Long-term occupational exposures on disability-free survival and mortality in older adults

BACKGROUND

The impact of long-term occupational exposures on health in older adults is increasingly relevant as populations age. To date, no studies have reported their impact on survival free of disability in older adults.

AIMS

We aimed to investigate the association between long-term occupational exposure and disability-free survival (DFS), all-cause mortality and cause-specific mortality in initially healthy older adults.

METHODS

We analysed data from 12 215 healthy participants in the ASPirin in Reducing Events in the Elderly (ASPREE) study whose mean age was 75 years. Their work history was collated with the 'ALOHA-plus JEM' (Job Exposure Matrix) to assign occupational exposures. The primary endpoint, DFS, was a composite measure of death, dementia or persistent physical disability. The secondary endpoint, mortality, was classified according to the underlying cause. Cox proportional hazard models were used to calculate hazard ratios and 95% confidence intervals, adjusted for confounders.

RESULTS

A total of 1835 individuals reached the DFS endpoint during the median 4.7 years follow-up period. Both ever-high and cumulative exposure to all dusts and all pesticides during a person's working years were associated with reduced DFS. Compared to no exposure, men with high exposure to dusts and pesticides had a reduced DFS. Neither of these exposures were significantly associated with all-cause mortality. Men with high occupational exposure to solvents and women exposed to dusts experienced higher all-cause and cancer-related mortality.

CONCLUSIONS

Long-term occupational exposure to all dusts and pesticides was associated with a reduced DFS and increased mortality in community-dwelling healthy older adults.

Financial Implications of Evolving Breast Cancer Radiotherapy Treatment Protocols

PURPOSE/OBJECTIVE(S)

Adjuvant radiotherapy for breast cancer represents a significant portion of radiotherapy (RT) treatments. The resource implications of evidence-based changes in treatment protocols must be defined to facilitate RT service planning. We designed a study to calculate the impact of past changes and create a model to allow prediction of costs implications for future changes.

MATERIALS/METHODS

Changes in RT treatment (shown in table 1) in the past 3 years were identified in consultation with clinical staff and by reviewing institutional treatment guidelines. Resource and infrastructure costs were calculated for each protocol. Staff time was calculated using standard time slots where known (e.g., CT simulation appointment) and estimates based on discussion with staff (e.g., time to plan whole breast RT). Cost / Gy was calculated based on Linac cost of €2.5M, 10% annual service charge over 12-year lifetime, 2.7 patients treated / hour (verified institutional metric) and standard 2Gy fraction, giving €37.72 / Gy. We did not include facilities costs nor account for differing treatment outcomes. We collected relevant data on a consecutive 6-month sample (Jan - Jun 2019) of women receiving adjuvant RT for breast cancer (n = 224). Total costs were calculated by applying costs for each protocol change to the women in this cohort eligible for the changes.

RESULTS

Protocol changes and costs are summarized in table 1. The use of DIBH for women <60 years receiving IMN RT (left and right sided) added a cost. The largest cost saving resulted from more selective tumor bed boost, a saving of €462,138. The potential impact of a 5-fraction boost for women with non-low risk DCIS was estimated.

CONCLUSION

In the cohort analyzed, identified changes in adjuvant breast radiotherapy resulted in overall savings due to updated indications for boost and the implementation of ultra-hypofractionated radiotherapy. We are now analyzing the impact of introducing simultaneous integrated boost and partial breast radiotherapy.

1005 HEALTH-RELATED QUALITY OF LIFE AND FUTURE RISK OF HEALTH OUTCOMES AMONG OLDER ADULTS LIVING IN AUSTRALIA AND THE UNITED STATES

Introduction

Poor health-related quality of life (HRQoL) is associated with higher morbidity and mortality in patient populations. However, whether HRQoL is associated with health outcomes among community-dwelling older people requires further investigation. This study aimed to examine whether HRQoL predicts cognitive decline, dementia, cardiovascular disease (CVD), and mortality in community-dwelling older people living in Australia and the United States.

Method

A cohort of 19,106 individuals from the ASPirin in Reducing Events in the Elderly (ASPREE) study, aged 65–98 years, initially free of dementia or CVD, and who completed the HRQoL 12-item short form (SF-12, version-2) at baseline (2010–2014), were followed until June 2017. The physical (PCS) and mental component scores (MCS) of SF-12 were generated using standardized norm-based method.

Results

Over a median of 4.7 years, there were 2,412 cognitive declines, 574 dementia, 922 incident CVD events, and 1,052 deaths. Using Cox proportional-hazard regression adjusted for a range of covariates, every 10-unit increase in PCS was associated with a 6% lower risk of cognitive decline, a 14% lower risk of incident CVD, and 17% lower risk of all-cause mortality, but was not associated with incident dementia. In contrast, higher MCS was only associated with a 12% and 15% lower risk of cognitive decline and dementia, respectively. Findings did not differ by sex.

Conclusion

Our study provides some of the first evidence that HRQoL can be used in combination with clinical data to identify the future risks of health outcomes among older individuals living in the community. Our findings support the decision of the Australian Commission on Safety and Quality in Health Care to incorporate the SF-12 into the annual Patient-Reported Outcome Measures (PROMs assessment.

Out-of-hospital cardiac arrest in elderly individuals

Background

Out-of-hospital cardiac arrest (OHCA) is associated with poor outcome, particularly in elderly people. Due to the shift in global demographics towards an ageing population, understanding risk factors for OHCA is essential for the development of primary prevention strategies. Thus, we aimed to identify predictors for OHCA in a large, community-dwelling cohort of elderly individuals.

