Programmed Death Ligand-1 and Tumor Mutation Burden Testing of Patients With Lung Cancer for Selection of Immune Checkpoint Inhibitor Therapies: Guideline From the College of American Pathologists, Association for Molecular Pathology, International Association for the Study of Lung Cancer, Pulmonary Pathology Society, and LUNGevity Foundation

CONTEXT.—

Rapid advancements in the understanding and manipulation of tumor-immune interactions have led to the approval of immune therapies for patients with non-small cell lung cancer. Certain immune checkpoint inhibitor therapies require the use of companion diagnostics, but methodologic variability has led to uncertainty around test selection and implementation in practice.

OBJECTIVE.—

To develop evidence-based guideline recommendations for the testing of immunotherapy/immunomodulatory biomarkers, including programmed death ligand-1 (PD-L1) and tumor mutation burden (TMB), in patients with lung cancer.

DESIGN.—

The College of American Pathologists convened a panel of experts in non-small cell lung cancer and biomarker testing to develop evidence-based recommendations in accordance with the standards for trustworthy clinical practice guidelines established by the National Academy of Medicine. A systematic literature review was conducted to address 8 key questions. Using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach, recommendations were created from the available evidence, certainty of that evidence, and key judgments as defined in the GRADE Evidence to Decision framework.

RESULTS.—

Six recommendation statements were developed.

CONCLUSIONS.—

This guideline summarizes the current understanding and hurdles associated with the use of PD-L1 expression and TMB testing for immune checkpoint inhibitor therapy selection in patients with advanced non-small cell lung cancer and presents evidence-based recommendations for PD-L1 and TMB testing in the clinical setting.

Initial Steps in Creating a Patient-Centric Addendum to Clinical Trial Informed Consent Forms

Introduction

The purpose of the informed consent form (ICF) is to outline the risks and benefits of an interventional clinical trial to potential participants. The aim of this study was to explore the feasibility of a short addendum to the ICF, summarizing key points most relevant to potential participants.

Methods

A sample of 20 ICFs was reviewed against the requirements of the U.S. federal regulation documents and assessed for readability. Alongside the ICF review, we conducted focus groups and one-on-one interviews with people with lung cancer (n = 9) to learn what information was most important when considering participation in a clinical trial using a hypothetical phase 3 ICF.

Results

The 20 ICFs reviewed were from phases 1 to 3, expanded-access, and single-patient trials covering predominantly NSCLC; 60% were global. The mean length of the ICFs was 21 (range: 15-34) pages. The average reading level was tenth grade whereas the average U.S. reading level was eighth grade. Readability varied by section, the "purpose of the study" section had the highest reading level. In the qualitative research component, participants were "overwhelmed" by the hypothetical ICF. Participants were also asked to list information for the addendum; their suggestions broadly map to federal regulations. An addendum with reference to sections in the ICF for additional details was well received.

Conclusions

The variations in ICF architecture and readability make it difficult for patients to make an informed decision to participate in a clinical trial. Implications extend beyond lung cancer, highlighting key areas for ICF improvements and providing a roadmap for developing a patient-centric addendum.

Patient Report on the Impact of Coronavirus Disease 2019 and Living With Lung Cancer

Introduction

Several studies have highlighted coronavirus disease 2019 (COVID-19)-related disruptions in treatment and care in people living with lung cancer. However, few studies have assessed patient-reported perspectives on treatment disruption. This study aims to report the patient perspectives on the impact of COVID-19, vaccination access, and coverage on people living with lung cancer.

Methods

Data are from a larger online longitudinal study being run by a lung cancer nonprofit organization, LUNGevity Foundation. The survey is open to all patients living with lung cancer and their caregivers. These analyses focus on data captured in the COVID-19 module and the vaccine questionnaire. Descriptive statistics were computed for categorical and ordinal variables.

Results

Overall, 164 people living with lung cancer completed the COVID-19 module. Of these, 54% reported disruption in access to treatment, appointments, participating in research and clinical trials. Participants living with stage IV disease were likely to be more concerned about COVID-19 (35%) compared with those with stage I, II, and III. More than half (66%) had tested for COVID-19 of this group 88% tested negative. There was a correlation among participants testing positive for COVID-19 and the number of household members who also tested positive for COVID-19. In the sample who completed the vaccine survey, almost all (98%) were vaccinated against COVID-19. When a recommendation came from a health care professional, an oncologist was the most likely referral source (33%).

Conclusions

An integrative patient-reported view on the impact of COVID-19 is important for adequate preparation to ensure undisrupted treatment and allocation of resources.

2022 cancer statistics: Focus on lung cancer

WHAT IS THIS SUMMARY ABOUT?

This is a plain language summary of a medical journal article called 'Cancer statistics, 2022'. The data in this summary provides detailed information about lung cancer and less detailed information about other cancers. The researchers from the original study used data gathered from previous years to produce a cancer forecast, predicting the number of new cancer diagnoses and deaths in the United States in 2022.

WHAT WERE THE RESULTS?

The review of the data up to 2019 found that compared to previous years: Advanced lung cancer diagnoses had decreased Local stage lung cancer diagnoses had increased Deaths had slowed for lung cancer Deaths continued to reduce for breast cancer, but the rate of this reduction had slowed down Female breast cancer diagnoses were slowly increasing each year Prostate cancer diagnoses stayed similar Local stage prostate cancer diagnoses stayed similar Advanced prostate cancer diagnoses had increased each year The researchers estimated that over 1.9 million new cancer cases would be diagnosed and over half a million cancer deaths would occur in the United States in 2022. This figure includes approximately 350 deaths per day from lung cancer, which was found to be the leading cause of cancer death in the United States.

WHAT DO THE RESULTS OF THE STUDY MEAN?

The study found that progress in reducing the number of people being diagnosed with breast and prostate cancer has stalled. Although there were fewer lung cancers diagnosed, this reduction was likely caused by changes in screening and advancements in lung cancer treatments. The American Cancer Society recommended that investing more funds in detecting cancers early as well as developing targeted treatments would help to reduce cancer death rates. This would also help to address the differences in access to cancer care that exist based on racial, social and economic inequalities.

Plain language summary and patient perspective of the revised STARS study: long-term results of a study that compared the effectiveness of radiotherapy to surgery in people with non-small-cell lung cancer

WHAT IS THIS SUMMARY ABOUT?

