Challenges and Opportunities in Breast Cancer Care in Low-Resourced Countries, Jordan as An Example

Jordan is a relatively small country with a rapidly growing population and a challenged economy. Breast cancer is the most diagnosed cancer among women worldwide and also in Jordan. Though the age-standardized rate (ASR) of breast cancer incidence is still lower than that in Western societies, the number of newly diagnosed cases continues to increase, involving younger women, and new cases are usually detected at more advanced stages. Improvements in breast cancer care across the health care continuum, including early detection, prevention, treatment, and survivorship and palliative care, have become very visible, but may not match the magnitude of the problem. More organized, goal-oriented work is urgently needed to downstage the disease and improve awareness of, access to, and participation in early detection programs. The cost of recently introduced anti-cancer therapies poses a great challenge, but the impact of these therapies on treatment outcomes, including overall survival, is becoming very noticeable. Though the concept of a multidisciplinary approach to breast cancer treatment is often used at most health care facilities, its implementation in real practice varies significantly. The availability of breast reconstruction procedures, survivorship programs, germline genetic testing, counselling, and palliative care is improving, but these are not widely practiced. In this manuscript, we review the status of breast cancer in Jordan and highlight some of the existing challenges and opportunities.

Germline Genetic Mutations in Adult Patients with Sarcoma: Insight into the Middle East Genetic Landscape

Data on germline mutations in soft tissue and bone sarcomas are scarce. We sought to identify the prevalence of germline mutations in adult sarcoma patients treated at a tertiary cancer center. Newly diagnosed patients were offered germline genetic testing via an 84-gene panel. The prevalence of pathogenic germline variants (PGVs) and their association with disease-, and patient- related factors are reported. A total of 87 patients were enrolled, the median age was 48 (19-78) years, and 47 (54%) were females. Gastrointestinal stromal tumors (n = 12, 13.8%), liposarcoma (n = 10, 11.5%), and Ewing sarcoma (n = 10, 11.5%) were the main subtypes. A total of 20 PGVs were detected in 18 (20.7%) patients. Variants of uncertain significance, in the absence of PGVs, were detected in 40 (45.9%) patients. Young age (p = 0.031), presence of a second primary cancer (p = 0.019), and female gender (p = 0.042) were correlated with the presence of PGVs. All identified PGVs have potential clinical actionability and cascade testing, and eight (44.44%) suggested eligibility for a targeted therapy. Almost one in five adult patients with soft tissue and bone sarcomas harbor pathogenic or likely pathogenic variants. Many of these variants are potentially actionable, and almost all have implications on cancer screening and family counselling. In this cohort from the Middle East, younger age, presence of a second primary tumor, and female gender were significantly associated with higher PGVs rates. Larger studies able to correlate treatment outcomes with genetic variants are highly needed.

Ocular and Periocular Metastasis in Breast Cancer: Clinical Characteristics, Prognostic Factors and Treatment Outcome

BACKGROUND

Breast cancer remains a leading cause of cancer-related mortality and morbidity worldwide. Ocular and periocular metastasis present as a rare but clinically significant manifestation. This study aims to explore demographics and clinical aspects of ocular and periocular metastasis in breast cancer patients.

METHODS

A retrospective cohort study comprising 45 breast cancer patients with ocular or periocular metastasis treated between 2013 and 2023. Patient demographics, tumor characteristics, diagnostic methods, treatment modalities, visual outcomes, and survival data were analyzed.

RESULTS

Among 9902 breast cancer patients, 0.5% developed ocular or periocular metastasis, constituting 2.4% of metastatic cases. The median age was 50 years. Ocular metastasis timing varied: 5% before breast cancer, 24% concurrent, 22% within a year, and 49% after. The most common presentations included incidental MRI findings (42%) and vision decline (31%). Metastasis involved the orbit (47%), choroid (40%), optic nerve (11%), and iris (2%), with 44% having bilateral involvement. Predictive factors included invasive lobular carcinoma (ILC) (p < 0.0001) and brain metastasis (p < 0.0001), with ILC exhibiting a sixfold higher likelihood of ocular metastasis than invasive ductal carcinoma (IDC). Primary treatment was radiation therapy (89%), yielding a 55% maintenance of excellent vision (<0.5), with 93% developing dry eye disease. Patients with ocular metastasis faced an increased risk of disease-related mortality (p < 0.0001), with 71% succumbing within 10 months post-diagnosis.

CONCLUSIONS

Ocular metastasis in breast cancer is rare (0.5%) but signifies poor outcome. It is linked to ILC and concurrent brain metastasis. Primary treatment involves radiation therapy, with a favorable visual prognosis.

Cerebral venous sinus thrombosis in a patient treated with ribociclib for metastatic breast cancer. Case reports and literature review

Breast cancer is the most diagnosed cancer among women worldwide. Cyclin dependent kinase 4/6 inhibitors (ribociclib, palbociclib, and abemaciclib) modulate endocrine resistance and are widely used treatment for patients with advanced-stage hormone receptor-positive, human epidermal growth factor receptor 2-negative breast cancer. Reports of both venous and arterial thromboembolic events, as a complication of cyclin dependent kinase 4/6 inhibitors, are increasingly recognized, but none involved cerebral venous sinus. We herein report on a 44-year-old female patient who initially presented with an early-stage breast cancer treated with surgery, chemotherapy, radiation therapy and finished 5 years of tamoxifen uneventfully. Eight years after her initial diagnosis, she relapsed with a solitary brain lesion which was resected and treated with radiation therapy, and was then started on aromatase inhibitors. Few months later, she progressed with biopsy-proven cervical and mediastinal lymph node metastasis. She was then switched to fulvestrant and ribociclib; both were well-tolerated. However, few weeks later she presented with increasing headache and mild dizziness. Imaging studies showed right lateral sinus acute non-occlusive thrombosis with no parenchymal changes. Patient was anticoagulated with low molecular weight heparin and follow-up visits showed stable disease with no bleeding.

Survival Trends in Pediatric Differentiated Thyroid Cancer: A Middle Eastern Perspective

Pediatric Differentiated Thyroid Cancer (pedDTC) is a rare pediatric malignancy with an increasing incidence over time. To date, there is a paucity of literature specifically addressing pedDTC within the context of Middle Eastern ethnicity. This retrospective study aimed to assess the risk-stratifying factors for overall survival (OS) and event-free survival (EFS) in pediatric DTC patients from Iraq and Jordan. The medical records of 81 patients from two tertiary cancer institutes were retrieved. Kaplan-Meier analysis was employed to investigate OS and EFS, and the Cox proportional hazards model was employed to estimate hazard ratios. All patients underwent surgery and radioactive iodine therapy, with a median age of 14 and an interquartile range of 12-15. Lymph node involvement was observed in 55% of cases, while distant metastases were present in 13.5%. After a median follow-up period of 68 months, the 10-year survival rate was determined to be 94%, while the 10-year EFS rate was 58%. EFS was negatively impacted by cervical lymph node metastases and early age of diagnosis (p ≤ 0.01, each). Therefore, pediatrics with initial cervical lymph node metastases and those diagnosed before puberty tend to experience poorer EFS, which may justify the need for more aggressive management plans.

Modifiable risk factors for cancer in the middle East and North Africa: a scoping review

PURPOSE

This scoping review examines controllable predisposing factors attributable to cancer in the Middle East and North Africa (MENA) region's adult population, highlighting opportunities to enhance cancer prevention programs.

DESIGN

We systematically searched the PubMed, Science Direct, and CINAHL, EMBASE, and Cochrane Library databases from 1997 to 2022 for articles reporting on the impact of modifiable risk factors on adult patients with cancer in the MENA region.

RESULTS

The review identified 42 relevant articles, revealing that tobacco consumption, obesity, physical inactivity, and diet are significant modifiable risk factors for cancer in the region. Tobacco smoking is a leading cause of lung, bladder, squamous cell carcinoma, and colorectal cancer. A shift towards a westernized, calorie-dense diet has been observed, with some evidence suggesting that a Mediterranean diet may be protective against cancer. Obesity is a known risk factor for cancer, particularly breast malignancy, but further research is needed to determine its impact in the MENA region. Physical inactivity has been linked to colorectal cancer, but more studies are required to establish this relationship conclusively. Alcohol consumption, infections, and exposure to environmental carcinogens are additional risk factors, although the literature on these topics is limited.

CONCLUSION

The review emphasizes the need for further research and the development of targeted cancer prevention strategies in the MENA region.

The Application of Existing Risk Assessment Models (RAMS) to Predict the Occurrence of Venous Thromboembolic Events among Patients with Classic Hodgkin Lymphoma

Background: A majority of patients included in risk assessment models (RAMs) developed to predict venous thromboembolic events (VTE) in lymphoma were non-Hodgkin lymphoma. Our study aims to evaluate the incidence and predictors of VTE, utilizing different RAMs, in patients with classic Hodgkin lymphoma (cHL) treated with adriamycin, bleomycin, vinblastine, and dacarbazine (ABVD). Methods: Adult patients with cHL, treated and followed at our center, were included. Correlations between different variables, Khorana score, and thrombosis in lymphoma (ThroLy) RAMs with VTE were examined using Fisher's exact test and logistic regression analysis. Results: A total of 321 patients were included, with a median age of 29 (range: 18-83) years. Of them, 169 (52.6%) had advanced-stage disease. Combined modality treatment was given to 169 (52.6%) patients. A total of 52 (16.2%) patients had relapsed or refractory disease. VTE were reported in 15 (4.7%) patients and were mostly during the administration of first-line (n = 8, 53.3%), or salvage chemotherapy (n = 6, 40.0%). There was no correlation between a Khorana score > 2 (p = 0.689) or ThroLy score > 3 (p = 0.335) and VTE. Older age (p = 0.014) and relapsed or refractory disease (p = 0.003) significantly correlated with VTE. Conclusions: VTE are uncommon in cHL. The commonly used RAMs failed to predict VTE. However, older age and relapsed or refractory disease significantly increased this risk.

COVID-19 Antibody Seroconversion in Cancer Patients: Impact of Therapy Cessation-A Single-Center Study

BACKGROUND

The effective development of COVID-19 vaccination has mitigated its harm. Using two laboratory methods, we investigated the efficacy of the BNT162b2 mRNA and BBIBP-CorV COVID-19 vaccines on seroconversion rates in cancer patients undergoing active cancer treatment.

METHODS

SARS-CoV-2 vaccines were scheduled for 134 individuals. The consenting participants submitted three venous blood samples. Three samples: T0, T1, and T2. The ABBOTT-SARS-CoV-2 IgG II Quant and Elecsys® Anti-SARS-CoV-2 assays were used to evaluate the samples and convert the antibody titers to WHO (BAU)/mL units.

RESULTS

Cancer patients exhibited a higher seroconversion rate at T2, regardless of vaccination type, and the mean antibody titers at T1 and T2 were higher than those at T0. BBIBP-CorV patients required a booster because BNT162b2 showed a higher seroconversion rate between T0 and T1. Statistics indicate that comparing Abbott and Roche quantitative antibody results without considering the sample collection time is inaccurate.

CONCLUSIONS

COVID-19 vaccines can still induce a humoral immune response in patients undergoing cancer-targeted therapy. The strength of this study is the long-term monitoring of antibody levels after vaccination in cancer patients on active therapy using two different immunoassays. Further multicenter studies with a larger number of patients are required to validate these findings.

