Next-Generation HER2-Targeted Antibody-Drug Conjugates in Breast Cancer

Human epidermal growth factor receptor 2 (HER2) tyrosine kinase is overexpressed in 20% of breast cancers and associated with a less favorable prognosis compared to HER2-negative disease. Patients have traditionally been treated with a combination of chemotherapy and HER2-targeted monoclonal antibodies such as trastuzumab and pertuzumab. The HER2-targeted antibody-drug conjugates (ADCs) trastuzumab emtansine (T-DM1) and trastuzumab deruxtecan (T-DXd) represent a novel class of therapeutics in breast cancer. These drugs augment monoclonal antibodies with a cytotoxic payload, which is attached by a linker, forming the basic structure of an ADC. Novel combinations and sequential approaches are under investigation to overcome resistance to T-DM1 and T-DXd. Furthermore, the landscape of HER2-targeted therapy is rapidly advancing with the development of ADCs designed to attack cancer cells with greater precision and reduced toxicity. This review provides an updated summary of the current state of HER2-targeted ADCs as well as a detailed review of investigational agents on the horizon. Clinical trials are crucial in determining the optimal dosing regimens, understanding resistance mechanisms, and identifying patient populations that would derive the most benefit from these treatments. These novel ADCs are at the forefront of a new era in targeted cancer therapy, holding the potential to improve outcomes for patients with HER2-positive and HER2-Low breast cancer.

Correlation of the Ki67 Working Group prognostic risk categories with the Oncotype DX Recurrence Score in early breast cancer

BACKGROUND

The relationship between Ki67 assessed by immunohistochemistry (IHC) and the Oncotype DX Recurrence Score (RS) is unclear. The objective of this study was to determine the correlation between the 21-gene RS and IHC-measured Ki67 with the prognostic classification groups recommended by the International Ki67 Working Group (IKWG).

METHODS

The authors performed a retrospective chart review of women who had hormone receptor (HR)-positive, human epidermal growth factor receptor 2-negative early breast cancer with zero to three positive lymph nodes and both Ki67 and the 21-gene RS performed at their institution from 2013 to 2021. Patients were categorized into low (≤5%), intermediate (6%-29%), and high Ki67 groups (≥30%) according to IKWG recommendations. Overall agreement and risk-stratified agreement between Ki67 and RS were assessed with the proportion of agreement and the κ statistic.

RESULTS

The study included 525 patients with HR-positive breast cancer. Among the 49% of patients with intermediate Ki67 values of 6%-29%, the distribution of low (0-10), intermediate (11-25), and high RS (26-100) was 19%, 66%, and 15%, respectively. There was slight agreement (κ = 0.01-0.20) between Ki67 and RS (κ = 0.027) in the overall population, although this was not significant (p = .1985). There was fair agreement (κ = 0.21-0.40) between high Ki67 and RS values (κ = 0.280; p < .0001). A higher progesterone receptor percentage was associated with lower RS values (p > .0001) but not lower Ki67 values. A positive nodal status and a larger tumor size were associated with higher Ki67 values (p = .0059 and p < .0001) but not with RS.

CONCLUSIONS

In this group of patients selected to have a 21-gene RS, there was no significant correlation between Ki67 and RS in the overall population, and there was fair agreement between high Ki67 and high RS values.

LAY SUMMARY

In patients with early-stage, hormone receptor-positive breast cancer, decisions on adjuvant chemotherapy are based on certain biological features of the cancer and genomic assays such as the Oncotype DX Recurrence Score (RS). The goal of this study was to determine the correlation between Ki67, a marker of proliferation, and the Oncotype DX RS, a 21-gene assay demonstrated to be predictive of an adjuvant chemotherapy benefit in patients with early-stage breast cancer. In 525 patients, the authors did not find a significant correlation between Ki67 and RS.

Oncology clinical trial disruption during the COVID-19 pandemic: a COVID-19 and cancer outcomes study

Background

COVID-19 disproportionately impacted patients with cancer as a result of direct infection, and delays in diagnosis and therapy. Oncological clinical trials are resource-intensive endeavors that could be particularly susceptible to disruption by the pandemic, but few studies have evaluated the impact of the pandemic on clinical trial conduct.

Patients and methods

This prospective, multicenter study assesses the impact of the pandemic on therapeutic clinical trials at two large academic centers in the Northeastern United States between December 2019 and June 2021. The primary objective was to assess the enrollment on, accrual to, and activation of oncology therapeutic clinical trials during the pandemic using an institution-wide cohort of (i) new patient accruals to oncological trials, (ii) a manually curated cohort of patients with cancer, and (ii) a dataset of new trial activations.

Results

The institution-wide cohort included 4756 new patients enrolled to clinical trials from December 2019 to June 2021. A major decrease in the numbers of new patient accruals (−46%) was seen early in the pandemic, followed by a progressive recovery and return to higher-than-normal levels (+2.6%). A similar pattern (from −23.6% to +30.4%) was observed among 467 newly activated trials from June 2019 to June 2021. A more pronounced decline in new accruals was seen among academically sponsored trials (versus industry sponsored trials) (P < 0.05). In the manually curated cohort, which included 2361 patients with cancer, non-white patients tended to be more likely taken off trial in the early pandemic period (adjusted odds ratio: 2.60; 95% confidence interval 1.00-6.63), and substantial pandemic-related deviations were recorded.

Conclusions

Substantial disruptions in clinical trial activities were observed early during the pandemic, with a gradual recovery during ensuing time periods, both from an enrollment and an activation standpoint. The observed decline was more prominent among academically sponsored trials, and racial disparities were seen among people taken off trial.

