POS0040-HPR PATIENT PERCEPTIONS OF IMPACT OF GLUCOCORTICOID THERAPY IN THE RHEUMATIC DISEASES: INTERNATIONAL DEVELOPMENT OF A TREATMENT-SPECIFIC PATIENT REPORTED OUTCOME MEASURE

Background

Glucocorticoids (GCs) are a key treatment for inflammatory rheumatic diseases, but they cause a wide range of adverse side-effects which are of concern both to patients and clinicians.

Objectives

The objective of this study was to explore the impact of GC therapy on health-related quality of life (HRQoL) during treatment for rheumatic diseases, as a basis for development of a Patient-Reported Outcome Measure (PROM) to be used in clinical trials and practice.

Methods

Patients from the UK, USA and Australia who were treated with GCs in the last two years for a rheumatic condition were invited to take part in semi-structured qualitative interviews. Purposive sampling was used to include participants with a range of demographic and disease features. A steering committee of patient research partners, clinicians and methodologists devised an initial conceptual framework, which informed interview prompts and cues. Interviews were carried out by experienced qualitative researchers who encouraged participants to tell their stories and talk about the effects, both adverse and beneficial, of their experiences and perceptions of treatment with GCs, to identify salient physical and psychological symptoms and aspects of HRQoL. The interview data were organised using NVivo, and inductive analysis identified initial themes and domains. Candidate questionnaire items were developed and refined using cognitive interviewing, linguistic assessment, and input from patient research partners.

Results

Sixty semi-structured qualitative interviews were conducted (UK n=34, USA n=10, Australia n=16). Mean participant age was 58 years; 39 (66.1%) were female. Purposive sampling of participants provided a broad range of demographic features, GC dosages and inflammatory rheumatic conditions, with 27% having connective tissue disease, 25% inflammatory arthritis, 30% systemic vasculitis and 16% other rheumatic conditions.

Initial domains were developed to identify key themes relating to treatment using GCs and their impact on HRQoL; see Figure 1.

Figure 1.

Steroid PRO Initial Themes

A long-list of 134 initial candidate questionnaire items was developed from the individual themes. These items were reviewed by a qualitative working group of patient research partners, researchers and clinicians to reduce duplication and ambiguity of items. The resulting 62 items were tested and refined by piloting with patient research partners, iterative rounds of cognitive interviews with patients with a range of rheumatic conditions from the UK, USA and Australia, and a linguistic translatability assessment, to define a draft questionnaire of 40 items.

Conclusion

This international qualitative study underpins the development of candidate items for a treatment-specific PROM for patients with rheumatic diseases. The draft questionnaire is currently being tested in an online large-scale survey to determine the final scale structure and measurement properties using Rasch analysis, factor analysis, test-retest, comparison with EQ5D, and known groups analysis.

Disclosure of Interests

Susan Bridgewater Grant/research support from: Vifor Pharma, Michael A Shepherd Grant/research support from: Vifor Pharma, Jill Dawson: None declared, Pamela Richards: None declared, Christine Silverthorne: None declared, Mwidimi Ndosi: None declared, Celia Almeida: None declared, Rachel J Black: None declared, Jonathan T.L. Cheah: None declared, Emma Dures: None declared, Nilasha Ghosh: None declared, Elizabeth A Hoon: None declared, Suellen Lyne: None declared, Iris Navarro-Millan Consultant of: Honorarium on Swedish Orpham Biovitrum (SOBI) advisory board 2021, Diyu Pearce-Fisher: None declared, Carlee Ruediger: None declared, Joanna Tieu: None declared, Kevin Yip: None declared, Sarah Mackie: None declared, Susan Goodman: None declared, Catherine Hill: None declared, Joanna Robson Speakers bureau: EULAR Symposium 2021 for Vifor Pharma, Consultant of: Honorarium for Vifor Pharma advisory board 2021, Grant/research support from: Vifor Pharma 2020-2022

Concurrent thyrolipomatosis and thymolipoma in a patient with myasthenia gravis: a case report and review of the literature

We present a case of a man with a background of myasthenia gravis who presented with a neck lump, which was diagnosed as thyrolipomatosis in continuity with a very large thymolipoma. Following removal of these lesions, the patient's myaesthenic symptoms improved. While thymolipomas are often seen in the context of myasthenia gravis, thyrolipomatosis is a rare entity and to our knowledge the concurrent finding of both lesions with myasthenia gravis has never been reported. We highlight the important imaging features of both entities and the clinical importance of recognising them.

POS0158-HPR UNDERSTANDING NURSE-LED CARE IN EARLY RA: INTERVIEW STUDY WITH RHEUMATOLOGY NURSE SPECIALISTS

Background:

Nurse-led care in early RA is not well defined in the literature and the current recommendations.

Objectives:

This study aimed to develop an understanding of what comprises nurse-led care in early RA from the perspective of rheumatology nurse specialists.

Methods:

This was a qualitative study using semi-structured telephone interviews with rheumatology nurse specialists in England (Summer 2020). Interviews were audio-recorded, transcribed verbatim and analysed using inductive thematic analysis.[1]

Results:

Sixteen nurses were recruited and interviews lasted between 30 to 60 minutes. Seven themes were identified.

Early disease management

Care was characterised by evidence-based RA management provided by experienced nurse specialists with a high degree of autonomy, in the context of a rheumatology multidisciplinary team. The aims of care were to: start treatment, keep in treatment, educate and support.

’So treat to target...escalating treatment as necessary, and addressing any concerns that the patients might have’ (CNS14)

Addressing psychosocial needs

Patients with early RA experience shock, fear, anger, grief and denial while feeling unwell with pain and fatigue. Nurses use a holistic, person-centred and empathetic approach to address psychosocial needs, building a working relationship, listening and creating trust.

’Because it all relates, and if they’re stressed because they’re not coping at work, then their arthritis isn’t going to be so good. So everything relates to one another really’ (CNS06)

Monitoring treatment, disease impact and patient outcomes

Nurses monitor disease activity and disease impact using validated outcome measures and by asking questions during the consultation. Good outcomes are disease control, managing disease impact, medication and side effects, wellbeing and keeping in work.

’When you get them stable, when you get them into remission, when they’re happy, when they’re feeling well, I think there’s lots of ways you can measure that’… (CNS13)

Coordinating care, referring and signposting

Nurses coordinate care, refer to other health professionals and signpost patients to relevant services and charities. Lack of access to psychology expertise was highlighted.

‘And whilst most of us have got some degree of understanding of…self management, or psychology…we’re not psychologists’ (CNS02)

Providing a ‘lifeline’

Nurse-led telephone advice services provide a ‘lifeline’ for patients. If patients struggle, they can call and speak with a specialist who knows them and their RA well.

’The advice line has been a lifeline to them, to be able to speak to someone, to be able to get a response quickly to their questions, they feel very well supported, they know that they can always call us’ (CNS16)

Service evaluation and auditing

The individual clinics are reviewed regularly. Patients are asked for feedback on their experience of appointments, if their needs were met and about changes to the service.

