The impact of race and ethnicity on diffuse large B-cell lymphoma outcomes within the veterans health administration (VHA)

We performed a retrospective chart review of 6266 randomly selected DLBCL patients treated in the VHA nationwide between 1/1/2011 and 12/31/2021. The 3178 patients who met inclusion criteria were predominantly male (97%) and white (75%). Median age of diagnosis for Black patients was 63 years vs 69 years for the entire cohort (p < 0.001). However, patients in each race/ethnicity subgroup presented with similar rates of stage I/II and III/IV disease, IPI score, cell of origin and HIT status. Outcomes analysis revealed similar treatment, response rates, median overall survival, and 1-, 3-, and 5-year survival across all subgroups. Hispanic patients had a 21% lower risk of death (HR = 0.79) than white patients, and Black patients had no significant difference in survival (HR = 0.98). This large retrospective study shows that when standard of care therapy is given within an equal access system, short-term treatment and survival outcomes are the same for all races.

The Impact of Time From Diagnosis to Initiation of Chemotherapy on Survival of Patients With Newly Diagnosed Diffuse Large B-Cell Lymphoma in the Veterans Health Administration

INTRODUCTION

Our retrospective study evaluates the impact of time from diagnosis to treatment (TDT) on outcomes of patients with newly diagnosed diffuse large B-cell lymphoma (DLBCL) treated within the Veterans Health Administration (VHA).

METHODS

VHA patients diagnosed with DLBCL between 2011 and 2019 were included, while those with primary central nervous system lymphoma were excluded. The median overall survival and progression-free survival were estimated with the Kaplan-Meier method. Univariate, bivariate, and multivariable analyses were performed using the Cox proportional hazards model. The odds ratio for refractory outcomes was calculated using logistic regression.

RESULTS

A total of 2448 patients were included. The median time from diagnosis to treatment of the cohort was 19 days. When comparing median progression-free survival, median overall survival, and the 2-year overall survival between the group that started treatment within 1 week and each of the other groups individually, there was a significant difference favoring improved survival in all groups with a TDT longer than 1 week (P < .0001). These patients also had a lower odds ratio for refractory outcomes. On multivariable analysis, TDT remained an independent prognostic factor.

CONCLUSION

Our study shows that a TDT equal to or less than 1 week is associated with adverse clinical factors, worse outcomes, and response in DLBCL, even after adjusting for multiple known poor prognostic factors. This was the first time that response to first-line therapy was correlated to time to treatment. Our findings support ongoing efforts to improve currently standardized prognostic tools and the incorporation of TDT into clinical trials to avoid selection bias.

Multiplex Immunofluorescence Captures Progressive Immune Exhaustion with Advancing Penile Squamous Cell Cancer Stage

Penile squamous cell carcinoma (PSCC) is a rare and deadly malignancy. Therapeutic advances have been stifled by a poor understanding of disease biology. Specifically, the immune microenvironment is an underexplored component in PSCC and the activity of immune checkpoint inhibitors observed in a subset of patients suggests immune escape may play an important role in tumorigenesis. Herein, we explored for the first time the immune microenvironment of 57 men with PSCC and how it varies with the presence of human papillomavirus (HPV) infection and across tumor stages using multiplex immunofluorescence of key immune cell markers. We observed an increase in the density of immune effector cells in node-negative tumors and a progressive rise in inhibitory immune players such as type 2 macrophages and upregulation of the PD-L1 checkpoint in men with N1 and N2-3 disease. There were no differences in immune cell densities with HPV status.

Abstract P1-05-20: COVID-19 Lockdown Resulting in Advanced Cancer and Worse Histology at Presentation in Hispanics

