Evaluating health disparities in access to genomic testing for metastatic non-small cell lung cancer patients

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Background: Over the past decade, genomic testing has become standard of care for metastatic non-small cell lung cancer (NSCLC). These tests qualify patients for additional anti-cancer therapies and should be performed in all patients. Small scale studies at the institutional level have revealed that there may be disparities in genomic testing in NSCLC and not all patients may have similar access to care. In this study, we use the IBM Explorys Electronic Health Record (EHR) database to conduct a nationwide retrospective, observational study to understand how gender, race, insurance type, and spoken language impacts the rate of genomic testing in metastatic NSCLC patients. Methods: From Jan 1st, 2015 to Dec 31st, 2020, the IBM Explorys EHR database comprised 128,119 lung cancer patients using the SNOMED-CT concept of Primary Malignant Neoplasm of the Lung (CID 93880001). As structured staging information was not available, metastatic NSCLC patients were imputed by removing patients who received thoracic surgeries (presumably stage I or II) and those who received radiation therapy (presumably stage III). Following imputation, 120,470 patients with metastatic NSCLC were queried for testing for EGFR, ALK, ROS1, and/or RET. Odds ratios and chi-squared tests were computed for gender, race, insurance type, and spoken language comparing patients that received genomics testing to those who did not. Results: Genomic testing was taken significantly more by male patients (OR: 1.35, p<0.0001), and by Caucasian patients (OR: 1.39, p<0.0001). Compared to the public insurance plans, the genomic testing was significantly more in patients with private insurance plans (OR: 2.48, p<0.0001) and self-pay patients (OR: 2.84, p<0.0001). Patients speaking English as their first language significantly less likely took genomic testing (OR: 0.81, p<0.05). Conclusions: This study aims to identify gaps in health disparities in gender, race/ethnicity, and insurance type for genomic testing that should be standard practice. Future investigation and attention to this issue appears necessary to begin moving from documenting disparities, to understanding them, and ultimately to reducing them.[Table: see text]

Early-onset colorectal cancer in younger patients: A population-based study

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Background: In the US, the incidence of colorectal cancer (CRC) is increasing in patients younger than 50 years who may present with advanced stage, high grade, left-sided colon or rectal cancers with signet ring cell histopathology, aggressive clinical course, and reduced overall survival. Understanding the characteristics of this population could inform screening, early detection, and optimal treatment. In this study, we describe the attributes of adults who are 50 years and younger with a first diagnosis of CRC and ascertain molecular testing rates and time to surgery by using data from a commercially insured cohort in the U.S. Methods: This retrospective study of patients ages 50 and younger with a first diagnosis of CRC utilizes the IBM MarketScan database, and focuses on claims from January 2013 to December 2018. Included patients had continuous insurance enrollment of 12 months before and 6 months after diagnosis. We determined rates of tumor testing for microsatellite instability (MSI) or immunohistochemistry (IHC) for mismatch repair (MMR) proteins and referral to genetic services in all patients, as well as mutational analysis of KRAS, NRAS, and BRAF in metastatic CRC patients. Time to surgical resection of primary tumor (TTS) in non-metastatic colon cancer patients was measured. Results: During the 5-year period, 10,577 patients ages 18 to 50 years had a first diagnosis of CRC, which was 15.6% of the 67,921 adults of all ages with CRC. Claims for MSI or IHC for MMR proteins within 120 days of initial diagnosis were done in 4,429 (41.9%) patients and referral to genetics services/counseling within 1 year of initial diagnosis were done in 443 (4.1%) patients. Among metastatic CRC patients, KRAS, NRAS, or BRAF tumor mutational analyses within 120 days of initial diagnosis were documented in 323 (31.5%). The median TTS ranged from 7 to 15 days with no statistically significant differences based on geographic region or health insurance plan type. Conclusions: Younger patients with early onset CRC had low rates of referral to genetics services, tumor MSI or IHC for MMR proteins testing, and KRAS, NRAS, and BRAF mutational analysis. There were no geographic or insurance type trends in TTS in non-metastatic colon cancer patients. Although underreporting is possible in our study, the findings of low utilization of genetic services and tumor genomic testing in these younger patients with early onset CRC should alert the oncology community to critical management gaps in the care of this population.

Factors associated with time to targeted therapy for patients with metastatic lung cancer with driver mutations

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Background: Targeted therapies are superior to chemotherapy in metastatic lung cancer with driver gene mutations. Delays in initiation of targeted therapies may result in faster symptom progression, decline in quality of life, and shortened survival. We examined factors associated with time to initiation of targeted therapy (TTT) in patients with metastatic lung cancer with selected driver mutations. Methods: In this retrospective cohort study, IBM MarketScan claims data was used to identify patients who had an initial diagnosis of metastatic lung cancer, defined as continuous insurance enrollment 12 months pre- to 6 months post-diagnosis, with tumor biomarker (i.e., EGFR, ALK, ROS1, BRAF V600E, NTRK)-directed targeted therapy performed within 6 months of the initial diagnosis, during the timeframe of 1/1/2013 to 12/31/2018. Trends in TTT were evaluated with Wilcoxon–Mann–Whitney. Quantile regression, a robust model that analyzed factors on different outcome-related quantiles, was used to identify associations among TTT and covariates including age, sex, comorbidity, insurance type, and US region. Results: Among 8977 patients identified with an initial diagnosis of metastatic lung cancer, 710 (7.9%) received targeted therapies within the 6-month timeframe, and 1040 (12%) had tumor biomarker testing performed. The overall median TTT was 21 days (IQR = 36 days). Median TTT decreased from 25 days in 2013 to 18 days in 2018 (p = 0.03). Factors associated with longer TTT (median, 50% quantile) were increasing age (p = 0.04), cardiovascular disease (“CVD”, p = 0.03), HIV (p = 0.04), and mild liver disease (p = 0.05). For the lower quantile ( < = 1 day, 5% quantile), female sex (p = 0.01), HIV (p = 0.04), and mild liver disease (p = 0.002) were associated with longer TTT. Having a PPO health plan extended TTT (p = 0.05) at the upper quantile (79 days, 90% quantile). Conclusions: Our study showed an encouraging 5-year trend of the median TTT decreasing by 28%. Numerous factors associated with longer TTT included increasing age, CVD, HIV, mild liver disease, female sex, and PPO plan. This study provides insights into patient-related factors associated with longer time to initiation of targeted therapies for patients with metastatic lung cancer with driver mutations. Additional research is needed to identify the reasons for longer TTT and to develop strategies to expedite delivery of optimal therapies.

