-2.99; P, 0.037. The 1-year OS was 74.7% in the OMC arm and 88% in the observation arm; the 2-year OS was 53.9% in the OMC arm and 75% in the observation arm. Conclusion: Adjuvant oral metronomic chemotherapy after radical CRT does not improve outcomes in patients with locally advanced esophageal or GEJ squamous cell carcinoma. Clinical trial information: CTRI/2015/09/006204.

Randomized, Parallel Group, Open-Label Bioequivalence Trial of Intramuscular Pegaspargase in Patients With Relapsed Acute Lymphoblastic Leukemia

PURPOSE

Pegylated asparaginase is comparatively safer than native asparaginase in the management of acute lymphoblastic leukemia (ALL). However, the high price and nonavailability in low- and middle-income countries limits its use. In 2014, the first generic of pegaspargase (Hamsyl) was approved in India for use as a second-line treatment option for ALL. The aim of this study was to assess whether the generic pegaspargase (the test product) was bioequivalent with the reference product (Oncaspar).

PATIENTS AND METHODS

This study was an open-label, parallel-group, comparative pharmacokinetic study in pediatric patients with relapsed ALL receiving their first dose (1,000 IU/m²) of pegaspargase administered intramuscularly. Patients were randomly assigned 1-to-1 to either the test or the reference product. The 2 formulations were considered equivalent if the 90% CIs for area under the plasma asparaginase activity–time curve (AUC_0-t) geometric mean test-to-reference ratio was within 75% to 133%.

RESULTS

Twenty-nine patients (6-18 years of age) were enrolled in this study, of whom 24 completed the study criteria and were considered for safety analysis (5 patients were ineligible for the assessment). Three patients were excluded from analysis, because of presence of anti-asparaginase antibodies, leaving 21 patients who were considered for bioequivalence pharmacokinetics data. The point estimate of AUC_0-t for the test-to-reference ratio was 95.05 (90% CI, 75.07% to 120.33%). Maximum plasma concentration, trough concentrations (day 14), half-life, volume of distribution, drug clearance, and changes in the asparagine and glutamine levels were not significantly different between products. Adverse events were comparable in both groups.

CONCLUSION

Generic and reference pegaspargase had equivalent pharmacokinetics with comparable safety. This could be a safe and cost-effective alternative for patients with ALL, especially in low- and middle-income countries.

Low-cost oral metronomic versus intravenous chemotherapy in recurrent, inoperable and metastatic head and neck cancer: Phase III Metro-CIS study

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Background: The NCCN preferred regimens for palliation in head and neck cancer, either EXTREME or KEYNOTE-048 are the only two regimens which have improved outcomes over chemotherapy, but they have limited applicability (1-3%) in low and middle-income countries due to the cost. Oral metronomic chemotherapy (OMC) has shown better outcomes than intravenous cisplatin; these results were obtained with a low incidence of adverse events and the cost of 1/100th of NCCN-preferred regimens in a Phase II study. Methods: This was a randomized Phase III non-inferiority open-label study. Adult patients with relapsed-recurrent or metastatic upfront palliatively treated squamous cell carcinoma of head and neck and ECOG PS 0-1 were eligible. Patients were randomized 1:1 between OMC (oral methotrexate 15 mg/m2 weekly with celecoxib 200 mg once daily or intravenous cisplatin (IVC) 75 mg/m2, 3-weekly for 6 cycles. CTCAE version 4.0 was used for adverse event recording. Response assessment (RECIST version 1.1) was performed every 2 months. EORTC QLQ-C 30 and EORTC QLQ -H&N 35 questionnaires were self-administered at baseline and 2-monthly thereafter. The primary endpoint was overall survival (OS) and was measured from the date of randomization to death. Assuming a 6-month OS in IVC arm of 40%, the non-inferiority margin of 13%, type 1 error of 5% (2-sided), type 2 error of 20% and lost-to-follow up rate of 20%, a total sample size of 422 subjects was required. Kaplan Meier method was used for the estimation of OS and progression-free survival (PFS). To determine non-inferiority the upper limit of 95% CI of difference between 6 months OS of the 2 arms had to be below 13%. Results: In the intention to treat analysis, the 6-months OS was 50.89% (95% CI, 43.3-57.97) and 62.26% (95% CI, 54.72-68.9) in the IVC and OMC arm respectively. The difference in 6-months OS between the 2 arms was - 11.37% (95% CI, -20.77 to -0.97). The median OS was 6.1 (95% CI, 5.33-6.93) versus 7.5 (95% CI, 6.5-8.8) months in IVC arm and OMC arm respectively ( P= .026). The unadjusted hazard ratio for death was 0.773 (95% CI, 0.615-0.97, P= .026). The median PFS was 1.67 (95% CI, 1.47-2.03) versus 3.23 (95% CI, 2.57-4.13) months in IVC and OMC arms respectively ( P< 0.001). Any grade 3 or above adverse events were seen in 61 (30.2%) versus 37 (18.9%) patients in IVC and OMC arm respectively ( P= .01). Conclusions: OMC improves outcomes in palliatively treated head and neck cancer and is a new standard of care in this setting, in addition to the EXTREME and KEYNOTE-048 regimen. Clinical trial information: CTRI/2015/11/006388 .

