Immune Escape in Glioblastoma: Mechanisms of Action and Implications for Immune Checkpoint Inhibitors and CAR T-Cell Therapy

Glioblastoma, the most common primary brain cancer in adults, is characterized by a poor prognosis and resistance to standard treatments. The advent of immunotherapy has revolutionized the treatment of several cancers in recent years but has failed to demonstrate benefit in patients with glioblastoma. Understanding the mechanisms by which glioblastoma exerts tumor-mediated immune suppression in both the tumor microenvironment and the systemic immune landscape is a critical step towards developing effective immunotherapeutic strategies. In this review, we discuss the current understanding of immune escape mechanisms in glioblastoma that compromise the efficacy of immunotherapies, with an emphasis on immune checkpoint inhibitors and chimeric antigen receptor T-cell therapy. In parallel, we review data from preclinical studies that have identified additional therapeutic targets that may enhance overall treatment efficacy in glioblastoma when administered alongside existing immunotherapies.

Demographics, Medical Comorbidities, and Functional Factors Associated with Radiation Therapy Regimen Length in Older Patients

PURPOSE/OBJECTIVE(S)

To determine demographic, comorbidity, and functional factors associated with radiation therapy (RT) regimen length in older patients.

MATERIALS/METHODS

Using data from the Medicare Current Beneficiary Survey (MCBS), we identified patients who were diagnosed with cancer from 2002-2019 and received RT. The MCBS dataset is comprised of linked patient survey and Medicare claims data. Days of RT were used as a proxy for fractions of RT each patient received. We used treatment guidelines to identify a minimum treatment threshold for each cancer type to differentiate patients with low RT utilization from normal or supra-palliative RT utilization. Statistical analyses of patient demographics, comorbidities, and activities of daily living (ADL) were performed using chi-square and t-tests.

RESULTS

A total of 880 patients were included in this analysis, of whom 669 had high RT utilization. Of the demographic factors considered, age 85+ was associated with longer RT regimen length (p = 0.045), as was being "other" or multi-race, community, or facility treatment setting, and residing in the south (p = 0.013, 0.006, 0.003, 0.038, respectively). Of medical comorbidities, only lung disease was associated with longer RT regime (p = 0.020). Longer RT regimen length was significantly associated with requiring assistance with any ADLs (bathing, dressing, eating, chair, walking, toileting, all with p <0.001).

CONCLUSION

This abstract identifies specific patient demographics, medical comorbidities, and ADL limitations which may be associated with RT regimen length in older patients. Future work should focus on optimizing patients and delivery systems for RT and the relationship between pre- and post-treatment ADLs.

The Role of Coronary Artery Calcium Score to Assess Risk of Cardiovascular Disease in Irradiated Esophageal Cancer Patients

PURPOSE/OBJECTIVE(S)

Coronary artery calcium (CAC) score is an important predictive imaging marker of cardiovascular disease (CVD). While studies have found positive association between CAC score and cardiac toxicity in irradiated lung and breast cancer patients, there are no studies assessing CAC scores in esophageal cancer (EC). While a cardiac-gated CT is required for standard Agatston CAC score, visual assessment of CAC via ordinal scoring on non-gated CT has shown good concordance with Agatston score. In this study, we sought to examine whether visual assessment of CAC, measured on standard of care, non-contrast chest CT, predicts the development of adverse cardiovascular events (ACVE) in irradiated EC patients.

MATERIALS/METHODS

This is a single institution retrospective study of EC patients treated with RT from 2010-2021. We included patients with available PET/CT at diagnosis or chest CT simulation scan without contrast, and excluded those with history of percutaneous coronary intervention, coronary bypass surgery, or prior thoracic RT. Pre-treatment characteristics, clinical factors, and grade ≥ 3 (G3+) adverse cardiovascular events (ACVE) (CTCAEv5.0) were evaluated. Visual assessment of CAC was performed using ordinal method (CAC scored from 0 to 12), by a thoracic radiologist. Fine and Gray regression was used to compute hazard ratios for time to first ACVE. Univariate analyses using Cox proportional hazards were used for overall survival (OS). ACVEs were recorded from start of oncologic treatment and OS calculated after completion of RT.

RESULTS

A total of 118 patients were analyzed with a median follow-up of 16 months. Median age was 67 years, 65% male, 43% white, 59% with EC of distal esophagus, and 59% had squamous cell carcinoma. Median mean heart dose was 21.93 Gy (range 0.15-36.94). 24% developed G3+ ACVEs: atrial fibrillation 9%, stroke 6%, heart failure 4%, pulmonary embolism 4%, pericardial effusion 3%, myocardial infarction 2%, heart block 2%, and cardiac death 1%. On univariate analyses, CAC >1 vs. CAC ≤ 1 trended towards increased risk of ACVE (HR = 1.95, 95% CI = 0.89-4.26; p = 0.094), however it is not predictive of OS (HR = 1.31, 95% CI = 0.75-2.30; p = 0.343). Proportion of patients with ACVEs was greater in CAC>1 group (Table). When compared to patients with CAC ≤ 1, those with CAC >1 were older (median age 62 vs 72 years, p = 0.0015), less likely to be never smokers (38% vs 30%, p = 0.0437), and more likely to have hypertension (43% vs 64%, p = 0.0197), and hyperlipidemia (30% vs 47%, p = 0.0557).

CONCLUSION

This is the first study to investigate the relationship between CAC score and ACVEs in EC. While the study was underpowered (likely due to low rates of recorded ACVEs), to detect a significant association between CAC score and ACVEs, there was a trend towards increased risk of ACVEs in patients with a CAC score >1 by visual ordinal scoring. Further prospective evaluation with a larger cohort is warranted.