Abstract 4341: Regional disparities in time to treatment for breast conserving surgery and mastectomy in women with early-stage breast cancer

BACKGROUND:

Although several studies have reported regional differences in type of surgery performed for early-stage breast cancer (ESBCa), no research has examined geographic trends in time from diagnosis to surgical treatment (TtS), a quality measure for early-stage breast cancer care. Given evidence for improved survival outcomes of expedited TtS, we assessed how TtS for both breast conserving surgery (BCS) and mastectomy (MAST) has changed over time within region.

METHODS:

IBM® MarketScan® claims data were used to select women diagnosed with non-metastatic invasive ESBCa from January 2012 to March 2018. Eligibility criteria included: 1) absence of other cancers 2) ≥ 6 months of continuous insurance enrollment pre- and post- diagnosis 3) treatment with BCS or MAST within 6 months. Days elapsed between diagnosis and first surgery was the dependent variable. Region-specific quantile regression models of median TtS were estimated, which included a vector of patient- and community-level covariates.

RESULTS:

A total of 57,299 women met the inclusion criteria. Among those receiving MAST (n=18,825), 11% had neoadjuvant chemotherapy and 40% had adjuvant chemotherapy. In the BCS cohort (n=38,474), 4% had neoadjuvant chemotherapy, 28% had adjuvant chemotherapy, and 25% had adjuvant radiation therapy. As expected, receipt of neoadjuvant chemotherapy prolonged TtS by 116-128 days (p&lt;0.01). From 2012 to 2017, TtS for MAST significantly increased in the South (3.8 days; p&lt;0.01) and West (8.0 days; p&lt;0.01). Women residing in more urban areas waited longer by 21.9 days in the NE (p=0.01) and 14.2 days in the South (p&lt;0.01). For patients in Black communities, TtS for MAST was greater by 20.7 days (p=0.02) in the Midwest (MW) and 57.8 days in the West (p=0.04). Among women living in more Hispanic areas, median TtS for MAST was lower by 43.4 days (p=0.02) in the Northeast (NE), but was higher by 23.0 days (p&lt;0.01) in the West. In all regions except the NE, TtS for BCS significantly (p&lt;0.01) increased from 2012 to 2017 by between 3.0 (MW) to 6.5 days (West). In more urban areas, women in the NE (14.4 days; p&lt;0.01) and West (20.2 days; p=0.03) had longer TtS. In the NE, women in communities with higher densities of Asians (-19.2 days; p=0.01), Blacks (-20.0 days; p=0.04) and Hispanics (-24.3 days; p=0.05) experienced shorter wait times. However, women from more Hispanic communities in the South had longer TtS for BCS by 6.7 days (p=0.02).

CONCLUSIONS:

Understanding these geographical variations is important to identify potential region-specific and community-level factors influencing time to primary surgery in order to address healthcare inequalities in breast cancer treatment quality. These findings call for policy attention in areas where surgical delays that potentially impact outcomes could be addressed.

Citation Format: Irene Dankwa-Mullan, M Christopher Roebuck, Joseph Tkacz, Judy George, Fredy Reyes, Yull Edwin Arriaga. Regional disparities in time to treatment for breast conserving surgery and mastectomy in women with early-stage breast cancer [abstract]. In: Proceedings of the Annual Meeting of the American Association for Cancer Research 2020; 2020 Apr 27-28 and Jun 22-24. Philadelphia (PA): AACR; Cancer Res 2020;80(16 Suppl):Abstract nr 4341.

A retrospective evaluation of treatment decision making for thyroid cancer using clinical decision support in Brazil

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Background: Artificial intelligence-driven clinical decision-support systems such as Watson for Oncology (WfO) may aid cancer care in economically challenged health systems. Evidence of the applicability of such tools in resource-constrained settings is limited. The study objective was to evaluate treatment agreement between physician-prescribed therapy and WfO recommended treatment options in thyroid cancer in Brazil. An in-depth evaluation of discordant cases by a blinded expert panel of medical oncologists and cancer surgeons was performed to identify preferred therapies and predictors of discordance. Methods: Thyroid cancer patients treated at the Instituto do Câncer do Ceará, Brazil from July 2018 to June 2019, but not processed in WfO, were selected for entry into WfO in January 2020. Blinded to treatment-plan source (i.e., WfO or historical), the expert panel reviewed all WfO therapeutic options and historical physician-prescribed treatment plans for discordant cases and selected their preferred treatment options. Clinical and demographic characteristics were analyzed using logistic regression. Results: Thyroid cancer patients (n = 83) evaluated for concordance between WfO therapeutic options and historical treatments were mostly female (91%) and between the ages of 18 - 78 years (mean 47.7). Concordance between historical physician-prescribed treatment decisions and WfO was 73.5% (61/83). Demographics and clinical characteristics associated with discordance are shown in Table. For all discordant cases (n = 22), preferred treatment decisions, as determined by the expert panel, were in agreement with WfO. Conclusions: High concordance between WfO recommended treatment options and historical treatment decisions for thyroid cancer was observed at Instituto do Câncer do Ceará. For discordant cases, a blinded expert panel agreed with WfO recommended treatment options in all cases, demonstrating there may be a role for decision support in aiding individual oncologists to make best-practice and evidence-informed treatment decisions. [Table: see text]

Disparities in receipt of and time to adjuvant therapy after lumpectomy

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Background: Adjuvant treatment after breast conserving surgery (BCS) has been shown to improve outcomes, but the degree of uptake varies considerably. We sought to examine factors associated with post-BCS receipt of and time to treatment (TTT) for adjuvant radiation therapy (ART), cytotoxic chemotherapy (ACT) and endocrine therapy (AET) among women with breast cancer. Methods: IBM MarketScan claims data were used to select women diagnosed with non-metastatic invasive breast cancer from 01/01/2012 to 03/31/2018, who received primary BCS without any neoadjuvant therapy, and who had continuous insurance eligibility 60 days post-BCS. Logistic and quantile regressions were used to identify factors associated with receipt of adjuvant therapy (ART, ACT, AET) and median TTT in days for ART (rTTT), ACT (cTTT), and AET (eTTT), respectively, after adjustment for covariates including age, year, region, insurance plan type, comorbidities, and a vector of ZIP3-level measures (e.g., community race/ethnicity-density, education level) from the 2019 Area Health Resource Files. Results: 36,270 patients were identified: 11,996 (33%) received ART only, 4,837 (13%) received ACT only, 3,458 (10 %) received AET only, 5,752 (16%) received both ART and AET, and 9,909 (27%) received no adjuvant therapy within 6 months of BCS. (318) 1% of patients received combinations of either ART, AET or ACT. Relative to having no adjuvant therapy, patients > 80 years were significantly less likely to receive ART only (relative risk ratio [RRR] 0.65), ACT only (RRR 0.05), or combination ART/AET (RRR 0.66) but more likely to receive AET alone (RRR 3.61) (all p < .001). Patients from communities with high proportions of Black (RRR 0.14), Asian (RRR 0.13), or Hispanic (RRR 0.45) residents were significantly less likely to receive combination ART and AET (all p < .001). Having HIV/AIDS (+11 days; p = .01) and residing in highly concentrated Black (+8.5 days; p = .01) and Asian (+12.2 days; p = .04) communities were associated with longer rTTT. Longer cTTT was associated with having comorbidities of cerebrovascular disease (+6.0 days; p < .001), moderate to severe liver disease (+12.3 days; p < .001) and residing in high-density Asian communities (+18.0 days; p < .001). Shorter eTTT (-11.4 days; p = .06) and cTTT (-14.8 days; p < .001) was observed in patients with comorbidities of dementia. Conclusions: Results from this cohort of privately insured patients demonstrate disparities in receipt of post-BCS adjuvant radiation and systemic therapy along multiple demographic dimensions and expose opportunities to promote timely receipt of care.

