Primary care usage at the end of life: a retrospective cohort study of cancer patients using linked primary and hospital care data

PURPOSE

Health service use is most intensive in the final year of a person's life, with 80% of this expenditure occurring in hospital. Close involvement of primary care services has been promoted to enhance quality end-of-life care that is appropriate to the needs of patients. However, the relationship between primary care involvement and patients' use of hospital care is not well described. This study aims to examine primary care use in the last year of life for cancer patients and its relationship to hospital usage.

METHODS

Retrospective cohort study in Victoria, Australia, using linked routine care data from primary care, hospital and death certificates. Patients were included who died related to cancer between 2008 and 2017.

RESULTS

A total of 758 patients were included, of whom 88% (n = 667) visited primary care during the last 6 months (median 9.1 consultations). In the last month of life, 45% of patients were prescribed opioids, and 3% had imaging requested. Patients who received home visits (13%) or anticipatory medications (15%) had less than half the median bed days in the last 3 months (4 vs 9 days, p < 0.001, 5 vs 10 days, p = 0.001) and 1 month of life (0 vs 2 days, p = 0.002, 0 vs 3 days, p < 0.001), and reduced emergency department presentations (32% vs 46%, p = 0.006, 31% vs 47% p < 0.001) in the final month.

CONCLUSION

This study identifies two important primary care processes-home visits and anticipatory medication-associated with reduced hospital usage and intervention at the end of life.

Deep learning for transesophageal echocardiography view classification

Transesophageal echocardiography (TEE) imaging is a vital tool used in the evaluation of complex cardiac pathology and the management of cardiac surgery patients. A key limitation to the application of deep learning strategies to intraoperative and intraprocedural TEE data is the complexity and unstructured nature of these images. In the present study, we developed a deep learning-based, multi-category TEE view classification model that can be used to add structure to intraoperative and intraprocedural TEE imaging data. More specifically, we trained a convolutional neural network (CNN) to predict standardized TEE views using labeled intraoperative and intraprocedural TEE videos from Cedars-Sinai Medical Center (CSMC). We externally validated our model on intraoperative TEE videos from Stanford University Medical Center (SUMC). Accuracy of our model was high across all labeled views. The highest performance was achieved for the Trans-Gastric Left Ventricular Short Axis View (area under the receiver operating curve [AUC] = 0.971 at CSMC, 0.957 at SUMC), the Mid-Esophageal Long Axis View (AUC = 0.954 at CSMC, 0.905 at SUMC), the Mid-Esophageal Aortic Valve Short Axis View (AUC = 0.946 at CSMC, 0.898 at SUMC), and the Mid-Esophageal 4-Chamber View (AUC = 0.939 at CSMC, 0.902 at SUMC). Ultimately, we demonstrate that our deep learning model can accurately classify standardized TEE views, which will facilitate further downstream deep learning analyses for intraoperative and intraprocedural TEE imaging.

mRNA-1273 and BNT162b2 COVID-19 vaccines elicit antibodies with differences in Fc-mediated effector functions

The successful development of several coronavirus disease 2019 (COVID-19) vaccines has substantially reduced morbidity and mortality in regions of the world where the vaccines have been deployed. However, in the wake of the emergence of viral variants that are able to evade vaccine-induced neutralizing antibodies, real-world vaccine efficacy has begun to show differences across the two approved mRNA platforms, BNT162b2 and mRNA-1273; these findings suggest that subtle variation in immune responses induced by the BNT162b2 and mRNA-1273 vaccines may confer differential protection. Given our emerging appreciation for the importance of additional antibody functions beyond neutralization, we profiled the postboost binding and functional capacity of humoral immune responses induced by the BNT162b2 and mRNA-1273 vaccines in a cohort of hospital staff. Both vaccines induced robust humoral immune responses to wild-type severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and to variants of concern. However, differences emerged across epitope-specific responses, with higher concentrations of receptor binding domain (RBD)- and N-terminal domain-specific IgA observed in recipients of mRNA-1273. Antibodies eliciting neutrophil phagocytosis and natural killer cell activation were also increased in mRNA-1273 vaccine recipients as compared to BNT162b2 recipients. RBD-specific antibody depletion highlighted the different roles of non-RBD-specific antibody effector functions induced across the mRNA vaccines. These data provide insights into potential differences in protective immunity conferred by these vaccines.