...‘It’s really important to ask them initially what they expect to have from the consultation...We’ve always had really good feedback in general’… (CNS02)

COVID-19 challenges and opportunities

The pandemic caused major disruptions to the services, prohibiting most face-to-face consultations which was an essential aspect of clinical assessments. Despite the challenges imposed by the pandemic, the services adapted fast, using telephone, video clinics and digital solutions, which streamlined procedures and improved documentation and communication.

‘I do have to rely on them telling me what’s going on, because I can’t see it at the moment’ (CNS14)

’With Covid we’re doing it over the telephone, and we’re getting them to watch the video [injection tutorial] before we have the appointment with them’ (CNS04)

Conclusion:

Nurse-led care in early arthritis is a specialist service, addressing complex needs of patients, using evidence based and person-centred approaches. Innovation and service improvement are seen as part of the role.

References:

[1]Braun V, Clarke V. Successful Qualitative Research. First edition. London: SAGE 2013.

Disclosure of Interests:

None declared

AB0834 DEVELOPMENT OF A CONCEPTUAL FRAMEWORK FOR A PATIENT REPORTED OUTCOME MEASURE TO CAPTURE PATIENTS’ PERCEPTIONS OF GLUCOCORTICOID THERAPY DURING TREATMENT FOR RHEUMATIC DISEASES

Background:

Glucocorticoids (GCs) are a key treatment for the autoimmune rheumatic diseases; however, they produce numerous physical and psychological side effects.1 The Outcome Measures in Rheumatology (OMERACT) Glucocorticoid Working Group have identified that there are no Patient Reported Outcome Measures (PROMs) for assessing the impact of systemic GC therapy across multiple rheumatic diseases from the patient’s perspective.2,3

Objectives:

The aim is to explore the impact of GCs on the symptoms and health-related quality of life of adults with rheumatic inflammatory diseases, to inform items for inclusion in a PROM. Key considerations will include patient perceptions of GC therapy at diagnosis and over the course of treatment, for use in future randomised controlled trials or in clinical practice.

Methods:

An international steering committee comprising researchers, rheumatology clinicians, methodologists and patient partners in the UK, Australia and USA developed an initial conceptual framework informed by a review of the literature. Semi-structured interviews were conducted in each country with patients who had an autoimmune rheumatic disease and had received GC therapy. The interviews explored salient aspects of health-related quality of life associated with being treated with GCs.

Results:

Interviews have been completed in three continents with patients who had a range of demographic features, rheumatological conditions and duration and dosage of GC therapy. Figure 1 shows the initial conceptual framework for developing the GC PROM (Steroid PRO).

Figure 1.

Conclusion:

This conceptual framework will act as an evolving guide in the development of a PROM for assessing patients’ perspectives of systemic glucocorticoid therapy. Future work will include inductive analysis of qualitative transcripts to inform candidate questionnaire items, cognitive interviewing, linguistic translatability assessment, and an international validation survey to define the final PROM questionnaire and its measurement properties.

References:

[1]Cheah JTL, Robson JC, Black RJ, et al. The patient’s perspective of the adverse effects of glucocorticoid use: A systematic review of quantitative and qualitative studies. From an OMERACT working group. Semin Arthritis Rheum. 2020 Oct; 50(5):996-1005.

[2]Black RJ, Robson JC, Goodman SM, et al. A Patient-reported Outcome Measure for Effect of Glucocorticoid Therapy in Adults with Inflammatory Diseases Is Needed: Report from the OMERACT 2016 Special Interest Group. J Rheumatol. 2017; 44(11):1754-8.

[3]Cheah JTL, Black RJ, Robson JC, et al. Toward a Core Domain Set for Glucocorticoid Impact in Inflammatory Rheumatic Diseases: The OMERACT 2018 Glucocorticoid Impact Working Group. J Rheumatol. 2019; 46(9):1179-1182.

Disclosure of Interests:

Susan Bridgewater Grant/research support from: Grant from Vifor Pharma for an independent investigator-led study to develop a PRO for steroids, Jill Dawson: None declared, Mwidimi Ndosi: None declared, Rachel J Black: None declared, Jonathan T.L. Cheah: None declared, Emma Dures: None declared, Nilasha Ghosh: None declared, Elizabeth A Hoon: None declared, Iris Navarro-Millan Consultant of: Received consultant fees from SOBI, Diyu Pearce-Fisher: None declared, Pamela Richards: None declared, Carlee Ruediger: None declared, Christine Silverthorne: None declared, Joanna Tieu Grant/research support from: Vifor Pharma, Sarah Mackie Consultant of: Consultancy on behalf of institution for Roche/Chugai, Sanofi, AbbVie and AstraZeneca, Grant/research support from: Educational grant from Roche to attend EULAR2019, Susan Goodman: None declared, Catherine Hill: None declared, Joanna Robson Speakers bureau: Vifor Pharma for educational webinar, Grant/research support from: Grant from Vifor Pharma for an independent investigator-led study to develop a PRO for steroids

Bridging the age gap in breast cancer: cluster randomized trial of two decision support interventions for older women with operable breast cancer on quality of life, survival, decision quality, and treatment choices

BACKGROUND

Rates of surgery and adjuvant therapy for breast cancer vary widely between breast units. This may contribute to differences in survival. This cluster RCT evaluated the impact of decision support interventions (DESIs) for older women with breast cancer, to ascertain whether DESIs influenced quality of life, survival, decision quality, and treatment choice.

METHODS

A multicentre cluster RCT compared the use of two DESIs against usual care in treatment decision-making in older women (aged at least ≥70 years) with breast cancer. Each DESI comprised an online algorithm, booklet, and brief decision aid to inform choices between surgery plus adjuvant endocrine therapy versus primary endocrine therapy, and adjuvant chemotherapy versus no chemotherapy. The primary outcome was quality of life. Secondary outcomes included decision quality measures, survival, and treatment choice.

RESULTS

A total of 46 breast units were randomized (21 intervention, 25 usual care), recruiting 1339 women (670 intervention, 669 usual care). There was no significant difference in global quality of life at 6 months after the baseline assessment on intention-to-treat analysis (difference -0.20, 95 per cent confidence interval (C.I.) -2.69 to 2.29; P = 0.900). In women offered a choice of primary endocrine therapy versus surgery plus endocrine therapy, knowledge about treatments was greater in the intervention arm (94 versus 74 per cent; P = 0.003). Treatment choice was altered, with a primary endocrine therapy rate among women with oestrogen receptor-positive disease of 21.0 per cent in the intervention versus 15.4 per cent in usual-care sites (difference 5.5 (95 per cent C.I. 1.1 to 10.0) per cent; P = 0.029). The chemotherapy rate was 10.3 per cent at intervention versus 14.8 per cent at usual-care sites (difference -4.5 (C.I. -8.0 to 0) per cent; P = 0.013). Survival was similar in both arms.

