Top 10 research priorities for early-stage colorectal cancer: a Canadian patient-oriented priority-setting partnership

BACKGROUND

Colorectal cancer, one of the most commonly diagnosed cancers, is now being detected earlier and treatments are improving, which means that patients are living longer. Partnering with Canadian clinicians, patients and researchers, we aimed to determine research priorities for those living with early-stage colorectal cancer in Canada.

METHODS

We followed the well-established priority-setting partnership outlined by the James Lind Alliance to identify and prioritize unanswered questions about early-stage (i.e., stages I-III) colorectal cancer. The study was conducted from September 2018 to September 2020. We surveyed patients, caregivers and clinicians from across Canada between June 2019 and December 2019. We categorized the responses using thematic analysis to generate a list of unique questions. We conducted an interim prioritization survey from April 2020 to July 2020, with patients, caregivers and clinicians, to determine a shorter list of questions, which was then reviewed at a final meeting (involving patients, caregivers and clinicians) in September 2020. At that meeting, we used a consensus-based process to determine the top 10 priorities.

RESULTS

For the initial survey, 370 responses were submitted by 185 individuals; of the 98 individuals who provided demographic information, 44 (45%) were patients, 16 (16%) were caregivers, 7 (7%) were members of an advocacy group, 26 (27%) were health care professionals and 5 (5%) were categorized as "other." The responses were refined to create a list of 66 unique unanswered questions. Twenty-five respondents answered the interim prioritization survey: 13 patients (52%), 2 caregivers (8%), 3 advocacy group members (12%) and 7 health care professionals (28%). This led to a list of the top 30 questions. The final consensus meeting involved 20 individuals (10 patients [50%], 3 caregivers [15%] and 7 health care professionals [35%]), who agreed to the top 10 research priorities. The priorities covered a range of topics, including screening, treatment, recurrence, management of adverse effects and decision-making.

INTERPRETATION

We determined the top research priorities for early-stage colorectal cancer using a collaborative partnership of stake-holders from across Canada. The priorities covered a broad range of topics that could be addressed by future research, including improved screening practices, the role of personalized medicine, the management of adverse effects of treatment, decision-making and prevention of recurrence.

A Population-based Study of Treatment Patterns and Survival of Patients With De Novo Stage IV Non-Small Cell Lung Cancer

BACKGROUND

Treatment strategies for metastatic non-small cell lung cancer (NSCLC) are evolving rapidly and can be highly variable. Real-world evidence of treatment patterns and outcomes can provide an understanding of our current practice and offer insights on ways to incorporate emerging therapies into our treatment paradigm. In this population-based study, we investigated treatments and outcomes of stage IV NSCLC patients from a large Canadian province.

METHODS

Patients diagnosed with de novo stage IV NSCLC from April 1, 2010 to March 31, 2015 were identified. Data for baseline characteristics, treatments, and outcomes were obtained from provincial data sources, including the cancer registry and electronic medical records. We classified systemic treatments as chemotherapy, targeted therapy (anti-epidermal growth factor receptor, and anti-anaplastic lymphoma kinase) and immunotherapy (checkpoint inhibitors) and characterized clinical outcomes by treatment type.

RESULTS

A total of 6438 patients were identified with NSCLC, of whom 3606 (56%) had de novo stage IV disease. The median age of diagnosis was 69 (range: 20 to 100) years and 52.4% were men. First-line palliative treatments included: chemotherapy in 19.5% (n=703), targeted agents in 5.7% (n=204), immunotherapy in 1% (n=1), radiotherapy in 6.8% (n=246), and best supportive care in 74.8% (n=2,698). Median overall survival (mOS) from diagnosis for the whole cohort was 3.8 months. Within subgroups, mOS was 18.0 months for targeted therapies, 9.4 months for chemotherapy, and 2.5 months for best supportive care. Only 1.0% of patients (n=34) received immunotherapy at any line.

