Abstract A090: Community partnerships expand access to tumor molecular profiling

Background: In oncology, the promise of precision medicine relies fundamentally on the identification of genetic mutations that can be targeted therapeutically. Tumor molecular profiling is becoming standard of care for many cancers, however, not all cancer patients have access to genetic testing of their tumors. Lack of access to tumor molecular profiling for underrepresented minority (URM) patients contributes to cancer health disparities faced by URMs on two fronts. First, genomic profiling may provide real-time information that can alter a patient’s course of treatment, if actionable mutations are identified. Second, lack of understanding of genomic differences based on racial and ethnic ancestry may lead to ineffective treatments for URMs. Community partnerships provide one way to improve access to tumor molecular profiling for URMs. Objective: Memorial Sloan Kettering Cancer Center’s (MSKCC) Cancer Health Equity Research Program (CHERP) partners with community hospitals/centers (Kings County Hospital, Queens Cancer Center and the Ralph Lauren Cancer Center) to increase access to MSK-IMPACT™ (Integrated Mutation Profiling of Actionable Cancer Targets). MSK-IMPACT™ is a targeted tumor sequencing test used to detect gene mutations and other genetic aberrations in cancer. MSKCC staff work on-site at CHERP partner sites to assist in patient accrual, specimen collection, and specimen shipping to MSKCC. By collaborating with community sites, whose populations are predominantly URMs, MSKCC increases the diversity of the IMPACT biobank while also providing cutting-edge treatment and prevention options to patients based on IMPACT results. Results: Since opening IMPACTED (IMPACT to End Disparities) at our CHERP partner sites in 2016, 391 patients have consented to have their tumor sequenced (as of June 2019). Consistent with the aims of CHERP, the IMPACTED cohort is diverse, including 60% Black, 12% Asian, 20% other/unknown and 25% Hispanic. Two hundred fifty-six patients have had samples successfully sequenced using MSK-IMPACT™, 43% of which had at least one actionable alteration identified. Additionally, 14 patients have had positive germline results, revealing mutations that were not identified prior to their participation on IMPACT. Discussion: MSKCC’s partnerships with several community cancer providers had led to the successful enrollment of almost 400 URMs onto MSKCC’s MSK-IMPACT™ study, which seeks to identify the molecular drivers of a patient’s cancer. Providing access to tumor molecular profiling is a necessary first step to addressing cancer disparities experiences by URMs. However, access alone is not sufficient. Challenges still remain in finding appropriate treatment options, including clinical trials, when mutations are identified and in getting patients access to treatments when they are available. Working closely with our community partners will help us to address these challenges and decrease cancer disparities experiences by URMs.

Citation Format: Thomas Reynolds, Kellie Jack, Margaret Kemeny, Linda Bulone, Jason Gonsky, Lewis J. Kampel, David Hyman, David B. Solit, Claire Conklin, Shadai McMillan, Nicole DeSimone, Jesse Galle, Sandy Naupari, Carol L. Brown. Community partnerships expand access to tumor molecular profiling [abstract]. In: Proceedings of the Twelfth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2019 Sep 20-23; San Francisco, CA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(6 Suppl_2):Abstract nr A090.

Abstract PR03: Disparities in work status after treatment for breast cancer: A controlled, longitudinal study

Low-income and minority groups appear to be at increased risk of post-treatment job loss and its sequelae, including financial strain and bankruptcy. However, the drivers of disparities in job loss are not understood. We surveyed employed women aged 18-64 with stage I-III breast cancer who spoke Chinese, English, Korean, or Spanish. Baseline surveys (telephone or online) were administered during adjuvant treatment; follow-up surveys were conducted 4 months after completion of active treatment except endocrine and targeted therapy (i.e., trastuzumab with or without pertuzumab). The primary outcome was post-treatment work status (working full- or part-time vs. any other work status). We used healthy peers to control for disparities in non-cancer unemployment and multivariable analyses to identify predictors of work status in patients. Our sample (n=479) was 28% Latina, 23% black, 21% non-Latina white, 19% Chinese, and 7% Korean; 56% were foreign-born. Overall, 31% had a household income <200% of the federal poverty level; 26% were under-/uninsured; 33% worked in service/manufacturing jobs at baseline, 19% in sales/administrative jobs, and 47% in management/profession jobs. Most underwent chemotherapy (85%). Four months after treatment completion, 71% of the survivors reported that they were working. The proportion of working patients versus controls was 0.69 for Chinese, 0.73 for Korean, 0.75 for Latinas, 0.78 for blacks, and 0.98 for non-Latina whites. Independent predictors of not working among patients were receipt of chemotherapy (OR 2.20; 95% CI 1.04-4.64); older age (OR 1.06; 95% CI 1.03-1.09); black (OR 2.37; 95% CI 1.01-5.56), Chinese (OR 2.91; 95% CI 1.20-7.05), or Korean (OR 3.68; 95% CI 1.24-10.98) race (vs. non-Latina white); household income <200% of poverty (OR 3.00; 95% CI 1.68-5.35); and service/manufacturing job-type at baseline (OR 2.41; 95% 1.30-4.44, vs. manager/professional). Having an employer who was not accommodating also predicted not working post-treatment (OR 3.05; 95% CI 1,88-4.95). Breast cancer exerts a disparate negative impact on work status in minority and low-income women, which persists after controlling for disparities in background unemployment. Women who work in service or manufacturing jobs are at greater risk. Furthermore, receipt of chemotherapy is a predictor of job loss, even after controlling for race and income. However, employer accommodations appear to abrogate the negative impact of chemotherapy on work status. Interventions are needed to promote job retention in minority and low-income women, particularly those who lack work accommodations or are in high-risk jobs.

