A randomized trial to evaluate the effects of a supervised exercise program on insomnia in patients with non-metastatic breast cancer undergoing chemotherapy: design of the FATSOMCAN study

BACKGROUND

Up to 70% of breast cancer patients report symptoms of insomnia during and after treatment. Despite the ubiquity of insomnia symptoms, they are under-screened, under-diagnosed and poorly managed in breast cancer patients. Sleep medications treat symptoms but are ineffective to cure insomnia. Other approaches such as cognitive behavioral therapy for insomnia, relaxation through yoga and mindfulness are often not available for patients and are complex to implement. An aerobic exercise program could be a promising treatment and a feasible option for insomnia management in breast cancer patients, but few studies have investigated the effects of such a program on insomnia.

METHODS

This multicenter, randomized clinical trial evaluate the effectiveness of a moderate to high intensity physical activity program (45 min, 3 times per week), lasting 12 weeks, in minimizing insomnia, sleep disturbances, anxiety/depression, fatigue, and pain, and in enhancing cardiorespiratory fitness. Patients with breast cancer be recruited from six hospitals in France and randomly allocated to either the "training" or the "control" group. Baseline assessments include questionnaires [Insomnia Severity Index (ISI), Pittsburgh Sleep Quality Index questionnaire (PSQI), Hospital Anxiety Depression Scale (HADS), Epworth Sleepiness Scale (ESS)], home polysomnography (PSG), and 7-day actigraphy coupled with completion of a sleep diary. Assessments are repeated at the end of training program and at six-month follow-up.

DISCUSSION

This clinical trial will provide additional evidence regarding the effectiveness of physical exercise in minimizing insomnia during and after chemotherapy. If shown to be effective, exercise intervention programs will be welcome addition to the standard program of care offered to patients with breast cancer receiving chemotherapy.

TRIAL REGISTRATION

National Clinical Trials Number (NCT04867096).

Cardiotoxicity is mitigated after a supervised exercise program in HER2-positive breast cancer undergoing adjuvant trastuzumab

Background

Trastuzumab is used, alone or in conjunction with standard chemotherapy, to treat HER2-positive breast cancer (BC). Although it improves cancer outcomes, trastuzumab. can lead to cardiotoxicity. Physical exercise is a safe and effective supportive therapy in the management of side effects, but the cardioprotective effects of exercise are still unclear.

Objectives

The primary aim of this study was to test whether trastuzumab-induced cardiotoxicity [left ventricular ejection fraction (LVEF) under 50%, or an absolute drop in LVEF of 10%] was reduced after a supervised exercise program of 3 months in patients with HER2-positive breast cancer. Secondary endpoints were to evaluate (i) cardiotoxicity rates using other criteria, (ii) cardiac parameters, (iii) cardiorespiratory fitness and (iv) whether a change in LVEF influences the cardiorespiratory fitness.

Methods

89 women were randomized to receive adjuvant trastuzumab in combination with a training program (training group: TG; n = 46) or trastuzumab alone (control group: CG; n = 43). The primary and secondary endpoints were evaluated at the end of the supervised exercise program of 3 months (T3).

Results

After exercise program, 90.5 % of TG patients and 81.8% of CG patients did not exhibit cardiotoxicity. Furthermore, whatever the used criterion, percentage of patients without cardiotoxicity were greater in TG (97.6 and 100% respectively) than in CG (90.9 and 93.9% respectively). LVEF and GLS values remained stable in both groups without any difference between the groups. In contrast, at T3, peak VO2 (+2.6 mL.min−1.kg−1; 95%CI, 1.8 to 3.4) and maximal power (+21.3 W; 95%CI, 17.3 to 25.3) increased significantly in TG, whereas they were unchanged in CG (peak VO2: +0.2 mL.min−1.kg−1; 95%CI, −0.5 to 0.9 and maximal power: +0.7 W, 95%CI, −3.6 to 5.1) compared to values measured at T0. No correlation between LVEF changes and peak VO2 or maximal power was observed.

Conclusion

A 12-week supervised exercise regimen was safe and improved the cardiopulmonary fitness in particular peak VO2, in HER2-positive BC patients treated with adjuvant trastuzumab therapy. The study is under powered to come to any conclusion regarding the effect on cardiotoxicity.

Clinical trial registration

www.ClinicalTrials.gov, identifier: NCT02433067.