SARS-CoV-2 antibodies protect against reinfection for at least 6 months in a multicentre seroepidemiological workplace cohort

Identifying the potential for SARS-CoV-2 reinfection is crucial for understanding possible long-term epidemic dynamics. We analysed longitudinal PCR and serological testing data from a prospective cohort of 4,411 United States employees in 4 states between April 2020 and February 2021. We conducted a multivariable logistic regression investigating the association between baseline serological status and subsequent PCR test result in order to calculate an odds ratio for reinfection. We estimated an odds ratio for reinfection ranging from 0.14 (95% CI: 0.019 to 0.63) to 0.28 (95% CI: 0.05 to 1.1), implying that the presence of SARS-CoV-2 antibodies at baseline is associated with around 72% to 86% reduced odds of a subsequent PCR positive test based on our point estimates. This suggests that primary infection with SARS-CoV-2 provides protection against reinfection in the majority of individuals, at least over a 6-month time period. We also highlight 2 major sources of bias and uncertainty to be considered when estimating the relative risk of reinfection, confounders and the choice of baseline time point, and show how to account for both in reinfection analysis.

Identifying the potential for SARS-CoV-2 reinfection is crucial for understanding possible long-term epidemic dynamics. Analysis of a seroepidemiological cohort suggests that primary infection with SARS-CoV-2 protects against reinfection in the majority of individuals, at least over a six month period.

A decision support tool for the detection of pancreatic cancer in general practice: A modified Delphi consensus

BACKGROUND/OBJECTIVES

Diagnosis of pancreatic cancer is often delayed, contributing to patient and family distress and leading to worse survival. We aimed to develop a decision support tool to support primary care providers to identify patients that should undergo investigations for pancreatic cancer, and to recommend initial diagnostic pathways.

METHODS

A modified Delphi process, including a series of three surveys, was undertaken to ascertain clinical expert opinion on which combinations of signs, symptoms and risk factors should be included in a tool for the early identification of pancreatic cancer. A group of clinical specialists finalised the development of the tool during a focus group meeting.

RESULTS

The tool presents individual or combinations of signs, symptoms, and risk factors in three tiers which direct the urgency of investigation. Tier 1 includes 5 clinical presentation and risk factors clusters that indicate the need for urgent investigation of the pancreas. A further five clusters are included as Tier 2 aiming to elimate other causes and reduce the time to investigating the pancreas. Tier 3 includes a list of non-specific signs, symptoms and risk factors that indicate the need to consider pancreatic cancer as a potential diagnosis, but without specific recommendations for investigation.

CONCLUSIONS

Prospective validation studies are now required prior to implementation in the primary care setting. Implementation into primary care practice and as an educational resource may facilitate rapid diagnosis and improve outcomes such as distress and survival.

Epidemiological and Immunological Features of Obesity and SARS-CoV-2

Obesity is a key correlate of severe SARS-CoV-2 outcomes while the role of obesity on risk of SARS-CoV-2 infection, symptom phenotype, and immune response remain poorly defined. We examined data from a prospective SARS-CoV-2 cohort study to address these questions. Serostatus, body mass index, demographics, comorbidities, and prior COVID-19 compatible symptoms were assessed at baseline and serostatus and symptoms monthly thereafter. SARS-CoV-2 immunoassays included an IgG ELISA targeting the spike RBD, multiarray Luminex targeting 20 viral antigens, pseudovirus neutralization, and T cell ELISPOT assays. Our results from a large prospective SARS-CoV-2 cohort study indicate symptom phenotype is strongly influenced by obesity among younger but not older age groups; we did not identify evidence to suggest obese individuals are at higher risk of SARS-CoV-2 infection; and remarkably homogenous immune activity across BMI categories suggests immune protection across these groups may be similar.

Subtle immunological differences in mRNA-1273 and BNT162b2 COVID-19 vaccine induced Fc-functional profiles

The successful development of several COVID-19 vaccines has substantially reduced morbidity and mortality in regions of the world where the vaccines have been deployed. However, in the wake of the emergence of viral variants, able to evade vaccine induced neutralizing antibodies, real world vaccine efficacy has begun to show differences across the mRNA platforms, suggesting that subtle variation in immune responses induced by the BNT162b2 and mRNA1273 vaccines may provide differential protection. Given our emerging appreciation for the importance of additional antibody functions, beyond neutralization, here we profiled the postboost binding and functional capacity of the humoral response induced by the BNT162b2 and mRNA-1273 in a cohort of hospital staff. Both vaccines induced robust humoral immune responses to WT SARS-CoV-2 and VOCs. However, differences emerged across epitopespecific responses, with higher RBD- and NTD-specific IgA, as well as functional antibodies (ADNP and ADNK) in mRNA-1273 vaccine recipients. Additionally, RBD-specific antibody depletion highlighted the different roles of non-RBD-specific antibody effector function induced across the mRNA vaccines, providing novel insights into potential differences in protective immunity generated across these vaccines in the setting of newly emerging VOCs.