Pathogenic germline variants in patients with breast cancer: conversations across generations, practices and patients' attitude

Background: Breast cancer susceptibility genes such as BRCA1, BRCA2, PALB2, CHEK2 and many others are increasingly recognized among our patient population. In addition to their impact on treatment decisions of tested patients themselves, identifying at-risk family members offer opportunities for cancer preventive measures. Methods: This is an observational cross-sectional study of adult breast cancer patients with positive breast-cancer-susceptibility germline variants who received treatment at our institution. Patients with variants of uncertain significance (VUS), or who refused to give consent, were excluded. The data was collected from an eligible sample of breast cancer patients using a structured questionnaire developed by the study team and tested for validity and reliability, as well as a clinical chart review form. Patients were invited to participate in the study during their scheduled oncology clinics visit. Results: 169 patients were enrolled, including 42 (24.9%) with pathogenic/likely pathogenic (P/LP) BRCA1 variants, 84 (49.7%) with BRCA2 and 43 (25.4%) with non-BRCA variants. All patients were female and the mean age was 45 ± 9.9 years. Among 140 eligible patients, 104 (74.3%) underwent prophylactic mastectomy, while 79 (59.0%) of 134 eligible patients had prophylactic bilateral salpingo-oophorectomy (BSO). Results were communicated with family members by majority (n = 160, 94.7%), including 642 first degree female relatives, and 286 (44.5%) of them have taken no action. Fear of positive test results, cost of testing, unwillingness to undergo preventive measures, and social stigma were cited as barriers to genetic testing in 54%, 50%, 34% and 15%, respectively. Conclusion: Risk-reducing interventions including mastectomy and BSO were carried by majority of patients with P/LP variants. However, though the rate of communication of genetic testing results with family members was high, proper preventive measures were relatively low. Cost and fear of cancer diagnosis, were the leading causes that prevented cascade testing in our cohort.

Treatment options for patients with hormone receptor-positive, HER2-negative advanced-stage breast cancer: maintaining cyclin-dependent kinase 4/6 inhibitors beyond progression

Breast cancer is the most commonly diagnosed cancer in women worldwide. Over the past decade, the treatment paradigm for patients with metastatic breast cancer (MBC) has taken an important shift towards better survival and improved quality of life (QOL), especially for those with hormone receptor (HR)-positive diseases which represent the majority of breast cancer subtypes. The introduction of cyclin-dependent kinase 4/6 (CDK4/6) inhibitors in the upfront therapy of such patients has resulted in dramatic improvement in progression-free survival (PFS) and overall survival (OS), too. However, almost all patients would, sooner or later, develop disease progression and necessitate transition to different lines of treatment that may include chemotherapy. The idea of maintaining CDK4/6 inhibitors beyond disease progression seems attractive, as this approach has the potential to improve outcome in this setting despite the fact that the true benefit, in terms of survival, might not carry the same weight as it initially does. Researchers have been investigating potential mechanisms of resistance and identify possible biological markers for response after disease progression. Much of the available data is retrospective; however, few randomized clinical trials were recently published and few more are ongoing, addressing this point. In this paper, we intend to review the available published studies investigating the potential role for keeping CDK4/6 inhibitors in play beyond disease progression.

COMPASS-CAT versus Khorana risk assessment model for predicting venous thromboembolic events in patients with non-small cell lung cancer on active treatment with chemotherapy and/or immunotherapy, the CK-RAM study

Cancer patients are at higher risk for venous thromboembolism (VTE). Several risk assessment models (RAM), including the Khorana and COMPASS-CAT, were developed to help predict the occurrence of VTE in cancer patients on active anti-cancer therapy. We aim to study the prevalence and predictors of VTE among patients with non-small cell lung cancer (NSCLC) and compare both RAMs in predicting VTE in patients with NSCLC were retrospectively reviewed. Variables known to increase the risk of VTE were collected and risk of VTE was assessed using both Khorana and COMPASS-CAT RAM. A total of 508 patients (mean age ± SD, 58.4 ± 12.2 years) were enrolled. Most (n = 357, 70.3%) patients had adenocarcinoma, and 333 (65.6%) patients had metastatic disease. VTE were confirmed in 76 (15.0%) patients. Rates were higher among patients with metastatic disease (19.8%, p < 0.001), adenocarcinoma (17.4%, p = 0.01) and those treated with immunotherapy (23.5%, p = 0.014). VTE rates were 21.2%, 14.1% and 13.9% among those with high (n = 66), intermediate (n = 341) and low (n = 101) Khorana risk scores, respectively (p = 0.126). On the other hand, 190 (37.4%) were classified as high risk by the COMPASS-CAT RAM; 52 (27.4%) of them had VTE compared to 24 (7.5%) of the remaining 318 (62.6%) classified as Low/Intermediate risk level, p < 0.001. In conclusion, patients with NSCLC are at high risk for VTE, especially those with adenocarcinoma, metastatic disease and when treated with immunotherapy. Compared to Khorana RAM, COMPASS-CAT RAM was better in identifying more patients in high-risk group, with higher VTE rate.

Management of breast cancer patients with BRCA gene mutations in Jordan: perspectives and challenges

BACKGROUND

This paper explores and discusses local challenges oncologists face for diagnosing and managing breast cancer patients with BRCA gene mutations in Jordan.

METHODS

A task force involving key opinion leaders, experts in the management of breast cancer, and stakeholders in healthcare systems where genetic testing is available in Jordan discussed current evidence and local real-life practice. The task force then formulated recommendations to achieve better patient outcomes and satisfaction based on evidence-based medicine and their clinical experience in BRCA-mutated breast cancer management.

RESULTS AND CONCLUSION

Eligibility of patients for genetic testing, physician acceptance and willingness to integrate genetic testing into routine practice is encouraging but remains restricted by testing availability and financial coverage. Until more data is available, genetic testing should be targeted for breast cancer patients based on tumor subtypes, as well as family and personal history of cancer, as per international guidelines. Whenever possible, genetic testing should aim to detect all actionable genes through a multigene panel including BRCA1/2. Major challenges faced in clinical practice in Jordan include fear of genetic discrimination and social stigmatization, as well as hesitancy toward risk-reducing surgery. Pre-testing counseling is therefore critical to promote acceptance of genetic testing. Since geneticists are in short supply in Jordan, genetic counseling can be offered through a specially trained genetic counselor or through a hybrid system that includes oncologist-based counselling. In addition to cancer prevention, germline genetic testing may assist in the selection of specific anti-cancer therapy, such as PARP inhibitors, in patients with BRCA1/2 mutation. Nationwide initiatives are also needed to ensure access to PARP inhibition therapy and provide financial coverage for genetic screening, mastectomies and reconstructive surgery across Jordan.

Aggressiveness of Cancer Care at End of Life in Patients with Metastatic Breast Cancer in Jordan

Background

Contrary to Western societies, more than 15% of patients with breast cancer in Jordan are diagnosed with stage IV disease. In this study, we evaluate the value of early palliative care integration in the end-of-life care of such patients.

Methods

All consecutive adult patients who died between 2014 to 2018, while under the care of our institution, with a confirmed diagnosis of breast cancer at the time of death, irrespective of place of death, were retrospectively reviewed.

Results

During the study period, a total of 433 patients, median age 51.6 years, were included in the analysis. Among the whole group, 102 (23.6%) were referred to palliative care service early (≥30 days prior to death), 182 (42.0%) had late referral (<30 days from death), while 149 (34.4%) were never referred and were followed up by their medical oncologists. During the last 30 days prior to death, patients who were never referred to palliative care were more likely to visit the Emergency Room (ER) more than once (OR 1.89, 95% CI 1.20-2.99, p = 0.006), more likely to be admitted to the hospital more than once (OR 2.27, 95% CI 1.38-3.73, p = 0.001), and more likely to be admitted to the intensive care unit (ICU) (OR 3.07, 95% CI 1.48-6.38, p = 0.0027). Fewer patients in the "no referral" group died with advance directives compared to those who had early or late referral; 60.8%, 75.0% and 82.5%, respectively, p = 0.0003. Survival of patients followed by medical oncologist was not better than those referred to palliative care, either late or early; median survival was 19.0, 19.1 and 23.8 months, respectively (p = 0.2338).

Conclusion

Findings suggest that earlier palliative care referral is associated with less aggressive end-of-life care, leading to less frequent ER visits, hospital and ICU admissions during the last month of life, and does not compromise survival.

Surgical options for patients with early-stage breast cancer and pathogenic germline variants: an oncologist perspectives

Breast cancer continues to be the most common cancer diagnosed among women worldwide. Family history of breast cancer is frequently encountered, and 5-15% of patients may carry inherited pathogenic germline variants, identification of which can be helpful for both; patients themselves and their unaffected close relatives. The availability and affordability of molecular diagnostics, like next generation sequencing (NGS), had resulted in wider adoption of such technologies to detect pathogenic variants of cancer-predisposing genes. International guidelines had recently broadened the indications for germline genetic testing to include much more patients, and also expanded the testing to include multi-gene panels, while some professional societies are calling for universal testing of all newly diagnosed patients with breast cancer, regardless of their age, personal or family history. The risk of experiencing a contralateral breast cancer (CBC) or ipsilateral recurrence, is well known. Such risk is highest with variants like BRCA1 and BRCA2, but less well-studied with other less common variants. The optimal local therapy for women with BRCA-associated breast cancer remains controversial, but tends to be aggressive and may involve bilateral mastectomies, which may not have any survival advantage. Additionally, surgical management of unaffected women, known to carry a pathogenic cancer-predisposing gene, may vary from surveillance to bilateral mastectomies, too. The oncological safety, and the higher satisfaction of unaffected women and patients with new surgical techniques, like the skin-sparing (SSM) and nipple-sparing (NSM) mastectomies, eased up the process of counselling. In this review, we address the oncological safety of less aggressive surgical options for both; patients and unaffected carriers.

Long-Term Survival Analysis and Prognostic Factors of Arabic Patients with Differentiated Thyroid Carcinoma: A 20-Year Observational Study at the King Hussein Cancer Center (KHCC) Involving 528 Patients

DTC accounts for the majority of endocrine tumors. While the incidence of thyroid cancer has been increasing globally over the past few decades, papillary thyroid carcinoma (PTC) generally shows an excellent prognosis, except in cases with aggressive clinicopathological features. This study aimed to assess the 5- and 10-year overall survival (OS) and progression-free survival (PFS) of 528 Arabic patients diagnosed with primary DTC from 1998 to 2021. Additionally, the study aimed to analyze the impact of various factors on both OS and PFS. An univariable survival analysis was conducted using Kaplan-Meier curves. The 5- and 10-year OS for patients with DTC have exceeded 95%. Additionally, PFS showed very good rates (ranging between 96.5 and 85% at 5 and 10 years, respectively). Age, male gender, risk of recurrence, and distant metastasis were identified as the main negative prognostic factors for both OS and PFS, while RAI treatment was found to be a significant factor in improving OS. Moreover, adherence to the King Hussein Cancer Center's (KHCC) CPG demonstrated significant improvement in PFS. These findings highlight common prognostic factors and favorable outcomes in Arabic patients with DTC treated at a tertiary cancer center using standard of care approaches.

Differences in Treatment Outcomes Between Patients with HER2-Low versus HER2-Zero, Hormone Receptor-Positive Advanced-Stage Breast Cancer Treated with Ribociclib

Background

Metastatic breast cancers (MBC) with no expression of human epidermal growth factor receptor-2 (HER2) are recently classified into two groups; HER2-zero [HER2-immunohistochemistry (IHC) score of 0 (IHC-0)] and HER2-low, defined as those with IHC score of 1+ or 2+ with negative in situ hybridization (ISH) assay. We investigate differences in treatment outcomes between both groups treated with endocrine therapy (ET) and the CDK4/6 inhibitor ribociclib.

Methods

Data were retrospectively collected for patients with HR-positive+/HER2-negative MBC who received ribociclib with an aromatase inhibitor (AI) or fulvestrant and were divided into two groups: HER2-zero and HER2-low.