HERibuline: Eribulin mesylate and Trastuzumab in pretreated HER2-positive advanced breast cancer—A report of region’s practice

e13020

Background: Until 2020, in human epidermal growth factor receptor 2 (HER2)-positive advanced breast cancer (ABC), the two first lines of metastatic treatment were well defined but after, many options were possible, most often combining targeted therapy plus chemotherapy. Eribulin mesylate is indicated for the treatment of patients with ABC previously treated by anthracycline and taxane regimens in the advanced setting. Here, we present the results of eribuline and trastuzumab (E/T) combination in HER2-positive ABC previously treated. Methods: Patients with HER2-positive ABC treated with the E/T combination from our region cancer institute were included in this retrospective study. The primary endpoint was progression-free survival (PFS). Secondary endpoints included overall survival (OS), overall response rate (ORR), clinical benefit rate (CBR) and safety. Results: Between November 2013 and July 2019, a total of 34 consecutive patients with HER2-positive ABC were included. The median number of previous lines for advanced setting was 4 (range 2-7). Patients treated by taxanes and anthracyclines represented 91% and 47% respectively; 50%, 79% and 62% were previously treated with pertuzumab, trastuzumab emtansine and lapatinib respectively. After a median follow up of 24.8 months, median PFS was 6.2 months (95% CI [3.35-7.13]) and median OS was 12.6 months (95% CI [7.13-18.56]). The ORR and CBR were 38% and 53%, respectively. No unexpected adverse event was observed. The most frequent grade 3-4 toxicity was hematologic (44.1%). Conclusions: Recently, new therapies have revolutionized the management of HER2-positive ABC and patients benefit from a prolonged overall survival associated with a maintained performance status. However, in pretreated and advanced metastatic setting, there are few scientific evidence to guide the choice of treatments. A combination of E/T could be an effective option in patients with good performance status and willing to receive treatment.

Cognitive dysfunction among patients referred for transcatheter aortic valve implantation: results of the Montreal Cognitive Assessment and clinical impact at 6 months

Background

Detection of Cognitive Dysfunction (CD) is not routinely performed among patients undergoing Transcatheter Aortic Valve Implantation (TAVI). We sought to determine whether CD has an impact on the clinical course of these patients, during hospitalization at the time of TAVI and up to 6 months afterwards.

Methods

The MoCA was performed before TAVI by an experienced operator in an unselected population of patients referred for TAVI. CD was defined according to the MoCA score: No CD if score ≥26, mild CD if score 18–25, moderate if 10–17 and severe if <10. Multivariate Cox logistic regression analysis was used to determine the impact of CD on procedural success of TAVI, length of stay, 6 month survival, re-admission, and change in clinical status (changes in NYHA class and/or functional status).

Results

MoCA was performed in 83 consecutive patients. TAVI was performed using femoral access and local anesthesia in all patients. There were no procedural deaths, and 2 deaths at 6 months. The median age was 85 years, and median Euroscore I was 11.62. The median MOCA score was 22, CD was excluded in 17 (20%), mild in 50 (60%), moderate in 15 (18%) and severe in one patient. No difference was observed in rate of procedural success, 6 month mortality, re-admission, degree of dyspnea by NYHA between the different cognitive groups. Length of stay after the TAVI procedure was lower in patients without CD, compared to those with CD at any level: 3±1 days versus 4.3±1 days, p=0.045, and p=0.02 by multivariate analysis (figure).

Conclusion

Among patients referred for TAVI, mild or moderate CD was observed in 80% of patients. Patients without CD had a shorter length of stay at the time of TAVI, but CD was not associated with worse prognosis or clinical status at 6 months.

Funding Acknowledgement

Type of funding sources: None.

An original risk score to predict early major bleeding in acute pulmonary embolism: the Syncope, Anemia, Renal Dysfunction (PE-SARD) bleeding score

Background

Improved prediction of the risk of early major bleeding in pulmonary embolism (PE) is needed to optimize acute management.

Methods

Using data from a multicenter prospective registry including 2,754 patients, we performed multivariable logistic regression analysis to build a risk score to predict early (up to hospital discharge) major bleeding events. We validated the endpoint model internally using bootstrapping in the derivation dataset by sampling with replacement for 500 iterations. We compared the performance of this novel score to that of the VTE-BLEED and RIETE models.

