Characteristics of patients with hematologic malignancies without seroconversion post-COVID-19 third vaccine dosing

Objectives

The objective of this study is to explore the characteristics of the subset of patients with hematologic malignancies (HMs) who had little to no change in SARS-CoV-2 spike antibody index value levels after a third mRNA vaccine dose (3V) and to compare the cohort of patients who did and did not seroconvert post-3V to get a better understanding of the demographics and potential drivers of serostatus.

Study design

This retrospective cohort study analyzed SARS-CoV-2 spike IgG antibody index values pre and post the 3V data on 625 patients diagnosed with HM across a large Midwestern United States healthcare system between 31 October 2019 and 31 January 2022.

Methods

To assess the association between individual characteristics and seroconversion status, patients were placed into two groups based on IgG antibody status pre and post the 3V dose, (-/+) and (-/-). Odds ratios were used as measures of association for all categorical variables. Logistic regressions were used to measure the association between HM condition and seroconversion.

Results

HM diagnosis was significantly associated with seroconversion status (P = 0.0003) with patients non-Hodgkin lymphoma six times the odds of not seroconverting compared with multiple myeloma patients (P = 0.0010). Among the participants who were seronegative prior to 3V, 149 (55.6%) seroconverted after the 3V dose and 119 (44.4%) did not.

Conclusion

This study focuses on an important subset of patients with HM who are not seroconverting after the COVID mRNA 3V. This gain in scientific knowledge is needed for clinicians to target and counsel these vulnerable patients.

Quantifying the Value of the Molecular Tumor Board: Discordance Recommendation Rate and Drug Cost Avoidance

PURPOSE

Molecular tumor boards (MTBs) provide interventions that assist the patient's primary oncologist's interpretation and application of precision oncology and avoid clinical and financial toxicities of prescribing inappropriate targeted therapy. In this article, we describe a novel method for illustrating MTBs value and recommendation discordance rate and report associated drug cost avoidance data.

METHODS

From January 1, 2021, to December 31, 2021, patients assessed by our program's MTB were retrospectively evaluated. Recommendation discordance was defined as any disagreement between MTB therapeutic recommendations and those provided in the next-generation sequencing vendor's report.

RESULTS

In 2021, our program processed 1,119 next-generation sequencing orders via external vendors for 1,029 unique patients with a variety of solid tumor and hematologic malignancies. During this period, 962 patients were reviewed through our MTB process. MTB recommendation discordance rate was high (229 of 502; 45.6%) and varied across test vendors. Rationales for discordance included the following: low level of evidence (88% of patients), alternative standard of care available (60%), and tolerability concerns (42%), among others. Discordance was highest for Vendor C (30%), followed by Vendor A (24%) and Vendor B (8%). The most common drug classes not supported were mTOR, PARP, MEK, and PIK3CA inhibitors when recommended by vendors in off-label settings. MTB interventions accounted for $3,209,070 in US dollars in potential drug cost avoidance.

CONCLUSION

Therapeutic recommendation discordance rates can provide quantitative insight into the benefit of MTB. Discordance-associated drug cost avoidance further demonstrates MTB's financial value. These measures may be used as part of the justification for this service line within a cancer care program.

Real-World Third COVID-19 Vaccine Dosing and Antibody Response in Patients With Hematologic Malignancies

Purpose

This study sought to describe the changes in immune response to a third dose of either Pfizer's or Moderna's COVID-19 mRNA vaccine (3V) among patients with hematologic malignancies, as well as associated characteristics.

Methods

This retrospective cohort study analyzed pre-3V and post-3V data on 493 patients diagnosed with hematologic malignancies across a large Midwestern health system between August 28, 2021, and November 1, 2021. For antibody testing, S1 spike antigen of the SARS-CoV-2 virus titer was used to determine serostatus.

Results

Among 493 participants, 274 (55.6%) were seropositive both pre- and post-3V (+/+) while 115 (23.3%) seroconverted to positive from prior negative following the third dose (-/+). The remaining 104 (21.1%) were seronegative both before and after 3V (-/-). No participant was seropositive pre-3V and seronegative post-3V (+/-). Results showed a statistically significant increase in the proportion of seropositivity after receiving a third COVID-19 vaccine (P<0.00001). Response to 3V was significantly associated with the 3V vaccine type (P=0.0006), previous COVID-19 infection (P=0.0453), and malignancy diagnosis (P<0.0001). Likelihood of seroconversion (-/+) after 3V was higher in the group of patients with multiple myeloma or related disorders compared to patients with lymphoid leukemias (odds ratio: 8.22, 95% CI: 2.12-31.79; P=0.0008).

Conclusions

A third COVID-19 vaccination is effective in producing measurable seroconversion in many patients with hematologic malignancies. Oncologists should actively encourage all their patients, especially those with multiple myeloma, to receive a 3V, given the high likelihood of seroconversion.

Characteristics of patients with hematologic malignancies without seroconversion post-COVID19 third vaccine dosing (3V): Real-world data from large midwestern healthcare system

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Background: Patients (Pts) with hematologic malignancies (HM) are at greater risk of severe morbidity and mortality caused by COVID19 and show a lower response to the two-dose COVID19 mRNA vaccine series. The primary vaccine series now includes a third dose of the COVID19 vaccine (3V) for immunocompromised Pts. The objective of this study was to explore the characteristics of HM patients who had no change in SARS-CoV-2 spike protein titer levels post 3V (-/-) to gain a better understanding of the drivers of serostatus. Methods: This retrospective cohort study analyzed Pt data on SARS-CoV-2 spike IgG antibody titers pre- and post- 3V across the healthcare system. This study included 268 fully vaccinated HM Pts diagnosed with HM between October 31, 2019 and January 31, 2022 and had a negative serostatus prior to 3V. Post 3V titers were obtained 21 days after 3V. Demographics, association between characteristics and seroconversion status, and odds ratios were all assessed (table). Results: Pts with Non-Hodgkin lymphoma (NHL) had 6 times the odds of not seroconverting compared to multiple myeloma (MM) (CI 1.88 – 19.12, P = .0010). NHL also have about 14 times the odds of not seroconverting compared to Pts diagnosed with other HM conditions, which included: neoplasms of uncertain behavior and disorders of white blood cells (CI 1.72 – 112.44, P = .0021). 90% of seronegative Pts showed no spike IgG antibody reaction to 3V as indicated by pre- and post- 3V index values. Demographics, previous COVID19 infection, and vaccine type were not significantly associated with seroconversion. Conclusions: HM patients who are not seroconverting after 3V, suggest a prioritized population for continued increased behavioral precautions, additional vaccination efforts, including a fourth dose of an mRNA COVID19 vaccine, as well as passive immunity boosting through monoclonal and polyclonal antibodies.[Table: see text]

Neoadjuvant chemotherapy is associated with improved outcomes in patients with stage 1A and 1B pancreatic cancer undergoing surgery: An NCDB study

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Background: The use of neoadjuvant chemotherapy (NAC) for pancreatic ductal adenocarcinoma (PDAC) has shown clear advantages in locally advanced and borderline resectable disease. The benefit in upfront resectable PDAC is debated. Moreover, in early clinical stages IA/IB, potential benefits including improved R0 resection rate, decreased tumor upstaging, and survival, are not clear. We hypothesize that NAC will be associated with improved outcomes and survival compared to adjuvant therapy in patients with clinical stage IA/IB PDAC. Methods: The National Cancer Database (NCDB) PUFs (2004-2017) were used to perform a retrospective review of patients with clinical stage IA or IB PDAC undergoing surgery. Treatment groups were selected based on timing of chemotherapy. Patients receiving chemotherapy or surgery alone were excluded. Results: We identified 6,613 patients with clinical stage IA or IB PDAC who underwent surgery. The neoadjuvant therapy group (NAT) included 1,533 patients who received neoadjuvant or perioperative chemotherapy, and the adjuvant therapy group (AT) contained 5080 patients who received chemotherapy after surgery. Patients in the NAT had higher rates of T1 and T2 disease and lower rates of T3 pathology compared to the AT (pT1: 18.7% vs 7.8%; pT2: 20.1 vs 18.6%; pT3: 59.3% vs 72.1%, p<0.0001). Additionally, the NAT had significantly higher rates of N0 disease and less N1 pathology (pN0: 54.6% vs 37.5%; pN1: 45.4% vs 62.5%, p<0.0001). The R0 resection rate was higher in the NAT (83.2% vs 62.3%, p=0.0197) and there was less lymphovascular invasion (LVI) compared to the AT (34.8% vs 48.1%, p<0.0001). Using Kaplan Meier estimates, the NAT was associated with improved overall survival (OS) compared to the AT (median OS: 33.4 vs 27.5 months, p<0.0001). On multivariable analysis, R0 resection (HR=0.715, CI: 0.619-0.825, p<0.0001), LVI (HR=1.126, 95% CI: 1.038-1.222, p=0.0043) but not receipt of NAC (HR=0.94, 95% CI: 0.852-1.038, p=0.2229) were independent risk factors for OS. Conclusions: NAC is beneficial in patients with stage IA/IB PDAC undergoing surgical resection as it is associated with improved oncologic outcomes including increased R0 resection rate, decreased tumor upstaging, lymph node metastasis, and LVI. Furthermore, patients receiving NAC were found to have improved survival over those getting adjuvant therapy. Based on these results, we recommend all patients diagnosed with PDAC be considered for NAC prior to surgery. [Table: see text]