This is a summary of a research study called revised STARS. The STARS study involved people with non-small-cell lung cancer, also known as NSCLC. The cancer was less than 5 cm in size and had not spread to other parts of the body (known as stage 1 cancer). The study compared the effectiveness of surgery versus a type of radiotherapy treatment, called stereotactic ablative radiotherapy (also known as SABR) as a treatment for people with NSCLC. Researchers wanted to find out how likely people were to be alive after treatment or if their cancer had grown or spread to other parts of their body (also known as progressed).

WHAT WERE THE RESULTS?

The study found that the long term outcomes were similar between SABR and surgery. People with NSCLC were as likely to be alive 3 years after treatment with SABR compared to surgery.

WHAT DO THE RESULTS OF THE STUDY MEAN?

SABR may be an alternative to surgery for people with stage 1 NSCLC which is less than 5 cm in size and has not spread to other parts of the body Clinical Trial Registration: NCT02357992 (ClinicalTrials.gov).

Plain language summary and patient perspective of the American Society for Clinical Oncology guideline: management of stage 3 non-small-cell lung cancer

WHAT IS THIS SUMMARY ABOUT?

This is a plain language summary of a guideline on the management of stage 3 non-small-cell lung cancer, also known as NSCLC. This guideline was written by the American Society for Clinical Oncology (ASCO for short) and published in the Journal of Clinical Oncology.

WHY WERE THE GUIDELINES DEVELOPED?

The purpose of the ASCO guideline is to provide recommendations to healthcare professionals in the US including oncologists, surgeons, pathologists, radiologists, and nurses on how best to diagnose and treat people with stage 3 NSCLC.

HOW WERE THE GUILDEINES DEVELOPED?

The ASCO guideline is based on the latest research and scientific evidence to make certain the recommendations are up to date and based on reliable data and best practice. In 2021, a group of experts were asked by ASCO to form an Expert Panel. The Expert Panel reviewed the results of 127 clinical research studies on NSCLC that were done between 1990 and 2021. They looked at how NSCLC had been diagnosed and treated in these studies, as well as at patients' survival and quality of life. The Expert Panel used these findings and their own expertise to form their recommendations and produce the 2021 ASCO Guideline called 'Management of Stage 3 Non-Small-Cell Lung Cancer: ASCO Guideline'.

WHAT INFORMATION DOES THE GUIDELINE CONTAIN?

The guideline aims to answer the following questions: What are the most precise ways to confirm and stage NSCLC in people suspected of having a stage 3 disease? Which patients with stage 3 NSCLC can be treated most successfully with surgery? Which patients who can be treated with surgery could also have an additional therapy before their surgery? Which patients who can be treated with surgery could also have an additional treatment after their surgery? Which treatment and/or management is most suitable for patients who cannot have surgery?

Plain language summary and patient perspective of the European Society for Medical Oncology expert consensus statements on treating EGFR-positive non-small-cell lung cancer

WHAT IS THIS SUMMARY ABOUT?

This article provides a plain language summary and patient perspective of a new set of recommendations made by the European Society for Medical Oncology (ESMO for short). These recommendations are also called expert consensus statements. They cover the management of people with a type of lung cancer called epidermal growth factor receptor-positive non-small-cell lung cancer (EGFR-positive NSCLC for short).

WHY WERE THE RECOMMENDATIONS DEVELOPED?

The ESMO Clinical Practice Guidelines are used by healthcare professionals when treating people with cancer, but they don't necessarily have all the information healthcare professionals need to make decisions for with people with EGFR-positive NSCLC. So, in 2021, 32 healthcare professionals who are experts in treating people with EGFR-positive NSCLC worked together to produce recommendations to fill these gaps about EGFR-positive NSCLC. This was called a consensus-building process and it also included patient advocates.

WHAT RECOMMENDATIONS DID THEY MAKE?

The experts discussed four main topics including how people with different stages of EGFR-positive NSCLC are diagnosed and treated, and how clinical studies are done. They reviewed the scientific information that exists on these subjects. They reached an agreement and developed the recommendations that are summarized here.

Plain language summary and patient perspective of the 2020 lung cancer screening recommendations by the US Preventive Services Task Force

WHAT IS THIS SUMMARY ABOUT?

This summary describes the research carried out by the United States Preventive Services Task Force (USPSTF for short) during a review and update of their lung cancer screening recommendations made in 2013. The USPSTF reviewed the results of clinical studies that used a type of scan called low dose computed tomography (LDCT for short). They wanted to see how successful LDCT was at finding lung cancers in people ho hadn't shown any physical signs of lung cancer, but had a history of smoking and were over 50 years of age.

WHAT WERE THE RESULTS?

The review found that performing yearly LDCT scans in people who are at high risk of developing lung cancer is beneficial, as it means that some patients will be diagnosed earlier than they would be without this type of screening. People considered to be at high risk of developing lung cancer include: Adults aged 50 to 80 years who have smoked a pack of 20 cigarettes per day for 20 years or two packs per day for 10 years; OR Adults aged 50 to 80 years who currently smoke or have stopped smoking within the last 15 years.

WHAT DO THE RESULTS OF THE STUDY MEAN?

The information gained from reviewing the research enabled the USPSTF to update their lung cancer screening recommendations.

A qualitative study of interactions with oncologists among patients with advanced lung cancer

INTRODUCTION

To support the care of lung cancer patients, oncologists have needed to stay current on treatment advancements and build relationships with a new group of survivors in an era where lung cancer survivorship has been re-defined. The objectives of the study were to (1) understand the perspectives of advanced lung cancer patients whose tumors have oncogenic alterations about their care experiences with their oncologist(s) and (2) describe the perceptions of advanced lung cancer patients about seeking second opinions and navigating care decisions.

METHODS

In this qualitative study, patients with advanced lung cancer (n = 25) on targeted therapies were interviewed to discuss their ongoing experience with their oncologists. We used deductive and inductive qualitative approaches in the coding of the data. We organized the data using the self-determination framework.

RESULTS

Patients described both positive and negative aspects of their care as related to autonomy, provider competency, and connectedness. Patients sought second opinions for three primary reasons: expertise, authoritative advice, and access to clinical trial opportunities. When there is disagreement in the treatment plan between the primary oncologist and the specialist, there can be confusion and tension, and patients have to make difficult choices about their path forward.

CONCLUSIONS

Patients value interactions that support their autonomy, demonstrate the competency of their providers, and foster connectedness. To ensure that patients receive quality and goal-concordant care, developing decision aids and education materials that help patients negotiate recommendations from two providers is an area that deserves further attention.