Associations between concordance with oncology clinical decision support and clinical outcomes in lung cancer patients

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Background: Watson for Oncology (WfO) is an artificial intelligence-based clinical decision-support system which provides therapeutic options and associated scientific evidence to cancer-treating physicians. Oncologists at Bumrungrad International Hospital (BIH) have used WfO since 2015. We examined the association between concordance of WfO therapeutic options and BIH treatment decisions with short-term clinical outcomes for lung cancer patients. Methods: This study included lung cancer patients seen at BIH for treatment and follow-up care and for whom WfO was used from 2015 to 2018. Charts were reviewed for concordance with WfO, documentation of disease progression, response to treatment, and survival. We evaluated concordance between oncologists’ treatments and therapeutic options listed as “recommended” by WfO. We evaluated association between WfO concordance and partial or complete response rates over a 24-month period by comparison of proportions with odds ratio. Progression-free survival (PFS, time from diagnosis until progression or death) was evaluated by Kaplan-Meier log-rank test. Results: Seventy-nine lung cancer patients were included. We identified a trend towards higher response rates in concordant cases (59.2%, N = 32), as compared to discordant (48.0%, N = 12), with an odds ratio of 1.56 (see table). There was not a significant difference in PFS between concordant and discordant cohorts. Conclusions: In this small-cohort, retrospective study, lung cancer patients receiving treatments that are concordant with WfO recommended therapeutic options trended towards higher response rates than patients with discordant treatments. Use of a clinical decision-support system may help support cancer-treating physicians in delivering best practice and evidence-based care that may improve short-term outcomes. Prospective studies with larger samples and other cancer types are underway. [Table: see text]

Biomarker testing patterns and trends among patients with metastatic lung cancer

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Background: Guidelines for biomarker testing of metastatic lung cancer patients aid oncologists in making targeted treatment decisions. Despite evidence demonstrating the benefits of genomic and immune biomarker identification in these patients, variations in testing exist. This population-based, retrospective, observational study examined trends in testing rates and timing, assessing associations between testing and patient characteristics, sociodemographic factors, and regional patterns using insurance claims data. Methods: We evaluated patterns of biomarker testing in the IBM MarketScan database between 1/1/2013-12/31/2018. Inclusion criteria consisted of lung cancer patients with an initial diagnosis of metastasis within the study period, continuous insurance coverage from 12 months before to 4 months post-diagnosis, and biomarker testing (EGFR, ALK, ROS1, BRAF V600E, NTRK, PD-L1) within 4 months of diagnosis. Temporal trends were evaluated by the Cochran-Armitage method. Multivariate logistic regression evaluated associations between testing rates and patient-specific factors (i.e., age, gender, comorbid conditions), insurance type, and region (i.e., Northeastern, North central, Southern, and Western) in the United States (US). Results: Of the 8977 patients with metastatic lung cancer, 1040 (12%) had claims for biomarker testing. During the study period, testing rates increased significantly, from 8.4% in 2013 to 20.6% in 2018 (P <.0001); the likelihood of testing increased by year (2014, OR 1.20, 95% CI 0.97 - 1.48 vs. 2018, OR 2.83, 95% CI 2.26 - 3.54). Of patients tested, 25.8% (N = 268) were tested on the day of diagnosis, 70.7 % (N = 735) within 30 days, and 85.6% (N = 890) within 60 days. A lower likelihood of testing was associated with increasing age (OR = 0.97, 95% CI 0.96 - 0.98), enrollment in preferred provider health plans (OR 0.69, 95% CI 0.53 – 0.93), or pre-existing comorbidities of congestive heart failure (OR 0.76, 95% CI 0.59 – 0.98) or diabetes (OR 0.82, 95% CI 0.68 – 0.99). Testing was more likely to occur in females (OR 1.24, 95% CI 1.09 – 1.42), age < 55 years (OR 1.67, 95% CI 1.32 – 2.12) or residence in Northeastern US (OR 1.26, 95% CI 1.05 -1.51). Conclusions: Biomarker testing rates for an insured cohort of metastatic lung cancer patients increased significantly over time, but the likelihood of testing varied based on age, sex, insurance type, comorbidities, and region. Results of this study may inform policy or outreach strategies by highlighting population-based factors influencing biomarker testing rates.

A review of gynecological cancers studies of concordance with individual clinicians or multidisciplinary tumor boards for an artificial intelligence-based clinical decision-support system

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Background: Watson for Oncology (WfO) is an artificial intelligence-based clinical decision-support system that offers potential therapeutic options to cancer-treating physicians. We reviewed studies of concordance between therapeutic options offered by WfO and treatment decisions made by individual clinicians (IC) and multidisciplinary tumor boards (MTB) in practice in gynecological cancers. Methods: We searched PubMed and an internal database to identify peer-reviewed WfO concordance studies of gynecological cancers published between 01/01/2015 and 06/30/2019. Concordance was defined as agreement between therapeutic options recommended or offered for consideration by WfO and treatment decisions made by IC or MTB. Mean concordance was calculated as a weighted average based on the number of patients per study. Statistical significance was evaluated by z-test of two proportions. Results: Our search identified 5 retrospective studies with 635 patients with cervical and ovarian cancers in China and Thailand; 4 compared WfO to MTB and 1 to IC. Overall WfO concordance with MTB and IC for both cancers was 77.2% (SD 11.6%). The concordance between MTB and WfO in cervical and ovarian cancers was 80.5% and 86.2%, respectively ( P = .21); IC concordance with WfO in cervical and ovarian cancers was 65.2% and 73.2%, respectively ( P = .18). MTB concordance with WfO for both cancers combined was 81.5%, significantly higher than the 67.9% IC concordance with WfO for both cancers ( P = .01). Conclusions: Studies of cervical and ovarian cancers demonstrated a statistically significantly higher concordance of MTB and WfO than IC and WFO, suggesting a role for WfO in supporting treatment-decision making in gynecological cancers that aligns with decisions made by MTB. Larger prospective studies are needed to evaluate the technical performance, usability, workflow integration, and clinical impact of WfO in gynecological cancers.[Table: see text]