A pilot study to reliably measure the tissue concentration of mitomycin C after hyperthermic intraperitoneal chemotherapy in patients with gastrointestinal malignancies

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Background: HIPEC with MMC is a treatment for gastrointestinal cancers metastatic to the peritoneal cavity. The pharmacokinetics of MMC in plasma, peritoneal fluid, and urine are described. The amount of MMC in intraabdominal tissues after HIPEC are not well described. The aim of this study is to evaluate if MMC concentrated in tissue samples after HIPEC by high performance liquid chromatography (HPLC) from patients with gastrointestinal neoplasms. Methods: HIPEC was performed at 40°C with 40mg of MMC for 90 minutes, after which the peritoneal cavity was flushed, anastomoses created as needed, and the wound closed. Eligible patients were treated at a single institution, ≥18 years old, and underwent HIPEC with MMC. Samples were taken of the omentum, peritoneum, liver core biopsy, tumor, and mesenteric fat before and after HIPEC. All patients signed informed consent. Samples were frozen in liquid nitrogen, minced, and sonicated in 500µL of phosphate buffered saline. The homogenized samples were centrifuged, and the supernatant was analyzed by HPLC for MMC. The HPLC was performed using a Dionex Ultimate 3000. Analysis was performed with a Kinetex - 5µm Biphenyl 100A – 150 x 4.6mm column. MMC was detected with a Diode Array Detector 3000 with fixed UV at 365nm, 280nm, 254nm, and 210nm. The mobile phase used isocratic 40% acetonitrile and 60% water at 0.5 ml/min. The analysis volume was 10µL. Samples were blinded prior to analysis and analyzed in triplicate. Results: Thirteen patients were enrolled, 11 were female, the average age was 57 years (range: 30 – 85). Diagnoses were low-grade appendiceal mucinous neoplasm (7), high-grade appendiceal mucinous neoplasm (1), appendiceal adenocarcinoma (1), colon adenocarcinoma (1), colon mucinous adenocarcinoma (1), peritoneal mesothelioma (1), and small bowel mucinous adenocarcinoma (1). Complete tissue samples were available for 10 patients. Two patients had complete cytoreduction and did not have tumor for analysis after HIPEC. One patient refused liver biopsy. MMC was not detected in any sample prior to HIPEC. After HIPEC, MMC was most often detected in peritoneum (12 of 13 cases) and tumor (9 of 11). MMC was less often detected in omentum (5 of 13), mesenteric fat (2 of 13), or liver (1 of 12). Conclusions: MMC concentrated in 92% of peritoneal samples, 82% of tumor samples, and less often in liver tissue. MMC is hydrophilic which may contribute to the low detection rates in omentum and mesenteric fat. A reliable method to measure MMC concentration in normal and malignant tissues is novel and may have clinical implications. Our next steps are to expand the cohort of patients and evaluate whether tissue concentration is associated with clinical outcomes.

Abstract 2618: Staged analysis of standard of care tumor molecular testing among patients with metastatic colorectal cancer in the community health system setting

Background: National Comprehensive Cancer Network guidelines have recommended metastatic colorectal cancer patients (mCRC pts) undergo BRAF, KRAS, NRAS, and microsatellite instability/mismatch repair deficiency (MSI/MMR) testing since 2015. Previous studies have reported molecular testing rates from academic and community cancer centers, but there is a lack of information on testing rates in community health systems (HS) which account for approximately half of US cancer care.

Methods: Tumor molecular testing rates were assessed in a first stage analysis for pts with mCRC in HS, in order to inform a second stage analysis focused on treatment decisions and pt outcomes. For the first stage analysis, we randomly selected 200 pts (50 pts from each of 4 HS sites) diagnosed with mCRC between 1/1/2015 and 9/1/2020. The 200 pts were identified through technology-enabled curation, followed by retrospective review performed by certified tumor registrars. An anticipated cohort of 1000 evaluable pts is planned for the second stage analysis.

Results: 53% of pts were tested for all four biomarkers at some point during their care (Table). Pts more likely to have been tested include those: from HS Site 1 (P = 4.2x10-5); age &lt;65 years old at mCRC diagnosis (P = 0.014); and with commercial insurance (P = 0.015). Among pts tested, the median times from metastatic diagnosis to BRAF, KRAS, and NRAS testing results were 35, 33, and 34 days, respectively.

Conclusion: This first stage analysis of molecular testing in mCRC pts revealed variation in testing rates by site, biomarker, and patient characteristics, which may in part be explained by the implementation of a precision medicine testing program at HS Site 1. A second stage analysis assessing the impact of biomarker testing on treatment decisions and pt outcomes will be guided by this initial characterization of testing rates and possible confounders.

Biomarker testing rates among metastatic colorectal patients across four health system sitesSite 1 (n=50)Site 2 (n=50)Site 3 (n=50)Site 4 (n=50)BRAF tested43 (86%)25 (50%)24 (48%)26 (52%)Count (%)KRAS tested44 (88%)35 (70%)32 (64%)35 (70%)Count (%)NRAS tested42 (84%)23 (46%)26 (52%)30 (60%)Count (%)MSI/MMR tested49 (98%)37 (74%)44 (88%)44 (88%)Count (%)All biomarkers tested40 (80%)19 (38%)20 (40%)26 (52%)Count (%)

Citation Format: Chenan Zhang, Mahder Teka, Francesca F. Coutinho, Joseph R. Burkhart, Louise E. Widmer, Ronda G. Broome, Mary T. Tran, Michael A. Thompson, Antony M. Ruggeri, Jennifer J. Godden, James L. Weese, Douglas J. Reding, Anna B. Berry, Yanina Natanzon, Thomas D. Brown. Staged analysis of standard of care tumor molecular testing among patients with metastatic colorectal cancer in the community health system setting [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2021; 2021 Apr 10-15 and May 17-21. Philadelphia (PA): AACR; Cancer Res 2021;81(13_Suppl):Abstract nr 2618.

Rapid real-world data analysis of patients with cancer, with and without COVID-19, across distinct health systems

Background

The understanding of the impact of COVID‐19 in patients with cancer is evolving, with need for rapid analysis.

Aims

This study aims to compare the clinical and demographic characteristics of patients with cancer (with and without COVID‐19) and characterize the clinical outcomes of patients with COVID‐19 and cancer.

Methods and Results

Real‐world data (RWD) from two health systems were used to identify 146 702 adults diagnosed with cancer between 2015 and 2020; 1267 COVID‐19 cases were identified between February 1 and July 30, 2020. Demographic, clinical, and socioeconomic characteristics were extracted. Incidence of all‐cause mortality, hospitalizations, and invasive respiratory support was assessed between February 1 and August 14, 2020. Among patients with cancer, patients with COVID‐19 were more likely to be Non‐Hispanic black (NHB), have active cancer, have comorbidities, and/or live in zip codes with median household income <$30 000. Patients with COVID‐19 living in lower‐income areas and NHB patients were at greatest risk for hospitalization from pneumonia, fluid and electrolyte disorders, cough, respiratory failure, and acute renal failure and were more likely to receive hydroxychloroquine. All‐cause mortality, hospital admission, and invasive respiratory support were more frequent among patients with cancer and COVID‐19. Male sex, increasing age, living in zip codes with median household income <$30 000, history of pulmonary circulation disorders, and recent treatment with immune checkpoint inhibitors or chemotherapy were associated with greater odds of all‐cause mortality in multivariable logistic regression models.

Conclusion

RWD can be rapidly leveraged to understand urgent healthcare challenges. Patients with cancer are more vulnerable to COVID‐19 effects, especially in the setting of active cancer and comorbidities, with additional risk observed in NHB patients and those living in zip codes with median household income <$30 000.

Leveraging performance improvement (PI) strategies to decrease emergency department visits and inpatient admissions of patients receiving IV chemotherapy

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Background: Per CMS, “in 2011, about 22% of cancer patients receive chemotherapy each year with treatment totaling $34.4 billion.” The number of patients receiving chemo in a hospital outpatient department (HOPD) continually increases. As patients attempt side effect management at home, their symptoms may worsen, and provider access may be limited. These conditions contribute to hospital admissions and ED visits for treatment management. After review of internal data and system patterns, in response, Aurora Cancer Care (ACC)’s leadership developed (market/site-specific) PI strategies focusing on decreasing overall ED utilization and IP admissions for patients actively receiving IV chemotherapy. Methods: The first step of the project was developing a systemized report capturing specific data points, including reason for visit, time of day, day of week, and patient’s cancer type. The population included all payor patients with an ED visit/IP admission within 30 days of receiving chemo. A subcommittee of system operational leaders brainstormed and implemented processes such as enhancing patient triage, restructuring APC workflow, introducing the “Call Us First Campaign” education initiative, re-evaluating clinic access for pain management medications, and distributing free thermometers to patients allowing accurate assessment of symptoms while at home. Results: All chemotherapy infusions were studied for 4Q 2018 and 1Q 2020 totaling 2,018 and 2,064 infusions respectively. The implementation of PI strategies resulted in significant improvements not only in overall IP admissions and ED visits, but also in key areas such as time of day and primary diagnosis (see table). Conclusions: PI strategies have demonstrated an impact on decreasing both IP admissions and ED visits while continuing to evolve. This engagement has contributed to change in practice patterns, aligned our institution with better side effect management at home while relieving the burden to patients during chemotherapy treatment. In addition, as admissions decrease, treatment costs are impacted as well. [Table: see text]

Abstract S10-02: Using real-world data (RWD) from an integrated platform for rapid analysis of patients with cancer with and without COVID-19 across distinct health systems

Introduction: Reports suggest worsened outcomes in patients with cancer (pts) and COVID-19 (Cov), varying by geography and local peak dynamics. We describe characteristics and clinical outcomes of pts with and without Cov.