Proceedings From the ASCO/College of American Pathologists Immune Checkpoint Inhibitor Predictive Biomarker Summit

PURPOSE

Immune checkpoint inhibition (ICI) therapy represents one of the great advances in the field of oncology, highlighted by the Nobel Prize in 2018. Multiple predictive biomarkers for ICI benefit have been proposed. These include assessment of programmed death ligand-1 expression by immunohistochemistry, and determination of mutational genotype (microsatellite instability or mismatch repair deficiency or tumor mutational burden) as a reflection of neoantigen expression. However, deployment of these assays has been challenging for oncologists and pathologists alike.

METHODS

To address these issues, ASCO and the College of American Pathologists convened a virtual Predictive Factor Summit from September 14 to 15, 2021. Representatives from the academic community, US Food and Drug Administration, Centers for Medicare and Medicaid Services, National Institutes of Health, health insurance organizations, pharmaceutical companies, in vitro diagnostics manufacturers, and patient advocate organizations presented state-of-the-art predictive factors for ICI, associated problems, and possible solutions.

RESULTS

The Summit provided an overview of the challenges and opportunities for improvement in assay execution, interpretation, and clinical applications of programmed death ligand-1, microsatellite instability-high or mismatch repair deficient, and tumor mutational burden-high for ICI therapies, as well as issues related to regulation, reimbursement, and next-generation ICI biomarker development.

CONCLUSION

The Summit concluded with a plan to generate a joint ASCO/College of American Pathologists strategy for consideration of future research in each of these areas to improve tumor biomarker tests for ICI therapy.

A New Approach to Simplifying and Harmonizing Cancer Clinical Trials-Standardizing Eligibility Criteria

Importance

Clinical trial sponsors rely on eligibility criteria to control the characteristics of patients in their studies, promote the safety of participants, and optimize the interpretation of results. However, in recent years, complex and often overly restrictive inclusion and exclusion criteria have created substantial barriers to patient access to novel therapies, hindered trial recruitment and completion, and limited generalizability of trial results. A LUNGevity Foundation working group developed a framework for lung cancer clinical trial eligibility criteria. The goals of this framework are to (1) simplify eligibility criteria, (2) facilitate stakeholders' (patients, clinicians, and sponsors) search for appropriate trials, and (3) harmonize trial populations to support intertrial comparisons of treatment effects.

Observations

Clinicians and representatives from the pharmaceutical industry, the National Cancer Institute, the US Food and Drug Administration (FDA), the European Medicines Agency, and the LUNGevity Foundation undertook a process to identify and prioritize key items for inclusion in trial eligibility criteria. The group generated a prioritized library of terms to guide investigators and sponsors in the design of first-line, advanced non-small cell lung cancer clinical trials intended to support marketing application. These recommendations address disease stage and histologic features, enrollment biomarkers, performance status, organ function, brain metastases, and comorbidities. This effort forms the basis for a forthcoming FDA draft guidance for industry.

Conclusions and Relevance

As an initial step, the recommended cross-trial standardization of eligibility criteria may harmonize trial populations. Going forward, by connecting diverse stakeholders and providing formal opportunity for public input, the emerging FDA draft guidance may also provide an opportunity to revise and simplify long-standing approaches to trial eligibility. This work serves as a prototype for similar efforts now underway for other cancers.

International Association for the Study of Lung Cancer (IASLC) Study of the Impact of COVID-19 on International Lung Cancer Clinical Trials

INTRODUCTION

To evaluate the effects of the global coronavirus disease 2019 (COVID-19) pandemic on lung cancer trials, we surveyed investigators and collected aggregate enrollment data for lung cancer trials across the world before and during the pandemic.

METHODS

A Data Collection Survey collected aggregate monthly enrollment numbers from 294 global lung cancer trials for 2019 to 2020. A 64-question Action Survey evaluated the impact of COVID-19 on clinical trials and identified mitigation strategies implemented.

RESULTS

Clinical trial enrollment declined from 2019 to 2020 by 14% globally. Most reductions in enrollment occurred in April to June where we found significant decreases in individual site enrollment (p = 0.0309). Enrollment was not significantly different in October 2019 to December of 2019 versus 2020 (p = 0.25). The most frequent challenges identified by the Action Survey (N = 172) were fewer eligible patients (63%), decrease in protocol compliance (56%), and suspension of trials (54%). Patient-specific challenges included access to trial site (49%), ability to travel (54%), and willingness to visit the site (59%). The most frequent mitigation strategies included modified monitoring requirements (47%), telehealth visits (45%), modified required visits (25%), mail-order medications (25%), and laboratory (27%) and radiology (21%) tests at nonstudy facilities. Sites that felt the most effective mitigation strategies were telehealth visits (85%), remote patient-reported symptom collection (85%), off-site procedures (85%), and remote consenting (89%).

CONCLUSIONS

The COVID-19 pandemic created many challenges for lung cancer clinical trials conduct and enrollment. Mitigation strategies were used and, although the pandemic worsened, trial enrollment improved. A more flexible approach may improve enrollment and access to clinical trials, even beyond the pandemic.

Abstract PO-064: Health literacy as a tool to drive equitable action for lung cancer screening in high-risk communities

In the United States, communities at risk of developing lung cancer include rural populations, low socioeconomic status (SES) and the under-insured, immigrants, aged populations, racial and ethnic minority groups, and LGBTQIA communities. Many of these high-risk communities are diagnosed at much later stages than high SES whites. When lung cancer is detected early, survival rates are higher due to the possibility of curative surgery. Lung cancer screening (LCS) using low-density computed tomography (LDCT) has been recommended by the USPSTF since 2013. Guidelines for those who meet the USPSTF LCS criteria were expanded in 2021. A major barrier to accessing screening by vulnerable populations is the lack of health literate LCS education materials that can be used to engage and empower these groups and motivate them to seek screening. Research Question: How do we develop health literate (HL), culturally sensitive, and linguistically appropriate health information about LCS to high-risk communities and make them available through trusted community partners? Methods: A multi-phased approach that included material creation, testing, and dissemination was conceptualized by LUNGevity Foundation in partnership with Health Literacy Media (HLM) and a leading expert in accessible patient education. Using an IRB-approved protocol, the study team identified a representative population of persons (N=40 in 15 states) with online recruitment facilitated by NCI community cancer center outreach leaders in high-risk geographies. The participants gave extensive quantitative and qualitative feedback via virtual focus groups or in-depth interviews to obtain opinions and insights into how easily LUNGevity Foundation's Screening and Early Detection Booklet was understood. Revised materials were created using HL best practices, and re-tested with new community members to ensure acceptability, accessibility, and HL. Then, additional materials with relevant health topics were developed consistent with HL principles for extensive testing with communities. An additional 24 people in 11 states took part in 1 of 4, 1 ½ hour focus groups for final review. New HL lung cancer screening materials were made available to NCI community outreach leaders via LUNGevity Foundation's trusted national community engagement network. Results: The participants raised important insights about eligibility for and accessibility to screening. Based on their insights and recommendations, HLM transformed one large booklet into 4 fact sheets and 6 mini booklets. Final materials were disseminated to vulnerable populations via LUNGevity Foundation's trusted community engagement network. Conclusions: The feasibility of creating patient-centered health literate materials that also incorporate community engagement is established. Using LCS as an example, we were able to successfully create materials that were acceptable to high-risk communities. We recommend offering understandable and accessible information to all communities regardless of their literacy or education levels.

