Inflammation-based Indexes Upon Adjuvant Chemotherapy Initiation as a Predictor of Relapse After Curative Resection of Colorectal Cancer With an Oxaliplatin-based Regimen

Background/Aim: We investigated the clinical efficacy of inflammation-based indexes in predicting unfavourable relapse-free survival (RFS) in patients with stage II/III colorectal cancer (CRC) receiving oxaliplatin-based adjuvant chemotherapy. Patients and Methods: A retrospective analysis was performed on 45 patients who underwent curative resection for stage II/III CRC followed by oxaliplatin-based adjuvant chemotherapy after 8 weeks. Upon adjuvant chemotherapy initiation, all patients were evaluated for lymphocyte count (LC), neutrophil/lymphocyte ratio (NLR), lymphocyte/monocyte ratio (LMR), platelet/lymphocyte ratio (PLR), modified Glasgow Prognostic Score (mGPS) and prognostic nutritional index (PNI), after which their correlation with relapse was analysed. Results: Univariate analysis identified LC <1,350/mm3, NLR ≥2.03, LMR <5.15, PLR ≥209, mGPS 2, and early discontinuation of chemotherapy within two months as significant risk factors for RFS. Multivariate analysis identified LMR <5.15, PLR > 209 and mGPS 2 as significant independent risk factors for unfavourable RFS. Conclusion: Measurement of LMR, PLR, and mGPS upon adjuvant therapy initiation can be a useful tool for predicting recurrence after curative surgery for stage II/III CRC.

Prevalence of soil-transmitted helminth infections, schistosomiasis, and lymphatic filariasis before and after preventive chemotherapy initiation in the Philippines: A systematic review and meta-analysis

Objective To estimate the impact of preventive chemotherapy on the prevalence and intensity of soil-transmitted helminth (STH) infections, schistosomiasis, and lymphatic filariasis in the Philippines, using systematic review and meta-analysis. Methods We included reports reporting prevalence of STH infections, schistosomiasis, or lymphatic filariasis in the Philippines published until 31 March 2021. Peer-reviewed studies were identified in electronic databases. Grey literature reports by the University of the Philippines and the Department of Health were also included. Pooled infection prevalence, before and after the initiation of preventive chemotherapy, stratified by age group, was calculated using the inverse variance heterogeneity model. Findings A total of 109 reports were included in the review and meta-analysis. Overall prevalence of moderate-heavy intensity Ascaris lumbricoides (6.6%) and Trichuris trichiura (2.7%) infection after initiation of preventive chemotherapy were significantly lower than the prevalence prior to initiation (23.6% for A. lumbricoides and 12.2% for T. trichiura). Prevalence reductions were also found in school and preschool-age children for A. lumbricoides and T. trichiura. Studies conducted after preventive chemotherapy initiation had significantly lower overall prevalence of moderate-heavy intensity schistosomiasis (3.1% vs 0.2%) and of schistosomiasis in school-age children (30.5% vs 1%). Pooled prevalence of lymphatic filariasis prior to preventive chemotherapy initiation was 3.2% across 12 provinces, while currently only two provinces still have prevalence of more than 1%. There were no published studies reporting prevalence of lymphatic filariasis after initiation of preventive chemotherapy. Heterogeneity was high with I2 mostly above 90%. Conclusion The burden of STH infections and schistosomiasis in children were significantly lower in studies conducted following the initiation of preventive chemotherapy. Eliminating morbidity and interrupting transmission, however, may require expanded control initiatives including community-wide treatment, and improved water, sanitation, and hygiene. Lymphatic filariasis burden has decreased since the implementation of preventive chemotherapy, with all but two provinces having reached the elimination of lymphatic filariasis as a public health problem.