Methods: RWD at 2 Midwestern health systems from the Syapse Learning Health Network were used to identify adults with active cancer (AC) or past history of cancer (PHC). AC pts were identified by encounters with ICD-10 code for malignant neoplasm or receipt of an anticancer agent within 12 months prior to February 15, 2020; PHC pts were identified by encounters with an active cancer code from May 15, 2015 to February 15, 2019 and no receipt of anticancer therapy within the prior 12 months. Cov was defined by diagnostic codes and laboratory results from February 15 to May 13, 2020. Comorbidities were assessed prior to February 15, 2020; hospitalizations (hosp), invasive mechanical ventilation (IMV), and all-cause mortality (M) were assessed from February 15 to May 27, 2020.

Results: We identified 800 pts with Cov (0.5%) out of a total of 154,585 pts with AC or PHC. Compared to AC pts without Cov (AC WO, 39,402), AC pts with Cov (AC Cov, 388) were more likely to be non-Hispanic Black (NHB, 39% vs. 9%), have renal failure (RF, 24% vs. 12%), cardiac arrhythmias (33% vs. 19%), congestive heart failure (CHF, 16% vs. 8%), obesity (19% vs. 14%), pulmonary circulation disorder (PCD, 9% vs. 4%), and a zip code with median annual household income (ZMI) &lt;$30k (18% vs. 5%). Comorbidity and income were similarly distributed for PHC pts with Cov (PHC Cov, 412). Compared to PHC pts without Cov (PHC WO, 114,383), coagulopathy (coag) was more common in PHC Cov pts (10% vs. 5%). Hosp for AC Cov pts was higher than for AC WO pts (81% vs. 15%). Hosp for PHC Cov pts was also higher than for PHC WO pts (68% vs. 6%). Hosp was highest for NHB pts in both AC Cov and PHC Cov groups (88% and 72%) and for AC Cov pts in low ZMI (94% in &lt;$30K). Pts &lt;50 years old had hosp rates of 79% (AC Cov) and 49% (PHC Cov). IMV rate for AC Cov pts was higher than for PHC Cov pts (21% vs. 14%). Rates of IMV for AC Cov pts were highest in low ZMI (27%) and in pts with coag (36%). M by group was: AC Cov 16%; AC WO 1%; PHC Cov 11%; PHC WO 1%. Among AC Cov pts, M was higher for men (19% vs. 13%) and pts with PCD (31%), RF (25%), or diabetes (DM, 24%); among PHC Cov pts, M was also higher for men (14% vs. 8%) and pts with coag (30%), valvular disease (27%), or PCD (24%). Increasing age, DM, RF, and PCD were associated with increased risk of M for AC Cov pts in age, race/ethnicity, and comorbidity-adjusted logistic regression; increasing age and coag were associated with M in PHC Cov pts.

Conclusion: In this rapid characterization from RWD, pts with Cov have higher rates of pre-existing cardiopulmonary/vascular and renal conditions and increased risk of hospitalization, IMV, and mortality than pts without Cov. Higher Cov risk and worse outcomes in NHB and lower-income pts suggest health care disparities. Whether these outcomes are due to comorbidities or acute sequelae merits further study, as does investigation of alternative definitions for real-world populations and outcomes.

Citation Format: Shirish M. Gadgeel, Michael A. Thompson, Monika A. Izano, Clara Hwang, Tom Mikkelsen, James L. Weese, Frank M. Wolf, Andrew Schrag, Sheetal Walters, Harpreet Singh, Jonathan Hirsch, Thomas D. Brown, Paul G. Kluetz. Using real-world data (RWD) from an integrated platform for rapid analysis of patients with cancer with and without COVID-19 across distinct health systems [abstract]. In: Proceedings of the AACR Virtual Meeting: COVID-19 and Cancer; 2020 Jul 20-22. Philadelphia (PA): AACR; Clin Cancer Res 2020;26(18_Suppl):Abstract nr S10-02.

Use of treatment pathways reduce cost and increase entry into clinical trials in patients (pts) with non-small cell lung cancer (NSCLC)

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Background: VIA Oncology evidence-based pathways have been integrated into our medical oncology workflows since November 2014. Within 3 months, compliance was high for our 42 medical oncologists at 19 sites working with a common EHR with over 85% of pts treated on pathway. The aim of this study was to determine if there was a significant difference in the overall cost of treatment between pts treated on pathway versus off pathway, and whether on pathway pts had a lower rate of ED use and unplanned admissions within 30 days of chemotherapy as required in the new CMS directives. Methods: Newly diagnosed NSCLC pts diagnosed between January 1, 2017 to December 31, 2018 were identified from the tumor registry for the system. The VIA database was queried to separate these pts into two groups – those pts who were treated on pathway, and those who were off pathway. In addition, we divided pts into early diagnosis, advanced/curative, and advanced/non-curative. The data warehouse was utilized to determine the total charges of adjuvant medical oncology treatment for these pts. In addition, data was extracted for the same groups to determine those pts who sought ED evaluation and or hospital admission within 30 days of chemotherapy treatment (CMS-35). Statistical analysis was performed using Chi-square/Fisher’s exact test to compare proportions and t-test for independent samples to compare treatment costs and ED/hospitalizations between the on and off pathway groups. Results: During the 2 years, 407 (81.4%) NSCLC pts were treated on pathway (including clinical trials); 93 (18.6%) were off pathway. All patients undergoing treatment were ECOG 0-2 Performance Status. Mean cost for treating the on-pathway group was $104,436 compared to $183,717 for the off-pathway pts (p = 0.01). Since implementing pathways, clinical trial entry rose from 27 to 66/yr. 25.8% of on pathway compared to 29% of off pathway fell into the CMS 35 group. Conclusions: Standardized usage of evidence-based pathways can be used successfully across a large number of providers over wide geography. Adherence to pathways results in significant cost savings for each patient and significant rise in clinical trial entry.

Comparing survival outcomes for neoadjuvant therapy versus adjuvant therapy in the management of stage 1 pancreatic adenocarcinoma: A National Cancer Database study

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Background: We are in the midst of a paradigm shift in the treatment of stage 1 pancreatic ductal adenocarcinoma (PDAC) from surgery first followed by adjuvant therapy (AT) to Neoadjuvant therapy (NAT) first followed by surgery and this is reflected in the current NCCN guidelines as well. Data comparing these two modalities are limited. AIM: To compare long term survival between Surgery + AT and NAT + Surgery in a large National Cancer Database for stage 1 PDAC. Methods: We identified patients with the NCDB with surgically resected AJCC clinical stage 1, 1A, and 1B PDAC between 2004-2016. Patients were stratified into two groups to assess outcomes: AT and NAT. Patients with incomplete survival and sequence of therapy were excluded. Baseline demographic data, 90-Day Mortality, Median survival, and Hazard ratios (HR) for survival was evaluated. Results: 9017 pts with Clinical stage 1, 1A, 1B PDAC between 2004-2016 were identified. Of these 7453 pts had surgery followed by AT; and 1564 pts had NAT followed by surgery. There was a statistically significant difference in age (66.0±9.9 years for AT vs. 64.7±9.78 years for NAT, p &lt; 0.001) but no difference in Charlson Comorbidity Scoring (p = 0.618) or sex (p = 0.073). 90-Day Mortality was 0.35% in the AT group compared to 0.83% in the NAT group (p = &lt; 0.001). Median survival was 28.5 (95% CI 26.5-29.9) months in the NAT group compared to 25.4 (95% CI 24.7-26.1) months in the AT group. With AT as the reference group for survival, there was a HR of 0.904 (95% CI 0.845-0.968, p = 0.003) for NAT. Conclusions: In this retrospective cohort of patients, NAT was associated with increased overall survival. However, NAT was associated with an increased 90 day mortality. A randomized, controlled trial is necessary to further support the superiority of NAT in the management of stage 1 PDAC.

Oncology precision medicine for hepatobiliary and pancreatic cancer: Insights and updates upon an institutional review

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Background: Hepatobiliary cancers - hepatocellular carcinoma (HCC), intra or extrahepatic cholangiocarcinoma (I/EC), and gallbladder carcinoma (GB) - and pancreatic adenocarcinoma (PC) do have actionable alterations (AA). The importance of testing early in a patient’s (pts) course to identify oncology precision medicine (OPM) options could be paramount for progression free survival (PFS). Methods: We identified pts with HCC, IC, EC, GB or PC in our OPM database since the centralization of our system. Pts who underwent molecular panel testing had AA’s identified and stratified by cancer type. Treatment course was analyzed using swimmers plots. Results: 456pts were diagnosed with HCC, IC, EC, GB or PC. 104/456pts (23%) were ordered for molecular testing and 88/456pts (19.3%) completed testing: 18/88pts (20.4%) I/EC, 2/88pts (2.3%) HCC, 5/88pts (5.7%) GB, and 63/88pts (71.6%) PC. Of the PC pts, 3/63 (4.8%) had a BRCA mutation. These pts did not receive targeted therapy. Overall, 5/88pts (5.7%) had a BRAF mutation (2 PC, 2 I/EC, 1GB). Thus, 8/88 (9.1%) of tested pts became eligible for some form of targeted therapy over their treatment course. Of those with a BRAF mutation, only 2/5 pts had OPM testing sent with initial diagnostic workup, and 2/5 eventually began targeted therapy. One had a progression free survival (PFS) of 2.5months while the other discontinued secondary to toxicity. Conclusions: Our data showed that we are testing a minority of pts with pancreas and hepatobiliary cancers. Of those tested, it may have occurred too late in the course of illness to improve outcomes. Given the potential utility of uncovering potential germline alterations like BRCA1/2 as well as pragmatic AAs including somatic BRCA and BRAF, we are moving to a more systematic evaluation of pts to capture and respond to these issues.