Results

A total of 257 patients, median age 48 (22-87) years, all with MBC who were treated with ET and ribociclib were enrolled. One hundred and thirty-seven (53.3%) patients had de novo MBC, and majority (n = 162, 63.0%) received ribociclib as a first-line therapy. In total, 114 (44.4%) patients had HER2-zero (IHC-0), while 143 (55.6%) others had HER2-low disease. The overall response rate (ORR) was 52.0% for the HER2-zero group compared to 39.4% for the HER2-low group, p = 0.005. The median PFS was 22.2 (95% confidence interval [CI], 19.4-NR) months for HER2-zero versus 17.3 (95% CI, 14.1-20.6) months for HER2-low, P = 0.0039. In multivariable analysis, HER2-low expression remained significant determinant of inferior PFS after adjusting for other factors, including the site of metastasis, prior chemotherapy, and the line of treatment.

Conclusion

In patients with MBC treated with ET and ribociclib, level of HER2 negativity may affect treatment outcomes; patients with HER2-zero had better response rate and PFS compared to those with HER2-low disease. These findings, if confirmed in larger studies, may help oncologists select patients with HER2-low for better treatment options.

Delays in Initiating Anti-Cancer Therapy for Early-Stage Breast Cancer-How Slow Can We Go?

Breast cancer is the most commonly diagnosed cancer among women worldwide, and is a leading cause of cancer-related deaths. When diagnosed at an early stage, appropriate and timely treatment results in a high cure rate and better quality of life. Delays in initiating anti-cancer therapy, including surgical resection, adjuvant/neoadjuvant chemotherapy and radiation therapy are commonly encountered, even in developed health care systems. Existing comorbidities that mandate referral to other services, genetic counseling and testing that may dictate the extent and type of anti-cancer therapy and insurance coverage, are among the most commonly cited factors. However, delays can be unavoidable; for over three years, health care systems across the globe were busy dealing with the unprecedented COVID-19 pandemic. War across hot zones around the globe resulted in millions of refugees; most of them have no access to cancer care, and when/where available, there may be significant delays. Thus, cancer patients across the globe will probably continue to suffer from significant delays in diagnosis and appropriate treatment. Many retrospective reports showed significant negative impacts on different aspects of treatment outcomes and on patients' psychosocial wellbeing and productivity. In this paper, we review the available data on the impact of delays in initiating appropriate treatment on the outcomes of patients with early-stage breast cancer.

Comparative Assessment of the Kinetics of Cellular and Humoral Immune Responses to COVID-19 Vaccination in Cancer Patients

OBJECTIVE

The kinetics of immune responses to various SARS-CoV-2 vaccines in cancer patients were investigated.

METHODS

In total, 57 cancer patients who received BNT162b2-RNA or BBIBP-CorV vaccines were enrolled. Cellular and humoral immunity were assessed at three-time points, before the first vaccine dose and 14-21 days after the first and second doses. Chemiluminescent microparticle immunoassay was used to evaluate SARS-CoV-2 anti-spike IgG response, and QuantiFERON^® SARS-CoV-2 kit assessed T-cell response.

RESULTS

Data showed that cancer patients' CD4⁺ and CD8⁺ T cell-median IFN-γ secretion of SARS-CoV-2 antigens increased after the first and second vaccine doses (p = 0.027 and p = 0.042). BNT162b2 vaccinees had significantly higher IFN-γ levels to CD4⁺ and CD8⁺ T cell epitopes than BBIBP-CorV vaccinees (p = 0.028). There was a positive correlation between IgG antibody titer and T cell response regardless of vaccine type (p < 0.05).

CONCLUSIONS

This study is one of the first to investigate cellular and humoral immune responses to SARS-CoV-2 immunization in cancer patients on active therapy after each vaccine dose. COVID-19 immunizations helped cancer patients develop an effective immune response. Understanding the cellular and humoral immune response to COVID-19 in cancer patients undergoing active treatment is necessary to improve vaccines and avoid future SARS pandemics.

Prevalence, Patterns, and Predictors of Venous Thromboembolic Events in Patients Undergoing Salvage Chemotherapy and Autologous Stem Cell Transplantation for Relapsed Lymphomas

BACKGROUND AND OBJECTIVES

Almost 25% of patients with lymphoma may have relapse or develop refractory disease, and a majority of such patients undergo salvage chemotherapy and autologous stem cell transplantation (ASCT). Data on venous thromboembolism (VTE) in this setting are scarce. This study aimed to investigate the prevalence and factors that may increase the risk of VTE in such patients.

PATIENTS AND METHODS

Adult patients who were diagnosed with lymphoma and received salvage chemotherapy and ASCT were included in the study, and the subgroup with radiologically confirmed VTE were identified. Correlations between different clinical and laboratory variables and VTE were evaluated.

RESULTS

A total of 216 patients (median age, 31 [range, 19-60] years) were enrolled in the study. Most patients (n = 140, 64.8%) had Hodgkin's lymphoma, while 54 (25.0%) had diffuse large B-cell lymphoma. A total of 36 (16.7%) patients had VTE, mostly as upper extremity deep vein thrombosis (n = 28, 77.8%); 18 (50%) of the cases were related to central venous catheter insertion. Thrombosis rates were higher among patients with high lactate dehydrogenase (LDH) level (29.2% vs. 5.9%, p < 0.001), those with mediastinal involvement (25.9% vs. 11.5%, p = 0.025). and those with longer hospital stay (22.3% vs.9.5%, p = 0.036). In the multivariate analysis, high LDH level (odds ratio (OR), 6.53; p < 0.001), mediastinal involvement (OR, 2.70; p = 0.005) and hospital stay ≥24 days (OR, 2.71; p = 0.007) were all associated with significantly higher VTE rates.

CONCLUSION

Patients with relapsed lymphoma undergoing salvage chemotherapy and ASCT are at higher risk for VTE, especially in those with high LDH level, mediastinal involvement, and prolonged hospital stay. If no contraindications exist, thromboprophylaxis might be considered in these settings.

Abstract P2-03-03: Neutrophil-to-Lymphocyte Ratio (NLR) as a Potential Prognostic Marker in Patients with Hormone Receptor-Positive/HER2-Negative Advanced-Stage Breast Cancer Treated with CDK4/6 Inhibitors: A Focus on Ribociclib

Background: Cyclin-dependent kinase (CDK) 4/6 inhibitors combined with endocrine therapies (ET) have become the mainstay treatment for patients with hormone receptor (HR)-positive, HER2-negative advanced-stage breast cancer. However, there is no established prognostic markers to predict its efficacy to better guide its utilization. Neutrophil-to-lymphocyte ratio (NLR), an indicator of the host systemic inflammatory/immune response, is widely studied marker in various settings in different cancer sites with variable but promising results. In this study, we evaluate the impact of NLR, as a prognostic biomarker, at baseline and prior to the third and fourth cycles of ET/ribociclib in patient with advanced-stage breast cancer. Methods: Data on consecutive patients with HR-positive/HER2−negative advanced-stage disease treated with ribociclib and an aromatase inhibitor or fulvestrant, were retrospectively reviewed from our institutional cancer registry and patients’ electronic medical records. NLR was calculated from blood counts performed at base line prior to commencing the first cycle of ribociclib, then prior to the third and fourth cycles, too, and was considered high if ≥ 2. Ribociclib was given at the usual dose and schedule; 600 mg daily for 3 weeks on and one week off. Progression-free survival (PFS) was defined as the time from the initiation of CDK4/6 inhibitor to the date of radiological or clinical progression or death. Multivariate analysis for PFS was performed using Cox’s proportional hazards regression model, covariates included age at diagnosis, ECOG performance status (≥ 1 vs. 0), body mass index (BMI) (≥ 25 vs. &lt; 25), ribociclib beyond first line vs. first line, type of ET (aromatase inhibitors vs. fulvestrant), visceral metastasis, postmenopausal vs. premenopausal, smoking status and de novo metastasis vs. recurrent disease and histopathology. Results: Between June 2017 and May 2020, a total of 257 patients were included, median age was 48 (22-87) years. Majority (n=163, 63.3%) received ribociclib as a first-line, 211 (82.4%) had invasive ductal carcinoma, 137 (53.3%) patients had de novo metastasis and 122 (47.7%) were premenopausal. Progression-free survival was significantly lower among patients with high NLR (n=143, 55.6%) at baseline; 17.8 vs. 22.9 months, P= 0.028. A similar trend for lower PFS was also noted for high NLR measured prior to the third (20.6 vs. 18.6 months) and the fourth cycles (21.6 vs. 18.2 months), however both were not statistically significant; P=0.154 and 0.09, respectively. Multivariate analysis confirmed an independent association between high NLR and lower PFS (adjusted HR 1.46, 95% CI 1.03-2.06, P= 0.032). Visceral metastasis (aHR 1.57, 95% CI 1.11-2.23, P=0.012) and receiving ribociclib beyond the first line (aHR 1.96, 95% CI 1.38-2.77, P&lt; 0.001, were also independent factors predicting inferior PFS. Conclusions: To the best of our knowledge this is the largest study to show a significant association between high NLR at baseline and lower PFS in patients with HR+ advanced-stage breast cancer treated with ribociclib and ET. If confirmed, NLR at base line may provide reliable, accessible, and widely available prognostic marker that can be used easily in routine clinical practice.

Citation Format: Baha’ Sharaf, Assem Qaddoumi, Faris Tamimi, Hala Abu-Fares, Rand Daoud, Hikmat Abdel-Razeq. Neutrophil-to-Lymphocyte Ratio (NLR) as a Potential Prognostic Marker in Patients with Hormone Receptor-Positive/HER2-Negative Advanced-Stage Breast Cancer Treated with CDK4/6 Inhibitors: A Focus on Ribociclib [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 P2-03-03.

Abstract P6-02-02: Challenges and Dilemmas Following a Traceback Approach for Genetic Counseling and Genetic Testing for Pathogenic Germline Mutations among High-Risk Patients Previously Diagnosed with Breast Cancer

Background: Accounting for almost 20% of all cancer cases, breast cancer continues to be the most common cancer and the leading cause of cancer-related deaths among females. In our region, almost 50% of breast cancer patients are diagnosed at age 50 or younger. Around 5-15% of breast cancers are hereditary and mostly related to BRCA1 or BRCA2 gene mutations. Risk-reducing interventions, like bilateral mastectomies and oophorectomies, are highly recommended for carriers of pathogenic variants. More recently, data had shown that specific breast cancer treatment may be informed by BRCA1 or BRCA2 mutation status. Until very recently, genetic testing and genetic counseling services were prohibitively expensive and were not available or routinely offered. Given the recently identified high prevalence of pathogenic variants among our patients, and the wider availability and the lower cost of genetic testing, an opportunity exists to look back and offer such patients the chance to do genetic testing. Patients with positive tests can then be counseled, along with their close family members, for appropriate risk-reducing programs. Methods: Using our hospital-based cancer registry, we identified patients with breast cancer who fulfilled at least one of 3 approved indications for genetic testing but never had it. Eligible patients were those diagnosed at age 45 or younger, patients with triple-negative (TN) disease diagnosed at age 65 years or younger, and those with close blood relatives with breast or ovarian cancers. Patients were initially contacted over the phone and then seen by one of the investigators in our genetic counseling clinics. Testing was performed using next-generation sequencing (NGS)-based multi-gene panel (MGP) on a peripheral blood sample at a referral lab. Results: A total of 377 eligible patients were identified. The median age (range) was 48 (31-75) years. Genetic testing was performed on 198 (52.5%) and results were reported on 192. Age ≤45 years (n= 157, 79.3%) and TN-disease (n= 59, 29.8%) were the most common indications for testing. In total, 20 (10.4%) patients were found to have pathogenic/likely pathogenic variants; mostly in BRCA2 (n=9) and BRCA1 (n=7). An additional 4 patients had TP53, PALB2, and ATM. Variants of uncertain significance (VUS) were identified in 53 (27.6%) patients. Following the visit to the genetic counseling clinic, an additional 41 (22.9%) patients agreed to test. The remaining 136 (36.1%) failed to be tested because of lack of updated contact information (n=54, 39.7%), living outside the country (n=19, 14.0%) or lack of insurance coverage (n=36, 26.5%). Fear of social stigma, lack of interest, or emotional stress were the reason for refusal among 24 (17.6%) patients. Conclusions: The Traceback approach may provide an opportunity to diagnose pathogenic/likely pathogenic variants among previously diagnosed patients with breast cancer. The high percentage of patients couldn’t be tested for manageable reasons while fear of social stigma and emotional stress continued to be important barriers, especially in societies like ours. Given the important implications of genetic testing and its availability and affordability, reaching out to untested high-risk patients raises an ethical and professional dilemma that needs to be addressed from the physician, patients, and insurance perspectives.

