Global Equity in Clinical Trials: An ASCO Policy Statement

ASCO is a global professional society representing more than 50,000 physicians, other health care professionals, and advocates in over 100 countries specializing in cancer treatment, diagnosis, prevention, and advocacy. ASCO strives, through research, education, and promotion of the highest quality of patient care, to create a world where cancer is prevented or cured, and every survivor is healthy. In this pursuit, health equity remains the guiding institutional principle that applies to all its activities across the cancer care continuum. This ASCO policy statement emphasizes the urgent need for global equity in clinical trials, aiming to enhance access and representation in cancer research as it not only improves cancer outcomes but also upholds principles of fairness and justice in health care.

Daytime of leaf wounding determines plant biomass and affect the interplay between growth and defense in Brassica crops

Recent discoveries pointed out the importance of the mutual correlation between timing of environmental stress and plant fitness. However, the internal reshaping of plant growth under daily stress sensing, and their metabolic coordination remain to be investigated. Thus, we aim to study the connection between daytime, growth and defense to understand how plant fitness is affected by diurnal stress inputs. To accomplish that, we examined if simulated herbivory (leaf wounding) in the morning, mid-day or evening differentially influenced plant defensive states vs growth in three different crop species of the Brassica genus, broccoli (Brassica oleraceae), turnip greens (B. rapa) and rapeseed (B. napus). The data presented here revealed that plant's ability to tolerate wounding stress is diurnally regulated in Brassica crops. Trade-offs between plant biomass and investment in glucosinolates (GSL) and phenolics were affected by daytime of leaf stress. Negative correlations between plant biomass and induction of defensive compounds were found for morning and evening treated plants. However, these correlations were positives for mid-day treatment. Interestingly, we revealed new connection between plant growth and changes of aliphatic GSLs and flavonoids in response to wounding. These data suggest that metabolic stress-dependent circadian oscillations of leaves defenses could be one mechanism conferring competitive advantage to plants able to anticipate daily environmental variations by synchronize growth with them. Moreover, this work provides first insights of how secondary metabolites are linked to growth response in a timely manner.

ASCO Policy Statement on Biosimilar and Interchangeable Products in Oncology

As the voice of cancer care clinicians and the patients they serve, ASCO has taken steps to elevate awareness about biosimilar products and their use in oncology. In 2018, ASCO released its Statement on Biosimilars in Oncology which was subsequently published in the Journal of Clinical Oncology to serve as an educational tool which highlighted and provided guidance on several topical areas surrounding biosimilars. At the time of its publication, the US Food and Drug Administration (FDA) had approved eight biosimilar products for use in the United States, including one product for use as a supportive care agent in the cancer setting and two products for use in the treatment for cancer. This number has risen dramatically (40 approvals), with a total of 22 cancer or cancer-related biosimilar products approved since 2015. Recently, the FDA also approved the four interchangeable biosimilar products for diabetes, certain inflammatory diseases, and certain ophthalmic diseases. Given the current market dynamics and the regulatory landscape, this ASCO manuscript now seeks to propose several policy recommendations across the scope of value, interchangeability, clinician barriers, and patient education and access. This policy statement is intended to guide ASCO's future activities and strategies and serves to affirm our commitment to providing education to the oncology community on the use of biosimilars in the cancer setting.

Effects of amount and recurrence of leaf herbivory on the induction of direct and indirect defences in wild cotton

The induction of defences in response to herbivory is a key mechanism of plant resistance. While a number of studies have investigated the time course and magnitude of plant induction in response to a single event of herbivory, few have looked at the effects of recurrent herbivory. Furthermore, studies measuring the effects of the total amount and recurrence of herbivory on both direct and indirect plant defences are lacking. To address this gap, here we asked whether insect leaf herbivory induced changes in the amount and concentration of extrafloral nectar (an indirect defence) and concentration of leaf phenolic compounds (a direct defence) in wild cotton (Gossypium hirsutum). We conducted a greenhouse experiment where we tested single event or recurrent herbivory effects on defence induction by applying mechanical leaf damage and caterpillar (Spodoptera frugiperda) regurgitant. Single events of 25% and 50% leaf damage did not significantly influence extrafloral nectar production or concentration. Extrafloral nectar traits did, however, increase significantly relative to controls when plants were exposed to recurrent herbivory (two episodes of 25% damage). In contrast, phenolic compounds increased significantly in response to single events of  leaf damage but not to recurrent damage. In addition, we found. that local induction of extrafloral nectar production was stronger than systemic induction, whereas the reverse pattern was observed for phenolics. Together, these results reveal seemingly inverse patterns of induction of direct and indirect defences in response to herbivory in wild cotton.