The incorporation of cognitive-sparing techniques into prophylactic cranial irradiation in the management of small cell lung cancer

The use of prophylactic cranial irradiation (PCI) remains an important component in the management of small cell lung cancer (SCLC). This is due to the high rates of subclinical brain metastases at the time of diagnosis. Following a response to initial treatment, PCI historically has been associated with improvements in overall survival and decreased development of brain metastases in patients with limited stage (LS-SCLC) and extensive stage (ES-SCLC) SCLC. However, PCI is commonly withheld in these settings in favor of observation, largely due to its association with cognitive sequelae following treatment. While randomized data has demonstrated that in patients with ES-SCLC, PCI may be withheld in favor of close MRI surveillance without a detriment in overall survival or cognitive functioning, these patients did not undergo formal neuropsychological assessments. In recent years, cognitive sparing techniques incorporated into whole brain radiation therapy and PCI, such as the addition of memantine and hippocampal avoidance, have demonstrated significant improvements in cognitive outcomes. As the overall survival in patients with SCLC continues to improve due to the incorporation of novel systemic therapies (e.g., immune checkpoint inhibitors), the role of PCI and maximizing quality of life remains a highly relevant topic. This article reviews the role of PCI and cognitive-sparing techniques in the management of SCLC.

The Impact of Medicaid Expansion on Patients with Cancer in the United States: A Review

Since 2014, American states have had the option to expand their Medicaid programs as part of the Affordable Care Act (ACA), which was signed into law by former President Barack H. Obama in 2010. Emerging research has found that Medicaid expansion has had a significant impact on patients with cancer, who often face significant financial barriers to receiving the care they need. In this review, we aim to provide a comprehensive examination of the research conducted thus far on the impact of Medicaid expansion on patients with cancer. We begin with a discussion of the history of Medicaid expansion and the key features of the ACA that facilitated it. We then review the literature, analyzing studies that have investigated the impact of Medicaid expansion on cancer patients in terms of access to care, quality of care, and health outcomes. Our findings suggest that Medicaid expansion has had a positive impact on patients with cancer in a number of ways. Patients in expansion states are more likely to receive timely cancer screening and diagnoses, and are more likely to receive appropriate cancer-directed treatment. Additionally, Medicaid expansion has been associated with improvements in cancer-related health outcomes, including improved survival rates. However, limitations and gaps in the current research on the impact of Medicaid expansion on patients with cancer exist, including a lack of long-term data on health outcomes. Additionally, further research is needed to better understand the mechanisms through which Medicaid expansion impacts cancer care.

Impact of selection bias on outcomes in veterans with muscle-invasive bladder cancer receiving bladder preserving trimodality therapy

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Background: Retrospective studies using large registries comparing outcomes between radical cystectomy (RC) with or without neoadjuvant chemotherapy (NAC) to trimodality therapy (TMT), which includes transurethral resection of bladder tumor followed by chemoradiation, often cannot distinguish whether patients receiving TMT were eligible for cystectomy but declined or simply ineligible for cystectomy. The objective of this study was to compare survival outcomes of patients with MIBC receiving TMT stratified by whether they were cystectomy-eligible to patients receiving RC +/- NAC. Methods: We used the national Veterans Affairs’ (VA) database to identify patients diagnosed between 2000-2017 with urothelial histology, MIBC (T2-4a/N0-3/M0) who underwent RC or TMT. Overall survival (OS) was evaluated with multivariable Cox proportional hazards model. Bladder cancer-specific mortality (BCSM) was evaluated with multivariable Fine-Gray regression. We conducted a chart review of clinical notes to ascertain if patients were eligible for cystectomy. Results: Overall 2306 Veterans with MIBC were included: 1472 (64%) with RC without NAC, 506 (22%) with RC-NAC, 107 (4.6%) with TMT eligible for RC, and 221 (9.4%) with TMT ineligible for RC. Median follow up time was 4.7 years. Patients receiving RC were on average 10 years younger, had higher creatinine clearance, and fewer comorbidities than those receiving TMT. Cystectomy-eligible TMT patients had higher creatinine clearance and fewer comorbidities than those ineligible for cystectomy. On multivariable analysis, compared to RC-NAC, TMT in cystectomy-eligible patients was associated with similar OS (hazard ratio [HR] 0.99; 95% confidence interval [CI] 0.76 - 1.28; p = 0.93) and BCSM (HR 1.02; 95% CI 0.71-1.47; p = 0.91). Compared to RC-NAC, TMT in cystectomy-ineligible patients was associated with inferior OS (HR 1.39; 95% CI 1.13 - 1.71; p = 0.002) and BCSM (HR 1.61; 95% CI 1.23 - 2.10; p < 0.001). Conclusions: There is a significant selection bias among patients with MIBC receiving TMT. Cystectomy-eligible patients receiving TMT likely have similar survival outcomes as those receiving RC. Comparisons between RC and TMT in large registry data that lack information regarding eligibility for cystectomy in the TMT arm may be unreliable.

Metastasis and Mortality in Men With Low- and Intermediate-Risk Prostate Cancer on Active Surveillance

BACKGROUND

Active surveillance (AS) is a safe treatment option for men with low-risk, localized prostate cancer. However, the safety of AS for patients with intermediate-risk prostate cancer remains unclear.

PATIENTS AND METHODS

We identified men with NCCN-classified low-risk and favorable and unfavorable intermediate-risk prostate cancer diagnosed between 2001 and 2015 and initially managed with AS in the Veterans Health Administration. We analyzed progression to definitive treatment, metastasis, prostate cancer-specific mortality (PCSM), and all-cause mortality using cumulative incidences and multivariable competing-risks regression.