Citation Format: Faris Tamimi, Baha’ sharaf, Osama Salama, Sarah Edaily, Suhaib Khater, Mais AlKyam, Lama Abujamous, Khansa Azzam, Hala Abu-Fares, Haneen Abaza, Hikmat Abdel-Razeq. Challenges and Dilemmas Following a Traceback Approach for Genetic Counseling and Genetic Testing for Pathogenic Germline Mutations among High-Risk Patients Previously Diagnosed with Breast Cancer [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 P6-02-02.

Abstract P4-07-33: Differences in Treatment Outcomes Between Patients with HER2-Low versus HER2-Zero, Hormone Receptor-Positive Advanced-Stage Breast Cancer Treated with CDK4/6 Inhibitors

Background: The cyclin-dependent kinase 4 and 6 (CDK4/6) inhibitors transformed the care of patients with hormone receptor-positive (HR+), human epidermal growth factor receptor-2 (HER2)-negative (HR+/HER2−) advanced-stage breast cancer (aBC). Breast cancers with no expression of HER2 are recently classified into two groups: HER2-Zero subtype which include those with HER2-immunohistochemistry (IHC) score of 0 (IHC-0) and “HER2-low”, defined as HER2-IHC score of 1+ or (2+ with negative in situ hybridization (ISH) assay). There is increasing interest in the HER2-low subtype which is becoming a new distinct entity with promising data from recently reported clinical trials using novel anti-HER2 antibody-drug conjugates (ADC) in this subgroup. This study investigates the differences in treatment outcomes between patients with aBC with HER2-low versus those with HER2-Zero (IHC-0) disease treated with CDK4/6 inhibitors and endocrine therapy (ET). Methods: We retrospectively reviewed patients with (HR+/HER2−) aBC who received CDK4/6 inhibitors with an aromatase inhibitor (AI) or fulvestrant from June 2017 to May 2020 at a single cancer center. Data was extracted from patients’ electronic medical records and from our institutional cancer registry. Progression-free survival (PFS), defined as the time from the initiation of CDK4/6 inhibitors to the date of radiological or clinical progression or death, and was estimated by the Kaplan-Meier method and compared by the log-rank test. Multivariate Cox regression modeling was performed with covariates including progesterone receptor (PR) status, prior chemotherapy, site of metastasis (visceral versus bone-only disease), line of treatment (first-line or beyond), menopausal status, age (less than or ≥ 45) and number of metastatic sites (&lt; or ≥ 3). P-value &lt; 0.05 was considered statistically significant. Results: During the study period, a total of 256 patients with advanced-stage breast cancer who received ET and CDK4/6 inhibitors (ribociclib in all patients) were included, median age was 48 (22-87) years. Majority (n=162, 63.3%) received ribociclib as a first-line therapy while the others had it as a second line and beyond. 136 (53.1%) patients had de novo metastatic disease, and 122 (47.7%) were premenopausal. In total, 114 (44.5%) of the patients where HER2-Zero (IHC-0), while 142 (55.5%) others had HER2-low disease as defined above. The overall response rate (ORR) for the HER2-Zero group was 52% versus 39% for the HER2-low group (P= 0.005).The median PFS was 23.0 (95% confidence interval [CI], 19-40) months for HER2-Zero versus 17.0 (95% CI 14-20,) months for HER2-low; P= 0.0035. In multivariate analysis, HER2-low expression remained significant determinant of inferior PFS after adjusting for other factors including the line of treatment (aHR:2.10, 95% CI 1.03-4.27, P=0.041), age (aHR 2.20, 95% CI 1.29-3.77, P=0.004)), number of metastasis (aHR:1.96, 95% CI 1.32-2.91, P=0.001), and site of metastasis (aHR:1.64, 95%CI 1.058-2.55, P=0.027). Conclusion: In patients with advanced-stage breast cancer treated with CDK4/6 inhibitors and ET, level of HER2 negativity may affect treatment outcomes; patients with HER2-Zero had better PFS compared to those with HER2-low disease. These findings, if confirmed in larger studies, should help oncologists select patients with HER2-low for better treatment options including a combination of anti-HER2 therapy and CDK4/6 inhibitors.

Citation Format: Baha’ Sharaf, Hala Abu-Fares, Faris Tamimi, Suhaib Al-Sawajneh, Osama Salama, Rand Daoud, Abdulrahman A. Alhajahjeh, Sawsan Al-lababidi, Hikmat Abdel-Razeq. Differences in Treatment Outcomes Between Patients with HER2-Low versus HER2-Zero, Hormone Receptor-Positive Advanced-Stage Breast Cancer Treated with CDK4/6 Inhibitors [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 P4-07-33.

Abstract P4-06-06: Neoadjuvant B27 protocol in Triple-Negative Breast Cancer: Evaluation response rate, pathological complete response rates,toxicity,and the prognosis of Adolescent and Young Adult (AYA) age group compared to older population

Background: Neoadjuvant chemotherapy (NACT) is the standard early-stage triple-negative breast cancer (TNBC) treatment. Achieving pathological complete response (pCR) is considered an essential prognostic factor with favorable long-term outcomes. Younger patients have with poorer prognosis in breast cancer. To date, few studies are comparing the prognosis of AYA and older women (≥40) with breast cancer subtypes, specifically Triple-negative breast cancer (TNBC), as AYAs had higher proportions of this subtype. Method: Retrospective review was performed on female patients who received NACT at a King Hussien Cancer Center from January 2014 to June 2020. Data were collected from patients’ electronic medical records. TNBC was histopathologically confirmed. Logistic regression analysis of predictors of pathologic complete response (pCR). Survival curves were estimated with the Kaplan-Meier method. Multivariate analysis for EFS was performed using Cox’s proportional hazards regression model, covariates included age at diagnosis (AYA vs. ≥40), tumor size, nodal status LVI and pCR Result: We analyzed 211 women with stage I-III TNBC, including 62 (29.4%) women aged 18 to 39 years (AYA) and 149 (70.6%) ≥40 years. 138 (68.3%) were node positive, and 71 (34.8%) were T3/4 disease. Median follow-up was 28.1 months, median number of ER visit during NAC is 1 (0-11), 23 (10.9 %) patients had admission during neoadjuvant chemotherapy, most commonly due to febrile neutropenia 13 (56.9%). 37 (17.5%) patients did not complete NAC, due to disease progression in 22 (10.4%), and toxicity in 15 (7.1%) patients. 195 (92.4%) patients had surgery, including 75 (35.5%) had breast-conserving surgery (BCS). 166 (76.3%) patients had objective response, and 64 (30.3%) had pCR. 170 (80.6%) received adjuvant radiotherapy, and 38 (18%) received adjuvant capecitabine. No significant differences between the AYA and the ≥40 group in terms of clinicopathological, toxicity, pCR rate, and the rate of BCS. In univariate analysis, the LVI, nodal status, pCR, and age group were significant predictors of DFS. In multivariate analysis, only PCR and age are the only independent predictor of DFS. The median DFS was worse in the AYA population 47.8 (31.21-64.39) months vs. NR in ≥40 (p-value 0.013). In patients who achieved pCR, the estimated 5-years DFS for the AYA group was 56.1% versus 86.8% for the ≥40 group, (p-value 0.71). In patients with residual disease, PFS for AYA was 34.2 (95%CI 11.5-57) months vs. 59.5 months in the ≥40 group, (p 0.009). Conclusion: Although there is no difference in pCR between the AYA age group patient treated with NACT for TNBC and the older age group, the DFS is significantly worse in the AYA than the ≥40 age group in patients with residual disease. As well, DFS is numerically worse in the AYA age vs. the ≥40 age group in patients who achieved pCR.

Citation Format: Faris Tamimi, Baha’ Sharaf, Suhaib Khater, Suhaib Al-Sawajneh, Malek Horani, Khalid M. Elrabii, Anas Zayed, Hikmat Abdel-Razeq. Neoadjuvant B27 protocol in Triple-Negative Breast Cancer: Evaluation response rate, pathological complete response rates,toxicity,and the prognosis of Adolescent and Young Adult (AYA) age group compared to older population [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 P4-06-06.

FDG-PET/CT in the Monitoring of Lymphoma Immunotherapy Response: Current Status and Future Prospects

Cancer immunotherapy has been extensively investigated in lymphoma over the last three decades. This new treatment modality is now established as a way to manage and maintain several stages and subtypes of lymphoma. The establishment of this novel therapy has necessitated the development of new imaging response criteria to evaluate and follow up with cancer patients. Several FDG PET/CT-based response criteria have emerged to address and encompass the various most commonly observed response patterns. Many of the proposed response criteria are currently being used to evaluate and predict responses. The purpose of this review is to address the efficacy and side effects of cancer immunotherapy and to correlate this with the proposed criteria and relevant patterns of FDG PET/CT in lymphoma immunotherapy as applicable. The latest updates and future prospects in lymphoma immunotherapy, as well as PET/CT potentials, will be discussed.

Neoadjuvant endocrine therapy with or without palbociclib in low-risk patients: a phase III randomized double-blind SAFIA trial

BACKGROUND

The most prevalent subtype of breast cancer (BC) is luminal hormonal-positive breast cancer. The neoadjuvant chemotherapy regimens have side effects, emphasizing the need to identify new startegies.

OBJECTIVE

Analyze the complete pathologic response (pCR) rate and overall response in a low-risk hormone-positive subset of patients receiving neoadjuvant hormone treatment (NAHT) with or without Palbociclib (a CDK4/CDK6 inhibitor) to boost NAHT effectiveness.

MATERIALS AND METHODS

Based on the upfront 21-gene Oncotype DX or low-risk Breast Recurrence Score assay (RS™), the SAFIA trial is designed as a prospective multicenter international, double-blind neoadjuvant phase-III trial that selects operable with luminal BC patients that are HER2-negative for the induction hormonal therapy with Fulvestrant 500 mg ± Goserelin (F/G) followed by randomization of responding patients to palbociclib versus placebo. The pCR rate served as the study's main outcome, while the secondary endpoint was a clinical benefit.

RESULTS

Of the 354 patients enrolled, 253 initially responded and were randomized to either F/G fulvestrant with palbociclib or placebo. Two hundred twenty-nine were eligible for the evaluation of the pathologic response. No statistically significant changes were observed in the pCR rates for the patients treated with the F/G therapy with placebo or palbociclib (7% versus 2%, respectively) per the Chevallier classification (Class1 + Class2) (p = 0.1464) and 3% versus 10% assessed per Sataloff Classification (TA, NA/NB) (p = 0.3108). Palbociclib did not increase the rate of complete pathological response.

CONCLUSION

Neoadjuvant hormonal therapy is feasible in a selected population with a low RS score of < 31 CLINICAL TRIAL: NCT03447132.

Guideline-Based, Multi-Gene Panel Germline Genetic Testing for at-Risk Patients with Breast Cancer

Background

Genetic testing for at-risk patients with breast cancer should be routinely offered. Knowledge generated may influence both treatment decisions and cancer prevention strategies among the patients themselves and their relatives. In this study, we report on the prevalence and patterns of germline mutations, using commercially available next-generation sequencing (NGS)-based multi-gene panels (MGP).

