Geographic variation in utilization of doublet therapy for metastatic prostate cancer

41

Background: Clinical trials for men with metastatic prostate cancer have supported the use of combination therapies to improve survival outcomes, with recent work showing increased benefit of triplet regimens. However, real-world utilization of doublet therapy ( i.e., androgen deprivation therapy (ADT) plus a novel hormonal therapy (NHT)) and variation in use according to geographic region have not been evaluated in detail. With recent data supporting the use of triplet regimens we must understand what factors already impact doublet therapy utilization before we can intensify treatment further. Using data aggregated from a national cohort of community and academic medical oncology practices, we characterized real-world utilization of doublet therapy and examined factors associated with its use, including geographic region. Methods: Using ConcertAI RWD, clinical data of men with metastatic prostate cancer was linked with state-level measures of socioeconomic factors and healthcare resources from the Area Health Resources File. Logistic regression was used to evaluate associations between clinical and community characteristics and receipt of doublet therapy (vs ADT alone) within 90 days of diagnosis; models were adjusted for clinical factors, state level factors (excluding hospital beds, poverty, and education due to collinearity), and geographic region. Odds ratios (ORs) with 95% confidence intervals were reported. Results: A total of 1,763 men with M1 disease were eligible, with a mean age of 68.6 years at diagnosis. Nearly half (48%) lived in the Southern region, 9.3% in North East, 18.6% in West, and 23.7% in Midwest. Roughly 13.8% were Black, and 1.3% American Indian, and 1.1% Asian. One-third received ADT alone (37.8%). Regression analysis for ADT+NHT vs. ADT included 1,604 men, of which 84.6% received doublet therapy. Geographic region [vs Southern: Midwest, OR 0.6, 95% CI 0.4-0.9; Northeast, OR 0.4, 95% CI 0.2-0.7], larger state population [(log-transformed) OR 0.09, 95 % 0.02-0.3], prior surgery or radiation (vs none, OR 1.7, 95% CI 1.3-2.3), greater urologist density [(log-transformed), OR 0.1, 95% CI 0.02-0.8] and radiation oncologist density [(log-transformed), OR 12.9, 95% CI 2.8-60.2] were significantly associated with receipt of doublet therapy compared to ADT alone. Conclusions: Receipt of doublet therapy was impacted by geographic region and regional availability of specialty care (i.e. urologist and radiation oncologist density), emphasizing the relationship between regional medical expertise and care implementation. As the drive to improve care grows, our study highlights how treatment remains influenced by where you live and the need for identifying actionable targets for intervention and organizational change at the regional level.

Comparative effectiveness of abiraterone and enzalutamide in the first-line treatment of metastatic castration-resistant prostate cancer (mCRPC): A retrospective cohort study in a large database of deeply curated EHR real-world data (RWD) from community oncology practices in the US

175

Background: Abiraterone(A) and enzalutamide(E), both oral androgen receptor targeted agents, are available as first-line treatment options for mCRPC patients. Direct comparisons of efficacy have not been performed for mCRPC patients primarily receiving their cancer care outside of academic centers or integrated health care systems. The study aims to evaluate the real-world effectiveness between first-line A and E-containing regimens in mCRPC patients primarily receiving care in the US community oncology setting. Methods: Patients were selected from ConcertAI Patient 360 Prostate data product, a large de-identified database of deeply curated EHR RWD, sourced from data sharing agreements with community oncology practices. mCRPC patients treated with a first-line A or E-cont. regimen between 1/2011 and 6/2022 were included. OS, TTNT, TTD outcomes were described using KM estimates and evaluated with Cox proportional hazard (HR) model. Confounding was addressed with inverse probability treatment weighting (IPTW) propensity scores based on age, BMI, ECOG, prior anti-androgen exposure, smoking status, comorbidities, and nadir PSA. Sensitivity analysis evaluated KM and HR for each covariate strata. Hazard ratios were also evaluated with multiple imputation by chained equations for missing covariates. Results: From 3,578 mCRPC patients, 1,210 (33.8%) received E-cont. regimen and 1,357 (37.9%) received A-cont. regimen(ref) with a median of 8 months duration for both drugs. Adjusted HR (aHR) for all three outcomes showed a slight increase in effectiveness for E albeit not significant (OS (aHR 0.99, CI 0.87-1.12), TTNT (aHR 0.98, CI 0.89-1.08). Adjusted model including imputation (iHR) supported unimputed results (OS (iHR 0.97, CI 0.88-1.07), TTNT (aHR 0.94, CI 0.9-1.10). The HRs for OS, TTNT and TTD in sicker patients were consistent (2+ ECOG TTNT (aHR 0.95, 0.81-1.12)), (BMI >30, TTNT (aHR 0.84, 0.61-1.18)), and reached significance for some models (2+ ECOG TTD (aHR 0.66, 0.48-0.91)). Conclusions: First-line E-cont. regimens consistently showed increased effectiveness in outcomes compared to A-cont. regimens in mCRPC patients treated in community oncology setting. The effects sizes are modest and did not reach significance, however analysis of the sickest patients showed a trend of consistently larger effect sizes which reached significance for some outcomes. More work needs to be done to evaluate if these results support findings from other RWD sources.