Abstract P5-18-11: Impact of supportive therapies on tolerance of aromatase inhibitors in patients with early-stage, hormone-positive breast cancer

Background: Aromatase inhibitors (AI) are standard of care in the treatment of early-stage hormone positive (HR+) breast cancer (BC). Commonly, these medications cause significant side effects which limit tolerability and often require a change in therapy. Supportive therapies are an essential part of treatment plans to improve adherence and quality of life. Studies in the last decade have demonstrated the critical role of supportive management in mitigating side effects from AI, such as the reduction in AI related joint pain with acupuncture or use of low dose oxybutynin for hot flashes. The aim of this study was to evaluate the real world use of supportive therapies for AI toxicities over the last decade and to determine if they were associated with patient adherence to initial AI treatment. Methods: We performed a retrospective chart review of all female patients at our academic institution with early-stage, HR+ BC who were initiated on adjuvant AI therapy between 2011-2020. From the electronic medical record, we collected information on patient demographics, AI side effects (hot flashes, vaginal dryness, joint pains, osteopenia/osteoporosis), use of supportive therapies, and duration of first AI therapy. Primary endpoint was the rate of discontinuation of AI at 1 year among those who used supportive therapies compared with those who did not. The Wilcoxon rank sum test, Fisher's exact test, Kruskal-Wallis rank sum test, and Pearson's Chi-squared test methods were used to compare rates of discontinuation of front-line AI therapy for each group. Results: We identified 990 patients (pts) with early-stage, HR+ BC who were started on adjuvant AI between 2011-2020. Of these patients, 97% (n= 963) had AI related side effects yet only 51% (n=504) received supportive therapies. The overall discontinuation rate within 1 year was 14.8% (147 of 990 pts). Patients who received at least 1 supportive therapy were more likely to remain on AI and had a lower 1 year discontinuation rate of 10% (51 of 504 pts) compared to 20% (96 of 486 pts) for those who did not receive any supportive therapy (p&lt;0.001). The most commonly used supportive therapies were bone strengthening agents, with 35.6% (n=352) of patients receiving either denosumab or zoledronic acid, followed by acupuncture used in 11.2% (n=111) of patients. The use of acupuncture increased in 2018, compared to years prior (35 pts from 2011-2017, and 76 pts from 2018-2020). Similarly, oxybutynin use increased in 2019, compared to years prior (9 pts from 2011-2018, and 28 pts from 2019-2020). Upon further analysis, younger age was significantly associated with a higher 1 year discontinuation rate (median age 62 years in &lt;1 year AI treatment group, and 64 years in &gt;1 year AI treatment group, p=0.003). Race also appeared to have an impact on AI tolerance. Although only 31% (39 of 126 pts; p &lt; 0.001) of Black patients received supportive therapy, this group had the lowest 1 year discontinuation rate at 8.7% (11 of 126 pts). Conversely, 56% (277 of 491 pts) of White patients received at least one supportive therapy, yet had the highest 1 year discontinuation rate at 17% (83 of 491 pts). Conclusions: Supportive therapies are essential to help patients mitigate side effects of AI. Patients who received at least one supportive therapy had increased rates of AI adherence beyond 1 year compared to those who did not receive any supportive treatment. The most commonly used therapies were bone strengthening agents and acupuncture. Use of acupuncture and low dose oxybutynin have increased in the past 3 years and 2 years, respectively, following publication of their efficacy. It is critical to further evaluate the impact that race and age have in relation to duration of treatment and use of supportive management. Further studies on how to improve patient tolerability and adherence to AI therapy are needed.

Citation Format: Melanie W Kier, Zhiqiang Li, Brittney S Zimmerman, Rima Patel, Yunchen Yang, Mark Y Fink, Jason D Wells, Xiang Zhou, Scott Newman, Rong Chen, Eric Schadt, William Oh, Amy Tiersten. Impact of supportive therapies on tolerance of aromatase inhibitors in patients with early-stage, hormone-positive breast cancer [abstract]. In: Proceedings of the 2021 San Antonio Breast Cancer Symposium; 2021 Dec 7-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2022;82(4 Suppl):Abstract nr P5-18-11.

Abstract P1-17-06: Impact of body mass index on the efficacy of aromatase inhibitors in patients with metastatic breast cancer

Background: Aromatase inhibitors (AIs) are part of standard endocrine therapy for hormone receptor (HR)-positive breast cancer (BC) and are used in both adjuvant and metastatic settings. Since AIs work by inhibiting the conversion of androgens to estrogen in peripheral adipose tissue, the higher levels of estrogen in obese patients may lead to incomplete inhibition by AIs and influence their efficacy. A retrospective analysis of the ABCSG-12 trial found that overweight premenopausal patients with early-stage BC treated with anastrozole had a 60% increased risk of disease recurrence and more than doubling in risk of death compared with normal weight patients on anastrozole. Similarly, an exploratory analysis from the ATAC trial found that in post-menopausal women with early-stage BC, overall recurrence rates were lower in patients randomized to anastrozole versus tamoxifen but in women with body mass index (BMI) &gt; 30, there was no significant difference in disease recurrence between anastrozole and tamoxifen. While these findings raise concern for the efficacy of adjuvant AI therapy in obese patients with early-stage BC, this has not yet been demonstrated in the metastatic setting. The aim of this study was to determine the impact of BMI on efficacy of AIs in patients with metastatic HR-positive BC. Methods: We performed a retrospective chart review of all female patients with metastatic HR-positive BC on an AI in first- or second-line settings and seen at our academic institution between 2001-2020. The primary endpoint was progression-free survival (PFS), defined as the time from start of AI to disease progression or death from any cause. PFS was compared across BMI groups using Kaplan-Meier curves and log-rank tests. Cox proportional hazards regression model was used for univariate and multivariate analyses. Results: We identified 219 patients who had received an AI in the first- or second-line settings for metastatic HR-positive BC and with documented information on BMI. The median age was 59 with 45% of patients White, 29% African American, 16% Hispanic/Latino, 5.5% Asian and remainder other/unknown. 32% (71) had HER-2 positive disease. 82% (179) were on an AI in the first-line setting. Overall, 53% were on letrozole, 42% on anastrozole and 5.5% on exemestane. Of the 219 patients, 56% (123) had a low BMI (defined as &lt; 27 kg/m2) and 44% (96) had a high BMI (≥ 27 kg/m2; based on the Breast Cancer Weight Loss [BWEL] trial). The median PFS was 21.9 months (95% CI, 14.5 to 28.4) in the low BMI group versus 20.2 months (95% CI, 14.3 to 27.5) in the high BMI group with no statistically significant difference (p =0.73). There were 8 (6.5%) deaths in the low BMI group and 7 (7.3%) deaths in the high BMI group. Multivariate cox regression model did not demonstrate any significant impact of BMI on PFS when adjusting for age, race/ethnicity, HER2 status, type of AI, line of therapy, drug partner and type of metastatic disease (HR =0.91, 95% CI =0.64 to 1.30, p =0.6 for high BMI group). Subgroup analysis of patients on an AI in the first line setting also did not show a significant difference in PFS with median PFS 19.3 and 18 months in the low and high BMI groups, respectively. Conclusions: In patients on an AI for metastatic HR-positive breast cancer, there was no statistically significant difference in PFS in patients with low versus high BMI. While BMI influences efficacy of AIs in the adjuvant setting, our results demonstrate that in the metastatic setting, BMI does not significantly impact the efficacy of AIs among our patient population. This discrepancy could be due to other differences in disease characteristics that make complete aromatase inhibition more important in the adjuvant setting when disease burden is the lowest. Additional larger studies are needed to confirm this finding.

