Standardization of fertility preservation discussion amongst pediatric oncology and bone marrow transplant patients

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Background: As treatment for pediatric malignancies improves long term survival, physicians are shifting focus to late effects of therapy such as infertility. Currently, options for fertility preservation include cryopreservation of mature oocytes, sperm, and gonadal tissue, although barriers remain present. Within our division, we lacked a standard approach to discussing fertility preservation options. Methods: Records from 474 pediatric patients with new oncologic diagnoses at CMH from 2014-2020 were retrospectively reviewed. We evaluated the frequency that reproductive health discussions were documented in pubertal males and females requiring chemotherapy or radiation treatment. We implemented a standard fertility preservation note and patient handouts, then surveyed our department to identify diagnoses that place patients at risk for infertility and barriers to formalized fertility consultations. We then provided educational sessions to address these barriers with pre- and post-evaluation to measure efficacy. Our longitudinal assessment, encompassing multiple points of intervention, was compared to results from previous chart review (2010-2013). Results: Of 474 patients diagnosed between 2014-2020, 175 (90 females, 85 males) warranted a fertility discussion per inclusion criteria. 61 (67.8%) females received a fertility discussion and of those 8 (8.9%) completed oocyte or gonadal tissue preservation, all between 2017-2020. 52 (61.2%) males received a fertility discussion and 20 (23.5%) completed sperm cryopreservation, with even distribution pattern between 2014-2020. Following implementation of an electronic fertility consult process and standardized fertility preservation documentation, there was an increase in documented fertility discussions from 30% in 2014 to 63.6% in 2020. Internal department survey responses identified a lack of comfort with knowing fertility preservation options available and diagnoses that should prompt this conversation. Education sessions with pre- and post-provider assessment demonstrated more comfort discussing fertility preservation (average score increase from 3.44 to 4.33) and knowledge regarding diagnoses at higher risk of infertility (average score increase from 3.67 to 4.33). Conclusions: Integration of a standardized fertility preservation process and addressing barriers identified within our division have led to a 33.6% increase in fertility discussions over the last 6 years. While the data shows a promising increase in oocyte and ovarian tissue preservation, sperm banking completion rates remained unchanged. Further steps include incorporation of an automated fertility consultation order into electronic chemotherapy orders, hospital-wide identification of other high-risk patient populations, and continued education of patient, families, and the health care team.

Cost-Effectiveness of the International Late Effects of Childhood Cancer Guideline Harmonization Group Screening Guidelines to Prevent Heart Failure in Survivors of Childhood Cancer

PURPOSE

Survivors of childhood cancer treated with anthracyclines and/or chest-directed radiation are at increased risk for heart failure (HF). The International Late Effects of Childhood Cancer Guideline Harmonization Group (IGHG) recommends risk-based screening echocardiograms, but evidence supporting its frequency and cost-effectiveness is limited.

PATIENTS AND METHODS

Using the Childhood Cancer Survivor Study and St Jude Lifetime Cohort, we developed a microsimulation model of the clinical course of HF. We estimated long-term health outcomes and economic impact of screening according to IGHG-defined risk groups (low [doxorubicin-equivalent anthracycline dose of 1-99 mg/m2 and/or radiotherapy < 15 Gy], moderate [100 to < 250 mg/m2 or 15 to < 35 Gy], or high [≥ 250 mg/m2 or ≥ 35 Gy or both ≥ 100 mg/m2 and ≥ 15 Gy]). We compared 1-, 2-, 5-, and 10-year interval-based screening with no screening. Screening performance and treatment effectiveness were estimated based on published studies. Costs and quality-of-life weights were based on national averages and published reports. Outcomes included lifetime HF risk, quality-adjusted life-years (QALYs), lifetime costs, and incremental cost-effectiveness ratios (ICERs). Strategies with ICERs < $100,000 per QALY gained were considered cost-effective.

RESULTS

Among the IGHG risk groups, cumulative lifetime risks of HF without screening were 36.7% (high risk), 24.7% (moderate risk), and 16.9% (low risk). Routine screening reduced this risk by 4% to 11%, depending on frequency. Screening every 2, 5, and 10 years was cost-effective for high-risk survivors, and every 5 and 10 years for moderate-risk survivors. In contrast, ICERs were > $175,000 per QALY gained for all strategies for low-risk survivors, representing approximately 40% of those for whom screening is currently recommended.

CONCLUSION

Our findings suggest that refinement of recommended screening strategies for IGHG high- and low-risk survivors is needed, including careful reconsideration of discontinuing asymptomatic left ventricular dysfunction and HF screening in low-risk survivors.