RESULTS

The cohort included 9,733 men, of whom 1,007 (10.3%) had intermediate-risk disease (773 [76.8%] favorable, 234 [23.2%] unfavorable), followed for a median of 7.6 years. The 10-year cumulative incidence of metastasis was significantly higher for patients with favorable (9.6%; 95% CI, 7.1%-12.5%; P<.001) and unfavorable intermediate-risk disease (19.2%; 95% CI, 13.4%-25.9%; P<.001) than for those with low-risk disease (1.5%; 95% CI, 1.2%-1.9%). The 10-year cumulative incidence of PCSM was also significantly higher for patients with favorable (3.7%; 95% CI, 2.3%-5.7%; P<.001) and unfavorable intermediate-risk disease (11.8%; 95% CI, 6.8%-18.4%; P<.001) than for those with low-risk disease (1.1%; 95% CI, 0.8%-1.4%). In multivariable competing-risks regression, favorable and unfavorable intermediate-risk patients had significantly increased risks of metastasis and PCSM compared with low-risk patients (all P<.001).

CONCLUSIONS

Compared with low-risk patients, those with favorable and unfavorable intermediate-risk prostate cancer managed with AS are at increased risk of metastasis and PCSM. AS may be an appropriate option for carefully selected patients with favorable intermediate-risk prostate cancer, though identification of appropriate candidates and AS protocols should be tested in future prospective studies.

Clinical Data Prediction Model to Identify Patients With Early-Stage Pancreatic Cancer

PURPOSE

Pancreatic cancer is an aggressive malignancy with patients often experiencing nonspecific symptoms before diagnosis. This study evaluates a machine learning approach to help identify patients with early-stage pancreatic cancer from clinical data within electronic health records (EHRs).

MATERIALS AND METHODS

From the Optum deidentified EHR data set, we identified early-stage (n = 3,322) and late-stage (n = 25,908) pancreatic cancer cases over 40 years of age diagnosed between 2009 and 2017. Patients with early-stage pancreatic cancer were matched to noncancer controls (1:16 match). We constructed a prediction model using eXtreme Gradient Boosting (XGBoost) to identify early-stage patients on the basis of 18,220 features within the EHR including diagnoses, procedures, information within clinical notes, and medications. Model accuracy was assessed with sensitivity, specificity, positive predictive value, and the area under the curve.

RESULTS

The final predictive model included 582 predictive features from the EHR, including 248 (42.5%) physician note elements, 146 (25.0%) procedure codes, 91 (15.6%) diagnosis codes, 89 (15.3%) medications, and 9 (1.5%) demographic features. The final model area under the curve was 0.84. Choosing a model cut point with a sensitivity of 60% and specificity of 90% would enable early detection of 58% late-stage patients with a median of 24 months before their actual diagnosis.

CONCLUSION

Prediction models using EHR data show promise in the early detection of pancreatic cancer. Although widespread use of this approach on an unselected population would produce high rates of false-positive tests, this technique may be rapidly impactful if deployed among high-risk patients or paired with other imaging or biomarker screening tools.

Active surveillance for intermediate-risk prostate cancer in African American and non-Hispanic White men

BACKGROUND

The safety of active surveillance (AS) for African American men compared with non-Hispanic White (White) men with intermediate-risk prostate cancer is unclear.

METHODS

The authors identified patients with modified National Comprehensive Cancer Network favorable ("low-intermediate") and unfavorable ("high-intermediate") intermediate-risk prostate cancer diagnosed between 2001 and 2015 and initially managed with AS in the Veterans Health Administration database. They analyzed definitive treatment, disease progression, metastases, prostate cancer-specific mortality (PCSM), and all-cause mortality by using cumulative incidences and multivariable competing-risks (disease progression, metastasis, and PCSM) or Cox (all-cause mortality) regression.

RESULTS

The cohort included 1007 men (African Americans, 330 [32.8%]; Whites, 677 [67.2%]) followed for a median of 7.7 years; 773 (76.8%) had low-intermediate-risk disease, and 234 (23.2%) had high-intermediate-risk disease. The 10-year cumulative incidences of definitive treatment were not significantly different (African Americans, 83.5%; 95% confidence interval [CI], 78.5%-88.7%; Whites, 80.6%; 95% CI, 76.6%-84.4%; P = .17). Among those with low-intermediate-risk disease, there were no significant differences in the 10-year cumulative incidences of disease progression (African Americans, 46.8%; 95% CI, 40.0%-53.3%; Whites, 46.9%; 95% CI, 42.1%-51.5%; P = .91), metastasis (African Americans, 7.1%; 95% CI, 3.7%-11.8%; Whites, 10.8%; 95% CI, 7.6%-14.6%; P = .17), or PCSM (African Americans, 3.8%; 95% CI, 1.6%-7.5%; Whites, 3.8%; 95% CI, 2.0%-6.3%; P = .69). In a multivariable regression including the entire cohort, African American race was not associated with increased risks of definitive treatment, disease progression, metastasis, PCSM, or all-cause mortality (all P > .30).

CONCLUSIONS

Outcomes in the Veterans Affairs Health System were similar for African American and White men treated for low-intermediate-risk prostate cancer with AS.

Outcomes for Muscle-invasive Bladder Cancer with Radical Cystectomy or Trimodal Therapy in US Veterans

Background

Muscle-invasive bladder cancer (MIBC) remains undertreated despite multiple potentially curative options. Both radical cystectomy (RC) with or without neoadjuvant chemotherapy and trimodal therapy (TMT), including transurethral resection of bladder tumor followed by chemoradiotherapy, are standard treatments.