Citation Format: Rima Patel, Zhiqiang Li, Brittney S. Zimmerman, Marc Y. Fink, Jason D. Wells, Xiang Zhou, Kristin L. Ayers, Arielle Redfern, Scott Newman, Rong Chen, William K. Oh, Amy Tiersten. Impact of body mass index on the efficacy of aromatase inhibitors in patients with metastatic breast cancer [abstract]. In: Proceedings of the 2021 San Antonio Breast Cancer Symposium; 2021 Dec 7-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2022;82(4 Suppl):Abstract nr P1-17-06.

Impact of the COVID-19 Pandemic on Cancer Care and Quality of Life for Patients With Breast and Gynecologic Malignancies: A Single-Center Survey-Based Study

This study evaluated the mental health and cancer treatment-related impact of the first wave of the COVID-19 pandemic on patients with breast and gynecologic cancers. An 18-question survey was administered in June 2020 at a New York City-based cancer center to assess the quality of life (QOL) and overall health (OH) during both the pandemic time period from March 1, 2020, through June 30, 2020, and the pre-pandemic period (prior to March 1, 2020). Survey questions were answered on a 5-point Likert scale and a 7-point EORTC QLQ-C30 QOL scale. Differences in mean QOL and OH scores were evaluated using a paired t-test. QOL and OH were significantly worsened by the pandemic, with significant increases in anxiety, depression, and mood swings.

Impact of body mass index on the efficacy of aromatase inhibitors in patients with metastatic breast cancer

PURPOSE

Higher levels of estrogen in obese patients may lead to incomplete inhibition by aromatase inhibitors (AIs). The aim of this study was to determine the impact of body mass index (BMI) on efficacy of AIs in patients with metastatic hormone receptor (HR)-positive breast cancer (BC).

METHODS

We performed a retrospective chart review of all female patients with metastatic HR-positive BC on an AI in first- or second-line settings and seen at our academic institution between 2001 and 2020. The primary endpoint was progression-free survival (PFS), defined as the time from start of AI to disease progression or death from any cause.

RESULTS

We identified 219 patients who had received an AI in the first- or second-line settings for metastatic HR-positive BC and with documented information on BMI. Of the 219 patients, 56% (123) had a low BMI (defined as < 27 kg/m²) and 44% (96) had a high BMI (≥ 27 kg/m²). The median PFS was 21.9 months (95% CI 14.5 to 28.4) in the low BMI group versus 20.2 months (95% CI 14.3 to 27.5) in the high BMI group (p = 0.73).

CONCLUSION

While BMI influences efficacy of AIs in the adjuvant setting, our results suggest that in the metastatic setting, BMI may not impact the efficacy of AIs. This discrepancy could be due to other differences in disease characteristics that make complete aromatase inhibition more important in the adjuvant setting when disease burden is the lowest.

Care disruptions among patients with lung cancer: A COVID-19 and cancer outcomes study

Introduction

Patients with lung cancer (LC) are susceptible to severe outcomes from COVID-19. This study evaluated disruption to care of patients with LC during the COVID-19 pandemic.

Methods

The COVID-19 and Cancer Outcomes Study (CCOS) is a prospective cohort study comprised of patients with a current or past history of hematological or solid malignancies with outpatient visits between March 2 and March 6, 2020, at two academic cancer centers in the Northeastern United States (US). Data was collected for the three months prior to the index week (baseline period) and the following three months (pandemic period).

Results

313 of 2365 patients had LC, 1578 had other solid tumors, and 474 had hematological malignancies. Patients with LC were not at increased risk of COVID-19 diagnosis compared to patients with other solid or hematological malignancies. When comparing data from the pandemic period to the baseline period, patients with LC were more likely to have a decrease in in-person visits compared to patients with other solid tumors (aOR 1.94; 95% CI, 1.46–2.58), but without an increase in telehealth visits (aOR 1.13; 95% CI 0.85–1.50). Patients with LC were more likely to experience pandemic-related treatment delays than patients with other solid tumors (aOR 1.80; 95% CI 1.13–2.80) and were more likely to experience imaging/diagnostic procedure delays than patients with other solid tumors (aOR 2.59; 95% CI, 1.46–4.47) and hematological malignancies (aOR 2.01; 95% CI, 1.02–3.93). Among patients on systemic therapy, patients with LC were also at increased risk for decreased in-person visits and increased treatment delays compared to those with other solid tumors.

