A pilot study of gut microbiome modulation to enable efficacy of neoadjuvant checkpoint-based immunotherapy (IO) following chemotherapy in pancreatic ductal adenocarcinoma (PDAC)

TPS759

Background: Neoadjuvant therapy is now a standard strategy for localized PDAC, and this preoperative window provides an excellent opportunity in which to test novel therapeutic approaches. Trials using IO in PDAC have largely been unsuccessful, and immune tolerance is implicated as a major mechanism of IO resistance. The gut and tumor microbiome have emerged as key modulators of response to both IO and chemotherapy. High tumor microbial diversity has been linked to longer survival in PDAC, and gut microbiota may have the ability to colonize pancreatic tumors. There is preclinical evidence that endogenous microbiota promotes the immunosuppressive tumor microenvironment characteristic of PDAC through stimulation of pro-tumor regulatory T cells and myeloid-derived suppressor cells at the expense of anti-tumor activated CD4+ and CD8+ T cells. Further, preclinical data show that ablation of the gut microbiota may induce T cell activation, improve immune surveillance, and increase sensitivity to IO. We hypothesize that ablative antibiotics (abx) will activate tumor infiltrating T cells and enhance IO activity in PDAC. Methods: This is a multi-center, single-arm, open-label pilot study of pre-operative chemotherapy followed by abx and pembrolizumab to evaluate overall immune response to abx + IO. Eligible patients will have histologically confirmed, resectable PDAC, without probiotic consumption or use of immunosuppressive agents. Patients will be enrolled at diagnosis after undergoing a baseline biopsy. They will then receive mFOLFIRINOX every 2 weeks for 5 cycles. After completion of chemotherapy, ciprofloxacin 500 mg PO BID and metronidazole 500 mg PO TID will be administered for 21 days, and pembrolizumab 200 mg IV x1 will be given 7 days after initiation of abx. Patients will then undergo surgical resection and adjuvant therapy at the investigators’ discretion. On-treatment biopsy will be obtained prior to cycle 5 of mFOLFIRINOX. Blood and stool will be collected at baseline, during mFOLFIRINOX therapy, before and after pembrolizumab administration, and postoperatively. The primary endpoint is the overall immune response, which will be measured as activation of one or more of the T cell markers HLA-DR, CD38, CD25, Ki67, and CD69, defined as an increase in expression level of at least 20% from the on-treatment specimen to the surgical specimen, before and after abx + IO. Key secondary endpoints will be the evaluation of adverse events, R0 resection rate, histologic regression score, objective response rate, and overall survival rate. Correlative studies will be carried out to evaluate immune and microbiome changes in the blood and tissue following abx and pembrolizumab. These findings will be correlated with clinical endpoints. The target study accrual is 25 patients. Clinical trial information: NCT05462496 .

Human-centered design to improve clinical decision support systems (CDSS) to engage in serious illness communication (SIC) with patients with cancer in a gastrointestinal oncology clinic

433

Background: We previously reported the implementation of a machine learning (ML) model for mortality prediction that was integrated into a CDSS encouraging clinicians to have a SIC with at-risk cancer patients. The clinical utility of a ML model can change after implementation due to fluctuations in the organization’s patient population and clinical practices. It is important to establish a workflow to monitor and continually reinforce ML-powered CDSS to ensure that it continues to benefit patients. We report a workgroup structure that incorporates data driven evaluation of ML model performance and feedback from CDSS end users to optimize the acceptability of the CDSS. Methods: The workflow was piloted in the gastrointestinal (GI) oncology clinic from 11/2021-5/2022. A workgroup including members of the implementation team and end-users of the CDSS met monthly to review 1) a dashboard that displays model performance, 2) an electronic health record (EHR) report that summarizes use of the CDSS, 3) feedback from end users regarding their opinion of the CDSS and any barriers to implementation. We evaluated the accuracy of model predictions among subgroups as defined by mortality and unplanned hospital admissions or ED visit rates. Fisher’s Exact Test was used to identify differences between categorical variables. Numeric values including incidence rate ratios (IRRs) adjusted for age, sex, race, and gender with 95% confidence intervals (CIs) were calculated using Poisson regression. Results: 119 patients were evaluated by the model and 50 (42%) were assessed as high-risk. In the high-risk group, the oncology team evaluated 39 (78%) patients for appropriateness of a SIC; SIC was completed with 5 (10%) patients. During workgroup meetings, physicians shared that some of the high-risk predictions were for patients undergoing curative intent therapy. 0 out of 24 patients who received curative treatment died and 5 out of 26 patients who receive palliative treatment died. The log-rank p-value of 0.03 indicates that the survival distribution differs significantly over time between two groups. The adjusted IRR for unplanned hospital visits (palliative vs curative) was 2.55 (1.3-5.0). Adjusted mean hospital visits per month were 0.34 (0.21-0.51) vs 0.13 (0.06-0.21). Conclusions: The workgroup format is a feasible method to continuously review acceptability of a ML-powered CDSS. It may evaluate critical feedback from end users in a holistic manner that can augment a data driven evaluation of the model performance. The data implies that patients undergoing curative therapy have a decreased risk for mortality and unplanned hospital admissions or ED visits. The CDSS may be optimized by excluding these patients; however, longer follow up of this sub-population is needed to confirm that they have no additional risk factors.