Citation Format: Jeanne M. Regnante, Upal Basu Roy, Catina O'Leary, Linda M. Fleisher, Diane W. Webb, Linda Wenger, Andrea Ferris, Robert Winn. Health literacy as a tool to drive equitable action for lung cancer screening in high-risk communities [abstract]. In: Proceedings of the AACR Virtual Conference: 14th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2021 Oct 6-8. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2022;31(1 Suppl):Abstract nr PO-064.

Defining comprehensive biomarker-related testing and treatment practices for advanced non-small-cell lung cancer: Results of a survey of U.S. oncologists

BACKGROUND

An ASCO taskforce comprised of representatives of oncology clinicians, the American Cancer Society National Lung Cancer Roundtable (NLCRT), LUNGevity, the GO2 Foundation for Lung Cancer, and the ROS1ders sought to: characterize U.S. oncologists' biomarker ordering and treatment practices for advanced non-small-cell lung cancer (NSCLC); ascertain barriers to biomarker testing; and understand the impact of delays on treatment decisions.

METHODS

We deployed a survey to 2374 ASCO members, targeting U.S. thoracic and general oncologists.

RESULTS

We analyzed 170 eligible responses. For non-squamous NSCLC, 97% of respondents reported ordering tests for EGFR, ALK, ROS1, and BRAF. Testing for MET, RET, and NTRK was reported to be higher among academic versus community providers and higher among thoracic oncologists than generalists. Most respondents considered 1 (46%) or 2 weeks (52%) an acceptable turnaround time, yet 37% usually waited three or more weeks to receive results. Respondents who waited ≥3 weeks were more likely to defer treatment until results were reviewed (63%). Community and generalist respondents who waited ≥3 weeks were more likely to initiate non-targeted treatment while awaiting results. Respondents <5 years out of training were more likely to cite their concerns about waiting for results as a reason for not ordering biomarker testing (42%, vs. 19% with ≥6 years of experience).

CONCLUSIONS

Respondents reported high biomarker testing rates in patients with NSCLC. Treatment decisions were impacted by test turnaround time and associated with practice setting and physician specialization and experience.

Knowledge and Practice Patterns Among Pulmonologists for Molecular Biomarker Testing in Advanced Non-small Cell Lung Cancer

BACKGROUND

Targeted therapies for advanced non-small cell lung cancer (NSCLC) with oncogenic drivers have caused a paradigm shift in care. Biomarker testing is needed to assess eligibility for these therapies. Pulmonologists often perform bronchoscopy, providing tissue for both pathologic diagnosis and biomarker analysis. We performed this survey to define the existing knowledge and practices regarding the pulmonologists' role in biomarker testing for advanced NSCLC.

RESEARCH QUESTION

What is the current knowledge and practice of pulmonologists regarding biomarker testing and targeted therapies in advanced NSCLC?

STUDY DESIGN AND METHODS

This cross-sectional study was performed using an electronic survey of a random sample of 7,238 pulmonologists. Questions focused on diagnostic steps and biomarker analyses for NSCLC.

RESULTS

A total of 453 pulmonologists responded. Respondents vary by reported lung cancer patient volume, ranging from 51% evaluating one to four new cases per month to 19% evaluating > 10 cases per month. Interventional training, academic practice setting, and higher volume of endobronchial ultrasound with transbronchial needle aspiration (EBUS-TBNA) were associated with increased knowledge of practice guidelines for the number of recommended passes during EBUS-TBNA (P < .05). Academic pulmonologists more commonly performed or referred for EBUS-TBNA than community pulmonologists (96% and 83%, respectively; P < .0005). Higher testing rates were associated with interventional training, academic setting, and the presence of an institutional policy, whereas lower testing rates were associated with general pulmonologists, practice in community settings, and lack of a guiding institutional policy (P < .05).

INTERPRETATION

Substantial differences among pulmonologists' evaluation of advanced NSCLC, variation in knowledge of available biomarkers and the importance of targeted therapies, and differences in institutional coordination likely lead to underutilization of biomarker testing. Interventional training appears to drive improved knowledge and practice for biomarker testing more than practice setting. Improvements are needed in tissue acquisition and interdisciplinary coordination to ensure universal and comprehensive testing for eligible patients.

Modernizing Clinical Trial Eligibility Criteria: Recommendations of the ASCO-Friends of Cancer Research Performance Status Work Group

PURPOSE

Performance status (PS) is one of the most common eligibility criteria. Many trials are limited to patients with high-functioning PS, resulting in important differences between trial participants and patient populations with the disease. In addition, existing PS measures are subjective and susceptible to investigator bias.

EXPERIMENTAL DESIGN

A multidisciplinary working group of the American Society of Clinical Oncology and Friends of Cancer Research evaluated how PS eligibility criteria could be more inclusive. The working group recommendations are based on a literature search, review of trials, simulation study, and multistakeholder consensus. The working group prioritized inclusiveness and access to investigational therapies, while balancing patient safety and study integrity.

RESULTS

Broadening PS eligibility criteria may increase the number of potentially eligible patients for a given clinical trial, thus shortening accrual time. It may also result in greater participant diversity, potentially reduce trial participant and patient disparities, and enable clinicians to more readily translate trial results to patients with low-functioning PS. Potential impact on outcomes was explored through a simulation trial demonstrating that when the number of Eastern Cooperative Oncology Group PS2 participants was relatively small, the effect on the estimated HR and power was modest, even when PS2 patients did not derive a treatment benefit.

CONCLUSIONS

Expanding PS eligibility criteria to be more inclusive may be justified in many cases and could result in faster accrual rates and more representative trial populations.See related commentary by Giantonio, p. 2369.