Results from Melanoma Antigen Redirected Vaccine Stimulated Autologous Lymphocytes (MARVSmALo): A pilot study

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Background: Despite improvements in treatment with targeted agents and immunotherapeutics metastatic melanoma still has a guarded prognosis. Many melanoma cells upregulate the disialoganglioside GD2. Early GD2 chimeric antigen receptor (CAR) T-cell studies in neuroblastoma demonstrated no toxicity but limited ability to expand in vivo. Strategies to expand these GD2.CAR T cells might improve efficacy while retaining safety. This pilot study aimed to evaluate the safety and efficacy of first generation 14g2a.zeta chimeric antigen receptor ( GD2.CAR ) transduced, activated T cells enriched for vaccine specific cytotoxic T-Lymphocytes (tvs-CTL). Methods: Patients with metastatic melanoma in which standard therapy had failed were eligible if they had recovered from effects of prior therapy, did not have rapidly progressive disease, were free of melanoma involving the CNS and did not have a contraindication to receiving Hepatitis B, Polio or DTAP vaccine. Patients received each of these vaccines prior to cell harvest, 4 days before and 28 days after autologous T cell infusion. Patient 1 was treated with 2 x 108 cell dose and patients 2 and 3 were treated with 4x108 cell dose. We used QPCR to measure transgene copy number in patients before and after infusion. Interferon-gamma enzyme linked immunospot (ELISPOT) assay was used to measure the frequencies of tetanus, pertussis, diphtheria, poliovirus and tumor antigens-specific T cells in peripheral blood. Results: GD2.CAR-tvs-CTL were manufactured and infused in 3 patients. Overall the infusions were safe. Seven low grade adverse events possibly related to study participation were reported. The first 2 patients did not demonstrate robust in vivo expansion of GD2.CAR-tvs-CTLs by QPCR and had rapid disease progression. In patient 3 a significant expansion of GD2.CAR-tvs-CTLs, i.e. 18,250 copies/ug genomic DNA was observed on day 7 and cells persisted at 159 copies/ug DNA for up to 12 months (latest measured time point). High pertussis-specific responses were also observed by INF-gamma ELISPOT in this patient starting from day 14 after the vaccination through month 12. Conclusions: We have demonstrated that GD2.CAR T cells expanded and persisted in melanoma patient for up to 12 months. The use of vaccination before blood procurement for T cell manufacture and boosting virus-specific T cell after CAR T cell infusion is a safe strategy and may have helped induced higher transgene levels in one of three patients. Clinical trial information: NCT02482532 .

Desensitization to pegaspargase in children with acute lymphoblastic leukemia and lymphoblastic lymphoma

Hypersensitivity to pegaspargase is associated with inferior survival in pediatric patients with acute lymphoblastic leukemia and lymphoblastic lymphoma. In the past year, drug-supply shortages have led to the lack of an available alternative to pegaspargase. Rather than omit asparaginase from the treatment of acute lymphoblastic leukemia or lymphoblastic lymphoma patients with hypersensitivity to pegaspargase, we continued pegaspargase treatments for nine pediatric patients, utilizing a rapid desensitization protocol. There were no adverse events related to the pegaspargase during desensitization, and all patients who were checked had asparaginase serum levels above the threshold of 0.1 IU/mL at 7 to 14 days after pegaspargase therapy.

Abstract 2903: A novel compound induces synthetic lethality for p53 mutations in osteosarcoma cells

Osteosarcoma is the second-highest cause of cancer-related death in children and adolescents. Despite advances in chemotherapy and surgery, the survival rate for metastatic osteosarcoma remains below 30% for the last three decades. Discovery of new chemotherapy agents would be crucial for improving outcomes of osteosarcoma patients. Here, using high-throughput screening, we have found a new compound, called 2-{2-[(3,5-dimethoxybenzyl)sulfanyl]-1,3-thiazol-4-yl}-N-(2-thienylmethyl)acetamide (referred to as KU0171032), as an inducer of apoptosis in various canine and human osteosarcoma cells. This compound shows minimal effects on non-transformed osteoblast and fibroblast cells. Intriguingly, KU0171032-induced apoptosis is more robust in osteosarcoma cells having mutant p53 or null for p53, as compared to cells with wild-type p53. Knockdown of wild-type p53 in U2OS and SJSA-1 cells significantly enhances sensitivity to KU0171032 with increase in DNA damage and caspase-3 cleavage. Moreover, KU0171032 significantly reduces in vivo tumor growth of osteosarcoma cells with p53 knockdown or carrying mutant p53. Our results strongly suggest that KU0171032 shows synthetic lethality with p53 mutations in osteosarcoma cells. Given that loss of p53 activity is frequent event in many cancer types including osteosarcoma while normal cells usually retain wild-type p53, this compound could be used to develop novel therapeutic strategies that capitalize on vulnerabilities in osteosarcoma and other types of cancer.