Patients and Methods

Consecutive at-risk breast cancer patients, as determined by international guidelines, were offered germline genetic testing using a 20-gene NGS-based panel at a reference lab. Samples of peripheral blood were obtained for DNA extraction and genetic variants were classified as benign/likely benign (negative), pathogenic/likely pathogenic (positive) or variants of uncertain significance (VUS).

Results

A total of 1310 patients, median age (range) 43 (19-82) years, were enrolled. Age ≤45 years (n = 800, 61.1%) was the most common indication for testing. Positive family history of breast, ovarian, pancreatic or prostate cancers, and triple-negative disease were among the common indications. Among the whole group, 184 (14.0%) patients had pathogenic/likely pathogenic variants; only 90 (48.9%) were in BRCA1 or BRCA2, while 94 (51.9%) others had pathogenic variants in other genes; mostly in APC, TP53, CHEK2 and PALB2. Mutation rates were significantly higher among patients with positive family history (p = 0.009); especially if they were 50 years or younger at the time of breast cancer diagnosis (p < 0.001). Patients with triple-negative disease had relatively higher rate (17.5%), and mostly in BRCA1/2 genes (71.4%). Variants of uncertain significance (VUS) were reported in 559 (42.7%) patients; majority (90.7%) were in genes other than BRCA1 or BRCA2.

Conclusion

Pathogenic mutations in genes other than BRCA1/2 are relatively common and could have been missed if genetic testing was restricted to BRCA1/2. The significantly high rate of VUS associated with multi-gene panel testing can be disturbing.

Clinical Characteristics and Survival Outcomes of Patients with De Novo Metastatic Breast Cancer

Purpose

Though less than 5% of patients with breast cancer present with De Novo Metastasis (dnMBC) in Western societies, this percentage may reach 30% in developing countries. In this study, we present survival outcomes of patients diagnosed with dnMBC treated at a tertiary center in a developing country.

Patients and Methods

Using hospital-based database, consecutive patients with dnMBC diagnosed between 2013 and 2017 were identified. Demographic data, tumor characteristics, types of treatment, and survival data were retrospectively collected.

Results

A total of 435 patients were included; median age (range) at time of diagnosis was 51 (24-85) years. Most of the tumors expressed hormone receptors (81% Estrogen Receptor positive, 77% Progesterone Receptor positive). Human epidermal growth factor receptor-2 (HER2) overexpression was reported in 134 (30.9%) patients, while only 24 (5.5%) had Triple Negative (TN) disease. Bone, lung and liver were the most common sites of metastasis involved in 70.6%, 36.1%, and 32.0%, respectively. The median Overall Survival (OS) for all patients was 38 months, and 5-year OS was 32.6%. On univariate analysis, high tumor grade, advanced T-stage, TN-disease and metastasis to multiple sites, but not HER2 status, were associated with poor OS. On multivariate analysis, high tumor grade (Hazard Ratio =1.6, p=0.002), advanced T-stage (Hazard Ratio=1.6, p=0.003), and triple negative status (Hazard Ratio= 2.1, p=0.008) predicted poor OS.

Conclusion

The overall survival of patients with dnMBC remains poor. Better understanding of the disease behavior and factors affecting survival is required for optimal utilization of available regimens and new drugs to hopefully improve patients' outcomes.

Breast Cancer in Geriatric Patients: Current Landscape and Future Prospects

Breast cancer is the most common cancer diagnosed among women worldwide and more than half are diagnosed above the age of 60 years. Life expectancy is increasing and the number of breast cancer cases diagnosed among older women are expected to increase. Undertreatment, mostly due to unjustifiable fears of advanced-age and associated comorbidities, is commonly practiced in this group of patients who are under-represented in clinical trials and their management is not properly addressed in clinical practice guidelines. With modern surgery and anesthesia, breast surgeries are considered safe and is usually associated with very low complication rates, regardless of extent of surgery. However, oncoplastic surgery and management of the axilla can be tailored based on patients’- and disease-related factors. Most of chemotherapeutic agents, along with targeted therapy and anti-Human epidermal growth factor receptor-2 (HER2) drugs can be safely given for older patients, however, dose adjustment and close monitoring of potential adverse events might be needed. The recently introduced cyclin-D kinase (CDK) 4/6-inhibitors in combination with aromatase inhibitors (AI) or fulvestrant, which changed the landscape of breast cancer therapy, are both safe and effective in older patients and had substituted more aggressive and potentially toxic interventions. Despite its proven efficacy, adjusting or even omitting adjuvant radiation therapy, at least in low-risk older patients, is safe and frequently practiced. In this paper, we review existing data related to breast cancer management among older patients across the continuum; from resection of the primary tumor through adjuvant chemotherapy, radiation and endocrine therapy up to the management of recurrent and advanced-stage disease.

Clinical Characteristics, Prognostic Factors and Treatment Outcomes of Patients with Bone-Only Metastatic Breast Cancer

Introduction

Bone is the most frequent site of breast cancer metastasis. Differences between those who present with de novo bone-only metastasis (BOM) and those who progress to bone-only disease following a diagnosis of early-stage breast cancer are not clear. Such differences in clinical course might have an impact on the aggressiveness of treatment. This study presents the clinical and pathological features, along with treatment outcomes, of breast cancer patients with BOM in relation to the timing and type of bone metastasis.

Patients and Methods

Patients with breast cancer and BOM were retrospectively reviewed. De novo BOM was defined as bone metastasis diagnosed at presentation or within the first 4 months of follow-up. Treatment outcomes of patients with de novo, compared to those with subsequent BOM, are presented.

Results

242 patients, median age (range) at diagnosis was 52 (27–80) years were enrolled. The majority of the patients (77.3%) had de novo BOM with multiple sites of bone involvement (82.6%). At a median follow-up of 37.7 months, the median overall survival (OS) for patients with de novo BOM disease was significantly shorter than those who developed so subsequently; 40.8 months (95% CI, 51.1–184.1) compared to 80.9 months (95% CI, 36.4–47.9), p < 0.001. Tumor grade, hormone receptor status and type of bone lesions (lytic versus sclerotic) had a significant impact on survival outcomes.

Conclusion

Breast cancer with de novo BOM is a distinct clinical entity with unfavorable prognosis and is associated with shorter survival. Several risk factors for poor outcomes were identified and might inform treatment plans.

Management Strategies of Breast Cancer Patients with BRCA1 and BRCA2 Pathogenic Germline Variants

Most of breast cancer cases are sporadic; however, 15–20% are associated with family history, and some are inherited. Among those, deleterious mutations in BRCA1 and BRCA2 tumor suppressor genes are the most commonly encountered pathogenic germline variants (PGVs). Given the availability and affordability of multi-gene panel sequencing technologies, testing for PGVs is commonly practiced. With our enhanced understanding of cancer genetics and specific molecular alterations, the better acceptance of risk-directed screening and prevention, and the recent introduction of novel targeted therapies, management of BRCA-positive breast cancers is taking a new direction, focusing more on risk-reducing interventions, including mastectomy and salpingo-oophorectomy, and incorporating special treatment regimens, including platinum-based chemotherapy, and the recently-introduced PARP (poly (ADP)-ribose polymerase) inhibitors. Given the recent advances in reproductive technology and molecular medicine, younger women with PGVs may have the option of embryo selection through preimplantation genetic testing and diagnosis, thus preventing the potential transmission of the implicated genes to the next generations. In this review, we cover the clinical implications of identifying a pathogenic germline mutation in BRCA1 and BRCA2 genes in breast cancer patients, and their relatives, across the continuum of care – from cancer prevention and early detection, through active treatment and up to survivorship issues.

Enhancing International Cancer Organization Collaborations: King Hussein Cancer Center and Princess Margaret Cancer Centre Model for Collaboration

Collaborative partnerships, which link two health organizations with shared characteristics to achieve common goals and to improve healthcare quality, are becoming increasingly common in oncology. The purpose of this study is to review the collaboration between King Hussein Cancer Center (KHCC) and Princess Margaret Cancer Centre (PM). The context, input, process, and product (CIPP) model, a quasi-experimental form of program evaluation, has been applied to the KHCC-PM collaboration. This model is well suited to evaluate complex collaborations as it does not assume linear relationships. Data sources include stakeholders' judgements of the collaboration, assessment of achievements, and informal interviews with key participants involved in the program. KHCC and PM are recognized as high-caliber comprehensive cancer centers, with a common goal of delivering high-quality care to patients. Through personal relationships among faculty in the centers and the perceived opportunities for mutual benefit, KHCC and PM signed a memorandum of understanding in 2013 to enter into a formal partnership. This partnership has been an evolving process that started with collaboration on education and grew to include clinical care. Research is an area for potential future collaboration. Enabling factors in the collaboration include dedication of individuals involved, trusting relationships amongst faculty, and the reciprocal nature of the relationship. Challenges have been financial, competing interests, and the absence of a successful collaborative model to follow. The KHCC and PM collaboration has been successful. A strategic plan is being developed and followed to guide areas of expansion.

Presentation, management, and outcome of COVID-19 among patients with cancer in the Middle East and North Africa (MENA) region

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Background: Patients with cancer are vulnerable population that suffered during the COVID-19 pandemic from SARS-CoV-2 infection and from the pandemic’s impact on healthcare systems. We are presenting the findings of MENA Registry for COVID-19 and Cancer (MRCC) regarding the SARS-CoV-2 infection presentation, diagnosis, treatment, complications, and outcomes. Methods: MRCC was adapted from ASCO COVID-19 Registry and included patients with SARS-CoV-2 infection and underlying cancer diagnosis including a newly diagnosed cancer in the work-up phase or patients with active cancer receiving cancer therapy or supportive care, or within first year of adjuvant chemotherapy or after one year of curative therapy and receiving hormonal therapy. Registry included data on patients from 12 centers in eight countries in the MENA region, namely: Saudi Arabia, Jordan, Lebanon, Turkey, Egypt, Algeria, United Arab Emirates, and Morocco. The data included patient and disease characteristics, COVID-19 presentation, management, and outcomes. The follow up is differential as data get captured at different points of disease trajectory for each patient which may not reflect the final outcome. Results: Data on 1345 patients were captured in the study by December 7, 2021. Median age was 57.1 years (18-98), whereas 56.1% were females. The median follow-up was 98.5 days (0-554). The most common COVID-19 symptoms was fever (50.3%) and 26.8% of patients were asymptomatic. Out of the 959 patients with complete data on hospitalization, 554 (57.8%) were hospitalized and 126 of them (22.7%) were admitted to intensive care unit (ICU). The majority of hospitalized patients (60%) had respiratory complications and 13.9% had sepsis and 8.5% suffered acute renal injury. As shown in Table, more than quarter of the patients died with 47% of death from COVID-19 or related complication and 60.6% died at home. More than half of the patients were fully recovered from infection. Conclusions: Although more than half of the patients recovered form COVID-19 and more are expected to recover with a longer follow up, the death toll and complications remain high in this patient population. Future analysis of the impact of vaccination and better disease management as well as the impact of newer variants would provide a useful insight on managing this vulnerable population.[Table: see text]

