Risk factors and health behaviors associated with loneliness among cancer survivors during the COVID-19 pandemic

Loneliness may exacerbate poor health outcomes particularly among cancer survivors during the COVID-19 pandemic. Little is known about the risk factors of loneliness among cancer survivors. We evaluated the risk factors of loneliness in the context of COVID-19 pandemic-related prevention behaviors and lifestyle/psychosocial factors among cancer survivors. Cancer survivors (n = 1471) seen at Huntsman Cancer Institute completed a survey between August-September 2020 evaluating health behaviors, medical care, and psychosocial factors including loneliness during COVID-19 pandemic. Participants were classified into two groups: 'lonely' (sometimes, usually, or always felt lonely in past month) and 'non-lonely' (never or rarely felt lonely in past month). 33% of cancer survivors reported feeling lonely in the past month. Multivariable logistic regression showed female sex, not living with a spouse/partner, poor health status, COVID-19 pandemic-associated lifestyle factors including increased alcohol consumption and marijuana/CBD oil use, and psychosocial stressors such as disruptions in daily life, less social interaction, and higher perceived stress and financial stress were associated with feeling lonely as compared to being non-lonely (all p < 0.05). A significant proportion of participants reported loneliness, which is a serious health risk among vulnerable populations, particularly cancer survivors. Modifiable risk factors such as unhealthy lifestyle behaviors and psychosocial stress were associated with loneliness. These results highlight the need to screen for unhealthy lifestyle factors and psychosocial stressors to identify cancer survivors at increased risk of loneliness and to develop effective management strategies.

Age-related differences in employment, insurance, and financial hardship among colorectal cancer patients: a report from the ColoCare Study

PURPOSE

Employment and financial hardships are common issues for working-age colorectal cancer patients. We surveyed colorectal cancer survivors to investigate employment, insurance, and financial outcomes by age at diagnosis.

METHODS

Cross-sectional survey of six ColoCare Study sites regarding employment, insurance, and financial hardship outcomes. Eligible participants were 1 to 5 years from colorectal cancer diagnosis. Diagnosis age (18-49, 50-64, 65+ years) with outcomes of interest were compared using chi-square and t-tests. Multivariable logistic and Poisson regressions were fit to examine association of demographic factors with any material/psychological hardship (yes/no) and the count of hardships.

RESULTS

N = 202 participants completed the survey (age: 18-49 (n = 42, 20.8%), 50-64 (n = 79, 39.1%), 65+ (n = 81, 40.1%)). Most diagnosed age < 65 worked at diagnosis (18-49: 83%; 50-64: 64%; 65+ : 14%, p < 0.001) and continued working after diagnosis (18-49: 76%; 50-64: 59%; 65+ : 13%; p < 0.001). Participants age 18-49 reported cancer-related difficulties with mental (81.3%) and physical (89%) tasks at work more than those working in the older age groups (45%-61%). In regression models, among those reporting any hardship, the rates of material and psychological hardships were higher among those age 18-64 (Incidence Rate Ratios (IRR) range 1.5-2.3 vs. age 65+) and for those with < college (IRR range 1.3-1.6 vs. college +).

CONCLUSIONS

Younger colorectal cancer patients are more likely to work after a cancer diagnosis and during cancer treatment, but report higher levels of financial hardship than older patients.

IMPLICATIONS FOR CANCER SURVIVORS

Younger colorectal cancer patients may encounter financial hardship, thus may feel a need to work during and after treatment.

Functional quality of life among newly diagnosed young adult colorectal cancer survivors compared to older adults: results from the ColoCare Study

PURPOSE

Colorectal cancer (CRC) incidence and mortality are increasing among young adults (YAs) aged 18-39. This study compared quality of life (QOL) between YA and older adult CRC survivors in the ColoCare Study.

METHODS

Participants were grouped by age (years) as follows: 18-39 (YA), 40-49, 50-64, and 65 + . Functional QOL (physical, social, role, emotional, cognitive) and global QOL were assessed with the EORTC-QLQ-C30 at enrollment, 3, 6, and 12 months. Average scores were compared between groups over time using longitudinal mixed-effect modeling. Proportions with clinically meaningful QOL impairment were calculated using age-relevant thresholds and compared between groups over time using logistic regression with mixed effects.

RESULTS

Participants (N = 1590) were n = 81 YAs, n = 196 aged 40-49, n = 627 aged 50-64, and n = 686 aged 65 + . Average physical function was better among YAs than participants aged 50-64 (p = 0.010) and 65 + (p < 0.001), and average social function was worse among YAs than aged 65 + (p = 0.046). Relative to YAs, all age groups were less likely to report clinically meaningful social dysfunction (aged 40-49 OR = 0.13, 95%CI = 0.06-0.29; aged 50-64 OR = 0.10, 95%CI = 0.05-0.21; aged 65 + OR = 0.07, 95%CI = 0.04-0.15) and role dysfunction (aged 40-49 OR = 0.36, 95%CI = 0.18-0.75; aged 50-64 OR = 0.41, 95%CI = 0.22-0.78; aged 65 + OR = 0.32, 95%CI = 0.17-0.61). Participants aged 40-49 were also less likely to report physical dysfunction (OR = 0.42, 95%CI = 0.19-0.93).

CONCLUSION

YA CRC survivors reported better physical and worse social function compared to older CRC survivors, and YA CRC survivors were more likely to report clinically meaningful social, role, and physical disfunction. Future work should further investigate QOL using age-relevant benchmarks to inform best practices for CRC survivorship care.

TRIAL REGISTRATION

NCT02328677, registered December 2014.

Genomic Classification and Individualized Prognosis in Multiple Myeloma

PURPOSE

Outcomes for patients with newly diagnosed multiple myeloma (NDMM) are heterogenous, with overall survival (OS) ranging from months to over 10 years.

METHODS

To decipher and predict the molecular and clinical heterogeneity of NDMM, we assembled a series of 1,933 patients with available clinical, genomic, and therapeutic data.

RESULTS

Leveraging a comprehensive catalog of genomic drivers, we identified 12 groups, expanding on previous gene expression-based molecular classifications. To build a model predicting individualized risk in NDMM (IRMMa), we integrated clinical, genomic, and treatment variables. To correct for time-dependent variables, including high-dose melphalan followed by autologous stem-cell transplantation (HDM-ASCT), and maintenance therapy, a multi-state model was designed. The IRMMa model accuracy was significantly higher than all comparator prognostic models, with a c-index for OS of 0.726, compared with International Staging System (ISS; 0.61), revised-ISS (0.572), and R2-ISS (0.625). Integral to model accuracy was 20 genomic features, including 1q21 gain/amp, del 1p, TP53 loss, NSD2 translocations, APOBEC mutational signatures, and copy-number signatures (reflecting the complex structural variant chromothripsis). IRMMa accuracy and superiority compared with other prognostic models were validated on 256 patients enrolled in the GMMG-HD6 (ClinicalTrials.gov identifier: NCT02495922) clinical trial. Individualized patient risks were significantly affected across the 12 genomic groups by different treatment strategies (ie, treatment variance), which was used to identify patients for whom HDM-ASCT is particularly effective versus patients for whom the impact is limited.

CONCLUSION

Integrating clinical, demographic, genomic, and therapeutic data, to our knowledge, we have developed the first individualized risk-prediction model enabling personally tailored therapeutic decisions for patients with NDMM.

Spectrum of somatic mutational features of colorectal tumors in ancestrally diverse populations

Ancestrally diverse and admixed populations, including the Hispanic/Latino/a/x/e community, are underrepresented in cancer genetic and genomic studies. Leveraging the Latino Colorectal Cancer Consortium, we analyzed whole exome sequencing data on tumor/normal pairs from 718 individuals with colorectal cancer (128 Latino, 469 non-Latino) to map somatic mutational features by ethnicity and genetic ancestry. Global proportions of African, East Asian, European, and Native American ancestries were estimated using ADMIXTURE. Associations between global genetic ancestry and somatic mutational features across genes were examined using logistic regression. TP53 , APC , and KRAS were the most recurrently mutated genes. Compared to non-Latino individuals, tumors from Latino individuals had fewer KRAS (OR=0.64, 95%CI=0.41-0.97, p=0.037) and PIK3CA mutations (OR=0.55, 95%CI=0.31-0.98, p=0.043). Genetic ancestry was associated with presence of somatic mutations in 39 genes (FDR-adjusted LRT p<0.05). Among these genes, a 10% increase in African ancestry was associated with significantly higher odds of mutation in KNCN (OR=1.34, 95%CI=1.09-1.66, p=5.74×10 -3 ) and TMEM184B (OR=1.53, 95%CI=1.10-2.12, p=0.011). Among RMGs, we found evidence of association between genetic ancestry and mutation status in CDC27 (LRT p=0.0084) and between SMAD2 mutation status and AFR ancestry (OR=1.14, 95%CI=1.00-1.30, p=0.046). Ancestry was not associated with tumor mutational burden. Individuals with above-average Native American ancestry had a lower frequency of microsatellite instable (MSI-H) vs microsatellite stable tumors (OR=0.45, 95%CI=0.21-0.99, p=0.048). Our findings provide new knowledge about the relationship between ancestral haplotypes and somatic mutational profiles that may be useful in developing precision medicine approaches and provide additional insight into genomic contributions to cancer disparities.

Significance

Our data in ancestrally diverse populations adds essential information to characterize mutational features in the colorectal cancer genome. These results will help enhance equity in the development of precision medicine strategies.

Relationships Among Physical Activity, Sleep, and Cancer-related Fatigue: Results From the International ColoCare Study

BACKGROUND

Risk factors for cancer-related fatigue are understudied in colorectal cancer.

PURPOSE

This study aimed to address this critical gap in the literature by (a) describing changes in colorectal cancer-related fatigue and health behavior (physical activity, sleep problems) and (b) examining if physical activity and sleep problems predict fatigue trajectories from baseline (approximately at the time of diagnosis), to 6- and 12 months after enrollment.

METHODS

Patients participating in the international ColoCare Study completed self-report measures at baseline (approximately time of diagnosis), 6-, and 12 months assessing physical activity using the International Physical Activity Questionnaire (IPAQ) and fatigue and sleep using the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC-QLQ-C30). Mixed-effect models examined changes in physical activity, sleep problems, and fatigue. Cross-lagged panel models examined bidirectional relationships between physical activity or sleep and fatigue across time.

RESULTS

Colorectal cancer patients (n = 649) had a mean age of 61 ± 13 years. Most were male (59%), non-Hispanic White (91%), diagnosed with Stages III-IV (56%) colon cancer (58%), and treated with surgery (98%). Within-person cross-lagged models indicated higher physical activity at Month 6 was associated with higher fatigue at Month 12 (β = 0.26, p = .016). When stratified by cancer stage (I-II vs. III-IV), the relationship between physical activity at Month 6 and fatigue at Month 12 existed only for patients with advanced cancer (Stages III and IV, β = 0.43, p = .035). Cross-lagged associations for sleep and fatigue from baseline to Month 6 were only observed in patients with Stages III or IV cancer, however, there was a clear cross-sectional association between sleep problems and fatigue at baseline and Month 6.

CONCLUSIONS

Within-person and cross-lagged association models suggest fatiguability may become increasingly problematic for patients with advanced colorectal cancer the first year after diagnosis. In addition, sleep problems were consistently associated with higher fatigue in the first year, regardless of cancer stage.

TRIAL REGISTRATION

The international ColoCare Study was registered on clinicaltrials.gov, NCT02328677, in December 2014.

Trajectories and risk factors of fatigue following colorectal cancer diagnosis

AIM

This study sought to identify groups of colorectal cancer patients based upon trajectories of fatigue and examine how demographic, clinical and behavioural risk factors differentiate these groups.

METHOD

Patients were from six cancer centres in the United States and Germany. Fatigue was measured using the fatigue subscale of the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC QLQ-C30) at five time points (baseline/enrolment and 3, 6, 12 and 24 months after diagnosis). Piecewise growth mixture models identified latent trajectories of fatigue. Logistic regression models examined differences in demographic, clinical and behavioural characteristics between fatigue trajectory groups.