Implementation of a streamlined prior authorization process to improve clinician wellness and cancer care delivery

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Background: Prior authorizations (PAs) for chemotherapy are increasingly becoming a barrier to timely and quality care delivery for cancer patients. There is an extraordinary administrative burden placed on clinical teams to participate in peer to peers (P2P) and file appeals when authorization specialists are unable to efficiently find the necessary clinical data in the EHR. 1 This leads to delays in care, staff burnout driven by decreased job satisfaction, loss of revenue from decreased clinician productivity and from chemotherapy given emergently but not retroactively reimbursed. 2 In partnership with the cancer registry team and Epic, we propose a workflow that shifts the clerical work required for PAs from the clinical teams to the certified tumor registrars (CTRs) using smart form optimization so the finance team has all the required information in one place to successfully and efficiently process the PAs. Methods: A list of common data elements including performance status, cancer biomarkers, line of treatment, goals of treatment and stage were identified. We are leveraging the staging smart form in EPIC to auto-populate these elements when available and then use CTRs to enter cancer stage, fill in any gaps and validate the data. Once approved by the CTR, the chemotherapy plan will be available in the authorization work queue for efficient processing. In 2020, we had 1,389 chemotherapy plans entered and about 38% of these required clinical intervention for financial clearance. We will track the number of P2Ps being conducted post-implementation and compare this to numbers prior to implementation. We will use descriptive statistics and t-test to compare these values. We are anticipating a 25% decrease in P2Ps. We will survey oncology physicians in June 2022 to measure baseline perceived physician impact of PAs and burnout and then again in January 2023 to measure the impact post-implementation. Results: A wellness survey was administered to Medical Oncology faculty within the Mount Sinai Health System pre-pandemic in 2020 and in 2021 and among respondents, approximately 1/3 have moderate to severe burnout risk pre- and post-pandemic. Coordination of care and PAs were rated as the largest barriers to wellbeing, and this increased from 43% pre- to 71% post-pandemic indicating a significant area of opportunity to improve wellbeing among medical oncology faculty. Conclusions: By leveraging technology and non-clinical staff workflows to improve the processing of insurance PAs of ambulatory intravenous chemotherapy, we aim to improve timeliness of quality care delivery to patients and clinical staff wellness. West CP et.al. Physician burnout: contributors, consequences and solutions. J Intern Med. Jun 2018;283(6):516-529. Lin NU et al. Increasing Burden of Prior Authorizations in the Delivery of Oncology Care in the United States. J Oncol Pract. Sep 2018;14(9):525-528.

A multiplexed immunohistochemical consecutive staining on single slide (MICSSS) analysis of the immune microenvironment of bile duct cancers (BDC) pre and post neoadjuvantchemotherapy (NACT)

e16151

Background: NACT is increasingly being used in the management of locally advanced BTC. Emerging evidence suggests a potential key contributing role of tumor infiltrating immune cells in the prognosis & response to therapy. We set out to characterize immune modulation of tumor immune microenvironment composition in BTC following NACT. Methods: Patients (pts) with locally advanced BTC who underwent a diagnostic biopsy, then NACT followed by resection between 2014 & 2018 were identified & consented after IRB approval. MICSSS, a sample-sparing chromogenic consecutive multiplex tissue staining method, was performed with a series of immune markers (Table), to characterize T cell subsets, B cells, macrophages, mature dendritic cells (DCs), and immune checkpoints on pre & post NACT formalin-fixed paraffin-embedded tumor tissue sections. Density was calculated for each marker (+ve cells/mm2) following annotation of tissues by tumor, fibrosis, necrosis, stromal & tumor infiltrating lymphocyte-enriched areas. Results: Nine pts were enrolled. Final analysis included 5 pts with adequate tissue. Median age = 48 (41-56), with 4 female, 4 intrahepatic cholangiocarcinomas & 1 gallbladder. All pts received Gemcitabine/Cisplatin as NACT with a median of 5 (4-7) cycles. Median time from diagnosis to surgery was 4.3 (1.4-7.8) months & last cycle to surgery was 0.9 (0.6-1.5) month. All pts were MMR proficient, 1 Her2+ & 2 with FGFR2 amplification. NACT on average produced a depletion of all immune markers (Table). Given the small N, each pt was considered their own control & changes in mean cell densities post NACT were calculated. Pt2 with a 40-fold increase in PDL1 expression & 5-fold decrease in CD8:FOXP3 ratio notably had the shortest disease-free interval (DFI). Pt3 with the longest DFI had the largest increase in CD8:FOXP3 by about 8-fold combined with a decrease in PDL1. Conclusions: Preliminary results suggest NACT may modulate immune microenvironment despite overall immune cell depletion. Future studies should focus on strategies to expand immune modulation of the tumor microenvironment in BTC by NACT, including immune oncology agent priming prior to or after NACT.[Table: see text]