Results

Multivariate regression identified three predictors for the occurrence of 82 major bleeds (3.0%): Syncope (+1.5 points), Anemia defined by a hemoglobin level <12 g/dL (+2.5 points), and Renal Dysfunction defined by a glomerular filtration rate <60 mL/min (+1 point). The PE-SARD bleeding score was calculated by summing all the components. Overall, 52.2% of patients were classified as low bleeding-risk (score, 0 point), 35.2% intermediate-risk (score, 1–2.5 points), and 12.6% high-risk (score >2.5 points). Cumulative observed bleeding rates increased with increasing risk group, from 0.9% in the low-risk group to 9.0% in the high-risk group. The C-index was 0.744 (95% CI, 0.73–0.76) and Brier score 0.028 in the derivation cohort. Similar values were calculated from internal bootstrapping. Performance of the PE-SARD score was better than that observed with the VTE-BLEED and RIETE scores (figure).

Conclusions

The PE-SARD bleeding risk score is an original, user-friendly score to estimate the risk of early major bleeding in patients with acute PE.

Funding Acknowledgement

Type of funding sources: None. Figure 1

Available bleeding scoring systems poorly predict major bleeding in the acute phase of pulmonary embolism

Background

Bleeding prediction scores may help to guide acute management of patients with pulmonary embolism (PE). However, existing scoring systems have not been validated for in-hospital assessment. We aimed to compare 6 available bleeding scores, in a real-life cohort for the prediction of major in-hospital bleeding.

Methods

We recorded in-hospital characteristics of 2,754 PE patients included in a prospective observational multicenter cohort study contributing 18,028 person-days of follow-up. We assessed the VTE-BLEED, RIETE, ORBIT, HEMORRA2HAGES, ATRIA, and HAS-BLED scores at baseline. ISTH-defined bleeding events were independently adjudicated. The accuracy of the scores for the prediction of in-hospital bleeding was evaluated and compared.

Results

We observed 82 first in-hospital major bleeding events (3.0% (95% CI, 2.4–3.7)). Overall, the predictive power of bleeding scores was poor, with a C index ranging from 0.57 to 0.69 (Figure 1). The RIETE score had the numerically highest model fit and best discriminatory capacity, but without reaching statistical significance versus the ORBIT, HEMORR2HAGES, and ATRIA scores. The VTE-BLEED and HAS-BLED scores had significantly lower C indices, integrated discrimination improvement, and net reclassification improvement compared to the four others.

Conclusion

Currently available scoring systems have insufficient accuracy for the prediction of in-hospital major bleeding in patients with acute PE. The development of acute-PE-specific risk scores is needed to optimally target patients that warrant bleeding-prevention strategies.

Funding Acknowledgement

Type of funding sources: None. Figure 1

Assessment of cognitive dysfunction using the Montreal Cognitive Assessment test: rate, severity and comparison with the Clock test alone in a population of patients referred for TAVI

Background

Although not recommended in routine practice, the detection and quantification of Cognitive Dysfunction (CD) in older patients might have an impact on clinical decisions. We assessed the rate and severity of CD in an unselected population of patients referred for Transcatheter Aortic Valve Implantation (TAVI) using the Montreal Cognitive Assessment (MoCA) and using the Clock Drawing Test (ClockT) alone.

Methods

The MoCA was performed before TAVI by an experienced operator. The ClockT was scored out of 10 points according to the Rouleau rating scale. CD was defined according to the MoCA score: No CD if score ≥26, mild CD if score 18–25, moderate if 10–17 and severe if <10. Inter-observer reliability of scoring on the ClockT was estimated with the Bland-Altman method. Agreement between MoCA scores and the ClockT for ruling out and for detecting CD were measured with the Kappa coefficient.

Results

MoCA was performed in 83 consecutive patients referred for TAVI, median age 85 years. The mean time required for assessment was 11±2 min for the MoCA and 3±2 min for the ClockT. The mean MoCA score was 21±4.5: CD was excluded in 17 (20%) pts, mild CD was found in 50 (60%), moderate in 15 (18%) and severe in one (1%). The median ClockT score was 8 (interquartile 6; 9), with excellent inter-observer concordance (Kappa= 0.84). Overall, 51% of the variance of the MoCA score was explained by the ClockT alone according to multiple regression. A ClockT <7 detected a group with significantly lower MoCA score, compared to pts with higher ClockT scores (figure).

Conclusion

Among patients referred for TAVI, CD can be excluded using the MoCA test in 20%, while moderate or severe CD is observed in 18%. The ClockT alone is faster to implement, reliable to interpret and enabled detection of patients with moderate CD when Rouleau scoring was <7.

Funding Acknowledgement

Type of funding sources: None.