Objective

To evaluate real-world clinical outcomes of RC with neoadjuvant chemotherapy (RC-NAC), RC without NAC, TMT with National Comprehensive Cancer Network guideline–preferred radiosensitizing chemotherapy including cisplatin or mitomycin-C and 5-fluorouracil (pTMT), and TMT with nonpreferred chemotherapy (npTMT).

Design, setting, and participants

US veterans with nonmetastatic MIBC (T2-4aN0-3M0) were studied.

Outcome measurements and statistical analysis

Overall mortality (OM) was evaluated with multivariable Cox proportional hazard model. Bladder cancer-specific mortality (BCSM) was evaluated with multivariable Fine-Gray regression. Salvage cystectomy rates were obtained by chart review.

Results and limitations

Overall 2306 patients were included: 1472 (64%) with RC without NAC, 506 (22%) with RC-NAC, 163 (7%) with pTMT, and 165 (7%) with npTMT. On multivariable analysis, pTMT was associated with similar OM (hazard ratio [HR] 1.19; 95% confidence interval [CI] 0.94–1.50; p = 0.15) and BCSM (HR 1.34; 95% CI 0.99–1.83; p = 0.06) to RC-NAC; npTMT was associated with worse OM (HR 1.30; 95% CI 1.04–1.61; p = 0.02) and BCSM (HR 1.45; 95% CI 1.09–1.94; p = 0.01). RC without NAC was associated with similar OM (HR 1.08; 95% CI 0.95–1.24; p = 0.24) and BCSM (HR 1.02; 95% CI 0.86–1.21; p = 0.79). When stratified by age, among patients ≥65 yr of age, treatment with pTMT was associated with similar OM (HR 1.14; 95% CI 0.87–1.50; p = 0.35) and BCSM (HR 1.11; 95% CI 0.76–1.62; p = 0.60). Among patients <65 yr of age, pTMT was associated with worse OM (HR 1.82; 95% CI 1.14–2.91; p = 0.01) and BCSM (HR 2.51; 95% CI 1.52–4.13; p < 0.01). The 5-yr cumulative incidence of salvage cystectomy in the TMT group was 3.6%.

Conclusions

In MIBC, patients receiving pTMT have comparable survival in RC-NAC patients ≥65 yr and inferior survival in RC-NAC patients <65 yr. Salvage cystectomy rates were low.

Patient summary

Management of muscle-invasive bladder cancer is a multidisciplinary effort requiring thoughtful discussions with patients about treatment options, including trimodal therapy, which is an effective treatment option.

Impact of Radiation on Cardiovascular Outcomes in Older Resectable Esophageal Cancer Patients With Medicare

OBJECTIVES

Preoperative radiotherapy improves outcomes for operable esophageal cancer patients, though the proximity of the heart to the esophagus puts patients at risk of radiation-induced cardiovascular disease. This study characterizes the impact of radiotherapy and different radiation techniques on cardiovascular morbidity among a cohort of esophageal cancer patients.

MATERIALS AND METHODS

We identified 1125 patients aged 65 and older diagnosed between 2000 and 2011 with esophageal cancer who received surgery alone, or surgery preceded by either preoperative chemotherapy or preoperative chemoradiation from the Surveillance Epidemiology and End Results (SEER)-Medicare database. We used Medicare claims to identify severe perioperative and late cardiovascular events. Multivariable logistic regression and Fine-Gray models were used to determine the effect of presurgery treatment on the risk of perioperative and late cardiovascular disease.

RESULTS

Preoperative chemotherapy or chemoradiation did not significantly increase the risk of perioperative cardiovascular complications compared with surgery alone. Patients treated with preoperative chemoradiation had a 36% increased risk of having a late cardiovascular event compared with patients treated with surgery alone (subdistribution hazard ratio [SDHR]: 1.36; P=0.035). There was no significant increase in late cardiovascular events among patients treated with preoperative chemotherapy (SDHR: 1.18; P=0.40). Among patients treated with preoperative chemoradiation, those receiving intensity modulated radiotherapy had a 68% decreased risk of having a late cardiovascular event compared with patients receiving conventional radiation (SDHR: 0.32; P=0.007).

CONCLUSIONS

This study demonstrates an increased risk of cardiovascular complications among operative esophageal cancer patients treated with preoperative chemoradiation, though these risks might be reduced with more cardioprotective radiation techniques such as intensity modulated radiotherapy.

The Influence of Patient-Provider Language Concordance in Cancer Care: Results of the Hispanic Outcomes by Language Approach (HOLA) Randomized Trial

PURPOSE

Delivering linguistically competent care is critical to serving patients who have limited English proficiency (LEP) and represents a key national strategy to help reduce health disparities. Current acceptable standards of communication with patients who have LEP include providers communicating through professional interpretive services or bilingual providers speaking the patients' preferred language directly. This randomized clinical trial tests the effect of patient-provider language concordance on patient satisfaction.

METHODS AND MATERIALS

Eighty-three adult Spanish-speaking patients with cancer were randomly assigned to receive care from either (1) 1 of 2 bilingual physicians speaking to the patient directly in Spanish or (2) the same physicians speaking English and using a professional interpreter service. Validated questionnaires were administered to assess patient-reported satisfaction with both provider communication and overall care. Transcripts of initial consultations were analyzed for content variations.