Prostate cancer screening in low- and middle-income countries: the Mexican case

Prostate-specific antigen (PSA)-based early detection for prostate cancer is the subject of intense debate. Implementation of organized prostate cancer screening has been challenging, in part because the PSA test is so amenable to opportunistic screening. To the extent that access to cancer screening tests increases in low- and middle-income countries (LMICs), there is an urgent need to thoughtfully evaluate existing and future cancer screening strategies to ensure benefit and control costs. We used Mexico's prostate cancer screening efforts to illustrate the challenges LMICs face. We provide five considerations for policymakers for a smarter approach and implementation of PSA-based screening.

C-reactive Protein in HPV-Positive and HPV-Negative Oropharyngeal Cancer

OBJECTIVE

Evaluate serum C-reactive protein (CRP) in human papillomavirus (HPV)-positive oropharynx cancer as compared with HPV-negative oropharynx cancer and determine if CRP levels were associated with overall survival and/or recurrence-free survival.

STUDY DESIGN

Prospective cohort study.

SETTING

Tertiary care academic cancer center between 2007 and 2010.

SUBJECTS AND METHODS

Among patients with oropharynx cancer and confirmed HPV status, plasma CRP levels were measured with a high-sensitivity ELISA kit. Multivariable logistic regression analysis compared 4 categories of CRP (low, moderate, high, very high) between the HPV-positive and HPV-negative groups. Kaplan-Meier methods and Cox regression models were used to determine overall survival and recurrence-free survival by CRP level in both populations.

RESULTS

Between 113 HPV-positive and 110 HPV-negative patients, CRP levels were significantly higher in the HPV-positive group, but these levels did not demonstrate a statistically significant dose-response trend. Higher CRP levels were also associated with reduced overall survival ( P = .016) and recurrence-free survival ( P < .001) within the HPV-negative group in univariable analysis; in multivariate analysis, the comparisons were not significantly different. Within HPV-positive oropharynx cancer, CRP levels were not significantly associated with overall survival or recurrence-free survival in univariable or multivariable analyses.

CONCLUSION

Circulating CRP was higher in HPV-positive versus HPV-negative oropharynx cancer. Among HPV-negative patients, higher CRP levels were associated with reduced survival.

PD-L1 Expression in Men with Penile Cancer and its Association with Clinical Outcomes

BACKGROUND

It has been hypothesized that PD-L1 expression in tumor cells and tumor-infiltrating immune (TII) cells may contribute to tumor progression by inhibiting antitumor immunity.

OBJECTIVE

To investigate the association between PD-L1 expression in tumor cells and TII cells and clinical outcomes in penile cancer.

DESIGN, SETTING, AND PARTICIPANTS

A cohort of 222 men treated for penile squamous cell carcinoma (SqCC) at Örebro University Hospital between 1984 and 2008 with long-term follow-up (median 34 mo) was evaluated for PD-L1 expression in tumor cells and TII cells via immunohistochemistry.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Association between clinicopathological features and PD-L1 expression was estimated using χ² and Fisher's exact tests. For survival analyses, Kaplan-Meier curves with log-rank tests and multivariate Cox proportional hazards regression models were used.