This abstract is also being presented as Poster A100.

Citation Format: Victoria S. Blinder, Sujata Patil, Carolyn Eberle, Gabriel Jung, Lewis J. Kampel, Caroline Hwang, Ting Bao, Mark E. Robson, Manmeet Malik, Francesca Gany. Disparities in work status after treatment for breast cancer: A controlled, longitudinal study [abstract]. In: Proceedings of the Eleventh AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2018 Nov 2-5; New Orleans, LA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(6 Suppl):Abstract nr PR03.

Exercise trends among previously non-exercising breast cancer survivors: Analysis of an ethnically diverse sample

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Background: Exercise is associated with improved symptoms and breast cancer (BC) survival. Little is known about personal and social factors that determine exercise participation in diverse BCS. The study seeks to characterize exercise trends and distinguish factors associated with initiating exercise among pre-diagnosis employed, non-exercising, ethnically and socioeconomically diverse BCS. Methods: BCS were recruited from academic and community medical centers. Women with stage I-III BC were surveyed during and 4 months post-completion of active treatment (surgery +/- chemo +/- radiation). The primary outcome was exercise initiation 4 months post treatment. Variables were self-reported except for clinical cancer variables, which were abstracted from the medical record. Results: Our sample (n = 494) included 22% black, 20% Chinese, 8% Korean, 27% Latina, and 21% non-Latina white women (3% other). 56% were born outside of the US; 30% reported an income < 200% of the federal poverty level (FPL). 72% of BCS exercised the year before diagnosis; 28% did not. Significant correlates (p < 0.05) of NOT exercising pre-diagnosis included lack of post-secondary education, Chinese or Korean ethnicity, lack of alcohol consumption, and lower acculturation level, resilience, and income. Among 138 non-exercisers, 63% reported exercising at follow-up. Significant correlates of exercise initiation are listed in table. In a multivariable model that included age, acculturation, job loss, insurance status, chemo-, and radiotherapy (RT), receipt of RT was significantly associated with exercise initiation (OR 3.1, 95% CI 1.4-7.1). Conclusions: A BC diagnosis may be an impetus to initiate exercise among previously sedentary, employed women. Patients who undergo radiotherapy appear to be more likely to start exercising. Additional research is needed to understand why some patients initiate exercise while others do not. [Table: see text]

Tumor testing in men with prostate cancer to predict for germline DNA-damage repair mutations

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Background: Current guidelines recommend genetic testing for patients (pts) who have BRCA1/2 mutations on tumor-only testing, where germline is not subtracted. The clinical utility of this approach, and possible inclusion of other DDR genes associated with cancer susceptibility, has not been examined in men with prostate cancer. Methods: Pts with mostly advanced prostate cancer were prospectively enrolled to a matched tumor-germline DNA sequencing protocol and consented for disclosure of germline results. Germline analysis was done with an institutional, CLIA-certified next generation sequencing (NGS) platform (MSK-IMPACT) and analyzed for likely pathogenic or pathogenic germline mutations in at least 76 cancer susceptibility genes. Clinical data was retrieved from the medical record. We report on the frequencies in the germline and in the tumor of a subset of DDR genes. Results: 1243 men had analysis of both germline and tumor. Median age 64 (range 35-90). 12% had a second malignancy and 40% reported a relative with prostate cancer. 19% were of Ashkenazi Jewish (AJ) descent. 330 (27%) had any mutation in BRCA1/2, ATM, CHEK2, PALB2, RAD51C, RAD51D, MSH2, MSH6, MLH1, PMS2. 127 (10%) had a germline mutation, of which 36% were AJ founder mutations. For each gene, the percentage of mutations found in germline and tumor is shown in the table. Conclusions: Of prostate cancer pts found to have any DDR mutation on tumor-germline testing, 29% had a germline mutation. Proportion of germline mutations was highest for PALB2, CHEK2 and BRCA2. These findings not only support germline testing when BRCA1/2 mutations are found tumor-only sequencing, but also support germline testing when other DDR mutations are seen. Clinical trial information: NCT01775072. [Table: see text]