Older Age Instead of Body Mass Index Predicts Cancer-Associated Thrombosis: Validation of Khorana Score in Cancer Patients Undergoing Chemotherapy with East Asian Ethnicity

Khorana score has been the most widely used for the prediction of cancer-associated thrombosis (CAT) and recent pivotal phase III trials including AVERT and CASSINI adopted Khorana score in the inclusion criteria. However, most studies in development and use of Khorana score were conducted in Western cancer patients. The prevalence of VTE is known to be substantially lower in Asians than in the Western population. In case of body mass index (BMI), experts suggest an adjusted cut-off points of the classification of weight status in Asian population since they are usually thinner than Westerners. In addition, risk of CAT according to the sites of cancer may need reassessment since the characteristics of each site of cancer varies among geographic regions or ethnicity. For those reasons, we thought that Khorana score needs to be separately validated in Asian population and conducted a retrospective real-world analysis. By using the Observational Medical Outcomes Partnership Common Data Model (OMOP-CDM), we collected de-identified data of the newly diagnosed cancer patients who underwent chemotherapy from January 2016 to June 2019 at Seoul National University Hospital (SNUH), Seoul, South Korea. Patients were eligible if they 1) had a new diagnosis code of cancer and 2) had initiated chemotherapy within 3 months after the first recoding of the cancer diagnosis. The patients undergoing chemotherapy were identified based on their prescription of chemotherapeutic agents and the procedural code for the first-time patient education for chemotherapy. Among the selected cancer patients, values of complete blood cell counts (CBC), body weight, and height on the very day of or the day closest to the chemotherapy initiation were obtained. A patient was counted as having a VTE if he or she had both newly-recorded diagnosis code of VTE and new record of anticoagulant medication code within 1 week after the emergence of VTE diagnosis code. Cumulative incidence of CAT was estimated at the time of 3, 6, and 12 months after the date of chemotherapy initiation. A total of 10,588 patients with cancer and chemotherapy were eligible and only 1.33% (141 patients) had a CAT at 6 months after the chemotherapy initiation, suggesting lower overall incidence of CAT in Asian population. Pancreas (4.9%) was the most common primary cancer site but CAT incidence rate in patients with stomach cancer was limited to 1.6%, reflecting different characteristics of the disease between the East and the West. The CAT incidences in patients with lung cancer (1.4%) and lymphoma (1.1%) were lower than expected, in line with a recent meta-analysis (Mulder at al.; Haematologica 2019), but CAT incidences in patients with liver (3.4%) and biliary (3.0%) cancer were higher than expected considering the Khorana scoring system. Among 7,431 patients who had all data for the calculation of Khorana score, 5,549 patients (74.7%) had a BMI of &lt; 25 kg/m 2, followed by 1,633 patients (15.4%) with a BMI of 25.0-29.9 kg/m 2. Only 39 patients (0.4%) had a BMI of 35 &gt; kg/m 2, showing the difference of BMI distribution according to the ethnicity. Moreover, BMI was not associated with CAT development at all, whereas the 3 CBC parameters and the site of cancers were associated with CAT occurrence. In addition, patients who aged ≥ 65 years had significantly higher CAT risk compared to younger group. In a multivariate regression analysis (Table 1), age ≥ 65 years, leukocyte ≥ 11 x 10 3/μL, and sites of cancers were independently associated with the development of CAT. Hemoglobin &lt; 10 g/dL and platelet ≥ 350 x 10 3/μL showed a tendency of association but failed to reach statistical significance. When we classified the 7,431 patients according to the Khorana scoring system, 8.0% of the patients were considered as high risk group and their incidence of CAT at 6 months was 3.36% (Table 2), showing a smaller proportion of patients assigned to high risk group and their lower absolute risk of CAT compared to Western population. In conclusion, Khorana scoring system was only partially validated in Korean cancer patients who underwent first-line chemotherapy: BMI was not but older age was a good predictor for the prediction of CAT occurrence. Weighing the risk of CAT according to the sites of cancers also needs some improvement. Further studies for better CAT risk stratification reflecting ethnic or regional differences are warranted. Figure 1 Figure 1. Disclosures No relevant conflicts of interest to declare.