Adjuvant Chemotherapy Is Not Guided by Pathologic Treatment Effect After Neoadjuvant Chemotherapy in Pancreatic Cancer

OBJECTIVES

Currently, there is no guidance for optimal adjuvant chemotherapy selection after pancreatectomy with a partial or poor response to neoadjuvant therapy. This study seeks to describe an institution's practice patterns of adjuvant chemotherapy selection after neoadjuvant therapy.

METHODS

Patients at a single institution receiving neoadjuvant chemotherapy followed by pancreatectomy for pancreatic cancer were reviewed. Patients enrolled in trials or without follow-up were excluded. Types of chemotherapy, the College of American Pathologists pathologic tumor response, and medical oncology plans were recorded.

RESULTS

Forty-one patients met inclusion criteria. Pathologic review of treatment effect demonstrated that 3 patients (7.3%) had complete pathologic response, 3 (7.3%) had near complete pathologic response, 16 (39%) had partial response, and 14 (34.1%) had poor/no response to neoadjuvant chemotherapy. Fourteen of the 30 patients with partial or poor response (46.7%) received an alternate adjuvant regimen. Pathologic response to neoadjuvant chemotherapy specifically guided therapy in 11 (30.5%) patients.

CONCLUSIONS

Despite 73.1% of patients with partial or poor response to neoadjuvant chemotherapy, only 46.7% received a different adjuvant regimen. Medical oncologists infrequently considered treatment effect when choosing adjuvant therapy. Pathologic response to neoadjuvant chemotherapy should be considered when selecting adjuvant chemotherapy.

Abstract CT111: Results of a phase 1 dose escalation study of ERY974, an anti-glypican 3 (GPC3)/CD3 bispecific antibody, in patients with advanced solid tumors

Background: ERY974, a bispecific T cell-redirecting antibody, redirects T cells to tumor cells by engaging the CD3 antigen on T cells and the glypican 3 (GPC3) antigen selectively expressed on tumors. ERY974 demonstrates T cell-dependent cellular cytotoxicity in vitro and transient cytokine elevations in preclinical toxicology studies (Ishiguro et al. 2017). The primary objective of this dose escalation (DE) study was to determine ERY974's maximum tolerated dose in patients with locally advanced or metastatic solid tumors expressing GPC3. Methods: The study included adult patients with advanced or metastatic solid tumors not amenable to standard therapy, histologically confirmed, with measurable disease and a life expectancy ≥ 3 months, including patients with ≤ 1cm and ≤ 1 brain metastasis. Patients with interstitial lung disease, or acute/active chronic infection were excluded. ERY974 was administered IV and dosed weekly. DE was initiated with an accelerated titration design of single patient cohorts followed by three patient cohorts. To mitigate for the toxicity of cytokine release syndrome (CRS), steroid prophylaxis and a flexible study design was implemented which included a two-step intra-patient escalation (regimen A), and a three-step intra-patient escalation (regimen B). Results: 29 patients were enrolled in dose levels ranging from 0.003 μg/kg to 0.81 μg/kg. Treatment-related adverse events that occurred in greater than 20% of patients included CRS and pyrexia. Dose level 0.81 μg/kg (regimen A) was confirmed not tolerable due to DLTs of Grade 3 CRS and Grade 2 CRS in two out of three patients (assessed according to Lee, et al. 2014). The Grade 3 CRS was associated with Grade 3 transaminitis and a Grade 3 elevation of bilirubin. Both CRS events led to dose delay and dose reduction. Increases in IL-6, IL-8 and IL-10 were observed in patients with the CRS. The severity and frequency of CRS in regimen B were similar to those observed in regimen A at the same dose level. One partial response (per modified RECIST criteria) was observed in a patient with esophageal cancer treated with 0.54 μg/kg (regimen B) and having 40% of the tumor tissue staining positive for GPC3 via immunohistochemistry. Stable disease lasting 3 months or longer was observed in four patients. Conclusions: The observed responses and CRS side effects are markers of ERY974 biologic activity. At doses below 0.81 μg/kg (regimen A), ERY974 was generally well tolerated with a manageable toxicity profile, including ERY-induced CRS which was manageable with steroid administration and anti-IL6R therapy. Further research is required to determine if combined prophylactic anti-IL6R and steroid therapy is a more effective strategy for managing CRS. References: 1. Ishiguro, Takahiro, et al. Science translational medicine, 2017, 9.410: eaal4291. 2. Lee, Daniel W., et al. Blood, 2014, 124.2: 188-195.