CONCLUSION

The use of DESIs in older women increases knowledge of breast cancer treatment options, facilitates shared decision-making, and alters treatment selection. Trial registration numbers: EudraCT 2015-004220-61 (https://eudract.ema.europa.eu/), ISRCTN46099296 (http://www.controlled-trials.com).

The dysbiosis of ovine foot microbiome during the development and treatment of contagious ovine digital dermatitis

BACKGROUND

Contagious Ovine Digital Dermatitis (CODD) is an emerging and common infectious foot disease of sheep which causes severe welfare and economic problems for the sheep industry. The aetiology of the disease is not fully understood and control of the disease is problematic. The aim of this study was to investigate the polybacterial aetiopathogenesis of CODD and the effects of antibiotic treatment, in a longitudinal study of an experimentally induced disease outbreak using a 16S rRNA gene amplicon sequencing approach.

RESULTS

CODD was induced in 15/30 experimental sheep. During the development of CODD three distinct phenotypic lesion stages were observed. These were an initial interdigital dermatitis (ID) lesion, followed by a footrot (FR) lesion, then finally a CODD lesion. Distinct microbiota were observed for each lesion in terms of microbial diversity, clustering and composition. Porphyromonadaceae, Family XI, Veillonellaceae and Fusobacteriaceae were significantly associated with the diseased feet. Veillonellaceae and Fusobacteriaceae were most associated with the earlier stages of ID and footrot rather than CODD. Following antibiotic treatment of the sheep, the foot microbiota showed a strong tendency to return to the composition of the healthy state. The microbiota composition of CODD lesions collected by swab and biopsy methods were different. In particular, the Spirochaetaceae family were more abundant in samples collected by the biopsy method, suggesting that these bacteria are present in deeper tissues of the diseased foot.

CONCLUSION

In this study, CODD presented as part of a spectrum of poly-bacterial foot disease strongly associated with bacterial families Porphyromonadaceae, Family XI (a family in Clostridiales also known as Clostridium cluster XI), Veillonellaceae and Fusobacteriaceae which are predominately Gram-negative anaerobes. Following antibiotic treatment, the microbiome showed a strong tendency to return to the composition of the healthy state. The composition of the healthy foot microbiome does not influence susceptibility to CODD. Based on the data presented here and that CODD appears to be the severest end stage of sheep infectious foot disease lesions, better control of the initial ID and FR lesions would enable better control of CODD and enable better animal welfare.

Bridging the Age Gap: a prognostic model that predicts survival and aids in primary treatment decisions for older women with oestrogen receptor-positive early breast cancer

BACKGROUND

A prognostic model was developed and validated using cancer registry data. This underpins an online decision support tool, informing primary treatment choice for women aged 70 years or older with hormone receptor-positive early breast cancer.

METHODS

Data from women diagnosed between 2002 and 2010 in the English Northern and Yorkshire and West Midlands regions were used to develop the model. Primary treatment options of surgery with adjuvant endocrine therapy or primary endocrine therapy were compared. Models predicting the hazard of breast cancer-specific mortality and hazard of other-cause mortality were combined to derive survival probabilities. The model was validated externally using data from the Eastern Cancer Registration and Information Centre.

RESULTS

The model was developed using data from 23 842 women, and validated externally on a data set from 14 526 patients. The overall model calibration was good. At 2 and 5 years, predicted mortality from breast cancer and other causes differed from the observed rate by less than 1 per cent. At 5 years, there were slight overpredictions in breast cancer mortality (2629 predicted versus 2556 observed deaths; P = 0·142) and mortality from all causes (6399 versus 6320 respectively; P = 0·583). The discrepancy varied between subgroups. Model discrimination was 0·75 or above for all mortality measures.

CONCLUSION

A prognostic model for older women with oestrogen receptor-positive early breast cancer was developed and validated in the present study. This forms a basis for an online decision support tool (https://agegap.shef.ac.uk/).

SAT0643-HPR NURSE-LED CARE FROM THE PERSPECTIVE OF PEOPLE WITH EARLY RHEUMATOID ARTHRITIS: A QUALITATIVE SYSTEMATIC REVIEW

Background:

Nurse-led care has been shown to be clinically effective and cost effective in rheumatoid arthritis (RA) but the role of the nurse in early RA is not well defined. Evidence for processes of care in RA is limited and it is not known how well rheumatology nurse-led clinics meet care needs of people with early RA.

Objectives:

The aim of this study was to develop an understanding of rheumatology nurse-led care from the perspective of people with early RA.

Methods:

A qualitative systematic review was conducted. The review protocol is published in the International prospective register of systematic reviews.

In March 2019, the following databases were searched: MEDLINE, EMBASE, CINAHL, PsycINFO and OpenGrey. Due to lack of studies in early RA this review included adults with early and established inflammatory arthritis, qualitative studies with data on patients’ perspectives of nurse-led care, published in peer-reviewed journals in English between 2010 and 2019. Two reviewers screened titles, abstracts and full texts. Data were extracted and managed in tables. Joanna Briggs Institute Critical Appraisal Checklist was used for quality assessment of the included studies. A thematic synthesis was undertaken using the framework of Thomas and Harden.1

Results:

The search identified 1034 records. After screening and assessing for eligibility, 8 qualitative studies were included in the review (133 patients), 2 studies included people with early RA. Three main themes were identified (Figure 1).

Figure 1.

Themes of nurse-led care from the perspective of people with RA

Providing knowledge and skill. This theme delineated rheumatology nursing as providing professional expertise in the planning and delivery of care. The rheumatology nurse-led service included easy access via telephone helpline, consultations with the clinical nurse specialist for assessment of disease activity and care needs, planning of care, disease information and education, supporting self-management, and referral to rheumatologist and the multi-disciplinary team. People with RA highly valued the nurse expertise and specialist knowledge provided at nurse-led clinics.‘She was very good at informing me, so I have only praise for this ... because I have never had it like this before’. (Person with early RA).

Using a person-centred approach.This theme showed nurse-led care using a person-centred approach combined with empathy and good communication skills, which created a good therapeutic environment. People with RA appreciated the person-centeredness, empathy and involvement of the nurse. ‘She is very sensitive. She can see if I am feeling bad and comes straight to me and asks: “How are you today?” ...You are treated and taken seriously’. (Person with early RA).

Meeting patients‘ care needs. This theme presented nurse-led care as creating a sense of being empowered and psychologically supported in the management of RA and its impact. Nurse-led care made people with RA feel cared for, secure and confident. It added value to rheumatology care and made care complete.‘The thought of sticking a needle into my own stomach... it felt a bit like I would never manage to do that. However, they have been absolutely wonderful here ... and now I can do it myself’. (Person with early RA).

Conclusion:

Nurse-led care for people with RA is characterised by provision of rheumatology expertise using a person-centred approach, and patients‘ holistic care needs are being met. This study found a dearth of literature on perceptions of nurse-led care in people with early RA, which highlights the need for further research in this population.

References:

[1]Thomas J, Harden A. Methods for the thematic synthesis of qualitative research in systematic reviews.BMC Med Res Methodol2008; 8: 45.