RESULTS

Among 1615 participants (57% men, 86% non-Hispanic White, mean age 61 ± 13 years at diagnosis), three distinct groups were identified. In the high fatigue group (36%), fatigue significantly increased in the first 6 months after diagnosis and then showed statistically and clinically significant improvement from 6 to 24 months (P values < 0.01). Throughout the study period, average fatigue met or exceeded cutoffs for clinical significance. In the moderate (34%) and low (30%) fatigue groups, fatigue levels remained below or near population norms across the study period. Patients who were diagnosed with Stage II-IV disease and/or current smokers were more likely to be in the high fatigue than in the moderate fatigue group (P values < 0.05).

CONCLUSION

A large proportion of colorectal cancer patients experienced sustained fatigue after initiation of cancer treatment. Patients with high fatigue at the time of diagnosis may benefit from early supportive care.

Elevated EVL Methylation Level in the Normal Colon Mucosa Is a Potential Risk Biomarker for Developing Recurrent Adenomas

BACKGROUND

Individuals with adenomatous colorectal polyps undergo repeated colonoscopy surveillance to identify and remove metachronous adenomas. However, many patients with adenomas do not develop recurrent adenomas. Better methods to evaluate who benefits from increased surveillance are needed. We evaluated the use of altered EVL methylation as a potential biomarker for risk of recurrent adenomas.

METHODS

Patients with ≥1 colonoscopy had EVL methylation (mEVL) measured with an ultra-accurate methylation-specific droplet digital PCR assay on normal colon mucosa. The association between EVL methylation levels and adenoma or colorectal cancer was evaluated using three case/control definitions in three models: unadjusted (model 1), adjusting for baseline characteristics (model 2), and an adjusted model excluding patients with colorectal cancer at baseline (model 3).

RESULTS

Between 2001 and 2020, 136 patients were included; 74 healthy patients and 62 patients with a history of colorectal cancer. Older age, never smoking, and baseline colorectal cancer were associated with higher levels of mEVL (P ≤ 0.05). Each log base 10 difference in mEVL was associated with an increased risk of adenoma(s) or cancer at/after baseline for model 1 [OR, 2.64; 95% confidence interval (CI), 1.09-6.36], and adenoma(s) or cancer after baseline for models 1 (OR, 2.01; 95% CI, 1.04-3.90) and model 2 (OR, 3.17; 95% CI, 1.30-7.72).

CONCLUSIONS

Our results suggest that EVL methylation level detected in the normal colon mucosa has the potential to be a biomarker for monitoring the risk for recurrent adenomas.

IMPACT

These findings support the potential utility of EVL methylation for improving the accuracy for assigning risk for recurrent colorectal adenomas and cancer.

Risk Stratification for Early-onset Colorectal Cancer Screening: Are We Ready for Implementation?

Early-onset colorectal cancer (EOCRC) is increasing at alarming rates and identifying risk factors is a high priority. There is a need to develop risk stratification approaches for colorectal cancer screening among younger populations. Although there is a growing body of evidence identifying risk factors for EOCRC, including the report by Imperiale and colleagues in this issue, risk stratification for EOCRC screening has not been implemented into practice. This publication highlights how essential it is to bring research findings into practice and bridge the gaps between developing risk prediction modeling in epidemiology and implementation science. While encouraging, we are still a long way off from having a clinically applicable risk prediction tool. See related article by Imperiale et al., p. 513.

Metabolic Dysregulation Explains the Diverse Impacts of Obesity in Males and Females with Gastrointestinal Cancers

The prevalence of obesity, defined as the body mass index (BMI) ≥ 30 kg/m2, has reached epidemic levels. Obesity is associated with an increased risk of various cancers, including gastrointestinal ones. Recent evidence has suggested that obesity disproportionately impacts males and females with cancer, resulting in varied transcriptional and metabolic dysregulation. This study aimed to elucidate the differences in the metabolic milieu of adenocarcinomas of the gastrointestinal (GI) tract both related and unrelated to sex in obesity. To demonstrate these obesity and sex-related effects, we utilized three primary data sources: serum metabolomics from obese and non-obese patients assessed via the Biocrates MxP Quant 500 mass spectrometry-based kit, the ORIEN tumor RNA-sequencing data for all adenocarcinoma cases to assess the impacts of obesity, and publicly available TCGA transcriptional analysis to assess GI cancers and sex-related differences in GI cancers specifically. We applied and integrated our unique transcriptional metabolic pipeline in combination with our metabolomics data to reveal how obesity and sex can dictate differential metabolism in patients. Differentially expressed genes (DEG) analysis of ORIEN obese adenocarcinoma as compared to normal-weight adenocarcinoma patients resulted in large-scale transcriptional reprogramming (4029 DEGs, adj. p < 0.05 and |logFC| > 0.58). Gene Set Enrichment and metabolic pipeline analysis showed genes enriched for pathways relating to immunity (inflammation, and CD40 signaling, among others) and metabolism. Specifically, we found alterations to steroid metabolism and tryptophan/kynurenine metabolism in obese patients, both of which are highly associated with disease severity and immune cell dysfunction. These findings were further confirmed using the TCGA colorectal adenocarcinoma (CRC) and esophageal adenocarcinoma (ESCA) data, which showed similar patterns of increased tryptophan catabolism for kynurenine production in obese patients. These patients further showed disparate alterations between males and females when comparing obese to non-obese patient populations. Alterations to immune and metabolic pathways were validated in six patients (two obese and four normal weight) via CD8+/CD4+ peripheral blood mononuclear cell RNA-sequencing and paired serum metabolomics, which showed differential kynurenine and lipid metabolism, which corresponded with altered T-cell transcriptome in obese populations. Overall, obesity is associated with differential transcriptional and metabolic programs in various disease sites. Further, these alterations, such as kynurenine and tryptophan metabolism, which impact both metabolism and immune phenotype, vary with sex and obesity together. This study warrants further in-depth investigation into obesity and sex-related alterations in cancers that may better define biomarkers of response to immunotherapy.

Whole-Exome sequencing analysis identified TMSB10/TRABD2A locus to be associated with carfilzomib-related cardiotoxicity among patients with multiple myeloma

Background

Proteasome inhibitor Carfilzomib (CFZ) is effective in treating patients with refractory or relapsed multiple myeloma (MM) but has been associated with cardiovascular adverse events (CVAE) such as hypertension, cardiomyopathy, and heart failure. This study aimed to investigate the contribution of germline genetic variants in protein-coding genes in CFZ-CVAE among MM patients using whole-exome sequencing (WES) analysis.

Methods

Exome-wide single-variant association analysis, gene-based analysis, and rare variant analyses were performed on 603,920 variants in 247 patients with MM who have been treated with CFZ and enrolled in the Oncology Research Information Exchange Network (ORIEN) at the Moffitt Cancer Center. Separate analyses were performed in European Americans and African Americans followed by a trans-ethnic meta-analysis.

Results

The most significant variant in the exome-wide single variant analysis was a missense variant rs7148 in the thymosin beta-10/TraB Domain Containing 2A (TMSB10/TRABD2A) locus. The effect allele of rs7148 was associated with a higher risk of CVAE [odds ratio (OR) = 9.3 with a 95% confidence interval of 3.9-22.3, p = 5.42*10^-7]. MM patients with rs7148 AG or AA genotype had a higher risk of CVAE (50%) than those with GG genotype (10%). rs7148 is an expression quantitative trait locus (eQTL) for TRABD2A and TMSB10. The gene-based analysis also showed TRABD2A as the most significant gene associated with CFZ-CVAE (p = 1.06*10^-6).

Conclusions

We identified a missense SNP rs7148 in the TMSB10/TRABD2A as associated with CFZ-CVAE in MM patients. More investigation is needed to understand the underlying mechanisms of these associations.

Abstract 355: Examination of systemic myokine concentrations with risk of cachexia in non-metastatic colorectal cancer patients - Results from the ColoCare Study

BACKGROUND: Cachexia is a multifactorial metabolic syndrome associated with higher risk of mortality. The precise molecular mechanisms and biological pathways involved remain poorly characterized. A specific criterion of cachexia is loss of muscle mass. Myokines affect muscle mass and have profound effects on glucose and lipid metabolism, thus contributing to energy homeostasis and potentially cachexia. Only sparse data for patients with non-metastatic colorectal cancer exist. This study aims to investigate associations of systemic myokine concentrations with onset of cachexia in non-metastatic colorectal cancer patients.

METHODS: Serum samples from n=125 colorectal cancer patients (stage I-III) recruited from the ColoCare Study site at Huntsman Cancer Institute were collected prior to surgery (baseline). Assays were run with the Milliplex Human Myokine Magnetic panel containing beads such as FABP3, Oncostatin M, and FGF21. Patients were defined as cachectic, pre-cachectic, or non-cachectic based on the criteria by Fearon et al. based on sex, BMI, and weight loss over a period of six months. ANOVA were applied to analyze associations of myokines with cachexia at 12 month after surgery, adjusted by age at diagnosis, sex, tumor stage, and tumor site.

RESULTS: At the 12 months follow-up, 11% of patients were diagnosed with cachexia (n=14), 14% of patients with pre-cachexia (n=18), and 74% of patients were defined as non-cachectic. Patients with cachexia were more likely to be diagnosed with rectal cancer (57%) compared to pre-cachectic (17%) or non-cachectic patients (42%; p&lt;0.01). Patients who received neo-adjuvant treatment were more likely to be cachectic compared to pre-cachectic or non-cachectic patients (36% vs 11% vs 26%, respectively, p&lt;0.01). FABP3 at baseline was significantly different across the three groups, e.g., FABP3 was 11.4 pg/ml for cachectic patients, 10.5 pg/ml for pre-cachectic patients, and 10.4 pg/ml for non-cachectic patients (p=0.02). FABP3 was associated with 65% increased risk of cachexia in unadjusted models, e.g., Odds ratio 1.65, 95% Confidence Intervals 1.05-2.61; p=0.03). After additional adjustment for age, sex, tumor site, and tumor stage the result was non-significant (p=0.26). There were no statistically significant differences in FGF21 and Oncostatin M concentrations across cachexia stages. C

ONCLUSIONS: Cachectic patients presented higher FABP3 concentrations (p=0.02) which were associated with increased risk of cachexia, however these results were not significant after adjustment. In this study, cachectic patients were more likely to be diagnosed with rectal cancer. In summary, larger studies are needed to further evaluate FABP3 and other myokines as potential prognostic biomarkers for cachexia and consider differences by tumor site.

Citation Format: Jennifer Ose, Ellen Beswick, Simon Ta Van, Richard H. Viskochil, Christy A. Warby, Jeffrey T. Yap, Matthew F. Covington, Anne H. Nguyen, Jordan W. Stanford, Tengda Lin, Anita R. Peoples, Sheetal Hardikar, Christopher I. Li, William M. Grady, David Shibatta, Adetunji T. Toriola, Martin Schneider, Jane C. Figueiredo, Daniel Jeong, Erin M. Siegel, Cornelia M. Ulrich, Biljana Gigic. Examination of systemic myokine concentrations with risk of cachexia in non-metastatic colorectal cancer patients - Results from the ColoCare Study [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2023; Part 1 (Regular and Invited Abstracts); 2023 Apr 14-19; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2023;83(7_Suppl):Abstract nr 355.

Associations of combined physical activity and body mass index groups with colorectal cancer survival outcomes

BACKGROUND

Physical activity and BMI have been individually associated with cancer survivorship but have not yet been studied in combinations in colorectal cancer patients. Here, we investigate individual and combined associations of physical activity and BMI groups with colorectal cancer survival outcomes.

METHODS

Self-reported physical activity levels (MET hrs/wk) were assessed using an adapted version of the International Physical Activity Questionnaire (IPAQ) at baseline in 931 patients with stage I-III colorectal cancer and classified into 'highly active' and'not-highly active'(≥ / < 18 MET hrs/wk). BMI (kg/m2) was categorized into 'normal weight', 'overweight', and 'obese'. Patients were further classified into combined physical activity and BMI groups. Cox-proportional hazard models with Firth correction were computed to assess associations [hazard ratio (HR), 95% profile HR likelihood confidence interval (95% CI) between individual and combined physical activity and BMI groups with overall and disease-free survival in colorectal cancer patients.