Citation Format: Tomoo Iwakuma, Alejandro Parrales, Peter McDonald, Anuradha Roy, Mitchell W. Braun, Frank J. Schoenen, Jenna Wang, Steve Rogers, Melinda Broward, Tyce Bruns, Shrikant Anant, Dan A. Dixon, Fred Meyer, Katherine M. Chastain, Douglas H. Thamm, Scott J. Weir, Kathleen Neville, Joy M. Fulbright. A novel compound induces synthetic lethality for p53 mutations in osteosarcoma cells [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2018; 2018 Apr 14-18; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2018;78(13 Suppl):Abstract nr 2903.

Comparative oncology approach to drug repurposing in osteosarcoma

BACKGROUND

Osteosarcoma is an orphan disease for which little improvement in survival has been made since the late 1980s. New drug discovery for orphan diseases is limited by the cost and time it takes to develop new drugs. Repurposing already approved FDA-drugs can help overcome this limitation. Another limitation of cancer drug discovery is the lack of preclinical models that accurately recapitulate what occurs in humans. For OS using dogs as a model can minimize this limitation as OS in canines develops spontaneously, is locally invasive and metastasizes to the lungs as it does in humans.

METHODS

In our present work we used high-throughput screens to identify drugs from a library of 2,286 FDA-approved drugs that demonstrated selective growth inhibition against both human and canine OS cell lines. The identified lead compound was then tested for synergy with 7 other drugs that have demonstrated activity against OS. These results were confirmed with in vitro assays and an in vivo murine model of OS.

RESULTS

We identified 13 drugs that demonstrated selective growth inhibition against both human and canine OS cell lines. Auranofin was selected for further in vitro combination drug screens. Auranofin showed synergistic effects with vorinostat and rapamycin on OS viability and apoptosis induction. Auranofin demonstrated single-agent growth inhibition in both human and canine OS xenografts, and cooperative growth inhibition was observed in combination with rapamycin or vorinostat. There was a significant decrease in Ki67-positive cells and an increase in cleaved caspase-3 levels in tumor tissues treated with a combination of auranofin and vorinostat or rapamycin.

CONCLUSIONS

Auranofin, alone or in combination with rapamycin or vorinostat, may be useful new treatment strategies for OS. Future studies may evaluate the efficacy of auranofin in dogs with OS as a prelude to human clinical evaluation.

Phototherapy induced cutaneous eruption in a neonate with transient porphyrinemia

Phototherapy for hyperbilirubinemia has rare complications. We report a case of phototherapy induced eruption in a neonate with transient porphyrinemia. Our patient received phototherapy due to hyperbilirubinemia secondary to erythroblastosis fetalis (hemolytic disease of the newborn). He developed a cutaneous rash in the light-exposed areas of his skin. Erythrocyte and plasma porphyrins were elevated at the time. Phototherapy induced eruption with a transient porphyrinemia is rare. Upon review of the literature, we found only 5 other cases of patients with phototherapy induced rash and elevated porphyrins reported. We compared the five other reported cases to our case, looking at drug exposure, age, and receipt of exchange transfusion.

CONCLUSION

While this is an uncommon occurrence, transient porphyrinemia should be considered in neonates with phototherapy induced cutaneous eruption and erythroblastosis fetalis.

Caring for adult survivors of childhood cancer: A primary care based adult transition clinic

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Background: Long-term survival is an expected outcome for childhood cancer patients. Caring for adults who are childhood cancer survivors requires dedicated late effects monitoring. Recognizing transition challenges from pediatric to adult and oncologic to primary care settings, we developed a dedicated monthly survivorship transition clinic (STC) in an internal medicine office at the University of Kansas Medical Center. We describe the first year practice experience (2014-2015). Methods: Retrospective chart review was completed on 41 STC patients - age 20 to 52 years. Each survivor self-selected to establish in STC, with either consultative survivorship care (correspondence sent to existing primary care physician (PCP)) or combined primary and survivorship care (if no established PCP). Selections were recorded. Two oncology providers performed blinded independent reviews of treatment summaries and scored these using Children’s Hospital of Philadelphia Intensity of Treatment Rating scale (ITR-3). If scores differed, discussion determined consensus. Scores were provided to the STC and unblinded. ITR-3 scores were matched with data on subspecialty referral patterns for each survivor to determine if ITR-3 scores correlated with referral needs. Results: Of 41 patients, 26 (63%) requested PCP and survivorship care. Only 15 (37%) had an established PCP. Survivors were grouped by ITR-3 into low (1 or 2) or high (3 or 4) intensity scores. Subspecialty referrals in each group were analyzed as follows: total number of referrals / average referrals per survivor / median referral number. Referral data: low intensity group 14 / 1.27 / 1, high intensity group 96 / 3.56 / 3. Conclusions: Despite complex medical histories and long term follow-up needs, a high percentage of Midwest cancer survivors were in need of survivorship, PCP and subspecialty care emphasizing the importance of intentional transition efforts. ITR-3 scores correlated with subspecialty referral needs. Future research will include an increased number of survivors to determine further predicative value of this scale in estimating survivor needs complexity.