418 The Management of Distal Radius Fractures in Adults with A Removable Soft Cast During the Peak Of The Covid-19 Pandemic: Patient Reported Outcomes And Experiences

Introduction

Immobilisation tools for non-operative management of distal radius fractures (DRFs) in adults, include plaster casts, orthotic splints, and recently removable soft cast as per the BOAST COVID-19 guidelines. Limited evidence exists on the effectiveness of removable soft casts in adults with DRFs. We assessed patient reported functional outcomes and experiences of adults with DRFs managed non-operatively in a removable soft cast during the COVID-19 pandemic.

Method

We retrospectively reviewed adults with DRFs, treated with a removable soft cast for 6 weeks between 9^th April 2020 and 18^th May 2020. Functional scores - Disabilities of the Arms, Shoulders and Hands (DASH) and a 7-question Patient Reported Experience Questionnaire (PREQ) were conducted at 6 weeks, along with a record of complications. A DASH score of < 25 was deemed a satisfactory functional score.

Results

34 patients formed our cohort, with a 65% (22patients) completion rate, mean age of 69years. 82% had a DASH score < 25 and 18% had a DASH score > 25 at 6 weeks. 86% reported satisfactory comfort in the PREQ with 14% reporting discomfort. Two patients re-attended hospital with soft cast related problems.

Conclusions

Most adults with DRFs managed in a removable soft cast reported good early functional outcomes, satisfactory experiences, and no clinic visits at 6weeks.

Discrete SARS-CoV-2 antibody titers track with functional humoral stability

Antibodies serve as biomarkers of infection, but if sustained can confer long-term immunity. Yet, for most clinically approved vaccines, binding antibody titers only serve as a surrogate of protection. Instead, the ability of vaccine induced antibodies to neutralize or mediate Fc-effector functions is mechanistically linked to protection. While evidence has begun to point to persisting antibody responses among SARS-CoV-2 infected individuals, cases of re-infection have begun to emerge, calling the protective nature of humoral immunity against this highly infectious pathogen into question. Using a community-based surveillance study, we aimed to define the relationship between titers and functional antibody activity to SARS-CoV-2 over time. Here we report significant heterogeneity, but limited decay, across antibody titers amongst 120 identified seroconverters, most of whom had asymptomatic infection. Notably, neutralization, Fc-function, and SARS-CoV-2 specific T cell responses were only observed in subjects that elicited RBD-specific antibody titers above a threshold. The findings point to a switch-like relationship between observed antibody titer and function, where a distinct threshold of activity-defined by the level of antibodies-is required to elicit vigorous humoral and cellular response. This response activity level may be essential for durable protection, potentially explaining why re-infections occur with SARS-CoV-2 and other common coronaviruses.

Epidemiological and immunological features of obesity and SARS-CoV-2

Obesity is a key correlate of severe SARS-CoV-2 outcomes while the role of obesity on risk of SARS-CoV-2 infection, symptom phenotype, and immune response are poorly defined. We examined data from a prospective SARS-CoV-2 cohort study to address these questions. Serostatus, body mass index, demographics, comorbidities, and prior COVID-19 compatible symptoms were assessed at baseline and serostatus and symptoms monthly thereafter. SARS-CoV-2 immunoassays included an IgG ELISA targeting the spike RBD, multiarray Luminex targeting 20 viral antigens, pseudovirus neutralization, and T cell ELISPOT assays. Our results from a large prospective SARS-CoV-2 cohort study indicate symptom phenotype is strongly influenced by obesity among younger but not older age groups; we did not identify evidence to suggest obese individuals are at higher risk of SARS-CoV-2 infection; and, remarkably homogenous immune activity across BMI categories suggests natural- and vaccine-induced protection may be similar across these groups.