RESULTS AND LIMITATIONS

We found that 32.1% of the tumors and 64.2% of the TII cells expressed PD-L1. Our data demonstrate that penile SqCC patients with PD-L1-positive tumor cells or TII cells are at significant risk of lower cancer-specific survival and that the prognostic value of PD-L1 expression was strongest for tumor cell positivity. The use of tissue microarrays rather than whole sections may be viewed as a limitation.

CONCLUSIONS

Tumor PD-L1 expression independently identifies penile SqCC patients at risk of poor clinical outcomes.

PATIENT SUMMARY

We investigated how many patients with penile cancer had tumors that manufactured PD-L1, a protein that decreases the ability of the immune system to fight cancer. We found that up to one-third of penile tumors make this protein. Patients whose tumors make PD-L1 have more aggressive penile cancer and worse clinical outcomes.

Single agent and combination checkpoint inhibitors therapy: A post marketing safety analysis

125

Background: Immune Checkpoint Inhibitors (ICIs) are used to treat patients with a wide spectrum of malignancies. Individuals enrolled in clinical trials are usually more fit compared to patients seen in everyday practice. Therefore, it is important to evaluate the safety profile of these agents in real-world data. In addition, it is not clear if the safety of these agents is similar across all age groups. Methods: We reviewed the FDA Adverse Event Reporting System (FAERS) for adverse events associated with the use of PD-1 inhibitors (nivolumab and pembrolizumab); PD-L1 inhibitor (atezolizumab); and CTLA-4 inhibitor (ipilimumab). Our analysis was restricted to reports that included only an ICI as a suspect agent. For each agent, we performed a descriptive analysis of hospitalization (HO) and death (DE) outcomes, as well as select adverse events of special interest (AESI). We compared the distribution of each outcome within age groups ( < 65 years; 67-75; > 75) using Mantel-Haenszel chi -quare test for trend. Results: A total of 23,586 safety reports were included in our analysis. 415 for atezolizumab, 10,026 for nivolumab, 4,808 for pembrolizumab, 6,339 for ipilimumab, and 1,988 for the combination nivolumab plus ipilimumab. Increased age was associated with a statistically significant trend of more hospitalizations for all drugs except for the combination nivolumab plus ipilimumab where hospitalization rate was high ( > 80%) but similar across all age groups. Prevalence of any of the AESI was higher as age increased for all drugs (p < 0.0001) except for atezolizumab (p 0.12) and combination nivolumab plus ipilimumab (p 0.488). Proportion of older patients who experienced death was higher for pembrolizumab (p < 0.001), ipilimumab (p 0.002), and combination nivolumab plus ipilimumab (p < 0.001). Conclusions: Our analysis suggests that among patients treated with ICI, older individuals receiving pembrolizumab, Nivolumab or ipilimumab were more likely to develop immune related AEs, and to be hospitalized. An increased rate of death with higher age was seen with the use of pembrolizumab, ipilimumab, and combination nivolumab + ipilimumab. Older patients treated with ICIs should be monitored carefully for treatment-related AEs.

Alterations in oral bacterial communities are associated with risk factors for oral and oropharyngeal cancer

Oral squamous cell carcinomas are a major cause of morbidity and mortality, and tobacco usage, alcohol consumption, and poor oral hygiene are established risk factors. To date, no large-scale case-control studies have considered the effects of these risk factors on the composition of the oral microbiome, nor microbial community associations with oral cancer. We compared the composition, diversity, and function of the oral microbiomes of 121 oral cancer patients to 242 age- and gender-matched controls using a metagenomic multivariate analysis pipeline. Significant shifts in composition and function of the oral microbiome were observed with poor oral hygiene, tobacco smoking, and oral cancer. Specifically, we observed dramatically altered community composition and function after tooth loss, with smaller alterations in current tobacco smokers, increased production of antioxidants in individuals with periodontitis, and significantly decreased glutamate metabolism metal transport in oral cancer patients. Although the alterations in the oral microbiome of oral cancer patients were significant, they were of substantially lower effect size relative to microbiome shifts after tooth loss. Alterations following tooth loss, itself a major risk factor for oral cancer, are likely a result of severe ecological disruption due to habitat loss but may also contribute to the development of the disease.