RESULTS

'Not-highly active' compared to 'highly active' and 'overweight'/ 'obese' compared to 'normal weight' patients had a 40-50% increased risk of death or recurrence (HR: 1.41 (95% CI: 0.99-2.06), p = 0.03; HR: 1.49 (95% CI: 1.02-2.21) and HR: 1.51 (95% CI: 1.02-2.26), p = 0.04, respectively). 'Not-highly active' patients had worse disease-free survival outcomes, regardless of their BMI, compared to 'highly active/normal weight' patients. 'Not-highly active/obese' patients had a 3.66 times increased risk of death or recurrence compared to 'highly active/normal weight' patients (HR: 4.66 (95% CI: 1.75-9.10), p = 0.002). Lower activity thresholds yielded smaller effect sizes.

CONCLUSION

Physical activity and BMI were individually associated with disease-free survival among colorectal cancer patients. Physical activity seems to improve survival outcomes in patients regardless of their BMI.

Pre-Surgery Inflammatory and Angiogenesis Biomarkers as Predictors of 12-Month Cancer-Related Distress: Results from the ColoCare Study

BACKGROUND

Patients with colorectal cancer commonly suffer from complex psychological distress. Elevated distress may be linked to systemic biomarkers. We investigated associations of biomarkers of inflammation and angiogenesis with cancer-related distress (CTXD) score.

METHODS

N = 315 patients (stage I-IV) from 2 centers of the ColoCare Study were included: Huntsman Cancer Institute and University of Heidelberg. Biomarkers (e.g., IL6, VEGF-A, VEGF-D) were measured in serum collected pre-surgery and 12 months thereafter. The CTXD overall score and 4 subscales were collected 12 months after surgery and dichotomized to investigate biomarkers as predictors of distress 12 months after surgery; adjusted for age, sex, body mass index, tumor stage, center, and baseline levels of biomarkers.

RESULTS

Doubling of IL6 predicted future increased risk of overall distress [odds ratio (OR), 1.20; 95% confidence interval (CI), 1.02-1.41; P = 0.03]. VEGF-A-predicted future increased risk of high family strain (VEGF-A: OR, 1.21; 95% CI, 1.01-1.44; P = 0.04) and VEGF-D was associated with medical and financial demands (OR, 1.34; 95% CI, 1.01-1.74; P = 0.03).

CONCLUSIONS

This is the first study to show that systemic biomarkers are significantly associated with future CTXD score. Distress was not measured at baseline; we cannot rule out ongoing associations of inflammation and distress throughout treatment versus a direct effect of inflammation on distress. Nonetheless, these data add to evidence that biobehavioral processes interact and that systemic biomarkers are associated with cancer-related distress one year after surgery.

IMPACT

Exercise and diet interventions that lower systemic cytokine levels may impact longer-term CTXD score and improve quality of life of patients with colorectal cancer.

Low muscle mass is associated with a higher risk of all-cause and cardiovascular disease-specific mortality in cancer survivors

OBJECTIVES

Individuals with prior cancer diagnosis are more likely to have low muscle mass (LMM) than their cancer-free counterparts. Understanding the effects of LMM on the prognosis of cancer survivors can be clinically important. The aim of this study was to investigate whether risks for all-cause and cardiovascular disease (CVD)-specific mortality differ by status of LMM in cancer survivors and a matched cohort without cancer history.

METHODS

We used cohort data from the 1999-2006 and 2011-2014 National Health and Nutrition Examination Survey. Participants included 946 adults surviving for ≥1 since cancer diagnosis and a matched cohort (by age, sex, and race) without cancer history (N = 1857). LMM was defined by appendicular lean mass and body height (men <7.26 kg/m2, women <5.45 kg/m2). Death was ascertained via the National Death Index and cause of death was assessed via International Classification of Diseases, Tenth Revision. Multivariable Cox proportional hazards models were used to estimate adjusted hazard ratio (aHR) and 95% confidence interval (CI) of LMM.

RESULTS

The mean age of cancer survivors and matched cohort was 60.6 y (SD 15) and 60.2 y (SD 14.9), respectively. The median follow-up was 10.5 y for survivors and 10.9 y for matched cohort. Overall, 22.2% of cancer survivors and 19.7% of the matched cohort had LMM, respectively. In all, 321 survivors (33.9%) and 495 participants (26.7%) in the matched cohort died during follow-up. CVD-specific deaths were identified in 58 survivors (6.1%) and 122 participants in the matched cohort (6.6%). The multivariable Cox model suggested that LMM was positively associated with all-cause (aHR, 1.73; 95% CI, 1.31-2.29) and CVD-specific (aHR, 2.13; 95% CI, 1.14-4.00) mortality in cancer survivors. The associations between LMM and risk for all-cause (aHR, 1.24; 95% CI, 0.98-1.56) and CVD-specific (aHR, 1.21; 95% CI, 0.75-1.93) mortality were not statistically significant in the matched cohort.

CONCLUSION

Cancer survivors with LMM have an increased risk for all-cause and CVD-specific mortality. This increase appears to be larger than that in counterparts without cancer history.

Detectable Lipidomes and Metabolomes by Different Plasma Exosome Isolation Methods in Healthy Controls and Patients with Advanced Prostate and Lung Cancer

Circulating exosomes in the blood are promising tools for biomarker discovery in cancer. Due to their heterogeneity, different isolation methods may enrich distinct exosome cargos generating different omic profiles. In this study, we evaluated the effects of plasma exosome isolation methods on detectable multi-omic profiles in patients with non-small cell lung cancer (NSCLC), castration-resistant prostate cancer (CRPC), and healthy controls, and developed an algorithm to quantify exosome enrichment. Plasma exosomes were isolated from CRPC (n = 10), NSCLC (n = 14), and healthy controls (n = 10) using three different methods: size exclusion chromatography (SEC), lectin binding, and T-cell immunoglobulin domain and mucin domain-containing protein 4 (TIM4) binding. Molecular profiles were determined by mass spectrometry of extracted exosome fractions. Enrichment analysis of uniquely detected molecules was performed for each method with MetaboAnalyst. The exosome enrichment index (EEI) scores methods based on top differential molecules between patient groups. The lipidomic analysis detected 949 lipids using exosomes from SEC, followed by 246 from lectin binding and 226 from TIM4 binding. The detectable metabolites showed SEC identifying 191 while lectin binding and TIM4 binding identified 100 and 107, respectively. When comparing uniquely detected molecules, different methods showed preferential enrichment of different sets of molecules with SEC enriching the greatest diversity. Compared to controls, SEC identified 28 lipids showing significant difference in NSCLC, while only 1 metabolite in NSCLC and 5 metabolites in CRPC were considered statistically significant (FDR < 0.1). Neither lectin-binding- nor TIM4-binding-derived exosome lipids or metabolites demonstrated significant differences between patient groups. We observed the highest EEI from SEC in lipids (NSCLC: 871.33) which was also noted in metabolites. These results support that the size exclusion method of exosome extraction implemented by SBI captures more heterogeneous exosome populations. In contrast, lectin-binding and TIM4-binding methods bind surface glycans or phosphatidylserine moieties of the exosomes. Overall, these findings suggest that specific isolation methods select subpopulations which may significantly impact cancer biomarker discovery.

Abstract P010: Molecular mediators of the energy balance-colorectal cancer link: evaluating the gut microbiome and pro-inflammatory biomarkers

Background: Physical activity and BMI are convincingly associated with colorectal cancer risk, yet the underlying molecular mediators and their interplay in the energy balance-cancer link remain unclear. Possible counteracting effects of physical activity on obesity-induced metabolic changes, including systemic inflammation and changes in the gut microbiome, have yet to be studied. Here, we investigated associations of several combinations of physical activity and BMI with pro-inflammatory biomarkers and the gut microbiome and relationships between these two mediators among patients with colorectal cancer. Methods: N=579 patients with newly diagnosed colorectal cancer (stages I-IV) were included. Physical activity at baseline was assessed using an adapted International Physical Activity Questionnaire (IPAQ) and participants were classified as being ‘active’ or ‘inactive’ based on physical activity guidelines. BMI at baseline was abstracted from medical records and categorized into ‘normal weight’ and ‘overweight/obese’. Pro-inflammatory biomarkers (CRP, SAA, IL-6, IL-8, and TNF-α) were measured in pre-surgery serum samples. In a subset of patients (n=179), 16S rRNA gene sequencing was additionally performed in pre-surgery stool samples. Relative abundances were determined for each taxonomic level and used to calculate diversity metrics. Analyses were adjusted for sex, stage at diagnosis, neoadjuvant treatment, and study site. Results: ‘Obese’ patients had 88% and 17% higher CRP and TNF-α levels compared to ‘normal weight’ patients (p=0.03 and 0.02, respectively). Highest CRP levels were observed among ‘overweight or obese/inactive’ compared to ‘normal weight/active’ patients (p=0.03). Lower gut microbial diversity was observed among ‘inactive’ vs. ‘active’ patients (Shannon index: p=0.01, Simpson: p=0.03), ‘obese’ vs. ‘normal weight’ patients (Shannon index, Simpson, and Observed species: p=0.02, respectively), and ‘overweight or obese/inactive’ vs. ‘normal weight/active’ patients (Shannon index: p=0.02, Observed species: p=0.04). Two phyla and 12 genera (e.g., Actinobacteria and Fusobacteria, and Ruminococcus, Succinivibrio, Succiniclasticum) were differentially abundant across physical activity and BMI groups. High CRP and TNF-α levels were statistically significantly associated with lower alpha diversity metrics (p=0.02-0.05). Conclusions: This is the first evidence indicating that the gut microbiome may be a molecular mediator of the energy balance-colorectal cancer link. We further provide evidence of associations between physical activity and BMI groups with pro-inflammatory biomarkers. While BMI was identified as the key driver of inflammation, biomarker levels were higher among ‘inactive’ patients across BMI groups. Physical activity may offset obesity-induced inflammation and gut microbiome dysbiosis. Our results further provide new insights into the host-microbiome interactions with respect to systemic inflammation.

Citation Format: Caroline Himbert, W. Zac Stephens, Biljana Gigic, Tengda Lin, Jennifer Ose, Anjelica Ashworth, Christy Warby, David Nix, Jolanta Jedrzkiewicz, Anita R Peoples, Mary Bronner, Bartley Pickron, Courtney Scaife, Jessica N. Cohan, William M. Grady, Stacey A. Cohen, Mukta Krane, Petra Schrotz-King, Jane C. Figueiredo, Adetunji T. Toriola, Erin M. Siegel, Christopher I. Li, Alexis Ulrich, David Shibata, June L. Round, Lyen C. Huang, Martin Schneider, Sheetal Hardikar, Cornelia M Ulrich. Molecular mediators of the energy balance-colorectal cancer link: evaluating the gut microbiome and pro-inflammatory biomarkers. [abstract]. In: Proceedings of the AACR Special Conference: Precision Prevention, Early Detection, and Interception of Cancer; 2022 Nov 17-19; Austin, TX. Philadelphia (PA): AACR; Can Prev Res 2023;16(1 Suppl): Abstract nr P010.

Individual-level factors associated with COVID-19 vaccine acceptance among U.S. patients with cancer

INTRODUCTION

Vaccine hesitancy in the wake of the COVID-19 pandemic is a major public health concern in the US. Cancer patients are especially vulnerable to adverse COVID-19 outcomes and require targeted prevention efforts against COVID-19.

METHODS

We used longitudinal survey data from patients seen at Moffitt Cancer Center to identify attitudes, beliefs, and sociodemographic factors associated with COVID-19 vaccination acceptance among cancer patients. Patients with confirmed invasive cancer diagnosis through Cancer Registry data were asked about vaccine acceptance through the question "Now that a COVID-19 vaccine is available, are you likely to get it?" and dichotomized into high accepters (already received it, would get it when available) and low accepters (waiting for a doctor to recommend it, waiting until more people received it, not likely to get it).