Ribociclib-induced acute kidney injury: Uncover the MONALEESA’s dark face

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Background: The phase-3 MONALEESA-2,-3 and -7 randomized trials showed improved progression-free survival (PFS) and overall survival (OS) with the addition of cyclin D-cyclin-dependent kinase 4/6 (CDK4/6) inhibitor ribociclib to endocrine therapy in women with advanced-stage breast cancer. However, ribociclib induced acute renal injury is not recognized in these studies. In this report, we explore ribociclib-induced acute kidney injury (AKI) in breast cancer patients receiving ribociclib. Methods: We performed a retrospective chart review of all breast cancer patients who received ribociclib at our institution between April 2019 and September 2021. Patients and disease characteristics were collected, details of creatinine kinetics in relation to administration of ribociclib and other nephrotoxic drugs were obtained. Acute kidney injury grades (AKI-KDIGO classification) were captured. Results: 145 females, median age 60.0 years, all with advanced-stage breast cancer treated with aromatase inhibitors (AI) or fulvestrant plus ribociclib were reviewed. A total of 26 (17.9%) patients developed AKI; 3 were grade-I, 21 grade-II and 2 were grade-III. Rate of AKI was significantly higher (n = 15, 48.4%) among 31 patients on other concomitant nephrotoxic drugs, compared to 11 (9.6%) of 114 other patients, p = 0.001. Nephrotoxic drugs include non-steroidal anti-inflammatory (38%), metformin (30%), angiotensin-II receptor blockers (26%), and angiotensin-converting enzyme inhibitors (11%). Median time to develop AKI was 54 (range, 21-168) days, while the median time for creatinine recovery was 5 (range, 4-7) days after holding the drugs. Average creatinine increment for affected patients was 2.28 times the baseline level. Time to AKI was shorter, but not statistically significant, among patients on nephrotoxic drugs and recovery was faster after stopping these drugs (Table). Conclusions: Ribociclib-induced AKI is not uncommon and not adequately addressed. Though reversable in majority of patients, some patients may develop grade-III AKI or require treatment interruption. Nephrotoxic medications seem to significantly enhance ribociclib-associated renal injury. Withhold these medications with periodical assessment by nephrologist is strongly recommended in these patients. Larger studies are warranted to validate our findings. [Table: see text]

Patterns and prevalence of pathogenic germline mutations using multi-gene panel testing in patients with ovarian cancer: The Jordanian Exploratory Cancer Genetics (Jo-ECAG) Ovarian Study

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Background: Ovarian cancer is one of the most common gynecological malignancies. Because of the absence of effective screening methods, ovarian cancer is usually diagnosed at late stages contributing to high mortality rates. Patients with BRCA1 and BRCA2 pathogenic germline variants (PGVs) harbor elevated risk of developing both ovarian and breast cancer. Identifying PGVs may help optimize management options and improve outcomes. The worldwide prevalence of gene mutations is variable. Multiple series have demonstrated differences in PGVs according to ethnicity and geographic area. Data about prevalence of the aforementioned PGVs among Arab patients with ovarian cancer is not well understood. Methods: Patients with epithelial ovarian, fallopian tube or primary peritoneal carcinomatosis were referred for 20 or 84-multi-gene panel testing (MGPT). All patients had their diagnosis, treatment and follow up at a single cancer center. Following detailed counselling, MGPT was performed at no-cost to all patients at two reference laboratories. Descriptive statistics were performed, groups outcome was determined by two-tailed Fisher’s exact test and unpaired t-test. The study was approved by the Institutional Review Board (IRB) at King Hussein Cancer Center and all patients signed informed consent. Results: During the study period, 152 patients, median age (range): 50 (18-79) years were tested. Two patients had fallopian tube cancer, while all others had epithelial ovarian cancer. The majority (n = 100, 65.8%) had high-grade serous carcinoma, and 106 patients (69.7%) had metastatic disease on presentation. In total, 38 (25.0%) had PGVs while 47 (30.9%) others had variants of uncertain significance (VUS). PGVs were mostly in BRCA1 (n = 21, 13.8%) and in BRCA2 (n = 12, 7.9%), while only 5 (3.3%) had PGVs in non- BRCA1/2 genes ( CHECK2, MUTYH, PMS2, RAD51D, and RB1) . Age (< 50 versus ≥50) at diagnosis, histological tumor subtype, and disease stage had no impact on pathogenic variant rates. However, PGVt rates were significantly higher (60.0%, p = 0.022) among patients with positive family history of ovarian cancer and 40.4% (p = 0.017) among patients with positive family history of breast cancer. The two patients with fallopian tube cancer were both positive for BRCA1 PGVs. Only one patient underwent prophylactic bilateral mastectomies. Conclusions: PGVs in patients with ovarian cancer are common among Arabs and mostly in BRCA1/2 and rates are significantly higher among patients with family history of ovarian or breast cancers.

Characteristics and outcomes of COVID-19 in adult cancer patients: Tertiary cancer center experience

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Background: The COVID-19 pandemic has led to deteriorated outcomes among immunocompromised patients, significantly impacting cancer patients. However, little is known about the impact of the COVID-19 pandemic on cancer patients in low and middle-income countries. Therefore, we sought to investigate the characteristics and clinical outcomes of cancer patients with COVID-19 treated at a single institution. Methods: A retrospective chart review was performed for cancer patients treated at King Hussein Cancer Center. Patients who were diagnosed with laboratory-confirmed SARS-CoV-2 infection by Real-time Polymerase chain reaction test between April 2020 and October 2020 were identified. Results: Overall, 327 COVID-19-infected cancer patients were included. At the time of COVID-19 diagnosis, the median age was 55 years (range, 18-87 years), 146 patients (45%) were males. The most common neoplasms were breast cancer (n = 90, 27.5%), gastrointestinal cancers (n = 60, 18.3%), and lymphoma (n = 36, 11%). The majority of patients had comorbidities (n = 200, 61%), of which hypertension and diabetes mellitus were the most common. Testing reason was presence of symptoms in 183 (56%) patients, previous exposure in 10 (3.1%), and before elective procedure in 142 (43.4%). 118 patients (56.5%) were hospitalized and 18 patients (5.5%) required admission to the intensive care unit (ICU). At the time of the last follow-up, 76% (n = 249) remained alive, and 24% (n = 78) died, among which death was considered to be COVID related in 41 (52.5% of deaths). Mortality was significantly increased in patients with comorbidities (29%, vs 15.7 %; p = 0.008), the use of cardiac medications (34.3% vs. 18.1%; p = 0.001), active cancer status vs. remission (28.2% vs 11.6% p = 0.002), receiving chemotherapy in the last four weeks (27.6% vs 16.4%, p = 0.028), and when testing reason was the presence of symptoms vs exposure and elective (37.7% vs. 10% and 7.7% p = < 0.001) respectively. Chemotherapy was delayed in 109 (33.4%) patients and permanently discontinued in 57 (17.5%) patients. Among patients required hospitalization and needed ICU admission, mortality rates were 55.1% and 88.9% respectively. Conclusions: COVID-19 infection is associated with significant mortality and negatively affects treatment plans in cancer patients. A follow-up study will be needed to evaluate the effect of vaccination on the outcomes.

Implementation of universal, pan-cancer germline genetic testing in patients with cancer in Jordan

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Background: Detection of pathogenic germline variants (PGVs) has a significant and growing impact on the management of patients with many types of cancer. Most research to date evaluated individuals of European background, which can result in skewed genetic testing criteria and variant interpretation. Additional data are needed from diverse populations. This study aimed to investigate a universal germline testing strategy and the pattern and frequency of PGVs among all newly diagnosed cancer patients at a single center in Jordan. Methods: In this prospective, observational study, consecutive patients newly diagnosed with cancer were classified as meeting or not meeting National Comprehensive Cancer Network (NCCN) germline genetic testing criteria. All patients underwent an 84-gene panel test, independent of age, stage or family history. Demographics and clinical history were collected and analyzed from information provided by the clinicians on the test requisition form. Descriptive statistics were employed, and statistical significance was determined by two-tailed Fisher’s exact test and unpaired t test. Results: In total, 1377 cancer patients of Arabic background were enrolled, of which 831 (60.3%) met NCCN criteria (Table). PGVs were identified in 210 (15.3%). Excluding the 29 patients who were carriers for autosomal recessive conditions, 192 PGVs were identified in 181 (13.1%) patients. PGVs were most commonly identified in APC (p.I1307K variant, 55, 28.6%), BRCA2 (35, 18.2%), BRCA1 (21, 10.9%), and TP53 (12, 6.3%). While patients who met NCCN testing criteria were more likely to have a PGV (p<0.0001), 44 (24.30%) patients with PGVs did not meet criteria. Among those with PGVs, 177 (97.8%) were potentially eligible for increased screening per NCCN/expert opinion guidelines, 69 (38.1%) targeted therapies, and 89 (49.2%) clinical trials; this included 41 (22.7%), 6 (3.3%), and 14 (7.7%) patients, respectively, that did not meet NCCN testing criteria. 1445 variants of uncertain significance (VUS) were identified in 833 (57.7%) patients, but no difference in VUS rate was observed between those meeting and not meeting criteria (p=0.7354). Conclusions: Overall PGV rate among cancer patients from one center in Jordan was similar to that reported in the literature. While the VUS rate was high, similar rates were observed in those meeting and not meeting criteria. Testing restricted to guidelines could have missed approximately a quarter of patients with PGVs, >95% of whom might qualify for increased screening, targeted therapies, and/or clinical trials. [Table: see text]

Final result for SAFIA trial for neoadjuvant palbociclib in patients with operable luminal breast cancer responding to fulvestrant

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Background: Luminal, human epidermal growth factor receptor 2 (HER2)-negative breast cancer (BC) encompasses the most common subtype of breast malignancies. Neoadjuvant strategies of operable BC are primarily based upon chemotherapy (CT), while neoadjuvant hormone therapy (NAHT) has not been well studied in the Middle East and North Africa (MENA) region. However, these tumors might respond poorly to neoadjuvant CT with significant side effects, emphasizing the need to identify patients who could be candidates for NAHT. Methods: The SAFIA trial is a prospective multicentre, international, double-blind, neoadjuvant phase-III trial using upfront 21-gene Oncotype DX Breast Recurrence Score assay (RS) <31) to select operable Luminal HER2-negative patients for induction hormonal therapy with Fulvestrant 500 mg +/– Goserelin (F/G) before randomizing responding patients to F/G + Palbociclib (Cyclin-Dependent Kinase 4/6 inhibitor / CDK 4/6) versus F/G + Placebo. The primary endpoint of this study was the complete pathologic response (pCR) rate. Results: A total of 354 patients were enrolled, leading to 277 patients treated with induction F/G. Of these, 253 responding patients were randomized to F/G fulvestrant with palbociclib or Placebo. Two hundred and thirty patients were evaluable for pathologic response. No statistically significant differences were identified in terms of pCR rates between F/G with palbociclib or placebo: 2% versus 7%, respectively. According to the radiologic responses post- induction F/G, the hormone sensitivity rate was 89.8%, while the clinical benefit of 8–9 months of neoadjuvant F/G was 96%. Safety in the MENA population was acceptable with a grade 3-4 neutropenia rate of 25% in the F/G plus palbociclib arm. The feasibility of performing the 21-gene breast recurrence score assay on core biopsy specimens was optimal in 96.4% of cases. Conclusions: The addition of palbociclib to neoadjuvant F/G did not show any additional benefit in terms of pathologic response, including pCR in neoadjuvant therapy of Luminal HER2-negative BC responding to induction F/G. The use of an upfront 21-gene assay appeared feasible on biopsy specimens, and the identification of tumors with RS<31 allowed to select endocrine sensitive patients, leading ultimately to a 96% clinical benefit with 8–9 months of F/G neoadjuvant therapy. Clinical trial information: NCT03447132. [Table: see text]

Rates of Variants of Uncertain Significance Among Patients With Breast Cancer Undergoing Genetic Testing: Regional Perspectives

Purpose

Contrary to BRCA pathogenic variants, recommendations for management of variants of uncertain significance (VUS) are not clear and focus more on the patient’s family and personal history of cancer. Local and regional data on VUS are scarce. In this paper, we study patterns and frequency of VUS among breast cancer patients undergoing genetic testing.

Patients and Methods

Patients with breast cancer at high risk for pathogenic variants, as per the National Comprehensive Cancer Network (NCCN) guidelines, were tested at reference laboratories. Related surgical interventions were reviewed.