Methods

We analyzed data from 11,156 participants enrolled in a randomized, placebo-controlled primary prevention trial, investigating the effect of low-dose aspirin in individuals aged 70 years or above. At baseline all participants had no prior cardiovascular disease events, dementia or major physical disability. OHCA events occurring within 5 years were identified by probabilistic data-linkage with a state-wide out-of-hospital cardiac arrest registry. Possible predictors included age, sex, anthropometric measures, conventional cardiovascular risk factors, renal function and frailty. To evaluate the association with OHCA, we performed univariable and multivariable Cox regression analyses. In exploratory analyses we also evaluated the effect of low-dose aspirin on OHCA events.

Results

In the cohort 54.7% were female and median age was 74.1 years (Interquartile Range [IQR] 71.8–77.7). During a median follow up time of 4.7 years (IQR 3.4–6.0) we recorded 67 OHCA events with presumed cardiac cause. The incidence rate was 1.07 per 1,000 person-years (95% Confidence-Interval [CI] 0.80–1.40). The mortality rate following OHCA was 91.2% (n=62). Univariable Cox regression analyses identified age, sex, weight, abdominal circumference, serum creatinine, diabetes, arterial hypertension, intake of antihypertensive medication and pre-frailty as predictors for the outcome. In multivariable Cox regression analyses we identified age (Hazard Ratio [HR] 1.06, CI 1.00–1.13), female sex (HR 0.49, CI 0.26–0.94) and pre-frailty (HR 1.92, CI 1.03–3.58) to be independent predictors (Table). In exploratory analyses there was no effect of low-dose aspirin on OHCA (HR 1.52, CI 0.87–2.70).

Conclusion

In a large, contemporary cohort of healthy, elderly individuals we describe a significant incidence of OHCA events associated with a very high mortality. We identified age, sex and pre-frailty, but interestingly not conventional cardiovascular risk factors as independent predictors of OHCA. We could not show a benefit of low-dose aspirin treatment, although the number of events was small. Our findings emphasize the importance of preventive strategies for pre-frailty in elderly individuals.

Funding Acknowledgement

Type of funding sources: Public Institution(s). Main funding source(s): The ASPREE study was primarily funded by the National Institute of Aging and National Cancer Institute at the National Institutes of Health (grant number U01AG029824), the Australian National Health & Medical Research Council (grants 334047 & 1127060), Monash University (Australia) and the Victorian Cancer Agency (Australia). Multivariable Cox regression analyses

Characterization of Aerosol Hygroscopicity Over the Northeast Pacific Ocean: Impacts on Prediction of CCN and Stratocumulus Cloud Droplet Number Concentrations

During the Marine Aerosol Cloud and Wildfire Study (MACAWS) in June and July of 2018, aerosol composition and cloud condensation nuclei (CCN) properties were measured over the N.E. Pacific to characterize the influence of aerosol hygroscopicity on predictions of ambient CCN and stratocumulus cloud droplet number concentrations (CDNC). Three vertical regions were characterized, corresponding to the marine boundary layer (MBL), an above-cloud organic aerosol layer (AC-OAL), and the free troposphere (FT) above the AC-OAL. The aerosol hygroscopicity parameter (κ) was calculated from CCN measurements (κ CCN) and bulk aerosol mass spectrometer (AMS) measurements (κ AMS). Within the MBL, measured hygroscopicities varied between values typical of both continental environments (~0.2) and remote marine locations (~0.7). For most flights, CCN closure was achieved within 20% in the MBL. For five of the seven flights, assuming a constant aerosol size distribution produced similar or better CCN closure than assuming a constant "marine" hygroscopicity (κ = 0.72). An aerosol-cloud parcel model was used to characterize the sensitivity of predicted stratocumulus CDNC to aerosol hygroscopicity, size distribution properties, and updraft velocity. Average CDNC sensitivity to accumulation mode aerosol hygroscopicity is 39% as large as the sensitivity to the geometric median diameter in this environment. Simulations suggest CDNC sensitivity to hygroscopicity is largest in marine stratocumulus with low updraft velocities (<0.2 m s-1), where accumulation mode particles are most relevant to CDNC, and in marine stratocumulus or cumulus with large updraft velocities (>0.6 m s-1), where hygroscopic properties of the Aitken mode dominate hygroscopicity sensitivity.

Commentary: Demand Avoidance Phenomena, a manifold issue? Intolerance of uncertainty and anxiety as explanatory frameworks for extreme demand avoidance in children and adolescents - a commentary on Stuart et al. (2020)

Demand Avoidance Phenomena (DAP) is a neutral term for Pathological Demand Avoidance, which is sometimes conceptualised as an autism subtype. There is much ongoing controversy around the construct. In this commentary, I attempt to contextualise the recent article, Intolerance of Uncertainty and anxiety (Stuart et al., 2019) within wider discourses. This discussion provides tentative support for monotropism autism theory and the growing body of research indicating that DAP may not be developmentally persistent (a high rate of persons not meeting clinical threshold into adulthood). Going forward I would suggest that Stuart and colleagues' research should be replicated, in order to add to the DAP literature.

Renal impairment after ileostomy formation: a frequent event with long-term consequences

AIM

High stoma output and dehydration is common following ileostomy formation. However, the impact of this on renal function, both in the short term and after ileostomy reversal, remains poorly defined. We aimed to assess the independent impact on kidney function of an ileostomy after rectal cancer surgery and subsequent reversibility after ileostomy closure.