Using implementation science to examine impact of a social responsibility agenda on addressing cancer health disparities in Ceará, Brazil

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Background: Programs to address disparities in cancer care outcomes in resource-limited settings require attention to social determinants of health (SDoH) to achieve successful clinical care implementation. The Instituto de Câncer do Ceará, the largest cancer center in northeastern Brazil, has implemented a Social Responsibility Agenda (SRA) to guide equitable cancer care delivery. This goal of this study was to develop a framework for an implementation science (IS) study evaluating the longitudinal impact of the SRA on cancer outcomes. Methods: We outlined a mixed-methods and participatory study incorporating a process model, the Consolidated Framework for Implementation Research (CFIR) and the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) evaluation framework. A list of constructs and links to measurement tools associated with IS models were identified to guide the study phases. Results: We established a logic model to guide in evaluating the health and economic impact of the SRA. We identified >30 constructs and measures across domains of IS models. The table shows a driver diagram to inform the framework. Conclusions: Understanding determinants, key drivers and change concepts are important initial steps in an ongoing evaluation of the impact of evidence based SDoH interventions to address cancer disparities. [Table: see text]

Complete human papillomavirus vaccination coverage over a 13-year period in a large population of privately insured U.S. patients

1511

Background: In the US, Human Papillomavirus (HPV) vaccination coverage is low, particularly in adolescents aged 13-15 years with respect to the Healthy People 2020 goal of 80%. There has been variability in the definition of measuring vaccination coverage in published studies. We examined complete HPV vaccination coverage in a population of privately insured individuals in the US. Methods: This retrospective study used IBM MarketScan Commercial Database, years 2006 to 2018. Inclusion criteria were ages 9 to 45 years and continuous enrollment from age 9 years or from 2006. Complete HPV vaccination coverage was defined as receipt of 2 doses (age 9-15 years) or 3 doses (age 16-45 years) within 12 months and stratified by year, demographics, and US region. Mean vaccination costs per dose were summarized by vaccine brand and health plan type. Results: The table summarizes complete HPV vaccination coverage by selected age groups for 2006 (n=12,221,938), 2010 (n=4,692,633), 2014 (n=2,808,132), and 2018 (n=1,662,148). From 2017 to 2018, the percentage of members who received HPV vaccine increased; for females ages 13-15 by 1% and 16-17 by 5% while for males ages 13-15 by 6% and 16-17 by 15%. In 2018, by region, the highest coverage was in females aged 18-26 at 53% and males aged 16-17 at 43% in the Northeast, and mean cost for each brand was $120 (-6% from 2017), $165 (-3%) and $220 (+5%) for Cervarix (n=151), Gardasil (n=8,201) and Gardasil 9 (n=139,356), respectively. The rate of utilization of Gardasil 9 increased from 33% (2015) to 94% (2018) of all vaccines. The lowest mean HPV vaccine cost by health plan type and brand was with Point-of-Service (POS) and Cervarix at $106, and the highest was with POS with Capitation and Gardasil 9 at $243. Conclusions: In a commercially insured US population, complete HPV vaccination coverage was lower than the Healthy People 2020 goal, but increased over time. Coverage varied according to health plan type and by region. In 2018, Gardasil 9 had the highest mean cost but was the most utilized vaccine, which may be related to broader coverage of HPV types. This study was limited by the transient nature of member enrollment and complexity of measuring complete vaccination coverage. These results should inform policy makers and practicing clinicians about the gap in vaccination coverage. [Table: see text]

Systematic review of gastrointestinal cancer studies of concordance with expert opinion for a clinical decision support system (CDSS)

250

Background: Watson for Oncology (WfO), a cognitive CDSS, provides therapeutic options to cancer-treating physicians. We reviewed the concordance of WfO therapeutic options in gastrointestinal cancers with experts’ treatment decisions. Methods: Systematic review to identify WfO concordance studies in gastrointestinal cancers, published from June 2015 to June 2019. Concordance was defined as agreement between WfO “Recommended” and “For Consideration” treatment options and decisions made by experts. Mean concordance rates were calculated as an average, weighted by the number of patients in each study. Results: 2,407 patients were identified (Table). Overall treatment decision concordance was 67.2% (SD 25.7%). Concordance for rectal, colon, hepatocellular, and gastric cancers were 90.5% (SD 9.4%), 80.9% (SD 24.3%), 58.5%, and 47.5% (SD 33.9%), respectively. Concordance with WfO were significantly higher for rectal versus colon cancer ( p = .001), rectal versus gastric cancer ( p < .0001) and for colon versus gastric cancer ( p <.0001). Conclusions: Concordance between WfO and treatment decisions by experts for rectal and colon cancers were high. Concordance for HCC and gastric cancer were the lowest. A higher discordance in gastric cancer is likely related to disease-specific and management differences compared to United States practice. Variable concordance between expert clinical decisions and CDSS suggestions and can be minimized by localization efforts.

[Table: see text]

Concordance between a clinical decision-support system and treatments selected by clinicians as a function of cancer type or stage

95

Background: Watson for Oncology (WFO) is an artificial intelligence (AI) based clinical decision-support tool trained by Memorial Sloan Kettering. This retrospective observational study of breast, lung, colon and rectal cancer examined the concordance of treatment options provided by WFO to treatments selected by clinicians at Bumrungrad International Hospital (BIH) as a function of stage or cancer type. Methods: Concordance between WFO treatment options and treatments selected by BIH clinicians (WFO-BIH concordance) was defined as identical or equally acceptable treatments, as determined by a panel of experts blinded to the source of treatment. Relationships between stage or type of cancer and WFO-BIH concordant treatments were evaluated by Chi-squared analysis. Results: Analysis revealed a statistically significant association ( P = 0.02) between cancer stage and concordance. For all 4 cancer types combined, stages I-III demonstrated higher concordance than stage IV. A highly significant association ( P < 0.001) between concordance and cancer type was identified. Colon cancer demonstrated the highest concordance, followed by rectal, lung and breast cancer. Reasons for discordance, when given, related to oncologist or patient preferences, and treatment availability. Conclusions: BIH clinicians tended to agree more with WFO therapeutic options for stage I-III cancers and colon cancer in general, as compared to relatively less agreement for stage IV cancers and breast cancer in general, suggesting the need to understand reasons for discordance among all cancer types and stages. An AI tool, trained by experts in the U.S., provides treatment options consistent with some therapies selected in international settings, but preferences and treatment availability may affect choices made in practice. [Table: see text]