Childhood exposures among mothers and Hodgkin's lymphoma in offspring

BACKGROUND

Childhood exposures in mothers, signaled by number of older and younger siblings, have lifelong consequences for aspects of immune function. We hypothesized that these may influence young adult-onset Hodgkin's lymphoma (HL) risk in offspring.

MATERIALS AND METHODS

Swedish registers identified 2028 cases of young adult onset HL (diagnosed between ages 15-39 years) up to 2012 among those born since 1958; and 18,374 matched controls. Conditional logistic regression was used to assess HL risk associated with number of older and younger siblings of mothers.

RESULTS

Having a mother with more than two older siblings is associated with lower HL risk, and the association is statistically significant for mothers with three or more siblings, compared with none. The adjusted odds ratios (and 95% confidence intervals) are 1.04 (0.93-1.16); 0.95 (0.81-1.10); and 0.81 (0.66-0.98) for one, two, and three or more older siblings, respectively. There is no association between number of mothers' younger siblings and HL risk.

CONCLUSIONS

Exposures during the childhood of mothers may influence young onset adult HL risk in offspring, perhaps through vertical transmission of infectious agents, or through other long-term influences on maternal immune function.

Elevated IL-8, TNF-α, and MCP-1 in men with metastatic prostate cancer starting androgen-deprivation therapy (ADT) are associated with shorter time to castration-resistance and overall survival

BACKGROUND

Chemokines and cytokines have been implicated in progression to castration-resistant prostate cancer (CRPC).

METHODS

Retrospective data were accessed from 122 men with serum samples drawn at a median of 0.5 months after starting ADT for metastatic prostate cancer. MCP-1, IL-1-β, IL-2, IL-8, IL-6, and TNF-α levels were measured by multiplex electrochemiluminescence assays. A multivariable Cox model assessed the association of time to CRPC and overall survival by the protein levels and adjusted for clinical variables (age and prostate specific antigen (PSA) levels at start of ADT, race, ECOG status, and extent of metastases). Associations were reported as hazard ratio (HR) with 95% confidence interval (CI).

RESULTS

Median follow-up and overall survival were 44 and 42.2 months, respectively. ECOG performance status (≥1 vs. 0) was negatively associated with overall survival [HR = 2.8 (1.1-7.0), P = 0.03], and PSA nadir < 0.2 was predictive of longer time to development of CRPC [HR = 0.3 (0.2-0.5), P < 0.0001]. The HR for time to CRPC by protein above the median was 1.4 (95% CI: 0.9, 2.2, P = 0.13) for IL-8; 1.3 (95% CI: 0.8, 2, P = 0.18) for TNF-α; 1.0 (95% CI: 0.7, 1.6, P = 0.95) for MCP-1. The HR for median overall survival for protein levels above the median was: 1.9 (95% CI: 1.0, 3.5, P = 0.04) for IL-8; 2.0 (95% CI: 1.1, 3.5, P = 0.02) for TNF-α; 1.7 (95% CI: 1.7, 3.0, P = 0.08) for MCP-1. There was no association with IL-1-β, IL-2, or IL-6.

CONCLUSION

Higher levels of inflammation-associated cytokines correlate with poorer prostate cancer outcomes and may guide strategies to improve prostate cancer therapy.

Elevated insulin-like growth factor binding protein-1 (IGFBP-1) in men with metastatic prostate cancer starting androgen deprivation therapy (ADT) is associated with shorter time to castration resistance and overall survival

BACKGROUND

Insulin-like growth factor (IGF) and adipokines have been implicated in prostate cancer carcinogenesis.

METHOD

Data from 122 men with serum samples drawn within 3 months of starting ADT for metastatic prostate cancer was accessed retrospectively. IGF-1, IGF binding protein (BP)-1, leptin, and adiponectin levels were measured by multiplex electrochemiluminescence assays. A multivariable Cox model assessed the association of time to castration resistant prostate cancer (CRPC) and overall survival by the protein levels, adjusted for clinical variables, age and prostate specific antigen (PSA) levels at start of ADT, race, ECOG status, extent of metastases and were reported as hazard ratio (HR) with 95% confidence interval (CI).