Nurse navigation: The key to a seamless transition

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Background: Children's Mercy (CM) established a cancer survivorship clinic that cares for approximately 180 survivors a year. A third of the survivors are 18 years or older requiring transition to adult care. The importance of transitioning childhood cancer survivors from pediatric oncology care to adult primary care has been acknowledged in literature, but obstacles remain. Barriers include patient and provider anxiety, difficulty navigating the complex health care system and lack of knowledge regarding late effects. CM and The University of Kansas Cancer Center (KUCC) collaborated to decrease barriers to transition for childhood cancer survivors. Methods: The work group met for 2 years to develop the clinic at KUCC. Models and delivery of survivorship care, including the breast cancer survivorship clinic at KUCC, were reviewed. A shared nurse navigator was identified as an essential component to a seamless transition. Philanthropic support was obtained and job description was developed. Contracts were negotiated to allow the navigator to be present at both institutions. Results: The Survivorship Transition Clinic (STC) at KUCC launched July 2014, with a navigator supporting patients at CM as they begin their transition. The same navigator then meets with the patient at KUCC STC as they initiate care. The navigator provides treatment summaries, patient education and navigates the referral services for survivors. Since clinic launch, 16 survivors out of 16 have successfully transitioned from pediatric to adult survivorship care. Positive feedback was received from patient satisfaction surveys that were administered. A common theme showed a relief from anxiety due to having a contact person to facilitate communication among providers in a complex healthcare system. Conclusions: The nurse navigator has minimized anxiety about transition for patients and parents as she establishes a relationship with patients at CM, and then is able to provide continuity as they transition to the STC at KUMC. The navigator also improves communication between pediatric providers, adult primary care providers and sub-specialists caring for the patients. Overall, our transition process has been effective and is now serving as a model across both institutions.

A Collaborative Step-Wise Process to Implementing an Innovative Clinic for Adult Survivors of Childhood Cancer

With a 5 year survival rate of approximately 80%, there is an increasing number of childhood cancer survivors in the United States. Childhood cancer survivors are at an increased risk for physical and psychosocial health problems many years after treatment. Long-term follow-up care should include education, development of individualized follow up plans and screening for health problems in accordance with the Children's Oncology Group survivor guidelines. Due to survivor, provider and healthcare system related barriers, adult survivors of childhood cancer (ASCC) infrequently are receiving care in accordance to these guidelines. In this paper we describe the stepwise process and collaboration between a children's hospital and an adult academic medical center that was implemented to develop the Survivorship Transition Clinic and address the needs of ASCC in our region. In the clinic model that we designed ASCC follow-up with a primary care physician in the adult setting who is knowledgeable about late effects of childhood cancer treatment and are provided transition support and education by a transition nurse navigator.

Abstract 3689: Comparative oncology drug discovery for Osteosarcoma in dogs and humans

Introduction: The purpose of this study was to identify FDA approved drugs that initiate cell death or growth arrest in canine and human osteosarcoma (OS) cell lines in vitro followed by confirmation of anticancer activity in these cell lines. The ultimate objective of this comparative oncology project is to identify promising agents for the treatment of osteosarcoma in dogs and humans, a disease in which survival rates have remained low and stagnant for the last three decades.

Procedures: A library of 2,328 FDA approved drugs was screened for activity in 2 canine and 2 human OS cell lines, as well as in 1 corresponding normal cell line. Cell viability was measure using the Cell Titer-Glo™ Luminescent Cell Viability Assay (Promega). FDA approved drugs meeting pre-determined screening criteria for activity, selectivity, and potency were selected for confirmatory studies. Effects on cell proliferation were confirmed using cell counting using trypan blue exclusion performed over a 10 day period. Effects on cell cycle and apoptosis were performed using propidium iodide staining and flow cytometry.