Understanding Hematological Adverse Event Management through Health Care Resource Utilization, Costs, and Treatment Patterns of Patients with Extensive-Stage Small Cell Lung Cancer Treated in the Community Oncology Setting

BACKGROUND: Myelosuppressive hematological adverse events (anemia, neutropenia, and thrombocytopenia) are common complications of chemotherapy among cancer patients. Cytotoxic chemotherapy remains the cornerstone of treatment for extensive stage small cell lung cancer (ES-SCLC). This study assessed the health care resource utilization (HCRU), costs, and treatment patterns associated with myelosuppressive hematological adverse events (HAEs) among ES-SCLC patients treated with chemotherapy in the community oncology setting. METHODS: A retrospective observational study was conducted using The US Oncology Network iKnowMed electronic health records data from 1/1/2015 to 12/31/2020. Adult patients with ES-SCLC who initiated chemotherapy (chemotherapy alone or chemotherapy in combination with immunotherapy) between 1/1/2015 and 12/31/2019 were identified and further stratified into two study cohorts: with grade ≥3 HAE vs. without grade ≥3 HAE after chemotherapy initiation. Date of chemotherapy initiation was considered as the index date. Patients were followed longitudinally from index date until 12/31/2020, death or last patient record, whichever came first. HAEs were identified using iKnowMed structured data for laboratory values based on Common Terminology Criteria for Adverse Events v5.0 definitions for anemia, neutropenia, and thrombocytopenia. Health care resource utilization and outpatient costs, and treatment patterns were evaluated for both cohorts. Inpatient costs or costs for transfusions were not included due to data limitation. RESULTS: 778 patients had at least one grade ≥3 HAEs after the chemotherapy initiation (50.3% with grade 3 anemia, 46.0% with grade 3 neutropenia, 28.0% with grade 4 neutropenia, 33.8% with grade 3 thrombocytopenia, 18.1% with grade 4 thrombocytopenia). Among the 778 patients, 454 (58.4%) of patients had grade ≥3 HAEs in 2 or more lineages (21.3% for anemia and neutropenia, 21.0% for neutropenia and thrombocytopenia, 20.6% for anemia and thrombocytopenia, and 12.2% for all 3 lineages). 43.1% of patients were eligible for RBC transfusions and 3.9% eligible for platelet transfusions as indicated by lab value. 12.2% of patients had evidence of major bleeding events. 596 patients were included in the without grade ≥3 HAE cohort. Demographics and baseline ECOG scores were similar for the two cohorts (Table 1). Almost all patients (&gt;99%) received first-line chemotherapy at index (approximately 80% received platinum/etoposide regimen, 15% received platinum/etoposide in combination with immunotherapy) in both cohorts. Patients with grade ≥3 HAE had higher proportion of dose reductions (46.7% vs. 32.2%), treatment holds (12.7% vs. 5.9%), and treatment delays (92.3% vs. 84.3%) after chemotherapy initiation, all p&lt;0.001 when compared to the patients without grade ≥3 HAE. The total outpatient costs within 12 months post-index were higher for patients with grade ≥3 HAE ($37,613 vs. $31,176 p=0.004) (Table 2). Patients with grade ≥3 HAE had an average of 10.7 outpatient visits within 12 months post-index, vs 7.7 outpatient visits for those without grade ≥3 HAE (p&lt;0.0001). Patients with grade ≥3 HAE also had higher G-CSF use (64.1% vs. 57.2%, mean number of administrations 3.5 vs 2.4, mean cost per patient $9864 vs. $8011, all p&lt;0.01), ESA use (18.6% vs. 4.8%, 0.7 vs 0.12 administrations, mean cost per patient $786 vs. $151, all p&lt;0.01), and IV hydration (46.0% vs. 30.3%, 2.3 vs 1.2 administrations, mean cost per patient $148 vs $32, all p&lt;0.01) compared to the patients without grade ≥3 HAE. CONCLUSIONS: The results suggest there is significant burden of myelosuppressive hematological adverse events among ES-SCLC patients in a community oncology setting. A notable proportion of patients had HAEs in 2 or more lineages. Patients with grade ≥3 HAE appear to have more dose reductions, treatment delays, and more health care service utilizations than those without. Therapies to protect bone marrow from multilineage HAEs have potential to reduce such burden. Future research should investigate HCRU and cost burden in the inpatient setting to better understand the full scope of HAE management. Figure 1 Figure 1. Disclosures Goldschmidt: Ontada: Current Employment; Blue Ridge Cancer Care: Current Employment; Amgen: Honoraria, Speakers Bureau; BMS: Honoraria, Speakers Bureau; G1 Therapeutics: Honoraria, Speakers Bureau; TG Therapeutics: Honoraria. Monnette: Ontada: Current Employment, Current holder of individual stocks in a privately-held company; G1 Therapeutics: Consultancy; BMS: Consultancy. Shi: Ontada: Current Employment. Venkatasetty: Ontada: Current Employment. Huang: G1 Therapeutics: Current Employment, Current holder of individual stocks in a privately-held company, Current holder of stock options in a privately-held company. Chioda: G1 Therapeutics: Current Employment, Current holder of individual stocks in a privately-held company, Current holder of stock options in a privately-held company.