CONCLUSIONS

Survival benefit was dependent on type of treatment received, with significantly better mOS observed with the use of small-molecule targeted therapy against epidermal growth factor receptor mutations and anaplastic lymphoma kinase rearrangements, as compared with best supportive care.

Population-based Treatment Patterns and Outcomes for Stage III Non-Small Cell Lung Cancer Patients: A Real-world Evidence Study

BACKGROUND

Most patients with stage III non-small cell lung cancer (NSCLC) develop metastases and succumb to their cancer. Approaches to the treatment of stage III disease can be highly variable. Understanding current treatment patterns can inform the optimal integration of emerging therapies. In this study, we describe contemporary treatment patterns and outcomes for a population-based cohort of stage III NSCLC patients from a large Canadian province.

METHODS

On the basis of the provincial cancer registry, all adult patients diagnosed with stage III NSCLC from April 1, 2010 to March 31, 2015 were identified. Analyses of these patients' existing electronic medical records and administrative claims data were conducted to describe patient characteristics, treatment patterns, and survival outcomes.

RESULTS

In total, we screened 6438 patients diagnosed with NSCLC, of whom 1151 (17.9%) had stage III disease. Among them, 61.2% were stage IIIA, 36.4% were stage IIIB, and 2.4% were unspecified. Median age at diagnosis was 70 (22 to 94) years and 50.2% were men. In this cohort, a significant proportion of patients received only palliative radiotherapy (35.6%), palliative chemotherapy (8.8%), or best supportive care (24.8%) as initial treatment. Conversely, relatively few underwent concurrent chemoradiotherapy (11.7%) or trimodality therapy (1.7%). Surgery±adjuvant treatments were performed in 14.8% of stage III patients. Median overall survival was 13.2 months (95% confidence interval [CI], 12.2-14.0) among stage III patients. Patients who received initial curative treatment had statistically significant better survival compared with those who received noncurative treatment (P<0.001); median overall survival 29.8 months (95% CI, 22.3-34.6) and 8.9 months (95% CI, 7.6-11.6), respectively.

CONCLUSIONS

In a population-based setting that includes community, regional, and tertiary cancer centers, use of concurrent chemoradiotherapy and trimodality therapy in stage III NSCLC was low despite evidence supporting the potential benefits of these strategies.

SAT0414 THE PERFORMANCE OF A MULTI-MARKER GENETIC TEST TO IDENTIFY PATIENTS WITH PSORIATIC ARTHRITIS AMONG PSORIASIS PATIENTS

Background:

Improved understanding of the complex genetic architecture of psoriatic arthritis (PsA) along with the reduction in the cost of genetic testing provide an opportunity to assess the application of genetic testing for PsA diagnosis in clinical setting.

Objectives:

The study aimed to assess the performance of the multi-SNP genetic test in predicting a clinical diagnosis of PsA by a rheumatologist among psoriasis patients with musculoskeletal symptoms.

Methods:

328 patients with psoriasis and musculoskeletal symptoms that were referred to a rapid access clinic for suspected PsA were enrolled. Patients with a prior diagnosis of PsA were excluded. A rheumatologist evaluated all patients and classified them as “PsA” or “not PsA”. All patients who were classified as not PsA at baseline were reassessed 1 year later to determine whether they have developed PsA. We tested 2 outcomes: 1) diagnosis of PsA at baseline; and 2) diagnosis of PsA at baseline or at 1 year. A custom multi-SNP genetic assay was genotyped on a MassARRAY system (Agena Biosciences). The custom PsA weighted genetic panel included 42 variants in or near 20 genes based on genome-wide significance in PsA studies. We tested the ability of each genetic maker individually to predict PsA using logistic regression models adjusted for age and sex. Machine-learning methods including logistic regression, naïve bayes and random forest were used to identify the optimal prediction model. Age and sex were included in the prediction models.