Background In breast cancer, prognosis is marked by histology and stage at diagnosis. Patients presenting with HER-2 positive or triple negative breast (TNBC) often have a worse prognosis. Early detection of breast cancer is mainly based on yearly screening mammograms, which were disrupted during the lockdown stages of the COVID-19 pandemic. In general, underserved populations, especially the Hispanic population often lack access to preventive care due to lack of funding causing delays in access to timely care. The COVID-19 pandemic caused many patients to miss their annual mammogram screening due to lockdown causing subsequent presentation of more advanced cancer. We, therefore, hypothesized that more patients were diagnosed with advanced cancer after lockdown and worse histology in the Hispanic population compared to the non-Hispanic population of San Antonio, Texas. Methods We identified 3 cohorts retrospectively using chart review: Pre-covid-19 era was defined between 2018 to March 2020. Lockdown is defined as a period between April 2020 to December 2020 followed by the post-vaccine era from January 1st 2021 to 2022. Pearson’s Chi-squared and logistic regression tests were used to determine the relationship between time, histology at diagnosis and ethnicity. Results More Hispanic patients were found to present with HER2+ disease (OR: 1.65. p-value .047) compared to non-Hispanic women. When looking at presentation of HER2+ disease in the pre-covid-19 era, there was a 15.11% increase in the presentation of HER2+ disease in the post-vaccine era. When looking at the presentation of TNBC disease in women, there was not a significant correlation seen in the lockdown or post-vaccine period in Hispanic compared non-Hispanic women. Other factors such as funding status were associated with TNBC at presentation independently of ethnicity. In the lockdown era, the number of newly diagnosed breast cancer patients reached an all-time low and during the post-vaccine era, the patient numbers are back to the pre-covid era. Conclusion Ethnicity in part played a role in the number of patients presenting with more aggressive histology such as TNBC and Her 2 positive breast cancer in the post-vaccine era. These findings may be secondary to fact that certain ethnic groups are more likely to miss preventive screenings and the covid 19 pandemic lockdown exacerbated this problem. Diagnosis of advance cancer can further deter patients from seeking care due to socioeconomic factors and possibly increase mortality in these populations. These findings suggest that there seems to be a correlation between race and presentation of more aggressive histology caused by the effects of the pandemic in cancer care affecting minorities.

Citation Format: Juzar Hussain, Gabriel Roman Souza, Tamarah Aldawoodi, Lauren C. Jameson, Lauren Rahman, Nomso C. Agim, Jonathan Gelfond, Marcela Mazo-Canola. COVID-19 Lockdown Resulting in Advanced Cancer and Worse Histology at Presentation in Hispanics [abstract]. In: Proceedings of the 2022 San Antonio Breast Cancer Symposium; 2022 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2023;83(5 Suppl):Abstract nr P1-05-20.

Abstract P1-05-22: The Impact of the COVID-19 Pandemic on Breast Cancer Diagnoses in San Antonio, TX

Introduction: Breast cancer is the most frequently diagnosed cancer and the second leading cause of cancer death in women in the United States. The significant advances in care over the last decades are largely attributable to early detection and treatment. The pre-COVID-19 pandemic 5-year survival rate of breast cancer was in the range of 90%, however, there has been public concern that the pandemic has led to delayed diagnosis. The objective of this study was to determine if patients diagnosed during the pandemic had more advanced breast cancer at presentation compared to those diagnosed prior.

Methods: This is a retrospective study of patients with an ICD code for Breast Cancer seen within the University of Texas Health San Antonio MD Anderson Cancer Center between 1/1/2018 and 12/31/2021. Data abstractors collected information on gender, age, race, ethnicity, funding, screening mammogram dates, date of cancer diagnosis, stage at diagnosis, and treatment. Those diagnosed before 1/1/2018 or that received initial treatment outside our institution were excluded from the analysis. Pearson’s Chi-squared and logistic regression tests were used to determine the relationship between time and stage at diagnosis. The timeline was divided into three periods: from 01/01/2018 to 03/31/2020 as the pre-COVID era, from 04/01/2020 to 12/31/2020 as the lockdown period, and from 01/01/2021 to the present as the post-vaccine era.

Results: A total of 696 patients with breast cancer were included. There was a significant statistical difference between the cancer stage at diagnosis in the pre-COVID-19 era compared to the lockdown period and the post-vaccine era (p= 0.003, table 1). Therefore, patients diagnosed after the beginning of lockdown were more likely to have more advanced cancer as time progressed. The odds ratio for Tis stage was 0.38 (95% CI: 0.23-0.60; P &lt; 0.001) in the post-vaccine era compared to the pre-COVID era. The OR for Tis stage was not statistically significant (OR, 0.68; 95% CI: 0.42-1.10; P &lt; 0.12) when comparing the lockdown period to the pre-COVID era.

Conclusion: Patients diagnosed with breast cancer in the COVID-19 pandemic were more likely to present with more advanced disease at diagnosis compared to those diagnosed in the pre-COVID-19 era confirming our hypothesis. The OR of presenting with Tis disease when diagnosed during the post-vaccine compared to the pre-COVID-19 era was 0.38, however, this was not seen when comparing the lockdown period to the pre-pandemic era. We believe this difference was not significant because delays in cancer care may take months to years to take full effect.

Table 1. Breast cancer stage at diagnosis per period.