METHODS

This retrospective single-site cohort study identified patients undergoing rectal cancer resection from 2003 to 2017, with or without a diverting ileostomy. Renal function was calculated preoperatively, before ileostomy closure, and 6 months after ileostomy reversal (or matched times for patients without ileostomy). Demographics, oncological treatments and nephrotoxic drug prescriptions were assessed. Outcome measures were deterioration from baseline renal function and development of moderate/severe chronic kidney disease (CKD ≥ 3). Multivariate analysis was performed to assess independent risk factors for postoperative renal impairment.

RESULTS

Five hundred and eighty-three of 1213 patients had an ileostomy. Postoperative renal impairment occurred more frequently in ileostomates (9.5% absolute increase in rate of CKD ≥ 3; P < 0.0001) vs no change in patients without an ileostomy (P = 0.757). Multivariate analysis identified ileostomy formation, age, anastomotic leak and renin-angiotensin system inhibitors as independently associated with postoperative renal decline. Despite stoma closure, ileostomates remained at increased risk of progression to new or worse CKD [74/438 (16.9%)] compared to patients without an ileostomy [36/437 (8.2%), P = 0.0001, OR 2.264 (1.49-3.46)].

CONCLUSIONS

Ileostomy formation is independently associated with kidney injury, with an increased risk persisting after stoma closure. Strategies to protect against kidney injury may be important in higher risk patients (elderly, receiving renin-angiotensin system antihypertensives, or following anastomotic leakage).

Pediatric tracheostomy first tube change: When is it safe?

OBJECTIVES

The first tracheostomy tube change is typically performed on days 5-7 post-operatively, however recent international consensus guidelines suggested that, with maturation sutures, days 3-5 is appropriate. We evaluate whether a first tube change on day 2 post-operatively is safe and effective.

METHODS

We carried out a retrospective review of all patients undergoing tracheostomy between 2009 and 2018. Exclusion criteria were patients on whom the senior authors did not operate, operations done elsewhere, cases where maturation sutures were not used or a patient died prior to first tube change. We noted patient details, indication for tracheostomy, the need for long-term ventilation, timing of the first tube change, decannulation and need for surgical closure of persistent tracheocutaneous fistula.

RESULTS

93 patients were identified, of which 83 were included. The age range was 0-16 years, with the youngest day one of life and an overall mean age of 1.91 years. 59% of patients required long-term ventilation due to various co-morbidities. 26 patients (31%) underwent a first tube change on day 2 post-operatively. All these were uneventful and were irrespective of the patient's need for ventilation. Of the 42 patients who have subsequently been decannulated, 33 (79%) were noted to have a persistent tracheocutaneous fistula requiring surgical closure, four of whom needed revision closure.

CONCLUSIONS

This study shows that a first tube change on day 2 post-operatively is safe, facilitating earlier discharge from intensive care, allowing shorter length of sedation, earlier start to parent/carer training and wound assessment.

A bispecific antibody that targets IL-6 receptor and IL-17A for the potential therapy of patients with autoimmune and inflammatory diseases

Despite the success of current biological therapeutics for rheumatoid arthritis, these therapies, targeting individual cytokines or pathways, produce beneficial responses in only about half of patients. Therefore, better therapeutics are needed. IL-6 and IL-17A are proinflammatory cytokines in many autoimmune and inflammatory diseases, and several therapeutics have been developed to specifically inhibit them. However, targeting both of these cytokines with a bispecific therapeutic agent could account for their nonoverlapping proinflammatory functions and for the fact that IL-6 and IL-17A act in a positive feedback loop. Here, we present the development of MT-6194, a bispecific antibody targeting both IL-6R and IL-17A that was developed with the FynomAb technology. We also present data from mouse inflammatory disease experiments, indicating that simultaneous inhibition of both IL-6 and IL-17A yields enhanced efficacy compared with inhibition of each cytokine alone.

A preventative lifestyle intervention for older adults (lifestyle matters): a randomised controlled trial

Objectives

to test whether an occupation-based lifestyle intervention can sustain and improve the mental well-being of adults aged 65 years or over compared to usual care, using an individually randomised controlled trial.

Participants

288 independently living adults aged 65 years or over, with normal cognition, were recruited from two UK sites between December 2011 and November 2015.

Interventions

lifestyle Matters is a National Institute for Health and Care Excellence recommended multi-component preventive intervention designed to improve the mental well-being of community living older people at risk of decline. It involves weekly group sessions over 4 months and one to one sessions.

Main outcome measures

the primary outcome was mental well-being at 6 months (mental health (MH) dimension of the SF-36). Secondary outcomes included physical health dimensions of the SF-36, extent of depression (PHQ-9), quality of life (EQ-5D) and loneliness (de Jong Gierveld Loneliness Scale), assessed at 6 and 24 months.

Results

data on 262 (intervention = 136; usual care = 126) participants were analysed using intention to treat analysis. Mean SF-36 MH scores at 6 months differed by 2.3 points (95 CI: -1.3 to 5.9; P = 0.209) after adjustments.

Conclusions

analysis shows little evidence of clinical or cost-effectiveness in the recruited population with analysis of the primary outcome revealing that the study participants were mentally well at baseline. The results pose questions regarding how preventive interventions to promote well-being in older adults can be effectively targeted in the absence of proactive mechanisms to identify those who at risk of decline.

Trial Registration

ISRCTN67209155.

Is an ecosystem services-based approach developed for setting specific protection goals for plant protection products applicable to other chemicals?