Association of blood mercury levels with nonmelanoma skin cancer in the U.S.A. using National Health and Nutrition Examination Survey data (2003-2016)

BACKGROUND

Some studies have reported increased incidence or mortality of lung and brain cancers associated with occupations involving potential mercury exposure. Epidemiological evidence related to skin cancer is also limited.

OBJECTIVES

To investigate the association between blood mercury (Hg) levels and nonmelanoma skin cancer (NMSC).

METHODS

We used National Health and Nutrition Examination Survey data from 2003 to 2016. The exposures were blood total (tHg), inorganic (iHg) and methylmercury (MeHg). The outcome was a self-reported diagnosis of NMSC. We included participants aged ≥ 20 years who had information on blood mercury and sociodemographic factors. We conducted a logistic regression analysis to estimate odds ratios (ORs) and 95% confidence intervals (CIs) for the risk of NMSC associated with quartiles of blood Hg, after adjusting for the sociodemographic factors and survey year.

RESULTS

The number of participants was 29 413; mean age was 49 years and 52% were female. Compared with those with a tHg ≤ 0·47 μg L^-1 (Q1), those with a tHg > 1·74 μg L^-1 (Q4) had nearly double the odds of NMSC (OR 1·79, 95% CI 1·19-2·71; P_trend = 0·004). Similarly, those in the highest quartile of MeHg (> 1·44 μg L^-1 ) had 1·7 times greater odds of NMSC (OR 1·74, 95% CI 1·13-2·70; P_trend = 0·01) than those in the lowest quartile (≤ 0·21 μg L^-1 ). iHg levels were nonsignificantly positively associated with NMSC (P_trend = 0·08).

CONCLUSIONS

We found that higher blood tHg and MeHg levels were associated with a higher prevalence of NMSC. Linked Comment: Taylor. Br J Dermatol 2020; 183:413-414.

Upregulation of Atrogin-1/FBXO32 is not necessary for cartilage destruction in mouse models of osteoarthritis

OBJECTIVE

In a preliminary study, we found that recently identified catabolic regulators of osteoarthritis (OA), including hypoxia-inducible factor (HIF)-2α and members of the zinc-ZIP8-MTF1 axis, upregulate the E3 ubiquitin ligase, Atrogin-1 (encoded by Fbxo32), in chondrocytes. As the ubiquitination/proteasomal degradation pathways are tightly regulated to modulate the expression of catabolic factors in chondrocytes, we examined the in vivo functions of Atrogin-1 in mouse models of OA.

METHODS

The mRNA and protein levels of Atrogin-1 and other regulators of OA were determined in primary cultured mouse chondrocytes, OA human cartilage, and OA cartilage from wild-type (WT) and Fbxo32-knockout (KO) mice subjected to destabilization of the medial meniscus or intra-articular (IA) injection of adenoviruses expressing HIF-2α (Ad-Epas1), ZIP8 (Ad-Zip8), or Atrogin-1 (Ad-Fbxo32). The effect of Atrogin-1 overexpression on the cartilage of WT mice was examined by IA injection of Ad-Fbxo32.

RESULTS

Atrogin-1 mRNA levels in chondrocytes were markedly increased by treatment with interleukin-1β, HIF-2α, and members of the zinc-ZIP8-MTF1 axis. Atrogin-1 protein levels were also increased in OA cartilage from humans and various mouse OA models. However, the forced overexpression of Atrogin-1 in chondrocytes did not modulate the expression of cartilage matrix molecules or matrix-degrading enzymes. Moreover, overexpression of Atrogin-1 in the mouse joint tissues failed to cause OA pathogenesis, and Fbxo32 knockout failed to affect post-traumatic OA cartilage destruction in mice.

CONCLUSIONS

Although Atrogin-1 is upregulated in OA cartilage, overexpression of Atrogin-1 in the joint tissues or knockout of Fbxo32 does not affect OA cartilage destruction in mice.

Abstract OT1-03-18: COLET: A multistage, phase 2 study evaluating the safety and efficacy of cobimetinib in combination with paclitaxel as first-line treatment for patients with metastatic triple-negative breast cancer

Background: Cobimetinib (cobi) is a potent, highly selective inhibitor of MEK that has shown benefit when administered in combination with the BRAF inhibitor vemurafenib in BRAFV600-mutated metastatic melanoma. Preclinical data suggest that up-regulation of the MAPK pathway is a potential resistance mechanism against taxane chemotherapy. Clinically, the combination of MEK inhibition and taxane chemotherapy in non–small cell lung cancer patients (pts) has improved response rate (RR) and progression-free survival (PFS). Because most triple-negative breast cancer (TNBC) pts develop resistance to taxane chemotherapy and because genetic alterations (including mutations and gene amplifications) in the MAPK pathway are present in many TNBC tumors, the combination of taxane chemotherapy and MEK inhibition could be an effective treatment option.

