Significance of baseline and change in quality of life scores in predicting clinical outcomes in an international phase III trial of advanced pancreatic cancer: NCIC CTG PA.3

BACKGROUND

There is insufficient information regarding the prognostic significance of baseline and change in quality of life (QoL) scores on overall survival (OS) in advanced pancreatic cancer.

METHODS

QoL was assessed prospectively using the EORTC QLQ-C30 as part of the PA.3 trial of gemcitabine + erlotinib (G + E) vs. gemcitabine + placebo (G + P). Relevant variables and QoL scores at baseline and change at 8 weeks were analyzed by Cox stepwise regression to determine predictors of OS.

RESULTS

222 of 285 patients (pts) treated with G + E and 220 of 284 pts treated with G + P completed baseline QoL assessments. In a multivariable Cox analysis combining all pts, better QoL physical functioning (PF) score independently predicted longer OS (HR 0.86; CI: 0.80-0.93), as did non-white race (HR 0.64; CI: 0.44-0.95), PS 0-1 (HR 0.65; CI: 0.50-0.85), locally advanced disease (HR 0.55; CI: 0.43-0.71) and G + E (HR 0.78; CI: 0.64-0.96). Improvement in physical function at week 8 also predicted for improved survival (HR 0.89; CI: 0.81-0.97 for 10 point increase in score, p = 0.02).

CONCLUSION

In addition to clinical variables, patient reported QoL scores at baseline and change from baseline to week 8 added incremental predictive information regarding survival for advanced pancreatic cancer patients.

A Retrospective Evaluation of A Paediatric Consult Clinic Serving Uninsured Children in Canada

BACKGROUND: Children new to Canada may not have health insurance which limits access to health care and increases their vulnerability to poorer health outcomes. As part of a resident advocacy initiative, a monthly pediatric consult clinic was created within a community health clinic to serve uninsured children living in a suburb of a major Canadian city. At the time of its inception in 2009, 35% of patients seen in the health clinic did not have provincial health insurance and an additional 35-40% did not receive Interim Federal Health (IFH) that they were otherwise entitled to (Denburg et al., 2010).

OBJECTIVES: To describe the demographics and health issues of uninsured immigrant children referred to a pediatric consult clinic.

DESIGN/METHODS: This study is a retrospective chart review characterizing the patients seen from 2009 – 2013. We collected demographic information, presenting symptoms, diagnoses and clinical outcomes. After REB approval, 180 patients were identified and 159 charts were found. Data was extracted from each chart and coded into a database. Of these files, 38 were removed because of duplicate entries or if they were not seen in the clinic. A total of 121 charts were included in the final analysis. An audit was performed by a blinded reviewer to identify any discrepancies in transcription prior to descriptive analysis.

RESULTS: Over half (52.1%) of patients seen in our clinic were landed immigrants or Canadians, while 19.8% had refugee status. 49.3% of patients were in a 3-month waiting period for provincial health insurance, while 12.6% had IFH, 11.6% had OHIP and 21.5% had no insurance at all. Only 34% spoke English as their primary language. The top three presenting complaints were developmental, dermatologic and respiratory. The most common final diagnoses were psychiatric and behavioural, dermato-logic and nutritional. The majority of patients required counselling (67%), with 14% prescribed a short medication course and 20% requiring ongoing medication.

CONCLUSION: Almost 70% of patients seen had no insurance at the time of their visit, with most in the mandatory 3-month wait for provincial health coverage. Our study suggests that children still need access to health care during this period. The most common diagnoses related to mental health and development suggesting a high prevalence in immigrants and supporting the need to screen for these issues when caring for children new to Canada.