Shared-decision making in prostate cancer with clinical decision-support

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Background: Shared decision-making is the process of deliberately interacting with patients who wish to make informed value-based choices, when there are no indicated best treatment options. Given the wide variation in prostate cancer treatment options, clinical decision-support systems (CDSS) may effectively support treatment decisions for patients with challenging risk-benefit profiles. However, limited data are available regarding CDSS in shared decision making. This study aimed to assess the alignment of CDSS therapeutic options with treatment received through a shared decision process. Methods: We identified patients with prostate cancer (Gleason Groups 1-5) who were engaged in shared treatment decision making, (from August–September 2018) at the Instituto do Câncer do Ceará, Brazil. IBM Watson for Oncology (WfO), a CDSS was used for the study. Treatment decisions were compared with WfO options (active surveillance, clinical trial, chemotherapy [CT], hormone therapy [HT], radiation [RT], brachytherapy [brachy], surgery and systemic therapy with GnRH suppression) and categorized as concordant (equivalent), partially concordant (a partial match), or discordant. Results: Concordance between WfO and shared treatment decisions was observed in 54% (26/48) of patients, partial concordance in 15% (7/48) and discordance in 31% (15/48). Most frequent treatments were RT+HT combination therapy (25%) and prostatectomy (21%). 8/15 (53%) discordant cases were due to patient preference for treatment over active surveillance. Patient preference for treatment over active surveillance was the most common reason (53%) for discordance. Conclusions: Variation in prostate cancer treatment exists. CDSS therapy options may be useful in quantifying and modifying unwarranted variations in prostate cancer treatment. Future studies are important for understanding reasons for variations. [Table: see text]

Prescribing patterns for FOLFIRINOX in the real world

463

Background: FOLFIRINOX therapy is associated with improved outcome in patients with gastrointestinal cancers. The regimen can be associated with significant toxicity and empiric dose modifications are often used. We analyzed 1) real-world prescribing patterns of FOLFIRINOX and 2) toxicity of therapy. Methods: Patients undergoing FOLFIRINOX chemotherapy at an academic, NCI-Designated Comprehensive Cancer Center were identified and electronic medical records reviewed. Patients who received at least one dose of FOLFIRINOX were included. Chemotherapy dose, growth factor use and toxicity data was abstracted for the first 8 weeks. ‘Standard FOLFIRNOX’ was defined as the regimen utilized by Conroy et al (NEJM 2011). Any empiric reduction/withholding of drug dose for cycle 1 was classified as ‘modified FOLFIRINOX’. Bivariate analysis was performed on the data. Results: There were 111 patients seen between 5/2011-3/2017 and 94% had pancreatic cancer. Age range was 29-87 years and 52% were female. 59% received ‘modified FOLFIRINOX’ and 20% received empiric growth factors. Line of therapy for standard vs modified respectively was 71.1% vs 45.5% for 1st, 17.8% vs 36.4% for 2nd, and 11.1% vs 18.2% for beyond 2nd (p = 0.03). Patients with ‘modified FOLFIRINOX’ were more likely to have metastatic disease (p = 0.01), have received second line or beyond, and higher ECOG score (p = 0.03). Patients with ‘modified FOLFIRINOX’ had a trend toward fewer treatment-related ED visits or hospitalization vs ‘standard FOLFIRINOX’ (27.2% vs 42.2% p = 0.10) and fewer treatment delays (25.8% vs 42.2% p = 0.07). Conclusions: In the real world setting, a majority of patients on FOLFIRINOX receive empiric dose modifications. Although modified dose did not translate to a significant difference in ED visits, hospitalizations or treatment delays, there was a trend toward fewer events.

Palliative care and end-of-life health care utilization of pancreatic cancer patients at an urban safety-net hospital

489

Background: There has been an increase in Palliative care utilization in cancer patients. We examined trends of palliative care and intensive care utilization in pancreatic cancer patients in an urban setting safety net hospital. Methods: This is a retrospective analysis of pancreatic cancer patients seen at the Parkland Health and Hospital System between January 1999 and September 2016. Cancer cases and receipt of palliative care were identified from prospectively maintained registries. Health care utilization including intensive care unit (ICU) was reviewed. All statistical analysis was done using IBM SPSS version 24. Results: We identified 455 new diagnoses of pancreatic cancer, mean age 61 years, 227 (50%) female and 228 (50%) white. Of these, 277 (61%) received palliative care ever. Patient who received palliative care were more likely to be younger (mean age, 59.3+-12 vs 62.8 +- 12 years) and have stage 4 disease vs stage 1-3 disease (p 0.006, and p 0.003 respectively). There was no statistically significant difference in palliative care utilization between gender and ethnicity groups. 140 patients had a DNR order and 29 required ICU admission at any point. A first contact with palliative care consult was obtained < = 7 days before death for 29 (10%) patients, < = 30 days before death for 86 (31%) patients, 30-60 days before death for 50 (18%) and more than 60 days before death for 141 (51%) patients. Patients receiving palliative care were more likely to have a DNR status (p < 0.001) but had no difference in ICU use within the last 30 days of life (p 0.285). Conclusions: The rate of palliative care in patients with pancreatic cancer in this cohort from a safety net hospital is higher than nationally reported studies. Most patients received palliative care > 30 days before death. While patients received early palliative care, it did not result in reduced ICU care. Factors influencing ICU care utilization near the end of life need further study.

The effects of pioglitazone treatment on pancreatic cancer-related insulin resistance

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Background: Insulin resistance (IR) in pancreatic cancer (PC) patients is associated with cachexia and poor outcome. Pioglitazone (PIO) improves insulin sensitivity via activation of peroxisome proliferator-activated receptor (PPAR gamma). Effects of PIO on insulin sensitivity, glucose homeostasis, and circulating adipokine levels in PC have not been examined. Methods: Patients with metastatic PC were administered PIO 45mg/day orally for 8 weeks concurrent with chemotherapy. Patients with known DM at enrollment were identified Fasting plasma was collected at baseline, weeks 2, 4, 6, 8 of pioglitazone treatment and at 2 weeks-post treatment. The primary objective was to describe changes in indicators of IR, including glucoregulatory hormone levels, glucose tolerance, and inflammatory cytokines. Results: Fourteen patients (age 64y), with a mean BMI of 28 were enrolled. Mean adiponectin increased from baseline to week 8 of treatment (14.2± 3.3 and 46.9±11.4µg/ml, respectively, P ≤ 0.01), and returned to baseline levels at 2 weeks post-treatment (15.1±1.9 µg/ml). Markers of IR (serum glucose, insulin, glucagon, and response to an oral glucose bolus) did not correlate with tumor size, inflammatory cytokine levels, GM-CSF, or CA19-9. A dichotomous response to PIO treatment was observed between non-diabetic and T2DM patients. Fasting insulin increased 70.6±31.3% from baseline to treatment week 8 in patients with T2DM. In contrast, treatment of non-diabetic patients decreased fasting insulin by 40.2±6.3%, demonstrating a significant, P ≤ 0.01, difference in treatment response between PC patients with or without T2DM. Conclusions: We have demonstrated that PC patients respond to 8 weeks of PIO treatment with a significant rise in the insulin sensitizing adipokine, Adiponectin, with a complete wash-out after 2 weeks of cessation. PIO results in opposing fasting insulin responses in non-diabetic and DM patients suggests that diabetes status plays a significant role in the glucoregulatory effects of PIO treatment in PC patients. Clinical trial information Clinical trial information: NCT01838317.