RESULTS

Most patients (86.8% of 5,814) were high accepters of the COVID-19 vaccine. High accepters had more confidence in the effectiveness and safety of the vaccine than low accepters. Multivariable logistic regression showed older individuals (70-89 vs.18-49: OR:2.57, 95% CI:1.33-4.86), those with greater perceived severity of COVID-19 infection (very serious vs. not at all serious: OR:2.55, 95% CI:1.76-3.70), practicing more risk mitigation behaviors (per one standard deviation OR:1.75, 95% CI:1.57-1.95), and history of receiving the flu shot versus not (OR:6.56, 95% CI:5.25-8.20) had higher odds of vaccine acceptance. Individuals living with more than one other person (vs. alone: OR: 0.53, 95% CI: 0.35, 0.79) and those who were more socioeconomically disadvantaged (per 10 percentile points: OR: 0.89, 95 %CI: 0.85, 0.93) had lower odds of reporting vaccine acceptance.

CONCLUSION

Most patients with cancer have or would receive the COVID-19 vaccine. Those who are less likely to accept the vaccine have more concerns regarding effectiveness and side effects, are younger, more socioeconomically disadvantaged, and have lower perceptions of COVID-19 severity.

Differences in the gut microbiome by physical activity and BMI among colorectal cancer patients

Associations of energy balance components, including physical activity and obesity, with colorectal cancer risk and mortality are well established. However, the gut microbiome has not been investigated as underlying mechanism. We investigated associations of physical activity, BMI, and combinations of physical activity/BMI with gut microbiome diversity and differential abundances among colorectal cancer patients. N=179 patients with colorectal cancer (stages I-IV) were included in the study. Pre-surgery stool samples were used to perform 16S rRNA gene sequencing (Illumina). Physical activity (MET hrs/wk) during the year before diagnosis was assessed by questionnaire and participants were classified as being active vs. inactive based on guidelines. BMI at baseline was abstracted from medical records. Patients were classified into four combinations of physical activity levels/BMI. Lower gut microbial diversity was observed among 'inactive' vs. 'active' patients (Shannon: P=0.01, Simpson: P=0.03), 'obese' vs. 'normal weight' patients (Shannon, Simpson, and Observed species: P=0.02, respectively), and 'overweight/obese/inactive' vs. 'normal weight/active' patients (Shannon: P=0.02, Observed species: P=0.04). Results differed by sex and tumor site. Two phyla and 12 genera (Actinobacteria and Fusobacteria, Adlercreutzia, Anaerococcus, Clostridium, Eubacterium, Mogibacteriaceae, Olsenella, Peptinophilus, Pyramidobacter, RFN20, Ruminococcus, Succinivibrio, Succiniclasticum) were differentially abundant across physical activity and BMI groups. This is the first evidence for associations of physical activity with gut microbiome diversity and abundances, directly among colorectal cancer patients. Our results indicate that physical activity may offset gut microbiome dysbiosis due to obesity. Alterations in gut microbiota may contribute mechanistically to the energy balance-colorectal cancer link and impact clinical outcomes.

Associations of individual and combined physical activity and body mass index groups with pro-inflammatory biomarkers among colorectal cancer patients

BACKGROUND

Physical activity and obesity are well-established factors of colorectal cancer (CRC) risk and prognosis. Here, we investigate associations of individual and combined physical activity and BMI groups with pro-inflammatory biomarkers in CRC patients.

METHODS

Self-reported physical activity levels were classified as 'active' (≥8.75 MET-hrs/wk) vs. 'inactive' (<8.75 MET-hrs/wk) in n=579 stage I-IV CRC patients enrolled in the ColoCare Study. BMI [normal weight (≥18.5-<25kg/m2), overweight (≥25-<30kg/m2), and obese (≥30kg/m2)] was abstracted from medical records. Patients were classified into four combinations of physical activity levels and BMI. Biomarkers (CRP, SAA, IL-6, IL-8, and TNF-α) in pre-surgery serum samples were measured using Meso-Scale-Discovery platform. Regression models were used to compute relative percent differences in biomarker levels by physical activity and BMI groups.

RESULTS

'Inactive' patients had non-statistically significant higher IL-6 levels compared to 'active' patients (+36%, p=0.10). 'Obese' patients had 88% and 17% higher CRP and TNF-α levels compared to 'normal weight' patients (p=0.03 and 0.02, respectively). Highest CRP levels were observed among 'overweight or obese/inactive' compared to 'normal weight/active' patients (p=0.03).

CONCLUSION

We provide evidence of associations between individual and combined physical activity and BMI groups with pro-inflammatory biomarkers. While BMI was identified as the key driver of inflammation, biomarker levels were higher among 'inactive' patients across BMI groups.

IMPACT

This is the largest study in CRC patients investigating associations of energy balance components with inflammatory biomarkers. Our results suggest that physical activity may reduce obesity-induced inflammation in CRC patients and support the design of randomized controlled trials testing this hypothesis.

Presurgery Adhesion Molecules and Angiogenesis Biomarkers Are Differently Associated with Outcomes in Colon and Rectal Cancer: Results from the ColoCare Study

BACKGROUND

Cell-to-cell adhesion and angiogenesis are hallmarks of cancer. No studies have examined associations of adhesion molecules and angiogenesis biomarkers with clinical outcomes in colorectal cancer.

METHODS

In presurgery serum from n = 426 patients with colorectal cancer (stage I-III), we investigated associations of CRP, SAA, adhesion molecules (sICAM-1, sVCAM-1), and angiogenesis markers (VEGF-A and VEGF-D) with overall survival (OS), disease-free survival (DFS), and risk of recurrence. We computed HRs and 95% confidence intervals; adjusted for age, sex, BMI, stage, site, and study site, stratified by tumor site in exploratory analyses.

RESULTS

N = 65 (15%) were deceased, and 39 patients (14%) had a recurrence after a median follow-up of 31 months. We observed significant associations of biomarkers with OS, DFS, and risk of recurrence on a continuous scale and comparing top to bottom tertile, with HRs ranging between 1.19 and 13.92. CRP was associated with risk of death and recurrence in patients in the top tertile compared with patients in the bottom tertile, for example, risk of recurrence HRQ3-Q1: 13.92 (1.72-112.56). Significant heterogeneity between biomarkers and clinical outcomes was observed in stratified analysis by tumor site for CRP, SAA, sICAM-1, sVCAM-1, and VEGF-D. VEGF-D was associated with a 3-fold increase in risk of death for rectal cancer (HRlog2: 3.26; 95% CI, 1.58-6.70) compared with no association for colon cancer (HRlog2: 0.78; 95% CI, 0.35-1.73; Pheterogenity = 0.01).

CONCLUSIONS

Adhesion molecules and angiogenesis biomarkers are independent prognostic markers for colorectal cancer, with differences by tumor site.

IMPACT

There is need for tailored treatment for colon and rectal cancer.

Factors associated with changes in exercise behaviors during the COVID-19 pandemic

PURPOSE

There is limited information on how the COVID-19 pandemic has changed health behaviors among cancer patients. We examined changes in exercise behaviors since the pandemic and identified characteristics associated with these changes among cancer patients.

METHODS

Cancer patients (n = 1,210) completed a survey from August to September 2020 to assess COVID-19 pandemic-related changes in health behaviors and psychosocial factors. Patients were categorized into three groups: exercising less, exercising did not change, and exercising more. Patient characteristics were compared by exercise groups.

RESULTS

One-third of the patients reported a decreased amount of regular exercise, while 10% reported exercising more during the pandemic. Patients who exercised less were more likely to be unemployed/retired and have poor health status and psychosocial stressors such as disruptions in daily life while less likely to be former smokers (all p < 0.05). In contrast, patients who exercised more were younger, had stage IV diagnosis, and also reported disruptions in daily life (all p < 0.05). Patients who were living in rural areas were also more likely not to experience changes in exercise habits (all p < 0.05), although rural-urban status was not identified as a strong predictor.

CONCLUSION

A significant proportion of cancer patients experienced changes in exercise habits, especially exercising less, during the first 6 months of the COVID-19 pandemic. Age, employment status, tumor stage, health status, smoking status, and psychosocial factors were associated with changes in exercise behaviors. Our results highlight the importance of promoting physical activity guidelines for cancer survivorship during the COVID-19 pandemic and may help improve the identification of cancer patients susceptible to exercising less.

Abstract 36: Treatment patterns in stage I-III colorectal cancer patients over 65 years of age

Background: Older patients (&gt;65 years) are frequently under-represented in clinical trials that determine cancer treatment guidelines. We sought to characterize treatment patterns among older patients and identify factors for receipt of non-standard of care (SOC) treatment.

Methods: The National Cancer Database (NCDB) was queried to describe treatment patterns in stage I-III colorectal cancer patients (2004-2017) over 65 years of age. Patients with metastatic disease and non-adenocarcinoma histology were excluded. SOC therapy was defined as any recommended treatment option listed within site- and stage-specific National Comprehensive Cancer Network guidelines. Clinicodemographic characteristics and treatment patterns were compared between colon and rectal cancer patients by ten-year age-groups. Multivariable logistic regression analysis was used to determine factors associated with receipt of treatment, by tumor site and stage.

Results: Of the 498,285 patients who met inclusion criteria, 47% were 65-75 years while 15% were &gt;85 years old (median age: 76 years). The majority were non-Hispanic White (88%), female (52%), Medicare insured (86%), colon cancer patients (76%) with a Charlson comorbidity index (CCI) of 0 (63%). Significant differences in treatment patterns by age were observed; for e.g., 11% of stage I colon cancer patients &gt;85 years of age did not receive SOC surgical treatment but rather received radiation-only treatment compared to only 2% patients 65-75 years of age who received radiation-only treatment. In logistic regression analyses adjusted for diagnosis year, sex, race/ethnicity, CCI, insurance, income, education, hospital type, treatment facility, rurality, and geographic region, older patients were more likely to receive non-SOC treatments for colon cancer stage I [OR(95% CI) for 76-85 years 1.31(1.23,1.40); &gt;85 years 3.41(3.17,3.66)], stage II-III [OR(95% CI) for 76-85 years 1.96(1.92,2.01); &gt;85 years 3.50(3.40,3.60)], rectal cancer stage I [OR(95% CI) for 76-85 years 2.06(1.89,2.24); &gt;85 years 6.36(5.77,7.02)], and stage II-III [OR(95% CI) for 76-85 years 2.14(2.07,2.22); &gt;85 years 9.02(8.33,9.77)] compared to 65-75 year old patients. Other predictors of receiving non-SOC treatments for both colon and rectal cancers included Black race (p&lt;0.001), CCI &gt;3 (p&lt;0.001), lack of insurance (p&lt;0.001), and treatment at a community cancer clinic (p&lt;0.001).

Discussion: Compared to 65-75 year-old stage I-III colorectal cancer patients, older patients at all disease stages are more likely to not receive SOC treatment. Other predictors for receiving non-SOC treatment are Black race, presence of comorbidities, lack of insurance, and treatment at a community cancer clinic. Future observational and randomized studies are needed to define the optimal treatment paradigms in older colorectal cancer patients, identify and address disparities, and better support these patients.

Citation Format: Sheetal Hardikar, Christopher R. Weil, Shane Lloyd, Jessica N. Cohan, Mark A. Supiano, Jennifer Ose, Anita R. Peoples, Sumati V. Gupta, Kaitlyn Pelletier, Martine Extermann, Erin M. Siegel, David Shibata, Cornelia M. Ulrich. Treatment patterns in stage I-III colorectal cancer patients over 65 years of age [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2022; 2022 Apr 8-13. Philadelphia (PA): AACR; Cancer Res 2022;82(12_Suppl):Abstract nr 36.

Abstract 3417: Effects of plasma exosome isolation methods on detectable multiomic profiles in cancer patients and healthy controls

Introduction: Circulating exosomes in blood have been considered as a treasure chest for biomarker discovery in cancer. Due to their heterogeneity, different isolation methods may enrich distinct exosome cargos generating different omic profiles. In this study, we evaluated the effects of plasma exosome isolation methods on detectable multiomic profiles in cancer patients and healthy controls.

Methods: Plasma exosomes were isolated from prostate cancer patients (PC; N = 11), lung cancer patients (LC; N = 13), and matched healthy controls (HC; N = 10) using three methods [SBI (size exclusion), Takara (lectin binding), and Wako (Tim4 binding)]. Mass spectrometry was performed to determine exosome lipidome and metabolome profiles. To evaluate group-specific exosome enrichment, we developed an exosome enrichment index (EEI) by summing 50 smallest p-values after log2 transformation. Higher EEI indicates prefrential capture of significant exosome cargos from patients over controls.