Disclosure of Interests:

Anne-Marie Tetsche Sweeney: None declared, Candy McCabe: None declared, Caroline Flurey: None declared, Joanna Robson: None declared, Alice Berry: None declared, Pamela Richards: None declared, Mwidimi Ndosi Grant/research support from: Bristol Myers Squibb, Consultant of: Janssen, Pfizer

Analysis of Milk-Based Infant Formula. Phase IV. Iodide, Linoleic Acid, and Vitamins D and K: U.S. Food and Drug Administration-Infant Formula Council: Collaborative Study

In 1982, the U.S. Food and Drug Administration, the Infant Formula Council and its member companies, contract laboratories, and other government laboratories began a study of analytical methods for the nutrients listed in the Infant Formula Act of 1980. Phases I, II, III, and V have been completed. The present report provides data on Phase IV, in which 13 laboratories collaboratively studied an ion-selective electrode method for analyzing iodide, a gas chromatographic method for linoleic acid, and 2 liquid chromatographic (LC) methods each for vitamins D and K. Data were insufficient to evaluate one each of the LC methods studied for vitamins K and D. The relative standard deviations (RSD) are sufficient for the nutrient levels found in infant formula. RSDs (%) for repeatability (RSDr) and reproducibility (RSDR), respectively, were as follows: iodide, 4.0-11.4 and 13.5-18.2; linoleic acid, 1.0-1.6 and 3.5-5.1; vitamin K1, 3.2-16.0 and 6.2-19.4; and vitamin D3,4.2 and 35.0. The recommendation to adopt the method for vitamin D was supported by the results of a ministudy. All laboratories were capable of using these methods with little training. The methods for determination of iodide, linoleic acid, and vitamins D and K in ready-to-feed milkbased infant formula have been adopted first action by AOAC International.

Adjuvant Chemotherapy for Breast Cancer in Older Women: An Analysis of Retrospective English Cancer Registration Data

AIMS

Adjuvant chemotherapy is recommended as a treatment for women with high recurrence risk early breast cancer. Older women are less likely to receive chemotherapy than younger women. This study investigated the impact of chemotherapy on breast cancer-specific survival in women aged 70 + years using English registry data.

MATERIALS AND METHODS

Cancer registration data were obtained from two English regions from 2002 to 2012 (n = 29 728). The impact of patient-level characteristics on the probability of receiving adjuvant chemotherapy was explored using logistic regression. Survival modelling was undertaken to show the effect of chemotherapy and age/health status on breast cancer-specific survival. Missing data were handled using multiple imputation.

RESULTS

In total, 11 735 surgically treated early breast cancer patients were identified. Use of adjuvant chemotherapy has increased over time. Younger age at diagnosis, increased nodal involvement, tumour size and grade, oestrogen receptor-negative or human epidermal growth factor receptor 2-positive disease were all associated with increased probability of receiving chemotherapy. Chemotherapy was associated with a significant reduction in the hazard of breast cancer-specific mortality in women with high risk cancer, after adjusting for patient-level characteristics (hazard ratio 0.74, 95% confidence interval 0.67-0.81).

DISCUSSION

Chemotherapy is associated with an improved breast cancer-specific survival in older women with early breast cancer at high risk of recurrence . Lower rates of chemotherapy use in older women may, therefore, contribute to inferior cancer outcomes. Decisions on potential benefits for individual patients should be made on the basis of life expectancy, treatment tolerance and patient preference.

Instant 99mTc Compounds

The full potential use of technetium has not been achieved despite its ideal physical properties, dosimetry and availability because of the complex preparations required for 99mTc radiopharmaceuticals. One of the goals of our work is to develop techniques for the preparation of high-purity 99mTc compounds which can be easily prepared, ideally by adding pertechnetate to a prepared solution.

The use of stannous ion as reducing agent for technetium makes it possible to obtain such one-step, high-purity products. All non-radioactive components can be premixed in a single vial before addition of the radioactive pertechnetate. No final pH adjustment, further chemical manipulation or purification is required.

Procedures for two instantly labeled compounds have been developed to date: 99mTc DTPA and 99mTc HSA. The 99mTc DTPA is prepared by adding pertechnetate to a previously prepared solution of stannous ion and CaNa3 DTPA which has been stored at pH 4. The 99mTc HSA is prepared by adding pertechnetate to a solution of stannous ion and HSA. The parametric variations and analytical techniques involved in formulating these procedures are described. It appears that development of kits for other biologically interesting compounds may be possible using similar procedures.

A Comparison of the Cyclic Anhydride and Mixed Anhydride Methods for 111In-DTPA Chelation to Monoclonal Antibodies

The cyclic anhydride (CA) and the mixed anhydride (MA) of DTPA were synthesized and used to chelate 111In to an antimelanoma monoclonal antibody. The CA and MA methods showed mean labeling efficiencies of 25.7 and 20.5%, respectively (p = NS). The binding efficiency of labeled antibody to human melanoma cells in tissue culture also was similar (x̄ = 52 and 50%, respectively, p = NS), as was tumor uptake in nude mice at 96 hrs post-injection (16%-CA vs 12%-MA). The method required less complicated chemical syntheses, much less preparation time, and the product was stable over a much longer period. The results suggest that the CA method is preferable for bifunctional chelate labeling of monoclonal antibodies with 111In-DTPA.

Abstract P4-22-04: A randomized, double-blind, phase 2 study of ruxolitinib (RUX) or placebo (PBO) in combination with capecitabine (CAPE) in patients (pts) with advanced HER2-negative breast cancer (ABC) and elevated C-reactive protein (CRP), a marker of systemic inflammation