Results

Among a group of 1,197 patients with breast cancer who underwent genetic testing and counseling, 110 (9.2%) had VUS; most (n = 79, 71.8%) were in BRCA2. Median age (range) was 39 (25–66) years with 65 (59.1%) patients who were 40 years or younger at diagnosis. Among 103 patients with non-metastatic disease, 48 (46.6%) had breast-conserving surgery (BCS) while only 5 (4.9%) had bilateral mastectomies; all were due to bilateral disease and not prophylactic. VUS diagnosis was known prior to initial surgery in 34 (33.0%) patients; 11 (32.4%) of them had BCS only. Over the study period, only one VUS variant was upgraded to “likely positive.” The recent introduction of multiple-gene panel testing had resulted in a surge in VUS rate (22.2%) in genes other than BRCA1 or BRCA2, like PALB2, CHEK2, and ATM.

Conclusions

Rates of VUS are relatively high and increasing, mostly in non-BRCA1 or BRCA2, and this had no impact on the therapeutic or prophylactic surgical decisions. Adherence to guidelines is extremely important to avoid unnecessary procedures.

Thromboembolic Events in Patients with HER2-Negative, Hormone Receptor-Positive, Metastatic Breast Cancer Treated with Ribociclib Combined with Letrozole or Fulvestrant: A Real-World Data

Purpose

Patients and Methods

Results

Conclusion

Venous thromboembolism risk, prophylaxis and management in cancer patients with COVID-19: An unmet medical need

Cancer patients exhibit an increased risk of venous thromboembolism (VTE), with VTE being the second leading cause of morbidity and mortality in these patients. The implementation of lockdowns following the COVID-19 pandemic has resulted in decreased mobility and delayed access to care, thus further increasing the susceptibility to VTE. Cancer patients may also be at a higher risk of SARS-CoV-2 infection and have been shown to be more likely to experience severe COVID-19 disease compared to patients without cancer. Given that both cancer and COVID-19 exhibit a hypercoagulable state, stasis of blood flow, and endothelial injury, cancer patients with COVID-19 constitute a vulnerable population with a high risk of thrombosis and bleeding. However, to date there are limited studies evaluating whether cancer patients infected with SARS-CoV-2 have a higher VTE incidence than COVID-19 patients without cancer, how to assess the risk of VTE, prophylaxis and treatment in this special population. Herein, we highlight the urgent need for studies in cancer patients with COVID-19 to ensure appropriate patient care and improve clinical outcomes.

Expanding the Clinical Use of CDK4/6 Inhibitors in the Treatment of Hormone Receptor-Positive, HER2-Negative Breast Cancer from Metastatic Setting to Adjuvant Setting

More than two-thirds of patients with breast cancer present with hormone receptor (HR)-positive, human epidermal growth factor receptor-2 (HER2)-negative disease at their initial diagnosis. HR-positive breast cancer’s growth depends on Cyclin D1, a direct transcriptional target of estrogen receptors (ER). The recent introduction of cyclin-dependent kinase 4 and 6 (CDK4/6) inhibitors (palbociclib, ribociclib, and abemaciclib) has revolutionized the treatment of metastatic HR-positive, HER2-negative breast cancer in both endocrine-sensitive and endocrine-resistant settings and in both pre-and post-menopausal women. Multiple large randomized clinical trials had demonstrated improvement in progression-free survival (PFS) and, more recently, in overall survival (OS). Adjuvant endocrine therapy (ET) significantly reduces the risk of recurrence and death among patients with HR-positive early-stage breast cancer (EBC). However, up to 20% of these patients will experience local, regional or distal recurrences in the first ten years. Such resistance to ET motivated researchers to try CDK4/6 inhibitors in EBC, both in adjuvant and neoadjuvant settings. While many clinical trials are still ongoing, at least one study and two meta-analyses had shown beneficial results, based on which the US Food and Drug Administration had recently approved the use of one of these agents, abemaciclib, in combination with ET for the adjuvant therapy of patients with high-risk EBC. In this paper, we review the recently published and ongoing landmark clinical trials attempting to expand the use of CDK4/6 inhibitors, in combination with ET, in the adjuvant setting of EBC.

Supportive Care Needs Assessment for Cancer Survivors at a Comprehensive Cancer Center in the Middle East: Mending the Gap

Simple Summary

There are knowledge gaps regarding supportive care needs of cancer survivors in Jordan and the Arab region. Assessing unmet needs is crucial to achieving quality cancer care and patient satisfaction. In this study, we aimed to identify gaps in supportive care needs among adult cancer survivors seen at King Hussein Cancer Center in Amman, Jordan, explore predictors of unmet needs and assess the relationship between unmet supportive care needs and quality of life of adult cancer survivors. We confirmed the presence of several unmet needs in this population of cancer survivors that were evident in many domains. Late-stage diagnosis and quality of life as reported by study participants provided additional and independent information for unmet needs in several domains. Overall, this needs assessment identified problem areas for targeting interventions across the Jordanian cancer survivor population and understanding these findings highlights opportunities for intervention to address gaps in care.

Abstract

Background: Cancer survivors are often underprepared for what to expect post-treatment, and there are knowledge gaps regarding cancer survivors’ supportive care needs in Jordan and neighboring Arab countries. This study aimed to identify gaps in supportive care needs among adult cancer survivors seen at King Hussein Cancer Center in Amman, Jordan, and explore predictors of unmet needs. Methods: This was an observational cross-sectional study using a modified version of the Supportive Care Needs Survey 34 item short form (SCNS-SF34). Results: Two hundred and forty adult cancer survivors completed the study questionnaire. The assessed needs were highest in the financial domain, including covering living expenses, managing cancer treatment adverse effects and co-morbidities. The least prevalent reported needs were in sexuality and reproductive consultations. Late-stage diagnosis was independently associated with higher physical, psychological, health system/information, financial and overall need scores, with p-values of 0.032, 0.027, 0.052, 0.002 and 0.024, respectively. The overall quality of life score was independently and inversely associated with physical, psychological, health system/information, financial and overall need domains, with p-values of 0.015, <0.0001, 0.015, 0.004 and 0.0003, respectively. Conclusions: This needs assessment identified problem areas for targeting interventions across the Jordanian cancer survivor population, and understanding these findings highlights opportunities for intervention to address gaps in care.

Abstract P3-07-06: Guideline-based multi-gene panel (MGP) testing for germline pathogenic variants among patients diagnosed with breast cancer: Regional perspectives

Background: Genetic testing and genetic counseling for patients with breast cancer are routinely practiced as recommended by many professional societies and international guidelines including the National Comprehensive Cancer Network (NCCN). In addition to its major impact on cancer prevention, knowledge generated may impact cancer management, too. In this study, we evaluate the prevalence and patterns of germline mutations among at-risk breast cancer patients using commercially available next generation sequencing (NGS)-based multi-gene panel (MGP). Patients and Methods: Consecutive at-risk breast cancer patients, as recommended by the NCCN guidelines, were offered genetic testing using a 20-gene NGS-based panel performed at a reference genetic lab. Prior to testing, patients underwent extensive counseling by one of the investigators or their primary oncologist. Genetic variants were classified as benign or likely benign (negative), pathogenic or likely pathogenic (positive) or variants of uncertain significance (VUS). Clinical and pathological data were obtained from patients’ medical records, and detailed familial lineage for three generations was obtained by a cancer genetic counselor. Results: Between November 2019 and March 2021, a total of 714 patients were enrolled, the median age (range) was 39 (19-78) years. Among the whole group, 91 (12.7%) patients had pathogenic/likely pathogenic variants, mostly in BRCA1 and BRCA2 (n=50, 54.9%). However, 41 (45.1%) had pathogenic variants in genes other than BRCA1 or BRCA2; mostly in TP53, PALB2, CHECK2, BRIP2, ATM and MSH6.Mutation rates were significantly higher among a group of 182 women diagnosed at any age, with one or more close relatives with breast cancer (18.7% compared to 10.7%, p=0.007), and among 287 younger patients (diagnosed at age ≤ 50 years) with one or more close relatives with breast, ovarian, pancreatic, or prostate cancer (Gleason score ≥7); 17.1% vs. 9.8%, p=0.008. Additionally, patients with triple-negative disease (n=92) had higher pathogenic mutations; 17.4% vs. 12.1%, p=0.03. Variants of uncertain significance (VUS) were observed among 213 (29.8%) and majority (n=160, 75.1%) were in genes other than BRCA1 or BRCA2. Conclusions: Pathogenic mutations in genes other than BRCA1 or BRCA2 are relatively common and could have been missed, if genetic testing was restricted to BRCA1 or BRCA2. Patients with triple-negative disease and those with additional positive family history, have the highest mutation rates. On the other hand, expanding genetic testing using MGP resulted in a significantly higher rate of VUS, a finding that may increase the anxiety of patients and physicians, alike.

Citation Format: Hikmat Abdel-Razeq, Rama Almasri, Lama Abujamous, Mahmoud Al-Masri, Majd Hamed Allah, Faris Tamimi, Sarah Edaily, Fawzi Abuhijla, Osama Salama, Hazem Abdulelah, Rayan Bater. Guideline-based multi-gene panel (MGP) testing for germline pathogenic variants among patients diagnosed with breast cancer: Regional perspectives [abstract]. In: Proceedings of the 2021 San Antonio Breast Cancer Symposium; 2021 Dec 7-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2022;82(4 Suppl):Abstract nr P3-07-06.

Abstract P2-09-17: Family communication and attitude of patients with breast cancer toward positive pathogenic BRCA1 or BRCA2 mutations. A regional perspective

Background: Since the discovery of breast cancer susceptibility genes BRCA1 & BRCA2 and the availability of genetic testing, a considerable amount of research has been conducted to evaluate rates of genetic test acceptance and to understand the psychological and behavioural impact of genetic test results on both patients and their family members. This study aims to explore the experience of women who tested positive for a cancer-predisposing gene, and to identify risk reduction interventions patients had or planning to have and study if patients communicated genetic test results with at-risk family members and intervention made by the family members. Methods: A questionnaire was designed to assess socio-demographic factors, personal and family history of cancer, genetic test results and family notification of testing, and subsequent testing in relatives. Participants were invited to participate in the study during their visit to their oncologist clinic, in addition to patients that were invited via Teleclinic using different meeting platforms. Results: Ninety-nine patients with the pathogenic BRCA 1 or BRCA 2 mutations, who were diagnosed with breast cancer between the years 2005 and 2020, were enrolled in the study. The Mean age of participants was 45 years (range from 27 to 77 years). The patients reported different emotional reactions to the positive results of cancer genetic testing; 39 (39%) experienced feelings of anxiety, 69 (69%) were afraid about the risk of their children carrying the disease. While 24 (24%) of participants reported they felt comforted because they can take preventive measures for them and their family members and only 5 (5%) were worried about health insurance coverage. Thirteen (13%) of the patients reported that their social status had been affected by the genetic testing results. The majority (n=74, 74%) believed in the importance of communicating the results with their families. Ninety-eight (98%) patients have informed their family members of the results and only 1 (1%) did not inform anyone of the results. In total, 922 relatives were informed of the results of genetic testing and only 31 (3.3%) underwent genetic testing in response. A total of 379 first degree female relatives (mother, sister, and daughter) were informed about the genetic testing results and only 24 (6.6%) underwent genetic testing for BRCA mutations and only 8 (2%) patients underwent a prophylactic mastectomy. The reasons that prevented the informed family members from undergoing the genetic testing were diverse. As reported by the patients participating in the study, the cost of testing was the most reported reason in 54% of the time. And 52 patients (52%) considered fear from having a positive test as the main reason. The social stigma of carrying a cancer gene was also a factor in 16% of cases. Conclusion: Despite the high rate of communicating BRCA results with family members, there is lack of awareness of the proper preventive measures to be followed to decrease the risk of breast cancer.