Line of therapy and patient preferences regarding lung cancer treatment: a discrete-choice experiment

OBJECTIVE

A growing literature on patient preferences informs decisions in research, regulatory science, and value assessment, but few studies have explored how preferences vary across patients with differing treatment experience. We sought to quantify patient preferences for the benefits and risks of lung cancer treatment and test how preferences differed by line of therapy (LOT).

METHODS

Preferences were elicited using a discrete choice experiment (DCE) following rigorous patient and stakeholder engagement. The DCE spanned five attributes (each with three levels): progression-free survival (PFS), short-term side effects, long-term side effects, risk of developing late-onset side effects, and mode of administration (MOA) - each defined across 3 relevant levels. A D-efficient design was used to generate 3 survey blocks of 9 paired-profile choice tasks each and respondents were asked which profile they preferred and then if they preferred to have no treatment (opt-out). A mixed logit model, controlling for opt-out, was used to estimate preferences. Preferences and trade-offs between PFS and other attributes were compared across two groups: those receiving ≤1 LOT and those receiving ≥2 LOT.

RESULTS

Of the 466 participants, 42% received ≤1 LOT and 58% received ≥2 LOT. Stated preferences differed between the groups overall (p<.001) and specifically for 18 months of PFS (p<.001), moderate short-term side effects (p<.001), no long-term side effects (p=.03), and 30% chance of late-onset side effects (p=.02). Those receiving differing amounts of LOT were willing to trade different amounts of PFS to change from moderate to mild short-term side effects (p<.001), moderate to no (p<.001) and mild to no (p<.001) long-term side effects. There were also differing amounts of tradeoff acceptable between the groups for a 10% decrease in risk of late-onset side effects (p=.016), a decrease in MOA from infusion every 3 weeks to pills taken daily at any time (p=.005) and from pills taken daily without food to pills taken daily at any time (p<.001).

CONCLUSION

We demonstrate differences in preferences based on experience with LOT, suggesting that patient treatment experience may have an impact on their preferences. As patient preference data become an important component of treatment decision making, preference differences should be considered when recommending therapies at different stages in the treatment journey. Understanding patient preferences regarding treatment decisions is essential to informing shared decision-making and ensuring treatment plans are consistent with patients' goals.

Abstract PO-096: A guide for development of a successful and inclusive lung cancer research strategy based on U.S. best practices

Disparities in clinical research are well-documented, and part of the broader health care disparities we see as a byproduct of systemic and institutional racism. COVID-19 vaccine and treatment development has greatly amplified the need for all communities to have the same opportunity to participate in research. Lack of representation of minorities in lung cancer clinical trials have been reported over the past 20 years. We have previously reported that there is a disconnect between U.S. lung cancer clinical trials placement and where patients with lung cancer reside, especially racial minorities. Both NCCN and ASCO guidelines suggest that clinical trials be considered the standard-of-care for advanced-stage non-small cell lung cancer and extensive-stage small cell lung cancer patients in first- and subsequent- line settings. In addition, participation in clinical trials has been associated with improved overall survival in lung cancer regardless of cancer stage, insurance and other prognostic factors. In order to provide better outcomes and achieve health equity for historically underserved populations, we must work together with all stakeholders to increase representation of diverse populations in lung cancer research. Our Question: What is a successful and sustainable multi-stakeholder framework that will result in inclusive lung cancer research in the US? Our methods will expand on previous work in the identification of notable practices where the focus was on successful pan-cancer inclusive clinical trial practices in 8 US cancer centers. We will include notable practices and recommendations of all stakeholders and focus on successful lung cancer inclusive research practices including behavioral research, community-based research and clinical research. We will conduct a robust environmental scan to identify strategies and standards, process and capabilities and roles. We will specifically identify tools and references to engage patients with lung cancer where applicable and interview identified experts based on practice themes representing all key stakeholder groups. Authors have identified 14 preliminary practice themes representing all key stakeholder groups to guide our framework development: Leadership & Goals; Protocol development; Operations and process; Data collection standards and reporting; Site selection, Health literacy & translation of recruitment materials including informed consent; Bilingual research staff; Community & Patient Engagement; PCP engagement; Digital capablities, Budget elements; Employee engagement and training; IRB Approval; Investigator meeting standards. Our framework is intended deliver the foundation for a theoretical underpinning of a evidenced based practical guide toward fostering collaboration amongst and between health care systems, academia, industry, health care leaders, PCPs, and patient organizations to promote successful inclusive research practices in lung cancer and will provide a roadmap for other disease areas.

Citation Format: Jeanne M. Regnante, Narjust Duma, Quita Highsmith, David E. Gerber, Lorna McNeill, Upal Basu Roy, Gerren Wilson, Mary Stober Murray, Andrea A. Ferris, Fabian Sandoval, Moon S. Chen, Jr. A guide for development of a successful and inclusive lung cancer research strategy based on U.S. best practices [abstract]. In: Proceedings of the AACR Virtual Conference: Thirteenth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2020 Oct 2-4. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(12 Suppl):Abstract nr PO-096.

Abstract PO-244: Geographic relationship between U.S. lung cancer screening sites and patient prevalence and demographics in the Medicare Fee-for-service program

Lung cancer (LC) is the leading cause of cancer mortality in the United States. Smoking history and age (55-80) are eligibility criteria for LC screening. Lung Cancer Screening Centers of Excellence (SCOE) is a designation of the Go2 Foundation for Lung Cancer, which recognizes medical facilities for high-quality low-dose CT screening for early detection and coordinated process for appropriate follow-up and treatment. It is critical to study the geographic relationship between US LC SCOEs and LC prevalence among Medicare beneficiaries to improve access to the cancer continuum of care (CCC), especially for racial and ethnic minorities (REMs). Research question: To what extent do LC SCOE accessibility reflect the reality of LC patient prevalence and demographics in the US? Methods This work builds off on earlier research related to the domains of the CCC established by the IOM/NASEM. Researchers used the following three primary data sources: (1) Medicare Fee-for- Service (FFS) patient-level claims data from 2016, including the following data elements: prevalence, co-morbidities, hospital encounters, and costs for patients with ICD-10 codes for NCSLC and SCLC, by demographic (age, gender, race, and ethnicity). Geographic levels included zip code, county and state and were designated as high (greater than 0.87%) or low (less than 0.87%) prevalence, based on national average prevalence. (2) Screening Center placement data was sourced from 2020 Go2 Foundation for SCOEs. Researchers added zip codes for each SCOE facilitate analysis. (3) Researchers mapped data on the Lung Cancer Index™, a National Minority Quality Forum (NMQF) geographic information system (GIS).