Background: Systemic inflammation is associated with poor prognosis in pts with ABC. The JAK/STAT pathway is a key regulator of inflammatory signaling, associated with tumorigenesis, cell survival, and progression. We evaluated the efficacy and safety of RUX, a JAK1/JAK2 inhibitor, plus CAPE in pts with HER2-negative ABC and high systemic inflammation defined by the modified Glasgow Prognostic Score (mGPS). Methods: In this double-blind phase 2 trial, pts were randomized 1:1 to 21 day cycles of RUX+CAPE or PBO+CAPE: RUX 15 mg or PBO PO BID for 21 d; CAPE 1000 mg/m2 PO BID for 14 d. Key inclusion criteria were systemic inflammation by mGPS of 1 or 2 (ie, CRP >10 mg/L), ECOG performance status ≤2, ≤2 prior chemotherapy regimens, and no prior CAPE. The primary endpoint was overall survival (OS); key secondary endpoints were progression-free survival (PFS), objective response rate (ORR; complete [CR] + partial response [PR]) per RECIST v1.1, clinical benefit rate (CBR; CR + PR + stable disease for ≥6 mo), duration of response, and safety. Treatment differences in OS and PFS were analyzed by the log-rank test; HRs and CIs were analyzed by the Cox proportional hazards model. Results: Baseline characteristics were similar between pts randomized to RUX+CAPE (n=76) vs PBO+CAPE (n=73): mGPS status (1, 82.9% vs 83.6%), hormone receptor (HR) status (positive, 67.1% vs 63.0%), and number of prior chemotherapy regimens for ABC (0, 50.0% vs 50.7%; 1, 38.2% vs 34.2%; 2, 9.2% vs 13.7%). Median treatment durations were 85 d with RUX in the RUX+CAPE group and 65 d with PBO in the PBO+CAPE group. Median OS was 11.2 mo with RUX+CAPE vs 10.9 mo with PBO+CAPE (HR, 0.932; 95% CI, 0.59–1.46; P=0.762). Median OS was 6.1 mo with RUX+CAPE vs 5.5 mo with PBO+CAPE in HR-negative pts and 11.7 mo and 12.2 mo in HR-positive pts. Median PFS was 4.5 mo with RUX+CAPE and 2.5 mo with PBO+CAPE (HR, 0.737; 95% CI, 0.49–1.12; P=0.151). Median PFS was 2.1 mo with RUX+CAPE vs 2.2 mo with PBO+CAPE in HR-negative pts and 6.1 mo and 4.1 mo in HR-positive pts. ORRs were 28.9% and 13.7% (P=0.024) in the RUX+CAPE and PBO+CAPE arms, respectively. The CBRs were 13.2% and 6.8%, respectively (P=0.278). Worsening of hematologic toxicity was higher and rates of grade 3/4 palmar-plantar erythrodysethesia (PPE) were lower (1.4% vs 12.7%, respectively) with RUX+CAPE (Table).

Safety RUX+CAPE (n=71)PBO+CAPE (n=71)%All-GradeGrade 3/4All-GradeGrade 3/4Nonhematologic Adverse Event*Fatigue56.35.643.74.2Nausea54.98.549.35.6Diarrhea47.98.526.82.8PPE46.51.438.012.7Vomiting38.05.629.64.2Hypokalemia15.58.57.02.8Worsening of Hematologic Toxicity†Anemia80.323.956.37.0Lymphopenia40.815.545.112.7Neutropenia39.411.322.52.8Thrombocytopenia39.411.315.51.4*Most common all-grade (≥35%) or grade 3/4 (≥5%) events in the RUX+CAPE arm (safety group). †Laboratory abnormalities.

Conclusion: These data support the prognostic capabilities of the mGPS. The addition of RUX to CAPE for pts with ABC and high systemic inflammation was associated with an improved ORR compared with PBO+CAPE, but did not improve OS or PFS.

Citation Format: O'Shaughnessy J, DeMichele A, Ma C, Richards P, Yardley DA, Wright G, Kalinsky K, Steis R, Diab S, Kennealey G, Geschwindt R, Jiang W, Rugo H. A randomized, double-blind, phase 2 study of ruxolitinib (RUX) or placebo (PBO) in combination with capecitabine (CAPE) in patients (pts) with advanced HER2-negative breast cancer (ABC) and elevated C-reactive protein (CRP), a marker of systemic inflammation [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 P4-22-04.

Mass production of functional human pancreatic β-cells: why and how?

Diabetes (either type 1 or type 2) is due to insufficient functional β-cell mass. Research has, therefore, aimed to discover new ways to maintain or increase either β-cell mass or function. For this purpose, rodents have mainly been used as model systems and a large number of discoveries have been made. Meanwhile, although we have learned that rodent models represent powerful systems to model β-cell development, function and destruction, we realize that there are limitations when attempting to transfer the data to what is occurring in humans. Indeed, while human β-cells share many similarities with rodent β-cells, they also differ on a number of important parameters. In this context, developing ways to study human β-cell development, function and death represents an important challenge. This review will describe recent data on the development and use of convenient sources of human β-cells that should be useful tools to discover new ways to modulate functional β-cell mass in humans.

Abstract P1-14-05: Three distinct HER2 subtypes identified by BluePrint 80-gene functional subtyping predict treatment-specific response in the prospective neo-adjuvant NBRST registry

Background

Ideally classification by subtype predicts treatment response and overall outcome. BluePrint 80-gene functional molecular subtype is based on mRNA expression (as is intrinsic subtype) associated with intact translation to protein (unlike intrinsic subtype). BluePrint (BP) classifies patients into Luminal, Her2 or Basal-type. Presently subtype is approximated using conventional immunohistochemistry (IHC) and fluorescence in situ hybridization (FISH) ("conventional subtype") or assigned by gene expression profiling. The main objective of the prospective neo-adjuvant NBRST study is to compare drug sensitivity as defined by pathological Complete Response (pCR), using 80-gene functional subtype vs. conventional IHC/FISH subtyping. NBRST enrolled over 1,000 US patients between June 2011 and December 2014. In this analysis we present the results for IHC/FISH Her2-positive patients.

Methods

Here we report findings in the 260 NBRST patients who had IHC/FISH Her2+ breast cancer, according to ASCO CAP guidelines at the time of diagnosis. Treatment, including chemotherapy and HER2-targeted agents, was at the discretion of the physician adhering to NCCN approved or other peer-reviewed, established regimens over the course of the study. pCR was defined as T0/isN0. Fisher's exact test was used to compare pCR rates among IHC/FISH and functional subtypes and treatment groups.

Results

The 260 IHC/FISH Her2+ patients had median age 53 (range 23-81) and included T1-4, N0-3 tumors. Of 169 ER+/Her2+ tumors 49% were re-classified as BP Luminal, 43% as BP HER2, and 8% as BP Basal. The median ER% of ER+/Her2+/BP Luminal tumors was 93% (range 3-100), compared to 79% in ER+/Her2+/BP HER2 (range 1-91) and 8% in ER+/Her2+/BP Basal-type (range 2-99).The overall pCR rate in ER+/Her2+/BP Luminal was 17% (4% with chemo/trastuzumab; 39% chemo/trastuzumab/pertuzumab, p<0.0001) and statistically inferior (p<0.0001) to the 59% pCR rate in ER+/Her2+/BP HER2. Of 91 ER-/Her2+ tumors 74% were classified as BP HER2, 25% were re-classified BP Basal and <1% was BP Luminal. NCT pCR rates for ER-/Her2+/BP HER2 was 67% (64% with chemo/trastuzumab; 77% chemo/trastuzumab/pertuzumab, p=0.40) and significantly superior (p=0.026) to the 39% pCR rate in ER-/Her2+/BP Basal (p=0.026).

Conclusions

In the NBRST study, BP 80-gene functional subtype (based on mRNA expression and translation): 1. Re-classifies over half of all IHC/FISH ER+/Her2+ patients; 2. Predicts treatment response or resistance in Her2+ patients not segregated by conventional IHC/FISH classification and 3. Identifies ER+/Her2+ tumors that are sensitive to chemo/trastuzumab/pertuzumab but resistant to chemo/trastuzumab.