Phase 1 study of ARQ 761, a β-lapachone analog that promotes NQO1-mediated programmed cancer cell necrosis

2517

Background: NAD(P)H:quinone oxidoreductase 1 (NQO1) is a two-electron oxidoreductase expressed in multiple tumor types at levels 5- to 200-fold above normal tissue. ARQ761 is a β-lapachone hydroquinone analog that exploits the unique elevation of NQO1 found in solid tumors to cause tumor-specific cell death by eliciting a futile redox cycle generating high levels of reactive oxygen species and ultimately PARP1 hyperactivation-dependent cell death. Methods: 3+3 dose escalation study of 3 schedules (weekly, every other week, 2/3 weeks) of ARQ 761 as a 1-hr or 2-hr infusion. Eligible patients had refractory advanced solid tumors, ECOG 0-1, adequate organ function, and central venous access. Blood samples were analyzed for ARQ761 levels and NQO1 polymorphisms. Archival tumor tissue was analyzed for NQO1 staining intensity and prevalence. After 18 patients were analyzed, enrollment was restricted to patients with NQO1-positive tumors (defined as Histo-score ≥200). Results: A total of 42 patients were treated. Median number of prior lines of therapy was 4. For all schedules, the maximum tolerated dose (MTD) was 390 mg/m2 as a 2-hr infusion. DLT was hemolytic anemia. The most common treatment-related adverse events were anemia (79%), fatigue (45%), hypoxia (33%), hemolysis (17%), nausea (17%) and vomiting (17%). Transient grade 3 hypoxia, due to methemoglobinemia, occurred in 26% of patients. Among 31 evaluable patients, the best response was stable disease (n = 11) and progressive disease (n = 19). For the 18 analyzed cases analyzed prior to NQO1 enrollment biomarker, clinical benefit appeared associated with tissue NQO1 expression: disease control rate was 65% in NQO1-positive tumors and 18% in NQO1-negative tumors ( P=0.06). Analysis of all 31 evaluable patients did not show a significant difference in progression-free survival (PFS) according to NQO1 status ( P=0.26), but 3-mo PFS rate was numerically greater among NQO1-positive cases (40% versus 20%). Conclusions: ARQ 761 has clinical activity in NQO1-positive tumors. Principal toxicities include hemolytic anemia and methemoglobinemia. Combination studies are underway.

Safety and efficacy of docetaxel + b-701, a selective inhibitor of FGFR3, in subjects with advanced or metastatic urothelial carcinoma

4540

Background: Patients w/ locally advanced or metastatic urothelial carcinoma (UCC) have a poor prognosis. Prior to atezolizumab’s approval, there were no approved treatments (txs) for pts who progressed after chemotherapy. Even w/ immune checkpoint inhibitors, most pts require additional txs. FGFR3 is frequently overexpressed in UCC and 15-20% of pts w/ advanced disease have tumors w/ FGFR3 gene mutations or fusions. B-701 (formerly R3Mab) is a fully human monoclonal antibody against FGFR3 that blocks activation of the wildtype and genetically activated receptor. NCT02401542 is a phase (ph) 1b/2 study designed to evaluate the safety and efficacy of B-701 plus docetaxel (D) in advanced UCC pts. Methods: The study has a lead-in (n=20 pts) and a randomized ph (n=201). Eligible pts: Stage IV UCC, relapsed/refractory to 1 or 2 prior chemotherapy regimens not including taxanes with ECOG 0-1. Txs: B-701 at 25 mg/kg q3w (+ loading dose on C1D8) and D at 75 mg/m2 q3w. Efficacy assessed by RECIST 1.1. Primary obj: PFS and safety. Secondary obj: overall response rate (ORR); duration of response (DOR); disease control rate (DCR); overall survival (OS). Exploratory obj: association of FGFR3 status w/ efficacy and AEs. Results: As of 20 Jan 2017, 19 pts enrolled to lead-in ph w/median age 66 yrs, ECOG 1 58%, Hgb <10 gm/dL 5%, liver mets 26% and ≥ 2 prior regimens 63%. 17 evaluable for PFS/ORR. 5 pts w/ FGFR3 mut or TACC3-fus. Gr ≥3 AEs occurring in ≥2 pts: decreased neutrophils (26.3%), neutropenia (10.5%), decreased WBCs (10.5%). 2 pts had D dose reductions and 1 pt discontinued tx due to AE (disseminated intravascular coagulation). Conclusions: Preliminary results show that B-701 combines safely and effectively with D in UCC, with the combination being well tolerated and showing promising ORR and PFS in pts w/ FGFR3 mut/fus. The protocol has been amended to add Cohorts 2 (B-701+D) and 3 (B-701) (n=20 pts/cohort) for pts w/ FGFR3 mut/fus+ tumors only. Clinical trial information: NCT02401542. [Table: see text]

Interaction between regorafenib and warfarin therapy

651

Background: Regorafenib is an oral multi kinase inhibitor with clinical activity in colorectal cancer, gastrointestinal stromal tumors and hepatocellular cancer. Drug- drug interactions are commonly encountered in clinical practice and warfarin continues to be the most commonly prescribed anticoagulant among cancer patients in the clinic. The interaction of regorafenib with warfarin has not been studied. Methods: Patients at a single institution being prescribed regorafenib were identified and charts reviewed for concurrent warfarin therapy. Baseline characteristics, indications for regorafenib and warfarin therapy was determined. Patients were followed up to the first 8 weeks of combination therapy. Results: We identified 6 patients on concurrent regorafenib and warfarin. All patients had refractory colon cancer. Median age was 74, 4 were male and 5 white. Indication for warfarin was venous thromboembolism in 5 and atrial fibrillation in 1. Baseline INR ranged from 1.1 to 2.4. An increase in INR was seen in all six patients (peak INR range 4.5 to > 12) which improved with dose modification. Time to peak INR was less than 6 weeks (INR trends in all patients shown in figure 1). There were no bleeding complications noted in any patient. Conclusions: We report a clinically significant interaction between warfarin and regorafenib with patients demonstrating an increase in INR. Patients who are anticoagulated with warfarin and start regorafenib should be closely monitored and upfront warfarin dose reduction should be considered. Further drug-drug interaction studies are needed to determine the exact mechanism of drug-drug interaction between these medications.