Results: Our data showed that the SBI method generated the most identified lipids from exosome across all groups (LC = 935, PC = 939, and HC = 943), followed by Takara (245, 245 and 245) and Wako (205, 208 and 213). Compared to controls, LC patients had 31 higher and 5 lower lipid levels (FDR &lt; 0.1) using the SBI and 3 higher and 1 lower level (FDR &lt; 0.1) using Takara. We did not observe any differences between cancer and normal samples using Wako. The most detectable known metabolites were found in exosomes from SBI (LC = 188, PC = 191, and HC = 100), followed by Wako (LC = 107, PC = 107, and HC = 107) and Takara (LC = 99, PC = 100, and HC = 100). Of the metabolites from SBI, 5 were significantly higher (FDR&lt;0.1) in PC patients than in controls. The most significant metabolite in PC was L-Cystathionine, which has been shown to be upregulated in bone-metastatic PC3 cells. Neither Takara nor Wako exosome fractions showed differently expressed metabolites between any groups. Our EEI analysis showed the highest lipid EEI from SBI in PC (474.4) and LC (906.74), while a lower lipid EEI from Takara in PC (359.9), LC (495.58), and Wako in PC (307.5) and LC (148.1). Metabolite EEI showed an EEI range from 590.3 in SBI PC to 185.6 in Takara LC. SBI, again, achieved the highest EEI for both PC and LC (357.3).

Conclusion: These results support that the SBI method can capture more heterogeneous exosome populations, possibly because this size exclusion-based method does not discriminate exosomes with different protein components. In contrast, Takara and Wako methods target exosome surface proteins, enriching specific exosome subpopulations resulting in less diversity of detectable lipids and metabolites. Overall, these findings suggest that exosome isolation methods can select subpopulations and determine the exosome content, which will significantly impact exosome-based biomarker discovery.

Citation Format: Alex C. Soupir, Paul A. Stewart, Yury Nunez Lopez, Brandon J. Manley, Bruna Pellini, Jingsong Zhang, Qianxing Mo, Douglas C. Marchion, Min Lui, John M. Koomen, Erin M. Siegel, Liang Wang. Effects of plasma exosome isolation methods on detectable multiomic profiles in cancer patients and healthy controls [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2022; 2022 Apr 8-13. Philadelphia (PA): AACR; Cancer Res 2022;82(12_Suppl):Abstract nr 3417.

Abstract 3221: Differences in body composition among rectal cancer patients with neo-adjuvant treatment-related toxicity: Results from the ColoCare Study

BACKGROUND Neo-adjuvant chemoradiation is standard of care for patients diagnosed with stage II and III rectal cancer. This treatment can cause significant toxicities and may require treatment modifications. Obesity and low muscle mass (=sarcopenia) may portend increased toxicity to chemotherapy and/or radiation and may further affect mortality in rectal patients. The present study investigates associations of pre-treatment body composition parameters with toxicity in prospectively followed rectal cancer patients.

METHODS This initial analysis includes data from n=320 stage II and III rectal cancer patients from four study sites of the ColoCare Study. All patients underwent neo-adjuvant treatment. Pre-treatment CT scans were semi-automatically segmented at spinal level L3 vertebrae using SliceOmatic + ABACS software v5.0 rev13 to quantify: subcutaneous and visceral fat area (SFA/VFA, cm2) and skeletal muscle area (SMA, cm2). Information on toxicities was abstracted from medical charts and categorized into gastrointestinal, cardiovascular, and other system-specific toxicities. Median values were calculated for continuous variables (e.g., age at diagnosis, VFA, SFA, and SMA) and compared among patients who did versus did not experience toxicities. Frequencies and percentages were calculated for categorical variables.

RESULTS Among n=320 rectal cancer patients, n=48 (15%) patients experienced at least one toxicity that required treatment modification (defined as dose reduction or discontinuation of therapy). Patients who experienced toxicities were older (58 years vs 56 years), more likely to be male (63% vs 59%), and more likely to be diagnosed with stage III cancer (92% vs 69%) compared to patients who did not experience toxicities. Patients who had higher VFA (166 cm2 vs 148 cm2), lower SFA (197 cm2 vs 208 cm2), and lower SMA (144 cm2 vs 147 cm2) were more likely to experience toxicities compared to patients with lower VFA, higher SFA, or higher SMA.

CONCLUSIONS Body composition parameters may differ between rectal cancer patients who experience toxicities versus those who do not. Multivariate logistic regression and Cox proportional hazard analyses are underway to investigate in more detail the associations of body composition parameters (VFA, SFA, SMA), sarcopenia, and sarcopenic obesity with toxicity and survival in rectal cancer patients.

Citation Format: Jennifer Ose, Jeffrey T. Yap, Daniel Jeong, Simon Ta Van, Matthew F. Covington, Biljana Gigic, Johanna Nattenmueller, Benjamin Haaland, Tengda Lin, Sheetal Hardikar, Caroline Himbert, Anita R. Peoples, Anjelica Ashworth, Juergen Boehm, Petra Schrotz-King, Jane C. Figueiredo, Adetunji T. Toriola, Erin M. Siegel, Christopher I. Li, Alexis B. Ulrich, Martin Schneider, Hans-Ulrich Kauczor, David Shibata, Cornelia M. Ulrich. Differences in body composition among rectal cancer patients with neo-adjuvant treatment-related toxicity: Results from the ColoCare Study [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2022; 2022 Apr 8-13. Philadelphia (PA): AACR; Cancer Res 2022;82(12_Suppl):Abstract nr 3221.

Abstract 3227: Prognostic role of systemic inflammation in colon and rectal cancer patients: Results from the ColoCare Study

Purpose: Inflammation and angiogenesis are hallmarks of cancer development and progression. No studies have prospectively examined association of angiogenesis-related biomarkers with clinical outcomes in colon and rectal cancer.

Patients and Methods: In pre-surgery serum samples from n=426 non-metastatic colorectal cancer (CRC) patients (stage I-III), we investigated associations of inflammatory (e.g., CRP, SAA, sICAM-1, sVCAM-1) and angiogenesis biomarkers (VEGF-A, VEGF-D) with overall survival (OS), disease-free survival (DFS), and risk of recurrence. We computed hazard ratios (HR) and 95% confidence intervals (CI). Analyses were adjusted for age, sex, body mass index, stage, tumor site, and study site, and also exploratory stratified by tumor site (colon vs. rectum).

Results: N=65 patients (15%) were deceased and n=59 patients (15%) had a recurrence after a median follow-up of 31 months. Overall, doubling of CRP was associated with a ~24% increase in risk of death (OS: HRlog2: 1.24; 95% CI: 1.11-1.40), a 19% increase in risk of recurrence: HRlog2: 1.19; 95% CI: 1.08-1.32, and a non-statistically-significant 12% increase for DFS HRlog2: 1.12; 95% CI: 0.98-1.28. Similar associations were observed for SAA. Doubling of sICAM-1 was associated with a 4-fold increase in risk of death (OS: HRlog2: 4.05; 95% CI: 2.35-6.98). For the angiogenesis marker VEGF-D, significant heterogeneity was observed in analyses stratified by tumor site: doubling was associated with a 3-fold increase in risk of death for rectal cancer (OS: HR: 3.26; 95% CI: 1.58-6.70) and a 22% reduction in mortality for colon cancer (OS: HR: 0.78; 95% CI: 0.35-1.73; pheterogenity &lt;0.001). Similar heterogeneity was observed in associations of VEGF-D with DFS and risk of recurrence, although not statistically significant (pheterogeneity&lt;0.10).

Conclusion: Our data suggest that some biomarkers of inflammation and angiogenesis are prognostic markers for stage I-III CRC patients, with potential differences by tumor site for angiogenesis markers.

Citation Format: Jennifer Ose, Tengda Lin, Caroline Himbert, Christy A. Warby, Sheetal Hardikar, Juergen Boehm, Biljana Gigic, Petra Schrotz-King, Martin Schneider, Alexis B. Ulrich, David Shibata, Jane C. Figueiredo, Erin M. Siegel, Christopher I. Li, Adetunji T. Toriola, Cornelia M. Ulrich. Prognostic role of systemic inflammation in colon and rectal cancer patients: Results from the ColoCare Study [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2022; 2022 Apr 8-13. Philadelphia (PA): AACR; Cancer Res 2022;82(12_Suppl):Abstract nr 3227.

DACH1 mutation frequency in endometrial cancer is associated with high tumor mutation burden in a nationwide cohort

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Background: DACH1 is a novel transcriptional repressor and tumor suppressor gene. DACH1 mutations are associated with poor prognostic features and reduced overall survival in endometrial cancer, with an increased prevalence in the Appalachian region of Kentucky. Preliminary studies have suggested an association with an increase in tumor mutation burden. In this follow up study, we utilized the nationwide Oncology Research Information Exchange Network (ORIEN) to determine the frequency of DACH1 mutations in patients with endometrial cancer through a multi-institution analysis and evaluate its impact on RNA expression, clinical correlates, and outcomes. Methods: We obtained clinical and genomic data for 691 patients with endometrial cancer from nine U.S. institutions within the ORIEN collaborative. We examined the clinical attributes of the cancers with DACH1 status by comparing whole-exome sequencing (WES), RNA Sequencing (RNASeq), microsatellite instability (MSI), and tumor mutational burden (TMB). Results: Appalachian women with endometrial cancer had an increased frequency of DACH1 mutations (6/41 patients, 15%) compared to the non-Appalachian endometrial cancer population (24/581 patients, 4.1%) with p-value = 0.010, with the non-Appalachian DACH1 mutation frequency mirroring the rate of DACH1 gene mutation seen in TCGA at 3.8%. DACH1 mutated patients have a higher tumor mutation burden compared to DACH1 wild-type (32.2 vs. 4.62, p-value = 0.001) though no differences in microsatellite instability between DACH1 mutated and wild-type were present (p-value = 0.350). DACH1 mutations showed significant gene co-occurrence patterns with POLE, MLH1, MSH2, MSH6 and PMS2. Conclusions: DACH1 mutations are prevalent in Kentucky patients with endometrial cancer, particularly those from the Appalachian region. These results were again reflected in the TCGA PanCancer Atlas as well as the ORIEN multi-institution cohort. These mutations are associated with high tumor mutational burden and co-occur with genome destabilizing gene mutations. These findings suggest DACH1 as a candidate biomarker for future trials with immunotherapy, particularly in endometrial cancers.

A New Approach to Understanding Cancer-Related Fatigue: Leveraging the 3P Model to Facilitate Risk Prediction and Clinical Care

Simple Summary

For the growing number of cancer survivors worldwide, fatigue presents a major hurdle to function and quality of life. Treatment options for cancer-related fatigue are still emerging, and our current understanding of its etiology is limited. In this paper, we describe a new application of a comprehensive model for cancer-related fatigue: the predisposing, precipitating, and perpetuating (3P) factors model. We propose that the 3P model may be leveraged—particularly using metabolomics, the microbiome, and inflammation in conjunction with behavioral science—to better understand the pathophysiology of cancer-related fatigue.

Abstract

A major gap impeding development of new treatments for cancer-related fatigue is an inadequate understanding of the complex biological, clinical, demographic, and lifestyle mechanisms underlying fatigue. In this paper, we describe a new application of a comprehensive model for cancer-related fatigue: the predisposing, precipitating, and perpetuating (3P) factors model. This model framework outlined herein, which incorporates the emerging field of metabolomics, may help to frame a more in-depth analysis of the etiology of cancer-related fatigue as well as a broader and more personalized set of approaches to the clinical treatment of fatigue in oncology care. Included within this review paper is an in-depth description of the proposed biological mechanisms of cancer-related fatigue, as well as a presentation of the 3P model’s application to this phenomenon. We conclude that a clinical focus on organization risk stratification and treatment around the 3P model may be warranted, and future research may benefit from expanding the 3P model to understand fatigue not only in oncology, but also across a variety of chronic conditions.