Decreasing inpatient chemotherapy initiation delays at Memorial Regional Hospital.

225 Background: Between June and December 2019, hematology-oncology patients admitted for elective chemotherapy at Memorial Regional Hospital had a median delay of 10 hours to initiate chemotherapy infusion from time of admission. This contributes to increased cost to the healthcare system and patient dissatisfaction. By September 2020, elective inpatient median time from admission to chemotherapy initiation at Memorial Regional Hospital will be reduced by 20%. Methods: Multidisciplinary team formed to evaluate the time from admission to initiation of chemotherapy for patients who are electively admitted for chemotherapy in 8 Central based on time stamps available in the electronic health records. Patients electively admitted by a non MCI oncologist were excluded. Data collections included time stamp between each process from admission to administration of 1st chemotherapy. Longest time lapse between each process was counted as an occurrence/contributor to delay. Top 80% contributors identified from Pareto chart allowed team to identify countermeasures. Priority Matrix of implementation in PDSA cycle based on highest impact and ease of implementation. Statistical process control chart was developed. Results: (see table). Conclusions: PDSA Cycle 1, obtaining labs 24-48 hours prior to admission, resulted in a 10% reduction in chemotherapy initiation time. PDSA Cycle 2, enhancing “ok to treat” communication, resulted in a further reduction of time to treatment. The combination of PDSA Cycle 1 & 2 resulted in a 40% reduction in time to chemotherapy initiation, exceeding the planned aim of 20%. Balance measures reflected no reduction in the mean number of overnight stays between baseline and PDSA Cycle 2 (4 nights) that could contribute to a decreased cost. Results and recommendations to adopt at all inpatient oncology departments within the healthcare system will be presented to leadership for support. Data automation through collaborative efforts with information technology is in process to assist with continuous monitoring. Future state, the quality improvement tools gained from ASCO QTP will be utilized to evaluate and improve workflow issues in the outpatient oncology setting. Nationally recognized organizations are encouraged to propose a benchmark for admission time to first chemotherapy administration based on the evaluation of current available data. Additional studies are needed to evaluate chemotherapy treatment delays in other settings.[Table: see text]

A qualitative study informing about barriers and facilitators associated to chemotherapy initiation among breast cancer patients: Next steps for an intervention.