Preliminary Findings 1. There are 26,388 zip codes where Medicare beneficiaries with LC reside; of these, 7,757 zip codes (29.4%) show LC prevalence higher than the national average of 0.87%. 2. SCOEs are located in only 658 zip codes of the 26,388 zip codes with Medicare beneficiaries with LC. 3. There is variation in the location of SCOEs by LC prevalence. Only 99 of the 658 centers were located in areas of high prevalence suggesting that only 0.012% of high prevalence zip codes are served by SCOEs. 4. Additional analysis is ongoing to understand barriers to LC screening in areas with a high density of REMs, including examining prevalence of tobacco usage and in-depth interviews with community leaders. Conclusions Preliminary findings suggest that there is a dearth of Lung Cancer SCOEs in zip codes where there is a high prevalence among Medicare beneficiaries. The advent of precision medicine creates urgency to improve LC screening rates in general and especially for REMs, to generate equitable access to the cancer continuum of care. Lung cancer prevalence data can be a critical guide to screening center placement and care navigation.

Citation Format: Ingrid B. Piovanetti-Rivera, Upal Basu Roy, Jeanne M. Regnante, Taylor Stair, Mary Stober Murray. Geographic relationship between U.S. lung cancer screening sites and patient prevalence and demographics in the Medicare Fee-for-service program [abstract]. In: Proceedings of the AACR Virtual Conference: Thirteenth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2020 Oct 2-4. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(12 Suppl):Abstract nr PO-244.

Abstract PO-071: Collaborating to share evidence-based COVID-19 information across lung cancer patient advocacy groups

Background: The COVID-19 pandemic has presented an urgent and serious threat to multiple at-risk populations, including those with lung cancer (LC). This rapidly evolving crisis has seen a growing onslaught of information and guidance from multiple sources, much of which is confusing and conflicting. Thus, LC patient advocacy groups (PAGs) in the USA collaborated to share carefully vetted COVID-19 information for LC patients and caregivers online. Our goals were to gather evidence-based information that addressed concerns of LC patients and caregivers, translate it in a manner understandable for the general public, and share it with one voice across all LC nonprofits. This retrospective study examined whether the online LC community found this collaboration valuable and whether the weekly updates addressed useful topics in a trustworthy manner.

Methods: The first “Joint Statement on Coronavirus COVID-19 from Lung Cancer Advocacy Groups” was published on March 3, 2020. Updates were published most Mondays thereafter. We also produced an IASLC podcast. An online survey (conducted over a 5-day period in early June) asked USA LC patients and caregivers (1) if they were aware of the updates, (2) whether they found the updates useful, (3) which topic areas they found most helpful, and (4) what value they saw in the collaboration across LC advocacy groups. We also collected web statistics for each PAGs posts of this content.

Results: Cumulatively, online posts of the weekly updates received over 34,000 views between March 3 and the end of May and reached over 71,000 on Facebook. The podcast received twice the number of listens compared to the average of pre-COVID-19 podcasts on the IASLC and Soundcloud sites. Of the 83 LC patients and caregivers who responded to the online survey, three quarters were dealing with stage III or IV non-small cell LC, and half were older than 60. About 2/3 were aware of the weekly updates, and of those, over 80% found the statements helpful. The five most helpful topics were (1) effect of the pandemic on LC diagnosis, treatment, and clinical trials; (2) effect of the pandemic on LC research; (3) COVID-19 treatments and vaccines; (4) who is likely to have a severe case of COVID-19; and (5) what we know about developing immunity to COVID-19. Based on coding responses from an open-ended question, the majority of respondents found the collaboration valuable and trustworthy (for example, “Increased trust and credibility knowing all orgs are behind it”). The updates were found so valuable that they are also translated into Spanish by a pan-cancer Latin American PAG for their communities.

Conclusions: Lung cancer patients and caregivers, particularly those considered to be at higher risk for severe symptoms or death from COVID-19, found evidence-based, patient-focused collaborative updates about COVID-19 from major lung cancer PAGs informative, helpful, and trustworthy.

Citation Format: Amy C. Moore, Janet Freeman-Daily, Kim Norris, Becky Bunn, Jan Baranski, Cristina Chin, Upal Basu Roy. Collaborating to share evidence-based COVID-19 information across lung cancer patient advocacy groups [abstract]. In: Proceedings of the AACR Virtual Meeting: COVID-19 and Cancer; 2020 Jul 20-22. Philadelphia (PA): AACR; Clin Cancer Res 2020;26(18_Suppl):Abstract nr PO-071.

Abstract D081: Geographic relationship between lung cancer clinical trial sites and patient prevalence and demographics in the Medicare Fee-for-service program

Racial and ethnic minority groups have low rates of inclusion in cancer clinical trials (CCTs). For example, African American patients comprise 5% of patients enrolled in CCTs that support US Food and Drug Administration approval of new drugs but represent 13.3% of the general US population. Though cancer is the leading cause of death for Asian Americans, only 3% of CCTs is composed of Asian American participants. With the promise and rise of precision medicine, it is critical that study populations in clinical research reflect the changing US demographics. Expanding access to health data and analytics empower stakeholders to better understand and advocate for equitable research and treatment access in cancer. Research question: To what extent does the current US CCT site placement for non-small cell lung cancer (NCSLC) and small cell lung cancer (SCLC) reflect the reality of lung cancer patient prevalence and demographics in the US? Methods: Researchers used the following two primary data sources: (1) Medicare Fee-for-Service (FFS) patient-level claims data from 2016, including the following data elements: prevalence, co-morbidities, hospital encounters, and costs for patients with ICD-10 codes for NCSLC and SCLC, by demographic (age, gender, race, and ethnicity). Locations were designated as high (greater than 0.87%) or low (less than 0.87%) prevalence, based on national average prevalence. (2) CCT placement data was sourced from 2018 Clinical Trials.gov to determine ongoing NCLSC and SCLC studies where there are US study sites. Data were mapped on the Lung Cancer Index™, a National Minority Quality Forum (NMQF) geographic information system (GIS) with an interactive data warehouse and data visualization system, including geomapping. Preliminary data conclusions: 1) Of the 2812 interventional CCTs, the study team mapped 495 therapeutic, interventional, currently enrolling CCTs (after excluding trials for behavioral interventions and palliative care). 2) Of the 10015 zip codes mapped, 58.8% of those were designated as zones of high prevalence (HP) of lung cancer. Of the 5888 HP zip codes, only 10.5% had NSCLC trials and 5.6% percent had SCLC trials. 3) When analyzed by counties, of the 59% of counties with high prevalence of African American patients, only 3% and 1% of counties had more than 10 NSCLC trials and 10 SCLC trials respectively. Similarly, of the 24% of counties with high prevalence of Asian American lung cancer patients, only 3% and 1% of counties had more than 10 NSCLC and 10 SCLC trials respectively. Implications: While additional analyses are ongoing, preliminary findings suggest that there is a major disconnect between US lung CCT placement and where patients live. The advent of precision medicine creates urgency to improve CCT enrollment of racial and ethnic minority groups, for equitable benefit of resulting innovation and access to optimal treatment. Lung cancer prevalence, including by population demographics, at the zip code and county level can be a critical guide to CCT site placement.