Clearly defined protection goals specifying what to protect, where and when, are required for designing scientifically sound risk assessments and effective risk management of chemicals. Environmental protection goals specified in EU legislation are defined in general terms, resulting in uncertainty in how to achieve them. In 2010, the European Food Safety Authority (EFSA) published a framework to identify more specific protection goals based on ecosystem services potentially affected by plant protection products. But how applicable is this framework to chemicals with different emission scenarios and receptor ecosystems? Four case studies used to address this question were: (i) oil refinery waste water exposure in estuarine environments; (ii) oil dispersant exposure in aquatic environments; (iii) down the drain chemicals exposure in a wide range of ecosystems (terrestrial and aquatic); (iv) persistent organic pollutant exposure in remote (pristine) Arctic environments. A four-step process was followed to identify ecosystems and services potentially impacted by chemical emissions and to define specific protection goals. Case studies demonstrated that, in principle, the ecosystem services concept and the EFSA framework can be applied to derive specific protection goals for a broad range of chemical exposure scenarios. By identifying key habitats and ecosystem services of concern, the approach offers the potential for greater spatial and temporal resolution, together with increased environmental relevance, in chemical risk assessments. With modifications including improved clarity on terminology/definitions and further development/refinement of the key concepts, we believe the principles of the EFSA framework could provide a methodical approach to the identification and prioritization of ecosystems, ecosystem services and the service providing units that are most at risk from chemical exposure.

Toward the definition of specific protection goals for the environmental risk assessment of chemicals: A perspective on environmental regulation in Europe

This critical review examines the definition and implementation of environmental protection goals for chemicals in current European Union (EU) legislation, guidelines, and international agreements to which EU countries are party. The European chemical industry is highly regulated, and prospective environmental risk assessments (ERAs) are tailored for different classes of chemical, according to their specific hazards, uses, and environmental exposure profiles. However, environmental protection goals are often highly generic, requiring the prevention of "unacceptable" or "adverse" impacts on "biodiversity" and "ecosystems" or the "environment as a whole." This review aims to highlight working examples, challenges, solutions, and best practices for defining specific protection goals (SPGs), which are seen to be essential for refining and improving ERA. Specific protection goals hinge on discerning acceptable versus unacceptable adverse effects on the key attributes of relevant, sensitive ecological entities (ranging from organisms to ecosystems). Some isolated examples of SPGs for terrestrial and aquatic biota can be found in prospective ERA guidance for plant protection products (PPPs). However, SPGs are generally limited to environmental or nature legislation that requires environmental monitoring and retrospective ERA. This limitation is due mainly to the availability of baselines, which define acceptable versus unacceptable environmental effects on the key attributes of sentinel species, populations and/or communities, such as reproductive status, abundance, or diversity. Nevertheless, very few regulatory case examples exist in which SPGs incorporate effect magnitude, spatial extent, and temporal duration. We conclude that more holistic approaches are needed for defining SPGs, particularly with respect to protecting population sustainability, ecosystem function, and integrity, which are implicit in generic protection goals and explicit in the International Programme for Chemical Safety (IPCS) definition of "adverse effect." A possible solution, which the chemical industry is currently assessing, is wider application of the ecosystem services approach proposed by the European Food Safety Authority (EFSA) for the risk assessment of PPPs. Integr Environ Assess Manag 2017;13:17-37. © 2016 SETAC.

Avian influenza in Australia: a summary of 5 years of wild bird surveillance

BACKGROUND

Avian influenza viruses (AIVs) are found worldwide in numerous bird species, causing significant disease in gallinaceous poultry and occasionally other species. Surveillance of wild bird reservoirs provides an opportunity to add to the understanding of the epidemiology of AIVs.

METHODS

This study examined key findings from the National Avian Influenza Wild Bird Surveillance Program over a 5-year period (July 2007-June 2012), the main source of information on AIVs circulating in Australia.

RESULTS

The overall proportion of birds that tested positive for influenza A via PCR was 1.9 ± 0.1%, with evidence of widespread exposure of Australian wild birds to most low pathogenic avian influenza (LPAI) subtypes (H1-13, H16). LPAI H5 subtypes were found to be dominant and widespread during this 5-year period.

CONCLUSION

Given Australia's isolation, both geographically and ecologically, it is important for Australia not to assume that the epidemiology of AIV from other geographic regions applies here. Despite all previous highly pathogenic avian influenza outbreaks in Australian poultry being attributed to H7 subtypes, widespread detection of H5 subtypes in wild birds may represent an ongoing risk to the Australian poultry industry.

Transforming ecosystems: When, where, and how to restore contaminated sites

Chemical contamination has impaired ecosystems, reducing biodiversity and the provisioning of functions and services. This has spurred a movement to restore contaminated ecosystems and develop and implement national and international regulations that require it. Nevertheless, ecological restoration remains a young and rapidly growing discipline and its intersection with toxicology is even more nascent and underdeveloped. Consequently, we provide guidance to scientists and practitioners on when, where, and how to restore contaminated ecosystems. Although restoration has many benefits, it also can be expensive, and in many cases systems can recover without human intervention. Hence, the first question we address is: "When should we restore contaminated ecosystems?" Second, we provide suggestions on what to restore-biodiversity, functions, services, all 3, or something else--and where to restore given expected changes to habitats driven by global climate change. Finally, we provide guidance on how to restore contaminated ecosystems. To do this, we analyze critical aspects of the literature dealing with the ecology of restoring contaminated ecosystems. Additionally, we review approaches for translating the science of restoration to on-the-ground actions, which includes discussions of market incentives and the finances of restoration, stakeholder outreach and governance models for ecosystem restoration, and working with contractors to implement restoration plans. By explicitly considering the mechanisms and strategies that maximize the success of the restoration of contaminated sites, we hope that our synthesis serves to increase and improve collaborations between restoration ecologists and ecotoxicologists and set a roadmap for the restoration of contaminated ecosystems.