Citation Format: Rawan Mustafa, Khawla Ammar, Rana Damsees, Maryam El-Atrash, Rayan Bater, Sama Almasri, Faris Tamimi, Lama Abujamous, Hikmat Abdel-Razeq. Family communication and attitude of patients with breast cancer toward positive pathogenic BRCA1 or BRCA2 mutations. A regional perspective [abstract]. In: Proceedings of the 2021 San Antonio Breast Cancer Symposium; 2021 Dec 7-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2022;82(4 Suppl):Abstract nr P2-09-17.

Abstract P4-07-27: De novo metastatic breast cancer; clinical characteristics and treatment outcomes in a developing country

Background: Distant metastasis at the time of diagnosis of breast cancer is found in approximately 6% of new cases and much more in developing countries. Due to distinct biologic and molecular characteristics, de novo Metastatic Breast Cancer (dnMBC) is inherently different from recurrent metastatic breast cancer (rMBC). Data on de novo metastatic breast cancer is limited due to the heterogeneity of the disease and the lack of distinction between rMBC and dnMBC in most of the published literature. In this study, we aim to review the survival outcomes of patients diagnosed with dnMBC treated at a tertiary cancer center in a developing country and to identify factors that affect their outcome. Methods: Using hospital-based database, consecutive patients with pathologically proven dnMBC diagnosed between 2013 and 2017 inclusive were identified. Retrospective chart review was performed to collect demographic data, tumor characteristics, types of treatment, and dates of death/last follow-up. Overall survival (OS) was defined as the time from diagnosis to death from any cause or last follow-up. Survival was estimated using the Kaplan-Meier method and compared between subgroups using log-rank tests. Multivariate analysis was performed using cox regression method. Results: 435 patients (3 males) were included in the analysis. Median age (range) at time of diagnosis was 51 (24- 85) years, and 99 (22.8%) were younger than 40 years. Predominant histology was invasive ductal carcinoma (IDC) in 372 (75.2%) patients, followed by invasive lobular carcinoma (ILC) in 37 (8.5%) patients. Poor prognostic features of the primary tumor were present in majority of patients, including: high grade (n=201, 46%), advanced T-stage (T3/T4) (n=205, 47.2%), and lymph node involvement (n=322, 74%). Most of the tumors expressed hormone receptors (81% ER+, 77% PR+). HER-2neu overexpression was reported in 134 (30.9%) patients while only 24 (5.5%) had triple negative (TN) disease. The most common sites of distant metastases were bone (n=307, 70.6%) followed by lung (n=157, 36.1%) and liver (n=139, 32%). The median OS for all patients was 38 months, and 5-year OS was 32.6%. On univariate analysis, factors associated with poor OS were: GIII (5-year OS: 45.8% in GI and II vs 19.1% in GIII), log rank p&lt;0.001), advanced T-stage (5-year OS: 47% for T1/T2 vs 26.5% for T3/T4 tumors, log rank p&lt;0.001), TN status (5-year OS 0 % in TN vs 35% in non-TN, log rank p&lt;0.001), and metastasis to multiple sites (5-year OS: 50% for metastasis to a single site vs 24% for multiple sites (log rank p&lt;0.001). No difference in OS was observed based on HER-2neu overexpression. On multivariate analysis, high tumor grade (Hazard ratio (HR) =1.6, p=0.002), advanced T-stage (HR=1.6, p=0.003) and triple negative status (HR= 2.1, p=0.008) predicted poor OS. Conclusions: The overall survival of patients with dnMBC remains poor. Better understanding of the disease behaviour and factors affecting survival is required for optimal utilization of available regimens and new drugs to hopefully improve patients’ outcomes.

Citation Format: Hanan Almasri, Ayah Erjan, Hebah Abudawaba, Khaled Ashouri, Sara Mheid, Anoud Alnsour, Hikmat Abdel-Razeq. De novo metastatic breast cancer; clinical characteristics and treatment outcomes in a developing country [abstract]. In: Proceedings of the 2021 San Antonio Breast Cancer Symposium; 2021 Dec 7-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2022;82(4 Suppl):Abstract nr P4-07-27.

Abstract P4-02-15: Thromboembolic events (TEE) in patients with HER2-negative, hormone receptor-positive metastatic breast cancer treated with Ribociclib combined with Letrozole or Fulvestrant. Real-world data

Background: Breast cancer is the most common cancer diagnosed among women worldwide. More than 70% of breast cancers are hormone receptor (HR)-positive, for which endocrine therapy (ET) is the preferred initial treatment especially so for those with low burden disease. Majority of patients with HR-positive metastatic breast cancer (mBC) acquire resistance to endocrine therapy. CDK4/6 inhibitors modulate this resistance and are integral treatment for patients with advanced HR-positive, HER2-negative breast cancer. Since their approval, CDK4/6 inhibitors are widely used in clinical practice. Thromboembolic events (TEE) were not a major issue among patients treated on clinical trials. However, conflicting data starts to emerge describing higher than expected rates of both arterial and venous thrombosis in patients treated with CDK4/6 inhibitors. In this study, we use real world data to study TEE rates in patients treated with ribociclib in real-world settings.Methods: The study is a retrospective analysis of individual patients’ data. All consecutive patients with mBC treated with ribociclib combined with aromatase inhibitors or fulvestrant were reviewed. Data were collected from patients’ electronic medical records and from radiology department archives. All episodes of radiology confirmed arterial or venous thrombosis were recorded. TEE was considered ribociclib related if diagnosed while patients on the drug or withing 4 weeks after the last dose.Results: During the study period, a total of 305 patients were enrolled. Median age (range) was 49 (22-87) years. All patients had metastatic disease and 168 (55.1%) were de novo metastasis. Most (n=241, 79.0%) of the patients had visceral metastasis at time of ribociclib therapy; only 64 (20.9%) had bone-only disease. Ribociclib was used in combination with letrozole in first-line setting in 195 (63.9%) and with fulvestrant or letrozole in 110 (35.9%) patients who failed one or more lines of ET or chemotherapy. Median duration (range) of ribociclib therapy was 7 (1-45) months. Episodes of venous thromboembolism were confirmed in only 5 (1.6%) patients; 3 were PE with or without DVT and 2 were lower extremity DVT and all were symptomatic. Another patient had arterial thrombosis (lower limb ischemia). During the chart review, 7 (2.3%) more patients had a confirmed diagnosis of VTE prior to ribociclib and another 4 (1.3%) patients had a confirmed episode after (range: 2-7 months) stopping it. All patients were treated with low-molecular heparin (LMWH) with no complications. Given the small number of patients with TEE, no clinical or pathological predictors could be used to identify subgroups of patients at higher risk for TEE while on ribociclib.Conclusions: In real-world settings, and contrary to recent reports, breast cancer patients treated with ribociclib with AI or fulvestrant are not at higher risk for arterial or venous thromboembolic events. Patients had similar rates prior to initiation, and after stopping ribociclib.

Citation Format: Hikmat Abdel-Razeq, Faris Tamimi, Sarah Edaily, Baha' Sharaf, Mahmoud Abunasser, Osama Salama, Rashid Abdel-Razeq, Hazem Abdulelah, Rayan Bater. Thromboembolic events (TEE) in patients with HER2-negative, hormone receptor-positive metastatic breast cancer treated with Ribociclib combined with Letrozole or Fulvestrant. Real-world data [abstract]. In: Proceedings of the 2021 San Antonio Breast Cancer Symposium; 2021 Dec 7-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2022;82(4 Suppl):Abstract nr P4-02-15.

Vitiligo-Like Lesions in a Patient with Metastatic Breast Cancer Treated with Cyclin-Dependent Kinase (CDK) 4/6 Inhibitor: A Case Report and Literature Review

Background

Cyclin-dependent kinase (CDK) 4/6 inhibitors have revolutionized the treatment landscape of hormone receptor-positive (HR⁺), human epidermal growth factor receptor 2-negative (HER2⁻) metastatic breast cancer, with an impressive efficacy and safety profile. Cytopenia is the main adverse event, which is both predictable and manageable. Here, we report a case of CDK4/6 inhibitor-induced vitiligo-like lesions. Vitiligo or vitiligo-like lesions are a rare adverse event; only a few cases are reported in the literature.

Case Presentation

A 71-year-old female patient was diagnosed initially with early-stage right breast cancer (HR⁺/HER2⁻) and was treated with breast-conserving surgery followed by chemotherapy, radiotherapy, and hormonal therapy. A few years later, she developed metastatic disease to the hilar lymph nodes, and to multiple skeletal sites, including the left scapula, left shoulder, left iliac bone, and dorsal vertebrae, for which she was treated with ribociclib and letrozole. While on treatment, she developed hypopigmented lesions involving both hands, feet, and face, which were described as vitiligo-like lesions.

Conclusion

CDK4/6 inhibitor-induced vitiligo is a rare and unpredictable adverse event. This case report highlights the rarity of this adverse event, the dilemma related to the optimal treatment, and decisions related to continuation, holding, or switching CDK4/6 inhibitors.

Thrombosis and Anticoagulant Therapy Among Pediatric Cancer Patients: Real-Life Data

Background: Venous thromboembolism (VTE) in children is relatively rare, and more so among those with cancer. In this study, we report the characteristics and outcomes of children with cancer-associated thrombosis.

Methods: We reviewed institutional databases for all children with cancer and a diagnosis of VTE at King Hussein Cancer Center in Jordan. Variables reviewed are patients’ clinical characteristics, treatment for cancer, and anticoagulation therapy.

Results: Between January 2011 and December 2018, a total of 45 patients fulfilled the inclusion criteria, and the median age was 10.4 (0.8-17.9) years. The most common underlying diagnosis was acute lymphoblastic leukemia (n = 13, 29%). At the time of VTE, 29 (64.4%) patients were receiving chemotherapy, and eight (17.8%) had a central venous catheter (CVC). The majority of patients (n = 37, 82%) developed VTE within 30 days of hospitalization. Thrombosis mostly involved the extremities (n = 23, 51%) and sagittal vein (n = 12, 26.7%). All patients were treated with low-molecular-weight heparin (LMWH), complicated by bleeding in three (6.6%) patients.

Conclusion: In contrast to adults, VTE in pediatric cancer patients is more associated with chemotherapy and recent hospitalization. LMWH is a safe and effective therapy for children with cancer who develop VTE.

The Application of the ThroLy Risk Assessment Model to Predict Venous Thromboembolism in Patients with Diffuse Large B-Cell Lymphoma

Background

Patients with aggressive lymphomas are at higher risk for venous thromboembolism (VTE). ThroLy is a risk assessment model (RAM) derived to predict the occurrence of VTE in various types of lymphomas. In this study, we assess the clinical application of ThroLy RAM in a unified group of patients with diffuse large B-cell lymphoma (DLBCL).

Methods

Hospital databases were searched for patients with DLBCL and radiologically-confirmed VTE. Items in the ThroLy RAM, including prior VTE, reduced mobility, obesity, extranodal disease, mediastinal involvement, neutropenia and hemoglobin < 10.0 g/dL, were retrospectively reviewed.

Results

A total of 524 patients, median age 49 (range: 18-90) years were included. Patients had high disease burden; 57.3% with stage III/IV and 34.0% with bulky disease. All were treated on unified guidelines; 63 (12.0%) had primary refractory disease. Venous thromboembolic events were reported in 71 (13.5%) patients. Among 121 patients with high (> 3) ThroLy score, 22.3% developed VTE compared to 8.4% and 12.4% in those with low and intermediate risk scores, respectively (P = .014). Simplifying the ThroLy model into two risk groups; high-risk (score ≥ 3) and low risk (score < 3) can still segregate patients; VTE developed in 44 (17.2%) high-risk patients (n = 256) compared to 27 (10.1%) in the low-risk group (n = 268), P = .038. Neutropenia, a component of the ThroLy, was encountered in only 14 (2.7%) patients.

Conclusions

ThroLy RAM can identify patients with DLBCL at high risk for VTE. Model can be modified by dividing patients into two, rather than three risk groups, and further simplified by omitting neutropenia.