Summary: Nine FDA approved drugs were identified based on activity and selectivity. Auranofin, a FDA approved rheumatoid arthritis agent, was selected for cell proliferation and cell cycle evaluation due to its IC50 value in control cells in comparison to OS cell lines. Auranofin displayed cytostatic effects in canine and human OS cell lines at low doses and drugs appeared to induce G2 arrest in treated cells.

Conclusions: Auranofin is an FDA approved drug that demonstrates promising, selective anticancer activity in canine and human OS cell lines. The next steps are to determine whether this agent possesses additive or synergistic activity in combination with anticancer agents that have already demonstrated clinical activity in dogs and humans with OS. In vivo preclinical proof of concept will be determined in mouse xenograft studies and dogs with spontaneous OS for promising drug combinations. Subsequently, we hope to rapidly translate preclinical proof of concept findings to human OS patients.

Citation Format: Joy M. Fulbright, Kathleen Neville, Melinda Broward, Tyce A. Bruns, Anuradha Roy, Peter McDonald, Megan Ottomeyer, Douglas H. Thamm, Tomoo Iwakuma. Comparative oncology drug discovery for Osteosarcoma in dogs and humans. [abstract]. In: Proceedings of the 106th Annual Meeting of the American Association for Cancer Research; 2015 Apr 18-22; Philadelphia, PA. Philadelphia (PA): AACR; Cancer Res 2015;75(15 Suppl):Abstract nr 3689. doi:10.1158/1538-7445.AM2015-3689

Adult survivors of childhood cancer: Development of a regional transistions program

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Background: With increased survival rates, adult survivors of childhood cancers (ASCC) face lifelong screening and healthcare needs. Given increasing costs and demands across healthcare institutions, there is a significant need for survivorship models that emphasize regional collaboration, transition of pediatric patients to adult care, and focus on survivor-centered outcomes. Specific aims: Over the last two years, the presenters developed and implemented a survivor-centered regional approach to meet ASCC needs, addressing system, provider, and survivor barriers to successful transition and ongoing ASCC care. Methods: The presenters will describe community engagement strategies utilized to build a successful, sustainable survivor-centered approach across the region. The Midwest Cancer Alliance (MCA), the outreach arm of University of Kansas Cancer Center (KUCC), provides a supportive, neutral environment to bridge institution-specific concerns. Interdisciplinary teams from Children’s Mercy Hospital and University of Kansas’ Pediatrics department developed a formal working group with KUCC adult-focused partners. The group has taken an inclusive approach, bringing together pediatric and adult healthcare teams as well as expertise in outreach, patient navigation, telemedicine, education, and evaluation/research. Emphasis will be placed on how the team has prioritized needs-driven deliverables across metropolitan and rural communities. Results: The transitions program has maintained monthly working group meetings; completed a survivor needs assessment and disseminated findings; and initiated a cross-institutional transitions clinic. The team is collaborating on a comprehensive survivorship training approach to educate regional healthcare providers. The presenters will describe the team’s performance improvement processes to monitor outcomes and continuously refine the ASCC/AYA model. Conclusions: Community engagement is an ideal platform for regional program development to meet ASCC survivor needs. Future steps include measuring program outcomes, working toward EHR integration, increasing survivor input, and incorporating education into residency/fellowship training.

Use of radiation in treatment of central nervous system juvenile xanthogranulomatosis

Juvenile xanthogranulomatosis (JXG) represents a subset of non-Langerhan cell histiocytosis that typically manifests in younger children with skin lesions. Unresectable central nervous system (CNS) disease is difficult to treat. We describe the case of a 13-year-old successfully treated with adjuvant radiation therapy for symptomatic intracranial and leptomeningeal JXG. An extensive literature review was performed to identify all previous CNS JXG cases utilizing radiation, of which six of eight total patients demonstrated temporary or long-term improvement of neurologic disease. This suggests that radiation should be considered in cases unresponsive to conventional treatment options.

Review of cardiotoxicity in pediatric cancer patients: during and after therapy

With the improvement in survival from childhood cancer, late effects of therapy are becoming more apparent. Cardiac disease, one of these late effects, has a significant impact on the life of survivors of childhood cancers. Most survivors are followed by primary care doctors and adult subspecialists after they have graduated from pediatric centers. Since much of the cardiac toxicity of therapy occurs years off of therapy, it is important for these physicians to be aware of how to monitor survivors for the development of cardiac toxicities. In this paper we will discuss the incidence of cardiac disease during treatment and in survivors, what treatment modalities contribute to its development and modalities utilized to screen for cardiac disease. Recommendations for posttherapy monitoring will be emphasized.