The effects of pioglitazone treatment on pancreatic cancer-related insulin resistance

329

Background: Insulin resistance (IR) in pancreatic cancer (PC) patients is associated with cachexia and poor outcome. Pioglitazone (PIO) improves insulin sensitivity via activation of peroxisome proliferator-activated receptor (PPAR gamma). Effects of PIO on insulin sensitivity, glucose homeostasis, and circulating adipokine levels in PC have not been examined. Methods: Patients with metastatic PC were administered PIO 45mg/day orally for 8 weeks concurrent with chemotherapy. Patients with known DM at enrollment were identified Fasting plasma was collected at baseline, weeks 2, 4, 6, 8 of pioglitazone treatment and at 2 weeks-post treatment. The primary objective was to describe changes in indicators of IR, including glucoregulatory hormone levels, glucose tolerance, and inflammatory cytokines. Results: Fourteen patients (age 64y), with a mean BMI of 28 were enrolled. Mean adiponectin increased from baseline to week 8 of treatment (14.2± 3.3 and 46.9±11.4µg/ml, respectively, P ≤ 0.01), and returned to baseline levels at 2 weeks post-treatment (15.1±1.9 µg/ml). Markers of IR (serum glucose, insulin, glucagon, and response to an oral glucose bolus) did not correlate with tumor size, inflammatory cytokine levels, GM-CSF, or CA19-9. A dichotomous response to PIO treatment was observed between non-diabetic and T2DM patients. Fasting insulin increased 70.6±31.3% from baseline to treatment week 8 in patients with T2DM. In contrast, treatment of non-diabetic patients decreased fasting insulin by 40.2±6.3%, demonstrating a significant, P ≤ 0.01, difference in treatment response between PC patients with or without T2DM. Conclusions: We have demonstrated that PC patients respond to 8 weeks of PIO treatment with a significant rise in the insulin sensitizing adipokine, Adiponectin, with a complete wash-out after 2 weeks of cessation. PIO results in opposing fasting insulin responses in non-diabetic and DM patients suggests that diabetes status plays a significant role in the glucoregulatory effects of PIO treatment in PC patients. Clinical trial information: NCT01838317.

Regorafenib for previously treated metastatic colorectal cancer (mCRC): A subgroup analysis of 364 patients in the USA treated in the international, open-label phase IIIb CONSIGN study

735

Background: In the phase III CORRECT study, regorafenib significantly improved overall survival and progression-free survival (PFS) vs placebo in patients with treatment-refractory mCRC. CONSIGN (NCT01538680) was a large phase IIIb study that included 2872 patients from 25 countries; it was designed to provide continued access to regorafenib for patients with mCRC who failed standard therapy and to further characterize the safety of regorafenib. In CONSIGN, adverse events (AEs) and PFS were consistent with those reported in phase III studies. We present a retrospective subgroup analysis of patients enrolled in CONSIGN in the USA. Methods: Patients with mCRC who progressed on standard therapies and had an ECOG PS 0─1 received regorafenib 160 mg QD for the first 3 weeks of each 4-week cycle. Treatment was continued until disease progression, death, or unacceptable toxicity. The primary endpoint was safety. PFS (per investigator) was the only efficacy variable assessed. Results: A total of 364 patients in the USA were assigned to treatment (all evaluable for safety). The median age was 60 years; 38% and 62% had ECOG PS 0 and 1, respectively. KRAS mutation was present in 59%, KRAS wt in 38%; 74% had ≥ 3 prior regimens for metastatic disease. Median duration of treatment was 2.3 months (range: 0–30). Median PFS (95% CI) was 2.3 (2.0–2.6) months (2.1 months KRAS wt; 2.3 months KRAS mutant). NCI-CTCAE v4.0 grade ≥ 3 AEs occurred in 81% of patients and were considered drug-related in 53% (Table). Grade ≥ 3 hepatobiliary disorders occurred in 2%. Grade ≥ 3 treatment-emergent laboratory toxicities included bilirubin (9%), AST (6%), and ALT (3%). Conclusions: In patients from the USA enrolled in CONSIGN, the safety profile of regorafenib was consistent with that of the overall population and the known safety profile of regorafenib in mCRC. Median PFS was in the range of that reported in phase III trials. Clinical trial information: NCT01538680. [Table: see text]

Phase II trial of high-dose interleukin-2 (IL-2) and stereotactic radiation therapy (SABR) for metastatic clear cell renal cell carcinoma (ccRCC): Interim analysis

532

Background: We report a planned interim analysis of a single-arm, open-label, phase II trial of HD IL-2 and SABR in multiple ccRCC metastatic sites. Methods: Metastatic ccRCC patients eligible for IL-2 were enrolled and received SABR of 1 or 3 fractions (fx) to up to 6 sites. IL-2 (Proleukin) was administered within 84 hours from the last SABR fx at 600,000 IU/kg every 8h for up to 14 doses in a monitored setting followed by another week after a week break. Eligible (responding) patients received a second course in > 12 weeks. The primary endpoint is the response rate (RR) as evaluated by iRECIST. The study is powered to detect a 60% improvement compared to the historically reported 23% RR for IL-2. Results: 16 patients were enrolled between August 2013 and July 2015; two were withdrawn from the study due to cardiac events prior to receiving IL-2 infusions. The median follow up was 9 months. A median of 2 (1-3) sites were treated with SABR with a median dose of 24.5 Gy (21-27 Gy) for single fx and 30Gy for 3 fx (25-33 Gy). All patients received the first week of IL-2 with a median of 10.5/14 doses; 64% received the second week (9/14) with a median of 7/14 doses. Two patients refused a second week of IL-2 and one was unable to receive it due to thyrotoxicosis. PICC line DVT delayed the second week of IL-2 in two patients. 29% of patients (4/14) received a second course of IL-2. The rate of grade 3 toxicity was 64% with no > grade 3 toxicity. The overall toxicities were expected of IL-2 treatment, transient and resolved after treatment discontinuation. In two cases, grade 1 toxicity was attributed to SABR. At this interim, ten patients underwent at least two follow up scans and were evaluable for outcome analysis. The RR was 40%, with one patient presenting complete response and 3 patients showing partial response. The median duration of overall response was 5 months, with a median stable disease duration of 6 months. Local control rate for SABR-treated lesions was 95%. Conclusions: The addition of SABR to IL-2 increased the RR in mRCC patients of about 2-folds compared to IL-2 alone, despite the reduced number of patients receiving the second week of IL-2. No significant increase in toxicity was observed. Clinical trial information: NCT01896271.