Abstract P3-08-05: Validation of a nomogram for predicting recurrence among women with ductal carcinoma in situ and breast conserving surgery in an integrated health care system

Current management of ductal carcinoma in situ (DCIS) most often entails removing the lesion by breast-conserving surgery. Quantifying the risk of a patient's ipsilateral breast event (IBE) recurrence, either invasive cancer or DCIS, after breast conserving surgery remains a clinical concern. The aim of this study was to validate the Memorial Sloan-Kettering Cancer Center (MSKCC) nomogram to predict IBE recurrence in patients from our institution.

Patients and Methods

We retrospectively identified 608 patients in the Kaiser Permanente Northwest integrated healthcare system with a diagnosis of DCIS who had undergone local excision from 1990 through 2007. We assessed the performance of the MSKCC nomogram for predicting IBE recurrence using measures of discrimination (how well risk scores separate those with and without the event) and calibration (agreement between predicted and observed risk). We calculated Harrell's C and R2D to provide estimates of discrimination. We calculated the calibration slope by performing a Cox regression using the prognostic index (PI; predicted log relative hazard based on the original Cox coefficients), with a slope not significantly different from 1 indicating no difference in discrimination from the development sample. We also examined discrimination by comparing the KM curves of 4 risk groups and in a Cox regression as a predictor, which were created using Cox's method (4 groups using the 16th, 50th, & 84th percentiles), as no risk groups were defined in the MSKCC development study. We examined whether there was model misfit by testing each predictor in a Cox regression with an offset of the PI. Finally, we assessed calibration by plotting the observed rates and associated 95% CIs against the predicted probabilities for groups based on 4 risk groups and octiles.

Results

The median follow-up time for the KPNW cohort was 125 months. The 10-year IBE recurrence rate was 9.5%, 95% CI [7.0%, 13.0%). Harrell's C was .70, which is comparable to what has been found in other validation studies. The PI accounted for 22% of variation in time (R2D =.22, 95% CI [.08, .38]). The test of the calibration slope provided no support that discrimination in this sample differs from the development study (LR χ2(1)=0.21, p=.65). An examination of the Kaplan-Meier curves among the risk groups showed good separation of the high risk group compared to the others, but little separation between the lowest two risk groups. None of the predictors demonstrated evidence for differential weighting from the MSKCC coefficients (p values ranged from .08 to .97). Calibration was good for the lowest, low, and moderate risk groups, but there was underprediction in the high risk group. When examining calibration using octiles, we found a similar pattern to that of other validation studies in which the highest octile had the furthest departure from perfect agreement.

Conclusion

The MSKCC nomogram for predicting IBE recurrence in patients with DCIS who were treated with local excision have some utility, and our results are consistent with other validation efforts. However, there is much potential to further increase the prediction of recurrence beyond what is possible with the MSKCC nomogram.

Citation Format: Leo MC, Francisco M, Jenkins C, Weinmann S. Validation of a nomogram for predicting recurrence among women with ductal carcinoma in situ and breast conserving surgery in an integrated health care system [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P3-08-05.

American Society of Clinical Oncology Statement: Biosimilars in Oncology

As many biosimilars come to market in the next several years, their use in oncology will play an important role in the future care of patients with cancer. ASCO is committed to providing education and guidance to the oncology community on the use of biosimilars in the cancer setting; therefore, ASCO has developed this statement to offer guidance in the following areas: (1) naming, labeling, and other regulatory considerations, (2) safety and efficacy of biosimilars, (3) interchangeability, switching, and substitution, (4) value of biosimilars, and (5) prescriber and patient education.