The relationship between the development of rash and clinical and quality of life outcomes by Kras mutation status in patients with colorectal cancer treated with cetuximab in NCIC CTG CO.17

481

Background: The NCIC Clinical Trials Group CO.17 trial, conducted with the Australasian Gastrointestinal Trials Group, showed cetuximab monotherapy (CET vs. best supportive care [BSC]) improved overall (OS) and progression-free survival (PFS) and maintained quality of life (QoL) in patients previously treated for advanced colorectal cancer. Correlative analyses showed strong relationships between CET benefits and both rash development and Kras mutation status. Association between rash and CET benefits is now presented by Kras mutation status.

Methods: Rash was graded weekly by NCI CTC 2.0 criteria. Landmark-type analyses (LTA) were performed by excluding patients who died within 28 days and then grouping by rash severity (gr 2+ vs. gr 0/1) based both on worst grade ever developed (LTA1) and worst grade on or before day 28 (LTA2). Multivariate Cox models were conducted separately for wild-type (WT) and mutated (MUT) Kras tumors.

Results: More rash of severity gr 2+ was observed in WT than MUT patients treated with CET (57.3% vs. 44.4%; p = 0.08). The median OS, PFS, and HRs from LTA2 are presented for WT and MUT groups (see Table).

Conclusions: Rash severity was positively correlated with PFS and OS in Kras WT patients who received CET, although only for gr 2+ rash did OS significantly exceed that of BSC patients. In Kras MUT patients, neither gr 0/1 nor gr 2+ rash was associated with either improved PFS or OS vs. BSC patients. Quality of life outcomes will also be reported by Kras mutation status.

[Table: see text]

[Table: see text]

BCIRG 006: Docetaxel and trastuzumab-based regimens improve DFS and OS over AC-T in node positive and high risk node negative HER2 positive early breast cancer patients: Quality of life (QOL) at 36 months follow-up

19647

Background: The primary objective of the BCIRG 006 trial was to determine if the use of trastuzumab in early high-risk HER2-positive breast cancer significantly improved clinical outcomes. A secondary objective was to evaluate the QOL of patients receiving the 2 treatments. Methods: The BCIRG 006 trial compared adjuvant standard AC (doxorubicin/cyclophosphamide x 4 cycles) followed by docetaxel x 4 [AC-T] or 2 trastuzumab-containing regimens, AC followed by T with trastuzumab x 1 year [AC-TH] or TCarbo x 6 with trastuzumab x 1 year [TCH] in patients with node positive or high-risk node negative HER2-positive early breast cancer (n=3222). Results: The 2nd planned interim analysis, median follow-up at 36 months, showed that both AC-TH and TCH significantly improved the DFS and OS over the control (relative reduction risk of relapse 39% (P<0.0001) and 33% (P=0.0003) respectively, for AC-TH and TCH vs control). Relative reduction in the risk of death was 41% (P=0.0041) and 34% (P =0.017) respectively, for AC-TH and TCH vs control. Congestive heart failure occurred in 0.4% of patients in AC-T and TCH vs 1.9% of patients in AC-TH. Global safety profile was acceptable in all 3 arms and more favourable in TCH than AC-TH. QOL, a secondary endpoint of this trial, was assessed using the EORTC QLQC-30, BR-23, and EQ5D. We will present the primary QOL endpoints comparing Physical Function, Global Health Status, Future Perspectives, and Systemic Treatment Effects change scores from baseline to mid-chemotherapy, end of chemotherapy, and 12 months follow-up (with a 10% change considered clinically important). The proportion of patients with improved/stable/worsened QOL scores will be compared with chi-square tests. Other QOL exploratory analyses will be presented.