RESULTS

Median follow-up and overall survival were 44 and 42.2 months, respectively. ECOG performance status (≥ 1 vs. 0) was negatively associated with overall survival [H  = 2.8 (1.1-7.0), P = 0.03], and PSA nadir <0.2 was predictive of longer time to CRPC [HR = 0.3 (0.2-0.5), P < 0.0001]. The median time to CRPC by low, middle, and top IGFBP-1 tertile distribution was 20.7, 18.1, and 12.4 months, respectively, with HR for middle versus low tertile levels 3.1 (1.7-5), P = 0.0003, and for top versus low tertile levels was 2.4 (1.3-4.2), P = 0.003. The median overall survival by low, middle and top tertile IGFBP-1 level was 48.5, 46.4, and 32.8 months, respectively, with HR for top versus low tertile 2.5 (1.2-5.1), P = 0.01. There was no association with IGF-1, adiponectin and leptin.

CONCLUSION

Elevated IGFBP-1 appears to be associated with shorter time to CRPC and lower overall survival in men with metastatic prostate cancer.

Mycobacterium neoaurum bloodstream infection: report of 4 cases and review of the literature

We describe a cluster of 4 bloodstream infections with Mycobacterium neoaurum and 5 additional cases from the literature. Infections occurred mainly in immunocompromised hosts who had central venous catheters. Fever was universal at presentation, but local signs of inflammation were rare. Combination antimicrobial therapy and catheter removal resulted in clinical cure.

Electrochemiluminescent detection of bacteria in blood components

Transfusion-transmitted bacterial infections cause significant patient morbidity and mortality. This study aimed to improve the sensitivity of a nucleic acid-based electrochemiluminescence (ECL) assay for pretransfusion bacterial testing of cellular blood components. The approach is dependent on the detection of bacterial 16S ribosomal RNA (rRNA). The modifications studied included the use of a chaotrope-based lysis buffer with high-energy mechanical cell disruption by RiboLysis, increased ruthenium (Ru2+) labelling per 16S rRNA molecule and concomitant use of fluorescent nucleic acid dyes (CyQUANT, Syto 17 red and Syto 61 red). The methodological changes made did lead to more effective bacterial cell disruption and enhanced ECL signal generation. Nevertheless, assay sensitivity was only slightly improved at approximately 10(4)-10(5) colony forming units per mL (CFU mL(-1)) and the results were highly inconsistent. The method is still not sensitive to the required 10(2) CFU mL(-1) and remains impractical for routine use in blood centres.

Biomechanical evaluation of the dynamic hip screw with two- and four-hole side plates

OBJECTIVES

To determine the biomechanical strength and stiffness of a dynamic hip screw (DHS; Synthes USA, Paoli, PA, U.S.A.) with a two-hole side-plate as compared with a four-hole side-plate design for the reconstruction of unstable three-part intertrochanteric fractures.

DESIGN

Eight matched pairs of embalmed human femurs were tested in two modes: (a) 2,000 cycles of simulated physiologic loading; (b) test to failure.

SETTING

Laboratory. Simulated single leg stance using a simulated pelvic loading mechanism with abductor loading. Strain and displacement sensors were used to measure fragment shear and distraction and surface strain in the proximal side plate.

SPECIMENS

Eight pairs of skeletonized embalmed cadaveric specimens were selected on the basis of femoral neck angle and absence of old fracture, anatomic anomaly, or pathology.

INTERVENTION

The specimens were divided into two groups: (a) left femurs received the two-hole side-plate design; (b) right femurs received the four-hole side-plate design. All fractures were reconstructed by the same surgeon using the manufacturer's instructions.

MAIN OUTCOME MEASUREMENTS

Implant placement was verified by radiographic measurement of tip-to-apex distance. In cyclic testing, the amount of femoral neck fragment migration in both distraction and shear was quantified. Strain magnitude in the side plate was measured in both cyclic and failure testing. The peak load withstood by the reconstruction was quantified in the failure test.