Gefitinib Versus Gefitinib Plus Pemetrexed and Carboplatin Chemotherapy in EGFR-Mutated Lung Cancer

PURPOSE

Standard first-line therapy for EGFR-mutant advanced non-small-cell lung cancer (NSCLC) is an epidermal growth factor receptor (EGFR)-directed oral tyrosine kinase inhibitor. Adding pemetrexed and carboplatin chemotherapy to an oral tyrosine kinase inhibitor may improve outcomes.

PATIENTS AND METHODS

This was a phase III randomized trial in patients with advanced NSCLC harboring an EGFR-sensitizing mutation and a performance status of 0 to 2 who were planned to receive first-line palliative therapy. Random assignment was 1:1 to gefitinib 250 mg orally per day (Gef) or gefitinib 250 mg orally per day plus pemetrexed 500 mg/m² and carboplatin area under curve 5 intravenously every 3 weeks for four cycles, followed by maintenance pemetrexed (gefitinib plus chemotherapy [Gef+C]). The primary end point was progression-free survival (PFS); secondary end points included overall survival (OS), response rate, and toxicity.

RESULTS

Between 2016 and 2018, 350 patients were randomly assigned to Gef (n = 176) and Gef+C (n = 174). Twenty-one percent of patients had a performance status of 2, and 18% of patients had brain metastases. Median follow-up time was 17 months (range, 7 to 30 months). Radiologic response rates were 75% and 63% in the Gef+C and Gef arms, respectively (P = .01). Estimated median PFS was significantly longer with Gef+C than Gef (16 months [95% CI, 13.5 to 18.5 months] v 8 months [95% CI, 7.0 to 9.0 months], respectively; hazard ratio for disease progression or death, 0.51 [95% CI, 0.39 to 0.66]; P < .001). Estimated median OS was significantly longer with Gef+C than Gef (not reached v 17 months [95% CI, 13.5 to 20.5 months]; hazard ratio for death, 0.45 [95% CI, 0.31 to 0.65]; P < .001). Clinically relevant grade 3 or greater toxicities occurred in 51% and 25% of patients in the Gef+C and Gef arms, respectively (P < .001).

CONCLUSION

Adding pemetrexed and carboplatin chemotherapy to gefitinib significantly prolonged PFS and OS but increased toxicity in patients with NSCLC.

"Randomised controlled trial of scalp cooling for the prevention of chemotherapy induced alopecia"

Background

Randomized controlled trials (RCT) of scalp cooling (SC) to prevent chemotherapy induced alopecia (CIA) did not evaluate its effect on hair regrowth (HR) and was conducted in a predominantly taxane (T) treated population. We conducted an RCT of SC in a setting of anthracycline (A) and taxane chemotherapy (CT) and assessed its effect on CIA and HR.