Study design: COLET (WO29497) is a multistage study designed to evaluate the safety of and to estimate the efficacy of cobi  paclitaxel in pts with metastatic or locally advanced TNBC who have not previously received systemic therapy for metastatic disease. The study will be conducted in 2 stages: an initial safety run-in stage of approximately 12 pts, followed by a randomized stage in which approximately 100 pts will be randomly assigned in a 1:1 ratio to receive either cobi + paclitaxel or placebo + paclitaxel. Pts will receive paclitaxel 80 mg/m2 on Days 1, 8, and 15 of each 28-day cycle and cobi/placebo 60 mg/day on Days 3-23 of each 28-day cycle until progression of disease or toxicity occurs.

Key eligibility criteria:

• Metastatic or locally advanced (not amenable to curative resection) TNBC

• No prior systemic therapy for metastatic or unresectable locally advanced TNBC

• Neoadjuvant or adjuvant chemotherapy or radiation therapy is allowed if completed &gt;6 months before the start of study treatment

• Measureable disease using Response Evaluation Criteria In Solid Tumors, version 1.1 (RECIST v1.1)

• History of or active untreated or unstable brain metastases or requiring corticosteroids for brain metastases precludes eligibility

• Left ventricular ejection fraction (LVEF) greater than the institutional lower limit of normal or above 50%

Specific aims of the safety run-in stage: Determine the safety and tolerability of cobi when administered in combination with paclitaxel.

Specific aims of the randomized stage: Investigator-assessed PFS (primary end point); safety; pharmacokinetics; the effect of intrinsic subtypes and genetic alterations in PFS; mechanisms of resistance; and health-related quality of life.

Accrual: Approximately 112 pts from sites across Europe, North America, and the Asia-Pacific region.

Statistical methods: In the randomized stage, pts will be followed up until a total of 60 PFS events occur across the 2 arms. This provides 77% power to detect a hazard ratio of 0.5 at a two-sided significance level of 0.05.

Contact information: Registered with ClinicalTrials.gov, identifier NCT02322814. For more information, please contact Roche/Genentech trials, 888-662-6728 (US only) or reference study ID WO29479 at www.roche.com/about_roche/roche_worldwide.htm.

Citation Format: Kim S-B, Miles D, Rhee J, Yan Y, Hsu J, Brufsky A. COLET: A multistage, phase 2 study evaluating the safety and efficacy of cobimetinib in combination with paclitaxel as first-line treatment for patients with metastatic triple-negative breast cancer. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr OT1-03-18.

A Spanish version of the Skin Cancer Index: a questionnaire for measuring quality of life in patients with cervicofacial nonmelanoma skin cancer

INTRODUCTION

The Skin Cancer Index (SCI) is the first specific patient-reported outcome measure for patients with cervicofacial nonmelanoma skin cancer. To date, only the original English version has been published.

OBJECTIVES

To develop a Spanish version of the SCI that is semantically and linguistically equivalent to the original, and to evaluate its measurement properties in this different cultural environment.

MATERIAL AND METHODS

A cross-sectional study was conducted of the cultural adaptation and empirical validation of the questionnaire, analysing the psychometric properties of the new index at different stages.

RESULTS

Of 440 patients recruited to the study, 431 (95%) completed the Spanish version of the SCI questionnaire, in a mean time of 6·3 min (SD 2·9). Factor analysis of the scale revealed commonality and loading values of < 0·5 for three of the 15 items. The remaining 12 items converged into two components: appearance/social aspects (seven items) and emotional aspects (five items). Both domains presented a high level of internal consistency, with Cronbach's alpha values above 0·8. The convergent-discriminant validity analysis produced correlations higher than 0·3 for the mental component of the Short Form Health Survey-12v2 Health Questionnaire (correlation coefficient 0·39) and the Dermatology Quality of Life Index (correlation coefficient -0·30). In the test-retest, nine of the 12 items produced a weighted kappa value exceeding 0·4, and for the remaining three items, the absolute agreement percentage exceeded 60%.