Use of mechanical pulmonary reperfusion and fibrinolysis in acute massive pulmonary embolism requiring extracorporeal membrane oxygenation support: a systematic review and meta-analysis

Background and objectives

The optimal pulmonary revascularization strategy in acute massive pulmonary embolism (PE) requiring the implantation extra corporeal membrane oxygenation remains controversial, and data are sparse.

Methods

We conducted a systematic review and meta-analysis of available evidence regarding the use of mechanical reperfusion (i.e. surgical or catheter-based embolectomy) and fibrinolytic strategies (i.e. systemic fibrinolysis, catheter-directed fibrinolysis, or as stand-alone therapy) in terms of mortality and bleeding outcomes.

Results

The literature search identified 835 studies, 17 of which were included or a total of 321 PE patients with ECMO. In total, 31.1% were treated with mechanical pulmonary reperfusion, while 78.9% received fibrinolytic strategies. The mortality rate was 23.0% in the mechanical reperfusion group and 43.1% in the fibrinolysis group (Figure). The pooled OR for mortality with mechanical reperfusion was 0.46 (95% CI, 0.213–0.997; I2=28.3%) versus fibrinolysis. The rate of bleeding in PE patients under ECMO was 29.1% in the mechanical reperfusion group and 26.0% in the fibrinolytic reperfusion (OR, 1.09; 95% CI, 0.46–2.54; I2=0.0%) among 10 eligible studies with available bleeding data. The meta-regression model did not identify any relationship between the covariates “more than one pulmonary reperfusion therapy” and “ECMO implantation before pulmonary reperfusion therapy”, and outcomes.

Conclusions

The results of the present meta-analysis and meta-regression suggest that surgical embolectomy yields the best results, regardless of the timing of VA-ECMO implantation in the reperfusion timeline, and regardless of whether fibrinolysis has been administered or not.

Funding Acknowledgement

Type of funding sources: None.

Feasibility of health-related quality of life (HRQoL) assessment for cancer patients using electronic patient-reported outcome (ePRO) in daily clinical practice

INTRODUCTION

Routine Electronic Monitoring of Health-Related Quality of Life (HRQoL) (REMOQOL) in clinical care with real-time feedback to physicians could help to enhance patient-centered care. We evaluated the feasibility of REMOQOL in the French context in the QOLIBRY study. The primary objective was to assess the patients' compliance with REMOQOL.

METHODS

The QOLIBRY study was a single-center, prospective study conducted in the University Hospital of Besançon (France). Eligible patients were those treated with systemic therapies for breast, lung or colorectal cancer at any stage. Patients were invited to complete the EORTC QLQ-C30 questionnaire and cancer-site-specific modules before each visit on tablets and/or computers in the hospital or at home. During the consultation, physicians had real-time access to visual summaries of HRQoL scores. Compliance was assessed as adequate if at least 66% of HRQoL assessments were completed during the 4 months of follow-up.

RESULTS

Between March 2016 and October 2018, 177 patients were included in the QOLIBRY study. Median age was 64 years (IQR 54-71). The proportion of patients with an adequate compliance rate was 95.5% (n = 63) in the breast cancer cohort, 98.2% (n = 55) in the colorectal cancer cohort, and 90.9% (n = 50) in the lung cancer cohort. The physicians checked the HRQoL results in 73.1% of visits and prescribed supportive care and adapted patient management in 8.3% and 5.2% of visits, respectively.

CONCLUSION & PERSPECTIVES

The results of QOLIBRY study suggest that REMOQOL is feasible in the French context. However, information about HRQoL monitoring, training of the physicians in the use of the software, and recommendations for using HRQoL results to guide care are essential and must be improved.

High post-procedural transvalvular gradient or delayed gradient increase after transcatheter aortic valve implantation: the FRANCE-2 registry

Background

Mean gradient (MG) elevation can be detected immediately post-procedure or secondarily during follow-up. Comparison between these two parameters and impact on outcomes has not previously been investigated.

Objectives

The study aimed to identify incidence, influence on prognosis and parameters associated with immediate high post-procedural mean transvalvular gradient (PPMG) and delayed mean gradient increase (DMGI), in the FRANCE 2 (French Aortic National CoreValve and Edwards 2) registry.

Methods

The registry includes all consecutive symptomatic patients with severe aortic stenosis. Three groups were analyzed: 1) PPMG <20mmHg without DMGI >10 mmHg (control); 2) PPMG <20mmHg with DMGI >10 mmHg (group 1); 3) PPMG ≥20 mmHg (group 2).