Results:

78 patients were classified as PsA (PsA-baseline) and the remaining 250 patients as not PsA. After 1 year, 17 additional patients developed PsA resulting in 95 patients with PsA at 1 year (PsA-1 year). The association between the tested SNPs and PsA is shown in Table 1. 5 SNPs located at LCE3A (rs10888503), TNIP1 (rs146571698) and IL-23R (rs4655683, rs2201841 and rs12044149) were associated with PsA-baseline or PsA-1 year (all p<0.05). Of the three machine-learning methods used, logistic regression was found to have the best prediction properties (highest AUC). Overall, the performance of prediction models to classify patients as PsA was modest (see Table 2). The AUC, sensitivity and specificity of the models to predict PsAat baselinewere: 0.62, 0.15, 0.97, respectively andat 1 year: 0.62, 0.15, 0.94.

Table 1.

The association between (selected top markers)

ChromSNPGenePsA diagnosis at baseline (N=78)PsA diagnosis at 1 year (N=95)OR95% CIP valueOR95% CIP value1rs10888503LCE3A1.781.21, 2.620.0031.521.06, 2.170.026rs12191877HLA-C0.520.31, 0.890.0170.630.39, 1.010.0576rs2894207HLA-C*60.570.35, 0.930.0250.620.39, 0.990.0456rs13214872HLA-C0.570.34, 0.960.0350.650.41, 1.050.0786rs12189871HLA-C0.550.30, 1.010.0550.680.40, 1.170.1696rs4406273HLA-C0.570.32, 1.020.0570.670.40, 1.120.1225rs146571698TNIP12.030.97, 4.240.0612.071.02, 4.180.0441rs4655683IL-23R1.420.97, 2.080.0691.521.06, 2.170.0221rs2201841IL-23R0.720.50, 1.050.0870.680.48, 0.960.0541rs12044149IL-23R1.340.88,2.060.1671.601.07, 2.390.021Table 2.

Performance of the genetic assay in predicting PsA

2A. Prediction of PsA at baseline (N=78)MethodTPTNFPFNAccuracySensitivitySpecificityAUCLogistic Regression122428660.770.150.970.62Naïve Bayes2720347510.700.350.810.61Random Forest1423713640.770.180.950.562B. Prediction of PsA at 1 year (N=95)MethodTPTNFPFNAccuracySensitivitySpecificityAUCLogistic Regression1521815800.710.150.940.62Naïve Bayes2120330740.680.220.870.62Random Forest1620429790.670.170.880.55

Conclusion:

Despite the association of several genetic markers with PsA, genetic testing has marginal effect on predicting a diagnosis of PsA among patients with psoriasis and musculoskeletal symptoms.

Disclosure of Interests:

Lihi Eder Grant/research support from: Abbvie, Lily, Janssen, Amgen, Novartis, Consultant of: Janssen, Speakers bureau: Abbvie, Lily, Janssen, Amgen, Novartis, Quan Li: None declared, Dana Jerome: None declared, Chandra Farrer: None declared, Tanya Burry: None declared, Proton Rahman Grant/research support from: Janssen and Novartis, Consultant of: Abbott, AbbVie, Amgen, BMS, Celgene, Lilly, Janssen, Novartis, and Pfizer., Speakers bureau: Abbott, AbbVie, Amgen, BMS, Celgene, Lilly, Janssen, Novartis, Pfizer

The time windows of the sense of agency

The sense of agency depends on some internal cues that derive from action control, as well as external cues like contextual information and prior information (degree of contingency between an action and is effect). We assessed whether external agency cues are combined with internal agency cues to affect the sense of agency. In two experiments participants performed a movement (button press) that elicited, after a varying delay, an effect (ball appearing on a screen), and reported their sense of agency over the effect (full, partial or no-agency) while internal cues (premotor information) and external cues (contextual and prior information) were manipulated. We assessed the effect of agency cues on the delays at which the sense of agency varied. The delays were increased with premotor signals but were decreased with contextual information. These findings favour a model of integration of internal and external agency cues over time.