CONCLUSIONS

The Spanish version of the SCI quality of life scale has been satisfactorily adapted and validated for use in Spanish-speaking countries and populations.

Demographic and serological characteristics of Asian Americans with hepatitis B infection diagnosed at community screenings

There is limited information regarding follow-up and hepatitis B serological status of Asian Americans diagnosed with chronic hepatitis B (CHB) through community screening. The aims of this study were to evaluate the prevalence and characterize CHB among Asians living in Los Angeles, assess follow-up of individuals with CHB diagnosed at screening and compare with patients with CHB followed by community gastroenterologists. Between October 2007 and May 2010, 7387 Asians were tested for HBV. HBsAg positive individuals (CHB) underwent additional testing for ALT, HBeAg/anti-HBe and HBV DNA. Patients with CHB were contacted 6 months later to determine whether they received follow-up care. We compared serological patterns of these individuals with CHB to patients with CHB who were seen for the first time (treatment naïve) by community gastroenterologists during the study period. Prevalence of CHB was 5.2%. About 99% patients with CHB were foreign-born, and only 27% could read/write English. 297 (77%) patients with CHB could be reached 6 months after diagnosis; 43% did not receive follow-up care, mostly because of lack of medical insurance. Patients with CHB followed by gastroenterologists were more likely to have insurance (69% vs 26%, P < 0.0001). 90% patients with CHB at screening were HBeAg negative/anti-HBe positive with 62% having inactive disease compared to only 30% of patients seen by gastroenterologists (P < 0.0001). Among CHB participants, 13% met criteria for treatment compared to 51% of patients with CHB (P < 0.0001). Only a small number of CHB screening participants require antiviral therapy. Lack of medical insurance is the main reason for most patients with CHB not seeking follow-up care after screening.

OS094. Subclinical left ventricular dysfunction in preeclamptic women with preserved left ventricular ejection fraction: A 2D speckle tracking imaging study

INTRODUCTION

Patients with preeclampsia are at risk for cardiovascular disease [1,2]. Changes in cardiac function are subtle in preeclampsia and are quantitatively difficult with conventional imaging. Strain measurements using speckle-tracking echocardiography have been used to sensitively quantifyabnormalities in other disease settings [3].

OBJECTIVES

The objective of this study was to evaluate changes in myocardial strain using speckle tracking echocardiography in women with and without preeclampsia. We hypothesized that global left systolic strain measures would prove more sensitive than conventional left ventricular ejection fraction in detecting early changes in systolic LV function manifesting as subclinical disease prior to overt progression.

METHODS

We evaluated the feasibility and sensitivity of strain imaging using speckle tracking echocardiography. Thirty-six women were enrolled in this pilot study; 28 were analyzed: 11 with preeclampsia and 17 without preeclampsia. Echocardiographic Ejection fraction and global peak longitudinal ,radial and circumferential strain were measured.

RESULTS

Global Median longitudinal strain was significantly worsened in women with preeclampsia compared to women without preeclampsia (P<0.0001). Similar results were observed for global radial strain (P=0.006) and circumferential strain (P=0.03). There was no significant difference in ejection fraction between the groups (P=0.52) (Table 1). Data are presented as median (interquartile range).

CONCLUSION

Myocardial strain imaging using speckle tracking is more sensitive than left ventricular ejection fraction to detect differences in left ventricular systolic function in women with and without preeclampsia.

Endoscopic versus direct vision for saphenous vein graft harvesting in coronary artery bypass surgery

AIM

Recent reports have suggested harvesting of the greater saphenous vein for coronary artery bypass (CABG) using endoscopic techniques (endoscopic) results in early graft closure, higher rates of myocardial infarction (MI) and death. We explored the impact of this technique performed by experienced operators on postoperative morbidities, MI and death in our CABG patients.

METHODS

All non-emergent patients presenting for first time CABG surgery from 2006 to June 2009 were included. Data pertaining to surgery, readmissions, cardiac catheterization and interventions during long term follow-up were extracted from our local STS and ACC registries. Linear and logistic regressions with clinical covariates were conducted to determine if vein harvest technique group predicted the major outcomes. Propensity score matching (PSM) was completed to simulate randomization and improve covariate balance across the endoscopic and direct vision groups.