Characterization of Epigenomic Alterations in HPV16+ Head and Neck Squamous Cell Carcinomas

BACKGROUND

Epigenetic changes associated with human papillomavirus (HPV)-driven tumors have been described; however, HPV type-specific alterations are less well understood. We sought to compare HPV16-specific methylation changes with those in virus-unassociated head and neck squamous cell carcinomas (HNSCC).

METHODS

Within The Cancer Genome Atlas, 59 HPV16+ HNSCC, 238 nonviral HNSCC (no detectable HPV or other viruses), and 50 normal head and neck tissues were evaluated. Significant differentially methylated regions (DMR) were selected, and key associated genes were identified. Partial least squares models were generated to predict HPV16 status in additional independent samples.

RESULTS

HPV infection in HNSCC is associated with type-specific methylomic profiles. Multiple significant DMRs were identified between HPV16+, nonviral, and normal samples. The most significant differentially methylated genes, SYCP2, MSX2, HLTF, PITX2, and GRAMD4, demonstrated HPV16-associated methylation patterns with corresponding alterations in gene expression. Phylogenetically related HPV types (alpha-9 species; HPV31, HPV33, and HPV35) demonstrated a similar methylation profile to that of HPV16 but differed from those seen in other types, such as HPV18 and 45 (alpha-7).

CONCLUSIONS

HNSCC linked to HPV16 and types from the same alpha species are associated with a distinct methylation profile. This HPV16-associated methylation pattern is also detected in cervical cancer and testicular germ cell tumors. We present insights into both shared and unique methylation alterations associated with HPV16+ tumors and may have implications for understanding the clinical behavior of HPV-associated HNSCC.

IMPACT

HPV type-specific methylomic changes may contribute to understanding biologic mechanisms underlying differences in clinical behavior among different HPV+ and HPV- HNSCC.

Factors associated with self-reported social isolation among patients with cancer during the COVID-19 pandemic

OBJECTIVE

We aimed to identify patient-level demographic and behavioral characteristics associated with higher social isolation among patients with cancer throughout the coronavirus disease 2019 (COVID-19) pandemic.

METHOD

Moffitt Cancer Center patients seen on or after January 1, 2015, had a last known alive vital status, a valid e-mail address, and were 18-89 years old, were emailed a survey regarding social isolation. We collected information on age, sex, race, ethnicity, marital status, smoking, self-reported cancer diagnosis, cancer treatment, and perceived life changes due to the COVID-19 pandemic. We calculated a COVID-19 risk mitigation score by summing the frequency of risk mitigation behaviors (e.g., mask wearing). Social isolation was assessed with the self-reported Patient-Reported Outcomes Measurement Information System (PROMIS) Social Isolation Short Form. Logistic regression models compared characteristics of participants reporting higher versus lower social isolation (T-scores >60 vs. ≤60).

RESULTS

Most participants (N = 9,579) were female (59.2%), White (93.0%), and non-Hispanic (92.5%). Participants at greater odds of higher social isolation were younger (per 10 years decrease odds ratio [OR] = 1.36, 95% confidence interval, CI [1.30, 1.43]), female (vs. male OR = 1.54, 95% CI [1.36, 1.74]), unmarried (vs. married OR = 1.83, 95% CI [1.62, 2.08]), current smokers (vs. never OR = 2.38, 95% CI [1.88, 3.00]), reporting more risk mitigation behaviors (per 1 SD; OR = 1.33, 95% CI [1.24, 1.42]), and more perceived life changes (vs. little/no change; OR = 2.64, 95% CI [2.08, 3.35]).

CONCLUSIONS

We identified younger age, females, unmarried, current smokers, more risk mitigation behaviors, and more perceived life changes increased odds of social isolation for patients with cancer during the COVID-19 pandemic. This can inform identification of patients with cancer at higher risk of social isolation for targeted mitigation strategies. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Evaluation of Antibody Response to SARS-CoV-2 mRNA-1273 Vaccination in Patients With Cancer in Florida

Importance

Patients with cancer experience high rates of morbidity and mortality after SARS-CoV-2 infection. Immune response to mRNA-1273 vaccination across multiple cancer types and treatments remains to be established.

Objective

To quantitate antibody responses after mRNA-1273 vaccination among patients with solid tumors and hematologic cancer and to assess clinical and treatment factors associated with vaccine response.

Design, Setting, and Participants

This cohort study included patients with cancer who were aged 18 years or older, spoke English or Spanish, had received their first mRNA-1273 dose between January 12 and 25, 2021, and agreed to blood tests before and after vaccination.

Exposures

Receipt of 1 and 2 mRNA-1273 SARS-CoV-2 vaccine doses.

Main Outcomes and Measures

Seroconversion after each vaccine dose and IgG levels against SARS-CoV-2 spike protein obtained immediately before the first and second vaccine doses and 57 days (plus or minus 14 days) after the first vaccine dose. Cancer diagnoses and treatments were ascertained by medical record review. Serostatus was assessed via enzyme-linked immunosorbent assay. Paired t tests were applied to examine days 1, 29, and 57 SARS-CoV-2 antibody levels. Binding antibody IgG geometric mean titers were calculated based on log10-transformed values.

Results

The 515 participants were a mean (SD) age of 64.5 (11.4) years; 262 (50.9%) were women; and 32 (6.2%) were Hispanic individuals and 479 (93.0%) White individuals; race and ethnicity data on 4 (0.7%) participants were missing. Seropositivity after vaccine dose 2 was 90.3% (465; 95% CI, 87.4%-92.7%) among patients with cancer, was significantly lower among patients with hematologic cancer (84.7% [255]; 95% CI, 80.1%-88.6%) vs solid tumors (98.1% [210]; 95% CI, 95.3%-99.5%), and was lowest among patients with lymphoid cancer (70.0% [77]; 95% CI, 60.5%-78.4%). Patients receiving a vaccination within 6 months after anti-CD20 monoclonal antibody treatment had a significantly lower seroconversion (6.3% [1]; 95% CI, 0.2%-30.2%) compared with those treated 6 to 24 months earlier (53.3% [8]; 95% CI, 26.6%-78.7%) or those who never received anti-CD20 treatment (94.2% [456]; 95% CI, 91.7%-96.1%). Low antibody levels after vaccination were observed among patients treated with anti-CD20 within 6 months before vaccination (GM, 15.5 AU/mL; 95% CI, 9.8-24.5 AU/mL), patients treated with small molecules (GM, 646.7 AU/mL; 95% CI, 441.9-946.5 AU/mL), and patients with low lymphocyte (GM, 547.4 AU/mL; 95% CI, 375.5-797.7 AU/mL) and IgG (GM, 494.7 AU/mL; 95% CI, 304.9-802.7 AU/mL) levels.

Conclusions and Relevance

This cohort study found that the mRNA-1273 SARS-CoV-2 vaccine induced variable antibody responses that differed by cancer diagnosis and treatment received. These findings suggest that patients with hematologic cancer and those who are receiving immunosuppressive treatments may need additional vaccination doses.

Impact of the COVID-19 pandemic on rural and urban cancer patients' experiences, health behaviors, and perceptions

Purpose

The COVID‐19 pandemic has disrupted many facets of life. We evaluated pandemic‐related health care experiences, COVID‐19 prevention behaviors and measures, health behaviors, and psychosocial outcomes among rural and urban cancer patients.

Methods

Among 1,472 adult cancer patients, who visited Huntsman Cancer Institute in the past 4 years and completed a COVID‐19 survey (August‐September 2020), we assessed the impact of the pandemic on medical appointments, prevention/health behaviors, and psychosocial factors, stratified by urbanicity.

Findings

Mean age was 61 years, with 52% female, 97% non‐Hispanic White, and 27% were residing in rural areas. Rural versus urban patients were more likely to be older, not employed, uninsured, former/current smokers, consume alcohol, and have pandemic‐related changes/cancellations in surgery appointments (all P<.05). Changes/cancellations in other health care access (eg, doctor's visits) were also common, particularly among urban patients. Urban versus rural patients were more likely to socially distance, use masks and hand sanitizer, and experience changes in exercise habits and in their daily lives (all P<.05). Less social interaction and financial stress were common among cancer patients but did not differ by urbanicity.

Conclusions

These findings suggest that the COVID‐19 pandemic had a substantial impact on cancer patients, with several challenges specific to rural patients. This comprehensive study provides unique insights into the first 6 months of COVID‐19 pandemic‐related experiences and continuity of care among rural and urban cancer patients predominantly from Utah. Further research is needed to better characterize the pandemic's short‐ and long‐term effects on rural and urban cancer patients and appropriate interventions.

Association of circulating leukocyte telomere length with survival in patients with colorectal cancer

INTRODUCTION

Telomere shortening, as seen with aging, can cause chromosomal instability and promote cancer progression. We investigated the association between circulating telomere length and overall and disease-free survival in a sub-cohort of patients with colorectal cancer.

METHODS

Baseline genomic DNA from blood leukocytes was extracted from N = 92 newly diagnosed stage I-IV patients with colorectal cancer enrolled at the ColoCare Study site in Heidelberg, Germany. Detailed information on clinicodemographic (including age) and lifestyle risk factors, and clinical outcomes (including recurrence and survival) was collected. Telomere length was measured in DNA using multiplex quantitative polymerase chain reaction. Kaplan Meier survival curves were generated comparing shorter to longer telomere lengths with log-rank testing.

RESULTS

The mean T/S ratio for study patients was 0.5 (range: 0.3-0.9). Shorter telomeres were associated with older age at baseline. Patients with shorter telomeres experienced a worse overall and disease-free survival, although this association did not reach statistical significance. Kaplan-Meier survival curves for those with circulating telomere length below vs. above the median showed poorer overall (log-rank p = 0.31) and disease-free survival (long-rank p = 0.23).

CONCLUSIONS

Our results suggest that individuals with shorter telomeres, as seen with aging, may experience a worse overall and disease-free survival after colorectal cancer diagnosis. Larger sample sizes with longer follow-up are needed to further evaluate telomere length as a prognostic biomarker in colorectal cancer progression.

Genome-wide host methylation profiling of anal and cervical carcinoma

HPV infection results in changes in host gene methylation which, in turn, are thought to contribute to the neoplastic progression of HPV-associated cancers. The objective of this study was to identify joint and disease-specific genome-wide methylation changes in anal and cervical cancer as well as changes in high-grade pre-neoplastic lesions. Formalin-fixed paraffin-embedded (FFPE) anal tissues (n = 143; 99% HPV+) and fresh frozen cervical tissues (n = 28; 100% HPV+) underwent microdissection, DNA extraction, HPV genotyping, bisulfite modification, DNA restoration (FFPE) and analysis by the Illumina HumanMethylation450 Array. Differentially methylated regions (DMR; t test q<0.01, 3 consecutive significant CpG probes and mean Δβ methylation value>0.3) were compared between normal and cancer specimens in partial least squares (PLS) models and then used to classify anal or cervical intraepithelial neoplasia-3 (AIN3/CIN3). In AC, an 84-gene PLS signature (355 significant probes) differentiated normal anal mucosa (NM; n = 9) from AC (n = 121) while a 36-gene PLS signature (173 significant probes) differentiated normal cervical epithelium (n = 10) from CC (n = 9). The CC progression signature was validated using three independent publicly available datasets (n = 424 cases). The AC and CC progression PLS signatures were interchangeable in segregating normal, AIN3/CIN3 and AC and CC and were found to include 17 common overlapping hypermethylated genes. Moreover, these signatures segregated AIN3/CIN3 lesions similarly into cancer-like and normal-like categories. Distinct methylation changes occur across the genome during the progression of AC and CC with overall similar profiles and add to the evidence suggesting that HPV-driven oncogenesis may result in similar non-random methylomic events. Our findings may lead to identification of potential epigenetic drivers of HPV-associated cancers and also, of potential markers to identify higher risk pre-cancerous lesions.

Cancer Detection and Classification by CpG Island Hypermethylation Signatures in Plasma Cell-Free DNA

Simple Summary

The detection of DNA methylation changes in blood has emerged as a promising approach for cancer diagnosis and management. Our group has previously optimized a blood DNA methylation profiling technology that is based on affinity capture of methylated DNA, termed cfMBD-seq. The aim of this study was to assess the potential clinical feasibility of cfMBD-seq. We applied cfMBD-seq to the blood samples of cancer patients and identified methylation signatures that can not only discriminate cancer patients from cancer-free individuals but can also enable accurate multi-cancer classification. Our findings will help to expand on existing blood-based molecular diagnostic tests and identify novel methylation biomarkers for early cancer detection and classification.

