Analysis of Intent and Reason for Oncologic Therapy Administration in Cancer Patients Admitted to the Intensive Care Unit

Purpose To investigate the intent of, and reason for, administration of oncologic therapies in the intensive care unit (ICU). Methods Single center, retrospective, cohort study of patients with cancer who received oncologic therapies at a tertiary cancer center ICU between April 1, 2019 and March 31, 2020. Oncologic therapies included traditional cytotoxic chemotherapy, targeted therapy, immunotherapy, hormonal or biologic therapy directed at a malignancy and were characterized as initiation (initial administration) or continuation (part of an ongoing regimen). Results 84 unique patients (6.8% of total ICU admissions) received oncologic therapies in the ICU; 43 (51%) had hematologic malignancies and 41 (49%) had solid tumors. The intent of oncologic therapy was palliative in 63% and curative in 27%. Twenty-two (26%) patients received initiation and 62 (74%) received continuation oncologic therapies. The intent of oncologic therapy was significantly different by regimen type (initiation vs. continuation, p = <0.0001). Initiation therapy was more commonly prescribed with curative intent and continuation therapy was more commonly administered with palliative intent (p = <0.0001). Oncologic therapies were given in the ICU mainly for an oncologic emergency (56%) and because the patients happened to be in the ICU for a non-oncologic critical illness when their oncologic therapy was due (34.5%). Conclusion Our study provides intensivists with a better understanding of the context and intent of oncologic therapies and why these therapies are administered in the ICU.

Health-related quality of life one year after the diagnosis of oesophageal cancer: a population-based study from the Swedish National Registry for Oesophageal and Gastric Cancer

Background Population-based patient reported outcome data in oesophageal cancer are rare. The main purpose of this study was to describe health-related quality of life (HRQOL) 1 year after the diagnosis of oesophageal cancer, comparing subgroups of curatively and palliatively managed patients. Methods This is a nationwide population-based cohort study, based on the Swedish National Registry for Oesophageal and Gastric Cancer (NREV) with prospectively registered data, including HRQOL instruments from the European Organisation for Research and Treatment of Cancer including the core and disease specific questionnaires (EORTC QLQ-C30 and QLQ-OG25). Patients diagnosed with oesophageal cancer between 2009 and 2016 and with complete HRQOL data at 1 year follow-up were included. HRQOL of included patients was compared to a reference population matched by age and gender to to a previous cohort of unselected Swedish oesophageal cancer patients. Linear regression was performed to calculate mean scores with 95% confidence intervals (CI) and adjusted linear regression analysis was used to calculate mean score differences (MD) with 95% CI. Results A total of 1156 patients were included. Functions and global health/quality of life were lower in both the curative and palliative cohorts compared to the reference population. Both curatively and palliatively managed patients reported a severe symptom burden compared to the reference population. Patients who underwent surgery reported more problems with diarrhoea compared to those treated with definitive chemoradiotherapy (dCRT) (MD -14; 95% CI − 20 to − 8). Dysphagia was more common in patiens treated with dCRT compared to surgically treated patients (MD 11; 95% CI 4 to 18). Those with palliative intent due to advanced tumour stage reported more problems with dysphagia compared to those with palliative intent due to frailty (MD -18; 95% CI − 33 to − 3). Conclusions One year after diagnosis both curative and palliative intent patients reported low function scores and severe symptoms. Dysphagia, choking, and other eating related problems were more pronounced in palliatively managed patients and in the curative intent patients treated with dCRT.

Outcomes of COVID-19 and risk factors in patients with cancer - a cohort study

Background Patients with cancer who develop COVID-19 are at higher risk for severe disease and death. We aimed to study the outcomes of patients with cancer who were infected with SARS CoV2, and identify risk factors for adverse outcomes after COVID-19. Methods We included patients with cancer, who were diagnosed with SARS CoV2 between 11th April 2020 and February 2021 at a tertiary referral cancer centre in India. We collected data on age, sex, coexisting medical conditions, type of cancer, intent of cancer management, cancer treatment details, and severity and outcome of COVID-19. The primary outcome was a composite of severe COVID (defined as grade 6 or more on the WHO ordinal scale) or death within 30 days. We performed multivariable logistic regression analysis to identify risk factors for severe COVID or death. Results We obtained data on 1253 patients with cancer and SARS CoV2 infection, of whom 293 (23.6%) had hematological malignancies. The severity of COVID was mild (grade 1 to 3 on WHO ordinal scale) in 1014 (81%) patients, moderate (WHO grade 4 or 5) in 167 (13%) patients and severe (WHO grade 6 or 7) in 72 (6%) patients. The primary outcome was seen in 160 patients (12.8%) and the all-cause 30-day mortality was 10.9% (138 deaths). Advanced age [adjusted OR 1.84 (0.86; 3.94)], history of smoking [aOR 1.78 (1.10; 2.91)], palliative intent of treatment [aOR 3.57 (2.48 to 5.12)] and presence of more than 2 comorbidities [aOR 1.66 (1.03 to 2.67)] were significant risk factors for severe COVID or death. Advanced age and palliative intent of treatment remained significant risk factors for 30-day mortality. Recent systemic anti-cancer therapy, sex or cancer type did not influence outcomes. Conclusion Most patients with cancer who developed COVID-19 in our setting had mild disease; the elderly and those treated with palliative intent were at higher risk of severe COVID-19 or death. Recent cancer therapy did not impact COVID-19 severity or outcomes suggesting that in most patients with cancer, the management of cancer should continue uninterrupted during the pandemic.