[Table: see text]

Oncology precision medicine for hepatobiliary and pancreatic cancer: An institutional review

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Background: Hepatobiliary cancers - hepatocellular carcinoma (HCC), intra or extrahepatic cholangiocarcinoma (I/EC), and gallbladder carcinoma (GB) - and pancreatic adenocarcinoma (PC) remain a leading cause of death with little improvement in long-term outcome. Recent studies have suggested that these cancers harbor actionable mutations to varying degrees. The aim of our study was to examine the number of patients (Pts) with these primary tumors who underwent molecular testing in a large vertically integrated health system. Subsequently, we analyzed the percentage of that population who may be candidates for oncology precision medicine (OPM) directed therapy. Methods: We identified Pts with HCC, IC, EC, GB in an IRB reviewed OPM database of our system over a one year period. Pts who underwent molecular panel testing were selected out, and their molecular alterations were identified and stratified by cancer type. Results: 304 total Pts were identified. 61 (20%) underwent molecular testing broken down as follows: 17/132 (13%) I/EC and HCC, 3/11 (27%) GB, and 41/161 (25%) PC. Quantity not sufficient for testing was in 10/61 (16%), of which 5/10 (50%) were resubmitted and tested successfully. 6/61 (10%) were cancelled or deemed not appropriate. Test recommended potential actionability was 8/17 (47%) of I/EC and HCC, 2/3 (67%) of GB, and 25/41 (61%) of PC. Conclusions: OPM is a dynamic area of increasing testing and learning. We found 13-27% of hepatobiliary and pancreatic Pts had molecular testing, which suggests the potential to increase molecular screening for this difficult group of tumors. Total genetic alterations (TGA) and clinically relevant genomic alterations (CRGA) per patient are similar to Ross et al. ( http://ow.ly/k52a30nBMnU ) for GB. Final interpretation regarding pragmatic actionability (patient on drug) and clinical outcomes are still under investigation.[Table: see text]

Use of treatment pathways reduce cost and decrease ED utilization and unplanned hospital admissions in patients (pts) with stage II breast cancer

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Background: VIA Oncology evidence-based pathways have been integrated into our medical oncology workflows since November 2014. Within 3 months, compliance was high for our 42 medical oncologists at 19 sites working with a common EHR with over 85% of pts treated on pathway. The aim of this study was to determine if there was a significant difference in the overall cost of treatment between pts treated on pathway versus off pathway, and whether on pathway pts had a lower rate of ED use and unplanned admissions within 30 days of chemotherapy as required in the new CMS directives. Methods: Newly diagnosed stage 2 breast cancer pts diagnosed between January 1, 2016 to December 31, 2017 were identified from the tumor registry for the system. The VIA database was queried to separate these pts into two groups–those pts who were treated on pathway, and those who were off pathway. The data warehouse was utilized to determine the total charges of adjuvant medical oncology treatment for these pts. In addition, data was extracted for the same groups to determine those pts who sought ED evaluation and or hospital admission within 30 days of chemotherapy treatment. Statistical analysis was performed utilizing Fisher’s exact test to compare proportions and t-test to compare treatment costs and ED/hospitalizations between the on and off pathway groups. Results: During the 2 years, 412 (93%) Stage 2 breast cancer pts were treated on pathway (including clinical trials); 32 (7%) were off pathway. 81% of the on-pathway group were + for ER and/or PR and 17% were HER-2 +; 78% of the off-pathway group were + for ER and/or PR and 38% were HER-2 +. Mean cost for treating the on-pathway group was $111,067 compared to $200,717 for the off-pathway pts (p=0.01). 18.8% of the off-pathway pts were seen in the ED / unplanned admissions and had more multiple visits compared to 12.1% of on-pathway pts within 30 days of chemotherapy (p=0.026). Conclusions: Standardized usage of evidence based pathways can be used successfully across a large number of providers over wide geography. Adherence to pathways results in significant cost savings for each patient, and significant reduction in ED/hospital utilization for on pathway patients.

Implementation of a low-dose computerized tomography (LDCT) lung cancer screening program (LCSP) across a large integrated health system

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Background: The LDCT LCSP was launched as a critical component of our Cancer Program to support tobacco cessation efforts and increase early detection. Initially it was offered as a self-referral low cost screening. The program was expanded when the Affordable Care Act and Center for Medicare/Medicaid Services covered it as a preventative services benefit in January 2015. Methods: 9 LDCT LCSP locations were implemented between 2014-September 2016. Program data are submitted to the American College of Radiology Lung Cancer Data Registry since 2016. In 2017, a Best Practice Alert was created within our electronic health record (EHR) to alert the primary care clinician if his/her patient met criteria for a LDCT. Each of the sites managed their own programs up until September 2018 when a dedicated team (Team) of two nurses and one data support specialist was justified. The Team focus is to increase awareness of the LDCT LCSP and criteria for eligibility, improve tobacco history taking and pack year documentation in the EHR, increase smoking cessation counseling and referral, and facilitate presentation of all Lung RADS category 4 cases for review at one of our two Multidisciplinary Lung Cancer Case Conferences. Standardized management of key incidental findings was developed for coronary artery calcification, non-lung masses, thoracic aortic aneurysm, and critical pulmonary conditions. To date, we have not examined the impact of the LDCT LCSP on smoking cessation rates. All 9 program sites have been named a Screening Center of Excellence by the Lung Cancer Alliance. Results: In 2016, 1849 LDCT Screenings were performed, 4701 (154% increase) in 2017 and 7154 (52.5% increase) in 2018. Cancer Detection rates were 1.3% in 2016, 1.8% in 2017 and 1.3% for January-June 2018. Cancer registry data reports a 9% increase in Stage 0, 1, 2A and a 7.2% decrease in Stage IV at time of diagnosis from 2014-2017. Conclusions: The implementation of a LDCT LCSP has increased the percentage of patients diagnosed at an earlier stage of lung cancer. With standardized management of key incidental findings, we anticipate improvement in early detection and management of cardiac and pulmonary diseases.

Racial disparity in gastrointestinal cancer: Insight from national cancer database

607

Background: The number of cases of cancers originating from the gastrointestinal (GI) tract and from other associated GI organs has increased 28% between the years 2004-2014. The incidence and overall survival for GI tract related cancers shows systematic racial disparity. Our goal was evaluate racial disparity for overall survival and mortality among patients with GI tract cancers. Methods: We used the national cancer database to evaluate data from 12 types of GI tract cancers (esophagus, stomach, gallbladder, intrahepatic bile duct, extrahepatic bile duct, liver, pancreas, small intestine, colon, rectosigmoid, rectum, and anal) between the years 2004-2014. The racial categories included non-Hispanic white (NHW), non-Hispanic black (NHB), Hispanic, and Other (All other races were combined into an ‘Other’ category). We used Kaplan-Meier estimator with log-rank test for comparing the survival probability among the four race categories. We also used Cox regression to find out the hazard ratio for mortality adjusting for the age, sex, and Charlson index. Results: The study population included a total of 2,044,565 patients diagnosed with one of the GI tract cancers. Of the total 55% were male, 72% NHW 12% NHB, 0.4% Hispanic, and the rest were classified as ‘other’ race (16%) which includes majority of white or black Hispanic and Asian (82%), The mean age at diagnosis of the patients was 66.8 ± 11.3 years. Overall survival was better for the Hispanic group, followed by the ‘Other’ group, NHW and NHB (P < 0.001). Adjusted for age, sex, and for Charlson index, the hazards ratio was 0.93 (95% CI, 0.90-096, p < 0.001) for Hispanic vs other, 1.15 (95% CI, 1.14-1.16, p < 0.001) for NHB vs other, 0.98 (95% CI, 0.97-0.98, p < 0.001) for NHW vs others. Mortality rate among Hispanic, NHW, NHB, and other was 46.4%, 59.4%, 59.6%, 56.7%. Conclusions: With a very large study population the survival for Hispanic patient population as well as the ‘Other’ (majority of patients were Asian) category had higher overall survival probability and low rate mortality compared to other race categories. Possible hypotheses include dietary preferences, underlying genetic profile and environmental factors. Further studies are needed to confirm the hypotheses.