A phase II study of bavituximab and sorafenib in advanced hepatocellular carcinoma (HCC)

345

Background: Bavituximab a first-in-class immunomodulator targeting phosphatidylserine (PS), a lipid externalized on tumor and endothelial cells. Preclinical and phase I studies demonstrated that sorafenib upregulates PS externalization and can be given safely with bavituximab. We evaluated the safety and clinical activity of bavituximab plus sorafenib in HCC. Methods: Patients with advanced HCC deemed ineligible for curative therapy with no previous systemic treament, ECOG score ≤ 2, Child Pugh score A or B7 received bavituximab, 3 mg/kg IV weekly, and sorafenib, 400 mg PO BID until disease progression or intolerable toxicity. 38 patients were accrued providing a power of 80% and two-sided significance level of 10% to show an 8.2 month time to progression compared to historical control, 5.5 months. Secondary endpoints included safety and tolerability, 4-month progression free survival, overall survival, and response rates. Correlative studies using pre- and post-treatment tumor biopsies included IHC analysis of regulatory, cytotoxic, and helper T cells in addition to macrophage infiltrates. Results: 38 patients were accrued, 7 still on treatment. Patient characteristics: median age: 60.5 years, male 74%, HCV: 79%, Black: 47%/Hispanic: 29%/White: 21%, previous treatment 37%, and metastases: 24%. Median follow-up is currently 6.1 months with current median TTP of 6.8 months (95% CI 3,10). Four month PFS is 76% and there are no partial or complete responses. Treatment related adverse events were observed in 53% of patients, one grade 3 (GI bleed), four grade 2 (DVT, anorexia, diarrhea, and infusion reaction). Most common grade 1 events were diarrhea (18%), fatigue (16%), and anorexia (16%). Six patients had tissue analyzed pre- and post-treatment, 2 of 6 demonstrated increase tumor infiltration of CD4+, CD8+, and macrophages with a corresponding decrease in Tregs. Conclusions: Bavituximab and sorafenib were well tolerated in patients with advanced HCC. When compared with historical controls, combination therapy demonstrated an improvement in TTP and PFS at four months. Combination therapy increases immune tumor infiltrates. Clinical trial information: NCT01264705.

Chemotherapy (CT) for advanced biliary tract cancers (BTC): A retrospective analysis from UT Southwestern Medical Center (UTSW) and Parkland Hospital (PH)

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Background: CT is the main treatment option for patients (pts) with advanced BTC. There is limited randomized data to guide treatment selection. Based on phase 3 data, gemcitabine (G)/cisplatin (C) is an acceptable 1st line CT, but 5-FU based regimens are also used. We reviewed data from our institution to elucidate treatment preferences and responses. Methods: This is a retrospective analysis of pts treated at UTSW and PH from Jan 2008 to Dec 2011. Patient lists were obtained from the tumor registry at each hospital from Jan 2008 to Dec 2011. Results: 60 pts had inoperable or metastatic disease. 26/60 pts did not receive CT due to poor functional status. 34/60 pts received 1st-line CT- 26 cholangiocarcinoma, 7 gall bladder cancer, 1 ampullary cancer. 10/34 pts were not evaluated for treatment response due to lack of follow-up. Of the remaining 24 pts, 12 received 2nd line CT. In combined analysis of 1st and 2nd line CT in pts with adequate clinic follow-up, G alone (n=10) or in combination (with C n=9, C+ Cetuximab (CX) n=1, Oxaliplatin n=5, Capecitabine (CAP) n=1, Docetaxel n=1) was the most frequently used CT. 2 pts received CAP with radiation. 6 pts received 5-FU based regimen (FOLFOX n=1, FOLFOX/CX n=1, FOLFIRI n=1, FOLFIRI/CX n=1, FOLFIRI/panitumumab n=2). In 1st line, best response (BR)—partial response (PR) 4 pts, stable disease (SD) 14 pts, progressive disease (PD) 6 pts. Response duration range (RDR) in 1st line was 2-22 months (m). In 2nd line, BR—PR 1 pt, SD 7 pts, PD 2 pts. RDR in 2nd line was 2-10 m. Of the 4 pts who received CT combined with an EGFR inhibitor (EGFRI), 2 had SD, 2 had PR; RDR 3-10 m. Disease control (DC) rate (PR+SD) from 1st line CT 53%, 2nd line CT 67%. All 4 pts who received EGFRI in combination with CT showed evidence of DC. Conclusions: CT is effective in BTC with benefit seen in the majority of treated pts. 43% of pts were unable to receive CT which underscores the poor outlook in this malignancy. Interestingly we noted that even in our small subgroup who received EGFRI based combination CT, there was clinical benefit even in 2nd line CT. There is some published data to support this finding. EGFRI based CT should be further studied in this population.

Brain metastases (BMs) from metastatic renal cell carcinoma (RCC) in patients (pts) treated with molecularly targeted agents (MTAs)

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Background: Historically, the frequency of BMs from RCC is ~11%. Recent reports have suggested an improvement in the incidence of BMs with tyrosine kinase inhibitors (TKIs). What is not known is the impact of MTAs on the prevalence of BMs in metastatic RCC. Methods: We conducted a retrospective review of all pts with metastatic RCC treated with MTAs at a tertiary care center, UT Southwestern Harold C. Simmons Comprehensive Cancer Center, from 2006–2010. Statistical analyses were performed using the Cox proportional hazards model and the Kaplan-Meier method. Results: Fifty nine pts met inclusion criteria. 8 more pts presented with BMs and were not included in the incidence and survival analyses. Median age was 64.6 yrs. Per MSKCC criteria, 3 pts were in favorable (5%), 41 in intermediate (70%), and 15 in poor (25%) prognostic groups. Sites of metastases at presentation included lungs (65%), lymph nodes (40%), bones (30%), and liver (25.4%). Mean follow up time was 16 months, and at last follow up 24 pts were alive. The incidence of BMs was 11.9% (7/59) and the prevalence was 22% (15/67). Median overall survival was 1.97 yrs (95% CI, 1.04-3.89). Median survival for pts who developed BMs vs. without BMs was 1.21 yrs vs. 1.98 yrs (p=0.17). In multivariable analyses, only lack of nephrectomy was associated with increased risk of BMs, HR=9.819 (95 CI, 1.65-58.38; p=0.012). Conclusions: In our study, the incidence of BMs in RCC pts treated with MTAs was similar to what has been historically reported. In contrast, the prevalence of BMs was much higher at 22%. This is the first study to report the prevalence of BMs in patients with metastatic RCC treated with MTAs. As in other tumor types, the life-time risk of BMs appears to increase with the availability of highly-active MTAs.