Results

From January 2010 to January 2012, 4201 consecutive patients were prospectively enrolled in the registry. The control group comprised 2078 patients; the group 1, 131 patients; and the group 2, 144 patients. DMGI exceeded 10 mmHg in 5.6%, and was not associated with greater 4-year mortality than in control group (32.6% vs. 40.1%, p=0.27, respectively). PPMG was at least 20 mmHg in 6.1%, and was associated with higher 4-year mortality than in control group (48.7% versus 40.1%, p=0.005, respectively) (Figure 1). Two-thirds of patients with initial PPMG ≥20 mmHg had finally a MG <20 mmHg at 1 year, with mortality similar to controls (39.2% vs. 40.1%, p=0.73).

Conclusions

Patients with PPMG >20 mmHg 1 year post-TAVI had higher 4-year mortality than the general population of the registry, unlike patients with MG normalization at 1 year.

Figure 1

Funding Acknowledgement

Type of funding source: Public Institution(s). Main funding source(s): French National Society of Cardiology

Renal function improves mortality prediction in acute pulmonary embolism: results of a multicentre cohort study with external validation in the RIETE registry

Background

Renal dysfunction may influence outcomes after pulmonary embolism (PE). We determined the incremental value of adding renal function impairment (estimated glomerular filtration rate, eGFR <60 ml/min/1.73m2) on top of the 2019 ESC prognostic model, for the prediction of 30-day all-cause mortality in acute PE patients from a prospective, multicenter cohort.

Methods and results

We identified which of three eGFR formulae predicted death most accurately. Changes in global model fit, discrimination, calibration and net reclassification index (NRI) were evaluated with addition of eGFR. We prospectively included consecutive adult patients with acute PE diagnosed as per ESC guidelines. Among 1,943 patients, (mean age 67.3±17.1, 50.4% women), 107 (5.5% (95% CI 4.5–6.5%)) died during 30-day follow-up. The eGFRMDRD4 formula was the most accurate for prediction of death. The observed mortality rate was higher for intermediate-low risk (OR 1.8, 95% CI 1.1–3.4) and high-risk PE (OR 10.3, 95% CI 3.6–17.3), and 30-day bleeding was significantly higher (OR 2.1, 95% CI 1.3–3.5) in patients with vs without eGFRMDRD4 <60 ml/min/1.73m2. The addition of eGFRMDRD4 information improved model fit, discriminatory capacity, and calibration of the ESC models. NRI was significantly improved (p<0.001), with 18% reclassification of predicted mortality, specifically in intermediate and high-risk PE. External validation using data from the RIETE registry confirmed our findings (Table).

Conclusion

Addition of eGFRMDRD4-derived renal dysfunction on top of the ESC prognostic algorithm yields significant reclassification of risk of death in intermediate and high-risk PE. Impact on therapy remains to be determined.

Funding Acknowledgement

Type of funding source: Private grant(s) and/or Sponsorship. Main funding source(s): BMS-Pfizer Alliance, Bayer Healthcare

5032Evaluation of the EAPCI OCT criteria for optimization of angioplasty in the DOCTORS study population

Background

The recent expert consensus of the EAPCI suggested OCT criteria for the optimization of PCT after stent implantation. Using the data from the randomized, controlled DOCTORS study, we aimed to analyze the proportion of OCT criteria that were met immediately after stent implantation, and to evaluate the changes made to the revascularization strategy in order to optimize the procedure.

Methods

The DOCTORS study population consisted of patients admitted for non ST elevation myocardial infarction (NSTEMI) and presenting an indication for PCI with stent implantation of the target lesion. In the 120 patients randomized to the OCT-guided group, OCT was performed after initial coronary angiography and repeated immediately after stent implantation. The operator was required to evaluate quantitative measures of the reference diameter and reference area of the vessel and the length of the lesion based on the OCT images acquired before PCI. All OCT images were analyzed in a centralized core laboratory by 2 independent operators blinded to the angiographic findings. Post-PCI optimization targets to be achieved following stent implantation included optimal stent expansion (minimal stent area (MSA)/average reference lumen >80%), avoidance of landing zone in plaque burden >50% or lipid rich tissue; avoidance of large malapposition regions (axial distance <0.4 mm and <1 mm length), no extensive irregular tissue protrusion, and limited dissections (<60°, flap limited to intima, <2 mm length).