[Table: see text]

Quality of life in patients with advanced colorectal cancer treated with cetuximab: Results of the NCIC CTG and AGITG CO.17 trial

4002

Background: Cetuximab prolongs survival in pretreated advanced colorectal cancer (CRC) patients (pts). For these pts, the effect of palliative treatment on quality of life (QOL) is also an important outcome. Methods: CO.17 was a randomized controlled trial (n=572) of cetuximab combined with best supportive care (BSC) vs BSC alone in pts with pretreated epidermal growth factor receptor-positive advanced CRC. Primary endpoint was survival. QOL was a secondary endpoint using the EORTC QLQ-C30 at baseline, 4, 8, 16, and 24 weeks (wks). Primary endpoint for QOL compared physical function (PF) and global health status (Global) mean changes from baseline to 8 and 16 wks using Wilcoxon test. Negative change scores denote worsening QOL. The proportion of pts in either arm with at least a 10 unit deterioration at 8 and 16 wks from baseline was compared using Fischer’s exact test. Kaplan-Meier estimates and logrank tests on median time to definitive QOL deterioration, defined as at least a 10 unit deterioration in PF or Global, were evaluated. Exploratory analyses of all other scale and symptom change scores at 8 and 16 wks were also performed. Results: Compliance rates for QOL questionnaires was high at baseline, 94% each arm, but did drop off over time: 73% vs 60% at week 8 and 60% vs 39% at week 16 for cetuximab vs BSC, respectively. PF change scores at 8 wks were -3.9 for cetuximab vs -8.6 for BSC (p=.046); at 16 wks -5.9 vs -12.5 (p=.027). Global change scores were -0.5 vs -7.1 (p=.008) and -3.6 vs -15.2 (p=.008) at 8 and 16 wks respectively. The proportion of pts with deteriorating PF was 25% for cetuximab vs 35% for BSC at 8 wks (p=.051) and 30 vs 43% at 16 wks (p=.069). Deteriorating Global was seen in 23 vs 38% at 8 wks (p=.004) and 31 vs 49% at 16 wks (p=.0011). Time to PF deterioration was 5.4 months [95% CI 3.8–5.7] for cetuximab vs 3.7 months [2.0–3.9] for BSC (p=.022). Time to Global deterioration was 5.4 [3.9–5.7] vs 3.7 months [2.1–3.9] (p=.062). Exploratory analyses of all other scale and symptom change scores at 8 and 16 wks showed all differences of p<.05 also favored cetuximab. Conclusions: Cetuximab provides palliation in pretreated pts with advanced CRC, delaying deterioration in QOL as well as improving survival.

[Table: see text]

A prospective pharmacogenetic study of thymidylate synthase (TS) polymorphisms in high risk stage II or stage III colon cancer patients treated with 5-fluorouracil (5-FU) and leucovorin (LV)

13018

Background: Retrospective studies suggest TS polymorphisms predict toxicity from TS inhibitors as well as therapeutic response. The TS promoter has a variable number of tandem repeats (VNTR) polymorphism containing putative E-box binding sites that bind upstream stimulatory factor (USF) -1 and -2. One E-box binding site exists in TSER*2 and 2 binding sites exist in TSER*3. A single nucleotide polymorphism (SNP) at position 12 (G→C) in TSER*3’s 2nd repeat abolishes binding of USF-1/2. Combined effects of VNTR and SNP means individuals may have 2, 3 or 4 enhancer regions. We hypothesized that decreased enhancer numbers predicts for patients at risk for grade ≥3 mucositis, diarrhea, neutropenia, and overall toxicity and performed a prospective pharmacogenetic study of TS polymorphisms in adjuvant colon cancer patients treated with 5-FU/LV. Methods: High risk Stage II or Stage III colon cancer patients treated with 5FU/LV (425 mg/m2/ 20 mg/m2) daily for 5 days every 4 weeks had blood drawn for genotyping prior to starting therapy. Patients were assessed for toxicity using NCI CTC 2.0 in cycle 1. Three year disease-free survival will also be assessed. Results: 103 patients were enrolled and genotyped with 95 evaluable for toxicity. Patient characteristics: median age 61yrs (36–79): M 52%/F 48%; Stage III 77%, Stage II 23%. Frequency of genotypes containing 2 enhancers (TSER*2/ TSER*2, TSER*2 / TSER*3C, TSER*3C/ TSER*3C), 3 enhancers (TSER*2/ TSER*3G, TSER*3C/ TSER*3G) and 4 enhancers (TSER*3G/ TSER*3G) was 0.64, 0.31, and 0.05 respectively. No significant difference was seen in overall toxicity, mucositis, diarrhea and neutropenia based on TS polymorphism genotypes. Frequency of recurrence in 2 enhancer patients was 13% versus 26% in 3/4 enhancer patients but this did not reach statistical significance (p = 0.16). Conclusions: This prospective study does not confirm previously published retrospective studies suggesting that TS VNTR and SNP predict toxicity from TS inhibitors in patients treated with 5-fluorouracil for colon cancer. There is a trend for prediction of recurrence which requires further follow-up.