Discussion

Patients with LC experienced increased cancer care disruption compared to patients with other malignancies during the early phase of the COVID-19 pandemic. Focused efforts to ensure continuity of care for this patient population are warranted.

Secondary Invasive Breast Events among Patients with Hormone-Positive Breast Cancer and High-Risk Oncotype DX Recurrence Scores 26-30 and ≥31

BACKGROUND

The Oncotype DX Recurrence Score (ODx RS) is the most widely adopted genomic assay used to guide treatment for patients with early-stage, hormone-positive (HR+) breast cancer (BC), with higher scores predicting greater risk of recurrence and benefit from chemotherapy. Patients with ODx RS >25 typically recieve adjuvant chemotherapy; however, data regarding efficacy of chemotherapy for reducing recurrence in this population have been mixed.

OBJECTIVES

This study aimed to evaluate outcomes of patients with early-stage HR+ BC with high-risk ODx RS (26-30 and ≥31) in order to assess treatment patterns and outcomes. We hypothesized that the benefit of chemotherapy in these groups may be minimal and that select patients may forgo chemotherapy in favor of more aggressive endocrine therapy and ovarian suppression.

METHODS

We performed a retrospective analysis of 515 patients with early-stage, HR+ BC with high-risk ODx RS 26-30 and ≥31 treated between 2006 and 2018. Patients were stratified by RS: low-risk (≤10), intermediate-risk (11-25), and high-risk (≥26). The Kaplan-Meier method was used to estimate the time to secondary invasive breast events (SIBE) or distributions overall and among different RS groups with the log rank test used to compare distributions between groups.

RESULTS

Rates of chemotherapy administration were 7% among the low-risk group, 18% among the intermediate-risk group, and 83% among high-risk patients with 41 SIBE (8%) reported. When stratified by ODx RS, 5-year rates of SIBE were 4%, 6%, and 16% for low-risk, intermediate-risk, and high-risk RS, respectively. Among the 27 lymph node (LN)-negative patients with ODx RS 26-30, 74% received chemotherapy. The 5-year rate of SIBE was 25% among patients who received chemotherapy and 33% among those who did not (p = 0.5489). Among the 23 LN-negative patients with ODx RS ≥31, 91% of patients received chemotherapy. The 5-year rate of SIBE was 0% both with and without chemotherapy.

CONCLUSIONS

There was no statistically significant difference in SIBE for patients with high-risk ODx RS based on chemotherapy treatment. More aggressive endocrine therapy with ovarian suppression has become an alternative to chemotherapy among patients with intermediate-risk ODx RS (16-25). This approach may be useful among patients with high-risk ODx RS, with additional studies needed in this patient population.

Abstract S06-02: Disruption to care of patients with thoracic malignancies: A COVID-19 and cancer outcomes study

Introduction: Patients with thoracic malignancies are susceptible to severe outcomes from coronavirus disease 2019 (COVID-19). The aim of this study was to evaluate the disruption to care of patients with thoracic malignancies during the COVID-19 pandemic. Methods: The COVID-19 and Cancer Outcomes Study (CCOS) is a multicenter prospective cohort study comprised of adult patients with a current or past history of hematological malignancy or invasive solid tumor who had an outpatient medical oncology visit on the index week between March 2 and March 6, 2020 at the Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai in New York, NY (MSSM) or the Dana-Farber Cancer Institute in Boston, MA (DFCI). An electronic data capture platform was used to collect patient-, cancer-, and treatment-related variables during the three months prior to the index week (the baseline period) and the following three months (the pandemic period). Two-by-three contingency tables with Fisher’s exact tests were computed. All tests were two-tailed and considered statistically significant for p&lt;0.05. All analyses were done in the R statistical environment (v3.6.1). Results: The overall cohort included 2365 patients, of which 313 had thoracic malignancies, 1578 had other solid tumors, and 474 had hematological malignancies. At a median follow-up of 84 days (95% confidence interval, 82-84), 13 patients with thoracic malignancies (4.1%) had developed COVID-19 (vs. other solid: 63 [4.0%] and hematological: 52 [11.0%]; p&lt;0.001). When comparing data from the pandemic period to the baseline period, patients with thoracic malignancies had a decrease in the number of in-person outpatient visits (thoracic: 209 [66.8%] vs. other solid: 749 [47.5%] vs. hematological: 260 [54.9%]; p&lt;0.001) and an increase in the number of telehealth visits (thoracic: 126 [40.3%] vs. other solid: 465 [29.5%] vs. hematological: 168 [35.4%]; p&lt;0.001). During the pandemic period, 33 (10.5%) patients with thoracic malignancies experienced treatment delays due to the pandemic (vs. other solid: 127 [8.0%] and hematological: 79 [16.7%]; p&lt;0.001), and 26 (8.3%) patients with thoracic malignancies experienced delays in cancer imaging or diagnostic procedures (vs. other solid: 63 [4.0%] and hematological: 26 [5.5%]; p=0.003). Discussion: In this prospective cohort study, patients with thoracic malignancies were not at increased risk of developing COVID-19 compared to patients with other cancers, but experienced significant cancer care disruption during the COVID-19 pandemic with a higher likelihood of decreased in-person visits and increased telehealth visits compared to patients with other malignancies. Focused efforts to ensure continuity of care for this vulnerable patient population are warranted.