American Society of Clinical Oncology Position Statement: Strategies for Reducing Cancer Health Disparities Among Sexual and Gender Minority Populations

ASCO is committed to addressing the needs of sexual and gender minority (SGM) populations as a diverse group at risk for receiving disparate care and having suboptimal experiences, including discrimination, throughout the cancer care continuum. This position statement outlines five areas of recommendations to address the needs of both SGM populations affected by cancer and members of the oncology workforce who identify as SGM: (1) patient education and support; (2) workforce development and diversity; (3) quality improvement strategies; (4) policy solutions; and (5) research strategies. In making these recommendations, the Society calls for increased outreach and educational support for SGM patients; increased SGM cultural competency training for providers; improvement of quality-of-care metrics that include sexual orientation and gender information variables; and increased data collection to inform future work addressing the needs of SGM communities.

Abstract S5-01: DCIS biological risk profile predicts risk of recurrence after breast conserving surgery in a Kaiser Permanente NW population

Background: Patients with DCIS and their physicians need tools that provide better information about the individual patient's biological risk profile to help make treatment decisions. Prelude and the Kaiser Permanente Northwest Center for Health Research (KPCHR) validated a biological risk signature based test to assess ipsilateral breast event (IBE) risk after breast conserving surgery (BCS) with radiation (+RT) or without radiation therapy (-RT).

Methods: The Prelude DCIS test was independently validated in a retrospective cohort from the Kaiser Permanente Northwest (KPNW) integrated healthcare system in patients diagnosed with DCIS from 1990- 2007 and treated with BCS±RT(n=608). KPCHR performed central pathology review to identify patients meeting study eligibility criteria with formalin fixed paraffin embedded (FFPE) tissue samples (n=475); KPCHR also reviewed medical records to collect patient, treatment, and outcome data. FFPE patient samples were provided to Prelude for testing. REMARK guidelines were followed.

A panel of biomarkers (HER2, PR, Ki-67, COX2, p16/INK4A, FOXA1 and SIAH2) were assayed by the Prelude CLIA lab and scored by board-certified pathologists (n=455). Prelude's DCIS test was executed independently using biomarker and clinicopathologic data while blinded to patient outcome data. The risk results were provided to KPCHR under a Data Transfer Authority. KPCHR biostatisticians executed a predefined and co-developed statistical analysis plan. IBE rates were assessed using Kaplan-Meier survival analysis. Hazard ratios (HR) were determined using Cox proportional hazards analysis, with RT as a covariate.

Results: The Prelude DCIS test score was statistically associated with total IBE as a continuous linear variable (0-10 unit scale) on a per unit basis, HR of 1.12, 95% CI [1.03,1.23], p=0.01. The DCIS test score (0-10) corresponded to recurrence risks ranging from 10% to 42% (≤2, >7) for patients treated with BCS-RT and ranging from 4% to 11% (≤2, >7) for patients treated with BCS+RT. Patients treated with BCS ±RT with an elevated test score (≤3 vs >3) had a higher recurrence risk, n=455, HR=1.87 [1.03 - 3.38], p=0.04. In patients treated with BCS-RT in this sample, patients with a higher DCIS signature had an elevated recurrence risk, n=78, HR=2.37, 95% CI [0.82, 6.85], p=0.11. The 10-year contralateral breast event rate was 4%, 95% CI [2%, 6%]. Median follow-up time was 10.4 years.

Discussion: Patients diagnosed with DCIS and treated with BCS ±RT, were stratified into clinically relevant low and elevated risk groups (≤3 vs >3) in an independent validation of the Prelude DCIS test. Patients in the elevated risk group had substantially higher likelihood of 10-year total IBE. The number of patients treated with BCS -RT was limited and while the stratification by risk group for BCS -RT was in the expected direction, it did not reach statistical significance. Two additional validation studies are scheduled to be completed in 2016.

10-YEAR IBE RISKBCS –RTBCS +RTRisk, [95% CI]PrevalenceNRisk, [95% CI]PrevalenceNBaseline Total Risk20%, [12%, 32%]100%788%, [5%, 11%]100%377Low Risk Group (≤3)10% [3%, 29%]53%415%, [2%, 10%]40%149Elevated Risk Group (>3)30%, [17%, 51%]47%3710%, [6%, 15%]60%228

Citation Format: Bremer T, Whitworth P, Leo M, Barry T, Goldstein N, Ganders C, Francisco M, Leesman G, Linke S, Patel R, Pellicane J, Weinmann S. DCIS biological risk profile predicts risk of recurrence after breast conserving surgery in a Kaiser Permanente NW population [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr S5-01.