No significant financial relationships to disclose.

The experience of a sample of Canadian men with breast cancer

10549

Background: Breast cancer is the most frequently diagnosed malignancy among North American women, accounting for about 30% of all new cases each year. Although male breast cancer accounts for less than 1% of all breast cancer cases, recent reports indicate significantly increasing incidence. Research suggests that men diagnosed with breast cancer experience serious psychologic issues including feeling less masculine by having a woman’s disease, feeling isolated with a rare malignancy and feeling uncomfortable seeking or receiving support. Men may also experience post-surgical effects including changed appearance of the male chest and decreased arm strength. There have been numerous large-scale studies examining womens’ experiences with breast cancer. To date, there have been no North American studies examining what a man experiences with a breast cancer diagnosis. The objective of this qualitative study was to determine the experiences of a sample of Canadian men diagnosed with breast cancer. Methods: After ethics approval, an invitation letter and consent form were mailed to those individuals listed as “male”, “breast cancer”, and “alive”, in the Alberta Cancer Registry. 20 men responded indicating their interest. After written consent, audiotaped interviews were conducted. As little is known about a man’s experience with breast cancer, an exploratory qualitative methodology was utilized. Results: We found a great variability among the participants with respect to whom they disclosed their diagnosis, how they viewed their masculinity after a breast cancer diagnosis and their views on life after a cancer experience. All participants stated that there was a major lack of awareness about male breast cancer, both in the public and health professional domain. All participants identified a lack of written information specific for men with breast cancer. All participants denied interest in traditional “support” groups, but would have welcomed the opportunity to speak with a man who had gone through similar diagnosis and treatment. Conclusions: Needs identified by the respondents include increased medical and public awareness of male breast cancer as well as specific written information. Further research is necessary to identify supports and resources helpful for male patients.

No significant financial relationships to disclose.

Strategies for reaching Asian Americans with health information

INTRODUCTION

Cultural, linguistic, and economic barriers place many Asian Americans in jeopardy of missing opportunities for disease prevention, early diagnosis, prompt treatment, and participation in clinical trials. One way to learn how to address these barriers is through the development of a demonstration health education and prevention program focused on an indicator disease such as cancer.

METHODS

In 1994, the University of California, San Diego (UCSD) Cancer Center began a highly focused cancer education program. Staffing was done with a variety of bicultural and bilingual undergraduates recruited from local colleges and trained to work as community health educators. Asian grocery stores were selected as optimal educational sites. Adaptation of sheltered English teaching techniques and hands-on teaching aids helped to overcome language and educational barriers. The educational intervention was evaluated using unobtrusive measures.

RESULTS

With the volunteers' help, culturally sensitive means to disseminate information on cancer were evaluated. A variety of approaches evolved that effectively bridged many communication barriers. Fear of cancer itself, belief that thinking about cancer could provoke the onset of the disease, and financial barriers to care proved to be just as formidable barriers to cancer education in this ethnic group as they are in others. Using student volunteers and donated store space, this educational program was conducted with minimal expense.

CONCLUSION

Reaching this population with the help of ethnically and linguistically compatible students was effective, but the barriers they faced when trying to connect with their potential audience were still considerable. Rigorous evaluation of the strategies used in this intervention is warranted.