Survival outcomes between surgery with adjuvant therapy compared to neoadjuvant therapy with surgery in stage I pancreatic adenocarcinoma: Results from a large national cancer database

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Background: There has been a paradigm shift in the treatment of stage 1 pancreatic adenocarcinoma (PAC) from surgery first followed by adjuvant therapy (AT) to Neoadjuvant therapy (NAT) first followed by surgery and this is reflected in the current NCCN guidelines as well. Data comparing these two modalities are limited. AIM: To compare long time survival between surgery vs Surgery + AT and NAT + Surgery in a large National Cancer Database. Methods: We identified patients with surgically resected AJCC clinical stage 1, 1A, and 1B PAC between 2004-2014. Patients were stratified into 3 groups to assess outcomes. Exclusion criteria: those with incomplete survival and sequence of therapy data. Hazard ratios (HR) were calculated for evaluation of survival, as well as for 30-Day and 90-Day Mortality between the 3 groups. Results were adjusted for age and Deyo-Charlson comorbidity index. Results: A total of 9684 pts with Clincal stage 1, 1A, 1B PAC between 2004-2014 were identified. Of these 2266 pts underwent surgery alone; 6222 had surgery followed by AT; and 1196 pts had neoadjuvant therapy followed by surgery. There was a HR of 0.995 (95% CI 0.935-1.058 p = 0.864) and 0.984 (95% CI 0.924-1.048, p = 0.617) for 30- and 90-Day mortality comparing upfront surgery to NAT, respectively. With AT as the reference group for survival, there was a HR of 1.362 (95% CI 1.286-1.443, p < 0.001) for surgery only and HR of 0.929 (95% CI 0.859-1.004, p = 0.064) for NAT. Conclusions: 1. Surgery alone had worse overall survival. 2. There was no significant difference in overall survival when comparing AT and NAT 3. A prospective randomized trial evaluating the differences in survival is needed.

Survival outcomes comparable between endoscopic resection and surgical resection for T1b esophageal adenocarcinoma

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Background: Current guidelines recommend esophagectomy for submucosal T1b esophageal cancer. Data regarding efficacy of endoscopic resection (ER) of T1b esophageal cancer are limited. Our goal was to compare survival outcomes of ER as opposed to conventional surgical resection (SR) in a large cohort of patients with T1b cancers from a large national database. Methods: Data were obtained from the large national database maintained by the Commission on Cancer. Patients with T1b esophageal cancers with clinical stage 1A and 1B who underwent ER and SR between 2010 and 2014 were identified using the American Joint Committee on Cancer (AJCC Version 7). Patients undergoing ER and SR were identified. Patients who underwent neoadjuvant therapy or had incomplete survival data were excluded. The primary outcome was survival for age and Deyo-Charlson comorbidity index. We also evaluated 30-Day and 90-Day Mortality outcomes. Results: There were 1071 patients with T1b esophageal cancer with complete mortality data. After selecting and excluding patients above, 141 patients were identified who underwent EET and 286 who underwent esophagectomy. Average age was 71.5 years in the ER group and 64.5 years in the SR group (p < 0.001). In the group, 30-Day mortality after surgery was 1/134 (0.8%, 7 missing) compared to surgery with 30-Day mortality of 6/283 (2.1%, 3 missing) (P = 0.308). 90-Day mortality after surgery for the ER group was 3/134 (2.2%, 7 missing) compared with the surgery with 90-Day mortality of 11/281 (3.9%, 5 missing) (P = 0.377). Adjusted for age and Deyo-Charlson comorbidity index, there was a HR of 1.051 (95% CI 0.695-1.589, p = 0.815) for mortality associated with surgery compared with ER. Mean follow-up of 42.6 months for the ER group and 55.7 months for surgery group. Conclusions: Based on the data from a large national cancer data base ER seems to be comparable to SR in terms of short term (30 day and 90 day) mortality. Overall survival seems to be similar in both groups Prospectively done randomized studies comparing ER versus SR are desirable.

Coordinating an Oncology Precision Medicine Clinic Within an Integrated Health System: Lessons Learned in Year One

Precision medicine is a term describing strategies to promote health and prevent and treat disease based on an individual's genetic, molecular, and lifestyle characteristics. Oncology precision medicine (OPM) is a cancer treatment approach targeting cancer-specific genetic and molecular alterations. Implementation of an OPM clinical program optimally involves the support and collaboration of multiple departments, including administration, medical oncology, pathology, interventional radiology, genetics, research, and informatics. In this review, we briefly introduce the published evidence regarding OPM's potential effect on patient outcomes and discuss what we have learned over the first year of operating an OPM program within an integrated health care system (Aurora Health Care, Milwaukee, WI) comprised of multiple hospitals and clinics. We also report our experience implementing a specific OPM software platform used to embed molecular panel data into patients' electronic medical records.

A collaborative program for educating urban youth about HPV risk and cancer prevention

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Background: HPV infection is the most common sexually transmitted disease. Exposure to this infection is associated with cancer later in life. Public data regarding HPV vaccination rates and health disparity (as evidenced by low-income, high teen birth and STI rates) were identified. Methods: Based on the supposition that health disparity is associated with low socioeconomic status, a Wisconsin state map provided by the Center for Urban Population Health identified 29 zip codes in the City of Milwaukee, and are broken by low, medium, and high income brackets. An HPV education program, in partnership with Milwaukee Public Schools (MPS), was developed with a focus on the low income bracket to emphasize infection exposure and the safety and efficacy of the HPV vaccine in cancer prevention. This included education on safe relationships and emphasis on personal health advocacy. Program development was aimed at the health literacy of youth. Collaboration occurred with MPS leadership and their established health curriculum to ensure the HPV program accommodated the academic level of the freshman health classroom. Results: The data is reflective of HPV vaccine series completion rates within the zip codes where the HPV program was presented. Logistic regression was used and a significant rise for HPV completion rates by year (p = 0.0003) and by zip code (p < 0.0001) were observed. Conclusions: As the program evolves, program evaluations and public data continue to be reviewed along with feedback from various stakeholders to maintain the quality and integrity of the program. Additionally, Aurora Health Care has received requests to share this HPV program best practice with other institutions to expand it throughout urban areas of Wisconsin and Illinois.[Table: see text]

Engaging managing physicians in clinical staging prior to the initiation of cancer treatment

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Background: Managing physicians (medical oncologist, radiation oncologist, surgeons) have a responsibility to clinically stage patients prior to the initiation of cancer treatment. Clinical staging not only directs the treatment plan, but identifies appropriate clinical trials and estimates prognosis. We sought to determine whether engagement of managing physicians would result in increased clinical staging for various types of cancer. Methods: Baseline data on clinical staging for breast, colorectal (colon, rectal, anal, rectosigmoid junction)*, thoracic (lung esophageal)†, genitourinary (prostate, penis, testes)‡, and pancreatic primary cancers were obtained. The data were grouped by disease type and sub-specialty of the managing physicians. Based on that data, several performance improvement initiatives were implemented to provide managing physicians the opportunity to clinically stage the cancer patient prior to the initiation of treatment. The initiatives for completing and documenting staging were: a tutorial on use of Problem List in the electronic medical record (EMR); modification of history & physical and consult notes to include a field for staging; sharing among sub-specialties the smart lists within the template to allow for customization of existing templates; and 1:1 review with physicians who had outliers without clinical staging. Results: Clinical staging documented prior to the initiation of cancer treatment significantly increased in all five types of cancers studied (p < .01; Table). Conclusions: Though collaborative efforts by managing physicians continues to evolve, in many cases, use of the electronic medical record through a variety of performance improvement initiatives has facilitated documentation of clinical staging of cancer patients prior to the initiation of treatment. This engagement changed practice patterns, aligned our institution with best practice guidelines and aided in treatment selection for the best possible patient outcomes. [Table: see text]

Implementing survivorship care planning in a large integrated cancer program

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Background: Aurora Health Care is comprised of 15 hospitals and 22 oncology clinics. Aurora Cancer Care (ACC), a Commission on Cancer (CoC) accredited program, diagnoses and treats 7,000 adult cancer patients annually, more than any other healthcare system in Wisconsin. The CoC’s Survivorship Standard 3.3 requires accredited cancer programs to provide cancer patients with survivorship counseling and a written care plan. ACC was challenged to develop a consistent model of survivorship care that can work at multiple sites across the system. Methods: Workflow planning and education began at all oncology clinics in fourth quarter of 2014. Thirteen disease specific survivorship care plan templates were built into the EMR with some-auto population functionality. A system wide delivery plan was launched in first quarter of 2015 with the goal of targeting 10% of eligible patients. Initial focus was on breast cancer patients with some sites also including other cancers. The model of survivorship care is an “embedded consultation” in medical or surgical oncology with an advanced practice provider (APP) completing the care plan and meeting with the patient at the end of first line treatment. Results: Initial required volumes were estimated based on 2013 registry data with a goal of completing approximately 700 care plans in 2015 to meet the 10% CoC standard. During Q1 & Q2 of 2015, 444 care plans were generated and given to patients, mostly for breast cancer survivors. The most significant barrier surrounded retrieving data from the EMR. Conclusions: Data from the first half of 2015 demonstrates success with the approach. Aurora Cancer Care will exceed the benchmark of 700 care plans. There has been a high level of engagement with the APPs who have taken ownership of survivorship care planning, contributing to the success of the program thus far. Because of difficulty retrieving data from the EMR, manual tracking was still required. Future modifications will address this and other barriers.