RESULTS

Compared with patients receiving care through professional interpretive services, patients cared for in direct Spanish reported significantly improved general satisfaction, technical quality of care (mean composite score [MCS], 4.41 vs 4.06; P = .005), care team interpersonal manner (MCS, 4.37 vs 3.88; P = .004), communication (MCS, 4.50 vs 4.25; P = .018), and time spent with patient,(MCS, 4.30 vs 3.92; P = .028). Specific to physician communication, patients rated direct-Spanish care more highly in perceived opportunity to disclose concerns (MCS 4.91 vs 4.62; P = .001), physician empathy (MCS, 4.94 vs 4.59; P <.001), confidence in physician abilities (MCS, 4.84 vs 4.51; P = .001), and general satisfaction with their physician (MCS, 4.88 vs 4.59; P <.001). Analyzing the content of consultation encounters revealed differences between study arms, with the direct-Spanish arm having more physician speech related to patient history verification (mean number of utterances, 13 vs 9; P = .01) and partnering activities (mean utterances, 16 vs 5; P <.001). Additionally, patients in the direct-Spanish arm were more likely to initiate unprompted speech (mean utterances, 11 vs 3; P <.001) and asked their providers more questions (mean utterances, 11 vs 4; P = .007).

CONCLUSIONS

This study shows improved patient-reported satisfaction among patients with cancer who had LEP and were cared for in direct Spanish compared with interpreter-based communication. Further research into interventions to mitigate the patient-provider language barrier is necessary to optimize care for this population.

Transoral robotic surgery for human papillomavirus-associated oropharynx squamous cell carcinoma: Recurrence and survival in the Veterans Affairs health system

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Background: Most transoral robotic surgery (TORS) literature comes from single and multi-institutional studies at tertiary-care academic intuitions. Long-term outcomes for patients with HPV-mediated oropharyngeal squamous cell carcinoma (HPV-OPSCC) treated with upfront TORS in other hospital settings across the United States are largely unknown. We present long-term recurrence and survival outcomes from a novel Veterans Health Administration (VHA) longitudinal dataset that includes patient-level data. Methods: Retrospective analysis of national VHA patients with p16-positive OPSCC diagnosed between January 2010 and December 2016, treated with TORS primary tumor resection with neck dissection. Outcome measures included: Cancer-specific survival (CSS), progression free survival (PFS), overall survival (OS), recurrence, extranodal extension (ENE), positive surgical margin (PSM), and adjuvant therapy regimen. Results: One hundred sixty-one patients were included of whom 29 (18%) were low-risk [0-1 metastatic lymph nodes, negative margins]; 45 (28%) intermediate-risk [close surgical margins, 2 to 4 metastatic nodes, LVI or PNI, pathologic T3 or T4 tumor]; and 87 (54%) high-risk [PSM, ENE, and/or ≥ 5 metastatic nodes]. ENE was present in 41% of cases and 24% of cases had positive surgical margins. Median follow-up was 5.6 years (95% CI 3.0-9.3). The 5-year CSS rates for low, intermediate, and high-risk groups were: 100%, 90.0% (95% CI 75.4-96.1%), and 88.7% (78.3-94.2%). On univariable analysis, pathologic factors associated with inferior CSS were: pT3-T4 tumor category (HR 3.81, 95% CI 1.31-11; p = 0.01), presence of more than four metastatic lymph nodes (HR 3.41, 95% CI 1.20-11; p = 0.02), and ENE (HR 3.53, 95% CI 1.06-12; p = 0.04). Close or PSM were not associated with CSS (HR 0.67, 95% CI 0.21 – 2.14; p = 0.50). In the low-risk group, 48% avoided adjuvant therapy and although there were five recurrences, none died from cancer. The intermediate-risk group was treated with adjuvant radiation in 64% of cases, and chemoradiation in 29% of cases; and there were five locoregional recurrences and three distant recurrences. Adjuvant chemoradiation was used in 68% of high-risk cases. Of the seven total patients with distant recurrences, six died of their disease. Conclusions: Our findings in this national cohort of Veterans with HPV-OPSCC demonstrate that TORS followed by adjuvant therapy yields favorable survival outcomes. Tumor-category, ENE, and more than four nodal metastases were the strongest adverse features in our data, and surgical margins did not have a significant impact on survival. Further investigations with large cohorts and prospective clinical trials are needed to elucidate the true oncologic implications of high-risk features and to identify patients best suited for de-intensified treatment.

Cost-effectiveness of Nivolumab-Ipilimumab Combination Therapy for the Treatment of Advanced Non-Small Cell Lung Cancer

IMPORTANCE

Treatment with nivolumab-ipilimumab combination therapy was found to improve overall survival compared with chemotherapy among patients with advanced non-small cell lung cancer (NSCLC) in the CheckMate 227 clinical trial. However, these drugs are substantially more expensive than chemotherapy and, given the high incidence of advanced NSCLC, the incorporation of dual immune checkpoint inhibitors into the standard of care could have substantial economic consequences.

OBJECTIVE

To assess whether nivolumab-ipilimumab combination therapy is a cost-effective first-line treatment for patients with advanced NSCLC.

DESIGN, SETTING, AND PARTICIPANTS

This economic evaluation designed a Markov model to compare the cost-effectiveness of nivolumab-ipilimumab combination therapy with platinum-doublet chemotherapy as first-line treatment for patients with advanced NSCLC. The Markov model was created to simulate patients with advanced NSCLC who were receiving either nivolumab-ipilimumab combination therapy or platinum-doublet chemotherapy. Transition probabilities, including disease progression, survival, and treatment toxic effects, were derived using data from the CheckMate 227 clinical trial. Costs and health utilities were obtained from published literature. Data analyses were conducted from November 2019 to September 2020.