Results

Among the 120 patients who had an OCT run performed immediately after stent implantation, 50 patients (42%) had stent under-expansion, 59 (49%) had landing zone in plaque burden >50% or lipid rich tissue, 27 (22.5%) had stent malapposition, 25 (20.8%) had extensive irregular tissue protrusion and 45 (37.5%) had extensive edge dissection. Only 2 patients (1.7%) fullfiled all criteria of post-PCI optimization immediately after stent implantation, while no criterion was reached in 15 patients (12.5%). Post-stent overdilation was performed in all patients with stent underexpansion, and in 22/27 patients (81.5%) with stent malapposition. Additional stent implantation was performed in 32 patients (24 for landing zone in plaque burden >50% and 8 for extensive adventitial edge dissection). Overall, the use of OCT led the operator to optimize the procedural strategy in 60 patients (50%).

Conclusion

The proportion of suboptimal results as evaluated by OCT and based on the EAPCI criteria immediately after stent implantation was very high in the DOCTORS study, even though the choice of stent in these patients was based on pre-PCI OCT data. The post-PCI OCT findings led to a change of strategy to optimize the procedure in 50% of patients. It remains to be determined through a larger prospective study whether this optimization of PCI strategy is associated with a clinical benefit in the long term.

P2767Outcomes and incremental prognostic value of renal function impairment after acute pulmonary embolism

Background

We explored the relation between adverse outcomes after acute pulmonary embolism (PE)and renal dysfunction classified by estimated glomerular filtration rate (eGFR) using the CKD-EPI equation. We assessed the incremental value of adding eGFR CKD-EPI to the ESC score for predicting 30d mortality.

Methods

Prospective, multicenter study of 1664 acute PE admitted from 01/2011 to 12/2017. Pts were categorized in 4 eGFR groups: Group 1 (eGFR ≥60 ml/min/1.73m2, n=1178), group 2 (45–59; n=257); group 3 (30–44; n=150), group 4 (≤29; n=79).

Results

All-cause and CV death at 30 days and 6 months were higher in group 3 (p=0.005 and p=0.03) and group 4 (p<0.001 and p<0.001 respectively) vs group 1. Major bleeding at 30d and 6m was higher in group 2 vs group 1 (p=0.003 for both). Renal dysfunction combined with the ESC prognostic algorithm for prediction of 30d death improved discriminatory capacity of the model and enabled reclassification in different risk categories in 27% of pts (Table).

Without eGFR CKD-EPI OR (95% CI) With eGFR CKD-EPI OR (95% CI) ESC algorithm 2.59 (1.95–3.43) 2.30 (1.72–3.07) eGFR CKD-EPI – 2.60 (1.62–4.7) Measures of fit   Bayes information criterion 607.30 599.32   Akaike information criterion 596.47 583.06   C-statistic 0.71* 0.77*   P (Hosmer-Lemeshow) 0.057 0.43   Integrated discrimination improvement – 0.054 (0.052–0.056)   Net reclassification improvement – 0.93 (0.90–0.95) Prognostic performance   Sensitivity 62.5 (51.2–72.3) 76.2 (61.5–90.2)   Specificity 64.2 (49.1–74.4) 69.9 (47.6–83.5)   Positive predictive value 10.1 (8.2–11.3) 16.2 (14.2–18.2)   Negative predictive value 0.97 (0.96–0.98) 98.1 (97.2–99.2)   Positive likelihood ratio 1.96 (1.12–3.41) 2.12 (1.54–3.12)   Negative likelihood ratio 0.50 (0.25–1.81) 0.54 (0.20–1.56)   Youden index 0.31 (0.28–0.34) 0.39 (0.36–0.41) Difference in C-statistic: *p=0.04.

Conclusion

Renal function impairment increases the rate of adverse events after acute PE. Combined with the ESC early mortality risk score, eGFR improves risk classification.

468Patients eligible for proprotein convertase subtilisin/kexin type9 inhibitors (pcsk9i) after acute myocardial infarction. The ESC position applied to patients included in the FAST-MI 2015 registry

Background

PCSK9i on top of high intensity statins have shown clinical benefit in patients after Acute Myocardial Infarction (AMI) who are not at LDL-c target. The ESC Task Force has defined guidance for the prescription of PCSK9i. Among patients discharged after AMI, the rate of those eligible for PCSCK9i is poorly documented.

Methods

We used data from the nationwide French FAST-MI 2015 registry. PSCK9-eligible patients were defined as those discharged with high intensity statins with expected-LDL>140 mg/dL, or >100mg/dL if they had additional high risk features such as diabetes with renal dysfunction or hypertension, multivessel coronary disease, associated peripheral artery disease or recurrent MI. The expected LDL-c was estimated from admission LDL-c and changes in lipid-lowering treatment. The rate of eligible patients was estimated from actual treatment and optimized treatment (i.e. addition of ezetimibe).