[Sense of body in schizophrenia]

First-rank symptoms of schizophrenia have been related to an impaired sense of agency (the sense of causing and controlling an action). The sense of agency is considered as one of the two components of self-recognition, the other component being the sense of body (awareness of one's body). The present study aimed at evaluating whether first-rank symptoms can be considered as a general impairment in self-recognition that will also concern the sense of body. A group of schizophrenic patients with first-rank symptoms, a group of schizophrenic patients without first-rank symptoms and a group of normal subjects were compared in a self-recognition task where they first had to execute hand movements simultaneously with the experimenter and subsequently to indicate the position either of their own or the experimenter's hand. The visualized locations of the hands could rotate by 0 degrees , 90 degrees , -90 degrees or 180 degrees from their real locations. This rotation allowed us to induce a distorted sense of body since there was a visual discontinuity between the patient's hand and the rest of his/her body. If patients present a perturbed sense of body we would expect a greater impairment in discriminating between their own hand and the experimenter's hand as the rotation values increased. This preliminary study shows that patients with first-rank symptoms are more impaired than normal subjects in distinguishing between their own hands and the experimenter's hands when the visualization of the locations of their hands were rotated respective to their real locations. However, both group of patients performed equally, thus showing that sense of body impairment is not specific to first-rank symptoms. These symptoms, compared to other symptoms of schizophrenia do not reflect general self-recognition impairment but rather a specific impairment of the sense of agency.

The role of proprioception in action recognition

This study aimed at evaluating the role of proprioception in the process of matching the final position of one's limbs with an intentional movement. Two experiments were realised with the same paradigm of conscious recognition of one's own limb position from a distorted position. In the first experiment, 22 healthy subjects performed the task in an active and in a passive condition. In the latter condition, proprioception was the only available information since the central signals related to the motor command were likely to be absent. The second experiment was realised with a deafferented patient who suffers from a complete haptic deafferentation, including loss of proprioception. The results first argue in favour of a dominant role of proprioception in action recognition, but they also stress the possible role of central signals. The process of matching the final position of one's limbs with an intended movement and thus of action recognition would be achieved through a comparison process between the predicted sensory consequences of the action, which are stored in its internal model, and the actual sensory consequences of that action.

Modulating the experience of agency: a positron emission tomography study

This study investigated agency, the feeling of being causally involved in an action. This is the feeling that leads us to attribute an action to ourselves rather than to another person. We were interested in the effects of experimentally modulating this experience on brain areas known to be involved in action recognition and self-recognition. We used a device that allowed us to modify the subject's degree of control of the movements of a virtual hand presented on a screen. Four main conditions were used: (1) a condition where the subject had a full control of the movements of the virtual hand, (2) a condition where the movements of the virtual hand appeared rotated by 25 degrees with respect to the movements made by the subject, (3) a condition where the movements of the virtual hand appeared rotated by 50 degrees, and (4) a condition where the movements of the virtual hand were produced by another person and did not correspond to the subject's movements. The activity of two main brain areas appeared to be modulated by the degree of discrepancy between the movement executed and the movement seen on the screen. In the inferior part of the parietal lobe, specifically on the right side, the less the subject felt in control of the movements of the virtual hand, the higher the level of activation. A reverse covariation was observed in the insula. These results demonstrate that the level of activity of specific brain areas maps onto the experience of causing or controlling an action. The implication of these results for understanding pathological conditions is discussed.

Experiencing oneself vs another person as being the cause of an action: the neural correlates of the experience of agency