Citation Format: Howard Safran, Mihaela Druta, Michael Morse, Filipa Lynce, Sofya Pintova, Khaldoun Almhanna, Daniel Weiss, Athos Gianella-Borradori, Yoshitaka Ogita, Roland Morley, Mikiko Nakamura, Junnosuke Matsushima, Takahiro Ishiguro. Results of a phase 1 dose escalation study of ERY974, an anti-glypican 3 (GPC3)/CD3 bispecific antibody, in patients with advanced solid tumors [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2021; 2021 Apr 10-15 and May 17-21. Philadelphia (PA): AACR; Cancer Res 2021;81(13_Suppl):Abstract nr CT111.

Conducting Goals-of-Care Discussions Takes Less Time Than Imagined

PURPOSE

To describe the length of encounter during visits where goals-of-care (GoC) discussions were expected to take place.

METHODS

Oncologists from community, academic, municipal, and rural hospitals were randomly assigned to receive a coaching model of communication skills to facilitate GoC discussions with patients with newly diagnosed advanced solid-tumor cancer with a prognosis of < 2 years. Patients were surveyed after the first restaging visit regarding the quality of the GoC discussion on a scale of 0-10 (0 = worst; 10 = best), with ≥ 8 indicating a high-quality GoC discussion. Visits were audiotaped, and total encounter time was measured.

RESULTS

The median face-to-face time oncologists spent during a GoC discussion was 15 minutes (range, 10-20 minutes). Among the different hospital types, there was no significant difference in encounter time. There was no difference in the length of the encounter whether a high-quality GoC discussion took place or not (15 v 14 minutes; P = .9). If there was imaging evidence of cancer progression, the median encounter time was 18 minutes compared with 13 minutes for no progression (P = .03). In a multivariate model, oncologist productivity, patient age, and Medicare coverage affected duration of the encounter.

CONCLUSION

Oncologists can complete high-quality GoC discussions in 15 minutes. These data refute the common misperception that discussing such matters with patients with advanced cancer requires significant time.

Effects of a Communication Intervention Randomized Controlled Trial to Enable Goals-of-Care Discussions

PURPOSE

Patients with advanced cancer often have a poor understanding of cancer incurability, which correlates with more aggressive treatment near the end of life (EOL). We sought to determine whether training oncologists to elicit patient values for goals-of-care (GoC) discussions will increase and improve these discussions. We explored its impact on use of aggressive care at EOL.

METHODS

We enrolled and used block randomization to assign 92% of solid tumor oncologists to 2-hour communication skills training and four coaching sessions. We surveyed 265 patient with newly diagnosed advanced cancer with < 2-year life expectancy at baseline and 6 months. We assessed prevalence and quality of GoC communication, change in communication skills, and use of aggressive care in the last month of life.

RESULTS

Intervention (INT) oncologists' (n = 11) skill to elicit patient values increased (27%-55%), while usual care (UC) oncologists' (n = 11) skill did not (9%-0%; P = .01). Forty-eight percent (n = 74) INT v 51% (n = 56) UC patients reported a GoC discussion (P = .61). There was no difference in the prevalence or quality of GoC communication between groups (global odds ratio, 0.84; 95% CI, 0.57 to 1.23). Within 6 months, there was no difference in deaths (18 INT v 16 UC; P = .51), mean hospitalizations (0.47 INT v 0.42 UC; P = .63), intensive care unit admissions (5% INT v 9% UC; P = .65), or chemotherapy (26% INT v 16% UC; P = .39).

CONCLUSION

Use of a coaching model focused on teaching oncologists to elicit patient values improved that skill but did not increase prevalence or quality of GoC discussions among patients with advanced cancer. There was no impact on high care utilization at EOL.

Impact of High-Quality Goals-of-Care Discussions on Oncologist Productivity

PURPOSE

To study factors that have an impact on the conduct of high-quality goals of care (GoC) discussions and productivity of oncologists among four different practice settings in patients with advanced cancer.

METHODS

Solid-tumor oncologists from community, academic, municipal, and rural hospitals were randomly assigned to receive a coaching model of communication skills to help them facilitate a GoC discussion with newly diagnosed patients with advanced cancer who had a less-than-2-year prognosis. Patients were surveyed after the first restaging visit regarding the quality of the GoC discussion on a scale of 0 to 10 (0, worst; 10, best) with a score of 8 or better indicating a high-quality GoC discussion. Productivity was measured by work revenue value units (wRVUs) per hour for the day each oncologist saw the study patient after imaging.

RESULTS

The four sites differed significantly in the socioeconomic patient populations they served and in the characteristics of the oncologists who cared for the patients. Overall median productivity across the four sites was 3.6 wRVU/hour, with the highest observed in the community hospital (4.3 wRVU/hour) and the lowest in the rural setting (2.9 wRVU/hour; P < .001). There was no significant difference in productivity observed when high-quality GOC discussion occurred versus when it did not (3.6 v 3.7 wRVU/hour; P = .86).