Efficacy of thiopurines and adalimumab in preventing Crohn's disease recurrence in high-risk patients - a POCER study analysis

BACKGROUND

Crohn's disease recurs in the majority of patients after intestinal resection.

AIM

To compare the relative efficacy of thiopurines and anti-TNF therapy in patients at high risk of disease recurrence.

METHODS

As part of a larger study comparing post-operative management strategies, patients at high risk of recurrence (smoker, perforating disease, ≥2nd operation) were treated after resection of all macroscopic disease with 3 months metronidazole together with either azathioprine 2 mg/kg/day or mercaptopurine 1.5 mg/kg/day. Thiopurine-intolerant patients received adalimumab induction then 40 mg fortnightly. Patients underwent colonoscopy at 6 months with endoscopic recurrence assessed blind to treatment.

RESULTS

A total of 101 patients [50% male; median (IQR) age 36 (25-46) years] were included. There were no differences in disease history between thiopurine- and adalimumab-treated patients. Fifteen patients withdrew prior to 6 months, five due to symptom recurrence (of whom four were colonoscoped). Endoscopic recurrence (Rutgeerts score i2-i4) occurred in 33 of 73 (45%) thiopurine vs. 6 of 28 (21%) adalimumab-treated patients [intention-to-treat (ITT); P = 0.028] or 24 of 62 (39%) vs. 3 of 24 (13%) respectively [per-protocol analysis (PPA); P = 0.020]. Complete mucosal endoscopic normality (Rutgeerts i0) occurred in 17/73 (23%) vs. 15/28 (54%) (ITT; P = 0.003) and in 27% vs. 63% (PPA; P = 0.002). The most advanced disease (Rutgeerts i3 and i4) occurred in 8% vs. 4% (thiopurine vs. adalimumab).

CONCLUSIONS

In Crohn's disease patients at high risk of post-operative recurrence adalimumab is superior to thiopurines in preventing early disease recurrence.

Discovery and characterization of COVA322, a clinical-stage bispecific TNF/IL-17A inhibitor for the treatment of inflammatory diseases

Biologic treatment options such as tumor necrosis factor (TNF) inhibitors have revolutionized the treatment of inflammatory diseases, including rheumatoid arthritis. Recent data suggest, however, that full and long-lasting responses to TNF inhibitors are limited because of the activation of the pro-inflammatory T_H17/interleukin (IL)-17 pathway in patients. Therefore, dual TNF/IL-17A inhibition is an attractive avenue to achieve superior efficacy levels in such diseases. Based on the marketed anti-TNF antibody adalimumab, we generated the bispecific TNF/IL-17A-binding FynomAb COVA322. FynomAbs are fusion proteins of an antibody and a Fyn SH3-derived binding protein. COVA322 was characterized in detail and showed a remarkable ability to inhibit TNF and IL-17A in vitro and in vivo. Through its unique mode-of-action of inhibiting simultaneously TNF and the IL-17A homodimer, COVA322 represents a promising drug candidate for the treatment of inflammatory diseases. COVA322 is currently being tested in a Phase 1b/2a study in psoriasis (ClinicalTrials.gov Identifier: NCT02243787).

A novel framework for discharge uncertainty quantification applied to 500 UK gauging stations

A generalized framework for discharge uncertainty estimation is presentedAllows estimation of place-specific discharge uncertainties for many catchmentsLocal conditions dominate in determining discharge uncertainty magnitudes.

Abstract 658: A bispecific HER2 targeting FynomAb with superior anti-tumor activity and novel mode of action

Upregulation of HER2 is a hallmark of 20% to 30% of invasive breast cancers, rendering this receptor an attractive target for cancer therapy. Although HER2 targeting agents have provided substantial clinical benefit as cancer therapeutics, there is a need for the development of new agents aiming at circumventing anti-HER2 resistance.

Fynomers are small 7 kDa globular proteins derived from the SH3 domain of the human Fyn kinase (Fyn SH3) that can be engineered to bind with antibody-like affinity and specificity to virtually any target of choice. Fynomers can be fused to N-terminal and/or C-terminal ends of antibodies to generate multispecific therapeutics (FynomAbs) with tailored architectures. FynomAbs can be produced using standard antibody technology (GMP production yield of 3.3 g/L at 1000 L scale achieved), and show IgG-like biophysical properties and pharmacokinetic profiles.

Based on the approved antibody pertuzumab we have created a panel of bispecific FynomAbs which target two epitopes on HER2. The activity of the HER2 targeting FynomAbs was found to depend on the FynomAb architecture, i.e. the spatial arrangement of the binding sites of antibody and the Fynomer.

The most potent of these FynomAbs, termed COVA208, demonstrated superior tumor cell growth inhibition in vitro compared to pertuzumab and trastuzumab. COVA208 was characterized in detail and showed an increased ability to induce rapid HER2-internalization and apoptosis in vitro. Moreover, it elicited a stronger inhibition of downstream HER2 signaling which was accompanied by a reduction of HER2, HER3 and EGFR levels in vitro and in vivo. The therapeutic potential of COVA208 has been demonstrated in vivo in four different HER2 mouse models, where COVA208 exhibited excellent anti-tumor activity. Importantly, COVA208 demonstrated superior activity in vivo compared to trastuzumab and pertuzumab.