EXPOSURES

Nivolumab-ipilimumab combination therapy.

MAIN OUTCOMES AND MEASURES

The primary study outcomes were quality-adjusted life-years (QALYs) and cost in 2020 US dollars. Cost-effectiveness was measured using an incremental cost-effectiveness ratio (ICER), with an ICER less than $100 000 per QALY considered cost-effective. Model uncertainty was assessed with 1-way and probabilistic sensitivity analyses.

RESULTS

Treatment with nivolumab-ipilimumab combination therapy was associated with an increase in overall cost of $201 900 and improved effectiveness of 0.50 QALYs compared with chemotherapy, yielding an ICER of $401 700 per QALY. The study model was sensitive to the cost and duration of immunotherapy. Treatment with nivolumab-ipilimumab combination therapy became cost-effective when monthly treatment costs were reduced from $26 425 to $5058 (80.9% reduction) or when the maximum duration of immunotherapy was reduced from 24.0 months to 1.4 months. The model was not sensitive to assumptions about survival or programmed cell death 1 ligand 1 status. A probabilistic sensitivity analysis indicated that, at a willingness-to-pay threshold of $100 000 per QALY, nivolumab-ipilimumab combination therapy was less cost-effective than chemotherapy 99.9% of the time.

CONCLUSIONS AND RELEVANCE

In this study, first-line treatment with nivolumab-ipilimumab combination therapy was not found to be cost-effective at current prices despite clinical trial data indicating that this regimen increases overall survival among patients with advanced NSCLC.

Prognostic utility of pretreatment neutrophil-lymphocyte ratio in survival outcomes in localized non-small cell lung cancer patients treated with stereotactic body radiotherapy: Selection of an ideal clinical cutoff point

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Neutrophil-lymphocyte ratio is a promising prognostic marker for several cancers.

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NLR is not useful as a marker of lung cancer survival in localized lung cancer.

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NLR has potential as a marker of competing mortality risk in localized lung cancer.

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NLR cutoff of 4.0 is proposed as a clinically useful cutoff point.

Background and purpose

Neutrophil-lymphocyte ratio (NLR) has been associated with overall survival (OS) in non-small cell lung cancer (NSCLC). We aimed to assess the utility of NLR as a predictor of lung cancer-specific survival (LCS) and identify an optimal, pretreatment cutoff point in patients with localized NSCLC treated with stereotactic body radiotherapy (SBRT) within the Veterans Affairs’ (VA) national database.

Materials and methods

In the VA database, we identified patients with biopsy-proven, clinical stage I NSCLC treated with SBRT between 2006 and 2015. Cutoff points for NLR were calculated using Contal/O’Quigley’s and Cox Wald methods. Primary outcomes of OS, LCS, and non-lung cancer survival (NCS) were evaluated in Cox and Fine-Gray models.

Results

In 389 patients, optimal NLR cutoff was identified as 4.0. In multivariable models, NLR > 4.0 was associated with decreased OS (HR 1.44, p = 0.01) and NCS (HR 1.68, p = 0.01) but not with LCS (HR 1.32, p = 0.09). In a subset analysis of 229 patients with pulmonary function tests, NLR > 4.0 remained associated with worse OS (HR 1.51, p = 0.02) and NCS (HR 2.18, p = 0.01) while the association with LCS decreased further (HR 1.22, p = 0.39).

Conclusion

NLR was associated with worse OS in patients with localized NSCLC treated with SBRT; however, NLR was only associated with NCS and not with LCS. Pretreatment NLR, with a cutoff of 4.0, offers potential as a marker of competing mortality risk which can aid in risk stratification in this typically frail and comorbid population. Further studies are needed to validate pretreatment NLR as a clinical tool in this setting.

Impact of equal access healthcare on race disparities in bladder cancer

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Background: Outcomes in bladder cancer are disproportionately worse for black patients compared to white patients. We hypothesize these disparities arise in part due to differences in access to healthcare and therefore may be mitigated in an equal access healthcare system, such as the Veterans Affairs’ (VA) system. Here, we examine outcomes by race for patients with bladder cancer within the VA system and then compare these outcomes to those in the Surveillance, Epidemiology, and End Results (SEER) database. Methods: We performed a retrospective cohort study using VA Informatics and Computing Infrastructure (VINCI) and SEER. We included all patients diagnosed with bladder cancer, American Joint Committee on Cancer (AJCC) stage 0-4 diagnosed between 2000 and 2018. Endpoints of overall survival (OS), bladder cancer-specific survival (BCS), and non-bladder cancer-specific survival (NCS) were evaluated in multivariable Cox and Fine-Gray models. Results: Using the VA dataset, we identified 36322 veterans (9.0% black, 91.0% white) with bladder cancer. Black veterans were more likely to have more comorbidities, reside in zip codes with lower median income and education levels, and present with higher stage disease (AJCC stages 2-4) than white veterans (23.3% vs 19%). In multivariable models accounting for disease stage among other covariables, there were no statistically significant differences in any survival endpoint (Table). Using the SEER dataset, we identified 130998 patients (5.9% black, 94.1% white) with bladder cancer. In similar multivariable models, SEER’s black patients had statistically significant inferior outcomes in all survival endpoints compared to SEER’s white patients (Table). Conclusions: While racial disparities for patients with bladder cancer in the SEER database were observed, no differences in survival outcomes between black and white patients were observed in the VA healthcare system. Of note, black veterans presented with more advanced stage, suggesting a delay in diagnosis or a more aggressive cancer phenotype compared to white patients. Our findings underscore the need to bridge healthcare disparities across diverse racial groups. Our study highlights the beneficial impact of an equal access healthcare system in reducing financial and social barriers to healthcare to counteract racial health disparities. Further research is required to delineate these disparities and guide appropriate screening strategies. [Table: see text]

Association Between African American Race and Clinical Outcomes in Men Treated for Low-Risk Prostate Cancer With Active Surveillance

IMPORTANCE

There is concern that African American men with low-risk prostate cancer may harbor more aggressive disease than non-Hispanic White men. Therefore, it is unclear whether active surveillance is a safe option for African American men.