The present study is aimed at identifying the neural correlates of two kinds of attribution: experiencing oneself as the cause of an action (the sense of agency) or experiencing another person as being the cause of that action. The experimental conditions were chosen so that they differed only in their requirement to attribute an action to another person or to oneself. The same motor task and the same visual stimuli were used in the experimental conditions. Subjects used a joystick to drive a circle along a T-shaped path. They were told that the circle would be driven either by themselves or by the experimenter. In the former case subjects were requested to drive the circle, to be aware that they drove the circle, and thus to mentally attribute the action seen on the screen to themselves. In the latter case they were also requested to perform the task, but they were aware that action seen on the screen was driven by the experimenter. In accord with previous studies, the results showed that being aware of causing an action was associated with activation in the anterior insula, whereas being aware of not causing the action and attributing it to another person was associated with activation in the inferior parietal cortex. These two regions are involved in the perception of complex representations of the self and of its interactions with the external world. We suggest that the anterior insula is concerned with the integration of all the concordant multimodal sensory signals associated with voluntary movements. The inferior parietal cortex, in contrast, represents movements in an allocentric coding system that can be applied to the actions of others as well as the self.

A role for the ventral visual stream in reporting movements

In this experiment we contrast the neural activity associated with reporting a stimulus attribute with the activity that occurs when the same stimulus attribute is used to guide behavior. Reporting the characteristics of a stimulus differs from simply tracking that stimulus since reporting requires that a stimulus is explicitly recognized and associated with an arbitrary response. In one condition the subject used his right finger to follow a square that moved randomly on a screen. In a second condition he had to indicate changes in the direction of the square's movements by touching one of two report buttons with his right finger. Two other conditions were added to control for the differences in the form of movement between the two primary conditions. When the reporting condition was contrasted with the tracking condition (controlling for the differences in the form of movement), areas in the ventral visual system (the left ventral prefrontal cortex and the left inferior temporal cortex) were activated. This study shows that contrasting a manual task which involves a report with a manual task which does not activates the ventral visual system. However, the observation of additional activity in other areas suggests that, while activity in the ventral stream is necessary for reporting, it is not sufficient.

Defective recognition of one's own actions in patients with schizophrenia

OBJECTIVE

The possibility that delusions of influence could be related to abnormal recognition of one's own actions was investigated in persons with schizophrenia.

METHOD

Schizophrenic patients with (N=6) and without (N=18) delusions of influence were compared with normal subjects (N=29) on an action recognition task. The image of a virtual right hand holding a joystick was presented to the subjects through a mirror so that the image was superimposed on their real hand holding a real joystick. Subjects executed discrete movements in different directions. Angular biases and temporal delays were randomly introduced in some trials, such that the movement of the virtual hand departed from the movement executed by the subjects. After each trial, subjects were asked whether the movement they saw was their own.

RESULTS

Compared with normal subjects, both patient groups made significantly more recognition errors in trials with temporal delays. In trials with angular biases, the error rate of patients with delusions of influence significantly differed from that of comparison subjects and from that of patients without delusions of influence.

CONCLUSIONS

The findings support the hypothesis that delusions of influence are associated with a quantifiable difficulty in correct self-attribution of actions. This difficulty may be related to a specific impairment of a neural action attribution system.

Advanced colorectal cancer treated with combined 5-fluorouracil and folinic acid: the experience within a surgical department

Thirty-seven patients with advanced colorectal cancer were treated with fluorouracil (5-FU) and folinic acid (FA) (Jan 1990-Dec 1992). Clinical assessment and administration of chemotherapy was incorporated as part of the daily work load of a busy general surgical unit. Records were available for all 37 patients and showed that 13 patients (Treatment failures, Group B) failed to receive more than 3 monthly cycles of treatment, while the remaining 24 received 6 or greater cycles (Treatment completed, Group A). There was no survival advantage demonstrated for the complete study cohort (n = 37) when compared to an historical group (n = 1038) of untreated patients. Median survival in Group A (14.2 months) was significantly greater (chi-squared, P < 0.0001) than survival in Group B (6.7 months). Toxicity was common with 43% experiencing mouth ulcers or stomatitis (13% severe). Three per cent had dose-limiting diarrhoea and myelotoxicity was minimal. There were six partial responses and 16 patients had no change in their disease status while on treatment. Current regimen of 5-FU/FA are well-tolerated with low toxicity but show no survival advantage for advanced colorectal cancer. However, these regimens may be administered within the confines of general surgical practice.