The bispecific FynomAb COVA208 has the potential to enhance the clinical efficacy and expand the scope of HER2-directed therapies, and delineates a paradigm for designing a new class of antibody-based therapeutics for other receptor targets.

Citation Format: Babette Schade, Simon Brack, Isabella Attinger-Toller, Kristina Klupsch, Richard Woods, Helen Hachemi, Ulrike von der Bey, Susann Koönig-Friedrich, Julian Bertschinger, Dragan Grabulovski. A bispecific HER2 targeting FynomAb with superior anti-tumor activity and novel mode of action. [abstract]. In: Proceedings of the 105th Annual Meeting of the American Association for Cancer Research; 2014 Apr 5-9; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2014;74(19 Suppl):Abstract nr 658. doi:10.1158/1538-7445.AM2014-658

Factors associated with delayed time to adjuvant chemotherapy in stage iii colon cancer

BACKGROUND

Adjuvant chemotherapy started more than 56 days after colon cancer resection has been associated with lesser overall survival among patients with stage iii colon cancer. The objective of the present population-based study was to determine, in referred patients with resected stage iii colon cancer, factors associated with delayed time to adjuvant chemotherapy (ttac), defined as more than 56 days from the date of surgery.

METHODS

Eligible patients had been diagnosed with stage iii colon cancer and had received at least 1 cycle of adjuvant chemotherapy at one of the four regional cancer treatment sites during 2008-2009. Prognostic and treatment information was prospectively collected through the BC Cancer Agency's GI Cancers Outcomes Unit, and Charlson comorbidity score was retrospectively determined by chart review. Chi-square and Wilcoxon rank-sum tests were used to measure associations between the timing of adjuvant chemotherapy and select prognostic and treatment variables.

RESULTS

Median ttac from surgery for the 395 included patients was 58 days, with 54% of the patients receiving adjuvant chemotherapy beyond the recommended 56 days. On multivariate analysis, only treatment at the highest-volume site was independently associated with delayed ttac. Comorbidity index, age, performance status, T stage, tumour location, and oral chemotherapy (compared with intravenous) were not independently associated with delayed ttac. Delays were observed during each interval associated with the patient's transition from surgery to first cycle of adjuvant chemotherapy.

CONCLUSIONS

More than half the patients failed to receive adjuvant chemotherapy within the recommended ttac of 56 days. Delayed ttac was associated with process-related delays rather than with patient- or disease-related factors. Efforts to improve timely referral, triage of consultations, and chemotherapy wait lists are required.

A bispecific HER2-targeting FynomAb with superior antitumor activity and novel mode of action

Upregulation of HER2 is a hallmark of 20% to 30% of invasive breast cancers, rendering this receptor an attractive target for cancer therapy. Although HER2-targeting agents have provided substantial clinical benefit as cancer therapeutics, there is a need for the development of new agents aiming at circumventing anti-HER2 resistance. On the basis of the approved antibody pertuzumab, we have created a panel of bispecific FynomAbs, which target two epitopes on HER2. FynomAbs are fusion proteins of an antibody and a Fyn SH3-derived binding protein. One bispecific FynomAb, COVA208, was characterized in detail and showed a remarkable ability to induce rapid HER2 internalization and apoptosis in vitro. Moreover, it elicited a strong inhibition of downstream HER2 signaling by reducing HER2, HER3, and EGFR levels in vitro and in vivo. Importantly, COVA208 demonstrated superior activity in four different xenograft models as compared with the approved antibodies trastuzumab and pertuzumab. The bispecific FynomAb COVA208 has the potential to enhance the clinical efficacy and expand the scope of HER2-directed therapies, and delineates a paradigm for designing a new class of antibody-based therapeutics for other receptor targets.

Postoperative recurrence of Crohn's disease: impact of endoscopic monitoring and treatment step-up

AIM

Eighty per cent of patients with Crohn's disease require surgery, of whom 70% will require a further operation. Recurrence occurs at the anastomosis. Although often recommended, the impact of postoperative colonoscopy and treatment adjustment is unknown.

METHOD

Patients with a bowel resection over a 10-year period were reviewed and comparison made between those who did and did not have a postoperative colonoscopy within 1 year of surgery, and those who did or did not have a step-up in drug therapy.

RESULTS

Of 222 patients operated on, 136 (65 men, mean age 33 years, mean disease duration 8 years, median follow-up 4 years) were studied. Of 70 patients with and 66 without postoperative colonoscopy, clinical recurrence occurred in 49% and 48% (NS) and further surgery in 9% and 5% (NS). Eighty-nine per cent of colonoscoped patients had a decision based on the colonoscopic findings: of these, 24% had a step-up of drug therapy [antibiotics (n =10), aminosalicylates (n=2), thiopurine (n=5), methotrexate (n=1)] and 76% had no step-up in drug therapy. In colonoscoped patients clinical recurrence occurred in 9 (60%) of 15 patients with, and 23 (49%) of 47 without step-up and surgical recurrence in 2 (13%) of 15 and 4 (9%) of 47 (NS).

CONCLUSION

Clinical recurrence occurs in a majority of patients soon after surgery. In this cohort, there was no clinical benefit from colonoscopy or increased drug therapy within 1 year after operation. However, the response to the endoscopic findings was not standardized and immunosuppressive therapy was uncommon. Standardizing timing of colonoscopy and drug therapy, including more intense therapy, may improve outcome, although this remains to be proven.