Methods

Non-metastatic breast cancer women undergoing (neo) adjuvant CT were randomized to receive SC using the Paxman scalp cooling system during every cycle of CT, or no SC. The primary end point (PEP) was successful hair preservation (HP) assessed clinically and by review of photographs after CT. HR was assessed at 6 and 12 weeks.

Results

51 patients were randomized to SC (34) or control arm (17) in a 2:1 ratio. Twenty-five (49%) patients received A followed by T and the two arms were balanced with respect to this factor. HP rate was significantly higher in SC arm compared to control arm (56.3% vs 0%, P = 0.000004). HR was higher in SC arm compared to control at 6 weeks (89% vs 12%; P < 0.001) and 12 weeks (100% vs 59%, P = 0.0003). Loss of hair at PEP evaluation, which was a quality of life measure, was significantly lower in SC versus control arm (45% vs 82%, P = 0.016). There were no grade 3–4 cold related adverse effects.

Conclusions

Women with breast cancer receiving A or T chemotherapy receiving SC were significantly more likely to have less than 50% hair loss after CT, superior hair regrowth and improvement in patient reported outcomes, with acceptable tolerance. It merits wider usage.

Phase III randomized trial comparing gefitinib to gefitinib with pemetrexed-carboplatin chemotherapy in patients with advanced untreated EGFR mutant non-small cell lung cancer (gef vs gef+C)

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Background: Standard first-line therapy for EGFR mutant advanced non-small cell lung cancer (NSCLC) is an EGFR-directed oral TKI. We evaluated whether adding pemetrexed-carboplatin to oral TKI would improve outcomes. Methods: Phase III randomized trial in advanced chemotherapy-naïve NSCLC harboring EGFR sensitizing mutation (exon 19, 21 or 18) with performance status (PS) 0 to 2 planned for palliative therapy. Patients were stratified for PS and EGFR mutation and randomly assigned (computer-generated randomization by independent biostatistician) 1:1 to gefitinib 250 mg orally daily (gef) or gefitinib 250 mg orally daily with pemetrexed 500 mg/m2 IV and carboplatin AUC 5 IV every 3 weeks for 4 cycles, followed by maintenance pemetrexed 500 mg/m2 IV every 3 weeks (gef+C). Restaging was every 2 to 3 mths; therapy continued until progression or intolerable toxicity. Primary end point was progression-free survival (PFS); secondary end points included overall survival (OS), toxicity and response rate. Survival endpoints were assessed in the intention-to-treat population. Results: Between Aug 2016 and Aug 2018, 350 patients were randomly assigned to gef (n = 177) and gef+C (n = 173). Median age was 54 yrs, 48% were females, 84% never-smokers, 21% were PS 2 and 18% had brain metastases. Median follow-up in surviving patients was 17 months (range, 7 to 30). Radiologic response rates were 81% and 69% in gef+C and gef respectively, P = 0.012. 234 patients (67%) have had events for PFS, 98 in gef+C and 136 in gef. Estimated median PFS was significantly longer with gef+C than gef (16 months, [95% CI, 13.7 to 18.3] vs. 8 months [95% CI, 7.1 to 8.9]; hazard ratio for disease progression or death, 0.5; 95% CI, 0.39 to 0.65; P < 0.001). 120 patients (34%) have died, 42 in gef+C and 78 in gef. Estimated median OS was significantly longer with gef+C than gef (not reached vs. 18 months [95% CI, 14.28 to 21.72]; hazard ratio for death, 0.45; 95% CI, 0.31 to 0.66; P < 0.001). Clinically relevant ≥ grade 3 toxicities occurred in 51% and 25% of patients in gef+C and gef arms respectively, P < 0.001. Conclusion: Adding pemetrexed-carboplatin chemotherapy to gefitinib significantly prolonged progression free and overall survival but also increased toxicity. Pemetrexed-carboplatin-gefitinib represents a new standard first-line therapy for EGFR mutant NSCLC. Clinical trial information: CTRI/2016/08/007149.