Citation Format: Whitworth P, Beitsch P, Baron P, Beatty J, Pellicane JV, Murray MK, Dul CL, Mislowsky AM, Nash CH, Richards PD, Lee LA, Stork-Sloots L, de Snoo F, Untch S, Gittleman M, Akbari S, Rotkis MC. Three distinct HER2 subtypes identified by BluePrint 80-gene functional subtyping predict treatment-specific response in the prospective neo-adjuvant NBRST registry. [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 P1-14-05.

Abstract P4-14-10: Pertuzumab overcomes chemotherapy/trastuzumab resistance in ER+/Her2+ tumors classified as luminal functional subtype by the 80-gene BluePrint assay in the prospective neo-adjuvant breast registry symphony trial (NBRST)

Background

The prospective Neo-adjuvant Breast Registry Symphony Trial (NBRST) enrolled over 1000 US patients between June 2011 and December 2014. The aim of NBRST study is to compare chemosensitivity as defined by pathological Complete Response (pCR) using the 80-gene BluePrint functional subtype profile vs. conventional IHC/FISH subtyping. Treatment was at the discretion of the physician utilizing standard NCCN regimens. Pertuzumab, a monoclonal antibody, inhibits the dimerization of HER2 with other HER receptors. Pertuzumab received US FDA approval for the neo-adjuvant treatment of HER2-positive breast cancer in September 2013. Essentially all patients with HER2 positive cancers were treated with chemotherapy + trastuzumab and after this date pertuzumab was added, creating 2 distinct groups of Her2 treated patients.

The aim of the current analysis is to compare the pCR rate of trastuzumab (H) vs trastuzumab and pertuzumab (H + P) by conventional and BluePrint functional subtype.

Methods

The current analysis includes women from the NBRST study, with histologically proven breast cancer, who received neo-adjuvant chemotherapy plus H or H + P and who provided written informed consent. Pathological assessment of Her2 was done according to ASCO CAP guidelines at the time of diagnosis. BluePrint (BP) classifies patients into Luminal, HER2 or Basal-type. pCR is defined as T0/isN0. All pCRs were verified with a de-identified copy of the surgical pathology report. Fisher's exact test was used to compare pCR rates within different subgroups.

Results

252 IHC/FISH Her2+ patients received H (166) or H + P (86). The median age was 53 (range 23-81). 8% was stage I, 68% stage II and 24% stage III. 65% were ER positive.

BP classified 55% of patients as HER2, 32% as Luminal, and 14% as Basal-type.

The pCR rates and p-values within different subgroups of clinical Her2+ patients are provided in the table below.

pCR rates and p-values within different subgroups of clinical Her2+ patients(n)H (pCR rate)H + P (pCR rate)p-valueTotal (n=252)40%59%0.005IHC/FISH Her2+/ER+ (163)30%57%0.001IHC/FISH Her2+/ER- (89)69%63%0.82BP HER2 (138)57%78%0.01BP Luminal (80)4%38%0.0002BP Basal (34)47%38%0.69

Conclusions

Addition of pertuzumab to trastuzumab significantly increased response rate in ER+/Her2+, BP HER2 and BP Luminal patients but not in ER-negative and BP Basal patients.

Pertuzumab overcame resistance to NCT/trastuzumab in a substantial proportion of the IHC/FISH Her2+/BP Luminal subgroup; indicated by a significantly increased pCR rate.

Citation Format: Peter B, Pat W, Paul B, Jennifer B, Pellicane JV, Murray MK, Dul CL, Mislowsky AM, Nash CH, Richards PD, Lee LL, Stork-Sloots L, de Snoo F, Untch S, Gittleman M, Akbari S, Rotkis MC. Pertuzumab overcomes chemotherapy/trastuzumab resistance in ER+/Her2+ tumors classified as luminal functional subtype by the 80-gene BluePrint assay in the prospective neo-adjuvant breast registry symphony trial (NBRST). [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 P4-14-10.

Abstract P4-14-29: One-third of HER2 positive patients have 80-gene luminal subtype that is resistant to chemo-trastuzumab but sensitive to chemo-trastuzumab-pertuzumab: Critical implications for the adjuvant setting from the NBRST phase 4 neoadjuvant study

Background

The phase 4 Neo-adjuvant Breast Registry Symphony Trial (NBRST) enrolled over 1,000 US patients between June 2011 and December 2014. The aim of NBRST study is to compare chemo-sensitivity as defined by pathological Complete Response (pCR) using the 80-gene BluePrint (BP) functional subtype profile vs. conventional IHC/FISH subtyping. Treatment was at the discretion of the physician utilizing standard NCCN regimens. Pertuzumab, a monoclonal antibody, inhibits the dimerization of HER2 with other HER receptors. Pertuzumab received US FDA approval for the neo-adjuvant treatment of HER2-positive breast cancer in September 2013. Essentially all patients with HER2 positive cancers were treated with chemotherapy + trastuzumab and after this date pertuzumab was added, creating 2 distinct groups of Her2-treated patients.

The aim of the current analysis is to compare the pCR rate of chemo-trastuzumab (c-t) vs chemo-trastuzumab plus pertuzumab (c-t-p) by conventional and 80-gene BP functional subtype. 80-gene BP functional subtype was derived by supervised cluster analysis for concordant mRNA and protein expression.

Methods

The current analysis includes women from the NBRST study, with histologically proven breast cancer, who received neo-adjuvant treatment, had 80-gene subtyping and provided written informed consent. Pathological assessment of HER2 was performed according to ASCO CAP guidelines at the time of diagnosis. 80-gene BluePrint (BP) classifies patients into Luminal, HER2 or Basal-type. pCR is defined as T0/isN0. All pCRs were verified with a de-identified copy of the surgical pathology report. Fisher's exact test was used to compare pCR rates within different subgroups.

Results

286 IHC/FISH HER2+ patients received c-t (175) or c-t-p (111). Of these 80-gene BP subtype classified 53% as HER2-type, 33% as Luminal-type and 14% as Basal-type. 64% were ER positive.

The pCR rates and p-values within different subgroups of clinical HER2+ patients are provided in the table below.

 c-tc-t-p (n)pCR ratep-valueTotal (n=286)41%57%0.01BP HER2 (153)58%73%0.06 BP Luminal (93) 6% 39% 0.0002BP Basal (40)45%1.0IHC/FISH HER2+/ER+ (183)31%53%0.003IHC/FISH HER2+/ER- (103)59%64%0.68

Conclusions

One-third of ASCO/CAP Her2+ patients had 80-gene BP Luminal subtype and demonstrated resistance to c-t (pCR 6%). Addition of Pertuzumab overcame resistance in this group (pCR 39%). This finding in the neoadjuvant setting suggests a substantial potential benefit in the adjuvant setting and thus an urgent need to consider treatment in at-risk patients as well as confirmatory tissue analysis from independently reported trials.

Citation Format: Beitsch P, Whitworth P, Baron P, Beatty J, Pellicane JV, Murray MK, Dul C, Mislowsky AM, Nash CH, Richards PD, Lee LA, Stork-Sloots L, de Snoo F, Untch S, Gittleman M, Akbari S, Rotkis MC. One-third of HER2 positive patients have 80-gene luminal subtype that is resistant to chemo-trastuzumab but sensitive to chemo-trastuzumab-pertuzumab: Critical implications for the adjuvant setting from the NBRST phase 4 neoadjuvant study. [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 P4-14-29.