Citation Format: Gabriel Roman Souza, Tamarah Aldawoodi, Juzar Hussain, Lauren C. Jameson, Lauren Rahman, Nomso C. Agim, Jonathan Gelfond, Marcela Mazo-Canola. The Impact of the COVID-19 Pandemic on Breast Cancer Diagnoses in San Antonio, TX [abstract]. In: Proceedings of the 2022 San Antonio Breast Cancer Symposium; 2022 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2023;83(5 Suppl):Abstract nr P1-05-22.

Impact of equal access by race and ethnicity on patients in the Veterans Health Administration (VHA) treated for diffuse large B-cell lymphoma (DLBCL)

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Background: Racial and ethnic disparities in access to care and outcomes are well-established and are critical issues across several malignancies, including DLBCL. Previous studies from national registry datasets have shown racial disparities in DLBCL disease characteristics, treatment and outcomes. The VHA is an equal access system providing a unique environment to investigate cancer disparities across the disease continuum. Methods: This is a retrospective chart review of 4033 randomly selected patients with an ICD code for lymphoma treated within the VHA between 01/01/2011 and 12/31/2017. Data abstractors collected baseline patient and disease characteristics and treatment responses for those with an initial diagnosis of DLBCL in that time frame. Survival time was determined via electronic health record query on 11/30/2021. Chi-square tests were used to analyze relationship between race and variables of interest. Cox proportional hazards model was used to estimate hazard ratios (HR) for race and controlling factors. Results: 2141 DLBCL patients met our inclusion criteria. 97% were male. Majority were Non-Hispanic Whites (NHW 75%) followed by Non-Hispanic Blacks (NHB 12.5%), Hispanics (H 5.7%) and others (O 6.8%). NHB were diagnosed at younger median age (63 years) when compared to the NHW, H and O (68 years). There was no statistically significant difference in stage at diagnosis, IPI score, cell of origin (COO) and hit status amongst racial subgroups. Outcomes analysis (Table) revealed similar treatment and response rates, median OS, 1- and 2- year survival across all racial subgroups. However, after adjusting for age, IPI, COO, and exposure to agent orange, and including up to 10-years of survival data, H had 36% lower risk of death (HR=0.64, 95% CI 0.44-0.93) than NHW, while NHB and O had similar outcomes to NHW. Conclusions: This large retrospective study is a continuation of our group’s work (Williams et al, 2020) that doubles the cohort size and confirms that when standard of care therapy is given with equal access to care, short-term treatment and survival outcomes are same for all races. Further studies are needed to analyze risk factors associated with differences in long term outcomes.[Table: see text]

Clinical Trials Targeting Neurofibromatoses-associated Tumors: A Systematic Review

Background

There is a paucity of literature that comprehensively analyzes previous and current clinical trials targeting neurofibromatoses-related tumors. This article aims to provide readers with drug development efforts targeting these tumors by analyzing translational and clinical findings.

Methods

This systematic review was written according to the PRISMA guidelines. Inclusion criteria were clinical trials involving patients with neurofibromatosis type 1, type 2, or schwannomatosis that were treated with therapies targeting neurofibromatoses-associated tumors and that were registered on clinicaltrials.gov. In addition, a search was performed in PubMed, Web of Science, Google Scholar, and Embase European for articles fully describing these clinical trials.

Results

A total of 265 clinical trials were registered and screened for eligibility. Ninety-two were included in this systematic review involving approximately 4636 participants. The number of therapies analyzed was more than 50. Drugs under investigation mainly act on the MAPK/ERK and PI3K/AKT/mTOR pathways, tumor microenvironment, or aberrantly over-expressed cell surface receptors. Selumetinib was the most effective medication for treating a neurofibromatosis type 1-associated tumor with approximately 68%–71% partial response for inoperable or progressive plexiform neurofibromas in children 2 years of age and older and bevacizumab for a neurofibromatosis type 2-related tumor with approximately 36%–41% partial response for vestibular schwannomas in patients 12 years of age and older.

Conclusions

This systematic review presents the results of previous clinical investigations and those under development for neurofibromatoses-associated tumors. Clinicians may use this information to strategize patients to appropriate clinical trials.

