Evaluating a Video-Based, Personalized Webpage in Genitourinary Oncology Clinical Trials: A Phase 2 Randomized Trial

Background

The pace of drug discovery and approvals has led to expanding treatments for cancer patients. Although extensive research exists regarding barriers to enrollment in oncology clinical trials, there are limited studies evaluating processes to optimize patient education, oral anticancer therapy administration, and adherence for patients enrolled in clinical trials. In this study, we assess the feasibility of a video-based, personalized webpage for patients enrolled in genitourinary oncology clinical trials involving 1 or more oral anticancer therapy.

Objective

The primary objective of this trial was to assess the differences in the number of patient-initiated violations in the intervention arm compared with a control arm over 4 treatment cycles. Secondary objectives included patient satisfaction, frequently asked questions by patients on the intervention arm, patient-initiated calls to study team members, and patient-reported stress levels.

Methods

Eligible patients enrolling on a therapeutic clinical trial for a genitourinary malignancy were randomized 2:1 to the intervention arm or control arm. Patients randomized to the intervention arm received access to a video-based, personalized webpage, which included videos of patients’ own clinic encounters with their providers, instructional videos on medication administration and side effects, and electronic versions of educational documents.

Results

A total of 99 patients were enrolled (89 were evaluable; 66 completed 4 cycles). In total, 71% (40/56) of patients in the intervention arm had 1 or more patient-initiated violation compared with 70% (23/33) in the control arm. There was no difference in the total number of violations across 4 cycles between the 2 arms (estimate=−0.0939, 95% CI−0.6295 to 0.4418, P value=.73). Median baseline satisfaction scores for the intervention and control arms were 72 and 73, respectively, indicating high levels of patient satisfaction in both arms. Median baseline patient-reported stress levels were 10 and 13 for the intervention and control arms, respectively, indicating low stress levels in both arms at baseline.

Conclusions

This study is among the first to evaluate a video-based, personalized webpage that provides patients with educational videos and video recordings of clinical trial appointments. Despite not meeting the primary endpoint of reduced patient-initiated violations, this study demonstrates the feasibility of a video-based, personalized webpage in clinical trials. Future research assessing this tool might be better suited for realms outside of clinical trials and might consider the use of an endpoint that assesses patient-reported outcomes directly. A major limitation of this study was the lack of prior data for estimating the null hypothesis in this population.

Everolimus and pazopanib (E/P) benefit genomically selected patients with metastatic urothelial carcinoma

BACKGROUND

Metastatic urothelial carcinoma (mUC) is a genomically diverse disease with known alterations in the mTOR pathway and tyrosine kinases including FGFR. We investigated the efficacy and safety of combination treatment with everolimus and pazopanib (E/P) in genomically profiled patients with mUC.

METHODS

mUC patients enrolled on a Phase I dose escalation study and an expansion cohort treated with E/P were included. The primary end point was objective response rate (ORR); secondary end points were safety, duration of response (DOR), progression-free survival (PFS) and overall survival (OS). Patients were assessed for mutations and copy number alterations in 300 relevant cancer-associated genes using next-generation sequencing and findings were correlated with outcomes. Time-to-event data were estimated with Kaplan-Meier methods.

RESULTS

Of the 23 patients enrolled overall, 19 had mUC. ORR was 21% (one complete response (CR), three partial responses (PR), eight with stable disease (SD). DOR, PFS and OS were 6.5, 3.6, and 9.1 months, respectively. Four patients with clinical benefit (one CR, two PR, one SD) had mutations in TSC1/TSC2 or mTOR and a 5th patient with PR had a FGFR3-TACC3 fusion.

CONCLUSIONS

Combination therapy with E/P is safe in mUC and select patients with alterations in mTOR or FGFR pathways derive significant clinical benefit.

A video-based, personalized web page (VBPWP) as a complement to clinical trial (CT) patient management