Abstract

Cell-free DNA (cfDNA) methylation has emerged as a promising biomarker for early cancer detection, tumor type classification, and treatment response monitoring. Enrichment-based cfDNA methylation profiling methods such as cfMeDIP-seq have shown high accuracy in the classification of multiple cancer types. We have previously optimized another enrichment-based approach for ultra-low input cfDNA methylome profiling, termed cfMBD-seq. We reported that cfMBD-seq outperforms cfMeDIP-seq in the enrichment of high-CpG-density regions, such as CpG islands. However, the clinical feasibility of cfMBD-seq is unknown. In this study, we applied cfMBD-seq to profiling the cfDNA methylome using plasma samples from cancer patients and non-cancer controls. We identified 1759, 1783, and 1548 differentially hypermethylated CpG islands (DMCGIs) in lung, colorectal, and pancreatic cancer patients, respectively. Interestingly, the vast majority of DMCGIs were overlapped with aberrant methylation changes in corresponding tumor tissues, indicating that DMCGIs detected by cfMBD-seq were mainly driven by tumor-specific DNA methylation patterns. From the overlapping DMCGIs, we carried out machine learning analyses and identified a set of discriminating methylation signatures that had robust performance in cancer detection and classification. Overall, our study demonstrates that cfMBD-seq is a powerful tool for sensitive detection of tumor-derived epigenomic signals in cfDNA.

Impact of the COVID-19 pandemic on exercise habits among cancer patients

Purpose There is limited information on how the COVID-19 pandemic has changed health behaviors among cancer patients. We examined the impact of the pandemic on changes in exercise behaviors and identified characteristics associated with these changes among cancer patients. Methods Cancer patients (n  =  1,361) completed a survey from August-September 2020 to assess COVID-19 pandemic-related changes in health behaviors and psychosocial factors. Patients were categorized into 3 groups: exercising less, exercising did not change, and exercising more. Patient characteristics were compared by exercise groups. Results One-third of the patients reported a decreased amount of regular exercise, while 11% reported exercising more during the pandemic. Patients who exercised less were more likely to be unemployed/retired, undergoing active treatment, and had increased pandemic-related alcohol consumption and psychosocial stressors such as loneliness and financial stress (all p  < 0.05). In contrast, patients who exercised more were younger, female, full-time employed, did not consume alcohol, and had good health status and more social interactions (all p  < 0.05). Patients who were living in rural areas and did not experience changes in daily life, were also more likely not to experience changes in exercise habits (all p  < 0.05). Conclusion Our results indicate that a significant proportion of cancer patients experienced changes in exercise habits during the first 6 months of the COVID-19 pandemic. Age, sex, employment status, health status, alcohol consumption, and psychosocial factors were associated with changes in exercise behaviors. Providers should monitor for changes in health behaviors, such as exercise, because of their importance in improving cancer survivorship.

Improving Electronic Survey Response Rates Among Cancer Center Patients During the COVID-19 Pandemic: Mixed Methods Pilot Study

BACKGROUND

Surveys play a vital role in cancer research. During the COVID-19 pandemic, the use of electronic surveys is crucial to improve understanding of the patient experience. However, response rates to electronic surveys are often lower compared with those of paper surveys.

OBJECTIVE

The aim of this study was to determine the best approach to improve response rates for an electronic survey administered to patients at a cancer center during the COVID-19 pandemic.

METHODS

We contacted 2750 patients seen at Moffitt Cancer Center in the prior 5 years via email to complete a survey regarding their experience during the COVID-19 pandemic, with patients randomly assigned to a series of variations of prenotifications (ie, postcard, letter) or incentives (ie, small gift, modest gift card). In total, eight combinations were evaluated. Qualitative interviews were conducted to understand the level of patient understanding and burden with the survey, and quantitative analysis was used to evaluate the response rates between conditions.

RESULTS

A total of 262 (9.5%) patients completed the survey and 9 participated in a qualitative interview. Interviews revealed minimal barriers in understanding or burden, which resulted in minor survey design changes. Compared to sending an email only, sending a postcard or letter prior to the email improved response rates from 3.7% to 9.8%. Similarly, inclusion of an incentive significantly increased the response rate from 5.4% to 16.7%, especially among racial (3.0% to 12.2%) and ethnic (6.4% to 21.0%) minorities, as well as among patients with low socioeconomic status (3.1% to 14.9%).

CONCLUSIONS

Strategies to promote effective response rates include prenotification postcards or letters as well as monetary incentives. This work can inform future survey development to increase response rates for electronic surveys, particularly among hard-to-reach populations.

Clinical Characteristics and Outcomes of Colorectal Cancer in the ColoCare Study: Differences by Age of Onset

Early-onset colorectal cancer has been on the rise in Western populations. Here, we compare patient characteristics between those with early- (<50 years) vs. late-onset (≥50 years) disease in a large multinational cohort of colorectal cancer patients (n = 2193). We calculated descriptive statistics and assessed associations of clinicodemographic factors with age of onset using mutually-adjusted logistic regression models. Patients were on average 60 years old, with BMI of 29 kg/m², 52% colon cancers, 21% early-onset, and presented with stage II or III (60%) disease. Early-onset patients presented with more advanced disease (stages III-IV: 63% vs. 51%, respectively), and received more neo and adjuvant treatment compared to late-onset patients, after controlling for stage (odds ratio (OR) (95% confidence interval (CI)) = 2.30 (1.82-3.83) and 2.00 (1.43-2.81), respectively). Early-onset rectal cancer patients across all stages more commonly received neoadjuvant treatment, even when not indicated as the standard of care, e.g., during stage I disease. The odds of early-onset disease were higher among never smokers and lower among overweight patients (1.55 (1.21-1.98) and 0.56 (0.41-0.76), respectively). Patients with early-onset colorectal cancer were more likely to be diagnosed with advanced stage disease, to have received systemic treatments regardless of stage at diagnosis, and were less likely to be ever smokers or overweight.

Improving Survey Response Rates Among Patients at a Cancer Center During a Global Pandemic

This study evaluated approaches for recruiting patients at a cancer center to an electronic survey about their experience with the COVID-19 pandemic. Eight groups (n = 2,750 patients total) were contacted via email to complete a 15-minute survey. Groups consisted of: 1) a detailed email only, 2) a brief email only, 3) a mailed letter and brief email, 4) a mailed letter, small prize in the envelope, and brief email, 5) a mailed postcard and brief email, 6) a brief email and $10 gift card, 7) a mailed letter, brief email and $10 gift card, and 8) a mailed postcard, brief email, and $10 gift card. Patients were considered eligible if they had a valid email address, were seen at the cancer center since January 1, 2015, had English as a preferred language, a last known vital status of alive, an address inside the cancer center's catchment area, and were between 40 and 89 years old. Patients were over sampled for Hispanic ethnicity and African American race, then randomly sampled. Response rates were evaluated overall, by race/ethnicity, gender, time since visit to the cancer center and age. Multiple logistic regression was used to assess the odds of completing the survey. 259 patients (9.4%) completed the survey across all pilot groups. Response rates varied by pilot group, ranging from 2.6% response for a detailed email only, to 18.4% response for a brief email, postcard and gift card. The latter group was also among the highest for response rates among Hispanics (25.6%) and Non-Hispanic/Non-White patients (15.9%). In a multivariate model adjusting for race, ethnicity, age, and gender, we found those who received a gift card had 1.86 times (95% CI: 1.40–2.48) higher odds of completing the survey than those who did not. Additionally, those who received a postcard or letter compared to those who only received an email had 1.46 times (95% CI: 1.05–2.04) higher odds of completing the survey. In our study of cancer patients seen at a major cancer center, prompting potential study participants with a letter or postcard before an email improved response rates. Further including a gift card increased response rates, particularly for underrepresented minorities. Future analyses include evaluating response rates by insurance status and cancer type.

Abstract S04-03: Impact of the COVID-19 pandemic on social and health behaviors among rural and urban cancer patients at Huntsman Cancer Institute (HCI)

Purpose: The COVID-19 pandemic has disrupted many facets of life for rural and urban patients with cancer. Here, we characterize the impact of the pandemic on social and health behaviors of rural and urban cancer patients. Methods: N=1,326 adult cancer patients, who visited HCI in the last 4 years and enrolled in either Total Cancer Care or Precision Exercise Prescription studies, completed a COVID-19 survey. The survey was administered between Aug and Sept 2020 and included questions on demographic and clinical information as well as employment status, health behaviors, and COVID-19 prevention measures. Results: The mean age was 61 (19-92) years, with 54% female, 97% non-Hispanic White, 80% stage I-III, 42% employed full or part-time, 25% living in rural counties, and 85% reporting good to excellent overall health. Cancer patients in rural compared to urban counties were more likely to be older (rural=63 vs. urban=60 years; p=0.01), retired or not employed (rural=63% vs. urban=56%; p=0.04), not have health insurance coverage (rural=4% vs. urban=2%; p=0.01), and have ever smoked (rural=35% vs. urban=24%; p=0.001). However, urban patients reported “somewhat” to “a lot” of change in their daily lives more frequently than rural patients (urban=86% vs. rural=77%; p&lt;0.001), but there were no differences in change in social interaction or feeling lonely between populations. Changes in health behaviors namely exercise habits due to the pandemic were more common in patients residing in urban vs. rural counties (urban=51% vs. rural=39%; p&lt;0.001), with more urban patients either exercising less (urban=23% vs. rural=17%) or more frequently (urban=12% vs. rural=8%); however, there were no significant differences with respect to changes in alcohol consumption between these groups. In terms of prevention measures, urban patients compared to rural patients were more likely to use face masks “fairly” or “very often” (urban=94% vs. rural=83%; p&lt;0.001) and also felt they were more likely to contract a COVID-19 infection (22% vs. 14%; p=0.003), but there were no differences for other risk mitigation behaviors, such as hand sanitizer use. Conclusion: These findings suggest that the first 6 months of the COVID-19 pandemic had disparate effects on cancer patients living in rural and urban counties. Rural patients were more likely to have risk factors associated with poor health outcomes, such as not having health insurance coverage and having a history of smoking. However, urban patients were more likely to experience larger changes in their daily lives and exercise habits. Urban patients were more likely to follow preventive measures (e.g., wearing face masks) and felt they were at a greater risk of contracting the virus. Further research is needed to better characterize the pandemic's short- and long-term effects on cancer patients in rural and urban settings and appropriate interventions. Funding: U01CA206110, R01CA211705.

Citation Format: Bailee Daniels, Caroline Himbert, Cassandra A. Hathway, Tengda Lin, Karen Salas, Anjelica Ashworth, Anne C. Kirchhoff, Anna Beck, Cindy Matsen, Courtney Scaife, Cristina Christenson, Douglas Grossman, Howard Colman, Jason P. Hunt, Jennifer Ose, Jonathan Tward, Kevin B. Jones, Michael Deininger, Mikaela Larson, Paul LaStayo, Thomas Varghese, Tracy Onega, Wallace L. Akerley, Frank J. Penedo, Erin M. Siegel, Cornelia M. Ulrich, Shelley S. Tworoger, Anita R. Peoples. Impact of the COVID-19 pandemic on social and health behaviors among rural and urban cancer patients at Huntsman Cancer Institute (HCI) [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 S04-03.