Abstract P4-16-01: Accelerated hypofractionated whole breast radiotherapy for localized breast cancer: the effect of a boost on patient reported long-term cosmetic outcome

PURPOSE: Equivalent long-term local control and cosmetic outcomes between conventional and accelerated, hypofractionated whole breast radiotherapy (AWBRT) for early-stage breast cancer have been demonstrated. However, there is uncertainty about the long-term cosmetic outcome of a boost to the tumor bed following AWBRT (AWBRT+B). The primary outcome of this study was to evaluate the cosmetic effect of a boost using a patient reported questionnaire. The cosmetic subscale in the questionnaire was used to compare the appearance of the treated versus non treated breast between the boost and non-boost groups.

MATERIALS AND METHODS: Between 2000 and 2005, 4392 women 75 years and under with unilateral early-stage breast cancer received AWBRT alone or AWBRT+B. Random samples of 800 women treated with AWBRT alone and 800 women treated with AWBRT+B were identified from the 3960 women still alive at least 5 years after treatment without contralateral disease. The women were contacted by mail to complete a questionnaire based on the Breast Cancer Treatment Outcomes Scale (22 questions regarding cosmetic, pain and functional outcomes). Cochrane-Armitage (CA) trend test and Wilcoxon Rank-sum (WR) were used to compare baseline patient and treatment variables to long-term cosmetic outcomes between the two treatment groups.

RESULTS: 312 women (154 received AWBRT alone and 158 received AWBRT+B) completed the questionnaire. The median (range) age of respondents was 57 (40–75) years in the AWBRT alone group and 52 (32–75) years in the AWBRT+B group (p &lt; 0.001). The median (range) follow-up time after radiotherapy treatment was 8.7 (5.5–11.5) years in the AWBRT alone group and 7.8 (5.5–11.5) years in the AWBRT+B group (p &lt; 0.001). Boost doses ranged between 7.5 Gy in 3 fractions to 16 Gy in 8 fractions. The most commonly used boost regimen was 10 Gy in 4 fractions (70% of respondents). Women treated with AWBRT+B also had higher T stage, higher grade, were more likely to have had chemotherapy and trended towards having an increased number of positive nodes compared to the AWBRT alone group. Current weight, ER status, and use of hormonal therapy were similar between both groups.

When comparing the overall appearance of the treated to untreated breast, there was no significant difference between the women who received AWBRT alone and those who received AWBRT+B (42% stating no or slight difference vs. 41%) (p = 0.87 CA). Focusing on the cosmetic subscale in the questionnaire, the average summed score for the AWBRT alone group was slightly worse to the score for the AWBRT+B group (2.3 vs. 2.1, p = 0.02 WR). On the functional subscale, the average summed score for the AWBRT alone group was worse than the AWBRT+B group (1.8 versus 1.5, p &lt; 0.001 WR). On the pain subscale, the average summed score for the AWBRT alone group was better than the AWBRT+B group (1.6 versus 2.0, p &lt; 0.0001 WR). However, when the pain subscale was only applied to the area around the scar, the two groups were similar (2.0 for AWBRT alone and 2.0 for AWBRT+B, p = 0.71).

CONCLUSION: Similar to conventionally fractionated WBRT, patients who receive a boost after AWBRT self-report long-term slightly worse cosmetic and pain outcomes compared AWBRT alone.

Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr P4-16-01.

Metastatic paediatric colorectal carcinoma

A 16-year-old girl presented to our unit with crampy abdominal pain, change in bowel habit, a subjective impression of weight loss and a single episode of haematochezia. She was found to have a rectosigmoid adenocarcinoma and proceeded to laparoscopic anterior resection, whereupon peritoneal metastases were discovered. She received chemotherapy and is alive and well ten month later with no radiological evidence of disease. Colorectal carcinoma is rare in the paediatric population but is increasing in incidence. Early diagnosis is critical to enable optimal outcomes.

P4-19-05: A Population-Based Study of Guideline-Based BRCA Screening in Male Breast Carcinoma

Purpose: The British Columbia Cancer Agency (BCCA) Hereditary Cancer Program (HCP) is a publicly funded, centralized program that provides BRCA testing to patients with male breast cancer (MBC) who meet specified referral criteria (aimed at detecting a mutation in &gt; 10% of those tested). Criteria include: MBC with Ashkenazi heritage, MBC with one other family member with breast or ovarian cancer, MBC diagnosed at &lt; 35 years, Bilateral MBC with first diagnosed at &lt; 50 year. In this context, the purpose was to study referral patterns for hereditary counselling and outcomes of BRCA testing within a population-based study of male breast carcinoma.

Patients and Methods

Records of consecutive cases of invasive MBC diagnosed from 2000 to 2010 were reviewed. We documented any recorded personal and family history of cancer. For those meeting the HCP referral criteria we recorded whether a referral was made and the outcome of any genetic testing.

Results: Of 158 cases of MBC, 23 (14.6%) patients (21 met referral criteria; 2 did not) were seen for genetic counselling, of whom 21 were offered BRCA1/2 testing, and 19 accepted testing. Of 19 patients with BRCA1/2 genetic test results, 3 (16%) had a pathogenic mutation identified; one in the BRCA1 gene (c.1387_1390delinsGAAAG) and two in the BRCA2 gene (***c.755_758delACAG; c.1813dupA). In a further 4 cases (21%) an unclassified variant in BRCA1 was identified. In the remaining 12 cases (63%), testing was uninformative.