Case-mix analysis and variation in rates of non-surgical treatment of older women with operable breast cancer

BACKGROUND

Non-surgical management of older women with oestrogen receptor (ER)-positive operable breast cancer is common in the UK, with up to 40 per cent of women aged over 70 years receiving primary endocrine therapy. Although this may be appropriate for frailer patients, for some it may result in treatment failure, contributing to the poor outcomes seen in this age group. Wide variation in the rates of non-operative management of breast cancer in older women exists across the UK. Case mix may explain some of this variation in practice.

METHODS

Data from two UK regional cancer registries were analysed to determine whether variation in treatment observed between 2002 and 2010 at hospital and clinician level persisted after adjustment for case mix. Expected case mix-adjusted surgery rates were derived by logistic regression using the variables age, proxy Charlson co-morbidity score, deprivation quintile, method of cancer detection, tumour size, stage, grade and node status.

RESULTS

Data on 17,129 women aged 70 years or more with ER-positive operable breast cancer were analysed. There was considerable variation in rates of surgery at both hospital and clinician level. Despite adjusting for case mix, this variation persisted at hospital level, although not at clinician level.

CONCLUSION

This study demonstrates variation in selection criteria for older women for operative treatment of early breast cancer, indicating that some older women may be undertreated or overtreated, and may partly explain the inferior disease outcomes in this age group. It emphasizes the urgent need for evidence-based guidelines for treatment selection criteria in older women with breast cancer.

The in vitro effects of sulfadoxine/pyrimethamine and artemether/lumefantrine on the viscoelasticity of erythrocyte membrane of healthy females

Fansidar® (sulfadoxine/pyrimethamine) and Coartem® (artemether/lumefantrine) are drugs that destroy malarial parasites and also produce free radicals which cause hemolysis of malaria-parasitized erythrocytes. This study investigated the effect of these drugs on the viscoelasticity of erythrocytes of ten healthy female subjects using the BioProfiler. The concentration for each of the two drugs were determined based on the therapeutic dose as normal, half the therapeutic dose as low and double the therapeutic dose as high. For Fansidar®, the concentrations were 0.15/0.01 mg/ml (low), 0.30/0.02 mg/ml (normal) and 0.60/0.04 mg/ml (high) based on the adult therapeutic dose of 1500/75 mg of sulfadoxine/pyrimethamine in the drug combination. For Coartem®, the concentrations were 0.03/0.19 mg/ml (low), 0.06/0.38 mg/ml (normal) and 0.12/0.76 mg/ml (high) based on the adult therapeutic dose of 320/1920 mg of artermether/lumefantrine in the drug combination. There was a statistically significant (p < 0.05) decrease in viscosity, elasticity and relaxation time with Coartem® at normal and high doses. Fansidar® also showed significant (p < 0.05) reductions in these parameters only in the high dose. This suggests that Coartem® generated significant free radicals at normal and high doses, with Fansidar® only in the high dose, resulting in increased hemolysis and ultimately reduced viscoelasticity.

Co-localisation and secretion of glucagon-like peptide 1 and peptide YY from primary cultured human L cells

AIMS/HYPOTHESIS

Targeting the secretion of gut peptides such as glucagon-like peptide 1 (GLP-1) and peptide YY (PYY) is a strategy under development for the treatment of diabetes and obesity, aiming to mimic the beneficial alterations in intestinal physiology that follow gastric bypass surgery. In vitro systems are now well established for studying the mouse enteroendocrine system, but whether these accurately model the human gut remains unclear. The aim of this study was to establish and characterise human primary intestinal cultures as a model for assessing GLP-1 and PYY secretion in vitro.

METHODS

Fresh surgical biopsies of human colon were digested with collagenase to generate primary cultures from which GLP-1 and PYY secretion were assayed in response to test stimuli. GLP-1 and PYY co-localisation were assessed by flow cytometry and immunofluorescence microscopy.

RESULTS

GLP-1 and PYY were found localised in the same cells and the same secretory vesicles in human colonic tissue samples. GLP-1 release was increased to 2.6-fold the control value by forskolin + isobutylmethylxanthine (10 μmol/l each), 2.8-fold by phorbol myristate acetate (1 μmol/l) and 1.4-fold by linoleic acid (100 μmol/l). PYY release was increased to 2.0-, 1.8- and 1.3-fold by the same stimuli, respectively. Agonists of G-protein-coupled receptor (GPR)40/120 and G-protein-coupled bile acid receptor 1 (GPBAR1) each increased GLP-1 release to 1.5-fold, but a GPR119 agonist did not significantly stimulate secretion.

CONCLUSIONS/INTERPRETATION

Primary human colonic cultures provide an in vitro model for interrogating the human enteroendocrine system, and co-secrete GLP-1 and PYY. We found no evidence of PYY-specific cells not producing GLP-1. GLP-1 secretion was enhanced by small molecule agonists of GPR40/120 and GPBAR1.

Predominant role of active versus facilitative glucose transport for glucagon-like peptide-1 secretion

AIMS/HYPOTHESIS

Several glucose-sensing pathways have been implicated in glucose-triggered secretion of glucagon-like peptide-1 (GLP-1) from intestinal L cells. One involves glucose metabolism and closure of ATP-sensitive K(+) channels, and another exploits the electrogenic nature of Na(+)-coupled glucose transporters (SGLTs). This study aimed to elucidate the role of these distinct mechanisms in glucose-stimulated GLP-1 secretion.

METHODS

Glucose uptake into L cells (either GLUTag cells or cells in primary cultures, using a new transgenic mouse model combining proglucagon promoter-driven Cre recombinase with a ROSA26tdRFP reporter) was monitored with the FLII(12)Pglu-700 μδ6 glucose sensor. Effects of pharmacological and genetic interference with SGLT1 or facilitative glucose transport (GLUT) on intracellular glucose accumulation and metabolism (measured by NAD(P)H autofluorescence), cytosolic Ca(2+) (monitored with Fura2) and GLP-1 secretion (assayed by ELISA) were assessed.

RESULTS

L cell glucose uptake was dominated by GLUT-mediated transport, being abolished by phloretin but not phloridzin. NAD(P)H autofluorescence was glucose dependent and enhanced by a glucokinase activator. In GLUTag cells, but not primary L cells, phloretin partially impaired glucose-dependent secretion, and suppressed an amplifying effect of glucose under depolarising high K(+) conditions. The key importance of SGLT1 in GLUTag and primary cells was evident from the impairment of secretion by phloridzin or Sglt1 knockdown and failure of glucose to trigger cytosolic Ca(2+) elevation in primary L cells from Sglt1 knockout mice.