Epidemiology of blood stream infections in pediatric patients at a Tertiary Care Cancer Centre

BACKGROUND

Blood stream infections (BSI) are among the most common causes of preventable deaths in children with cancer in a developing country. Knowledge of its etiology as well as antibiotic sensitivity is essential not only for planning antimicrobial policy, but also the larger infection prevention and control measures.

AIMS

To describe the etiology and sensitivity of BSI in the pediatric oncology unit at a tertiary cancer center.

MATERIALS AND METHODS

All the samples representative of BSI sent from pediatric oncology unit during the period of January to December, 2013 were included in the study, and analyzed for microbiological spectrum with their antibiotic sensitivity.

RESULTS

A total of 4198 samples were representative of BSI. The overall cultures positivity rate was 6.97% with higher positivity rate (10.28%) from central lines. Of the positive cultures, 208 (70.9%) were Gram-negative bacilli (GNB), 71 (24.2%) were Gram-positive organisms, and 14 (4.7%) were Candida species. Lactose fermenting Enterobacteriaceae i.e., Escherichia coli (28.4%), Klebsiella pneumoniae (22.1%), and Enterobacter (4.8%) accounted for 55.3% of all GNB. Pseudomonas accounted for 53 (25.5%) and Acinetobacter 19 (9.1%) of GNB. Among Gram-positive isolates, staphylococci were the most frequent (47.8%), followed by Streptococcus pneumoniae 17 (23.9%), beta-hemolytic streptococci 11 (15.5%), and enterococci 9 (12.68%). Of GNB, 45.7% were pan-sensitive, 24% extended spectrum beta-lactamase (ESBL) producers, 27% were resistant to carbapenems, and 3.4% resistant to colistin. Pseudomonas was most sensitive, and Klebsiella was least sensitive of GNB. Of the staphylococcal isolates, 41.67% were methicillin-resistant Staphylococcus aureus (MRSA) and 10% of Coagulase Negative Stapylococci (CONS) were methicillin.

CONCLUSION

A high degree of ESBL producers and carbapenem-resistant Enterobacteriaceae is concerning; with emerging resistance to colistin, raising the fear of a return to the preantibiotic era. An urgent intervention including creating awareness and establishment of robust infection control and antibiotic stewardship program is the most important need of the hour.

Alarming prevalence of community-acquired multidrug-resistant organisms colonization in children with cancer and implications for therapy: A prospective study

BACKGROUND

Infection or colonization with multidrug-resistant organisms (MDRO) is associated with high mortality and morbidity. Knowledge of MDRO colonization may help in planning empirical antibiotic approach in neutropenic patients, which is known to improve patient outcomes. While routine cultures are positive and may help direct antibiotic therapy in only up to 15% neutropenic patients, surveillance cultures are positive in more than 90% of cancer patients.

AIMS

To assess the rate of MDRO carrier status at presentation and rate of conversion to MDRO during the treatment.

MATERIALS AND METHODS

Rectal swabs of all the outpatients presenting to pediatric oncology unit were sent within 7 days from date of registration from January 2014 to December 2014. Furthermore, stool cultures/rectal swabs of all patients who got directly admitted to the pediatric ward at presentation were sent within 24 h. Repeat rectal swabs were sent again for patients from this cohort when they got readmitted to the ward at least 15 days after last discharge or when clinically indicated.