Citation Format: Sheena Bhalla, Ziad Bakouny, Andrew L. Schmidt, John A. Steinharter, Douglas A. Tremblay, Mark M. Awad, Alaina J. Kessler, Robert I. Haddad, Michelle Evans, Fiona Busser, Michael Wotman, Catherine R. Curran, Brittney S. Zimmerman, Gabrielle Bouchard, Tomi Jun, Pier V. Nuzzo, Qian Qin, Laure Hirsch, Jonathan Feld, Kaitlin M Kelleher, Danielle Seidman, Hsin-Hui Huang, Chris Labaki, Heather M. Anderson-Keightly, Sarah Abou Alaiwi, Talia D. Rosenbloom, Penina S. Stewart, Matthew D. Galsky, Toni K. Choueiri, Deborah B. Doroshow. Disruption to care of patients with thoracic malignancies: A COVID-19 and cancer outcomes study [abstract]. In: Proceedings of the AACR Virtual Meeting: COVID-19 and Cancer; 2021 Feb 3-5. Philadelphia (PA): AACR; Clin Cancer Res 2021;27(6_Suppl):Abstract nr S06-02.

Prognostic Factors and Survival Outcomes among Patients with Breast Cancer and Brain Metastases at Diagnosis: A National Cancer Database Analysis

INTRODUCTION

The aim of this study was to assess for clinicopathologic and socioeconomic features that predict improved survival for patients with advanced breast cancer with synchronous brain metastases at diagnosis.

METHODS

We utilized the National Cancer Database (NCDB) to identify all patients with brain metastases present at diagnosis, with adequate information on receptor status (ER, PR, Her2), clinical T stage of cT1-4, clinical M1, with 3,943 patients available for analysis. The association between brain metastases patterns and patient/disease variables was examined by robust Poisson regression model. Cox proportional hazards model was used to quantify the associations between overall survival (OS) and these variables.

RESULTS

In univariable analysis, OS was significantly associated with the number of sites of metastases (p < 0.0001). Patients with 2 or more additional extracranial sites of metastases had significantly worse OS (median 8.8 months, 95% confidence interval [CI] 7.8, 9.9) than patients with brain metastases only (median OS 10.6 months, 95% CI 9.4, 12.9) or brain metastases plus one other extracranial site of metastases (median OS 13.1 months, 95% CI 11.8, 14.4). Risk factors which predicted poor prognosis included triple-negative disease, high comorbidity score, poorly differentiated tumors, invasive lobular histology, multi-organ involvement of metastases, and government or lack of insurance. Factors which improve survival include younger age and Hispanic race.

DISCUSSION/CONCLUSION

Using a large NCDB, we identified various factors associated with prognosis for patients with brain metastases at the time of breast cancer diagnosis. Insurance status and related socioeconomic challenges provide potential areas for improvement in care for these patients. This information may help stratify patients into prognostic categories at the time of diagnosis to improve treatment plans.

Abstract PS6-27: Secondary invasive breast events (SIBE) among patients with oncotype DX recurrence scores (RS) 26-30 and &gt;31: Results from a large oncotype database

Background: Oncotype RS is a 21-gene assay used to predict the likelihood of distant recurrence and benefit of chemotherapy in patients with lymph node negative (LN-), hormone positive (HR+) breast cancer (BC). The Oncotype RS is used to identify patients who may be spared chemotherapy in the adjuvant setting without adverse impact on survival or secondary invasive breast events (SIBE). Results of the TAILORx trial (Sparano et al, 2018) provided evidence that chemotherapy can likely be spared for most patients with oncotype RS&lt;25, with chemotherapy benefit potentially related to chemotherapy-induced menopause. More aggressive endocrine therapy with concurrent ovarian suppression in pre-menopausal women may mitigate the need for chemotherapy among patients with higher RS. We developed a large oncotype database to determine rates of SIBE (ipsilateral recurrence, contralateral breast cancer or metastatic recurrence) among patients with higher genomic risk (Oncotype RS 26-30 and &gt; 31) to determine the benefit of chemotherapy among these groups. Methods:We identified 887 patients with early-stage, HR+ BC treated between 2006-2018. Among these patients, 515 had treatment and follow-up data available for SIBE analysis. Median follow-up for SIBE was 62 months with 41 SIBE (8%) including both LN+ and LN- patients. When stratified by RS using conservative cutoffs (Sparano et al, 2018): low risk (&lt;10), intermediate risk (11-25), and high risk (&gt;26), 5 year rates of SIBE were 4%, 6% and 16% respectively. The Kaplan Meier method was used to estimate the time to SIBE distributions overall and among different RS groups with the log rank test used to compare distributions between groups. Results: Among 887 patients, 616 (69%) were post-menopausal. A total of 654 (74%) patients had surgical management, of which 226 underwent mastectomy (35%) and 428 underwent lumpectomy (65%). Among the 630 patients who received adjuvant therapy, 14 (2%) received chemotherapy alone, 143 (23%) received a combination of chemotherapy/endocrine therapy and 473 (75%) received endocrine therapy alone. Twenty-four patients (3%) refused one or more recommended therapies. Three hundred fourteen patients (50%) also received radiation therapy. Rates of chemotherapy administration were 8% among low RS, 16% among intermediate RS and 82% among high RS patients (73% for RS 26-30 and 90% for RS &gt;31). One-hundred eighty six of 887 patients were missing chemotherapy administration data as they were likely treated at another center. Patients with treatment data available and adequate follow up were included in the SIBE analysis (n=515). Among the 27 LN- patients with RS 26-30, twenty (74%) received chemotherapy and the remaining seven (26%) did not. The five year rate of SIBE was 25% among patients who received chemotherapy and 33% among those who did not receive chemotherapy; p=0.5489. Among the 23 LN negative patients with RS &gt;31, twenty-one (91%) patients received chemotherapy and the remaining two (9%) did not. The five year rate of SIBE was 0% in both patients who received chemotherapy and in patients who did not receive chemotherapy; p-value not estimable in this subgroup due to no SIBE in either group. Conclusion: In this large oncotype database, there was no statistically significant difference in SIBE for patients with higher genomic risk (RS 26-30 and &gt;31) whether or not they received chemotherapy. This data was limited by small numbers of patients in these sub-groups. More aggressive endocrine therapy with ovarian suppression has become an alternative option to spare chemotherapy in intermediate risk patients (RS 11-25). This approach may be useful among patients with even higher risk oncotype scores. Prospective randomized studies may be useful to determine utility of chemotherapy among patients with RS &gt;26.