RESULTS

One thousand nine hundred and eighty-eight (N.=1988) patients were evaluated in this study (N.=1734 endoscopic group and N.=254 direct vision group). The perioperative major adverse outcomes (mortality within 30 days, stroke, reoperation for bleeding, prolonged ventilation and readmission within 30 days) were 17.8% in the endoscopic group and 25.2% in the direct vision group. The rate of leg infections was 0.3% for the endoscopic group and 1.6% for the direct vision group. After adjustment for covariates, the direct vision group had significantly greater risk for prolonged ventilation (P=0.03), MACE (P=0.02) and mortality within 30 days (P=0.01), but only marginally greater risk for leg infections (P=0.052). In the isolated CABG patients, operative death was 1% for the endoscopic group and 1.7% in the direct vision group (P=0.62). After PSM the endoscopic group was similar on all outcomes except for having fewer MACE (P=0.04). In a mean follow-up of 22.1±10.5 months, there were no significant differences in the overall rate and time to event for repeat revascularization, death and myocardial infarction. With maximum follow up of 39.6 months, 84 deaths were documented (N.=67 endoscopic and N.=17 direct vision).

CONCLUSION

The outcomes captured by the number of postoperative morbidities, incidence of myocardial infarction and/or the rate of death for the endoscopic technique were comparable to patients in whom the open techniques was used. There was a trend towards a decrease in leg infections with the use of the endoscopic device. Based on this study we consider the device safe and effective with experienced operators.

CYP2A6 and ERCC1 polymorphisms correlate with efficacy of S-1 plus cisplatin in metastatic gastric cancer patients

Background:

We evaluated the association between polymorphisms of cytochrome P450 2A6 (CYP2A6)/excision repair cross-complementation group 1 (ERCC1)/X-ray repair cross-complementing group 1(XRCC1) and treatment outcomes of metastatic gastric cancer (MGC) patients treated with S-1/cisplatin.

Methods:

Among MGC patients (n=108), who received S-1 (40 mg m⁻² b.i.d., days 1–14) and cisplatin (60 mg m⁻², day 1) every 3 weeks, we analysed the wild-type allele (W) and variants (V) of CYP2A6 (*4, *7, *9, *10), and the polymorphisms of ERCC1 (rs11615, rs3212986) and XRCC1 (rs25487).

Results:

Patients having fewer CYP2A6 variants had better response rates (W/W vs W/V other than *1/*4 vs V/V or *1/*4=66.7 vs 58.3 vs 32.3% P=0.008), time to progression (TTP) (7.2 vs 6.1 vs 3.5 months, P=0.021), and overall survival (23.2 vs 15.4 vs 12.0 months, P=0.004). ERCC1 19442C>A (rs3212986) was also associated with response rate (C/C, 46.7% vs C/A, 55.3% vs A/A, 87.5%) (P=0.048) and TTP (4.4 vs 7.6 vs 7.9 months) (P=0.012). Patients carrying both risk genotypes of CYP2A6 (V/V or 1/*4) and ERCC1 19442C>A (C/C) vs those carrying none showed an adjusted odds ratio of 0.113 (P=0.004) for response, and adjusted hazard ratios of 3.748 (P=0.0001) for TTP and 2.961 (P=0.006) for death.

Conclusion:

Polymorphisms of CYP2A6 and ERCC1 19442C>A correlated with the efficacy of S-1/cisplatin.

Phase II study of a triplet regimen of S-1 combined with irinotecan and oxaliplatin in patients with metastatic gastric cancer: clinical and pharmacogenetic results

BACKGROUND

The aim of this study was to investigate the efficacy and safety of S-1/irinotecan/oxaliplatin (TIROX) in metastatic gastric cancer (MGC) and the association between treatment outcome and uridine diphosphate-glucuronosyltransferase (UGT) 1A polymorphisms.

PATIENTS AND METHODS

Patients with previously untreated MGC received S-1 40 mg/m(2) b.i.d. on days 1-14 and irinotecan 150 mg/m(2) plus oxaliplatin 85 mg/m(2) on day 1 every 3 weeks.