Long-term cancer survivors treated with multiple courses of repeat radiation therapy

Introduction and background Through recent advances in cancer care, the number of long-term survivors has continuously increased. As a result, repetitive use of local radiotherapy for curative or palliative indications might have increased as well. This analysis aims to describe patterns of care and outcome of patients treated with multiple courses of repeat radiotherapy. Materials and methods All patients treated with radiotherapy between 2011 and 2019 at our department of Radiation Oncology were included into this analysis. A course of radiotherapy was defined as all treatment sessions to one anatomical site under one medical indication. Demographics, cancer and treatment characteristics and overall survival of patients having undergone multiple radiotherapy courses (minimum n = 5) were evaluated. Results The proportion of cancer patients treated with a minimum five courses of radiotherapy increased continuously from 0.9% in 2011 to 6.5% in 2019. In the 112 patients treated with a minimum of five radiotherapy courses, the primary tumor was lung in 41.9% (n = 47), malignant melanoma in 8.9% (n = 10) and breast in 8.0% (n = 9) of cases. A median interval of 3 years (maximum 8 years) elapsed between the first and the last radiotherapy course. The maximum number of courses in a single patient were n = 10. Treatment intent was curative or palliative in 46.4% and 53.6% for the first radiotherapy, respectively. The proportion of curative intent decreased to 11.6% at the 5th, and the last radiotherapy course was following a palliative intent in all patients. Five-year overall survival measured from the 1st radiotherapy course was 32.7%. Median overall survival was 3.3, 2.4, 1.3, and 0.6 years when measured from the 1st, the 1st palliative, the 5th and last course of radiotherapy, respectively. Discussion and conclusion A continuously increasing number of patients is treated with multiple courses of radiotherapy throughout their long-term cancer survivorship.

EP.FRI.274 Nasogastric decompression in small bowel obstruction

Aim The aim of this study is to review the surgeon’s compliance and efficacy of nasogastric decompression in management of small bowel obstruction. Method This is a retrospective 6 months study from 1st January 2020 to 30th June 2020. Results 73 patients were managed for SBO during this period. Adhesions (43.8%) was identified as the most common cause of small bowel obstruction followed by hernias (27.4%). 51 (70%) patients had nasogastric decompression planned on admission, although there was history of vomiting in 85% of patients at admission. Forty two patients (58%) had nasogastric decompression. Majority (71%) of these patients had NG inserted within 24 hours, only 2 of these patients had it inserted on admission. Of the 44 patients managed conservatively for their SBO, 19 had NG decompression. Two patients died during admission (both managed with palliative intent). Conclusion The routine use of nasogastric decompression in SBO is still common despite the lack of randomized control trial. Its use is associated with an increase in duration of hospital stay. Although the optimal timing of placement of NG tube is not known, our study shows that placement within 6 hours of admission may shorten the duration of hospital stay.

Electrochemotherapy as a Trigger to Overcome Primary Resistance to Anti-PD-1 Treatment: A Case Report of Melanoma of the Scalp

BackgroundImmunotherapy with immune checkpoint inhibitors is one of the main therapies for advanced melanoma. Nevertheless, albeit remarkable, immunotherapy results are still unsatisfactory as more than half of patients progress, and resistance to treatment still has a dramatic impact on clinical outcomes. Local treatments such as radiotherapy or electrochemotherapy (ECT), in addition to local control with palliative intent, have been shown to release tumoral neoantigens that can stimulate a robust systemic antitumor immune response.Case PresentationWe report the case of a patient with multiple nodular melanoma lesions of the scalp initially treated with local ECT. Soon after the procedure, multiple new lesions appeared close to the treated ones, therefore the patient started a systemic treatment with the anti-PD-1 nivolumab. The lesions of the scalp did not respond to immunotherapy, presenting a loco-regional spreading. To control the bleeding and painful lesions, we performed a second ECT, while continuing systemic immunotherapy. The treated lesions responded to the second procedure, while the other lesions continued progressing in number and dimension. Unexpectedly, after 2 months from the second ECT, the patient presented a progressive shrinkage of both treated and untreated lesions until complete remission. Concomitantly, he developed immune-related adverse events including grade 4 thyroid toxicity, grade 2 vitiligo-like depigmentation and grade 2 pemphigoid. At present, after 18 months from the first ECT and 14 months from the starting of anti-PD-1 immunotherapy, the patient is in good clinical condition and complete remission of disease still persists.ConclusionThis case highlights the potential role of ECT in increasing tumor immunogenicity and consequently in inducing a powerful immune response overcoming primary resistance to checkpoint inhibitor immunotherapy.