Citation Format: Brittney S Zimmerman, Krystal Cascetta, Natalie Berger, Serena Tharakan, Kelly Suchman, Julia Blanter, Erin Moshier, Meng Ru, Shabnam Jaffer, Amy Tiersten. Secondary invasive breast events (SIBE) among patients with oncotype DX recurrence scores (RS) 26-30 and &gt;31: Results from a large oncotype database [abstract]. In: Proceedings of the 2020 San Antonio Breast Cancer Virtual Symposium; 2020 Dec 8-11; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2021;81(4 Suppl):Abstract nr PS6-27.

Abstract SS2-02: Patient perception of breast and gynecologic cancer care during the SARS-CoV-2 (COVID-19) pandemic in NYC: A single center survey-based study

Background: The 2019 novel coronavirus has become a world-wide pandemic which has disproportionately affected patients undergoing treatment for cancer. Within the field of medical oncology, dramatic changes in practice patterns occurred rapidly to accommodate transition of resources, while maintaining safety of oncology patients. At our large cancer treatment center in NYC, there have been significant changes in the delivery of surgical and medical treatments, with a shift towards neo-adjuvant therapy, oral chemotherapy administration, extended ovarian suppression, as well as closure or delay of many clinical trials. This study aims to determine the impact of the COVID-19 pandemic on the perceived oncology related care of patients with breast/gynecologic cancers as measured by survey results, as well as the impact on quality of life (QOL) and overall health (OH). Methods: A 34-question survey was administered to all patients receiving care at our outpatient center between March 1, 2020 and June 30, 2020. Of the 622 patients who received the survey via RedCap online or physical copy in clinic, 211 (34%) completed the survey. Survey questions were answered on a 5-point Likert scale and 7-point EORTC QLQ-C30 QOL scale. There is no existing COVID specific questionnaire, therefore we designed several original questions. Difference in mean QOL scores prior to the pandemic and at the end of the response period were evaluated using a paired t-test. Results: Of the 184 patients who responded to the question about their diagnostic history, 54 (30%) of patients had a history of DCIS (ductal carcinoma in situ)/ADH (atypical ductal hyperplasia)/LCIS (lobular carcinoma in situ), 94 (51%) had a history of invasive breast cancer, 6 (3%) had a gynecologic malignancy and 30 (16%) responded “other.” Due to the COVID pandemic, 121 patients (58%) reported that they had a medical oncology visit cancelled, delayed or changed from in-person to video telehealth. Of the 156 respondents that had endocrine therapy or chemotherapy scheduled, 26 (17%) reported a cancellation or delay of their medical treatment. As a result of the pandemic, 186 (91%), 110 (57%) and 119 (60%) of patients reported new or increased levels of anxiety, depression and mood swings, respectively. A minority of patients (n=39, 19%) felt that the COVID pandemic negatively impacted their cancer care, and a majority (n=151, 73%) felt that the changes in delivering cancer care during the pandemic were in their best interest (somewhat/strongly agree). Overall, QOL was reported with a mean (SD) of 5.5 (1.3) out of 7 (1=very poor, 7-excellent) prior to the pandemic, and 5.1 (1.4) out of 7 by the end of the pandemic period (March 1 through June 30, 2020); p&lt;0.0001. Fifty-three (26%) of patients reported having excellent (7) QOL prior to pandemic which decreased to 32 (16%) after the pandemic period; p&lt;0.0001. Overall health was reported with a mean (SD) of 5.3 (1.3) out of 7 prior to the pandemic, and 5.1 (1.3) out of 7 by the end of the response period; p=0.0368. Conclusions: The COVID-19 pandemic required major changes in the care of patients with breast and gynecologic cancer in order to balance continued oncologic care with safety of COVID exposure. In our study population, 17% of patients at our center reported a delay or cancellation in their medical treatment and 58% reported a change to their medical oncology visits. Despite this, only 19% of all patients felt that the changes in care delivery as a result of the COVID-19 pandemic negatively impacted their cancer care, and the large majority (73%) felt that the changes were made in their best interest. The QOL for our patients was significantly affected by the pandemic, with increases in anxiety, depression and mood swings, and a numeric decrease in QOL and OH.

Citation Format: Brittney S Zimmerman, Danielle Seidman, Natalie Berger, Krystal P Cascetta, Michelle Nezolosky, Kara Trlica, Alisa Ryncarz, Caitlin Keeton, Erin Moshier, Amy Tiersten. Patient perception of breast and gynecologic cancer care during the SARS-CoV-2 (COVID-19) pandemic in NYC: A single center survey-based study [abstract]. In: Proceedings of the 2020 San Antonio Breast Cancer Virtual Symposium; 2020 Dec 8-11; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2021;81(4 Suppl):Abstract nr SS2-02.