Citation Format: Upal Basu Roy, Liou Xu, Laura Lee Hall, Gary Puckrein, Andrea Ferris, Jeanne Regnante. Geographic relationship between lung cancer clinical trial sites and patient prevalence and demographics in the Medicare Fee-for-service program [abstract]. In: Proceedings of the Twelfth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2019 Sep 20-23; San Francisco, CA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(6 Suppl_2):Abstract nr D081.

Grounding evaluation design in the socio-ecological model of health: a logic framework for the assessment of a national routine immunization communication initiative in Kyrgyzstan

Childhood routine immunization (RI) is a highly effective public health intervention for the prevention of infectious diseases. Despite high immunization rates, a 2018 Knowledge, Attitudes, and Practices (KAP) study by the United Nations Children's Fund (UNICEF) noted a growing practice of vaccine refusal among parents and primary caregivers as well as clusters of significantly lower immunization coverage in some provinces. Moreover, a 2018 Joint Appraisal report by GAVI (Global Vaccine Alliance) has highlighted a decrease in immunization rates among children under 1 year of age from 96.1% to 92% for some vaccines. As a result, UNICEF is spearheading a national communication initiative to increase the rates of RI in Kyrgyzstan. This initiative includes strengthening interpersonal communication skills of local healthcare workers, improving the quality and accuracy of media coverage via a tailored outreach to the Kyrgyz media, as well as fostering community engagement to give voice to local champions and engage hesitant parents and vaccine refuters. UNICEF has also partnered with a research team for the design phase of a suitable evaluation framework. Grounded in the socio-ecological model (SEM) of health, the framework recognizes the interconnection of behavioral, social, and policy change, and includes not only activity-specific indicators (process indicators) but also progress, outcome, and impact indicators to document results among key groups and stakeholders at different levels of the SEM, and, ultimately, on immunization rates in Kyrgyzstan. The framework reflects the importance of an integrated and multilevel approach to intervention and communication design, and integrates the SEM with a logic model that connects different components of the initiative. This paper introduces this evaluation framework, including implications for the evaluation of child health programs, and other public health, communication, and international development interventions.

Expanding Access to Lung Cancer Clinical Trials by Reducing the Use of Restrictive Exclusion Criteria: Perspectives of a Multistakeholder Working Group

Low rates of adult patient participation have been a persistent problem in cancer clinical trials and have continued to be a barrier to efficient drug development. The routine use of significant exclusion criteria has contributed to this problem by limiting participation in studies and creating significant clinical differences between the study cohorts and the real-world cancer patient populations. These routine exclusions also unnecessarily restrict opportunities for many patients to access potentially promising new therapies during clinical development. Multiple efforts are underway to broaden eligibility criteria, allowing more patients to enroll in studies and generating more robust data regarding the effect of novel therapies in the population at large. Focusing specifically on lung cancer as an example, a multistakeholder working group empaneled by the LUNGevity Foundation identified 14 restrictive and potentially outdated exclusion criteria that appear frequently in lung cancer clinical trials. As a part of the project, the group evaluated data from multiple recent lung cancer studies to ascertain the extent to which these 14 criteria appeared in study protocols and played a role in excluding patients (screen failures). The present report describes the working group's efforts to limit the use of these routine exclusions and presents clinical justifications for reducing the use of 14 criteria as routine exclusions in lung cancer studies, potentially expanding trial eligibility and improving the generalizability of the results from lung cancer trials.

US Cancer Centers of Excellence Strategies for Increased Inclusion of Racial and Ethnic Minorities in Clinical Trials

PURPOSE:

Participation of racial and ethnic minority groups (REMGs) in cancer trials is disproportionately low despite a high prevalence of certain cancers in REMG populations. We aimed to identify notable practices used by leading US cancer centers that facilitate REMG participation in cancer trials.

METHODS:

The National Minority Quality Forum and Sustainable Healthy Communities Diverse Cancer Communities Working Group developed criteria by which to identify eligible US cancer centers—REMGs comprise 10% or more of the catchment area; a 10% to 50% yearly accrual rate of REMGs in cancer trials; and the presence of formal community outreach and diversity enrollment programs. Cancer center leaders were interviewed to ascertain notable practices that facilitate REMG accrual in clinical trials.

RESULTS:

Eight cancer centers that met the Communities Working Group criteria were invited to participate in in-depth interviews. Notable strategies for increased REMG accrual to cancer trials were reported across five broad themes: commitment and center leadership, investigator training and mentoring, community engagement, patient engagement, and operational practices. Specific notable practices included increased engagement of health care professionals, the presence of formal processes for obtaining REMG patient/caregiver input on research projects, and engagement of community groups to drive REMG participation. Centers also reported an increase in the allocation of resources to improving health disparities and increased dedication of research staff to REMG engagement.

CONCLUSION:

We have identified notable practices that facilitate increased participation of REMGs in cancer trials. Wide implementation of such strategies across cancer centers is essential to ensure that all populations benefit from advances in an era of increasingly personalized treatment of cancer.

HSR19-099: Harnessing the Voice of Patients With Genetic Mutations in NSCLC Treatment

Background: Targeted therapies for non-small lung cancer (NSCLC) have vastly improved survival and other outcomes for patients whose tumors have genetic mutations such as ALK, BRAF, EGFR, and ROS1. Identification of genetic mutations often indicates a mutation-specific course of therapy; however, the relationship between genetic mutation status, patient treatment preferences, and other determinants of patient value in NSCLC cancer care is not well understood. Methods: Qualitative study utilizing focus groups and in-depth interviews were conducted with metastatic NSCLC patients who had received systemic therapy. Interviews explored how patients valued and prioritized factors and attributes associated with NSCLC therapy. Interviews were audio-recorded, transcribed, and coded for key themes using MAXQDA qualitative data analysis software (VERBI, GmbH). Thematic analysis identified determinants of value that patients with genetic mutations considered most important in decision-making. Results: Of 19 total participants with metastatic NSCLC (mean [SD] age, 55.8 [12.6] years; 79% female), 15 (79%) reported a known genetic mutation. Most participants valued oncogene testing and indicated that they had developed a distinct identity based on their specific mutation. Further, participants in our study with identified mutations reported facing distinctly different decisions than those without known mutations. Participants also highlighted unmet needs for diagnosis, treatment, and support tailored to their patient subgroup, including a critical need for better provider training and awareness of genetic testing and mutation-specific treatment options. Across patient subgroups, mutation-specific social media and support networks were highly valued for the care and treatment information they provide, especially among those with rare mutations, limited treatment options, or less-experienced providers. Conclusions: Our study suggests important differences among NSCLC patients based on identified genetic mutations. As treatment for NSCLC evolves, so do the needs and preferences of patients, especially those with driver mutations. Our findings highlight the need for a better understanding of how mutation status may impact patient goals and preferences in order to provide the highest value care to each patient.