RESULTS

Forty-four patients were enrolled. In intent-to-treat analysis, the objective response rate was 75%, including the complete response (CR) rate of 14%. The median time to progression and overall survival was 10.2 and 17.6 months, respectively. Ten (26%) of the 39 patients with primary gastric tumor showed biopsy-confirmed gastric CR. Grade 3/4 neutropenia developed in 66% of patients and grade 3 febrile neutropenia in 16%. The most common grade 3 nonhematologic toxic effects were abdominal pain (18%), anorexia (16%), and diarrhea (14%). UGT1A polymorphisms were associated with significantly higher incidence of grade 4 leukopenia (UGT1A1*6), neutropenia (UGT1A1*6, UGT1A6*2, and UGT1A7*3), grade 3/4 febrile neutropenia (UGT1A1*6), and grade 3 abdominal pain (UGT1A1*6).

CONCLUSIONS

The TIROX regimen induced marked tumor reduction and promising survival with a manageable toxicity profile in MGC patients. UGT1A genotype may be predictive of TIROX toxicity.

Does triple-negative breast cancer (TNBC) have distinct clinicopathologic characteristics and prognostic significance?

21088

Background: Studies have suggested that TNBC, defined by estrogen receptor-negative, progesterone receptor-negative, and HER2-negative, may represent the subset of breast cancer(BC) with different biologic behavior. Here we investigated the clinicopathologic characteristics of TNBC and its prognostic significance in Korean BC patients. Methods: Patients diagnosed as invasive BC and underwent curative surgery at Seoul National University Hospital between Jan. 2000 and Jun. 2003, were reviewed, retrospectively. We excluded the patients whose immunohistochemistry for hormone receptor nor HER2 status had not been evaluated, and who had been treated with adjuvant trastuzumab or neoadjuvant chemotherapy (CT). Clinicopathologic variables (age, T and N stage, endovascular or lymphatic tumor emboli, nuclear and histologic grade, p53, bcl2, Ki67) and 3 year relapse free survival (3YRFS) rate of TNBC were compared with those of non- TNBC. Results: 1,136 patients were eligible for analysis. The median follow-up was 48.7 months. 341 patients underwent breast conserving surgery followed by adjuvant radiotherapy. 249 patients were TNBC and 62.1% of those were node negative. 86.4% of node negative TNBC, 88.3% of node positive TNBC, 53.9% of node negative non-TNBC, and 90.2% of node positive non-TNBC received adjuvant CT. Compared with non-TNBC, TNBC was correlated with younger age (age<35,14.1% vs. 8.2%, p=0.013), higher nuclear and histologic grade(62.2% vs. 23.6%, p=0.001;60.2% vs. 24.6%, p=0.001, respectively); positive staining for p53 (p=0.001) and higher positivity for Ki67 (p=0.001), suggesting the biologic aggressiveness of TNBC. During the follow-up periods, 17.3% of TNBC were relapsed. In particular, 3YRFS in node negative TNBC and non-TNBC were 86% and 96%, respectively (p<0.001). But, in node positive BC, 3YRFS was not different between TNBC and non-TNBC (80.6% vs. 83%, p=0.99). Conclusions: We confirm that TNBC shows more aggressive clinicopathologic characteristics and in particular, higher relapse in node negative BC. Thus, triple-negativity(TN) may be integrated into risk factor analysis in node negative BC. Final results of more detailed molecular analysis for TNBC would be available in the meeting.

No significant financial relationships to disclose.

Multiplexed genotyping using a novel digitally inscribed bead-based system

21089

Background: Genotyping of clinical samples has been limited to low levels of multiplexing, ranging from one to a few dozen single nucleotide polymorphisms (SNPs) per sample. By increasing multiplexing levels, a clinical lab can increase information content per sample, decreasing costs and sample material requirements. Methods: We have adapted the GoldenGate® Assay for simultaneously genotyping 96 to 1,536 SNPs to the BeadXpress™ System, a new high-throughput platform that utilizes digitally inscribed VeraCode™ beads in a compact fluidic instrument. Genotyping on this platform ranges from 96 to 384 multiplexing, using the same GoldenGate Assay that has proven highly robust for millions of genotypes. In preliminary tests, we have observed greater than 99% call rates, and greater than 99.5% rates for reproducibility and heritability. In a test of 96 SNP genotypes chosen for a study of colorectal cancer, a point mutation in the MSH2 gene, previously implicated in predisposition to several cancers, was correctly genotyped when compared to qPCR analysis of the same samples. Conclusion: Together with genotyping data from reference samples, the GoldenGate Assay on the BeadXpress System has yielded highly reproducible and accurate genotypes, suggesting that this approach will prove useful for rapid refinement of SNPs for development of clinical genotyping tests.

No significant financial relationships to disclose.