Early response evaluation using 18F-FDG-PET/CT does not influence management of patients with metastatic gastrointestinal stromal tumors (GIST) treated with palliative intent

Aim The aim of this study was to investigate the impact of 18F-FDG-PET/CT on treatment decision making in metastatic gastrointestinal stromal tumor (GIST) patients. Methods This study retrospectively evaluated 18F-FDG-PET/CT scans to monitor response of metastatic GIST patients treated with palliative intent. Data from the Dutch GIST Registry was used. Early scans (<10 weeks after start of treatment) and late scans (>10 weeks after start of treatment) were scored on the impact in change of treatment. Results Sixty-one PET/CT scans were performed for treatment evaluation in 39 patients with metastatic GIST of which 36 were early scans and 25 were late scans. Early PET/CT scans led to a change in management in 5.6% of patients and late PET/CT scans led to a change in management in 56% of patients. Change in management was more often seen after scans with lack of metabolic response (48% vs. 11% in scans with metabolic response, p=0.002). Neither metabolic response nor change in treatment were more often seen in patients with KIT mutations compared to patients with non-KIT mutations (metabolic response 65% KIT vs. 46% non-KIT, p=0.33, and change in management 28% KIT vs. 21% non-KIT, p=0.74). Conclusion 18F-FDG-PET/CT is not recommended for early response evaluation in an unselected patient population with metastatic GIST, since it does not influence treatment decisions. 18F-FDG-PET/CT, however, can be useful for late response assessment, especially in case of indeterminate CT results.

1060 Upper Tract Urothelial Carcinoma (UTUC) – What Can We Learn from Historical Cases

Background UTUC has a poor prognosis with many patients presenting late, often without cardinal symptoms such as visible haematuria. Aims of this study were to assess presenting features, diagnostic tests and outcomes of patients with UTUC. Method Retrospective data collection was performed for patients diagnosed with UTUC (ureteric /renal) between Jan 2013-Dec 2017. Data was collected on demographics, presenting features, diagnostic tests, presence of concurrent bladder UC and outcome/survival. Results 67 patients were diagnosed with UTUC, 37 renal pelvis and 30 ureteric. The median age was 74 years (Range 49-90 years), M:F-2:1. 39 (58.2%) presented with haematuria, 1 having non-visible. 9 (13.4%) had loin pain, 4 (6.0%) systemic features (weight loss/lethargy), 15 (22.4%) other (detected on surveillance imaging, renal impairment). 61 had an USS of which 12 (19.7%) were normal and 49 demonstrated hydronephrosis or mass (80.3%). 21 (31.3%) had concurrent bladder UC. 9 (13.4%) prior to UTUC diagnosis (2 post cystectomy and 7 prior superficial UC) and 12 post diagnosis. 50 (74.6%) of UTUC were treated curatively with surgery and 17 (25.4%) palliated. The 2- and 5-year survival for those treated with curative intent was 79.9% and 58.5% compared to 31.25 and 7.5% for those treated with palliative intent. Conclusions Most patients with UTUC presented with visible hematuria, pain, or systemic features. USS has a high sensitivity, but cases will still be missed. The presence of prior bladder cancer is a significant risk factor and regular upper tract monitoring should be performed in high-risk patients (post-cystectomy, high-risk non muscle-invasive UC).

545 Assessing the Impact Of COVID-19 On the Diagnosis and Management of Bladder Cancer in The United Kingdom – The West Midlands Experience

Introduction The British Association of Urological Surgeons (BAUS) issued an interim strategy for the management of bladder cancer as a contingency measure during the COVID-19 pandemic. We aim to assess the actual implementation of these recommendations and deviation from the standard of care in the West Midlands. Method A questionnaire was devised and sent to bladder cancer leads of 12 NHS Trusts in the region in June 2020. Responses were analysed and compared with the BAUS COVID-19 strategy. Results 11 centres were aware of the BAUS COVID-19 strategy. 2 centres were offering teleconsultations only for 2-week-wait referrals, and 6 centres had changed their practice for non-visible haematuria referrals. All centres were offering TURBTs for new and high-risk tumours. 8 centres had clear MDT documentation of NICE risk-stratifications of all bladder tumours and 10 centres were also documenting any changes in treatment. Only 7 centres continued to give BCG to newly diagnosed NMIBC. All centres continued with staging CT for newly diagnosed MIBC. Patients were still being referred for cystectomies, however few were performed. Radiation as curative and palliative intent continued. Of the 5 regional cancer centres, only 1 continued with cystectomies as normal, whereas 2 performed the procedure on a case-by-case basis, and the procedure was delayed/deferred in the other 2 centres. Conclusions Diagnostics, and definitive management of bladder cancer has been severely affected by COVID-19. In particular, deferred intravesical BCG and delayed radical treatment can have a dire impact on the long-term outcomes of the patients presenting during the pandemic.