CONCLUSION

Despite differences in patient populations and oncologists' characteristics between the four practice settings, the conduct of high-quality GoC discussions did not affect productivity.

Genistein combined with FOLFOX or FOLFOX-Bevacizumab for the treatment of metastatic colorectal cancer: phase I/II pilot study

BACKGROUND

Epidemiologic and preclinical data suggest isoflavones have anticancer activity in colorectal malignancy prevention and treatment. This is the first clinical trial assessing safety and tolerability of Genistein in combination with chemotherapy in metastatic colorectal cancer.

METHODS

Patients who had histologically confirmed metastatic colorectal cancer and had not received previous treatment were eligible to enroll. Subjects were treated with FOLFOX or FOLFOX-Bevacizumab as per the investigator choice. Genistein was administered orally for 7 days every 2 weeks, beginning 4 days prior to chemotherapy and continuing through days 1-3 of infusional chemotherapy. Primary endpoint was safety and secondary endpoints included cycle 6 response rate, best overall response rate (BOR), and median progression-free survival (PFS).

RESULTS

Thirteen patients received chemotherapy with Genistein in this trial. The most common adverse events related to Genistein alone were mild and included headaches, nausea, and hot flashes. One subject was observed to have grade 3 hypertension. No increase in chemotherapy-related adverse events was observed when Genistein was added. BOR and median PFS were 61.5% and 11.5 months, respectively.

CONCLUSION

We observed that adding Genistein to FOLFOX or FOLFOX-Bevacizumab was safe and tolerable. Efficacy results are notable and warrant verification in larger clinical trials.

CLINICAL TRIAL REGISTRATION

The study was registered at ClinicalTrials.gov Identifier: NCT01985763.

Abstract B207: Nivolumab +/- Ipilimumab in patients with hypermutated cancers detected in blood: NIMBLE

Background: During DNA replication, there is an increased risk for base substitution due to replicative errors caused by DNA polymerases, which have error rates of approximately 10-5 per base pair per cell division. One of the mechanisms to counteract these errors involves real-time proofreading via exonuclease activity present in both DNA polymerase ε, which synthesizes the leading strand and is encoded by POLE, and DNA polymerase δ, which is involved in lagging strand synthesis and encoded by POLD1. Mutations in POLE or POLD1 are associated with an increase in DNA replication error rates and high tumor mutational burden (TMB). High TMB may confer sensitivity to immunotherapy with checkpoint inhibitors. The prevalence of POLE/POLD1 mutations is 5-10% across a wide assortment of tumor types, and POLE/POLD1 mutations can be identified through plasma circulating free DNA (cfDNA) testing. Therefore, POLE/POLD1 mutated tumors present an attractive target for treatment with the immune checkpoint inhibitors nivolumab and ipilimumab. Methods: This is an international multicenter, open-label, randomized phase II noncomparative trial of nivolumab alone or in combination with ipilimumab for the treatment of patients with advanced hypermutated solid tumors detected by a blood-based assay. While the intent is to expand this study into a platform to test additional liquid biomarker assays, the biomarker selection of eligible patients will initially be based on detection of either POLE or POLD1 mutations by cfDNA. Patients with POLE or POLD1 mutations identified on previous tumor tissue testing via the CLIA certified testing platform are also eligible. Patients will be randomized 1:1 to receive either nivolumab monotherapy (240mg IV every 2 weeks) or in combination with ipilimumab (1mg/kg IV every 6 weeks) until progression. Stratification factors are ECOG performance status (0,1) and number of prior treatments (0, 1-2,3 or more). Other key eligibility criteria include: histologically confirmed metastatic or unresectable solid tumors (except primary CNS tumors), tissue block (or minimum 20 slides) available from primary or metastatic tumor, measurable disease per RECIST 1.1, ≥ 18 years of age, received at least 1 standard cancer therapy (unless patient refused) for their tumor type and progressed on most recent regimen, and received no prior immunotherapy. A sample size of 50 evaluable patients in each arm will achieve 90% power to show a clinically meaningful objective response rate (ORR). These calculations assume nivolumab monotherapy p0 &lt; 13%, p1 &gt; 30%, and in combination with ipilimumab therapy p0 &lt; 30%, p1 &gt;50%. Objectives: The primary objective is to evaluate the ORR of nivolumab monotherapy and of nivolumab + ipilimumab in randomized patients with detectable POLE or POLD1 mutations as determined by plasma cfDNA. Secondary objectives are to evaluate efficacy by ORR and duration of response in all treated patients with detectable POLE or POLD1 mutations in either plasma cfDNA or tumor tissue as well as to assess correlation between POLE/D1 mutations in tumor and POLE/D1 mutations in blood. Exploratory endpoints include determining progression-free survival and overall survival, correlation between POLE/POLD1 mutations occurring within or outside of the exonuclease domain and TMB as determined by whole exome and RNA sequencing, and correlation between TMB assessed in plasma cfDNA and assessed directly in tumor tissue. NCT03461952.