OBJECTIVE

To compare clinical outcomes of African American and non-Hispanic White men with low-risk prostate cancer managed with active surveillance.

DESIGN, SETTING, AND PARTICIPANTS

Retrospective cohort study in the US Veterans Health Administration Health Care System of African American and non-Hispanic White men diagnosed with low-risk prostate cancer between January 1, 2001, and December 31, 2015, and managed with active surveillance. The date of final follow-up was March 31, 2020.

EXPOSURES

Active surveillance was defined as no definitive treatment within the first year of diagnosis and at least 1 additional surveillance biopsy.

MAIN OUTCOMES AND MEASURES

Progression to at least intermediate-risk, definitive treatment, metastasis, prostate cancer-specific mortality, and all-cause mortality.

RESULTS

The cohort included 8726 men, including 2280 African American men (26.1%) (median age, 63.2 years) and 6446 non-Hispanic White men (73.9%) (median age, 65.5 years), and the median follow-up was 7.6 years (interquartile range, 5.7-9.9; range, 0.2-19.2). Among African American men and non-Hispanic White men, respectively, the 10-year cumulative incidence of disease progression was 59.9% vs 48.3% (difference, 11.6% [95% CI, 9.2% to 13.9%); P < .001); of receipt of definitive treatment, 54.8% vs 41.4% (difference, 13.4% [95% CI, 11.0% to 15.7%]; P < .001); of metastasis, 1.5% vs 1.4% (difference, 0.1% [95% CI, -0.4% to 0.6%]; P = .49); of prostate cancer-specific mortality, 1.1% vs 1.0% (difference, 0.1% [95% CI, -0.4% to 0.6%]; P = .82); and of all-cause mortality, 22.4% vs 23.5% (difference, 1.1% [95% CI, -0.9% to 3.1%]; P = 0.09).

CONCLUSIONS AND RELEVANCE

In this retrospective cohort study of men with low-risk prostate cancer followed up for a median of 7.6 years, African American men, compared with non-Hispanic White men, had a statistically significant increased 10-year cumulative incidence of disease progression and definitive treatment, but not metastasis or prostate cancer-specific mortality. Longer-term follow-up is needed to better assess the mortality risk.

Cost effectiveness of combination ipilimumab-nivolumab in advanced non-small-cell lung cancer

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Background: The combination of nivolumab and ipilimumab was found to improve overall survival compared to chemotherapy in patients with advanced non-small-cell lung cancer (NSCLC) in the Checkmate 227 trial. However, nivolumab and ipilimumab are significantly more expensive than chemotherapy, and given the high incidence of advanced lung cancer, incorporating dual checkpoint inhibitors into the standard of care could have substantial economic consequences. In this study, we evaluated the cost effectiveness of combination ipilimumab and nivolumab for the treatment of advanced NSCLC. Methods: We designed a Markov model simulating the three treatment arms of the Checkmate 227 trial: nivolumab plus ipilimumab, nivolumab monotherapy, and chemotherapy. Transition probabilities, such as disease progression, survival, and treatment toxicities, were derived from trial data. Costs (in 2019 United States dollars) and health utilities were estimated from published literature. Incremental cost-effectiveness ratios (ICERs), expressed as dollar per quality-adjusted life-year (QALY), were calculated, with results less than $100,000/QALY considered cost-effective from a healthcare payer perspective. We assessed model uncertainty with one-way and probabilistic sensitivity analyses. Results: In our base-case model, nivolumab and ipilimumab combination therapy increased overall cost by $227,700 and improved effectiveness by 0.55 QALY compared to chemotherapy, resulting in an ICER of $413,400/QALY. Nivolumab monotherapy increased overall cost by $98,500 and improved effectiveness by 0.05 QALY compared to chemotherapy, resulting in an ICER of $1,885,400/QALY. Our model was most sensitive to both the cost and duration of dual immunotherapy. Combination immunotherapy became cost effective at an ICER under $100,000/QALY if monthly costs of treatment were reduced from $26,586 to $8,844 (a 67% reduction) or if maximum allowed duration of immunotherapy was reduced from 24 to 4 months. The model was not sensitive to assumptions about survival differences between the study arms. Probabilistic sensitivity analysis showed that at a willingness-to-pay threshold of $100,000/QALY, dual immunotherapy was less cost-effective than chemotherapy 99.99% of the time. Conclusions: Combination nivolumab and ipilimumab immunotherapy is not cost-effective at current prices despite increasing overall survival for patients with advanced NSCLC.