RESULTS AND CONCLUSIONS

Peak load in the failure test was not found to be statistically different between the two-hole and four-hole designs. In cyclic testing, the two-hole configuration exhibited statistically smaller fragment migration in both shear and distraction than the four-hole design (p < 0.05). The strain magnitude in the side plate was not statistically different in the cyclic or failure tests. The femurs with a greater neck angle failed by crushing of the bone in the neck. The femurs with a lesser neck angle failed due to bending of the hardware. The results of this investigation revealed that the two-hole DHS is biomechanically as stable as the four-hole DHS in cyclic and failure loads under the conditions tested. These results, in concert with clinical experience, can be used to support the use of the two-hole DHS for the reconstruction of intertrochanteric fractures without a diaphyseal extension.

Direct detection of bacteria in cellular blood products using bacterial ribosomal RNA-directed probes coupled to electrochemiluminescence

Various techniques for detecting bacteria in blood products exist; however, none has been widely accepted. Our method permits direct bacterial detection in both platelet concentrates (PC) and packed red blood cells (RBC). This novel procedure targets bacterial ribosomal RNA (rRNA) but does not utilize culture or nucleic acid amplification. The assay comprises five steps: (1) release of bacterial rRNA by cell lysis with a combination of detergents and high heat; (2) hybridization of bacterial rRNA using a biotin- and a ruthenium (ORIGEN)-labelled oligonucleotide probe pair; (3) capture of labelled rRNA with streptavidin-coated magnetic beads; (4) concentration of labelled rRNA/bead complexes out of solution and onto an electrode surface with a magnet; (5) detection of ruthenium-labelled bacterial rRNA by application of voltage and consequent generation of the electrochemiluminescent (ECL) signal. Results using PC and RBC samples, spiked with clinically relevant gram-negative and -positive bacterial species, consistently demonstrated a linear relationship between ECL signal (equates to rRNA level) and colony forming units (CFU) mL(-1). Signals were generated in the range of 1400-80000 and 3500-500000 ECL units for unwashed and washed samples, respectively. This is equivalent to 10(5)-10(8)CFU mL(-1). These data demonstrate that therapeutic blood products significantly contaminated with bacteria may be identified prior to issue.

A new apheresis procedure for the preparation of high-quality red cells and plasma

BACKGROUND

Multicomponent apheresis is an alternative way of preparing blood components that avoids the delay between collection and separation seen with standard whole-blood techniques.

STUDY DESIGN AND METHODS

An apheresis device has been modified to facilitate the combined collection of a unit (250 mL) of red cells (RBCs) and a high-volume unit (475 mL) of plasma. The procedure, using 8-percent ACD-A, has been tested in two European blood centers. Each center performed 20 procedures for in vitro evaluation of collected RBCs and plasma and 10 procedures for evaluation of in vivo RBC recovery. All RBCs were white cell reduced by filtration. One-half of the RBC units were stored in the additive solution Adsol and one-half in another such solution (Erythro-Sol).

RESULTS

The target volumes of RBCs and plasma were obtained in 27 minutes (range, 20-44 min) by using three to six cycles in a single-needle procedure. Saline (275 mL) was used to replace fluid volume withdrawn in excess of standard whole-blood donation. No side effects occurred, with the exception of minor signs of hypocalcemia. RBC ATP was well maintained (>65% at Day 42) during storage; 2,3-DPG was less well maintained, with virtually none remaining at Day 21 in either Adsol or Erythro-Sol. The RBC in vivo recoveries, after 42 days of storage at 4+/-2 degrees C determined by the single-label method, were 86.7+/-7.2 percent (Erythro-Sol) and 84.4+/-8.1 percent (Adsol). Mean plasma factor VIII levels were >100 percent in all test groups.

CONCLUSION

A novel automated technique for the simultaneous collection and preparation of RBCs and plasma has been evaluated. The apheresis procedure was acceptable and well tolerated by donors, and it resulted in high-quality blood components. Further optimization of the system should yield a practicable component suitable for routine use in blood banks.