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Background: Most advances in the diagnosis and treatment (Tx) of patients (pts) with genitourinary (GU) cancers are the result of pt involvement in CTs. There is a clear need to identify ways to improve CT processes for pts and research teams (RTs). The goal of this project is to assess the use of a VBPWP to improve pt compliance, safety, CT quality, and RT efficiency in GU CTs of oral agents. Methods: This is an unblinded, randomized trial using a VBPWP as an intervention (INT) for pts with advanced non-metastatic (M0) or metastatic (M1) GU cancers. Pts consented but not yet started on CTs of oral agents are randomized 2:1 to the INT or control arm. The INT includes videos of provider-pt encounters and educational videos related to dosing and adverse events (AEs). Target accrual is 99 pts. The primary end point is number of cumulative pt violations (PVs) over 4 cycles (4Cs) of INT. PVs are defined as improper dosing, non-compliance, and failure to report AEs or hospitalizations. Herein we report an early pooled analysis of pts who completed 4Cs. Results: 90 pts enrolled (61 M1, 67 prostate, 22 kidney). 58 pts completed ≥ 4Cs. 58% (n = 33) of pts had ≥ 1 PV on study (Table). Despite RT instructions, overall, 7%, 9%, and 3% of pts failed to return pill bottles or report AEs, missed a dose of Tx on 3 occasions, or took a wrong dose, respectively. Median total score of the Functional Assessment of Chronic Illness Therapy Tx Satisfaction-Pt Satisfaction (FACIT-TS-PS) measure was 72 (n = 45) at baseline (BL) and did not significantly change after 4Cs (73, n = 48). Scores of 73 indicate high levels of pt satisfaction. The Perceived Stress Scale (PSS) 10-Item indicated pt stress levels were highest at BL (score = 28) and improved after 1C of Tx (score = 24). Scores ≥ 20 indicate high stress. Stress levels did not significantly change after 4Cs. Conclusions: Longer follow up is needed to compare outcomes between pts randomized to the video INT compared to the control arm. Data show that the majority had ≥ 1 PV. This suggests the need to improve education for CT pts. The use of a VBPWP as a complement to standard CT pt education is feasible and may have the potential to increase pt safety and CT quality. [Table: see text]

An exploratory study of radium-223 and vascular endothelial growth factor targeted therapy (VEGF TT) in patients (pts) with metastatic renal cell carcinoma (mRCC) and bone metastases (BM)

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Background: BM frequently occur in pts with mRCC and are associated with worse survival. The primary aim was to investigate the effect of radium-223 with VEGF TT on bone turnover markers (BTMs) in mRCC pts with BM. Methods: Pts were stratified into cohort 1 (C1) if treatment (tx) naive (n=15) to receive pazopanib 800 mg daily or cohort 2 (C2) if previously treated (n=15) to receive sorafenib (SOR) 400 mg twice BID and could escalate to 600 mg BID at progression. All pts received radium-223 55 kBq/kg every 4 weeks x 6. A safety run-in was performed after 6 pts per cohort completed 2 cycles with criteria to halt enrollment if grade ≥3 tx-related adverse events (TRAEs) were observed in ≥80% of pts. Herein, we report the results of the safety run-in and early safety, biomarker, and imaging data for C2. Results: In the safety run-in, 5/12 (42%) pts experienced TRAEs including anemia, fatigue, liver test elevation, amylase elevation, rash, hand-foot-syndrome, and hypertension, and therefore enrollment continued. In C2, most pts had clear cell mRCC (n=10, 67%) and 47% (n=7) had liver metastases. 60% (n=9) received ≥3 prior txs. At the time of analysis, 8 (53%) pts discontinued tx with both agents for progression and 1 (7%) for toxicity. 5 pts (33%) received 6 doses of radium-223 and 2 (13%) remain on tx. 4 pts (27%) had SOR reductions and 4 (27%) had escalations. 5 pts (33%) had grade 3 TRAEs. Changes in BTM were assessed (Table). 33% of pts (n=5) had stable disease by RECIST, 27% (n=4) by Positron Emission Tomography Response Criteria in Solid Tumors, and 40% by MD Anderson Bone Response Criteria at first response assessment (FRA). Conclusions: Early data suggests that tx with radium-223 and SOR is safe and feasible. Tx resulted in early declines in BTM. Longer follow-up is needed to characterize the safety and effect on BTM. Clinical trial information: NCT02406521. [Table: see text]

Abstract LB-136: High concordance of whole-exome sequencing of cell-free DNA and matched biopsies enables genomic discovery in metastatic cancer

Background: Circulating cell-free DNA (cfDNA) has largely been used to monitor blood for specific tumor mutations, but genome-wide discovery from cfDNA has not been well established. Here, we establish a scalable approach for whole-exome sequencing (WES) of cfDNA, making it possible to perform comprehensive genomic characterization of metastatic cancer in a routine and minimally-invasive manner.

Comprehensive genomic characterization of metastatic cancer stands to uncover novel alterations of clinical significance. A major challenge is that metastatic tumors are infrequently biopsied. Cell-free DNA is shed abundantly into the bloodstream from metastatic tumors, presenting an opportunity for genomic discovery in advanced cancers that are rarely biopsied in routine clinical care. We report an efficient process to qualify and sequence whole-exomes from cfDNA at scale and systematically compare the somatic mutations, indels, and copy number alterations detected in WES of cfDNA to WES of matched tumor biopsies.