Citation Format: Naiyer Rizvi, Patricia Tang, Nina Bhardwaj, Timothy A. Chan, Jeffrey S. Weber, Michael Vickers, Sofya Pintova, Holger Hirte, Neil H. Segal, Neesha Dhani, Daniel Cho, Stephen Chia, Caitlin Burns, Donsheng Tu, Laura Pearce, Alison Urton, Martin Smoragiewicz, Janet Dancey. Nivolumab +/- Ipilimumab in patients with hypermutated cancers detected in blood: NIMBLE [abstract]. In: Proceedings of the Fourth CRI-CIMT-EATI-AACR International Cancer Immunotherapy Conference: Translating Science into Survival; Sept 30-Oct 3, 2018; New York, NY. Philadelphia (PA): AACR; Cancer Immunol Res 2019;7(2 Suppl):Abstract nr B207.

Disparities in length of goals of care conversations between oncologists and patients with advanced cancer

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Background: Studies show minority patients have inadequate discussions about treatment, prognosis, and goals of care (GoC) which translate into substandard treatment, worse quality of life, and poorer survival than whites. However, there is a paucity of data on the quality of communication among minority patients with advanced cancer. We studied factors impacting the oncologists’ time spent during GoC discussion visits with their minority and non-minority patients. Methods: At community, academic, municipal, and rural hospitals, we recruited and randomized solid tumor oncologists and their newly diagnosed advanced cancer patients with <2-year prognosis to participate in a RCT, testing a coaching model of communication skills training. Patients were surveyed after post-imaging visits. These visits were audiotaped and median encounter time recorded. We define GoC discussions as patients report that their doctor talked about preferences for cancer treatment and clarified things most important to them given their illness. Comparisons were made using non-parametric tests. We used mix-effect models for risk adjustment. Results: For 22 randomized oncologists in the study,142 post-imaging encounters were audiotaped. Of these, 38% were non-Hispanic White, 32% non-Hispanic Black and 19% Hispanic. The median face to face time oncologists spent during a GoC encounter with an advanced cancer minority patient was 12 minutes compared to 17 minutes for non-minorities (p=0.002). Median encounter times varied between the four sites, ranging from 10 minutes to 18 minutes, p=0.009. For visits that took place after progression of disease, duration of visit was 18 minutes versus 13 minutes if there were no progression, p=0.007. After controlling for clustering of the patients within the hospitals and progression of disease, time spent with minority patients remained less than with non-minority patients (15 min vs. 18 min, p=0.02). Conclusions: Oncologists' time spent conducting GoC conversations with minority cancer patients is significantly less than with non-minority patients. Evaluating factors that contribute to this disparity is critically important to ensure minority patients receive high-quality cancer care. Clinical trial information: NCT02374255.

Does coaching goals of care discussion skills make a difference?

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Background: Advanced cancer patients often have a poor understanding of their cancer prognosis. Goals of Care (GoC) discussions provide information about the cancer, its treatment & prognosis and elicit patient values. Little is known about the best ways to enhance patient understanding, clarify values and move GoC discussions earlier in the disease process. We report the effect of coaching oncologists on GoC discussions. Methods: We recruited oncologists & their advanced cancer patients with < 2 year prognosis to a RCT testing a coaching model communication skills training. Patients were surveyed after their post-imaging visit. We define GoC discussions as patient report that their doctor talked about their cancer prognosis and clarified things most important to them given their disease. Outcome variables assess the impact of GoC on patients’ knowledge on what to expect and clarity of values. Results: We enrolled 22/25 (88%) oncologists and 70% of eligible patients of whom 96 (55%) completed a survey. On average, doctors were 44 yrs old (32-66) and in practice 14.5 yrs (5-40). Patients’ mean age was 62 yrs (20-95), 40% females, 58% white, 24% Latino & 22 % black. Overall, 2/3 of patients reported their treatment’s goal was to cure their cancer; 14% reported cure to be unlikely. Patients felt more knowledgeable (79% vs 21%; p = 0.02) when their doctors discussed treatments, side effects & quality of life. When patients were asked about things important to them, they report being a bit clearer about their values (65% vs 35%; p = 0.16). Compared to controls, intervention patients felt more knowledgeable (78% v 63%; p = 0.17) but did not feel clearer about their values (60% v 54%; p = 0.59). Multivariate modeling found that poor health literacy (OR = 0.2; 95%CI: 0.07-0.82), having a GoC discussion (OR = 10.2; 1.7-63.1) and being in the intervention group (OR = 8.8; 1.4-55.2) significantly affected knowledge (model c = 0.88; p < 0.01). However, discussing what’s important to patients did not help patients feel clearer about their values (OR = 2.7; 0.6-12.2; model c = 0.82; p < 0.05). Conclusions: Using a coaching model to teach oncologists communication skills may improve patients’ understanding of what to expect with their cancer but does not impact their clarity of values. Clinical trial information: NCT02374255.