Results

Among 5291 pts included, 4715 (89%) were discharged with statins, at high intensity in 3655 (71%). Expected LDL was 71mg/dL (IQ 56, 95). Among patients discharged with high intensity statins, 3146 (59%) had an expected LDL-c<100/mg (figure, in green). PCSK9-eligible patients were those with LDL-c>140mg/dL (n=178, 3.3%, in red) and, among those with LDL-c 100–140mg/dL (n=331, 6.2%, in yellow), patients who had additional risk features (n=227 (4%)). As a result, the population eligible for PSCK9i according to the ESC guidance would represent 7.6% (405 pts) of the population admitted with AMI. Expanding the indication to patients with statins, but not at high intensity would add 159 (3%). Conversely, optimizing discharge treatment with ezetimibe would reduce the rate of eligible patients to 3% (181 pts, in brown).

Conclusions

In real life, according to the ESC Task Force, 7.6% of the whole population admitted for AMI would be eligible for PCK9i. This rate could be reduced to 3% with the addition of ezetimibe.

P1250Validation of quantitative flow reserve and residual quantitative flow reserve to predict fractional flow reserve post stenting from the DOCTORS study population

Background

Quantitative flow reserve (QFR) is a computation of fractional flow reserve (FFR) based on angiography without use of a pressure wire. The ability to predict post-PCI FFR using residual QFR after virtual stenting (pre-PCI), and using QFR (post-PCI) remains unknown. We sought to evaluate the correlation and diagnosis accuracy of residual QFR and post-PCI QFR to predict post-PCI FFR.

Methods

From the DOCTORS (Does Optical Coherence Tomography Optimize Results of Stenting) study population, we blindly analyzed the following from angiography, and compared them to post-PCI FFR: pre-PCI residual contrast QFR (cQFR) and fixed QFR (fQFR), and post-PCI cQFR and fQFR.

Results

93 post-PCI QFR measurements and 84 residual QFR measurements were compared to post-PCI FFR measurements in 93 patients. Compared to the post-PCI FFR mean value of 0.92±0.05, mean values of residual cQFR, residual fQFR, post-PCI cQFR and post-PCI fQFR were, respectively: 0.94±0.05, 0.93±0.05, 0.93±0.06 and 0.93±0.05 (p values >0.05 for all pairs except for residual cQFR versus FFR (p=0.01)). Pearson correlation coefficients of residual cQFR, residual fQFR, post-PCI cQFR and post-PCI fQFR compared with post-PCI FFR were, respectively: 0.62, (95% CI: 0.46–0.73); 0.61, (95% CI: 0.45–0.73); 0.75, (95% CI: 0.64–0.83) and 0.73, (95% CI: 0.62–0.81). Area under the curves for these indices with a post-PCI FFR cutoff value of 0.90 were, respectively: 0.79, 0.78, 0.85 and 0.84.

Conclusions

cQFR and fQFR correlated well and had similar diagnostic performance. Pre-PCI QFR analysis with virtual PCI, and post-PCI QFR analysis, correlated well with post-PCI FFR, and had similar diagnostic accuracy. Further studies are needed to prospectively validate a QFR-guided PCI strategy.

A phase 2 randomized trial to evaluate the impact of a supervised exercise program on cardiotoxicity at 3 months in patients with HER2 overexpressing breast cancer undergoing adjuvant treatment by trastuzumab: design of the CARDAPAC study

Background

The overexpression of human epidermal growth factor receptor-2 (HER2) in breast cancer is a poor prognosis. Trastuzumab improves overall survival but is associated with cardiotoxicity, especially a decline in left ventricular ejection fraction (LVEF). In addition, chemotherapy and radiotherapy increase fatigue and pain, decrease physical capacity and health-related quality of life. To date, no study has evaluated the benefits of physical activity on the side effects of treatment in patients with HER2 positive breast cancer. The aim of this study is to evaluate the impact of 3 months’ exercise intervention on myocardial function and in particular on the rate of cardiotoxicity.