Conclusions: The BRCA1/2 mutation detection rate of 16% is in line with the expected rate of &gt;10% using established selection criteria. Expanding the criteria at this time to include all male breast cancers would be expected to decrease the detection rate below 10% with the potential to negatively impact on the publicly-funded and finite resources of the Hereditary Cancer Program and Cancer Genetics Laboratory.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P4-19-05.

P5-14-17: Stage IV at Presentation – Are HER2 Positive Tumors Overrepresented?

Background: A minority of patients are diagnosed with Stage IV breast cancer at presentation. Recent studies (Dawood 2010) have suggested a better outcome for de novo vs. recurrent Stage IV but they did not account for the variation of molecular subtype. We questioned whether HER2 overexpressing tumors were over-represented in de novo Stage IV disease, and whether this impacted on survival compared to other subtypes. Further, if different subtypes are more likely to present with metastatic disease, then this factor may need to be considered when developing guidelines for staging. With such considerations in mind, the purpose of this study was to determine the breast cancer subtypes according to stage. The main hypothesis was that HER2 positive tumors would be more prevalent in stage IV presentations. Methods: Using the Breast Cancer Outcomes Unit database from the BC Cancer Agency (BCCA), patients referred to the BCCA with a new diagnosis of breast cancer between 2005 and 2010 were selected. Patients with a previous or synchronous contralateral breast cancer, male cases, and patients with referrals for reasons other than new disease were excluded. Four subtypes according to available markers were defined: ER+/HER2−, ER+/HER2+, ER-/HER2+, and ER-/HER2−.

Results: Using these criteria, 485 cases of de novo stage IV disease and 10,723 stages I — III cases were extracted. After excluding cases with missing data, our final cohort consisted of 10,186 stage I-III cases and 425 stage IV cases. Distribution by subtype is presented in the Table below.

Impact of internal mammary node inclusion in the radiation treatment volume on the outcomes of patients with breast cancer treated with locoregional radiation after six years of follow-up

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Background: There is ongoing controversy about radiotherapy (RT) to internal mammary nodes (IMNs). Proponents of IMN RT cite the survival benefit seen in postmastectomy RT trials that included IMNs. However, others point out that benefit cannot be definitively attributed to IMN inclusion, as other lymph node regions were included in the RT arms. The issue is important, as IMN RT potentially increases cardiac and respiratory morbidity.

Methods: 2,413 women referred to a provincial RT program with newly diagnosed node positive, or T3/4N0 non-M1 invasive breast cancer, treated with a complete course of locoregional RT from 2001 to 2006, were retrospectively identified in a provincial database. IMN RT inclusion versus exclusion was determined through review of patient charts and RT treatment plans. Breast cancer-specific survival (BCSS), relapse-free survival (RFS), and overall survival (OS) were compared between the two groups using univariate and multivariable analyses.

Results: Analyses were performed at a median follow-up of 6.2 years. 41.4% of the subjects received IMN RT. The 5-year BCSS for the IMN inclusion and exclusion group was 84.8% versus 82.9%, respectively (HR 0.93 [95% CI 0.76, 1.14]; p=.51); the 5-year RFS was 87.4% versus 86.9% (HR 0.993 [0.83, 1.19]; p=0.94); and the 5-year OS was 84.8% versus 82.9% (HR 0.84 [0.70, 1.01]; p=0.06). After controlling for potentially confounding variables, there was no significant difference in BCSS (HR 0.96 [0.78, 1.18], p=0.88), RFS (HR 1.02 [0.84, 1.22], p=0.87), or OS (HR 0.91 [0.76, 1.10]; p=0.35).

Conclusions: After a median follow-up of 6.2 years, this population-based study shows no benefit from including IMNs in the locoregional RT volume after adjusting for other prognostic and treatment variables.

Is breast-conserving therapy a safe option for patients with tumor multicentricity and multifocality?

BACKGROUND

We compared outcomes after breast-conserving therapy (BCT) and mastectomy in multicentric (MC)/multifocal (MF) versus unifocal breast cancer.

PATIENTS AND METHODS

Women with stage I-II disease were classified as having unifocal or MC/MF disease. MC/MF and other prognostic factors were compared using binary logistic regression analysis. Univariate and multivariate analyses (MVAs) for relapse were carried out using cumulative incidence curves and Fine and Gray regression models. For the BCT group, matched analysis was added.

RESULTS

Median follow-up was 7.9 years, 11 983 having BCT (unifocal: 11 683, MC/MF: 300) and 7771 having mastectomy (unifocal: 6884, MC/MF: 887). MC/MF patients treated with BCT were 50-69 years old, free of extensive ductal carcinoma in situ (DCIS), and had smaller tumors. The cumulative 10-year local recurrence rates among unifocal and MC/MF disease were 4.6% [95% confidence interval (CI) 4.1% to 5.0%] versus 5.5% (95% CI 2.6% to 9.9%) for the BCT group, P = 0.76 and 5.8% (95% CI 5.2% to 6.5%) versus 6.5% (95% CI 4.7% to 8.7%) for the mastectomy group, P = 0.77. MC/MF was not a significant factor for relapse or survival on MVA. In the matched analysis, relapse rates were similar in the unifocal and MC/MF groups, P = 0.60.

CONCLUSION

BCT is a reasonable option in selected MC/MF cases, particularly those women aged 50-69 years old with small (<1 cm) MF tumors and without an extensive DCIS component.