Does oncologist productivity impact goals of care discussions?

e21675

Background: Oncologists are pressed to care for higher volumes of advanced cancer patients. Interviews with oncologists revealed their concern that goals of care (GoC) discussions take time. We studied the impact of oncologists’ productivity on their conduct of meaningful GOC discussions with patients. Methods: At academic, municipal and rural hospitals, we recruited & randomized solid tumor oncologists & their newly diagnosed advanced cancer patients with <2 year prognosis to participate in a RCT testing a coaching model of communication skills training. All oncologists were encouraged to have GoC discussions at the visit after imaging to restage. Patients are surveyed after that post-imaging visit. We define GoC discussions as patient report that their doctor talked about preferences for cancer treatment and clarified things most important to them given their illness. We measure quality of GoC discussions by patients’ rating. Productivity was measured by work revenue value units (wRVUs) per hour for the day each oncologist saw the study patient post-imaging. Results: We enrolled 22/25 oncologists (88%); to date 77 patients completed surveys. Productivity did not vary significantly by hospital though oncologists generated greater wRVUs at the municipal hospital (p=0.2203). Overall, 36% of patients report having a high quality GoC discussion. There was no significant relationship between level of productivity and conduct of high quality GoC discussion. Multivariate model controlling for hospital and intervention found no relationship between productivity and conduct of high quality GoC discussion. Conclusions: Despite concerns about the time required to conduct GoC discussions, we found that productivity did not affect oncologists’ ability to conduct high quality GoC discussions nor did conduct of a GoC reduce productivity. The prevalence of high quality GoC discussions was low. [Table: see text]

Impact of inpatient radiation on length of stay and health care costs

BACKGROUND

Health care costs are rising. Identifying areas for health care utilization savings may reduce costs.

OBJECTIVE

To identify oncology patients receiving inpatient radiotherapy with the purpose of measuring length of stay (LoS) and hospital charges.

METHODS

During July 2013 the oncology service physicians at Mount Sinai Medical Center in New York City were surveyed daily to identify patients receiving inpatient radiation. Actual LoS, acuity LoS were determined from the chart review. Expected LoS was calculated using the University Healthsystem Consortium database. Charges associated with actual LoS, acuity LoS, and expected LoS were then reported. Actual and expected LoS were compared for inpatient radiotherapy and nonradiotherapy groups.

RESULTS

7 patients were identified as having remained in the hospital to receive radiation treatment. In that cohort, the average actual LoS and charges per patient were 40.1 and $48,724, compared with acuity LoS and charges of 25.6 days and $34,089 and expected LoS and charges of 7.7 days and $10,028. Mean LoS and charges attributed to radiation alone amounted to 11 days and $12,514. The mean actual LoS of oncology patients admitted during the same time period who did not receive radiation was 6.7 days, compared with 40.1 days for patients who received radiation (𝑃 < .0001).

LIMITATIONS

Inability to access actual reimbursement data prevented exact cost calculations, small sample size, and single-institution focus.

CONCLUSIONS

Delivery of radiation therapy during inpatient hospitalization extends LoS and contributes to higher health care costs. Methods to facilitate the delivery of outpatient radiotherapy may result in cost savings.

Effect of inpatient radiation delivery on length of stay and health care costs

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Background: Healthcare costs continue to rise. Identifying areas for healthcare utilization savings may be useful in reducing costs. The goal of this pilot study was to identify oncologic patients who remained in the hospital to receive radiotherapy treatment with the purpose of measuring length of stay (LOS) and charges associated with delivering inpatient radiation. Methods: Between July 1, 2013 and July 31, 2013 patients receiving inpatient radiation were identified. Actual LOS and end of acuity LOS were determined from the chart review. Expected LOS was calculated using the UHC database. Charges associated with actual LOS, end of acuity LOS and expected LOS were then reported. Comparisons of the actual and expected LOS were made between the radiation and non-radiation cohorts. Results: Seven patients were identified as remaining in the hospital to receive radiation treatment. There were 50 solid oncology patients admitted during July 2013 that did not receive radiation therapy. The seven patient cohort accounted in total for 281 days of hospitalization, with an average of 40.1 (+/-43.3) days per patient. The end of acuity LOS averaged 25.6 (+/-42.8) days per patient. The mean LOS attributed to radiation alone was 10.7 days. In contrast, the actual LOS for the 50 patients admitted to the solid tumor oncology service without radiation treatment, was 6.7 +/-4.9 days. The patients receiving radiation had a statistically significant longer actual LOS 40.1 vs 6.7 days (p<0.0001). The expected LOS for patients who received radiation was on average 7.7 days versus 5.2 days in the cohort that did not receive radiation, (p=0.0098). In the radiation cohort, the charges associated with the actual LOS per patient, end of acuity LOS per patient and expected LOS per patient were respectively $48,724, $34,089 and $10,028. The charges attributed to radiation alone amounted to $12,514 per patient. Conclusions: Delivery of radiation therapy during inpatient hospitalization extends LOS and contributes to higher healthcare costs. Methods to address this issue may result in cost savings.