RESULTS

Baseline surveillance rectal swabs were sent for 618 patients, which included 528 children with hematological malignancies and 90 children with solid tumors. Forty-five (7.3%) showed no growth. Of the remaining 573, 197 (34.4%) patients were colonized by two organisms and 30 (5.2%) by three organisms. Three hundred and thirty-four (58.4%) showed extended spectrum beta-lactamase (ESBL) Enterobacteriaceae, of which 165 (49.5%) were ESBL sensitive to beta-lactam with beta-lactamase inhibitors combinations and 169 (50.5%) were resistant to combinations. One hundred and sixteen (20.2%) were carbapenem-resistant Enterobacteriaceae (CRE) and 65 (11.4%) had vancomycin-resistant enterococci in baseline cultures. Only 63 (21%) patients were colonized by a sensitive organism in their baseline surveillance cultures. Morbidity (Intensive Care Unit stay) and mortality was higher in patients colonized by MDR organisms. There was a significant correlation between the place of residence and CRE colonization status with the highest rate (60%) of CRE colonization observed in children from East India. The repeat cultures showed the further conversion of sensitive isolates to MDRO in 80% of these children, of which 40% each converted from non-ESBL and non-CRE to ESBL and CRE, respectively.

CONCLUSION

This is the first study illustrating the alarming high prevalence of community-acquired MDRO colonization, especially CRE, which has grave implications for therapy for children with cancer potentially compromising delivery of aggressive chemotherapy and affecting outcomes. This incidence further increases during the course of treatment. Knowing the baseline colonization also guides us for the planning of chemotherapy as well as antibiotic approach and infection control strategies. Local antibiotics stewardship including education of the healthcare workers as well as national level interventions to prevent antibiotic misuse in the community is critical to minimize this problem.

Abstract P4-14-07: Outcome with use of 12 weeks of adjuvant or neoadjuvant trastuzumab in a resource constrained setting

Background: Adjuvant trastuzumab has improved overall survival in women with HER2 receptor positive breast cancer. However, only a small fraction (4%) of eligible patients in resource constrained settings have access to this drug. A patient assistance program of 12 weeks of adjuvant or neoadjuvant trastuzumab was thus started for those who did not have any access to trastuzumab due to financial constraints. We undertook a retrospective analysis of outcomes in women who were enrolled between January 2011 to December 2012 in this patient assistance program.

Methods: Patients received four cycles of anthracycline based chemotherapy (AC/CAF/ EC/CEF) and 12 doses of weekly paclitaxel (80mg/m2) with trastuzumab (4mg/kg loading followed by 2mg/kg) in the neoadjuvant or adjuvant setting in either sequence (anthracycline followed by taxane trastuzumab or taxane trastuzumab followed by anthracycline). Patients received adjuvant hormonal therapy depending on the hormone receptor status. The primary endpoint of this analysis was disease free survival (DFS).

Results: A total of 103 patients with HER2 receptor positive breast cancer were analysed. The median age was 46 (24-65) years, 50% were premenopausal, 60.7% had stage III disease (86.8% had node positive disease) and 37% patients had ER and or PR positive disease. Forty patients (38.8%) had breast conserving surgery while the rest had modified radical mastectomy. At a median follow-up of 34 (7-46) months the 3-year DFS and overall survival was 77.2% and 82.7% respectively. Among patients who developed recurrence one had only local recurrence, 4 had both local and distant recurrence and 11 had distant metastasis alone. Of the 15 patients who developed distant metastasis 7 had brain involvement . Symptomatic cardiac dysfunction developed in four patients, two of whom died while in the other 2 ejection fraction recovered. The results are summarised in the table.

Patient Characteristic and outcome with 12 weks of adjuvant or neoadjuvant TrastuzumabNumber of PatientsNode Positive (%)Hormone Positive (%)DFS at 3 yearsOS at 3 yearsBrain Mets(%)Grade 3/4 Cardiac Toxicity(%)10386.83777.282.76.83.9

Conclusions: These results suggest that 12 weeks of neoadjuvant or adjuvant trastuzumab is an acceptable alternative in patients who lack access to full 1 year of trastuzumab.

Citation Format: Ghosh J, Joy Phillip DS, Ghosh J, Gupta S, Bajpai J, Gulia S, Parmar V, Nair N, Budrukkar AN, Jalali R, Desai SB, Sawant S, Dhir AA, Kembhavi S, Hawaldar R, Banavali SD, Badwe RA. Outcome with use of 12 weeks of adjuvant or neoadjuvant trastuzumab in a resource constrained setting. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P4-14-07.