Getting quality data back to frontline providers

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Background: Oncology quality performance metrics may be improved by establishing a coordinated process for getting data back to providers. However, establishing ownership of quality metric data can be a challenge, especially in a large, integrated health system. Methods: Aurora Cancer Care’s team developed quality charters and a coordinated process for its 15-hospital, integrated health system that outlines a course of action for metric selection, data distribution, peer review and development of process improvement plans. A weighted tool was developed and implemented to prioritize measure selection. The weighted tool described and scored each quality measure against its performance improvement opportunity, ease in data collection, national benchmarks, regulatory and reimbursement impact, value to the patient and consideration of the resources required to implement change. The final score was used to prioritize and select measures. The System Multidisciplinary Disease-Specific Quality Subcommittees established quality measures. Abstraction began, outliers were reviewed and results were disseminated to the System Cancer Leadership Council as well as the 15 hospitals via the Regional Cancer Quality Subcommittees (RCQS). The RCQS chairs and quality directors meet quarterly with the system quality liaison to ensure the communication of data back to the front-line providers. Results: We found a rise in the percentages of invasive rectal cancers diagnosed with endorectal ultrasound or magnetic resonance imaging (no stage IV) (2012: 76%, 2013: 84%) and treated with total mesorectal excision (no stage IV) (2012: 72%, 2013: 87%). In addition, increases in the examination of at least 12 regional lymph nodes for invasive colorectal cancer (2012: 93%, 2013: 98%; p<0.05) and partial, rather than total, nephrectomy for renal cancer patients with T1a tumors (2012: 71%, 2013: 95%; p<0.05) were statistically significant. Conclusions: Though our coordinated process to get quality data back to providers continues to evolve, our front-line providers have shown greater enthusiasm for the data, engaged in behavior modification and become more accountable with process improvement plans that are integral to establishing the best patient outcomes.

Postoperative Ileus-Related Morbidity Profile in Patients Treated with Alvimopan after Bowel Resection

BACKGROUND

Postoperative ileus (POI), an interruption of coordinated bowel motility after operation, is exacerbated by opioids used to manage pain. Alvimopan, a peripherally acting mu-opioid receptor antagonist, accelerated gastrointestinal (GI) recovery after bowel resection in randomized, double-blind, placebo-controlled, multicenter phase III POI trials. The effect of alvimopan on POI-related morbidity for patients who underwent bowel resection was evaluated in a post-hoc analysis.

STUDY DESIGN

Incidence of POI-related postoperative morbidity (postoperative nasogastric tube insertion or POI-related prolonged hospital stay or readmission) was analyzed in four North American trials for placebo or alvimopan 12 mg administered 30 minutes or more preoperatively and twice daily postoperatively until hospital discharge (7 or fewer postoperative days). GI-related adverse events and opioid consumption were summarized for each treatment. Estimations of odds ratios of alvimopan to placebo and number needed to treat (NNT) to prevent one patient from experiencing an event of POI-related morbidity were derived from the analysis.

RESULTS

Patients receiving alvimopan 12 mg were less likely to experience POI-related morbidity than patients receiving placebo (odds ratio = 0.44, p < 0.001). Fewer patients receiving alvimopan (alvimopan, 7.6%; placebo, 15.8%; NNT = 12) experienced POI-related morbidity. There was a lower incidence of postoperative nasogastric tube insertion, and other GI-related adverse events on postoperative days 3 to 6 in the alvimopan group than the placebo group. Opioid consumption was comparable between groups.

CONCLUSIONS

Alvimopan 12 mg was associated with reduced POI-related morbidity compared with placebo, without compromising opioid-based analgesia in patients undergoing bowel resection. Relatively low NNTs are clinically meaningful and reinforce the potential benefits of alvimopan for the patient and health care system.

Phase III trial of alvimopan, a novel, peripherally acting, mu opioid antagonist, for postoperative ileus after major abdominal surgery

PURPOSE

Postoperative ileus presents significant clinical challenges that potentially prolong hospital stay, contribute to readmission, and increase morbidity. There is no approved treatment for postoperative ileus. Alvimopan is a novel, peripherally acting, mu opioid receptor antagonist currently in development for the management of postoperative ileus.

METHODS

Patients undergoing partial colectomy or simple or radical hysterectomy were randomized to receive alvimopan 6 mg (n = 152), alvimopan 12 mg (n = 146), or placebo (n = 153) orally 2 hours before surgery and twice daily thereafter until discharge or for up to seven days. The primary efficacy end point, time to return of gastrointestinal function, was a composite measure of passage of flatus or stool and tolerating solid food. Secondary end points included time to the hospital discharge order written. Adverse events were monitored throughout the study.

RESULTS

Mean time to gastrointestinal recovery was significantly reduced in patients treated with alvimopan 6 mg vs. placebo (hazard ratio = 1.45; P = 0.003), with a smaller reduction seen with alvimopan 12 mg (hazard ratio = 1.28; P = 0.059). Mean time to the hospital discharge order written was significantly accelerated in patients treated with alvimopan 6 mg (hazard ratio = 1.50; P < 0.001). The most common treatment-emergent adverse events across all treatment groups were nausea, vomiting, and hypotension; the incidence of nausea and vomiting was reduced by 53 percent in the alvimopan 12-mg group.

CONCLUSIONS

In patients undergoing major abdominal surgery, alvimopan accelerated gastrointestinal recovery and time to the hospital discharge order written compared with placebo and was well tolerated.

Neoadjuvant chemotherapy, radical resection with intraoperative radiation therapy (IORT): improved treatment for gastric adenocarcinoma

BACKGROUND

Adenocarcinoma of the stomach and gastroesophageal junction results in substantial morbidity, locoregional recurrence, and death. Surgical procedures, even with adjuvant therapy, have not significantly improved survival. This study evaluated the toxicity, response rate, locoregional control, and survival of patients with locally advanced gastric cancer that was treated with neoadjuvant multimodality therapy.

METHODS

Patients with stage IIIA or early stage IV gastric adenocarcinoma received neoadjuvant 5-fluorouracil, Leucovorin, Adriamycin, and Cisplatin and underwent gastrectomy or esophagogastrectomy with intraoperative radiotherapy (IORT; 1000 cGY) to the gastric bed and postoperative radiation therapy.

RESULTS

Nine of 15 patients (60%) with transmural extension and/or nodal metastases received IORT. There were 2 pathologically complete responses at the primary site. Eleven of 15 patients (73%) had tumor in perigastric lymph nodes; however, 9 of 15 patients (60%) had mucin-filled nodes without tumor cells. Neoadjuvant treatment did not increase operative morbidity rates. Ten of 15 patients (67%) remain free of disease (median, 27 months; range, 6-60 months). Five patients died 13 to 41 months (median, 17 months) after diagnosis.

CONCLUSIONS

Neoadjuvant multimodality therapy with neoadjuvant 5-fluorouracil, Leucovorin, Adriamycin, and Cisplatin, radical resection with IORT, and postoperative radiation therapy is safe, can downstage tumors, provides improved locoregional control, and appears to cause significant tumor regression that may result in long-term survival or cure.

Phase II trial of preoperative radiation therapy and chemotherapy for patients with localized, resectable adenocarcinoma of the pancreas: an Eastern Cooperative Oncology Group Study

PURPOSE

A prospective, multiinstitutional trial was initiated in 1991 to examine the tolerance to and efficacy of a program of preoperative chemoradiotherapy (CTRT) and surgical resection for patients with localized adenocarcinoma of the pancreas.

PATIENTS AND METHODS

Fifty-three patients were assessable for analysis, with a median follow-up of 52 months for survivors. Radiation therapy (RT) totaling 5,040 cGy in 180 cGy fractions with mitomycin 10 mg/m2 day 2 and fluorouracil (5-FU) 1,000 mg/m2/d continuous infusion days 2 through 5 and 29 through 32 were given as preoperative adjuvant therapy. Twelve patients did not proceed to surgery (one death, one toxicity, three local progression, six distant metastases, one intercurrent illness), whereas 41 patients underwent surgery. Of these, 17 patients did not have resection (11, hepatic and/or peritoneal metastases and six local extension that precluded resection). Twenty-four patients had tumor resection (19 Whipple, four total pancreatectomy, one distal pancreatectomy).

RESULTS

Treatment toxicity was primarily hematologic, although a comparable number suffered biliary tract complications, either from obstruction or cholangitis as a result of an occluded stent or the primary tumor. There was one postoperative death. Median survival for the entire group and for the 24 patients with resection was 9.7 and 15.7 months. This survival rate reflected the advanced state of most resected cancers (positive peritoneal cytology, three patients; margins within 2 mm, 13 patients; involved lymph nodes, four patients; and need for superior mesenteric vein (SMV) resection, four patients). Tumor progression was most frequent at metastatic sites.

CONCLUSION

This preoperative CTRT protocol was feasible and safe in a cooperative group setting. Entry of patients with advanced tumors probably accounted for the suboptimal resectability and survival results.

Modulation of colon tumor oncogene expression by cancer patient-derived lipids

In an effort to understand the role of specific fats on carcinogenesis, we have studied the effects of lipids derived from cancer patients on components associated with the regulation of proliferation. The treatment of tumor cells with patient-derived fats produced increased cell proliferation, as indicated by shorter doubling times. The effects of patient-derived lipids on the expression of ras, c-jun, c-erbB-2, and p53 gene products were examined. The cellular expression of the ras proto-oncogene product was increased in both colon tumor cell lines, following lipid treatment. However, c-jun proto-oncogene expression was elevated in HT-29 cells and appeared unchanged in SK-Co-1 cells after lipid treatment. Treatment of HT-29 tumor cells with patient-derived fats produced an enhancement of the p53 gene product, whereas fat treatment reduced p53 expression in SK-Co-1 tumor cells. Further separation of the patient-derived fats indicated that the amplification of p53 gene expression in HT-29 cells could be achieved primarily by addition of the diacylglycerides fraction. Addition of the purified fatty acids, comprising the diglyceride fraction, indicated that the fatty acids, 16:1, 18:0, and 18:1, induced the most significant increases in p53 expression by HT-29 cells. These alterations caused by cancer patient-derived fats are consistent with the loss of normal growth regulation and may explain the epidemiologic association between certain fats and carcinogenesis.