Methods

This multicenter, randomized clinical trial will include 112 patients treated by adjuvant trastuzumab for HER2 positive breast cancer to investigate the effects of a 3 months’ supervised exercise program (intermittent exercise, combining moderate and high intensities; 55 minutes duration, 3 times per week), on the rate of cardiotoxicity [defined by either a decrease of the LVEF under 50% or an absolute drop of LVEF of 10%] between baseline and at 3 months and on strength, aerobic capacity, metabolic, inflammatory and hormonal parameters. Health-related quality of life, fatigue, pain and level of physical activity will also be assessed. Participants are randomly allocated to one of the two groups (“training group” vs “standard oncological care”). Performance-based and self-reported outcomes are assessed at baseline, at the end of supervised exercise program and at six months follow-up.

Discussion

Although physical exercise is recommended to reduce the side effects of adjuvant treatments in breast cancer patients, no randomized study has been conducted to assess the benefits of a physical training program in patients with HER2 overexpressing breast cancer. Cardiac toxicity of trastuzumab may be minimized with an exercise program combining high and moderate intensities. This type of program may be safe, feasible and effective but also increase cardiorespiratory fitness and improve health-related quality of life. If these benefits are confirmed, this exercise intervention could be systematically proposed to patients during the course of treatment by trastuzumab in addition to standard oncological care.

Trial registration

National Clinical Trials Number (NCT02433067); Registration 28 april 2015.

A phase II-III, multicenter, randomized, open study evaluating the feasibility and efficacy of a supervised home-based standard physical exercise program for metastatic cancer patients receiving oral targeted therapy: The UNICANCER SdS 01 QUALIOR study (ID-RCB: 2015-A01922-47)

TPS10126

Background: Fatigue is a frequent side effect with oral targeted therapies (OTT). Physical activity has been reported to improve fatigue and quality of life (QoL). However, few studies focused on metastatic cancer patients and mainly among patients treated with chemotherapy. Furthermore, recent guidelines recommend evaluation and optimization of standardized exercise programs. The aim of our study is to evaluate home-based standard physical exercise program (SPEP) for metastatic cancer patients treated with OTT. Methods: This phase II-III study will randomize (2:1) patients starting first-line OTT for metastatic cancer between an individualized SPEP supervised by a personal coach, and recommended physical exercises via a booklet. Eligible patients will have received ≤2 lines of metastatic chemotherapy, ECOG PS ≤2, controlled pain (VAS < 3/10), and life expectancy ≥3 months. The phase II part (120 patients) will evaluate the feasibility of a 3-month SPEP using the rate of patients performing ≥50% of SPEP (2-stage Fleming: one-sided α = 5%; β = 85%). An interim analysis is planned after the phase II. The phase III will compare the efficacy of an SPEP as opposed to recommendations to reduce fatigue and/or improve physical well-being (PWB) dimensions of QoL (evaluated with FACT-G and FACT-F questionnaires). To show a difference of ≥5 points in PWB and 2.5 for fatigue (α = 2.5%; β = 80%), 312 patients are required in the phase III trial. . Secondary objectives include: PFS, OS, other dimensions of QoL, tolerability and observance of OTT, change in body composition, physical benefits, and a medico-economic study. The SPEP was developed by specialized coaches involved in physical activity and cancer. The study has Ethic committee approval and accrual is planned in 18 French centers in April 2017, for 30 months. This is the first randomized trial dedicated to patients with metastatic cancer treated with OTT evaluating the feasibility and the efficacy of a well design home based SPEP on fatigue and physical well-being.

[Prevalence and management of pain in patients with metastatic cancer in Franche-Comté]

INTRODUCTION

Pain management is a major public health problem, especially in oncology. In order to assess professional practice, the IRFC-FC conducted a survey amongst patients with metastatic osteophilic solid tumor in Franche-Comté. The aims were to assess the pain prevalence, and its characteristics, its management and its impact on patients' quality of life in patients in pain.

METHODS

An observational, prospective and multicenter survey was conducted using a self-report questionnaire. Patients with metastatic breast or prostate cancer managed in 5 day-hospitals of the IRFC-FC over a period of three months were included.

RESULTS

Two hundred thirty-three questionnaires were analyzed. Pain prevalence rate was 48.5%. Three quarters of patients in pain had chronic background pain, moderate to severe, with or without breakthrough pain. Considering their pain intensity and their analgesic therapy, 42.0% of patients seem to have an inadequate treatment. Eighty-five percent of treated patients reported to be compliant and felt that their pain was well managed despite a strong impact on their quality of life.

CONCLUSION

The setting of a specific clinical pathway is essential to secure the standardized, optimal and efficient management of patients in pain. The assessment of patient satisfaction and quality of life must be integrated in clinical practice to identify patients in pain for which the treatment is inappropriate.