Sarcomatoid carcinoma of kidney, presenting with leucocytosis as paraneoplastic syndrome: A case report and short review

Renal cell carcinoma is the ninth most common malignancy. The commonest histopathological type is clear cell carcinoma. The occurrence of sarcomatoid carcinoma is very rare and confers a very poor prognosis. Only 10-20% patients present with paraneoplastic syndromes. Out of the common paraneoplastic syndromes, leucocytosis is one of the least reported. Here, we present a case of sarcomatoid carcinoma of kidney who presented with low-grade fever and leucocytosis, followed by a short review of literature. This is one of the rare situations where a rare histologic variant presents with a rare finding.

Metronomic therapy: chemotherapy revisited

Cytotoxic antiproliferative chemotherapeutic agents are the mainstay of treatment in cancers. Chemotherapy is usually administered every 2-3 weeks. Along with acute toxicity and long-term effects of cumulative doses, this strategy potentially allows regrowth of the tumor in the interval period and leads to the emergence of resistant populations of tumor cells. Moreover, even with intense chemotherapy, the outcome is stagnating for most of the tumors. There has been recent interest in the use of chemotherapy in fractionated doses which is far below the maximum tolerated dose. This is called metronomic scheduling of chemotherapy. Here, we review the biology and evidence for metronomic chemotherapy.

Comparison of isolates and antibiotic sensitivity pattern in pediatric and adult cancer patients; is it different?

BACKGROUND

Infection is a common cause of mortality and morbidity in cancer patients. Organisms are becoming resistant to antibiotics; age appears to be one of the factors responsible. We analyzed common organisms and their antibiotic sensitivity pattern in the correlation with age.

METHODS

This is a single institutional, retrospective analysis of all culture positive adult and pediatric cancer patients from January 2007 to December 2007. For statistical analysis, Chi-square test for trend was used and P values were obtained. Of 1251 isolates, 262 were from children <12 years of age and 989 were from adolescents and adults (>12 years of age). Gram-negative organisms were predominant (64.95) while Gram-positive constituted 35.09% of isolates.

RESULTS

The most common source in all age groups was peripheral-blood, accounting to 47.8% of all samples. The most common organisms in adults were Pseudomonas aeruginosa (15.3%) while in children it was coagulase negative Staphylococcus aureus (19.8%). Antibiotic sensitivity was different in both groups. In pediatric group higher sensitivity was seen for Cefoparazone-sulbactum, Cefipime, Amikacin, and Tobramycin. No resistance was found for Linezolid.

CONCLUSIONS

The isolates in both children and adults were predominantly Gram-negative though children had proportionately higher Gram-positive organisms. High-dose cytarabine use, cotrimoxazole prophylaxis, and frequent use of central lines in children especially in hematological malignancies could explain this observation. Children harbor less antibiotic resistance than adults; Uncontrolled, cumulative exposure to antibiotics in our community with increasing age, age-related immune factors and variable bacterial flora in different wards might explain the higher antibiotic resistance in adults. Thus age is an important factor to be considered while deciding empirical antibiotic therapy.

Therapeutic drug monitoring for imatinib: Current status and Indian experience

Imatinib is the current gold standard for treatment of chronic myeloid leukemia (CML). Recent pharmacokinetic studies have shown considerable variability in trough concentrations of imatinib due to variations in its metabolism, poor compliance, or drug-drug interactions and highlighted its impact on clinical response. A trough level close to 1000 ng/mL, appears to be correlated with better cytogenetic and molecular responses. Therapeutic Drug Monitoring (TDM) for imatinib may provide useful added information on efficacy, safety and compliance than clinical assessment alone and help in clinical decision making. It may be particularly helpful in patients with suboptimal response to treatment or treatment failure, severe or rare adverse events, possible drug interactions, or suspected nonadherence. Further prospective studies are needed to confirm relationship between imatinib plasma concentrations with response, and to define effective plasma concentrations in different patient populations.