Methods: We consented 86 patients with metastatic breast or prostate cancers for blood collection. We isolated cfDNA and germline DNA from blood and performed low coverage sequencing to estimate tumor content based on genome-wide copy number. We screened patient blood samples and prioritized those with higher tumor fractions for WES. In parallel, we analyzed cfDNA and germline DNA from healthy donors to calibrate our methods and assess false positive rate for genomic alterations.

Results: We found the vast majority of patients with metastatic prostate or breast cancer to have detectable tumor-derived cfDNA. WES of cfDNA from healthy donors revealed very low false positive rates for somatic mutations, indels and copy number alterations (SCNAs). By analyzing WES of cfDNA and tumor biopsies from dozens of patients with metastatic breast or prostate cancers, we established guidelines for the coverage and tumor fraction required for mutation discovery in WES of cfDNA. We found WES of cfDNA to uncover 91% of the clonal mutations, 59% of the subclonal mutations, and 75% of the SCNAs detected in WES of matched tumor biopsies. In several cases, we observed mutations exclusive to cfDNA that were confirmed in later blood draws, suggesting that cfDNA-exclusive mutations may be derived from unsampled metastases. In some cases, cfDNA revealed clinically actionable mutations that were not detected in matched tumor biopsies.

Conclusions: WES of cfDNA uncovers the majority of somatic mutations, indels, and SCNAs found in matched tumor biopsies of metastatic cancer. The high degree of concordance suggests that comprehensive sequencing of cfDNA can be leveraged for genomic discovery in settings where conventional biopsies are difficult to access. Furthermore, the detection of mutations in cfDNA that are not detected in concurrent biopsies suggests that cfDNA may be complementary to tumor biopsies for both translational studies and precision cancer medicine.

Citation Format: Viktor A. Adalsteinsson, Gavin Ha, Sam Freeman, Atish D. Choudhury, Daniel G. Stover, Heather A. Parsons, Gregory Gydush, Sarah Reed, Denis Loginov, Dimitri Livitz, Daniel Rosebrock, Ignat Leshchiner, Ofir Cohen, Coyin Oh, Jaegil Kim, Chip Stewart, Mara Rosenberg, Huiming Ding, Maxwell R. Lloyd, Sairah Mahmud, Karla E. Helvie, Margaret S. Merrill, Rebecca A. Santiago, Edward P. O’Connor, Seong H. Jeong, Joseph F. Kramkowski, Jens G. Lohr, Laura Polacek, Nelly Oliver, Lori Marini, Joshua Francis, Lauren C. Harshman, Eliezer M. Van Allen, Eric P. Winer, Nancy U. Lin, Mari Nakabayashi, Mary-Ellen Taplin, Levi A. Garraway, Todd R. Golub, Jesse S. Boehm, Nikhil Wagle, Gad Getz, Matthew Meyerson, Christopher J. Love. High concordance of whole-exome sequencing of cell-free DNA and matched biopsies enables genomic discovery in metastatic cancer. [abstract]. In: Proceedings of the 107th Annual Meeting of the American Association for Cancer Research; 2016 Apr 16-20; New Orleans, LA. Philadelphia (PA): AACR; Cancer Res 2016;76(14 Suppl):Abstract nr LB-136.

Postcryopreservation growth of human CFU-GM: sequential examination of methodologic factors

Postcryopreservation growth of human CFU-GM might provide insight into the reconstitutive potential of human marrow preparations cryopreserved for subsequent autologous hematopoietic reconstitution. Ultimately, the utility of such measurements will depend on: whether comparison of pre- and postcryopreservation CFU-GM values is a guide to loss of reconstitutive potency during or following cryopreservation, and whether such measurements are consistent and reproducible. In our hands, direct, unmanipulated plating of CFU-GM after freezing and thawing resulted in extremely poor CFU-GM growth. Consequently, we undertook a set of sequential experiments designed to optimize technical conditions for growing human CFU-GM after cryopreservation. Utilizing stepwise examinations of washing, multiple plating factors, dilution rate, and diluent, we were able to increase consistently fractional recovery of postcryopreservation CFU-GM growth per 2 X 10(5) cells plated from 8% to 56%. Our results underscore the importance that technical factors (other than freezing conditions) play in the postcryopreservation growth of human CFU-GM.