Fractions of Selaginella convoluta (Arn.) Spring (Selaginellaceae) attenuate the nociceptive behavior events in mice

Selaginella convoluta (Arn.) Spring is a species popularly known as "jericó", and used in folk medicine as analgesic and anti-inflammatory. This study aimed to investigate in mice the antinociceptive and anti-inflammatory activities of the hexane (Sc-Hex) and chloroform (Sc-CHCl3) fractions (100, 200 and 400 mg/kg) obtained by partition of crude ethanol extract from S. convoluta. The preliminary phytochemical analysis of the fractions was performed. Antinociceptive activity was evaluated by writhing, formalin and hot-plate tests. Anti-inflammatory activity was evaluated using carrageenan-induced pleurisy. The rota-rod test was used to evaluate motor coordination. Preliminary phytochemical screening showed that the Sc-Hex and the Sc-CHCl3 were positive for the presence of flavonoids, anthracene derivatives, quinones, triterpenes and steroids. Inhibition of writhing was observed for fractions tested. The Sc-Hex at all doses tested was effective in reducing the nociceptive behavior produced by formalin only in the second phase. However, the Sc-CHCl3 decreased the paw licking time in the first and second phases. In the hot plate no significant effect was observed for any fraction. In the rota-rod test, treated mice did not demonstrate any significant motor performance changes. In the carrageenan-induced pleurisy, Sc-CHCl3 (200 mg/kg) reduced cell migration to the pleural cavity. These results reveal the antinociceptive properties of S. convoluta , which support, in part, its traditional use, since the fractions did not presented significant activity in the inflammatory response profile. We further verify that this antinociceptive effect could be by activation of nociceptive peripheral pathway.

Assessment of the antibacterial, cytotoxic and antioxidant activities of Morus nigra L. (Moraceae)

This study was carried out to assess the antibacterial, cytotoxic and antioxidant activities of extracts of Morus nigra L. HPLC was used to determine the fingerprint chromatogram of the crude ethanolic extract (Mn-EtOH). The antibacterial effect was assessed through the method of microdilution. The cytotoxicity was tested against human tumour cell lines using the 3-(4,5-dimethyl-2-thiazolyl)-2,5-diphenyl-2H-tetrazolium bromide (MTT) assay. The total phenolic and flavonoid contents were also assessed through the Folin-Ciocalteu and aluminum chloride methods, respectively. Antioxidant activities of the extracts were evaluated by using 2,2-diphenyl-1-picrylhydrazil (DPPH) radical scavenging and β-carotene-linoleic acid bleaching methods. The presence of phenolic compounds in Mn-EtOH was confirmed using HPLC. The extracts showed activity against most microorganisms tested. The extracts did not show any expressive antiproliferative effect in the assessment of cytotoxicity. The most significant total phenolic content was 153.00 ± 11.34 mg of gallic acid equivalent/g to the ethyl acetate extract (AcOEt). The total flavonoid content was 292.50 ± 70.34 mg of catechin equivalent/g to the AcOEt extract, which presented the best antioxidant activity (IC50 50.40 ± 1.16 μg/mL) for DPPH scavenging. We can conclude that this species shows strong antibacterial and antioxidant activities, as well as weak cytotoxic effects.

Abstract P4-01-15: A high-throughput three-dimensional cell migration assay (BiO assay) for toxicity screening for breast cancer applications

Common in vitro assays for drug toxicity screening are not accurate predictors of human in vivo toxicity as they are performed on two-dimensional (2D) surfaces that do not mimic native cellular environments. Three-dimensional (3D) cell culture systems, like magnetic levitation, offer representative culture environments, with spatial control to design assays for drug toxicity applications. In this study, a label-free 3D in vitro assay for high-throughput toxicity screening (BiO Assay) of breast cancer cells was developed.

Confluent flasks of cancerous and non-cancerous mammary gland epithelial cells (MDA-231 and MCF-10A) were incubated overnight with a magnetic nanoparticle assembly, to which they bind. The next day, these cells were detached from the flask, and with the external application of a magnetic field, levitated to the air-liquid interface, where cells aggregated and interact to form larger 3D structures. These 3D structures were levitated for 24 hours to induce extracellular matrix formation. Afterwards, the structures were mechanically disrupted and patterned into rings using ring-shaped magnets. The magnetic field was removed, drugs, like doxorubicin, were added at varying concentrations, and the rings were allowed to close. This assay was validated against a 2D viability assay. A mobile device was programmed to capture the rings at specified timepoints, and image analysis was performed to track ring closure as a function of drug concentration and time.

MDA-231s and MCF10As were successfully formed into 3D cultures using magnetic levitation, and patterned into rings. We found significantly different results in drug sensitivity between cells grown in 2D and 3D. In conclusion, the BiO Assay is a simple assay that measures drug toxicity in a culture system similar to the native cellular environment.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P4-01-15.