Can combination metronomic therapy overcome chemoresistance in cholangiocarcinoma? A literature review

Cholangiocarcinoma (CCa) is relatively resistant to chemotherapy as well as radiation therapy, and complete resection is the main curative therapy for these patients. The prognosis for patients with unresectable intrahepatic CCa (iCCa) is extremely poor. A 55-year-old woman presented at our hospital with abdominal pain. After evaluation, she was diagnosed to have multifocal iCCa. She did not opt for standard chemotherapy and therefore received oral metronomic therapy with a combination of celecoxib, etoposide, and cyclophosphamide for a total of 30 months. Presently, she is 57 months post diagnosis and 27 months post cessation of all treatment and continues to be in complete radiological remission. In the present report, we review the literature and discuss whether metronomic scheduling of biologic agents and anticancer drugs will be able to overcome chemoresistance and improve the outcome in cholangiocarcinoma. References for the review were identified through searches of Pubmed for the last 10 years as well as searches of the files of the authors themselves. The final list was generated on the basis of originality and relevance to this review.

Metronomic chemotherapy in advanced oral cancers

CONTEXT

To assess the feasibility of metronomic chemotherapy in the palliative care setting.

AIMS

To study the toxicity profile and efficacy of metronomic chemotherapy for palliation in oral cavity cancers.

SETTINGS AND DESIGN

Retrospective analysis of prospectively collected data.

MATERIALS AND METHODS

Subjects receiving metronomic chemotherapy from August 2010 to January 2011 for palliation in oral cancers subjected to certain criteria were included. Metronomic chemotherapy offered was a combination of twice daily celecoxib 200 mg and weekly methotrexate 15 mg/m 2 .The chemotherapy was continued till disease progression, intolerable side effects or patients' desire to stop. The toxicity profile was reported in accordance with common terminology criteria for adverse events (CTCAE) version 4.02. The efficacy was noted in terms of symptom control, response rates, progression free survival (PFS) and overall survival (OS).

STATISTICAL ANALYSIS USED

SPSS version 16 has been utilized. Descriptive analysis has been presented. The Kaplan-Meier survival analysis was performed for estimation of the PFS and OS.

RESULTS

Eighteen patients with a median age of 50.5 years, 13 males and 5 females, participated in the study. Five patients had received no previous treatment while the rest had some form of previous treatment. ECOG performance status was 1 in 14 patients and 2 in 4 patients. Grade 3-4 mucositis was seen in one patient. Clinical benefit rate was 66.67%. The estimated median PFS and median OS were 5.2 months and not reached respectively.

CONCLUSIONS

Use of metronomic chemotherapy seems promising and well tolerated in this setting. Large trials are warranted to confirm these results.

The effect of age on the bacteria isolated and the antibiotic-sensitivity pattern in infections among cancer patients

BACKGROUND

Patients with cancer are predisposed to infections. Antimicrobial patterns and antibiotic sensitivity change with increasing age, making choice of empirical therapy more complicated.

MATERIALS AND METHODS

This single-center study aims to try and assess the influence of age on microbiology and antibiotic sensitivity of organisms causing infection in patients with malignant disease.

RESULTS

The five most common bacterial pathogens isolated were Pseudomonas sp (245, 26.2%) > Enterocococcus sp (109, 11.66%) > Staphylococcus aureus (107, 11.44%) > Escherichia coli (106, 11.34%) > Klebsiella sp (99, 10.59%). There was no significant change in the distribution of Gram-positive and Gram-negative bacteria with age. However, there was an increase in the occurrence of the Enterobacteriacea group and a decrease in infections caused by nonlactose fermenters with increasing age. The ESBL production increased from 10.52% (12-19 years) to 24.88% (> 50 years) as did oxacillin resistance (from 14.3% to 28.1%) among S. aureus isolates. The activity of most antimicrobial agents decreased with increasing age. The decreasing trend of activity was statistically significant for meropenam (73.3-41.2%) against Pseudomonas sp. and for the activity of the aminoglycosides for Acinetobacter sp (61.1-17.4% for amikacin).