Long-term follow-up of local excision and radiation therapy for invasive rectal cancer

PURPOSE

Little is known regarding the long-term outcome of patients with rectal cancer treated by local excision and radiation therapy. We updated our institutional experience with this approach.

METHODS

From January 1986 to December 1991, 23 patients (median age, 64 (range, 30-80) years) with mobile, moderately differentiated adenocarcinoma of the rectum were offered transanal excision. Two patients with large T3 tumors, who were judged intraoperatively to be unsuited for a local procedure, received radical resection and were excluded from analysis. Twenty-one patients underwent transanal excision en bloc (14) or piece-meal (7) through a resectoscope. Seven patients (74 percent) had either extensive medical problems or refused a colostomy. Patients received a median of 5,040 cGy postoperatively, and 15 also received 500 cGy preoperatively on protocol. Two patients received concomitant chemotherapy. Median follow-up is 56 months for all patients and 67 months for survivors (range, 27-92 months).

RESULTS

There were 2 T1, 15 T2, and 4 T3 tumors. The distance from the anal verge was a median of 4 (range, 1-7) cm. The median tumor size was 3 (range, 2-7) cm. Sixteen patients had more than one-third of the wall involved. Four patients (19 percent) developed a local recurrence at 26, 30, 33, and 48 (median, 31.5) months. Three were salvaged (abdominoperineal resection = 2; low anterior resection = 1) and remain disease-free 18, 36, and 37 months postoperatively. Four patients (19 percent) developed metastases (lung = 3; liver = 1) at 3, 22, 25 and 44 months after initial treatment (median, 23.5 months). The actuarial five-year overall, disease-free and recurrence-free survival are 77, 75, and 58 percent, respectively. Twelve patients (57 percent) have no evidence of disease while retaining their rectum. There was one postoperative death.

CONCLUSIONS

Long-term follow-up confirms that local excision and radiation therapy is of value in patients with mobile tumors of the rectum. It suggests that this treatment can be offered to those patients who refuse a colostomy or are medically compromised and may be an acceptable option for selected patients with T2 or T3, mobile adenocarcinomas of the rectum.

A pilot study of preoperative chemoradiation for patients with localized adenocarcinoma of the pancreas

BACKGROUND

We hypothesized that delivering adjuvant radiotherapy (RT) preoperatively with chemotherapy might enhance local control of the cancer and patient tolerance for the intervention.

METHODS

Thirty-four patients with localized pancreatic cancer (24 head, 8 head and body, 2 body and tail) were treated during the past 6 years with an intramural protocol consisting of 5-fluorouracil (1,000 mg/m2 on days 2 to 5 and 29 to 32) and mitomycin-C (10 mg/m2 on day 2) given with preoperative external beam RT (median 5,040 cGy). Nine patients did not have surgery: 1 refused, 1 died of cholangitis, and 7 were noted to have distant (5) or unresectable local cancer (2) after RT. Of the 25 patients who underwent celiotomy, 11 had liver (8) or peritoneal (3) metastases and 3 had palliative pancreatectomies (2 with liver metastasectomy and 1 with hepatic artery and portal vein replacement). The remaining 11 patients (44% of the cohort with surgery, 32% of all patients) had potentially curative (PC) resections (5 total pancreatectomy, 5 Whipple, 1 distal pancreatectomy). Median tumor diameter by computed tomographic scan was 3.75 cm (range 3 to 5) for the 11 patients who received PC resections and 4.5 cm (range 3 to 7.5) for all patients. Of the 11 patients with PC resections, 8 had evidence of superior mesenteric, portal or splenic venous involvement and 4 had been deemed unresectable at previous celiotomies.

RESULTS

One patient developed respiratory failure and one died postoperatively, yielding a 9% rate of major morbidity and mortality. Median follow-up of the surviving patients with curative resection is 33 months (range 14 to 70). Their median survival from the time of tissue diagnosis is 45 months with a median disease-free survival of 27 months. The product limit estimate of 5-year survival is 40% (95% confidence bounds +29%, -30%). One patient had a microscopically positive resection margin, which was a falsely negative frozen section margin at the pancreatic neck. Two patients had positive regional lymph nodes. Five patients have been diagnosed with recurrent cancer. Only 1 has had a local/regional component to the recurrence.

CONCLUSIONS

Preoperative RT and chemotherapy followed by resection is well tolerated and safe for patients with locally advanced pancreatic cancer. This approach provides tumor free resection margins and offers prolonged survival to patients with truly localized pancreatic cancer.

A single institutional experience with preoperative chemoradiotherapy for stage I-III pancreatic adenocarcinoma

In order to determine whether preresectional chemoradiotherapy (CTRT) would influence resectability, local control, and survival of patients with localized pancreatic adenocarcinoma, a 5 1/2-year prospective study of 39 patients treated with preoperative radiation therapy, 5-Fluorouracil (5-FU), and Mitomycin C has been performed. Thirty patients had celiotomy after CTRT (1/39 died while receiving CTRT, one refused surgery, and seven had extrapancreatic disease progression). Seventeen (57%) had resections (seven total, two distal subtotal, and eight Whipple pancreaticoduodenectomies). All had clear margins of excision, and only one had any positive lymph nodes in the resected specimen. Eleven patients with resection had Stage I cancers (5 T1b, 6 T2), five had Stage II, and one had a Stage III lesion. Previous bypass surgery, age, clinical response to CTRT, and tumor size had no influence on resectability. Two patients died postoperatively (12%) early in the series. Three others suffered major morbidity (chylous ascites requiring peritoneovenous shunt, ARDS, and prolonged afferent loop obstruction leading to a fatal liver abscess 5 months after surgery). Two patients with resection are alive without recurrence at 48 months after tissue diagnosis, and six others are also alive without recurrence, after from 6 to 23 months. In summary, resectability is probably enhanced and nodal metastases and resection margins are downstaged by preoperative CTRT. Demonstration of an improved survival benefit awaits further observation and phase III trials.

Neoadjuvant chemoradiation in pancreatic and duodenal carcinoma. A Phase II Study

BACKGROUND

Low resectability rate and high locoregional recurrence are major factors contributing to the failure of surgical treatment for localized pancreatic adenocarcinoma. A Phase II study involving preoperative 5-fluorouracil (5-FU) and mitomycin C and radiation therapy was evaluated.

METHODS

Thirty-one patients with biopsy-proven carcinoma (24, head of pancreas; 2, body; 5 duodenum) were treated with preoperative radiation therapy, 5040 cGy (180 cGy/fraction, 5 days/week), concurrent with 5-FU, 1000 mg/m2/day continuous infusion (days 2-5, 28-32) and mitomycin C 10 mg/m2 bolus (day 2). Ten patients had previous laparotomy or bypass surgery and were deemed unresectable; 21 had percutaneous, endoscopic retrograde choleangiopancreatic, or transhepatic stent biopsies.

RESULTS

Toxicity included neutropenic fever (2 patients), biliary sepsis (2 patients), and nausea and vomiting requiring total parenteral nutrition. One patient died of biliary sepsis before completion of chemoradiation and 11 patients showed evidence of metastatic disease (clinical or occult). Resectability rate was 38% (10/26) for pancreatic carcinoma and 80% (4/5) for duodenal carcinoma. Pathology of the resected specimens revealed extensive necrosis and hyalinization with clear margins in all cases. Lymph node metastases were found in one case of pancreatic carcinoma. The four resected duodenal carcinomas contained no residual tumor in the specimens. At a median follow-up of 29 months, the median survival time for those with pancreatic carcinoma was not yet reached in the resection group and was 8 months in the nonresection group. The corresponding actuarial 5-year survival rates were 58% and 0%, respectively.

CONCLUSIONS

Neoadjuvant chemoradiation therapy was given safely to patients with pancreatic and duodenal carcinoma. It facilitated complete resection in 38% of patients with pancreatic carcinoma and 80% of those with duodenal carcinoma. A significant downstaging of positive margins and regional lymph nodes occurs as a result of preoperative chemoradiation.

Radiation-induced intestinal injury

Radiation therapy is administered to approximately one third of patients with cancer as part of their treatment plan. Radiation-induced bowel injury is a major cause of morbidity in these patients. The pathophysiology of this condition as well as recommendations for the management of acute and chronic radiation enteritis are discussed. In general, except for patients presenting with signs of an acute abdomen, conservative management yields the best clinical results.

Enhancement of antitumor effects of combined chemoimmunotherapy

The spontaneously metastatic murine pancreatic tumor, PAN 2, was used to evaluate established regimens of combined chemoimmunotherapy with 5-fluorouracil (5-FU) and levamisole and new protocols based on the immunomodulator, thymopoietin pentapeptide (TP-5). The combination of 5-FU and levamisole reduced the final tumor size by 32% and the mean number of lung metastases by 71%. Based on flow cytometric analysis, the combination treatment increased the percent of helper/inducer (CD4+) lymphocytes and reduced the number of effector (suppressor/cytotoxic) lymphocytes (CD8+). A second combination using 5-FU and TP-5 produced a reduction in tumor growth rate of 52%, with an 88% suppression of lung metastases with TP-5/5-FU (vs. levamisole/5-FU) treatment. The TP-5 treatment also increased splenic T-lymphocyte responsiveness to nonspecific mitogens by 2.3-fold. These results suggest a correlation between enhanced T-lymphocyte functional parameters and reduced tumor growth and metastatic spread produced by these combination therapies. Since TP-5 has been demonstrated to be a superior immunomodulator compared to levamisole, the greater therapeutic effect of TP-5 vs. levamisole further supports the postulated role of immunopotentiation in the success of combined chemoimmunotherapy.