Sickle cell trait: is there an increased VTE risk in pregnancy and the postpartum?

Blacks are purported to have a higher venous thromboembolism (VTE) risk than whites. We hypothesized that this might be due, in part, to the greater presence of sickle cell trait (SCT) among blacks. We investigated whether the presence of SCT resulted in a higher VTE incidence in a population predisposed to VTE, the pregnant/postpartum women. Methods: Using a mirrored clinical database that prospectively gathered in- and out-patient information for the years 1998–2008, we collected demographic data, including hemoglobin electrophoreses, on all pregnant/postpartum non-Hispanic women who delivered at a large, diverse, urban hospital. We identified those women who developed VTE either while pregnant or postpartum during those 11 years. Charts initially identified as potential VTE cases were subjected to review to ensure accuracy of VTE coding. Results: Of 12,429 women, 679 non-Hispanic SCT black women, 5,465 non-Hispanic Hemoglobin AA (women with HbA as the only hemoglobin present on electrophoresis, with normal amounts of the minor hemoglobins) black women and 1,162 non-Hispanic HbAA white women were included in the analysis. SCT prevalence was high (11.1%) within this black population as compared to 8.3% in the general non-white population. Proportions with VTE were similar for black SCT and black HbAA groups: 0.44% for the SCT group, 0.49% for non-Hispanic black HbAA women. Black HbAA women had a non-significantly higher proportion of VTE than white HbAA women 0.49% vs 0.26% (RR 1.9, 95%CI:0.6,6.3, p = 0.28). Women with VTE were older than those without VTE (32.2 vs. 27.6 years, p = 0.0002) and the majority of VTE occurred postpartum in all groups, and significantly in the HbAA groups. There was no increase in the incidence of pulmonary emboli in the SCT group. Conclusion: In the largest analysis to date, we could not detect a meaningful difference in peripartum VTE incidence between women with and without sickle cell trait.

Abstract 4000: Genistein-induced reduction of Wnt/beta-catenin pathway activity in colorectal cancer cell lines correlates with inhibition of proliferation and colony growth in soft agar

Introduction. The majority of colorectal cancers (CRC) have mutationally-driven constitutive activation of the Wnt pathway. Despite this, tumor cells remain responsive to Wnt signals arising at the cell membrane through the interaction of extracellular Wnt ligands and cell surface frizzled receptors; the strength of the Wnt signal can be modified by Wnt pathway inhibitors (sFRP) in the tumor microenvironment. Genistein, a natural product from soy, is known to remove epigenetic blockage of sFRP promoters and decrease nuclear beta-catenin expression, a marker for Wnt pathway activation. In this study we have examined the effect of genistein on Wnt throughput in CRC cell lines and on proliferation in tissue culture and growth in soft agar.

Methods. Human CRC cell lines HT29, DLD1 and RKO were transfected with Wnt/beta-catenin reporter plasmids and treated with different concentrations of genistein. Pathway activity was measured using a super TOP-flash luminescence reporter construct. Proliferation was estimated with an MTT assay. A soft agar assay was utilized to define non-adherent colony formation.

Results. Genistein reduced proliferation of HT29 and DLD1 at 50uM, with an inhibitory P50 at 100uM. RKO cells were inhibited at lower concentrations. Inhibition of soft agar colony growth occurred at similar concentrations. Wnt/beta-catenin activity was significantly inhibited at 75uM for HT29 (p=0.025) and at 50uM for DLD1. The reduction in proliferation and colony growth correlated with reduced Wnt signaling, with the latter most strongly correlated (R2=0.81 vs. 0.47 for the former). Cells growing independently of anchorage were more sensitive to genistein treatment than those attached to the plastic : colony counts decreased for RKO 8-fold at 50 uM while proliferation on plastic decreased less than 4x; colony counts decreased for HT29 7-fold for at 100 uM while proliferation on plastic decreased less than 2x.

Conclusions. Genistein reduces Wnt/beta-catenin activity in CRC cell lines; this reduction correlates with cell proliferation in vitro and with soft agar colony growth. Cells growing in an anchorage-independent fashion appear more sensitive to genistein treatment. Further investigation into the mechanisms of this effect in CRC is ongoing. These data suggest that genistein may be a useful adjunctive therapy for patients with CRC.

Citation Format: Sofya Pintova, Kestutis Planoutis, Marina Planutiene, Randall F. Holcombe. Genistein-induced reduction of Wnt/beta-catenin pathway activity in colorectal cancer cell lines correlates with inhibition of proliferation and colony growth in soft agar . [abstract]. In: Proceedings of the 104th Annual Meeting of the American Association for Cancer Research; 2013 Apr 6-10; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2013;73(8 Suppl):Abstract nr 4000. doi:10.1158/1538-7445.AM2013-4000