CONCLUSIONS

This suggests that empirical antibiotic therapy needs to be changed on the basis of the age of the patient. It also appears that combination therapy is essential for the empirical treatment of infections in elderly patients with cancer.

Immunophenotypic profile of acute leukemia: critical analysis and insights gained at a tertiary care center in India

BACKGROUND

To analyze the spectrum of various types and subtypes of acute leukemia.

METHODS

Two thousand five hundred and eleven consecutive new referral cases of acute leukemia (AL) were evaluated based on WHO classification.

RESULTS

It included 1,471 cases (58%) of acute lymphoblastic leukemia (ALL), 964 cases (38%) of acute myeloid leukemia (AML), 45 cases (1.8%) of chronic myelogenous leukemia in blast crisis (CMLBC), 37 cases (1.5%) of biphenotypic acute leukemia (BAL), 1 case of Triphenotypic AL, and 2 cases of acute undifferentiated leukemia (AUL). Common subtypes of ALL were B-cell ALL (76%), which comprised of intermediate stage/CALLA positive (73%), early precursor/proBALL (3%). T-cell ALL constituted 24% (351 cases) of ALL. Common subtypes of AML included AMLM2 (27%), AMLM5 (15%), AMLM0 (12%), AMLM1 (12%), APML (11%), and AML t(8;21) (9%). CMLBC was commonly of myeloid blast crisis subtype (40 cases).

CONCLUSION

B-cell ALL was the commonest subtype in children and AML in adults. Overall incidence of AML in adults was low (53% only). CD13 was most sensitive and CD117 most specific for determining myeloid lineage. A minimal primary panel of nine antibodies consisting of three myeloid markers (CD13, CD33, and CD117), B-cell lymphoid marker (CD19), T-cell marker (CD7), with CD45, CD10, CD34, and HLADR could assign lineage to 92% of AL. Cytogenetics findings lead to a change in the diagnostic subtype of myeloid malignancy in 38 (1.5%) cases.

Constitutional and somatic RB1 mutation spectrum in nonfamilial unilateral and bilateral retinoblastoma in India

An epidemiologic survey has indicated a comparatively high prevalence of retinoblastoma (Rb) in Asian countries. Recently, the development of preventive strategies in nonfamilial Rb has become a major goal. The present studies were designed for identification and characterization of constitutional and somatic RB1 gene mutations by conventional cytogenetics, fluorescent in situ hybridization (FISH) and polymerase chain reaction-single strand conformation polymorphism (PCR-SSCP)-DNA sequencing. Of 34 patients 32 were nonfamilial and 2 were familial Rb. Maternal inheritance of del (13q14) was common. FISH was sensitive in detecting monoallelic RB1 deletion/deletion mosaicism as a first genetic hit in 20% of cases. Somatic and germline RB1 point mutations affected exons 3, 17, 20, and 21 and these were identified as novel mutations. Involvement of exon 20 as a predisposing mutation in sporadic unilateral retinoblastoma (URB) probably suggests the susceptibility of exon 20 to unknown etiologic factors in our population. A de novo RB1 deletion along with transmitted RB1 point mutation from an asymptomatic parent was identified as a unique predisposing RB1 mutation chimerism in a URB case that later evolved to bilateral retinoblastoma (BRB). The predisposing mutations such as del (13q), RB1 mono-allelic deletion and RB1 point mutation in sporadic Rb were de novo as well as transmitted mutations from asymptomatic/symptomatic parents. The RB1 mutation incidence was comparatively higher (25%) in nonfamilial Rb with emphasis on high prevalence in sporadic URB (18% versus 0%-9% in the literature series). The present studies demonstrated the efficacy of a multitechnique approach to detect various types of constitutional RB1 mutations such as RB1 deletion, deletion mosaicism, point mutation, mutation chimerism in patients of symptomatic/asymptomatic parents.