247 Background: (Neo)Adjuvant chemotherapy decreases the risk of recurrence and improves overall survival among breast cancer patients; however, delays in chemotherapy initiation are associated with adverse outcomes. The causes of delay are complex and include interrelated social, economic, cultural, environmental, and health system factors . Project Start was a qualitative study designed to assess and identify the multilevel factors contributing to the barriers and facilitators of chemotherapy initiation. Methods: English or Spanish-speaking women, ≥18 years, diagnosed with primary invasive breast cancer experiencing (neo)-adjuvant chemotherapy initiation delay ( ≥60 days) were included. Participants completed semi-structured interviews designed to explore perceptions about individual, community, and system-level barriers and facilitators contributing to chemotherapy initiation. Interviews were audio-recorded, transcribed verbatim, and coded using the Sort and Sift, Think and Shift qualitative approach to identify concepts and themes within and across transcripts. To supplement qualitative data, sociodemographic data and health literacy/numeracy, physician trust, and social support questionnaires were obtained. Results: Participants (n = 22) identified as: Latina (n = 8); Black (n = 5); and non-Latina White (n = 9). While the interview guide included questions addressing chemotherapy delays, explicit insight into chemotherapy delay was rare. Participants described barriers and facilitators at the patient, family, medical, and community levels. Barriers at the patient level included patient’s hesitancy to initiate chemo due to shock, fear, and denial. Within the family level, we learned of participant’s family roles (e.g., caregiving, income), treatment costs, and the need for emotional support (e.g., not shutting family members out). Participants sought out and relied heavily on support from their communities (e.g., churches, other patients, survivors). Patients described their reliance on the medical team for information, the trust needed to navigate their treatment process, and the challenge of managing information associated with their treatment. Participants described the importance of self-efficacy to take an active role in treatment. Conclusions: Project Start is informing the design of a pilot study aimed to test the acceptability and feasibility of a navigation intervention. Using facilitators and barriers identified from Project Start, we are developing a checklist that will serve as a tool to identify the support each patient needs. Once areas of need are identified, appropriate referrals will be made in a personalized and culturally sensitive way with the goal of increasing self-efficacy and activating patients to avoid treatment delays.

Severe Hypertriglyceridemia Induced by Docetaxel: A Novel Case Report

Docetaxel (DOC) is one of the most effective agents for breast cancer treatment. Here, we report docetaxel-induced severe hypertriglyceridemia in a patient previously diagnosed with hyperlipidemia and corresponding therapeutic intervention. A postmenopausal woman, with previously controlled hyperlipidemia using rosuvastatin 5 mg daily, was diagnosed with stage IIB breast cancer with human epidermal growth factor receptor-2 overexpression; she received DOC (75 mg/m²), pertuzumab, and trastuzumab treatment as neoadjuvant chemotherapy. The serum triglyceride level was mildly higher than normal, and cholesterol level was normal at baseline. The serum triglyceride level was almost stable after chemotherapy initiation but suddenly increased to grade 3 (770 mg/dL) after the third cycle of the treatment without any symptoms. Sustained-release bezafibrate 400 mg was administered, resulting in a significant decrease to the baseline level; bezafibrate was discontinued on day 28 of the fourth chemotherapy as neoadjuvant chemotherapy was completed. The level was stable around the baseline level during adjuvant chemotherapy with pertuzumab and trastuzumab. Therefore, DOC-induced severe hypertriglyceridemia was strongly indicated in this case. The mechanism underlying the symptoms remains unclear; we speculate that it could be a resultant of a decrease in lipid metabolism as the patient had grade 2 diarrhea. Moreover, her backgrounds, such as mild hypertriglyceridemia, postmenopausal, diabetes, and obesity, in addition to DOC administration might have affected the outcome. Fibrate administration and cessation of treatment were as effective as in previous reports. DOC-induced hypertriglyceridemia presents with the possibility of severe complications. Elucidation of the exact mechanisms and epidemiological features is required for better management.

Metastatic mucoepidermoid carcinoma of the lung: A case report

Mucoepidermoid carcinoma (MEC) is a rare form of lung malignancy that is classified into high-grade and low-grade according to its histological characteristics. High-grade mucoepidermoid carcinoma (HMC) is more aggressive form of malignancy which involves lymph node and distant metastasis. Here, we report a 62-year-old female with complaints of dry cough and generalized weakness was diagnosed to have high grade mucoepidermoid carcinoma of lung metastases to lymph nodes, pleura, left adrenal and skeleton. Diagnosis was confirmed by Computed Tomography (CT) which showed numerous lung nodules, biopsy revealing metastatic deposit of mucoepidermoid and Positron Emission Tomography (PET) indicating primary left lung malignancy with metastasis. Despite chemotherapy initiation, the prognosis remained poor.