Circulating tumor cells (CTCs) N-terminal androgen receptor expression to identify patients (pts) with castrate resistant prostate cancer (CRPC) who are more sensitive to chemotherapy

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Background: Loss of the retinoblastoma tumor suppressor (RB) function was identified as a major means to develop CRPC; the expression of the androgen receptor (AR) is under stringent RB control; and tumors devoid of RB function are hypersensitive to treatment with chemotherapy. Exploratory analysis evaluated baseline N-terminal AR expression in CTCs in men with chemotherapy-naïve CPRC and correlated to changes in PSA, leading us to inquire if this biomarker may identify pts sensitive to chemotherapy. Methods: In a multicenter phase II randomized trial of approved doses of abiraterone acetate/prednisone (AA-Arm 1) or combination AA and standard doses of cabazitaxel (AA/CBZ-Arm 2). Patients on AA received CBZ upon progression. Baseline CTCs were obtained on all pts and expression of N-terminal AR expression was performed by Epic Sciences. Positive AR N-terminal expression (AR+) was based on the presence of at least 1 CTC or CK- cell with AR N-terminal signal expression above the 3.0 positivity threshold. Serial PSAs were determined at baseline and every 3 weeks with routine labs and imaging every 12 weeks. Results: To date, 42 of 80 pts have been enrolled: 22 pts to AA, and 20 pts to AA/CBZ. Both regimens were well tolerated with 8/42 (19%) pts experiencing treatment-related grade 3 or 4 toxicities. Blood from 35 patients underwent CTC analysis. Seventy-seven percent of pts (27/35) had detectable CTCs; 11 of 35 pts (31%) had AR overexpression. Of the pts with AR+ CTCs, 1/5 pts treated with AA, and 5/6 pts treated with AA/CBZ had a PSA decline > 50% from baseline. Conclusions: Real-time CTC analysis of N-terminal AR expression was feasible and data suggests that this may identify a cohort of pts who may benefit from the combination of CBZ with AA. Further studies are ongoing to evaluate whether cellular heterogeneity and RB expression in CTCs play a role in identifying pts who would benefit from chemotherapy. The trial is coordinated by the Prostate Cancer Clinical Trials Consortium, LLC and funded by Sanofi US Services Inc. and Prostate Cancer Foundation. Clinical trial information: NCT02218606.

Disseminated intravascular coagulation with excessive fibrinolysis in prostate cancer: a case series and review of the literature

OBJECTIVES

To describe the clinical characteristics, diagnostic features, prognosis, and outcome of patients with prostate cancer and disseminated intravascular coagulation with excessive fibrinolysis (DIC XFL).

METHODS

We performed a retrospective analysis of prostate cancer patients seen at a single center from March 21, 2000, to July 31, 2006, with a fibrinogen level <150 mg/dl and two of the following criteria: platelets <150 × 10(9)/l, D-dimer >0.5 μg/ml, prothrombin time and activated partial thromboplastin time exceeding normal values, hemorrhage and/or thrombosis. Patients with comorbid conditions that cause coagulopathy were excluded.

RESULTS

Forty-two patients met the inclusion criteria. Most patients had high-grade prostate cancer (26% had Gleason 7 and 45% had Gleason 8-10). Three patients developed DIC XFL following surgery and 39 patients in the setting of metastatic disease; 93% were resistant to castration, and 50% had received prior taxanes. No deep-vein thromboses were documented. Management included blood transfusion, heparin, hormones, and chemotherapy. Median survival was 4 weeks. DIC XFL reversal was seen in 20% of metastatic patients, all of whom received new chemotherapy regimens. Median survival in this group was 26 weeks.

CONCLUSIONS

DIC XFL is a rare complication of prostate cancer. Untreated, the risk of hemorrhage is high and the prognosis poor. Reversal of DIC XFL appears to correlate with response to new anticancer therapy.