Abstract SS2-08: Patient perception of telehealth services for breast and gynecologic cancer care during the SARS-CoV-2 (COVID-19) pandemic in NYC: A single center survey-based study

Background: Prior to the COVID-19 pandemic, telehealth was rarely utilized in providing oncologic care. At our large NYC based outpatient clinic, telehealth services were quickly adapted for utilization for visits that could be completed outside of the clinic, in order to limit patient exposure to the novel coronavirus. This survey-based study aimed to assess patient perceptions of the utility of telehealth in their oncologic care during a time of national crisis. Methods: A 34-question survey was administered to all patients receiving care at our outpatient center between March 1, 2020 and June 30, 2020 including those who had visits delayed or cancelled during this time period. Of the 622 patients who received the survey via RedCap online or physical copy in clinic, 211 (34%) completed the survey. For evaluation of the Telehealth provided during the pandemic, we have adapted the validated SUTAQ (Service User Technology Acceptability Questionnaire) which assesses patient acceptability of telehealth via measures of accessibility, comfort, usability, privacy and security, confidentiality, satisfaction, convenience and health benefits with in-home telemonitoring. Results: All patients who completed the survey had a history of DCIS/ADH/LCIS, invasive breast cancer or gynecologic malignancy. Of the total survey respondents, 72 (35%) participated in a telehealth visit during the four month evaluation period. For all survey questions, “agreement” was considered if the patient selected mildly, moderately or strongly agreed on the SUTAQ scale. Of patients who participated in telehealth visits, 66 (92%) felt that the telehealth saved them time, 52 (72%) felt it increased their access to care and 56 (81%) felt it helped improve their health. Only 8 (12%) of patients felt that telehealth made them feel uncomfortable and 4 (6%) worried about confidentiality related to telehealth usage. Overall, 65 (92%) of patients were satisfied with the telehealth services they received and 64 (89%) would recommend these services to people with similar health conditions. Twenty-five (35%) felt that telehealth can be a replacement for their normal health care and 67 (93%) reported it could be a good addition to their care. Fifty-four (76%) would be interested in participating in telehealth visits in the future. Conclusions: Overall, patients expressed satisfaction with the use of telehealth services for oncologic care during the COVID pandemic. Although most patients do not feel that this is a suitable replacement for their in person care, they expressed that it was certainly a good addition to their care. A large majority of patients expressed interest in continuing to participate in telehealth visits in the future. Telehealth services should be carefully adapted as a long term addition to the in person clinical care of patients with cancer. These services should be utilized to optimize patient satisfaction, save time and increase access to care, especially among high risk patients.

Citation Format: Brittney S Zimmerman, Danielle Seidman, Natalie Berger, Krystal P Cascetta, Michelle Nezolosky, Kara Trlica, Alisa Ryncarz, Caitlin Keeton, Erin Moshier, Amy Tiersten. Patient perception of telehealth services for breast and gynecologic cancer care during the SARS-CoV-2 (COVID-19) pandemic in NYC: A single center survey-based study [abstract]. In: Proceedings of the 2020 San Antonio Breast Cancer Virtual Symposium; 2020 Dec 8-11; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2021;81(4 Suppl):Abstract nr SS2-08.

Patient Perception of Telehealth Services for Breast and Gynecologic Oncology Care during the COVID-19 Pandemic: A Single Center Survey-based Study

Prior to the coronavirus disease 2019 (COVID-19) pandemic, telehealth was rarely utilized for oncologic care in metropolitan areas. Our large New York City based outpatient breast/gynecologic cancer clinic administered an 18-question survey to patients from March to June 2020, to assess the perceptions of the utility of telehealth medicine. Of the 622 patients, 215 (35%) completed the survey, and of the 215 respondents, 74 (35%) had participated in a telehealth visit. We evaluated the use of telehealth services using the validated Service User Technology Acceptability Questionnaire. Sixty-eight patients (92%) reported that telehealth services saved them time, 54 (73%) reported telehealth increased access to care, and 58 (82%) reported telehealth improved their health. Overall, 67 (92%) of patients expressed satisfaction with the use of telehealth services for oncologic care during the COVID-19 pandemic. Telehealth services should be carefully adopted as an addition to in-person clinical care of patients with cancer.

Acquired amegakaryocytic thrombocytopenia as a rare cause of thrombocytopenia during pregnancy

A rare case of acquired amegakaryocytic thrombocytopenia (AATP) in a 35-year-old woman who presented with anaemia and thrombocytopenia at 22 weeks gestation. The first diagnostic impression was of an evolving aplastic anaemia; however, the patient was simultaneously diagnosed with severe vitamin B₁₂ deficiency in the setting of vegetarianism. Once the cyanocobalamin deficiency was corrected, a repeat bone marrow biopsy revealed an isolated depletion of megakaryocytes, which suggested the diagnosis of AATP. Supportive care was provided for her anaemia and thrombocytopenia and she delivered a healthy baby girl with a normal platelet count. The patient was subsequently started on romiplostim with steady improvement in her platelet counts. This rare AATP case presentation highlights the importance of a well-structured diagnostic approach to thrombocytopenia during pregnancy and supports the successful use of thrombopoietin agonists for the management of AATP.

Abstract P1-07-28: Retrospective analysis of clinicopathologic features predictive of oncotype DX discordance in estrogen receptor positive, node negative breast cancer patients

BACKGROUND: Oncotype DX (ODX) is a validated recurrence score (RS) used to predict the risk of recurrence and benefit of chemotherapy in ER positive, node negative breast cancer patients. Prior to ODX, treatment recommendations regarding adjuvant chemotherapy and mortality approximation have taken into account clinical and pathologic risk factors. A discordance rate of 7-19% between risk allocating pathologic factors and ODX RS has been previously reported with progesterone receptor (PR) negativity noted as a defining clinical feature in numerous cases. The association between other clinicopathologic features and discordance is less certain.

METHODS: ODX data and clinicopathologic features were retrospectively reviewed for 724 breast cancer tumors belonging to 704 patients between 2006 and 2016. ODX discordance was defined as either 1-step discordance or 2-step discordance between ODX risk group (low, intermediate, high) and tumor grade (TG) (well differentiated, moderately differentiated, poorly differentiated). Tumors with 1-step discordance received a discordance score (DS) of 1 while those with 2-step discordance received a DS of 2. The database was subsequently analyzed using Paik's RS cutoffs as well as those outlined in the TAILORx trial. An odds ratio (OR) of &gt;1 was consistent with discordance.