Intratumoral rIL2-based immunotherapy in B16 melanoma

Limiting factors in systemic recombinant interleukin-2 (rIL2) therapy may be overcome by intratumoral (IT) administration. A series of experiments was conducted to assess the efficacy of IT rIL2 alone and in combination with LAK cells and IFN-gamma. C57BL/6 mice bearing B16-F10 subcutaneous tumors were randomly assigned to treatment groups including: noninjected controls, IT placebo (NaCl, D5W), IT bovine serum albumin (BSA), IT rIL2 (centrally and peripherally), IT rIL2/LAK, IT rIL2/IFN-gamma, and intraperitoneal (IP) rIL2. A tumor size-dependent dose of cytokine was injected daily and LAK cells were given weekly. Systemic immune response was assessed by splenocyte mitogenesis and T-cell subset distribution using thymidine radioassay and flow cytometry, respectively. In terms of survival and tumor growth rate, IT rIL2 was superior to noninjected control, IT placebo, IT BSA, and IP rIL2 (P less than 0.05). The addition of IT LAK cells conferred no therapeutic advantage. The combination of rIL2 and gamma IFN-gamma had a slight survival benefit over rIL2 alone (30.8 days vs 20.4 days). Histologic analysis demonstrated an increase presence of intratumoral macrophages in the IT rIL2-treated tumors (P less than 0.05). Lymphocyte mitogenesis and L3T4+ subset were not altered by any treatment. In vitro thymidine uptake by tumor cells was not affected by rIL2 nor IFN-gamma alone but the combination of rIL2 and IFN-gamma resulted in significant tumor cell growth inhibition. Spontaneous lung metastases were more prevalent following central IT rIL2 (75% vs 29%, P = 0.07) not accountable by needle trauma but avoidable by the use of peritumoral injection.(ABSTRACT TRUNCATED AT 250 WORDS)

Conservative management of extensive low-lying rectal carcinomas with transanal local excision and combined preoperative and postoperative radiation therapy. A report of a phase I-II trial

Between 1986 and 1990, 16 patients were enrolled in a prospective Phase I/II study of transanal local excision and combined preoperative and postoperative radiation therapy (RT). All patients had biopsy-proven adenocarcinoma extending to within 6 cm of the anal verge and involvement of at least one third of the rectal circumference with tumor. Five of 16 patients (32%) had T3 tumors, and only two patients had T1 tumors. Patients received a single 500 cGy fraction of RT to the pelvis within 24 hours before surgery and underwent transanal excision followed by postoperative RT (median dose, 5040 cGy). With a median follow-up of 33 months, overall 3-year actuarial survival was 94%. Two patients had isolated local recurrences (both successfully salvaged), and four had distant metastases but maintained local control. The 3-year actuarial rates of continuous freedom from any relapse, continuous local control, and no evidence of disease at last follow-up were 53%, 80%, and 71%, respectively. Only three of 16 patients required colostomy, resulting in a 3-year actuarial colostomy-free rate of 77%. There was a trend toward a higher rate of relapse (P = 0.066) in patients with T3 tumors than those with T1 and T2 tumors. Sphincter-preserving therapy for low-lying rectal carcinomas using local excision and combined preoperative and postoperative RT is feasible, although improved local and adjuvant therapy is needed for patients with T3 lesions.

Gastric cancer--surgical approach

Although the incidence of carcinoma of the stomach has steadily declined over the last 50 years, approximately 23,000 new cases will be diagnosed in the United States this year and 13,700 patients will die. Despite marked improvement in operative techniques, fewer than 20 per cent of those diagnosed with gastric cancer beyond the most superficial levels of invasion will survive for over five years. Gastric tumours spread by local, lymphatic, and aggressive intra-peritoneal routes as well as hematogenous dissemination. Over 87 per cent of recurrences have local or regional components. Radiation therapy may decrease local and regional recurrences in those patients with transmural tumours. The neoadjuvant use of etoposide, adriamycin, and platinum may yield complete clinical and pathologic responses in patients found to have 'unresectable' tumours. Other chemotherapy regimens have been shown to have some effect on advanced disease and may have a role in the neoadjuvant setting. Our current recommendations for the treatment of gastric cancer in a controlled trial setting would be neoadjuvant chemotherapy followed by R2 resection, postoperative +/- intraoperative radiation therapy with the possibility of postoperative chemotherapy. Hopefully, this aggressive multimodality approach will significantly improve the five year survival for this disease.

Contribution of patient history to the glutathione S-transferase activity of human lung, breast and colon tissue

Overexpression of the glutathione S-transferases (GSTs) and their involvement in the detoxification of anticancer agents has prompted numerous investigations of the enzyme activity of human tumor tissue. This study represents an in-depth evaluation of the contribution of patient history and pathological status to the GST activity of various human tissues. GST activity was elevated significantly in tumors of the lung, breast and colon as compared to unmatched and matched normal tissue from the same organ. The GST activity of primary breast tumors varied significantly with the stage of the tumor. Breast tumors previously treated with both radiation and chemotherapy had significantly lower levels of GST activity than untreated tumors. Neither progesterone nor estrogen receptor content was associated with the GST activity in primary breast tumors. Colon metastases possessed higher levels of GST activity than primary colon tumors but enzyme activity was independent of the Duke's classification of the tumor. Only tumors of the left colon had levels of GST activity that were higher than those of adjacent normal mucosa. No relationship was evident between either age or sex and the GST activity of any of the tissues examined. GST activity levels may reflect the site-specific ability of tissues to provide cellular protection against xenobiotics.

Risk factors for immediate prosthetic postmastectomy reconstruction

The charts of 44 women who underwent 47 immediate postmastectomy prosthetic breast reconstructions (IPMPBR) with subpectoral prostheses (long-term implant, long-term expandable implant or tissue expanders followed by long-term prosthetic placement) were retrospectively reviewed. Follow-up was from 3 to 49 months (median 18 months). Patient ages ranged from 31 to 77 years (median 42) but 82 per cent were under 60 years old. Indications for mastectomy were infiltrating cancer in 30 patients, intraductal cancer in 11, lobular carcinoma in situ in two and prophylaxis in one. There were 11 patients with pathologic Stage I, 15 with Stage II, three with Stage III and one with Stage IV breast cancer. Adjuvant chemotherapy (CTX) was given to 17 women, adjuvant hormonal treatment to nine, and radiation therapy (RT) to five. One patient had prosthesis extrusion and removal. Two patients had late periprosthetic infections (PPI) with consequent prosthesis removal. CTX did not have a significant association with PPI (two of 14 with CTX vs 0 of 29 without, P = 0.1). However, fill port migrations, prosthesis deflations, and greater than 1 complication were significantly associated with these infections (two of three vs 0 of 38, P = 0.004; two of two vs 0 of 45, P = 0.001; two of four vs 0 of 43, P = 0.006). Skin flap cellulitis and postoperative seroma were also associated with PPI (P less than 0.003 and less than 0.006, respectively). These factors were all also significantly associated with involuntary prosthesis loss (n = 3).(ABSTRACT TRUNCATED AT 250 WORDS)

Lymphokine-activated killer cell suppressor factor in malignant effusions

We examined the possibility that tumor-released products inhibit lymphokine-activated killer cell activation. Lymphokine-activated killer cells from human peripheral blood lymphocytes were activated with recombinant interleukin 2 for 4 days in the presence of malignant effusions or conditioned media from cultured cell lines (10% vol/vol). Eight of 10 malignant effusions/media suppressed the induction of lymphokine-activated killer cell cytotoxicity, as measured in a 4-hour sodium chromate release assay. Seven of 10 effusions/media inhibited lymphokine-activated killer cell proliferation. Suppression was both dose and time dependent. A representative suppressive effusion was fractionated by agarose gel chromatography, treated with detergents disruptive of ionic bonds and lipids, and refractionated using polyacrylamide gel chromatography. Seven suppressive fractions ranging in molecular weight from 1 x 10(5) to 3 x 10(5) d were isolated. It is speculated that this suppressor factor may represent a large multimeric structure with ionic-bonded individual suppressive components.

Development of lung metastases after curative intraperitoneal chemotherapy in a rat colon cancer model

A model of colon peritoneal carcinomatosis was developed by injecting 5 x 10(7) viable tumor cells intraperitoneally into Fisher 344 rats. All 40 control rats developed bulky abdominal tumor with ascites and died of peritoneal carcinomatosis and bowel obstruction (median survival 5 weeks). One day after tumor implantation, treatment group rats received a single intraperitoneal injection of single agent or combination chemotherapy. The most active intraperitoneal single agents were 5-fluorouracil, cisplatin, and etoposide. The most active combination was 5-fluorouracil and cisplatin. Combination chemotherapy produced a significant increase in median, 10-week, and 20-week survival (vs control and single agent). Six of 11 (55%) rats treated with intraperitoneal combination chemotherapy dying between 10-20 weeks died of lung metastasis with cure of intraperitoneal tumor. The increased ability of intraperitoneal combination chemotherapy to cure intraperitoneal disease was offset by the development of lung metastasis.