Cost-effectiveness of combined atezolizumab/nab-paclitaxel for advanced triple-negative breast cancer

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Background: The IMpassion 130 trial found prolonged progression-free and overall survival among PD-L1-positive, advanced triple-negative breast cancer (TNBC) patients receiving atezolizumab and nab-paclitaxel versus nab-paclitaxel alone. These results were the basis of the first FDA approval of a breast cancer immunotherapeutic agent. With the high cost of combined therapy we present a cost-effectiveness analysis of the addition of atezolizumab to nab-paclitaxel for the treatment of advanced TNBC in PD-L1-positive patients. Methods: We constructed a Markov model to simulate cancer progression, survival, and toxicity in advanced TNBC patients receiving atezolizumab and nab-paclitaxel compared to nab-paclitaxel alone. Transition probabilities were derived from the IMpassion 130 trial, while costs (in 2019 US dollars) and health utilities were estimated from the literature. Cost effectiveness was assessed with incremental cost-effectiveness ratios (ICERs), expressed as dollar per quality-adjusted life-year (QALY), with values of less than $100,000/QALY considered cost effective. We conducted one-way and probabilistic sensitivity analyses to examine model uncertainty. Results: Our base-case model found that treatment with atezolizumab and nab-paclitaxel increased overall cost by $120,800 and improved effectiveness by 0.11 QALYs compared with nab-paclitaxel alone, leading to an ICER of $1,101,000/QALY. The base-case model was not sensitive to any single variable. Women in the combined atezolizumab and nab-paclitaxel arm spent more time with stable disease before progression and with progressive disease before death compared to those treated with nab-paclitaxel alone. In our base-case analysis the addition of atezolizumab was not cost effective at any price of atezolizumab secondary to the high costs of stable and progressive disease. If we assumed lower costs of stable disease and progression, our model became sensitive to the cost of atezolizumab. A probabilistic sensitivity analysis found that adding atezolizumab would be cost ineffective 99.9% of the time at a willingness-to-pay of $100,000/QALY. Conclusions: Despite improved clinical outcomes, the addition of atezolizumab would not be considered cost effective in part due to the high costs of stable disease and disease progression among women with advanced TNBC. Novel therapeutics in this costly patient cohort will need to bend the cost curve of stable and progressive disease before becoming cost effective at thresholds acceptable by today’s standards.

Cost-effectiveness analysis of stereotactic ablative radiotherapy in patients with oligometastatic cancer

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Background: The SABR-COMET randomized clinical trial found that stereotactic ablative radiotherapy (SABR) improved outcomes among cancer patients with oligometastatic disease. Yet, the cost of SABR along with the large number of patients with oligometastatic disease raises the important question of value. This study sought to evaluate the cost-effectiveness of SABR compared to standard therapy among cancer patients with oligometastatic disease. Methods: We constructed a Markov model to simulate treatment with stereotactic ablative radiotherapy or standard therapy among patients with oligometastatic cancers. The model derived transition probabilities from clinical trial data to estimate risks of toxicity, disease progression and survival. Healthcare costs and health utilities were estimated from the literature. Cost-effectiveness was estimated with an incremental cost-effectiveness ratio (ICER) defined as dollars per quality-adjusted life year (QALY), with an ICER less than $100,000/QALY considered cost-effective. One-way and probabilistic sensitivity analyses were used to examine model uncertainty. Results: The addition of SABR increased total costs by $54,279 and improved effectiveness by 1.20 QALYs compared with standard therapy, leading to an ICER of $45,162/QALY. The model was sensitive to assumptions about tumor progression, though the model was not sensitive to assumptions about survival or cost of treatment. The cost of SABR would need to increase approximately six-fold from $12,241 to $78,151 before SABR becomes cost-ineffective. Probabilistic sensitivity analyses demonstrated that SABR was the cost-effective treatment option 97.2% of the time. Conclusions: The addition of SABR increased costs and improved quality adjusted survival, overall leading to a cost-effective treatment strategy for patients with oligometastatic cancer.

A novel prediction model to identify patients with early-stage pancreatic cancer

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Background: Pancreatic cancer has an insidious presentation with four-in-five patients presenting with disease not amenable to potentially curative surgery. Efforts to screen patients for pancreatic cancer using population-wide strategies have proven ineffective. We applied a machine learning approach to create an early prediction model drawing on the content of patients’ electronic health records (EHRs). Methods: We used patient data from OptumLabs which included de-identified data extracted from patient EHRs collected between 2009 and 2017. We identified patients diagnosed with pancreatic cancer at age 40 or later, which we categorized into early-stage pancreatic cancer (ESPC; n = 3,322) and late-stage pancreatic cancer (LSPC; n = 25,908) groups. ESPC cases were matched to non-pancreatic cancer controls in a ratio of 1:16 based on diagnosis year and geographic division, and the cohort was divided into training (70%) and test (30%) sets. The prediction model was built using an eXtreme Gradient Boosting machine learning algorithm of ESPC patients’ EHRs in the year preceding diagnosis, with features including patient demographics, procedure and clinical diagnosis codes, clinical notes and medications. Model discrimination was assessed with sensitivity, specificity, positive predictive value (PPV) and area under the curve (AUC) with a score of 1.0 indicating perfect prediction. Results: The final AUC in the test set was 0.841, and the model included 583 features, of which 248 (42.5%) were physician note elements, 146 (25.0%) were procedure codes, 91 (15.6%) were diagnosis codes, 89 (15.3%) were medications and 9 (1.54%) were demographic features. The most important features were history of pancreatic disorders (not diabetes or cancer), age, income, biliary tract disease, education level, obstructive jaundice and abdominal pain. We evaluated model performance at varying classification thresholds. When applied to patients over 40 choosing a threshold with a sensitivity of 20% produced a specificity of 99.9% and a PPV of 2.5%. The model PPV increased with age; for patients over 80, PPV was 8.0%. LSPC patients identified by the model would have been detected a median of 4 months before their actual diagnosis, with a quarter of these patients identified at least 14 months earlier. Conclusions: Using EHR data to identify early-stage pancreatic cancer patients shows promise. While widespread use of this approach on an unselected population would produce high rates of false positives, this technique could be employed among high risk patients, or paired with other screening tools.