Abstract S04-02: Effects of demographic and behavioral factors on social isolation in a cancer center population during COVID-19 pandemic

The COVID-19 pandemic has led to extensive social changes, which may increase the risk of experiencing social isolation, particularly in cancer patients who are at high risk of having poor outcomes if infected with COVID-19. It is unclear if pandemic-related risk mitigation behaviors (e.g., limiting attendance at social gatherings, mask wearing) influence social isolation. We leveraged data from 9,514 patients with cancer, or at high risk for cancer, from Moffitt Cancer Center to examine whether social isolation is associated with sociodemographic factors and risk mitigation behaviors. Eligible patients who had an appointment at the cancer center in the past five years, reported an email address, and had consented to the institutional biobanking protocol were invited to complete a survey regarding demographic, behavioral, and lifestyle factors as well as social isolation measured using the 4-item PROMIS Social Isolation scale. The raw PROMIS score was converted to a T-score and was split at 50, the average for the general U.S. population, and univariable and multivariable logistic regression was performed. Behavioral factors were measured on a Likert scale, ranging from “never” or “not at all”, to “very often” or “a lot”, and were evaluated continuously. Most participants were female (60.5%), Non-Hispanic White (90.3%), and had been diagnosed with cancer (89.6%); mean age was 64 years old. Only 3.5% reported ever testing positive for COVID-19, and 4.6% reported currently smoking. In univariable models, younger age, women, current smokers, and Hispanic ethnicity or Non-White race were associated with higher odds of social isolation. Among risk mitigation behaviors, leaving the house less often, attending social gatherings less often, a greater change in day-to-day life due to the pandemic, less physical contact with others outside their home, and wearing a mask more often were also associated with increased odds of social isolation. In the multivariable model including significant univariate factors, older patients (OR, per one year: 0.97; 95%CI: 0.97-0.98) and males (OR, vs. females: 0.64; 95%CI: 0.58-0.71) had lower odds of social isolation. Further, perceived changes in day-to-day life (OR, per one unit increase: 1.64 95%CI: 1.56-1.73), leaving the house less often (OR, per one unit increase: 0.75; 95%CI: 0.71-0.80), and attending social gatherings less often (OR, per one unit increase: 0.92 95%CI: 0.84-0.95) remained associated with social isolation. Overall, behavior change to mitigate risk of COVID-19 infection was associated with more social isolation for cancer patients and survivors. Women, younger patients, and current smokers may be particularly at risk, suggesting targeted interventions to reduce feelings of social isolation in these populations may be warranted.

Citation Format: Cassandra A. Hathaway, Brian D. Gonzalez, Amanda Bloomer, Erin M. Siegel, Cornelia M. Ulrich, Anita R. Peoples, Frank J. Penedo, Shelley S. Tworoger. Effects of demographic and behavioral factors on social isolation in a cancer center population during COVID-19 pandemic [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 S04-02.

Tumor immune infiltration estimated from gene expression profiles predicts colorectal cancer relapse

A substantial fraction of patients with stage I-III colorectal adenocarcinoma (CRC) experience disease relapse after surgery with curative intent. However, biomarkers for predicting the likelihood of CRC relapse have not been fully explored. Therefore, we assessed the association between tumor infiltration by a broad array of innate and adaptive immune cell types and CRC relapse risk. We implemented a discovery-validation design including a discovery dataset from Moffitt Cancer Center (MCC; Tampa, FL) and three independent validation datasets: (1) GSE41258 (2) the Molecular Epidemiology of Colorectal Cancer (MECC) study, and (3) GSE39582. Infiltration by 22 immune cell types was inferred from tumor gene expression data, and the association between immune infiltration by each cell type and relapse-free survival was assessed using Cox proportional hazards regression. Within each of the four independent cohorts, CD4+ memory activated T cell (HR: 0.93, 95% CI: 0.90-0.96; FDR = 0.0001) infiltration was associated with longer time to disease relapse, independent of stage, microsatellite instability, and adjuvant therapy. Based on our meta-analysis across the four datasets, 10 innate and adaptive immune cell types associated with disease relapse of which 2 were internally validated using multiplex immunofluorescence. Moreover, immune cell type infiltration was a better predictors of disease relapse than Consensus Molecular Subtype (CMS) and other expression-based biomarkers (Immune-AICMCC:238.1-238.9; CMS-AICMCC: 241.0). These data suggest that transcriptome-derived immune profiles are prognostic indicators of CRC relapse and quantification of both innate and adaptive immune cell types may serve as candidate biomarkers for predicting prognosis and guiding frequency and modality of disease surveillance.

Fusobacterium nucleatum and Clinicopathologic Features of Colorectal Cancer: Results From the ColoCare Study

BACKGROUND

Fusobacterium nucleatum (Fn), a bacterium associated with a wide spectrum of infections, has emerged as a key microbe in colorectal carcinogenesis. However, the underlying mechanisms and clinical relevance of Fn in colorectal cancer (CRC) remain incompletely understood.

PATIENTS AND METHODS

We examined associations between Fn abundance and clinicopathologic characteristics among 105 treatment-naïve CRC patients enrolled in the international, prospective ColoCare Study. Electronic medical charts, including pathological reports, were reviewed to document clinicopathologic features. Quantitative real-time polymerase chain reaction (PCR) was used to amplify/detect Fn DNA in preoperative fecal samples. Multinomial logistic regression was used to analyze associations between Fn abundance and patient sex, age, tumor stage, grade, site, microsatellite instability, body mass index (BMI), alcohol consumption, and smoking history. Cox proportional hazards models were used to investigate associations of Fn abundance with overall survival in adjusted models.

RESULTS

Compared to patients with undetectable or low Fn abundance, patients with high Fn abundance (n = 22) were 3-fold more likely to be diagnosed with rectal versus colon cancer (odds ratio [OR] = 3.01; 95% confidence interval [CI], 1.06-8.57; P = .04) after adjustment for patient sex, age, BMI, and study site. Patients with high Fn abundance also had a 5-fold increased risk of being diagnosed with rectal cancer versus right-sided colon cancer (OR = 5.32; 95% CI, 1.23-22.98; P = .03). There was no statistically significant association between Fn abundance and overall survival.

CONCLUSION

Our findings suggest that Fn abundance in fecal samples collected prior to surgery varies by tumor site among treatment-naïve CRC patients. Overall, fecal Fn abundance may have diagnostic and prognostic significance in the clinical management of CRC.

Utilizing a large-scale biobanking registry to assess patient priorities and preferences for cancer research and education

Patients consented to biobanking studies typically do not specify research conducted on their samples and data. Our objective was to gauge cancer biobanking participant preferences on research topics. Patient-participants of a biobanking study at a comprehensive cancer center who had an appointment within the last 5 years, had a valid email address, and with a last known vital status of alive, were emailed a newsletter containing a link to a survey about preferences and priorities for research. The survey assessed demographics and research interest in three domains: cancer site, cancer-related topics, and issues faced by cancer patients. 37,384 participants were contacted through email to participate in the survey. 16,158 participants (43.2%) opened the email, 1,626 (4.3% overall, 10% of those who opened the email) completed the survey, and 1,291 (79.4% of those who completed the survey) selected at least one research priority. Among those who selected at least one research priorities for cancer-relevant topics, the most commonly selected were cancer treatment (66%), clinical trials (54%), and cancer prevention (53%). Similarly, the most selected priorities for cancer-related issues faced by patients were physical side effects of cancer (57%), talking to the oncologist (53%), and emotional challenges due to cancer (47%). Differences by gender were observed, with females reporting more interest in research generally. Cancer patients participating in a biobanking protocol prioritized research on treatments, prevention and side effects, which varied by gender.

Abstract A32: Process improvement in online consenting for the Moffitt Cancer Center Total Cancer Care biobanking protocol

Introduction: Broad-based institutional biobanking protocols are crucial for advancing personalized medicine in cancer research. However, in-person consenting is resource intensive and interrupts clinic flow. Ethical standards support online consenting for biobanking protocols, which has the potential to reach more participants for enrollment. Herein, we discuss challenges in implementing broad-based online patient consenting at the Moffitt Cancer Center (MCC) for our institutional biobanking protocol, Total Cancer Care (TCC), and subsequent steps to better integrate this process with clinical care on-boarding. We hypothesized that implementation of online patient consenting would broaden patient enrollment into TCC and the redesigned process would increase the number of online patient consents by at least 5-fold.

Methods: TCC started as the institutional biobanking protocol in 2006. TCC online consent was implemented in Feb. 2013 (Phase 1) and redesigned in Oct. 2018 (Phase 2). Phase 1 was developed with the guidance of ethicists and patient advisors, and consisted of (a) communication via email, (b) education online with text, video, and FAQs, (c) review and initialing of the Informed Consent form (ICF), and (d) typed name signature on ICF. The Phase 2 redesign created a more streamlined process that was integrated into the MCC New Patient To-Do list, a clinical on-boarding platform. The revised version used interactive material, a shorter animated video, and an electronically signed ICF. We compared the number of online patient consents in Phase 1 and 2 and have preliminary data on patient acceptance of Phase 2.

Results: Since 2006, 108,898 MCC patients enrolled into TCC. 342 patients enrolled online in Phase I between 2013–2018 (5/mo). In the initial 6 weeks of Phase 2, there was a 13-fold increase in online consenting (n=98, 65/mo) compared to Phase 1. According to web analytics, TCC pages in Phase 2 were viewed 991 times compared to 432 views over 6 weeks in Phase 1. In general, patient characteristics were similar between those who enrolled online and those who enrolled in person during the same timeframe, with a slightly higher percentage of online vs. in-person enrollees being female (57% vs. 53%, respectively). In a small survey of new patients who viewed the clinical on-boarding platform in Phase 2, 76% reviewed the TCC material without issue whereas 20% did not review the TCC material.

Conclusions: While online consenting has tremendous potential, we had very low uptake of patient education and consenting in our initial design (Phase 1). Challenges included a lack of visibility within the patient portal and a dependency on email as the primary mode of directing patients to online consenting. Alternatively, we have seen initial success with our second phase of online consenting that was directly integrated with patient on-boarding. Initial success highlights the potential of this modality to increase patient enrollment into biobanking studies. Further evaluation of this approach is ongoing.

Citation Format: Erin M. Siegel, Kyle P. Hawkins, Lynne Hildreth, Timothy Grose, David Stringfellow, Amanda Bloomer, Shelley Tworoger, Dana Rollison, Scott Gilbert, Thomas A. Sellers. Process improvement in online consenting for the Moffitt Cancer Center Total Cancer Care biobanking protocol [abstract]. In: Proceedings of the AACR Special Conference on Modernizing Population Sciences in the Digital Age; 2019 Feb 19-22; San Diego, CA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(9 Suppl):Abstract nr A32.

Associations between physical activity, sedentary behavior, and urinary oxidized guanine in colorectal cancer patients: results from the ColoCare Study

To determine associations between physical activity (PA), sedentary behavior (SB), and oxidative stress in colorectal cancer patients, ColoCare Study participants in Germany wore an accelerometer 6 and/or 12 months after surgery. Spearman partial correlations were used to assess associations between PA and urinary concentrations of oxidized guanine, a validated marker of oxidative stress. There were no significant associations between PA or SB and oxidized guanine in n = 76 measurements (ng/mg creatinine; r = 0.03, p = 0.76 for PA, r = -0.05, p = 0.69 for SB). Novelty Objectively measured PA was not associated with a marker of oxidative stress in colorectal cancer patients.

Risk factors for cancer-related distress in colorectal cancer survivors: one year post surgery

PURPOSES

Cancer-related distress is known to persist long after completion of treatment. Factors related to distress are largely unexplored in colorectal cancer (CRC) survivors. We examined changes over time and risk factors for distress in CRC patients over the first year after surgery.

METHODS

We included 212 CRC patients with data at 6 and 12 months post-surgery from the ColoCare Study in Heidelberg, Germany. Sociodemographic and lifestyle factors, social support, and health-related quality of life (HrQOL) prior to surgery were evaluated as predictors of cancer-related distress. Distress was measured with the Cancer and Treatment Distress instrument (CTXD). Linear regression analyses examined associations between risk factors and distress.

RESULTS

Distress subscale scores varied significantly over time: health burden subscale score increased (P < .001), while finances (P = .004), medical demands (P < .001), and identity (P < .001) subscale scores decreased over time. Uncertainty and family strain subscale scores did not change. Younger age, lower income, advanced tumor stage, poorer social support, and poorer baseline HrQOL predicted higher level distress at 6 and 12 months.

CONCLUSION

Cancer-related distress continues unresolved after surgery. Although some risk factors are difficult to alter, those at highest risk can be identified earlier for possible preventive strategies.

IMPLICATIONS FOR CANCER SURVIVORS

Screening for risk factors pre-surgery would allow for targeted interventions including strategies to improve resources for those with low support, thereby reducing long-term distress in CRC survivors.