Myeloid Zinc Finger 1 and GA Binding Protein Co-Operate with Sox2 in Regulating the Expression of Yes-Associated Protein 1 in Cancer Cells

The transcription factor (TF) yes-associated protein 1 (YAP1) is a major effector of the tumor suppressive Hippo signaling pathway and is also necessary to maintain pluripotency in embryonic stem cells. Elevated levels of YAP1 expression antagonize the tumor suppressive effects of the Hippo pathway that normally represses YAP1 function. High YAP1 expression is observed in several types of human cancers and is particularly prominent in cancer stem cells (CSCs). The stem cell TF Sox2, which marks and maintains CSCs in osteosarcomas (OSs), promotes YAP1 expression by binding to an intronic enhancer element and YAP1 expression is also crucial for the maintainance of OS stem cells. To further understand the regulation of YAP1 expression in OSs, we subjected the YAP1 intronic enhancer to scanning mutagenesis to identify all DNA cis-elements critical for enhancer function. Through this approach, we identified two novel TFs, GA binding protein (GABP) and myeloid zinc finger 1 (MZF1), which are essential for basal YAP1 transcription. These factors are highly expressed in OSs and bind to distinct sites in the YAP1 enhancer. Depletion of either factor leads to drastically reduced YAP1 expression and thus a reversal of stem cell properties. We also found that YAP1 can regulate the expression of Sox2 by binding to two distinct DNA binding sites upstream and downstream of the Sox2 gene. Thus, Sox2 and YAP1 reinforce each others expression to maintain stemness and tumorigenicity in OSs, but the activity of MZF1 and GABP is essential for YAP1 transcription. Stem Cells 2017;35:2340-2350.

Two FGF Receptor Kinase Molecules Act in Concert to Recruit and Transphosphorylate Phospholipase Cγ

The molecular basis by which receptor tyrosine kinases (RTKs) recruit and phosphorylate Src Homology 2 (SH2) domain-containing substrates has remained elusive. We used X-ray crystallography, NMR spectroscopy, and cell-based assays to demonstrate that recruitment and phosphorylation of Phospholipase Cγ (PLCγ), a prototypical SH2 containing substrate, by FGF receptors (FGFR) entails formation of an allosteric 2:1 FGFR-PLCγ complex. We show that the engagement of pTyr-binding pocket of the cSH2 domain of PLCγ by the phosphorylated tail of an FGFR kinase induces a conformational change at the region past the cSH2 core domain encompassing Tyr-771 and Tyr-783 to facilitate the binding/phosphorylation of these tyrosines by another FGFR kinase in trans. Our data overturn the current paradigm that recruitment and phosphorylation of substrates are carried out by the same RTK monomer in cis and disclose an obligatory role for receptor dimerization in substrate phosphorylation in addition to its canonical role in kinase activation.

Community-led cancer action councils in Queens, New York: process evaluation of an innovative partnership with the Queens library system

INTRODUCTION

Community-based participatory research (CBPR) has great potential to address cancer disparities, particularly in racially and ethnically diverse and underserved neighborhoods. The objective of this study was to conduct a process evaluation of an innovative academic-community partnership, Queens Library HealthLink, which aimed to reduce cancer disparities through neighborhood groups (Cancer Action Councils) that convened in public libraries in Queens, New York.

METHODS

We used a mixed-methods approach to conduct 69 telephone survey interviews and 4 focus groups (15 participants) with Cancer Action Council members. We used 4 performance criteria to inform data collection: action or attention to sustainability, library support for the council, social cohesion and group leadership, and activity level. Focus group transcripts were independently coded and cross-checked for consensus until saturation was achieved.

RESULTS

Members reported benefits and barriers to participation. Thirty-three original focus group transcript codes were organized into 8 main themes related to member experiences: 1) library as a needed resource, 2) library as a reputable and nondenominational institution, 3) value of library staff, 4) need for a HealthLink specialist, 5) generation of ideas and coordination of tasks, 6) participation challenges, 7) use of community connections, and 8) collaboration for sustainability.

CONCLUSION

In response to the process evaluation, Cancer Action Council members and HealthLink staff incorporated member suggestions to improve council sustainability. The councils merged to increase intercouncil collaboration, and institutional changes were made in funding to sustain a HealthLink specialist beyond the grant period.

Early onset of craniosynostosis in an Apert mouse model reveals critical features of this pathology

Activating mutations of FGFRs1-3 cause craniosynostosis (CS), the premature fusion of cranial bones, in man and mouse. The mechanisms by which such mutations lead to CS have been variously ascribed to increased osteoblast proliferation, differentiation, and apoptosis, but it is not always clear how these disturbances relate to the process of suture fusion. We have reassessed coronal suture fusion in an Apert Fgfr2 (S252W) mouse model. We find that the critical event of CS is the early loss of basal sutural mesenchyme as the osteogenic fronts, expressing activated Fgfr2, unite to form a contiguous skeletogenic membrane. A mild increase in osteoprogenitor proliferation precedes but does not accompany this event, and apoptosis is insignificant. On the other hand, the more apical coronal suture initially forms appropriately but then undergoes fusion, albeit at a slower rate, accompanied by a significant decrease in osteoprogenitor proliferation, and increased osteoblast maturation. Apoptosis now accompanies fusion, but is restricted to bone fronts in contact with one another. We correlated these in vivo observations with the intrinsic effects of the activated Fgfr2 S252W mutation in primary osteoblasts in culture, which show an increased capacity for both proliferation and differentiation. Our studies suggest that the major determinant of Fgfr2-induced craniosynostosis is the failure to respond to signals that would halt the recruitment or the advancement of osteoprogenitor cells at the sites where sutures should normally form.