CONCLUSIONS/INTERPRETATION

SGLT1 acts as the luminal glucose sensor in L cells, but intracellular glucose concentrations are largely determined by GLUT activity. Although L cell glucose metabolism depends partially on glucokinase activity, this plays only a minor role in glucose-stimulated GLP-1 secretion.

P1-12-10: Phase II Study Evaluating Lapatinib (L) in Combination with Albumin Bound Paclitaxel (ab-Pac) in Women Who Have Received 0–1 Chemotherapy Regimen for HER2 Overexpressing (HER2+) Metastatic Breast Cancer (MBC)

Background: L, a dual kinase inhibitor of epidermal growth factor receptor (EGFR) and the human epidermal growth factor receptor-2 (HER2), approved for the treatment of HER2+ MBC in combination with capecitabine following progression after trastuzumab, anthracycline, and taxane. L in combination with chemotherapy has significantly improved progression free survival in patients (pts) with HER2+ MBC. Ab-Pac is a cremophor free, albumin-bound paclitaxel approved for use in pts with MBC demonstrating superior efficacy and safety when compared to other taxanes.

Methods: Phase II study (LPT111111) evaluated the efficacy and safety of L in combination with ab-Pac in 60 pts with histologically confirmed stage IV HER2+ (IHC 3+/FISH+) invasive MBC. Pts received 0–1 prior chemotherapeutic regimen in the metastatic setting and no prior treatment with L. Prior taxane therapy permitted provided this was &gt; 12 months prior to study entry, LVEF&gt;50%, peripheral neuropathy &lt; 2, prior CNS mets permitted, and prior endocrine therapy permitted. Pts received ab-Pac (125 mg/m2 IV on Days 1, 8, 15, q28 days) plus L (1250 mg daily). Planned safety analysis of the first 5 pts prompted a protocol amendment with a 20% dose reduction for both agents due to Grade (G) 3 neutropenia and diarrhea. Subsequent pts received ab-Pac (100 mg/m2 IV on Day 1, 8, 15, q28 days) in combination with L (1000 mg daily). Pts with SD or a response continued L alone until progression. Response assessments performed every 2 cycles. The primary endpoint was overall response rate (ORR) and secondary endpoints were progression-free survival (PFS), time to response, duration of response and overall survival (OS).

Results: Here we present the final analysis of all subjects receiving at least 6 months of protocol therapy. Median age is 56 years; 45 pts (75%) received treatment as 1st line therapy and 15 (25%) as 2nd line; 57% hormone receptor positive and 43% negative; 42% received trastuzumab and 40% received a taxane in either (neo) adjuvant or metastatic setting. After a median of 5.6 months, 7% pts had a complete response, 47% a partial response and 17% had stable disease, the ORR was 53% [95% CI: 41% to 66%]. The median time to response was 7.8 wks [95% CI: 7.4 to 8.1] with a median duration of response of 48.7 wks [95% CI: 31.7 to 57.1]. The median PFS was 39.7 wks [95% CI: 34.1 to 63.9]. Duration of exposure to ab-Pac; 48% received less than 6 cycles, 30% received 6 cycles and 22% received greater than 6 cycles. Table 1 shows the most common G ≥2 treatment-related toxicities.

P3-16-18: Phase 2, Open-Label Study of EZN-2208 (PEG-SN38) in Patients with Previously Treated Metastatic Breast Cancer

Background

EZN-2208 is a water-soluble PEGylated conjugate of SN38 that results in parenteral delivery, increased solubility, higher exposure, and longer apparent half-life of SN38, as well as more profound deoxyribonucleic acid (DNA) damage and inhibition of angiogenesis. EZN-2208 results in prolonged exposure of tumors to SN38 via preferential accumulation of EZN-2208 in the tumor and prolonged release of SN38 in the blood.

Methods: This trial evaluated EZN-2208 delivered as a 1-h IV infusion weekly for 3 wks in 4-wk cycles. The primary objective was to determine the overall response rate (RR) in female patients with metastatic breast cancer (MBC) who had received prior adjuvant or metastatic therapy with either 1) anthracycline and taxane (AT) or 2) anthracycline, taxane, and capecitabine (Xeloda®) (ATX). Secondary objectives included evaluation of RR based on tumor receptor status, duration of response, progression-free survival (PFS), overall survival (OS), and safety and toxicity. Response was evaluated using RECIST (v1.1).

Results: 148 patients received EZN-2208 in the AT (n=65; median age = 56 y [31-84 y]) or ATX (n=83; median age = 55 y [36-83 y]) cohorts. All 65 patients in the AT cohort had received 0–2 lines of prior cytotoxic therapy for MBC; for the ATX cohort, 31 patients (37%) had received 0–2 prior lines of cytotoxic therapy for MBC, 50 patients (60%) had received 3–4 prior lines, and 2 patients (2%) had received 5 prior lines. Preliminary results follow; final data will be presented at the meeting. Median (range) cycles of EZN-2208 was 2.3 (0.3-14) for AT and 2 (0.3-15) for ATX. Best overall response is shown in the table. RR (PR+uPR) was 22% for AT and 10% for ATX.

Median (95% CI) time to progression was 3.8 mo (3.6−7.4) for AT and 3.3 mo (1.8−3.7) for ATX. Median (95% CI) duration of response was 4.0 mo (3.7−5.6) for AT and 5.2 mo (1.9-..) for ATX. 6-mo PFS (95% CI) was 34% (19%-50%) for AT and 19% (9%-29%) for ATX. Median PFS (95% CI) was 3.8 mo (2.7−5.6) for AT and 2.9 mo (1.83.7) for ATX. Median OS (95% CI) was 9.1 mo (6.1−12.7) for AT and 7.9 mo (6.4−12.9) for ATX. Grade 3 or 4 drug-related adverse events (&gt;10% of patients in either arm) included neutropenia (43%, 33%), diarrhea (11%, 8%), and leukopenia (11%, 6%).

Nonfreezing cold-induced injuries

Non-freezing cold injury (NFCI) is the Cinderella of thermal injuries and is a clinical syndrome that occurs when tissues are exposed to cold temperatures close to freezing point for sustained periods. NFCI is insidious in onset, often difficult to recognize and problematic to treat, and yet the condition accounts for significant morbidity in both military and civilians who work in cold conditions. Consequently recognition of those at risk, limiting their exposure and the appropriate and timely use of suitable protective equipment are essential steps in trying to reduce the impact of the condition. This review addresses the issues surrounding NFCI.

A clinical review of the management of frostbite

Frostbite is a thermal injury that can occur when temperatures drop low enough for tissue to freeze. On rewarming the tissues, an inflammatory process develops which is often associated with tissue loss. The extent of the tissue loss reflects the severity of the cold exposure and includes factors such as temperature, duration, wind chill, altitude, and systemic hypothermia. This review discusses the epidemiology, the pathophysiological processes involved, and the clinical management of frostbite injuries. Practical advice is given on both the field and hospital management and how to seek expert advice from remote situations. The review also discusses newer developments in frostbite treatment such as intra-vascular thrombolysis and adjunctive treatments such as the use of intravenous vasodilators.