RESULTS: Among 724 tumor samples, ODX ER score (p=0.000), ODX PR score (p=0.000), ODX HER2 score (p=0.000), TG (p=0.000), mitotic count (MC) (p=0.0012), DCIS grade (p=0.0046), DCIS type (comedo necrosis vs. non-comedo necrosis) (p=0.0335) and micropapillary features (p=0.0044) were significantly associated with RS. Median age of cohort was 59 years and median tumor size was 1.2 cm.

Of 724 tumors, 619 from 604 subjects were eligible for assessment of discordance. Median RS was 16. Using Paik's RS cutoffs, 64.3% discordance was observed: 52.5% 1-step discordance (DS 1) and 11.8% 2-step discordance (DS 2). The TAILORx categorization yielded a discordance rate of 44.3%: 40.1% 1-step discordance and 4.2% 2-step discordance.

On univariate analysis and using Paik's RS cutoffs, young age (p= 0.0240), high MC (p=0.0006), large tumor size (&gt;20 mm) (p=0.0209), the presence of DCIS (p=0.0480), high DCIS grade (p= 0.0033), and high ODX PR and ER scores (p= 0.0000) were significant clinicopathologic features predictive of discordance. On multivariate analysis, high MC (p= 0.0000), high ODX PR and ER scores (p=0.0000) remained significant as well as premenopausal status (p=0.026).

Per TAILORx cutoffs, univariate analysis revealed younger age (p= 0.0060), high MC (p= 0.0270), premenopausal status (p= 0.0124), and high ODX PR and ER scores (p= 0.0000) as significant for discordance. On multivariate analysis, high ODX PR and ER scores (p= 0.0000) remained significant.

CONCLUSION: In this retrospective ODX database, premenopausal status, high MC, high ODX PR and ER scores as per Paik's RS cutoffs were significant predictors for ODX discordance while high ODX PR and ER scores were significant predictors per the RS's outlined in the TAILORx trial. RS cutoffs per the TAILORX trial appear to create less discordance between RS and TG than the original cutoffs outlined by Paik and colleagues.

Citation Format: Cascetta KP, Zimmerman BS, Eggert L, Molot MC, Ru M, Nayak A, Bleiweiss I, Tiersten A. Retrospective analysis of clinicopathologic features predictive of oncotype DX discordance in estrogen receptor positive, node negative breast cancer patients [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P1-07-28.

Abstract P1-07-16: Retrospective analysis of oncotype DX recurrence score (RS) and discordance in patients with node-negative, ER+ breast cancer with recurrence

BACKGROUND: Oncotype RS is a 21-gene assay used to predict the likelihood of distant recurrence and benefit of chemotherapy in patients with node-negative, tamoxifen treated breast cancer. We developed a database to determine tumor recurrence rates and identify cases of discordance between Oncotype RS and tumor grade (TG). Our goal was to recognize patients with discordant tumors who had breast cancer recurrence and to understand the implications for patient management.

METHODS/RESULTS: We analyzed patient and tumor characteristics from 704 breast cancer patients between 2006-2016. Of these patients, there were thirteen recurrences (n=13), or 1.9% recurrence rate at a median follow-up of 4.2 years. When stratified by RS, recurrence rates were 1%, 2.4% and 4.3% in low, intermediate and high-risk groups respectively. Of the 13 patients who recurred, 31% had a low RS (&lt;18), 54% had an intermediate RS (18-30) and 15% had a high RS (&gt;31). The median RS was 23 and median age at time of recurrence was 55 years (62% postmenopausal). Tumor characteristics at time of recurrence were notable for: 77% metastatic, 23% locally recurrent, 85% PR positive, 69% moderately-differentiated (MD) and 31% poorly-differentiated (PD). No well-differentiated (WD) tumors recurred.

We defined Oncotype discordance as either 1-step or 2-step difference between Oncotype risk group (low, intermediate, high) and tumor grade (WD, MD, PD). Prior studies have demonstrated 7-19% “2-step discordance” between TG and RS (i.e. PD tumors with low-risk RS or WD tumors with high-risk RS). Of the 13 recurrences in our database, 46% were at least 1-step discordant, compared with 64.3% in our overall database. Among these recurrences, we compared discordant versus concordant tumors using two-sided T-tests. We found that fewer patients were treated with systemic chemotherapy in the discordant group (p=0.045), which was statistically significant. Among discordant patients, only one received chemotherapy, though all displayed MD or PD tumor grade. Discordant tumors tended to have lower RS (mean 17 vs. 27, p=0.34) and tended to be larger (mean 1.88cm vs. 1.33cm), however this was not statistically significant (p=0.84). Notably, the two largest tumors were both discordant. There were no significant differences in terms of age, Oncotype ER/PR score or mitotic count.

CONCLUSION: Although the sample size of recurrent patients is small, our data may suggest that patients with discordant tumors of low-risk Oncotype RS but higher TG may be receiving inadequate treatment (i.e. no chemotherapy). In addition to RS, other factors such as discordance, TG and tumor size should perhaps be considered when determining treatment plans.

Characteristics of Breast Cancer Recurrences in Oncotype DX DatabaseSubject #Age (years)Oncotype RSTumor GradeDiscordancePath PR%Tumor Size (cm)Chemotherapy14111MDY600.9N25811MDY1001.7N35713MDY301.0N45515MDY902.7N56122MDN301.5Y64522MDN901.8Y75323MDN00.9N83324MDN951.4Y96324PDY802.9U104129MDN801.1Y116530PDY102.1Y124933PDN01.6Y136135PDN51.0YMD=moderately-differentiated, PD=poorly-differentiated, Y=Yes, N=No, U=Unknown

Citation Format: Zimmerman BS, Cascetta KP, Ru M, Eggert L, Molot MC, Nayak A, Bleiweiss I, Tiersten A. Retrospective analysis of oncotype DX recurrence score (RS) and discordance in patients with node-negative, ER+ breast cancer with recurrence [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P1-07-16.